Nurses and electronic health records in a Canadian hospital: examining the social organisation and programmed use of digitised nursing knowledge.

Institutional ethnography (IE) is used to examine transformations in a professional nurse's work associated with her engagement with a hospital's electronic health record (EHR) which is being updated to integrate professional caregiving and produce more efficient and effective health care. We review in the technical and scholarly literature the practices and promises of information technology and, especially of its applications in health care, finding useful the more critical and analytic perspectives. Among the latter, scholarship on the activities of economising is important to our inquiry into the actual activities that transform 'things' (in our case, nursing knowledge and action) into calculable information for objective and financially relevant decision-making. Beginning with an excerpt of observational data, we explicate observed nurse-patient interactions, discovering in them traces of institutional ruling relations that the nurse's activation of the EHR carries into the nursing setting. The EHR, we argue, materialises and generalises the ruling relations across institutionally located caregivers; its authorised information stabilises their knowing and acting, shaping health care towards a calculated effective and efficient form. Participating in the EHR's ruling practices, nurses adopt its ruling standpoint; a transformation that we conclude needs more careful analysis and debate.

Nurses' views and current practice of trauma-informed pediatric nursing care.

Grounded in research on posttraumatic stress etiology, "trauma-informed pediatric care" integrates understanding of posttraumatic stress, and specific practices to reduce posttraumatic stress, into clinical care of ill or injured children. Across five level I or II pediatric trauma centers, 232 nurses completed a survey of knowledge, opinions, self-rated competence, and current practice with regard to trauma-informed nursing care. Participants were knowledgeable and generally held favorable opinions about trauma-informed care. The majority considered themselves moderately competent in a range of relevant skills; their recent practice showed most variability with regard to teaching patients and parents how to cope with upsetting experiences.

Evaluation of a Dragons' Den-inspired symposium to spread primary health care innovations in Quebec, Canada: a mixed-methods study using quality-improvement e-surveys.

BACKGROUND: On May 24, 2017, the Quebec College of Family Physicians held an innovation symposium inspired by the television show Dragons' Den, at which innovators pitched their innovations to Dragon-Facilitators (i.e., decision-makers) and academic family medicine clinical leads. We evaluated the effects of the symposium on the spread of primary health care innovations. METHODS: We conducted a mixed-methods evaluation of the symposium. We collected data related to Rogers' innovation-decision process using 3 quality-improvement e-surveys (distributed between May 2017 and February 2018). The first survey evaluated spread outputs (innovation discovery, intention to spread, improvements) and was sent to all participants immediately after the symposium. The second evaluated short-term spread outcomes (follow-ups, successes, barriers) and was sent to innovators 3 months after the symposium. The third evaluated medium-term spread outcomes (spread, perceived impact) and was sent to innovators and clinical leads 9 months after the symposium. We analyzed the data using descriptive statistics, content analysis and joint display. RESULTS: Fifty-one innovators, 66 clinical leads (representing 42 clinics) and 37 Dragon-Facilitators attended the symposium. The response rates for the surveys were 61% (82/134) for the immediate post-symposium survey of all participants; 68% (21/31) for the 3-month survey of innovators; and 49% (48/97) for the 9-month survey of clinical leads and innovators. Immediately after the symposium, clinical leads and Dragon-Facilitators reported a high likelihood of adopting an innovation (mean ± standard deviation 8.02 ± 1.63 on a 10-point Likert scale) and 87% (53/61) agreed that they had discovered innovations at the symposium. Nearly all innovators (95%, 20/21) intended to follow up with potential adopters. After 3 months, 62% (13/21) of innovators had followed up in some way. After 9 months, 72% of clinical leads (18/25) had implemented at least 1 innovation, and 52% of innovators (12/23) had spread or were in the process of spreading innovations. INTERPRETATION: The innovation symposium supported participants in achieving the early stages of spreading primary health care innovations. Replicating such symposia may help spread other health care innovations.

Modulatory effect of a complex fraction derived from colostrum on fibroblast contractibility and consequences on repair tissue.

A complex compound (immune ('IM') fraction) from colostrum-derived whey was investigated for its potential wound healing properties. One of its most intriguing in vitro abilities was to significantly inhibit the contraction of collagen gel while fibroblast density remained as in control gels. This antagonist effect was dose dependent and fibroblasts in these gels did not exhibit any stress fibres. Subsequently, in vivo studies have been conducted in two wound models in guinea pigs. Daily application on full-thickness wounds of a liquid formulation of the IM fraction (first model) significantly delayed wound closure by contraction compared to what normally occurred in control wounds. In another wound model, a gel formulation of the IM fraction was applied on scar tissues, which resulted in a minimised residual scar on 5/8 wounds compared to corresponding wound areas seen prior to treatment. Conversely, most control wounds exhibited scar tissue from which 3/8 resembled hypertrophic scar tissue. Wound tissue treated with IM fraction covered a significantly larger area than in the control wounds, whereas the collagen deposition was unchanged as in the presence of α-smooth muscle actin. Thus, IM fraction may act by modulating the contraction rate and wound remodelling.

