Factors influencing health-related quality of life among long-term care residents experiencing pain: a systematic review protocol

BACKGROUND

Pain is highly burdensome, affecting over 30% of long-term care (LTC) residents. Pain significantly reduces residents' health-related quality of life (HRQoL), limits their ability to perform activities of daily living (ADLs), restricts their social activities, and can lead to hopelessness, depression, and unnecessary healthcare costs. Although pain can generally be prevented or treated, eliminating pain may not always be possible, especially when residents have multiple chronic conditions. Therefore, improving the HRQoL of LTC residents with pain is a priority goal. Understanding factors influencing HRQoL of LTC residents with pain is imperative to designing and evaluating targeted interventions that complement pain management to improve residents' HRQoL. However, these factors are poorly understood, and we lack syntheses of available research on this topic. This systematic review protocol outlines the methods to identify, synthesize, and evaluate the available evidence on these factors.

METHODS

This mixed methods review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We will systematically search Medline, EMBASE, PsycINFO, CINAHL, Scopus, Cochrane Database of Systematic Reviews and ProQuest Dissertation and Thesis Global from database inception. We will include primary studies and systematically conducted reviews without restrictions to language, publication date, and study design. We will also include gray literature (dissertation and reports) and search relevant reviews and reference lists of all included studies. Two reviewers will independently screen articles, conduct quality appraisal, and extract data. We will synthesize results thematically and conduct meta-analyses if statistical pooling is possible. Residents and family/friend caregivers will assist with interpreting the findings.

DISCUSSION

This proposed systematic review will address an important knowledge gap related to the available evidence on factors influencing HRQoL of LTC residents with pain. Findings will be crucial for researchers, LTC administrators, and policy makers in uncovering research needs and in planning, developing, and evaluating strategies in addition to and complementary with pain management to help improve HRQoL among LTC residents with pain.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023405425.

Safer Care for Older Persons in (residential) Environments (SCOPE): a pragmatic controlled trial of a care aide-led quality improvement intervention

BACKGROUND

The increased complexity of residents and increased needs for care in long-term care (LTC) have not been met with increased staffing. There remains a need to improve the quality of care for residents. Care aides, providers of the bulk of direct care, are well placed to contribute to quality improvement efforts but are often excluded from so doing. This study examined the effect of a facilitation intervention enabling care aides to lead quality improvement efforts and improve the use of evidence-informed best practices. The eventual goal was to improve both the quality of care for older residents in LTC homes and the engagement and empowerment of care aides in leading quality improvement efforts.

METHODS

Intervention teams participated in a year-long facilitative intervention which supported care aide-led teams to test changes in care provision to residents using a combination of networking and QI education meetings, and quality advisor and senior leader support. This was a controlled trial with random selection of intervention clinical care units matched 1:1 post hoc with control units. The primary outcome, between group change in conceptual research use (CRU), was supplemented by secondary staff- and resident-level outcome measures. A power calculation based upon pilot data effect sizes resulted in a sample size of 25 intervention sites.

RESULTS

The final sample included 32 intervention care units matched to 32 units in the control group. In an adjusted model, there was no statistically significant difference between intervention and control units for CRU or in secondary staff outcomes. Compared to baseline, resident-adjusted pain scores were statistically significantly reduced (less pain) in the intervention group (p=0.02). The level of resident dependency significantly decreased statistically for residents whose teams addressed mobility (p<0.0001) compared to baseline.

CONCLUSIONS

The Safer Care for Older Persons in (residential) Environments (SCOPE) intervention resulted in a smaller change in its primary outcome than initially expected resulting in a study underpowered to detect a difference. These findings should inform sample size calculations of future studies of this nature if using similar outcome measures. This study highlights the problem with measures drawn from current LTC databases to capture change in this population. Importantly, findings from the trial's concurrent process evaluation provide important insights into interpretation of main trial data, highlight the need for such evaluations of complex trials, and suggest the need to consider more broadly what constitutes "success" in complex interventions.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03426072, registered August 02, 2018, first participant site April, 05, 2018.

HEALTHCARE AIDE-FOCUSED INTERVENTIONS TO IMPROVE PAIN MANAGEMENT IN LONG-TERM CARE

Pain is endemic for residents of long-term care homes, with many residents experiencing pain daily. Given that healthcare aides provide most daily care for residents, they are ideally situated to deliver timely assessment and non-drug interventions for managing resident pain. In this Cochrane-style systematic review, we searched 7 databases to identify intervention studies that included long-term care residents aged ≥60 years who received interventions to reduce chronic pain. Interventions were either delivered by healthcare aides at the resident level or were directed at healthcare aides to improve their pain management practices. We screened 400 titles/abstracts and 152 full-text articles. Nine studies met inclusion criteria and were included in a narrative review. Due to the limited number of studies and variety of study designs, data were insufficient to perform meta-analyses or thematic analysis. Three studies described pain interventions delivered by healthcare aides at the resident level reporting significant improvement of pain. Six studies described pain interventions delivered to healthcare aides. Results of these interventions were inconsistent; 2 reported significant improvements in pain-related outcomes (e.g., resident pain, monitoring of pain), 3 reported insignificant changes, and 1 reported a positive correlation between measured pain and pain medication use. We concluded that despite the paucity of research in this area, this systematic review provides preliminary support for pain interventions by healthcare aides for long-term care residents. Future research exploring interventions for healthcare aides to take greater roles in pain management could unlock further improvements in resident care.

