Browsing by Author "Hoben, Matthias"
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Item Open Access Adult day programs and their effects on individuals with dementia and their caregivers (ADAPT-DemCare): a realist synthesis to develop program theories on the how and why(2024-10-23) Nguyen, Hung; Rahman, Atiqur; Ubell, Andrea; Goodarzi, Zahra; Maxwell, Colleen J.; Allana, Saleema; Tate, Kaitlyn; Symonds-Brown, Holly; Weeks, Lori; Caspar, Sienna; Mann, Jim; Hoben, MatthiasAbstract Background Adult day programs aim to facilitate aging in place by supporting the health and well-being of persons with dementia and providing respite to their caregivers. However, studies on the effects of day programs are inconclusive, and we especially lack insights into the context conditions and mechanisms of day programs that may produce different outcomes for different groups of persons with dementia and their caregivers. Our objective was to conduct a realist review, synthesizing research on day programs to develop program theories explaining how and why day programs do or do not produce positive or negative outcomes for different groups of persons with dementia, and caregivers. Methods We identified 14 literature reviews (including 329 references published between 1975 and 2021) on adult day programs. From this initial pool of studies, we will include those that focused on day program attendees with dementia or meaningful cognitive impairment, and/or their caregivers, and that report how day program contexts (C) and mechanisms (M) bring about outcomes (O) for attendees and caregivers. We will extract CMO statements (i.e., narratives that explain how and why day programs do or do not bring about certain outcomes for whom and under what circumstances). Using additional focused searches, citation mapping, citation tracking, and discussions with our researcher and expert team members, we will identify additional references. CMO statements will be synthesized, transformed into hypotheses, and linked and visualized to form program theories. Using focus groups and the James Lind Alliance Priority Setting Partnership method, we will discuss and prioritize our CMO statements and refine our program theories with 32 experts (older adults, caregivers, Alzheimer societies, caregiver organizations, day program staff and managers, and health system and policy decision makers). Discussion By identifying essential elements and processes of day programs and related knowledge gaps, this study will generate much-needed knowledge to leverage the full potential of day programs so they can provide appropriate care, preventing premature institutionalization, and unnecessary acute and primary care use. This will ultimately improve the quality of life of persons with dementia and their caregivers, alleviate caregiver burden, and reduce social costs. Systematic review registration PROSPERO CRD42024504030Item Open Access Associations between specialized dementia care, COVID-19 and central nervous system medication use in assisted living: a population-based repeated cross-sectional study(2024-08-14) Maxwell, Colleen J.; Dampf, Hana; Squires, Jillian P.; Hogan, David B.; Cotton, Cecilia A.; MMath, Erik Y.; Hsu, Zoe; Hoben, MatthiasAbstract Background Assisted living (AL) is an increasingly common residential setting for persons with dementia; yet concerns exist about sub-optimal care of this population in AL given its lower levels of staffing and services. Our objectives were to (i) examine associations between AL setting (dementia care vs. other), COVID-19 pandemic waves, and prevalent antipsychotic, antidepressant, anti-dementia, benzodiazepine, and anticonvulsant drug use among residents with dementia/cognitive impairment, and (ii) explore associations between resident and home characteristics and prevalent medication use. Methods We conducted a population-based, repeated cross-sectional study using linked clinical and health administrative databases for all publicly funded AL homes in Alberta, Canada, examined between January 2018 - December 2021. The quarterly proportion of residents dispensed a study medication was examined for each setting and period (pandemic vs. comparable historical [2018/2019 combined]) focusing on four pandemic waves (March-May 2020, September 2020-February 2021, March-May 2021, September-December 2021). Log-binomial GEE models estimated prevalence ratios (PR) for period (pandemic vs. historical periods), setting (dementia care vs. other) and period-setting interactions, adjusting for resident (age, sex) and home (COVID-19 cases, health region, ownership) characteristics. Results On March 1, 2020, there were 2,779 dementia care and 3,013 other AL residents (mean age 83, 69% female) with dementia/cognitive impairment. Antipsychotic use increased during waves 2–4 in both settings, but this was more pronounced in dementia care than other AL during waves 3 and 4 (e.g., adjusted [adj]PR 1.20, 95% CI 1.14–1.27 vs. adjPR 1.09, 95% CI 1.02–1.17, interaction p = 0.023, wave 3). Both settings showed a statistically significant but modest increase in antidepressant use and decrease in benzodiazepine use. For dementia care AL residents only, there was a statistically significant increase in gabapentinoid use during several waves (e.g., adjPR 1.32, 95% CI 1.10–1.59, wave 3). Other than a modest decrease in prevalent