In recent years, improving the quality of care for nursing home residents has generated a considerable amount of attention. In response, quality indicators (QIs), based on available evidence and expert consensus, have been identified within the Resident Assessment Instrument – Minimum Data Set 2.0 (RAI-MDS 2.0), and validated as proxy measures for quality of nursing home care. We sought to identify practice sensitive QIs; that is, those QIs believed to be the most sensitive to clinical practice.
We enlisted two experts to review a list of 35 validated QIs and to select those that they believed to be the most sensitive to practice. We then asked separate groups of practicing physicians, nurses, and policy makers to (1) rank the items on the list for overall “practice sensitivity” and then, (2) to identify the domain to which the QI was most sensitive (nursing care, physician care, or policy maker).
After combining results of all three groups, pressure ulcers were identified as the most practice sensitive QI followed by worsening pain, physical restraint use, the use of antipsychotic medications without a diagnosis of psychosis, and indwelling catheters. When stratified by informant group, although the top five QIs stayed the same, the ranking of the 13 QIs differed by group.
In addition to identifying a reduced and manageable set of QIs for regular reporting, we believe that focusing on these 13 practice sensitive QIs provides both the greatest potential for improving resident function and slowing the trajectory of decline that most residents experience.
Nursing home; Performance measurement; RAI-MDS; Quality indicators
Organizational context is recognized as an important influence on the successful implementation of research by healthcare professionals. However, there is relatively little empirical evidence to support this widely held view.
The objective of this study was to identify dimensions of organizational context and individual (nurse) characteristics that influence pediatric nurses’ self-reported use of research. Data on research use, individual, and contextual variables were collected from registered nurses (N = 735) working on 32 medical, surgical and critical care units in eight Canadian pediatric hospitals using an online survey. We used Generalized Estimating Equation modeling to account for the correlated structure of the data and to identify which contextual dimensions and individual characteristics predict two kinds of self-reported research use: instrumental (direct) and conceptual (indirect).
Significant predictors of instrumental research use included: at the individual level; belief suspension-implement, research use in the past, and at the hospital unit (context) level; culture, and the proportion on nurses possessing a baccalaureate degree or higher. Significant predictors of conceptual research use included: at the individual nurse level; belief suspension-implement, problem solving ability, use of research in the past, and at the hospital unit (context) level; leadership, culture, evaluation, formal interactions, informal interactions, organizational slack-space, and unit specialty.
Hospitals, by focusing attention on modifiable elements of unit context may positively influence nurses’ reported use of research. This influence of context may extend to the adoption of best practices in general and other innovative or quality interventions.
There is emerging evidence that context is important for successful transfer of research knowledge into health care practice. The Alberta Context Tool (ACT) is a Canadian developed research-based instrument that assesses 10 modifiable concepts of organizational context considered important for health care professionals’ use of evidence. Swedish and Canadian health care have similarities in terms of organisational and professional aspects, suggesting that the ACT could be used for measuring context in Sweden. This paper reports on the translation of the ACT to Swedish and a testing of preliminary aspects of its validity, acceptability and reliability in Swedish elder care.
The ACT was translated into Swedish and back-translated into English before being pilot tested in ten elder care facilities for response processes validity, acceptability and reliability (Cronbach’s alpha). Subsequently, further modification was performed.
In the pilot test, the nurses found the questions easy to respond to (52%) and relevant (65%), yet the questions’ clarity were mainly considered ‘neither clear nor unclear’ (52%). Missing data varied between 0 (0%) and 19 (12%) per item, the most common being 1 missing case per item (15 items). Internal consistency (Cronbach’s Alpha > .70) was reached for 5 out of 8 contextual concepts. Translation and back translation identified 21 linguistic- and semantic related issues and 3 context related deviations, resolved by developers and translators.
Modifying an instrument is a detailed process, requiring time and consideration of the linguistic and semantic aspects of the instrument, and understanding of the context where the instrument was developed and where it is to be applied. A team, including the instrument’s developers, translators, and researchers is necessary to ensure a valid translation. This study suggests preliminary validity, reliability and acceptability evidence for the ACT when used with nurses in Swedish elder care.
