How to Implement and Sustain Better Oral Health in Home Care for Older People: A Realist Mixed Method Case Study

Background Robust evidence demonstrates good oral health is essential for healthy ageing, yet it is described as one of the most neglected aspects of care experienced by older people. The aged care sector’s lack of insight into the consequences of poor oral health and inadequate oral health content in entry-level nursing and aged care qualifications are cited as contributing factors. Although various interventions have demonstrated short-term oral healthcare improvements, longlong-term sustainability has been elusive. Aim To identify the factors that influenced the implementation and sustainability of an evidence-based community aged care (home care) model called ‘Better Oral Health in Home Care’ between Time 1 i mplementation 2012 20142014) and Time 2 (p ost implementation 2017 2018)2018). This included evaluating the relevance of the m odel’s learning and teaching package for students undertaking entry level nursing or aged care qualifications. Design The study was a realist mixed method case study based on three interrelated elements of inquiry. Participants included home care staff, clients, students and educators. Qualitative and quantitative data analyses were reported on in three publications. The first publication, guided by the Promoting Action on Research Implementation in Health Services framework, explored the implementation of the model at Time 1. The second publication used the Kirkpatrick model to evaluate the relevance of the learning and teaching package for students undertaking entry-level nursing or aged care qualifications. The third publication applied Normalisation Process Theory with Realist Evaluation to explain the extent to which the model had been embedded in sustainable practice at Time 2. Results At Time 1, the model led to improvements in older people’s oral health by providing community-based prevention and early detection of oral health problems. Process analysis identified multi-level facilitation as instrumental to the successful development of tailored implementation strategies that were highly suitable to home care. Home care workers’ responses to the learning and teaching package were positive; they reported improved oral health knowledge and skills. The package was also found to be relevant for students undertaking entry-level nursing or aged care qualifications. High levels of student and educator satisfaction were reported, with students describing positive attitudes and significant improvements in oral health knowledge and skills. At Time 2, findings showed that ongoing benefits for clients, continued use of the model and sustained home care workforce capacity had not eventuated. A range of contextual factors were identified, and a lack of facilitation hindered the model’s long-term sustainability. Conclusion This study uniquely captured the journey from implementation to evaluating sustainability in a way not previously demonstrated in oral healthcare research. The realist approach provided a deeper understanding of how contextual factors influenced the ability of home care staff to implement and sustain oral healthcare at macro, meso and micro levels of practice. This study contributes to a theoretical understanding of the importance of facilitation as a key element in the processes of implementation and sustainability. Practical strategies and recommendations for future research are suggested, highlighting the need for greater inter-sectorial collaboration to embed sustainable evidence-based oral healthcare for older people.Thesis (Ph.D.) -- University of Adelaide, Adelaide Nursing School, 201

Ethnic identity development among Black high school students

The purpose of this study was to determine if there were differences in ethnic identity as a function of gender and academic grade level and to determine if there was an interaction between gender and grade level among Black adolescents. The Multigroup Ethnic Identity Measure (MEIM) was administered to 179 Black male and female high school students from diverse socioeconomic backgrounds recruited from two urban high schools in a Midwestern metropolitan area with a population of 105,000. The sample included 9th, 10th, 11th, and 12th graders ranging in age from 14 to 19 with a mean age of 16.3 for the entire population. Results showed that, on the total scale score, ethnic identity, and on the three subscale scores on the MEIM (affirmation/ belonging, ethnic behavior and ethnic identity achievement), there were no statistically significant differences in ethnic identity development as a function of gender and grade level. There was no statistically significant interaction between gender and grade level. These findings are discussed in terms of their implications for further research

Frailty in Indigenous populations: A scoping review

Background: Indigenous populations experience high rates of age-related illness when compared to their non-Indigenous counterparts. Frailty is a challenging expression of aging and an important public health priority. The purpose of this review was to map what the existing literature reports around frailty in Indigenous populations and to highlight the current gaps in frailty research within the Indigenous landscape. Method: Scoping review of English language original research articles focusing on frailty within Indigenous adult populations in settler colonial countries (Australia, Canada, New Zealand and USA). Ten electronic databases and eight relevant institutional websites were searched from inception to October 2020. Results: Nine articles met our inclusion criteria, finding this population having a higher prevalence of frailty and frailty occurring at younger ages when compared to their non-Indigenous counterparts, but two did not use a formal frailty tool. Females presented with higher levels of frailty. No culturally specific frailty tool was identified, and the included articles did not assess strategies or interventions to manage or prevent frailty in Indigenous peoples. Conclusions: There was little definitive evidence of the true frailty prevalence, approaches to frailty screening and of potential points of intervention to manage or prevent the onset of frailty. Improvements in the quality of evidence are urgently needed, along with further research to determine the factors contributing to higher rates of frailty within Indigenous populations. Incorporation of Indigenous views of frailty, and instruments and programs that are led and designed by Indigenous communities, are crucial to address this public health priority

Levels of frailty and frailty progression in older urban- and regional-living First Nations Australians

