Carrie McAiney

A unique practice model for Nurse Practitioners in long‐term care homes

AIM This paper is a report of a study examining a practice model for Nurse Practitioners (NPs) working in long-term care (LTC) homes and its impact on staff confidence, preventing hospital admission, and promoting early hospital discharge. BACKGROUND The recent introduction of NPs in LTC homes in Ontario, Canada, provided an opportunity to explore unique practice models. In a pilot project, two full-time equivalent NPs provided primary care to a consortium of 22 homes serving approximately 2900 residents. The practice model was based on the specific needs of the homes and residents. METHODS The NPs working in this project prospectively collected data (from July 2003 until June 2004) on their clinical activities and resident outcomes. Directors of Care (n = 18) of the participating homes completed a questionnaire (March 2004) assessing the impact on prevention of hospitalization and staff confidence. FINDINGS The NPs had 2315 clinical contacts in the 1-year period; the majority (64%) were follow-up contacts. Many contacts were for uncomplicated medical problems or more complex but straightforward medical issues, and had positive outcomes. Hospital admission was prevented in 39-43% of cases. NPs had a positive impact on improving staff confidence, but no impact on facilitating early discharge from hospital. CONCLUSION Practice models designed to meet the distinctive needs of LTC homes and residents can enhance quality of care, even with low NP:resident ratios. Participation of key stakeholders in the identification of care priorities and planning contributed to the success of this model.

Sustained Transfer of Knowledge to Practice in Long-Term Care: Facilitators and Barriers of a Mental Health Learning Initiative

This article explores facilitators and barriers to the impact and sustainability of a learning initiative to increase capacity of long-term care (LTC) homes to manage the mental health needs of older persons, through development of in-house Psychogeriatric Resource Persons (PRPs). Twenty interviews were conducted with LTC staff. Management support, particularly designation of time for PRP activities, development of PRP teams, and supportive learning strategies were significant factors affecting sustained knowledge transfer. Continuing education that is provided and evaluated on an ongoing basis, secures management commitment, is integrated within a broader system strategy, and provides on–the–job support has the greatest potential to affect care.

Theoretical foundations guiding culture change: The work of the Partnerships in Dementia Care Alliance

Longstanding concerns about quality care provision, specifically in the area of long-term care, have prompted calls for changing the culture of care to reflect more client-driven and relationship-centred models. Despite an increase in culture change initiatives in both Canada and the United States, there is insufficient information about the theories and approaches that guide culture change. The purpose of this paper is to describe a culture change initiative currently underway in Canada, the Partnerships in Dementia Care Alliance, and the theoretical foundations informing our work. More specifically, we describe how the theoretical and philosophical underpinnings of the Alzheimer Disease and Related Dementias framework, the authentic partnership approach, participatory action research and Appreciative Inquiry have been integrated to guide a culture change process that encourages working collaboratively, thinking and doing differently and re-imagining new possibilities for changing the culture of dementia care.

Resident and family perceptions of the nurse practitioner role in long term care settings: a qualitative descriptive study

BackgroundResearch evidence supports the positive impact on resident outcomes of nurse practitioners (NPs) working in long term care (LTC) homes. There are few studies that report the perceptions of residents and family members about the role of the NP in these settings. The purpose of this study was to explore the perceptions of residents and family members regarding the role of the NP in LTC homes.MethodsThe study applied a qualitative descriptive approach. In-depth individual and focus group interviews were conducted with 35 residents and family members from four LTC settings that employed a NP. Conventional content analysis was used to identify themes and sub-themes.ResultsTwo major themes were identified: NPs were seen as providing resident and family-centred care and as providing enhanced quality of care. NPs established caring relationships with residents and families, providing both informational and emotional support, as well as facilitating their participation in decision making. Residents and families perceived the NP as improving availability and timeliness of care and helping to prevent unnecessary hospitalization.ConclusionsThe perceptions of residents and family members of the NP role in LTC are consistent with the concepts of person-centred and relationship-centred care. The relationships NPs develop with residents and families are a central means through which enhanced quality of care occurs. Given the limited use of NPs in LTC settings, there is an opportunity for health care policy and decision makers to address service inadequacies through strategic deployment of NPs in LTC settings. NPs can use their expert knowledge and skill to assist residents and families to make informed choices regarding their health care and maintain a positive care experience.

