CONNECT for quality: protocol of a cluster randomized controlled trial to improve fall prevention in nursing homes

<p>Abstract</p> <p>Background</p> <p>Quality improvement (QI) programs focused on mastery of content by individual staff members are the current standard to improve resident outcomes in nursing homes. However, complexity science suggests that learning is a social process that occurs within the context of relationships and interactions among individuals. Thus, QI programs will not result in optimal changes in staff behavior unless the context for social learning is present. Accordingly, we developed CONNECT, an intervention to foster systematic use of management practices, which we propose will enhance effectiveness of a nursing home Falls QI program by strengthening the staff-to-staff interactions necessary for clinical problem-solving about complex problems such as falls. The study aims are to compare the impact of the CONNECT intervention, plus a falls reduction QI intervention (CONNECT + FALLS), to the falls reduction QI intervention alone (FALLS), on fall-related process measures, fall rates, and staff interaction measures.</p> <p>Methods/design</p> <p>Sixteen nursing homes will be randomized to one of two study arms, CONNECT + FALLS or FALLS alone. Subjects (staff and residents) are clustered within nursing homes because the intervention addresses social processes and thus must be delivered within the social context, rather than to individuals. Nursing homes randomized to CONNECT + FALLS will receive three months of CONNECT first, followed by three months of FALLS. Nursing homes randomized to FALLS alone receive three months of FALLs QI and are offered CONNECT after data collection is completed. Complexity science measures, which reflect staff perceptions of communication, safety climate, and care quality, will be collected from staff at baseline, three months after, and six months after baseline to evaluate immediate and sustained impacts. FALLS measures including quality indicators (process measures) and fall rates will be collected for the six months prior to baseline and the six months after the end of the intervention. Analysis will use a three-level mixed model.</p> <p>Discussion</p> <p>By focusing on improving local interactions, CONNECT is expected to maximize staff's ability to implement content learned in a falls QI program and integrate it into knowledge and action. Our previous pilot work shows that CONNECT is feasible, acceptable and appropriate.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov: <a href="http://www.clinicaltrials.gov/ct2/show/NCT00636675">NCT00636675</a></p

Local interaction Strategies and Capacity for Better Care in Nursing Homes: A Multiple Case Study

To describe relationship patterns and management practices in nursing homes (NHs) that facilitate or pose barriers to better outcomes for residents and staff. Methods: We conducted comparative, multiple-case studies in selected NHs (N = 4). Data were collected over six months from managers and staff (N = 406), using direct observations, interviews, and document reviews. Manifest content analysis was used to identify and explore patterns within and between cases. Results: Participants described interaction strategies that they explained could either degrade or enhance their capacity to achieve better outcomes for residents; people in all job categories used these 'local interaction strategies'. We categorized these two sets of local interaction strategies as the 'common pattern' and the 'positive pattern' and summarize the results in two models of local interaction. Conclusions: The findings suggest the hypothesis that when staff members in NHs use the set of positive local interaction strategies, they promote inter-connections, information exchange, and diversity of cognitive schema in problem solving that, in turn, create the capacity for delivering better resident care. We propose that these positive local interaction strategies are a critical driver of care quality in NHs. Our hypothesis implies that, while staffing levels and skill mix are important factors for care quality, improvement would be difficult to achieve if staff members are not engaged with each other in these ways.National Institutes of Health 2 R01NR003178-04A2Claude A. Pepper Older American's Independence Center AG-11268Paul A. Beeson Award NIA AG024787VA Health Services Research and Development EDU 08-417John A. Hartford Building Academic Geriatric Nursing Claire M. Fagin FellowshipBusiness Administratio

Making sense of health information technology implementation: A qualitative study protocol