Questionnaire; Translation; Validity; Health care context; Research utilization; Nursing
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.
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.
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.
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.
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.
Health information technologies; Mobile technology; Personal digital assistant; Nursing informatics; Information-seeking; Organizational context; Evidence-based practice; PARIHS model
Changes in health status, triggered by events such as infections, falls, and geriatric syndromes, are common among nursing home (NH) residents and necessitate transitions between NHs and Emergency Departments (EDs). During transitions, residents frequently experience care that is delayed, unnecessary, not evidence-based, potentially unsafe, and fragmented. Furthermore, a high proportion of residents and their family caregivers report substantial unmet needs during transitions. This study is part of a program of research whose overall aim is to improve quality of care for frail older adults who reside in NHs. The purpose of this study is to identify successful transitions from multiple perspectives and to identify organizational and individual factors related to transition success, in order to inform improvements in care for frail elderly NH residents during transitions to and from acute care. Specific objectives are to:
1. define successful and unsuccessful elements of transitions from multiple perspectives;
2. develop and test a practical tool to assess transition success;
3. assess transition processes in a discrete set of transfers in two study sites over a one year period;
4. assess the influence of organizational factors in key practice locations, e.g., NHs, emergency medical services (EMS), and EDs, on transition success; and
5. identify opportunities for evidence-informed management and quality improvement decisions related to the management of NH – ED transitions.
This is a mixed-methods observational study incorporating an integrated knowledge translation (IKT) approach. It uses data from multiple levels (facility, care unit, individual) and sources (healthcare providers, residents, health records, and administrative databases).
Key to study success is operationalizing the IKT approach by using a partnership model in which the OPTIC governance structure provides for team decision-makers and researchers to participate equally in developing study goals, design, data collection, analysis and implications of findings. As preliminary and ongoing study findings are developed, their implications for practice and policy in study settings will be discussed by the research team and shared with study site administrators and staff. The study is designed to investigate the complexities of transitions and to enhance the potential for successful and sustained improvement of these transitions.
Seniors; Elderly; Transitions; Quality of care; Handovers; Communications; Emergency Departments; Emergency Medical Services; Nursing homes; Measurement
Researchers strive to optimize data quality in order to ensure that study findings are valid and reliable. In this paper, we describe a data quality control program designed to maximize quality of survey data collected using computer-assisted personal interviews. The quality control program comprised three phases: (1) software development, (2) an interviewer quality control protocol, and (3) a data cleaning and processing protocol. To illustrate the value of the program, we assess its use in the Translating Research in Elder Care Study. We utilize data collected annually for two years from computer-assisted personal interviews with 3004 healthcare aides. Data quality was assessed using both survey and process data. Missing data and data errors were minimal. Mean and median values and standard deviations were within acceptable limits. Process data indicated that in only 3.4% and 4.0% of cases was the interviewer unable to conduct interviews in accordance with the details of the program. Interviewers' perceptions of interview quality also significantly improved between Years 1 and 2. While this data quality control program was demanding in terms of time and resources, we found that the benefits clearly outweighed the effort required to achieve high-quality data.
In Canada, healthcare aides (also referred to as nurse aides, personal support workers, nursing assistants) are unregulated personnel who provide 70-80% of direct care to residents living in nursing homes. Although they are an integral part of the care team their contributions to the resident care planning process are not always acknowledged in the organization. The purpose of the Safer Care for Older Persons [in residential] Environments (SCOPE) project was to evaluate the feasibility of engaging front line staff (primarily healthcare aides) to use quality improvement methods to integrate best practices into resident care. This paper describes the process used by teams participating in the SCOPE project to select clinical improvement areas.
The study employed a collaborative approach to identify clinical areas and through consensus, teams selected one of three areas. To select the clinical areas we recruited two nursing homes not involved in the SCOPE project and sampled healthcare providers and decision-makers within them. A vote counting method was used to determine the top five ranked clinical areas for improvement.
Responses received from stakeholder groups included gerontology experts, decision-makers, registered nurses, managers, and healthcare aides. The top ranked areas from highest to lowest were pain/discomfort management, behaviour management, depression, skin integrity, and assistance with eating.
Involving staff in selecting areas that they perceive as needing improvement may facilitate staff engagement in the quality improvement process.
