Patients' Perceptions of Reasons Contributing to Delay in Seeking Help at the Onset of a Diabetic Foot Ulcer: A Grounded Theory Study.

PURPOSE: The purpose of this study was to explore patients' perception of reasons contributing to delay in seeking help and referral to a wound care specialist at the onset of a diabetic foot ulcer (DFU). DESIGN: Constructivist grounded theory study. SUBJECTS AND SETTING: The sample comprised 30 individuals with active DFU attending a wound care clinic in southeastern Ontario, Canada. METHODS: Participants were selected through purposive and theoretical sampling. Semistructured interviews were conducted with participants until no new properties of the patterns emerged. All interviews were transcribed, coded, and analyzed using methods informed by constructivist grounded theory. RESULTS: The reasons contributing to delay to seek help and referral to a wound care specialist were (1) limited knowledge about foot care, (2) unaware of diabetic foot problems, (3) underestimation of ulcer presentation, (4) I thought I could fix it myself, (5) inaccurate diagnosis, and (6) trial and error approach by a nonspecialized wound care provider. CONCLUSIONS: Study findings suggest that patients and primary healthcare providers need additional education regarding the management of diabetic foot disease and DFU.

Re-imaging Clinical Education: The Interdependence of the Self-Regulated Clinical Teacher and Nursing Student.

The interdependence of student learning strategies and teacher's pedagogical practices is critical to clinical practice learning. While research demonstrates that formative assessment feedback is important for student learning, clinical teachers do not necessarily have the competencies to provide effective feedback to support students' self-regulated learning (SRL). An examination of clinical education through SRL lenses articulates two roles for clinical teachers in nursing clinical education: self-regulated learner and self-regulated teacher. Teachers as self-regulated learners are practice-content experts and must also learn how to explicitly help students become self-regulated learners. The latter is the self-regulated teacher role, and a self-regulated teacher is an effective clinical teacher. Minimal research addresses the ways in which clinical teachers' effectiveness could be improved if they took on a self-regulated teacher role. A model of SRL and teaching in clinical practice education is presented and its potential to enhance clinical teacher effectiveness and student SRL articulated.

Using graphic illustrations to uncover how a community of practice can influence the delivery of compassionate healthcare.

Our modern-day frenetic healthcare culture has progressed to a state where healthcare professionals tend to detach themselves from the emotions of their patients/clients, rather than embed compassion into their daily practice. The AMS Phoenix Project: A Call to Caring was implemented with the goal to instil and sustain empathy and compassion in environments where clinicians learn and work. The purpose of this study is to report on how an interprofessional community of practice (CoP) of healthcare educators can contribute to a cultural shift in promoting and delivering compassion in healthcare through health professionals education. Using an imaginative creative autoethnography that adopts a narrative design through graphic illustrations, data were collected from 25 members of the Phoenix@Queen's CoP during a 1-day retreat. Data collection included a graphic recorder who visually depicted all retreat dialogue, field notes that highlighted emergent themes and artefacts produced during the day. Audio recordings of the discussions were used as secondary sources of data. Using thematic analysis, three themes emerged: the call to caring is a long and winding road with many barriers and rewards; CoP members experienced personal growth in and through the community; and the Phoenix@Queen's CoP matters in terms of professional relationships, leadership and moving forward a shared agenda about practising compassionate healthcare. This study describes the development of a CoP that moves away from traditional committees and discussions to an experiential creation of connections and shared meaning by its members. By using autoethnography, and by demonstrating how graphic illustration can be an innovative and creative method for recording and interpreting group discussions, we have demonstrated the accelerated development of an authentic CoP. With a richer and more authentic community, the shared goals of healthcare professional educators are more likely to be achieved.

Patient, Treatment, and Health Care Utilization Variables Associated with Adherence to Metabolic Monitoring Practices in Children and Adolescents Taking Second-Generation Antipsychotics.

