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Choroschun K, Estabrooks CA, Duan Y, Chamberlain S, Shrestha S, Cummings GG, Iaconi A, Norton PG, Song Y, Hoben M. Organizational Context and Facilitation Interactions on Delirium Risk in Long-Term Care: A Cross-Sectional Study. J Am Med Dir Assoc 2024; 25:105000. [PMID: 38663451 DOI: 10.1016/j.jamda.2024.03.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 03/15/2024] [Accepted: 03/15/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVES Organizational context (eg, leadership) and facilitation (eg, coaching behaviors) are thought to interact and influence staff best practices in long-term care (LTC), including the management of delirium. Our objective was to assess if organizational context and facilitation-individually, and their interactions-were associated with delirium in LTC. DESIGN Retrospective cross-sectional analysis of secondary data. SETTING AND PARTICIPANTS We included 8755 residents from 281 care units in 86 LTC facilities in 3 Canadian provinces. METHODS Delirium (present/absent) was assessed using the Resident Assessment Instrument-Minimum Data Set 2.0 (RAI-MDS 2.0). The Alberta Context Tool (ACT) measured 10 modifiable features of care unit organizational context. We measured the care unit's total care hours per resident day and the proportion of care hours that care aides contributed (staffing mix). Facilitation included the facility manager's perception of RAI-MDS reports' adequacy and pharmacist availability. We included unit managers' change-oriented organizational citizenship behavior (OCB) and an item reflecting how often care aides recommended policy changes. Associations of organizational context, facilitation, and their interactions with delirium were analyzed using mixed-effects logistic regressions, controlling for covariates. RESULTS Delirium symptoms were prevalent in 17.4% of residents (n = 1527). Manager-perceived adequacy of RAI-MDS reports was linked to reduced delirium symptoms [odds ratio (OR) = 0.63]. Higher care hours per resident day (OR = 1.2) and an available pharmacist in the facility (OR = 1.5) were associated with increased delirium symptoms. ACT elements showed no direct association with delirium. However, on care units with low social capital scores (context), increased unit managers' OCB decreased delirium symptoms. On care units with high vs low evaluation scores (context), increased staffing mix reduces delirium symptoms more substantially. CONCLUSIONS AND IMPLICATIONS Unit-level interactions between organizational context and facilitation call for targeted quality improvement interventions based on specific contextual factors, as effectiveness may vary across contexts.
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Affiliation(s)
| | - Carole A Estabrooks
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Yinfei Duan
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Stephanie Chamberlain
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Shovana Shrestha
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Greta G Cummings
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Alba Iaconi
- Institute of Health Policy, Health, Management and Evaluation, School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Peter G Norton
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Yuting Song
- School of Nursing, Qingdao University, Qingdao, China
| | - Matthias Hoben
- School of Health Policy and Management, Faculty of Health, York University, Toronto, Ontario, Canada
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Oda K, Majeed S, Parsons J, Boyd M, Smith M. Putting the Mouth Into the Head-to-Toe Assessment: Nursing Oral Health Assessment Training With an Oral Health Therapist. J Nurs Educ 2023; 62:399-402. [PMID: 37413674 DOI: 10.3928/01484834-20230509-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND Oral care is one of the most neglected nursing practices, lacking oral care protocols, efficient training, and awareness of the benefits for clients. In particular, there is a gap in research for nursing oral health assessment training for nursing curricula. METHOD This study explored the effects of interprofessional collaboration (IPC) training between nurses and oral health therapists (OHT) using newly developed oral health assessment tools with an aim of reducing barriers for nursing oral health assessment. The self-efficacy and confidence of nursing students in oral health assessment were evaluated using pre- and posttraining surveys, and a focus group. RESULTS Nursing students' confidence in incorporating oral health assessment into head-to-toe assessment improved after training. CONCLUSION Nursing oral health assessment training with IPC, onsite OHT support, and oral health assessment tools improved the confidence and attitudes of nursing students in oral health assessment and care provision. [J Nurs Educ. 2023;62(7):399-402.].
