The quality of care delivered to residents in long-term care in Australia: an indicator-based review of resident records (CareTrack Aged study).

BACKGROUND: This study estimated the prevalence of evidence-based care received by a population-based sample of Australian residents in long-term care (LTC) aged ≥ 65 years in 2021, measured by adherence to clinical practice guideline (CPG) recommendations. METHODS: Sixteen conditions/processes of care amendable to estimating evidence-based care at a population level were identified from prevalence data and CPGs. Candidate recommendations (n = 5609) were extracted from 139 CPGs which were converted to indicators. National experts in each condition rated the indicators via the RAND-UCLA Delphi process. For the 16 conditions, 236 evidence-based care indicators were ratified. A multi-stage sampling of LTC facilities and residents was undertaken. Trained aged-care nurses then undertook manual structured record reviews of care delivered between 1 March and 31 May 2021 (our record review period) to assess adherence with the indicators. RESULTS: Care received by 294 residents with 27,585 care encounters in 25 LTC facilities was evaluated. Residents received care for one to thirteen separate clinical conditions/processes of care (median = 10, mean = 9.7). Adherence to evidence-based care indicators was estimated at 53.2% (95% CI: 48.6, 57.7) ranging from a high of 81.3% (95% CI: 75.6, 86.3) for Bladder and Bowel to a low of 12.2% (95% CI: 1.6, 36.8) for Depression. Six conditions (skin integrity, end-of-life care, infection, sleep, medication, and depression) had less than 50% adherence with indicators. CONCLUSIONS: This is the first study of adherence to evidence-based care for people in LTC using multiple conditions and a standardised method. Vulnerable older people are not receiving evidence-based care for many physical problems, nor care to support their mental health nor for end-of-life care. The six conditions in which adherence with indicators was less than 50% could be the focus of improvement efforts.

Counting what counts: assessing quality of life and its social determinants among nursing home residents with dementia.

BACKGROUND: Maximizing quality of life (QoL) is a major goal of care for people with dementia in nursing homes (NHs). Social determinants are critical for residents' QoL. However, similar to the United States and other countries, most Canadian NHs routinely monitor and publicly report quality of care, but not resident QoL and its social determinants. Therefore, we lack robust, quantitative studies evaluating the association of multiple intersecting social determinants with NH residents' QoL. The goal of this study is to address this critical knowledge gap. METHODS: We will recruit a random sample of 80 NHs from 5 Canadian provinces (Alberta, British Columbia, Manitoba, Nova Scotia, Ontario). We will stratify facilities by urban/rural location, for-profit/not-for-profit ownership, and size (above/below median number of beds among urban versus rural facilities in each province). In video-based structured interviews with care staff, we will complete QoL assessments for each of ~ 4,320 residents, using the DEMQOL-CH, a validated, feasible tool for this purpose. We will also assess resident's social determinants of QoL, using items from validated Canadian population surveys. Health and quality of care data will come from routinely collected Resident Assessment Instrument - Minimum Data Set 2.0 records. Knowledge users (health system decision makers, Alzheimer Societies, NH managers, care staff, people with dementia and their family/friend caregivers) have been involved in the design of this study, and we will partner with them throughout the study. We will share and discuss study findings with knowledge users in web-based summits with embedded focus groups. This will provide much needed data on knowledge users' interpretations, usefulness and intended use of data on NH residents' QoL and its health and social determinants. DISCUSSION: This large-scale, robust, quantitative study will address a major knowledge gap by assessing QoL and multiple intersecting social determinants of QoL among NH residents with dementia. We will also generate evidence on clusters of intersecting social determinants of QoL. This study will be a prerequisite for future studies to investigate in depth the mechanisms leading to QoL inequities in LTC, longitudinal studies to identify trajectories in QoL, and robust intervention studies aiming to reduce these inequities.

Characterizing worker compensation claims in long-term care and examining the association between facility characteristics and severe injury: a repeated cross-sectional study from Alberta, Canada.