OBJECTIVE: Children and adolescents with a range of psychiatric disorders are increasingly being prescribed atypical or second-generation antipsychotics (SGAs). While SGAs are effective at treating conduct and behavioural symptoms, they infer significant cardiometabolic risk. This study aims to explore what patient, treatment, and health care utilization variables are associated with adherence to Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA) metabolic monitoring guidelines. METHOD: A retrospective chart review of 294 children and adolescents accessing a large outpatient psychiatry setting within a 2-year study period (2014-2016) was conducted. Baseline and follow-up metabolic monitoring, demographic, treatment, and health care utilization variables were then assessed over a 1-year period of interest. RESULTS: Metabolic monitoring practices did not adhere to CAMESA guidelines and were very poor over the 1-year observation period. There were significant differences between children (ages 4-12 years, n = 99) and adolescents (ages 13-18 years, n = 195). In adolescents, factors associated with any baseline metabolic monitoring were a higher number of psychiatry visits (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.10 to 1.41), longer duration of contact (OR, 14; 95% CI, 2.31 to 82.4), and use of other non-SGA medications (OR, 3.2; 95% CI, 1.17 to 8.94). Among children, having an emergency room visit (OR, 3.4; 95% CI, 1.01 to 11.71) and taking aripiprazole (OR, 7.4; 95% CI, 2.02 to 27.45) increased the odds of receiving baseline metabolic monitoring. CONCLUSION: Findings from this study highlight the need for better metabolic monitoring for children and adolescents taking SGAs. Enhanced focus on opportunities for multidisciplinary collaboration is needed to improve the quality of care offered to this population.

Nurses' Perspectives on the Geriatric Nursing Practice Environment and the Quality of Older People's Care in Ontario Acute Care Hospitals.

Background Cultivating hospital environments that support older people's care is a national priority. Evidence on geriatric nursing practice environments, obtained from studies of registered nurses (RNs) in American teaching hospitals, may have limited applicability to Canada, where RNs and registered practical nurses (RPNs) care for older people in predominantly nonteaching hospitals. Purpose This study describes nurses' perceptions of the overall quality of care for older people and the geriatric nursing practice environment (geriatric resources, interprofessional collaboration, and organizational value of older people's care) and examines if these perceptions differ by professional designation and hospital teaching status. Methods A cross-sectional survey, using Dillman's tailored design, that included Geriatric Institutional Assessment Profile subscales, was completed by 2005 Ontario RNs and registered practical nurses to assess their perceptions of the quality of care and geriatric nursing practice environment. Results Scores on the Geriatric Institutional Assessment Profile subscales averaged slightly above the midpoint except for geriatric resources which was slightly below. Registered practical nurses rated the quality of care and geriatric nursing practice environment higher than RNs; no significant differences were found by hospital teaching status. Conclusions Nurses' perceptions of older people's care and the geriatric nursing practice environment differ by professional designation but not hospital teaching status. Teaching and nonteaching hospitals should both be targeted for geriatric nursing practice environment improvement initiatives.

A Multi-Method Study of the Geriatric Learning Needs of Acute Care Hospital Nurses in Ontario, Canada.

Older people are at risk of experiencing functional decline and related complications during hospitalization. In countries with projected increases in age demographics, preventing these adverse consequences is a priority. Because most Canadian nurses have received little geriatrics content in their basic education, understanding their learning needs is fundamental to preparing them to respond to this priority. This two-phased multi-method study identified the geriatrics learning needs and strategies to address the learning needs of acute care registered nurses (RNs) and registered practical nurses (RPNs) in the province of Ontario, Canada. In Phase I, a survey that included a geriatric nursing knowledge scale was completed by a random sample of 2005 Ontario RNs and RPNs. Average scores on the geriatric nursing knowledge scale were in the "neither good nor bad" range, with RNs demonstrating slightly higher scores than RPNs. In Phase II, 33 RN and 24 RPN survey respondents participated in 13 focus group interviews to help confirm and expand survey findings. In thematic analysis, three major themes were identified that were the same in RNs and RPNs: (a) geriatric nursing is generally regarded as simple and custodial, (b) older people's care is more complex than is generally appreciated, and (c) in the current context, older people's care is best learned experientially and in brief on-site educational sessions. Healthcare providers, policy-makers, and educators can use the findings to develop educational initiatives to prepare RNs and RPNs to respond to the needs of an aging hospital population.

