Intervention research in highly unstable environments

Protocol for a multi-country implementation research study to assess the feasibility, acceptability, and effectiveness of context-specific actions to train and support facilitators to deliver sexuality education to young people in out-of-school settings

Comprehensive sexuality education (CSE) is a well-established component of the package of interventions required to improve adolescent sexual and reproductive health and rights. As the international community has increased its emphasis on equity and leaving no-one behind with the Agenda for Sustainable Development, attention has been drawn to the need for complementary CSE programmes to reach young people who are not in school, or whose needs are not met by in-school CSE programmes. CSE in out-of-school contexts presents unique considerations, especially those related to facilitation. In this manuscript, we present the protocol for a multi-country implementation research study in Colombia, Ethiopia, Ghana, and Malawi to assess the feasibility, acceptability, and effectiveness of context-specific actions to prepare and support facilitators to deliver CSE in out-of-school settings to defined groups of young people with varying needs and circumstances. This study will be led by the World Health Organization and the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, in partnership with local research institutions. It will be nested within a multi-country programme led by UNFPA, in partnership with local implementing partners and with financial support from the Government of Norway. This study will shed new insight into what it takes to effectively deliver CSE in out-of-school contexts, to enhance progress towards the achievement of SDG 3 "Ensure healthy lives and promote wellbeing for all at all ages" and SDG 5 "Achieve gender equality and empower all women and girls".

A Fresh Look at the Nursing Home Workforce Crisis: Transforming Nursing Care Delivery Models

The current State of the Science Commentary focuses on workforce challenges in the nursing home (NH) setting that lie within the purview of professional nursing-what professional nurses can do to promote high-quality person-centered care within a context of existing resources-individually and broadly across the collective profession. Historically, three models of care delivery have characterized the way in which nursing care is organized and delivered in different settings: primary nursing, functional nursing, and team nursing. Based on the existing evidence, we call for scientific leadership in the redesign, testing, and implementation of a nursing care delivery model that operationalizes relationship-centered team nursing. This integrative model incorporates successful evidence-based approaches that have the potential to improve quality of care, resident quality of life, and staff quality of work life: clear communication, staff empowerment, coaching styles of supervision, and family/care partner involvement in care processes. In addition to the needed evidence base for NH care delivery models, it is imperative that educational programs incorporate content and clinical experiences that will enable the future nursing workforce to fill the leadership gap in NH care delivery. [Research in Gerontological Nursing, 16(1), 5-13.].

Implementing cognitive remediation in substance use treatment: The impact of staff perceptions

Cognitive remediation (CR) programs are new to substance treatment and research needs to evaluate their implementation. The context of implementation, specifically staff perceptions, is critical to changing practice. The aim of this study was to identify treatment staff members' perceptions about the benefits and challenges of a new CR intervention in their workplace. The study conducted semi-structured interviews with staff at a residential substance treatment center when the CR program was first being implemented and again six months later. The study interviewed eight staff members in each round (>50% of staff members in the unit) from all role designations. A critical perspective shaped a thematic analysis of challenges to implementation. The study identified benefits of the CR program to clients and staff. However, only one staff member participated in training to deliver the program. In principle, staff members support the program, but this does not necessarily translate into active involvement, even when the study conducted staff engagement activities. CR programs are likely to improve functional outcomes for people in substance rehabilitation programs. However, this study suggests that staff accepting and valuing a new intervention is not enough to sustain it. For CR programs to be feasible, management should schedule and support staff training, and facilitate staff participation in that training. Organizational factors are likely to play a significant role in implementation success or failure, and further research should explore how the organizational culture of alcohol and other drug services impacts the implementation of CR therapy.

Effects of a person-centred and thriving-promoting intervention on nursing home staff job satisfaction: A multi-centre, non-equivalent controlled before-after study

Aim

To evaluate the effects of a person‐centred and thriving‐promoting intervention in nursing homes on staff job satisfaction, stress of conscience and the person‐centredness of care and of the environment.

Design

A multi‐centre, non‐equivalent control group, before–after trial design.

Methods

Staff (N = 341) from six nursing homes in Australia, Norway and Sweden were assigned to the intervention or the control group and both groups were evaluated before the intervention, immediately after and by 6 months follow‐up. Staff completed a questionnaire about job satisfaction (primary endpoint), stress of conscience and the person‐centredness of care and of the environment (secondary endpoints). Linear regression models were used to identify the mean scores and to analyse group differences to test the effects of the intervention.

Results

The intervention had no statistically significant effects on staff job satisfaction, level of stress of conscience or the perceived person‐centredness of care and of the environment.

A stepped wedge trial of efficacy and scalability of a virtual clinical pharmacy service (VCPS) in rural and remote NSW health facilities

Background

Medication errors are a leading cause of mortality and morbidity. Clinical pharmacy services provided in hospital can reduce medication errors and medication related harm. However, few rural or remote hospitals in Australia have a clinical pharmacy service. This study will evaluate a virtual clinical pharmacy service (VCPS) provided via telehealth to eight rural and remote hospitals in NSW, Australia.