OBJECTIVES: To explore the prevalence of frailty, association between frailty and mortality, and transitions between frailty states in urban- and regional-living First Nations Australians.STUDY DESIGN: Secondary analysis of longitudinal data from the Koori Growing Old Well Study. First Nations Australians aged 60 years or more from five non-remote communities were recruited in 2010-2012 and followed up six years later (2016-2018). Data collected at both visits were used to derive a 38-item Frailty Index (FI). The FI (range 0-1.0) was classified as robust (&lt;0.1), pre-frail (0.1- &lt; 0.2), mildly (0.2- &lt; 0.3), moderately (0.3- &lt; 0.4) or severely frail (≥0.4).MAIN OUTCOME MEASURES: Association between frailty and mortality, examined using logistic regression and transitions in frailty (the percentage of participants who changed frailty category) during follow-up.RESULTS: At baseline, 313 of 336 participants (93 %) had sufficient data to calculate a FI. Median FI score was 0.26 (interquartile range 0.21-0.39); 4.79 % were robust, 20.1 % pre-frail, 31.6 % mildly frail, 23.0 % moderately frail and 20.5 % severely frail. Higher baseline frailty was associated with mortality among severely frail participants (adjusted odds ratio 7.11, 95 % confidence interval 2.51-20.09) but not moderately or mildly frail participants. Of the 153 participants with a FI at both baseline and follow-up, their median FI score increased from 0.26 to 0.28.CONCLUSIONS: Levels of frailty in this First Nations cohort are substantially higher than in similar-aged non-Indigenous populations. Screening for frailty before the age of 70 years may be warranted in First Nations Australians. Further research is urgently needed to determine the factors that are driving such high levels of frailty and propose solutions to prevent or manage frailty in this population.</p

Can oral healthcare for older people be embedded into routine community aged care practice? A realist evaluation using normalisation process theory

This author accepted manuscript is made available following 12 month embargo from date of publication (December 2018) in accordance with the publisher’s archiving policyBackground An intervention ‘Better Oral Health in Home Care’ was introduced (2012–2014) to improve the oral health of older people receiving community aged care services. Implementation of the intervention was theoretically framed by the Promoting Action on Research Implementation in Health Services framework. Process outcomes demonstrated significant improvements in older people’s oral health. Objective To evaluate the extent to which the intervention has been embedded and sustained into routine community aged care practice 3 years after the initial implementation project. Design A Realist Evaluation applying Normalisation Process Theory within a single case study setting. Setting Community aged care (home care) provider in South Australia, Australia. Participants Purposeful sampling was undertaken. Twelve staff members were recruited from corporate, management and direct care positions. Two consumers representing high and low care recipients also participated. Methods Qualitative methods were applied in two subcases, reflecting different contextual settings. Data were collected via semi-structured interviews and analysed deductively by applying the Normalisation Process Theory core constructs (with the recommended phases of the Realist Evaluation cycle). Retrospective and prospective analytic methods investigated how the intervention has been operationalised by comparing two timeframes: Time 1 (Implementation June 2012–December 2014) and Time 2 (Post-implementation July 2017–July 2018). Results At Time 1, the initial program theory proposed that multi-level facilitation contributed to a favourable context that triggered positive mechanisms supportive of building organisational and workforce oral healthcare capacity. At Time 2, an alternative program theory of how the intervention has unfolded in practice described a changed context following the withdrawal of the project facilitation processes with the triggering of alternative mechanisms that have made it difficult for staff to embed sustainable practice. Conclusion Findings concur with the literature that successful implementation outcomes do not necessarily guarantee sustainability. The study has provided a deeper explanation of how contextual characteristics have contributed to the conceptualisation of oral healthcare as a low priority, basic work-ready personal care task and how this, in turn, hindered the embedding of sustainable oral healthcare into routine community aged care practice. This understanding can be used to better inform the development of strategies, such as multi-level facilitation, needed to navigate contextual barriers so that sustainable practice can be achieved

Looking out across the front yard: aboriginal peoples' views of frailty in the community - A qualitative study

OBJECTIVE: Frailty is one of the most significant challenges to healthy ageing. Aboriginal Australians experience some of the highest levels of frailty worldwide, and despite this, no studies have explored frailty from an Aboriginal perspective. This is important because Aboriginal understandings and priorities in frailty may differ from Western/mainstream frailty frameworks. Furthermore, this lack of research severely hampers healthcare planning and service delivery. As a starting point, this study aims to understand the experiences, attitudes, and perceptions that Aboriginal older adults hold regarding frailty.DESIGN: A qualitative study that utilized the Indigenous research method of Yarning for data collection as a culturally appropriate process for engaging Aboriginal peoples. Yarning circles and one-on-one yarns with 22 Aboriginal adults aged 45+ years living in one Australian capital city took place online and over the phone to explore the views that Aboriginal adults hold around frailty. Data were analysed thematically by Aboriginal researchers.RESULTS: Seven key thematic areas were identified: (1) Keep in with culture; (2) Physical markers of frailty; (3) Frailty throughout the life course; (4) Social, cultural, and psychological understandings of frailty; (5) We want information about frailty; (6) Appropriate and positive wording; (7) Frailty assessment.CONCLUSIONS: There was interest and engagement in the concept of frailty by Aboriginal older adults and approaches to frailty that extend beyond the physical to address cognitive, psychosocial, cultural and spiritual domains are likely to be more acceptable to this population. Culture and community connectivity are essential elements in preventing and alleviating frailty and have wider positive implications for Aboriginal health and wellbeing. Existing tools in practice to assess frailty are not aligned with Aboriginal cultural norms. Culturally appropriate frailty assessment methods co-designed with the community which incorporate holistic and multidimensional approaches are urgently needed.</p

