Cultural competence and cultural safety in Canadian schools of nursing: a mixed methods study.

Cultural competence and cultural safety are essential knowledge in contemporary nursing care. Using a three-phase, mixed methods sequential triangulation design, this study examines the extent to which Anglophone Schools of Nursing in Canada have integrated cultural competence and/or cultural safety into the undergraduate nursing curricula. Factors that influence successful integration are identified through the lens of Donabedian's structure, process, and outcome model. Results suggest that several facilitating factors are present, such as leadership, partnerships and linkages, and educational supports for students. Of particular concern is the lack of policies to recruit and retain Aboriginal faculty, financial resources, and outcome evaluation indicators. A conceptual model of integration is offered to explain how Schools of Nursing function to support the implementation of these concepts into their curriculum. This study provides theoretical and practical implications for initiation and improvement of cultural competence and/or cultural safety integration strategies in Schools of Nursing.

Nurse practitioners in Ontario primary healthcare: referral patterns and collaboration with other healthcare professionals.

The purpose of this study is to examine referrals of nurse practitioners providing primary healthcare (PHC NPs) to better understand how PHC NPs collaborate with other healthcare professionals and contribute to interprofessional care. The analysis is based on the data from a survey of 378 PHC NPs registered in Ontario, Canada in 2008. Overall, 69% of PHC NPs made referrals to family physicians (FPs) and 67% of PHC NPs received referrals from FPs. Almost 50% of PHC NPs had bidirectional referrals between them and FPs. Eighty-nine percent of PHC NPs made referrals to specialist physicians. Bidirectional referrals between PHC NPs and social workers and mental health workers were common in family health teams and community health centers. Patterns of referrals (bidirectional, unidirectional and no referrals) between PHC NPs and FPs, social workers, mental and allied health workers in various practice settings indicate development of collaborative relationships between PHC NPs and other healthcare professionals and reflect the influence of practice models on delivery of interprofessional care. These findings are discussed in light of the development of NPs' role and integration of PHC NPs in the Ontario healthcare system. Implications for policy changes and future research are also suggested.

Students' perceptions of interprofessional learning through facilitated online learning modules.

BACKGROUND: Asynchronous e-learning is an appealing option for interprofessional education (IPE) as it addresses the geographic and timetabling barriers often encountered when organizing activities across educational programs. AIM: This study examined the extent to which pre-licensure students were able to learn with, from, and about each other through completion of innovative online IPE learning modules. METHODS: Seventy-seven students completed e-learning modules developed through a consortium of educational institutions. Evaluation was primarily qualitative through focus groups, interviews, analyses on off-line discussions and an online feedback form. RESULTS: Qualitative analyses of the discussion fora revealed that students were able to solve problems collaboratively, clarify their professional roles, and provide information from their professional perspective. Focus groups and interviews reinforced that students recognized the importance of working together and implicate clinical education as an important venue to reinforce learning about collaborative practice. Analyses of the online feedback form suggest the need for clear processes related to group assignments and deadlines. CONCLUSION: Students learned about each other's role, solved problems together and had positive perceptions of the online modules as a venue for interprofessional learning. Results are encouraging to those interested in using e-learning in IPE as part of an overall curriculum.

Integration of nurse practitioners into Ontario's primary health care system: variations across practice settings.

Annual tracking surveys of nurse practitioners in the Canadian province of Ontario conducted by the Centre for Rural and Northern Health Research for the Ministry of Health and Long-Term Care provide a picture of current employment and practice. The authors present an update on the most recent survey of primary health care nurse practitioners (PHC NPs), conducted in 2008.The study sample consisted of 378 NPs registered in Ontario in 2008 and practising in PHC. Differences in demographic, employment, and practice characteristics in a variety of practice settings are explored. Geographic distribution, education, autonomy of the NP, and the practice profiles varied across settings. The findings document the integration of NPs into Ontario's health-care system and suggest a need to further describe the models of practice and their impact on PHC outcomes.

Stroke education for nurses through a technology-enabled program.