Influences of post-implementation factors on the sustainability, sustainment, and intra-organizational spread of complex interventions

Background

Complex interventions are increasingly applied to healthcare problems. Understanding of post-implementation sustainment, sustainability, and spread of interventions is limited. We examine these phenomena for a complex quality improvement initiative led by care aides in 7 care homes (long-term care homes) in Manitoba, Canada. We report on factors influencing these phenomena two years after implementation.

Methods

Data were collected in 2019 via small group interviews with unit- and care home-level managers (n = 11) from 6 of the 7 homes using the intervention. Interview participants discussed post-implementation factors that influenced continuing or abandoning core intervention elements (processes, behaviors) and key intervention benefits (outcomes, impact). Interviews were audio-recorded, transcribed verbatim, and analyzed with thematic analysis.

Results

Sustainment of core elements and sustainability of key benefits were observed in 5 of the 6 participating care homes. Intra-unit intervention spread occurred in 3 of 6 homes. Factors influencing sustainment, sustainability, and spread related to intervention teams, unit and care home, and the long-term care system.

Conclusions

Our findings contribute understanding on the importance of micro-, meso-, and macro-level factors to sustainability of key benefits and sustainment of some core processes. Inter-unit spread relates exclusively to meso-level factors of observability and practice change institutionalization. Interventions should be developed with post-implementation sustainability in mind and measures taken to protect against influences such as workforce instability and competing internal and external demands. Design should anticipate need to adapt interventions to strengthen post-implementation traction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08026-x.

SCOPE: safer care for older persons (in residential) environments-a pilot study to enhance care aide-led quality improvement in nursing homes

Background

Nursing home residents require daily support. While care aides provide most of this support they are rarely empowered to lead quality improvement (QI) initiatives. Researchers have shown that care aide-led teams can successfully participate in a QI intervention called Safer Care for Older Persons in Residential Care Environments (SCOPE). In preparation for a large-scale study, we conducted a 1-year pilot to evaluate how well coaching strategies helped teams to enact this intervention. Secondarily, we measured if improvements in team cohesion and communication, and resident quality of care, occurred.

Methods

This study was conducted using a prospective single-arm study design, on 7 nursing homes in Winnipeg Manitoba belonging to the Translating Research in Elder Care research program. One QI team was selected per site, led by care aides who partnered with other front-line staff. Each team received facilitated coaching to enact SCOPE during three learning sessions, and additional support from quality advisors between these sessions. Researchers developed a rubric to evaluate how well teams enacted their interventions (i.e., created actionable aim statements, implemented interventions using plan-do-study-act cycles, and used measurement to guide decision-making). Team cohesion and communication were measured using surveys, and changes in unit-level quality indicators were measured using Resident Assessment Instrument-Minimum Data Set data.

Results

Most teams successfully enacted their interventions. Five of 7 teams created adequate-to-excellent aim statements. While 6 of 7 teams successfully implemented plan-do-study-act cycles, only 2 reported spreading their change ideas to other residents and staff on their unit. Three of 7 teams explicitly stated how measurement was used to guide intervention decisions. Teams scored high in cohesion and communication at baseline, and hence improved minimally. Indicators of resident quality care improved in 4 nursing home units; teams at 3 of these sites were scored as ‘excellent’ in two or more enactment areas, versus 1 of the 3 remaining teams.

Conclusions

Our coaching strategies helped most care aide-led teams to enact SCOPE. Coaching modifications are needed to help teams more effectively use measurement. Refinements to our evaluation rubric are also recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-00975-8.

