The Hidden Complexity of Long-Term Care: how context mediates knowledge translation and use of best practices

Working on differentiated nursing practices in hospitals: A learning history on enacting new nursing roles

OBJECTIVE

This study aims to better understand how new future-oriented nursing roles are enacted in a general hospital.

DESIGN

A learning history, that is, a participatory action-oriented research design to explore and foster organizational learning.

METHODS

Data collection consisted of a (historical) document analysis, the shadowing of differentiated nursing practices (36 h), 22 open interviews, 4 oral history interviews, 2 focus groups and a podcast series (7 h) created with participants.

RESULTS

The data gathered revealed three important themes regarding enacting new nursing roles: (1) stretching the nature of nursing work, (2) using earlier experiences and (3) collectively tackling taboos.

CONCLUSIONS

Differentiated nursing practices and enacting new nursing roles have long and complex histories. Attempts to differentiate are often met with resistance from within the nursing profession. This study shows how the new role of nurse coordinator was negotiated in nursing teams. With a bottom-up approach focused on collective responsibilities. By acknowledging and reflecting on the past, spaces were enacted in which the role of nurse coordinator became one role, among others, in the delivery of patient care.

IMPACT

This study provides an innovative perspective on differentiated nursing practices by focusing on the past, the present and the future. We found that local, situated conditions can be taken as starting points when new nursing roles are enacted. In addition, shifting focus from individual nursing roles to nursing team development, emphasizing collective responsibilities, softens strong (historically) grown emotions and creates spaces in which new roles become negotiable.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Understanding Adaptive Leadership in the Context of Nursing Homes

Rapidly growing populations of older adults rely heavily on formal long-term care services such as those provided in nursing homes. Nursing home staff are confronted with complex challenges. We explored how staff (N = 88), particularly care aides, interpreted challenges and responded to them by taking adaptive leadership roles, and engaging in technical and adaptive work in nursing homes. We conducted analysis of the ethnographic case studies. In long-term care settings, staff face complex challenges in improving resident care due to contextual barriers. These include demanding work conditions and inadequate resources. Additionally, top-down communications, despite being well-intentioned, often lead to misinterpretation and a lack of staff motivation. Nonetheless, we found that certain staff managed to overcome these contextual barriers and effectively execute change initiatives by assuming adaptive leadership roles. Formal leaders have a vital role in empowering staff, including care aides, and facilitating their adaptive leadership behaviors.

Relationship between staff and quality of care in care homes: StaRQ mixed methods study

Background

Quality of life and care varies between and within the care homes in which almost half a million older people live and over half a million direct care staff (registered nurses and care assistants) work. The reasons are complex, understudied and sometimes oversimplified, but staff and their work are a significant influence.

Objective(s)

To explore variations in the care home nursing and support workforce; how resident and relatives' needs in care homes are linked to care home staffing; how different staffing models impact on care quality, outcomes and costs; how workforce numbers, skill mix and stability meet residents' needs; the contributions of the care home workforce to enhancing quality of care; staff relationships as a platform for implementation by providers.

Design

Mixed-method (QUAL-QUANT) parallel design with five work packages. WP1 - two evidence syntheses (one realist); WP2 - cross-sectional survey of routine staffing and rated quality from care home regulator; WP3 - analysis of longitudinal data from a corporate provider of staffing characteristics and quality indicators, including safety; WP4 - secondary analysis of care home regulator reports; WP5 - social network analysis of networks likely to influence quality innovation. We expressed our synthesised findings as a logic model.

Setting

English care homes, with and without nursing, with various ownership structures, size and location, with varying quality ratings.

Participants

Managers, residents, families and care home staff.

Findings

Staffing's contribution to quality and personalised care requires: managerial and staff stability and consistency; sufficient staff to develop 'familial' relationships between staff and residents, and staff-staff reciprocity, 'knowing' residents, and skills and competence training beyond induction; supported, well-led staff seeing modelled behaviours from supervisors; autonomy to act. Outcome measures that capture the relationship between staffing and quality include: the extent to which resident needs and preferences are met and culturally appropriate; resident and family satisfaction; extent of residents living with purpose; safe care (including clinical outcomes); staff well-being and job satisfaction were important, but underacknowledged.

Limitations

Many of our findings stem from self-reported and routine data with known biases - such as under reporting of adverse incidents; our analysis may reflect these biases. COVID-19 required adapting our original protocol to make it feasible. Consequently, the effects of the pandemic are reflected in our research methods and findings. Our findings are based on data from a single care home operator and so may not be generalised to the wider population of care homes.

Conclusions

Innovative and multiple methods and theory can successfully highlight the nuanced relationship between staffing and quality in care homes. Modifiable characteristics such as visible philosophies of care and high-quality training, reinforced by behavioural and relational role modelling by leaders can make the difference when sufficient amounts of consistent staff are employed. Greater staffing capacity alone is unlikely to enhance quality in a cost-effective manner. Social network analysis can help identify the right people to aid adoption and spread of quality and innovation. Future research should focus on richer, iterative, evaluative testing and development of our logic model using theoretically and empirically defensible - rather than available - inputs and outcomes.

Study registration

This study is registered as PROSPERO CRD42021241066 and Research Registry registration: 1062.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/144/29) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.

Ambiguities in Preventing Infections in Nursing Homes: Care Workers Experiences and Implications for Future Policies

Preventing infections in nursing homes is highly challenging, given the ambiguous nature of nursing homes as care institutions and places to live. Yet, little is known about how care workers experience preventing infections in this context. Understanding the ambiguities experienced by care workers in nursing homes when enacting infection prevention is crucial to preparing for future health crises. This study investigates and identifies the ambiguities care workers faced and experienced when preventing infections during the COVID-19 pandemic. Interviews and observations were combined to capture narratives and behaviors related to infection prevention and care work. By using thematic analysis, three types of ambiguity were identified: (a) an Ambiguous sense of purpose, (b) Environmental ambiguity, and (c) Information ambiguity. The findings provide a nuanced understanding of the ambiguities care workers face and experience in nursing homes when preventing infections and indicate that such ambiguities impact their behaviors and attitudes. From this study, it is possible to conclude that policymakers must consider nursing homes' ambiguous characteristics in infection prevention programs.

Realist synthesis protocol for understanding which strategies are effective to prevent urinary tract infection in older people in care homes

AIM

To identify and characterize strategies, which contribute to the prevention of urinary tract infection (UTI) in older people living in care homes.

DESIGN

The realist synthesis has four iterative stages to (1) develop initial programme theory; (2) search for evidence; (3) test and refine theory supported by relevant evidence and (4) formulate recommendations. Data from research articles and other sources will be used to explore the connection between interventions and the context in which they are applied in order to understand the mechanisms, which influence the outcomes to prevent UTI.

METHODS

A scoping search of the literature and workshops with stakeholders will identify initial programme theories. These theories will be tested and refined through a systematic search for evidence relating to mechanisms that trigger prevention and recognition of UTI in older people in care homes. Interviews with key stakeholders will establish practical relevance of the theories and their potential for implementation.

DISCUSSION

UTI is the most commonly diagnosed infection in care home residents. Evidence on the effectiveness of strategies to prevent UTI in long-term care facilities does not address the practicality of implementing these approaches in UK care homes. The realist synthesis is designed to examine this important gap in evidence.