Using a situational awareness global assessment technique for interprofessional obstetrical team training with high fidelity simulation.

Evidence suggests that breakdowns in communication and a lack of situation awareness contribute to poor performance of medical teams. In this pilot study, three interprofessional obstetrical teams determined the feasibility of using the situation awareness global assessment technique (SAGAT) during simulated critical event management of three obstetrical scenarios. After each scenario, teams were asked to complete questionnaires assessing their opinion of how their performance was affected by the introduction of questions during a SAGAT stop. Fifteen obstetrical professionals took part in the study and completed the three scenarios in teams consisting of five members. At nine questions per stop, more participants agreed or strongly agreed that there were too many questions per stop (57.1%) than when we asked six questions per stop (13%) and three questions per stop (0%). A number of interprofessional differences in response to this interprofessional experience were noted. A team SAGAT score was determined by calculating the proportion of correct responses for each individual. Higher scores were associated with better adherence to outcome times, although not statistically significant. A robust study design building on our pilot data is needed to probe the differing interprofessional perceptions of SAGAT and the potential association between its scores and clinical outcome times.

Effectiveness of early discharge planning in acutely ill or injured hospitalized older adults: a systematic review and meta-analysis.

BACKGROUND: Older age and higher acuity are associated with prolonged hospital stays and hospital readmissions. Early discharge planning may reduce lengths of hospital stay and hospital readmissions; however, its effectiveness with acutely admitted older adults is unclear. METHODS: In this systematic review, we compared the effectiveness of early discharge planning to usual care in reducing index length of hospital stay, hospital readmissions, readmission length of hospital stay, and mortality; and increasing satisfaction with discharge planning and quality of life for older adults admitted to hospital with an acute illness or injury.We searched the Cochrane Library, DARE, HTA, NHSEED, ACP, MEDLINE, EMBASE, CINAHL, Proquest Dissertations and Theses, PubMed, Web of Science, SciSearch, PEDro, Sigma Theta Tau International's registry of nursing research, Joanna Briggs Institute, CRISP, OT Seeker, and several internet search engines. Hand-searching was conducted in four gerontological journals and references of all included studies and previous systematic reviews. Two reviewers independently extracted data and assessed risk of bias. Data were pooled using a random-effects meta-analysis. Where meta-analysis was not possible, narrative analysis was performed. RESULTS: Nine trials with a total of 1736 participants were included. Compared to usual care, early discharge planning was associated with fewer hospital readmissions within one to twelve months of index hospital discharge [risk ratio (RR) = 0.78, 95% CI = 0.69 - 0.90]; and lower readmission lengths of hospital stay within three to twelve months of index hospital discharge [weighted mean difference (WMD) = -2.47, 95% confidence intervals (CI) = -4.13 - -0.81)]. No differences were found in index length of hospital stay, mortality or satisfaction with discharge planning. Narrative analysis of four studies indicated that early discharge planning was associated with greater overall quality of life and the general health domain of quality of life two weeks after index hospital discharge. CONCLUSIONS: Early discharge planning with acutely admitted older adults improves system level outcomes after index hospital discharge. Service providers can use these findings to design and implement early discharge planning for older adults admitted to hospital with an acute illness or injury.

New Nurses' Perceptions on Transition to Practice: A Thematic Analysis.

