Towards equitable representation in long-term residential care: widening the circle to ensure "essential voices" in research teams.

The COVID-19 pandemic exposed long-standing inequities in Canada's long-term residential care (LTRC) sector with life-threatening consequences. People from marginalized groups are overrepresented among those who live in, and work in LTRC facilities, yet their voices are generally silenced in LTRC research. Concerns about these silenced voices have sparked debate around ways to change LTRC policy to better address long-standing inequities and enhance the conditions that foster dignity for those who live and work in LTRC. Weaving an analysis of historical and cultural attitudes about LTRC, and promising strategies for engaging people with lived experience, we argue that the voices of people with lived experience of life and work (paid and unpaid) in LTRC are essential for ethically and effectively shifting long-standing inequities. Lessons from a 4-year, national, multi-disciplinary research study, known as the Seniors Adding Life to Years (SALTY) project, suggest that resident-determined quality of life can be prioritized by centring the perspectives of residents, their family/friends, direct care workers, volunteers, and people living with dementia in the research process. Accordingly, we highlight strategies to include these voices so that meaningful and impactful system change can be realized.

This article argues that long-term residential care facilities in Canada have a long history of perpetuating social inequalities, beginning with seventeenth century poor houses and almshouses, from which long-term residential care facilities evolved in North America. We highlight that those who currently reside in long-term residential care are more likely to be people with less social power­for example women, people living with dementia, and people with low-income. These residents are rarely included in research projects as co-designers of research, co-producers of knowledge, or experts on the realities of long-term residential care. We explore strategies for addressing these underrepresented voices and inequalities in research by highlighting promising examples of resident, family, and worker-engagement emerging from a pre-pandemic to early pandemic pan-Canadian research project on quality of life in long-term residential care. We argue that long-term residential care residents, their family/friend caregivers, people living with dementia, and direct care workers have voices that are essential in residential care design and research engagement strategies. By prioritizing these voices in research, we can better amplify their critical perspectives in broader policy and decision-making processes that guide meaningful and impactful system change.

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.

Recommendations from long-term care reports, commissions, and inquiries in Canada.

Background: Multiple long-term care (LTC) reports have issued similar recommendations for improvement across Canadian LTC homes. Our primary objective was to identify the most common recommendations made over the past 10 years. Our secondary objective was to estimate the total cost of studying LTC issues repeatedly from 1998 to 2020. Methods: The qualitative and cost analyses were conducted in Canada from July to October 2020. Using a list of reports, inquiries and commissions from The Royal Society of Canada Working Group on Long-Term Care, we coded recurrent recommendations in LTC reports. We contacted the sponsoring organizations for a cost estimate, including direct and indirect costs. All costs were adjusted to 2020 Canadian dollar values. Results: Of the 80 Canadian LTC reports spanning the years of 1998 to 2020, 24 (30%) were based on a national level and 56 (70%) were focused on provinces or municipalities. Report length ranged from 4 to 1491 pages and the median number of contributors was 14 (interquartile range, IQR, 5-26) per report. The most common recommendation was to increase funding to LTC to improve staffing, direct care and capacity (67% of reports). A median of 8 (IQR 3.25-18) recommendations were made per report. The total cost for all 80 reports was estimated to be $23,626,442.78. Conclusions: Problems in Canadian LTC homes and their solutions have been known for decades. Despite this, governments and non-governmental agencies continue to produce more reports at a monetary and societal cost to Canadians.

Early warning and rapid public health response to prevent COVID-19 outbreaks in long-term care facilities (LTCF) by monitoring SARS-CoV-2 RNA in LTCF site-specific sewage samples and assessment of antibodies response in this population: prospective study protocol.