Quality improvement; Healthcare providers; Quality care; Long-term care
Engaging end-users of research in the process of disseminating findings may increase the relevance of findings and their impact for users. We report findings from a case study that explored how involvement with the Translating Research in Elder Care (TREC) study influenced management and staff at one of 36 TREC facilities. We conducted the study at ‘Restwood’ (pseudonym) nursing home because the Director of Care engaged actively in the study and TREC data showed that this site differed on some areas from other nursing homes in the province. The aims of the case study were two-fold: to gain a better understanding of how frontline staff engage with the research process, and to gain a better understanding of how to share more detailed research results with management.
We developed an Expanded Feedback Report for use during this study. In it, we presented survey results that compared Restwood to the best performing site on all variables and participating sites in the province. Data were collected regarding the Expanded Feedback Report through interviews with management. Data from staff were collected through interviews and observation. We used content analysis to derive themes to describe key aspects related to the study aims.
We observed the importance of understanding organizational routines and the impact of key events in the facility’s environment. We gleaned additional information that validated findings from prior feedback mechanisms within TREC. Another predominant theme was the sense that the opportunity to engage in a research process was reaffirming for staff (particularly healthcare aides)—what they did and said mattered, and TREC provided a means of having one’s voice heard. We gained valuable insight from the Director of Care about how to structure and format more detailed findings to assist with interpretation and use of results.
Four themes emerged regarding staff engagement with the research process: sharing feedback reports from the TREC study; the meaning of TREC to staff; understanding organizational context; and using the study feedback for improvement at Restwood. This study has lessons for researchers on how to share research results with study participants, including management.
This report is an introduction to a series of three research papers that describe the evolution of the approaches taken by the Translating Research in Elder Care (TREC) research team during its first four years to feed back the research findings to study participants. TREC is an observational multi-method health services research project underway in 36 nursing homes in the prairie provinces of Canada. TREC has actively involved decision makers from the sector in all stages from initial planning, through data collection to dissemination activities. However, it was not planned as a fully integrated knowledge translation project. These three papers describe our progress towards fully integrated knowledge translation—with respect to timely and requested feedback processes. The first paper reports on the process and outcomes of creating and evaluating the feedback of research findings to healthcare aides (unregulated health professionals). These aides provide over 80% of the direct care in our sample and actively requested the feedback as a condition of their continued cooperation in the data acquisition process. The second paper describes feedback from nursing home administrators on preliminary research findings (a facility annual report) and evaluation of the reports’ utility. The third paper discusses an approach to providing a more in-depth form of feedback (expanded feedback report) at one of the TREC nursing homes.
Survey and interview feedback from healthcare aides is presented in the first paper. Overall, healthcare aides’ opinions about presentation of the feedback report and the understand ability, usability, and usefulness of the content were positive. The second paper describes the use of telephone interviews with facility administrators and indicates that the majority of contextual areas (e.g., staff job satisfaction) addressed in facility annual report to be useful, meaningful, and understandable. More than one-half of the administrators would have liked to have received information on additional areas. The third paper explores how a case study that examined how involvement with the TREC study influenced management and staff at one of the TREC nursing homes. The importance of understanding organizational routines and the impact of corporate restructuring were key themes emerging from the case study. In addition, the Director of Care suggested changes to the structure and format of the feedback report that would have improved its usefulness.
We believe that these findings will inform others undertaking integrated knowledge translation activities and will encourage others to become more engaged in feedback processes.
This project occurred during the course of the Translating Research in Elder Care (TREC) program of research. TREC is a multilevel and longitudinal research program being conducted in the three Canadian Prairie Provinces of Alberta, Saskatchewan, and Manitoba. The main purpose of TREC is to increase understanding about the role of organizational context in influencing knowledge use in residential long-term care settings. The purpose of this study was to evaluate healthcare aides’ (HCAs) perceptions of a one-page poster designed to feed back aggregated data (including demographic information and perceptions about influences on best practice) from the TREC survey they had recently completed.
A convenience sample of 7 of the 15 nursing homes participating in the TREC research program in Alberta were invited to participate. Specific facility-level summary data were provided to each facility in the form of a one-page poster report. Two weeks following delivery of the report, a convenience sample of HCAs was surveyed using one-to-one structured interviews.
