Geriatric Nursing 36 (2015) 98e105
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Feature Article
Improving person-centered mobility care in nursing homes: A feasibility study Janice Taylor, PhD, MGeron, BAppSc (Pty) a, *, Anna Barker, BPhty, MPhty (Geriatrics), PhD b, Heather Hill, PhD, MEd, BA c, Terry P. Haines, PhD, GCert (Health Economics), BPhysiotherapy (Hons) d, e a
Monash University, Faculty of Medicine, Nursing and Health Sciences, Building 1, 270 Ferntree Gully Rd, Notting Hill, Melbourne, Victoria 3168, Australia b Department of Epidemiology and Preventive Medicine, Monash University, Level 6, Alfred Centre, 99 Commercial Rd., Melbourne 3004, Australia c Quality Relationships-Quality Care, Australia d Allied Health Research Unit, Southern Health, Kingston Centre, Warrigal Rd., Cheltenham, Victoria 3192, Australia e Southern Physiotherapy Clinical School, Monash University, Melbourne, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 August 2014 Received in revised form 7 November 2014 Accepted 10 November 2014 Available online 28 February 2015
Person-centered care is often equated with quality nursing home care. At the same time, quality mobility care contributes to residents’ independence and quality of life. Realist evaluation and mixed methods were employed to evaluate the feasibility of a multi-faceted training intervention focused on personcentered mobility care. Staff and ambulatory residents of a ninety bed Australian nursing home with 3 unitsdone dementia-specificdparticipated. The intervention consisted of training sessions, weekly mobility care huddles and reflective practice sessions with individual staff. This study demonstrated the feasibility of an intervention aiming to improve person-centered mobility care in nursing homes; it was practical and well accepted. Study methods and outcome measures were suitable. Outcome measures demonstrated capacity to determine the effectiveness of the intervention in a larger randomized controlled trial. Focus groups provided insights regarding the context and mechanisms of change. Future research is recommended to evaluate intervention effectiveness and sustainability. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Collaboration Mixed methods Mobility care Nursing home Person-centered care Realist evaluation Reflective practice
Background Person-centered care is often equated with quality nursing home care1 and involves consideration of residents’ choice, autonomy, independence and control.2,3 The need for person-centered care is evidenced by calls to share best practice in personalized dementia care in the United Kingdom,4 within national guidelines for dementia care in Sweden,5 and through consumer-directed care recommendations enshrining choice and control for older people in Australia.6 At the same time, mobility is an aspect of residents’ daily activities that contributes to their independence and quality of life.7,8 Many residents require some form of staff assistancedreferred to as mobility caredto achieve activities of daily living, but staff promotion of residents’ autonomy, independence and control during mobility is frequently absent.9 This can result in
* Corresponding author. E-mail address: [email protected] (J. Taylor). 0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.11.002
dependence being imposed on residents with consequent physical deconditioning, reduced mobility, skin breakdown, and falls.9e11 To the best of our knowledge, no studies have evaluated the use of person-centered approaches during mobility care. Personcentered strategies and support for staff have reduced agitation in people with dementia12 and enhanced residents’ and staff’s experiences during hygiene care.13 Functional training designed for staff to conduct in addition to usual care can improve residents’ mobility,14,15 however this approach has not been widely adopted, possibly due to inadequate staffing.15 Person-centered approaches may improve the quality of mobility care and resident mobility outcomes.16 Person-centered approaches incorporate individualized care.16,17 Individualized mobility care requires staff to understand residents’ mobility capacity and to safely meet residents’ mobility needs through use of mobility enhancing strategies that encourage and allow residents to move themselves where possible.9,18 This is particularly important during transfers on and off furniture, a function that determines residents’ continued safe ambulation.19
J. Taylor et al. / Geriatric Nursing 36 (2015) 98e105
Person-centered mobility care has a broader focus than individualized care20; the quality of the residentestaff interaction is the primary consideration with staff being ready to respond flexibly in the moment to the needs of the resident as a whole.21,22 Inadequate staff training and support can act as barriers to person-centered mobility care but may be addressed by multi-faceted interventions based on collaborative training approaches.23 Traditional didactic models of training are less successful in securing staff behavior change than when combined with collaborative and interactive models of training.24 Facility cultures based on relationships and an enriched and supportive environment are also recommended for effective practice change.22,25 Huddlesdsmall gatherings of staff for learning purposesdhave been successfully employed to ensure safe manual handling practice.26 Reflective practice can also facilitate practice development.22,27 In particular, reflective practice may improve nursing home staff’s situation awareness and intuitive decision-making that are important when high levels of uncertainty and unpredictability exist, as they often do during mobility care.28,29 Motivational interviewing,30 promoted as a tool for knowledge translation,31 is a further means of working with staff’s change process through active listening and use of reflections. The purpose of the current study was to evaluate the feasibility of an intervention to improve person-centered mobility care during resident transfers.32 Specific purposes of the study included to test recruitment, resources, methodologies, acceptability and outcome measures as well as to estimate sample sizes for a randomized controlled trial. Analysis of outcomes provided information regarding potential effect sizes. As a study’s feasibility is also dependent upon interventions being contextually appropriate,33 we evaluated the context of the current intervention. Method Realist evaluation34 and mixed methods in a convergent parallel design35 were employed to evaluate the feasibility of this complex intervention. Realist evaluation is a pragmatic approach that considers relationships and the social environment and explores study context, mechanisms and outcomes to better understand what worked, for whom, in what circumstances, in what respects and how.36 The context of this study was person-centered mobility care improvements in a nursing home setting. The mechanisms were the intervention and use of mixed methods including a usual care controlled, pre-post design. Kirkpatrick’s hierarchy of educational outcomes guided evaluation at 4 levels: (1) participant reaction; (2) participant learning; (3) participant behavior change; and (4) outcomes.37 Focus groups provided qualitative data to assist with evaluation of the study. Setting and participants The study was conducted in a ninety bed nursing home with 3 high care units, including one that was dementia-specific, in Melbourne, Australia. Purposeful samples of staff and residents were recruited. Inclusion criteria for residents were to be consenting, ambulant with or without gait aids, permanent stay and classified as requiring high care services as assessed by regulated Australian Aged Care Assessment Teams. Residents who were short stay and non-consenting were excluded. Inclusion criteria for staff were to be consenting and employed to provide direct care. Casual and agency staff were excluded. Management assisted with recruitment by distributing explanatory statements to residents, their families and staff.
99
Ethical issues Ethics approval from Monash University Human Research Ethics Committee and organizational permission were gained for the study. Participant staff and residents provided written informed consent. Third party consent was gained from residents’ proxies when residents had a diagnosis of dementia or cognitive impairment. Unit coordinators, who knew the residents well, deemed when proxy consent was necessary. The first author (ww) approached some residents, with management permission and following advice from unit coordinators regarding who was able to give informed consent, to assist with recruitment. Participants in focus groups consented to sessions being audio-recorded. Facility consent was obtained for unobtrusive observations of staff and residents in public areas. The intervention The intervention was a collaborative training program conducted over sixteen weeks. Person- and relationship-centered frameworks,21,25 consistent with the notions of transformational learning and appreciative action,38,39 guided development of the intervention. Two researchers conducted the intervention. The primary intervention facilitator had twenty-six years’ of experience as a physiotherapist in nursing homes and an emic understanding of the culture surrounding mobility care. She was assisted during training sessions by a dementia care consultant trained as a social worker and dance therapist. Neither had a relationship with the facility or staff beyond this study. The intervention underwent preliminary testing in another nursing home. Content Staff were trained in the use of person-centered approaches and mobility enhancing strategies during mobility care including how to approach, interact and communicate with residents and how to promote the correct biomechanics for independent transfers. Key features of the multi-faceted program included: reinforcement of safe manual handling; use of a mobility care decision tool; provision of person-centered and mobility enhancing strategies; and environmental considerations such as the need for appropriate seating and correct use of gait aids. Format Table 1 illustrates the timing and key aspects of the intervention. Training formats included: two 1-h training sessions; weekly mobility care huddles; and reflective practice with individual staff. Facilitation methods during training and in huddles varied but the focus was on use of experiential and interactive methods and included the plan-do-study-act cycle40 (Table 2). Motivational interviewing was employed during reflective practice sessions. Both motivational interviewing and reflective practice are consistent with the notions of transformational learning and appreciative action. Data collection Staff measures Staff satisfaction (training) (Kirkpatrick’s level 1 e reaction) e measured using a fourteen item questionnaire designed to determine whether staff’s expectations were met, how they rated the training and what they learned from it. Response items included items with a 5 point Likert scale and open-ended questions (See Appendix). Staff satisfaction (program as a whole) (Kirkpatrick’s level 1 e reaction) e measured using a twenty-six item questionnaire designed to determine whether staff’s expectations of the program
100
J. Taylor et al. / Geriatric Nursing 36 (2015) 98e105
Table 1 Timing and key aspects of the training. Intervention component
Dec 10th 2013 & Feb 6th 2014
Dec 31st 2013 to April 10th 2014
Training
Huddles
Reflective practice
Content/ procedure
Content & procedure: Staff knowledge test (Quiz) e Pre-training 1. Highlight key points: Learning objectives Importance of sit to stand Being with and for the resident rather than “helping” them 2. Experiential exercise e leading and following (movement awareness) 3. Skills training:
Procedure: 1. Week before, notification of the huddle and time was written in unit diaries 2. On the day the nurse supervisor was reminded about the event and a convenient time was confirmed 3. The huddle and time were advertised on a clip board in a location visible to staff 4. The huddle conducted on the unit with those staff able to attend
Procedure: 1. Reminder of the program and its purpose 2. Introduction to purpose of reflective practice 3. Discussion related to issues arising related to person-centred mobility care 4. Encouragement of reflective practice 5. Use of motivational interviewing techniques where appropriate
Demonstration and practice e transfers 4. Discussion of new learning 5. Handouts provided: List of strategies for: (i) Person-centered approaches (ii) mobility enhancement (iii) safety Decision-making tool 6. Questions
Follow-up: - A record of the huddle written and placed in unit diaries - The record was also placed in a “Mobility Care Huddle Folder” placed on each unit
Frequency
Length
Staff knowledge test (Quiz) e Post-training evaluation 2 sessions (2 groups of 12 and 9 different participants*) * one nurse supervisor repeated the training 1 hour each
Repeat sessions: - Opening to reflection of issues previously raised - Motivational interviewing techniques used where appropriate
One per unit every 3rd week
3 sessions per week with various staff
10e20 min (3 sessions were 60 min. Of these one was scheduled as a workshop for senior nurses and two were PDSA cycle sessions 2 on one unit where staff were allowed to attend.