Avoiding Cribari gridlock 2: The standardized triage assessment tool outperforms the Cribari matrix method in 38 adult and pediatric trauma centers.

OBJECTIVES: The Cribari Matrix Method (CMM) is the current standard to identify over/undertriage but requires manual trauma triage reviews to address its inadequacies. The Standardized Triage Assessment Tool (STAT) partially emulates triage review by combining CMM with the Need For Trauma Intervention, an indicator of major trauma. This study aimed to validate STAT in a multicenter sample. METHODS: Thirty-eight adult and pediatric US trauma centers submitted data for 97,282 encounters. Mixed models estimated the effects of overtriage and undertriage versus appropriate triage on the odds of complication, odds of discharge to a continuing care facility, and differences in length of stay for both CMM and STAT. Significance was assessed at p <0.005. RESULTS: Overtriage (53.49% vs. 30.79%) and undertriage (17.19% vs. 3.55%) rates were notably lower with STAT than with CMM. CMM and STAT had significant associations with all outcomes, with overtriages demonstrating lower injury burdens and undertriages showing higher injury burdens than appropriately triaged patients. STAT indicated significantly stronger associations with outcomes than CMM, except in odds of discharge to continuing care facility among patients who received a full trauma team activation where STAT and CMM were similar. CONCLUSIONS: This multicenter study strongly indicates STAT safely and accurately flags fewer cases for triage reviews, thereby reducing the subjectivity introduced by manual triage determinations. This may enable better refinement of activation criteria and reduced workload.

Expanding what we know about off-peak mortality in hospitals.

For more than 30 years, a negative "off-peak effect" on patient outcomes has been associated with weekend and/or nighttime hospitalization in more than 25 diagnostic groups. Descriptive studies have verified the presence of this off-peak effect on patient outcomes but have done little to explain its cause. Institutional ethnography is a promising method for describing challenges nurses encounter and deal with on off-peak shifts and for exploring how those challenges arose in institutions designed to avoid such outcomes. The authors discuss their research and suggest a number of steps that nurse administrators might take to enhance their knowledge for handling off-peak challenges in their hospitals.

Assessing the scalability of innovations in primary care: a cross-sectional study.

BACKGROUND: Canadian health funding currently prioritizes scaling up for evidence-based primary care innovations, but not all teams prepare for scaling up. We explored scalability assessment among primary care innovators in the province of Quebec to evaluate their preparedness for scaling up. METHODS: We performed a cross-sectional survey from Feb. 18 to Mar. 18, 2019. Eligible participants were 33 innovation teams selected for the 2019 Quebec College of Family Physicians' Symposium on Innovations. We conducted a Web-based survey in 2 sections: innovation characteristics and the Innovation Scalability Self-administered Questionnaire. The latter includes 16 criteria (scalability components) grouped into 5 dimensions: theory (1 criterion), impact (6 criteria), coverage (4 criteria), setting (3 criteria) and cost (2 criteria). We classified innovation types using the International Classification of Health Interventions. We performed a descriptive analysis using frequency counts and percentages. RESULTS: Out of 33 teams, 24 participated (72.7%), with 1 innovation each. The types of innovation were management (15/24), prevention (8/24) and therapeutic (1/24). Most management innovations focused on patient navigation (9/15). In order of frequency, teams had assessed theory (79.2%) and impact (79.2%) criteria, followed by cost (77.1%), setting (59.7%) and coverage (54.2%). Most innovations (16/24) had assessed 10 criteria or more, including 10 management innovations, 5 prevention innovations and 1 therapeutic innovation. Implementation fidelity was the least assessed criterion (6/24). INTERPRETATION: The scalability assessments of a primary care innovation varied according to its type. Management innovations, which were the most prevalent and assessed the most scalability components, appear to be most prepared for primary care scale-up in Canada.

Beyond the physical injuries: child and parent coping with medical traumatic stress after pediatric trauma.

Experiencing a traumatic event and then the required care for the physical injuries can elicit stress symptoms in the injured child and parents. Stress-related symptoms affect a significant number of injured children and can have an impact on emotional and physical health outcomes after injury. Yet the majority of children who suffer from posttraumatic stress disorder postinjury go undiagnosed and untreated. Medical traumatic stress symptoms that occur often as adaptive responses initially can persist. Acute stress disorder is diagnosed when the stress symptoms persist less than 1 month postinjury and affect normal functioning. Inclusion of screening for acute stress and the development of models and guidelines are needed to systematically incorporate the care for the emotional trauma as an integral part of pediatric trauma care. Pediatric trauma nurses with knowledge and resources are in a position to minimize potentially traumatic aspects of the care they deliver, recognize traumatic stress symptoms, and help parents to support their child's coping and promote appropriate help seeking.