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Heid AR, Abbott KM, Rovine MJ, Eshraghi K, Madrigal C, Crumbie V, Van Haitsma K. The Stability of Nursing Home Residents' Ratings of Importance of Recreation Preferences Over One Year. J Appl Gerontol 2022; 41:1942-1951. [PMID: 35506670 DOI: 10.1177/07334648221089239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Long-term stability of nursing home (NH) residents' everyday preference remains unknown. We examined 1-year stability in reports of importance of 34-recreational activity preferences (8-MDS 3.0 Section F items; 26-Preferences for Everyday Living Inventory-NH items) by NH residents (N = 161). We examined mean differences on demographic and clinical characteristics of residents for preferences showing change. Importance ratings of preferences were highly stable over 1-year, with 91% of items retaining the same valence of importance for the majority of the sample (<20% change). Three preferences showed greater change. More functionally able residents were more likely to change their importance on "being with groups of people," and older residents were more likely to change their preferences for being "involved in religious practices" and "around animals such as pets". Overall, annual assessments of recreational activity preferences capture an accurate representation of preferences with reassessment only needed in a few circumstances.
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Affiliation(s)
| | - Katherine M Abbott
- Department of Sociology and Gerontology, Scripps Gerontology Center, Miami University, Oxford, OH, USA
| | - Michael J Rovine
- Graduate School of Education, University of Pennsylvania, Philadelphia, PA, USA
| | - Karen Eshraghi
- The Pennsylvania State University, College of Nursing, University Park, PA, USA
| | - Caroline Madrigal
- Advanced Fellow in Health Services Research, Center for Innovation in Long-Term Services & Supports, Providence VA, Providence, RI, USA
| | - Victoria Crumbie
- The Pennsylvania State University, College of Nursing, University Park, PA, USA
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Musa MK, Akdur G, Brand S, Killett A, Spilsbury K, Peryer G, Burton JK, Gordon AL, Hanratty B, Towers AM, Irvine L, Kelly S, Jones L, Meyer J, Goodman C. The uptake and use of a minimum data set (MDS) for older people living and dying in care homes: a realist review. BMC Geriatr 2022; 22:33. [PMID: 34996391 PMCID: PMC8739629 DOI: 10.1186/s12877-021-02705-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 12/07/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Care homes provide long term care for older people. Countries with standardised approaches to residents' assessment, care planning and review (known as minimum data sets (MDS)) use the aggregate data to guide resource allocation, monitor quality, and for research. Less is known about how an MDS affects how staff assess, provide and review residents' everyday care. The review aimed to develop a theory-driven understanding of how care home staff can effectively implement and use MDS to plan and deliver care for residents. METHODS The realist review was organised according to RAMESES (Realist And Meta-narrative Evidence Synthesis: and Evolving Standards) guidelines. There were three overlapping stages: 1) defining the scope of the review and theory development on the use of minimum data set 2) testing and refining candidate programme theories through iterative literature searches and stakeholders' consultations as well as discussion among the research team; and 3) data synthesis from stages 1 and 2. The following databases were used MEDLINE via OVID, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ASSIA [Applied Social Sciences Citation Index and Abstracts]) and sources of grey literature. RESULTS Fifty-one papers informed the development of three key interlinked theoretical propositions: motivation (mandates and incentives for Minimum Data Set completion); frontline staff monitoring (when Minimum Data Set completion is built into the working practices of the care home); and embedded recording systems (Minimum Data Set recording system is integral to collecting residents' data). By valuing the contributions of staff and building on existing ways of working, the uptake and use of an MDS could enable all staff to learn with and from each other about what is important for residents' care CONCLUSIONS: Minimum Data Sets provides commissioners service providers and researchers with standardised information useful for commissioning planning and analysis. For it to be equally useful for care home staff it requires key activities that address the staff experiences of care, their work with others and the use of digital technology. REGISTRATION PROSPERO registration number CRD42020171323.