anti-dementia drug use for both settings in wave 2, no other significant pandemic effects were observed. Conclusions The persistence of the pandemic-associated increase in antipsychotic and antidepressant use in AL residents coupled with a greater increase in antipsychotic and gabapentinoid use for dementia care settings raises concerns about the attendant risks for residents with cognitive impairment.Item Open Access Comparing effects of two higher intensity feedback interventions with simple feedback on improving staff communication in nursing homes—the INFORM cluster-randomized controlled trial(2020-09-10) Hoben, Matthias; Ginsburg, Liane R; Easterbrook, Adam; Norton, Peter G; Anderson, Ruth A; Andersen, Elizabeth A; Boström, Anne-Marie; Cranley, Lisa A; Lanham, Holly J; Weeks, Lori E; Cummings, Greta G; Holroyd-Leduc, Jayna M; Squires, Janet E; Wagg, Adrian S; Estabrooks, Carole AAbstract Background Effective communication among interdisciplinary healthcare teams is essential for quality healthcare, especially in nursing homes (NHs). Care aides provide most direct care in NHs, yet are rarely included in formal communications about resident care (e.g., change of shift reports, family conferences). Audit and feedback is a potentially effective improvement intervention. This study compares the effect of simple and two higher intensity levels of feedback based on goal-setting theory on improving formal staff communication in NHs. Methods This pragmatic three-arm parallel cluster-randomized controlled trial included NHs participating in TREC (translating research in elder care) across the Canadian provinces of Alberta and British Columbia. Facilities with at least one care unit with 10 or more care aide responses on the TREC baseline survey were eligible. At baseline, 4641 care aides and 1693 nurses cared for 8766 residents in 67 eligible NHs. NHs were randomly allocated to a simple (control) group (22 homes, 60 care units) or one of two higher intensity feedback intervention groups (based on goal-setting theory): basic assisted feedback (22 homes, 69 care units) and enhanced assisted feedback 2 (23 homes, 72 care units). Our primary outcome was the amount of formal communication about resident care that involved care aides, measured by the Alberta Context Tool and presented as adjusted mean differences [95% confidence interval] between study arms at 12-month follow-up. Results Baseline and follow-up data were available for 20 homes (57 care units, 751 care aides, 2428 residents) in the control group, 19 homes (61 care units, 836 care aides, 2387 residents) in the basic group, and 14 homes (45 care units, 615 care aides, 1584 residents) in the enhanced group. Compared to simple feedback, care aide involvement in formal communications at follow-up was 0.17 points higher in both the basic ([0.03; 0.32], p = 0.021) and enhanced groups ([0.01; 0.33], p = 0.035). We found no difference in this outcome between the two higher intensity groups. Conclusions Theoretically informed feedback was superior to simple feedback in improving care aides’ involvement in formal communications about resident care. This underlines that prior estimates for efficacy of audit and feedback may be constrained by the type of feedback intervention tested. Trial registration ClinicalTrials.gov ( NCT02695836 ), registered on March 1, 2016Item Open Access Conceptual and relational advances of the PARIHS and i-PARIHS frameworks over the last decade: a critical interpretive synthesis(2022-12-07) Duan, Yinfei; Iaconi, Alba; Wang, Jing; Perez, Janelle S.; Song, Yuting; Chamberlain, Stephanie A.; Shrestha, Shovana; Choroschun, Katharina; Hoben, Matthias; Beeber, Anna; Anderson, Ruth A.; Cummings, Greta G.; Lanham, Holly J.; Norton, Peter G.; Estabrooks, Carole A.; Berta, WhitneyAbstract Background The number of research publications reporting the use of the Promoting Action on Research Implementation in Health Services (PARIHS) framework and the integrated PARIHS (i-PARIHS) framework has grown steadily. We asked how the last decade of implementation research, predicated on the (i-)PARIHS framework (referring to the PARIHS or i-PARIHS framework), has contributed to our understanding of the conceptualizations of, relationships between, and dynamics among the core framework elements/sub-elements. Building on the Helfrich et al. (2010) review of research on the PARIHS framework, we undertook a critical interpretive synthesis to: (1) identify conceptual and relational advances in the (i-)PARIHS framework and (2) identify conceptual and relational aspects of the (i-)PARIHS framework that warrant further work. Methods We performed a systematic search in PubMed/PubMed Central, Ovid MEDLINE, CINAHL, JSTOR, SCOPUS, Web of Science, and PsycInfo. Articles were eligible for synthesis if they (a) were peer-reviewed articles, written in English, and published between January 2009 and December 2021, (b) applied the (i-)PARIHS framework explicitly to guide implementation research, and (c) made conceptual (expanding the conceptualization of core elements) and/or relational contributions (elaborating relationships among elements/sub-elements, or theorizing the relationships using empirical data). We used a critical interpretive synthesis approach to synthesize conceptual-relational advances of the (i-)PARIHS framework. Results Thirty-seven articles