10e30 min
were met and how. Response items included items with a 5 point Likert scale and open-ended questions (See Appendix). Staff knowledge (Kirkpatrick’s level 2 e learning) e measured using a staff knowledge test and rater’s guide designed for the purpose (See Appendix). This tool underwent preliminary testing for face and content validity with several care staff at another facility. Staff completed the test before and after training.
Staff mobility care during transfers (Kirkpatrick’s level 3 e behavior change) e measured using a Transfer Observation Instrument (TOI) adapted from a tool developed for earlier qualitative research and designed to assess staff’s mobility care with respect to safety, use of mobility enhancing strategies, and personcenteredness (See Appendix). Categorical ratings of positive, neutral and negative were assigned to each TOI assessment using a
Table 2 Facilitation methods employed during huddles and reflective practice. Mechanism
Method
Details
Indicated for
Motivational interviewing (MI) Reflective practice
Specific to MI
Conversation
Coachinga
Huddles
Case studya
Conversation. Personalized active participation. Members of team gathered, chose a known resident and discussed current concerns. Outcomes were fed back to the participants and other team members. Members of the team gathered for a planned session, ideas were evoked and recorded on flip charts then analyzed to develop action plans Members of the team gathered for a facilitator directed session on a topic specific to the study. Team involvement and cohesion were encouraged. Members of the team gathered for a planned session. The PDSA cycle was followed. Members of the team gathered for demonstration and practice of a technique
Supporting change process Self-discovery Problem-solving Self-discovery Involving all learners Practice and application Problem-solving Teamwork Self-discovery Problem-solving Collecting wide range of views Teamwork
Brainstorma
Action learninga
Plan-Do-Study-act (PDSA) Demonstration and practicea a
Focusing on knowledge & skills Developing analytical skills Identifying differences & alternatives Process review Decision-making Identifying differences & alternatives Focusing on a specific issue
Problem-solving Workflow Involvement in real work Self-discovery
Teamwork Deepening understanding of issues
Examining specific steps in practice processes
Designing, implementing and monitoring changes
Development of psychomotor and interpersonal skills
Adapted from Tovey MD, Lawlor DR. Training in Australia: design, delivery, evaluation, management. 2nd ed. Pearson: Prentice Hall; 2004 (Table 6.1, p 219).
J. Taylor et al. / Geriatric Nursing 36 (2015) 98e105
101
Table 3 Facility and unit characteristics. Facility
Unit A (High care)
No. of staff No. of resident beds No. of ambulatory residents
B (High care)
C (High care, dementia-specific)
149 90 27 24
30 31 29 12 8 7 12 8 4 1:4 1:4 1:4 1:5 1:5 1:5 35 h over 4 days per week across the 3 units Mandatory annual training for staff On-site manual handling coordinator Refreshers conducted with in-house trainers who have received specific manual handling trainer training
Commencement Completion
Morning shift resident: Care staff ratios (Medicators & RN’s not included) Afternoon shift resident: Care staff ratios (Medicators & RN’s not included) Hours of physiotherapy per week Manual handling training
relating to staff behavior and residents’ experience of mobility care was analyzed using the ManneWhitney test. Pre-post testing was conducted on the matched interval data from the resident PMS scores and the staff knowledge test using the paired t test. Quantitative analysis was conducted by the first and last authors (ww, zz).
rule developed by the current authors for the purpose of this study. Resident measures Resident mobility (Kirkpatrick’s level 4 e outcomes) e measured using the Physical Mobility Scale (PMS). This instrument has been extensively tested for validity and reliability for nursing home residents.41,42 Residents’ degree of autonomy during, and experience of, mobility care (Kirkpatrick’s level 4 e outcomes) e measured using the Transfer Observation Instrument as a proxy measure. This tool assessed resident responses to care as well as staff mobility care performance.
Qualitative Focus groups and open-ended questions from questionnaires were analyzed by ww using thematic analysis43 with the assistance of NVivo software.44 Themes emerging from focus groups were identified. Co-authors’ (xx, yy, zz) provided face validity to the emergent categories and themes by cross-checking against transcriptions.
Qualitative data Focus groups were conducted to add depth to findings and were audio-recorded.
Results The facility and unit characteristics are shown in Table 3. The facility policy on safe manual handling was consistent with the Australian Nursing Federation “No Lifting” policy.45 Twelve ambulant residents with a mean age of 83 (SD 5), comprising 5 males and 7 females, participated in the study (Fig. 1). All ambulated with 4 wheeled walkers bar one who did not use a gait aid.
Data analysis Quantitative Quantitative data from questionnaires was analyzed using descriptive statistics. The unmatched categorical data from the TOI
86 residents in the facility
59 residents did not meet the inclusion criteria 27 residents (31% of total residents) met the inclusion criteria 15 ambulatory residents were not recruited
12 residents (44% of ambulatory residents) were recruited
Unit A
Unit B
Unit C
6 ambulatory residents recruited, enrolled at baseline
2 ambulatory residents recruited, enrolled at baseline
4 ambulatory residents recruited, enrolled at baseline
(none lost to death, relocation or withdrawal)
(none lost to death, relocation or withdrawal)
(none lost to death, relocation or withdrawal)
Fig. 1. Resident recruitment and participant numbers.
102
J. Taylor et al. / Geriatric Nursing 36 (2015) 98e105 Table 5 Levels of staff participation.
149 direct care staff met inclusion criteria
98 direct care workers not recruited 51 (34%) direct care staff recruited, enrolled at baseline in 3 units (none lost to relocation or withdrawal)
17 11 8 6 3 3 1 49
(35) (22) (17) (12) (6) (6) (2) (100)
Two participants (the Manager and a Nurse supervisor) attended an evaluation focus group only. They were, however, involved in interactions and conversations, as were many other participants and other staff, with the researcher during the project. a One nurse supervisor attended both training sessions.
Fifty-one direct care staff participated (Fig. 2) and their characteristics are shown in Table 4. Levels of staff participation in varying aspects of the intervention are shown in Table 5. Twenty staff attended one of two training sessions. Fifteen weekly huddles were conducteddone huddle per unit every third week. Nine staff attended more than one huddle. Staff were encouraged by their peers and nurse supervisors to attend. Huddle outcomes were fed back to other staff in the form of written reports stored on the unit as a reference. Thirty-nine reflective practice sessions of ten to 30 min duration were conducted with twenty-one staff and twelve participants attended more than one such session. No adverse events were reported for residents or staff as a result of this intervention. Staff outcomes Staff satisfaction The response rate to training evaluation questionnaires was one hundred per cent. Forty per cent of staff rated the training as “excellent” and sixty per cent as “good”. Averaging responses, all agreed or strongly agreed that desired outcomes were achieved. Some commented that there needed to be more time, discussion and demonstration. Twelve staff, or twenty-three per cent of the fifty-one staff participants, comprising 8 carers, 2 nurses, one lifestyle staff and the physiotherapist, completed program evaluation questionnaires. Of these, 9 had participated in reflective practice sessions and 7 had attended mobility care huddles. Averaging responses, all agreed that their expectations had been met, the facilitator had been helpful and respectful, that improvements had occurred in teamwork and their sense of belonging, feelings of
Table 4 Staff participant characteristics. Staff characteristics, N ¼ 51 (34% of total 149 direct care workers)
No. of staff (%)
Huddle only Huddle and reflective practice Training onlya Training, huddle and reflective practice Training and huddle Training and reflective practice Reflective practice only Total b
Fig. 2. Staff recruitment and participant numbers.