Reducing depression in older home care clients: design of a prospective study of a nurse-led interprofessional mental health promotion intervention

BackgroundVery little research has been conducted in the area of depression among older home care clients using personal support services. These older adults are particularly vulnerable to depression because of decreased cognition, comorbid chronic conditions, functional limitations, lack of social support, and reduced access to health services. To date, research has focused on collaborative, nurse-led depression care programs among older adults in primary care settings. Optimal management of depression among older home care clients is not currently known. The objective of this study is to evaluate the feasibility, acceptability and effectiveness of a 6-month nurse-led, interprofessional mental health promotion intervention aimed at older home care clients with depressive symptoms using personal support services.Methods/DesignThis one-group pre-test post-test study aims to recruit a total of 250 long-stay (> 60 days) home care clients, 70 years or older, with depressive symptoms who are receiving personal support services through a home care program in Ontario, Canada. The nurse-led intervention is a multi-faceted 6-month program led by a Registered Nurse that involves regular home visits, monthly case conferences, and evidence-based assessment and management of depression using an interprofessional approach. The primary outcome is the change in severity of depressive symptoms from baseline to 6 months using the Centre for Epidemiological Studies in Depression Scale. Secondary outcomes include changes in the prevalence of depressive symptoms and anxiety, health-related quality of life, cognitive function, and the rate and appropriateness of depression treatment from baseline to 12 months. Changes in the costs of use of health services will be assessed from a societal perspective. Descriptive and qualitative data will be collected to examine the feasibility and acceptability of the intervention and identify barriers and facilitators to implementation.DiscussionData collection began in May 2010 and is expected to be completed by July 2012. A collaborative nurse-led strategy may provide a feasible, acceptable and effective means for improving the health of older home care clients by improving the prevention, recognition, and management of depression in this vulnerable population. The challenges involved in designing a practical, transferable and sustainable nurse-led intervention in home care are also discussed.Trial RegistrationClinicalTrials.gov: NCT01407926

Managing Heart Failure in the Long-Term Care Setting: Nurses’ Experiences in Ontario, Canada

BackgroundImplementation of heart failure guidelines in long-term care (LTC) settings is challenging. Understanding the conditions of nursing practice can improve management, reduce suffering, and prevent hospital admission of LTC residents living with heart failure. ObjectiveThe aim of the study was to understand the experiences of LTC nurses managing care for residents with heart failure. MethodsThis was a descriptive qualitative study nested in Phase 2 of a three-phase mixed methods project designed to investigate barriers and solutions to implementing the Canadian Cardiovascular Society heart failure guidelines into LTC homes. Five focus groups totaling 33 nurses working in LTC settings in Ontario, Canada, were audiorecorded, then transcribed verbatim, and entered into NVivo9. A complex adaptive systems framework informed this analysis. Thematic content analysis was conducted by the research team. Triangulation, rigorous discussion, and a search for negative cases were conducted. Data were collected between May and July 2010. ResultsNurses characterized their experiences managing heart failure in relation to many influences on their capacity for decision-making in LTC settings: (a) a reactive versus proactive approach to chronic illness; (b) ability to interpret heart failure signs, symptoms, and acuity; (c) compromised information flow; (d) access to resources; and (e) moral distress. DiscussionHeart failure guideline implementation reflects multiple dynamic influences. Leadership that addresses these factors is required to optimize the conditions of heart failure care and related nursing practice.

