Nurse practitioner led implementation of huddles for staff in long term care homes during the COVID-19 pandemic.

BACKGROUND: Staff working in long-term care (LTC) homes during COVID-19 frequently reported a lack of communication, collaboration, and teamwork, all of which are associated with staff dissatisfaction, health concerns, lack of support and moral distress. Our study introduced regular huddles to support LTC staff during COVID-19, led by a Nurse Practitioner (NP). The objectives were to evaluate the process of huddle implementation and to examine differences in outcomes between categories of staff (direct care staff, allied care and support staff, and management) who attended huddles and those who did not. METHODS: All staff and management at one LTC home (< 150 beds) in Ontario, Canada were included in this pre-experimental design study. The process evaluation used a huddle observation tool and focused on the dose (duration, frequency) and fidelity (NP's adherence to the huddle guide) of implementation. The staff attending and non-attending huddles were compared on outcomes measured at post-test: job satisfaction, physical and mental health, perception of support received, and levels of moral distress. The outcomes were assessed with validated measures and compared between categories of staff using Bayesian models. RESULTS: A total of 42 staff enrolled in the study (20 attending and 22 non-attending huddles). Forty-eight huddles were implemented by the NP over 15 weeks and lasted 15 min on average. Huddles were most commonly attended by direct care staff, followed by allied care/support, and management staff. All huddles adhered to the huddle guide as designed by the research team. Topics most often addressed during the huddles were related to resident care (46%) and staff well-being (34%). Differences were found between staff attending and non-attending huddles: direct care staff attending huddles reported lower levels of overall moral distress, and allied care and support staff attending huddles perceived higher levels of support from the NP. CONCLUSIONS: NP-led huddles in LTC homes may positively influence staff outcomes. The process evaluation provided some understanding of why the huddles may have been beneficial: the NP addressed resident care issues which were important to staff, encouraged a collaborative approach to solving issues on the unit, and discussed their well-being. TRIAL REGISTRATION NUMBER: NCT05387213, registered on 24/05/2022.

Nurse practitioner/physician collaborative models of care: a scoping review protocol.

BACKGROUND: Before the COVID-19 pandemic, many long-term care (LTC) homes experienced difficulties in providing residents with access to primary care, typically delivered by community-based family physicians or nurse practitioners (NPs). During the pandemic, legislative changes in Ontario, Canada enabled NPs to act in the role of Medical Directors thereby empowering NPs to work to their full scope of practice. Emerging from this new context, it remains unclear how NPs and physicians will best work together as primary care providers. NP/physician collaborative models appear key to achieving optimal resident outcomes. This scoping review aims to map available evidence on existing collaborative models of care between NPs and physicians within LTC homes. METHODS: The review will be guided by the research question, "What are the structures, processes and outcomes of collaborative models of care involving NPs and Physicians in LTC homes?" This scoping review will be conducted according to the methods framework for scoping reviews outlined by Arksey and O'Malley and refined by Levac et al., Colquhoun et al., and Daudt et al., as well as the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Statement. Electronic databases (MEDLINE, Embase + Embase Classic, APA PsycInfo, Cochrane Central Register of Controlled Trials, AMED, CINAHL, Ageline, and Scopus), grey literature, and reference lists of included articles will be searched. English language studies that describe NP and physician collaborative models within the LTC setting will be included. DISCUSSION: This scoping review will consolidate what is known about existing NP/physician collaborative models of care in LTC homes. Results will be used to inform the development of a collaborative practice framework for long-term care clinical leadership.

Assessing the implementation of nurse practitioner-led huddles in long-term care using the Consolidated Framework for Implementation Research (CFIR).

BACKGROUND: The COVID-19 pandemic created major challenges in long-term care (LTC) homes across Canada and globally. A nurse practitioner-led interdisciplinary huddle intervention was developed to support staff wellbeing in two LTC homes in Ontario, Canada. The objective of this study was to identify the constructs strongly influencing the process of implementation of huddles across both sites, capturing the overall barriers and facilitators and the intervention's intrinsic properties. METHODS: Nineteen participants were interviewed about their experiences, pre-, post-, and during huddle implementation. The Consolidated Framework for Implementation Research (CFIR) was used to guide data collection and analysis. CFIR rating rules and a cross-comparison analysis was used to identify differentiating factors between sites. A novel extension to the CFIR analysis process was designed to assess commonly influential factors across both sites. RESULTS: Nineteen of twenty selected CFIR constructs were coded in interviews from both sites. Five constructs were determined to be strongly influential across both implementation sites and a detailed description is provided: evidence strength and quality; needs and resources of those served by the organization; leadership engagement; relative priority; and champions. A summary of ratings and an illustrative quote are provided for each construct. CONCLUSION: Successful huddles require long-term care leaders to consider their involvement, the inclusion all team members to help build relationships and foster cohesion, and the integration of nurse practitioners as full-time staff members within LTC homes to support staff and facilitate initiatives for wellbeing. This research provides an example of a novel approach using the CFIR methodology, extending its use to identify significant factors for implementation when it is not possible to compare differences in success.

