Opioid deprescribing in long-term care in Ontario: A comparison of resident and facility characteristics.

Residents of long-term care (LTC) homes have potentially painful conditions and are prescribed opioids to manage their pain, despite the risks associated with the use of these high-risk medications. Therefore, the overall aim of this study was to describe the associations between resident and facility characteristics of residents prescribed long-term opioid therapy and those who remained on opioids or had opioids deprescribed. We conducted a retrospective cohort study utilizing health administrative databases housed within ICES. Our cohort included 26,592 of 121,564 LTC residents (21.9%) of Ontario LTC homes who were prescribed long-term opioid therapy at cohort inception. Of these residents, 4,299 (16.2%) residents had opioids deprescribed during the follow-up period. Opioid deprescribing was associated with younger age, high comorbidity, and co-prescription with benzodiazepines and gabapentinoids. Our findings suggest that there is variation in the characteristics of residents who continued long-term opioid therapy and those who subsequently had opioids deprescribed, and these characteristics need to be considered as part of individualized pain management plans of care.

A longitudinal, narrative study of professional socialisation among health students.

PURPOSE: Interprofessional collaboration (IPC) among health professionals is well-recognised to enhance care delivery and patient outcomes. Emerging evidence suggests that the early socialisation of students in health professional programmes to teamwork may have a positive impact on their future as collaborative practitioners. With a purpose of contributing to growing evidence on the processes of professional identity construction, and to explore how early expectations and perceptions of IPC develop during professional socialisation and pre-licensure education, our study examined the early professional socialisation experiences among five groups of health professional students. METHOD: A qualitative, narrative approach was used to examine early professional socialisation among five programmes of health professional students (dentistry, medicine, nursing, pharmacy, physiotherapy) at an Atlantic Canadian University. In March and October 2016, students participated in interviews after first term (n = 44) and first year of study (n = 39). Interviews focused on participants' professional identify formation, as well as their perceptions and experiences of IPC. The authors analysed interview transcripts using narrative analysis. RESULTS: Findings identify that despite the espoused importance of IPC within health professional training, students have a limited understanding of their professional roles and are largely focused on developing a uniprofessional, vs. interprofessional identity. Clinical experiences, role models and exposure to teamwork are critical to contextualise collaborative practice and enhance the development of an interprofessional identity. CONCLUSIONS: Findings can be used to guide the development of curricula that promote interprofessional identity development and IPC during early professional socialisation.

Pre-entry perceptions of students entering five health professions: implications for interprofessional education and collaboration.

Dysfunctional interprofessional teams are a threat to health system performance and the delivery of quality patient outcomes. Implementing strategies that prepare future health professionals to be effective collaborators requires a comprehensive understanding of how early professional socialization and professional identity formation occur. We present findings from a qualitative study, grounded in narrative methodology, examining early professional socialization among students across five health professional programs (dentistry, medicine, nursing, pharmacy, physiotherapy) in the first year of health professional training. Between April and September 2015, students (n = 49) entering programs at an Atlantic Canadian University participated in one-on-one, audiotaped interviews starting before formal program orientation. Pre-entry interviews focused on factors influencing students' career choice and expectations of future profession and interprofessional collaboration (IPC). Findings revealed that many different experiences influenced participants' career choice and framed the social positioning of their future career (e.g., leadership, prestige, autonomy). Participant narratives revealed the existence of stereotypes pertaining to their chosen and other health professions. Study findings provided insights that may help strengthen initiatives to promote positive professional identity formation within the context of IPC. Implications of this research highlight the need for the early introduction of IPC including pre-entry recruitment messaging for prospective health professionals.

Fostering positive spaces in public health using a cultural humility approach.