Today's nurse faces many challenges in the workplace. Required to keep up in a constantly changing knowledge-based environment, he or she must balance complex professional responsibilities, staffing shortages, and increased acuity among the patient population. Continuing education must, therefore, be highly flexible and responsive to the personal and professional needs of the nurse learner. Technology-supported continuing education is suggested to be an appropriate way of meeting the learning needs of busy working nurses. The Stroke Best Practices for Nursing project used three complementary and integrated educational technologies-a-Web-based learning site, Web casting (live and archived), and two-way interactive videoconferencing--to deliver a minicourse focused on best practice stroke care to nurses working in northeastern and northwestern Ontario, a geographical area of approximately 600 km. In total, 96 nurses participated in the educational part of the program; 46 of the 96 (47%) took part in the assessment of the program. On the basis of this assessment strategy and the nurses' requests for other programs that do not use traditional face-to-face classrooms and lecture, the value of using educational technologies in health-based continuing education was strongly identified. This article describes key components of the project and celebrates the partnership among the organizing stakeholders: faculty in the school of nursing at the Laurentian University, the West Greater Toronto Area Stroke Network, and the Ontario Telemedicine Network. The article further describes findings related to the program's impact on participants' perceptions of competence as caregivers for stroke patients, participants' confidence using technology for educational purposes, and participants' satisfaction with the overall program.

Scaling up the global nursing health workforce: contributions of an international organization.

In this paper key highlights of the scholarly work presented at the Toronto 2008 Global Alliance for Nursing Education & Scholarship (GANES) conference are summarized, challenges opportunities and issues facing nursing education globally arising from the conference discourse are outlined and initial steps are suggested as a way forward to a shared global view of baccalaureate and graduate nursing education and scholarship. This shared view arises from beginning understandings of the issues and opportunities we face globally starting with and building upon the lessons learned from the literature and from the experiences of nursing educators and nursing education organization locally, regionally, nationally and internationally. The theme of the groundbreaking GANES Toronto conference was "Educating the future nursing and health workforce: A global challenge". One hundred seventy delegates from 17 countries attended the event, with over 80 papers presented. A primary focus of GANES is the contribution of a strategic alliance of national nursing education organizations to contribute to nursing education leading practices and policy that address the scaling up of global nursing and health workforce. The founding members of GANES see a clear link between a strong educational infrastructure and strong scholarship activities in nursing and the ability of a society to be healthy and prosperous. Evidence presented at the recent GANES conference supports that belief. Through the strength of partnerships and other capacity-building efforts, member countries can support each other to address the global nursing education and health challenges while respecting the local issues.

A study of critical thinking, teacher-student interaction, and discipline-specific writing in an online educational setting for registered nurses.

Based on work conducted by Laurentian University's School of Nursing and Centre for Continuing Education in Sudbury, Ontario, Canada, working in conjunction with community partners, this article looks at the findings of an analysis of nurses' writing activity in a university-level web-based module for evidence of critical thinking using Johns' Model of Structured Reflection (1995). Also considered are student-teacher interactions and discipline-specific writing. The findings suggest that high levels of critical thinking by nurse learners and growth in thinking and writing competence over time can occur in an online setting. Further highlighted are the role of the instructor, assignment design, and support in fostering such development.

Habitus, stress, and the body: the everyday production of health and cardiovascular risk.

The incidence of coronary heart disease (CHD) and the distribution of contributory risk factors are closely linked with social patterns of advantage and disadvantage. The authors conducted eight focus groups in urban, northern, and rural sites in Ontario, Canada. Participants were all at high absolute risk for or had been diagnosed with CHD. Analysis centered on habitus, which forms the pivotal link between the person and "place." The authors focused on participants' dialogue about stress because it dealt with the impingements of the social world and resultant constraints on health-related activities in everyday places. Participants described four types of places or social positions in their "stress talk": work-places, transitional spaces, gendered situations, and exclusions. Places can support or constrain health related activities in many ways. Habits and practices linked with stress by participants were enduringly associated with these contexts, suggesting that place, body, and health are inseparable and coconstituted.

An examination of retention factors among registered nurses in Northeastern Ontario, Canada: Nurses intent to stay in their current position.