Developing an RAI-MDS Behavior-Based Pain Scale for Long-Term Care Residents With Advanced Dementia

In Canadian and many international long-term care (LTC) facilities, pain assessment frequently relies on data from the Resident Assessment Instrument – Minimum Data Set 2.0 (RAI-MDS). The RAI-MDS produces a two-item scale, measuring both pain frequency and pain intensity. This scale correlates well with self-reported pain in cognitively intact LTC residents, but despite repeated testing, is less valid for use in residents with more advanced cognitive impairment who are unable to self-report their pain. In this study we aimed to develop and validate a behaviour-based pain assessment scale for long-term care residents using data available in the RAI-MDS. To construct our initial scale, we reviewed the literature and compiled a list of observable indicators of pain (e.g., grimacing) and linked these with 28 similar items available in the RAI-MDS. Using Delphi techniques, we further refined this to 20 items. We then evaluated the psychometric properties of our scale using two independent, representative samples, of urban LTC residents in Western Canada. Exploratory factor analyses were conducted in sample one (n=16,282) and confirmatory factor analyses (CFA) were then conducted in sample two (n=15,785) in order to test, and confirm, our model. A two-factor solution was identified grouping RAI-MDS items into subscales 1) change in status (e.g., new onset restlessness) and 2) behaviours (e.g., crying). Commonly recognized model fit indices were acceptable suggesting the adequacy of the two-factor solution. Results provide preliminary support for the use of behavioural-based pain assessment scale using RAI-MDS data. Further evaluation and validation of our scale is warranted.

Sustainment, Sustainability, and Spread Study (SSaSSy): protocol for a study of factors that contribute to the sustainment, sustainability, and spread of practice changes introduced through an evidence-based quality-improvement intervention in Canadian nursing homes

Background

Implementation scientists and practitioners, alike, recognize the importance of sustaining practice change, however post-implementation studies of interventions are rare. This is a protocol for the Sustainment, Sustainability and Spread Study (SSaSSy). The purpose of this study is to contribute to knowledge on the sustainment (sustained use), sustainability (sustained benefits), and spread of evidence-based practice innovations in health care. Specifically, this is a post-implementation study of an evidence-informed, Care Aide-led, facilitation-based quality-improvement intervention called SCOPE (Safer Care for Older Persons (in long-term care) Environments). SCOPE has been implemented in nursing homes in the Canadian Provinces of Manitoba (MB), Alberta (AB) and British Columbia (BC). Our study has three aims: (i) to determine the role that adaptation/contextualization plays in sustainment, sustainability and spread of the SCOPE intervention; (ii) to study the relative effects on sustainment, sustainability and intra-organizational spread of high-intensity and low-intensity post-implementation “boosters”, and a “no booster” condition, and (iii) to compare the relative costs and impacts of each booster condition.

Methods/design

SSaSSy is a two-phase mixed methods study. The overarching design is convergent, with qualitative and quantitative data collected over a similar timeframe in each of the two phases, analyzed independently, then merged for analysis and interpretation. Phase 1 is a pilot involving up to 7 units in 7 MB nursing homes in which SCOPE was piloted in 2016 to 2017, in preparation for phase 2. Phase 2 will comprise a quasi-experiment with two treatment groups of low- and high-intensity post-implementation “boosters”, and an untreated control group (no booster), using pretests and post-tests of the dependent variables relating to sustained care and management practices, and resident outcomes. Phase 2 will involve 31 trial sites in BC (17 units) and AB (14 units) nursing homes, where the SCOPE trial concluded in May 2019.

Discussion

This project stands to advance understanding of the factors that influence the sustainment of practice changes introduced through evidence-informed practice change interventions, and their associated sustainability. Findings will inform our understanding of the nature of the relationship of fidelity and adaptation to sustainment and sustainability, and afford insights into factors that influence the intra-organizational spread of practice changes introduced through complex interventions.

Depressive symptoms in long term care facilities in Western Canada: a cross sectional study

BACKGROUND

The main objective is to better understand the prevalence of depressive symptoms, in long-term care (LTC) residents with or without cognitive impairment across Western Canada. Secondary objectives are to examine comorbidities and other factors associated with of depressive symptoms, and treatments used in LTC.

METHODS

11,445 residents across a random sample of 91 LTC facilities, from 09/2014 to 05/2015, were stratified by owner-operator model (private for-profit, public or voluntary not-for-profit), size (small: < 80 beds, medium: 80-120 beds, large > 120 beds), location (Calgary and Edmonton Health Zones, Alberta; Fraser and Interior Health Regions, British Columbia; Winnipeg Health Region, Manitoba). Random intercept generalized linear mixed models with depressive symptoms as the dependent variable, cognitive impairment as primary independent variable, and resident, care unit and facility characteristics as covariates were used. Resident variables came from the Resident Assessment Instrument - Minimum Data Set (RAI-MDS) 2.0 records (the RAI-MDS version routinely collected in Western Canadian LTC). Care unit and facility variables came from surveys completed with care unit or facility managers.

RESULTS

Depressive symptoms affects 27.1% of all LTC residents and 23.3% of LTC resident have both, depressive symptoms and cognitive impairment. Hypertension, urinary and fecal incontinence were the most common comorbidities. Cognitive impairment increases the risk for depressive symptoms (adjusted odds ratio 1.65 [95% confidence interval 1.43; 1.90]). Pain, anxiety and pulmonary disorders were also significantly associated with depressive symptoms. Pharmacologic therapies were commonly used in those with depressive symptoms, however there was minimal use of non-pharmacologic management.

