Communities of practice to facilitate change in health professions education: A realist synthesis.

BACKGROUND: Communities of practice could contribute to transformations in health professions education to meet complex and emerging challenges. However, little is known about the underlying mechanisms of communities of practice in this setting, and how context influences outcomes. OBJECTIVE: To understand when, why and how communities of practice with health professions education faculty work to facilitate higher education change. DESIGN: A realist synthesis according to the RAMESES standards and steps described by Pawson and colleagues. REVIEW METHODS: Early scoping of the literature informed the development of an initial program theory to describe underlying assumptions about how communities of practice in higher education, implemented with health professions education faculty, were likely to work. The theory was tested and further refined through a realist synthesis. A systematic search for evidence using search terms 'faculty', 'communities of practice' and 'higher education' and related terms was supplemented with citation tracking and hand searching of significant authors and journals. Following study appraisal, data were extracted and synthesised from 21 manuscripts describing 16 communities of practice. The realist synthesis focused on identifying patterns in context-mechanism-outcome interactions, and the alignment with substantive theory. RESULTS: From the included manuscripts, ten context-mechanism-outcome configurations were identified that describe a range of individual, interpersonal and institutional outcomes of communities of practice with health professions education faculty and context-mechanism interactions that contribute to achieving these outcomes. CONCLUSIONS: This study expands theoretical understandings of how and why communities of practice work. There is value in communities of practice in the higher education sector, primarily in the field of health professions education. Communities of practice implemented in the context of complex change with participants who have a desire to participate can facilitate change in health professions education, including institutional level changes, through reflection, experiential learning and creating a shared agenda for change. Findings from this study can be used by policy and decision-makers within health education to best apply communities of practice to achieve meaningful outcomes.

Main Mechanisms of Remote Monitoring Programs for Cardiac Rehabilitation and Secondary Prevention: A SYSTEMATIC REVIEW.

PURPOSE: The objective of this report was to identify the main mechanisms of home-based remote monitoring programs for cardiac rehabilitation (RM CR) and examine how these mechanisms vary by context. METHODS: This was a systematic review using realist synthesis. To be included, articles had to be published in English between 2010 and November 2020 and contain specific data related to mechanisms of effect of programs. MEDLINE All (1946-) via Ovid, Embase (1974-) via Ovid, APA PsycINFO (1806-), CINAHL via EBSCO, Scopus databases, and gray literature were searched. RESULTS: From 13 747 citations, 91 focused on cardiac conditions, with 23 reports including patients in CR. Effective RM CR programs more successfully adapted to different patient home settings and broader lives, incorporated individualized patient health data, and had content designed specifically for patients in cardiac rehabilitation. Relatively minor but common technical issues could significantly reduce perceived benefits. Patients and families were highly receptive to the programs and viewed themselves as fortunate to receive such services. The RM CR programs could be improved via incorporating more connectivity to other patients. No clear negative effects on perceived utility or outcomes occurred by patient age, ethnicity, or sex. Overall, the programs were seen to best suit highly motivated patients and consolidated rather than harmed existing relationships with health care professionals and teams. CONCLUSIONS: Remote monitoring CR programs are perceived by patients to be beneficial and attractive. Future RM CR programs should consider adaptability to different home settings, incorporate individualized health data, and contain content specific to patient needs.

Effectiveness, feasibility, and acceptability of behaviour change tools used by family doctors: a global systematic review.

BACKGROUND: Priority patients in primary care include people from low-income, rural, or culturally and linguistically diverse communities, and First Nations people. AIM: To describe the effectiveness, feasibility, and acceptability of behaviour change tools that have been tested by family doctors working with priority patients. DESIGN AND SETTING: A global systematic review. METHOD: Five databases were searched for studies published from 2000 to 2021, of any design, that tested the effectiveness or feasibility of tangible, publicly available behaviour change tools used by family doctors working with priority patients. The methodological quality of each study was appraised using the Mixed Methods Appraisal Tool. RESULTS: Thirteen of 4931 studies screened met the eligibility criteria, and described 12 tools. The health-related behaviours targeted included smoking, diet and/or physical activity, alcohol and/or drug use, and suicidal ideation. Six tools had an online/web/app-based focus; the remaining six utilised only printed materials and/or in-person training. The effectiveness of the tools was assessed in 11 studies, which used diverse methods, with promising results for enabling behaviour change. The nine studies that assessed feasibility found that the tools were easy to use and enhanced the perceived quality of care. CONCLUSION: Many of the identified behaviour change tools were demonstrated to be effective at facilitating change in a target behaviour and/or feasible for use in practice. The tools varied across factors, such as the mode of delivery and the way the tool was intended to influence behaviour. There is clear opportunity to build on existing tools to enable family doctors to assist priority patients towards achieving healthier lifestyles.

Exploring behaviour change in general practice consultations: A realist approach.

