Tracey L. Yap

Building a Community of Research Practice: Intragroup Team Social Dynamics in Interdisciplinary Mixed Methods

This article explicates the intragroup social dynamics and work of a nursing and education research team as a community of research practice interested in organizational cultures and occupational subcultures. Dynamics were characterized by processes of socialization through reeducation and group social identity formation that enabled members to cross discipline-bordered traditions and produce interdisciplinary mixed methods combinations. Combinations were achieved at the paradigm level through the generation of a shared viewing position and theoretical model. At methods and technique levels, such achievements were accomplished through methodological capitalization and prioritization and the development of a quantitative culture assessment tool that can be used in combination with complementary qualitative observation and interview protocols. Recommendations for other teams are provided.

Multidimensional Team-Based Intervention Using Musical Cues to Reduce Odds of Facility-Acquired Pressure Ulcers in Long-Term Care: A Paired Randomized Intervention Study

To test the effectiveness of a pressure ulcer (PU) prevention intervention featuring musical cues to remind all long‐term care (LTC) staff (nursing and ancillary) to help every resident move or reposition every 2 hours.

Development and Psychometric Testing of the Nursing Culture Assessment Tool

A valid and reliable nursing culture assessment tool aimed at capturing general aspects of nursing culture is needed for use in health care settings to assess and then reshape indicated troubled areas of the nursing culture. This article summarizes the Nursing Culture Assessment Tool’s (NCAT) development and reports on a cross-sectional, exploratory investigation of its psychometric properties. The research aims were to test the tool’s psychometric properties; discover its dimensionality; and refine the item structure to best represent the construct of nursing culture, an occupational subset of organizational culture. Empirical construct validity was tested using a sample of licensed nurses and nursing assistants (n = 340). Exploratory and confirmatory factor analysis (CFA) and logistical regression yielded a 6-factor, 19-item solution. Evidence supports the tool’s validity for assessing nursing culture as a basis for shaping the culture into one that supports change, thereby accelerating, improving, and advancing nursing best practices and care outcomes.

Sustaining complex interventions in long-term care: a qualitative study of direct care staff and managers

BackgroundLittle is known about the sustainability of behavioral change interventions in long-term care (LTC). Following a cluster randomized trial of an intervention to improve staff communication (CONNECT), we conducted focus groups of direct care staff and managers to elicit their perceptions of factors that enhance or reduce sustainability in the LTC setting. The overall aim was to generate hypotheses about how to sustain complex interventions in LTC.MethodsIn eight facilities, we conducted 15 focus groups with 83 staff who had participated in at least one intervention session. Where possible, separate groups were conducted with direct care staff and managers. An interview guide probed for staff perceptions of intervention salience and sustainability. Framework analysis of coded transcripts was used to distill insights about sustainability related to intervention features, organizational context, and external supports.ResultsStaff described important factors for intervention sustainability that are particularly challenging in LTC. Because of the tremendous diversity in staff roles and education level, interventions should balance complexity and simplicity, use a variety of delivery methods and venues (e.g., group and individual sessions, role-play/storytelling), and be inclusive of many work positions. Intervention customizability and flexibility was particularly prized in this unpredictable and resource-strapped environment. Contextual features noted to be important include addressing the frequent lack of trust between direct care staff and managers and ensuring that direct care staff directly observe manager participation and support for the program. External supports suggested to be useful for sustainability include formalization of changes into facility routines, using “train the trainer” approaches and refresher sessions. High staff turnover is common in LTC, and providing materials for new staff orientation was reported to be important for sustainability.ConclusionsWhen designing or implementing complex behavior change interventions in LTC, consideration of these particularly salient intervention features, contextual factors, and external supports identified by staff may enhance sustainability.Trial registrationClinicalTrial.gov, NCT00636675

The Systematic Development of a Tailored E-Mail Intervention for Health Behavior Change Toward Increasing Intentional Physical Activity

Although the benefits of physical activity are well known, most adults in the United States are relatively sedentary, with about 60% of adults not regularly physically active and 25% of those not active at all. This inactivity places the population at risk for many chronic diseases. Understanding optimal ways of both communicating with and educating employees regarding intention to reduce risk of ill health and enhance well-being through physical activity was the fundamental aim of this health communication research study. The authors designed a series of theory-based, tailored e-mail messages, which were evaluated for content validity by health care experts and focus groups. Focus groups were held according to the stage-of-change level of the participants, and two clear domains emerged: persuasion and decision domains. Improving societal well-being in a cost-effective manner using e-mail remains to be seen; however, creating interventions to engineer sufficient impact on health behavior decision making is an investment worth exploring.

Study of Individualization and Bias in Nursing Home Fall Prevention Practices

Little is known about how nursing home staff use resident characteristics to individualize care delivery or whether care is affected by implicit bias.

An Evidence-Based Cue-Selection Guide and Logic Model to Improve Pressure Ulcer Prevention in Long-term Care.