Methods

A stepped wedge cluster randomised trial design will use routinely collected data from patients’ electronic medical records (n = 2080) to evaluate the VCPS at eight facilities. The sequence of steps is randomised, allowing for control of potential confounding temporal trends. Primary outcomes are number of medication reconciliations completed on admission and discharge. Secondary outcomes are length of stay, falls and 28 day readmissions. A cost-effectiveness analysis (CEA) and cost-benefit analysis (CBA) will be conducted. The CEA will answer the question of whether the VCPS is more cost-effective compared to treatment as usual; the CBA will consider the rate of return on investing in the VCPS. A patient experience measure (n = 500) and medication adherence questionnaire (n = 100 pre and post) will also be used to identify patient responses to the virtual service. Focus groups will investigate implementation from hospital staff perspectives at each site.

Analyses of routine data will comprise generalised linear mixed models. Descriptive statistical analysis will summarise patient experience responses. Differences in medication adherence will be compared using linear regression models. Thematic analysis of focus groups will identify barriers and facilitators to VCPS implementation.

Discussion

We aim to demonstrate the effectiveness of virtual pharmacy interventions for rural populations, and inform best practice for using virtual healthcare to improve access to pharmacy services. It is widely recognised that clinical pharmacists are best placed to reduce medication errors. However, pharmacy services are limited in rural and remote hospitals. This project will provide evidence about ways in which the benefits of hospital pharmacists can be maximised utilising telehealth technology. If successful, this project can provide a model for pharmacy delivery in rural and remote locations.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) -ACTRN12619001757101 Prospectively registered on 11 December 2019. Record available from: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378878&isReview=true

Conducting Clinical Research in Post-acute and Long-term Nursing Home Care Settings: Regulatory Challenges

Despite multiple initiatives in post-acute and long-term nursing home care settings (NHs) to improve the quality of care while reducing health care costs, research in NHs can prove challenging. Extensive regulation for both research and NHs is designed to protect a highly vulnerable population but can be a deterrent to conducting research. This article outlines regulatory challenges faced by NHs and researchers, such as protecting resident privacy as well as health information and obtaining informed consent. The article provides lessons learned to help form mutually beneficial partnerships between researchers and NHs to conduct studies that grow and advance NH research initiatives and clinical care.

Taking Another Look: Thoughts on Behavioral Symptoms in Dementia and Their Measurement

This article proposes taking another look at behavioral symptoms of dementia (BSDs) both from a theoretical perspective that informs research and practice and from a measurement perspective. We discuss why this rethinking of behaviors impacts current models of care and our ability to better detect outcomes from interventions. We propose that BSDs be viewed from a pattern perspective and provide some suggestions for how to identify and measure these patterns that can influence the timing and type of intervention. Evidence suggests that BSDs are complex, sequential, patterned clusters of behavior recurring repeatedly in the same individual and escalate significantly without timely intervention. However, BSDs are frequently viewed as separate behaviors rather than patterns or clusters of behaviors, a view that affects current research questions as well as the choice, timing, and outcomes of interventions. These symptoms cause immense distress to persons with the disease and their caregivers, trigger hospitalizations and nursing home placement, and are associated with increased care costs. Despite their universality and that symptoms manifest across disease etiologies and stages, behaviors tend to be underrecognized, undertreated, and overmanaged by pharmacological treatments that may pose more harm than benefit.

Challenges of conducting research in long-term care facilities: a systematic review

Background

The aim of this review is to describe the challenges and barriers to conducting research in long-term care facilities.

Methods

A literature search was conducted in Ovid MEDLINE, Embase, Cochrane Central, PsycINFO and CINAHL. Keywords used included “long term care”, “nursing home”, “research”, “trial”, “challenge” and “barrier”, etc. Resulting references were screened in order to identify relevant studies that reported on challenges derived from first-hand experience of empirical research studies. Challenges were summarized and synthesized.

Results

Of 1723 references, 39 articles were selected for inclusion. To facilitate understanding we proposed a classification framework of 8 main themes to categorize the research challenges presented in the 39 studies, relating to the characteristics of facility/owner/administrator, resident, staff caregiver, family caregiver, investigator, ethical or legal concerns, methodology, and budgetary considerations.

Conclusions

Conducting research in long-term care facilities is full of challenges which can be categorized into 8 main themes. Investigators should be aware of all these challenges and specifically address them when planning their studies. Stakeholders should be involved from an early stage and flexibility should be built into both the methodology and research budget.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0934-9) contains supplementary material, which is available to authorized users.

A theory-based hybrid II implementation intervention to improve pain management in Swiss nursing homes: A mixed-methods study protocol

AIM

To present a protocol for evaluating an implementation intervention to improve pain management in nursing homes by addressing behaviour change of the care workers.

BACKGROUND

Pain management in nursing homes often is inadequate despite the availability of evidence-based pain management guidelines. Barriers to pain management in nursing homes occur on several levels including lack of knowledge and negative beliefs towards pain of care workers. A comprehensive approach incorporating contextual and behavioural factors is needed to sustainably improve pain management practice.

DESIGN

A hybrid type II effectiveness-implementation design comprising an incomplete non-randomized stepped-wedge design and concurrent focus groups is proposed.

METHODS

A convenience sample of six nursing homes will be included. Implementation of a facility pain management policy will be facilitated by introduction of a facility pain champion and training of all care workers in pain assessment and management. Quantitative outcomes assessed at baseline, after 3 and 6 months include self-efficacy in pain management and attitudes to pain of care workers and functional interference from pain and pain intensity in residents. Feasibility and acceptability of the intervention and implementation strategies and potential barriers to implementation will be explored in focus groups and interviews. (Protocol approved in October 2017).