BACKGROUND: Implementing new practices, such as health information technology (HIT), is often difficult due to the disruption of the highly coordinated, interdependent processes (e.g., information exchange, communication, relationships) of providing care in hospitals. Thus, HIT implementation may occur slowly as staff members observe and make sense of unexpected disruptions in care. As a critical organizational function, sensemaking, defined as the social process of searching for answers and meaning which drive action, leads to unified understanding, learning, and effective problem solving -- strategies that studies have linked to successful change. Project teamwork is a change strategy increasingly used by hospitals that facilitates sensemaking by providing a formal mechanism for team members to share ideas, construct the meaning of events, and take next actions. METHODS: In this longitudinal case study, we aim to examine project teams' sensemaking and action as the team prepares to implement new information technology in a tiertiary care hospital. Based on management and healthcare literature on HIT implementation and project teamwork, we chose sensemaking as an alternative to traditional models for understanding organizational change and teamwork. Our methods choices are derived from this conceptual framework. Data on project team interactions will be prospectively collected through direct observation and organizational document review. Through qualitative methods, we will identify sensemaking patterns and explore variation in sensemaking across teams. Participant demographics will be used to explore variation in sensemaking patterns. DISCUSSION: Outcomes of this research will be new knowledge about sensemaking patterns of project teams, such as: the antecedents and consequences of the ongoing, evolutionary, social process of implementing HIT; the internal and external factors that influence the project team, including team composition, team member interaction, and interaction between the project team and the larger organization; the ways in which internal and external factors influence project team processes; and the ways in which project team processes facilitate team task accomplishment. These findings will lead to new methods of implementing HIT in hospitals

Healthcare teams as complex adaptive systems : understanding team behaviour through team members’ perception of interpersonal interaction

Background: Complexity science has been introduced in healthcare as a theoretical framework to better understand complex situations. Interdisciplinary healthcare teams can be viewed as Complex Adaptive Systems (CAS) by focusing more on the team members' interaction with each other than on the characteristics of individual team members. Viewing teams in this way can provide us with insights into the origins of team behaviour. The aim of this study is to describe the functioning of a healthcare team as it originates from the members' interactions using the CAS principles as a framework and to explore factors influencing workplace learning as emergent behaviour. Methods: An interview study was done with 21 palliative home-care nurses, 20 Community nurses and 18 general practitioners in Flanders, Belgium. A two-step analysis consisted of a deductive approach, which uses the CAS principles as coding framework for interview transcripts, followed by an inductive approach, which identifies patterns in the codes for each CAS principle. Results: All CAS principles were identified in the interview transcripts of the three groups. The most prevalent principles in our study were principles with a structuring effect on team functioning: team members act autonomously guided by internalized basic rules; attractors shape the team functioning; a team has a history and is sensitive to initial Conditions; and a team is an open system, interacting with its environment. The other principles, focusing on the result of the structuring principles, were present in the data, albeit to a lesser extent: team members' interactions are non-linear; interactions between team members can produce unpredictable behaviour; and interactions between team members can generate new behaviour. Patterns, reflecting team behaviour, were recognized in the coding of each CAS principle. Patterns of team behaviour, identified in this way, were linked to interprofessional competencies of the Interprofessional Collaboration Collaborative. Factors influencing workplace learning were identified. Conclusions: This study provides us with insights into the origin of team functioning by explaining how patterns of interactions between team members define team behaviour. Viewing healthcare teams as Complex Adaptive Systems may offer explanations of different aspects of team behaviour with implications for education, practice and research

Certified Nursing Assistants' Explanatory Models of Nursing Home Resident Depression

In this study, we explored how Certified Nursing Assistants (CNAs) understood resident depression. Interviews with 18 CNAs, working in two nursing homes were guided by Kleinman’s Explanatory Models of Illness framework. Interview data were content analyzed and CNAs’ descriptions of depression were compared to the MDS 2.0 Mood Screen and to DSM-IV-TR Depression Criteria. CNAs identified causes, signs, and symptoms of depression, but they were unsure about the duration and normalcy of depression in residents. Although they had no formal training, CNAs felt responsible for detecting depression and described verbal and non-verbal approaches that they used for emotional care of depressed residents. CNAs hold potential to improve the detection of depression and contribute to the emotional care of residents. Attention to knowledge deficits and facility barriers may enhance this capacity

Uso terapêutico e cosmético de compostos produzidos por microrganismos : uma revisão bibliográfica

