A new model of care and in-house general practitioners for residential aged care facilities: a stepped wedge, cluster randomised trial.

OBJECTIVES: To evaluate whether an alternative model of care in aged care facilities, including in-house general practitioners, influenced health outcomes for residents. DESIGN: Stepped wedge, cluster randomised controlled trial over 90 weeks (31 December 2012 - 21 September 2014), with a 54-week pre-trial retrospective data period (start: 19 December 2011) and a 54-week post-trial prospective data collection period (to 4 October 2015). PARTICIPANTS, SETTING: Fifteen residential aged care facilities operated by Bupa Aged Care in metropolitan and regional cities in four Australian states. INTERVENTION: Residential aged care facilities sought to recruit general practitioners as staff members; care staff roles were redefined to allow registered nurses greater involvement in care plan development. MAIN (PRIMARY) OUTCOME MEASURES: Numbers of falls; numbers of unplanned transfers to hospital; polypharmacy. RESULTS: The new model of care could be implemented in all facilities, but four could not recruit in-house GPs at any time during the trial period. Intention-to-treat analyses found no statistically significant effect of the intervention on the primary outcome measures. Contamination-adjusted intention-to-treat analyses identified that the presence of an in-house GP was associated with reductions in the numbers of unplanned hospital transfers (incidence rate ratio [IRR], 0.53; 95% CI, 0.43-0.66) and admissions (IRR, 0.52; 95% CI, 0.41-0.64) and of out-of-hours GP call-outs (IRR, 0.54; 95% CI, 0.36-0.80), but also with an increase in the number of reported falls (IRR, 1.37; 95% CI, 1.20-1.58). CONCLUSIONS: Recruiting GPs to work directly in residential aged care facilities is difficult, but may reduce the burden of unplanned presentations to hospitals and increase the reporting of adverse events. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry, ACTRN12613000218796 (25 February 2013).

Using action research to build mentor capacity to improve orientation and quality of nursing students' aged care placements: what to do when the phone rings.

AIMS AND OBJECTIVES: To describe whether an action research approach can be used to build capacity of residential aged care facility staff to support undergraduate nursing students' clinical placements in residential aged care facilities, using development of an orientation programme as an exemplar. BACKGROUND: Aged care facilities are unpopular sites for nursing students' clinical placements. A contributing factor is the limited capacity of staff to provide students with a positive placement experience. Strategies to build mentor capability to shape student placements and support learning and teaching are critical if nursing students are to have positive placements that attract them to aged care after graduation, an imperative given the increasing care needs of the ageing population worldwide. DESIGN: Action research approach employing mixed-methods data collection (primarily qualitative with a quantitative component). METHODS: Aged care facility staff (n = 32) formed a mentor group at each of two Tasmanian facilities and met regularly to support undergraduate nursing students (n = 40) during placements. Group members planned, enacted, reviewed and reflected on orientation procedures to welcome students, familiarise them with the facility and prepare them for their placement. Data comprised transcripts from these and parallel student meetings, and orientation data from student questionnaires from two successive placement periods (2011/2012). RESULTS: Problems were identified in the orientation processes for the initial student placements. Mentors implemented a revised orientation programme. Evaluation demonstrated improved programme outcomes for students regarding knowledge of facility operations, their responsibilities and emergency procedures. CONCLUSION: Action research provides an effective approach to engage aged care facility staff to build their capacity to support clinical placements. RELEVANCE TO CLINICAL PRACTICE: Building capacity in the aged care workforce is vital to provide appropriate care for residents with increasing care needs.

We are not all coping: a cross-sectional investigation of resilience in the dementia care workforce.

BACKGROUND: Research on workforce development for high-quality dementia care more often focuses on enhancing employee knowledge and skill and less on managing employee stress and coping at work. OBJECTIVE: To review employee stress and coping in response to high job demands in community-based dementia care organizations in Tasmania, Australia. METHODS: Stress and coping in response to job roles of 25 community-based dementia care workers were reviewed using self-report questionnaire data. Data were analysed for descriptive results and at an individual case level. Individual participant scores were reviewed for clinically significant stress and coping factors to create worker profiles of adjustment. RESULTS: Two adjustment profiles were found. The 'global resilience' profile, where workers showed positive adjustment and resilience indicating they found their jobs highly rewarding, were very confident in their abilities at work and had a strong match between their personal and organizational values. The second 'isolated distress' profile was only found in a minority and included poor opportunities for job advancement, a missmatch in personal and work values or clinically high levels of psychological distress. CONCLUSION: Aged care workplaces that advocate employee well-being and support employees to cope with their work roles may be more likely to retain motivated and committed staff. Future research should consider employee stress and coping at the workforce level, and how this can influence high-quality care delivery by applying the measures identified for this study. Comparative research across different care settings using meta-analytic studies may then be possible.