INTRODUCTION: The COVID-19 pandemic has an excessive impact on residents in long-term care facilities (LTCF), causing high morbidity and mortality. Early detection of presymptomatic and asymptomatic COVID-19 cases supports the timely implementation of effective outbreak control measures but repetitive screening of residents and staff incurs costs and discomfort. Administration of vaccines is key to controlling the pandemic but the robustness and longevity of the antibody response, correlation of neutralising antibodies with commercial antibody assays, and the efficacy of current vaccines for emerging COVID-19 variants require further study. We propose to monitor SARS-CoV-2 in site-specific sewage as an early warning system for COVID-19 in LTCF and to study the immune response of the staff and residents in LTCF to COVID-19 vaccines. METHODS AND ANALYSIS: The study includes two parts: (1) detection and quantification of SARS-CoV-2 in LTCF site-specific sewage samples using a molecular assay followed by notification of Public Health within 24 hours as an early warning system for appropriate outbreak investigation and control measures and cost-benefit analyses of the system and (2) testing for SARS-CoV-2 antibodies among staff and residents in LTCF at various time points before and after COVID-19 vaccination using commercial assays and neutralising antibody testing performed at a reference laboratory. ETHICS AND DISSEMINATION: Ethics approval was obtained from the University of Alberta Health Research Ethics Board with considerations to minimise risk and discomforts for the participants. Early recognition of a COVID-19 case in an LTCF might prevent further transmission in residents and staff. There was no direct benefit identified to the participants of the immunity study. Anticipated dissemination of information includes a summary report to the immunity study participants, sharing of study data with the scientific community through the Canadian COVID-19 Immunity Task Force, and prompt dissemination of study results in meeting abstracts and manuscripts in peer-reviewed journals.

Fractured Care: A Window Into Emergency Transitions in Care for LTC Residents With Complex Health Needs.

Objective: For long-term care (LTC) residents, transfers to emergency departments (EDs) can be associated with poor health outcomes. We aimed to describe characteristics of residents transferred, factors related to decisions during transfer, care received in emergency medical services (EMS), ED settings, outcomes on return to LTC, and times of transfer segments along the transition. Method: We prospectively followed 637 transitions to an ED in British Columbia and Alberta, Canada, over a 12-month period. Data were captured through an electronic Transition Tracking Tool and interviews with health care professionals. Results: Common events triggering transfer were falls (26.8%), sudden change in condition (23.5%), and shortness of breath (19.8%). Discrepancies existed between reason for transfer, EMS reported chief complaint, and ED diagnosis. Many transfers resulted in resident return directly to LTC (42.7%). Discussion: Avoidable transfers may put residents at risk of receiving inappropriate care. Standardized communication strategies to highlight changes in resident condition are warranted.

Fusion Validity: Theory-Based Scale Assessment via Causal Structural Equation Modeling.

Fusion validity assessments employ structural equation models to investigate whether an existing scale functions in accordance with theory. Fusion validity parallels criterion validity by depending on correlations with non-scale variables but differs from criterion validity because it requires at least one theorized effect of the scale, and because both the scale and scaled-items are included in the model. Fusion validity, like construct validity, will be most informative if the scale is embedded in as full a substantive context as theory permits. Appropriate scale functioning in a comprehensive theoretical context greatly enhances a scale's validity. Inappropriate scale functioning questions the scale but the scale's theoretical embedding encourages detailed diagnostic investigations potentially challenging specific items, the procedure used to calculate scale values, or aspects of the theory, but also possibly recommends incorporating additional items into the scale. The scaled items should have survived prior content and methodological assessments but the items may or may not reflect a common factor because items having diverse causal backgrounds can sometimes fuse to form a unidimensional entity. Though items reflecting a common cause can be assessed for fusion validity, we illustrate fusion validity in the more challenging context of a scale comprised of diverse items and embedded in a complicated theory. Specifically we consider the Leadership scale from the Alberta Context Tool with care aides working in Canadian long-term care homes.

Learning to lead: a review and synthesis of literature examining health care managers' use of knowledge.

BACKGROUND: Scholarship cites health care managers (HCMs) as not using research evidence in their management practice. The purpose of this review was to evaluate the effectiveness of interventions to enhance HCMs use of research evidence in practice. METHODS: We carried out a systematic review and focus groups to validate the review findings. We searched 10 electronic databases for studies reporting on interventions for HCMs to enhance research utilization in their practice. Qualitative studies were analysed using Hoon's approach to meta-synthesis. RESULTS: Seven, primarily qualitative, studies of varying quality (reported in 11 articles) met our inclusion criteria. Interventions to enhance research use by HCMs included: informal and formal training, computer-based application, executive-level knowledge translation activities and residency programmes. Studies did not report efficacy of interventions or impacts of increasing managers' use of research on staff or patient outcomes. Meta-synthesis yielded four contextual factors influencing the perceived effectiveness of interventions to enhance research use by HCMs: organizational culture, competing priorities, time as a resource and capacity building. Included studies differed in how they defined research and demonstrated varying understandings of research among HCMs, limiting the generalizability of work in this field. CONCLUSIONS: Healthcare managers are increasingly called upon to make evidence-based decisions in practice, but the small number of studies and diverse strategies employed hinder our ability to identify any intervention to increase use of evidence as superior. Future studies in this area should clearly articulate the definition of research evidence they base their decisions on. Registration: PROSPERO (CRD42014006256).