BACKGROUND: Despite the physical demands and risks inherent to working in long-term care (LTC), little is known about workplace injuries and worker compensation claims in this setting. The purpose of this study was to characterize workplace injuries in LTC and to estimate the association between worker and organizational factors on severe injury. METHODS: We used a repeated cross-sectional design to examine worker compensation claims between September 1, 2014 and September 30, 2018 from 25 LTC homes. Worker compensation claim data came from The Workers Compensation Board of Alberta. LTC facility data came from the Translating Research in Elder Care program. We used descriptive statistics to characterize the sample and multivariable logistic regression to estimate the association between staff, organizational, and resident characteristics and severe injury, measured as 31+ days of disability. RESULTS: We examined 3337 compensation claims from 25 LTC facilities. Less than 10% of claims (5.1%, n = 170) resulted in severe injury and most claims did not result in any days of disability (70.9%, n = 2367). Most of the sample were women and over 40 years of age. Care aides were the largest occupational group (62.1%, n = 2072). The highest proportion of claims were made from staff working in voluntary not for profit facilities (41.9%, n = 1398) followed by public not for profit (32.9%, n = 1098), and private for profit (n = 25.2%, n = 841). Most claims identified the nature of injury as traumatic injuries to muscles, tendons, ligaments, or joints. In the multivariable logistic regression, higher staff age (50-59, aOR: 2.26, 95% CI 1.06-4.83; 60+, aOR: 2.70, 95% CI 1.20-6.08) was associated with more severe injury, controlling for resident acuity and other organizational staffing factors. CONCLUSIONS: Most claims were made by care aides and were due to musculoskeletal injuries. In LTC, few worker compensation claims were due to severe injury. More research is needed to delve into the specific features of the LTC setting that are related to worker injury.

Exploring nursing home resident and their care partner priorities for care using the Action-Project Method.

BACKGROUND: Nursing home (NH) residents' experiences are embedded within their relationships to others. Our objectives were to describe how residents and care partners (family or staff members) jointly construct, discuss, and act on care priorities. METHODS: We used Action-Project Method, a qualitative method focused on action within social context. We recruited 15 residents and 12 care partners (5 family and 7 staff members) from 3 urban NHs in Alberta, Canada. Residents and care partners participated in a video-recorded conversation about their experiences in the NH, then individually reviewed the video-recording to add context to the conversation. Following transcription, preliminary narrative construction, and participant feedback, the research team conducted in-depth analysis to identify participant actions, goals, and projects, including those jointly shared by dyad members. RESULTS: All participants' intentions could be broadly described as "making time in the NH as good as possible" and projects were grouped into five categories: resident identity, relationships (both presence and absence), advocacy, positivity, and respectful care. Participants often raised issues of short-staffing as a significant barrier to respectful care. Care partners, especially staff, used positivity to redirect residents from difficult topics. Joint projects could be identified in some, but not all, cases. CONCLUSIONS: We found that maintaining a sense of identity, fostering relationships, and receiving respectful care were important to residents but that short-staffing created barriers. Methods to capture these aspects of the resident experience are needed but should not be influenced by care partners' tendency towards positivity in resident interactions.

Inappropriate use of clinical practices in Canada: a systematic review.

BACKGROUND: Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada. METHODS: We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level. RESULTS: We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%-56.6%). Underuse (median 43.9%, IQR 23.8%-66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%-30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%-85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%-35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%-71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%-97.3%, n = 9). INTERPRETATION: We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

Care aides' perceptions of caring for residents with a history of psychological trauma in Western Canadian care homes.

OBJECTIVE: To explore care aide perceptions of caring for residents who aides perceived had past psychological trauma. METHODS: Through cognitive interviews, we developed a definition of trauma for four survey questions about caring for residents with psychological trauma. We added these questions to our routine care aide survey in 91 care homes in Western Canada (September 2019 to February 2020). We asked if care aides perceived that they were caring for residents with trauma, how often, types of trauma experienced, and what indication led them to perceive a resident had experienced trauma. We analyzed data using content analysis (open-ended questions) and regression analyses (closed-ended questions). RESULTS: Three thousand seven hundred and sixty five care aides responded (70% response rate) to the survey, and 53% perceived caring for one or more residents with a history of psychological trauma in the previous 2 weeks. Within six categories of traumatic events, abuse (35%) and war exposure (26%) were most common. Most common indications of trauma reported by care aides (five categories) were reliving the experience or having intrusive symptoms (28%) and avoidant behaviors (24%). Care aides were more likely to report caring for a resident who they perceived had experienced past psychological trauma if they were younger, spoke English as their first language, self-reported experiencing more aggression from residents, or who worked in not-for-profit homes. CONCLUSIONS: This preliminary study supports the need for further study of care aides' perceptions and experiences of caring for residents with past trauma, and the effects of caring for these residents on quality of work life.