One hundred twenty-three HCAs responded to the evaluation survey. Overall, HCAs’ opinions about presentation of the feedback report and the understandability, usability, and usefulness of the content were positive. For each report, analysis of data and production and inspection of the report took up to one hour. Information sessions to introduce and explain the reports averaged 18 minutes. Two feedback reports (minimum) were supplied to each facility at a cost of CAN$2.39 per report, for printing and laminating.
This study highlights not only the feasibility of producing understandable, usable, and useful feedback reports of survey data but also the value and importance of providing feedback to survey respondents. More broadly, the findings suggest that modest strategies may have a positive and desirable effect in participating sites.
This project is part of the Translating Research in Elder Care (TREC) program of research, a multi-level and longitudinal research program being conducted in 36 nursing homes in three Canadian Prairie Provinces. The overall goal of TREC is to improve the quality of care for older persons living in nursing homes and the quality of work life for care providers. The purpose of this paper is to report on development and evaluation of facility annual reports (FARs) from facility administrators’ perspectives on the usefulness, meaningfulness, and understandability of selected data from the TREC survey.
A cross sectional survey design was used in this study. The feedback reports were developed in collaboration with participating facility administrators. FARs presented results in four contextual areas: workplace culture, feedback processes, job satisfaction, and staff burnout. Six weeks after FARs were mailed to each administrator, we conducted structured telephone interviews with administrators to elicit their evaluation of the FARs. Administrators were also asked if they had taken any actions as a result of the FAR. Descriptive and inferential statistics, as well as content analysis for open-ended questions, were used to summarize findings.
Thirty-one facility administrators (representing thirty-two facilities) participated in the interviews. Six administrators had taken action and 18 were planning on taking action as a result of FARs. The majority found the four contextual areas addressed in FAR to be useful, meaningful, and understandable. They liked the comparisons made between data from years one and two and between their facility and other TREC study sites in their province. Twenty-two indicated that they would like to receive information on additional areas such as aggressive behaviours of residents and information sharing. Twenty-four administrators indicated that FARs contained enough information, while eight found FARs ‘too short’. Administrators who reported that the FAR contained enough information were more likely to take action within their facilities than administrators who reported that they needed more information.
Although the FAR was brief, the presentation of the four contextual areas was relevant to the majority of administrators and prompted them to plan or to take action within their facility.
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.
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.
Current Controlled Trials ISRCTN11598502.
Almost 90% of residents living in long-term care facilities have limited mobility which is associated with a loss of ability in activities of daily living, falls, increased risk of serious medical problems such as pressure ulcers, incontinence and a significant decline in health-related quality of life. For health workers caring for residents it may also increase the risk of injury. The effectiveness of rehabilitation to facilitate mobility has been studied with dedicated research assistants or extensively trained staff caregivers; however, few investigators have examined the effectiveness of techniques to encourage mobility by usual caregivers in long-term care facilities.
This longitudinal, quasi-experimental study is designed to demonstrate the effect of the sit-to-stand activity carried out by residents in the context of daily care with health care aides. In three intervention facilities health care aides will prompt residents to repeat the sit-to-stand action on two separate occasions during each day and each evening shift as part of daily care routines. In three control facilities residents will receive usual care. Intervention and control facilities are matched on the ownership model (public, private for-profit, voluntary not-for-profit) and facility size. The dose of the mobility intervention is assessed through the use of daily documentation flowsheets in the health record. Resident outcome measures include: 1) the 30-second sit-to-stand test; 2) the Functional Independence Measure; 3) the Health Utilities Index Mark 2 and 3; and, 4) the Quality of Life - Alzheimer's Disease.
There are several compelling reasons for this study: the widespread prevalence of limited mobility in this population; the rapid decline in mobility after admission to a long-term care facility; the importance of mobility to quality of life; the increased time (and therefore cost) required to care for residents with limited mobility; and, the increased risk of injury for health workers caring for residents who are unable to stand. The importance of these issues is magnified when considering the increasing number of people living in long-term care facilities and an aging population.
