The Reflection Room®: Moving from Death-Avoiding to Death-Discussing.

We developed, implemented, and evaluated a participatory arts-based storytelling initiative called the Reflection Room project. Our aim was to investigate if visiting a Reflection Room, (1) creates opportunities for disclosing emotions and processing thoughts, (2) increases comfort discussing dying and death, and (3) supports advance care planning (ACP), conversations. In the pilot phase of the Reflection Room project, a Reflection Room was installed in 25 sites across Canada from 2016-2017. Data collection included reflection cards (n = 463), and surveys completed by visitors upon exiting a room (n = 271) and 3 months later (n = 50). Analysis involved theoretically driven coding, inductive content analysis, and descriptive statistics. We found reflections contained both emotional disclosures and reflective processing. Survey data indicated visiting a Reflection Room increased comfort in thinking and talking about dying and death as well as the likelihood of engaging in ACP. In the future, we will explore the extent to which the project fosters social connections and well-being.

A rapid scoping review of end-of-life conversations with frail older adults in Canada.

OBJECTIVE: To explore what is known about end-of-life (EOL) conversations with frail older adults across all settings including primary care in Canada, and to understand the barriers to, and recommendations for, EOL conversations. DATA SOURCES: Comprehensive searches were conducted in CINAHL (EBSCO), Embase (Ovid), MEDLINE (Ovid), AgeLine (EBSCO), Sociological Abstracts (ProQuest), and Applied Social Sciences Index and Abstracts (ProQuest). Searches used text words and subject headings (eg, MeSH, Emtree) related to 3 concepts: frailty, Canada, and EOL conversations. STUDY SELECTION: Twenty-one English-language articles were selected (ie, 4 reviews, 10 commentaries, 3 quantitative studies, 3 qualitative studies, 1 mixed-methods study) that included information about EOL conversations with frail older adults in the Canadian health care context. SYNTHESIS: In terms of having EOL conversations with frail older adults, this study found that many clinicians do not often and adequately discuss frailty and impending death with their older patients. Moreover, patients and their care partners do not have enough knowledge about frailty and death to make informed EOL decisions, leading to patients choosing more aggressive therapies instead of care focused on symptom management. In terms of barriers to EOL discussions, common barriers included a lack of trust between clinician and patient, inadequate EOL training for clinicians, and ineffective clinician communication with patients and families. Recommendations for improving EOL conversations include regular screening for frailty to prompt conversations about care and the use of an interprofessional approach. CONCLUSION: More empirical research is needed that uses exploratory methods to shed light on the contextual factors that may act as a barrier to EOL conversations. More research is also needed on the roles and responsibilities of interprofessional teams in screening for frailty and engaging in EOL conversations. Moreover, there is a need to better understand how frail older patients and their families want EOL conversations to unfold and what best facilitates these conversations.

Toward Treatment Integrity: Developing an Approach to Measure the Treatment Integrity of a Dialectical Behavior Therapy Intervention With Homeless Youth in the Community.

The current paper discusses an approach to measuring treatment integrity of dialectical behavioral therapy (DBT) when implemented within two programs providing services to street-involved youth in the community. Measuring treatment integrity is a critical component of effective implementation of evidence-based interventions in clinical practice, since sound treatment integrity increases confidence in client outcomes and intervention replicability. Despite being an essential part of implementation science, few studies report on treatment integrity, with limited research addressing either measurement tools or maintenance of treatment integrity. To address the lack of available treatment integrity measures, researchers in the current study developed and piloted a treatment integrity measure which pertain to the individual and group components of DBT. A total of 20 recordings were assessed using the treatment integrity measure. Results indicate that the community agency staff (e.g. youth workers, social workers & nurses) implemented the intervention as intended; increasing confidence in the outcome variables, the staffs' training and the replicability of the intervention. This article offers one approach to addressing treatment integrity when implementing evidence-based interventions, such as DBT in a community setting, and discusses the need for effective and feasible integrity measures that can be adopted in order to strengthen mental health practice in community settings.

