Interprofessional Program Research Articles

Interprofessional education clinical placement program: a qualitative case study approach

ABSTRACT The goal of health professional education programs is to produce competent graduates, with an ability to work collaboratively as effective healthcare team members. We explored the reflections of students and clinical facilitators, in response to participation in a structured interprofessional education (IPE) clinical placement program. In our qualitative study we used an exploratory case study design. In our analysis, we highlight the benefits of interprofessional practice. Key themes identified by students included: limited opportunities to engage in IPE across their course; lack of clarity around IPE; value of IPE for students, practitioners, and patient outcomes; and need for IPE opportunities to be integrated into placements. Key themes identified by the clinical facilitators included: being reminded of the value of IPE for students and patients; preparation for IPE placements need to be embedded in curricula; coordination and communication of IPE learning activities need to be clear for staff and students; and IPE should continue as part of the broader clinical education agenda. Our findings reinforce the notion that students and clinical facilitators value the importance of IPE for student learning within the clinical placement setting. The outcomes offer valuable insights for universities and hospital and health care contexts for setting up and implementing IPE activities, and we provide recommendations for improving ongoing IPE efforts within clinical placement setting.

Teaching empathy in an interprofessional setting with a focus on decategorization: Introducing I-Team

The Interprofessional Training in Empathy, Affect, & Mindfulness (I-TEAM) was designed to promote and cultivate collectivity and a sense of shared identity and values among health profession students. This study showcases the theoretical foundation, evaluation-based protocol, and findings of the pilot I-TEAM program. To evaluate the impact of the pilot offering of I-TEAM, we employed a rigorous multimethod protocol consisting of surveys (pre and post), observations, and interviews. Students significantly improved in empathy, and positively shifted their perceptions of other health professions. Moreover, student-oriented goals for the program and fundamental aspects of the IPEC competencies were shown to be addressed through the I-TEAM program. Centralizing an interprofessional program on the principles of decategorization and shared experiences, may have a positive impact on students’ perceptions of other health professions as well as ability and willingness to connect with others on an emotional and cognitive level (i.e. empathy).

Addressing the Opioid Epidemic: Strategies for Interprofessional Health Education

INTRODUCTION Opioid use disorder impacts families in the United States from all walks of life with premature loss of life and devastating financial and social consequences. An online interprofessional program was designed and implemented to assist pre-licensure health professions students to understand the complexities of the opioid epidemic. The program included information related to the epidemic’s impact on individuals, patients, families and the community, solutions to this crisis, and the benefit of interprofessional care in to addressing the epidemic. METHODS The purpose of this study was to explore students’ perceptions of individuals experiencing opioid use disorder and the value of interprofessional care. There were 217 students of medicine, dental, nursing, emergency medical services, and physical therapy who participated in the discussion-board format activity that enabled them to acquire new knowledge and apply it to two unfolding case studies of individuals experiencing opioid use disorder. RESULTS Thematic analysis was applied to the discussion that was generated from the activity. Six themes were identified from the discussion board responses: 1) Opioid use disorder can happen to anyone, 2) Mismanaged health care contributes to opioid addiction, 3) Overwhelming life stressors can impact opioid use, 4) Seeking relief from chronic pain can dominate a person’s life, 5) A strong sense of empathy and compassion is essential for health professionals, and 6) Interprofessional collaboration improves outcomes. CONCLUSION This educational strategy was an effective approach to engage students in informed discussions regarding the complexities of the epidemic and to appreciate the benefit of interprofessional care in addressing opioid use disorder.

Proactive inter-professional program to manage malignant bowel obstruction (MBO) in women with advanced gynecological cancer: Improving quality of care, education and awareness of malignant bowel obstruction among patients and health care providers

Objective: The aim of this study was to integrate and optimize the role of patient and health care provider education in the management of malignant bowel obstruction (MBO) in women with advanced gynecological cancers. The interprofessional MBO management program includes a clinical screening tool to identify patients at risk, a color-coded nurse-led symptom management algorithm, a standardized assessment tool, documentation template, bowel management regime, and education materials for patients and health care providers.