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.

Designing clinical indicators for common residential aged care conditions and processes of care: the CareTrack Aged development and validation study.

BACKGROUND: People who live in aged care homes have high rates of illness and frailty. Providing evidence-based care to this population is vital to ensure the highest possible quality of life. OBJECTIVE: In this study (CareTrack Aged, CT Aged), we aimed to develop a comprehensive set of clinical indicators for guideline-adherent, appropriate care of commonly managed conditions and processes in aged care. METHODS: Indicators were formulated from recommendations found through systematic searches of Australian and international clinical practice guidelines (CPGs). Experts reviewed the indicators using a multiround modified Delphi process to develop a consensus on what constitutes appropriate care. RESULTS: From 139 CPGs, 5609 recommendations were used to draft 630 indicators. Clinical experts (n = 41) reviewed the indicators over two rounds. A final set of 236 indicators resulted, mapped to 16 conditions and processes of care. The conditions and processes were admission assessment; bladder and bowel problems; cognitive impairment; depression; dysphagia and aspiration; end of life/palliative care; hearing and vision; infection; medication; mobility and falls; nutrition and hydration; oral and dental care; pain; restraint use; skin integrity and sleep. CONCLUSIONS: The suite of CT Aged clinical indicators can be used for research and assessment of the quality of care in individual facilities and across organizations to guide improvement and to supplement regulation or accreditation of the aged care sector. They are a step forward for Australian and international aged care sectors, helping to improve transparency so that the level of care delivered to aged care consumers can be rigorously monitored and continuously improved.

How Does the Facilitation Effort of Clinical Educators Interact With Aspects of Organizational Context to Affect Research Use in Long-term Care? Evidence From CHAID Analysis.

PURPOSE: Organizational context influences the effect of facilitation efforts on research use in care settings. The interactions of these factors are complex. Therefore, the use of traditional statistical methods to examine their interrelationships is often impractical. Big Data analytics can automatically detect patterns within the data. We applied the chi-squared automatic interaction detection (CHAID) algorithm and classification tree technique to explore the dynamic and interdependent relationships between the implementation science concepts-context, facilitation, and research use. DESIGN: Observational, cross-sectional study based on survey data collected from a representative sample of nursing homes in western Canada. METHODS: We assessed three major constructs: (a) Conceptual research utilization (CRU) using the CRU scale; (b) facilitation of research use measured by the frequency of contacts between the frontline staff and a clinical educator, or person who brings new ideas to the care unit; and (c) organizational context at the unit level using the Alberta Context Tool (ACT). CHAID analysis was performed to detect the interactions between facilitation and context variables. Results were illustrated in a classification tree to provide a straightforward visualization. FINDINGS: Data from 312 care units in three provinces were included in the final analysis. Results indicate significant multiway interactions between facilitation and various aspects of the organizational context, including leadership, culture, evaluation, structural resources, and organizational slack (staffing). Findings suggested the preconditions of the care settings where research use can be maximized. CONCLUSIONS: CHAID analysis helped transform data into usable knowledge. Our findings provide insight into the dynamic relationships of facilitators' efforts and organizational context, and how these factors' interplay and their interdependence together may influence research use. CLINICAL RELEVANCE: Knowledge of the combined effects of facilitators' efforts and various aspects of organizational context on research use can contribute to effective strategies to narrow the evidence-practice gap in care settings.

Characteristics and unmet care needs of unbefriended residents in long-term care: a qualitative interview study.