OBJECTIVES: While general practice involves supporting patients to modify their behaviour, General Practitioners (GPs) vary in their approach to behaviour change during consultations. We aimed to identify mechanisms supporting GPs to undertake successful behaviour change in consultations for people with T2DM by exploring (a) the role of GPs in behaviour change, (b) what happens in GP consultations that supports or impedes behaviour change and (c) how context moderates the behaviour change consultation. METHODS: Semi-structured interviews with academic clinicians (n = 13), GPs (n = 7) and patients with T2DM (n = 16) across Australia. Data were analysed thematically using a realist evaluation approach. RESULTS: Perspectives about the role of GPs were highly variable, ranging from the provision of test results and information to a relational approach towards shared goals. A GP-patient relationship that includes collaboration, continuity and patient-driven care may contribute to a sense of successful change. Different patient and GP characteristics were perceived to moderate the effectiveness and experience of behaviour change consultations. DISCUSSION: When patient factors are recognised in consultations, a relational approach becomes possible and priorities around behaviour change, that might be missed in a transactional approach, can be identified. Therefore, GP skills for engaging patients are linked to a person-centred approach.

Why Do so Few People with Heart Failure Receive Cardiac Rehabilitation?

Many people with heart failure do not receive cardiac rehabilitation despite a strong evidence base attesting to its effectiveness, and national and international guideline recommendations. A more holistic approach to heart failure rehabilitation is proposed as an alternative to the predominant focus on exercise, emphasising the important role of education and psychosocial support, and acknowledging that this depends on patient need, choice and preference. An individualised, needs-led approach, exploiting the latest digital technologies when appropriate, may help fill existing gaps, improve access, uptake and completion, and ensure optimal health and wellbeing for people with heart failure and their families. Exercise, education, lifestyle change and psychosocial support should, as core elements, unless contraindicated due to medical reasons, be offered routinely to people with heart failure, but tailored to individual circumstances, such as with regard to age and frailty, and possibly for recipients of cardiac implantable electronic devices or left ventricular assist devices.

Behaviour change for type 2 diabetes: perspectives of general practitioners, primary care academics, and behaviour change experts on the use of the 5As framework.

BACKGROUND: The 5As framework is a recognized underpinning of behaviour change guidelines, teaching, and research in primary care. Supporting patients to improve their lifestyle behaviours, including diet and physical activity, is a common aspect of type 2 diabetes mellitus (T2DM) management. The 5As framework often informs behaviour change for patients with T2DM. OBJECTIVE: To explore the experience and perspectives of general practitioners (GPs) and primary care academics and behaviour change experts regarding using the 5As framework when caring for patients with T2DM to better understand how and why the 5As are effective in practice. METHODS: We recruited 20 practising GPs, primary care academics, and behaviour change experts for an individual semistructured interview and analysed the data using a realist evaluation approach. RESULTS: There were diverse accounts of how GPs use the 5As in practice and few of the participants could name each "A." The 5As were commonly regarded as a framework best suited to beginners and although GPs expressed they followed the broad direction of the 5As, they did not consciously follow the framework in an instructive manner. Elements that could enhance the 5As included more emphasis on motivational interviewing, changing how "Ask" is included in the consultation, and increased person-centredness. CONCLUSION: Although it is a ubiquitous framework in primary care, the 5As are understood in diverse ways and applied variably in practice. There is room to enhance how the 5As support behaviour change consultations to optimize outcomes in primary care.

General practitioners (GPs) are usually involved in helping patients with diabetes to improve their diet, physical activity, and other lifestyle behaviours. The 5As are a framework designed to be used to structure behaviour change conversations­5As stand for Ask, Assess, Advise, Assist, and Arrange. We interviewed 20 people who were either GPs or experts in behaviour change. They had different ways of explaining the intent and usage of the 5As but consistently saw them as a framework for new practitioners. No one used the 5As consciously in their consultations with patients. The participants had multiple suggestions for how the 5As could be enhanced to support better care for patients living with diabetes. These included: more focus on motivational interviewing techniques, changing the number or order of the 5As steps, more focus on teamwork as well as the individual cultural needs of the patients. This work can inform further research on how patients can be better supported by GPs through evidence-based behaviour change care.

Obesity management in primary care: systematic review exploring the influence of therapeutic alliance.

PURPOSE: To identify the influence of the therapeutic alliance on the effectiveness of obesity interventions delivered in primary care. METHOD: Systematic review of randomized controlled trials of primary care interventions for adult patients living with obesity. Comprehensive search strategy using the terms 'obesity', 'primary care' and 'intervention' of seven databases from 1 January 1998 to March 2018. Primary outcome was difference in weight loss in interventions where a therapeutic alliance was present. RESULTS: From 10 636 studies, 11 (3955 patients) were eligible. Only one study had interventions that reported all aspects of therapeutic alliance, including bond, goals and tasks. Meta-analysis was not included due to high statistical heterogeneity and low numbers of trials; as per our protocol, we proceeded to narrative synthesis. Some interventions included the regular primary care practitioner in management; very few included collaborative goal setting and most used prescriptive protocols to direct care. CONCLUSIONS: We were surprised that so few trials reported the inclusion of elements of the therapeutic alliance when relational aspects of primary care are critical for effectiveness. Interventions could be developed to maximize therapeutic relationships and research reports should describe interventions comprehensively. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42018091338 in PROSPERO (International prospective register of systematic reviews).

