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It is well established in research, practice, and policy that unpaid caregivers (family and friends of people with care needs) experience stress in their role. Supports that have been put in place by policy planners and program developers to support caregivers may not be accessed by caregivers at all or may do little to reduce their stress. Accessing personal resources (education, finances), in addition to social resources (individual connections) and societal resources (community supports) are critical in fostering resilience in caregivers (helping them adapt to stress and adversity). Social capital theorists argue that creating connections at various levels can improve access to resources. This research, through qualitative interviews (n = 21), identifies the different levels of resources required to address the needs of caregivers. Our findings indicate that interventions that focus on access to personal-level resources (education, funding) are important, but are on their own insufficient. Of more importance were interventions that work to improve relationships between formal providers and families; access to interdisciplinary teams; cross-sectoral collaborations; and inter-organization relationships, highlighting that a system that works together is likely to improve caregivers' access to resources.

To ensure a safe transition of mental health patients from hospital to community settings, greater attention is being given to discharge planning. However, assessing the quality of discharge planning has been challenging due to wide variations in its definition. To facilitate evaluation of discharge planning, its meaning in the mental health literature was systematically explored. This concept analysis is part of a larger study to develop an instrument to measure the quality of discharge planning processes in mental health care. Walker and Avant's (2011) concept analysis approach was adopted to provide a comprehensive definition of discharge planning. Electronic databases and grey literature were searched and analysed according to Grant and Booth's (2009) systematic search and review process. Literature published between 1900 and 2018 was reviewed. Forty-nine articles meeting the inclusion criteria were included in the analysis. Discharge planning is a complex, multifaceted concept with six defining attributes: comprehensive needs assessment; collaborative, patient-centered care; resource availability management; care and service coordination; discharge planner role; and a discharge plan. Discharge planning begins with the initial rapid assessment and symptom stabilization of a patient on admission, coincides with treatment planning, and is associated with hospital readmissions and continuity of care. The mental health literature was reviewed to analyse different interpretations of discharge planning. The conceptual definition provided can assist healthcare providers, organizational leaders, and policymakers to design and implement effective discharge planning policies and guidelines. Providing clarity regarding discharge planning also provides a critical foundation for developing an instrument.

Understanding of intervention sustainability processes is limited. Failure to sustain evidence-based innovations means that intended improvements are short-lived, scale-up and spread are unlikely, and real losses are incurred on research investments. We explored the sustainability of a health care aide (HCA)-led quality improvement (QI) initiative, Safer Care for Older Persons (in residential) Environments (SCOPE), that was implemented in long-term care homes (LTCHs) in Manitoba, Canada. Based on our understanding of factors influencing post-implementation sustainability processes, we developed and piloted a “low-dose” and “high-dose” “Booster” intervention to extend the two-year post-implementation period over which SCOPE was naturally sustained. Both versions of the “Booster” involved the following components: a HCA-led team with management support, a workshop to review SCOPE QI approaches and tools, a binder of QI resources, and supports from an experienced Quality Advisor (QA). We collected data from various sources to depict the most accurate account of QI sustainability and conducted thematic analysis to understand each team’s experience with sustainability processes. We used a qualitative assessment rubric to evaluate the impact of the “Booster” conditions on the teams’ performance against core SCOPE components. Our results suggest that the “Booster” served to establish more relaxed expectations and generally renew interest in LTCH QI initiatives. The calibre of management support was associated with teams’ performance and management support varied with the level of QA support. These pilot results will inform the next study phase, which examines longer-term sustainability of QI initiatives in LTCHs beyond the initial 2-year post-implementation period.

Our understanding of the post-implementation sustainment, sustainability, and spread (SSS) of complex quality improvement interventions is limited. We explored factors that influenced the SSS of a care aide-led quality improvement initiative (Safer Care for Older Persons (in residential) Environments [SCOPE]) implemented in 6 Manitoba long-term care homes two years after the conclusion of SCOPE in 2017. We analyzed small group interview data collected from all unit- and facility-level managers who participated in SCOPE and were still working in these facilities. We asked about SCOPE implementation, post-SCOPE quality improvement activities, factors that influenced them, and about inter-unit spread of SCOPE following the project’s conclusion. The interviews were audio-recorded, transcribed verbatim, de-identified, and analyzed using thematic analysis. Five of the 6 facilities reported sustained SCOPE quality improvement activities, tools, and facilitative structures. In the same 5 facilities, SCOPE benefits (e.g., increases in care aide empowerment and self-efficacy, manager belief in care aide capacity) continued post-implementation. Spread beyond the original SCOPE units had occurred in 3 facilities. Factors that influenced the SSS of SCOPE were related to the team (e.g., care aides' quality improvement capacity), to the unit and facility (e.g., culture of innovation and change), and to the long-term care system (e.g., competing imperatives). Some factors influencing SSS differ from factors known to influence implementation. The identified factors affecting SSS highlight the influence of social dynamics (i.e., interactions, communication, relationships) among staff on SSS. Further research is warranted to explore interactions among these influencing factors and how they lead to SSS.

ObjectiveTo synthesise the existing literature on care transition planning from the perspectives of older adults, caregivers and health professionals and to identify the factors that may influence these stakeholders’ transition decision-making processes.DesignA scoping review guided by Arksey and O’Malley’s six-step framework. A comprehensive search strategy was conducted on 7 January 2021 to identify articles in five databases (MEDLINE, Embase, CINAHL Plus, PsycINFO and AgeLine). Records were included when they described care transition planning in an institutional setting from the perspectives of the care triad (older adults, caregivers and health professionals). No date or study design restrictions were imposed.SettingThis review explored care transitions involving older adults from an institutional care setting to any other institutional or non-institutional care setting. Institutional care settings include communal facilities where individuals dwell for short or extended periods of time and have access to healthcare services.ParticipantsOlder adults (aged 65 or older), caregivers and health professionals.Results39 records were included. Stakeholder involvement in transition planning varied across the studies. Transition decisions were largely made by health professionals, with limited or unclear involvement from older adults and caregivers. Seven factors appeared to guide transition planning across the stakeholder groups: (a) institutional priorities and requirements; (b) resources; (c) knowledge; (d) risk; (e) group structure and dynamic; (f) health and support needs; and (g) personality preferences and beliefs. Factors were described at microlevels, mesolevels and macrolevels.ConclusionsThis review explored stakeholder involvement in transition planning and identified seven factors that appear to influence transition decision-making. These factors may be useful in advancing the delivery of person and family-centred care by determining how individual-level, group-level and system-level values guide decision-making. Further research is needed to understand how various stakeholder groups balance these factors during transition planning in different health contexts.

Background: Nursing home residents require daily support. While care aides provide most of this support they are rarely empowered to lead quality improvement (QI) initiatives. A previous proof of principle study, called Safer Care for Older Persons in Residential Care Environments (SCOPE), demonstrated that care aide-led teams can successfully participate in QI interventions. In preparation for a large-scale study, this one-year pilot evaluated how well the bundle of SCOPE coaching strategies helped care-aide led teams to enact these interventions. A secondary aim was to determine if improvements in resident quality of care occurred. Methods: Using a modified IHI Breakthrough Collaborative Series model in a prospective single-arm study design, we randomly sampled 7 nursing homes in Winnipeg, Manitoba from the longitudinal Translating Research in Elder Care (TREC) cohort. Each SCOPE team had 5-7 front-line staff led by care aides. Teams received coaching to enact the intervention (i.e., to create actionable aim statements, implement QI interventions using plan-do-study-act [PDSA] cycles, use measurement to guide decision making) during three learning congresses, networked and shared learning experiences during these sessions, and received additional support from quality advisors between congresses. We used self-report data to code intervention enactment (‘poor’, ‘adequate’, ‘excellent’), and also measured improvement in team cohesion and communication. Secondarily, we observed changes in unit-level quality indicators using RAI-MDS 2.0 data.Results: Most teams successfully enacted SCOPE. Five of 7 teams created adequate-to-excellent aim statements throughout the pilot (e.g., statements were specific, measurable, time-bound). While 6 of 7 teams successfully implemented PDSAs, only 2 reported spreading their idea to involve more than a few residents and/or staff on their unit. Three of 7 teams explicitly stated how measurement was used to guide decisions. Team cohesion and communication scored high at baseline, and hence improved minimally. Resident quality indicators improved in 4 of the 7 nursing home units. Conclusions: Our bundled coaching strategies helped most care aide-led teams to enact SCOPE. Coaching modifications are needed in follow-up studies to help teams more effectively use measurement, and to spread successful interventions within the unit. More detailed and robust approaches are also needed to monitor treatment enactment.