"I don't see the whole picture of their health": a critical ethnography of constraints to interprofessional collaboration in end-of-life conversations in primary care.

CONTEXT: Interprofessional collaboration is recommended in caring for frail older adults in primary care, yet little is known about how interprofessional teams approach end-of-life (EOL) conversations with these patients. OBJECTIVE: To understand the factors shaping nurses' and allied health clinicians' involvement, or lack of involvement in EOL conversations in the primary care of frail older adults. METHODS/SETTING: A critical ethnography of a large interprofessional urban Family Health Team in Ontario, Canada. Data production included observations of clinicians in their day-to-day activities excluding direct patient care; one-to-one semi-structured interviews with clinicians; and document review. Analysis involved coding data using an interprofessional collaboration framework as well as an analysis of the normative logics influencing practice. PARTICIPANTS: Interprofessional clinicians (n = 20) who cared for mildly to severely frail patients (Clinical Frailty Scale) at the Family Health Team. RESULTS: Findings suggest primary care nurses and allied health clinicians have the knowledge, skills, and inclination to engage frail older adults in EOL conversations. However, the culture of the clinic prioritizes biomedical care, and normalizes nurses and allied health clinicians providing episodic task-based care, which limits the possibility for these clinicians' engagement in EOL conversations. The barriers to nurses' and allied health clinicians' involvement in EOL conversations are rooted in neoliberal-biomedical ideologies that shapes the way primary care is governed and practiced. CONCLUSIONS: Our findings help to explain why taking an individual-level approach to addressing the challenge of delayed or avoided EOL conversations, is unlikely to result in practice change. Instead, primary care teams can work to critique and redevelop quality indicators and funding models in ways that promote meaningful interprofessional practice that recognize the expertise of nursing and allied health clinicians in providing high quality primary care to frail older patients, including EOL conversations.

Biomedicalization of end-of-life conversations with medically frail older adults - Malleable and senescent bodies.

The common practice of delaying and/or avoiding end-of-life conversations with medically frail older adults is an important clinical issue. Most research investigating this practice focuses on clinician training and developing conversation skills. Little is known about the socio-political factors shaping the phenomenon of end-of-life conversations between clinicians and medically frail older patients. Using the critical lens of biomedicalization we consider how two dominant discourses, successful aging and frailty, and subsequent constructions of bodies as malleable or senescent, shape patient subjectivities and influence normative expectations about appropriate healthcare conversations and the consumption of biomedicine for medically frail adults. We highlight the uneven ways medically frail older adults are clinically positioned as successful or frail agers and briefly discuss how gender, class, and race may impact this tension and ambiguity. We conclude by arguing that end-of-life conversations with medically frail older adults is constrained by the pervasiveness of the successful aging discourse and the tendency within medical institutions to construct older bodies as malleable and in need of medical intervention to promote health and longevity.

Exploring Health Care Professionals' Perceptions of Incidents and Incident Reporting in Rehabilitation Settings.

OBJECTIVES: Research exploring patient safety in rehabilitation settings is limited. This study's aim was to describe team members' perceptions of incidents and incident reporting in rehabilitation settings. METHODS: Semistructured interviews were conducted with 18 health care professionals from multiple rehabilitation units (medical, neurological, and orthopedic) at 2 inner-city rehabilitation centers. Five hypothetical scenarios were presented to participants during the interviews. Participants were asked to classify the scenarios and whether they would report any identified incidents. Data were analyzed using a descriptive thematic approach. RESULTS: Participants classified events based on 2 parameters: the nature of the outcome and deviation from professional practice. Factors influencing participants' decisions to file incident reports included their classification of the events in the scenarios (i.e., events classified as critical incidents were more often reported than those classified as incident or near miss); the severity of the impact on the client; and their profession's perceived role in reporting specific incidents. When participants said they would report incidents, all agreed that they would report only objective facts. CONCLUSIONS: The study findings demonstrate gaps between incident-reporting policy and practice, and opportunities to address these gaps. Organizational leaders can work with all health care professions to support their roles in reporting. Interprofessional team building, focused on valuing all team members, may improve interprofessional communication and reporting. Setting standards for classifying events could increase consistency in reporting. Ultimately, encouraging reporting of near misses and incidents can create a culture of learning focused on problem solving and improved patient safety.