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Affiliation(s)
- Massirfufulay Kpehe Musa
- Centre for Research in Public health and Community Care (CRIPACC), School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Gizdem Akdur
- Centre for Research in Public health and Community Care (CRIPACC), School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Sarah Brand
- National Institute for Health Research Applied Research Collaboration South West Peninsula (PenARC), University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, UK
| | - Anne Killett
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Karen Spilsbury
- School of Healthcare, University of Leeds, Leeds, UK
- NIHR Applied Research Collaboration, Yorkshire and Humber, Leeds, UK
| | - Guy Peryer
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | | | - Adam Lee Gordon
- School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Applied Research Collaboration, East Midlands (ARC-EM), Leicester, UK
| | - Barbara Hanratty
- Population Health Sciences Institute, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, UK
- NIHR Applied Research Collaboration, North East and North Cumbria, Newcastle, UK
| | - Ann-Marie Towers
- Centre for Health Services Studies, University of Kent, Canterbury, UK
- NIHR Applied Research Collaboration, Surrey and Sussex, Kent, UK
| | - Lisa Irvine
- Centre for Research in Public health and Community Care (CRIPACC), School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Sarah Kelly
- Cambridge Public Health, University of Cambridge, Cambridge, UK
| | - Liz Jones
- National Care Forum, Friars House, Manor House Drive, Coventry, UK
| | - Julienne Meyer
- Care for Older People, School of Health Sciences, Division of Nursing, City, University of London, London, UK
| | - Claire Goodman
- Centre for Research in Public health and Community Care (CRIPACC), School of Health and Social Work, University of Hertfordshire, Hatfield, UK
- NIHR Applied Research Collaboration East of England, Cambridge, UK
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Krausch-Hofmann S, Tran TD, Janssens B, Declerck D, Lesaffre E, de Almeida Mello J, Declercq A, De Lepeleire J, Duyck J. Assessment of oral health in older adults by non-dental professional caregivers-development and validation of a photograph-supported oral health-related section for the interRAI suite of instruments. Clin Oral Investig 2021; 25:3475-3486. [PMID: 33196870 PMCID: PMC8137625 DOI: 10.1007/s00784-020-03669-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 10/29/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVES An optimized oral health-related section and a video training were developed and validated for the interRAI suite of instruments. The latter is completed by professional non-dental caregivers and used in more than 40 countries to assess care needs of older adults. METHODS The optimized oral health-related section (ohr-interRAI) consists of nine items and a video training that were developed in consecutive phases. To evaluate psychometric properties, a study was conducted in 260 long-term care residents. Each resident was assessed by a dentist and by four caregivers (two who received the video training, two who did not). RESULTS Mean kappa values and percent agreement between caregivers and dentist ranged between κ = 0.60 (80.2%) for dry mouth and κ = 0.13 (54.0%) for oral hygiene. The highest inter-caregiver agreement was found for dry mouth with κ = 0.63 [95% CI: 0.56-0.70] (81.6%), while for the item palate/lips/cheeks only κ = 0.27 [95% CI: 0.18-0.36] (76.7%) was achieved. Intra-caregiver agreement ranged between κ = 0.93 [95% CI: 0.79-1.00] (96.4%) for dry mouth and κ = 0.45 [95% CI: 0.06-0.84] (82.8%) for gums. Logistic regression analysis showed only small differences between caregivers who watched the video training and those who did not. CONCLUSIONS Psychometric properties of the optimized ohr-interRAI section were improved compared to previous versions. Nevertheless, particularly the items based on inspection of the mouth require further refinement and caregiver training needs to be improved. CLINICAL RELEVANCE Valid assessment of oral health by professional caregivers is essential due to the impaired accessibility of regular dental care for care-dependent older adults.