Development and preliminary psychometric properties of the General Practitioner Attitudes and Confidence Scale (GPACS-D) for dementia.

BACKGROUND: International evidence suggests that dementia is under-diagnosed in the community and that General Practitioners (GPs) are often reluctant to engage to their fullest capability with patients who exhibit cognitive symptoms. This is potentially reflected by a lack of GP knowledge about the syndrome. However, it is also recognised that attitudes and confidence are important in relation to how and to what extent a GP approaches a person with dementia. This research sought to develop a reliable and valid measure of GPs attitudes and confidence towards dementia. METHODS: The General Practitioner Attitudes and Confidence Scale for Dementia (GPACS-D) was developed via a four stage process, including initial content development, pretesting, pilot testing and psychometric evaluation, including Principal Component Analysis (PCA). Participants were recruited for pre-testing (n = 12), test-retest (n = 55), and dementia workshop pre-and post-education evaluation (n = 215). RESULTS: The process of scale development and psychometric evaluation resulted in a 20-item measure of GP attitudes and confidence towards dementia, with 4 items removed due to poor reliability, low sensitivity, or lack of model fit. Among 55 respondents who completed the scale on two occasions with no intervening education, Kappa coefficient scores per item ranged from fair (n = 2, candidates for removal), moderate (n = 5), substantial (n = 15), and almost perfect (n = 2). A test of the sensitivity of item scores to change following dementia education among 215 GPs indicated that, with the exception of one item, all scale responses exhibited significant differences between pre-and post-workshop scores, indicating acceptable sensitivity. With one further item removed due to a low communality score, the final PCA undertaken with the remaining 20 items supports a four-component solution, which accounted for 51.9 % of the total variance. CONCLUSION: The GPACS-D provides a reliable and preliminarily valid measure of GP attitudes and confidence towards dementia. The scales provide useful information for medical educators and researchers who are interested in evaluating and intervening in GP perceptions of the syndrome and their capacity to provide effective care.

Ibuprofen regulates the expression and function of membrane-associated serine proteases prostasin and matriptase.

BACKGROUND: The glycosylphosphatidylinositol-anchored extracellular membrane serine protease prostasin is expressed in normal bladder urothelial cells. Bladder inflammation reduces prostasin expression and a loss of prostasin expression is associated with epithelial-mesenchymal transition (EMT) in human bladder transitional cell carcinomas. Non-steroidal anti-inflammatory drugs (NSAIDs) decrease the incidence of various cancers including bladder cancer, but the molecular mechanisms underlying the anticancer effect of NSAIDs are not fully understood. METHODS: The normal human bladder urothelial cell line UROtsa, the normal human trophoblast cell line B6Tert-1, human bladder transitional cell carcinoma cell lines UM-UC-5 and UM-UC-9, and the human breast cancer cell line JIMT-1 were used for the study. Expression changes of the serine proteases prostasin and matriptase, and cyclooxygenases (COX-1 and COX-2) in these cells following ibuprofen treatments were analyzed by means of reverse-transcription/quantitative polymerase chain reaction (RT-qPCR) and immunoblotting. The functional role of the ibuprofen-regulated prostasin in epithelial tight junction formation and maintenance was assessed by measuring the transepithelial electrical resistance (TEER) and epithelial permeability in the B6Tert-1 cells. Prostasin's effects on tight junctions were also evaluated in B6Tert-1 cells over-expressing a recombinant human prostasin, silenced for prostasin expression, or treated with a functionally-blocking prostasin antibody. Matriptase zymogen activation was examined in cells over-expressing prostasin. RESULTS: Ibuprofen increased prostasin expression in the UROtsa and the B6Tert-1 cells. Cyclooxygenase-2 (COX-2) expression was up-regulated at both the mRNA and the protein levels in the UROtsa cells by ibuprofen in a dose-dependent manner, but was not a requisite for up-regulating prostasin expression. The ibuprofen-induced prostasin contributed to the formation and maintenance of the epithelial tight junctions in the B6Tert-1 cells. The matriptase zymogen was down-regulated in the UROtsa cells by ibuprofen possibly as a result of the increased prostasin expression because over-expressing prostasin leads to matriptase activation and zymogen down-regulation in the UROtsa, JIMT-1, and B6Tert-1 cells. The expression of prostasin and matriptase was differentially regulated by ibuprofen in the bladder cancer cells. CONCLUSIONS: Ibuprofen has been suggested for use in treating bladder cancer. Our results bring the epithelial extracellular membrane serine proteases prostasin and matriptase into the potential molecular mechanisms of the anticancer effect of NSAIDs.

Residents with mild cognitive decline and family members report health students 'enhance capacity of care' and bring 'a new breath of life' in two aged care facilities in Tasmania.