Impact of Dementia on Patterns of Home Care After Inpatient Rehabilitation Discharge for Older Adults After Hip Fractures.

OBJECTIVE: To describe differences in home care use in the 30 days after discharge from inpatient rehabilitation after a hip fracture among older adults with dementia compared with those without dementia. DESIGN: Retrospective cohort study of individually linked health administrative data. SETTING: Community-dwelling older adults after discharge from inpatient rehabilitation facilities in Ontario, Canada. PARTICIPANTS: A total of 17,263 older adults (N=17,263), of whom 2489 had dementia (14.4%), who were treated for hip fracture in acute care and then admitted to inpatient rehabilitation facilities between January 1, 2011 and March 31, 2017. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The proportion receiving home care services and number of visits (physiotherapy, occupational therapy, nursing, personal/homemaking) in the 30 days after discharge were compared by dementia status with multivariate models, stratified by sex. RESULTS: Compared with those without dementia, adults with dementia were older, had lower functional scores, and were more likely to receive home care services in the 30 days after discharge from inpatient rehabilitation (87.0% vs 79.0%, P<.001), including personal/homemaking services (66.1% vs 46.4%, P<.001) and occupational therapy (45.3% vs 37.4, P<.001) but not physiotherapy (55.8% vs 56.2%, P=.677) or nursing (19.6% vs 18.7%, P=.268). After adjustment, older adults with dementia were more likely to receive home care in both men (odds ratio [OR] =2.01; 95% confidence interval [CI], 1.57-2.57) and women (OR=1.50; 95% CI, 1.30-1.74) as well as more services (rate ratio men=1.60; 95% CI, 1.44-1.79; rate ratio women=1.50; 95% CI, 1.41-1.60). CONCLUSIONS: Among older adults discharged from inpatient rehabilitation, older adults with dementia received home care services more often than older adults without dementia. However, irrespective of sex and dementia status, almost half of this population (44%) did not receive physiotherapy. We recommend that, resources permitting, all older adults receive physiotherapy to facilitate recovery.

Understanding transitional care programs for older adults who experience delayed discharge: a scoping review.

BACKGROUND: Many hospitalized older adults cannot be discharged because they lack the health and social support to meet their post-acute care needs. Transitional care programs (TCPs) are designed to provide short-term and low-intensity restorative care to these older adults experiencing or at risk for delayed discharge. However, little is known about the contextual factors (i.e., patient, staff and environmental characteristics) that may influence the implementation and outcomes of TCPs. This scoping review aims to answer: 1) What are socio-demographic and/or clinical characteristics of older patients served by TCPs?; 2) What are the core components provided by TCPs?; and 3) What patient, caregiver, and health system outcomes have been investigated and what changes in these outcomes have been reported for TCPs? METHODS: The six-step scoping review framework and PRISMA-ScR checklist were followed. Studies were included if they presented models of TCPs and evaluated them in community-dwelling older adults (65+) experiencing or at-risk for delayed discharge. The data synthesis was informed by a framework, consistent with Donabedian's structure-process-outcome model. RESULTS: TCP patients were typically older women with multiple chronic conditions and some cognitive impairment, functionally dependent and living alone. The review identified five core components of TCPs: assessment; care planning and monitoring; treatment; discharge planning; and patient, family and staff education. The main outcomes examined were functional status and discharge destination. The results were discussed with a view to inform policy makers, clinicians and administrators designing and evaluating TCPs as a strategy for addressing delayed hospital discharges. CONCLUSION: TCPs can influence outcomes for older adults, including returning home. TCPs should be designed to incorporate interdisciplinary care teams, proactively admit those at risk of delayed discharge, accommodate persons with cognitive impairment and involve care partners. Additional studies are required to investigate the contributions of TCPs within integrated health care systems.

Ectopic Expression of Neurod1 Is Sufficient for Functional Recovery following a Sensory-Motor Cortical Stroke.