Gender Female Male Position Carer Nurse supervisor MH trainer Lifestyle staff Nurse Manager Physiotherapist Years’ experience >10 2e5 0e1 5e10 1e2
Intervention mode experienced
N (%) 42 (82) 9 (18) 25 9 5 5 4 2 1
(49) (17) (10) (10) (8) (4) (2)
16 16 7 7 5
(32) (32) (13) (13) (10)
being valued and sense of support. Staff felt the culture of their unit had improved. Positive comments included the value of reflective practice and an increased understanding of person-centeredness. All agreed their sense of safety and their understanding of residents’ mobility needs and how to assist residents had improved. Some staff suggested more training was needed and that sessions should be well advertised so all staff could attend. Staff knowledge The staff knowledge test, conducted before and after training with a total of seventeen staffd3 cases were deleted due to missing datadshowed a mean improvement of seventeen per cent (t test, p ¼ 0.0005) in participants’ knowledge (pre-test mean 41%, SD ¼ 19%; post-test mean ¼ 58%, SD ¼ 17%). Staff mobility care during transfers Two samples of staff behavior during mobility care events were obtained using the Transfer Observation Instrument pre- and post-intervention. The samples were collected over 7.5 h preintervention and 13 h post-intervention. Both samples comprised twenty-seven residentestaff interactions. Pre-post testing of the samples of staff behavior indicated improvements; instances of mobility care categorized as positive increased by twenty-two per cent and negative instances of mobility care decreased by twentysix per cent (ManneWhitney, p ¼ 0.0148). Resident outcomes Resident mobility Residents’ mean PMS decreased by 8% (t test, p ¼ 0.02). There was no significant change in the transfer or ambulation items (G and H respectively) of the PMS score. Residents’ degree of autonomy during, and experience of, mobility care The twenty-two per cent increase in positive and twenty-six per cent decrease in negative instances of mobility care indicated improvement in residents’ autonomy and control during, and experience of, mobility care. Focus group findings Two focus groups were conducted with a total of ten staff comprising 7 females and 3 males. Seven staff had more than ten years’ experience in residential aged care. Participants included a physiotherapist, one lifestyle staff member, 4 carers including 2 who were manual handling trainers, 3 nurse supervisors and the facility manager. Emergent themes were aligned to the study’s use
J. Taylor et al. / Geriatric Nursing 36 (2015) 98e105
of realist evaluation; Theme (1) The need for change, became “The change context” and Theme (2) The way to change, became “Mechanisms of change”. Themes were often interwoven and overlapping. Themes also supported evidence from outcome data suggesting that benefits such as improvements in mobility care occurred during this study. The change context The need for person-centered approaches to mobility care was highlighted by a high possibility of adverse events such as resident skin tears, bruising, aggressive behaviors and falls during mobility care. It was felt that ultimately, staff were the ones responsible for providing safe and quality care: Some staff don’t realize because they don’t think. They don’t use their brain and think forward what they’re actually doing and they wonder why they’re getting punched in the mouth, spat on, scratched and kicked. I find them grabbing, grabbing the resident like that to, you know, pull a sleeve up and they’re grabbing like that and the resident is thinking “Well my shoulder’s hurting and they’re pulling”. You know skin tears have gone down a lot but I’m noticing again there’s a lot of residents (sic) starting to get bruises. (Manual handling trainer-1, FG-1) If a resident slides out of the standing machine or the sling because you haven’t put them in properly, secured them, or you’re doing it on your own and you’ve let go and they fall out and get killed, you’re the one responsible, not management. You’re the one and this really needs to be hit home. (Manual handling trainer-1, FG-1) Participants indicated that they needed constant reminders regrading mobility optimization and person-centeredness: It’s certainly made more (staff) more aware that we aren’t transferring the residents correctly, particularly residents who have 4 wheel frames, cause we’re so quick to get them up. we’re not allowing enough time for them to do more themselves. We tend to want to try and help them, don’t we? (Nurse supervisor-1, FG-2) So, that’s just enforced something that I have forgotten; to approach the resident with lots of love and care and explain to the resident. (Lifestyle staff, FG-1) The program supported the value of helping staff have a sense of purpose and achievement: . the program has really helped me to know how to transfer the patient from the bed, bed to the chair, chair to the toilet. (Carer-1, FG-1) One nurse supervisor indicated that when staff were busy, attendance at huddles could be lower. There were no comments about staff needing more time to provide mobility care that was person-centered and mobility enhancing. Practice change resulting from this intervention, as with any training intervention, was dependent on staff engagement: Some (staff) of course are more interested than others. A lot of them are very interested. (Nurse supervisor-2, FG-2) Mechanisms of change Staff understood that this program was not in conflict with or duplicating their regular manual handling training but building upon and integrating safe manual handling into a broader approach. A participant indicated there was value in having an external person driving the change:
103
. the more strategies and things that you come up (with) and ideas. and you bring them here. we can listen. (Manual handling trainer-2, FG-1) There was generally an awareness that such a program needed to continue: . they would slip if it (their knowledge and skills)’s not refreshed I suppose, or valued; they would go back into their old ways I think. (Nurse supervisor-, FG-2) Consistency of approach across staff and shifts was considered important: . because it’s 24 hours care, you really need all staff basically to be doing it consistently all the time. (Manual handling trainer-1, FG-1) It was recognized that everyone needed to be involved, working towards a common purpose. It was highlighted that in-house staff, such as physiotherapists, might find it challenging to provide similar training and support within their scheduled hours: . it’s been good, showing the different things. cause as I said (physio) is flat out doing his own thing. (Nurse supervisor, FG-1) Discussion The current study indicated that a multi-faceted personcentered mobility care intervention conducted by external research-facilitators was feasible. There were no concerns related to recruitment, resources, methodology, acceptability or the outcome measures employed. Standard deviations of the PMS were determined to enable sample size estimates for a larger randomized controlled trial. Statistical analysis of outcomes provided information regarding their potential effect size. Circumstances of the study (context) This study focused on the complex practical concerns of implementing an intervention that was safe, mobility optimizing and person-centered. The study highlighted the need for the intervention to reduce adverse events and to engage and support staff responsible for care at the front-line. The context in which mobility care occurs is constantly changing; systems and processes may need to adapt.46 This study supported the proposition that staff decision-making and leadership are important to quality care.23,47,48 System aides such as care plans or administrative controls are commonly employed in nursing homes. However, staff also make decisions in more intuitive ways and system-aides alone may not be sufficient to improve decision-making and practice.29 What worked and how (mechanism) We posit that the integrated and adaptive capacity of this intervention was a driver of the apparent improvement in mobility care practice. The intervention incorporated a variety of training and facilitation methods as facilitators may need to choose from a range of methods according to the context. Furthermore, the flexible and collaborative way the research-facilitators interacted with staffda form of modelingdmay have been a key factor in helping staff understand how to, in turn, be more responsive, flexible and person-centered during mobility care. Management support was obtained and several staff were enthusiastic about the program. Such support may be sufficient to transform a facility culture into one that is person- and relationship-centered47 and thus able to support collaborative approaches
104
J. Taylor et al. / Geriatric Nursing 36 (2015) 98e105
towards person-centered mobility care improvements. The aim would be to gradually involve everyone and for routines and consistency of approach to be directed towards the common purpose of person-centered mobility care. Transformational culture change may require a targeted approach over a long time and depend on an organization’s executive sponsorship of alternate philosophies, systems and processes from the beginning of an intervention. For whom and in what respects (outcomes) Discussion of study effects need to be qualified as the purpose of this study was to evaluate study feasibility rather than effectiveness. Nevertheless, the intervention appeared to have some effect at the four levels of Kirkpatrick’s hierarchy of educational outcomes which is supported by findings from questionnaires and the focus groups. There was a positive reaction to the program and learning and practice change towards more person-centered mobility care were apparent. Use of the Transfer Observation Instrument may be a valid means of determining both staff behavior change and quality mobility care from the resident’s perspective. Alternate methods for determining residents’ experiences, such as resident interviews and self-ratings of care satisfaction may not provide a more complete nor true picture of residents’ experiences.49,50 For example, residents with dementia, may be unable to communicate coherently. Furthermore, residents may not understand their rights nor want to complain, possibly for fear of retribution, when it comes to inadequate care. Caution is required in interpreting the resident mobility outcomes. A study with larger numbers and a greater degree of control and that can investigate effects over time may assist in determining the effect of this intervention on resident mobility. Strengths and limitations The Transfer Observation Instrument (TOI), used to evaluate staff’s assistive performance during mobility care, was developed specifically for this study as no other suitable tools were found. Use of the TOI and the associated interpretive rule provided a structured framework for recording staff person-centered mobility care competencies. There was potential for bias in this study as one researcher who delivered the intervention also collected and analyzed observational data. Future intervention studies should employ well-trained observers blind to intervention and control groups. Conclusion This study demonstrated a feasible approach to development of person-centered mobility care practice in nursing homes through staff training, huddles and reflective practice. Mobility care is a complex phenomenon where simple strategies cannot be expected to result in practice improvement. The intervention in this study was practical and well accepted. Study methods and outcome measures were suitable. Outcome measures demonstrated capacity to determine the effectiveness of the intervention in a larger randomized controlled trial. Further testing of this adaptive and flexible intervention designed to improve person-centered mobility care is warranted. Future evaluation of intervention sustainability is also recommended. Acknowledgments Janice Taylor was awarded a grant (S13-003) through the Australian Physiotherapy Research Foundation to conduct this study. Dr. Anna Barker is supported by an National Health & Medical