BackgroundThere is recognition that the overuse of procedures, testing, and medications constitutes low-value care which strains the healthcare system and, in some circumstances, can cause unnecessary stress and harm for patients. Initiatives across dozens of countries have raised awareness about the harms of low-value care but have had mixed success and the levels of reductions realized have been modest. Similar to the complex drivers of implementation processes, there is a limited understanding of the individual and social behavioral aspects of de-implementation. While researchers have begun to use theory to elucidate the dynamics of de-implementation, the research remains largely atheoretical. The use of theory supports the understanding of how and why interventions succeed or fail and what key factors predict success. The purpose of this scoping review was to identify and characterize the use of theoretical approaches used to understand and/or explain what influences efforts to reduce low-value care.MethodsWe conducted a review of MEDLINE, EMBASE, CINAHL, and Scopus databases from inception to June 2021. Building on previous research, 43 key terms were used to search the literature. The database searches identified 1998 unique articles for which titles and abstracts were screened for inclusion; 232 items were selected for full-text review.ResultsForty-eight studies met the inclusion criteria. Over half of the included articles were published in the last 2 years. The Theoretical Domains Framework (TDF) was the most commonly used determinant framework (n= 22). Of studies that used classic theories, the majority used the Theory of Planned Behavior (n= 6). For implementation theories, Normalization Process Theory and COM-B were used (n= 7). Theories or frameworks were used primarily to identify determinants (n= 37) and inform data analysis (n= 31). Eleven types of low-value care were examined in the included studies, with prescribing practices (e.g., overuse, polypharmacy, and appropriate prescribing) targeted most frequently.ConclusionsThis scoping review provides a rigorous, comprehensive, and extensive synthesis of theoretical approaches used to understand and/or explain what factors influence efforts to reduce low-value care. The results of this review can provide direction and insight for future primary research to support de-implementation and the reduction of low-value care.

Objective Our objective was to assess how, and to what extent, a systems-level perspective is considered in decision-making processes for health interventions by illustrating how studies define the boundaries of the system in their analyses and by defining the decision-making context in which a systems-level perspective is undertaken. Method We conducted a scoping review following the Joanna Briggs Institute methodology. MEDLINE, EMBASE, Cochrane Library, and EconLit were searched and key search concepts included decision making, system, and integration. Studies were classified according to an interpretation of the “system” of analysis used in each study based on a four-level model of the health system (patient, care team, organization, and/or policy environment) and using categories (based on intervention type and system impacts considered) to describe the decision-making context. Results A total of 2,664 articles were identified and 29 were included for analysis. Most studies (16/29; 55%) considered multiple levels of the health system (i.e., patient, care team, organization, environment) in their analysis and assessed multiple classes of interventions versus a single class of intervention (e.g., pharmaceuticals, screening programs). Approximately half (15/29; 52%) of the studies assessed the influence of policy options on the system as a whole, and the other half assessed the impact of interventions on other phases of the disease pathway or life trajectory (14/29; 48%). Conclusions We found that systems thinking is not common in areas where health technology assessments (HTAs) are typically conducted. Against this background, our study demonstrates the need for future conceptualizations and interpretations of systems thinking in HTA.

Background: Communities represent a highly relevant source of knowledge with regard to not only healthcare performance but also sociocultural context, yet their role in learning health systems has not been studied. Situating the learning health system as an organization, this paper explores the phenomenon of organizational learning from or with communities (defined as one of ‘the people,’ such as a town, a specific patient group or another group directly receiving a healthcare service).Methods: We conducted a scoping review to determine what is known about organizational learning from or with communities that the organization serves, and to contribute to a more comprehensive evidence base for building and operating learning health systems. In March 2019, we systematically searched six academic databases and grey literature, applying no date limits, for English language materials that described organizational learning in relation to knowledge transfer between an organization and a community. Numerous variables were charted in Excel and synthesized using frequencies and thematic analysis. We updated this search in August 2020. Results: In total, 42 documents were included in our analysis. We found a disproportionate emphasis on learning explicit knowledge from community rather than on tacit knowledge or learning in equal partnership with community. Our review also revealed inconsistently defined concepts, tenuously linked with their theoretical and empirical foundations. Our findings provide insight to understand the organization-community learning relationship, including motives and power differentials; types of knowledge to be learned; structures and processes for learning; and transformative learning outcomes.Conclusions: Our review makes a singular contribution to organizational learning literatures by drawing from diverse research disciplines such as health services, business and education to map what is known about learning from or with community. Broadly speaking, learning health systems literature would benefit from additional research and theory-building within a sociological paradigm so as to establish key concepts and associations to understand the nature of learning with community, as well as the practices that make it happen.

Background: Increasing demands on Canada’s healthcare system require patients to take on more active roles in their health. Effective self-management has been linked to improved health outcomes; and there is evidence that effective behaviors, and subsequent healthcare utilization, are linked to self-efficacy and health literacy; however, this link has had minimal testing in the cancer context. Our aim is to examine the association between self-efficacy, health literacy, chemotherapy self-management behaviors, and health service utilization. Design and methods: A cross-sectional survey that included validated measures of self-efficacy, health literacy, chemotherapy self-management, and health service utilization was completed by participants (N = 213). Multivariable modeling using hierarchical linear regression was used to examine the association between variables. Results: Self-efficacy contributed significantly to explaining variation in chemotherapy self-management score. Health literacy was not significantly associated with any of the dependent variables. Conclusion: Participants with higher self-efficacy had higher chemotherapy self-management scores compared to participants with low self-efficacy. Contrary to evidence in the chronic disease self-management literature, this study demonstrated that health literacy was not associated with chemotherapy self-management behavior nor was it associated with self-efficacy. Building patient self-efficacy in the context of chemotherapy self-management could be particularly helpful both in the cancer center and in the domain of oral chemotherapy management at home where patients are required to take on significant responsibility for self-management.

This chapter analyses the labour market for Personal Support Workers (PSWs). It focuses on Canada as an illustrative case. The literature suggests that, while it is helpful to consider the PSW labour market as a whole from a neo-Weberian perspective, it is better thought of as a series of sub-markets – comprising the hospital, long-term care, and home and community care sectors. These may differ in terms of such factors as wages, benefits, hours worked and working conditions, as well as in the socio-demographic characteristics of PSWs working in each care sector. To the extent that sectoral differences in PSW characteristics affect labour supply behaviours and outcomes – as, for example, in creating differences in the proportion of PSWs nearing retirement age – the heterogeneous nature of the PSW labour market is an important consideration in resource planning. The chapter also explores how PSWs compare to other health professions such as nursing, and makes select references to the international PSW literature in charting a forward course.

This article examines provincial policy influence on long-term care (LTC) professionals’ advice-seeking networks in Canada’s Maritime provinces. The effects of facility ownership, geography, and region-specific political landscapes on LTC best-practice dissemination are examined. We used sociometric statistics and network sociograms, calculated from surveys with 169 senior leaders in LTC facilities, to identify advice-seeking network structures and to select 11 follow-up interview participants. Network structures were distinguished by density, sub-group number, opinion leader, and boundary spanner distribution. Network structure was affected by ownership model in Nova Scotia and Prince Edward Island, and by regional geography in New Brunswick. Political instability within each province’s LTC system negatively affected network actors’ capabilities to enact innovation. Moreover, provincial policy variations influence advice-seeking network structures, facilitating and constraining relationship development and networking. Consequently, local policy context is essential to informing dissemination strategy design or implementation.

Objective Efforts to scale up evidence-based health care interventions are seen as a key strategy to address complex health system challenges. However, scale-up efforts have shown significant variability. We address the gap between scale-up theory and practice by exploring the socio-cultural factors at play in the evaluation and scale-up of three interventions within the clinical field. Methods A qualitative multiple case study was conducted to characterize the evaluation and scale-up efforts of three interventions. We interviewed 18 participants, including clinicians and researchers across the three cases. Using Pierre Bourdieu’s concepts of field and capital as a theoretical lens, we conducted a thematic analysis of the data. Results Despite the espoused goals of ensuring that health service interventions are always based on high-quality evidence within the clinical field, this study demonstrates that the outcomes of the evaluations are not the only factor in the decision to engage in scale-up efforts. Important socio-cultural factors also come into play. Bourdieu uses the term capital to refer to the resources that agents compete for and with their acquisition, accumulate power and/or social standing. The type of evidence valued in the clinical field and the ability to leverage capital in demonstrating that value are also important factors. Conclusions Determining if an intervention is effective and should be scaled up is more complex in practice than described in the literature. Efforts are needed to explicitly include the role of social processes in the current frameworks guiding scaling-up efforts.

