EPI 245Hendre Protocol Assignment #1
1. What evidence are you proposing to translate into practice?
Daily oral care improves general health and quality of life in geriatric population.
A. Justify that this evidence is “ready for translation.”
Many older adults are able to retain their natural teeth for a longer duration than before. Older adults often walk a fine line between independent and dependent state. When the balance shifts and they become more dependent oral health is significantly affected. Old age, systemic disease, mental health, disability and limited insurance make oral care even more challenging.
It is proven that poor oral hygiene can worsen the impact of systemic diseases. Maintaining good oral hygiene prevents decay, periodontal disease, infection and pain. It also reduced the risk for aspiration pneumonia and fungal infections. It prevents malnourishment and improves general health and quality of life.
B. Identify a single, key behavior change target for your translational activity.
CNA’s work closely with older adults and help them with ADL’s. They are involved in providing direct oral care to the dependent older adults. Training and educating CNA’s
- •To deliver daily oral care using effective brushing techniques
- •To appropriately use available dental care products
- •To identify gross changes in oral cavity
Will improve oral hygiene and quality of life of the dependent older adults.
2. Conduct a “gap analysis” of your target behavior. Look to diverse sources for “best guess” estimates if specific measures are not available.
A. What is the quality (performance) gap?
It is well known that CNA’s are hard pressed on time and have to balance patient care and turnover all the time. They do not have sufficient time to use oral care devices and products appropriately. The patient population is too frail, depressed or disabled to provide effecient self care.
B. What is the outcome gap?
In this study we expect that training CNA’s will improve their knowledge and confidence to provide oral care but a change in patients, nurses and managements attitude is also necessary in order to be make actual daily care possible.
3. Is there evidence that changing performance will improve health (clinical outcomes)?
There is a strong evidence suggesting that training auxiliary staff improves oral health outcomes and quality of life in older adults. Studies have shown that daily oral care keeps the opportunistic microorganisms under control hence reducing cavity formation, periodontal disease, and systemic and fungal infections.
References:
1. Ageing, dementia and oral health. Foltyn P1.
2.Oral health of older people admitted to hospital for needs assessment. Ling GY, Love RM, MacFadyen EE, Thomson WM.
3.Oral health status among long-term hospitalized adults: a cross sectional study Leon Bilder,1 Nirit Yavnai,2 and Avi Zini3
4. Oral Hygiene Reduces the Mortality from Aspiration Pneumonia in Frail Elders F. Müller1,*
5. Oral health in the elderly patient and its impact on general well-being: a nonsystematic review José Antonio Gil-Montoya,1 Ana Lucia Ferreira de Mello,2 Rocío Barrios,3 Miguel Angel Gonzalez-Moles,4 and Manuel Bravo3
6. The integration of oral health care into day-to-day care in nursing homes: a qualitative study. De Visschere L1, de Baat C, De Meyer L, van der Putten GJ, Peeters B, Söderfelt B, Vanobbergen J.
7. Effect of oral healthcare education on knowledge, attitude and skills of care home nurses: a systematic literature review. de Lugt-Lustig KH1, Vanobbergen JN, van der Putten GJ, De Visschere LM, Schols JM, de Baat C.
8. Oral health-related quality of life among institutionalized patients after dental rehabilitation. Ilhan B1, Cal E, Dündar N, Güneri P, Dağhan S.
Assignment #2
- 1.Define the community/communities for your project and explain why each is a stakeholder for your study.
CNA’s are the principal stakeholders in this study as they are the one who provide direct oral care to the patients in the long-term care facility.
LVN’s & NP’s/ Nurse Managers: They overlook CNA’s, assign them work and receive feedback from them
Hospital Administration: The long term care facility where we are going to perform the study
Patients: They are the one who receive care and actual outcomes can be measured by observing their oral health status
2. Describe your plan for approaching potential community partners to ask for their involvement.
The hospital is always looking for ways to improve health outcomes for their residents on this basis I will approach the administration and the nursing staff through existing contacts at the hospital. The CNA’s will be approached through the nursing staff once the participating units are identified. Patients will be approached at dental clinic or on the units to seek participation
3. Identify which stages of your project you'll incorporate community input, and describe what types of input you'll solicit.
