Implementation of the single site order in long-term care:: what we can learn from using the consolidated framework for implementation research

Context: To mitigate the risk of spread of COVID-19 in long-term care (LTC), the Public Health Agency of Canada instituted several rapid redesign and resource redeployment practices, including single-site policies. Objective: This study aims to understand factors that influence implementation of the Single Site Order (SSO). Methods: Consolidated Framework for Implementation Research (CFIR) guided data collection and analysis. Ten leadership team members and 18 staff were interviewed across 4 LTC homes in British Columbia (BC), Canada. In NVivo 12, a deductive framework analysis was used. Findings: Seven notable CFIR constructs (intervention source, evidence strength and quality, costs, culture, networks and communication, readiness for implementation, and patient needs and resources) were found to be most influential in the implementation of the SSO. We present these constructs and the factors within. Limitations: Our study was limited to the BC context. However, we believe that the findings offer useful insights into the complexity of policy implementation in LTC. Implications: In a system already facing staffing concerns and a highly dependent and increasingly frail resident population, implementation of the SSO further taxed already stretched resources

Observation of the Early Structural Changes Leading to the Formation of Protein Superstructures.

Formation of superstructures in protein aggregation processes has been indicated as a general pathway for several proteins, possibly playing a role in human pathologies. There is a severe lack of knowledge on the origin of such species in terms of both mechanisms of formation and structural features. We use equine lysozyme as a model protein, and by combining spectroscopic techniques and microscopy with X-ray fiber diffraction and ab initio modeling of Small Angle X-ray Scattering data, we isolate the partially unfolded state from which one of these superstructures (i.e., particulate) originates. We reveal the low-resolution structure of the unfolded state and its mechanism of formation, highlighting the physicochemical features and the possible pathway of formation of the particulate structure. Our findings provide a novel detailed knowledge of such a general and alternative aggregation pathway for proteins, this being crucial for a basic and broader understanding of the aggregation phenomena.This is the author's accepted manuscript and will be under embargo until the 3rd of September 2015. The final version is published by ACS in The Journal of Physical Chemistry Letters here: http://pubs.acs.org/doi/abs/10.1021/jz501614e

An exploration of the mobility experiences of active older adults with low income

Mobility enables older adults to maintain their physical health, independence and participation in society. In general, mobility has predominantly been understood in functional terms. Mobility is most often measured as physical movement and/or travel behaviour. Less attention has been paid to the subjective and temporal dimensions of older adults’ mobility experiences. In addition, older adults with low incomes are under-represented in mobility research. This dissertation uses a constructivist grounded theory methodology to describe the mobility experiences of active older adults with low income. The studies within this dissertation are set in Metro Vancouver; they utilize data from a group of 6 participants selected from a cross-sectional study of 161 older adults of low income. The first study demonstrates how a novel approach (grounded visualization) can be used to explore sociospatial and temporal complexities of older adults' mobility. A grounded visualization approach can provide a deeper understanding of the multi-faceted nature of older adults' mobility experiences. Findings illustrate that time is necessary for older adults' engagement with place; familiarity influences spatial perceptions of local and distant ‘neighbourhoods’; and older adults prioritize destinations that allow them to engage in multiple activities. The second study provides an in-depth qualitative description of the mobility experiences of older adults living with low income. The following themes were found to support mobility: maintaining a sense of self, being resourceful, openness to engagement, engaging in superficial contact, experiencing social capital, accessing transportation, leaving the immediate neighbourhood and facing affordability influence active mobility choices over time. The third study adapts a mobility conceptual framework to re-frame our understanding of older adults’ mobility experiences. The adapted framework offers a physiological, subjective, contextual and temporal approach that provides a more comprehensive conceptualization of the nature and processes of older adults’ mobility. The adapted framework uses a sliding scale in order to demonstrate the fluid, multi-faceted and interrelated nature of the various elements that influence mobility over time. Taken collectively, these studies fill methodological and conceptual gaps in the literature and provide data on an understudied population. The adapted framework can be incorporated into new approaches to study older adults’ mobility.Graduate and Postdoctoral StudiesGraduat

How Central Support Built Capacity to Deliver a Health Promoting Intervention for Older Adults