Background The context of care provided in long-term care homes is changing, as an increasing number of older adults are entering long-term care with advance stages of illness and higher care needs. Long-term care homes are quickly becoming the place of death for an increasing number of older adults, despite recent literature identifying inadequate and suboptimal levels of end-of-life care. Within long-term care, healthcare assistants represent 60%-70% of the unregulated workforce and provide 70%-90% of the direct care to residents. Research indicates that a high level of uncertainty exists surrounding the role of healthcare assistants in end-of-life care, with numerous studies reporting the role of healthcare assistants to be 'unclear' with varying levels of responsibilities and autonomy. Objective The purpose of this scoping review was to explore healthcare assistants' experiences and perspectives of their role in end-of-life care in long-term care. Methods We applied Arksey and O'Malley's methodological framework, with recommendations from Levac and colleagues' guiding principles. Electronic databases and the grey literature were searched for relevant articles. Search concepts included end-of-life care and healthcare assistants. Articles were included in this review if they explored healthcare assistants' experiences or perspectives of providing end-of-life care in long-term care. The peaceful end of life theory by Ruland and Moore (1998) was used to organise data extraction and analysis. Results A total of n = 15 articles met the inclusion criteria. The most predominant role-required behaviours reported by healthcare assistants were as follows: psychosocial support to significant others, knows the resident's care wishes and physical care with respect and dignity. The most predominant extra-role behaviours reported by healthcare assistants were as follows: becoming emotionally involved, acting as extended family and ensuring residents do not die alone. Conclusions Findings from this review expanded the concept of end-of-life care by illustrating the role-required and extra-role behaviours healthcare assistants perform when providing end-of-life care in long-term care. Implications for practice Findings from this scoping review highlight the numerous behaviours healthcare assistants perform outside their role description in order to provide end-of-life care to dying residents in long-term care. These findings could inform policymakers and managers of long-term care homes.

Background Integrated knowledge translation refers to researcher and research user partnerships to co-generate and implement knowledge. This type of partnership may be critical to success in increasing knowledge use and impact, but the conceptualisation of its initiation has not been fully developed. Initiating this type of partnership has proven to be challenging but crucial to its success. The purpose of this study was to conduct a meta-narrative review of partnership initiation concepts, processes, enablers, barriers and outcomes in the disciplines of healthcare and social sciences where examples of researcher and research user partnerships were found. Methods Seven research traditions were identified. Three were in the discipline of social sciences (including psychology, education and business) and five were in the discipline of healthcare (including medicine, nursing, public health, health services research). Searches were conducted in MEDLINE, EMBASE, CINAHL, ABI Inform, ERIC, PsychInfo and the Cochrane Library on June 9, 2017. Fifty titles and abstracts were screened in triplicate; data were extracted from three records in duplicate. Narratives comprised of study characteristics and conceptual and empirical findings across traditions were tabulated, summarised and compared. Results A total of 7779 unique results were identified and 17 reviews published from 1998 to 2017 were eligible. All reviews identified a partnership initiation phase referred to as ‘early’ or ‘developmental’, or more vaguely as ‘fuzzy’, across six traditions – integrated knowledge translation, action research, stakeholder engagement, knowledge transfer, team initiation and shared mental models. The partnership initiation processes, enablers, barriers and outcomes were common to multiple narratives and summarised in a Partnership Initiation Conceptual Framework. Our review revealed limited use or generation of theory in most included reviews, and little empirical evidence testing the links between partnership initiation processes, enablers or barriers, and outcomes for the purpose of describing successful researcher and research user partnership initiation. Conclusions Narratives across multiple research traditions revealed similar integrated knowledge translation initiation processes, enablers, barriers and outcomes, which were captured in a conceptual framework that can be employed by researchers and research users to study and launch partnerships. While partnership initiation was recognised, it remains vaguely conceptualised despite lengthy research in several fields of study. Ongoing research of partnership initiation is needed to identify or generate relevant theory, and to empirically establish outcomes and the determinants of those outcomes.

The implementation and change management literatures support the importance of leadership at all organizational levels to achieve meaningful change. Recent scholarship on strategic change processes has highlighted leadership of middle management, in particular. This chapter aims to better understand middle management’s contribution to strategic change processes in health care. The extant literature is synthesized and mapped out in order to better understand how middle managers contribute to and engage in strategic change processes and further explores current and future contributions of middle managers to these processes. Middle managers may be able to meaningfully influence all aspects of the strategic change process, but risk becoming barriers to the strategic change process without sufficient access to resources and an empowering environment from senior leadership.

Background Work attitudes have been associated with work productivity. In health care, poor work attitudes have been linked to poor performance, decreased patient safety, and quality care. Hence, the importance, ascribed in the literature, of work that clearly identifies the relationships between and among work attitudes and work behaviors linked to performance. Purpose The purpose of this study is to better understand the relationships between work attitudes-perceived organizational justice, perceived organizational support (POS), affective commitment-consistently associated with a key type of performance outcome among nurses' organizational citizenship behaviors (OCBs). Methodology A survey was developed and administered to frontline nurses working in the province of Ontario, Canada. Data analysis used path analytic techniques. Results Direct associations were identified between interpersonal justice and POS, procedural justice and POS, and POS and affective commitment to both one's supervisor and one's co-workers. Affective commitment to patients and career was directly associated with OCBs. Affective commitment to one's co-worker was directly associated with OCBs directed toward individuals, as affective commitment to one's organization was with OCBs directed toward the organization. Finally, OCBIs and OCBs were directly associated. Conclusions Examining the relationships of these constructs in a single model is novel and provides new information regarding their complexity. Findings suggest that prior approaches to studying these relationships may have been undernuanced, and conceptualizations may have led to somewhat inaccurate conclusions regarding their associations. Practice implications With limited resources, knowledge of nurse work attitudes can inform human resource practices and operational policies involving training programs in employee communication, transparency, interaction, support, and performance evaluation.

Background Increasing demands on health care systems require patients to take on more active roles in their health. Effective self-management has been linked to improved health outcomes, and evidence shows that effective self-management is linked to health literacy (HL). HL is an important predictor of successful self-management in other chronic diseases but has had minimal testing in cancer. Methods A scoping review was conducted to examine and summarize what is known about the association between HL and self-management behaviors and health service utilization in the cancer setting. The methodological framework articulated by Arksey and O'Malley was used and was further refined with the Joanna Briggs Institute methodology. Inclusion criteria included the following: peer review; publication in English; and adult patients and caregivers of all races, ethnicities, and cultural groups. Use of a validated instrument to measure HL was required. Results The search yielded 2414 articles. After the removal of duplicates and the performance of title scans and abstract reviews, the number was reduced to 44. Of the 44 full-text articles reviewed, 17 met the inclusion criteria. A number of important self-management behaviors and related outcomes were found to be associated with HL. These included the uptake of cancer screening, the receipt of prescribed chemotherapy, and a greater risk of postoperative complications. Conclusions This literature review shows that HL is associated with important self-management behaviors in cancer. The implications of these associations for individuals with inadequate HL and for the health care system are significant. More research is needed to explore these associations.