BACKGROUND: The purpose of the study was to examine factors related to the retention of registered nurses in northeastern Ontario, Canada. OBJECTIVE/METHOD: A cross-sectional survey of registered nurses working in northeastern Ontario, Canada was conducted. Logistic regression analyses were used to consider intent to stay in current employment in relation to the following: 1) demographic factors, and 2) occupation and career satisfaction factors. RESULTS: A total of 459 (29.8% response rate) questionnaires were completed. The adjusted odds logistic regression analysis of RNs who intended to remain in their current position for the next five years, demonstrated that respondents in the 46 to 56 age group (OR: 2.65; 95% CI: 1.50 to 4.69), the importance of staff development in the organization (OR: 3.04; 95% CI: 1.13 to 8.13) northeastern Ontario lifestyle (OR: 2.61; 95% CI: 1.55 to 4.40), working in nursing for 14 to 22.5 years (OR: 2.55; 95% CI: 1.10 to 5.93), and working between 0 to 1 hour of overtime per week (OR: 1.20; 95% CI: 1.20 to 4.64) were significant factors in staying in their current position for the next five years. CONCLUSIONS: This study shows that a further understanding of the work environment could assist with developing retention for rural nurses. Furthermore, employers may use such information to ameliorate the working conditions of nurses, while researchers may use such evidence to develop interventions that are applicable to improving the working conditions of nurses.

Workplace System Factors of Obstetric Nurses in Northeastern Ontario, Canada: Using a Work Disability Prevention Approach.

BACKGROUND: The purpose of this study was to examine the relationship nursing personal and workplace system factors (work disability) and work ability index scores in Ontario, Canada. METHODS: A total of 111 registered nurses were randomly selected from the total number of registered nurses on staff in the labor, delivery, recovery, and postpartum areas of four northeastern Ontario hospitals. Using a stratified random design approach, 51 participants were randomly selected in four northeastern Ontario cities. RESULTS: A total of 51 (45.9% response rate) online questionnaires were returned and another 60 (54.1% response rate) were completed using the paper format. The obstetric workforce in northeastern Ontario was predominately female (94.6%) with a mean age of 41.9 (standard deviation = 10.2). In the personal systems model, three variables: marital status (p = 0.025), respondent ethnicity (p = 0.026), and mean number of patients per shift (p = 0.049) were significantly contributed to the variance in work ability scores. In the workplace system model, job and career satisfaction (p = 0.026) had a positive influence on work ability scores, while work absenteeism (p = 0.023) demonstrated an inverse relationship with work ability scores. In the combined model, all the predictors were significantly related to work ability scores. CONCLUSION: Work ability is closely related to job and career satisfaction, and perceived control at work among obstetric nursing. In order to improve work ability, nurses need to work in environments that support them and allow them to be engaged in the decision-making processes.

The relationship between quality of work life and location of cross-training among obstetric nurses in urban northeastern Ontario, Canada: A population-based cross sectional study.

OBJECTIVES: The purpose of this mixed methods study was to examine the quality of work life of registered nurses working in obstetrics at 4 hospitals in northeastern Ontario and explore demographic and occupational factors related to nurses' quality of work life (QWL). MATERIAL AND METHODS: A stratified random sample of registered nurses (N = 111) selected from the 138 eligible registered nurses (80.4%) of staff in the labor, delivery, recovery, and postpartum areas at the 4 hospitals participated. Logistic regression analyses were used to consider QWL in relation to the following: 1) demographic factors, and 2) stress, employment status and educational attainment. RESULTS: In the logistic regression model, the odds of a higher quality of work life for nurses who were cross trained (nurses who can work across all areas of obstetrical care) were estimated to be 3.82 (odds ratio = 3.82, 95% confidence interval: 1.01-14.5) times the odds of a higher quality of work life for nurses who were not cross trained. CONCLUSIONS: This study highlights a relationship between quality of work life and associated factors including location of cross-training among obstetrical nurses in northeastern Ontario. These findings are supported by the qualitative interviews that examine in depth their relationship to QWL. Given the limited number of employment opportunities in the rural and remote regions, it is paramount that employers and employees work closely together in creating positive environments that promote nurses' QWL.

Occupational Stress Management and Burnout Interventions in Nursing and Their Implications for Healthy Work Environments: A Literature Review.

This article reports on a literature review of workplace interventions (i.e., creating healthy work environments and improving nurses' quality of work life [QWL]) aimed at managing occupational stress and burnout for nurses. A literature search was conducted using the keywords nursing, nurses, stress, distress, stress management, burnout, and intervention. All the intervention studies included in this review reported on workplace intervention strategies, mainly individual stress management and burnout interventions. Recommendations are provided to improve nurses' QWL in health care organizations through workplace health promotion programs so that nurses can be recruited and retained in rural and northern regions of Ontario. These regions have unique human resources needs due to the shortage of nurses working in primary care.

