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护理之家(NH)居民跌倒等不良后果的干预措施，但试图将这些干预措施转化为使用当前标准的护理质量改进(QI)技术的实践尚未成功。使用复杂性科学框架，我们之前的RO1表明，NH员工之间的低连接、信息流和认知多样性解释了为跌倒等复杂问题提供的低质量护理。“连接”是一种多成分干预，鼓励员工使用简单的策略与他人建立新的联系，增强信息流，并使用认知多样性。我们的试点测试表明，员工可以学习提高他们互动的密度和质量，而且这种行为变化与降低失败率的趋势有关。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干预中培育的更高水平的联系、信息流和认知多样性是必要的。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，将NHS(n=16)随机分为CONNECT和标准FLOW QI计划(CONNECT+FELS)或单独FLOW。我们估计将有800名居民和576名工作人员参加。在疗养院中，具体目的是：1)比较CONNECT干预加跌倒减少QI干预(CONNECT+FLOWS)和跌倒减少QI干预(跌倒)对跌倒风险降低指标(立位血压、感觉障碍、鞋类适合性、步态；辅助设备；厕所需求、环境和精神药物)的影响；2)比较CONNECT+跌倒与单独跌倒对跌倒发生率和损伤性跌倒的影响，并确定这些影响是否通过跌倒风险降低指标的变化来调节；3)比较CONNECT+跌倒对复杂性科学指标(沟通、决策参与、当地互动、安全氛围、员工对质量的看法)的影响，并确定这些指标是否中介了对跌倒风险降低指标和跌倒比率和伤害性跌倒的影响。复杂性科学测量的横断面观察在基线、3个月、6个月和9个月进行。测量第一次干预前6个月和最终干预完成后6个月的居民跌倒风险降低指标、坠落率和伤害性跌倒。降低跌倒风险的指标是主要结果。次要结果衡量标准包括跌倒比率、伤害性跌倒和复杂性科学衡量标准(沟通、参与决策、当地互动、安全氛围、员工对质量的看法)。分析将使用三层混合模型来考虑疗养院内患者和工作人员的复杂嵌套，并控制与跌倒风险相关的协变量，包括设施基线跌倒比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.