IMPACT

Our evidence-informed programme theory will help inform programmes to improve practice to reduce the incidence of UTI in older people living in care homes and related research. Patient and public involvement will be crucial to ensuring that our findings reach carers and the public.

PATIENT AND PUBLIC CONTRIBUTION

Involvement of patient and public representatives is embedded throughout the study to ensure it is underpinned by multiple perspectives of importance to care home residents. Our co-investigator representing patient and public involvement is a lay member of the team and will chair the Project Advisory Group, which has two additional lay members. This will help to ensure that our findings and resources reach carers and the public and represent their voice in our publications and presentations to professional and lay audiences.

The impact of knowledge management on the quality of services in nursing homes

Introduction

Current management strategies in nursing homes (NH) aim to ensure effective knowledge management (KM) in order to provide both best possible services to residents, and care for staff in NH. Teamwork in NH is essential for effective delivery of the highest quality of services. As a result, NH are increasingly adopting KM activities to enable knowledge creation, storage, transfer, and implementation in an environment facing many challenges such as lack of staff, increasing demands, and expectations of residents.

Methods

In our quantitative study, we examined how two Slovenian state NH that adopted the E-Qalin quality management model (European quality-improving learning model) adapted their KM, and what impact their quality management system and KM activities actually have on the quality of services. Furthermore, we examined how two Slovenian private NH that have not adopted a certified quality management program (like ISO or E-Qalin) tackle the issue of quality of services from the KM perspective. The sample consisted of 80 nursing professionals. In every NH that is part of this study, teamwork is essential and every individual that was involved in our survey is part of a team. In our study, we analyzed relationships between individual variables using linear regression.

Results

We found a significant and positive relationship between knowledge creation, transfer, and implementation in NH with and without the E-Qalin certificate. We found a significant and positive relationship between knowledge storage and the quality of services only in NH without a E-Qualin certificate. It seems that when connecting multidisciplinary fields such as NH and KM, there is still a lack of awareness and knowledge on the topic of KM, which might be one of the reasons for some bias in the answers provided by respondents. We also found different teamwork approaches in NH with and without a E-Qalin certificate. Our research results therefore emphasize the need to gain additional insight into quality management and KM in the environment of NH.

Conclusion

Teamwork based on knowledge storage, transfer, the implementation of existing knowledge, and creation of new knowledge are essential for well-trained professionals and, as a result, contribute to continuous improvement in service quality. Implementation of KM is well received by NH, and enables them to better meet the needs and expectations of residents. More importantly, nursing staff also share and pass on tacit knowledge through teamwork. Finally, all of the NH in our study that implemented quality and KM activities noted an improvement in the quality of services that are offered to residents in practice. Our results indicate that the topic of KM in NH is interesting, and it has a positive impact on the quality of services in practice. However, the problem of awareness and knowledge on the topic of KM in the environment of NH still exists, highlighting the need for further research, additional insight, and dissemination of knowledge to every interested stakeholder functioning in the field of NH. The results of the study make an important contribution to the research of KM in NH, focusing on the transfer of tacit knowledge.

Understanding health information exchange processes within Canadian long-term care: A scoping review

BACKGROUND

Providing supportive care to long-term care residents with complex medical conditions generates substantial amounts of health information. This information must be documented, shared and acted upon by the various care providers within the circle of care.

OBJECTIVES

The purpose of this scoping review is to describe the current digital health information exchange (HIE) processes used within Canadian long-term care facilities (LTCFs).

METHODS

The scoping review followed Arksey and O'Malley's approach to the methodology. Electronic databases (e.g. CINAHL, MEDLINE and SCOPUS) were searched between 2010 and 2020 using terms including 'health information exchange', 'communication' and 'health information technology'. Articles were included if they were Canadian-based and relevant to our definition of health information exchange.

RESULTS

The search yielded 2091 citations for title and abstract screening; 78 citations were selected for independent full-text review, 42 of those met study criteria. The findings revealed gaps between the expectations of HIE for quality health care and the realities of HIE processes that impact the provision of care in long-term care.

CONCLUSIONS

We conclude that increased provider engagement and effective use of HIE processes is recommended to improve the safety and quality of health care in the long-term care sector.

IMPLICATIONS FOR PRACTICE

HIE implementation should be preceded a review of various aspects of workflow to identify information gaps and inefficiencies that can be addressed by digitization.

Sustaining Knowledge Translation Practices: A Critical Interpretive Synthesis

BACKGROUND

The health policy and systems research literature increasingly observes that knowledge translation (KT) practices are difficult to sustain. An important issue is that it remains unclear what sustainability of KT practices means and how it can be improved. The aim of this study was thus to identify and explain those processes, activities, and efforts in the literature that facilitate the sustaining of KT practices in health policy-making processes.

METHODS

We used a critical interpretive synthesis (CIS) to review the health policy and systems research and Science and Technology Studies (STS) literature. The STS literature was included as to enrich the review with constructivist social scientific perspectives on sustainability and KT. The CIS methodology allowed for creating new theory by critically combining both literatures. We searched the literature by using PubMed, Google Scholar, Web of Science, and qualitative sampling. Searches were guided by pre-set eligibility criteria and all entries were iteratively analysed using thematic synthesis.

RESULTS

Eighty documents were included. Our synthesis suggests a shift from sustainability as an end-goal towards sustaining as actors' relatively mundane work aimed at making and keeping KT practices productive. This 'sustaining work' is an interplay of three processes: (i) translating, (ii) contexting, and (iii) institutionalising. Translating refers to activities aimed at constructing and extending networks. Contexting emphasises the activities needed to create contexts that support KT practices. Institutionalising addresses how actors create, maintain, and disrupt institutions with the aim of sustaining KT practices.

CONCLUSION

The 'sustaining work' perspective of our CIS emphasises KT actors' ongoing work directed at sustaining KT practices. We suggest that this perspective can guide empirical study of sustaining work and that these empirical insights, combined with this CIS, can inform training programmes for KT actors, and thereby improve the sustainability of KT practices.

Staff scheduling for residential care under pandemic conditions: The case of COVID-19

The COVID-19 pandemic severely impacted residential care delivery all around the world. This study investigates the current scheduling methods in residential care facilities in order to enhance them for pandemic conditions. We first define the basic problem that addresses decisions associated with the assignment and scheduling of staff members, who perform a set of tasks required by residents during a planning horizon. This problem includes the minimization of costs associated with the salary of part-time staff members, total overtime, and violations of service time windows. Subsequently, we adapt the basic problem to pandemic conditions by considering the impacts of communal spaces (e.g., shared rooms) and a cohorting policy (classification of residents based on their risk of infection) on the spread of infectious diseases. We introduce a new objective function that minimizes the number of distinct staff members serving each room of residents. Likewise, we propose a new objective function for the cohorting policy that aims to minimize the number of distinct cohorts served by each staff member. A new constraint is incorporated that forces staff members to serve only one cohort within a shift. We present a population-based heuristic algorithm to solve this problem. Through a comparison with two benchmark solution approaches (a mathematical programme and a non-dominated archiving ant colony optimization algorithm), the superiority of the heuristic algorithm is shown regarding solution quality and CPU time. Finally, we conduct numerical analyses to present managerial implications.