Os microrganismos, que estão intrinsecamente ligados a patologias, apresentam enorme potencial de serem utilizados para a produção de diversos tipos de medicamentos, terapias, ferramentas de diagnóstico, cosméticos e outras substâncias utilizadas pela indústria médica e cosmética. A medicina utiliza produtos de microrganismos para a produção de medicamentos e tratamentos para diversas condições, assim como a cosmética os utiliza na produção de ativos para tratamentos estéticos e na composição de cosméticos. Os grandes avanços na biotecnologia e na engenharia genética permitiram que esses organismos fossem manipulados e utilizados para a produção de uma diversidade de compostos a nível industrial, tornando-se uma das mais importantes alternativas sustentáveis e de baixo custo na produção de insumos médicos e cosméticos.Microorganisms, which are intrinsically linked to pathologies, have enormous potential to be used for the production of various types of drugs, therapies, diagnostic tools, cosmetics and other substances used by the medical and cosmetic industry. Medicine uses products from microorganisms to produce drugs and treatments for various conditions. Also, ita can be used in the production of actives for esthetic treatments and in the composition of cosmetics. The great advances in biotechnology and genetic engineering have allowed these organisms to be manipulated and used to produce a variety of compounds at an industrial level, making them one of the most important sustainable and low-cost alternatives in the production of medical and cosmetic inputs

Dementia care for residents in rural nursing homes : a process evaluation of the enhancing care program

Persons with dementia experience impairments in cognitive, behavioral, and functional ability, often leading to long-term care placement. The Enhancing Care Program was developed by the Alzheimer Society of Canada to assist organizations in improving care for this population. Although this program has been implemented in many facilities, the majority have been located in urban settings and there has been limited formal evaluation. Little is known about dementia care in rural facilities, or about how programs are implemented in rural settings. The Enhancing Care Program is based on eleven guidelines that outline best practices for caring for individuals with dementia. With the assistance of a facilitator from the Alzheimer Society, a multi-disciplinary team from the facility assesses their current ability to meet each guideline. In subsequent meetings, the team establishes specific, measurable goals to improve care in targeted areas. The two purposes of this study were to conduct a process evaluation of the Enhancing Care Program and to develop theory relating to the implementation of a program in two rural long-term care facilities. Observations were made over the course of seven months as teams worked through the guidelines and set goals. Focus group interviews consisting of team members took place at the end of the observation period. In addition, individual interviews were conducted with general staff, the facility managers, and the facilitator from the Alzheimer Society. Grounded theory methodology informed the research and analysis process. The theory that emerged, The Process of Building Effective Teams, explains the transition of the participants from collections of individuals to cohesive units that functioned as teams. Five key categories were developed in the theory: trust, respectful and open communication, transformational leadership, creating change collectively, and enhanced team culture. As part of the process evaluation of the Enhancing Care Program, 24 recommendations were made for program improvements

Measurement of the diffractive cross-section in deep inelastic scattering

Diffractive scattering of $\gamma^* p \to X + N$, where $N$ is either a proton or a nucleonic system with $M_N~<~4$~GeV has been measured in deep inelastic scattering (DIS) at HERA. The cross section was determined by a novel method as a function of the $\gamma^* p$ c.m. energy $W$ between 60 and 245~GeV and of the mass $M_X$ of the system $X$ up to 15~GeV at average $Q^2$ values of 14 and 31~GeV$^2$. The diffractive cross section $d\sigma^{diff} /dM_X$ is, within errors, found to rise linearly with $W$. Parameterizing the $W$ dependence by the form d\sigma^{diff}/dM_X \propto (W^2)^{(2\overline{\mbox{\alpha_{_{I\hspace{-0.2em}P}}}} -2)} the DIS data yield for the pomeron trajectory \overline{\mbox{\alpha_{_{I\hspace{-0.2em}P}}}} = 1.23 \pm 0.02(stat) \pm 0.04 (syst) averaged over $t$ in the measured kinematic range assuming the longitudinal photon contribution to be zero. This value for the pomeron trajectory is substantially larger than \overline{\mbox{\alpha_{_{I\hspace{-0.2em}P}}}} extracted from soft interactions. The value of \overline{\mbox{\alpha_{_{I\hspace{-0.2em}P}}}} measured in this analysis suggests that a substantial part of the diffractive DIS cross section originates from processes which can be described by perturbative QCD. From the measured diffractive cross sections the diffractive structure function of the proton F^{D(3)}_2(\beta,Q^2, \mbox{x_{_{I\hspace{-0.2em}P}}}) has been determined, where $\beta$ is the momentum fraction of the struck quark in the pomeron. The form F^{D(3)}_2 = constant \cdot (1/ \mbox{x_{_{I\hspace{-0.2em}P}}})^a gives a good fit to the data in all $\beta$ and $Q^2$ intervals with $a = 1.46 \pm 0.04 (stat) \pmComment: 45 pages, including 16 figure