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1.  Spreading and sustaining best practices for home care of older adults: a grounded theory study 
Improving health care quality requires effective and timely spread of innovations that support evidence-based practices. However, there is limited rigorous research on the process of spread, factors influencing spread, and models of spread. It is particularly important to study spread within the home care sector given the aging of the population, expansion of home care services internationally, the high proportion of older adult users of home care services, and the vulnerability of this group who are frail and live with multiple chronic conditions. The purpose of this study was to understand how best practices related to older adults are spread within home care organizations.
Four home care organizations in Ontario, Canada that had implemented best practices related to older adults (falls prevention, pain management, management of venous leg ulcers) participated. Using a qualitative grounded theory design, interviews were conducted with frontline providers, managers, and directors at baseline (n =44) and 1 year later (n =40). Open, axial, and selective coding and constant comparison analysis were used.
A model of the process of spread of best practices within home care organizations was developed. The phases of spread included (1) committing to change, (2) implementing on a small scale, (3) adapting locally, (4) spreading internally to multiple users and sites, and (5) disseminating externally. Factors that facilitated progression through these phases were (1) leading with passion and commitment, (2) sustaining strategies, and (3) seeing the benefits. Project leads, champions, managers, and steering committees played vital roles in leading the spread process. Strategies such as educating/coaching and evaluating and feedback were key to sustaining the change. Spread occurred within the home care context of high staff and manager turnover and time and resource constraints.
Spread of best practices is optimized through the application of the phases of spread, allocation of resources to support spread, and implementing strategies for ongoing sustainability that address potential barriers. Further research will help to understand how best practices are spread externally to other organizations.
PMCID: PMC4225037  PMID: 25377627
Spread; Practice guidelines; Home care; Older adults; Grounded theory
2.  A Review of Advance Care Planning Programs in Long-Term Care Homes: Are They Dementia Friendly? 
Nursing Research and Practice  2014;2014:875897.
Background. Persons living with dementia in the long-term care home (LTCH) setting have a number of unique needs, including those related to planning for their futures. It is therefore important to understand the advance care planning (ACP) programs that have been developed and their impact in order for LTCH settings to select a program that best suits residents' needs. Methods. Four electronic databases were searched from 1990 to 2013, for studies that evaluated the impact of advance care planning programs implemented in the LTCH setting. Studies were critically reviewed according to rigour, impact, and the consideration of the values of residents with dementia and their family members according to the Dementia Policy Lens Toolkit. Results and Conclusion. Six ACP programs were included in the review, five of which could be considered more “dementia friendly.” The programs indicated a variety of positive impacts in the planning and provision of end-of-life care for residents and their family members, most notably, increased ACP discussion and documentation. In moving forward, it will be important to evaluate the incorporation of residents with dementia's values when designing or implementing ACP interventions in the LTCH settings.
PMCID: PMC3976775  PMID: 24757563
4.  Resident and family perceptions of the nurse practitioner role in long term care settings: a qualitative descriptive study 
BMC Nursing  2013;12:24.
Research evidence supports the positive impact on resident outcomes of nurse practitioners (NPs) working in long term care (LTC) homes. There are few studies that report the perceptions of residents and family members about the role of the NP in these settings. The purpose of this study was to explore the perceptions of residents and family members regarding the role of the NP in LTC homes.
The study applied a qualitative descriptive approach. In-depth individual and focus group interviews were conducted with 35 residents and family members from four LTC settings that employed a NP. Conventional content analysis was used to identify themes and sub-themes.
Two major themes were identified: NPs were seen as providing resident and family-centred care and as providing enhanced quality of care. NPs established caring relationships with residents and families, providing both informational and emotional support, as well as facilitating their participation in decision making. Residents and families perceived the NP as improving availability and timeliness of care and helping to prevent unnecessary hospitalization.