The Influence of Context on Implementation and Improvement: Protocol for a Mixed Methods, Secondary Analyses Study

Background

Caring for the well-being of older adults is one of the greatest challenges in modern societies. Improving the quality of care and life for older adults and the work lives of their care providers calls for effective knowledge translation of evidence-based best practices.

Objective

This study’s purpose is to contribute to knowledge translation by better understanding the roles of organizational context (workplace environment) and facilitation (process or role) in implementation and improvement success. Our study has 2 goals: (1) to advance knowledge translation science by further developing and testing the Promoting Action on Research Implementation in Health Services framework (which outlines how implementation relies on the interplay of context, facilitation, and evidence) and (2) to advance research by optimizing implementation success via tailoring of modifiable elements of organizational context and facilitation.

Methods

This is secondary analyses of 15 years of longitudinal data from the Translating Research in Elder Care (TREC) program’s multiple data sources. This research is ongoing in long-term care (LTC) homes in western Canada. TREC data include the following: 5 waves of survey collection, 2 clinical trials, and regular ongoing outcome data for LTC residents. We will use a sequential exploratory and confirmatory mixed methods design. We will analyze qualitative and quantitative data holdings in an iterative process: (1) comprehensive reanalysis of qualitative data to derive hypotheses, (2) quantitative modeling to test hypotheses, and (3) action cycles to further refine and integrate qualitative and quantitative analyses. The research team includes 4 stakeholder panels: (1) system decision- and policy makers, (2) care home managers, (3) direct care staff, and (4) a citizen engagement group of people living with dementia and family members of LTC residents. A fifth group is our panel of external scientific advisors. Each panel will engage periodically, providing their perspectives on project direction and findings.

Results

This study is funded by the Canadian Institutes of Health Research. Ethics approval was obtained from the University of Alberta (Pro00096541). The results of the secondary analyses are expected by the end of 2023.

Conclusions

The project will advance knowledge translation science by deepening our understanding of the roles of context, the interactions between context and facilitation, and their influence on resident and staff quality outcomes. Importantly, findings will inform understanding of the mechanisms by which context and facilitation affect the success of implementation and offer insights into factors that influence the implementation success of interventions in nursing homes.

International Registered Report Identifier (IRRID)

DERR1-10.2196/40611

Working Dynamics of Licensed Nurses and Nurse Aides in Nursing Homes: A Scoping Review

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.].

Motives and strategies of CEOs for stimulating sharing and application of knowledge in the care and support for people with intellectual disabilities

Purpose

Within intellectual disability care organizations (IDCOs), it is vital that professionals share and apply knowledge to improve the quality of care for their service users. Given that chief executive officers (CEOs) play a pivotal role in enabling these processes, this paper aims to investigate both the underlying motives and strategies behind CEOs’ organizational knowledge leadership and their contribution to improving these knowledge processes.

Design/methodology/approach

In this exploratory qualitative study, 11 CEOs from IDCOs in the Netherlands who are actively involved in knowledge management within their organizations were interviewed. An inductive thematic analysis was conducted.

Findings

CEOs’ motives for stimulating knowledge processes among professionals in IDCOs arise from the internal (e.g. the CEOs themselves) and external (e.g. policy) contexts. This study also identified four strategies adopted by CEOs to stimulate sharing and application of knowledge: providing organizational conditions for effective knowledge processes; focused attention on talent development; acknowledgment and deployment of knowledge holders; and knowledge-driven participation in collaborative partnerships. These strategies are used in combination and have been shown to reinforce one another.

Practical implications

An overview of strategies for stimulating knowledge processes is now available.

Originality/value

The results display the leadership of CEOs in knowledge strategies. Insights into their perceptions and values are provided while elaborating on their motives to take this role.

Fostering the implementation of transitional care innovations for older persons: prioritizing the influencing key factors using a modified Delphi technique

Background

Transitions in care for older persons requiring long-term care are common and often problematic. Therefore, the implementation of transitional care innovations (TCIs) aims to improve necessary or avert avoidable care transitions. Various factors were recognized as influencers to the implementation of TCIs. This study aims to gain consensus on the relative importance level and the feasibility of addressing these factors with implementation strategies from the perspectives of experts. This work is within TRANS-SENIOR, an innovative research network focusing on care transitions.

Methods

A modified Delphi study was conducted with international scientific and practice-based experts, recruited using purposive and snowballing methods, from multiple disciplinary backgrounds, including implementation science, transitional care, long-term care, and healthcare innovations. This study was built on the findings of a previously conducted scoping review, whereby 25 factors (barriers, facilitators) influencing the implementation of TCIs were selected for the first Delphi round. Two sequential rounds of anonymous online surveys using an a priori consensus level of > 70% and a final expert consultation session were performed to determine the implementation factors’: i) direction of influence, ii) importance, and iii) feasibility to address with implementation strategies. The survey design was guided by the Consolidated Framework for Implementation Research (CFIR). Data were collected using Qualtrics software and analyzed with descriptive statistics and thematic analysis.

Results

Twenty-nine experts from 10 countries participated in the study. Eleven factors were ranked as of the highest importance among those that reached consensus. Notably, organizational and process-related factors, including engagement of leadership and key stakeholders, availability of resources, sense of urgency, and relative priority, showed to be imperative for the implementation of TCIs. Nineteen factors reached consensus for feasibility of addressing them with implementation strategies; however, the majority were rated as difficult to address. Experts indicated that it was hard to rate the direction of influence for all factors.

Conclusions

Priority factors influencing the implementation of TCIs were mostly at the organizational and process levels. The feasibility to address these factors remains difficult. Alternative strategies considering the interaction between the organizational context and the outer setting holds a potential for enhancing the implementation of TCIs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02672-2.

What Constitutes Preferred Long-Term Care Provided in Residential Aged Care Facilities? An Empirical Comparison of the Preferences of the General Population, Residents, and Family Members

OBJECTIVES

Relatively few studies to date have examined the preferences of members of the general population as potential future consumers of long-term aged care services. This study aimed to use discrete choice experiment methodology to compare the preferences of 3 groups: the general population, residents, and family members of people living in long-term aged care.

METHODS

A total of 6 salient attributes describing the physical and psychosocial care in long-term residential aged care were drawn from qualitative research with people with a lived experience of aged care and were used to develop the discrete choice experiment questionnaire. The 6 attributes included: the level of time care staff spent with residents, homeliness of shared spaces, the homeliness of their own rooms, access to outside and gardens, frequency of meaningful activities, and flexibility with care routines. The questionnaire was administered to 1243 respondents including consumers (residents [n = 126], family member carers [n = 416]), and members of the general population (n = 701).

RESULTS

For both the general population and resident samples, having their own room feeling "home-like" exhibited the largest impact upon overall preferences. For the family member sample, care staff being able to spend enough time exhibited the largest impact. Tests of poolability indicated that the resident and general population samples estimates could be pooled. The null hypothesis of equal parameters between the groups was rejected for the family members, indicating significant differences in preferences relative to the resident and the general population samples.

CONCLUSIONS

This study illustrates that preferences for residential aged care delivery may vary depending upon perspective and experience.