CONCLUSION

The proposed intervention implementation has been developed in a participatory approach involving relevant stakeholders. To further improve the contextual fit, development of implementation strategies was guided by the consolidated framework of implementation research. Findings of this research are expected to inform adaptions to the implementation of the intervention.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT03471390.

Advancing Innovation in Skilled Nursing Facilities through Academic Collaborations

There is growing recognition that acute hospitalization contributes to marked functional decline in older adult populations. Nearly 20% of all hospitalized older adults in the United States are discharged to skilled nursing facilities (SNFs) to address these functional deficits. However, current approaches to care in SNFs may not adequately restore function, which may contribute to low community discharge rates and high hospital readmission rates. Barriers to rehabilitation innovation in SNFs include management, staff, patient, and researcher-level factors. This clinical commentary builds upon clinical innovation strategies in other health care settings by describing barriers in the context of the SNF environment. Fostering collaboration between academic clinical researchers and SNFs may be the answer to advancing rehabilitation practices and care delivery, thereby improving outcomes in this vulnerable population.

Testing the evidence integration triangle for implementation of interventions to manage behavioral and psychological symptoms associated with dementia: Protocol for a pragmatic trial

Behavioral and psychological symptoms of dementia (BPSD) include aggression, agitation, resistiveness to care, depression, anxiety, apathy, and hallucinations. BPSD are common in nursing home residents and can be ameliorated using person-centered approaches. Despite regulatory requirements, less than 2% of nursing homes consistently implement person-centered behavioral approaches. In a National Institute of Nursing Research-funded research protocol, we are implementing a pragmatic cluster randomized clinical trial designed to enable staff in nursing homes to reduce BPSD using behavioral approaches while optimizing function, preventing adverse events, and improving quality of life of residents. The implementation is based on use of the Evidence Integration Triangle (EIT), a parsimonious, community-engaged participatory framework that is well suited to the complexity and variability in the nursing home environment. A total of 50 nursing home communities will be randomized to EIT-4-BPSD or education only. Primary Aim 1 is to determine if communities exposed to EIT-4-BPSD demonstrate evidence of implementation evaluated by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) criteria. Primary Aim 2 is to evaluate the feasibility, utility, and cost of the EIT approach in EIT-4-BPSD communities.

A randomized trial of heart failure disease management in skilled nursing facilities (SNF Connect): Lessons learned

BACKGROUND/AIMS

Conducting clinical trials in skilled nursing facilities is particularly challenging. This manuscript describes facility and patient recruitment challenges and solutions for clinical research in skilled nursing facilities.

METHODS

Lessons learned from the SNF Connect Trial, a randomized trial of a heart failure disease management versus usual care for patients with heart failure receiving post-acute care in skilled nursing facilities, are discussed. Description of the trial design and barriers to facility and patient recruitment along with regulatory issues are presented.

RESULTS

The recruitment of Denver-metro skilled nursing facilities was facilitated by key stakeholders of the skilled nursing facilities community. However, there were still a number of barriers to facility recruitment including leadership turnover, varying policies regarding research, fear of litigation and of an increased workload. Engagement of facilities was facilitated by their strong interest in reducing hospital readmissions, marketing potential to hospitals, and heart failure management education for their staff. Recruitment of patients proved difficult and there were few facilitators. Identified patient recruitment challenges included patients being unaware of their heart failure diagnosis, patients overwhelmed with their illness and care, and frequently there was no available proxy for cognitively impaired patients. Flexibility in changing the recruitment approach and targeting skilled nursing facilities with higher rates of admissions helped to overcome some barriers.

CONCLUSION

Recruitment of skilled nursing facilities and patients in skilled nursing facilities for clinical trials is challenging. Strategies to attract both facilities and patients are warranted. These include aligning study goals with facility incentives and flexible recruitment protocols to work with patients in "transition crisis."

Implementing a pressure ulcer prevention bundle in an adult intensive care

BACKGROUND

The incidence of pressure ulcers (PUs) in intensive care units (ICUs) is high and numerous strategies have been implemented to address this issue. One approach is the use of a PU prevention bundle. However, to ensure success care bundle implementation requires monitoring to evaluate the care bundle compliance rate, and to evaluate the effectiveness of implementation strategies in facilitating practice change.

AIMS

The aims of this study were to appraise the implementation of a series of high impact intervention care bundle components directed at preventing the development of PUs, within ICU, and to evaluate the effectiveness of strategies used to enhance the implementation compliance.

METHOD

An observational prospective study design was used. Implementation strategies included regular education, training, audit and feed-back and the presence of a champion in the ICU. Implementation compliance was measured along four time points using a compliance checklist.

RESULTS

Of the 60 registered nurses (RNs) working in the critical care setting, 11 participated in this study. Study participants demonstrated a high level of compliance towards the PU prevention bundle implementation (78.1%), with 100% participant acceptance. No significant differences were found between participants' demographic characteristics and the compliance score. There was a significant effect for time in the implementation compliance (Wilks Lambda=0.29, F (3, 8)=6.35, p<0.016), indicating that RNs needed time to become familiar with the bundle and routinely implement it into their practice. PU incidence was not influenced by the compliance level of participants.