Culturally competent frameworks used within health care systems are contributing to the discrimination and marginalization of sexually and/or gender diverse persons. In this discursive paper, we argue that cultural humility ought to be implemented as the best practice approach for fostering sexually and gender diverse positive spaces in public health settings. A paradigm shift away from cultural competence frameworks toward cultural humility is necessary. This shift can be achieved by enhancing educational opportunities for public health nursing students and professionals and by recruiting organizational leaders to be champions for systemic change. In order to achieve this, we must establish effective educational programs that espouse cultural humility practices and develop valid measurement tools for assessing the provision of culturally humble care. This would equip educators, students, practitioners, and organizational leaders with the necessary tools to guide and assess their performance. Integrating a culturally humble approach will ultimately enhance self-reported cultural safety in public health spaces and reduce health inequities experienced by sexually and/or gender diverse clients and staff members.

A study of leading indicators for occupational health and safety management systems in healthcare.

BACKGROUND: In Ontario, Canada, approximately $2.5 billion is spent yearly on occupational injuries in the healthcare sector. The healthcare sector has been ranked second highest for lost-time injury rates among 16 Ontario sectors since 2009 with female healthcare workers ranked the highest among all occupations for lost-time claims. There is a great deal of focus in Ontario's occupational health and safety system on compliance and fines, however despite this increased focus, the injury statistics are not significantly improving. One of the keys to changing this trend is the development of a culture of healthy and safe workplaces including the effective utilization of leading indicators within Occupational Health and Safety Management Systems (OHSMSs). In contrast to lagging indicators, which focus on outcomes retrospectively, a leading indicator is associated with proactive activities and consists of selected OHSMSs program elements. Using leading indicators to measure health and safety has been common practice in high-risk industries; however, this shift has not occurred in healthcare. The aim of this project is to conduct a longitudinal study implementing six elements of the Ontario Safety Association for Community and Healthcare (OSACH) system identified as leading indicators and evaluating the effectiveness of this intervention on improving selected health and safety workplace indicators. METHODS: A quasi-experimental longitudinal research design will be used within two Ontario acute care hospitals. The first phase of the study will focus on assessing current OHSMSs using the leading indicators, determining potential facilitators and barriers to changing current OHSMSs, and identifying the leading indicators that could be added or changed to the existing OHSMS in place. Phase I will conclude with the development of an intervention designed to support optimizing current OHSMSs in participating hospitals based on identified gaps. Phase II will pilot test and evaluate the tailored intervention. DISCUSSION: By implementing specific elements to test leading indicators, this project will examine a novel approach to strengthening the occupational health and safety system. Results will guide healthcare organizations in setting priorities for their OHSMSs and thereby improve health and safety outcomes.

Clinical interventions, implementation interventions, and the potential greyness in between -a discussion paper.

BACKGROUND: There is increasing awareness that regardless of the proven value of clinical interventions, the use of effective strategies to implement such interventions into clinical practice is necessary to ensure that patients receive the benefits. However, there is often confusion between what is the clinical intervention and what is the implementation intervention. This may be caused by a lack of conceptual clarity between 'intervention' and 'implementation', yet at other times by ambiguity in application. We suggest that both the scientific and the clinical communities would benefit from greater clarity; therefore, in this paper, we address the concepts of intervention and implementation, primarily as in clinical interventions and implementation interventions, and explore the grey area in between. DISCUSSION: To begin, we consider the similarities, differences and potential greyness between clinical interventions and implementation interventions through an overview of concepts. This is illustrated with reference to two examples of clinical interventions and implementation intervention studies, including the potential ambiguity in between. We then discuss strategies to explore the hybridity of clinical-implementation intervention studies, including the role of theories, frameworks, models, and reporting guidelines that can be applied to help clarify the clinical and implementation intervention, respectively. CONCLUSION: Semantics provide opportunities for improved precision in depicting what is 'intervention' and what is 'implementation' in health care research. Further, attention to study design, the use of theory, and adoption of reporting guidelines can assist in distinguishing between the clinical intervention and the implementation intervention. However, certain aspects may remain unclear in analyses of hybrid studies of clinical and implementation interventions. Recognizing this potential greyness can inform further discourse.

Exploration of pressure ulcer and related skin problems across the spectrum of health care settings in Ontario using administrative data.