were eligible for synthesis. Twenty-four offered conceptual contributions, and 18 offered relational contributions (5 articles contributed in both ways). We found conceptual expansion of all core (i-)PARIHS elements, with most emphasis on context (particularly outer context and leadership), facilitation, and implementation success. Articles also gave insights into the complex relationships and relational dynamism among these elements, characterized as contingent, interactive, multilevel, and temporal effects. Conclusions We observed developmental advances of the (i-)PARIHS framework and proposed several directions to further advance the framework. Conceptualization of (i-)PARIHS elements (particularly evidence/innovation and recipients) need to be further developed by specifying conceptual and operational definitions of underlying sub-elements. Relationships among (i-)PARIHS elements/sub-elements need to be further elaborated through empirical studies that consider situational contingencies and causal complexities. This will require examining necessity and sufficiency of (i-)PARIHS elements/sub-elements in relation to implementation outcomes, interactions among elements, and mechanism-based explanations.Item Open Access Depressive symptoms in long term care facilities in Western Canada: a cross sectional study(2019-12-02) Hoben, Matthias; Heninger, Abigail; Holroyd-Leduc, Jayna; Knopp-Sihota, Jennifer; Estabrooks, Carole; Goodarzi, ZahraAbstract Background The main objective is to better understand the prevalence of depressive symptoms, in long-term care (LTC) residents with or without cognitive impairment across Western Canada. Secondary objectives are to examine comorbidities and other factors associated with of depressive symptoms, and treatments used in LTC. Methods 11,445 residents across a random sample of 91 LTC facilities, from 09/2014 to 05/2015, were stratified by owner-operator model (private for-profit, public or voluntary not-for-profit), size (small: < 80 beds, medium: 80–120 beds, large > 120 beds), location (Calgary and Edmonton Health Zones, Alberta; Fraser and Interior Health Regions, British Columbia; Winnipeg Health Region, Manitoba). Random intercept generalized linear mixed models with depressive symptoms as the dependent variable, cognitive impairment as primary independent variable, and resident, care unit and facility characteristics as covariates were used. Resident variables came from the Resident Assessment Instrument – Minimum Data Set (RAI-MDS) 2.0 records (the RAI-MDS version routinely collected in Western Canadian LTC). Care unit and facility variables came from surveys completed with care unit or facility managers. Results Depressive symptoms affects 27.1% of all LTC residents and 23.3% of LTC resident have both, depressive symptoms and cognitive impairment. Hypertension, urinary and fecal incontinence were the most common comorbidities. Cognitive impairment increases the risk for depressive symptoms (adjusted odds ratio 1.65 [95% confidence interval 1.43; 1.90]). Pain, anxiety and pulmonary disorders were also significantly associated with depressive symptoms. Pharmacologic therapies were commonly used in those with depressive symptoms, however there was minimal use of non-pharmacologic management. Conclusions Depressive symptoms are common in LTC residents –particularly in those with cognitive impairment. Depressive symptoms are an important target for clinical intervention and further research to reduce the burden of these illnesses.Item Open Access Examining fidelity in the INFORM trial: a complex team-based behavioral intervention(2020-09-16) Ginsburg, Liane R; Hoben, Matthias; Easterbrook, Adam; Andersen, Elizabeth; Anderson, Ruth A; Cranley, Lisa; Lanham, Holly J; Norton, Peter G; Weeks, Lori E; Estabrooks, Carole AAbstract Background Fidelity in complex behavioral interventions is underexplored. This study examines the fidelity of the INFORM trial and explores the relationship between fidelity, study arm, and the trial’s primary outcome—care aide involvement in formal team communications about resident care. Methods A concurrent process evaluation of implementation fidelity was conducted in 33 nursing homes in Western Canada (Alberta and British Columbia). Study participants were from 106 clinical care units clustered in 33 nursing homes randomized to the Basic and Enhanced-Assisted Feedback arms of the INFORM trial. Results Fidelity of the INFORM intervention was moderate to high, with fidelity delivery and receipt higher than fidelity enactment for both study arms. Higher enactment teams experienced a significantly larger improvement in formal team communications between baseline and follow-up than lower enactment teams (F(1, 70) = 4.27, p = .042). Conclusions Overall fidelity enactment was associated with improvements in formal team communications, but the study arm was not. This suggests that the intensity with which an intervention is offered and delivered may be less important than the intensity with which intervention participants enact the core components of an intervention. Greater attention to fidelity assessment and publication of fidelity results through studies such as this one is critical to improving the utility of published trials.Item Open Access Exploring nursing home resident and their care partner priorities for care using the