The perceptions of residents and family members of the NP role in LTC are consistent with the concepts of person-centred and relationship-centred care. The relationships NPs develop with residents and families are a central means through which enhanced quality of care occurs. Given the limited use of NPs in LTC settings, there is an opportunity for health care policy and decision makers to address service inadequacies through strategic deployment of NPs in LTC settings. NPs can use their expert knowledge and skill to assist residents and families to make informed choices regarding their health care and maintain a positive care experience.
PMCID: PMC3849937  PMID: 24074157
Nurse practitioner; Long term care; Qualitative descriptive; Perceptions; Residents; Family members; Person-centred care
5.  Association between caregiver quality of life and the care provided to persons with Alzheimer’s disease: protocol for a systematic review 
Systematic Reviews  2013;2:17.
Primary informal caregivers provide a substantial amount of the care and support for persons with Alzheimer’s disease (AD). This review aims to investigate the association between the quality of life (QoL) of primary informal AD caregivers and the level of care that these caregivers provide to persons with AD.
Studies involving primary informal caregivers of persons with AD will be included in the review. These studies will be required to focus on the care that caregivers provide for their loved ones. The primary outcome is level or quality of care. The main independent variable is caregiver QoL. In addition to QoL, we will include studies that examine other independent variables that are considered to be important components of QoL. These variables include social support, caregiver burden, caregiver wellbeing, and caregiver depression.
We will search Medline-OVID, Embase-OVID, Cochrane Central-OVID, and PsycINFO-OVID from inception onwards. Two raters will independently screen each article using pre-established inclusion/exclusion criteria. Screening will take place at two levels: title and abstract, and full text. Conflicts will be resolved by discussion or by a third reviewer. We will assess the risk of bias of each included study using standardized quality assessment tools for specific types of designs. A narrative synthesis method will be used to describe our findings. Quantitative summary and meta-analysis will be conducted if appropriate. We will employ GRADE to evaluate the strength of the evidence in this review.
Results of this systematic review will show whether and how caregiver QoL is related to the level of care that caregivers provide to persons with AD.
PMCID: PMC3610300  PMID: 23497507
Alzheimer’s disease (AD); Caregiver; Quality of life (QoL); Level of care; Quality of care; PROSPERO registration number: CRD42013003613
6.  A proposed systems approach to the evaluation of integrated palliative care 
There is increasing global interest in regional palliative care networks (PCN) to integrate care, creating systems that are more cost-effective and responsive in multi-agency settings. Networks are particularly relevant where different professional skill sets are required to serve the broad spectrum of end-of-life needs. We propose a comprehensive framework for evaluating PCNs, focusing on the nature and extent of inter-professional collaboration, community readiness, and client-centred care.
In the absence of an overarching structure for examining PCNs, a framework was developed based on previous models of health system evaluation, explicit theory, and the research literature relevant to PCN functioning. This research evidence was used to substantiate the choice of model factors.
The proposed framework takes a systems approach with system structure, process of care, and patient outcomes levels of consideration. Each factor represented makes an independent contribution to the description and assessment of the network.
Realizing palliative patients' needs for complex packages of treatment and social support, in a seamless, cost-effective manner, are major drivers of the impetus for network-integrated care. The framework proposed is a first step to guide evaluation to inform the development of appropriate strategies to further promote collaboration within the PCN and, ultimately, optimal palliative care that meets patients' needs and expectations.
PMCID: PMC2876145  PMID: 20459734
7.  Insights about the process and impact of implementing nursing guidelines on delivery of care in hospitals and community settings 
Little is known about the impact of implementing nursing-oriented best practice guidelines on the delivery of patient care in either hospital or community settings.
A naturalistic study with a prospective, before and after design documented the implementation of six newly developed nursing best practice guidelines (asthma, breastfeeding, delirium-dementia-depression (DDD), foot complications in diabetes, smoking cessation and venous leg ulcers). Eleven health care organisations were selected for a one-year project. At each site, clinical resource nurses (CRNs) worked with managers and a multidisciplinary steering committee to conduct an environmental scan and develop an action plan of activities (i.e. education sessions, policy review). Process and patient outcomes were assessed by chart audit (n = 681 pre-implementation, 592 post-implementation). Outcomes were also assessed for four of six topics by in-hospital/home interviews (n = 261 pre-implementation, 232 post-implementation) and follow-up telephone interviews (n = 152 pre, 121 post). Interviews were conducted with 83/95 (87%) CRN's, nurses and administrators to describe recommendations selected, strategies used and participants' perceived facilitators and barriers to guideline implementation.