CONCLUSION

The implementation strategies used showed a positive impact on compliance. Assessing and evaluating implementation compliance is critical to achieve a desired outcome (reduction in PU incidence). This study's findings also highlighted that while RNs needed time to familiarise themselves with the care bundle elements, their clinical practice was congruent with the bundle elements.

Mental Health Stress, Family Resources and Psychological Distress: A Longitudinal Mediation Analysis in African American Grandmothers Raising Grandchildren

OBJECTIVES

This study examines the effectiveness of a multidisciplinary intervention for African American grandmothers raising grandchildren on the relationship between dichotomized levels of mental health stress (low vs. high) and elevated levels of psychological distress, mediated by perceptions of family resources.

METHOD

A nonrandom sample of African American grandmothers (N = 679) was assessed to test the predictive relations among study constructs in the context of a prospective mediational model.

RESULTS

Perception of family resources contributes to lower psychological distress among custodial grandmothers exhibiting low and high levels of mental health stress. There was no significant difference in the strength of the mediated effects between the 2 mental health stress groups.

CONCLUSION

The findings suggest appropriate resource-focused interventions can enhance grandmothers' subjective assessments of family resources and reduce psychological distress. However, additional research is needed to ascertain the consistency and generalizability of findings.

The process, outcomes, and challenges of feasibility studies conducted in partnership with stakeholders: a health intervention for women survivors of intimate partner violence

Feasibility studies play a crucial role in determining whether complex, community-based interventions should be subject to efficacy testing. Reports of such studies often focus on efficacy potential but less often examine other elements of feasibility, such as acceptance by clients and professionals, practicality, and system integration, which are critical to decisions for proceeding with controlled efficacy testing. Although stakeholder partnership in feasibility studies is widely suggested to facilitate the research process, strengthen relevance, and increase knowledge transfer, little is written about how this occurs or its consequences and outcomes. We began to address these gaps in knowledge in a feasibility study of a health intervention for women survivors of intimate partner violence (IPV) conducted in partnership with policy, community and practitioner stakeholders. We employed a mixed-method design, combining a single-group, pre-post intervention study with 52 survivors of IPV, of whom 42 completed data collection, with chart review data and interviews of 18 purposefully sampled participants and all 9 interventionists. We assessed intervention feasibility in terms of acceptability, demand, practicality, implementation, adaptation, integration, and efficacy potential. Our findings demonstrate the scope of knowledge attainable when diverse elements of feasibility are considered, as well as the benefits and challenges of partnership. The implications of diverse perspectives on knowledge transfer are discussed. Our findings show the importance of examining elements of feasibility for complex community-based health interventions as a basis for determining whether controlled intervention efficacy testing is justified and for refining both the intervention and the research design.

The process, outcomes, and challenges of feasibility studies conducted in partnership with stakeholders: a health intervention for women survivors of intimate partner violence

Feasibility studies play a crucial role in determining whether complex, community-based interventions should be subject to efficacy testing. Reports of such studies often focus on efficacy potential but less often examine other elements of feasibility, such as acceptance by clients and professionals, practicality, and system integration, which are critical to decisions for proceeding with controlled efficacy testing. Although stakeholder partnership in feasibility studies is widely suggested to facilitate the research process, strengthen relevance, and increase knowledge transfer, little is written about how this occurs or its consequences and outcomes. We began to address these gaps in knowledge in a feasibility study of a health intervention for women survivors of intimate partner violence (IPV) conducted in partnership with policy, community and practitioner stakeholders. We employed a mixed-method design, combining a single-group, pre-post intervention study with 52 survivors of IPV, of whom 42 completed data collection, with chart review data and interviews of 18 purposefully sampled participants and all 9 interventionists. We assessed intervention feasibility in terms of acceptability, demand, practicality, implementation, adaptation, integration, and efficacy potential. Our findings demonstrate the scope of knowledge attainable when diverse elements of feasibility are considered, as well as the benefits and challenges of partnership. The implications of diverse perspectives on knowledge transfer are discussed. Our findings show the importance of examining elements of feasibility for complex community-based health interventions as a basis for determining whether controlled intervention efficacy testing is justified and for refining both the intervention and the research design.

Fidelity Decision Making in Social and Behavioral Research: Alternative Measures of Dose and Other Considerations

This article advances the discussion of treatment fidelity in social and behavioral intervention research by analyzing fidelity in an intervention study conducted within participating long-term care settings of the Collaborative Studies of Long-Term Care. The authors used the Behavior Change Consortium's (BCC) best practices for enhancing treatment fidelity recommendations in the areas of study design, provider training, treatment delivery, treatment receipt, and treatment enactment to evaluate fidelity-related decisions. Modifications to the original fidelity strategies were necessary in all areas. The authors revised their dose score and compared it with two constructed alternative measures of fidelity. Testing alternative measures and selecting the best measure post hoc allowed them to observe chance differences in relationship to outcomes. When the end result is to translate behavioral interventions into real practice settings, it is clear that some degree of flexibility is needed to ensure optimal delivery. Based on the relationship of program elements to the outcomes, a multicomponent intervention dose measure was more appropriate than one related to individual elements alone. By assessing the extent to which their strategies aligned with the BCC recommendations, the authors offer an opportunity for social work researchers to learn from their challenges and decision-making process to maximize fidelity.