Undergraduate health professions students’ perceptions of athletic training students before and after an interprofessional case study program

ABSTRACT Students pursuing careers in health professions may initially approach their training with preconceived ideas and perceptions of those who practice different health-related careers. Little research has been conducted on athletic training students and professional stereotypes or athletic training students and interprofessional education in general. Because interprofessional education may provide some positive effects on stereotypes, the goal of this study was to measure undergraduate health professions student stereotypes of athletic training students before and after an interprofessional case study program. Undergraduate nursing and public health interprofessional case study program participants assessed various relational and intrapersonal capabilities for their own professions and the athletic training profession, pre-post-program. For nursing student participants with athletic training students on their team, perceptions of their own profession and the athletic training profession significantly (p <.05) increased as compared to those with no athletic training student on their team. For public health student participants, although scores increased, no significant differences were found. Interprofessional collaborative experiences may decrease negative stereotypes of other professions, including athletic training.

Age-friendly student senior connection: students’ experience in an interprofessional pilot program to combat loneliness and isolation among older adults during the COVID-19 pandemic

ABSTRACT Loneliness and isolation are concerning consequences of social distancing and other stay-at-home orders for older adults globally, amidst the COVID-19 pandemic. To combat loneliness and isolation among older adults residing in California, the Keck School of Medicine collaborated with other health profession schools at the University of Southern California (USC) to create the Age-Friendly Student Senior Connection (AFSSC). A total of 115 interprofessional graduate students were linked with older adults. Students engaged in 30 to 60 minute phone calls with older adults 2 to 5 times per week for 6 weeks. Student preparation included asynchronous video and web-based learning, weekly synchronous de-briefing sessions with a participating faculty member via Zoom, phone, and e-mail support from faculty, and information about resources for older adults. Faculty held weekly meetings throughout the pilot and developed new resources to respond to older adult needs, as reported by students. A total of 102 students completed pre-program and post-program surveys. Preliminary results show statistically significant changes in the reported benefits and outcomes from students participating in the program.

A Microdebriefing Crisis Resource Management Program for Simulated Pediatric Resuscitation in a Community Hospital: A Feasibility Study.

Crisis Resource Management (CRM) is a team training tool used in healthcare to enhance team performance and improve patient safety. Our program intends to determine the feasibility of high-fidelity simulation for teaching CRM to an interprofessional team in a community hospital and whether a microdebriefing intervention can improve performance during simulated pediatric resuscitation. We conducted a single-center prospective interventional study with 24 teams drawn from 4 departments. The program was divided into an initial assessment simulation case (pre), a 40-minute microdebriefing intervention, and a final assessment simulation case (post). Post and pre results were analyzed for each team using t tests and Wilcoxon signed-rank tests. Primary outcome measures included (a) completion of program, (b) percent enrollment, (c) participant reaction, and (d) support of continued programs on completion. Secondary outcomes included (a) change in teamwork performance, measured by the Clinical Teamwork Scale; (b) change in time to initiation of chest compressions and defibrillation; and (c) pediatric advanced life support adherence, measured by the Clinical Performance Tool. We successfully completed a large-scale training program with high enrollment. Twenty-four teams with 162 participants improved in Clinical Teamwork Scale scores (42.8%-57.5%, P < 0.001), Clinical Performance Tool scores (61.7%-72.1%, P < 0.001), and time to cardiopulmonary resuscitation initiation (70.6-34.3 seconds, P < 0.001). Our center ran a well-attended, well-received interprofessional program in a community hospital site demonstrating that teaching CRM skills can improve simulated team performance in a diverse experienced cohort.

Transfer of an interprofessional emergency caesarean section training program: using questionnaire combined with outcome data of newborn

PuproseAn emergency caesarean section is a potentially life-threatening situation both for the mother and the newborn. Non-technical skills can be improved by simulation training and are necessary to manage this urgent situation successfully. The objective of this study was to investigate, if training of emergency caesarean section can be transferred into daily work to improve the outcome parameters pH an APGAR of the newborn.MethodsIn this pre-post study, 141 professionals took part in a training for emergency caesarean section. Participants received a questionnaire, based on the tools “Training Evaluation Inventory” and “Transfer Climate Questionnaire” 1 year after training. Outcome data of the newborn were collected from the hospitals information system.ResultsExcept the scale “extinction”, Cronbach’s alpha was higher than 0.62. All scales were rated lower than 2.02 on a 5-point Likert Scale (1 = fullest approval; 5 = complete rejection). “Negative reinforcement” was rated with 2.87 (SD 0.73). There were no significant differences in outcome data prior. The questionnaire fulfils criteria for application except the scale “extinction”.ConclusionThe presented training course was perceived as useful by the professionals and attitudes toward training were positive; the content was positively reinforced in practice 1 year after training. Parameters of the newborn did not change. It is conceivable that other outcome parameters (e.g. posttraumatic stress disorder) are addressed by the training. The development of relevant outcome parameters for the quality of emergency sections needs further investigation.