Pressure ulcers have consistently resisted prevention efforts in long-term care facilities nationwide. Recent research has described cueing innovations that—when selected according to the assumptions and resources of particular facilities—support best practices of pressure ulcer prevention. This article synthesizes that research into a unified, dynamic logic model to facilitate effective staff implementation of a pressure ulcer prevention program.

Using the Nursing Culture Assessment Tool (NCAT) in Long-Term Care: An Update on Psychometrics and Scoring Standardization

An effective workforce performing within the context of a positive cultural environment is central to a healthcare organization’s ability to achieve quality outcomes. The Nursing Culture Assessment Tool (NCAT) provides nurses with a valid and reliable tool that captures the general aspects of nursing culture. This study extends earlier work confirming the tool’s construct validity and dimensionality by standardizing the scoring approach and establishing norm-referenced scoring. Scoring standardization provides a reliable point of comparison for NCAT users. NCAT assessments support nursing’s ability to evaluate nursing culture, use results to shape the culture into one that supports change, and advance nursing’s best practices and care outcomes. Registered nurses, licensed practical nurses, and certified nursing assistants from 54 long-term care facilities in Kentucky, Nevada, North Carolina, and Oregon were surveyed. Confirmatory factor analysis yielded six first order factors forming the NCAT’s subscales (Expectations, Behaviors, Teamwork, Communication, Satisfaction, Commitment) (Comparative Fit Index 0.93) and a second order factor—The Total Culture Score. Aggregated facility level comparisons of observed group variance with expected random variance using rwg(J) statistics is presented. Normative scores and cumulative rank percentages and how the NCAT can be used in implementing planned change are provided.

Effect of promoting high-quality staff interactions on fall prevention in nursing homes: A cluster-randomized trial

Importance New approaches are needed to enhance implementation of complex interventions for geriatric syndromes such as falls. Objective To test whether a complexity science–based staff training intervention (CONNECT) promoting high-quality staff interactions improves the impact of an evidence-based falls quality improvement program (FALLS). Design, Setting, and Participants Cluster-randomized trial in 24 nursing homes receiving either CONNECT followed by FALLS (intervention), or FALLS alone (control). Nursing home staff in all positions were asked to complete surveys at baseline, 3, 6, and 9 months. Medical records of residents with at least 1 fall in the 6-month pre- and postintervention windows (n = 1794) were abstracted for fall risk reduction measures, falls, and injurious falls. Interventions CONNECT taught staff to improve their connections with coworkers, increase information flow, and use cognitive diversity in problem solving. Intervention components included 2 classroom sessions, relationship mapping, and self-monitoring. FALLS provided instruction in the Agency for Healthcare Research and Quality’s Falls Management Program. Main Outcomes and Measures Primary outcomes were (1) mean number of fall risk reduction activities documented within 30 days of falls and (2) median fall rates among residents with at least 1 fall during the study period. In addition, validated scales measured staff communication quality, frequency, timeliness, and safety climate. Results Surveys were completed by 1545 staff members, representing 734 (37%) and 811 (44%) of eligible staff in intervention and control facilities, respectively; 511 (33%) respondents were hands-on care workers. Neither the CONNECT nor the FALLS-only facilities improved the mean count of fall risk reduction activities following FALLS (3.3 [1.6] vs 3.2 [1.5] of 10); furthermore, adjusted median recurrent fall rates did not differ between the groups (4.06 [interquartile range {IQR}, 2.03-8.11] vs 4.06 [IQR, 2.04-8.11] falls/resident/y). A modest improvement in staff communication measures was observed overall (mean, 0.03 [SE, 0.01] points on a 5-point scale; P = .03) and for communication timeliness (mean, 0.8 [SE, 0.03] points on a 5-point scale; P = .02). There was wide variation across facilities in intervention penetration. Conclusions and Relevance An intervention targeting gaps in staff communication and coordination did not improve the impact of a falls quality improvement program. New approaches to implementing evidence-based care for complex conditions in the nursing home are urgently needed. Trial Registration clinicaltrials.gov Identifier: NCT00636675

Implementation of a Recovery-Oriented Training Program for Psychiatric Nurses in the Inpatient Setting: A Mixed-Methods Hospital Quality Improvement Study

This mixed-methods hospital quality improvement (QI) study primarily aimed to reduce the use of mechanical restraints in a short-stay inpatient psychiatric setting by facilitating change in care delivery through recovery-oriented nursing practice. The implementation of an evidence-based education for psychiatric-mental health registered nurses (PMH-RNs) intended to improve their knowledge of, and attitudes toward, recovery-focused mental health treatment principles. Findings suggest that recovery-oriented training programs for PMH-RNs can be a potentially useful hospital strategy for restraint reduction. In this article, the authors report their findings using the SQUIRE 2.0 framework for publication of QI studies (Ogrinc et al., 2015).