Most implementation frameworks note that a central support unit (CSU) is key to successful implementation and scale-up of evidence based interventions (EBIs). However, few studies investigated core functions of CSUs— such as capacity building—to better understand their essential role in implementing EBIs at scale. Therefore, the aims of our study are to (1) describe the role that a CSU plays to build capacity in delivery partner organizations, to enable implementation and scale-up of a health promoting intervention (Choose to Move (CTM)) for older adults, and (2) identify elements within capacity building strategies deemed essential to effectively implement CTM in diverse community contexts CTM is a flexible, scalable, community-based health promoting physical activity (PA) and social connectedness intervention for older adults. In 2018-2020, eight health and social service societies, rural or remote municipalities, or community based organizations delivered 22 CTM programs that served 322 older adults. We conducted in depth interviews with delivery partners (n=23), and a focus group with the central support system (n= 4). CSU provided a sounding board to organizations to create buy-in (adoption) and plan ahead. Essential elements within capacity building strategies included: a support unit champion, enhance delivery partner skills, self efficacy and confidence; interactive assistance to answer questions and clarify materials. There is a key role for capacity building under the stewardship of the CSU to promote implementation success. Investigating specific elements within capacity building strategies that drive implementation success continues to be a relevant question for implementation science researchers, that deserves further attention.Medicine, Faculty ofFamily Practice, Department ofReviewedFacultyResearche

Rapidly adapting an effective health promoting intervention for older adults—choose to move—for virtual delivery during the COVID-19 pandemic

Background The COVID-19 (COVID) pandemic shifted way of life for all Canadians. ‘Stay-at-home’ public health directives counter transmission of COVID but may cause, or exacerbate, older adults’ physical and social health challenges. To counter unintentional consequences of these directives, we rapidly adapted an effective health promoting intervention for older adults—Choose to Move (CTM)—to be delivered virtually throughout British Columbia (BC). Our specific objectives were to 1. describe factors that influence whether implementation of CTM virtually was acceptable, and feasible to deliver, and 2. assess whether virtual delivery retained fidelity to CTM’s core components. Methods We conducted a 3-month rapid adaptation feasibility study to evaluate the implementation of CTM, virtually. Our evaluation targeted two levels of implementation within a larger socioeconomic continuum: 1. the prevention delivery system, and 2. older adult participants. We implemented 33 programs via Zoom during BC’s 1st wave acute and transition stages of COVID (April–October 2020). We conducted semi-structured 30-45 min telephone focus groups with 9 activity coaches (who delivered CTM), and semi-structured 30-45 min telephone interviews with 30 older adult participants, at 0- and 3-months. We used deductive framework analysis for all qualitative data to identify themes. Results Activity coaches and older adults identified three key factors that influenced acceptability (a safe and supportive space to socially connect, the technological gateway, and the role of the central support unit) and two key factors that influenced feasibility (a virtual challenge worth taking on and CTM flexibility) of delivering CTM virtually. Activity coaches also reported adapting CTM during implementation; adaptations comprised two broad categories (time allocation and physical activity levels). Conclusion It was feasible and acceptable to deliver CTM virtually. Programs such as CTM have potential to mitigate the unintended consequences of public health orders during COVID associated with reduced physical activity, social isolation, and loneliness. Adaptation and implementation strategies must be informed by community delivery partners and older adults themselves. Pragmatic, virtual health promoting interventions that can be adapted as contexts rapidly shift may forevermore be an essential part of our changing world.Other UBCReviewedOtherUnknow

“It makes me feel not so alone”: features of the Choose to Move physical activity intervention that reduce loneliness in older adults

Background: Despite the well-known health benefits of physical activity (PA), older adults are the least active citizens. Older adults are also at risk for loneliness. Given that lonely individuals are at risk for accelerated loss of physical functioning and health with age, PA interventions that aim to enhance social connectedness may decrease loneliness and increase long-term PA participation. The objectives of this mixed-method study are to: (1) evaluate whether an evidence-based PA intervention (Choose to Move; CTM) influenced PA and loneliness differently among self-identified ‘lonely’ versus ‘not lonely’ older adults and (2) to describe factors within CTM components most likely to promote social connectedness/reduce loneliness. Methods: CTM is a flexible, scalable, community-based health promoting physical activity intervention for older adults. Two community delivery partner organizations delivered 56 CTM programs in 26 urban locations across British Columbia. We collected survey data from participants (n = 458 at baseline) at 0 (baseline), 3 (mid-intervention) and 6 (post-intervention) months. We conducted in depth interviews with a subset of older adults to understand how CTM facilitated or impeded their PA and social connectedness. Results: PA increased significantly from baseline to 3 months in lonely and not lonely participants. PA decreased significantly from 3 to 6 months in lonely participants; however, PA at 6 months remained significantly above baseline levels in both groups. Loneliness decreased significantly from baseline to 3 and 6 months in participants identifying as lonely at baseline. Factors within CTM components that promote social connectedness/reduce loneliness include: Activity coach characteristics/personality traits and approaches; opportunity to share information and experiences and learn from others; engagement with others who share similar/familiar experiences; increased opportunity for meaningful interaction; and accountability. Conclusion: Health promoting interventions that focus on PA and social connectedness through group-based activities can effectively reduce social isolation and loneliness of older adults. Given the ‘epidemic of loneliness’ that plagues many countries currently, these kinds of interventions are timely and important. Research that further delineates mechanisms (e.g., sharing experiences vs. lectures), that modify the effect of an intervention on social connectedness outcomes for older adults engaged in community-based PA programs would be a welcome addition to the literature.Medicine, Faculty ofOther UBCFamily Practice, Department ofReviewedFacult