Action-Project Method(2023-03-08) Gruneir, Andrea; Hoben, Matthias; Easterbrook, Adam; Jensen, Charlotte; Buencamino, Monica; Tompalski, Jaclyn; Chamberlain, Stephanie A.; Ekhlas, Sadaf; Bever, Gillian; Murphy, Ruth; Estabrooks, Carole A.; Keefe, Janice; Marshall, SheilaAbstract Background Nursing home (NH) residents’ experiences are embedded within their relationships to others. Our objectives were to describe how residents and care partners (family or staff members) jointly construct, discuss, and act on care priorities. Methods We used Action-Project Method, a qualitative method focused on action within social context. We recruited 15 residents and 12 care partners (5 family and 7 staff members) from 3 urban NHs in Alberta, Canada. Residents and care partners participated in a video-recorded conversation about their experiences in the NH, then individually reviewed the video-recording to add context to the conversation. Following transcription, preliminary narrative construction, and participant feedback, the research team conducted in-depth analysis to identify participant actions, goals, and projects, including those jointly shared by dyad members. Results All participants’ intentions could be broadly described as “making time in the NH as good as possible” and projects were grouped into five categories: resident identity, relationships (both presence and absence), advocacy, positivity, and respectful care. Participants often raised issues of short-staffing as a significant barrier to respectful care. Care partners, especially staff, used positivity to redirect residents from difficult topics. Joint projects could be identified in some, but not all, cases. Conclusions We found that maintaining a sense of identity, fostering relationships, and receiving respectful care were important to residents but that short-staffing created barriers. Methods to capture these aspects of the resident experience are needed but should not be influenced by care partners’ tendency towards positivity in resident interactions.Item Open Access Fidelity is not easy! Challenges and guidelines for assessing fidelity in complex interventions(2021-05-29) Ginsburg, Liane R.; Hoben, Matthias; Easterbrook, Adam; Anderson, Ruth A.; Estabrooks, Carole A.; Norton, Peter G.Abstract Background Fidelity in complex behavioural interventions is underexplored and few comprehensive or detailed fidelity studies report on specific procedures for monitoring fidelity. Using Bellg’s popular Treatment Fidelity model, this paper aims to increase understanding of how to practically and comprehensively assess fidelity in complex, group-level, interventions. Approach and lessons learned Drawing on our experience using a mixed methods approach to assess fidelity in the INFORM study (Improving Nursing home care through Feedback On perfoRMance data—INFORM), we report on challenges and adaptations experienced with our fidelity assessment approach and lessons learned. Six fidelity assessment challenges were identified: (1) the need to develop succinct tools to measure fidelity given tools tend to be intervention specific, (2) determining which components of fidelity (delivery, receipt, enactment) to emphasize, (3) unit of analysis considerations in group-level interventions, (4) missing data problems, (5) how to respond to and treat fidelity ‘failures’ and ‘deviations’ and lack of an overall fidelity assessment scheme, and (6) ensuring fidelity assessment doesn’t threaten internal validity. Recommendations and conclusions Six guidelines, primarily applicable to group-level studies of complex interventions, are described to help address conceptual, methodological, and practical challenges with fidelity assessment in pragmatic trials. The current study offers guidance to researchers regarding key practical, methodological, and conceptual challenges associated with assessing fidelity in pragmatic trials. Greater attention to fidelity assessment and publication of fidelity results through detailed studies such as this one is critical for improving the quality of fidelity studies and, ultimately, the utility of published trials. Trial registration ClinicalTrials.gov NCT02695836. Registered on February 24, 2016Item Open Access How context links to best practice use in long-term care homes: a mixed methods study(2024-06-07) Duan, Yinfei; Wang, Jing; Lanham, Holly J.; Berta, Whitney; Chamberlain, Stephanie A.; Hoben, Matthias; Choroschun, Katharina; Iaconi, Alba; Song, Yuting; Perez, Janelle S.; Shrestha, Shovana; Beeber, Anna; Anderson, Ruth A.; Hayduk, Leslie; Cummings, Greta G.; Norton, Peter G.; Estabrooks, Carole A.Abstract Background Context (work environment) plays a crucial role in implementing evidence-based best practices within health care settings. Context is multi-faceted and its complex relationship with best practice use by care aides in long-term care (LTC) homes are understudied. This study used an innovative approach to investigate how context elements interrelate and influence best practice use by LTC care aides. Methods In this secondary analysis study, we combined coincidence analysis (a configurational comparative method) and qualitative analysis to examine data collected through the Translating Research in Elder Care (TREC) program. Coincidence analysis of clinical microsystem (care unit)-level data aggregated from a survey of 1,506 