Facilitating Implementation of Research Evidence (FIRE): an international cluster randomised controlled trial to evaluate two models of facilitation informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework.

BACKGROUND: Health care practice needs to be underpinned by high quality research evidence, so that the best possible care can be delivered. However, evidence from research is not always utilised in practice. This study used the Promoting Action on Research Implementation in Health Services (PARIHS) framework as its theoretical underpinning to test whether two different approaches to facilitating implementation could affect the use of research evidence in practice. METHODS: A pragmatic clustered randomised controlled trial with embedded process and economic evaluation was used. The study took place in four European countries across 24 long-term nursing care sites, for people aged 60 years or more with documented urinary incontinence. In each country, sites were randomly allocated to standard dissemination, or one of two different types of facilitation. The primary outcome was the documented percentage compliance with the continence recommendations, assessed at baseline, then at 6, 12, 18, and 24 months after the intervention. Data were analysed using STATA15, multi-level mixed-effects linear regression models were fitted to scores for compliance with the continence recommendations, adjusting for clustering. RESULTS: Quantitative data were obtained from reviews of 2313 records. There were no significant differences in the primary outcome (documented compliance with continence recommendations) between study arms and all study arms improved over time. CONCLUSIONS: This was the first cross European randomised controlled trial with embedded process evaluation that sought to test different methods of facilitation. There were no statistically significant differences in compliance with continence recommendations between the groups. It was not possible to identify whether different types and "doses" of facilitation were influential within very diverse contextual conditions. The process evaluation (Rycroft-Malone et al., Implementation Science. doi: 10.1186/s13012-018-0811-0) revealed the models of facilitation used were limited in their ability to overcome the influence of contextual factors. TRIAL REGISTRATION: Current Controlled Trials ISRCTN11598502 . Date 4/2/10. The research leading to these results has received funding from the European Union's Seventh Framework Programme (FP7/2007-2013) under grant agreement no. 223646.

Development and Content Validation of a Transcultural Instrument to Assess Organizational Readiness for Knowledge Translation in Healthcare Organizations: The OR4KT.

BACKGROUND: Implementing effective interventions in healthcare requires organizations to be ready to support change. This study aimed to develop, adapt transculturally, and assess the content and face validity of the Organizational Readiness for Knowledge Translation (OR4KT) tool. The OR4KT was designed to measure the readiness of healthcare organizations to implement evidence-informed change across a variety of services. METHODS: Based on systematic reviews of the literature, a Delphi exercise, and expert consultation, we first generated an initial pool of items. Second, we developed and assessed content validity of the pilot OR4KT questionnaire in English. Third, we created French and Spanish versions using a sequential forward and backward translation approach, and transcultural adaptation by a consensus process. Finally, we conducted pilot studies in three contexts - the Basque country region (Spain), and the provinces of Québec and Ontario (Canada) - where 30 experts assessed the face validity of the three versions of OR4KT. RESULTS: We selected 59 items, grouped in 6 dimensions (organizational climate, context, change content, leadership, organizational support, and motivation) for the final English version of OR4KT. Translation and transcultural adaptation did not identify any content or language problems. Our findings indicate that the English, French and Spanish versions of OR4KT are linguistically equivalents and have high face validity. Only minor revisions to the wording of some items were recommended. CONCLUSION: The OR4KT holds promise as a measure of readiness for knowledge translation (KT) in healthcare organizations. The validity and reliability of the three versions of the OR4KT will be assessed in real-life contexts of implementation of evidence-based changes in healthcare.

Oral/dental items in the resident assessment instrument - minimum Data Set 2.0 lack validity: results of a retrospective, longitudinal validation study.