Background Implementation scientists and practitioners, alike, recognize the importance of sustaining practice change, however post-implementation studies of interventions are rare. This is a protocol for the Sustainment, Sustainability and Spread Study (SSaSSy). The purpose of this study is to contribute to knowledge on the sustainment (sustained use), sustainability (sustained benefits), and spread of evidence-based practice innovations in health care. Specifically, this is a post-implementation study of an evidence-informed, Care Aide-led, facilitation-based quality-improvement intervention called SCOPE (Safer Care for Older Persons (in long-term care) Environments). SCOPE has been implemented in nursing homes in the Canadian Provinces of Manitoba (MB), Alberta (AB) and British Columbia (BC). Our study has three aims: (i) to determine the role that adaptation/contextualization plays in sustainment, sustainability and spread of the SCOPE intervention; (ii) to study the relative effects on sustainment, sustainability and intra-organizational spread of high-intensity and low-intensity post-implementation “boosters”, and a “no booster” condition, and (iii) to compare the relative costs and impacts of each booster condition. Methods/design SSaSSy is a two-phase mixed methods study. The overarching design is convergent, with qualitative and quantitative data collected over a similar timeframe in each of the two phases, analyzed independently, then merged for analysis and interpretation. Phase 1 is a pilot involving up to 7 units in 7 MB nursing homes in which SCOPE was piloted in 2016 to 2017, in preparation for phase 2. Phase 2 will comprise a quasi-experiment with two treatment groups of low- and high-intensity post-implementation “boosters”, and an untreated control group (no booster), using pretests and post-tests of the dependent variables relating to sustained care and management practices, and resident outcomes. Phase 2 will involve 31 trial sites in BC (17 units) and AB (14 units) nursing homes, where the SCOPE trial concluded in May 2019. Discussion This project stands to advance understanding of the factors that influence the sustainment of practice changes introduced through evidence-informed practice change interventions, and their associated sustainability. Findings will inform our understanding of the nature of the relationship of fidelity and adaptation to sustainment and sustainability, and afford insights into factors that influence the intra-organizational spread of practice changes introduced through complex interventions.

Purpose The purpose of this paper is to examine how the design and implementation of learning models for performance management can foster continuous learning and quality improvement within a publicly funded, multi-site community hospital organization. Design/methodology/approach Niagara Health’s patient flow performance management system, a learning model, was studied over a 20-month period. A descriptive case study design guided the analysis of qualitative observational data and its synthesis with organizational learning theory literature. Emerging from this analysis were four propositions to inform the implementation of learning models and future research. Findings This performance management system was observed to enable: ongoing performance-related knowledge exchange by creating opportunities for routine social interaction; collective recognition and understanding of practice and performance patterns; relationship building, learning for improvement, and “higher order” learning through dialogue facilitated using humble inquiry; and, alignment of quality improvement efforts to organizational strategic objectives through a multi-level feedback/feed-forward communication structure. Research limitations/implications The single organization and descriptive study design may limit the generalizability of the findings and introduce confirmation bias. Future research should more comprehensively evaluate the impact of learning models on organizational learning processes and performance outcomes. Practical implications This study offers novel insight which may inform the design and implementation of learning models for performance management within and beyond the study site. Originality/value Few studies have examined the mechanics of performance management systems in relation to organizational learning theory and research. Broader adoption of learning models may be key to the development of continuously learning and improving health systems.

Aims and objectives To increase understanding of the relationships between organisational justice, affective commitment and turnover intention in health care. Background Turnover in health care is a serious concern, as it contributes to the global nursing shortage and is associated with declines in quality of care, patient safety and patient outcomes. Turnover also impacts care teams and is associated with decreased staff cohesion and morale. Methods A survey was developed and administered to frontline nurses working in the Province of Ontario, Canada. The data were used to test a hypothetical model developed from a review of the literature. The relationships amongst the three constructs were evaluated using structural equation modelling and mediation analysis. Results The hypothesised model was generally supported, although we were limited to considerations of interpersonal justice, affective commitment to one's organisation and turnover intention. Interpersonal justice is associated with affective commitment to one's organisation, which is negatively associated with turnover intention. Interpersonal justice was also found to be directly and negatively associated with turnover intention. Affective commitment to one's organisation was also found to mediate the relationship between interpersonal justice and turnover intention. Conclusions The examination of relationships within the "employee retention triad" in a single, comprehensive model is novel and provides new information regarding relational complexity and insights into what healthcare leaders can do to retain employees. Relevance to clinical practice Reducing turnover may help to decrease some of the stressors related to turnover for clinical staff remaining at the organisation such as constant onboarding and orientation of new hires, working with less experienced staff and increased workload due to decreased staffing.

Improving Nursing Home Care Through Feedback On perfoRMance Data (INFORM) was a complex, theory-based, three-arm, parallel cluster-randomized trial. In 2015–2016, we successfully implemented two theory-based feedback strategies (compared to a standard approach to feedback) to increase nursing home (NH) care aides’ involvement in formal communications about resident care (formal interactions [FI], the primary outcome). Here, we report the extent to which FI was sustained 2.5 years following withdrawal of intervention supports. We also report on several determinants of sustainability. We analyzed data from 18 NHs (46 units, 529 care aides) in the control group, 19 NHs (60 units, 731 care aides) in the basic assisted feedback group (BAF), and 14 homes (41 units, 537 care aides) in the enhanced assisted feedback group (EAF). We assessed sustainability of FI, using repeated measures, hierarchical mixed models, adjusted for care aide, care unit and facility variables. In EAF, FI scores increased from T1 (baseline) to T2 (end of intervention) (1.30–1.42, p=0.010), remaining stable at T3 (long-term follow-up) (1.39 p=0.065). FI scores in BAF increased from T1 to T2 (1.33–1.44, p=0.003) and continued to increase at T3 (1.49, p

Health Support Workers (HSWs) provide up to 80% of care to residents and clients in the long-term care (LTC) and home and community care (HCC) sectors but have received little research attention compared with the regulated professions. The authors explore similarities and differences in the work psychology of HSWs employed in LTC and HCC settings. Data were collected via survey from 276 LTC and 184 HCC HSWs. Descriptive statistics and path analyses were conducted. HSWs in LTC and HCC settings have significant, positive associations between organizational citizenship behaviors directed toward the organization (OCB-Os) and psychological empowerment, as well as intention to stay (ITS) and job satisfaction. For LTC sector HSWs, there are significant relationships between OCB-Os and quality of work life (QWL), ITS and work engagement, and individual performance and both job satisfaction and QWL. For the HCC sector, OCB-Os and ITS are significantly and directly related to organizational commitment. This study has implications for organizations interested in developing targeted interventions to improve the retention of HSWs.

PurposeHealth literate discharge practices meet patient and family health literacy needs in preparation for care transitions from hospital to home. The purpose of this paper is to measure health literate discharge practices in Ontario hospitals using a new organizational survey questionnaire tool and to perform psychometric testing of this new survey.Design/methodology/approachThis survey was administered to hospitals in Ontario, Canada. Exploratory factor analysis and reliability testing were performed.FindingsThe participation rate of hospitals was 46 percent. Exploratory factor analysis demonstrated that there were five factors. The survey, and each of the five factors, had moderate to high levels of reliability.Research limitations/implicationsThere is a need to expand the focus of further research to examine the experiences of patients and families. Repeating this study with a larger sample would facilitate further survey development.Practical implicationsMeasuring health literate discharge practices with an organizational survey will help hospital managers to understand their performance and will help direct quality improvement efforts to improve patient care at hospital discharge and to decrease hospital readmission.Originality/valueThere has been little research into how patients are discharged from hospital. This study is the first to use an organizational survey tool to measure health literate discharge practices.

Background In health care, accountability is being championed as a promising approach to meeting the dual imperatives of improving care quality while managing constrained budgets. Purposes Few studies focus on public sector organizations' responsiveness to government imperatives for accountability. We applied and adapted a theory of organizational responsiveness to community care agencies operating in Ontario, Canada, asking the question: What is the array of realized organizational responses to government-imposed accountability requirements among community agencies that receive public funds to provide home and community care? Methodology/approach A sequential complementary mixed methods approach was used. It gathered data through a survey of 114 home and community care organizations in Ontario and interviews with 20 key informants representing 13 home and community care agencies and four government agencies. It generated findings using a parallel mixed analysis technique. Findings In addition to responses predicted by the theory, we found that organizations engage in active, as well as passive, forms of compliance; we refer to this response as internal modification in which internal policies, practices, and/or procedures are changed to meet accountability requirements. We also found that environmental factors, such as the presence of an association representing organizational interests, can influence bargaining tactics. Practice implications Our study helps us to better understand the range of likely responses to accountability requirements and is a first step toward encouraging the development of accountability frameworks that favor positive outcomes for organizations and those holding them to account. Tailoring agreements to organizational environments, aligning perceived compliance with behaviors that encourage improved performance, and allowing for flexibility in accountability arrangements are suggested strategies to support beneficial outcomes.

