Risking vulnerability: Enacting moral agency in the is/ought gap in mental health care.

AIM: To explore how healthcare providers in acute care mental health settings navigate ethically challenging situations, enact moral agency, practice in congruence with ethical standards and mitigate moral distress (MD). DESIGN: Grounded theory, a qualitative methodology. METHODS: Over 18 months between 2015 and 2017, we reviewed documents, conducted observations and interviewed multidisciplinary participants (N = 27) from inpatient and emergency departments. Participants either provided direct care (N = 14) or were in leadership positions (N = 13). Data were analysed iteratively using constant comparison, coding, memoing and theorizing, which continued until saturation was reached in July 2016. FINDINGS: The basic social process of how healthcare professionals enacted moral agency, Risking Vulnerability, occurred in the context of Systemic Inhumanity, a constant source of MD. Participants Risked Vulnerability, balancing professional obligations, clinical expertise and organizational processes with their own vulnerability in the system as they strove to practice ethically. Risking Vulnerability was composed of Pushing Back, Working Through Team Relationships and Struggling with Inhumanity. CONCLUSION: Healthcare professionals' moral agency occurred at the nexus of structure (organizational constraints) and agency (persons). Given this, interventions for MD should be directed at all levels of healthcare to support moral agency, promote ethical practice and improve care. IMPACT: Sociopolitical elements such as austerity measures undermined ethical practice at the level of direct care. Enactment of moral agency is dynamic, influencing experiences of MD: participants supported by leadership or colleagues to enact moral agency noted that they were not stuck in MD. Interventions supporting moral agency throughout the healthcare system are necessary to mitigate experiences of MD. Findings enhance our understanding of the role of action in the experience of MD.

Using a mixed-methods design to examine nurse practitioner integration in British Columbia.

AIM: To discuss and provide examples of how mixed-methods research was used to evaluate the integration of nurse practitioners (NPs) into a Canadian province. BACKGROUND: Legislation enabling NPs to practise in British Columbia (BC) was enacted in 2005. This research evaluated the integration of NPs and their effect on the BC healthcare system. DATA SOURCES: Data were collected using surveys, focus groups, participant interviews and case studies over three years. REVIEW METHODS: Data sources and methods were triangulated to determine how the findings addressed the research questions. DISCUSSION: The challenges and benefits of using the multiphase design are highlighted in the paper. CONCLUSION: The multiphase mixed-methods research design was selected because of its applicability to evaluation research. The design proved to be robust and flexible in answering research questions. IMPLICATIONS FOR PRACTICE/RESEARCH: As sub-studies within the multiphase design are often published separately, it can be difficult for researchers to find examples. This paper highlights ways that a multiphase mixed-methods design can be conducted for researchers unfamiliar with the process.

Nurse practitioners changing health behaviours: one patient at a time.

In 2005, legislation was enacted allowing nurse practitioners (NPs) to practise in British Columbia, Canada. Although substantial human and financial resources had been dedicated to the implementation of the role, no evaluation has been conducted to date. As part of a larger multiphase, mixed-methods study design, which evaluated the integration of NPs into the British Columbia healthcare system, this article describes findings related to changes that result for patients and the implications for the healthcare system when NPs become part of the care process. Using survey and interview data, themes that emerged were patient satisfaction, access to care, and behavioural changes. Findings suggest that patients are satisfied with the care they receive from NPs and that NPs make positive changes to health behaviour.

Electronic Record Adoption and Use among Nurse Practitioners in British Columbia.

There has been a research focus on physician adoption of electronic medical records (EMRs). However, there has been less research into nurse practitioner (NP) use of EMRs. The authors present findings on the adoption and use of EMRs by NPs arising from a survey of the patterns of NP practices in the Canadian province of British Columbia. The research reveals a high rate of NP adoption of EMRs, with 82% of respondents indicating that they were using the technology. However, only 19% of NPs were using fully electronic records while 63% were using hybrid records, with only components of the electronic record being available. Respondents were found to be using several EMR features and functions, namely patient demographics, clinical notes, medication lists, laboratory results, and patient problems. NPs' high rate of EMR adoption suggests that there is much to be learned regarding the effect of eHealth strategies on EMR adoption.