A reevaluation of the costs of heart failure and its implications for allocation of health resources in the United States

The annual cost of heart failure (HF) is estimated at $39.2 billion. This has been acknowledged to underestimate the true costs for care. The objective of this analysis is to more accurately assess these costs. Publicly available data sources were used. Cost calculations incorporated relevant factors such as Medicare hospital cost-to-charge ratios, reimbursement from both government and private insurance, and out-of-pocket expenditures. A recently published Atherosclerosis Risk in Communities (ARIC) HF scheme was used to adjust the HF classification scheme. Costs were calculated with HF as the primary diagnosis (HF in isolation, or HFI) or HF as one of the diagnoses/part of a disease milieu (HF syndrome, or HFS). Total direct costs for HF were calculated at $60.2 billion (HFI) and $115.4 billion (HFS). Indirect costs were $10.6 billion for both. Costs attributable to HF may represent a much larger burden to US health care than what is commonly referenced. These revised and increased costs have implications for policy makers.

Implementation of a school-based internet obesity prevention program for adolescents

OBJECTIVE

To evaluate the reach, adoption, and implementation of HEALTH[e]TEEN, a school-based Internet obesity prevention program, and examine differences in student participation and satisfaction by school, gender, age, and race/ethnicity.

DESIGN

Concurrent mixed method evaluation.

SETTING

Three public high schools in Connecticut.

PARTICIPANTS

Three hundred eighty-four adolescents, 8 teachers.

INTERVENTION(S)

HEALTH[e]TEEN vs HEALTH[e]TEEN plus coping skills training.

MAIN OUTCOME MEASURE(S)

Demographic and state-available data, measurements of student satisfaction and participation, interviews with school administrators and teachers.

ANALYSIS

Mixed and logistic models, content analysis.

RESULTS

The sample (n = 384) was diverse (35% white), with a mean age of 15.3 years and mean body mass index of 24.7 kg/m(2). Student participation (83% of lessons completed) and satisfaction (mean 3.6 out of 5) was high. Schools implementing the program in class had higher satisfaction and participation compared with schools that implemented the program as homework (P ≤ .001 and < .001, respectively). Girls had higher satisfaction and participation compared with boys (P = .02 and .03, respectively). Younger students had higher participation compared with older students, but no difference in satisfaction was noted (P = .03).

CONCLUSIONS AND IMPLICATIONS

Two school-based Internet programs to decrease obesity reached diverse adolescents, and were adopted and implemented with high student satisfaction and participation. Implementation of the intervention was influenced by setting (classroom vs homework), teacher characteristics, student age, and gender.

The triple challenge of recruiting older adults with dementia and high medical acuity in skilled nursing facilities

PURPOSE

To describe strategies, culled from experience, for responding to several recruitment challenges in an ongoing randomized clinical trial of delirium in persons with dementia.

ORGANIZING CONSTRUCT

Delirium in people with dementia is common across all cultures. Little research supports the use of specific interventions for delirium. Recruitment of an adequate sample is critical to the validity of findings from intervention studies that form the foundation for evidence-based practice.

METHODS

The trial referenced in this article tests the efficacy of cognitive stimulation for resolving delirium in people with dementia. Participants are recruited at the time of admission to one of eight community-based skilled nursing facilities (SNFs). Eligible participants are 65 years of age or older and community dwelling, and have a diagnosis of dementia and delirium. Recruitment challenges and strategies were identified during weekly team meetings over a 2-year period.

FINDINGS

Recruitment challenges include factors in the external and internal environment and the participants and their families. Strategies that address these challenges include early site evaluation and strong communication approaches with staff, participants, and families.

CONCLUSIONS

The recruitment of an adequate sample of acutely ill older adults with dementia in SNFs can pose a challenge to investigators and threaten the validity of findings. Recruitment strategies that help improve the validity of future studies are described.

CLINICAL RELEVANCE

Worldwide, over 100 million people will have dementia by 2050, placing them at increased risk for delirium. Recruitment strategies that improve the quality of nursing research and, by extension, the care and prevention of delirium in older adults with dementia during rehabilitation in SNFs are greatly needed.

An internet obesity prevention program for adolescents

PURPOSE

To compare the effectiveness of two school-based internet obesity prevention programs for diverse adolescents on body mass index (BMI), health behaviors, and self-efficacy, and to explore moderators of program efficacy. It was hypothesized that the addition of coping skills training to a health education and behavioral support program would further enhance health outcomes.

METHODS

A randomized clinical trial with cluster randomization by class and repeated measures with follow-up at 3 and 6 months was conducted (n = 384). BMI was assessed by use of standard procedures. Sedentary behavior, physical activity, nutrition behavior, self-efficacy, and satisfaction were assessed with self-report measures. Data analysis consisted of mixed model analyses with autoregressive covariance structure for repeated data by use of intent-to-treat procedures.

RESULTS

The mean age of students was 15.31 years (±0.69), with a mean BMI of 24.69 (±5.58). The majority were girls (62%) and of diverse race/ethnicity (65% non-white). There were no significant differences between groups on any outcomes and no change in BMI over time. There were significant improvements in health behaviors (sedentary behavior, moderate and vigorous physical activity, healthy eating, fruit and vegetable intake, sugar beverages, and junk food intake) and self-efficacy. Gender and lesson completion moderated select health outcomes. There was excellent participation and high satisfaction with the programs.

