Facilitators and barriers of change toward an elder-friendly surgical environment: perspectives of clinician stakeholder groups.

BACKGROUND: Current acute care surgical practices do not focus on the unique needs of older adults. Adverse outcomes in older patients result from a complex interrelationship between baseline vulnerability and insults experienced during hospitalization. The purpose of this study is to assess the organizational readiness and the barriers and facilitators for the implementation of elder-friendly interventions in the acute care of unplanned abdominal surgery patients. METHODS: This cross-sectional mixed methods study included a convenience sample of clinician stakeholder groups. Eight focus groups were conducted with 33 surgical team members including: 10 health care aides, 6 licensed practical nurses, 6 registered nurses, 4 nurse managers and 7 surgeons, to identify barriers and facilitators to the implementation of an elder-friendly surgical unit. Audio recordings of the focus groups were transcribed verbatim and analysed using interpretive description techniques. Transcripts were coded along with explanatory memos to generate a detailed description of participant experiences. Themes were identified followed by refining the codes. Participants also completed the Organizational Readiness for Implementing Change questionnaire. Differences in organizational readiness scores across clinician stakeholder groups were assessed using Kruskal-Wallice tests. Mann-Whitney tests (Bonferroni's corrections for multiple comparisons) were conducted to assess pair-wise relationships. RESULTS: The focus group data were conceptualized to represent facilitators and barriers to change at two levels of care delivery. Readiness to change at the organizational level was evident in five categories that reflected the barriers and facilitators to implementing an elder-friendly surgical unit. These included education, environment, staffing, policies and other research projects. At the individual level barriers and facilitators were apparent in staff members' acceptance of new roles and duties with other staff, family and patients. Examples of these included communication, teamwork and leadership. The mean change commitment and change efficacy scores on the Organizational Readiness for Implementing Change Questionnaire were 3.7 (0.8) and 3.5 (0.9) respectively. No statistically significant differences were detected between the stakeholder groups. CONCLUSIONS: Staff are interested in contributing to improved care for elderly surgical patients; however, opportunities were identified to enhance facilitators and reduce barriers in advance of implementing the elder-friendly surgical unit intervention.

Psychological adjustment to spinal cord injury: the contribution of coping, hope and cognitive appraisals.

This study explored the degree to which current cognitions, in terms of appraisals and hope, are associated with the use of coping strategies and psychological adjustment to spinal cord injury (SCI). A cross-sectional survey design was used. A range of comprehensive, standard self-report measures were administered to 54 newly injured people with SCI. Correlation analyses were used to explore associations between factors. Forward hierarchical multiple regression analyses were also employed to examine the degree to which appraisals and hope predicted coping and adjustment. Hope and primary appraisals of threat were significantly correlated with the coping strategy of fighting spirit. Hope was a better predictor of coping than appraisals were. Of all the variables considered, appraisals showed the strongest association with adjustment, accounting for 12 per cent of the variance in anxiety and 34 per cent of the variance in depression. Coping variables did not explain more variance in depression than threat and challenge appraisals. Current cognitions, in particular primary appraisals of threat, are important in the process of psychological adjustment to SCI. Greater emphasis needs to be placed on appraisals in future coping research and interventions.

The psychometric analysis of a brief and sensitive measure of perceived manageability.

This study was conducted to determine the psychometric properties of the newly developed Perceived Manageability Scale (PMnac). The study was retrospective in design. Two hundred sixty-one inpatients with a spinal cord injury were recruited from The National Spinal Injuries Centre (NSIC), Stoke Mandeville Hospital, UK, as part of a convenience sample. The PMnac was developed to measure an individual's perceived manageability of their situation. The Mood Questionnaire is used to assess an individual's current mood. Both scales are part of the Needs Assessment Checklist; a psychometrically valid and reliable outcome tool and vital part of the rehabilitation pathway at the NSIC. Results indicated that out of the six items in the scale, five were found to load onto one factor. The remaining item (item number five) did not load onto this factor structure and was consequently removed from subsequent analyses. With the removal of this item, the PMnac was found to yield high internal validity correlations, internal consistency coefficients and significant sensitivity to change. The PMnac is a psychometrically reliable and valid clinical measure of an individual's perceived manageability of their situation.

Coming together and pulling apart: Exploring the influence of functional status on co-resident relationships in assisted living.

Social relationships can have considerable influence on physical and mental well-being in later life, particularly for those in long-term care settings such as assisted living (AL). Research set in AL suggests that other residents are among the most available social contacts and that co-resident relationships can affect life satisfaction, quality of life, and well-being. Functional status is a major factor influencing relationships, yet AL research has not studied in-depth or systematically considered the role it plays in residents' relationships. This study examines the influences of physical and mental function on co-resident relationships in AL and identifies the factors shaping the influence of functional status. We present an analysis of qualitative data collected over a one-year period in two distinct AL settings. Data collection included: participant observation, informal interviews, and formal in-depth interviews with staff, residents, administrators and visitors, as well as surveys with residents. Grounded theory methods guided our data collection and analysis. Our analysis identified the core category, "coming together and pulling apart", which signifies that functional status is multi-directional, fluid, and operates in different ways in various situations and across time. Key facility- (e.g., admission and retention practices, staff intervention) and resident-level (e.g., personal and situational characteristics) factors shape the influence of functional status on co-resident relationships. Based on our findings, we suggest strategies for promoting positive relationships among residents in AL, including the need to educate staff, families, and residents.