Objectives: This study explored the impact of being 'unbefriended' for residents in Canadian long-term care (LTC) homes. Residents are 'unbefriended' if they lack decision-making capacity and family or friends to act as their legal representative. Research suggests that unbefriended individuals may have unmet needs and experience poor quality of care due to their limited social support. Our specific objectives were to identify resident characteristics, their unmet care needs, and implications for quality of care and quality of life.Methods: We conducted semi-structured interviews with 39 LTC staff and 3 public guardians. Interviews took place between March 2017 and September 2017. All interviews were audio recorded and transcribed verbatim. We analyzed the interviews using content analysis.Results: We found two groups of unbefriended LTC residents: (1) individuals with no living conjugate partner or children and (2) individuals with histories of substance use, homelessness, and estrangement from family. Unbefriended residents have no one to help meet needs for social interaction and engagement or to assist in purchasing needed personal items and uninsured services. LTC staff report significant care issues with unbefriended residents at end of life, including more aggressive behaviors and inappropriate care practices.Conclusion: Our findings demonstrate alarming issues in quality of life and quality of care for unbefriended residents. Unbefriended residents had limited social support and difficulty accessing even basic personal items. We discuss implications for policy and practice.

How does integrated knowledge translation (IKT) compare to other collaborative research approaches to generating and translating knowledge? Learning from experts in the field.

BACKGROUND: Research funders in Canada and abroad have made substantial investments in supporting collaborative research approaches to generating and translating knowledge as it is believed to increase knowledge use. Canadian health research funders have advocated for the use of integrated knowledge translation (IKT) in health research, however, there is limited research around how IKT compares to other collaborative research approaches. Our objective was to better understand how IKT compares with engaged scholarship, Mode 2 research, co-production and participatory research by identifying the differences and similarities among them in order to provide conceptual clarity and reduce researcher and knowledge user confusion about these common approaches. METHODS: We employed a qualitative descriptive method using interview data to better understand experts' perspectives and experiences on collaborative research approaches. Participants' responses were analysed through thematic analysis to elicit core themes. The analysis was centred around the concept of IKT, as it is the most recent approach; IKT was then compared and contrasted with engaged scholarship, Mode 2 research, co-production and participatory research. As this was an iterative process, data triangulation and member-checking were conducted with participants to ensure accuracy of the emergent themes and analysis process. RESULTS: Differences were noted in the orientation (i.e. original purpose), historical roots (i.e. disciplinary origin) and partnership/engagement (i.e. role of partners etc.). Similarities among the approaches included (1) true partnerships rather than simple engagement, (2) focus on essential components and processes rather than labels, (3) collaborative research orientations rather than research methods, (4) core values and principles, and (5) extensive time and financial investment. Core values and principles among the approaches included co-creation, reciprocity, trust, fostering relationships, respect, co-learning, active participation, and shared decision-making in the generation and application of knowledge. All approaches require extensive time and financial investment to develop and maintain true partnerships. CONCLUSIONS: This qualitative study is the first to systematically synthesise experts' perspectives and experiences in a comparison of collaborative research approaches. This work contributes to developing a shared understanding of collaborative research approaches to facilitate conceptual clarity in use, reporting, indexing and communication among researchers, trainees, knowledge users and stakeholders to advance IKT and implementation science.

If we cannot measure it, we cannot improve it: Understanding measurement problems in routine oral/dental assessments in Canadian nursing homes-Part I.

OBJECTIVE: To compare Resident Assessment Instrument-Minimum Data Set 2.0 (RAI) oral/dental items collected by nursing home (NH) care staff to (a) assessments collected by trained research assistants (RAs) and (b) "gold standard" clinical assessments by dental hygienists (DHs). BACKGROUND: Routine collection of RAI oral/dental items is mandatory in most Canadian NHs. However, the performance of these items is less than optimal and oral/dental problems are severely under-reported. Accurate assessment is a prerequisite for preventing, detecting and treating oral health problems. Not knowing the reasons for performance problems is a barrier to improving performance of the RAI oral/dental items. MATERIALS AND METHODS: We included 103 NH residents from 4 NHs in Edmonton, Alberta, Canada. Using Kappa statistics, we compared the agreement of residents' last (no older than 90 days) RAI assessment with RAI assessments completed by trained RAs and "gold standard" clinical assessments by DHs. We also assessed the inter-rater reliability (IRR) of RA and DH assessments. RESULTS: Care staff assessments had poor agreement with RA and DH assessments (Kappa < 0.2 for most items). RAs and DHs identified more oral/dental problems than care staff. However, IRR of RA assessments was low (Kappa < 0.7 for 7/9 items). IRR of DH assessments was acceptable (Kappa > 0.7) for most items. CONCLUSIONS: The quality of RAI oral/dental assessments can be improved by better training care staff and ensuring appropriate time to do the assessments. However, remaining problems-even with trained RAs-suggest that rewording some of the items or supplementing them by more robust tools may be required.