CONCLUSIONS

School-based internet obesity prevention programs are appealing to adolescents and improve health behaviors. The differential effect of coping skills training may require longer follow-up.

School-based internet obesity prevention programs for adolescents: a systematic literature review

In response to the childhood obesity epidemic, numerous studies on school-based Internet obesity prevention interventions have been conducted. The purpose of this systematic review is to describe, synthesize, and evaluate the research on school-based Internet obesity prevention programs for adolescents. Medline, CINAHL, and PsycInfo were searched from January 1995 to August 2012 to locate relevant studies. Ninety-one reports were initially identified, with 12 meeting the inclusion criteria. Studies had variable control groups, program content, and sample characteristics. Though few authors reported on implementation processes or body mass index (BMI) outcomes, the majority of studies were effective in improving health behaviors in the short term. Most studies were judged to have a high or unclear risk of bias in at least two domains, thus the quality of evidence for this body of literature is moderate. Further research is needed to examine programs of longer duration, optimal dose and timing of programs, cost-effectiveness, and mediators and moderators of intervention outcomes.

Tool for evaluating research implementation challenges: a sense-making protocol for addressing implementation challenges in complex research settings

Background

Many challenges arise in complex organizational interventions that threaten research integrity. This article describes a Tool for Evaluating Research Implementation Challenges (TECH), developed using a complexity science framework to assist research teams in assessing and managing these challenges.

Methods

During the implementation of a multi-site, randomized controlled trial (RCT) of organizational interventions to reduce resident falls in eight nursing homes, we inductively developed, and later codified the TECH. The TECH was developed through processes that emerged from interactions among research team members and nursing home staff participants, including a purposive use of complexity science principles.

Results

The TECH provided a structure to assess challenges systematically, consider their potential impact on intervention feasibility and fidelity, and determine actions to take. We codified the process into an algorithm that can be adopted or adapted for other research projects. We present selected examples of the use of the TECH that are relevant to many complex interventions.

Conclusions

Complexity theory provides a useful lens through which research procedures can be developed to address implementation challenges that emerge from complex organizations and research designs. Sense-making is a group process in which diverse members interpret challenges when available information is ambiguous; the groups’ interpretations provide cues for taking action. Sense-making facilitates the creation of safe environments for generating innovative solutions that balance research integrity and practical issues. The challenges encountered during implementation of complex interventions are often unpredictable; however, adoption of a systematic process will allow investigators to address them in a consistent yet flexible manner, protecting fidelity. Research integrity is also protected by allowing for appropriate adaptations to intervention protocols that preserve the feasibility of ‘real world’ interventions.

Sampling challenges in nursing home research

BACKGROUND

Research on end-of-life care in nursing homes is hampered by challenges in retaining facilities in samples through study completion. Large-scale longitudinal studies in which data are collected on-site can be particularly challenging.

OBJECTIVES

To compare characteristics of nursing homes that dropped from the study to those that completed the study.

METHODS

One hundred two nursing homes in a large geographic 2-state area were enrolled in a prospective study of end-of-life care of residents who died in the facility. The focus of the study was the relationship of staff communication, teamwork, and palliative/end-of-life care practices to symptom distress and other care outcomes as perceived by family members. Data were collected from public data bases of nursing homes, clinical staff on site at each facility at 2 points in time, and from decedents' family members in a telephone interview.

RESULTS

Seventeen of the 102 nursing homes dropped from the study before completion. These non-completer facilities had significantly more deficiencies and a higher rate of turnover of key personnel compared to completer facilities. A few facilities with a profile typical of non-completers actually did complete the study after an extraordinary investment of retention effort by the research team.

CONCLUSION

Nursing homes with a high rate of deficiencies and turnover have much to contribute to the goal of improving end-of-life care, and their loss to study is a significant sampling challenge. Investigators should be prepared to invest extra resources to maximize retention.

Director of nursing current job tenure and past experience and quality of care in nursing homes

BACKGROUND

Directors of nursing (DONs) are central to quality of care in nursing homes (NHs) because of their role in coordinating and overseeing nursing care. Research is needed to test the association between DON characteristics and quality using large, representative samples of NHs and global measures of quality. One such measure is the quality measure (QM) rating from the Centers for Medicare & Medicaid Services' Five-Star Quality Rating, which aggregates 10 individual QMs into a single rating.

PURPOSE

This study examined whether DON current job tenure or past experience (a) differed across levels of the QM rating, (b) was associated with QM ratings, and (c) was associated with any of the individual 10 QM scores that comprise QM ratings.

METHODOLOGY

Data for a nationally representative sample of 1,174 NHs were obtained from the 2004 National Nursing Home Survey, publicly reported QMs, and an Area Resource File. Wald tests were used to test differences in mean DON current job tenure and past experience across levels of the QM rating. Multinomial logistic and Poisson regression analyses were used to examine the association between DON current job tenure and past experience and QM ratings and QM scores, respectively, controlling for selected market and organizational characteristics.

FINDINGS

Nursing homes with longer DON current job tenure tended to have higher QM ratings. Longer DON current job tenure was associated with higher QM ratings and lower QM scores for several individual QMs, suggesting higher quality. The past experience of the DON did not differ across levels of the QM rating and was not associated with QM ratings or QM scores.

PRACTICE IMPLICATIONS

This study highlights the need for owners and administrators to support DONs as they either the transition into the role of the DON for the first time or learn to effectively fulfill their role in a new NH.