Impact of the single site order in LTC : exacerbation of an overburdened system

Background: The long-term care (LTC) sector has been at the epicentre of COVID-19 in Canada. This study aimed to understand the impact that the Single Site Order (SSO) had on staff and leadership in four LTC homes in the Lower Mainland of British Columbia, Canada. Methods A mixed method study was conducted by analyzing administrative staffing data. Overtime, turnover, and job vacancy data were extracted and analyzed from four quarters before (April 2019 – March 2020) and four quarters during the pandemic (April 2020 – March 2021) using scatterplots and two-part linear trendlines across total direct care nursing staff and by designation (i.e., registered nurses (RNs), licenced practical nurses (LPNs) and care aids (CAs)). Virtual interviews were conducted with a purposive sample of leadership (10) and staff (18) from each of the four partner care homes (n = 28). Transcripts were analyzed in NVivo 12 using thematic analysis. Results Quantitative data indicated that the total overtime rate increased from before to during the pandemic, with RNs demonstrating the steepest rate increase. Additionally, while rates of voluntary turnover showed an upward trend before the pandemic for all direct care nursing staff, the rate for LPNs and, most drastically, for RNs was higher during the pandemic, while this rate decreased for CAs. Qualitative analysis identified two main themes and sub-themes: (1) overtime (loss of staff, mental health, and sick leave) and (2) staff turnover (the need to train new staff, and gender/race) as the most notable impacts associated with the SSO. Conclusions The results of this study indicate that the outcomes due to COVID-19 and the SSO are not equal across nursing designations, with the RN shortage in the LTC sector highly evident. Quantitative and qualitative data underscore the substantial impact the pandemic and associated policies have on the LTC sector, namely, that staff are over-worked and care homes are understaffed.Applied Science, Faculty ofMedicine, Faculty ofNon UBCFamily Practice, Department ofNursing, School ofReviewedFacultyResearcherGraduateUnknow

Effects of assisted and variable mechanical ventilation on cardiorespiratory interactions in anesthetized pigs

The physiological importance of respiratory sinus arrhythmia (RSA) and cardioventilatory coupling (CVC) has not yet been fully elucidated, but these phenomena might contribute to improve ventilation/perfusion matching, with beneficial effects on gas exchange. Furthermore, decreased RSA amplitude has been suggested as an indicator of impaired autonomic control and poor clinical outcome, also during positive-pressure mechanical ventilation (MV). However, it is currently unknown how different modes of MV, including variable tidal volumes (VT), affect RSA and CVC during anesthesia. We compared the effects of pressure controlled (PCV) versus pressure assisted (PSV) ventilation, and of random variable versus constant VT, on RSA and CVC in eight anesthetized pigs. At comparable depth of anesthesia, global hemodynamics, and ventilation, RSA amplitude increased from 20 ms in PCV to 50 ms in PSV (p < 0.05). CVC was detected (using proportional Shannon entropy of the interval between each inspiration onset and the previous R-peak in ECG) in two animals in PCV and seven animals in PSV. Variable VT did not significantly influence these phenomena. Furthermore, heart period and systolic arterial pressure oscillations were in phase during PCV but in counter-phase during PSV. At the same depth of anesthesia in pigs, PSV increases RSA amplitude and CVC compared to PCV. Our data suggest that the central respiratory drive, but not the baroreflex or the mechano-electric feedback in the heart, is the main mechanism behind the RSA increase. Hence, differences in RSA and CVC between mechanically ventilated patients might reflect the difference in ventilation mode rather than autonomic impairment. Also, since gas exchange did not increase from PCV to PSV, it is questionable whether RSA has any significance in improving ventilation/perfusion matching during M