Identifying how nursing care directly affects patients is essential to improving care quality, reducing costs, and determining nursing's contribution to overall organizational performance. This scoping review examined methods used for developing nursing process health care indicators. Key concepts and sources of evidence were identified to lay a foundation for future development and identification of valid and reliable nursing process health care indicators.

Background Health care researcher-research user partnerships, referred to as integrated knowledge translation (IKT), have been adopted on an international basis, and are an effective means of co-generating and implementing evidence into policy and practice. Prior research suggests that an initiation period is essential for establishing functional partnerships. To characterize IKT initiation and describe determinants of IKT initiation success, this study explored IKT initiation processes, enablers, and barriers among researchers and research users involved in IKT partnerships. Methods A descriptive qualitative approach was used compliant with COREQ standards. Canadian researchers and research users in research collaborations were identified on publicly-available directories and web sites, and referred by those interviewed. They were asked to describe how partnerships were initiated, influencing factors, the length of initiation, and interventions needed to support initiation. Sampling was concurrent with data collection and analysis to achieve thematic saturation. Data were analyzed using constant comparative technique by all members of the research team. Results In total, 22 individuals from 6 provinces were interviewed (9 researchers, 11 research users, 2 connectors). They confirmed that IKT initiation is a distinct early phase of partnerships. The period ranged from 6 months to 2 years for 75.0% of participants in pre-existing partnerships, to 6 years for newly-formed partnerships. High-level themes were: Newly identifying and securing partners is an intensive process; Processes and activities take place over a protracted period through multiple interactions; Identifying and engaging committed partners is reliant on funding; and Partnership building is challenged by maintaining continuity and enthusiasm. Participants underscored the need for an IKT partner matching forum, IKT initiation toolkit, and funding for non-research activities required during IKT initiation to establish functional researcher-research user partnerships. Themes were largely similar regardless of participant years of experience with IKT or being involved in a new versus pre-existing partnership. Conclusions IKT initiation is a recognized and important early phase of IKT that establishes functional partnerships, and once established, ongoing partnership for subsequent projects is likely. Further research is needed to develop and evaluate approaches recommended by participants for stimulating IKT initiation.

Background This review of scholarly work in health care knowledge translation advances understanding of implementation components that support the complete and timely integration of new knowledge. We adopt a realist approach to investigate what is known from the current literature about the impact of, and the potential relationships between, context, complexity and implementation process. Methods Informed by two distinct pathways, knowledge utilization and knowledge translation, we utilize Rogers’ Diffusion of Innovations theory (DOI) and Harvey and Kitson’s integrated- Promoting Action on Research Implementation in Health Service framework (PARIHS) to ground this review. Articles from 5 databases; Medline, Scopus, PsycInfo, Web of Science, and Google Scholar and a search of authors were retrieved. Themes and patterns related to these implementation components were extracted. Literature was selected for inclusion by consensus. Data extraction was iterative and was moderated by the authors. Results A total of 67 articles were included in the review. Context was a central component to implementation. It was not clear how and to what extent context impacted implementation. Complexity was found to be a characteristic of context, implementation process, innovations and a product of the relationship between these three elements. Social processes in particular were reported as influential however; descriptions of how these social process impact were limited. Multiple theoretical and operational models were found to ground implementation processes. We offer an emerging conceptual model to illustrate the key discoveries. Conclusions The review findings indicate there are dynamic relationship between context, complexity and implementation process for enhancing uptake of evidence-based knowledge in hospital settings. These are represented in a conceptual model. Limited empiric evidence was found to explain the nature of the relationships.

Background We report on the impact of two system-level policy interventions (the Long-Term Care Homes Act [LTCHA] and Public Reporting) on publicly reported physical restraint use and non-publicly reported potentially inappropriate use of antipsychotics in Ontario, Canada. Methods We used interrupted time series analysis to model changes in the risk-adjusted use of restraints and antipsychotics before and after implementation of the interventions. Separate analyses were completed for early ([a] volunteered 2010/2011) and late ([b] volunteered March 2012; [c] mandated September 2012) adopting groups of Public Reporting. Outcomes were measured using Resident Assessment Instrument Minimum Data Set (RAI-MDS) data from January 1, 2008 to December 31, 2014. Results For early adopters, enactment of the LTCHA in 2010 was not associated with changes in physical restraint use, while Public Reporting was associated with an increase in the rate (slope) of decline in physical restraint use. By contrast, for the late-adopters of Public Reporting, the LTCHA was associated with significant decreases in physical restraint use over time, but there was no significant increase in the rate of decline associated with Public Reporting. As the LTCHA was enacted, potentially inappropriate use of antipsychotics underwent a rapid short-term increase in the early volunteer group, but, over the longer term, their use decreased for all three groups of homes. Conclusions Public Reporting had the largest impact on voluntary early adopters while legislation and regulations had a more substantive positive effect upon homes that delayed public reporting.

Objectives: To identify how the natural environment (NE) in healthcare has been conceptualized. Background: The NE appears to afford significant therapeutic benefits. A clear concept of the NE in healthcare affords a shared understanding from which to advance science to facilitate comparisons across contexts. In this article, the various meanings of the NE were brought together into one framework by which to map its themes and their relationships. Method: A scoping review was conducted using database searches in MEDLINE, EMBASE, PsycINFO, CINAHL, and Cochrane for articles published up to July 2018. The bibliography of the included articles were manually searched for published books. Results: This review includes 137 peer-reviewed articles and research-based books from 27 countries. A conceptual framework was developed to identify five themes that conceptualize the NE in healthcare: (1) definitions of the NE in healthcare, (2) processes of the NE in healthcare, (3) usages of the NE in healthcare, (4) opinions about the NE in healthcare, and (5) NE’s impacts on health and work outcomes in healthcare. These themes are filtered by the NE’s physical and programmatic designs; changes in one affect the others. Definitions of the NE are described as human-made space, located in the indoors and outdoors, containing elements of nature and designed with the purpose to positively influence humans. Processes are described as the participatory approach in NE's development and its therapeutic goals. Usages are categorized into nature contact, frequency of usage, and accessibility. Opinions are accounted for by perceptions, preference, and satisfaction. Outcomes are related to physical health, mental health and well-being and work. Conclusions: This framework contributes to the conceptual discussion and emphasizes NE’s complementarity to the biomedical healthcare system.

BackgroundThere is recognition that the overuse of procedures, tests and medications strains the healthcare system financially and can cause unnecessary stress and harm to patients. In recent years, several initiatives have targeted the reduction or elimination of low-value practices in healthcare. Research suggests that passive interventions, such as the publication of guidelines, are often not sufficient to change behaviour and that active change interventions - interventions which actively implement strategies to change practices - are required to effect significant, sustained practice change. The purpose of this scoping review is to identify and characterise studies of active change interventions designed to reduce or eliminate low-value healthcare practices.MethodsWe will conduct a review of MEDLINE, EMBASE, CINAHL and Scopus databases from inception. Building on previous research, 40 key terms will be used to search literature. The screening process will be conducted separately by two researchers, with discrepancies resolved by a third. Empirical studies of active change interventions used to reduce or eliminate low-value practices will be included. Descriptive statistics and thematic analysis will be used to categorise the characteristics of the studies.Ethics and disseminationEthics approval is not required for this study. This scoping review will provide insights into the impact of several characteristics of active change interventions, including the number of interventions (single-faceted or multifaceted) and the level of implementation (individual or organisational). These results can provide guidance and direction for future research in de-implementation. The results will be disseminated through presentations at national and international conferences and the publication of a manuscript.