Interprofessional Teams and the Office-Based Opioid Treatment (OBOT) Workforce

INTRODUCTION The current opioid crisis in the U.S. has led to an increased number of office-based opioid treatment (OBOT) programs that provide medication for opioud use disorder (MOUD) in primary care settings. MOUD (formerly known as medication assisted treatment) requires a medication and psychosocial component of care and thus, expertise from multiple types of providers. To help inform workforce development policies and strategies to train the future OBOT workforce, this study examined: (1) the provider composition of OBOT teams, (2) team members’ respective duties, and (3) communication patterns. METHODS Interviews with a convenience sample (N=12) of providers working as members of OBOT teams in outpatient primary care settings across the U.S. Interviews were recorded and transcribed. Qualitative coding was used to identify patterns relevant to study objectives. RESULTS OBOT teams always included (1) a Drug Enforcement Administration (DEA)-waivered prescriber (typically physicians) as is mandated federally. However, other team members included; (2) a behavioral health provider (typically licensed clinical social workers); (3) a MOUD registry coordinator (varied in degree/background); and (4) other operational staff (typically medical assistants). OBOT clinics offering therapeutic behavioral interventions were more likely to employ multiple behavioral health providers, though there was variation in the types of behavioral health interventions utilized. CONCLUSION The demand for OBOT treatment teams presents a significant opportunity for interprofessional training of health professionals. Educators, policymakers, and researchers should evaluate the composition and service capacity of the current OBOT workforce in order to develop comprehensive interprofessional training programs that address the physical, psychopharmacological, behavioral health, and psychosocial components of care necessary for OUD treatment and recovery.

Interprofessional Occupational Therapy and Music Therapy Piano Keyboard Intervention for Preschoolers with Visual Impairments: A Non-Randomized Pilot Case Study

ABSTRACT People of all ages can appreciate and engage in the occupation of music. Music can be enjoyed through listening, playing an instrument, singing, and dancing. It has significance in many people’s lives; however, few intervention programs outside the field of music therapy exist that capitalize on the therapeutic potential of music in pediatric populations with disabilities. More specifically, when utilized in an enriched sensory environment, the auditory stimuli and feedback music naturally provide becomes a therapeutic tool especially for children with visual impairments. We designed an interprofessional intervention program, combining the expertise of an occupational therapist and of a music therapist to systematically teach piano keyboarding to preschool children with impaired vision. We conducted a small, mixed methods non-randomized pilot case study to determine how such a program could be successfully embedded into a preschool setting, to examine if fine motor skills improve post-intervention, and to study the perceived effects on participants and their families. Participants were selected from an urban preschool classroom designed specifically for children with visual impairments, and four students met the inclusion and exclusion criteria. Preliminary results suggest that fine motor skills did improve after participating in this program for 20 minutes twice a week, over a 6-week period. Participants found the “just right challenge” through song selection and progressed toward defined song mastery within 1–2 sessions, maintaining motivation and enjoyment. In addition, the program was successfully integrated into the preschool schedule and a parent interview revealed favorable perceptions of the programs and its effects.

Building a Viable Weight Management Program in a Patient-Centered Medical Home.

