The intraprofessional and interprofessional relations of neurorehabilitation nurses: a negotiated order perspective.

AIMS: To report a study of the negotiation practices of neurorehabilitation nurses with one another and with allied health professionals to understand nursing relations. BACKGROUND: Negotiated order theory offers a promising theoretical lens with which to explore negotiation between nurses and other professionals. This study is the first to apply the perspective to nurse-nurse and nurse-allied health professional relations. DESIGN: The study is a secondary analysis of findings from a multi-site arts-based intervention to improve patient-centred neurorehabilitation practice. METHODS: Interviews and ethnographic observations were conducted (2008-2011) in two neurorehabilitation units in Ontario, Canada. Participants (n = 31) included registered and practical nurses, nurse leaders, and allied health professionals from physical, occupational, and recreational therapy, speech language pathology, and social work. FINDINGS: Neurorehabilitation nursing is characterized by heavy workload, high patient acuity, and poor interprofessional collaboration. This practice context was negotiated by nurses through two strategies: (1) intraprofessional collegialism, accomplished through tactics including task and knowledge sharing, emotional support, coercive threats, and suppression of dissension; and (2) vying for an autonomous essential nursing role in interprofessional practice, accomplished by claiming unique nursing knowledge based on 24/7 nursing proximity, the expansion of the division of professional labour with allied health professionals and modifying physical therapy care plans. CONCLUSION: The intraprofessional context and negotiations therein were linked in significant ways to interprofessional negotiations. Understanding this complexity has important implications for improving patient safety and interprofessional practice interventions.

Improving client-centered brain injury rehabilitation through research-based theater.

Traumatic brain injury often results in physical, behavioral, and cognitive impairments perceived by health care practitioners to limit or exclude clients' full participation in treatment decision making. We used qualitative methods to evaluate the short- and long-term impact of "After the Crash: A Play About Brain Injury," a research-based drama designed to teach client-centered care principles to brain injury rehabilitation staff. We conducted interviews and observations with staff of two inpatient neurorehabilitation units in Ontario, Canada. Findings demonstrate the effectiveness of the play in influencing practice through the avoidance of medical jargon to improve clients' understanding and participation in treatment; newfound appreciation for clients' needs for emotional expression and sexual intimacy; increased involvement of family caregivers; and avoidance of staff discussions as if clients were unaware. These findings suggest that research-based drama can effect reflexivity, empathy, and practice change to facilitate a client-centered culture of practice in brain injury rehabilitation.

Tacit knowledge of caring and embodied selfhood.

The tacit knowledge paradigm is gaining recognition as an important source of knowledge that informs clinical decision-making. It is, however, limited by an exclusive focus on knowledge acquired through clinical practice, and a consequent neglect of the primordial and socio-cultural significance of embodied selfhood, precisely what provides the foundational structure of tacit knowledge of caring and facilitates its manifestation. Drawing on findings from a qualitative study of 43 dementia care practitioners in Ontario, Canada that utilised research-based drama and focus group methodology, we argue that embodied selfhood is fundamental to tacit knowledge of caring. Results are analysed drawing upon the theoretical precepts of embodied selfhood that are rooted in Merleau-Ponty's (1962) reconceptualisation of perception and Bourdieu's (1977, 1990) notion of habitus. We conclude with a call for further exploration of the body as a site of the production of tacit knowledge.

Expressions of personhood in Alzheimer's disease: an evaluation of research-based theatre as a pedagogical tool.

A growing number of scholars are turning to dramatic performance as an innovative approach to disseminating the results of qualitative research. With an interest in this aesthetic practice, the authors transformed ethnographic research on personhood in Alzheimer's disease into a dramatic production, Expressions of Personhood in Alzheimer's , which was performed at the outset of focus group discussions with health practitioners. In this article, the authors report the results of an evaluation of health practitioners' perceptions of this theatrical adaptation as a pedagogical tool. Data from the focus group discussions and a self-administered post-performance survey suggest that there was a perceived relevance of the production to practitioners' practices, an increased understanding gained from attending the production, and a strong endorsement of the use of drama as an educational tool for disseminating information about dementia care.

Factors influencing exercise participation by older adults requiring chronic hemodialysis: a qualitative study.