Intersectionality and heart failure: what clinicians and researchers should know and do.

PURPOSE OF REVIEW: To review the application of intersectionality to heart failure. Intersectionality refers to the complex ways in which disenfranchisement and privilege intersect to reproduce and influence health and social outcomes. RECENT FINDINGS: Intersectionality challenges approaches that focus on a single or small number of socio-demographic characteristics, such as sex or age. Instead, approaches should take account of the nature and effects of a full range of socio-demographic factors linked to privilege, including: race and ethnicity, social class, income, age, gender identity, disability, geography, and immigration status. Although credible and well established across many fields - there is limited recognition of the effects of intersectionality in research into heart disease, including heart failure. This deficiency is important because heart failure remains a common and burdensome syndrome that requires complex pharmacological and nonpharmacological care and collaboration between health professionals, patients and caregivers during and at the end-of-life. SUMMARY: Approaches to heart failure clinical care should recognize more fully the nature and impact of patients' intersectionality- and how multiple factors interact and compound to influence patients and their caregivers' behaviours and health outcomes. Future research should explicate the ways in which multiple factors interact to influence health outcomes.

Views of Patients With Heart Failure on Their Value-Based Self-care Decisions: A Qualitative Study.

BACKGROUND: Self-care adherence remains low in patients with heart failure (HF); little is known about the influence of patients' values on self-care decisions and behaviors. OBJECTIVES: The aim of this study was to explore how participants living with HF perceive their values and how those values are reportedly expressed in self-care decision making. METHODS: The Interpretative Phenomenological Analysis approach was used. Semistructured interviews were conducted with 12 patients 60 years or older; with New York Heart Association class II and III HF; and able to speak, read, and understand English. Participants recruited via convenience sampling (January-December 2016) from 2 urban sites in Western Canada. RESULTS: Values were reported to pivotally influence HF self-care decisions and behaviors. Overarching themes addressed aspects of values and decision making: notably, directness and complexity. Two main types of values, functional and emotional values, were involved in both adherent and nonadherent decisions. Values were often in flux, with the pursuit of these values being frequently in conflict with physical ability and changing over time. CONCLUSION: Two types of values serve influence self-care decisions and adherence. As HF and its self-care prevent patients from pursuing their prioritized values, patients are often nonadherent. Thus, patients with HF should be supported to find alternative ways to enact their values.

Nursing interventions in autologous stem cell transplantation for autoimmune diseases.

AIMS: To identify clinical symptoms and nursing interventions for stem cell therapy in autoimmune diseases. DESIGN: This is a retrospective, cross-sectional study. METHODS: This study was undertaken with patients diagnosed with type 1 diabetes or multiple sclerosis, undergoing autologous haematopoietic stem cell transplantation from January 2004 - December 2018. Data were registered in a questionnaire, taken during the conditioning regimen comprising cyclophosphamide and rabbit anti-thymocyte globulin. Descriptive statistics and Fisher's exact test were used for data analysis. RESULTS: There were 68 and 23 patients in the multiple sclerosis and type 1 diabetes groups respectively. Skin rash, nausea, vomiting and fever were more frequent and diverse in the type 1 diabetes group. Steroids were used as prophylaxis for anti-thymocyte globulin-associated allergic reactions in 97% of multiple sclerosis patients. Most of the identified symptoms and nursing interventions were more associated with one or other disease group (p < .05) and were more frequent in the type 1 diabetes group. CONCLUSION: Patients with autoimmune diseases who underwent stem cell therapy present differences in their repertoire of adverse events and require disease-specific nursing actions. IMPACT: Our results may enable nurses to establish transplant and disease-specific guidelines to improve prevention and management of adverse events and therefore optimize patient care and therapeutic success.

Trust within your team during a pandemic.

The concept of trust is essential for high-functioning general practice teams during a pandemic.

Life and priorities before death: A narrative inquiry of uncertainty and end of life in people with heart failure and their family members.

BACKGROUND: Most patients with advanced heart failure are ill-prepared and poorly supported during the end of life. To date, research has focused primarily on generalized patient accounts of the management or self-care phase of the syndrome. Little research has examined the end of life in depth or from the perspectives of family members. AIMS: The purpose of this study is to describe how people diagnosed with heart failure and their family members describe uncertainty related to impending death. METHODS AND RESULTS: A narrative inquiry was undertaken using a social constructionist perspective. Twenty participants took part in over 60 interviews: 12 participants with heart failure (eight male and four female; mean = 67.3 years) and eight family members (mean = 61.6 years) engaged in two in-depth interviews, approximately 3-4 months apart, followed by a telephone follow-up 2-3 months later. Six key themes/storylines were identified. These included: prognosis messages received from physicians; whenever I die, I die; loss isn't new to me but … ; carrying on amidst the fragility of life; ultimately living not knowing; and the need to prepare. CONCLUSION: The six key storylines of death and dying with advanced heart failure were consistent for both patients and family members. There was a desire for better communication with physicians. Many participants were critical of how the prognosis of advanced heart failure was communicated to them, even if they anticipated the news. Participants wanted frank, open conversations with their healthcare providers that both acknowledged that they were at end of life but did not remove all hope.