BACKGROUND: Oral health in nursing home residents is poor. Robust, mandated assessment tools such as the Resident Assessment Instrument - Minimum Data Set (RAI-MDS) 2.0 are key to monitoring and improving quality of oral health care in nursing homes. However, psychometric properties of RAI-MDS 2.0 oral/dental items have been challenged and criterion validity of these items has never been assessed. METHODS: We used 73,829 RAI-MDS 2.0 records (13,118 residents), collected in a stratified random sample of 30 urban nursing homes in Western Canada (2007-2012). We derived a subsample of all residents (n = 2,711) with an admission and two or more subsequent annual assessments. Using Generalized Estimating Equations, adjusted for known covariates of nursing home residents' oral health, we assessed the association of oral/dental problems with time, dentate status, dementia, debris, and daily cleaning. RESULTS: Prevalence of oral/dental problems fluctuated (4.8 %-5.6 %) with no significant differences across time. This range of prevalence is substantially smaller than the ones reported by studies using clinical assessments by dental professionals. Denture wearers were less likely than dentate residents to have oral/dental problems (adjusted odds ratio [OR] = 0.458, 95 % confidence interval [CI]: 0.308, 0.680). Residents lacking teeth and not wearing dentures had higher odds than dentate residents of oral/dental problems (adjusted OR = 2.718, 95 % CI: 1.845, 4.003). Oral/dental problems were more prevalent in persons with debris (OR = 2.187, 95 % CI: 1.565, 3.057). Of the other variables assessed, only age at assessment was significantly associated with oral/dental problems. CONCLUSIONS: Robust, reliable RAI-MDS 2.0 oral health indicators are vital to monitoring and improving oral health related quality and safety in nursing homes. However, severe underdetection of oral/dental problems and lack of association of well-known oral health predictors with oral/dental problems suggest validity problems. Lacking teeth and not wearing dentures should be considered an indicator for urgent oral/dental treatment needs.

Health system context and implementation of evidence-based practices-development and validation of the Context Assessment for Community Health (COACH) tool for low- and middle-income settings.

BACKGROUND: The gap between what is known and what is practiced results in health service users not benefitting from advances in healthcare, and in unnecessary costs. A supportive context is considered a key element for successful implementation of evidence-based practices (EBP). There were no tools available for the systematic mapping of aspects of organizational context influencing the implementation of EBPs in low- and middle-income countries (LMICs). Thus, this project aimed to develop and psychometrically validate a tool for this purpose. METHODS: The development of the Context Assessment for Community Health (COACH) tool was premised on the context dimension in the Promoting Action on Research Implementation in Health Services framework, and is a derivative product of the Alberta Context Tool. Its development was undertaken in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua in six phases: (1) defining dimensions and draft tool development, (2) content validity amongst in-country expert panels, (3) content validity amongst international experts, (4) response process validity, (5) translation and (6) evaluation of psychometric properties amongst 690 health workers in the five countries. RESULTS: The tool was validated for use amongst physicians, nurse/midwives and community health workers. The six phases of development resulted in a good fit between the theoretical dimensions of the COACH tool and its psychometric properties. The tool has 49 items measuring eight aspects of context: Resources, Community engagement, Commitment to work, Informal payment, Leadership, Work culture, Monitoring services for action and Sources of knowledge. CONCLUSIONS: Aspects of organizational context that were identified as influencing the implementation of EBPs in high-income settings were also found to be relevant in LMICs. However, there were additional aspects of context of relevance in LMICs specifically Resources, Community engagement, Commitment to work and Informal payment. Use of the COACH tool will allow for systematic description of the local healthcare context prior implementing healthcare interventions to allow for tailoring implementation strategies or as part of the evaluation of implementing healthcare interventions and thus allow for deeper insights into the process of implementing EBPs in LMICs.

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.

A protocol for advanced psychometric assessment of surveys.