If we cannot measure it, we cannot improve it: Understanding measurement problems in routine oral/dental assessments in Canadian nursing homes-Part II.

OBJECTIVE: To evaluate the response process validity of the Resident Assessment Instrument-Minimum Data Set 2.0 (RAI) oral/dental items and the organisational processes for assessing nursing home (NH) residents' oral/dental status. BACKGROUND: Although care aides provide most direct care to NH residents, including oral care, they are not directly involved in structured care planning activities, including RAI assessments. This most likely affects the accuracy of RAI assessments, as well quality of care. However, we neither know how well regulated and unregulated care staff understand the RAI oral/dental items, nor what processes are used in completing oral/dental assessments. METHODS: We conducted nine focus groups with 44 care aides, nurses, allied health providers, clinical specialists and managers. We discussed randomly selected RAI oral/dental assessments with focus group participants, including participants' understanding of the items and why the options were selected. Participants also explained the communication and process for completing the RAI. RESULTS: Participants' perceptions of the oral/dental items aligned fairly well with the item definitions. However, responses primarily focused on severe oral/dental problems with obvious physical characteristics (eg black teeth denoting caries). For non-visual oral problems, such as pain, staff relied on resident verbalisation. No formal mechanisms were described for care aides to update nurses on residents' oral health needs. CONCLUSIONS: Performance problems of RAI oral/dental items are largely rooted in poor communication between care aides and nurses and not integrating care aides in assessment processes. We need policies that address these problems in order to improve NH residents' poor oral health.

The early retiree divests the health workforce: a quantitative analysis of early retirement among Canadian Registered Nurses and allied health professionals.

BACKGROUND: Early retirement (before age 65) is the norm among registered nurses (RNs) and allied health professionals (AHPs) employed in Canada's public system. As a country whose population is rapidly aging, it is in Canada's best interest to try and extend the work lives of RNs and AHPs. OBJECTIVES: (1) To test the predictive validity of our conceptual model of early retirement among publicly employed, Canadian RNs and AHPs and (2) to compare, across professions, model fit and factor significance METHODS: We conducted multivariable logistic regression in two data sets, one consisting of 483 retired RNs and the other of 177 retired AHPs. The number of AHP respondents limited our ability to comprehensively test the model. RESULTS: Eighty-five percent of RNs and 77% of AHPs had retired early. (1) Results indicate that 25% of variance in RN early retirement and 19% of variance in AHP early retirement was explained by included variables. (2) Organizational restructuring increased odds of early retirement by more than 100% among RNs and AHPs. Among RNs (but not AHPs), both financial possibility and caregiving responsibilities predicted early retirement at statistically significant levels, while a "desire to stop working" predicted retirement at or after 65 years of age. CONCLUSIONS: Clearly, there is much more to learn about RN and AHP pathways to early retirement. Further research, ideally research exploring the role of workplace characteristics, attitudes, and beliefs towards retirement and work-related factors, could deepen our understanding of the phenomenon of RN/AHP early retirement.

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.

Factors affecting job satisfaction in long-term care unit managers, directors of care and facility administrators: A secondary analysis.