Urban First Nations Men: Narratives of Positive Identity and Implications for Culturally Safe Care.

PURPOSE: Dominant discourse contains negative stereotypical images of First Nations males that are steeped in colonialism. These racialized images can influence First Nations men's sense of self as well as the care that nurses deliver. The objective was to (a) explore practices that support positive First Nations identity and (b) provide suggestions for practicing culturally safe care. DESIGN: The theory of Two-Eyed Seeing guided this study. Data were collected via two semistructured interviews and Anishnaabe Symbol-Based Reflection from three First Nations men living in Toronto, Canada. FINDINGS: Having mentors, knowing family histories, and connecting with healthy Aboriginal communities fostered positive First Nations identities for participants. IMPLICATIONS: There is potential to advance nursing practice by enacting creative means that may support client's positive First Nations identity and well-being. Nursing education that focuses on strength-based and decolonizing frameworks, as well as reflexive practices that promote culturally safe care, is needed.

Engaging Street-Involved Youth in Dialectical Behaviour Therapy: A Secondary Analysis.

OBJECTIVE: The objective of this secondary analysis was to identify factors associated with engagement of street-involved youth in a Dialectical Behavioural Therapy (DBT) intervention. METHODS: This was a cross-sectional correlational study. Youth were recruited from two agencies providing services to street-involved youth in Canada. Mental health indicators were selected for this secondary analysis to gain a better understanding of characteristics that may account for levels of engagement. RESULTS: Three distinct groups of participants were identified in the data, a) youth who expressed intention to engage, but did not start DBT (n=16); b) youth who started DBT but subsequently dropped out (n=39); and c) youth who completed the DBT intervention (n=67). Youth who did engage in the DBT intervention demonstrated increased years of education; increased depressive symptoms and suicidality; and lower levels of resilience and self-esteem compared to youth participants who did not engage in the intervention. CONCLUSIONS: These findings indicate that it is possible to engage street-involved youth in a DBT intervention who exhibit a high degree of mental health challenges. Despite the growing literature describing the difficult psychological and interpersonal circumstances of street-involved youth, there remains limited research regarding the process of engaging these youth in service.

OBJECTIF: L'objectif de cette analyse secondaire était d'identifier les facteurs associés à l'engagement des adolescents de la rue dans une intervention de thérapie comportementale dialectique (TCD). MÉTHODES: Il s'agissait d'une étude corrélationnelle transversale. Les adolescents ont été recrutés dans deux organismes offrant des services aux adolescents de la rue du Canada. Des indicateurs de la santé mentale ont été sélectionnés pour cette analyse secondaire afin de mieux comprendre les caractéristiques qui peuvent rendre compte des niveaux d'engagement. RÉSULTAT: Trois groupes de participants distincts ont été identifiés dans les données: a) les adolescents qui ont exprimé l'intention de s'engager, mais n'ont pas commencé la TCD (n = 16); b) les adolescents qui ont commencé la TCD mais l'ont ensuite abandonnée (n = 39); et c) les adolescents qui ont terminé l'intervention de TCD (n = 67). Les adolescents qui se sont engagés dans l'intervention de TCD ont démontré plus d'années de scolarité, des symptômes accrus de dépression et de suicidabilité, et des niveaux plus faibles de résilience et d'estime de soi comparativement aux adolescents participants qui ne se sont pas engagés dans l'intervention. CONCLUSIONS: Ces résultats indiquent qu'il est possible d'engager dans une intervention de TCD des adolescents de la rue qui présentent un degré élevé de problèmes de santé mentale. Malgré la littérature croissante décrivant les circonstances psychologiques et interpersonnelles difficiles des adolescents dans la rue, la recherche demeure limitée à l'égard du processus d'engager ces adolescents dans les services.