Aims The aims of this scoping literature review are to examine and summarize the organizational-level factors, context, and processes that influence the use of evidence-based practice in healthcare organizations. Methods A scoping literature review was done to answer the question: What is known from the existing empirical literature about factors, context, and processes that influence the uptake, implementation, and sustainability of evidence-based practice in healthcare organizations? This review used the Arksey and O'Malley framework to describe findings and to identify gaps in the existing research literature. Inclusion and exclusion criteria were developed to screen studies. Relevant studies published between January 1991 and March 2014 were identified using four electronic databases. Study abstracts were screened for eligibility by two reviewers. Following this screening process, full-text articles were reviewed to determine the eligibility of the studies by the primary author. Eligible studies were then analyzed by coding findings with descriptive labels to distinguish elements that appeared relevant to this literature review. Coding was used to form categories, and these categories led to the development of themes. Results Thirty studies met the eligibility criteria for this literature review. The themes identified were: the process organizations use to select evidence-based practices for adoption, use of a needs assessment, linkage to the organization's strategic direction, organizational culture, the organization's internal social networks, resources (including education and training, presence of information technology, financial resources, resources for patient care, and staff qualifications), leadership, the presence of champions, standardization of processes, role clarity of staff, and the presence of social capital. Conclusion Several gaps were identified by this review. There is a lack of research on how evidence-based practices may be sustained by organizations. Most of the research done to date has been cross-sectional. Longitudinal research would give insight into the relationship between organizational characteristics and the uptake, implementation, and sustainability of evidence-based practice. In addition, although it is clear that financial resources are required to implement evidence-based practice, existing studies contain a lack of detail about the cost of adopting and using new practices. This scoping review contains a number of implications for healthcare administrators, managers, and providers to consider when adopting and implementing evidence-based practices in healthcare organizations.

Supplemental Digital Content is available in the text., Deceased-donor renal transplant (DDRT) is an expensive and potentially risky health intervention with the prospect of improved life and lower long-term costs compared with dialysis. Due to the increasing shortage of kidneys and the associated rise of transplantation costs, certain patient groups may not benefit from transplantation in a cost-effective manner compared with dialysis. The objective of this systematic review was to provide a comprehensive synthesis of evidence on the cost-effectiveness of DDRT relative to dialysis to treat adults with end-stage renal disease and patient-, donor-, and system-level factors that may modify the conclusion. A systematic search of articles was conducted on major databases including MEDLINE, Embase, Scopus, EconLit, and the Health Economic Evaluations Database. Eligible articles were restricted to those published in 2001 or thereafter. Two reviewers independently assessed the suitability of studies and excluded studies that focused on recipients with age

Introduction: There are currently multiple integrated care IC models and pilots developed to enhance collaborative care delivery for older adults living with complex health and social needs. Technology innovations are increasingly embedded in the delivery of IC for this population. These include, electronically-delivered: information communication, shared-care planning, early risk identification, decision support, self-management support and remote monitoring. However, at various stages of implementation, there are common setbacks that influence the adoption and spread of these technologies and overall IC delivery. The objective of this systematic review is to examine the following questions: 1 Across different implementation stages of IC for older adults with complex needs, what are the key enablers of technology adoption; 2 how do these factors interact to influence successful technology adoption across various levels of IC including at the: individual, provider, team, organizational and across care settings. Theory/Methods: A detailed search strategy was developed, and conducted in following databases: Medline/PubMed, EMBASE, PsychINFO, CINAHL and Scopus. When articles described barriers or challenges that emerged from the implementation of technology in IC, they were systematically recorded. Following a multilevel thematic analysis, these statements were mapped against a combination of two frameworks: 1- the Consolidating Framework for Research Implementation CFIR; 2- the Fit between Individuals Task and Technology framework FITT Results: Preliminary results of this systematic review found that technologies were predominantly implemented to enhance integration at the provider-teams level, followed by at the organizational level. The most frequently reported influencers of adoption were related to the providers’ knowledge and perceptions of the technology, and how it impacted their ability to perform their responsibilities. This was followed by the technology characteristics; particularly its seamlessness or disruptiveness to the existing systems of work. As well as how adaptive and responsive the technology was to the goals and needs of the: older adults, providers, organization and the system. Factors such as organizational and system leadership, environmental culture and the ability to engage key players in the co-design and implementation of technologies were also key influencers. Conclusions key findings: These early findings highlight the need to tailor technological innovations to the IC setting, as well as the importance of considering change management strategies to enhance the system readiness and responsiveness to change. Supporting stakeholders before and during the processes of implementing IC technologies will increase their effectiveness in being flexible and adaptive to system changes. Limitations: The results presented are based on preliminary findings, however, an extensive systematic review is underway. A significant limitation is that the review did not deeply examine older adult and caregiver factors that could influence the implementation of technology in IC. A comprehensive systematic review and qualitative analysis will further examine this necessary dimension of technology implementation. Suggestions for future research: Results of the review will be used to inform the development of a tool that assesses the cross-sectoral capability of adopting technologies that support IC for older adults living with complex needs.

Background There is recognition that the overuse of procedures, testing and medications strains the healthcare system financially and can cause unnecessary stress and harm for patients. In recent years, several initiatives—such as Choosing Wisely—have targeted the reduction or elimination of low-value practices in healthcare. Researchers have begun to use theory or develop frameworks to elucidate the dynamics of de-implementation and support efforts to reduce low-value practices. The purpose of this scoping review was to identify and characterize the use of theories and frameworks to understand and address the reduction of low-value healthcare practices. Methods We conducted a systematic review of MEDLINE, EMBASE, CINAHL and Scopus databases from inception to January 2018. Building on previous research, 44 key terms were used to search the literature. To be included, papers had to present an explicit theoretical approach or framework. The database searches identified 725 unique articles for which titles and abstracts were screened for inclusion; 74 items were selected for full text review. Results Forty studies met the inclusion criteria. Over 50% of included articles were published in the last two years. Of studies which used a theoretical approach, the majority used psychological theories, such as the Theory of Planned Behaviour or applied behavioural science concepts to develop interventions. The included studies demonstrated a maturating of the use of theory in this field, with a progression from the use of classic theories to multi-theory frameworks to dual processing models. Theories or frameworks were used primarily to identify barriers and facilitators or develop conceptual clarity. Articles used theory to understand how provider decision-making, knowledge or perceptions of social pressure play a role in overuse. The majority of studies addressed low-value care at the provider level. Antibiotic overuse, polypharmacy and appropriate prescribing were the practices targeted most frequently in the included studies. Conclusions De-implementation is an emerging field of research. This scoping review was the first to review the use of theory in efforts to reduce low-value practice. The results of this review can provide direction and insight for future primary research in the use of theory to support de-implementation and reduction of low-value healthcare practices.

Background Interest in public involvement in health research projects has led to increased attention on the coordination of public involvement through research organisations, networks and whole systems. We draw on previous work using the ‘health research system’ framework to explore organisational actors and stewardship functions relevant to governance for public involvement. Methods To inform efforts in Ontario, Canada, to mobilise public involvement across the provincial health research enterprise, we conducted an exploratory, qualitative descriptive study of efforts in two jurisdictions (England, United Kingdom, and Alberta, Canada) where there were active policy efforts to support public involvement, alongside jurisdiction-wide efforts to mobilise health research. Focusing on the efforts of public sector organisations with responsibility for funding health research, enabling public involvement, and using research results, we conducted in-depth, semi-structured interviews with 26 expert informants and used a qualitative thematic approach to explore how the involvement of publics in health research has been embedded and supported. Results We identified three sets of common issues in efforts to advance public involvement. First, the initial aim to embed public involvement leveraged efforts to build self-conscious research ‘systems’, and mobilised policy guidance, direction, investment and infrastructure. Second, efforts to sustain public involvement aimed to deepen involvement activity and tackle diversity limitations, while managing the challenges of influencing research priorities and forging common purpose on the evaluation of public involvement. Finally, public involvement was itself an influential force, with the potential to reinforce – or complicate – the ties that link actors within research systems, and to support – or constrain – the research system’s capacity to serve and strengthen health systems. Conclusions Despite differences in the two jurisdictions analysed and in the organisation of public involvement within them, the supporters and stewards of public involvement sought to leverage research systems to advance public involvement, anticipated similar opportunities for improvement in involvement processes and identified similar challenges for future involvement activities. This suggests the value of a health research system framework in governance for public involvement, and the importance of public involvement for the success of health research systems and the health systems they aim to serve.