Research Council Career Development Award. Assoc Prof. Haines is supported by an National Health & Medical Research Council Career Development Award. Supplementary data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.gerinurse.2014.11.002. References 1. Edvardsson D, Fetherstonhaugh D, Nay R. Promoting a continuation of self and normality: person-centred care as described by people with dementia, their family members and aged care staff. J Clin Nurs. 2010;19(17/18):2611e2618. 2. Bradshaw SA, Palyfors ED, Riazi A. Living well in care homes: a systematic review of qualitative studies. Age Ageing. 2012;41(4):441e450. 3. McCormack B, McCance T. Personhood and person-centredness. In: McCormack B, McCance T, eds. Person-centred Nursing: Theory and Practice. Oxford: Wiley-Blackwell; 2010:5e20. 4. Dementia Challenge Champion Group. Progress on Prime Minister’s Challenge on Dementia: Year Two. Available from: http://dementiachallenge.dh.gov.uk/2014/ 05/07/champion-groups-letter/; 2014. Accessed 12.07.14. 5. Edvardsson D, Sandman PO, Borell L. Implementing national guidelines for person-centered care of people with dementia in residential aged care: effects on perceived person-centeredness, staff strain, and stress of conscience. Int Psychogeriatr. 2014;26(7):1171e1179. 6. Australian Productivity Commission. Caring for Older Australians: Productivity Commission Inquiry Report. No 53, 28 June. Retrieved from: http://www.pc. gov.au/projects/inquiry/aged-care/report; 2011. Accessed 27.02.13. 7. Bourret EM, Bernick LG, Cott CA, Kontos PC. The meaning of mobility for residents and staff in long-term care facilities. J Adv Nurs. 2002;37(4):338e345. 8. Edwards H, Gaskill D, Sanders F, et al. Resident-staff interactions: a challenge for quality residential aged care. Australas J Ageing. 2003;22(1):31e37. 9. Taylor J, Sims J, Haines TP. “I accept it (staff assistance); no choice”: an ethnographic study of residents’ attitudes towards mobility within nursing homes. Int J Older People Nurs. 2013;9(4):258e268. http://dx.doi.org/10.1111/ opn.12029. 10. Brillhart B. Pressure sore and skin tear prevention and treatment during a 10-month program. Rehabil Nurs. 2005;30(3):85e91. 11. Barker AL, Nitz J, Low Choy NL, Haines T. Mobility has a non-linear association with falls risk among people in residential care: an observational study. J Physiother. 2012;58:117e125. 12. Chenoweth L, King MT, Jeon Y-H, et al. Caring for Aged Dementia Care Resident Study (CADRES) of person-centred care, dementia-care mapping, and usual care in dementia: a cluster-randomised trial. Lancet Neurol. 2009;8(4):317e 325 [Erratum appears in Lancet Neurol. 2009 May;8(5):419]. 13. Sloane PD, Hoeffer B, Mitchell CM, et al. Effect of person-centered showering and the towel bath on bathing-associated aggression, agitation, and discomfort in nursing home residents with dementia: a randomized, controlled trial. J Am Geriatr Soc. 2004;52(11):1795e1804. 14. Ouslander JG, Griffiths PC, McConnell E, Riolo L, Kutner M, Schnelle J. Functional incidental training: a randomized, controlled, crossover trail in Veterans Affairs nursing homes. J Am Geriatr Soc. 2005;53(7):1091e1100. 15. Schnelle JF, Alessi CA, Simmons SF, Al-Samarrai NR, Beck JC, Ouslander JG. Translating clinical research into practice: a randomized controlled trial of exercise and incontinence care with nursing home residents. J Am Geriatr Soc. 2002;50:1476e1483. 16. Taylor J, Sims J, Haines TP. Quality improvements in resident mobility care: using person- and relationship-centred frameworks. Gerontologist. 2013;54(3): 501e513. http://dx.doi.org/10.1093/geront/gn082. Epub 2013 Aug 9. 17. Brooker D. What is person-centred care in dementia? Rev Clin Gerontol. 2004;13:215e222. 18. Kindblom-Rising K, Wahlstrom R, Ekman S, Buer N, Nilsson-Wikmar L. Nursing staff’s communication modes in patient transfer before and after an educational intervention. Ergonomics. 2010;53(10):1217e1277. 19. Taylor J, Sims J, Haines TP. The impact of manual handling on nursing home resident mobility during transfers on and off furniture: a systematic review. J Gerontol Nurs. 2011;37(8):48e56. 20. Morgan S, Yoder LH. A concept analysis of person-centred care. J Holist Nurs. 2012;30(1):6e15. 21. Kitwood T. Dementia Reconsidered: The Person Comes First. Buckingham: Open University Press; 1997. 22. McCormack B, Manley K, Titchen A. Practice Development in Nursing and Healthcare. 2nd ed. Oxford: Wiley-Blackwell; 2013. 23. Taylor J, Sims J, Haines TP. Quality mobility care in nursing homes: a model of moderating and mediating factors to guide intervention development. Res Gerontol Nurs. 2014;7(6):284e291. http://dx.doi.org/10.3928/1940492120140731-01. 24. Forsetlund L, Bjørndal A, Rashidian A, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2009;(2).
J. Taylor et al. / Geriatric Nursing 36 (2015) 98e105 25. Nolan M, Davies S, Ryan T, Keady J. Relationship-centred care and the ‘Senses’ framework. J Dementia Care. 2008 Jan-Feb;16(1):26e28. 26. Nelson A, Matz M, Chen F, Siddharthan K, Lloyd J, Fragala G. Development and evaluation of a multifaceted ergonomics program to prevent injuries associated with patient handling tasks. Int J Nurs Stud. 2006;43(6):717. 27. Ghaye T, Lillyman S. Reflection: Principles and Practices for Healthcare Professionals. 2nd ed. London: Quay Books; 2010. 28. Stubbings L, Chaboyer W, McMurray A. Nurses’ use of situation awareness in decision-making: an integrative review. J Adv Nurs. 2012;68(7):1443e1453. 29. Taylor J, Sims J, Haines TP. The emergent relevance of care staff decisionmaking and situation awareness to mobility care in nursing homes: an ethnographic study. J Adv Nurs. 2014;70(12):2767e2778. http://dx.doi.org/ 10.1111/jan.12432. Epub 2014 Apr 15. 30. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd ed. New York: Guilford Press; 2002. 31. Lal S, Korner-Bitensky N. Motivational interviewing: a novel intervention for translating rehabilitation research into practice. Disabil Rehabil. 2013;35(11): 919e923. 32. Arain M, Campbell MJ, Cooper CL, Lancaster GA. What is a pilot or feasibility study? A review of current practice and editorial policy. BMC Med Res Methodol. 2010;10:67. 33. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. Int J Nurs Stud. 2013;50(5):587e592. 34. Pawson R, Tilley N. Realist Evaluation. Available from: http://scholar.google. com.au.ezproxy.lib.monash.edu.au/scholar?hl¼en&q¼realistþevaluation&btnG¼ &as_sdt¼1%2C5&as_sdtp¼; 2004. Accessed 26.10.13. 35. Creswell JW, Plano Clark VL. Designing and Conducting Mixed Methods Research. Thousand Oaks, CA: Sage Publications; 2007. 36. Rycroft-Malone R, Fontenla M, Bick D, Seers K. A realistic evaluation: the case of protocol-based care. Implement Sci. 2010;5(38). 37. Kirkpatrick D. Evaluating Training Programs: The Four Levels. 2nd ed. San Francisco: Berrett-Koehler Publishers; 1998. 38. Marchi S. Participatory and appreciative action and reflection in adult learning: Transformation as appreciative reflection. In: Wang V, ed. Encyclopedia of
39. 40.
41.
42. 43.
44. 45. 46.
47. 48.
49.
50.
105
Information Communication Technologies and Adult Education Integration. Hershey, PA: IGI Global; 2011:723e739. http://dx.doi.org/10.4018/978-1-61692906-0.ch043. Ghaye T, Lillyman S. Empowerment Through Reflection: A Guide for Practitioners and Healthcare Teams. 2nd ed. London: Quay Books; 2012. Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. Br Med J Qual Saf; 2013;1e9. http://dx.doi.org/10.1136/bmjqs2013-001862. Barker AL, Nitz JC, Choy NLL, Haines TP. Clinimetric evaluation of the Physical Mobility Scale supports clinicians and researchers in residential aged care. Arch Phys Med Rehabil. 2008;89(11):2140e2145. Nitz JC, Hourigan SR. Measuring mobility in frail older people: reliability and validity of the Physical Mobility Scale. Australas J Ageing. 2006;25(1):31e35. Pope C, Ziebland S, Mays N. Analysing qualitative data. In: Pope C, Mays N, eds. Qualitative Research in Health Care. 3rd ed. Malden: Blackwell Publishing Ltd; 2006:63e81. QSR International. NVivo 9, http://www.qsrinternational.com/products_nvivo. aspx; 2010. Australian Nursing Federation. ANF Policy: No Lifting. Retrieved from: http:// anmf.org.au/pages/workplace-health-safety; 2008. Accessed 14.10.14. Mold JW, Peterson KA. Primary care practice-based research networks: working at the interface between research and quality improvement. Ann Fam Med. 2005;3(May/June):S12eS20. Tyler DA, Parker VA. Nursing home culture, teamwork, and culture change. J Res Nurs. 2011;16(1):37e49. http://dx.doi.org/10.1177/1744987110366187. Chaudhuri T, Yeatts DE, Cready CM. Nurse aide decision making in nursing homes: factors affecting empowerment. J Clin Nurs. 2013;22(17/18):2572e 2585. Simmons SF, Schnelle JF. Strategies to measure nursing home residents’ satisfaction and preferences related to incontinence and mobility care: implications for evaluating intervention effects. Gerontologist. 1999;39(3):345e355. Dean R, Proudfoot R, Lindesay J. The quality of interactions schedule (QUIS): development, reliability and use in the evaluation of two domus units. Int J Geriatr Psychiatry. 1993;8:819e826.
