James Conklin

What Are Priorities for Deprescribing for Elderly Patients? Capturing the Voice of Practitioners: A Modified Delphi Process

Polypharmacy and inappropriate medication use among older adults contribute to adverse drug reactions, falls, cognitive impairment, noncompliance, hospitalization and mortality. While deprescribing - tapering, reducing or stopping a medication - is feasible and relatively safe, clinicians find it difficult to carry out. Deprescribing guidelines would facilitate this process. The aim of this paper is to identify and prioritize medication classes where evidence-based deprescribing guidelines would be of benefit to clinicians. A modified Delphi approach included a literature review to identify potentially inappropriate medications for the elderly, an expert panel to develop survey content and three survey rounds to seek consensus on priorities. Panel participants included three pharmacists, two family physicians and one social scientist. Sixty-five Canadian geriatrics experts (36 pharmacists, 19 physicians and 10 nurse practitioners) participated in the survey. Twenty-nine drugs/drug classes were included in the first survey with 14 reaching the required (≥ 70%) level of consensus, and 2 new drug classes added from qualitative comments. Fifty-three participants completed round two, and 47 participants completed round three. The final five priorities were benzodiazepines, atypical antipsychotics, statins, tricyclic antidepressants, and proton pump inhibitors; nine other drug classes were also identified as being in need of evidence-based deprescribing guidelines. The Delphi consensus process identified five priority drug classes for which expert clinicians felt guidance is needed for deprescribing. The classes of drugs that emerged strongly from the rankings dealt with mental health, cardiovascular, gastroenterological, and neurological conditions. The results suggest that deprescribing and overtreatment occurs through the full spectrum of primary care, and that evidence-based deprescribing guidelines are a priority in the care of the elderly.

Knowledge brokers in a knowledge network: the case of Seniors Health Research Transfer Network knowledge brokers

BackgroundThe purpose of this paper is to describe and reflect on the role of knowledge brokers (KBs) in the Seniors Health Research Transfer Network (SHRTN). The paper reviews the relevant literature on knowledge brokering, and then describes the evolving role of knowledge brokering in this knowledge network.MethodsThe description of knowledge brokering provided here is based on a developmental evaluation program and on the experiences of the authors. Data were gathered through qualitative and quantitative methods, analyzed by the evaluators, and interpreted by network members who participated in sensemaking forums. The results were fed back to the network each year in the form of formal written reports that were widely distributed to network members, as well as through presentations to the network’s members.ResultsThe SHRTN evaluation and our experiences as evaluators and KBs suggest that a SHRTN KB facilitates processes of learning whereby people are connected with tacit or explicit knowledge sources that will help them to resolve work-related challenges. To make this happen, KBs engage in a set of relational, technical, and analytical activities that help communities of practice (CoPs) to develop and operate, facilitate exchanges among people with similar concerns and interests, and help groups and individuals to create, explore, and apply knowledge in their practice. We also suggest that the role is difficult to define, emergent, abstract, episodic, and not fully understood.ConclusionsThe KB role within this knowledge network has developed and matured over time. The KB adapts to the social and technical affordances of each situation, and fashions a unique and relevant process to create relationships and promote learning and change. The ability to work with teams and to develop relevant models and feasible approaches are critical KB skills. The KB is a leader who wields influence rather than power, and who is prepared to adopt whatever roles and approaches are needed to bring about a valuable result.

Knowledge-to-action processes in SHRTN collaborative communities of practice: A study protocol

BackgroundThe Seniors Health Research Transfer Network (SHRTN) Collaborative is a network of networks that work together to improve the health and health care of Ontario seniors. The collaborative facilitates knowledge exchange through a library service, knowledge brokers (KBs), local implementation teams, collaborative technology, and, most importantly, Communities of Practice (CoPs) whose members work together to identify innovations, translate evidence, and help implement changes.This project aims to increase our understanding of knowledge-to-action (KTA) processes mobilized through SHRTN CoPs that are working to improve the health of Ontario seniors. For this research, KTA refers to the movement of research and experience-based knowledge between social contexts, and the use of that knowledge to improve practice. We will examine the KTA processes themselves, as well as the role of human agents within those processes. The conceptual framework we have adopted to inform our research is the Promoting Action on Research Implementation in Health Services (PARIHS) framework.Methods/designThis study will use a multiple case study design (minimum of nine cases over three years) to investigate how SHRTN CoPs work and pursue knowledge exchange in different situations. Each case will yield a unique narrative, framed around the three PARIHS dimensions: evidence, context, and facilitation. Together, the cases will shed light on how SHRTN CoPs approach their knowledge exchange initiatives, and how they respond to challenges and achieve their objectives. Data will be collected using interviews, document analysis, and ethnographic observation.DiscussionThis research will generate new knowledge about the defining characteristics of CoPs operating in the health system, on leadership roles in CoPs, and on the nature of interaction processes, relationships, and knowledge exchange mechanisms. Our work will yield a better understanding of the factors that contribute to the success or failure of KTA initiatives, and create a better understanding of how local caregiving contexts interact with specific initiatives. Our participatory design will allow stakeholders to influence the practical usefulness of our findings and contribute to improved health services delivery for seniors.