BACKGROUND: Care provided by student doctors and nurses is well received by patients in hospital and primary care settings. Whether the same is true for aged care residents of nursing homes with mild cognitive decline and their family members is unknown. OBJECTIVE: To investigate the perspectives of aged care residents with mild cognitive decline and their family members on interdisciplinary student placements in two residential aged care facilities (RACF) in Tasmania. DESIGN, SETTING AND PARTICIPANTS: A mixed methods design was employed with both qualitative and quantitative data collected. All participants were interviewed and completed a questionnaire on residents' quality of life, during or after a period of student placements in each facility (October-November, 2012). Qualitative data were coded for themes following a grounded theory approach, and quantitative data were analysed using SPSS. RESULTS: Twenty-one participants (13 residents and 8 family members) were recruited. Four themes were identified from the qualitative data and included (i) increased social interaction and facility vibrancy; (ii) community service and personal development, (iii) vulnerability and sensitivity (learning to care) and (iv) increased capacity and the confidence of enhanced care. Residents' quality of life was reported to be mostly good in the presence of the students, despite their high care needs. CONCLUSION: Residents with mild cognitive decline and their family members perceive a wide array of benefits of student provided care in RACFs including increased social interaction. Future quantitative research should focus on whether changes in care occur for residents as a result of student involvement.

Can a community of practice enhance a palliative approach for people drawing close to death with dementia?

This action research study was conducted to trial a strategy intended to support a consistent, high-quality, palliative approach for people with dementia drawing close to death-the implementation of a community of practice. Professionals from community/residential care and hospitals formed this community of practice, which took on the role of an action research group. The group was supported to identify and address practice problems. Four action plans were implemented; outcomes from two are reported. When actioning the plan 'providing education and information for the staff', the staff's ratings of sessions and resources were positive but impacts upon knowledge, views, or confidence were small. When actioning 'supporting families', families providing care in non-hospital settings received information about severe dementia from suitably prepared staff, plus contact details to access support. Family feedback was primarily positive. Reference to additional practice change frameworks and inclusion of specialist palliative care professionals are recommendations for future initiatives; also focusing on targeted, achievable goals over longer timeframes.

Perspectives of the community-based dementia care workforce: "occupational communion" a key finding from the Work 4 Dementia Project.

BACKGROUND: Community care workers' experience of delivering support to people with dementia is less researched than that of residential workers. The purpose of the study is to explore community-based dementia care workers' perspectives about their roles and the contextual variables that impact upon their work experiences. METHOD: A qualitative design was employed. Twenty-five community dementia care workers (average age 53 years, majority female and employed casually) participated in standardized semi-structured interviews about their job roles, training, employer agenda, organizational support, and intention to stay. A deductive approach to Interpretive Phenomenological Analysis was adopted to identify key themes. RESULTS: Three themes highlighted workers' experiences. Occupational communion described strong attachment to clients and a desire for greater connection with colleagues. Job demands described the challenges of work, which varied with intensity. Job resources ranged from positive (strong organizational commitment) to negative (poor pay and conditions). Occupational communion was identified as a concept that exists at the interface between social and organization psychology that was perceived to be essential for adaptive coping. Identifying themes informed a conceptual model for designing intervention components aimed at improving workers' skills, capabilities, and employer supportive functions. CONCLUSION: Occupational communion may be particularly relevant for women's caring careers and future research is needed to explore the relevance of this concept for men. To determine reliable change associated with interventions that target occupational communion, further investigation is required in relation to measurement approaches.

The precarious resilience of aged care employees enrolled in an Australian online dementia course: A cross-sectional study of occupational health and well-being.

OBJECTIVE: Australian aged care workforce surveys offer limited information about those who engage in online dementia education regarding their occupational health and well-being. A salutogenic approach was applied to an aged care context to quantitatively assess both positive and negative aspects of health at work to inform the development of workplace interventions tailored to those interested in self-development. METHODS: Physical, psychological and occupational health were measured in an online cross-sectional survey of general health, chronic conditions, psychological distress, positive and negative affect, job satisfaction, access to workplace amenities and turnover intentions of aged care workers undertaking an online dementia course in October 2014. RESULTS: Participants (N = 662) rated their general physical health as good and a minority experienced chronic conditions such as obesity. Overall, workers had average levels of positive and negative affect and low distress. However, 25% were likely to have a mental health condition. While most were employed on a permanent basis (80%) and reported moderate job satisfaction, 18% were likely to leave their job. There were some gaps in workplace amenities to support health and well-being: for example, 13% reported no access to lunch break areas. CONCLUSIONS: Results suggest precarious resilience in aged care workers enrolled in an Australian online dementia course. Workplace interventions that focus on preventative health strategies are required to address the health risks associated with higher than national averages of obesity and mental health, and reduce exposure of workers to physical and psychological harms.