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Affiliation(s)
- Stefanie Krausch-Hofmann
- KU Leuven Department of Oral Health Sciences, Population Studies in Oral Health, Kapucijnenvoer 7/a - box 7001, 3000 Leuven, Belgium
| | - Trung Dung Tran
- KU Leuven Department of Public Health and Primary Care, Biostatistics and Statistical Bioinformatics Centre (L-BioStat), Kapucijnenvoer 35/a - box 7001, 3000 Leuven, Belgium
| | - Barbara Janssens
- Ghent University Department of Oral Health Sciences, Special Needs in Oral Health, Gerodontology, C.-Heymanslaan 10, entrance 25, 9000 Ghent, Belgium
| | - Dominique Declerck
- KU Leuven Department of Oral Health Sciences, Population Studies in Oral Health, Kapucijnenvoer 7/a - box 7001, 3000 Leuven, Belgium
| | - Emmanuel Lesaffre
- KU Leuven Department of Public Health and Primary Care, Biostatistics and Statistical Bioinformatics Centre (L-BioStat), Kapucijnenvoer 35/a - box 7001, 3000 Leuven, Belgium
| | - Johanna de Almeida Mello
- KU Leuven LUCAS, Centre for Care Research and Consultancy, Minderbroedersstraat 8 - box 5310, 3000 Leuven, Belgium
| | - Anja Declercq
- KU Leuven LUCAS, Centre for Care Research and Consultancy, Minderbroedersstraat 8 - box 5310, 3000 Leuven, Belgium
- KU Leuven CESO, Center for Sociological Research, Parkstraat 45 - box 3601, 3000 Leuven, Belgium
| | - Jan De Lepeleire
- KU Leuven Department of Public Health and Primary Care, Academic Centre for General Practice, Kapucijnenvoer 33/j - box 7001, 3000 Leuven, Belgium
| | - Joke Duyck
- KU Leuven Department of Oral Health Sciences, Biomaterials/BIOMAT, Kapucijnenvoer 7/a - box 7001, 3000 Leuven, Belgium
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Jockusch J, Hopfenmüller W, Sobotta BAJ, Nitschke I. Interrater reliability and concurrent validity of oral/dental items in the resident assessment instrument minimum data set 2.0. Gerodontology 2020; 38:66-81. [PMID: 33084126 DOI: 10.1111/ger.12493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 07/20/2020] [Accepted: 08/01/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine interrater reliability and concurrent validity of oral/dental items in the Resident Assessment Instrument Minimum Data Set (RAI-MDS) 2.0. BACKGROUND RAI-MDS is a standardised instrument used in nursing to determine health status and nursing needs. The extent to which oral/dental items in the RAI-MDS describe dental treatment needs concerning oral health has been questioned. MATERIALS AND METHODS This study evaluated the interrater reliability (dentist vs. nurse) and validity of oral/dental items in the Swiss version of RAI-MDS 2.0 (areas: K-nutritional status, L-oral/dental status) using professional oral examinations as a benchmark. Data of 168 residents of five long-term care facilities in the canton of Zurich, Switzerland, were collected within 1 year between October 2017 and December 2018. The statistical evaluation used descriptive statistics and Cohen's kappa (95% CI). RESULTS RAI-MDS items K1a, chewing (κ 0.098, 95% CI: 0.004-0.19); K1c, pain (κ 0.039, 95% CI: -0.03 to 0.11); L1a, debris (κ 0.117, 95% CI: 0.02-0.21); L1c, dental status (κ 0.229, 95% CI: 0.12-0.34); L1d, dental disease (κ 0.129, 95% CI: 0.02-0.24); L1e, periodontal diseases (κ -0.005, 95% CI: -0.07 to -0.03); and L1f, daily cleaning (κ -0.031, 95% CI: -0.05 to -0.01) showed weak or no agreement, whereas L1b, denture status (κ 0.634, 95% CI: 0.52-0.75), showed substantial agreement. CONCLUSION Oral/dental items in RAI-MDS lack reliability and validity. Recognition of oral health situation/treatment needs by nursing staff does not seem to be possible with the current version of this tool.