This is a prospective cohort study using population-level administrative data to describe the scope of pressure ulcers in terms of its prevalence, incidence risk, associating factors and the extent to which best practices were applied across a spectrum of health care settings. The data for this study includes the information of Ontario residents who were admitted to acute care, home care, long term care or continuing care and whose health care data is contained in the resident assessment instrument-minimum data set (RAI-MDS) and the health outcomes for better information and care (HOBIC) database from 2010 to 2013. The analysis included 203 035 unique patients. The overall prevalence of pressure ulcers was approximately 13% and highest in the complex continuing care setting. Over 25% of pressure ulcers in long-term care developed one week after discharge from acute care hospitalisation. Individuals with cardiovascular disease, dementia, bed mobility problems, bowel incontinence, end-stage diseases, daily pain, weight loss and shortness of breath were more likely to develop pressure ulcers. While there were a number of evidence-based interventions implemented to treat pressure ulcers, only half of the patients received nutritional interventions.

Managing and mitigating conflict in healthcare teams: an integrative review.

AIM: To review empirical studies examining antecedents (sources, causes, predictors) in the management and mitigation of interpersonal conflict. BACKGROUND: Providing quality care requires positive, collaborative working relationships among healthcare team members. In today's increasingly stress-laden work environments, such relationships can be threatened by interpersonal conflict. Identifying the underlying causes of conflict and choice of conflict management style will help practitioners, leaders and managers build an organizational culture that fosters collegiality and create the best possible environment to engage in effective conflict management. DESIGN: Integrative literature review. DATA SOURCES: CINAHL, MEDLINE, PsycINFO, Proquest ABI/Inform, Cochrane Library and Joanne Briggs Institute Library were searched for empirical studies published between 2002-May 2014. REVIEW METHODS: The review was informed by the approach of Whittemore and Knafl. Findings were extracted, critically examined and grouped into themes. RESULTS: Forty-four papers met the inclusion criteria. Several antecedents influence conflict and choice of conflict management style including individual characteristics, contextual factors and interpersonal conditions. Sources most frequently identified include lack of emotional intelligence, certain personality traits, poor work environment, role ambiguity, lack of support and poor communication. Very few published interventions were found. CONCLUSION: By synthesizing the knowledge and identifying antecedents, this review offers evidence to support recommendations on managing and mitigating conflict. As inevitable as conflict is, it is the responsibility of everyone to increase their own awareness, accountability and active participation in understanding conflict and minimizing it. Future research should investigate the testing of interventions to minimize these antecedents and, subsequently, reduce conflict.

Part 1: The influence of personal and situational predictors on nurses' aspirations to management roles: preliminary findings of a national survey of Canadian nurses.

AIM: To examine the influence of personal and situational factors on direct-care nurses' interests in pursuing nursing management roles. BACKGROUND: Nursing managers are ageing and nurses do not appear to be interested in nursing management roles, raising concerns about a nursing leadership shortage in the next decade. Little research has focused on factors influencing nurses' career aspirations to nursing management roles. METHODS: A national survey of nurses from nine Canadian provinces was conducted (n = 1241). Multiple regression was used to test a model of personal and situational predictors of nurses' career aspirations to management roles. RESULTS: Twenty-four per cent of nurses expressed interest in pursuing nursing management roles. Personal and situational factors explained 60.2% of nurses' aspirations to management roles. Age, educational preparation, feasibility of further education, leadership self-efficacy, career motivation, and opportunity to motivate others were the strongest predictors of aspirations for management roles. CONCLUSIONS: Personal factors were more strongly associated with career aspirations than situational factors. There is a steady decline in interest in management roles with increasing age. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing leadership training to develop leadership self-efficacy (particularly for younger nurses) and organizational support for pursuing advanced education may encourage nurses to pursue nursing management roles.

Part 2: Nurses' career aspirations to management roles: qualitative findings from a national study of Canadian nurses.