Background: Interpersonal relationships among professionals drive both the adoption and rejection of consequential innovations. Through relationships, decision-makers learn which colleagues are choosing to adopt innovations, and why. The purpose of our study was to understand how and why long-term care (LTC) leaders in a pan-Canadian interpersonal network provide and seek advice about care improvement innovations, for the eventual dissemination and implementation of these innovations. Methods: We used a mixed methods approach. An online survey was sent to senior leaders in 958 LTC facilities in 11 Canadian provinces and territories. Participants were asked to name up to three individuals whose advice they most value when considering care improvement and practice innovations. Sociometric analysis revealed the structure of provincial-level advice networks and how those networks were linked. Using sociometric indicators, we purposively selected 39 key network actors to interview to explore the nature of advice relationships. Data were analyzed thematically. Results: In this paper, we report our qualitative findings. We identified four themes from the data. One theme related to characteristics of particular network roles: opinion leaders, advice seekers, and boundary spanners. Opinion leaders and boundary spanners have long tenures in LTC, a broad knowledge of the network, and share an interest in advancing the sector. Advice seekers were similarly committed to LTC; they initially seek and then, over time, exchange advice with opinion leaders and become an important source of information for them. A second theme related to characterizing advice seeking relationships as formal, peer-to-peer, mentoring, or reciprocal. The third and fourth themes described motivations for providing and seeking advice, and the nature of advice given and sought. Advice seekers initially sought information to resolve clinical care problems; however, over time, the nature of advice sought expanded to include operational and strategic queries. Opinion leaders sought to expand their networks and to solicit information from their more established advice seekers that might benefit the network and advance LTC. Conclusions: New knowledge about the distinct roles that different network actors play vis-a-vis one another offers healthcare professionals, researchers, and decision- and policy-makers insights that are useful when formulating best practice dissemination strategies.

Purpose The purpose of this paper is to examine how the design and implementation of learning models for performance management can foster continuous learning and quality improvement within a publicly funded, multi-site community hospital organization. Design/methodology/approach Niagara Health's patient flow performance management system, a learning model, was studied over a 20-month period. A descriptive case study design guided the analysis of qualitative observational data and its synthesis with organizational learning theory literature. Emerging from this analysis were four propositions to inform the implementation of learning models and future research. Findings This performance management system was observed to enable: ongoing performance-related knowledge exchange by creating opportunities for routine social interaction; collective recognition and understanding of practice and performance patterns; relationship building, learning for improvement, and "higher order" learning through dialogue facilitated using humble inquiry; and, alignment of quality improvement efforts to organizational strategic objectives through a multi-level feedback/feed-forward communication structure. Research limitations/implications The single organization and descriptive study design may limit the generalizability of the findings and introduce confirmation bias. Future research should more comprehensively evaluate the impact of learning models on organizational learning processes and performance outcomes. Practical implications This study offers novel insight which may inform the design and implementation of learning models for performance management within and beyond the study site. Originality/value Few studies have examined the mechanics of performance management systems in relation to organizational learning theory and research. Broader adoption of learning models may be key to the development of continuously learning and improving health systems.

Although it has long been recognized that employees' workplace affective commitment can be directed at a variety of foci, theory and research on this multifocal perspective remain underdeveloped, possibly due to the lack of a short, yet comprehensive measure. The purpose of the present study was to assess the psychometric properties of a newly developed short (24-item) version of the Workplace Affective Commitment Multidimensional Questionnaire (WACMQ-S), covering affective commitment directed at the organization, supervisor, coworkers, customers, tasks, profession, work, and career. Using two independent samples of English - (N = 676, including 648 females) and French - (N = 733, including 593 females) speaking healthcare professionals and the newly developed bifactor-ESEM framework, the present study supported the factor validity, composite reliability, test-retest reliability, linguistic invariance, and criterion-related validity (in relation to turnover intentions, in-role performance, and organizational citizenship behaviors) of the WACMQ-S ratings. The results also demonstrated the superiority of a bifactor-ESEM representation of WACMQ-S ratings, confirming the importance of taking into account employees' global levels of commitment to their work life. Finally, the results also proved to be fully generalizable to subsamples of hospital and community healthcare professionals, as well as of nurses and beneficiary attendants.

Background Our overarching study objective is to further our understanding of the work psychology of Health Support Workers (HSWs) in long-term care and home and community care settings in Ontario, Canada. Specifically, we seek novel insights about the relationships among aspects of these workers’ work environments, their work attitudes, and work outcomes in the interests of informing the development of human resource programs to enhance elder care. Methods We conducted a path analysis of data collected via a survey administered to a convenience sample of Ontario HSWs engaged in the delivery of elder care over July–August 2015. Results HSWs’ work outcomes, including intent to stay, organizational citizenship behaviors, and performance, are directly and significantly related to their work attitudes, including job satisfaction, work engagement, and affective organizational commitment. These in turn are related to how HSWs perceive their work environments including their quality of work life (QWL), their perceptions of supervisor support, and their perceptions of workplace safety. Conclusions HSWs’ work environments are within the power of managers to modify. Our analysis suggests that QWL, perceptions of supervisor support, and perceptions of workplace safety present particularly promising means by which to influence HSWs’ work attitudes and work outcomes. Furthermore, even modest changes to some aspects of the work environment stand to precipitate a cascade of positive effects on work outcomes through work attitudes.

Background Complexity thinking is increasingly being embraced in healthcare, which is often described as a complex adaptive system (CAS). Applying CAS to healthcare as an explanatory model for understanding the nature of the system, and to stimulate changes and transformations within the system, is valuable. Main text A seminar series on systems and complexity thinking hosted at the University of Toronto in 2016 offered a number of insights on applications of CAS perspectives to healthcare that we explore here. We synthesized topics from this series into a set of six insights on how complexity thinking fosters a deeper understanding of accepted ideas in healthcare, applications of CAS to actors within the system, and paradoxes in applications of complexity thinking that may require further debate: 1) a complexity lens helps us better understand the nebulous term “context”; 2) concepts of CAS may be applied differently when actors are cognizant of the system in which they operate; 3) actor responses to uncertainty within a CAS is a mechanism for emergent and intentional adaptation; 4) acknowledging complexity supports patient-centred intersectional approaches to patient care; 5) complexity perspectives can support ways that leaders manage change (and transformation) in healthcare; and 6) complexity demands different ways of implementing ideas and assessing the system. To enhance our exploration of key insights, we augmented the knowledge gleaned from the series with key articles on complexity in the literature. Conclusions Ultimately, complexity thinking acknowledges the “messiness” that we seek to control in healthcare and encourages us to embrace it. This means seeing challenges as opportunities for adaptation, stimulating innovative solutions to ensure positive adaptation, leveraging the social system to enable ideas to emerge and spread across the system, and even more important, acknowledging that these adaptive actions are part of system behaviour just as much as periods of stability are. By embracing uncertainty and adapting innovatively, complexity thinking enables system actors to engage meaningfully and comfortably in healthcare system transformation.

BACKGROUND: The Workplace Affective Commitment Multidimensional Questionnaire (W ACMQ) measures affective commitment towards eight work-related targets. While this questionnaire was developed in the business sector, we believe that the multi-target conceptualization of affective commitment has applicability to complex health care contexts where providers of care, in the production and delivery of care, likely develop commitment toward a multiplicity of targets. Affective commitment is a strong predictor of extra-role workplace behavior; indispensable behaviors which enable health systems to function. OBJECTIVE: The aim of this psychometric exercise is to content validate the WACMQ questions for use in health care. METHODS: Two focus groups were conducted, consisting of nurses working in acute care and emergency hospitals in Ontario. Linguistic validation and cognitive debriefing were used. RESULTS: A total of 14 modifications to the wording of items on the original WACMQ questionnaire were made. CONCLUSIONS: This modified version of the WACMQ reflects the need for researchers in health care settings to acknowledge the complex context of health care and the attendant complexities of worker attitudes. Health care workers can experience affective commitment toward leadership (clinical or administrative), co-workers (nurses or interprofessional), patients, their profession, organization, work or tasks. Further, in some health care settings, features like union membership may have important implications when examining affective commitment or behaviors. Psychometric properties of the modified WACMQ will be established in an upcoming study that will examine the relationships between extra-role behaviors, commitment, perceived organizational support and justice within acute care and emergency departments of hospitals operating in Ontario.

Increasing demands on health care systems require patients to take on more active roles in their health. Effective self-management has been linked to improved health outcomes, and evidence shows that effective self-management is linked to health literacy (HL). HL is an important predictor of successful self-management in other chronic diseases but has had minimal testing in cancer.A scoping review was conducted to examine and summarize what is known about the association between HL and self-management behaviors and health service utilization in the cancer setting. The methodological framework articulated by Arksey and O'Malley was used and was further refined with the Joanna Briggs Institute methodology. Inclusion criteria included the following: peer review; publication in English; and adult patients and caregivers of all races, ethnicities, and cultural groups. Use of a validated instrument to measure HL was required.The search yielded 2414 articles. After the removal of duplicates and the performance of title scans and abstract reviews, the number was reduced to 44. Of the 44 full-text articles reviewed, 17 met the inclusion criteria. A number of important self-management behaviors and related outcomes were found to be associated with HL. These included the uptake of cancer screening, the receipt of prescribed chemotherapy, and a greater risk of postoperative complications.This literature review shows that HL is associated with important self-management behaviors in cancer. The implications of these associations for individuals with inadequate HL and for the health care system are significant. More research is needed to explore these associations.