Background and Purpose. In this paper, we present a protocol for advanced psychometric assessments of surveys based on the Standards for Educational and Psychological Testing. We use the Alberta Context Tool (ACT) as an exemplar survey to which this protocol can be applied. Methods. Data mapping, acceptability, reliability, and validity are addressed. Acceptability is assessed with missing data frequencies and the time required to complete the survey. Reliability is assessed with internal consistency coefficients and information functions. A unitary approach to validity consisting of accumulating evidence based on instrument content, response processes, internal structure, and relations to other variables is taken. We also address assessing performance of survey data when aggregated to higher levels (e.g., nursing unit). Discussion. In this paper we present a protocol for advanced psychometric assessment of survey data using the Alberta Context Tool (ACT) as an exemplar survey; application of the protocol to the ACT survey is underway. Psychometric assessment of any survey is essential to obtaining reliable and valid research findings. This protocol can be adapted for use with any nursing survey.

FIRE (Facilitating Implementation of Research Evidence): a study protocol.

BACKGROUND: Research evidence underpins best practice, but is not always used in healthcare. The Promoting Action on Research Implementation in Health Services (PARIHS) framework suggests that the nature of evidence, the context in which it is used, and whether those trying to use evidence are helped (or facilitated) affect the use of evidence. Urinary incontinence has a major effect on quality of life of older people, has a high prevalence, and is a key priority within European health and social care policy. Improving continence care has the potential to improve the quality of life for older people and reduce the costs associated with providing incontinence aids. OBJECTIVES: This study aims to advance understanding about the contribution facilitation can make to implementing research findings into practice via: extending current knowledge of facilitation as a process for translating research evidence into practice; evaluating the feasibility, effectiveness, and cost-effectiveness of two different models of facilitation in promoting the uptake of research evidence on continence management; assessing the impact of contextual factors on the processes and outcomes of implementation; and implementing a pro-active knowledge transfer and dissemination strategy to diffuse study findings to a wide policy and practice community. SETTING AND SAMPLE: Four European countries, each with six long-term nursing care sites (total 24 sites) for people aged 60 years and over with documented urinary incontinence METHODS AND DESIGN: Pragmatic randomised controlled trial with three arms (standard dissemination and two different programmes of facilitation), with embedded process and economic evaluation. The primary outcome is compliance with the continence recommendations. Secondary outcomes include proportion of residents with incontinence, incidence of incontinence-related dermatitis, urinary tract infections, and quality of life. Outcomes are assessed at baseline, then at 6, 12, 18, and 24 months after the start of the facilitation interventions. Detailed contextual and process data are collected throughout, using interviews with staff, residents and next of kin, observations, assessment of context using the Alberta Context Tool, and documentary evidence. A realistic evaluation framework is used to develop explanatory theory about what works for whom in what circumstances. TRIAL REGISTRATION: Current Controlled Trials ISRCTN11598502.

The role of organizational context and individual nurse characteristics in explaining variation in use of information technologies in evidence based practice.

BACKGROUND: There is growing awareness of the role of information technology in evidence-based practice. The purpose of this study was to investigate the role of organizational context and nurse characteristics in explaining variation in nurses' use of personal digital assistants (PDAs) and mobile Tablet PCs for accessing evidence-based information. The Promoting Action on Research Implementation in Health Services (PARIHS) model provided the framework for studying the impact of providing nurses with PDA-supported, evidence-based practice resources, and for studying the organizational, technological, and human resource variables that impact nurses' use patterns. METHODS: A survey design was used, involving baseline and follow-up questionnaires. The setting included 24 organizations representing three sectors: hospitals, long-term care (LTC) facilities, and community organizations (home care and public health). The sample consisted of 710 participants (response rate 58%) at Time 1, and 469 for whom both Time 1 and Time 2 follow-up data were obtained (response rate 66%). A hierarchical regression model (HLM) was used to evaluate the effect of predictors from all levels simultaneously. RESULTS: The Chi square result indicated PDA users reported using their device more frequently than Tablet PC users (p = 0.001). Frequency of device use was explained by 'breadth of device functions' and PDA versus Tablet PC. Frequency of Best Practice Guideline use was explained by 'willingness to implement research,' 'structural and electronic resources,' 'organizational slack time,' 'breadth of device functions' (positive effects), and 'slack staff' (negative effect). Frequency of Nursing Plus database use was explained by 'culture,' 'structural and electronic resources,' and 'breadth of device functions' (positive effects), and 'slack staff' (negative). 'Organizational culture' (positive), 'breadth of device functions' (positive), and 'slack staff '(negative) were associated with frequency of Lexi/PEPID drug dictionary use. CONCLUSION: Access to PDAs and Tablet PCs supported nurses' self-reported use of information resources. Several of the organizational context variables and one individual nurse variable explained variation in the frequency of information resource use.