Stroke is the leading cause of adult disability worldwide. The majority of stroke survivors are left with devastating functional impairments for which few treatment options exist. Recently, a number of studies have used ectopic expression of transcription factors that direct neuronal cell fate with the intention of converting astrocytes to neurons in various models of brain injury and disease. While there have been reports that question whether astrocyte-to-neuron conversion occurs in vivo, here, we have asked if ectopic expression of the transcription factor Neurod1 is sufficient to promote improved functional outcomes when delivered in the subacute phase following endothelin-1-induced sensory-motor cortex stroke. We used an adeno-associated virus to deliver Neurod1 from the short GFAP promoter and demonstrated improved functional outcomes as early as 28 days post-stroke and persisting to at least 63 days post-stroke. Using Cre-based cell fate tracking, we showed that functional recovery correlated with the expression of neuronal markers in transduced cells by 28 days post-stroke. By 63 days post-stroke, the reporter-expressing cells comprised ~20% of all the neurons in the perilesional cortex and expressed markers of cortical neuron subtypes. Overall, our findings indicate that ectopic expression of Neurod1 in the stroke-injured brain is sufficient to enhance neural repair.

What Do We Know About Nurse Practitioner/Physician Care Models in Long-Term Care: Results of a Scoping Review.

OBJECTIVES: Due to the rise of the nurse practitioner (NP) role in long-term care settings, it is important to understand the underlying structures and processes that influence NP and physician care models. This scoping review aims to answer the question, "What are the structures, processes, and outcomes of care models involving NPs and physicians in long-term care (LTC) homes?" A secondary aim was to describe the structural enablers and barriers across care models. RESEARCH DESIGN AND METHODS: Seven databases were searched. Studies that described NPs and physicians working in LTC were identified and included in the review. We stratified the findings by care model and synthesized using the Donabedian model, which evaluates health care quality based on 3 dimensions: structure, process, and outcome. We then categorized macro, meso, and micro structural enablers and barriers. RESULTS: Sixty papers were included in the review. The main structural influencers within 5 care models included policies on scope of practice, clarity of role description, and workload. A limited number of papers referred to the process of enabling the development of a working relationship. Thirty-five (49%) studies described resident, staff, and health system outcomes. CONCLUSIONS AND IMPLICATIONS: Although structural characteristics of NP and physician care models are described in-depth, there is less detail on the processes that occur within the NP and physician care models. We highlight structural barriers and enablers within the care models, allowing for recognition of the importance of organizational influence on the NP and physician relationship. Future work should focus on the processes of the relationships in the models by identifying the drivers and initiators of collaboration between NPs and physicians and how these relationships influence outcomes.

Development and Evaluation of a Nurse Practitioner Huddles Toolkit for Long Term Care Homes.

Long-term care homes (LTCHs) were disproportionately affected by the coronavirus disease (COVID-19) pandemic, creating stressful circumstances for LTCH employees, residents, and their care partners. Team huddles may improve staff outcomes and enable a supportive climate. Nurse practitioners (NPs) have a multifaceted role in LTCHs, including facilitating implementation of new practices. Informed by a community-based participatory approach to research, this mixed-methods study aimed to develop and evaluate a toolkit for implementing NP-led huddles in an LTCH. The toolkit consists of two sections. Section one describes the huddles' purpose and implementation strategies. Section two contains six scripts to guide huddle discussions. Acceptability of the intervention was evaluated using a quantitative measure (Treatment Acceptability Questionnaire) and through qualitative interviews with huddle participants. Descriptive statistics and manifest content analysis were used to analyse quantitative and qualitative data. The project team rated the toolkit as acceptable. Qualitative findings provided evidence on design quality, limitations, and recommendations for future huddles.

Nurse Practitioners Navigating the Consequences of Directives, Policies, and Recommendations Related to the COVID-19 Pandemic in Long-Term Care Homes.

OBJECTIVES: New models for the workforce are required in long-term care (LTC) homes, as was made evident during the Coronavirus Disease 2019 (COVID-19) pandemic. Nurse Practitioner (NP)-led models of care represent an effective solution. This study explored NPs' roles in supporting LTC homes as changes in directives, policies, and recommendations related to COVID-19 were introduced. DESIGN: Qualitative exploratory study. CONTEXT: Thirteen NPs working in LTC homes in Ontario, Canada. METHODS: Semi-structured interviews were conducted in March/April 2021. A five-step inductive thematic analysis was applied. FINDINGS: Analysis generated four themes: leading the COVID-19 vaccine rollout; promoting staff wellbeing related to COVID-19 fatigue; addressing complexities of new admissions; and negotiating evolving collaborative relationships. CONCLUSIONS: Nurse practitioners were instrumental in supporting LTC homes through COVID-19 regulatory changes producing unintended consequences. The NPs' leadership in transforming care is equally essential in LTC homes as in other established healthcare settings, such as primary and acute care.