This clinical trial is registered with ClinicalTrials.gov (trial registration number: NCT01474616).
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.
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).
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.
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.
In healthcare, a gap exists between what is known from research and what is practiced. Understanding this gap depends upon our ability to robustly measure research utilization.
The objectives of this systematic review were: to identify self-report measures of research utilization used in healthcare, and to assess the psychometric properties (acceptability, reliability, and validity) of these measures.
We conducted a systematic review of literature reporting use or development of self-report research utilization measures. Our search included: multiple databases, ancestry searches, and a hand search. Acceptability was assessed by examining time to complete the measure and missing data rates. Our approach to reliability and validity assessment followed that outlined in the Standards for Educational and Psychological Testing.
Of 42,770 titles screened, 97 original studies (108 articles) were included in this review. The 97 studies reported on the use or development of 60 unique self-report research utilization measures. Seven of the measures were assessed in more than one study. Study samples consisted of healthcare providers (92 studies) and healthcare decision makers (5 studies). No studies reported data on acceptability of the measures. Reliability was reported in 32 (33%) of the studies, representing 13 of the 60 measures. Internal consistency (Cronbach's Alpha) reliability was reported in 31 studies; values exceeded 0.70 in 29 studies. Test-retest reliability was reported in 3 studies with Pearson's r coefficients > 0.80. No validity information was reported for 12 of the 60 measures. The remaining 48 measures were classified into a three-level validity hierarchy according to the number of validity sources reported in 50% or more of the studies using the measure. Level one measures (n = 6) reported evidence from any three (out of four possible) Standards validity sources (which, in the case of single item measures, was all applicable validity sources). Level two measures (n = 16) had evidence from any two validity sources, and level three measures (n = 26) from only one validity source.
This review reveals significant underdevelopment in the measurement of research utilization. Substantial methodological advances with respect to construct clarity, use of research utilization and related theory, use of measurement theory, and psychometric assessment are required. Also needed are improved reporting practices and the adoption of a more contemporary view of validity (i.e., the Standards) in future research utilization measurement studies.
Organizational context has the potential to influence the use of new knowledge. However, despite advances in understanding the theoretical base of organizational context, its measurement has not been adequately addressed, limiting our ability to quantify and assess context in healthcare settings and thus, advance development of contextual interventions to improve patient care. We developed the Alberta Context Tool (the ACT) to address this concern. It consists of 58 items representing 10 modifiable contextual concepts. We reported the initial validation of the ACT in 2009. This paper presents the second stage of the psychometric validation of the ACT.
We used the Standards for Educational and Psychological Testing to frame our validity assessment. Data from 645 English speaking healthcare aides from 25 urban residential long-term care facilities (nursing homes) in the three Canadian Prairie Provinces were used for this stage of validation. In this stage we focused on: (1) advanced aspects of internal structure (e.g., confirmatory factor analysis) and (2) relations with other variables validity evidence. To assess reliability and validity of scores obtained using the ACT we conducted: Cronbach's alpha, confirmatory factor analysis, analysis of variance, and tests of association. We also assessed the performance of the ACT when individual responses were aggregated to the care unit level, because the instrument was developed to obtain unit-level scores of context.
Item-total correlations exceeded acceptable standards (> 0.3) for the majority of items (51 of 58). We ran three confirmatory factor models. Model 1 (all ACT items) displayed unacceptable fit overall and for five specific items (1 item on adequate space for resident care in the Organizational Slack-Space ACT concept and 4 items on use of electronic resources in the Structural and Electronic Resources ACT concept). This prompted specification of two additional models. Model 2 used the 7 scaled ACT concepts while Model 3 used the 3 count-based ACT concepts. Both models displayed substantially improved fit in comparison to Model 1. Cronbach's alpha for the 10 ACT concepts ranged from 0.37 to 0.92 with 2 concepts performing below the commonly accepted standard of 0.70. Bivariate associations between the ACT concepts and instrumental research utilization levels (which the ACT should predict) were statistically significant at the 5% level for 8 of the 10 ACT concepts. The majority (8/10) of the ACT concepts also showed a statistically significant trend of increasing mean scores when arrayed across the lowest to the highest levels of instrumental research use.