Assessment of variation in the Alberta Context Tool: the contribution of unit level contextual factors and specialty in Canadian pediatric acute care settings.

BACKGROUND: There are few validated measures of organizational context and none that we located are parsimonious and address modifiable characteristics of context. The Alberta Context Tool (ACT) was developed to meet this need. The instrument assesses 8 dimensions of context, which comprise 10 concepts. The purpose of this paper is to report evidence to further the validity argument for ACT. The specific objectives of this paper are to: (1) examine the extent to which the 10 ACT concepts discriminate between patient care units and (2) identify variables that significantly contribute to between-unit variation for each of the 10 concepts. METHODS: 859 professional nurses (844 valid responses) working in medical, surgical and critical care units of 8 Canadian pediatric hospitals completed the ACT. A random intercept, fixed effects hierarchical linear modeling (HLM) strategy was used to quantify and explain variance in the 10 ACT concepts to establish the ACT's ability to discriminate between units. We ran 40 models (a series of 4 models for each of the 10 concepts) in which we systematically assessed the unique contribution (i.e., error variance reduction) of different variables to between-unit variation. First, we constructed a null model in which we quantified the variance overall, in each of the concepts. Then we controlled for the contribution of individual level variables (Model 1). In Model 2, we assessed the contribution of practice specialty (medical, surgical, critical care) to variation since it was central to construction of the sampling frame for the study. Finally, we assessed the contribution of additional unit level variables (Model 3). RESULTS: The null model (unadjusted baseline HLM model) established that there was significant variation between units in each of the 10 ACT concepts (i.e., discrimination between units). When we controlled for individual characteristics, significant variation in the 10 concepts remained. Assessment of the contribution of specialty to between-unit variation enabled us to explain more variance (1.19% to 16.73%) in 6 of the 10 ACT concepts. Finally, when we assessed the unique contribution of the unit level variables available to us, we were able to explain additional variance (15.91% to 73.25%) in 7 of the 10 ACT concepts. CONCLUSION: The findings reported here represent the third published argument for validity of the ACT and adds to the evidence supporting its use to discriminate patient care units by all 10 contextual factors. We found evidence of relationships between a variety of individual and unit-level variables that explained much of this between-unit variation for each of the 10 ACT concepts. Future research will include examination of the relationships between the ACT's contextual factors and research utilization by nurses and ultimately the relationships between context, research utilization, and outcomes for patients.

Measuring organizational readiness for knowledge translation in chronic care.

BACKGROUND: Knowledge translation (KT) is an imperative in order to implement research-based and contextualized practices that can answer the numerous challenges of complex health problems. The Chronic Care Model (CCM) provides a conceptual framework to guide the implementation process in chronic care. Yet, organizations aiming to improve chronic care require an adequate level of organizational readiness (OR) for KT. Available instruments on organizational readiness for change (ORC) have shown limited validity, and are not tailored or adapted to specific phases of the knowledge-to-action (KTA) process. We aim to develop an evidence-based, comprehensive, and valid instrument to measure OR for KT in healthcare. The OR for KT instrument will be based on core concepts retrieved from existing literature and validated by a Delphi study. We will specifically test the instrument in chronic care that is of an increasing importance for the health system. METHODS: Phase one: We will conduct a systematic review of the theories and instruments assessing ORC in healthcare. The retained theoretical information will be synthesized in a conceptual map. A bibliography and database of ORC instruments will be prepared after appraisal of their psychometric properties according to the standards for educational and psychological testing. An online Delphi study will be carried out among decision makers and knowledge users across Canada to assess the importance of these concepts and measures at different steps in the KTA process in chronic care.Phase two: A final OR for KT instrument will be developed and validated both in French and in English and tested in chronic disease management to measure OR for KT regarding the adoption of comprehensive, patient-centered, and system-based CCMs. DISCUSSION: This study provides a comprehensive synthesis of current knowledge on explanatory models and instruments assessing OR for KT. Moreover, this project aims to create more consensus on the theoretical underpinnings and the instrumentation of OR for KT in chronic care. The final product--a comprehensive and valid OR for KT instrument--will provide the chronic care settings with an instrument to assess their readiness to implement evidence-based chronic care.