AIM: To identify demographic-, individual- and organisational-level predictors of job satisfaction among managers in residential long-term care (LTC) facilities. BACKGROUND: Job satisfaction predicts turnover among managers in LTC settings. However, factors affecting job satisfaction among LTC facility managers remain poorly understood. METHODS: A secondary analysis of data from Phase 2 of the Translating Research in Elder Care programme including 168 managers (unit managers, directors of care and facility administrators) from 76 residential LTC homes in three Canadian provinces. Michigan Organizational Assessment Questionnaire Job Satisfaction Subscale was used to measure job satisfaction. Predictors of job satisfaction determined using general estimating equations. RESULTS: The efficacy subscale of burnout was positively predicted job satisfaction at the individual level (B = .104, p = .046). At the organisational level, social capital (B = .224, p = .018), adequate orientation (B = .166, p = .015) and leadership (B = .155, p = .018) were associated with higher job satisfaction. CONCLUSIONS: These data suggest that improving LTC managers' self-perceived efficacy, leadership, social capital and adequate orientation may enhance their job satisfaction. IMPLICATIONS FOR NURSING MANAGEMENT: Predictors of managers' job satisfaction are modifiable and therefore may be amenable to intervention.

The minimally effective dose of sucrose for procedural pain relief in neonates: a randomized controlled trial.

BACKGROUND: Orally administered sucrose is effective and safe in reducing pain intensity during single, tissue-damaging procedures in neonates, and is commonly recommended in neonatal pain guidelines. However, there is wide variability in sucrose doses examined in research, and more than a 20-fold variation across neonatal care settings. The aim of this study was to determine the minimally effective dose of 24% sucrose for reducing pain in hospitalized neonates undergoing a single skin-breaking heel lance procedure. METHODS: A total of 245 neonates from 4 Canadian tertiary neonatal intensive care units (NICUs), born between 24 and 42 weeks gestational age (GA), were prospectively randomized to receive one of three doses of 24% sucrose, plus non-nutritive sucking/pacifier, 2 min before a routine heel lance: 0.1 ml (Group 1; n = 81), 0.5 ml (Group 2; n = 81), or 1.0 ml (Group 3; n = 83). The primary outcome was pain intensity measured at 30 and 60 s following the heel lance, using the Premature Infant Pain Profile-Revised (PIPP-R). The secondary outcome was the incidence of adverse events. Analysis of covariance models, adjusting for GA and study site examined between group differences in pain intensity across intervention groups. RESULTS: There was no difference in mean pain intensity PIPP-R scores between treatment groups at 30 s (P = .97) and 60 s (P = .93); however, pain was not fully eliminated during the heel lance procedure. There were 5 reported adverse events among 5/245 (2.0%) neonates, with no significant differences in the proportion of events by sucrose dose (P = .62). All events resolved spontaneously without medical intervention. CONCLUSIONS: The minimally effective dose of 24% sucrose required to treat pain associated with a single heel lance in neonates was 0.1 ml. Further evaluation regarding the sustained effectiveness of this dose in reducing pain intensity in neonates for repeated painful procedures is warranted. TRIAL REGISTRATION: ClinicalTrials.gov : NCT02134873. Date: May 5, 2014 (retrospectively registered).

SCOPEOUT: sustainability and spread of quality improvement activities in long-term care- a mixed methods approach.

BACKGROUND: Interventions to improve quality of care for residents of long-term care facilities, and to examine the sustainability and spread of such initiatives, remain a top research priority. The purpose of this exploratory study was to assess the extent to which activities initiated in a quality improvement (QI) collaborative study using care aide led teams were sustained or spread following cessation of the initial project and to identify factors that led to its success. METHODS: This study used an exploratory mixed methods study design and was conducted in seven residential long-term care facilities in two Canadian provinces. Sustainability and spread of QI activities were assessed by a questionnaire over five time points for 18 months following the collaborative study with staff from both intervention with non-intervention units. Semi-structured interviews were conducted with care managers at six and 12 months. QI team success in applying the QI model was ranked as high, medium, or low using criteria developed by the research team. Descriptive statistics, bivariate analyses, and General Estimating Equations were used to analyze the data. Interview data were analyzed using thematic analysis. RESULTS: In total, 683 surveys were received over the five time periods from 476 unique individuals on a facility unit. Seven managers were interviewed. A total of 533 surveys were analyzed. While both intervention and non-intervention units experienced a decline over time in all outcome measures, this decline was significantly less pronounced on intervention units. Facilities with medium and high success ranking had significantly higher scores in all four outcomes than facilities with a low success ranking. Care aides reported significantly less involvement of others in QI activities, less empowerment and less satisfaction with the quality of their work life than regulated care providers. Manager interviews provided evidence of sustainability of QI activities on the intervention units in four of the seven facilities up to 18 months following the intervention and demonstrated the need for continued staff and leadership engagement. CONCLUSION: Sustainability of a QI project which empowers and engages care aides is possible and achievable, but requires ongoing staff and leadership engagement.