Despite the recognized health and psychosocial benefits of exercise for older adults with end-stage renal disease (ESRD), exercise participation remains poor. Previous research has attributed low levels of exercise to patient-related factors such as lack of motivation and fear of adverse consequences. This qualitative study involving focus group discussions with hemodialysis patients, nephrology nurses, and family care providers explored specific motivators and barriers to exercise participation in older adults requiring hemodialysis. Nurse participants were chosen for the health care provider focus groups because their prolonged and sustained contact with hemodialysis patients during the dialysis treatment sessions positions them well to encourage and promote exercise. Motivators to exercise included patient aspirations to exercise and their experiences of improvements from exercising, as well as the formal incorporation of exercise into the overall dialysis treatment plan. Barriers to exercise included nurses' lack of encouragement to exercise, transportation issues, and the use of exercise equipment that precludes participation by patients who recline during dialysis and inhibits exercise encouragement by nurses due to concerns of equipment-related injury. These findings support the need for a broader recognition of the systemic factors that may impede exercise participation by older adults requiring hemodialysis. A shift is required in the culture of ESRD treatment programs towards a wellness perspective that includes expectations of exercise encouragement by the health care team and participation by patients.

Dementia care at the intersection of regulation and reflexivity: a critical realist perspective.

OBJECTIVES: To understand point-of-care decisions, and in particular rule breaking, by personal support workers (PSWs) regarding institutionalized elders with dementia within a context of legislative and organizational care mandates. METHODS: Qualitative baseline data including focus groups and semi-structured interviews with PSWs (n = 26) and supervisors (n = 9) were collected during a 2-year, multi-method trial of a 12-week interprofessional arts-informed educational intervention in two Alzheimer support units and were analyzed using a critical realist approach. RESULTS: PSW care decisions were the outcome of a discordant interrelationship between PSWs' reflective deliberations, and legislative and organizational care mandates. PSWs responded to discordance through rule breaking in order to provide individualized care. Unbeknownst to PSWs, rule breaking was contingent upon supervisors' case-by-case complicity as they strove to balance fears of regulatory citations with private assessment of the soundness of PSW logic. DISCUSSION: Quality care emerges at the intersection of policies governing long-term care, PSW rule breaking, and the supportive but undisclosed role supervisors play in these violations. Understanding this complexity has important implications for initiatives to improve care practices and to challenge legislation and policies that impede dementia care.

The experiences of using an anti-collision power wheelchair for three long-term care home residents with mild cognitive impairment.

PURPOSE: Presented are three case analyses of long-term care home residents with cognitive impairment who tested an anti-collision power wheelchair. We discuss technology design and research implications for this population. METHOD: Case studies involved 371 h of participant observation and 7 h of open-ended interview with residents (n = 3), family members (n = 3) and clinical staff (n = 11). Thematic analysis generated themes related to technological, psychological and social aspects of residents' inclination and disinclination towards power mobility use. RESULTS: Themes examined the discordance between others' and residents' reports of anti-collision power wheelchair use; a facet of response bias; unanticipated implications for independence and dependence; and implications of device design for self-presentation. CONCLUSIONS: Technology alone is insufficient to help residents to fully benefit from the autonomy that a wheelchair intervention can provide: close attention is required to the social and organisational factors of institutional life. For technology to be acceptable, the design must meet the functional and aesthetic needs of users. Considerations in the design of future power wheelchairs for residents with cognitive impairment include capabilities to drive on uneven surfaces, effort-reducing driving modes, improved user interface usability, and acceptable driving speed, size and appearance.

Neglecting the importance of the decision making and care regimes of personal support workers: a critique of standardization of care planning through the RAI/MDS.

PURPOSE: The Resident Assessment Instrument-Minimum Data Set (RAI/MDS) is an interdisciplinary standardized process that informs care plan development in nursing homes. This standardized process has failed to consistently result in individualized care planning, which may suggest problems with content and planning integrity. We examined the decision making and care practices of personal support workers (PSWs) in relation to the RAI/MDS standardized process. DESIGN AND METHODS: This qualitative study utilized focus groups and semi-structured interviews with PSWs (n = 26) and supervisors (n = 9) in two nursing homes in central Canada. RESULTS: PSWs evidenced unique occupational contributions to assessment via proximal familiarity and biographical information as well as to individualizing care by empathetically linking their own bodily experiences and forging bonds of fictive kinship with residents. These contributions were neither captured by RAI/MDS categories nor relayed to the interdisciplinary team. Causal factors for PSW exclusion included computerized records, low status, and poor interprofessional collaboration. Intraprofessional collaboration by PSWs aimed to compensate for exclusion and to individualize care. IMPLICATIONS: Exclusive institutional reliance on the RAI/MDS undermines quality care because it fails to capture residents' preferences and excludes input by PSWs. Recommendations include incorporating PSW knowledge in care planning and documentation and examining PSWs' nascent occupational identity and their role as interprofessional brokers in long-term care.