Nursing Informatics 2018

The curriculum associated with nursing informatics (NI) education is not standardized, therefore the perspectives of new and emerging nurse informaticians is important. How these curricula differences affect career opportunities of new nursing informaticians, and in turn influenced current career choices will be explored. Synthesizing opinions with themes extracted from a 2014 international study—Advancing nursi informatics in the next decade: Recommendations from an international survey will be summarized.</p

Infection of Arabidopsis by cucumber mosaic virus triggers jasmonate‐dependent resistance to aphids that relies partly on the pattern‐triggered immunity factor BAK1

Many aphid-vectored viruses are transmitted nonpersistently via transient attachment of virus particles to aphid mouthparts and are most effectively acquired or transmitted during brief stylet punctures of epidermal cells. In Arabidopsis thaliana, the aphid-transmitted virus cucumber mosaic virus (CMV) induces feeding deterrence against the polyphagous aphid Myzus persicae. This form of resistance inhibits prolonged phloem feeding but promotes virus acquisition by aphids because it encourages probing of plant epidermal cells. When aphids are confined on CMV-infected plants, feeding deterrence reduces their growth and reproduction. We found that CMV-induced inhibition of growth as well as CMV-induced inhibition of reproduction of M.&nbsp;persicae are dependent upon jasmonate-mediated signalling. BRASSINOSTEROID INSENSITIVE1-ASSOCIATED KINASE1 (BAK1) is a co-receptor enabling detection of microbe-associated molecular patterns and induction of pattern-triggered immunity (PTI). In plants carrying the mutant bak1-5 allele, CMV induced inhibition of M.&nbsp;persicae reproduction but not inhibition of aphid growth. We conclude that in wildtype plants CMV induces two mechanisms that diminish performance of M.&nbsp;persicae: a jasmonate-dependent and PTI-dependent mechanism that inhibits aphid growth, and a jasmonate-dependent, PTI-independent mechanism that inhibits reproduction. The growth of two crucifer specialist aphids, Lipaphis erysimi and Brevicoryne brassicae, was not affected when confined on CMV-infected A.&nbsp;thaliana. However, B.&nbsp;brassicae reproduction was inhibited on CMV-infected plants. This suggests that in A.&nbsp;thaliana CMV-induced resistance to aphids, which is thought to incentivize virus vectoring, has greater effects on polyphagous than on crucifer specialist aphids

Implementation of a Cardiogenic Shock Protocol and Data Review Process is Associated With Improved In-Hospital Survival

Background: Despite increasing use of mechanical circulatory support devices (MCS), cardiogenic shock (CS) mortality is persistently high, with worsening outcomes in later stages of CS. Delays in diagnosis and practice variation may contribute to in-hospital mortality. Methods: In June 2018, we devised and implemented a CS protocol at two hospitals from one health system in Portland, OR. The CS protocol was designed to promote early CS recognition, rapid notification of a multi-disciplinary specialty team lead by a heart failure cardiologist, invasive hemodynamic evaluation, and institution of MCS as appropriate. CS was defined by widely accepted clinical and hemodynamic criteria. Patient demographics, disease severity, process metrics, and clinical outcomes were prospectively collected and reviewed monthly by a multi-disciplinary CS task force. M&Ms were conducted routinely to identify improvement opportunities. The task force continually refined data collection, implemented protocol improvements, and educated providers and clinical staff in the emergency department, critical care, intermediate care, and cardiac telemetry units. Education centered on early recognition of CS, protocol for activation, and the time-sensitivity of CS outcomes. Results: From June 1, 2018 to October 1, 2019, identification of CS patients grew from five to 55 patients per month, with 311 total patients identified. Education initially emphasized CS identification and team activation, then expanded to definition of CS stages and hospital-specific protocols. Over 10 months, the CS mortality rate decreased by 30%. Ongoing optimization includes stratifying patients by primary discharge diagnosis, consistently documenting shock stages in the electronic medical record, and refining the transfer process from other hospitals. Conclusions: Implementation of a CS protocol with emphasis on early recognition, hemodynamic assessment, and implementation of MCS is associated with improved survival. Multi-disciplinary education and team engagement in data review are integral to continual process improvement. Character count: 1,818 Clinical Implications: A protocolized, multi-disciplinary approach can improve the outcome of CS