L'adoption par les médecins de la tenue de dossiers médicaux électroniques (DME) a fait l'objet de nombreuses recherches. Toutefois, les recherches portant sur l'utilisation de DME par les infirmières praticiennes (IP) se font beaucoup plus rares. Les auteures présentent les résultats d'une étude portant sur les tendances relevées chez les IP œuvrant dans la province canadienne de la Colombie-Britannique, relativement à l'adoption et l'utilisation de DME. L'étude révèle un taux élevé d'IP travaillant avec des DME, 82 % d'entre elles indiquant qu'elles utilisent maintenant cette technologie. Cependant, seulement 19 % d'IP travaillent avec des dossiers entièrement informatisés alors que 63 % utilisent des dossiers hybrides, la partie électronique du dossier ne comportant que certains éléments. Les personnes qui ont répondu utilisent plusieurs fonctions électroniques, notamment celles permettant la gestion des données démographiques du patient, des notes cliniques, des listes de médicaments et des résultats de laboratoire ainsi que des données sur les troubles du patient. Le taux élevé d'adoption de cette technologie chez les IP suggère la nécessité d'étudier davantage les effets des stratégies de cybersanté sur l'utilisation de DME.

Use of knowledge discovery techniques to understand nurse practitioner practice patterns and their integration into a healthcare system.

The objective of this study is to assess the feasibility of applying knowledge discovery techniques to identifying nurse practitioner practice patterns and enacted scope of practice. For the research, we plan to use data extracted from a Ministry of Health database. The data items are focused around: nurse practitioner demographics, health authorities, and encounter types. This analysis produces patterns that indicate relationships between the demographics, scope of practice and practice settings of nurse practitioners working in British Columbia.

Doing the best I can do: moral distress in adolescent mental health nursing.

The purpose of this research was to explore the process used by mental health nurses working with adolescents to ameliorate the experience of moral distress. Using grounded theory methodology, a substantive theory was developed to explain the process. All the incidents that led to the experience of moral distress were related to safety and resulted in the nurses asking themselves the question, "Is this the best I can do?" Engaging in dialogue was the primary means nurses used to work through the experience of moral distress. Engaging in dialogue was an ongoing process, and nurses sought out dialogue with a variety of people as they tried to make sense of their experience. Participants identified qualities of dialogue that were helpful or unhelpful as they sought to resolve their moral distress. Participants who had a positive experience of dialogue were able to answer the "Is this the best I can do" question satisfactorily and continue working with adolescents with a renewed focus on the therapeutic relationship. Participants who had a negative experience of dialogue are unable to answer the question and either left the unit or agency or talked about leaving.

Longing for ground in a ground(less) world: a qualitative inquiry of existential suffering.

BACKGROUND: Existential and spiritual concerns are fundamental issues in palliative care and patients frequently articulate these concerns. The purpose of this study was to understand the process of engaging with existential suffering at the end of life. METHODS: A grounded theory approach was used to explore processes in the context of situated interaction and to explore the process of existential suffering. We began with in vivo codes of participants' words, and clustered these codes at increasingly higher levels of abstractions until we were able to theorize. RESULTS: Findings suggest the process of existential suffering begins with an experience of groundlessness that results in an overarching process of Longing for Ground in a Ground(less) World, a wish to minimize the uncomfortable or anxiety-provoking instability of groundlessness. Longing for ground is enacted in three overlapping ways: by turning toward one's discomfort and learning to let go (engaging groundlessness), turning away from the discomfort, attempting to keep it out of consciousness by clinging to familiar thoughts and ideas (taking refuge in the habitual), and learning to live within the flux of instability and unknowing (living in-between). CONCLUSIONS: Existential concerns are inherent in being human. This has implications for clinicians when considering how patients and colleagues may experience existential concerns in varying degrees, in their own fashion, either consciously or unconsciously. Findings emphasize a fluid and dynamic understanding of existential suffering and compel health providers to acknowledge the complexity of fear and anxiety while allowing space for the uniquely fluid nature of these processes for each person. Findings also have implications for health providers who may gravitate towards the transformational possibilities of encounters with mortality without inviting space for less optimistic possibilities of resistance, anger, and despondency that may concurrently arise.