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Feature Article
Improving person-centered mobility care in nursing homes: A feasibility study Janice Taylor, PhD, MGeron, BAppSc (Pty) a, *, Anna Barker, BPhty, MPhty (Geriatrics), PhD b, Heather Hill, PhD, MEd, BA c, Terry P. Haines, PhD, GCert (Health Economics), BPhysiotherapy (Hons) d, e a
Monash University, Faculty of Medicine, Nursing and Health Sciences, Building 1, 270 Ferntree Gully Rd, Notting Hill, Melbourne, Victoria 3168, Australia b Department of Epidemiology and Preventive Medicine, Monash University, Level 6, Alfred Centre, 99 Commercial Rd., Melbourne 3004, Australia c Quality Relationships-Quality Care, Australia d Allied Health Research Unit, Southern Health, Kingston Centre, Warrigal Rd., Cheltenham, Victoria 3192, Australia e Southern Physiotherapy Clinical School, Monash University, Melbourne, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 August 2014 Received in revised form 7 November 2014 Accepted 10 November 2014 Available online 28 February 2015
Person-centered care is often equated with quality nursing home care. At the same time, quality mobility care contributes to residents’ independence and quality of life. Realist evaluation and mixed methods were employed to evaluate the feasibility of a multi-faceted training intervention focused on personcentered mobility care. Staff and ambulatory residents of a ninety bed Australian nursing home with 3 unitsdone dementia-specificdparticipated. The intervention consisted of training sessions, weekly mobility care huddles and reflective practice sessions with individual staff. This study demonstrated the feasibility of an intervention aiming to improve person-centered mobility care in nursing homes; it was practical and well accepted. Study methods and outcome measures were suitable. Outcome measures demonstrated capacity to determine the effectiveness of the intervention in a larger randomized controlled trial. Focus groups provided insights regarding the context and mechanisms of change. Future research is recommended to evaluate intervention effectiveness and sustainability. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Collaboration Mixed methods Mobility care Nursing home Person-centered care Realist evaluation Reflective practice
Background Person-centered care is often equated with quality nursing home care1 and involves consideration of residents’ choice, autonomy, independence and control.2,3 The need for person-centered care is evidenced by calls to share best practice in personalized dementia care in the United Kingdom,4 within national guidelines for dementia care in Sweden,5 and through consumer-directed care recommendations enshrining choice and control for older people in Australia.6 At the same time, mobility is an aspect of residents’ daily activities that contributes to their independence and quality of life.7,8 Many residents require some form of staff assistancedreferred to as mobility caredto achieve activities of daily living, but staff promotion of residents’ autonomy, independence and control during mobility is frequently absent.9 This can result in
* Corresponding author. E-mail address: [email protected] (J. Taylor). 0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.11.002
dependence being imposed on residents with consequent physical deconditioning, reduced mobility, skin breakdown, and falls.9e11 To the best of our knowledge, no studies have evaluated the use of person-centered approaches during mobility care. Personcentered strategies and support for staff have reduced agitation in people with dementia12 and enhanced residents’ and staff’s experiences during hygiene care.13 Functional training designed for staff to conduct in addition to usual care can improve residents’ mobility,14,15 however this approach has not been widely adopted, possibly due to inadequate staffing.15 Person-centered approaches may improve the quality of mobility care and resident mobility outcomes.16 Person-centered approaches incorporate individualized care.16,17 Individualized mobility care requires staff to understand residents’ mobility capacity and to safely meet residents’ mobility needs through use of mobility enhancing strategies that encourage and allow residents to move themselves where possible.9,18 This is particularly important during transfers on and off furniture, a function that determines residents’ continued safe ambulation.19
J. Taylor et al. / Geriatric Nursing 36 (2015) 98e105
Person-centered mobility care has a broader focus than individualized care20; the quality of the residentestaff interaction is the primary consideration with staff being ready to respond flexibly in the moment to the needs of the resident as a whole.21,22 Inadequate staff training and support can act as barriers to person-centered mobility care but may be addressed by multi-faceted interventions based on collaborative training approaches.23 Traditional didactic models of training are less successful in securing staff behavior change than when combined with collaborative and interactive models of training.24 Facility cultures based on relationships and an enriched and supportive environment are also recommended for effective practice change.22,25 Huddlesdsmall gatherings of staff for learning purposesdhave been successfully employed to ensure safe manual handling practice.26 Reflective practice can also facilitate practice development.22,27 In particular, reflective practice may improve nursing home staff’s situation awareness and intuitive decision-making that are important when high levels of uncertainty and unpredictability exist, as they often do during mobility care.28,29 Motivational interviewing,30 promoted as a tool for knowledge translation,31 is a further means of working with staff’s change process through active listening and use of reflections. The purpose of the current study was to evaluate the feasibility of an intervention to improve person-centered mobility care during resident transfers.32 Specific purposes of the study included to test recruitment, resources, methodologies, acceptability and outcome measures as well as to estimate sample sizes for a randomized controlled trial. Analysis of outcomes provided information regarding potential effect sizes. As a study’s feasibility is also dependent upon interventions being contextually appropriate,33 we evaluated the context of the current intervention. Method Realist evaluation34 and mixed methods in a convergent parallel design35 were employed to evaluate the feasibility of this complex intervention. Realist evaluation is a pragmatic approach that considers relationships and the social environment and explores study context, mechanisms and outcomes to better understand what worked, for whom, in what circumstances, in what respects and how.36 The context of this study was person-centered mobility care improvements in a nursing home setting. The mechanisms were the intervention and use of mixed methods including a usual care controlled, pre-post design. Kirkpatrick’s hierarchy of educational outcomes guided evaluation at 4 levels: (1) participant reaction; (2) participant learning; (3) participant behavior change; and (4) outcomes.37 Focus groups provided qualitative data to assist with evaluation of the study. Setting and participants The study was conducted in a ninety bed nursing home with 3 high care units, including one that was dementia-specific, in Melbourne, Australia. Purposeful samples of staff and residents were recruited. Inclusion criteria for residents were to be consenting, ambulant with or without gait aids, permanent stay and classified as requiring high care services as assessed by regulated Australian Aged Care Assessment Teams. Residents who were short stay and non-consenting were excluded. Inclusion criteria for staff were to be consenting and employed to provide direct care. Casual and agency staff were excluded. Management assisted with recruitment by distributing explanatory statements to residents, their families and staff.
99
Ethical issues Ethics approval from Monash University Human Research Ethics Committee and organizational permission were gained for the study. Participant staff and residents provided written informed consent. Third party consent was gained from residents’ proxies when residents had a diagnosis of dementia or cognitive impairment. Unit coordinators, who knew the residents well, deemed when proxy consent was necessary. The first author (ww) approached some residents, with management permission and following advice from unit coordinators regarding who was able to give informed consent, to assist with recruitment. Participants in focus groups consented to sessions being audio-recorded. Facility consent was obtained for unobtrusive observations of staff and residents in public areas. The intervention The intervention was a collaborative training program conducted over sixteen weeks. Person- and relationship-centered frameworks,21,25 consistent with the notions of transformational learning and appreciative action,38,39 guided development of the intervention. Two researchers conducted the intervention. The primary intervention facilitator had twenty-six years’ of experience as a physiotherapist in nursing homes and an emic understanding of the culture surrounding mobility care. She was assisted during training sessions by a dementia care consultant trained as a social worker and dance therapist. Neither had a relationship with the facility or staff beyond this study. The intervention underwent preliminary testing in another nursing home. Content Staff were trained in the use of person-centered approaches and mobility enhancing strategies during mobility care including how to approach, interact and communicate with residents and how to promote the correct biomechanics for independent transfers. Key features of the multi-faceted program included: reinforcement of safe manual handling; use of a mobility care decision tool; provision of person-centered and mobility enhancing strategies; and environmental considerations such as the need for appropriate seating and correct use of gait aids. Format Table 1 illustrates the timing and key aspects of the intervention. Training formats included: two 1-h training sessions; weekly mobility care huddles; and reflective practice with individual staff. Facilitation methods during training and in huddles varied but the focus was on use of experiential and interactive methods and included the plan-do-study-act cycle40 (Table 2). Motivational interviewing was employed during reflective practice sessions. Both motivational interviewing and reflective practice are consistent with the notions of transformational learning and appreciative action. Data collection Staff measures Staff satisfaction (training) (Kirkpatrick’s level 1 e reaction) e measured using a fourteen item questionnaire designed to determine whether staff’s expectations were met, how they rated the training and what they learned from it. Response items included items with a 5 point Likert scale and open-ended questions (See Appendix). Staff satisfaction (program as a whole) (Kirkpatrick’s level 1 e reaction) e measured using a twenty-six item questionnaire designed to determine whether staff’s expectations of the program
100
J. Taylor et al. / Geriatric Nursing 36 (2015) 98e105
Table 1 Timing and key aspects of the training. Intervention component
Dec 10th 2013 & Feb 6th 2014
Dec 31st 2013 to April 10th 2014
Training
Huddles
Reflective practice
Content/ procedure
Content & procedure: Staff knowledge test (Quiz) e Pre-training 1. Highlight key points: Learning objectives Importance of sit to stand Being with and for the resident rather than “helping” them 2. Experiential exercise e leading and following (movement awareness) 3. Skills training:
Procedure: 1. Week before, notification of the huddle and time was written in unit diaries 2. On the day the nurse supervisor was reminded about the event and a convenient time was confirmed 3. The huddle and time were advertised on a clip board in a location visible to staff 4. The huddle conducted on the unit with those staff able to attend
Procedure: 1. Reminder of the program and its purpose 2. Introduction to purpose of reflective practice 3. Discussion related to issues arising related to person-centred mobility care 4. Encouragement of reflective practice 5. Use of motivational interviewing techniques where appropriate
Demonstration and practice e transfers 4. Discussion of new learning 5. Handouts provided: List of strategies for: (i) Person-centered approaches (ii) mobility enhancement (iii) safety Decision-making tool 6. Questions
Follow-up: - A record of the huddle written and placed in unit diaries - The record was also placed in a “Mobility Care Huddle Folder” placed on each unit
Frequency
Length
Staff knowledge test (Quiz) e Post-training evaluation 2 sessions (2 groups of 12 and 9 different participants*) * one nurse supervisor repeated the training 1 hour each
Repeat sessions: - Opening to reflection of issues previously raised - Motivational interviewing techniques used where appropriate
One per unit every 3rd week
3 sessions per week with various staff
10e20 min (3 sessions were 60 min. Of these one was scheduled as a workshop for senior nurses and two were PDSA cycle sessions 2 on one unit where staff were allowed to attend.