The growing prevalence of obesity in the United States and globally highlights the need for innovative strategies to provide obesity treatment in primary care settings. This report describes and evaluates the Weight Management Program (WMP), an interprofessional program in an academic family medicine clinic delivering intensive behavioral therapy (IBT) following evidenced-based guidelines. We extracted WMP participant health data from the electronic health record and evaluated retrospectively. Eligible participants completed at least four WMP visits and had a baseline weight, blood pressure, and hemoglobin A1c (HbA1c) recorded within 1 year prior to their first visit. Paired t tests were used to assess changes in, weight, HbA1c and systolic and diastolic blood pressures from baseline. WMP counseled 673 patients over 3,895 visits from September 2015 to June 2019. Of these, 186 met eligibility criteria (at least four visits), with a median of eight visits (mean=11.3, SD=8.1). Participants saw an average weight decrease during program participation of 9.7 lbs (P&lt;.001), an average decrease in HbA1c of 0.2 points (P=.004), and an average blood pressure reduction of 2.8 mmHg systolic (P=.002) and 1.9 mmHg diastolic (P=.03). One-third of participants (n=60) achieved clinically significant weight loss (&gt;5%) at 18 months. The program has become financially sustainable through billing for preventive counseling services and a $125 out-of-pocket enrollment fee. WMP provides one model for primary care practices to develop a financially sustainable and evidence-based behavioral therapy weight management program for their patients with obesity. Future work will include assessment of longer-term program benefits, quality metrics, and health care costs.

Random forest machine learning algorithm predicts virologic outcomes among HIV infected adults in Lausanne, Switzerland using electronically monitored combined antiretroviral treatment adherence

ABSTRACT Machine Learning (ML) can improve the analysis of complex and interrelated factors that place adherent people at risk of viral rebound. Our aim was to build ML model to predict RNA viral rebound from medication adherence and clinical data. Patients were followed up at the Swiss interprofessional medication adherence program (IMAP). Sociodemographic and clinical variables were retrieved from the Swiss HIV Cohort Study (SHCS). Daily electronic medication adherence between 2008–2016 were analyzed retrospectively. Predictor variables included: RNA viral load (VL), CD4 count, duration of ART, and adherence. Random Forest, was used with 10 fold cross validation to predict the RNA class for each data observation. Classification accuracy metrics were calculated for each of the 10-fold cross validation holdout datasets. The values for each range from 0 to 1 (better accuracy). 383 HIV+ patients, 56% male, 52% white, median (Q1, Q3): age 43 (36, 50), duration of electronic monitoring of adherence 564 (200, 1333) days, CD4 count 406 (209, 533) cells/mm3, time since HIV diagnosis was 8.4 (4, 13.5) years, were included. Average model classification accuracy metrics (AUC and F1) for RNA VL were 0.6465 and 0.7772, respectively. In conclusion, combining adherence with other clinical predictors improve predictions of RNA.

The Homeless Hospital Liaison Program: An Interprofessional Program to Improve Students' Skills at Facilitating Transitions of Care for Patients Experiencing Homelessness.

Traditional medical school curricula lack specific training on caring for individuals experiencing homelessness, and the literature suggests that medical students' attitudes toward these individuals become increasingly negative during medical school. To increase discharge planning support for individuals experiencing homelessness, the Homeless Hospital Liaison (HHL) program was developed at the University Medical Center New Orleans in January 2017-May 2017. Student liaisons are recruited from all 4 years of medical school and a graduate-level social work program. Liaisons administer a social needs questionnaire to assess patients' connections to services and identify gaps in care, coordinate with hospital social workers to avoid duplicating work, coordinate with the medical team, help patients complete any needed documentation or applications for social benefits, provide patients with referrals to outpatient resources, and provide patients assistance with a variety of basic needs. As of December 2017, HHL has trained 70 students (65 medical students and 5 social work students) to serve as liaisons and has enrolled 99 patients. For the majority of these patients, student liaisons were able to facilitate successful referrals to community-based services. Future directions of the HHL program include developing a formal, staffed consult service at the hospital (e.g., the HHL program was awarded hospital funding for 2 full-time staff in the summer of 2019, which will increase the HHL's capacity); assessing the program's effect on student knowledge, attitudes, and proficiency related to individuals experiencing homelessness and/or interprofessional collaboration; and assessing the impact of the program on patients' experiences.

Longitudinal evaluation of attitudes to interprofessional collaboration: time for a change?