While statistically significant improvements in 5% to 83% of indicators were observed in each organization, more than 80% of indicators for breastfeeding, DDD and smoking cessation did not change. Statistically significant improvements were found in > 50% of indicators for asthma (52%), diabetes foot care (83%) and venous leg ulcers (60%). Organizations with > 50% improvements reported two unique implementation strategies which included hands-on skill practice sessions for nurses and the development of new patient education materials. Key facilitators for all organizations included education sessions as well as support from champions and managers while key barriers were lack of time, workload pressure and staff resistance.
Implementation of nursing best practice guidelines can result in improved practice and patient outcomes across diverse settings yet many indicators remained unchanged. Mobilization of the nursing workforce to actively implement guidelines and to monitor the delivery of their care is important so that patients may learn about and receive recommended healthcare.
PMCID: PMC2279128  PMID: 18241349
8.  Implementing nursing best practice guidelines: Impact on patient referrals 
BMC Nursing  2007;6:4.
Although referring patients to community services is important for optimum continuity of care, referrals between hospital and community sectors are often problematic. Nurses are well positioned to inform patients about referral resources. The objective of this study is to describe the impact of implementing six nursing best practice guidelines (BPGs) on nurses' familiarity with patient referral resources and referral practices.
A prospective before and after design was used. For each BPG topic, referral resources were identified. Information about these resources was presented at education sessions for nurses. Pre- and post-questionnaires were completed by a random sample of 257 nurses at 7 hospitals, 2 home visiting nursing services and 1 public health unit. Average response rates for pre- and post-implementation questionnaires were 71% and 54.2%, respectively. Chart audits were completed for three BPGs (n = 421 pre- and 332 post-implementation). Post-hospital discharge patient interviews were conducted for four BPGs (n = 152 pre- and 124 post-implementation).
There were statistically significant increases in nurses' familiarity with resources for all BPGs, and self-reported referrals to specific services for three guidelines. Higher rates of referrals were observed for services that were part of the organization where the nurses worked. There was almost a complete lack of referrals to Internet sources. No significant differences between pre- and post-implementation referrals rates were observed in the chart documentation or in patients' reports of referrals.
Implementing nursing BPGs, which included recommendations on patient referrals produced mixed results. Nurses' familiarity with referral resources does not necessarily change their referral practices. Nurses can play a vital role in initiating and supporting appropriate patient referrals. BPGs should include specific recommendations on effective referral processes and this information should be tailored to the community setting where implementation is taking place.
PMCID: PMC1947981  PMID: 17598917
9.  Effectiveness of preventive primary care outreach interventions aimed at older people 
Canadian Family Physician  2005;51(9):1245.
To determine the effectiveness of preventive primary care outreach interventions aimed at older people. Knowing whether such interventions are effective could help busy family physicians make choices about which preventive care services to provide.
We searched MEDLINE, CINAHL, AgeLine, Cochrane Controlled Trials Register, and EMBASE databases and reviewed the reference lists of retrieved articles.
We included studies of preventive primary care interventions aimed at patients 65 years and older if the studies were randomized controlled trials and if any of the following outcomes was reported: mortality, living in the community, admission to acute care hospitals, and admission to long-term care. We defined preventive primary care outreach as proactive, provider-initiated care, which can be provided by nurses, physicians, other professionals, or volunteers, that is in addition to usual care and is provided in primary care settings. Such care can be provided through home visits, office visits, telephone contacts, or a combination of these methods.
We assessed the quality of studies and extracted descriptive information on study populations, interventions, and outcomes for 19 trials involving 14 911 patients. Summary odds ratios were estimated for each outcome using a random effects model.