BACKGROUND: New nurses' transition to the workforce is often described as challenging and stressful. Concerns over this transition to practice are well documented, with the hypothesis that transition experiences influence the retention of new nurses in the workforce and profession. METHODS: In a cross-sectional survey (N = 217) to assess new nurse transition in the province of Ontario, Canada, an open-ended item was included to solicit specific examples of the transition experience. The comments underwent thematic analysis to identify the facilitators and barriers of transition to practice for new nurses. RESULTS: Comments were provided by 196 respondents. Three facilitator themes (supportive teams; feeling accepted, confident, and prepared; new graduate guarantee) and four barrier themes (feeling unprepared; discouraging realities and unsupportive cultures; lacking confidence/feeling unsure; false hope) to new nurse transition emerged. CONCLUSIONS: Concerns of nursing shortages are heightened in the current COVID-19 pandemic, reinforcing the priority of retaining new nurses in the workforce. The reported themes offer insight into the contribution of a supportive work environment to new nurses' transition. The recommendations focus on aspects of supportive environments and educational strategies, including final practicums, to assist nursing students' development of self-efficacy and preparation for the workplace.

Measuring Scope of Practice Enactment Among Primary Care Registered Nurses.

BACKGROUND: Scope of practice enactment is poorly understood in the primary care setting. PURPOSE: The following research objectives were addressed: (1) to revise and adapt the Actual Scope of Practice (ASCOP) questionnaire for use in the primary care setting, and (2) to determine internal consistency, construct validity, and sensitivity of the modified instrument. METHODS: To address the first objective, a narrative literature review and synthesis and an expert panel review was conducted. To address the second objective, a cross-sectional survey of 178 registered nurses who worked in primary care was conducted. RESULTS: The ASCOP, with few modifications, addressed key attributes of nursing scope of practice in the primary care setting. The modified instrument yielded acceptable alpha coefficients ranging from 0.66 to 0.91. Total mean score of 4.8 (SD = .67) suggests that registered nurses within interprofessional primary care teams almost always engage in activities reflected in the modified instrument. CONCLUSIONS: The modified instrument is the first instrument validated to measure nursing scope of practice enactment in the primary care setting. Findings from this study support the use of the modified ASCOP questionnaire as a reliable and valid measure of scope of practice enactment among primary care registered nurses.

The Comparison of Role Conflict Among Registered Nurses and Registered Practical Nurses Working in Acute Care Hospitals in Ontario Canada.

OBJECTIVES: The study aimed to describe and compare nurses' perceptions of role conflict by professional designation [registered nurse (RN) vs registered practical nurse (RPN)] in three primary areas of practice (emergency department, medical unit, and surgical unit). METHODS: This analysis used data (n = 1,981) from a large cross-sectional survey of a random sample of RNs and RPNs working as staff nurses in acute care hospitals in Ontario, Canada. Role conflict was measured by the Role Conflict Scale. RESULTS: A total of 1,981 participants (RN = 1,427, RPN = 554) met this study's eligibility criteria and provided complete data. In general, RN and RPN mean total scale scores on role conflict hovered around the scale's mid-point (2.72 to 3.22); however, RNs reported a higher mean score than RPNs in the emergency department (3.22 vs. 2.81), medical unit (2.95 vs 2.81) and surgical unit (2.90 vs 2.72). Where statistically significant differences were found, the effect sizes were negligible to medium in magnitude with the largest differences noted between RNs and RPNs working in the emergency department. CONCLUSIONS: The results suggest the need to implement strategies that diminish role conflict for both RNs and RPNs.

Patients' Journey Toward Engagement in Self-Management of Diabetic Foot Ulcer in Adults With Types 1 and 2 Diabetes: A Constructivist Grounded Theory Study.

