Outcomes of Nursing Management Practice in Nursing Homes

项目摘要 尽管一些临床试验已经确定了减少不良后果的干预措施，如跌倒 疗养院(NH)居民，试图将这些干预措施转化为实践，使用广泛接受的 质量改进(QI)技术并不成功。我们之前的R01，使用了一个复杂性 科学框架表明，NH员工之间的联系、信息流和认知多样性较低 这在很大程度上解释了为跌倒等复杂问题提供的低质量护理。额外的试点工作 显示我们的“连接”干预促进了员工的学习，以提高他们的密度和质量 互动。CONNECT是基于我们之前的案例研究的多组件干预， 鼓励工作人员参与网络建设并使用简单的战略来加强信息流动， 员工之间的联系，以及认知的多样性。我们假设高水平的连接、信息 在对复杂的老年问题进行任何QI干预之前，流动和认知多样性是必要的，例如 如跌倒，就能成功。 这项为期5年的研究将使用前瞻性、整群随机、结果评估盲法设计， NHS(n=16)随机分为连接+跌倒或单独跌倒。我们估计有560名居民和 将有576名工作人员参加。具体目标是(1)目标1(主要)比较影响 连接干预加上跌倒减少QI干预(连接+跌倒)到跌倒减少QI 单独干预(FLOWS)，对NH居民进行与跌倒相关的结局衡量；(2)目标2(探索性)： 比较连接+瀑布与单独瀑布对NH跌倒相关流程措施的影响 居民，并确定这些是否调解了对与跌倒相关的结果衡量标准的影响。(3)目标3 (探索性)：比较连接+跌倒与单独跌倒对员工互动指标的影响，如下所示 由NH工作人员报告，并确定这些是否调解了对秋季相关流程措施的影响 以及与跌倒相关的结果衡量标准。员工互动和住院医生跌倒相关结果的测量 分别在基线、干预后、3个月和6个月进行测量。跌倒的比率和复发跌倒的比例是 初步研究结果。探索性措施包括与跌倒相关的流程措施和员工互动 措施(沟通、参与、组对组互动、心理安全和安全 文化)。分析将使用3级混合模型来考虑患者和工作人员的复杂嵌套 在家庭内，以及对与跌倒风险相关的协变量的控制，包括基线设施跌倒比率。 为了促进虚弱的NH人口的健康，至关重要的是确定干预措施以改善 研究成果转化为实际工作。连接干预集成了 具有卫生服务研究原理的行为/复杂性科学，并有改进的潜力 在NHS中照顾虚弱的老年人中的许多复杂的医疗和心理社会问题。

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.