Outcomes of Nursing Management Practice in Nursing Homes

描述（由申请人提供）：尽管有效性试验已经确定了减少不良后果的干预措施，如养老院（NH）居民跌倒，但使用当前护理质量改进（QI）技术标准将这些干预措施转化为实践的尝试尚未成功。使用复杂性科学框架，我们之前的RO1表明，NH员工之间的低联系、信息流和认知多样性解释了对跌倒等复杂问题提供的低质量护理的大部分原因。我们的“CONNECT”试点测试是一种多组件干预，鼓励员工使用简单的策略与他人建立新的联系，加强信息流，并利用认知多样性，结果表明，员工可以学习提高互动的密度和质量，这种行为的变化与降低跌倒率的趋势有关。我们假设，在对复杂的老年问题（如跌倒）进行任何QI干预之前，在CONNECT干预中培养的更高水平的连接、信息流和认知多样性是必要的。这项为期5年的研究将采用前瞻性、集群随机、结果评估盲法设计，NHs （n=16）随机分为CONNECT和标准跌倒QI计划（CONNECT + falls）或单独跌倒。我们估计将有800名居民和576名工作人员参加。具体目标是在养老院：1)比较CONNECT干预加减少跌倒QI干预（CONNECT+ falls）与减少跌倒QI干预（falls）对降低跌倒风险指标（直立血压、感觉障碍、鞋类适宜性、步态、辅助装置、如厕所需求、环境和精神药物）的影响；2)比较CONNECT+FALLS与单独FALLS对跌倒率和伤害性跌倒的影响，并确定这些影响是否由跌倒风险降低指标的变化介导；3)比较CONNECT+FALLS与单独FALLS对复杂性科学指标（沟通、参与决策、当地互动、安全气候、员工对质量的看法）的影响，并确定这些因素是否对降低跌倒风险指标、跌倒率和伤害性跌倒产生影响。在基线、3个月、6个月和9个月时进行复杂性科学测量的横断面观察。在第一次干预前的6个月和最后一次干预完成后的6个月，测量居民跌倒风险降低指标、跌倒率和伤害性跌倒。减少跌倒风险指标是主要结果。次要结果指标包括跌倒率、伤害性跌倒和复杂性科学指标（沟通、参与决策、当地互动、安全气候、员工对质量的看法）。分析将使用3级混合模型来考虑疗养院内患者和工作人员的复杂筑巢情况，并控制与跌倒风险相关的协变量，包括基线设施跌倒率和工作人员流失率。

DESCRIPTION (provided by applicant): Although efficacy trials have identified interventions that reduce adverse outcomes such as falls in nursing home (NH) residents, attempts to translate those interventions into practice using current standard of care quality improvement (QI) techniques have not been successful. Using a complexity science framework, our previous RO1 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. Our pilot test of "CONNECT", a multi-component intervention that encourages staff use simple strategies to make new connections with others, enhance information flow, and use cognitive diversity, demonstrated that staff can learn to improve the density and quality of their interactions, and that this change in behavior is associated with a trend to lower fall rates. We hypothesize that higher levels of connection, information flow and cognitive diversity fostered in the CONNECT Intervention 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 and a standard falls QI program (CONNECT + FALLS) or FALLS alone. We estimate that 800 residents and 576 staff members will participate. Specific aims are to, in nursing homes: 1) Compare the impact of the CONNECT intervention plus a falls reduction QI intervention (CONNECT+FALLS) to a falls reduction QI intervention (FALLS) on fall risk reduction indicators (orthostatic blood pressure, sensory impairment, footwear appropriateness, gait; assistive device; toileting needs, environment, and psychotropic medication); 2) Compare the impact of CONNECT+FALLS to FALLS alone on fall rates and injurious falls, and determine whether these are mediated by the change in fall risk reduction indicators; 3) Compare the impact of CONNECT+FALLS to FALLS alone on complexity science measures (communication, participation in decision making, local interactions, safety climate, staff perceptions of quality) and determine whether these mediate the impact on fall risk reduction indicators and fall rates and injurious falls. Cross-sectional observations of complexity science measures are taken at baseline, at 3 months, at 6 months, and at 9 months. Resident fall risk reduction indicators, fall rates, and injurious falls are measured for the 6 months prior to the first intervention and the 6 months after the final intervention is completed. Fall risk reduction indicators are the primary outcome. Secondary outcome measures include fall rates, injurious falls, and complexity science measures (communication, participation in decision making, local interactions, safety climate, staff perceptions of quality). Analysis will use a 3-level mixed model to account for the complex nesting of patients and staff within nursing homes, and to control for covariates associated with fall risk, including baseline facility fall rates and staff turnover rates. PUBLIC HEALTH RELEVANCE: 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 and 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.