Individual and organizational predictors of allied healthcare providers' job satisfaction in residential long-term care.

BACKGROUND: Job satisfaction is a predictor of intention to stay and turnover among allied healthcare providers. However, there is limited research examining job satisfaction among allied health professionals, specifically in residential long-term care (LTC) settings. The purpose of this study was to identify factors (demographic, individual, and organizational) that predict job satisfaction among allied healthcare providers in residential LTC. METHODS: We conducted a secondary analysis of data from Phase 2 of the Translating Research in Elder Care program. A total of 334 allied healthcare providers from 77 residential LTC in three Western Canadian provinces were included in the analysis. Generalized estimating equation modeling was used to assess demographics, individual, and organizational context predictors of allied healthcare providers' job satisfaction. We measured job satisfaction using the Michigan Organizational Assessment Questionnaire Job Satisfaction Subscale. RESULTS: Both individual and organizational context variables predicted job satisfaction among allied healthcare providers employed in LTC. Demographic variables did not predict job satisfaction. At the individual level, burnout (cynicism) (ß = -.113, p = .001) and the competence subscale of psychological empowerment (ß = -.224, p = < .001), were predictive of lower job satisfaction levels while higher scores on the meaning (ß = .232, p = .001), self-determination (ß = .128, p = .005), and impact (ß = .10, p = .014) subscales of psychological empowerment predicted higher job satisfaction. Organizational context variables that predicted job satisfaction included: social capital (ß = .158, p = .012), organizational slack-time (ß = .096, p = .029), and adequate orientation (ß = .088, p = .005). CONCLUSIONS: This study suggests that individual allied healthcare provider and organizational context features are both predictive of allied healthcare provider job satisfaction in residential LTC settings. Unlike demographics and structural characteristics of LTC facilities, all variables identified as important to allied healthcare providers' job satisfaction in this study are potentially modifiable, and therefore amenable to intervention.

Impact of Managers' Coaching Conversations on Staff Knowledge Use and Performance in Long-Term Care Settings.

BACKGROUND: Extended lifespans and complex resident care needs have amplified resource demands on nursing homes. Nurse managers play an important role in staff job satisfaction, research use, and resident outcomes. Coaching skills, developed through leadership skill-building, have been shown to be of value in nursing. AIMS: To test a theoretical model of nursing home staff perceptions of their work context, their managers' use of coaching conversations, and their use of instrumental, conceptual and persuasive research. METHODS: Using a two-group crossover design, 33 managers employed in seven Canadian nursing homes were invited to attend a 2-day coaching development workshop. Survey data were collected from managers and staff at three time points; we analyzed staff data (n = 333), collected after managers had completed the workshop. We used structural equation modeling to test our theoretical model of contextual characteristics as causal variables, managers' characteristics, and coaching behaviors as mediating variables and staff use of research, job satisfaction, and burnout as outcome variables. RESULTS: The theoretical model fit the data well (χ2 = 58, df = 43, p = .06) indicating no significant differences between data and model-implied matrices. Resonant leadership (a relational approach to influencing change) had the strongest significant relationship with manager support, which in turn influenced frequency of coaching conversations. Coaching conversations had a positive, non-significant relationship with staff persuasive use of research, which in turn significantly increased instrumental research use. Importantly, coaching conversations were significantly, negatively related to job satisfaction. LINKING EVIDENCE TO ACTION: Our findings add to growing research exploring the role of context and leadership in influencing job satisfaction and use of research by healthcare practitioners. One-on-one coaching conversations may be difficult for staff not used to participating in such conversations. Resonant leadership, as expected, has a significant impact on manager support and job satisfaction among nursing home staff.