Putting On and Taking Off the Capulana: A Grounded Theory of How Mozambican Women Manage Gender Oppression.

Gender-based oppression is a pervasive global challenge, but has taken a back seat to other issues in Mozambique. The purpose of this grounded theory study was to explore how Mozambican women manage multiple oppressions in their lives in the context of the AIDS epidemic. Using interviews, documents, and constant comparison, we constructed a theory, Putting on and Taking Off the Capulana, to explain how women are socialized into and push back against the prevailing societal misogyny. The theory comprises four categories: Putting on the Capulana, Turning a Blind Eye, Playing the Game, and Taking Off the Capulana. Women adopt sex-role expectations, becoming socialized into patriarchal society. They are silent about their oppression, and society colludes in this. They use a strategic process to gain a sense of control over their situations. Finally, some women develop a critical consciousness and are able to resist their oppression in emancipatory ways.

Keeping Vigil over the Patient: a grounded theory of nurse anaesthesia practice.

AIM: This paper is a report of a study exploring the role and practice of nurse anaesthetists, with particular attention to describing how it is 'nursing'. BACKGROUND: In many countries, there is no nurse anaesthetist role. Recent events suggest that hesitancy about the role may be changing in Canada. Yet, there is limited understanding in Canada about nurse anaesthesia, and many nurses do not believe it is nursing. METHOD: This grounded theory study involved theoretical and purposive sampling to gather data through: (i) participant observation and face-to-face interviews at the 75th annual American Association of Nurse Anesthetists convention in August, 2006, (ii) follow-up telephone interviews and (iii) a 4-day site visit to a small city in the west of the United States to observe anaesthetists in practice and working with students, visit an educational program, and conduct further interviews. Data collection and analysis were iterative and continued until saturation was reached in December, 2007. FINDINGS: A basic social process of how nurse anaesthetists practise, Keeping Vigil over the Patient, was identified. Keeping Vigil over the Patient is comprised of four categories: Engaging with the Patient, Finessing the Human-Technology Interface, Massaging the Message and Foregrounding Nursing. CONCLUSION: Nursing was clearly evident in anaesthesia practice, reflecting a seamless integration of divergent ontological perspectives. Based on this examination, this role has considerable potential as a new advanced practice nursing role in countries where it has not yet been adopted.

Keeping vigil over the profession: a grounded theory of the context of nurse anaesthesia practice.

BACKGROUND: Nurse anaesthetists in the US have faced continued, repeated challenges to their profession. Regardless, they have met these challenges and have established themselves as major anaesthesia care providers. In this paper we address the research question: How do certified registered nurse anaesthetists (CRNAs) manage the socio-political context in which they provide care for their patients? METHODS: Grounded theory was used to explore how nurse anaesthetists protect and promote their profession. Purposive, snowball, and theoretical sampling was used and data were collected through participant observation and interviews conducted at a conference of the professional association, an educational program, by telephone, email exchanges, and time spent in operating rooms and an outpatient surgical clinic. Analysis included coding at increasingly abstract levels and constant comparison. RESULTS: The basic social process identified was Keeping Vigil Over the Profession, which explains how nurse anaesthetists protect and promote their profession. It is comprised of three contextual categories: Establishing Public Credibility through regulatory and educational standards, Political Vigilance and taking action in governmental and policy arenas, and Tending the Flock through a continuous information loop between local and administrative/political levels. CONCLUSIONS: From our study of the context of nurse anaesthesia practice, it is clear that CRNAs are dedicated to protecting their ability to provide high quality patient care by maintaining constant vigilance over their profession.

A closer look at the "supervision" and "direction" of certified registered nurse anesthetists.

A growing shortage of anesthesiologists in Canada has prompted discussion of how anesthesia provision can be expanded. Canadian anesthesiologists generally support a team approach in which physicians supervise alternative providers. In the U.S., nurses have worked as anesthetists for over 150 years, and their experiences of different models of anesthesia provision provide valuable insights into the potential pitfalls of the team approach as well as the benefits of autonomous nurse anesthetist roles. The authors conducted a qualitative study of the anesthesia team and the role of nurse anesthesia practice in the U.S., and here they present a summary of some of their preliminary findings and the implications for evolving models of care in Canada. Inefficiencies associated with the medical supervision and direction of Certified Registered Nurse Anesthetists are discussed.