Work ability and work-related stress: A cross-sectional study of obstetrical nurses in urban northeastern Ontario.

BACKGROUND: The aim of this study was to determine: 1) if quality of work life (QWL), location of cross-training, stress variables, and various demographic factors in nurses are associated with work ability, and 2) nursing occupational stress, QWL, and various associated factors are related with nurses' work ability. There is limited research examining the obstetrical nursing environment. Given the amount of time and energy people expend at the workplace, it is crucial for employees to be satisfied with their lives at work. METHODS: This cross sectional study was conducted in 2012 in four hospitals in northeastern Ontario, Canada. A stratified random sample of registered nurses (n= 111) were selected. RESULTS: The majority of participants were female (94.6%) ranging in age from 24 to 64 years (M = 41.9, s.d. = 10.2). For the stress and QWL model, one variable: QWL (home-work support - see Methods for definition) (p= 0.015), cross-trained (see Methods for definition) nurses (p= 0.048), and having more than 4 patients per shift (p= 0.024) significantly contributed to the variance in work ability scores. In the logistic regression model, the odds of a higher work ability for nurses who received home-work support were estimated to be 1.32 (95% CI, 1.06 to 1.66) times the odds of a higher work ability for nurses who did not receive home-work support. CONCLUSIONS: Work ability in the work environment of obstetrical nursing is important. To be high functioning, workplaces should maximize the use of their employees' actual and potential skills.

Therapeutic benefit of preventive telehealth counseling in the Community Outreach Heart Health and Risk Reduction Trial.

We evaluated whether telehealth counseling augments lifestyle change and risk factor decrease in subjects at high risk for primary or secondary cardiovascular events compared to a recommended guideline for brief preventive counseling. Subjects at high risk or with coronary heart disease (35 to 74 years of age, n = 680) were randomized to active control (risk factor feedback, brief advice, handouts) or telehealth lifestyle counseling (active control plus 6 weekly 1-hour teleconferenced sessions to groups of 4 to 8 subjects). Primary outcome was questionnaire assessment of adherence to daily exercise/physical activity and diet (daily vegetable and fruit intake and restriction of fat and salt) after treatment and at 6-month follow-up. Secondary outcomes were systolic and diastolic blood pressures, ratio of total to high-density lipoprotein cholesterol, and 10-year absolute risk for coronary disease. After treatment and at 6-month follow-up, adherence increased for telehealth versus control in exercise (29.3% and 18.4% vs 2.5% and 9.3%, respectively, odds ratio 1.60, 95% confidence interval 1.2 to 2.1) and diet (37.1% and 38.1% vs 16.7% and 33.3%, respectively, odds ratio 1.41, 95% confidence interval 1.1 to 1.9). Telehealth versus control had greater 6-month decreases in blood pressure (mean ± SE, systolic -4.8 ± 0.8 vs -2.8 ± 0.9 mm Hg, p = 0.04; diastolic -2.7 ± 0.5 vs -1.5 ± 0.6 mm Hg, p = 0.04). Decreases in cholesterol ratio and 10-year absolute risk were significant for the 2 groups. In conclusion, telehealth counseling augments therapeutic lifestyle change in subjects at high risk for cardiovascular events compared to a recommended guideline for brief preventive counseling.

Online interprofessional health sciences education: From theory to practice.

Online learning (e-learning) has a nascent but established history. Its application to interprofessional education (IPE), however, is relatively new. Over the past 2 decades the Internet has been used increasingly to mediate education. We have come past the point of "should we use the Internet for education" to "how should we use the Internet for education." Research has begun on the optimal development of online learning environments to support IPE. Developing online IPE should follow best practices in e-learning generally, though there are some special considerations for acknowledging the interprofessional context and clinical environments that online IPE is designed to support. The design, development, and deployment of effective online IPE must therefore pay special attention to the particular constraints of the health care worker educational matrix, both pre- and postlicensure. In this article we outline the design of online, interprofessional health sciences education. Our work has involved 4 educational and 4 clinical service institutions. We establish the context in which we situate our development activities that created learning modules designed to support IPE and its transfer into new interprofessional health care practices. We illustrate some best practices for the design of effective online IPE, and show how this design can create effective learning for IPE. Challenges exist regarding the full implementation of interprofessional clinical practice that are beginning to be met by coordinated efforts of multiple health care education silos.

