Kristie Porter

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

BackgroundQuality 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.Methods/designSixteen 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.DiscussionBy focusing on improving local interactions, CONNECT is expected to maximize staffs 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.Trial RegistrationClinicalTrials.gov: NCT00636675

Tool for evaluating research implementation challenges: A sense-making protocol for addressing implementation challenges in complex research settings

BackgroundMany challenges arise in complex organizational interventions that threaten research integrity. This article describes a T ool for E valuating Research Implementation Ch allenges (TECH), developed using a complexity science framework to assist research teams in assessing and managing these challenges.MethodsDuring the implementation of a multi-site, randomized controlled trial (RCT) of organizational interventions to reduce resident falls in eight nursing homes, we inductively developed, and later codified the TECH. The TECH was developed through processes that emerged from interactions among research team members and nursing home staff participants, including a purposive use of complexity science principles.ResultsThe TECH provided a structure to assess challenges systematically, consider their potential impact on intervention feasibility and fidelity, and determine actions to take. We codified the process into an algorithm that can be adopted or adapted for other research projects. We present selected examples of the use of the TECH that are relevant to many complex interventions.ConclusionsComplexity theory provides a useful lens through which research procedures can be developed to address implementation challenges that emerge from complex organizations and research designs. Sense-making is a group process in which diverse members interpret challenges when available information is ambiguous; the groups’ interpretations provide cues for taking action. Sense-making facilitates the creation of safe environments for generating innovative solutions that balance research integrity and practical issues. The challenges encountered during implementation of complex interventions are often unpredictable; however, adoption of a systematic process will allow investigators to address them in a consistent yet flexible manner, protecting fidelity. Research integrity is also protected by allowing for appropriate adaptations to intervention protocols that preserve the feasibility of ‘real world’ interventions.

CONNECT for better fall prevention in nursing homes: Results from a pilot intervention study

To determine whether an intervention that improves nursing home (NH) staff connections, communication, and problem solving (CONNECT) would improve implementation of a falls reduction education program (FALLS).

Understanding RN and LPN Patterns of Practice in Nursing Homes

Understanding how nurse regulators can ensure optimal registered nurse-licensed practical/vocational nurse (RN-LPN) collaborations for patient safety and care quality is critically important.To aid this understanding, researchers conducted a comparative, multiple-case study on RN and LPN practice in the areas of assessment, care planning, supervision, and delegation in two states, Minnesota and North Carolina. The researchers identified three factors that differentiated nursing practice patterns in nursing homes: the quality of the connections between RNs and LPNs, the degree of interchangeability between RNs and LPNs, and RN-to-LPN staffing ratios. Findings indicate several levers for improving RN-LPN collaborations and the capacity to provide higher quality care.

Connecting the learners: improving uptake of a nursing home educational program by focusing on staff interactions.

PURPOSE OF THE STUDY The CONNECT intervention is designed to improve staff connections, communication, and use of multiple perspectives for problem solving. This analysis compared staff descriptions of the learning climate, use of social constructivist learning processes, and outcomes in nursing facilities receiving CONNECT with facilities receiving a falls education program alone. DESIGN AND METHODS Qualitative evaluation of a randomized controlled trial was done using a focus group design. Facilities (n = 8) were randomized to a falls education program alone (control) or CONNECT followed by FALLS (intervention). A total of 77 staff participated in 16 focus groups using a structured interview protocol. Transcripts were analyzed using framework analysis, and summaries for each domain were compared between intervention and control facilities. RESULTS Notable differences in descriptions of the learning climate included greater learner empowerment, appreciation of the role of all disciplines, and seeking diverse viewpoints in the intervention group. Greater use of social constructivist learning processes was evidenced by the intervention group as they described greater identification of communication weaknesses, improvement in communication frequency and quality, and use of sense-making by seeking out multiple perspectives to better understand and act on information. Intervention group participants reported outcomes including more creative fall prevention plans, a more respectful work environment, and improved relationships with coworkers. No substantial difference between groups was identified in safety culture, shared responsibility, and self-reported knowledge about falls. IMPLICATIONS CONNECT appears to enhance the use of social constructivist learning processes among nursing home staff. The impact of CONNECT on clinical outcomes requires further study.

Perceptions of Nursing Practice Scale Pilot Study: Directors of Nursing in Nursing Homes

In nursing homes, the urgency to advance our measurement of nursing practice grows because nursing homes are increasingly regarded as an essential component of the care continuum needed to achieve national care quality goals. Prior qualitative case study research identified two key characteristics of nursing practice that differentiated how licensed nurses in nursing homes enacted their scope of practice: the degree to which registered nurses (RNs) and licensed practical nurses (LPNs) function interchangeably in providing nursing care and the quality of the connections between RNs and LPNs. RN-to-LPN staffing ratio was a critical, contextual factor shaping these characteristics. The purpose of this pilot study was to develop and validate an instrument of interchangeability and connections between RNs and LPNs regarding how they assess, plan care, supervise, and delegate in nursing homes. One hundred and one RN directors of nursing completed the self-administered, pencil-and-paper, pilot survey instrument. Both classical test theory and item response theory indicated adequate psychometric properties of the 8-item RN-LPN Differentiation scale (α = .78) and the 12-item RN-LPN Collaboration scale (α = .79). The RN-LPN Differentiation score differed by state ( p p