Teaching nurses teamwork: Integrative review of competency-based team training in nursing education.

Widespread demands for high reliability healthcare teamwork have given rise to many educational initiatives aimed at building team competence. Most effort has focused on interprofessional team training however; Registered Nursing teams comprise the largest human resource delivering direct patient care in hospitals. Nurses also influence many other health team outcomes, yet little is known about the team training curricula they receive, and furthermore what specific factors help translate teamwork competency to nursing practice. The aim of this review is to critically analyse empirical published work reporting on teamwork education interventions in nursing, and identify key educational considerations enabling teamwork competency in this group. CINAHL, Web of Science, Academic Search Complete, and ERIC databases were searched and detailed inclusion-exclusion criteria applied. Studies (n = 19) were selected and evaluated using established qualitative-quantitative appraisal tools and a systematic constant comparative approach. Nursing teamwork knowledge is rooted in High Reliability Teams theory and Crew or Crisis Resource Management sources. Constructivist pedagogy is used to teach, practice, and refine teamwork competency. Nursing teamwork assessment is complex; involving integrated yet individualized determinations of knowledge, skills, and attitudes. Future initiatives need consider frontline leadership, supportive followership and skilled communication emphasis. Collective stakeholder support is required to translate teamwork competency into nursing practice.

Nurse Practitioner Perceptions of the Impact of Electronic Medical Records Upon Clinical Practice.

A survey was conducted in the province of British Columba, Canada with nurse practitioners (NP). This paper reports on the quantitative and qualitative findings of the survey questions specifically focused on NP perceptions of the clinical impacts associated with using electronic medical records (EMRs) in a primary care setting. Findings suggest that although NPs perceived EMRs to improve the overall quality of clinical decisions, challenges remain in terms of tailoring the design of EMRs to address NP needs.

The tyranny of consensus: implications for nursing education.

The egalitarian appeal of decision making based on consensus has been valued as a strong alternative to other decision making approaches such as voting. In this paper, we identify some of the challenges inherent in this view, and suggest consideration of alternative decision making approaches needed at times to help nurse educators in their work with students and colleagues. As nurse educators, we have a responsibility to educate students about the meanings of consensus, to encourage open discussion about implicit values underlying behaviors, and help them appreciate the importance of dissent in a democratic society. Our challenge is to ensure that we are using, and teaching, the best decision making process for the circumstance.

Public health reform and health promotion in Canada.

More than 25 years have passed since the release of the Ottawa Charter for Health Promotion. This document represented a substantial contribution to public health in its emphasis on the economic, legal, political and cultural factors that influence health. With public health renewal underway across Canada, and despite overwhelming support in the public health community for the Ottawa Charter, how much its principles will be included in the renewal process remains unclear. In this paper, we present the historical understanding of health promotion in Canada, namely highlighting the contributions from the Lalonde Report, Alma Ata Declaration, the Ottawa Charter for Health Promotion and the more recent population health movement. We discuss public health renewal, using the province of British Columbia in Canada as an example. We identify the potential threats to health promotion in public health renewal as it unfolds.

How are electronic medical records used by nurse practitioners?

In this paper we describe how nurse practitioners (NPs) use electronic medical records (EMR) features and functions at: (1) an individual and (2) a clinic level to support patient wellness and chronic disease management activities. Fifteen NPs from British Columbia (BC), Canada participated in a qualitative, semi-structured interview study. NPs used EMRs with individual patients and at a clinic level to support wellness and chronic disease management activities. NP's used clinic notes, reminders, tasks and careplans to support wellness and disease management activities in individual patients while reports were used to manage patients at a clinic level.

Discovering health knowledge in the BC nurse practitioners encounter codes.

Integrating the Nurse Practitioner (NP) role into clinical practice settings is new in British Columbia (BC), Canada. Encounter codes are unique numeric codes assigned to specific types of patient care services performed by NPs. In this study we apply knowledge discovery techniques to analyze the encounter codes extracted from the BC Ministry of Health database to understand the most common practice activities carried out by NPs and what diseases patients sought care for from NPs. The analysis produced important information about NPs' practice patterns. This work leads to a better understanding of NP practice patterns in BC.