care aides across 36 Canadian LTC homes identified configurations (paths) of context elements linked consistently to care aides’ best practices use, measured with a scale of conceptual research use (CRU). Qualitative analysis of ethnographic case study data from 3 LTC homes (co-occurring with the survey) further informed interpretation of the configurations. Results Three paths led to very high CRU at the care unit level: very high leadership; frequent use of educational materials; or a combination of very high social capital (teamwork) and frequent communication between care aides and clinical educators or specialists. Conversely, 2 paths led to very low CRU, consisting of 3 context elements related to unfavorable conditions in relationships, resources, and formal learning opportunities. Our qualitative analysis provided insights into how specific context elements served as facilitators or barriers for best practices. This qualitative exploration was especially helpful in understanding 2 of the paths, illustrating the pivotal role of leadership and the function of teamwork in mitigating the negative impact of time constraints. Conclusions Our study deepens understanding of the complex interrelationships between context elements and their impact on the implementation of best practices in LTC homes. The findings underscore that there is no singular, universal bundle of context-related elements that enhance or hinder best practice use in LTC homes.Item Open Access Improving Nursing Home Care through Feedback On PerfoRMance Data (INFORM): Protocol for a cluster-randomized trial(2017-01-10) Hoben, Matthias; Norton, Peter G; Ginsburg, Liane R; Anderson, Ruth A; Cummings, Greta G; Lanham, Holly J; Squires, Janet E; Taylor, Deanne; Wagg, Adrian S; Estabrooks, Carole AAbstract Background Audit and feedback is effective in improving the quality of care. However, methods and results of international studies are heterogeneous, and studies have been criticized for a lack of systematic use of theory. In TREC (Translating Research in Elder Care), a longitudinal health services research program, we collect comprehensive data from care providers and residents in Canadian nursing homes to improve quality of care and life of residents, and quality of worklife of caregivers. The study aims are to a) systematically feed back TREC research data to nursing home care units, and b) compare the effectiveness of three different theory-based feedback strategies in improving performance within care units. Methods INFORM (Improving Nursing Home Care through Feedback On PerfoRMance Data) is a 3.5-year pragmatic, three-arm, parallel, cluster-randomized trial. We will randomize 67 Western Canadian nursing homes with 203 care units to the three study arms, a standard feedback strategy and two assisted and goal-directed feedback strategies. Interventions will target care unit managerial teams. They are based on theory and evidence related to audit and feedback, goal setting, complex adaptive systems, and empirical work on feeding back research results. The primary outcome is the increased number of formal interactions (e.g., resident rounds or family conferences) involving care aides – non-registered caregivers providing up to 80% of direct care. Secondary outcomes are a) other modifiable features of care unit context (improved feedback, social capital, slack time) b) care aides’ quality of worklife (improved psychological empowerment, job satisfaction), c) more use of best practices, and d) resident outcomes based on the Resident Assessment Instrument – Minimum Data Set 2.0. Outcomes will be assessed at baseline, immediately after the 12-month intervention period, and 18 months post intervention. Discussion INFORM is the first study to systematically assess the effectiveness of different strategies to feed back research data to nursing home care units in order to improve their performance. Results of this study will enable development of a practical, sustainable, effective, and cost-effective feedback strategy for routine use by managers, policy makers and researchers. The results may also be generalizable to care settings other than nursing homes. Trial registration ClinicalTrials.gov Identifier: NCT02695836 . Date of registration: 24 February 2016Item Open Access Prevalence and correlates of anxiety and depression in caregivers to assisted living residents during COVID-19: a cross-sectional study(2022-08-12) Lane, Natasha E.; Hoben, Matthias; Amuah, Joseph E.; Hogan, David B.; Baumbusch, Jennifer; Gruneir, Andrea; Chamberlain, Stephanie A.; Griffith, Lauren E.; McGrail, Kimberlyn M.; Corbett, Kyle; Maxwell, Colleen J.Abstract Background Family and friend caregivers play significant roles in advocating for and ensuring quality health and social care of residents in Assisted Living (AL) homes. However, little is known about how the COVID-19 pandemic and related visitor restrictions affected their health and mental well-being. We examined the prevalence and correlates of anxiety and depressive symptoms among caregivers of AL residents during the initial wave of COVID-19 in two Canadian provinces. Methods A cross-sectional web-based survey was conducted among family/friend caregivers of AL residents in Alberta and British Columbia (Oct 28, 2020—Mar 31, 2021) to collect data on their sociodemographic, health and caregiving