Development of a Chronic Care Model for Neurological Conditions (CCM-NC).

BackgroundPersons with neurological conditions and their families face a number of challenges with the provision of health and community-based services. The purpose of this study was to understand the existing health and community service needs and gaps in care and to use this information to develop a model to specify factors and processes that may improve the quality of care and health and well-being for persons with neurological conditions.MethodsWe conducted semi-structured interviews with health care professionals, community-based non-health care professionals working with individuals with neurological conditions, and policy makers –from the Ministries of Health, Community and Social Services, Transportation and Education– across Canada. We used a purposive sampling and snowballing approach to obtain maximum variation across professions, sector and geography (provinces and territories, rural and urban). Data analysis was an iterative, constant comparative process involving descriptive and interpretive analyses and was initially guided by the components of the Expanded Chronic Care Model.ResultsA total of 180 individuals completed the interviews: 39% (n = 70) health care professionals, 47% (n = 85) community-based non-health care professionals, and 14% (n = 25) policy makers. Based on the data we developed the Chronic Care Model for Neurological Conditions (CCM-NC). The major needs/gaps are represented by the following themes: acceptance and openness to neurological conditions, evidence informed policy, investments and funding, supported transitions, caregiver support, and life enhancing resources (education, employment, housing and transportation), knowledge and awareness of neurological conditions and availability and access to health services. The model maintains that intersectoral collaboration across the health system, community and policy components is needed. It recognizes that attitudes, policies, enhanced community integration and health system changes are needed to develop activated patients and families, proactive service delivery teams, a person-centred health system and healthy public policy for persons with neurological conditions.ConclusionThe CCM-NC will generate debate and discussion about the actions needed in each of the model components to enable people with neurological conditions to sustain healthier lives. Next steps include validating the model with persons with neurological conditions, in and outside of the Canadian context and developing and evaluating interventions to test the model.

Developmental evaluation as a strategy to enhance the uptake and use of deprescribing guidelines: protocol for a multiple case study

BackgroundThe use of developmental evaluation is increasing as a method for conducting implementation research. This paper describes the use of developmental evaluation to enhance an ongoing study. The study develops and implements evidence-based clinical guidelines for deprescribing medications in primary care and long-term care settings. A unique feature of our approach is our use of a rapid analytical technique.Methods/DesignThe team will carry out two separate analytical processes: first, a rapid analytical process to provide timely feedback to the guideline development and implementation teams, followed by a meta-evaluation and second, a comprehensive qualitative analysis of data after the implementation of each guideline and a final cross-case analysis. Data will be gathered through interviews, through observational techniques leading to the creation of field notes and narrative reports, and through assembling team documents such as meeting minutes. Transcripts and documents will be anonymized and organized in NVIVO by case, by sector (primary care or long-term care), and by implementation site. A narrative case report, directed coding, and open coding steps will be followed. Clustering and theming will generate a model or action map reflecting the functioning of the participating social environments.DiscussionIn this study, we will develop three deprescribing guidelines and will implement them in six sites (three family health teams and three long-term care homes), in a sequential iterative manner encompassing 18 implementation efforts. The processes of 11 distinct teams within four conceptual categories will be examined: a guideline priority-setting group, a guideline development methods committee, 3 guideline development teams, and 6 guideline implementation teams. Our methods will reveal the processes used to develop and implement the guidelines, the role and contribution of developmental evaluation in strengthening these processes, and the experience of six sites in implementing new evidence-based clinical guidelines. This research will generate new knowledge about team processes and the uptake and use of deprescribing guidelines in family health teams and long-term care homes, with a goal of addressing polypharmacy in Canada. Clinicians and researchers creating clinical guidelines to introduce improvements into daily practice may benefit from our developmental evaluation approach.