OBJECTIVES: Our aim in this study was to develop the first theory that could explain the processes of engagement in self-management for adults with diabetic foot ulcer (DFU). METHODS: A constructivist grounded theory, informed by Charmaz, and symbolic interactionism were used to guide the study design. RESULTS: The findings from 30 study participants with active DFU draw attention to the complexity that exists for individuals seeking to balance life and manage their diabetes and DFU. The categories/phases and set of associated concepts comprise the theory known as The Journey Toward Engagement in Self-Management. This theory consists of 5 phases: 1) perception of illness, 2) noticing foot changes, 3) realizing seriousness, 4) beginning to learn about self-management and 5) engaging in self-management. The theory's phases describe the processes of engagement in self-management from participants' unique experience of living and managing DFU. CONCLUSIONS: The results show the pathways taken by participants to learn about self-management practices and how engagement in day-to-day management of DFU occurred. Engagement in self-management of an active DFU is complex and a developmental process that differs from participant to participant and changes over time. Although most participants preferred to take a more passive role in self-management of DFU (seen in phase 4), others demonstrated confidence to advance to another stage (seen in phase 5). At the advanced stage, they took an active role in self-management by expressing their needs and preferences, and were involved in their own care and decision-making related to treatment options.

New Registered Nurse Transition to the Workforce and Intention to Leave: Testing a Theoretical Model.

BACKGROUND: The transition of new nurses into practice has been identified as challenging, and new nurses report having intentions to leave (ITL) jobs. Concerns of ITL are worrisome for the nursing profession, especially when faced with the need to replace an aging nursing workforce and to maintain quality patient care. PURPOSE: Guided by components of Meleis et al.'s mid-range transition theory, the purpose of this study was to test a theoretical model linking transition and ITL, as well as the personal, community and societal conditions of transition. METHODS: A predictive, non-experimental design using cross-sectional data was employed. Ontario registered nurses, who had graduated within two years, were randomly selected to complete a mailed questionnaire in 2015 (N = 217). Structural equation modeling was undertaken to test the model. RESULTS: The new nurses reported a relatively positive transition; yet, 44% of the respondents indicated leaving their first job, and 1% departed the nursing profession. A revised model of the constructs showed a more adequate fit with the data, but overall, the hypothesized model was not supported and methodological validity of tools questioned. From the modeling, lower role stress led to a positive transition. CONCLUSIONS: Given organizational and governmental investments in orientation and transition programs, challenges in measuring transition and ITL requires additional research. Our findings highlight the value of organizations supporting new nurses by reducing role stress through reasonable workloads and expectations, which in turn contributes to a positive transition.

I Cannot Afford Off-loading Boots: Perceptions of Socioeconomic Factors Influencing Engagement in Self-management of Diabetic Foot Ulcer.

This study aimed at uncovering the factors influencing individuals' ability to engage in self-management of diabetic foot ulcer (DFU) and presenting a theoretical model depicting these factors and the outcomes. We used constructivist grounded theory methodology to guide this study and recruited 30 participants with an active DFU attending a wound care clinic in Ontario, Canada. The study's findings indicate that participants' engagement in self-management of DFU was influenced by internal and external factors. While some factors contributed to enhance participants' engagement in everyday self-management, others seemed to have prevented them from achieving engagement and hence the desired DFU outcomes.

Developing a Sexual Orientation and Gender Identity Nursing Education Toolkit.

BACKGROUND: Current education lacks lesbian, gay, bisexual, transgender, questioning, intersex, and two-spirit (LGBTQI2S) content for health care providers (HCPs). Providing HCPs with understanding of LGBTQI2S health issues would reduce barriers. The Innovative Thinking to Support LGBTQI2S Health and Wellness trainee award supported the development of a website with virtual simulation games (VSGs) about providing culturally humble care to LGBTQI2S individuals to address this need. METHOD: An online educational toolbox was developed that included VSGs and resources. Development processes included a visioning meeting, development of learning objectives, and using a decision-point map for script writing. Bilingual VSGs were filmed, and the website was developed. RESULTS: The Sexual Orientation and Gender Identity Nursing Toolkit was created to advance cultural humility in practice. Learning modules focus on encounters using cultural humility to meet the unique needs of the LGBTQI2S community. CONCLUSION: Our innovative educational toolkit can be used to provide professional development of nurses and other HCPs to care for LGBTQI2S individuals. [J Contin Educ Nurs. 2020;51(9):412-419.].