ABSTRACT Longitudinal evaluation of interprofessional programming is necessary to understand the impact of interprofessional education (IPE) for collaborative practice. Attitude is one measure of intended behavior. The Interprofessional Attitude Scale (IPAS) was developed as an improved measure to examine the readiness for interprofessional education and collaborative practice. As a means to pilot a protocol for a longitudinal comprehensive evaluation of an interprofessional program with 13 health professional programs in 6 health science faculties, the IPAS was administered over a 3-year period to three cohorts of students. The results of the IPAS indicated no significant differences detected across the 3 years. Although there was a significant difference on the Patient Centredness subscale for Cohorts 2 and 3 the effect size was small. Previous experience in an interprofessional course was a predictor of more positive patient centeredness attitudes, but other IPE experience and years of education were not predictors of any interprofessional attitudes. Students from the Medicine & Dentistry (M&D) faculty ranked significantly lower on the teamwork roles and responsibilities subscale compared to the other faculties, except Rehabilitation Medicine (RM). However, once the outliers in RM were removed, there was a significant difference on this subscale between RM and M&D. This paper outlines the challenges with using the IPAS as part of a comprehensive program evaluation and identifies issues with longitudinal data collection for evaluation with large student cohorts.

An Interprofessional Team Performance Training Program for the Care of Vulnerable Patients in the Ambulatory Setting

Abstract Health professions trainees often want to care for vulnerable populations, but their good intentions can be tested by patients’ complex medical, psychological, and social needs. Well-functioning care teams can respond to these challenges through communication, coordination and supportive relationships, but this requires teams to train together. In this paper, we describe a year-long ambulatory curriculum that trains post-graduate primary care and mental health trainees in key aspects of teamwork and relationship-centered care as they care for patients with complex biopsychosocial problems. The curriculum was developed and implemented with two cohorts of trainees from primary care, mental health and pharmacy disciplines (n =31) that were immersed in an interprofessional team caring for homeless Veterans in a patient-centered medical home (PCMH). Our curriculum is relevant for any clinical site seeking to improve team-based care for patients with complex conditions. It is grounded in an evidence-derived team performance framework that addresses three key aspects of well-performing teams: meeting practices (standardizing time and processes for collaborative care using checklists), taskwork (understanding team members' roles and responsibilities, and how to improve care), and teamwork (building humanistic relationships with patients and team members, and communicating respectfully). The curriculum is experiential and requires trainees to work on an existing patient care team and participate in team-based care processes (e.g. huddles, team meetings, panel management). We address stakeholder engagement, faculty and team development, culture building and logistics. Using two previously validated instruments to assess trainee perceptions of team performance and personal burnout at 6 and 12 months, we found that the program led to improvements in trainees’ perspectives of team performance, their relationship skills, and the effectiveness of their meeting practices, while also avoiding burnout. Key factors contributing to the success of the program are co-locating the professions, faculty role-modeling of team practice and communication behaviors, promotion of a relationship-centered culture, regularly scheduled workplace learning activities and planned IP learning sessions that support team-based practice.

Learning person-centredness interprofessionally: an uneasy student journey

ABSTRACT Patient- or person-centered care is a discourse embraced by most clinicians involved in interprofessional care but generally overlooks thepersons of the practitioners and students involved. This paper explores students’ developing perceptions of person-centered care during participation in an interprofessional education program where interprofessional pairs of students partner with patients living with a long-term condition or life-changing event. Weekly focus groups with students and educators over the 7 weeks of the program revealed a rich evolving understanding of person-centredness amongst participant students as they built relationships with both their patient and student partner. Students and educators identified shifts in students’ interprofessional person-centered perspectives and practices, growing awareness of patient personhood and of stories as key to creating and maintaining space for listening and dialogue, and conscious attention to thoughtful, non-judgmental listening and responses. Although initially uncomfortable, uncertain and “stuck” students came to value working in a holistic relational partnership to explore what mattered to the patient, looking beyond the diagnosis to the multi-faceted nature of living with a life-changing condition or event. Importantly, students’ growing self-awareness and participation as persons enhanced person-centredness, leading to questioning of previous healthcare practice experiences where mutual person-centredness was overlooked. Uncertainty about student capability led some educators to reassert control of the process, which students perceived as counterproductive usurping of their personhood and professional autonomy. The research findings suggest that an interprofessional program focused on person-centered relationship building develops student awareness and understanding of mutual personhood but requires high levels of reciprocal trust.