The administrations input is required in identifying the NP’s who are interested in such a training and study and/ or who are actively involved in research.
The nursing staffs input is essential in study design, pre and post survey design, identifying the units in the hospital that are potential participants, appropriate time and place for training. We also seek their own feedback and informal feedback they received from the CNA’s about the entire training process.
CNA’s feedback will be collected formally through pre and post surveys and informally through focus group discussions. CNA’s will also be asked to create a list of problems they face afterwards while using the techniques thought in the training. There will be constant communication and open dialogue with the CNA’s to address their needs and find solutions to the difficulties they encounter.
Patient’s feedback will be collected before and frequently after study through informal interviews about CNA’s performance and their satisfaction and directly by accessing their oral health.
4. Name three ways you plan to share your results, beyond writing an academic article or presenting at an academic conference.
Share it with the nursing staff and CNA’s who participated in the training.
With the hospital administration
Other long term care facilities.
Assignment #3
1. Based on Shortell’s article “An empirical assessment of high-performing medical groups: results from a national study", describe the organization/system in which your intervention will take place using the specific predictor measures within Environment, Resource acquisition, Resource deployment and Quality-centered care (Table 1).
This study will take place at Laguna Honda Hospital and Rehabilitation Centre that is part of SF health network and is also one of the largest skilled nursing facilities.
Environment: It has been awarded five stars by medicare & Medicaid services and recipient of numerous awards. It serves diverse population in the city and provides wide array of services. Services are funded through medicare and medical reimbursements as well as numerous grants.
Resource acquisition: Hospital gets incentives from insurance companies for various care programs. Hospital increases its admission rate by offering multidisciplinary care model that helps to successfully place patients back in the community and provides home care for them for which they are compensated.
Resource deployment: Is part of wider SF health network. Has multidisciplinary staff with good retention. Is an educational and training facility for several professional students. Collaborates with different organizations in the city to expand reach of care.
Quality-centered care: Offers wide variety of programs to improve patients health & care. Also recognizes efforts of care providers and staff by appraising and presenting awards.
2. Discuss which of these factors might serve as barriers to successful implementation of your intervention, and how you will try to design an intervention to overcome these barriers.
Environment: Due to the size and hierarchical system it will take longer to approve any new study. Also due to higher rating score hospital is closely monitored for all the services it provides and initiatives it starts. This might result into more strict guidelines for performing any kind of study specially the one that involve patients. I can present HA with research studies that shows association between daily oral care and improved general health. I can also state this as QI project.
Resource acquisition: The hospital might have to hire more staff (CNA’s, LVN’s, nurse managers or hygienists and dentists) that will result in increase cost for them. I will try to make a point that this will improve quality of daily oral care, which in turn will prevent or decrease the number of adverse outcomes, improve general health and reduce costs related to prolong hospital stay due to acquired problems as a result of poor oral care. It will also increase patient admission rate.
such as aspiration pneumonia, cardiovascular diseases, diabetes management and nutrition.
Resource deployment: Does not appear to be a major concern due to structure. Once the hospital adopts a program it can be sustained through existing resources.
Quality-centered care: Care staff might not welcome a new addition to their routine. In order to make it appealing for care providers and recognizing the efforts they took in adopting this new standard of care I would suggest that hospital should award them by giving CE credits, certificates, and help them to become leaders and teach others.
Assignment #4
1. Identify an individual (e.g., patient or provider) or group (e.g., community group or organization) that contributes to or is involved in the principal behavior you are attempting to change. Specify the desired behavior change (who needs to change what, when, where and how)?
I am targeting the CNA’s to improve their oral care delivery skills at Laguna Honda Hospital by training them to provide good oral care to dependent disabled and frail population
2. Using any of the individual explanatory theories in “Theory at a Glance”, develop an explanatory model for the target behavior (above) that you will be attempting to influence with your intervention. This can be an extension/based on previously published literature or your best guess of expected findings. Figures are always very useful... keep it simple. You can also use the logic model of the problem concept as presented in Bartholemew and Mullen (Five roles for using theory and evidence in the design and testing of behavior change interventions). Be sure to include components beyond the individual, such as suggested by the socio-ecological model.