Building Research Capacity in Nursing Academia in 2020: Is the Road Less Perilous?

BACKGROUND: Building research capacity in nursing academic units continues to be a challenge. There are a number of external contextual factors and internal factors that influence individual faculty as well as the collective to engage successfully in research. PURPOSE: The overall aim of this opinion article is to provide an overview of the current external and internal, processes and structures, relevant to capacity of nursing faculty to engage in research. METHODS: To inform the external context, we reviewed national research funding trends for nursing. To inform the internal context, we provided an exemplar of the internal processes and structures designed to support research capacity building within our academic unit. RESULTS: Canadian Institutes of Health Research funding trends for research grants led by nurse principal applicants increased between 2010 and 2013, followed by a steady decline. In 2017 to 2018, there were only 24 research grants led by nurse principal applicants. These external challenges coupled with the traditional internal barriers, such as the imbalance between teaching and research time, threaten research capacity for nursing academics. CONCLUSION: Organizational strategies to promote research capacity within academic nursing units are a necessary requirement to move forward.

On the ball: leadership for patient safety and learning in critical care.

OBJECTIVE: To explore nursing leadership for patient safety in critical care and identify opportunities to improve leadership that promotes patient safety. BACKGROUND: There is limited systematic evidence about how nurses lead the microsystem of critical care and to the creation of a culture of patient safety. METHODS: Focus groups of multidisciplinary frontline providers and managers were used to gain insight into leadership that promotes patient safety and learning. RESULTS: Gains in critical care patient safety require a skilled nursing leader who is mindful of bedside situations and has real-time decision-making authority. Patient safety is seen as management of the moment, rather than a function of organizational systems and processes. CONCLUSION: Leadership for improved patient safety resides primarily with nurses who provide direct patient care. These nurse leaders play 3 critical roles: they are the "go-to," they are "on the ball," and they "keep the ball rolling."

International nurse migration: U-turn for safe workplace transition.

Increasing globalization of the nursing workforce and the desire for migrants to realize their full potential in their host country is an important public policy and management issue. Several studies have examined the challenges migrant nurses face as they seek licensure and access to international work. However, fewer studies examine the barriers and challenges internationally educated nurses (IEN) experience transitioning into the workforces after they achieve initial registration in their adopted country. In this article, the authors report findings from an empirically grounded study that examines the experience of IENs who entered Ontario's workforce between 2003 and 2005. We found that migrant nurses unanimously described nursing as 'different' from that in their country of origin. Specifically, IENs reported differences in the expectations of professional nursing practice and the role of patients and families in decision-making. In addition, problems with English language fluency cause work-related stress and cognitive fatigue. Finally, the experience of being the outsider is a reality for many IENs. This study provides important insights as policy and management decision-makers balance the tension between increasing the IEN workforce and the delivery of safe patient care.

Building knowledge for safer care: nursing research advancing practice.

Organizational and professional efforts to support nurses engaging in research projects that advance patient safety practices are needed. In this context, the purpose of this article is to provide a description of the design, implementation, and evaluation of a research capacity strategy designed for clinical nurses and the lessons learned. Participating nurses evolved from research novices to key champions in advancing nursing practice, patient safety, and quality improvement.

Building clinical and organizational resilience to reconcile safety threats, tensions and trade-offs: insights from theory and evidence.

Healthcare delivery settings are complex adaptive and tightly coupled, interrelated systems. Within the larger healthcare system, a key subsystem is the "clinical microsystem" level. It is at this level that clinicians are faced with high levels of uncertainty in their daily work - uncertainty that impacts the quality and safety of care that patients receive. The first aim of this paper is to enhance healthcare leaders' understanding of what is currently known about safety threats and strategies to manage the inherent tensions and trade-offs that occur in everyday practice. The second aim is to inform strategies that build clinical and organizational resilience through a multi-level framework derived from the collective theoretical and empirical work. Together, this information can strengthen safety practices throughout healthcare organizations.