This review showed that studies of preventive primary care outreach interventions aimed at older people were associated with a 17% reduction of mortality and a 23% increased likelihood of continuing to live in the community.
PMCID: PMC1479461  PMID: 16926937
10.  Effect of preventive primary care outreach on health related quality of life among older adults at risk of functional decline: randomised controlled trial 
Objective To evaluate the impact of a provider initiated primary care outreach intervention compared with usual care among older adults at risk of functional decline.
Design Randomised controlled trial.
Setting Patients enrolled with 35 family physicians in five primary care networks in Hamilton, Ontario, Canada.
Participants Patients were eligible if they were 75 years of age or older and were not receiving home care services. Of 3166 potentially eligible patients, 2662 (84%) completed the validated postal questionnaire used to determine risk of functional decline. Of 1724 patients who met the risk criteria, 769 (45%) agreed to participate and 719 were randomised.
Intervention The 12 month intervention, provided by experienced home care nurses in 2004-6, consisted of a comprehensive initial assessment using the resident assessment instrument for home care; collaborative care planning with patients, their families, and family physicians; health promotion; and referral to community health and social support services.
Main outcome measures Quality adjusted life years (QALYs), use and costs of health and social services, functional status, self rated health, and mortality.
Results The mean difference in QALYs between intervention and control patients during the study period was not statistically significant (0.017, 95% confidence interval −0.022 to 0.056; P=0.388). The mean difference in overall cost of prescription drugs and services between the intervention and control groups was not statistically significant, (−$C165 (£107; €118; $162), 95% confidence interval −$C16 545 to $C16 214; P=0.984). Changes over 12 months in functional status and self rated health were not significantly different between the intervention and control groups. Ten patients died in each group.
Conclusions The results of this study do not support adoption of this preventive primary care intervention for this target population of high risk older adults.
Trial registration Clinical trials NCT00134836.
PMCID: PMC3191725  PMID: 20400483
11.  Measuring the Effectiveness of Mentoring as a Knowledge Translation Intervention for Implementing Empirical Evidence: A Systematic Review 
Mentoring as a knowledge translation (KT) intervention uses social influence among healthcare professionals to increase use of evidence in clinical practice.
To determine the effectiveness of mentoring as a KT intervention designed to increase healthcare professionals’ use of evidence in clinical practice.
A systematic review was conducted using electronic databases (i.e., MEDLINE, CINAHL), grey literature, and hand searching. Eligible studies evaluated mentoring of healthcare professionals responsible for patient care to enhance the uptake of evidence into practice. Mentoring is defined as (a) a mentor more experienced than mentee; (b) individualized support based on mentee's needs; and (c) involved in an interpersonal relationship as indicated by mutual benefit, engagement, and commitment. Two reviewers independently screened citations for eligibility, extracted data, and appraised quality of studies. Data were analyzed descriptively.
Of 10,669 citations from 1988 to 2012, 10 studies were eligible. Mentoring as a KT intervention was evaluated in Canada, USA, and Australia. Exposure to mentoring compared to no mentoring improved some behavioral outcomes (one study). Compared to controls or other multifaceted interventions, multifaceted interventions with mentoring improved practitioners’ knowledge (four of five studies), beliefs (four of six studies), and impact on organizational outcomes (three of four studies). There were mixed findings for changes in professionals’ behaviors and impact on practitioners’ and patients’ outcomes: some outcomes improved, while others showed no difference.
Linking Evidence to Action
Only one study evaluated the effectiveness of mentoring alone as a KT intervention and showed improvement in some behavioral outcomes. The other nine studies that evaluated the effectiveness of mentoring as part of a multifaceted intervention showed mixed findings, making it difficult to determine the added effect of mentoring. Further research is needed to identify effective mentoring as a KT intervention.
PMCID: PMC4285206  PMID: 25252002
evidence-based practice; mentorship; outcome evaluation; professional issues/professional ethics/professional standards; advanced practice/advanced nursing practice; meta-analysis

Results 1-11 (11)