CONCLUSIONS

Depressive symptoms are common in LTC residents -particularly in those with cognitive impairment. Depressive symptoms are an important target for clinical intervention and further research to reduce the burden of these illnesses.

Implementing Frontline Worker-Led Quality Improvement in Nursing Homes: Getting to "How"

BACKGROUND

Despite emerging frameworks for quality improvement (QI) implementation, little is known about how the implementation process works, particularly in nursing home settings. A study was conducted to describe "how"' a complex frontline worker-led QI program was implemented in nursing homes.

METHODS

Six focus groups were conducted in February 2017 with participants of a year-long, multicomponent, unit-level QI intervention in seven nursing homes in the Canadian province of Manitoba. Constant comparative analysis was used to examine perspectives of different groups of QI program participants-35 health care aides, health professionals, and managers.

RESULTS

Five themes important to the implementation process were identified: (1) "supportive elements of the QI program structure," (2) "navigating the workplace," (3) "negotiating relationships," (4) "developing individual skills," and (5) "observable program impact." Data on theme integration suggest that "supportive elements of the QI program structure" (Theme 1), "developing individual skills" (Theme 4), and "observable program impact" (on residents, health care aides, and leaders; Theme 5) operated as part of a reinforcing feedback loop that boosted team members' ability to navigate the workplace, negotiate relationships, and implement the QI program.

CONCLUSION

Health care aide-led QI teams are feasible. However, a leadership paradox exists whereby worker-led QI programs also must incorporate concrete mechanisms to promote strong leadership and sponsor support to teams. The findings also point to the underexplored impact of interpersonal relationships between health care aides and professional staff on QI implementation.

Nurses' knowledge and perception of delirium screening and assessment in the intensive care unit: Long-term effectiveness of an education-based knowledge translation intervention

OBJECTIVES

To determine the impact of education on nurses' knowledge of delirium, knowledge and perception of a validated screening tool, and delirium screening in the ICU.

METHODS

A quasi-experimental single group pretest-post-test design.

SETTING

A 16 bed ICU in a Canadian urban tertiary care centre.

MAIN OUTCOME MEASURES

Nursing knowledge and perception were measured at baseline, 3-month and 18-month periods. Delirium screening was then assessed over 24-months.

RESULTS

During the study period, 197 surveys were returned; 84 at baseline, 53 at 3-months post education, and 60 at the final assessment period 18-months post intervention. The significant improvements in mean knowledge scores at 3-months post intervention (7.2, SD 1.3) were not maintained at 18-months (5.3, SD 1.1). Screening tool perception scores remained unchanged. Improvements in the perception of utility were significant at both time periods (p=0.03, 0.02 respectively). Physician value significantly improved at 18-months (p=0.01). Delirium screening frequency improved after education (p<0.001) demonstrating a positive correlation over time (p<0.01).

CONCLUSION

Multifaceted education is effective in improving delirium knowledge and screening; however, without sustained effort, progress is transient. Education improved perceived tool utility and over time utility perception and physician value improved.

Pathways for best practice diffusion: the structure of informal relationships in Canada's long-term care sector

Background

Initiatives to accelerate the adoption and implementation of evidence-based practices benefit from an association with influential individuals and organizations. When opinion leaders advocate or adopt a best practice, others adopt too, resulting in diffusion. We sought to identify existing influence throughout Canada’s long-term care sector and the extent to which informal advice-seeking relationships tie the sector together as a network.

Methods

We conducted a sociometric survey of senior leaders in 958 long-term care facilities operating in 11 of Canada’s 13 provinces and territories. We used an integrated knowledge translation approach to involve knowledge users in planning and administering the survey and in analyzing and interpreting the results. Responses from 482 senior leaders generated the names of 794 individuals and 587 organizations as sources of advice for improving resident care in long-term care facilities.

Results

A single advice-seeking network appears to span the nation. Proximity exhibits a strong effect on network structure, with provincial inter-organizational networks having more connections and thus a denser structure than interpersonal networks. We found credible individuals and organizations within groups (opinion leaders and opinion-leading organizations) and individuals and organizations that function as weak ties across groups (boundary spanners and bridges) for all studied provinces and territories. A good deal of influence in the Canadian long-term care sector rests with professionals such as provincial health administrators not employed in long-term care facilities.

Conclusions

The Canadian long-term care sector is tied together through informal advice-seeking relationships that have given rise to an emergent network structure. Knowledge of this structure and engagement with its opinion leaders and boundary spanners may provide a route for stimulating the adoption and effective implementation of best practices, improving resident care and strengthening the long-term care advice network. We conclude that informal relational pathways hold promise for helping to transform the Canadian long-term care sector.