Using drama to improve person-centred dementia care.

AIMS AND OBJECTIVES: We implemented a 12-week drama-based educational intervention to introduce to dementia practitioners person-centred care that emphasizes the notion of embodied selfhood (defined as non-verbal self-expression). BACKGROUND: Person-centred dementia care guidelines emphasize the assessment of individual needs, and where appropriate, the use of non-pharmacological interventions before resorting to pharmacological management. However, dementia care is not consistent with these guidelines suggesting conceptual limitations and reliance on passive knowledge translation strategies. DESIGN AND METHODS: Focus groups and semi-structured interviews with practitioners (n = 24) in two nursing homes in central Canada were undertaken to assess the effectiveness of the drama-based components of the intervention. RESULTS: Our findings suggest that drama was effective as an educational modality, and helped implement the person-centred approach into practice. Significant practice outcomes included: new awareness that residents' body movements and dispositions can convey meaning; seeking biographical information from families; increased time efficiency; and supporting residents' independence. CONCLUSIONS: Our findings make an important contribution to person-centred dementia care by broadening the notion of personhood, and by facilitating implementation using drama. IMPLICATIONS FOR PRACTICE: As an enhancement of person-centred care, the support of embodied selfhood may significantly improve residents' quality of life, quality of care, and practitioners' care-giving experience.

Mapping new theoretical and methodological terrain for knowledge translation: contributions from critical realism and the arts.

BACKGROUND: Clinical practice guidelines have been a popular tool for the improvement of health care through the implementation of evidence from systematic research. Yet, it is increasingly clear that knowledge alone is insufficient to change practice. The social, cultural, and material contexts within which practice occurs may invite or reject innovation, complement or inhibit the activities required for success, and sustain or alter adherence to entrenched practices. However, knowledge translation (KT) models are limited in providing insight about how and why contextual contingencies interact, the causal mechanisms linking structural aspects of context and individual agency, and how these mechanisms influence KT. Another limitation of KT models is the neglect of methods to engage potential adopters of the innovation in critical reflection about aspects of context that influence practice, the relevance and meaning of innovation in the context of practice, and the identification of strategies for bringing about meaningful change. DISCUSSION: This paper presents a KT model, the Critical Realism and the Arts Research Utilization Model (CRARUM), that combines critical realism and arts-based methodologies. Critical realism facilitates understanding of clinical settings by providing insight into the interrelationship between its structures and potentials, and individual action. The arts nurture empathy, and can foster reflection on the ways in which contextual factors influence and shape clinical practice, and how they may facilitate or impede change. The combination of critical realism and the arts within the CRARUM model promotes the successful embedding of interventions, and greater impact and sustainability. CONCLUSION: CRARUM has the potential to strengthen the science of implementation research by addressing the complexities of practice settings, and engaging potential adopters to critically reflect on existing and proposed practices and strategies for sustaining change.

After the crash: research-based theater for knowledge transfer.

INTRODUCTION: The aim of this project was to develop and evaluate a research-based dramatic production for the purpose of transferring knowledge about traumatic brain injury (TBI) to health care professionals, managers, and decision makers. METHODS: Using results drawn from six focus group discussions with key stakeholders (consumers, informal caregivers, and health care practitioners experienced in the field of TBI) and relevant scientific literature, a 50-minute play was produced for the purpose of conveying the experiences of TBI survivors, informal care providers, and health practitioners and best practice for TBI care. A self-administered postperformance survey was distributed to audience members at the end of four performances in Ontario, Canada, to evaluate the play's efficacy. Two hundred ninety-one questionnaires were completed. The questionnaire had five questions scored on a 5-item Likert scale with space for open-ended comments. RESULTS: Consistently high mean scores from the questionnaires indicate that theater is a highly efficacious and engaging method of knowledge transfer, particularly for complex material that deals with human emotion and interpersonal relationships. DISCUSSION: Responses supported the effectiveness of drama as a knowledge translation strategy and identified its potential to impact practice positively.