AIM: Our aim was to investigate direct-care nurses' interests in formal management roles and factors that facilitate their decision-making. BACKGROUND: Based on a projected shortage of nurses by 2022, the profession could be short of 4200 nurse managers in Canada within the next decade. However, no data are currently available that identify nurses' interests in assuming manager roles. METHODS: Using focus group methodology, we conducted 18 focus groups with 125 staff nurses and managers in four regions across Canada. RESULTS: Major themes and subthemes influencing nurses' decisions to pursue management roles included personal demographic (education, age, clinical experience and life circumstances), personal disposition (leadership skills, intrinsic rewards and professional commitment) and situation (leadership development opportunities, manager role perceptions and presence of mentors). Although nurses see management roles as positive opportunities, they did not perceive the rewards to be great enough to outweigh their concerns. CONCLUSIONS: Findings suggested that organizations need to provide support, leadership development and succession opportunities and to redesign manager roles for optimum success. IMPLICATIONS FOR NURSING MANAGEMENT: Leaders need to ensure that they convey positive images of manager roles and actively identify and support staff nurses with leadership potential.

New Nurses' Perceptions on Transition to Practice: A Thematic Analysis.

BACKGROUND: New nurses' transition to the workforce is often described as challenging and stressful. Concerns over this transition to practice are well documented, with the hypothesis that transition experiences influence the retention of new nurses in the workforce and profession. METHODS: In a cross-sectional survey (N = 217) to assess new nurse transition in the province of Ontario, Canada, an open-ended item was included to solicit specific examples of the transition experience. The comments underwent thematic analysis to identify the facilitators and barriers of transition to practice for new nurses. RESULTS: Comments were provided by 196 respondents. Three facilitator themes (supportive teams; feeling accepted, confident, and prepared; new graduate guarantee) and four barrier themes (feeling unprepared; discouraging realities and unsupportive cultures; lacking confidence/feeling unsure; false hope) to new nurse transition emerged. CONCLUSIONS: Concerns of nursing shortages are heightened in the current COVID-19 pandemic, reinforcing the priority of retaining new nurses in the workforce. The reported themes offer insight into the contribution of a supportive work environment to new nurses' transition. The recommendations focus on aspects of supportive environments and educational strategies, including final practicums, to assist nursing students' development of self-efficacy and preparation for the workplace.

R-E-S-P-E-C-T: A Key to Nurse Retention.

In Canada, nurses have known about the chronic shortage of nurses for years; the pandemic has just opened the floodgates. For the authors, the current nursing crisis and the accompanying response have led to flashbacks of the early 2000s, when extensive advocacy work took place to prevent a looming nursing crisis. In the key reports reviewed in this paper, the statement "lack of respect for nursing" has echoed over and over and over again and continues to be heard today throughout social media. Based on nurses' voices, meaningful respect starts with nurse leaders and administrators recognizing nurses' education, knowledge, values and experience; seeking and listening to nurses' voices and input on decisions affecting nursing; and striving for quality practice environments with reasonable workloads, adequate supplies and resources. While long-term planning must take place to correct this, there is no easy fix and no single strategy to turn the situation around quickly. Short-term strategies to relieve nurses' feelings of disrespect are a good place to start to retain nurses and stop the bleeding. It is time to work with all the nurses to find ground-level strategies to assure a sustainable and healthy nursing workforce for today and tomorrow. In this paper, the authors provide an overview of the meaning of respect both generally and from the nurses' perspective using the literature from the past 20 years. The authors then outline several implications for nurse leaders and administrators that are relevant today.

Measuring Scope of Practice Enactment Among Primary Care Registered Nurses.