The validation process in this study demonstrated additional empirical support for construct validity of the ACT, when completed by healthcare aides in nursing homes. The overall pattern of the data was consistent with the structure hypothesized in the development of the ACT and supports the ACT as an appropriate measure for assessing organizational context in nursing homes. Caution should be applied in using the one space and four electronic resource items that displayed misfit in this study with healthcare aides until further assessments are made.
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.
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.
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.
The current profile of residents living in Canadian nursing homes includes elder persons with complex physical and social needs. High resident acuity can result in increased staff workload and decreased quality of work life.
Safer Care for Older Persons [in residential] Environments is a two year (2010 to 2012) proof-of-principle pilot study conducted in seven nursing homes in western Canada. The purpose of the study is to evaluate the feasibility of engaging front line staff to use quality improvement methods to integrate best practices into resident care. The goals of the study are to improve the quality of work life for staff, in particular healthcare aides, and to improve residents' quality of life.
The study has parallel research and quality improvement intervention arms. It includes an education and support intervention for direct caregivers to improve the safety and quality of their care delivery. We hypothesize that this intervention will improve not only the care provided to residents but also the quality of work life for healthcare aides. The study employs tools adapted from the Institute for Healthcare Improvement's Breakthrough Series: Collaborative Model and Canada's Safer Healthcare Now! improvement campaign. Local improvement teams in each nursing home (1 to 2 per facility) are led by healthcare aides (non-regulated caregivers) and focus on the management of specific areas of resident care. Critical elements of the program include local measurement, virtual and face-to-face learning sessions involving change management, quality improvement methods and clinical expertise, ongoing virtual and in person support, and networking.
There are two sustainability challenges in this study: ongoing staff and leadership engagement, and organizational infrastructure. Addressing these challenges will require strategic planning with input from key stakeholders for sustaining quality improvement initiatives in the long-term care sector.
There is a lack of acceptable, reliable, and valid survey instruments to measure conceptual research utilization (CRU). In this study, we investigated the psychometric properties of a newly developed scale (the CRU Scale).
We used the Standards for Educational and Psychological Testing as a validation framework to assess four sources of validity evidence: content, response processes, internal structure, and relations to other variables. A panel of nine international research utilization experts performed a formal content validity assessment. To determine response process validity, we conducted a series of one-on-one scale administration sessions with 10 healthcare aides. Internal structure and relations to other variables validity was examined using CRU Scale response data from a sample of 707 healthcare aides working in 30 urban Canadian nursing homes. Principal components analysis and confirmatory factor analyses were conducted to determine internal structure. Relations to other variables were examined using: (1) bivariate correlations; (2) change in mean values of CRU with increasing levels of other kinds of research utilization; and (3) multivariate linear regression.
Content validity index scores for the five items ranged from 0.55 to 1.00. The principal components analysis predicted a 5-item 1-factor model. This was inconsistent with the findings from the confirmatory factor analysis, which showed best fit for a 4-item 1-factor model. Bivariate associations between CRU and other kinds of research utilization were statistically significant (p < 0.01) for the latent CRU scale score and all five CRU items. The CRU scale score was also shown to be significant predictor of overall research utilization in multivariate linear regression.
The CRU scale showed acceptable initial psychometric properties with respect to responses from healthcare aides in nursing homes. Based on our validity, reliability, and acceptability analyses, we recommend using a reduced (four-item) version of the CRU scale to yield sound assessments of CRU by healthcare aides. Refinement to the wording of one item is also needed. Planned future research will include: latent scale scoring, identification of variables that predict and are outcomes to conceptual research use, and longitudinal work to determine CRU Scale sensitivity to change.
Defining what constitutes a resident care unit in nursing home research is both a conceptual and practical challenge. The aim of this paper is to provide evidence in support of a definition of care unit in nursing homes by demonstrating: (1) its feasibility for use in data collection, (2) the acceptability of aggregating individual responses to the unit level, and (3) the benefit of including unit level data in explanatory models.