10e30 min
were met and how. Response items included items with a 5 point Likert scale and open-ended questions (See Appendix). Staff knowledge (Kirkpatrick’s level 2 e learning) e measured using a staff knowledge test and rater’s guide designed for the purpose (See Appendix). This tool underwent preliminary testing for face and content validity with several care staff at another facility. Staff completed the test before and after training.
Staff mobility care during transfers (Kirkpatrick’s level 3 e behavior change) e measured using a Transfer Observation Instrument (TOI) adapted from a tool developed for earlier qualitative research and designed to assess staff’s mobility care with respect to safety, use of mobility enhancing strategies, and personcenteredness (See Appendix). Categorical ratings of positive, neutral and negative were assigned to each TOI assessment using a
Table 2 Facilitation methods employed during huddles and reflective practice. Mechanism
Method
Details
Indicated for
Motivational interviewing (MI) Reflective practice
Specific to MI
Conversation
Coachinga
Huddles
Case studya
Conversation. Personalized active participation. Members of team gathered, chose a known resident and discussed current concerns. Outcomes were fed back to the participants and other team members. Members of the team gathered for a planned session, ideas were evoked and recorded on flip charts then analyzed to develop action plans Members of the team gathered for a facilitator directed session on a topic specific to the study. Team involvement and cohesion were encouraged. Members of the team gathered for a planned session. The PDSA cycle was followed. Members of the team gathered for demonstration and practice of a technique
Supporting change process Self-discovery Problem-solving Self-discovery Involving all learners Practice and application Problem-solving Teamwork Self-discovery Problem-solving Collecting wide range of views Teamwork
Brainstorma
Action learninga
Plan-Do-Study-act (PDSA) Demonstration and practicea a
Focusing on knowledge & skills Developing analytical skills Identifying differences & alternatives Process review Decision-making Identifying differences & alternatives Focusing on a specific issue
Problem-solving Workflow Involvement in real work Self-discovery
Teamwork Deepening understanding of issues
Examining specific steps in practice processes
Designing, implementing and monitoring changes
Development of psychomotor and interpersonal skills
Adapted from Tovey MD, Lawlor DR. Training in Australia: design, delivery, evaluation, management. 2nd ed. Pearson: Prentice Hall; 2004 (Table 6.1, p 219).
J. Taylor et al. / Geriatric Nursing 36 (2015) 98e105
101
Table 3 Facility and unit characteristics. Facility
Unit A (High care)
No. of staff No. of resident beds No. of ambulatory residents
B (High care)
C (High care, dementia-specific)
149 90 27 24
30 31 29 12 8 7 12 8 4 1:4 1:4 1:4 1:5 1:5 1:5 35 h over 4 days per week across the 3 units Mandatory annual training for staff On-site manual handling coordinator Refreshers conducted with in-house trainers who have received specific manual handling trainer training
Commencement Completion
Morning shift resident: Care staff ratios (Medicators & RN’s not included) Afternoon shift resident: Care staff ratios (Medicators & RN’s not included) Hours of physiotherapy per week Manual handling training
relating to staff behavior and residents’ experience of mobility care was analyzed using the ManneWhitney test. Pre-post testing was conducted on the matched interval data from the resident PMS scores and the staff knowledge test using the paired t test. Quantitative analysis was conducted by the first and last authors (ww, zz).
rule developed by the current authors for the purpose of this study. Resident measures Resident mobility (Kirkpatrick’s level 4 e outcomes) e measured using the Physical Mobility Scale (PMS). This instrument has been extensively tested for validity and reliability for nursing home residents.41,42 Residents’ degree of autonomy during, and experience of, mobility care (Kirkpatrick’s level 4 e outcomes) e measured using the Transfer Observation Instrument as a proxy measure. This tool assessed resident responses to care as well as staff mobility care performance.
Qualitative Focus groups and open-ended questions from questionnaires were analyzed by ww using thematic analysis43 with the assistance of NVivo software.44 Themes emerging from focus groups were identified. Co-authors’ (xx, yy, zz) provided face validity to the emergent categories and themes by cross-checking against transcriptions.
Qualitative data Focus groups were conducted to add depth to findings and were audio-recorded.
Results The facility and unit characteristics are shown in Table 3. The facility policy on safe manual handling was consistent with the Australian Nursing Federation “No Lifting” policy.45 Twelve ambulant residents with a mean age of 83 (SD 5), comprising 5 males and 7 females, participated in the study (Fig. 1). All ambulated with 4 wheeled walkers bar one who did not use a gait aid.
Data analysis Quantitative Quantitative data from questionnaires was analyzed using descriptive statistics. The unmatched categorical data from the TOI
86 residents in the facility
59 residents did not meet the inclusion criteria 27 residents (31% of total residents) met the inclusion criteria 15 ambulatory residents were not recruited
12 residents (44% of ambulatory residents) were recruited
Unit A
Unit B
Unit C
6 ambulatory residents recruited, enrolled at baseline
2 ambulatory residents recruited, enrolled at baseline
4 ambulatory residents recruited, enrolled at baseline
(none lost to death, relocation or withdrawal)
(none lost to death, relocation or withdrawal)
(none lost to death, relocation or withdrawal)
Fig. 1. Resident recruitment and participant numbers.
102
J. Taylor et al. / Geriatric Nursing 36 (2015) 98e105 Table 5 Levels of staff participation.
149 direct care staff met inclusion criteria
98 direct care workers not recruited 51 (34%) direct care staff recruited, enrolled at baseline in 3 units (none lost to relocation or withdrawal)
17 11 8 6 3 3 1 49
(35) (22) (17) (12) (6) (6) (2) (100)
Two participants (the Manager and a Nurse supervisor) attended an evaluation focus group only. They were, however, involved in interactions and conversations, as were many other participants and other staff, with the researcher during the project. a One nurse supervisor attended both training sessions.
Fifty-one direct care staff participated (Fig. 2) and their characteristics are shown in Table 4. Levels of staff participation in varying aspects of the intervention are shown in Table 5. Twenty staff attended one of two training sessions. Fifteen weekly huddles were conducteddone huddle per unit every third week. Nine staff attended more than one huddle. Staff were encouraged by their peers and nurse supervisors to attend. Huddle outcomes were fed back to other staff in the form of written reports stored on the unit as a reference. Thirty-nine reflective practice sessions of ten to 30 min duration were conducted with twenty-one staff and twelve participants attended more than one such session. No adverse events were reported for residents or staff as a result of this intervention. Staff outcomes Staff satisfaction The response rate to training evaluation questionnaires was one hundred per cent. Forty per cent of staff rated the training as “excellent” and sixty per cent as “good”. Averaging responses, all agreed or strongly agreed that desired outcomes were achieved. Some commented that there needed to be more time, discussion and demonstration. Twelve staff, or twenty-three per cent of the fifty-one staff participants, comprising 8 carers, 2 nurses, one lifestyle staff and the physiotherapist, completed program evaluation questionnaires. Of these, 9 had participated in reflective practice sessions and 7 had attended mobility care huddles. Averaging responses, all agreed that their expectations had been met, the facilitator had been helpful and respectful, that improvements had occurred in teamwork and their sense of belonging, feelings of
Table 4 Staff participant characteristics. Staff characteristics, N ¼ 51 (34% of total 149 direct care workers)
No. of staff (%)
Huddle only Huddle and reflective practice Training onlya Training, huddle and reflective practice Training and huddle Training and reflective practice Reflective practice only Total b
Fig. 2. Staff recruitment and participant numbers.