Perspectives of Primary-Care Providers on Heart Failure in Long-Term Care Homes

L’insuffisance cardiaque (IC) est fréquente chez les résidents en soins de longue durée (SLD), et peut représenter 40 pour cent des transferts aux soins aigus. Des lignes directrices de l’IC de la Société canadienne de cardiologie approuvent les traitements standards, mais les résidents de SLD sont moins susceptibles de recevoir un traitement.* Cette étude qualitative a utilisé des groupes de discussion pour explorer les perceptions, de 18 médécins et infirmières praticiennes dans trois foyers de l’Ontario, des pratiques de soins de l’IC et les défis de SLD. Par exemple, les participants ont rapporté les défis concernant aptitudes diagnostiques et les connaissances procédurales de l’IC. Ils ont également identifié la nécessité de la collaboration interprofessionnelle et la clarification des rôles pour améliorer les soins et les résultats de l’IC. Pour résoudre ces problèmes, les interventions multi-modales et l’enseignement de chevet sont requis. Le leadership a été considéré comme essentielle pour améliorer les soins de l’IC. Plusieurs préoccupations ont surgi concernant les lacunes dans les connaissances et les déficits cliniques chez les fournisseurs de soins primaires qui traitent l’insuffisance cardiaque chez les résidents de SLD. Pour améliorer les soins de l’IC à long terme, des solutions éducatives et interprofessionnelles multi-modales et cliniquement ciblées sont nécessaires. Heart failure (HF) is common among long-term care (LTC) residents, and may account for 40 per cent of acute-care transfers. Canadian Cardiovascular Society HF guidelines endorse standard therapies; yet LTC residents are less likely to receive treatment. This qualitative study employed focus groups to explore perceptions, from 18 physicians and nurse practitioners in three Ontario homes, on HF care practices and challenges. For example, participants reported challenges with HF diagnostic skills and procedural knowledge. They also identified the need for interprofessional collaboration and role clarification to improve HF care and outcomes. To address these challenges, multimodal interventions and bedside teaching are required. Leadership was viewed as essential to improve HF care. Several concerns arose regarding knowledge gaps and clinical deficits among primary-care providers who manage heart failure in LTC residents. Multimodal, clinically focused educational and interprofessional solutions are needed to improve HF care in long-term care.

Rural Geriatric Glue: A Nurse Practitioner-Led Model of Care for Enhancing Primary Care for Frail Older Adults within an Ecosystem Approach

This article describes the implementation of the Care for Seniors model of care, an innovative approach to improving care coordination and integration, and provides preliminary evidence of effective use of specialist resources and acute care services.

A Quality Assurance Study to Assess the One-Day Prevalence of Delirium in Elderly Hospitalized Patients

Background Research indicates that 40% of hospital-acquired delirium cases may be preventable. However, despite its clinical significance, delirium often goes unrecognized or is misdiagnosed. The purpose of this study was to assess the need for delirium education in acute care hospitals in Hamilton, Ontario. Methods Approximately 100 health professionals were trained as delirium screeners. On ‘Delirium Day’, all patients ≥ 65 years of age in non-critical care areas in all acute care sites in Hamilton were identified. Those willing to take part in the prevalence study were assessed for delirium using the Standardized Mini-Mental State Examination and the Confusion Assessment Method. The Research Ethics Boards at Hamilton Health Sciences and St. Joseph’s Healthcare Hamilton approved this quality assurance project. Results Of the 562 patients eligible for screening, eight were excluded and six did not have sufficient data collected to assess for delirium. Of the 548 individuals screened for delirium, 10.6% screened positive. Prevalence estimates ranged by site from 0% to 21% and type of unit from 3.8% to 16%. Recognition of delirium by nursing staff was fair; but, documentation was usually absent. Conclusion While the prevalence rates were somewhat lower than in other studies, the results support the need for education among health-care providers in the prevention, identification, and management of delirium.

Collaborative Care for Psychiatric Disorders in Older Adults: A Systematic Review:

Objective: To evaluate the mode of implementation, clinical outcomes, cost-effectiveness, and the factors influencing uptake and sustainability of collaborative care for psychiatric disorders in older adults. Design: Systematic review. Setting: Primary care, home health care, seniors’ residence, medical inpatient and outpatient. Participants: Studies with a mean sample age of 60 years and older. Intervention: Collaborative care for psychiatric disorders. Methods: PubMed, MEDLINE, Embase, and Cochrane databases were searched up until October 2016. Individual randomized controlled trials and cohort, case-control, and health service evaluation studies were selected, and relevant data were extracted for qualitative synthesis. Results: Of the 552 records identified, 53 records (from 29 studies) were included. Very few studies evaluated psychiatric disorders other than depression. The mode of implementation differed based on the setting, with beneficial use of telemedicine. Clinical outcomes for depression were significantly better compared with usual care across settings. In depression, there is some evidence for cost-effectiveness. There is limited evidence for improved dementia care and outcomes using collaborative care. There is a lack of evidence for benefit in disorders other than depression or in settings such as home health care and general acute inpatients. Attitudes and skill of primary care staff, availability of resources, and organizational support are some of the factors influencing uptake and implementation. Conclusions: Collaborative care for depressive disorders is feasible and beneficial among older adults in diverse settings. There is a paucity of studies on collaborative care in conditions other than depression or in settings other than primary care, indicating the need for further evaluation.