An observational study design was used. Research (project) managers, healthcare aides, care managers, nursing home administrators and directors of care from thirty-six nursing homes in the Canadian prairie provinces of Alberta, Saskatchewan and Manitoba provided data for the study. A definition of care unit was developed and applied in data collection and analyses. A debriefing session was held with research managers to investigate their experiences with using the care unit definition. In addition, survey responses from 1258 healthcare aides in 25 of the 36 nursing homes in the study, that had more than one care unit, were analyzed using a multi-level modeling approach. Trained field workers administered the Alberta Context Tool (ACT), a 58-item self-report survey reflecting 10 organizational context concepts, to healthcare aides using computer assisted personal interviews. To assess the appropriateness of obtaining unit level scores, we assessed aggregation statistics (ICC(1), ICC(2), η2, and ω2), and to assess the value of using the definition of unit in explanatory models, we performed multi-level modeling.
In 10 of the 36 nursing homes, the care unit definition developed was used to align the survey data (for analytic purposes) to specific care units as designated by our definition, from that reported by the facility administrator. The aggregation statistics supported aggregating the healthcare aide responses on the ACT to the realigned unit level. Findings from the multi-level modeling further supported unit level aggregation. A significantly higher percentage of variance was explained in the ACT concepts at the unit level compared to the individual and/or nursing home levels.
The statistical results support the use of our definition of care unit in nursing home research in the Canadian prairie provinces. Beyond research convenience however, the results also support the resident unit as an important Clinical Microsystem to which future interventions designed to improve resident quality of care and staff (healthcare aide) worklife should be targeted.
In the past forty years, many gains have been made in our understanding of the concept of research utilization. While numerous studies exist on professional nurses' use of research in practice, no attempt has been made to systematically evaluate and synthesize this body of literature with respect to the extent to which nurses use research in their clinical practice. The objective of this study was to systematically identify and analyze the available evidence related to the extent to which nurses use research findings in practice.
This study was a systematic review of published and grey literature. The search strategy included 13 online bibliographic databases: Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, EMBASE, HAPI, Web of Science, SCOPUS, OCLC Papers First, OCLC WorldCat, ABI Inform, Sociological Abstracts, and Dissertation Abstracts. The inclusion criteria consisted of primary research reports that assess professional nurses' use of research in practice, written in the English or Scandinavian languages. Extent of research use was determined by assigning research use scores reported in each article to one of four quartiles: low, moderate-low, moderate-high, or high.
Following removal of duplicate citations, a total of 12,418 titles were identified through database searches, of which 133 articles were retrieved. Of the articles retrieved, 55 satisfied the inclusion criteria. The 55 final reports included cross-sectional/survey (n = 51) and quasi-experimental (n = 4) designs. A sensitivity analysis, comparing findings from all reports with those rated moderate (moderate-weak and moderate-strong) and strong quality, did not show significant differences. In a majority of the articles identified (n = 38, 69%), nurses reported moderate-high research use.
According to this review, nurses' reported use of research is moderate-high and has remained relatively consistent over time until the early 2000's. This finding, however, may paint an overly optimistic picture of the extent to which nurses use research in their practice given the methodological problems inherent in the majority of studies. There is a clear need for the development of standard measures of research use and robust well-designed studies examining nurses' use of research and its impact on patient outcomes. The relatively unchanged self-reports of moderate-high research use by nurses is troubling given that over 40 years have elapsed since the first studies in this review were conducted and the increasing emphasis in the past 15 years on evidence-based practice. More troubling is the absence of studies in which attempts are made to assess the effects of varying levels of research use on patient outcomes.
Interventions that have a better than random chance of increasing nurses' use of research are important to the delivery of quality patient care. However, few reports exist of successful research utilization in nursing interventions. Systematic identification and evaluation of individual characteristics associated with and predicting research utilization may inform the development of research utilization interventions.
To update the evidence published in a previous systematic review on individual characteristics influencing research utilization by nurses.
As part of a larger systematic review on research utilization instruments, 12 online bibliographic databases were searched. Hand searching of specialized journals and an ancestry search was also conducted. Randomized controlled trials, clinical trials, and observational study designs examining the association between individual characteristics and nurses' use of research were eligible for inclusion. Studies were limited to those published in the English, Danish, Swedish, and Norwegian languages. A vote counting approach to data synthesis was taken.