Knowledge needs and use in long-term care homes for older people: A qualitative interview study of managers' views

We explore the views of managers' knowledge needs and use to optimise care practices and enhance the life experience for older people living, and staff working, in long-term care homes (with and without nursing). This paper contributes to previous research by offering insights into the knowledge types drawn upon and used by managers to inform efforts to better support gaining and mobilising knowledge. Using a pragmatic qualitative approach, we undertook 19 semi-structured interviews with managers and leaders in 15 care homes in the South West of England, varying in geographical location, size and type of ownership. We did a thematic analysis of the data using Framework Analysis. Our interpretations were informed by the existing literature on knowledge types. We identified three themes from our analysis as to managers' knowledge needs and use when implementing changes. First, views about training and formal reports or "explicit knowledge" consisting of the two sub-themes "gaining explicit knowledge" and "research knowledge". Second, perspectives relating to practical experience or "tacit knowledge" and judging the use of knowledge in particular cases or "phronesis". Third, the role of emotion in managers' knowledge needs and use. We found that having knowledge was positively valued by managers and leaders for improving care practices and enhancing the lives of people residing in care homes. Tacit knowledge and phronesis were particularly highly valued and we note challenges with the perceived applicability, relevance and use of research evidence. We identify that emotions are an important component within knowledge use and a need to further understand how to support the emotional wellbeing of managers so they can support care staff and residents. Greater consideration is needed as to how to optimise gaining and mobilising all knowledge types - "know-what," "know-how," "know-when" and "know-feel" - to benefit people living, and staff working, in care homes.

Translation and validation of the Alberta Context Tool for use in Norwegian nursing homes

PURPOSE

Organizational context is recognized as important for facilitating evidence-based practice and improving patient outcomes. Organizational context is a complex construct to measure and appropriate instruments that can quantify and measure context are needed. The aim of this study was to translate and cross-culturally adapt the Alberta Context Tool (ACT) to Norwegian, and to test the reliability and structural validity among registered nurses (RNs) and licenced practice nurses (LPNs) working in nursing homes.

METHODS

This study was a validation study utilizing a cross-sectional design. The sample consisted of n = 956 healthcare personnel from 28 nursing homes from a municipality in Norway. In the first stage, the ACT was translated before being administered in 28 nursing homes. In the second stage, internal consistency and structural validity were explored using Cronbach's alpha and confirmatory factor analysis.

RESULTS

A rigorous forward-and-back translation process was performed including a team of academics, experts, professional translators and the copyright holders, before an acceptable version of the ACT was piloted and finalized. The Norwegian version of the ACT showed good internal consistency with Chronbachs alpha above .75 for all concepts except for Formal interactions where the alpha was .69. Structural validity was acceptable for both RNs and LPNs with factors loadings more than .4 for most items.

CONCLUSIONS

The Norwegian version of the ACT is a valid measure of organizational context in Norwegian nursing homes among RNs and LPNs.

Experiential education through project-based learning: Sex and aging

Myths and stereotypes of sex in late-life prevail. Unless the workforce is prepared to address the sexual health needs of older adults, it is difficult to disrupt ageism in professional settings. We evaluated a two-day project-based workshop designed for undergraduate students about sex and aging. Using content analysis, we examined open-ended responses from 41 undergraduate students. Three themes depicted the value of experiential project-based learning. Participants (1) appreciated the opportunity to develop transferable pre-professional skills, (2) demonstrated comfort and utilized creative strategies to discuss a sensitive topic, and (3) attained a greater awareness of late-life sexual health and behavior. Providing training to undergraduate students helped close the knowledge gap about issues of late-life sexual health and behaviors. Participants developed skills for translating knowledge into practical resources. It is critical for gerontology educators to identify strategies to deliver sex and aging education to enhance services for older adults.

'Bare-bones' to 'silver linings': lessons on integrating a palliative approach to care in long-term care in Western Canada

Background

‘Whole-person’ palliative approaches to care (PAC) are important for enhancing the quality of life of residents with life-limiting conditions in long-term care (LTC). This research is part of a larger, four province study, the ‘SALTY (Seniors Adding Life to Years)’ project to address quality of care in later life.

A Quality Improvement (QI) project to integrate a PAC (PAC-QI) in LTC was implemented in Western Canada in four diverse facilities that varied in terms of ownership, leadership models, bed size and geography. Two palliative ‘link nurses’ were hired for 1 day a week at each site over a two-year time frame to facilitate a PAC and support education and training.

This paper evaluates the challenges with embedding the PAC-QI into LTC, from the perspectives of the direct care, or front-line team members. Sixteen focus groups were undertaken with 80 front-line workers who were predominantly RNs/LPNs (n = 25), or Health Care Aides (HCAs; n = 32). A total of 23 other individuals from the ranks of dieticians, social workers, recreation and rehabilitation therapists and activity coordinators also participated. Each focus group was taped and transcribed and thematically analyzed by research team members to develop and consolidate the findings related to challenges with embedding the PAC.

Results

Thematic analyses revealed that front-line workers are deeply committed to providing high quality PAC, but face challenges related to longstanding conditions in LTC notably, staff shortages, and perceived lack of time for providing compassionate care. The environment is also characterized by diverse views on what a PAC is, and when it should be applied. Our research suggests that integrated, holistic and sustainable PAC depends upon access to adequate resources for education, training for front-line care workers, and supportive leadership.

Conclusions

The urgent need for integrated PAC models in LTC has been accentuated by the current COVID-19 pandemic. Consequently, it is more imperative than ever before to move forwards with such models in order to promote quality of care and quality of life for residents and families, and to support job satisfaction for essential care workers.

Understanding the staff behaviours that promote quality for older people living in long term care facilities: A realist review

BACKGROUND

Little is known about how the workforce influences quality in long term care facilities for older people. Staff numbers are important but do not fully explain this relationship.

OBJECTIVES

To develop theoretical explanations for the relationship between long-term care facility staffing and quality of care as experienced by residents.

DESIGN

A realist evidence synthesis to understand staff behaviours that promote quality of care for older people living in long-term care facilities.

SETTING

Long-term residential care facilities PARTICIPANTS: Long-term care facility staff, residents, and relatives METHODS: The realist review, (i) was co-developed with stakeholders to determine initial programme theories, (ii) systematically searched the evidence to test and develop theoretical propositions, and (iii) validated and refined emergent theory with stakeholder groups.

RESULTS

66 research papers were included in the review. Three key findings explain the relationship between staffing and quality: (i) quality is influenced by staff behaviours; (ii) behaviours are contingent on relationships nurtured by long-term care facility environment and culture; and (iii) leadership has an important influence on how organisational resources (sufficient staff effectively deployed, with the knowledge, expertise and skills required to meet residents' needs) are used to generate and sustain quality-promoting relationships. Six theoretical propositions explain these findings.

CONCLUSION

Leaders (at all levels) through their role-modelling behaviours can use organisational resources to endorse and encourage relationships (at all levels) between staff, residents, co-workers and family (relationship centred care) that constitute learning opportunities for staff, and encourage quality as experienced by residents and families.

Relationship-Centered Mealtime Training Program Demonstrates Efficacy to Improve the Dining Environment in Long-Term Care

OBJECTIVES

Mealtimes in residential care tend to be task-focused rather than relationship-centered, impacting resident quality of life. CHOICE+ uses participatory approaches to make mealtimes more relationship-centered. The aim of this study was to demonstrate the efficacy of the 12-month external-facilitated implementation of CHOICE+ to improve the mealtime environment.

