Realist review of community coalitions and outreach interventions to increase access to primary care for vulnerable populations: a realist review.

BACKGROUND: There are meaningful gaps in equitable access to Primary Health Care (PHC), especially for vulnerable populations after widespread reforms in Western countries. The Innovative Models Promoting Access-to-Care Transformation (IMPACT) research program is a Canadian-Australian collaboration that aims to improve access to PHC for vulnerable populations. Relationships were developed with stakeholders in six regions across Canada and Australia where access-related needs could be identified. The most promising interventions would be implemented and tested to address the needs identified. This realist review was conducted to understand how community coalition and outreach (e.g., mobile or pop-up) services improve access for underserved vulnerable residents. OBJECTIVE: To inform the development and delivery of an innovative intervention to increase access to PHC for vulnerable populations. METHODS: A realist review was conducted in collaboration with the Local Innovative Partnership (LIP) research team and the IMPACT research members who conducted the review. We performed an initial comprehensive systematic search using MEDLINE, EMBASE, PsycINFO, and the Cochrane Library up to October 19, 2015, and updated it on August 8, 2020. Studies were included if they focused on interventions to improve access to PHC using community coalition, outreach services or mobile delivery methods. We included Randomized Controlled Trials (RCTs), and systematic reviews. Studies were screened by two independent reviewers and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used for data extraction and framework analysis to obtain themes. The LIP research team was also allowed to suggest additional papers not included at screening. RESULTS: We included 43 records, comprising 31 RCTs, 11 systematic reviews, and 1 case control study that was added by the LIP research team. We identified three main themes of PHC interventions to promote access for vulnerable residents, including: 1) tailoring of materials and services decreases barriers to primary health care, 2) services offered where vulnerable populations gather increases the "reach" of the interventions, 3) partnerships and collaborations lead to positive health outcomes. In addition, implementation designs and reporting elements should be considered. CONCLUSION: Realist reviews can help guide the development of locally adapted primary health care interventions.

Examining dual roles in long-term-care homes in rural Alberta: a qualitative study.

INTRODUCTION: In rural settings, many healthcare professionals experience intersections of professional and personal relationships, often known as dual roles. Dual roles are traditionally studied in terms of their potential for ethical conflicts or negative effects on care. In the existing scholarship, there is little discussion of dual roles in long-term care (LTC) settings, which present distinct conditions for care. Unlike other forms of health care, LTC work is provided daily, over longer periods, in care recipients' home environments. This article outlines results from a case study of LTC in rural Alberta, Canada and provides evidence of some of the challenges and, more notably, the considerable benefits of dual roles in these settings. METHODS: The qualitative data discussed in this article come from a multi-site comparative case study of rural LTC that, among other questions, asked, 'How do personal and professional lives intersect in rural LTC settings across the province?' These data were collected through the use of rapid ethnographies at three rural LTC homes across the province of Alberta. The research team conducted semi-structured, in-depth interviews (n=90) and field observations (~200 hours). Participants were asked about care team dynamics, the organization of care work, the role of the LTC home in the community, and the intersections of public and private lives. The results were coded and critically analyzed using thematic analysis. RESULTS: Dual roles were primarily described as beneficial for care provision. In many cases, dual roles provided participants with opportunities for reciprocity, enhanced person-centered care, and increased perceptions of trust and community accountability. Similar to what has been documented in the extant literature, dual roles also presented some challenges regarding personal and professional boundaries for those in leadership. However, the negative examples were outweighed by positive accounts of how dual roles can serve as a potential asset of rural LTC. CONCLUSION: There is a need for more nuanced conversations around the implications of dual roles. Policies and care approaches need to emphasize and support the use of good judgment and the responsible navigation of dual roles, rather than taking either a permissive or prohibitive approach. Leaders in rural LTC can promote conversations among care providers, with an emphasis on the cultural context of care provision and how dual roles play out in their specific professional practice. Blanket policies or educational approaches that frame dual roles as necessarily problematic are not only insensitive to the unique nature of rural LTC, but prohibitive of relational elements that these results suggest are highly supportive of person-centered care.