characteristics, as well as concerns about residents’ health and social care before and during the first wave of the pandemic. A clinically significant anxiety disorder and depressive symptoms were assessed with the GAD-7 and CES-D10 instruments, respectively. Separate multivariable (modified) Poisson regression models identified caregiver correlates of each mental health condition. Results Among the 673 caregivers completing the survey (81% for Alberta residents), most were women (77%), white (90%) and aged ≥ 55 years (81%). Clinically significant anxiety and depression were present in 28.6% and 38.8% of caregivers respectively. Both personal stressors (comorbidity level, income reduction, low social support) and caregiving stressors exacerbated by the pandemic were independently associated with caregiver anxiety and depression. The latter included increased concern about the care recipients’ depression (adjusted risk ratio [adjRR] = 1.84, 95% confidence interval [CI] 1.19–2.85 for caregiver anxiety and adjRR = 1.75, 95% CI 1.26–2.44 for caregiver depressive symptoms) and reported intention to withdraw the resident from AL because of COVID-19 (adjRR = 1.24, 95%CI 0.95–1.63 for caregiver anxiety and adjRR = 1.37, 95%CI 1.13–1.67 for caregiver depressive symptoms). Conclusions Caregivers of residents in AL homes reported significant personal and caregiving-related stressors during the initial wave of COVID-19 that were independently associated with an increased likelihood of experiencing clinically significant anxiety and depressive symptoms. Healthcare providers and AL staff should be aware of the prevalence and varied correlates of caregivers’ mental health during public health crises so that appropriate screening and support may identified and implemented.Item Open Access Reporting unit context data to stakeholders in long-term care: a practical approach(2022-11-21) Cranley, Lisa A.; Lo, T K. T.; Weeks, Lori E.; Hoben, Matthias; Ginsburg, Liane R.; Doupe, Malcolm; Anderson, Ruth A.; Wagg, Adrian; Boström, Anne-Marie; Estabrooks, Carole A.; Norton, Peter G.Abstract Background The importance of reporting research evidence to stakeholders in ways that balance complexity and usability is well-documented. However, guidance for how to accomplish this is less clear. We describe a method of developing and visualising dimension-specific scores for organisational context (context rank method). We explore perspectives of leaders in long-term care nursing homes (NHs) on two methods for reporting organisational context data: context rank method and our traditionally presented binary method—more/less favourable context. Methods We used a multimethod design. First, we used survey data from 4065 healthcare aides on 290 care units from 91 NHs to calculate quartiles for each of the 10 Alberta Context Tool (ACT) dimension scores, aggregated at the care unit level based on the overall sample distribution of these scores. This ordinal variable was then summed across ACT scores. Context rank scores were assessed for associations with outcomes for NH staff and for quality of care (healthcare aides’ instrumental and conceptual research use, job satisfaction, rushed care, care left undone) using regression analyses. Second, we used a qualitative descriptive approach to elicit NH leaders’ perspectives on whether the methods were understandable, meaningful, relevant, and useful. With 16 leaders, we conducted focus groups between December 2017 and June 2018: one in Nova Scotia, one in Prince Edward Island, and one in Ontario, Canada. Data were analysed using content analysis. Results Composite scores generated using the context rank method had positive associations with healthcare aides’ instrumental research use (p < .0067) and conceptual research use and job satisfaction (p < .0001). Associations were negative between context rank summary scores and rushed care and care left undone (p < .0001). Overall, leaders indicated that data presented by both methods had value. They liked the binary method as a starting point but appreciated the greater level of detail in the context rank method. Conclusions We recommend careful selection of either the binary or context rank method based on purpose and audience. If a simple, high-level overview is the goal, the binary method has value. If improvement is the goal, the context rank method will give leaders more actionable details.Item Open Access Safer Care for Older Persons in (residential) Environments (SCOPE): a pragmatic controlled trial of a care aide-led quality improvement intervention(2023-03-29) Wagg, Adrian; Hoben, Matthias; Ginsburg, Liane; Doupe, Malcolm; Berta, Whitney; Song, Yuting; Norton, Peter; Knopp-Sihota, Jennifer; Estabrooks, CaroleAbstract Background The increased complexity of residents and increased needs for care in long-term care (LTC) have not been met with increased staffing. There remains a need to improve the quality of care for residents. Care aides, providers of the bulk of direct care, are well placed to contribute to quality improvement efforts but are often excluded from so doing. This study examined the effect of a facilitation intervention enabling care aides to lead quality improvement efforts and improve the use of evidence-informed best practices. The eventual goal was to improve both the quality of care for older residents in LTC homes and