DESIGN

Modified stepped-wedge time series design.

SETTING AND PARTICIPANTS

Dining rooms in 3 homes were entered into the intervention every 4 months; total study length was 20 months. Pre- and postintervention evaluations were attained from residents (n = 27, n = 19) and staff (n = 39, n = 29) respectively.

METHODS

Five meals in each home were observed by a blinded trained assessor every 4 months using the Mealtime Scan+ to assess physical, social, and relationship-centered practices and overall quality of the dining environment. Repeated measures analysis determined change in mealtime environment scores. The Team member Mealtime Experience Questionnaire and 5 questions from the InterRAI Quality of Life Questionnaire for residents and family were administered at pre- and postintervention.

RESULTS

There were significant increases in physical and social environments, relationship-centered care practices, and overall quality of the mealtime environment during the intervention period at all sites (all P < .001) and significant site by intervention interactions for physical (P = .01) and relationship-centered care (P = .03). Statistically significant site differences were noted for relationship-centered care practices (P < .001) and overall quality of the dining environment (P < .002). There was no significant difference in staff and resident/family pre-/postintervention questionnaire results.

CONCLUSIONS AND IMPLICATIONS

The external facilitated model of CHOICE+ resulted in significant improvements in the mealtime environment. Although site context impacted implementation, this study demonstrates that mealtimes can be improved even in homes that have challenges. Future work should determine impact of these improvements on other outcomes such as resident quality of life, using more specific measures.

The role of motivation in the diffusion of innovations in Canada's long-term care sector: a qualitative study

Background

Long-term care facilities offer shelter and care for Canadian seniors; however, there are great variances in the quality of care that is provided to older adults across facilities. One factor that could contribute to this variation in quality is the diffusion and implementation of advice and innovations within this sector. This study sought to understand the motivations of identified opinion leaders within the Canadian long-term care sector to disseminate advice within their social networks. Research questions addressed specific drivers of motivation and the potential outcomes of having motivated opinion leaders present within interpersonal advice-seeking networks with respect to diffusion and implementation of innovations in the Canadian long-term care sector.

Methods

This secondary analysis study analyzed semi-structured qualitative interviews with opinion leaders (n = 13) and advice seekers of opinion leaders (n = 13) from a national, social network study, Advice Seeking Networks in Long Term Care (Cranley et al. 2019; Dearing et al. 2017). Constant comparison analysis was used and supported by a theoretical framework developed from diffusion of innovation theory and the COM-B framework.

Results

The motivations of opinion leaders in the Canadian long-term care sector were represented across seven themes: obligations of the position, value of education, systemness, relationships, supportiveness, passion, and caring nature.

Conclusions

This research provides further evidence that opinion leaders in the long-term care sector are motivated individuals and that they are using this motivation as a driver to create change and improve care practices. As residents of the long-term care sector continue to increase in number and complexity, the presence of motivated opinion leaders represents a promising outlook for the future through achieving specific outcomes such as the diffusion and implementation of innovations, an increased sense of community within the network, and increased readiness for the future.

The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature

BACKGROUND

The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework.

METHODS

This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail.

RESULTS

The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated.

CONCLUSIONS

In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.

Nursing staff participation in end-of-life nutrition and hydration decision-making in a nursing home: A qualitative study

AIM

To better understand the participation of nursing staff in end-of-life nutrition and hydration decision-making in an American nursing home.

DESIGN

A qualitative exploration with ethnographic focus.

METHODS

In April 2017, in-person, semi-structured interviews were performed with 19 nursing staff members in a nursing home located in the south-eastern United States. Additional information was gathered through participant observation during interviews and review of organizational and regulatory policies. Transcripts were coded and analysed using qualitative methods described by Roper and Shapira (2000).

RESULTS

Three primary themes relating to nursing staff participation in end-of-life nutrition and hydration decision-making were identified: (a) Formal decision-making: decisions made and implemented by persons with the authority to make legal and binding care decisions in the nursing home setting; (b) Informal decision-making: decisions not requiring medical orders; and (c) Influential factors: factors that influence actions of nursing staff.

CONCLUSION

A variety of factors have an impact on nursing staff participation in end-of-life nutrition and hydration decision-making. Participation is closely aligned with the type of decision, whether formal or informal, and role, whether Certified Nursing Assistant/Aide, Licensed Practical/Vocational Nurse, or Registered Nurse.

IMPACT

End-of-life nutrition and hydration decision-making in nursing homes differs from decision-making in other care settings and presents a challenge globally. Interventions that support the participation of nursing staff in end-of-life nutrition and hydration decision-making have the potential to positively impact the experiences of residents and family members faced with these issues in the nursing home setting.

Using Nonparticipant Observation as a Method to Understand Implementation Context in Evidence-Based Practice

BACKGROUND

The uptake of evidence-based knowledge in practice is influenced by context. Observations are suggested as a valuable but under-used approach in implementation research for gaining a holistic understanding of contexts.

AIM

The aim of this paper is to demonstrate how data from observations can provide insights about context and evidence use in implementation research.

METHODS

Data were collected over 24 months in a randomised trial with an embedded realist evaluation in 24 nursing homes across four European countries; notes from 183 observations (representing 335 hours) were triangulated with interview transcripts and context survey data (from 357 staff interviews and 725 questionnaire responses, respectively).

RESULTS

Although there were similarities in several elements of context within survey, interview and observation data, the observations provided additional features of the implementation context. In particular, observations demonstrated if and how the resources (staffing and supplies) and leadership (formal and informal, teamwork, and professional autonomy) affected knowledge use and implementation. Further, the observations illuminated the influence of standards and the physical nursing environment on evidence-based practice, and the dynamic interaction between different aspects of context.

LINKING EVIDENCE TO ACTION

Although qualitative observations are resource-intensive, they add value when used with other data collection methods, further enlightening the understanding of the implementation context and how evidence use and sharing are influenced by context elements. Observations can enhance an understanding of the context, evidence use and knowledge-sharing triad in implementation research.

Nursing staff's evaluation of facilitators and barriers during implementation of wireless nurse call systems in residential care facilities. A cross-sectional study

Background

Traditional nurse call systems used in residential care facilities rely on patients to summon assistance for routine or emergency needs. Wireless nurse call systems (WNCS) offer new affordances for persons unable to actively or consciously engage with the system, allowing detection of hazardous situations, prevention and timely treatment, as well as enhanced nurse workflows. This study aimed to explore facilitators and barriers of implementation of WNCSs in residential care facilities.

Methods

The study had a cross-sectional descriptive design. We collected data from care providers (n = 98) based on the Measurement Instrument for Determinants of Innovation (MIDI) framework in five Norwegian residential care facilities during the first year of WNCS implementation. The self-reporting MIDI questionnaire was adapted to the contexts. Descriptive statistics were used to explore participant characteristics and MIDI item and determinant scores. MIDI items to which ≥20% of participants disagreed/totally disagreed were regarded as barriers and items to which ≥80% of participants agreed/totally agreed were regarded as facilitators for implementation.

Results

More facilitators (n = 22) than barriers (n = 6) were identified. The greatest facilitators, reported by 98% of the care providers, were the expected outcomes: the importance and probability of achieving prompt call responses and increased safety, and the normative belief of unit managers. During the implementation process, 87% became familiar with the systems, and 86 and 90%, respectively regarded themselves and their colleagues as competent users of the WNCS. The most salient barriers, reported by 37%, were their lack of prior knowledge and that they found the WNCS difficult to learn. No features of the technology were identified as barriers.