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Theory Of Planned Behavior |
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Behavioral intention
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How likely are they to provide Oral Care(OC)? Likely: If they understand the importance of OC. If patient demands it. If an order is placed by higher authority such as nurses and physicians. If hospital policy demands good OC. Less Likely: Because they are hard pressed on time and providing OC to this population can be challenging due to patients physical or mental disability. Also other health related problems are considered more demanding by pts as well as healthcare providers. It can be due to the fact that they don’t get sufficient training to feel confident to use assistive OC devices and provide OC to this particular population.
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Attitude
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If they hold their own OC in high regards chances that they do same for their patients are more. But in the hospital even though OC comes under their scope it is not monitored nor is an expected standard of practice for them. |
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Subjective norm
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The key motivation factor for them to provide OC would be to include that in the standard of care guidelines. Making OC as a course eligible for CE credits and honoring them with a certificate of achievement after demonstrating good OC practice will recognize their efforts. |
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Perceived behavioral control
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It is a possibility that due the existence of an onsite dental clinic, OC including daily care is primarily seen as a duty/ authority of the dental clinic and CNA’s might feel less powerful or less in control to provide daily OC. |
3. Create your own version of Table 1 from Michie et al (Making psychological theory useful for implementing evidence based practice: a consensus approach) that reflects some of the different theoretical domains and interview questions, tailored to the behavior you want to change. Be sure to select several domains likely to be of interest based on the literature or your experience/best guess.
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Knowledge
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Do they know why OC is important? Do they know how plaque looks, feels and affects mouth and general health? Do They have sufficient training? Do they know right techniques to use dental products and material? |
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Skills |
What are the challenges encountered while providing OC? Do they know how to modify techniques based on those challenges? Do they know how to instruct or direct the patient? |
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Self-efficacy
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Are they confidant to provide OC? What can be done to empower them? Will use of products make them feel in control? |
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Beliefs about consequences
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What do they think will happen if standard of OC is not good? Are they aware of time spent on preventive OC Vs time spent in caring for patient after undesired outcomes such as pneumonia or tooth ache? Do they think they are using correct techniques? |
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Motivation and goals
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Are there any strict requirements for providing OC? How much do they want to learn about OC? What incentives they receive for taking the training?
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Memory, attention and decision processes
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How often they have to attend training sessions? Attending long or short sessions will help them stay focus? |
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Environmental context and resources
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Are all OC devices and products readily available? Do they have enough time for OC? Are there other more important tasks? |
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Social influences
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Where are they in the hierarchy? Who decides there roles and responsibilities? How does the nursing staff support them? What does the hospital administration do to make them more competent? |
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Emotion
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At times patient interactions are challenging. How does that affect their attitude towards care? Do they have too much work load? Are they afraid of doing something wrong? |
Assignment # 5
1. Use the COM-B model to identify what needs to change in order for ONE of your selected target behaviors to occur.
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COM-B Components |
What needs to happen for the target behavior to occur? |
Is there a need for change? |
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Physical capability (Physical skills) |
CNA’s need a hands on training and practice to improve their OH technique and confidence |
Yes, OH training given during 2 day CNA course is not suffiecient. |
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Psychological capability (Knowledge; Cognitive and interpersonal skills; Memory, attention and decision processes; Behavioral regulation) |
1. Educate about OH, its importance, benefits and complications 2. Empower CNA’s to be leaders of their group in order to support others 3. Give them freedom to make decisions to modify OH techniques to suit the needs of their patients. 4. |
Yes, there psychological capability needs to change as they do not |
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Physical opportunity (Environmental context and resources) |
1. Easy availability of OH products 2. Letting them try different products to find out the once they are comfortable using. |
Yes |
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Social opportunity (Social influences) |
1. Opportunity to ask questions without burden. 2. Opportunity to be leader of a group to help others.
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Yes |
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Reflective motivation (Professional/social role and identity; Beliefs about capabilities; Optimism; Beliefs about consequences; Intentions; Goals) |
1. Offering them a certificate for training 2. Providing opportunity to be a trainer. 3. Sharing results of improved/ worsen OH and setting goals for the next time period. |
Yes |
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Automatic motivation (Reinforcement; Emotion) |
Giving them opportunity to share their OH success stories about how they turned patients bad OH into good one. Looking at their own contribution towards patient health will emotionally reward them as well as motivate others. |
Yes |
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Behavioral diagnosis of the relevant COM-B components: |
List the COM-B categories you want to target with your intervention I would use all the COM-B categories.