the engagement and empowerment of care aides in leading quality improvement efforts. Methods Intervention teams participated in a year-long facilitative intervention which supported care aide-led teams to test changes in care provision to residents using a combination of networking and QI education meetings, and quality advisor and senior leader support. This was a controlled trial with random selection of intervention clinical care units matched 1:1 post hoc with control units. The primary outcome, between group change in conceptual research use (CRU), was supplemented by secondary staff- and resident-level outcome measures. A power calculation based upon pilot data effect sizes resulted in a sample size of 25 intervention sites. Results The final sample included 32 intervention care units matched to 32 units in the control group. In an adjusted model, there was no statistically significant difference between intervention and control units for CRU or in secondary staff outcomes. Compared to baseline, resident-adjusted pain scores were statistically significantly reduced (less pain) in the intervention group (p=0.02). The level of resident dependency significantly decreased statistically for residents whose teams addressed mobility (p<0.0001) compared to baseline. Conclusions The Safer Care for Older Persons in (residential) Environments (SCOPE) intervention resulted in a smaller change in its primary outcome than initially expected resulting in a study underpowered to detect a difference. These findings should inform sample size calculations of future studies of this nature if using similar outcome measures. This study highlights the problem with measures drawn from current LTC databases to capture change in this population. Importantly, findings from the trial’s concurrent process evaluation provide important insights into interpretation of main trial data, highlight the need for such evaluations of complex trials, and suggest the need to consider more broadly what constitutes “success” in complex interventions. Trial registration ClinicalTrials.gov , NCT03426072, registered August 02, 2018, first participant site April, 05, 2018.Item Open Access SCOPEOUT: sustainability and spread of quality improvement activities in long-term care- a mixed methods approach(2018-03-12) Cranley, Lisa A; Hoben, Matthias; Yeung, Jasper; Estabrooks, Carole A; Norton, Peter G; Wagg, AdrianAbstract Background Interventions to improve quality of care for residents of long-term care facilities, and to examine the sustainability and spread of such initiatives, remain a top research priority. The purpose of this exploratory study was to assess the extent to which activities initiated in a quality improvement (QI) collaborative study using care aide led teams were sustained or spread following cessation of the initial project and to identify factors that led to its success. Methods This study used an exploratory mixed methods study design and was conducted in seven residential long-term care facilities in two Canadian provinces. Sustainability and spread of QI activities were assessed by a questionnaire over five time points for 18 months following the collaborative study with staff from both intervention with non-intervention units. Semi-structured interviews were conducted with care managers at six and 12 months. QI team success in applying the QI model was ranked as high, medium, or low using criteria developed by the research team. Descriptive statistics, bivariate analyses, and General Estimating Equations were used to analyze the data. Interview data were analyzed using thematic analysis. Results In total, 683 surveys were received over the five time periods from 476 unique individuals on a facility unit. Seven managers were interviewed. A total of 533 surveys were analyzed. While both intervention and non-intervention units experienced a decline over time in all outcome measures, this decline was significantly less pronounced on intervention units. Facilities with medium and high success ranking had significantly higher scores in all four outcomes than facilities with a low success ranking. Care aides reported significantly less involvement of others in QI activities, less empowerment and less satisfaction with the quality of their work life than regulated care providers. Manager interviews provided evidence of sustainability of QI activities on the intervention units in four of the seven facilities up to 18 months following the intervention and demonstrated the need for continued staff and leadership engagement. Conclusion Sustainability of a QI project which empowers and engages care aides is possible and achievable, but requires ongoing staff and leadership engagement.Item Open Access Sustained effects of the INFORM cluster randomized trial: an observational post-intervention study(2021-08-23) Hoben, Matthias; Ginsburg, Liane R.; Norton, Peter G.; Doupe, Malcolm B.; Berta, Whitney B.; Dearing, James W.; Keefe, Janice M.; Estabrooks, Carole A.Abstract Background Numerous studies have examined the efficacy and effectiveness of health services interventions. However, much less research is available on the sustainability of study outcomes. The purpose of this study was to assess the lasting benefits of INFORM (Improving Nursing Home Care Through Feedback On perfoRMance data) and associated factors 2.5 years