Outcomes of Nursing Management Practice in Nursing Homes

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Project Summary Although several clinical trials have identified interventions that reduce adverse outcomes such as falls in nursing home (NH) residents, attempts to translate those interventions into practice using widely accepted quality improvement (QI) techniques have not been successful. Our previous R01, using a complexity science framework, has shown that low connection, information flow, and cognitive diversity among NH staff explains much of the poor quality of care delivered for complex problems such as falls. Additional pilot work showed that our "CONNECT" intervention fosters staff in learning to improve the density and quality of their interactions. CONNECT is a multi-component intervention based on our previous case study research that encourages staff to engage in network-building and use simple strategies to enhance information flow, connection among staff, and cognitive diversity. We hypothesize that high levels of connection, information flow and cognitive diversity are necessary before any QI intervention for a complex geriatric problem, such as falls, can be successful. This 5-year study will use a prospective, cluster-randomized, outcome assessment blinded design, with NHs (n=16) randomized to either CONNECT+FALLS or FALLS alone. We estimate that 560 residents and 576 staff members will participate. Specific aims are (1) Aim 1 (primary) Compare the impact of the CONNECT intervention plus a falls reduction QI intervention (CONNECT+FALLS) to the falls reduction QI intervention alone (FALLS), on fall-related outcome measures in NH residents; (2) Aim 2 (exploratory): Compare the impact of CONNECT+FALLS to FALLS alone on fall-related process measures in NH residents, and determine whether these mediate the impact on fall-related outcome measures. (3) Aim 3 (exploratory): Compare the impact of CONNECT+FALLS to FALLS alone on staff interaction measures, as reported by NH staff, and determine whether these mediate the impact on fall-related process measures and fall-related outcome measures. Measurements of staff interaction and residents' fall-related outcomes are taken at baseline, post intervention, 3 and 6 months. Fall rates and proportion of recurrent fallers is the primary study outcome. Exploratory measures include fall-related process measures and staff interaction measures (communication; participation, group-to-group interaction, psychological safety, and safety culture). Analysis will use a 3-level mixed model to account for the complex nesting of patients and staff within homes, and control for covariates associated with fall risk, including baseline facility fall rates. In order to promote the health of the frail NH population, it is essential to identify interventions to improve the translation of research advances into actual practice. The CONNECT intervention integrates behavioral/complexity science with principles of health services research, and has the potential to improve care in NHs for many complex medical and psycho-social problems among frail older adults.