Development of a Risk-adjustment Model for the Inpatient Rehabilitation Facility Discharge Self-care Functional Status Quality Measure

Background: Functional status measures are important patient-centered indicators of inpatient rehabilitation facility (IRF) quality of care. We developed a risk-adjusted self-care functional status measure for the IRF Quality Reporting Program. This paper describes the development and performance of the measure’s risk-adjustment model. Methods: Our sample included IRF Medicare fee-for-service patients from the Centers for Medicare & Medicaid Services’ 2008–2010 Post-Acute Care Payment Reform Demonstration. Data sources included the Continuity Assessment Record and Evaluation Item Set, IRF-Patient Assessment Instrument, and Medicare claims. Self-care scores were based on 7 Continuity Assessment Record and Evaluation items. The model was developed using discharge self-care score as the dependent variable, and generalized linear modeling with generalized estimation equation to account for patient characteristics and clustering within IRFs. Patient demographics, clinical characteristics at IRF admission, and clinical characteristics related to the recent hospitalization were tested as risk adjusters. Results: A total of 4769 patient stays from 38 IRFs were included. Approximately 57% of the sample was female; 38.4%, 75–84 years; and 31.0%, 65–74 years. The final model, containing 77 risk adjusters, explained 53.7% of variance in discharge self-care scores (P<0.0001). Admission self-care function was the strongest predictor, followed by admission cognitive function and IRF primary diagnosis group. The range of expected and observed scores overlapped very well, with little bias across the range of predicted self-care functioning. Conclusions: Our risk-adjustment model demonstrated strong validity for predicting discharge self-care scores. Although the model needs validation with national data, it represents an important first step in evaluation of IRF functional outcomes.

Evaluation of Cueing Innovation for Pressure Ulcer Prevention Using Staff Focus Groups

The purpose of the manuscript is to describe long-term care (LTC) staff perceptions of a music cueing intervention designed to improve staff integration of pressure ulcer (PrU) prevention guidelines regarding consistent and regular movement of LTC residents a minimum of every two hours. The Diffusion of Innovation (DOI) model guided staff interviews about their perceptions of the intervention’s characteristics, outcomes, and sustainability. Methods: This was a qualitative, observational study of staff perceptions of the PrU prevention intervention conducted in Midwestern U.S. LTC facilities (N = 45 staff members). One focus group was held in each of eight intervention facilities using a semi-structured interview protocol. Transcripts were analyzed using thematic content analysis, and summaries for each category were compared across groups. Results: The a priori codes (observability, trialability, compatibility, relative advantage and complexity) described the innovation characteristics, and the sixth code, sustainability, was identified in the data. Within each code, two themes emerged as a positive or negative response regarding characteristics of the innovation. Moreover, within the sustainability code, a third theme emerged that was labeled “brainstormed ideas”, focusing on strategies for improving the innovation. Implications: Cueing LTC staff using music offers a sustainable potential to improve PrU prevention practices, to increase resident movement, which can subsequently lead to a reduction in PrUs.

A novel program for ABSN students to generate interest in geriatrics and geriatric nursing research

The current shortage of nurse researchers in geriatrics adversely affects the capacity of nurses to conduct research to advance the evidence-based care of older adults. In an effort to generate interest in geriatrics and geriatric nursing research, the Duke University School of Nursing designed a summer internship for four students enrolled in the accelerated baccalaureate nursing (ABSN) program. This paper describes the experience of these ABSN students and the staff and faculty who worked with them. The program design, staff and faculty experiences, benefits and challenges, as well as recommendations for future programs are discussed. The purpose of this article is to highlight the benefits and challenges of offering research experiences to nursing students in an ABSN program to stimulate interest in geriatrics and geriatric nursing research.

Person-Directed Care Planning in Nursing Homes: Resident, Family, and Staff Perspectives:

Empowering individuals to direct their own care is central to person-centered care and health care policy. However, there is limited knowledge of how “person-directed care planning” (PDCP) can be achieved in particular settings. This study identifies key structures and processes for operationalizing and implementing PDCP in nursing homes. Using participatory inquiry, we convened “stakeholder engagement sessions” with residents, families, nursing staff, and managers/administrators in two North Carolina nursing homes (N = 24 sessions; N = 67 unique participants). Stakeholders discussed current care-planning processes and provided feedback on an emergent conceptual framework of PDCP. Three themes emerged through directed-content analysis: strategies included providing formal and informal opportunities to engage in care planning and ensuring effective follow-through; different roles were required among leadership, staff, residents, and families to accomplish PDCP; and limits on achieving PDCP included competing priorities and perceived regulatory and resource constraints. Results are discussed in terms of the specific competencies required for accomplishing PDCP.