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- 2.Use the APEASE criteria to identify appropriate intervention functions based on the behavioral diagnosis (See Table 2.3 in Michie et al Chapter 2)
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Candidate intervention functions
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Is the intervention function needed based on the behavioral diagnosis? |
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Education |
Yes |
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Persuasion |
Yes |
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Incentivisation |
Yes |
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Coercion |
No |
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Training |
Yes |
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Restriction |
No |
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Environmental restructuring |
Yes |
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Modelling |
Yes |
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Enablement |
Yes |
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Selected intervention functions: |
List the selected functions your intervention(s) will serve. Select based on APEASE criteria (affordability, practicability, effectiveness/cost-effectiveness, acceptability, side-effects/safety, equity). Education, training, environmental restructuring, enabling, modeling, positive persuasion and incentives. |
3. For one of the intervention functions you selected, select a specific behavior change technique you will employ in your intervention strategy and specify how it will be delivered.
a. BCW Intervention Function: Enablement
b. Behavior Change Technique: Social support
c. Mode of delivery: The dental team will provide ongoing support to the CNA’s by constant communication. During this communication we will identify the OH leaders within the group of CNA’s and train them so they can help and train others who are shy to reach out to dental team. Peer support will boost CNA’s comfort and performance.
Assignment # 6
1. Thinking about the protocol you are developing, identify the process and outcome indicators associated with the intervention/program and briefly describe an approach to measuring each.
Process Indicators: CNA Training
Approach to measure:
1. Change in CNA’s knowledge and attitude towards oral care.
2. Change in CNA comfort level while providing oral care.
3. Patient response/satisfaction.
4. Change in patients dental and health reports.
Outcome Indicators: Improve CNA’s
Knowledge and attitude.
Comfort level.
Skills.
Approach to measure:
1. Knowledge and attitude: is it improved?
2. Comfort level: Do they feel confident?
3. Skills: Do they know how to use all the products?
Can they modify techniques as per patient requirement?
4. If not, what are the barriers?
2. Define one or more “intermediate” outcome measures [reflecting changes in environment, organizational culture, systems of care, patient or public behavior, and/or clinician behaviors] that can inform you about the mechanism by which your intervention achieves its downstream effect on health and inform you about the acceptability of your intervention.
Intermediate Outcome Measures:
1. Change in CNA attitude, peer support
2. Support from nursing staff.
3. Environmental changes on the unit.
4. Demand from patients?
3. Identify a mixed methods study design and briefly describe the quantitative and qualitative data you will collect for program/intervention evaluation.
Qualitative Data:
Pre training focus groups: with CNA’s, nurses, patients, physicians, hospital administration to determine the severity of the issue, barriers in providing care, possible solutions and designing training sessions.
Post training interviews with patients and CNA’s
Quantitative Data:
Pre and post training survey about CNA’s knowledge and attitudes
Dental records: evaluation of patient’s oral hygiene
Hospital records: Change in number of secondary infections of dental origin.
Diet & Nutrition records
Assignment #7
1. Describe the study design you will employ in order to determine if your intervention has had an effect on the outcome variable of interest.
I will use a stepped-wedge design for this study. 9 units will be trained from 0 to 9 months and all units will be efficient and providing intervention by 12 mths.
2. Define the unit-of-analysis for your main outcome evaluation, the minimum meaningful effect size, and the sample size necessary to detect this effect size.
The unit of analysis for this study would be repeated in time evaluations of oral health and general health records.
I can also use paired t test to analyze unit mean before and after training.