Context and cardiovascular risk modification in two regions of Ontario, Canada: a photo elicitation study.

Cardiovascular diseases, which include coronary heart diseases (CHD), remain the leading cause of death in Canada and other industrialized countries. This qualitative study used photo-elicitation, focus groups and in-depth interviews to understand health behaviour change from the perspectives of 38 people who were aware of their high risk for CHD and had received information about cardiovascular risk modification while participating in a larger intervention study. Participants were drawn from two selected regions: Sudbury and District (northern Ontario) and the Greater Toronto Area (southern Ontario). Analysis drew on concepts of place and space to capture the complex interplay between geographic location, sociodemographic position, and people's efforts to understand and modify their risk for CHD. Three major sites of difference and ambiguity emerged: 1) place and access to health resources; 2) time and food culture; and 3) itineraries or travels through multiple locations. All participants reported difficulties in learning and adhering to new lifestyle patterns, but access to supportive health resources was different in the two regions. Even within regions, subgroups experienced different patterns of constraint and advantage. In each region, "fast" food and traditional foods were entrenched within different temporal and social meanings. Finally, different and shifting strategies for risk modification were required at various points during daily and seasonal travels through neighbourhoods, to workplaces, or on vacation. Thus health education for CHD risk modification should be place-specific and tailored to the needs and resources of specific communities.

Physical activity behavior, motivational readiness and self-efficacy among Ontarians with cardiovascular disease and diabetes.

This cross-sectional study examined physical activity and its correlates among 355 diabetes, 144 cardiovascular disease, 75 diabetes and cardiovascular disease, and 390 residents with cardiovascular risk factors. Community residents (N=2566) were screened by telephone, and 964 participants completed a self-report survey. Non-diabetes participants participated in a greater range of physical activities (p<.001), more frequently (p=.013). Diabetes participants had lower physical activity readiness and efficacy (ps<.009). In a regression model (p<.001), region and disease, work, marital and smoking status were significant correlates of physical activity frequency. Interventions which increase motivational readiness and efficacy among diabetics are required to prevent and delay complications, particularly in regions with environmental barriers such as cold weather and homogeneous, low-density land use.

Nursing-sensitive outcomes data collection in acute care and long-term-care settings.

BACKGROUND: Most administrative databases do not contain good information about nursing-sensitive outcomes. OBJECTIVES: To determine (a) the reliability of the instruments measuring nursing-sensitive outcomes, (b) whether the outcome measures are sensitive to changes in patients' health, and (c) whether the outcome measures are associated with nursing interventions. METHODS: The sample consisted of 890 patients from acute care hospitals and long-term-care facilities. A repeated measures design was used. Functional status was assessed on admission and discharge using Minimum Data Set 2.0 items. Symptom (pain, nausea, dyspnea, fatigue) frequency and severity were assessed with 4-point and 11-point numeric scales, respectively. Therapeutic self-care was assessed on discharge from acute care. Nursing interventions were assessed by documentation review. RESULTS: The outcome measures demonstrated very good interrater reliability with weighted Kappa ranging from .64 to .93. The internal consistency reliability was high for functional status and therapeutic self-care. The outcome tools were sensitive to change in patient condition. Select nursing interventions were related to functional status, therapeutic self-care, and symptom outcomes. DISCUSSION: The findings suggest that nurses are able to collect data on nursing-sensitive patient outcomes in a reliable and valid way.

Relationship between nursing interventions and outcome achievement in acute care settings.

The extent to which nursing interventions provided during hospitalization are associated with patients' therapeutic self-care and functional health outcomes was explored with a voluntary sample of 574 patients. Nurses collected data on patient outcomes at admission and discharge using the minimum data set (MDS) and the therapeutic self-care scale (TSCS). Research assistants audited charts for documentation of nursing interventions. The results indicated that nursing interventions aimed at exercise promotion, positioning, and self-care assistance predicted functional status outcome. Higher functional status outcome predicted therapeutic self-care ability at hospital discharge. The results demonstrate that nurses can use MDS and TSCS data on patient outcomes to gain insight into the effectiveness of their interventions.