Articulating new outcomes of nurse practitioner practice.

PURPOSE: The purpose of this article is to describe how two mid-range theories, Kolkaba's Comfort Theory and Antonovsky's Sense of Coherence can be used to illuminate the holistic nature of nurse practitioner (NP) practice. DATA SOURCES: Original research and theoretical papers related to both theories described. CONCLUSIONS: The NP role has been in existence for more than 40 years and can be found in healthcare systems in more than 60 countries around the world. Increasingly, NPs are assuming responsibility for providing primary health care to people with complex care needs. Although researchers have consistently demonstrated the NPs provide safe, effective care, and patients are satisfied with that care, theories demonstrating the holistic nature of NP practice are less evident. IMPLICATIONS FOR PRACTICE: Comfort Theory and Sense of Coherence can be used to demonstrate how the holistic nature of NP care results in patient-centered outcomes.

Fading vision: knowledge translation in the implementation of a public health policy intervention.

BACKGROUND: In response to several high profile public health crises, public health renewal is underway in Canada. In the province of British Columbia, the Ministry of Health initiated a collaborative evidence-informed process involving a steering committee of representatives from the six health authorities. A Core Functions (CF) Framework was developed, identifying 21 core public health programs. For each core program, an evidence review was conducted and a model core program paper developed. These documents were distributed to health authorities to guide development of their own renewed public health services. The CF implementation was conceptualized as an embedded knowledge translation process. A CF coordinator in each health authority was to facilitate a gap analysis and development of a performance improvement plan for each core program, and post these publically on the health authority website. METHODS: Interviews (n = 19) and focus groups (n = 8) were conducted with a total of 56 managers and front line staff from five health authorities working in the Healthy Living and Sexually Transmitted Infection Prevention core programs. All interviews and focus groups were digitally recorded, transcribed and verified by the project coordinator. Five members of the research team used NVivo 9 to manage data and conducted a thematic analysis. RESULTS: Four main themes emerged concerning implementation of the CF Framework generally, and the two programs specifically. The themes were: 'you've told me what, now tell me how'; 'the double bind'; 'but we already do that'; and the 'selling game.' Findings demonstrate the original vision of the CF process was lost in the implementation process and many participants were unaware of the CF framework or process. CONCLUSIONS: Results are discussed with respect to a well-known framework on the adoption, assimilation, and implementation of innovations in health services organizations. Despite attempts of the Ministry of Health and the Steering Committee to develop and implement a collaborative, evidence-informed policy intervention, there were several barriers to the realization of the vision for core public health functions implementation, at least in the early stages. In neglecting the implementation process, it seems unlikely that the expected benefits of the public health renewal process will be realized.

Existential suffering in the palliative care setting: an integrated literature review.

CONTEXT: Existential and spiritual concerns in relation to palliative end-of-life care have received increasing attention over the past decade. OBJECTIVES: To review the literature specifically related to existential suffering in palliative care in terms of the significance of existential suffering in end-of-life care, definitions, conceptual frameworks, and interventions. METHODS: A systematic approach was undertaken with the aim of identifying emerging themes in the literature. Databases using CINAHL (1980-2009), MEDLINE (1970-2009), and PsychINFO (1980-2009) and the search engine of Google Scholar were searched under the key words existential suffering, existential distress, existential pain, palliative and end of life care. RESULTS: The search yielded a total of 156 articles; 32% were peer-reviewed empirical research articles, 28% were peer-reviewed theoretical articles, and 14% were reviews or opinion-based articles. After manually searching bibliographies and related reference lists, 64 articles were considered relevant and are discussed in this review. Overall analysis identifies knowledge of the following: 1) emerging themes related to existential suffering, 2) critical review of those identified themes, 3) current gaps in the research literature, and 4) recommendations for future research. Findings from this comprehensive review reveal that existential suffering and deep personal anguish at the end of life are some of the most debilitating conditions that occur in patients who are dying, and yet the way such suffering is treated in the last days is not well understood. CONCLUSION: Given the broad range of definitions attributed to existential suffering, palliative care clinicians may need to be mindful of their own choices and consider treatment options from a critical perspective.