Conclusions

Overall, the care providers gave a positive evaluation of the WNCS implementation. The barriers to implementation were addressed by training and practicing technological skills, facilitated by the influence and support by the manager and the colleagues within the residential care unit. WNCSs offer a range of advanced applications and services, and further research is needed as more WNCS functionalities are implemented into residential care services.

Setting Priorities to Inform Assessment of Care Homes' Readiness to Participate in Healthcare Innovation: A Systematic Mapping Review and Consensus Process

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.

Pain Management in Nursing Home Residents: Findings from a Pilot Effectiveness-Implementation Study

OBJECTIVES

To evaluate the effectiveness and implementation of a multilevel pain management intervention in nursing homes (NHs) comprising a pain management guideline, care worker training, and pain champions.

DESIGN

An implementation science pilot study using a quasi-experimental effectiveness-implementation (hybrid II) design.

SETTING

Four NHs in Switzerland.

PARTICIPANTS

All consenting long-term residents aged 65 years and older with pain at baseline (N = 62) and all registered and licensed practical nurses (N = 61).

INTERVENTION

Implementation of a contextually adapted pain management guideline, interactive training workshops for all care workers, and specifically trained pain champions.

MEASUREMENTS

Interference from pain, worst and average pain intensity over the previous 24 hours; proxy ratings of pain with the Pain Assessment in Advanced Dementia scale; and care workers' appraisal of the guideline's reach, acceptability, and adoption.

RESULTS

Pain-related outcomes improved for self-reporting residents (n = 43) and residents with proxy rating (n = 19). Significant improvements of average pain from baseline to T1 (P = .006), and in worst pain from baseline to T1 (P = .003) and T2 (P = .004). No significant changes in interference from pain (P = .18). With regard to the implementation efforts, about 76% of care workers indicated they were familiar with the guideline; 70.4% agreed that the guideline is practical and matches their ideas of good pain assessment (75.9%) and treatment (79.7%).

CONCLUSION

Implementation of a multilevel pain management intervention did significantly improve average and worst pain intensity in NH residents. However, to effect clinical meaningful changes in interference from pain, a more comprehensive approach involving other disciplines may be necessary. J Am Geriatr Soc 67:2574-2580, 2019.

What influences the sustainability of an effective psychosocial intervention for people with dementia living in care homes? A 9 to 12-month follow-up of the perceptions of staff in care homes involved in the WHELD randomised controlled trail

OBJECTIVES

The study aims to understand the factors that care home staff felt enabled or hindered them in continuing to use the well-being and health for people with dementia (WHELD) psychosocial approach in their care home and investigate whether there was sustained activity 9 to 12 months after the study ended.

METHODS

This qualitative study is part of a wider clinical trial, which demonstrated effectiveness of a psychosocial intervention on quality of life outcomes and neuropsychiatric symptoms for residents. Forty-seven care home staff within nine care homes in the United Kingdom participated in focus groups, between 9 and 12 months after the intervention had finished. Inductive thematic analysis was used to identify themes and interpret the data.

RESULTS

The findings highlighted that staff continued to use a range of activities and processes acquired through the research intervention, after the study had ended. Three overarching themes were identified as influential: "recognising the value" of the approach for residents and staff, "being well practiced" with sufficient support and opportunity to consolidate skills prior to the withdrawal of the researchers, and "taking ownership of the approach" to incorporate it as usual care.

CONCLUSIONS

The WHELD approach can be sustained where the value of the approach is recognised, and sufficient support is provided during initial implementation for staff to build skills and confidence for it to become routine care. Further follow-up is required to understand longer term use and the impact for residents.

Older people nursing in care homes: An examination of nursing professionals' self-assessed competence and its predictors

BACKGROUND

The need for older people nursing expertise is increasing, and every effort is required to ensure that personnel taking care of older people are capable of providing high-quality care.

AIMS

To explore care home nursing professionals' self-rated competence in older people nursing and to identify predictors of this competence.

DESIGN

A cross-sectional survey design.

METHOD

Data were collected in August-September 2017 via an electronic questionnaire using the newly developed Nurse Competence in Care Home Scale (NCCHS). Participants (n = 781) were recruited via nurses' associations and social media. They were working in care homes either as licensed practical nurses (n = 680) or as registered nurse and/or in managerial position (n = 101).

FINDINGS

Approximately 65% of the respondents had "adequate competence," and 35% had "inadequate competence" in older people nursing based on self-assessed overall competence. Respondents rated their competence highest in "observation, communication, interaction" and lowest in "group guidance and activities" subscale. Age and further training were predictors of licensed practical nurses' competence, and length of work experience predicted registered nurses' competence.

CONCLUSIONS

Self-assessments revealed the need for competence development especially in relation to holistic support of a person's well-being. It is recommended that care home nurses, managers, educators and curriculum developers all strive to develop care home staff's ability to support residents' well-being holistically.

IMPLICATIONS FOR PRACTICE

Nursing personnel should consider all aspects of older people's well-being holistically. In care homes, it is essential to assess nursing staff competence and to provide possibilities for competence development for personnel.

Importance of Team Functioning as a Target of Quality Improvement Initiatives in Nursing Homes: A Qualitative Process Evaluation

INTRODUCTION

Quality improvement interventions demonstrate variable degrees of effectiveness. The aim of this work was to (1) qualitatively explore whether, how, and why an academic detailing intervention could improve evidence uptake and (2) identify perceived changes that occurred to inform outcomes appropriate for quantitative evaluation.

METHODS

A qualitative process evaluation was conducted involving semistructured interviews with nursing home staff. Interviews were analyzed inductively using the framework method.

RESULTS

A total of 29 interviews were conducted across 13 nursing homes. Standard processes to reduce falls are well-known but not fully implemented due to a range of mostly postintentional factors that influence staff behavior. Conflicting expectations around professional roles impeded evidence uptake; physicians report a disconnection between the information they would like to receive and the information communicated; and a high proportion of casual and part-time staff creates challenges for those looking to effect change. These factors are amenable to change in the context of an active, tailored intervention such as academic detailing. This seems especially true when the entire care team is actively engaged and when the intervention can be tailored to the varied determinants of behaviors across different team members.

DISCUSSION

Interventions aiming to increase evidence-based practice in the nursing home sector need to move beyond education to explicitly address team functioning and communication. Variability in team functioning requires a flexible intervention with the ability to tailor to individual- and home-level needs. Evaluations in this setting may benefit from measuring changes in team functioning as an early indicator of success.

Process, structural, and outcome quality indicators of nutritional care in nursing homes: a systematic review

Background

The quality of nursing homes (NHs) has attracted a lot of interest in recent years and is one of the most challenging issues for policy-makers. Nutritional care should be considered an important variable to be measured from the perspective of quality management. The aim of this systematic review is to describe the use of structural, process, and outcome indicators of nutritional care in NHs and the relationship among them.

Methods

The literature search was carried out in Pubmed, Embase, Scopus, and Web of Science. A temporal filter was applied in order to select papers published in the last 10 years. All types of studies were included, with the exception of reviews, conference proceedings, editorials, and letters to the editor. Papers published in languages other than English, Italian, and Spanish were excluded.