Nurse Practitioners Rising to the Challenge During the Coronavirus Disease 2019 Pandemic in Long-Term Care Homes.

BACKGROUND AND OBJECTIVES: There is an urgency to respond to the longstanding deficiencies in health human resources in the long-term care (LTC) home sector, which have been laid bare by the coronavirus disease 2019 (COVID-19) pandemic. Nurse practitioners (NPs) represent an efficient solution to human resource challenges. During the current pandemic, many Medical Directors in LTC homes worked virtually to reduce the risk of transmission. In contrast, NPs were present for in-person care. This study aims to understand the NPs' roles in optimizing resident care and supporting LTC staff during the pandemic. RESEARCH DESIGN AND METHODS: This exploratory qualitative study employed a phenomenological approach. A purposive sample of 14 NPs working in LTC homes in Ontario, Canada, was recruited. Data were generated using semistructured interviews and examined using thematic analysis. RESULTS: Four categories relating to the NPs' practices and experiences during the pandemic were identified: (a) containing the spread of COVID-19, (b) stepping in where needed, (c) supporting staff and families, and (d) establishing links between fragmented systems of care by acting as a liaison. DISCUSSION AND IMPLICATIONS: The findings suggest that innovative models of care that include NPs in LTC homes are required moving forward. NPs embraced a multitude of roles in LTC homes, but the need to mitigate the spread of COVID-19 was central to how they prioritized their days. The pandemic clearly accentuated that NPs have a unique scope of practice, which positions them well to act as leaders and build capacity in LTC homes.

Complexity of Nurse Practitioners' Role in Facilitating a Dignified Death for Long-Term Care Home Residents during the COVID-19 Pandemic.

Due to the interplay of multiple complex and interrelated factors, long-term care (LTC) home residents are increasingly vulnerable to sustaining poor outcomes in crisis situations such as the COVID-19 pandemic. While death is considered an unavoidable end for LTC home residents, the importance of facilitating a good death is one of the primary goals of palliative and end-of-life care. Nurse practitioners (NPs) are well-situated to optimize the palliative and end-of-life care needs of LTC home residents. This study explores the role of NPs in facilitating a dignified death for LTC home residents while also facing increased pressures related to the COVID-19 pandemic. The current exploratory qualitative study employed a phenomenological approach. A purposive sample of 14 NPs working in LTC homes was recruited. Data were generated using semi-structured interviews and examined using thematic analysis. Three categories were derived: (a) advance care planning and goals of care discussions; (b) pain and symptom management at the end-of-life; and (c) care after death. The findings suggest that further implementation of the NP role in LTC homes in collaboration with LTC home team and external partners will promote a good death and optimize the experiences of residents and their care partners during the end-of-life journey.

Health and social interventions to restore physical function of older adults post-hip fracture: a scoping review.

OBJECTIVES: Despite inpatient rehabilitation, many older adults post-hip fracture have difficulty returning to their prefracture levels of function and activity. This scoping review aims to identify interventions for community-dwelling older adults discharged from inpatient rehabilitation and examine the function and activity outcomes associated with these interventions. DESIGN: This scoping review followed Arksey and O'Malley's five-stage framework. DATA SOURCES: We searched MEDLINE, CINAHL, PsycINFO, EMBASE and Ageline electronic databases for English-language articles published between January 1946 and January 2020. ELIGIBILITY CRITERIA: We included studies with health and social interventions involving community-dwelling older adults and their caregivers after hip fracture and inpatient rehabilitation. The interventions were selected if initiated within 60 days post-hip fracture surgery. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers screened abstracts and full texts and extracted the data based on the inclusion criteria. A third reviewer adjudicated any disagreement and collated the extracted data. RESULTS: Of the 24 studies included in the review, most studies (79%) used exercise-based interventions, over half (63%) included activities of daily living training and/or home assessment and environment modification as intervention components, and three studies used social intervention components. Over half of the interventions (58%) were initiated in the inpatient setting and physiotherapists provided 83% of the interventions. Only seven studies (29%) involved tailored interventions based on the older adults' unique needs and progress in exercise training. Six studies (25%) enrolled patients with cognitive impairment, and only one study examined caregiver-related outcomes. Exercise-based interventions led to improved function and activity outcomes. 29 different outcome measures were reported. CONCLUSION: While exercise-based multicomponent interventions have evidence for improving outcomes in this population, there is a paucity of studies, including social interventions. Further, studies with standardised outcome measures are needed, particularly focusing on supporting caregivers and the recovery of older adults with cognitive impairment.