Palliative care for advanced dementia: a pilot project in 2 nursing homes

This article describes a pilot project involving training, case consultations, and administrative coaching over a period of 1 year aimed at introducing palliative care in 2 nursing homes among 31 residents with advanced dementia. Resident outcomes that examined numerous clinical measures were assessed at 3 points in time. Changes in the knowledge and attitudes of 80 staff members and 33 family members who participated in the multimodal intervention were also assessed at 3 points in time. Limited improvements were demonstrated on measures for residents, staff members, and family members at the first nursing home (site 1) and significant improvements were demonstrated at the other nursing home (site 2). Top leadership turned over 3 times at site 1 which limited the integration of palliative care, whereas leadership of site 2 remained stable. Implications for implementing a program of palliative care in nursing homes are discussed.

Understanding implementation processes of clinical pathways and clinical practice guidelines in pediatric contexts: a study protocol

Background

Canada is among the most prosperous nations in the world, yet the health and wellness outcomes of Canadian children are surprisingly poor. There is some evidence to suggest that these poor health outcomes are partly due to clinical practice variation, which can stem from failure to apply the best available research evidence in clinical practice, otherwise known as knowledge translation (KT). Surprisingly, clinical practice variation, even for common acute paediatric conditions, is pervasive. Clinical practice variation results in unnecessary medical treatments, increased suffering, and increased healthcare costs. This study focuses on improving health outcomes for common paediatric acute health concerns by evaluating strategies that improve KT and reduce clinical practice variation.

Design/Methods

Using a multiple case study design, qualitative and quantitative data will be collected from four emergency departments in western Canada. Data sources will include: pre- and post-implementation focus group data from multidisciplinary healthcare professionals; individual interviews with the local champions, KT intervention providers, and unit/site leaders/managers; Alberta Context Tool (ACT) survey data; and aggregated patient outcome data. Qualitative and quantitative data will be systematically triangulated, and matrices will be built to do cross-case comparison. Explanations will be built about the success or lack of success of the clinical practice guidelines (CPG) and clinical pathways (CPs) uptake based upon the cross-case comparisons.

Significance

This study will generate new knowledge about the potential causal mechanisms and factors which shape implementation. Future studies will track the impact of the CPG/CPs implementation on children's health outcome, and healthcare costs.

Reducing care-resistant behaviors during oral hygiene in persons with dementia

Background

Nursing home residents with dementia are often dependent on others for mouth care, yet will react with care-resistant behavior when receiving assistance. The oral health of these elders deteriorates in the absence of daily oral hygiene, predisposing them to harmful systemic problems such as pneumonia, hyperglycemia, cardiac disease, and cerebral vascular accidents. The purpose of this study is to determine whether care-resistant behaviors can be reduced, and oral health improved, through the application of an intervention based on the neurobiological principles of threat perception and fear response. The intervention, called Managing Oral Hygiene Using Threat Reduction, combines best mouth care practices with a constellation of behavioral techniques that reduce threat perception and thereby prevent or de-escalate care-resistant behaviors.

Methods/Design

Using a randomized repeated measures design, 80 elders with dementia from 5 different nursing homes will be randomized at the individual level to the experimental group, which will receive the intervention, or to the control group, which will receive standard mouth care from research team members who receive training in the proper methods for providing mouth care but no training in resistance recognition or prevention/mediation. Oral health assessments and care-resistant behavior measurements will be obtained during a 7-day observation period and a 21-day intervention period. Individual growth models using multilevel analysis will be used to estimate the efficacy of the intervention for reducing care-resistant behaviors in persons with dementia, and to estimate the overall efficacy of the intervention using oral health outcomes. Activity-based costing methods will be used to determine the cost of the proposed intervention.

Discussion

At the conclusion of this study, the research team anticipates having a proven intervention that prevents and reduces care-resistant within the context of mouth care. Long-term objectives include testing the effect of the intervention on systemic illnesses among persons with dementia; examining the transferability of this intervention to other activities of daily living; and disseminating threat reduction interventions to nursing home staff, which may radically change the manner in which care is provided to persons with dementia.

Trial Registration

ClinicalTrials.gov: NCT01363258

Evidence-based refinement of health and social services: exploring the possibilities of intravention research

To promote evidence-based refinement of quality health and social services delivery and care, decision makers, researchers, and practitioners often undertake intervention research. Intervention research tests and describes new strategies for achieving desired outcomes. But theoretical, methodological, and practical issues continue to plague even alternative participatory approaches to intervention research, raising questions about its potential for promoting quality health and social services and care. In response to this persistent challenge, the authors of this article propose a radical solution, namely intravention research, laying out its unique features as well as its theoretical and practical implications. Their conceptualization sets the stage for dialogue on options for advancing research methodologies and methods that might better promote evidence-informed health and social services.

Study protocol for the recreational stimulation for elders as a vehicle to resolve delirium superimposed on dementia (Reserve For DSD) trial

BACKGROUND

Delirium is a state of confusion characterized by an acute and fluctuating decline in cognitive functioning. Delirium is common and deadly in older adults with dementia, and is often referred to as delirium superimposed on dementia, or DSD. Interventions that treat DSD are not well-developed because the mechanisms involved in its etiology are not completely understood. We have developed a theory-based intervention for DSD that is derived from the literature on cognitive reserve and based on our prior interdisciplinary work on delirium, recreational activities, and cognitive stimulation in people with dementia. Our preliminary work indicate that use of simple, cognitively stimulating activities may help resolve delirium by helping to focus inattention, the primary neuropsychological deficit in delirium. Our primary aim in this trial is to test the efficacy of Recreational Stimulation for Elders as a Vehicle to resolve DSD (RESERVE- DSD).