Results

From the database search, 1063 potentially relevant studies were obtained. Of these, 19 full-text articles were considered eligible for the final synthesis. Most of the studies adopted an observational cross-sectional design. They generally assessed the quality of nutritional care using several indicators, usually including a mixture of many different structural, process, and outcome indicators. Only one of the 19 studies described the quality of care by comparing the results with the threshold values. Nine papers assessed the relationship between indicators and six of them described some significant associations—in the NHs that have a policy related to nutritional risk assessment or a suitable scale to weigh the residents, the prevalence or risk of malnutrition is lower. Finally, only four papers of these nine included risk adjustment. This could limit the comparability of the results.

Conclusion

Our findings show that a consensus must be reached for defining a set of indicators and standards to improve quality in NHs. Establishing the relationship between structural, process, and outcome indicators is a challenge. There are grounds for investigating this theme by means of prospective longitudinal studies that take the risk adjustment into account.

Facilitation roles and characteristics associated with research use by healthcare professionals: a scoping review

BACKGROUND

Implementing research findings into practice is a complex process that is not well understood. Facilitation has been described as a key component of getting research findings into practice. The literature on facilitation as a practice innovation is growing. This review aimed to identify facilitator roles and to describe characteristics of facilitation that may be associated with successful research use by healthcare professionals.

METHODS

We searched 10 electronic databases up to December 2016 and used predefined criteria to select articles. We included conceptual papers and empirical studies that described facilitator roles, facilitation processes or interventions, and that focused on healthcare professionals and research use. We used content and thematic analysis to summarise data. Rogers' five main attributes of an innovation guided our synthesis of facilitation characteristics.

RESULTS

Of the 38 488 articles identified from our online and manual search, we included 195 predominantly research studies. We identified nine facilitator roles: opinion leaders, coaches, champions, research facilitators, clinical/practice facilitators, outreach facilitators, linking agents, knowledge brokers and external-internal facilitators. Fifteen facilitation characteristics were associated with research use, which we grouped into five categories using Rogers' innovation attributes: relative advantage, compatibility, complexity, trialability and observability.

CONCLUSIONS

We found a diverse and broad literature on the concept of facilitation that can expand our current thinking about facilitation as an innovation and its potential to support an integrated, collaborative approach to improving healthcare delivery.

A Novel Implementation Strategy in Residential Care Settings to Promote EBP: Direct Care Provider Perceptions and Development of a Conceptual Framework

BACKGROUND

Innovative approaches are required to facilitate the adoption and sustainability of evidence-based care practices. We propose a novel implementation strategy, a peer reminder role, which involves offering a brief formal reminder to peers during structured unit meetings.

AIMS

This study aims to (a) identify healthcare aide (HCA) perceptions of a peer reminder role for HCAs, and (b) develop a conceptual framework for the role based on these perceptions.

METHODS

In 2013, a qualitative focus group study was conducted in five purposively sampled residential care facilities in western Canada. A convenience sample of 24 HCAs agreed to participate in five focus groups. Concurrent with data collection, two researchers coded the transcripts and identified themes by consensus. They jointly determined when saturation was achieved and took steps to optimize the trustworthiness of the findings. Five HCAs from the original focus groups commented on the resulting conceptual framework.

RESULTS

HCAs were cautious about accepting a role that might alienate them from their co-workers. They emphasized feeling comfortable with the peer reminder role and identified circumstances that would optimize their comfort including: effective implementation strategies, perceptions of the role, role credibility and a supportive context. These intersecting themes formed a peer reminder conceptual framework.

LINKING EVIDENCE TO ACTION

We identified HCAs' perspectives of a new peer reminder role designed specifically for them. Based on their perceptions, a conceptual framework was developed to guide the implementation of a peer reminder role for HCAs. This role may be a strategic implementation strategy to optimize the sustainability of new practices in residential care settings, and the related framework could offer guidance on how to implement this role.

"Make Me Feel at Ease and at Home": Differential Care Preferences of Nursing Home Residents

PURPOSE OF THE STUDY

Assessing and honoring older adults' preferences is a fundamental step in providing person-centered care in long-term care facilities. Researchers and practitioners have begun to develop measures to assess nursing home (NH) residents' everyday preferences. However, little is known about how residents interpret and conceptualize their preferences and what specific clinical response may be needed to balance health and safety concerns with preferences.

DESIGN AND METHODS

We used content analysis to examine interview responses on a subset of eight open-ended items from the Preferences of Every-day Living Inventory for Nursing Home (PELI-NH) residents with 337 NH residents (mean age 81). We considered how residents self-define various preferences of care and the associated importance of these preferences.

RESULTS

Residents identified preferences for interpersonal interactions (greetings, staff showing care, and staff showing respect), coping strategies, personal care (bathroom needs, setting up bedding), and healthcare discussions. Respondents highlighted specific qualities and characteristics about care interactions that are necessary to fully meeting their everyday preferences.

IMPLICATIONS

Results contribute to an emergent body of research that utilizes patient preferences to achieve the goals of person-centered care. The complexity of these responses substantiates the use of qualitative inquiry to thoroughly assess and integrate NH resident preferences into the delivery of person-centered care.

Collective action for implementation: a realist evaluation of organisational collaboration in healthcare

BACKGROUND

Increasingly, it is being suggested that translational gaps might be eradicated or narrowed by bringing research users and producers closer together, a theory that is largely untested. This paper reports a national study to fill a gap in the evidence about the conditions, processes and outcomes related to collaboration and implementation.

METHODS

A longitudinal realist evaluation using multiple qualitative methods case studies was conducted with three Collaborations for Leadership in Applied Health Research in Care (England). Data were collected over four rounds of theory development, refinement and testing. Over 200 participants were involved in semi-structured interviews, non-participant observations of events and meetings, and stakeholder engagement. A combined inductive and deductive data analysis process was focused on proposition refinement and testing iteratively over data collection rounds.

RESULTS

The quality of existing relationships between higher education and local health service, and views about whether implementation was a collaborative act, created a path dependency. Where implementation was perceived to be removed from service and there was a lack of organisational connections, this resulted in a focus on knowledge production and transfer, rather than co-production. The collaborations' architectures were counterproductive because they did not facilitate connectivity and had emphasised professional and epistemic boundaries. More distributed leadership was associated with greater potential for engagement. The creation of boundary spanning roles was the most visible investment in implementation, and credible individuals in these roles resulted in cross-boundary work, in facilitation and in direct impacts. The academic-practice divide played out strongly as a context for motivation to engage, in that 'what's in it for me' resulted in variable levels of engagement along a co-operation-collaboration continuum. Learning within and across collaborations was patchy depending on attention to evaluation.

CONCLUSIONS

These collaborations did not emerge from a vacuum, and they needed time to learn and develop. Their life cycle started with their position on collaboration, knowledge and implementation. More impactful attempts at collective action in implementation might be determined by the deliberate alignment of a number of features, including foundational relationships, vision, values, structures and processes and views about the nature of the collaboration and implementation.