A total of 42,770 titles were identified, of which 501 were retrieved. Of these 501 articles, 45 satisfied our inclusion criteria. Articles assessed research utilization in general (n = 39) or kinds of research utilization (n = 6) using self-report survey measures. Individual nurse characteristics were classified according to six categories: beliefs and attitudes, involvement in research activities, information seeking, education, professional characteristics, and socio-demographic/socio-economic characteristics. A seventh category, critical thinking, emerged in studies examining kinds of research utilization. Positive relationships, at statistically significant levels, for general research utilization were found in four categories: beliefs and attitudes, information seeking, education, and professional characteristics. The only characteristic assessed in a sufficient number of studies and with consistent findings for the kinds of research utilization was attitude towards research; this characteristic had a positive association with instrumental and overall research utilization.
This review reinforced conclusions in the previous review with respect to positive relationships between general research utilization and: beliefs and attitudes, and current role. Furthermore, attending conferences/in-services, having a graduate degree in nursing, working in a specialty area, and job satisfaction were also identified as individual characteristics important to research utilization. While these findings hold promise as potential targets of future research utilization interventions, there were methodological problems inherent in many of the studies that necessitate their findings be replicated in further research using more robust study designs and multivariate assessment methods.
Social networks are theorized as significant influences in the innovation adoption and behavior change processes. Our understanding of how social networks operate within healthcare settings is limited. As a result, our ability to design optimal interventions that employ social networks as a method of fostering planned behavior change is also limited. Through this proposed project, we expect to contribute new knowledge about factors influencing uptake of knowledge translation interventions.
Our specific aims include: To collect social network data among staff in two long-term care (LTC) facilities; to characterize social networks in these units; and to describe how social networks influence uptake and use of feedback reports.
Methods and design
In this prospective study, we will collect data on social networks in nursing units in two LTC facilities, and use social network analysis techniques to characterize and describe the networks. These data will be combined with data from a funded project to explore the impact of social networks on uptake and use of feedback reports. In this parent study, feedback reports using standardized resident assessment data are distributed on a monthly basis. Surveys are administered to assess report uptake. In the proposed project, we will collect data on social networks, analyzing the data using graphical and quantitative techniques. We will combine the social network data with survey data to assess the influence of social networks on uptake of feedback reports.
This study will contribute to understanding mechanisms for knowledge sharing among staff on units to permit more efficient and effective intervention design. A growing number of studies in the social network literature suggest that social networks can be studied not only as influences on knowledge translation, but also as possible mechanisms for fostering knowledge translation. This study will contribute to building theory to design such interventions.
Research utilization investigators have called for more focused examination of the influence of context on research utilization behaviors. Yet, up until recently, lack of instrumentation to identify and quantify aspects of organizational context that are integral to research use has significantly hampered these efforts. The Alberta Context Tool (ACT) was developed to assess the relationships between organizational factors and research utilization by a variety of healthcare professional groups. The purpose of this paper is to present findings from a pilot study using the ACT to elicit pediatric and neonatal healthcare professionals' perceptions of the organizational context in which they work and their use of research to inform practice. Specifically, we report on the relationship between dimensions of context, founded on the Promoting Action on Research Implementation in Health Services (PARIHS) framework, and self-reported research use behavior.
A cross-sectional survey approach was employed using a version of the ACT, modified specifically for pediatric settings. The survey was administered to nurses working in three pediatric units in Alberta, Canada. Scores for three dimensions of context (culture, leadership and evaluation) were used to categorize respondent data into one of four context groups (high, moderately high, moderately low and low). We then examined the relationships between nurses' self-reported research use and their perceived context.
A 69% response rate was achieved. Statistically significant differences in nurses' perceptions of culture, leadership and evaluation, and self-reported conceptual research use were found across the three units. Differences in instrumental research use across the three groups of nurses by unit were not significant. Higher self-reported instrumental and conceptual research use by all nurses in the sample was associated with more positive perceptions of their context.
Overall, the results of this study lend support to the view that more positive contexts are associated with higher reports of research use in practice. These findings have implications for organizational endeavors to promote evidence-informed practice and maximize the quality of care. Importantly, these findings can be used to guide the development of interventions to target modifiable characteristics of organizational context that are influential in shaping research use behavior.