Staff, space, and time as dimensions of organizational slack: a psychometric assessment.

BACKGROUND: : In the theoretical and research literature, organizational slack has been largely described in terms of financial resources and its impact on organizational outcomes. However, empirical research is limited by unclear definitions and lack of standardized measures. PURPOSE: : The aim of this study was to assess the psychometric properties of a new organizational slack measure in health care settings. METHODS: : A total of 752 nurses and 197 allied health care professionals (AHCPs) employed in seven pediatric Canadian hospitals completed the Alberta Context Tool, an instrument measuring organizational context, which includes the newly developed organizational slack measure. The nine-item, 5-point Likert organizational slack measure includes items assessing staff perceptions of available human resources (staffing), time, and space. We report psychometric assessments, bivariate analyses, and data aggregation indices for the measure. FINDINGS: : The findings indicate that the measure has three subscales (staff, space, and time) with acceptable internal consistency reliability (alphas for staff, space, and time, respectively:.83,.63, and.74 for nurses;.81,.52, and.76 for AHCPs), links theory and hypotheses (construct validity), and is related to other relevant variables. Within-group reliability measures indicate stronger agreement among nurses than AHCPs, more reliable aggregation results in all three subscales at the unit versus facility level, and higher explained variance and validity of aggregated scores at the unit level. PRACTICE IMPLICATIONS: : The proposed organizational slack measure assesses modifiable organizational factors in hospitals and has the potential to explain variance in important health care system outcomes. Further assessments of the psychometric properties of the organizational slack measure in acute and long-term care facilities are underway.

Nurse specialty subcultures and patient outcomes in acute care hospitals: A multiple-group structural equation modeling.

BACKGROUND: Hospital organizational culture is widely held to matter to the delivery of services, their effectiveness, and system performance in general. However, little empirical evidence exists to support that culture affects provider and patient outcomes; even less evidence exists to support how this occurs. OBJECTIVES: To explore causal relationships and mechanisms between nursing specialty subcultures and selected patient outcomes (i.e., quality of care, adverse patient events). METHOD: Martin's differentiation perspective of culture (nested subcultures within organizations) was used as a theoretical framework to develop and test a model. Hospital nurse subcultures were identified as being reflected in formal practices (i.e., satisfactory salary, continuing education, quality assurance program, preceptorship), informal practices (i.e., autonomy, control over practice, nurse-physician relationships), and content themes (i.e., emotional exhaustion). A series of structural equation models were assessed using LISREL on a large nurse survey database representing four specialties (i.e., medical, surgical, intensive care, emergency) in acute care hospitals in Alberta, Canada. RESULTS: Nursing specialty subcultures differentially influenced patient outcomes. Specifically, quality of care (a) was affected by nurses' control over practice, (b) was better in intensive care than in medical specialty, and (c) was related to lower adverse patient events; nurses in intensive care and emergency specialties reported fewer adverse events than did their counterparts in medical specialties. CONCLUSIONS: Understanding the meaning of subcultures in clinical settings would influence nurses and administrators efforts to implement clinical change and affect outcomes. More research is needed on nested subcultures within healthcare organizations for better understanding differentiated subspecialty effects on complexity of care and outcomes in hospitals.

The relational nature of case manager resource allocation decision making: an illustrated case.

We used ethnographic methods in the tradition of Spradley (1979) and constant comparative analysis to explore case manager resource allocation decision making. We interviewed; observed and shadowed 11 case managers within a children's home care program in a regional health authority in western Canada as they went about their daily work over a 5-month period. Our findings provide knowledge about the little-understood set of processes at the micro level of resource allocation. Although the case manager considers many factors, reported elsewhere (Fraser, Estabrooks, Allen, & Strang, 2009), they balance and weigh these factors within a relational context. The purpose of this article is to use Jenna's story as a case example to illustrate how the case manager balances and weighs the factors that influence their resource allocation decisions within this context. Jenna's story demonstrates the complex and multidimensional processes that are embedded in the relational nature of resource allocation decisions. We discuss home care case manager resource allocation decisions as viewed through the lens of relational ethics.