Gender Female Male Position Carer Nurse supervisor MH trainer Lifestyle staff Nurse Manager Physiotherapist Years’ experience >10 2e5 0e1 5e10 1e2
Intervention mode experienced
N (%) 42 (82) 9 (18) 25 9 5 5 4 2 1
(49) (17) (10) (10) (8) (4) (2)
16 16 7 7 5
(32) (32) (13) (13) (10)
being valued and sense of support. Staff felt the culture of their unit had improved. Positive comments included the value of reflective practice and an increased understanding of person-centeredness. All agreed their sense of safety and their understanding of residents’ mobility needs and how to assist residents had improved. Some staff suggested more training was needed and that sessions should be well advertised so all staff could attend. Staff knowledge The staff knowledge test, conducted before and after training with a total of seventeen staffd3 cases were deleted due to missing datadshowed a mean improvement of seventeen per cent (t test, p ¼ 0.0005) in participants’ knowledge (pre-test mean 41%, SD ¼ 19%; post-test mean ¼ 58%, SD ¼ 17%). Staff mobility care during transfers Two samples of staff behavior during mobility care events were obtained using the Transfer Observation Instrument pre- and post-intervention. The samples were collected over 7.5 h preintervention and 13 h post-intervention. Both samples comprised twenty-seven residentestaff interactions. Pre-post testing of the samples of staff behavior indicated improvements; instances of mobility care categorized as positive increased by twenty-two per cent and negative instances of mobility care decreased by twentysix per cent (ManneWhitney, p ¼ 0.0148). Resident outcomes Resident mobility Residents’ mean PMS decreased by 8% (t test, p ¼ 0.02). There was no significant change in the transfer or ambulation items (G and H respectively) of the PMS score. Residents’ degree of autonomy during, and experience of, mobility care The twenty-two per cent increase in positive and twenty-six per cent decrease in negative instances of mobility care indicated improvement in residents’ autonomy and control during, and experience of, mobility care. Focus group findings Two focus groups were conducted with a total of ten staff comprising 7 females and 3 males. Seven staff had more than ten years’ experience in residential aged care. Participants included a physiotherapist, one lifestyle staff member, 4 carers including 2 who were manual handling trainers, 3 nurse supervisors and the facility manager. Emergent themes were aligned to the study’s use
J. Taylor et al. / Geriatric Nursing 36 (2015) 98e105
of realist evaluation; Theme (1) The need for change, became “The change context” and Theme (2) The way to change, became “Mechanisms of change”. Themes were often interwoven and overlapping. Themes also supported evidence from outcome data suggesting that benefits such as improvements in mobility care occurred during this study. The change context The need for person-centered approaches to mobility care was highlighted by a high possibility of adverse events such as resident skin tears, bruising, aggressive behaviors and falls during mobility care. It was felt that ultimately, staff were the ones responsible for providing safe and quality care: Some staff don’t realize because they don’t think. They don’t use their brain and think forward what they’re actually doing and they wonder why they’re getting punched in the mouth, spat on, scratched and kicked. I find them grabbing, grabbing the resident like that to, you know, pull a sleeve up and they’re grabbing like that and the resident is thinking “Well my shoulder’s hurting and they’re pulling”. You know skin tears have gone down a lot but I’m noticing again there’s a lot of residents (sic) starting to get bruises. (Manual handling trainer-1, FG-1) If a resident slides out of the standing machine or the sling because you haven’t put them in properly, secured them, or you’re doing it on your own and you’ve let go and they fall out and get killed, you’re the one responsible, not management. You’re the one and this really needs to be hit home. (Manual handling trainer-1, FG-1) Participants indicated that they needed constant reminders regrading mobility optimization and person-centeredness: It’s certainly made more (staff) more aware that we aren’t transferring the residents correctly, particularly residents who have 4 wheel frames, cause we’re so quick to get them up. we’re not allowing enough time for them to do more themselves. We tend to want to try and help them, don’t we? (Nurse supervisor-1, FG-2) So, that’s just enforced something that I have forgotten; to approach the resident with lots of love and care and explain to the resident. (Lifestyle staff, FG-1) The program supported the value of helping staff have a sense of purpose and achievement: . the program has really helped me to know how to transfer the patient from the bed, bed to the chair, chair to the toilet. (Carer-1, FG-1) One nurse supervisor indicated that when staff were busy, attendance at huddles could be lower. There were no comments about staff needing more time to provide mobility care that was person-centered and mobility enhancing. Practice change resulting from this intervention, as with any training intervention, was dependent on staff engagement: Some (staff) of course are more interested than others. A lot of them are very interested. (Nurse supervisor-2, FG-2) Mechanisms of change Staff understood that this program was not in conflict with or duplicating their regular manual handling training but building upon and integrating safe manual handling into a broader approach. A participant indicated there was value in having an external person driving the change:
103
. the more strategies and things that you come up (with) and ideas. and you bring them here. we can listen. (Manual handling trainer-2, FG-1) There was generally an awareness that such a program needed to continue: . they would slip if it (their knowledge and skills)’s not refreshed I suppose, or valued; they would go back into their old ways I think. (Nurse supervisor-, FG-2) Consistency of approach across staff and shifts was considered important: . because it’s 24 hours care, you really need all staff basically to be doing it consistently all the time. (Manual handling trainer-1, FG-1) It was recognized that everyone needed to be involved, working towards a common purpose. It was highlighted that in-house staff, such as physiotherapists, might find it challenging to provide similar training and support within their scheduled hours: . it’s been good, showing the different things. cause as I said (physio) is flat out doing his own thing. (Nurse supervisor, FG-1) Discussion The current study indicated that a multi-faceted personcentered mobility care intervention conducted by external research-facilitators was feasible. There were no concerns related to recruitment, resources, methodology, acceptability or the outcome measures employed. Standard deviations of the PMS were determined to enable sample size estimates for a larger randomized controlled trial. Statistical analysis of outcomes provided information regarding their potential effect size. Circumstances of the study (context) This study focused on the complex practical concerns of implementing an intervention that was safe, mobility optimizing and person-centered. The study highlighted the need for the intervention to reduce adverse events and to engage and support staff responsible for care at the front-line. The context in which mobility care occurs is constantly changing; systems and processes may need to adapt.46 This study supported the proposition that staff decision-making and leadership are important to quality care.23,47,48 System aides such as care plans or administrative controls are commonly employed in nursing homes. However, staff also make decisions in more intuitive ways and system-aides alone may not be sufficient to improve decision-making and practice.29 What worked and how (mechanism) We posit that the integrated and adaptive capacity of this intervention was a driver of the apparent improvement in mobility care practice. The intervention incorporated a variety of training and facilitation methods as facilitators may need to choose from a range of methods according to the context. Furthermore, the flexible and collaborative way the research-facilitators interacted with staffda form of modelingdmay have been a key factor in helping staff understand how to, in turn, be more responsive, flexible and person-centered during mobility care. Management support was obtained and several staff were enthusiastic about the program. Such support may be sufficient to transform a facility culture into one that is person- and relationship-centered47 and thus able to support collaborative approaches
104
J. Taylor et al. / Geriatric Nursing 36 (2015) 98e105
towards person-centered mobility care improvements. The aim would be to gradually involve everyone and for routines and consistency of approach to be directed towards the common purpose of person-centered mobility care. Transformational culture change may require a targeted approach over a long time and depend on an organization’s executive sponsorship of alternate philosophies, systems and processes from the beginning of an intervention. For whom and in what respects (outcomes) Discussion of study effects need to be qualified as the purpose of this study was to evaluate study feasibility rather than effectiveness. Nevertheless, the intervention appeared to have some effect at the four levels of Kirkpatrick’s hierarchy of educational outcomes which is supported by findings from questionnaires and the focus groups. There was a positive reaction to the program and learning and practice change towards more person-centered mobility care were apparent. Use of the Transfer Observation Instrument may be a valid means of determining both staff behavior change and quality mobility care from the resident’s perspective. Alternate methods for determining residents’ experiences, such as resident interviews and self-ratings of care satisfaction may not provide a more complete nor true picture of residents’ experiences.49,50 For example, residents with dementia, may be unable to communicate coherently. Furthermore, residents may not understand their rights nor want to complain, possibly for fear of retribution, when it comes to inadequate care. Caution is required in interpreting the resident mobility outcomes. A study with larger numbers and a greater degree of control and that can investigate effects over time may assist in determining the effect of this intervention on resident mobility. Strengths and limitations The Transfer Observation Instrument (TOI), used to evaluate staff’s assistive performance during mobility care, was developed specifically for this study as no other suitable tools were found. Use of the TOI and the associated interpretive rule provided a structured framework for recording staff person-centered mobility care competencies. There was potential for bias in this study as one researcher who delivered the intervention also collected and analyzed observational data. Future intervention studies should employ well-trained observers blind to intervention and control groups. Conclusion This study demonstrated a feasible approach to development of person-centered mobility care practice in nursing homes through staff training, huddles and reflective practice. Mobility care is a complex phenomenon where simple strategies cannot be expected to result in practice improvement. The intervention in this study was practical and well accepted. Study methods and outcome measures were suitable. Outcome measures demonstrated capacity to determine the effectiveness of the intervention in a larger randomized controlled trial. Further testing of this adaptive and flexible intervention designed to improve person-centered mobility care is warranted. Future evaluation of intervention sustainability is also recommended. Acknowledgments Janice Taylor was awarded a grant (S13-003) through the Australian Physiotherapy Research Foundation to conduct this study. Dr. Anna Barker is supported by an National Health & Medical