Association between continuity and access in primary care: a retrospective cohort study.

BACKGROUND: Continuity of care is a tenet of primary care. Our objective was to explore the relation between a change in access to a primary care physician and continuity of care. METHODS: We conducted a retrospective cohort study among physicians in a primary care network in southwest Alberta who measured access consistently between 2009 and 2016. We used time to the third next available appointment as a measure of access to physicians. We calculated the provider and clinic continuity, discontinuity and emergency department use based on the physicians' own panels. Physicians who improved, worsened or maintained their level of access within a given year were assessed in multilevel models to determine the association with continuity of care at the physician and clinic levels and the emergency department. RESULTS: We analyzed data from 190 primary care physicians. Physicians with improved access increased provider continuity by 6.8% per year, reduced discontinuity by 2.1% per year, and decreased emergency department encounters by 78 visits per 1000 patients per year compared to physicians with stable access. Physicians with worsening access had a 6.2% decrease in provider continuity and an increased number of emergency department encounters (64 visits per 1000 panelled patients per year) compared to physicians with stable access. INTERPRETATION: Changes in access to primary care can affect whether patients seek care from their own physician, from another clinic or at the emergency department. Improving access by reducing the delay in obtaining an appointment with one's primary care physician may be one mechanism to improve continuity of care.

Letters to the Editor.

This article contains Letters from the Readears.

Mitigating Moral Distress in Dementia Care: Implications for Leaders in the Residential Care Sector.

In 2012, the World Health Organization estimated that the number of people living with dementia worldwide was approximately 35.6 million; they projected a doubling of this number by 2030, and tripling by 2050. Although the majority of people living with a dementia live in the community, residential facility care by nursing providers is a common part of the dementia journey in most countries. Previously published research confirms that caring for people living with dementia in such facilities often creates moral distress for nursing care providers. In this paper, the authors share additional findings from a two-year, two-phase, mixed methods study of moral distress as experienced by nursing caregivers of residents with dementia in residential care settings in a Western Canadian province. The findings relate to strategies to reduce moral distress in this caregiving group, with a particular focus on the role of supportive and responsive leadership. Important implications for practice and for leadership in the residential care sector are presented.

Development and validation of the Moral Distress in Dementia Care Survey instrument.

AIMS: To report on the development and validation of the Moral Distress in Dementia Care Survey instrument. BACKGROUND: Despite growing awareness of moral distress among nurses, little is known about the moral distress experiences of nursing staff in dementia care settings. To address this gap, our research team developed a tool for measuring the frequency, severity and effects of moral distress in nursing staff working in dementia care. DESIGN: The research team employed an exploratory sequential mixed method design to generate items for the moral distress questionnaire. Data were collected between January 2013 - June 2014. In this paper, we report on the development and validation of the Moral Distress in Dementia Care Survey instrument. METHODS: The Moral Distress in Dementia Care Survey instrument was piloted with a portion of the target population prior to a broader implementation. Appropriate statistical analyses and psychometric testing were completed. RESULTS: The team collected 389 completed surveys from registered nurses, licensed practical nurses and healthcare aides, representing a 43.6% response rate across 23 sites. The Moral Distress in Dementia Care Survey emerged as a reliable and valid instrument to measure the frequency, severity and effects of moral distress for nursing staff in dementia care settings. The relative value of the Moral Distress in Dementia Care Survey as a measurement instrument was superseded by its clinical relevance for dementia care staff. CONCLUSION: The Moral Distress in Dementia Care Survey is a potentially useful tool for estimating the frequency, severity and effects of moral distress in nursing staff working in dementia care settings and for the evaluation of measures taken to mitigate moral distress.

Caring in the wake of the rising tide: Moral distress in residential nursing care of people living with dementia.

