Exploring inappropriate levels of care in intensive care.

BACKGROUND: Levels of care deemed as inappropriate generate moral distress among nurses and other intensive care professionals. Inappropriate levels of care and related moral distress are frequently broached as individual and psychological phenomena, reduced to how individuals feel and think about specific cases. However, this tends to obscure the complex context in which these situations occur, and on which healthcare professionals can act. There is thus a need for a more contextual and team-level lens on inappropriate levels of care. RESEARCH OBJECTIVE: This study aims to explore and understand the issue of inappropriate levels of care in an intensive care unit (ICU) through a contextual and team-level lens. RESEARCH DESIGN: Semi-structured interviews were conducted with nurses, respiratory therapists, and intensivists. Thematic analysis focused on understanding the causes and consequences of inappropriate levels of care, as well as potential avenues for improvement. This study is part of a 5-phase participatory living lab project on inappropriate levels of care conducted in the ICU of a Montreal (Quebec, Canada) hospital. This paper relates the initial phases of the project, focusing on understanding the issue, with reported events spanning from June 2022 to May 2023. ETHICAL CONSIDERATIONS: Ethics approval was sought and granted by the Research Ethics Board of the CIUSSS de l'Est-de-l'Île-de-Montréal. FINDINGS/DISCUSSION: Five broad themes intrinsically related to the phenomenon of inappropriate levels of care were explored with and by participants: (1) the process of determining levels of care, (2) the distinction between appropriate and inappropriate levels of care, (3) causes of inappropriate levels of care, (4) consequences of inappropriate levels of care and (5) potential avenues for improvement. CONCLUSION: This research provides a comprehensive understanding of inappropriate levels of care in the ICU and emphasizes the relevance of team-level explorations of complex ethical issues.

Evaluation of three pedestrian phasing with audible pedestrian signals configurations in Quebec City (Canada): an exploratory study of blind or visually impaired persons' sense of safety, preferences, and expectations.

PURPOSE: This exploratory study aimed to evaluate the preferences, expectations, and sense of safety of blind or visually impaired persons regarding three types of pedestrian phasing with audible pedestrian signals configurations that exist in Quebec City (Canada). These include: 1) exclusive phasing with non-directional audible pedestrian signals; 2) exclusive phasing with directional audible pedestrian signals; and 3) concurrent phasing with directional audible pedestrian signals. METHODS: Thirty-two blind or visually impaired persons were asked to complete a survey. Their preferences and expectations regarding audible pedestrian signals were documented through a series of simulations. Their sense of safety regarding the three existing configurations were also documented. Subsequently, semi-directed, individual interviews with 11 of the individuals who had completed the survey were conducted to build off the collected information. RESULTS: No formal consensus regarding many of the issues discussed were established as participants' responses varied too significantly. However, findings suggest that the exclusive phasing with directional audible pedestrian signals configuration is perceived to be the safest option by the participants. CONCLUSION: This study may have practical implications on the design of intersections (e.g., selection of a type of pedestrian phasing with audible pedestrian signal) and the training of blind or visually impaired pedestrians.IMPLICATIONS FOR REHABILITATIONThe addition of audible pedestrian signals to pedestrian signals heightens the sense of safety of blind or visually impaired persons.This study may have practical implications on the design of intersections with audible pedestrian signals and the selection of a type of audible pedestrian signals based on intersection characteristics.Since many participants reported a lower sense of safety when faced with concurrent phasing, it is recommended that more intensive orientation and mobility interventions be provided to blind or visually impaired pedestrians who use this type of traffic signals.Educating road users about blind or visually impaired pedestrians appears also essential.

Field testing of two electronic mobility aid devices for persons who are deaf-blind.

PURPOSE: To test a methodology for assessing the effects of electronic mobility aid devices (EMAD) on the mobility of persons who are deaf-blind in real-life situations. METHOD: A single-subject desing was done with four users followed in a program for persons who are deaf-blind. Participants were trained to use two commercial EMADs: the Miniguide and the Breeze. The Canadian Measure of Occupational Performance (CMOP) was administered before training (T1), after training (T2) and three months later (T3). The Quebec User Evaluation of Satisfaction with assistive Technology (QUEST) was administered at T2 and T3. A follow-up interview was conducted with the participants and clinicians at T3 to evaluate the benefits of the EMAD and any problems. RESULTS: CMOP suggests that both performance and satisfaction improved following the use of both EMADs in four occupations (functional mobility, active leisure, community life and socialization). QUEST indicates high satisfaction with eight items except for one participant. Follow-up interviews revealed a wide variety of perceptions regarding EMAD use and seven problems although CMOP and QUEST indicated good satisfaction. CONCLUSION: A high satisfaction score on QUEST does not necessarily imply that an assistive device is efficient in all circumstances; follow-up interviews provided important complementary information. IMPLICATIONS FOR REHABILITATION: For people who are deaf-blind The Miniguide is reliable for detecting obstacles (vibrations are sent as a warning when approaching an obstacle). It is often used to know if taking the right route. It identifies entrances or openings (indicated by the vibrations stopping when pointing at a wall), which can replace the echo-location for blind persons with hearing impairments. The Miniguide helped to locate overhanging objects which are not detectable with a long cane. The Breeze can record landmarks for orientation and it possible to use those landmarks to go back alone later after taking a certain route for the first time with someone else. It helps to familiarize the person with new places. It can tell you where you are at any time. It helps with orientation and the participant also liked this feature because it helped with learning street names. The Miniguide and the Breeze were not efficient in all circumstances; there were some problems with the ergonomic (both), detecting snow banks (Miniguide), sensitiveness to the surroundings in crowded places (Miniguide) and exactitude for geo-localization (Breeze).