BACKGROUND: Scope of practice enactment is poorly understood in the primary care setting. PURPOSE: The following research objectives were addressed: (1) to revise and adapt the Actual Scope of Practice (ASCOP) questionnaire for use in the primary care setting, and (2) to determine internal consistency, construct validity, and sensitivity of the modified instrument. METHODS: To address the first objective, a narrative literature review and synthesis and an expert panel review was conducted. To address the second objective, a cross-sectional survey of 178 registered nurses who worked in primary care was conducted. RESULTS: The ASCOP, with few modifications, addressed key attributes of nursing scope of practice in the primary care setting. The modified instrument yielded acceptable alpha coefficients ranging from 0.66 to 0.91. Total mean score of 4.8 (SD = .67) suggests that registered nurses within interprofessional primary care teams almost always engage in activities reflected in the modified instrument. CONCLUSIONS: The modified instrument is the first instrument validated to measure nursing scope of practice enactment in the primary care setting. Findings from this study support the use of the modified ASCOP questionnaire as a reliable and valid measure of scope of practice enactment among primary care registered nurses.

Understanding organ donation processes and structures in ontario: A social network analysis approach.

BACKGROUND: Transplant rates in Ontario rose steeply in the decade prior to the COVID-19 pandemic. Reasons for that increase remain unclear, but the inter-organizational arrangement of organ donation programs may have contributed. However, there is a paucity of literature investigating these inter-organizational arrangements, with a limited understanding of how communication facilitates organ donation. Understanding these arrangements may help to re-establish rising organ donation rates post-pandemic. OBJECTIVE: To describe interprofessional interactions of Organ and Tissue Donation Coordinators (OTDCs) during organ donation cases, within organ donation programs in Ontario, from an organizational perspective (describing structure, context, process). METHODS: Mixed-method social network analysis (SNA) approach analyzing 14 organ donation cases just before the COVID-19 pandemic. RESULTS: Structure: Social network graphs depict the joint work performed by hospital staff and OTDCs, with a great part of the communication being processed through the OTDC. CONTEXT: Network density ranged from 0.05 to 0.24 across cases, and health care professionals perceived an atmosphere of shared vision and trust among team members. PROCESS: Most networks had a degree centralization <0.50 suggesting a decentralized information flow, and participants perceived decisions being jointly made. The characteristic path length of cases ranged from 1.6 to 3.2, suggesting potential for rapid information diffusion. Overall, data reinforced the OTDC role of intermediator within the communication process, and hospital staff perceived OTDCs as central players. Hospital staff and OTDCs reported frustration with some aspects of the flow of information during the organ allocation processes. CONCLUSION: Findings from this study provide a network map of communications within organ donation cases and reinforce the importance of the OTDC role. Opportunities for quality improvement within these processes are identified.

Acknowledging the Hidden Tsunami.

It is time to acknowledge what has been hidden inside Canada's healthcare system for decades but has become more visible during the COVID-19 pandemic: widespread stress, mental health problems and burnout in the nursing workforce. For the past 20+ years, repeated concerns about the mental health of nurses in Canada have been raised within many national reports, yet the rates have continued to rise.

Introduction: Creating Effective Ways to Support Nurses' Mental Health during COVID-19.

Unprecedented is one of the words that has been most frequently heard during the COVID-19 pandemic. We read daily about the ongoing challenges nurses and nurse leaders face in ways that one could not have imagined 15 months ago. With each wave of rising COVID-19 cases, we are reminded of the toll that this pandemic is having on nurses. Nurse leaders have described being scared of failing and not being able to guide or support their staff through the pandemic while recognizing the need to be a strong leader, resilient and adaptable to change every single day (Lapum et al. 2021). The uncertainty and complexity have been overwhelming, and throughout this crisis, nurse leaders have been continually asked to reach into their leadership toolboxes to find ways to support nurses within contexts that have rapidly changed over and over again.

In Pursuit of a More Unified Nursing Voice.

While nursing is a profession built on collaborative relationships, a lack of unity and historically disparate power structures have become entrenched within the profession during our long history. We are still having many of the same conversations today about the state of the profession as we were 30 years ago. If we want nurses graduating today to enjoy vibrant careers that will see them holding different sorts of conversations about the profession in 2040, then a blueprint for action to optimize intraprofessional practice is required. This paper provides an overview of a recent pan-Canadian report, paints a picture of the current landscape of nursing in Canada and outlines several key strategies to begin transforming intraprofessional practice.