after removal of study supports. INFORM was a complex, theory-based, three-arm, parallel cluster-randomized trial. In 2015–2016, we successfully implemented two theory-based feedback strategies (compared to a simple feedback approach) to increase nursing home (NH) care aides’ involvement in formal communications about resident care. Methods Sustainability analyses included 51 Western Canadian NHs that had been randomly allocated to a simple and two assisted feedback interventions in INFORM. We measured care aide involvement in formal interactions (e.g., resident rounds, family conferences) and other study outcomes at baseline (T1, 09/2014-05/2015), post-intervention (T2, 01/2017-12/2017), and long-term follow-up (T3, 06/2019–03/2020). Using repeated measures, hierarchical mixed models, adjusted for care aide, care unit, and facility variables, we assess sustainability and associated factors: organizational context (leadership, culture, evaluation) and fidelity of the original INFORM intervention. Results We analyzed data from 18 NHs (46 units, 529 care aides) in simple feedback, 19 NHs (60 units, 731 care aides) in basic assisted feedback, and 14 homes (41 units, 537 care aides) in enhanced assisted feedback. T2 (post-intervention) scores remained stable at T3 in the two enhanced feedback arms, indicating sustainability. In the simple feedback group, where scores were had remained lower than in the enhanced groups during the intervention, T3 scores rose to the level of the two enhanced feedback groups. Better culture (β = 0.099, 95% confidence interval [CI] 0.005; 0.192), evaluation (β = 0.273, 95% CI 0.196; 0.351), and fidelity enactment (β = 0.290, 95% CI 0.196; 0.384) increased care aide involvement in formal interactions at T3. Conclusions Theory-informed feedback provides long-lasting improvement in care aides’ involvement in formal communications about resident care. Greater intervention intensity neither implies greater effectiveness nor sustainability. Modifiable context elements and fidelity enactment during the intervention period may facilitate sustained improvement, warranting further study—as does possible post-intervention spread of our intervention to simple feedback homes.Item Open Access Sustainment, Sustainability, and Spread Study (SSaSSy): protocol for a study of factors that contribute to the sustainment, sustainability, and spread of practice changes introduced through an evidence-based quality-improvement intervention in Canadian nursing homes(2019-12-19) Berta, Whitney B; Wagg, Adrian; Cranley, Lisa; Doupe, Malcolm B; Ginsburg, Liane; Hoben, Matthias; MacEachern, Lauren; Chamberlain, Stephanie; Clement, Fiona; Easterbrook, Adam; Keefe, Janice M; Knopp-Sihota, Jennifer; Rappon, Tim; Reid, Colin; Song, Yuting; Estabrooks, Carole AAbstract Background Implementation scientists and practitioners, alike, recognize the importance of sustaining practice change, however post-implementation studies of interventions are rare. This is a protocol for the Sustainment, Sustainability and Spread Study (SSaSSy). The purpose of this study is to contribute to knowledge on the sustainment (sustained use), sustainability (sustained benefits), and spread of evidence-based practice innovations in health care. Specifically, this is a post-implementation study of an evidence-informed, Care Aide-led, facilitation-based quality-improvement intervention called SCOPE (Safer Care for Older Persons (in long-term care) Environments). SCOPE has been implemented in nursing homes in the Canadian Provinces of Manitoba (MB), Alberta (AB) and British Columbia (BC). Our study has three aims: (i) to determine the role that adaptation/contextualization plays in sustainment, sustainability and spread of the SCOPE intervention; (ii) to study the relative effects on sustainment, sustainability and intra-organizational spread of high-intensity and low-intensity post-implementation “boosters”, and a “no booster” condition, and (iii) to compare the relative costs and impacts of each booster condition. Methods/design SSaSSy is a two-phase mixed methods study. The overarching design is convergent, with qualitative and quantitative data collected over a similar timeframe in each of the two phases, analyzed independently, then merged for analysis and interpretation. Phase 1 is a pilot involving up to 7 units in 7 MB nursing homes in which SCOPE was piloted in 2016 to 2017, in preparation for phase 2. Phase 2 will comprise a quasi-experiment with two treatment groups of low- and high-intensity post-implementation “boosters”, and an untreated control group (no booster), using pretests and post-tests of the dependent variables relating to sustained care and management practices, and resident outcomes. Phase 2 will involve 31 trial sites in BC (17 units) and AB (14 units) nursing homes, where the SCOPE trial concluded in May 2019. Discussion This project stands to advance understanding of the factors that influence the sustainment of practice changes introduced through evidence-informed practice change interventions, and their associated sustainability. Findings will inform our understanding of the nature of the relationship of fidelity and adaptation to sustainment and sustainability, and afford insights into factors that influence the intra-organizational spread of practice changes introduced through complex interventions.