Objective Moral distress is increasingly being recognized as a concern for health care professionals. The purpose of this study was to explore the nature and prevalence of moral distress among nursing staff who care for people living with dementia. Methods This study was focused on nursing staff caring for people with dementia in long-term care and assisted living sites. The Moral Distress in Dementia Care Survey instrument was distributed to 23 sites and nursing staff rated the frequency and severity of situations that were identified as potentially causing moral distress. Results Moral distress is prevalent in the nursing staff who provide dementia care. Nursing staff reported experiencing moral distress at least daily or weekly. Both frequency and severity of moral distress increased with proximity to (amount of time spent at) the bedside. Moral distress had negative psychological and physiological effects on nursing staff, and affected intention to quit.

Sources of moral distress for nursing staff providing care to residents with dementia.

The World Health Organization estimates the number of people living with dementia at approximately 35.6 million; they project a doubling of this number by 2030 and tripling by 2050. Although the majority of people living with a dementia live in the community, residential facility care by nursing care providers is a significant component of the dementia journey in most countries. Research has also shown that caring for persons with dementia can be emotionally, physically, and ethically challenging, and that turnover in nursing staff in residential care settings tends to be high. Moral distress has been explored in a variety of settings where nurses provide acute or intensive care. The concept, however, has not previously been explored in residential facility care settings, particularly as related to the care of persons with dementia. In this paper, we explore moral distress in these settings, using Nathaniel's definition of moral distress: the pain or anguish affecting the mind, body, or relationships in response to a situation in which the person is aware of a moral problem, acknowledges moral responsibility, makes a moral judgment about the correct action and yet, as a result of real or perceived constraints, cannot do what is thought to be right. We report findings from a qualitative study of moral distress in a single health region in a Canadian province. Our aim in this paper is to share findings that elucidate the sources of moral distress experienced by nursing care providers in the residential care of people living with dementia.

Mitigating Moral Distress in Dementia Care: Implications for Leaders in the Residential Care Sector.

In 2012, the World Health Organization estimated that the number of people living with dementia worldwide was approximately 35.6 million; they projected a doubling of this number by 2030, and tripling by 2050. Although the majority of people living with a dementia live in the community, residential facility care by nursing providers is a common part of the dementia journey in most countries. Previously published research confirms that caring for people living with dementia in such facilities often creates moral distress for nursing care providers. In this paper, the authors share additional findings from a two-year, two-phase, mixed methods study of moral distress as experienced by nursing caregivers of residents with dementia in residential care settings in a Western Canadian province. The findings relate to strategies to reduce moral distress in this caregiving group, with a particular focus on the role of supportive and responsive leadership. Important implications for practice and for leadership in the residential care sector are presented.

Dementia care in the context of primary care reform: an integrative review.

OBJECTIVES: The purpose of this review was to determine the influence of the growing body of evidence about the attributes of high-performing primary care systems on the literature related to the primary care of people living with dementia. METHODS: In this integrative review, we examined a broad range of published and grey literature (2000-2013) about the primary care of dementia, using a systematic approach set up in advance of the literature search. The review was guided by two questions: What are the evident models of primary care for dementia? How do the models line up with the other attributes of high-performing primary care? RESULTS: Three models were noted: carved-out, co-managed, and integrative-hub, all informed by different assumptions about the role of primary care in dementia. The models varied in alignment with the attributes of high-performing primary care, although we found very little attention to accessibility, relational continuity or comprehensiveness of care. CONCLUSIONS: We know what we need to pay attention to in building our primary care system - and no population will put the performance of primary care more to the test over the next two decades than the rapidly growing number of people who will be living with complex chronic conditions like dementia. Recent literature around primary care and dementia shows promise in attending to some of the attributes of high-performing primary care, yet much more work is needed if we are to truly leverage the potential value of primary care in addressing the needs of these complex and numerous future patients.