Research Council Career Development Award. Assoc Prof. Haines is supported by an National Health & Medical Research Council Career Development Award. Supplementary data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.gerinurse.2014.11.002. References 1. Edvardsson D, Fetherstonhaugh D, Nay R. Promoting a continuation of self and normality: person-centred care as described by people with dementia, their family members and aged care staff. J Clin Nurs. 2010;19(17/18):2611e2618. 2. Bradshaw SA, Palyfors ED, Riazi A. Living well in care homes: a systematic review of qualitative studies. Age Ageing. 2012;41(4):441e450. 3. McCormack B, McCance T. Personhood and person-centredness. In: McCormack B, McCance T, eds. Person-centred Nursing: Theory and Practice. Oxford: Wiley-Blackwell; 2010:5e20. 4. Dementia Challenge Champion Group. Progress on Prime Minister’s Challenge on Dementia: Year Two. Available from: http://dementiachallenge.dh.gov.uk/2014/ 05/07/champion-groups-letter/; 2014. Accessed 12.07.14. 5. Edvardsson D, Sandman PO, Borell L. Implementing national guidelines for person-centered care of people with dementia in residential aged care: effects on perceived person-centeredness, staff strain, and stress of conscience. Int Psychogeriatr. 2014;26(7):1171e1179. 6. Australian Productivity Commission. Caring for Older Australians: Productivity Commission Inquiry Report. No 53, 28 June. Retrieved from: http://www.pc. gov.au/projects/inquiry/aged-care/report; 2011. Accessed 27.02.13. 7. Bourret EM, Bernick LG, Cott CA, Kontos PC. The meaning of mobility for residents and staff in long-term care facilities. J Adv Nurs. 2002;37(4):338e345. 8. Edwards H, Gaskill D, Sanders F, et al. Resident-staff interactions: a challenge for quality residential aged care. Australas J Ageing. 2003;22(1):31e37. 9. Taylor J, Sims J, Haines TP. “I accept it (staff assistance); no choice”: an ethnographic study of residents’ attitudes towards mobility within nursing homes. Int J Older People Nurs. 2013;9(4):258e268. http://dx.doi.org/10.1111/ opn.12029. 10. Brillhart B. Pressure sore and skin tear prevention and treatment during a 10-month program. Rehabil Nurs. 2005;30(3):85e91. 11. Barker AL, Nitz J, Low Choy NL, Haines T. Mobility has a non-linear association with falls risk among people in residential care: an observational study. J Physiother. 2012;58:117e125. 12. Chenoweth L, King MT, Jeon Y-H, et al. Caring for Aged Dementia Care Resident Study (CADRES) of person-centred care, dementia-care mapping, and usual care in dementia: a cluster-randomised trial. Lancet Neurol. 2009;8(4):317e 325 [Erratum appears in Lancet Neurol. 2009 May;8(5):419]. 13. Sloane PD, Hoeffer B, Mitchell CM, et al. Effect of person-centered showering and the towel bath on bathing-associated aggression, agitation, and discomfort in nursing home residents with dementia: a randomized, controlled trial. J Am Geriatr Soc. 2004;52(11):1795e1804. 14. Ouslander JG, Griffiths PC, McConnell E, Riolo L, Kutner M, Schnelle J. Functional incidental training: a randomized, controlled, crossover trail in Veterans Affairs nursing homes. J Am Geriatr Soc. 2005;53(7):1091e1100. 15. Schnelle JF, Alessi CA, Simmons SF, Al-Samarrai NR, Beck JC, Ouslander JG. Translating clinical research into practice: a randomized controlled trial of exercise and incontinence care with nursing home residents. J Am Geriatr Soc. 2002;50:1476e1483. 16. Taylor J, Sims J, Haines TP. Quality improvements in resident mobility care: using person- and relationship-centred frameworks. Gerontologist. 2013;54(3): 501e513. http://dx.doi.org/10.1093/geront/gn082. Epub 2013 Aug 9. 17. Brooker D. What is person-centred care in dementia? Rev Clin Gerontol. 2004;13:215e222. 18. Kindblom-Rising K, Wahlstrom R, Ekman S, Buer N, Nilsson-Wikmar L. Nursing staff’s communication modes in patient transfer before and after an educational intervention. Ergonomics. 2010;53(10):1217e1277. 19. Taylor J, Sims J, Haines TP. The impact of manual handling on nursing home resident mobility during transfers on and off furniture: a systematic review. J Gerontol Nurs. 2011;37(8):48e56. 20. Morgan S, Yoder LH. A concept analysis of person-centred care. J Holist Nurs. 2012;30(1):6e15. 21. Kitwood T. Dementia Reconsidered: The Person Comes First. Buckingham: Open University Press; 1997. 22. McCormack B, Manley K, Titchen A. Practice Development in Nursing and Healthcare. 2nd ed. Oxford: Wiley-Blackwell; 2013. 23. Taylor J, Sims J, Haines TP. Quality mobility care in nursing homes: a model of moderating and mediating factors to guide intervention development. Res Gerontol Nurs. 2014;7(6):284e291. http://dx.doi.org/10.3928/1940492120140731-01. 24. Forsetlund L, Bjørndal A, Rashidian A, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2009;(2).
J. Taylor et al. / Geriatric Nursing 36 (2015) 98e105 25. Nolan M, Davies S, Ryan T, Keady J. Relationship-centred care and the ‘Senses’ framework. J Dementia Care. 2008 Jan-Feb;16(1):26e28. 26. Nelson A, Matz M, Chen F, Siddharthan K, Lloyd J, Fragala G. Development and evaluation of a multifaceted ergonomics program to prevent injuries associated with patient handling tasks. Int J Nurs Stud. 2006;43(6):717. 27. Ghaye T, Lillyman S. Reflection: Principles and Practices for Healthcare Professionals. 2nd ed. London: Quay Books; 2010. 28. Stubbings L, Chaboyer W, McMurray A. Nurses’ use of situation awareness in decision-making: an integrative review. J Adv Nurs. 2012;68(7):1443e1453. 29. Taylor J, Sims J, Haines TP. The emergent relevance of care staff decisionmaking and situation awareness to mobility care in nursing homes: an ethnographic study. J Adv Nurs. 2014;70(12):2767e2778. http://dx.doi.org/ 10.1111/jan.12432. Epub 2014 Apr 15. 30. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd ed. New York: Guilford Press; 2002. 31. Lal S, Korner-Bitensky N. Motivational interviewing: a novel intervention for translating rehabilitation research into practice. Disabil Rehabil. 2013;35(11): 919e923. 32. Arain M, Campbell MJ, Cooper CL, Lancaster GA. What is a pilot or feasibility study? A review of current practice and editorial policy. BMC Med Res Methodol. 2010;10:67. 33. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. Int J Nurs Stud. 2013;50(5):587e592. 34. Pawson R, Tilley N. Realist Evaluation. Available from: http://scholar.google. com.au.ezproxy.lib.monash.edu.au/scholar?hl¼en&q¼realistþevaluation&btnG¼ &as_sdt¼1%2C5&as_sdtp¼; 2004. Accessed 26.10.13. 35. Creswell JW, Plano Clark VL. Designing and Conducting Mixed Methods Research. Thousand Oaks, CA: Sage Publications; 2007. 36. Rycroft-Malone R, Fontenla M, Bick D, Seers K. A realistic evaluation: the case of protocol-based care. Implement Sci. 2010;5(38). 37. Kirkpatrick D. Evaluating Training Programs: The Four Levels. 2nd ed. San Francisco: Berrett-Koehler Publishers; 1998. 38. Marchi S. Participatory and appreciative action and reflection in adult learning: Transformation as appreciative reflection. In: Wang V, ed. Encyclopedia of
39. 40.
41.
42. 43.
44. 45. 46.
47. 48.
49.
50.
105
Information Communication Technologies and Adult Education Integration. Hershey, PA: IGI Global; 2011:723e739. http://dx.doi.org/10.4018/978-1-61692906-0.ch043. Ghaye T, Lillyman S. Empowerment Through Reflection: A Guide for Practitioners and Healthcare Teams. 2nd ed. London: Quay Books; 2012. Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. Br Med J Qual Saf; 2013;1e9. http://dx.doi.org/10.1136/bmjqs2013-001862. Barker AL, Nitz JC, Choy NLL, Haines TP. Clinimetric evaluation of the Physical Mobility Scale supports clinicians and researchers in residential aged care. Arch Phys Med Rehabil. 2008;89(11):2140e2145. Nitz JC, Hourigan SR. Measuring mobility in frail older people: reliability and validity of the Physical Mobility Scale. Australas J Ageing. 2006;25(1):31e35. Pope C, Ziebland S, Mays N. Analysing qualitative data. In: Pope C, Mays N, eds. Qualitative Research in Health Care. 3rd ed. Malden: Blackwell Publishing Ltd; 2006:63e81. QSR International. NVivo 9, http://www.qsrinternational.com/products_nvivo. aspx; 2010. Australian Nursing Federation. ANF Policy: No Lifting. Retrieved from: http:// anmf.org.au/pages/workplace-health-safety; 2008. Accessed 14.10.14. Mold JW, Peterson KA. Primary care practice-based research networks: working at the interface between research and quality improvement. Ann Fam Med. 2005;3(May/June):S12eS20. Tyler DA, Parker VA. Nursing home culture, teamwork, and culture change. J Res Nurs. 2011;16(1):37e49. http://dx.doi.org/10.1177/1744987110366187. Chaudhuri T, Yeatts DE, Cready CM. Nurse aide decision making in nursing homes: factors affecting empowerment. J Clin Nurs. 2013;22(17/18):2572e 2585. Simmons SF, Schnelle JF. Strategies to measure nursing home residents’ satisfaction and preferences related to incontinence and mobility care: implications for evaluating intervention effects. Gerontologist. 1999;39(3):345e355. Dean R, Proudfoot R, Lindesay J. The quality of interactions schedule (QUIS): development, reliability and use in the evaluation of two domus units. Int J Geriatr Psychiatry. 1993;8:819e826.