Utilizing simulation to assess clinical decision making between physician assistant and physical therapy students

Abstract Discharge transitions are one of the highest risk activities in healthcare. Physical therapists (PTs) and physician assistants (PAs) have a critical role in discharge transitional planning in the acute care arena. Simulation based interprofessional education (SIM-IPE) is an emerging teaching technique involving participants from two or more professions engaged in a simulated experience. The aims of the interprofessional program were to compare the discharge transition recommendations of PT and PA students of a medically complex, acute care patient pre- and post- SIM-IPE and to compare the clinical decision-making rationale for the discharge transition recommendation pre- and post- SIM-IPE. PT and PA students participated in SIM-IPE encounters with standardized patients. The encounters focused on high-risk, problem-prone patients with variable discharge transition options. The most frequently recommended discharge transition pre- SIM-IPE was the same between the PT and PA students; however, there was a 29.5% discordance when comparing the rank ordering of discharge transition recommendations between PT and PA. Prior to the SIM-IPE, PT students gave the highest priority to functional status and home situation, and PA students gave the highest priority to medical status, medical prognosis, and medications. Following the SIM-IPE, PT students ranked medical status, medical prognosis, and medications higher as discharge transition clinical decision-making variables as compared with their pre- SIM-IPE data, and PA students ranked functional status and home situation higher as discharge transition clinical decision-making variables as compared to their pre- SIM-IPE data. In this teaching and learning experience, the SIM-IPE intervention appeared to influence clinical decision-making of participants.

Sustainable interprofessional learning on clinical placements: the value of observing others at work

ABSTRACT Clinical placements have the potential to offer meaningful interprofessional learning opportunities for pre-registration students. Informal, as opposed to structured interprofessional learning opportunities, may offer a sustainable solution to the challenges of scheduling formal interprofessional programs in the workplace. To investigate this concept, students on clinical placement from a range of professions were invited to observe another profession undertake a patient consultation, after which they completed a standardized reflective tool. A grounded theory research design was used to explore the educational value of the one-off interprofessional observations, through an analysis of student written reflections (n = 79) and staff perceptions collected by interview (n = 11). The qualitative data was iteratively analyzed throughout the study period. A range of learning outcomes were described post student observations, ranging from knowledge or skills that informed profession-specific practice, to how others’ roles related to patient needs, and the need for collaboration in order to provide high quality care. Staff orientation and facilitated reflection contributed to student learning. Positive learning value, though varying in depth, was identified through single interprofessional observations. Informal activities offer a sustainable interprofessional learning strategy that can be embedded into clinical placements; additional informal learning activities now warrant investigation.

Dementia care boot camp: interprofessional education for healthcare students

ABSTRACT Dementia prevalence is increasing exponentially and has a profound effect on individuals diagnosed as well as their family caregivers. Dementia care should be patient focused, not task or medically oriented. Patient-centered dementia care requires more staff time, is complex, and, as a result, financially threatens the healthcare system. Therefore, professionals must be prepared to meet the needs of this growing population. The aims of this mixed methods study were to examine the effect of a 16-h interprofessional program on healthcare students’ dementia knowledge, attitudes toward people with dementia, confidence for dementia care and empathy, and to understand the relationships among the listed variables. Nursing, occupational therapy assistant, pharmacy, and psychology students participated in a 16-h team-based learning Dementia Care Bootcamp. Students reported significant improvements in dementia attitudes and knowledge, confidence for dementia care and empathy immediately after Bootcamp and 3 months later. Significant relationships among listed variables were noted. Qualitative data complemented the quantitative findings. In addition, the concept of dementia care competency emerged. Students recognized the benefits of learning about, with and from others from diverse professions. Interprofessional education has great potential to improve students’ ability to care for people with dementia.

UTILIZING EFFECTIVE MENTORING STRATEGIES FOR RESEARCH SUCCESS: NYU SUMMER SCHOLARS PROGRAM

Since 1998 the Hartford Institute for Geriatric Nursing has offered a summer program designed to accelerate the development of research projects and trajectories for young scientists. This interprofessional program brings faculty and scholars together from across the globe representing all healthcare disciplines. In the week long program, scholars benefit from expert presentations and daily mentoring sessions with experts in gerontological research. In this symposium, scholars will discuss strategies they have used to successfully move from ideas for research, to development of proposals, conduct of research projects and planning career trajectories. We will present differing mentoring strategies and available mentoring opportunities for gerontological-focused scientists. Each scholar will present their work with topics including optimal medication management to sustain home placement: use of adaptive dance to improve mood and function in persons with Alzheimer’s disease; facilitating positive attitudes toward older adults in nursing students; the use of mindfulness to reduce symptoms of urinary incontinence; and, a novel intervention to reduce pressure ulcers in the nursing home.