Swiss family physicians' perceptions and attitudes towards knowledge translation practices

Background

Several studies have been performed to understand the way family physicians apply knowledge from medical research in practice. However, very little is known concerning family physicians in Switzerland. In an environment in which information constantly accumulates, it is crucial to identify the major sources of scientific information that are used by family physicians to keep their medical knowledge up to date and barriers to use these sources. Our main objective was to examine medical knowledge translation (KT) practices of Swiss family physicians.

Methods

The population consisted of French- and German-speaking private practice physicians specialised in family medicine. We conducted four interviews and three focus groups (n = 25). The interview guides of the semi-structured interviews and focus groups focused on (a) ways and means used by physicians to keep updated with information relevant to clinical practice; (b) how they consider their role in translating knowledge into practice; (c) potential barriers to KT; (d) solutions proposed by physicians for effective KT.

Results

Family physicians find themselves rather ambivalent about the translation of knowledge based on scientific literature, but generally express much interest in KT. They often feel overwhelmed by “information floods” and perceive clinical practice guidelines and other supports to be of limited usefulness for their practice. They often combine various formal and informal information sources to keep their knowledge up to date. Swiss family physicians report considering themselves as artisans, caring for patients with complex needs.

Conclusion

Improved performance of KT initiatives in family medicine should be tailored to actual needs and based on high quality evidence-based sources.

Collective action for knowledge mobilisation: a realist evaluation of the Collaborations for Leadership in Applied Health Research and Care

Background

The establishment of the Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) was the culmination of a number of policy initiatives to bridge the gap between evidence and practice. CLAHRCs were created and funded to facilitate development of partnerships and connect the worlds of academia and practice in an effort to improve patient outcomes through the conduct and application of applied health research.

Objectives

Our starting point was to test the theory that bringing higher education institutions and health-care organisations closer together catalyses knowledge mobilisation. The overall purpose was to develop explanatory theory regarding implementation through CLAHRCs and answer the question ‘what works, for whom, why and in what circumstances?’. The study objectives focused on identifying and tracking implementation mechanisms and processes over time; determining what influences whether or not and how research is used in CLAHRCs; investigating the role played by boundary objects in the success or failure of implementation; and determining whether or not and how CLAHRCs develop and sustain interactions and communities of practice.

Methods

This study was a longitudinal realist evaluation using multiple qualitative case studies, incorporating stakeholder engagement and formative feedback. Three CLAHRCs were studied in depth over four rounds of data collection through a process of hypothesis generation, refining, testing and programme theory specification. Data collection included interviews, observation, documents, feedback sessions and an interpretive forum.

Findings

Knowledge mobilisation in CLAHRCs was a function of a number of interconnected issues that provided more or less conducive conditions for collective action. The potential of CLAHRCs to close the metaphorical ‘know–do’ gap was dependent on historical regional relationships, their approach to engaging different communities, their architectures, what priorities were set and how, and providing additional resources for implementation, including investment in roles and activities to bridge and broker boundaries. Additionally, we observed a balance towards conducting research rather than implementing it. Key mechanisms of interpretations of collaborative action, opportunities for connectivity, facilitation, motivation, review and reflection, and unlocking barriers/releasing potential were important to the processes and outcomes of CLAHRCs. These mechanisms operated in different contexts including stakeholders’ positioning, or ‘where they were coming from’, governance arrangements, availability of resources, competing drivers, receptiveness to learning and evaluation, and alignment of structures, positions and resources. Preceding conditions influenced the course and journey of the CLAHRCs in a path-dependent way. We observed them evolving over time and their development led to the accumulation of different types of impacts, from those that were conceptual to, later in their life cycle, those that were more direct.

Conclusions

Most studies of implementation focus on researching one-off projects, so a strength of this study was in researching a systems approach to knowledge mobilisation over time. Although CLAHRC-like approaches show promise, realising their full potential will require a longer and more sustained focus on relationship building, resource allocation and, in some cases, culture change. This reinforces the point that research implementation within a CLAHRC model is a long-term investment and one that is set within a life cycle of organisational collaboration.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Factors associated with rushed and missed resident care in western Canadian nursing homes: a cross-sectional survey of health care aides

AIMS AND OBJECTIVES

To describe the nature, frequency and factors associated with care that was rushed or missed by health care aides in western Canadian nursing homes.

BACKGROUND

The growing number of nursing home residents with dementia has created job strain for frontline health care providers, the majority of whom are health care aides. Due to the associated complexity of care, health care aides are challenged to complete more care tasks in less time. Rushed or missed resident care are associated with adverse resident outcomes (e.g. falls) and poorer quality of staff work life (e.g. burnout) making this an important quality of care concern.

DESIGN

Cross-sectional survey of health care aides (n = 583) working in a representative sample of nursing homes (30 urban, six rural) in western Canada.

METHODS

Data were collected in 2010 as part of the Translating Research in Elder Care study. We collected data on individual health care aides (demographic characteristics, job and vocational satisfaction, physical and mental health, burnout), unit level characteristics associated with organisational context, facility characteristics (location, size, owner/operator model), and the outcome variables of rushed and missed resident care.

RESULTS

Most health care aides (86%) reported being rushed. Due to lack of time, 75% left at least one care task missed during their previous shift. Tasks most frequently missed were talking with residents (52% of health care aides) and assisting with mobility (51%). Health care aides working on units with higher organisational context scores were less likely to report rushed and missed care.

CONCLUSION

Health care aides frequently report care that is rushed and tasks omitted due to lack of time.

RELEVANCE TO CLINICAL PRACTICE

Considering the resident population in nursing homes today--many with advanced dementia and all with complex care needs--health care aides having enough time to provide physical and psychosocial care of high quality is a critical concern.

How does context influence collaborative decision-making for health services planning, delivery and evaluation?

Background

Collaboration among researchers (clinician, non-clinician) and decision makers (managers, policy-makers, clinicians), referred to as integrated knowledge translation (IKT), enhances the relevance and use of research, leading to improved decision-making, policies, practice, and health care outcomes. However IKT is not widely practiced due to numerous challenges. This research explored how context influenced IKT as a means of identifying how IKT could be strengthened.

Methods

This research investigated IKT in three health services programs for colon cancer screening, prostate cancer diagnosis, and the treatment of pancreatic cancer. Qualitative methods were used to explore contextual factors that influenced how IKT occurred, and its impact. Data were collected between September 1, 2012 and May 15, 2013 from relevant documents, observation of meetings, and interviews with researchers and decision-makers, analyzed using qualitative methods, and integrated.

Results

Data were analyzed from 39 documents, observation of 6 meetings, and 36 interviews. IKT included interaction at meetings, joint undertaking of research, and development of guidelines. IKT was most prevalent in one program with leadership, clear goals, dedicated funding and other infrastructural resources, and an embedded researcher responsible for, and actively engaged in IKT. This program achieved a variety of social, research and health service outcomes despite mixed individual views about the value of IKT and the absence of a programmatic culture of IKT. Participants noted numerous challenges including lack of time and incentives, and recommendations to support IKT. A conceptual framework of factors that influence IKT and associated outcomes was generated, and can be used by others to plan or evaluate IKT.

Conclusions

The findings can be applied by researchers, clinicians, managers or policy-makers to plan or improve collaborative decision-making for health services planning, delivery, evaluation or quality improvement. Further research is needed to explore whether these findings are widespread, and further understand how IKT can be optimized.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-014-0545-x) contains supplementary material, which is available to authorized users.