Closing the evidence, research, and practice loop: Examples of knowledge transfer and exchange from the field of aphasia

Background: Knowledge transfer and exchange (KTE) is an emerging area of expertise with potential to foster productive relationships between researchers and users of research in the field of aphasia. Effective KTE can increase the use of research evidence in policy and practice decisions and enable researchers to identify research questions that are relevant to potential users of research. In Canada it is now frequently mandatory for research applications to include a KTE plan. Aims: To provide a background to KTE by reviewing theoretical models and basic principles and elements of a KTE plan, as well as by highlighting potential contributions to the field of clinical aphasiology. Main contribution: Introduction of a new area of expertise to our field with examples of practical applications. Conclusions: The application of KTE principles and methods has positive implications for clinical and policy decision making in the field of clinical aphasiology. The authors thank staff at the Aphasia Institute, and all those involved in the think tank, conference, and community of practice referred to in the article. Thanks also to Ada Mok for administrative support.

eLearning, knowledge brokering, and nursing: strengthening collaborative practice in long-term care.

Interprofessional collaboration is vital to the delivery of quality care in long-term care settings; however, caregivers in long-term care face barriers to participating in training programs to improve collaborative practices. Consequently, eLearning can be used to create an environment that combines convenient, individual learning with collaborative experiential learning. Findings of this study revealed that learners enjoyed the flexibility of the Working Together learning resource. They acquired new knowledge and skills that they were able to use in their practice setting to achieve higher levels of collaborative practice. Nurses were identified as team leaders because of their pivotal role in the long-term care home and collaboration with all patient care providers. Nurses are ideal as knowledge brokers for the collaborative practice team. Quantitative findings showed no change in learners attitudes regarding collaborative practice; however, interviews provided examples of positive changes experienced. Face-to-face collaboration was found to be a challenge, and changes to organizations, systems, and technology need to be made to facilitate this process. The Working Together learning resource is an important first step toward strengthening collaboration in long-term care, and the pilot implementation provides insights that further our understanding of both interprofessional collaboration and effective eLearning.

Learning in the wild

This paper argues that learning is a natural social process that leads to the construction of meaning, which involves the creation of experiences of coherence, purpose, identity and competence. Learning that yields a coherent social context, a worthy or compelling purpose, a strong, integrated identity and increasing levels of competence results in an experience of meaningful work. Learning as a social process is characterized by the property of capacity. Any given group will have a capacity to learn and it will be difficult for that group to take on a learning challenge that is beyond its present capacity. If a group, for example, is short-handed and is carrying out work that members see as urgent and important, then the group may focus its efforts on maintaining its equilibrium and creating stability and may diminish its capacity to adapt to change by taking on new ideas and approaches. Such a group might also have a diminished capacity to bring newcomers into the community – which is the very thing that it needs to do if it is to overcome the problem of being short-handed. These propositions will be illustrated by a specific example: teams of frontline caregivers in a long-term care facility in Canada.

The essential transformation: How Masters students make sense and learn through transformative change

This article considers how the Human Systems Intervention Masters program at Concordia University in Montreal encourages and manages a transformation in the way students think about and act in the social world. The article explains the transformation in terms of a shift from a positivist/rational to a constructivist/narrative view of social phenomena, and how specific elements of the curriculum provoke the shift toward a more reflexive and participative way of working. The article also discusses the disconfirmation and uncertainty that can accompany the transformation, describes the structures and processes used to construct a container that provides psychological safety and emotional support for students, and considers ways in which the program might be improved.

Enhancing service delivery capacity through knowledge exchange: The Seniors Health Research Transfer Network

The Seniors Health Research Transfer Network (SHRTN) was launched in 2005 in Ontario to improve the quality of health care provided to seniors by facilitating knowledge exchange opportunities for formal and informal caregivers, researchers and policymakers. This article describes the conceptual basis and development of SHRTN, as well as achievements, challenges and lessons learned during its first year of operation, which ended in March 2006. We begin by discussing knowledge exchange networks and their conceptual basis. We then offer a brief history of SHRTN, tracing its origins to both a broad interprofessional interest in creating and sharing knowledge within and across organizations, and also to the efforts of a small group of early champions. After this, we describe the main events, achievements and surprises of SHRTNs first year. Experience with SHRTN has highlighted the importance of careful attention to governance issues in the organization of knowledge exchange networks, and the challenge of balancing management control with broad participation and flexibility. Collaboration can yield synergy and innovation, but requires commitment from participants. The SHRTN experience has demonstrated that planning and coordinating a provincial network that engages diverse stakeholders is a logistical challenge that requires dedicated infrastructure and funding support.