Rethinking the definition of major trauma: The need for trauma intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers.

BACKGROUND: Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS. METHODS: Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS greater than 15, RTS less than 7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS). RESULTS: The NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios [99.5% confidence interval]: NFTI = 9.44 [8.46-10.53]; ISS = 5.94 [5.36-6.60], RTS = 4.79 [4.29-5.34]; LOS incidence rate ratios (99.5% confidence interval): NFTI = 3.15 [3.08-3.22], ISS = 2.87 [2.80-2.94], RTS = 2.37 [2.30-2.45]). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk [99.5% confidence interval]: NFTI = 2.59 [2.52-2.66], ISS = 2.51 [2.44-2.59], RTS = 2.37 [2.28-2.46]). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS greater than 15 or RTS less than 7.84. CONCLUSION: In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS greater than 15 and RTS less than 7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments. LEVEL OF EVIDENCE: Prognostic, level IV.

Primary Care Providers' Barriers and Adherence to the U.S. Preventive Services Task Force Mammography Screening Guidelines.

Earlier detection through mammography screening, increased awareness, and improved treatment modalities has resulted in a decline in breast cancer incidence. Despite the availability of the clinical guidelines by the U.S. Preventive Services Task Force (USPSTF), adherence to these methods is only 42% (Meissener, Klabunde, Breen, & Zapka, 2011). The purpose of this scholarly project was to identify and improve provider's adherence to the USPSTF mammography screening clinical guidelines in three primary care clinics located in Southeastern North Carolina. The project included development of an educational program to increase awareness of the guidelines followed by measures to increase screening. A posteducation intervention chart review was completed to determine if there was an increase in adherence and use to the guidelines. Sample size included 90 retrospective chart reviews of the patients meeting the criteria for mammography screening. Based on the results, further recommendations were provided to the providers to improve adherence. Data analysis was conducted using descriptive statistics. The findings of this project identified barriers to the adherence to the USPSTF mammography screening guidelines among primary care providers in the three clinics selected. The educational intervention increased the adherence to the USPSTF mammography screening guideline from 15% to 16%.

Mental health research and cultural dominance: the social construction of knowledge for international development.

This institutional ethnographic work uses the first author's experience as an international development worker, educator, and community mental health nurse in West Africa to illustrate how official research and policy on mental health services reflect Western academic, corporate, economic, and cultural dominance. Focusing on a critical textual analysis of a survey intended to support funding applications to international aid/lending agencies, the authors show how official processes privilege Western policies/research approaches and subordinate local perspectives. If nurses, researchers, and policy-makers are to be effective in carrying out development work in Africa, they must learn to appreciate the subtle exertion of dominance inherent in Western approaches. The authors propose that understanding local knowledge be foregrounded rather than backgrounded to the complex global interpretive frames for international research and international development policy.

Knowledge for re-forming nursing's future: standpoint makes a difference.

We draw on our recent research that has convinced us of the importance of nurses' participating in re-forming health care on their own terms. The empirical evidence we present here shows how "boardroom knowledge" of health care is constructed with different priorities than is the knowledge of direct care on which nurses' safe, efficient, and effective work relies. The 2 forms of knowledge are not the same. Nurses' knowledge is routinely transposed through a procrustean process of "working up" direct care nurses' knowledge into new informational forms without attention to the importance of the full range of what nurses know from their unique standpoint.

Aid effectiveness and women's empowerment: practices of governance in the funding of international development.

Although the empowerment of women is a prominent goal in international development, feminist development professionals, activists, and scholars remain deeply dissatisfied with the limited extent to which women's empowerment is actually achieved. Their experiences and analyses raise questions about the connections and disjunctions between discourse, institutional practices, and everyday life. A major effort to reform development aid guided by the Paris Declaration on Aid Effectiveness raises new questions about the place of gender in development practice. Drawing on recently conducted research on women and development in Kyrgyzstan and using a range of institutional texts, we interrogate how development professionals and activists engage with the aid effectiveness discourse. Our analytic approach, institutional ethnography, shares with work on governmentality an empirical focus on practices undertaken by diversely situated people and how these practices constitute a particular field of action. Institutional ethnography directs analytic attention to the operation of texts as local and translocal coordinators of people's everyday activities. The product of this coordinated work is what we call, in this case, the development institution. For those concerned about women and development, we see the usefulness of making visible how global governance is accomplished in both enactments of and resistance to institutional practices, but in ways that do not necessarily benefit women.