Purpose– The purpose of this paper is to describe the development of a coherent conceptual framework that could guide research that enhances our understanding of the factors that influence extra-role workplace behaviors and work performance in health care. In health-care settings, work performance is dependent upon worker’s extra-role behaviors.Design/methodology/approach– The authors draw upon theory and current research in the field of organizational behavior and work motivation to explain the relationships between extra-role behaviors (ERBs), commitment, perceived organizational support (POS) and justice. These behaviors are related to a number of factors, including one’s affective commitment, POS and organizational justice. The influence of most of these concepts on work outcomes has been established in disparate studies, but their precedence in terms of influencing extra-role behaviors is not well understood.Findings– An augmented framework is produced, incorporating concepts of relevance to work motivation and work attitudes. Propositions, predicated on research evidence, are offered.Research limitations/implications– Spontaneous, emotional and/or reflexive behaviors are not accounted for in the conceptual framework.Practical implications– By adjusting interaction with employees, managers can bring about positive effects, facilitating constructive ERBs, which can improve work performance and productivity, patient safety, care quality and enable cost savings.Originality/value– This paper offers a novel comprehensive framework based upon a comprehensive literature review.

Background Despite emerging frameworks for quality improvement (QI) implementation, little is known about how the implementation process works, particularly in nursing home settings. A study was conducted to describe "how"' a complex frontline worker–led QI program was implemented in nursing homes. Methods Six focus groups were conducted in February 2017 with participants of a year-long, multicomponent, unit-level QI intervention in seven nursing homes in the Canadian province of Manitoba. Constant comparative analysis was used to examine perspectives of different groups of QI program participants—35 health care aides, health professionals, and managers. Results Five themes important to the implementation process were identified: (1) "supportive elements of the QI program structure," (2) "navigating the workplace," (3) "negotiating relationships," (4) "developing individual skills," and (5) "observable program impact." Data on theme integration suggest that "supportive elements of the QI program structure" (Theme 1), "developing individual skills" (Theme 4), and "observable program impact" (on residents, health care aides, and leaders; Theme 5) operated as part of a reinforcing feedback loop that boosted team members' ability to navigate the workplace, negotiate relationships, and implement the QI program. Conclusion Health care aide–led QI teams are feasible. However, a leadership paradox exists whereby worker-led QI programs also must incorporate concrete mechanisms to promote strong leadership and sponsor support to teams. The findings also point to the underexplored impact of interpersonal relationships between health care aides and professional staff on QI implementation.

Cet article examine les facteurs associes a l'inscription sur une liste d'attente pour une place en etablissements de soins de longue duree en Ontario (Canada). L'analyse a ete realisee a partir de donnees collectees avec l'Instrument d'evaluation des residents-Services a domicile (RAI-HC) dans le Reseau local d'integration des services de sante du Nord-Ouest (RLISS) en 2014. Notre analyse quantifie l'influence de facteurs associes aux beneficiaires de soins, aux aidants naturels et aux etablissements de soins sur la probabilite d'inscription sur une liste d'attente. Nous observons que ces trois facteurs sont significativement relies a l'inscription sur une telle liste. Les resultats de cette analyse pourraient avoir une incidence sur les politiques visant a reduire le nombre d'individus vivant dans la communaute qui sont inscrits sur une liste d'attente pour des etablissements de soins de longue duree. This article is based on a study that investigated factors associated with long-term care wait list placement in Ontario, Canada. We based the study's analysis on Resident Assessment Instrument for Home Care (RAI-HC) data for 2014 in the North West Local Health Integration Network (LHIN). Our analysis quantified the contribution of three factors on the likelihood of wait list placement: (1) care recipient, (2) informal caregiver, and (3) formal system. We find that all three factors are significantly related to wait list placement. The results of this analysis could have implications for policies aimed at reducing the number of wait-listed individuals in the community.

The Advice Seeking Networks in Long Term Care Study used social network analysis to understand the informal advice networks of senior leaders in Canadian long term care (LTC), with the goal of using this knowledge to inform future efforts to more effectively disseminate quality improvement innovations. In this abstract we describe one main component of the study, a qualitative analysis of interviews conducted with 39 opinion leaders, boundary spanners, and advice seekers identified in interpersonal advice networks in the sector. At each of the 958 LTC facilities spanning 11 of Canada’s 13 provinces and territories, we asked one senior leader to complete a survey identifying individuals who were informal sources of advice about quality improvement. The survey data from 482 respondents was then used to identify and interview network advice seekers by their out-degree scores, opinion leaders by their in-degree scores, and boundary spanners by their betweenness centrality scores. Results from thematic analysis of the interviews indicated that advice seekers tend to seek advice from those with whom they deem trustworthy and knowledgeable and with whom they share similar professional backgrounds and care philosophies. Opinion leaders possess an appetite for change and a strong sense of responsibility for improving care throughout the LTC system. They often have career trajectories that move them from clinical to administrative or oversight roles. Advice seeking relationships often endure over many years, transcending roles and even care sectors, and can evolve into reciprocal relationships.

Setting priorities for health services is a complex and value laden process. Over the past twenty years, there has been considerable scholarly attention paid to strengthening fairness and legitimacy using the prominent ethical framework, Accountability for Reasonableness (A4R). A variety of case studies applying A4R have advanced our conceptual understanding of procedural fairness, and have highlighted the significance of context through its application. There is a paucity of research, however, that rigorously examines how and to what extent context influences health priority setting processes and the establishment of procedural fairness. We argue here that to study context rigorously requires taking a holistic view of the system by examining the dynamics and interrelationships within it. Using the Transformative Systems Change Framework (TSCF), this investigation sought to examine the influence of system factors on priority setting practice and procedural fairness. A qualitative case study of Ethiopian district health planning was undertaken in 2010 and 2011. Methods included 58 qualitative interviews with decision makers, participant observation, and document analysis. Data analysis followed in three phases: i) an inductive analysis of district health priority setting to highlight experiences across each of the three districts selected, ii) deductive analysis applying A4R and the TSCF independently; and iii) a synthesis of concepts of priority setting practice and procedural fairness within a broader, theoretical understanding of the system. Through the application of the TSCF, a nuanced understanding of priority setting practice is revealed that situates this process within a system of interdependent components that include: norms, operations, regulations, and resources. This paper offers a practical guide attuned to system features influencing the design, implementation, and sustainability of greater fairness in health priority setting practice.

Background Initiatives to accelerate the adoption and implementation of evidence-based practices benefit from an association with influential individuals and organizations. When opinion leaders advocate or adopt a best practice, others adopt too, resulting in diffusion. We sought to identify existing influence throughout Canada’s long-term care sector and the extent to which informal advice-seeking relationships tie the sector together as a network. Methods We conducted a sociometric survey of senior leaders in 958 long-term care facilities operating in 11 of Canada’s 13 provinces and territories. We used an integrated knowledge translation approach to involve knowledge users in planning and administering the survey and in analyzing and interpreting the results. Responses from 482 senior leaders generated the names of 794 individuals and 587 organizations as sources of advice for improving resident care in long-term care facilities. Results A single advice-seeking network appears to span the nation. Proximity exhibits a strong effect on network structure, with provincial inter-organizational networks having more connections and thus a denser structure than interpersonal networks. We found credible individuals and organizations within groups (opinion leaders and opinion-leading organizations) and individuals and organizations that function as weak ties across groups (boundary spanners and bridges) for all studied provinces and territories. A good deal of influence in the Canadian long-term care sector rests with professionals such as provincial health administrators not employed in long-term care facilities. Conclusions The Canadian long-term care sector is tied together through informal advice-seeking relationships that have given rise to an emergent network structure. Knowledge of this structure and engagement with its opinion leaders and boundary spanners may provide a route for stimulating the adoption and effective implementation of best practices, improving resident care and strengthening the long-term care advice network. We conclude that informal relational pathways hold promise for helping to transform the Canadian long-term care sector.