METHODS/DESIGN

This randomized repeated measures clinical trial will involve participants being recruited and enrolled at the time of admission to post acute care. We will randomize 256 subjects to intervention (RESERVE-DSD) or control (usual care). Intervention subjects will receive 30-minute sessions of tailored cognitively stimulating recreational activities for up to 30 days. We hypothesize that subjects who receive RESERVE-DSD will have: decreased severity and duration of delirium; greater gains in attention, orientation, memory, abstract thinking, and executive functioning; and greater gains in physical function compared to subjects with DSD who receive usual care. We will also evaluate potential moderators of intervention efficacy (lifetime of complex mental activities and APOE status). Our secondary aim is to describe the costs associated with RESERVE-DSD.

DISCUSSION

Our theory-based intervention, which uses simple, inexpensive recreational activities for delivering cognitive stimulation, is innovative because, to our knowledge it has not been tested as a treatment for DSD. This novel intervention for DSD builds on our prior delirium, recreational activity and cognitive stimulation research, and draws support from cognitive reserve theory.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01267682

Evidence to support tooth brushing in critically ill patients

Tooth brushing in critically ill patients has been advocated by many as a standard of care despite the limited evidence to support this practice. Attention has been focused on oral care as the evidence accumulates to support an association between the bacteria in the oral microbiome and those respiratory pathogens that cause pneumonia. It is plausible to assume that respiratory pathogens originating in the oral cavity are aspirated into the lungs, causing infection. A recent study of the effects of a powered toothbrush on the incidence of ventilator-associated pneumonia was stopped early because of a lack of effect in the treatment group. This review summarizes the evidence that supports the effectiveness of tooth brushing in critically ill adults and children receiving mechanical ventilation. Possible reasons for the lack of benefit of tooth brushing demonstrated in clinical trials are discussed. Recommendations for future trials in critically ill patients are suggested. With increased emphasis being placed on oral care, the evidence that supports this intervention must be evaluated carefully.

Overcoming challenges for nurse-led research in the neonatal intensive care unit

Nurse researchers have made considerable contributions to the science of nursing. Conducting studies in the clinical environment is the best way to determine what interventions are most effective. Because most research is conducted by nurses from academic settings, they often are not viewed as credible by nurses in clinical practice, nor are they accepted readily into the neonatal intensive care unit (NICU) to conduct research. This article addresses the barriers to implementing and conducting studies in the NICU setting, and provides suggestions for creating collaborative and mutually satisfying relationships between nurse researchers and healthcare staff in the NICU. Partnerships built on mutual respect are necessary to have successful research outcomes, and to continue to build knowledge for the best neonatal care.

Strategies to engage clinical staff in subject recruitment

PURPOSE: In many countries, meeting subject recruitment goals is challenging for researchers relying on clinical staff members (CSMs) to identify or recruit subjects. This paper describes research strategies that improved staff engagement in three different studies conducted in US clinical settings. METHOD: The recruitment strategies described in this paper were identified during the process of consultation among three US researchers recruiting via CSMs. Strategies which successfully engaged CSMs are described. RESULTS: Our approach improved engagement with CSMs in three different US studies. Early engagement strategies included establishing trust, gathering input from CSMs, and using succinct training procedures as well as a study logo. Middle phase strategies included assigning recruitment, publishing a study newsletter, giving the CSMs compensation and appreciation for their participation, and expanding the subject pool. Completion strategies included closing with an appreciation meeting and adding merit letters to personnel files. CONCLUSION: Recruitment of an adequate number of subjects is often challenging, even within clinical settings where subject populations are abundant. CSMs have rightly prioritised clinical care over directing subjects to research studies. It is therefore critical that researchers recruiting in such clinical settings anticipate recruitment challenges and plan to implement appropriate engagement strategies in all phases of research.

Infectious diseases in the nursing home setting: challenges and opportunities for clinical investigation

The global population is aging. With the high prevalence of dementia and functional decline in older Americans, many aging adults with disabilities reside in nursing homes in their final stage of life. Immunosenescence, multiple comorbid diseases, and grouped quarter living all coalesce in nursing home residents to increase the risk for infectious disease. The unique issues involved with diagnosis, prognosis, and management of infectious diseases in nursing home residents make research based in the nursing home setting both necessary and exciting for the physician investigator. This review discusses the opportunities and challenges involved with research of the evolving public health problem of infections among nursing home residents.

Implementation fidelity in community-based interventions

Implementation fidelity is the degree to which an intervention is delivered as intended and is critical to successful translation of evidence-based interventions into practice. Diminished fidelity may be why interventions that work well in highly controlled trials may fail to yield the same outcomes when applied in real life contexts. The purpose of this paper is to define implementation fidelity and describe its importance for the larger science of implementation, discuss data collection methods and current efforts in measuring implementation fidelity in community-based prevention interventions, and present future research directions for measuring implementation fidelity that will advance implementation science.