COVID-19-Related Occupational Burnout and Moral Distress among Nurses: A Rapid Scoping Review.

BACKGROUND: The COVID-19 pandemic is placing unprecedented pressure on a nursing workforce that is already under considerable mental strain due to an overloaded system. Convergent evidence from the current and previous pandemics indicates that nurses experience the highest levels of psychological distress compared with other health professionals. Nurse leaders face particular challenges in mitigating risk and supporting nursing staff to negotiate moral distress and fatigue during large-scale, sustained crises. Synthesizing the burgeoning literature on COVID-19-related burnout and moral distress faced by nurses and identifying effective interventions to reduce poor mental health outcomes will enable nurse leaders to support the resilience of their teams. AIM: This paper aims to (1) synthesize existing literature on COVID-19-related burnout and moral distress among nurses and (2) identify recommendations for nurse leaders to support the psychological needs of nursing staff. METHODS: Comprehensive searches were conducted in Medline, Embase and PsycINFO (via Ovid); CINAHL (via EBSCOHost); and ERIC (via ProQUEST). The rapid review was completed in accordance with the World Health Organization Rapid Review Guide. KEY FINDINGS: Thematic analysis of selected studies suggests that nurses are at an increased risk for stress, burnout and depression during the ongoing COVID-19 pandemic. Younger female nurses with less clinical experience are more vulnerable to adverse mental health outcomes.

New Registered Nurse Transition to the Workforce and Intention to Leave: Testing a Theoretical Model.

BACKGROUND: The transition of new nurses into practice has been identified as challenging, and new nurses report having intentions to leave (ITL) jobs. Concerns of ITL are worrisome for the nursing profession, especially when faced with the need to replace an aging nursing workforce and to maintain quality patient care. PURPOSE: Guided by components of Meleis et al.'s mid-range transition theory, the purpose of this study was to test a theoretical model linking transition and ITL, as well as the personal, community and societal conditions of transition. METHODS: A predictive, non-experimental design using cross-sectional data was employed. Ontario registered nurses, who had graduated within two years, were randomly selected to complete a mailed questionnaire in 2015 (N = 217). Structural equation modeling was undertaken to test the model. RESULTS: The new nurses reported a relatively positive transition; yet, 44% of the respondents indicated leaving their first job, and 1% departed the nursing profession. A revised model of the constructs showed a more adequate fit with the data, but overall, the hypothesized model was not supported and methodological validity of tools questioned. From the modeling, lower role stress led to a positive transition. CONCLUSIONS: Given organizational and governmental investments in orientation and transition programs, challenges in measuring transition and ITL requires additional research. Our findings highlight the value of organizations supporting new nurses by reducing role stress through reasonable workloads and expectations, which in turn contributes to a positive transition.

Physiotherapy: an active, transformational, and authentic career choice.

Background: This paper arises from a larger study exploring early professional socialization across five professions: physiotherapy, nursing; dentistry; pharmacy; and medicine. Purpose: To explore the process of physiotherapy student professional identity development and the evolution of expectations and views of interprofessional practice in the first year of their program. Methods: One-on-one interviews at three time points: after being accepted into the physiotherapy program and before classes began (T1; n = 12); after term one (T2; n=9) and on completion of year one (T3; n = 7). Analyses employed narrative methodology, guided by anticipatory socialization and professional identity theories. Results: At T1, participants described their path towards physiotherapy, indicating career satisfaction as the core of their choice. Expectations of practice aligned with the normative social positioning of the profession. T2 and T3 interviews revealed that their pre-entry conceptualization of practice was both challenged and positively reinforced, leading them either to being satisfied with, or questioning their choice. Clinical placements created the most meaningful opportunities to understand their roles both as individual professionals and members of a collaborative team. Conclusion: Findings revealed the complex process of professional socialization in physiotherapy students with implications for admissions and formal and IPE curricula.