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Affiliation(s)
- Julia Jockusch
- Clinic of General, Special Care and Geriatric Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland
| | - Werner Hopfenmüller
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Bernhard A J Sobotta
- Department of Prosthodontics and Materials Science, Gerodontology Section, Universitätszahnmedizin Leipzig, Leipzig, Germany
| | - Ina Nitschke
- Clinic of General, Special Care and Geriatric Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland.,Department of Prosthodontics and Materials Science, Gerodontology Section, Universitätszahnmedizin Leipzig, Leipzig, Germany
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MacEntee MI, Brondani M, Avivi-Arber L, Bartlett D, Donnelly L, Duyck J, Hori K, Karve A, Persson GR, Kettratad-Pruksapong M, Schimmel M, Hon-Ching So F, Thomson WM, Yoon MN, Wyatt C. Clinical Oral Disorders in Adults Screening Protocol (CODA-SP) from the 2019 Vancouver IADR Consensus Symposium. Gerodontology 2020; 38:5-16. [PMID: 33009707 DOI: 10.1111/ger.12496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/10/2020] [Accepted: 08/21/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The Clinical Oral Disorder in Elders (CODE) index was proposed in 1999 to assess the oral health status and treatment needs of older people who typically were edentate or had few natural teeth. Since then, more people are retaining natural teeth into old age and have oral disorders similar to younger adults. In addition, there has been further guidance on screening for disease that includes changes to the clinical indicators of several oral disorders and greater sensitivity to people's concerns about their oral health and care needs. METHODS Experts in dental geriatrics assembled at a satellite symposium of the International Association of Dental Research in June 2019 to revise the objectives and content of the CODE index. Before the symposium, 139 registrants were asked for comments on the CODE index, and 11 content experts summarised current evidence and assembled reference lists of relevant information on each indicator. The reference lists provided the base for a narrative review of relevant evidence supplemented by reference tracking and direct searches of selected literature for additional evidence. RESULTS Analysis of the evidence by consensus of the experts produced the Clinical Oral Disorders in Adults Screening Protocol (CODA-SP). CONCLUSIONS The CODA-SP encompasses multiple domains of physical and subjective indicators with weighted severity scores. Field tests are required now to validate its effectiveness and utility in oral healthcare services, outcomes and infrastructure.
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Affiliation(s)
| | | | | | | | | | | | | | - Avanti Karve
- University of Sydney, Camperdown, NSW, Australia
| | | | | | | | | | | | | | - Chris Wyatt
- University of British Columbia, Vancouver, BC, Canada
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Yoon MN, Lu L(L, Ickert C, Estabrooks CA, Hoben M. If we cannot measure it, we cannot improve it: Understanding measurement problems in routine oral/dental assessments in Canadian nursing homes—Part II. Gerodontology 2020; 37:164-176. [DOI: 10.1111/ger.12467] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 01/23/2020] [Accepted: 01/27/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Minn N. Yoon
- School of Dentistry University of Alberta Edmonton Alberta Canada
| | - Lily (Ling) Lu
- Faculty of Nursing University of Alberta Edmonton Alberta Canada
| | - Carla Ickert
- School of Dentistry University of Alberta Edmonton Alberta Canada
| | | | - Matthias Hoben
- Faculty of Nursing University of Alberta Edmonton Alberta Canada
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Estabrooks CA, Straus SE, Flood CM, Keefe J, Armstrong P, Donner GJ, Boscart V, Ducharme F, Silvius JL, Wolfson MC. Restoring trust: COVID-19 and the future of long-term care in Canada. Facets (Ott) 2020. [DOI: 10.1139/facets-2020-0056] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The Royal Society of Canada Task Force on COVID-19 was formed in April 2020 to provide evidence-informed perspectives on major societal challenges in response to and recovery from COVID-19. The Task Force established a series of working groups to rapidly develop policy briefings, with the objective of supporting policy makers with evidence to inform their decisions. This paper reports the findings of the COVID-19 Long-Term Care (LTC) working group addressing a preferred future for LTC in Canada, with a specific focus on COVID-19 and the LTC workforce. First, the report addresses the research context and policy environment in Canada’s LTC sector before COVID-19 and then summarizes the existing knowledge base for integrated solutions to challenges that exist in the LTC sector. Second, the report outlines vulnerabilities exposed because of COVID-19, including deficiencies in the LTC sector that contributed to the magnitude of the COVID-19 crisis. This section focuses especially on the characteristics of older adults living in nursing homes, their caregivers, and the physical environment of nursing homes as important contributors to the COVID-19 crisis. Finally, the report articulates principles for action and nine recommendations for action to help solve the workforce crisis in nursing homes.
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Affiliation(s)
| | - Sharon E. Straus
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Janice Keefe
- Department of Family Studies and Gerontology, Mount Saint Vincent University, Halifax, NS, Canada
| | - Pat Armstrong
- Department of Sociology, York University, Toronto, ON, Canada
| | - Gail J. Donner
- Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Véronique Boscart
- CIHR/Schlegel Industrial Research Chair for Colleges in Seniors Care, Conestoga College, Kitchener, ON, Canada
| | | | - James L. Silvius
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael C. Wolfson
- School of Epidemiology and Public Health and Faculty of Law, University of Ottawa, Ottawa, ON, Canada
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