From pressure in the pipeline to accelerating ascension: a survey to understand professional experiences of and opportunities for Canadian women in the healthcare sector.

BACKGROUND: Much has been written about the state and persistent lack of progress regarding gender equity and the commonly referenced phenomenon of a 'leaking pipeline'. This framing focuses attention on the symptom of women leaving the workforce, rather than the well-documented contributing factors of hindered recognition, advancement, and financial opportunities. While attention shifts to identifying strategies and practices to address gender inequities, there is limited insight into the professional experiences of Canadian women, specifically in the female-dominated healthcare sector. METHODS: We conducted a survey of 420 women working across a range of roles within healthcare. Frequencies and descriptive statistics were calculated for each measure as appropriate. For each respondent, two composite Unconscious Bias (UCB) scores were created using a meaningful grouping approach. RESULTS: Our survey results highlight three key areas of focus to move from knowledge to action, including (1) identifying the resources, structural factors, and professional network elements that will enable a collective shift towards gender equity; (2) providing women with access to formal and informal opportunities to develop the strategic relational skills required for advancement; and (3) restructuring social environments to be more inclusive. Specifically, women identified that self-advocacy, confidence building, and negotiation skills were most important to support development and leadership advancement. CONCLUSIONS: These insights provide systems and organizations with practical actions they can take to support women in the health workforce amid a time of considerable workforce pressure.

Beliefs regarding COVID-19 vaccines among Canadian workers in the intellectual disability sector prior to vaccine implementation.

BACKGROUND: Workers supporting adults with intellectual disabilities (ID) experience significant stress in their essential role during COVID-19 due to the high risk of their clients contracting COVID-19 and having adverse outcomes. The purpose of the current study was to describe the attitudes of workers towards COVID-19 vaccination prior to vaccination rollout, with a view to informing strategies to promote vaccine uptake within this high-risk sector. METHODS: An online survey was sent via email to workers supporting adults with ID in Ontario, Canada, between January 21 and February 3, 2021 by agency leadership and union representatives. RESULTS: Three thousand and three hundred and seventy-one workers, representing approximately 11.2% of Ontario workers supporting adults with ID completed an online survey. Most reported that they were very likely (62%) or likely (20%) to get a COVID-19 vaccine (vaccination intent) although 18% reported they were less likely to do so (vaccination nonintent). Workers with vaccination nonintent were younger and were more likely to endorse the beliefs that (1) it will not benefit them or those around them, (2) it was not part of their job, (3) rapid development confers uncertainties and risks, and (4) they were scared of potential vaccine side effects. CONCLUSIONS: There is need to address common misconceptions among workers supporting adults with ID to help activate them as vaccine advocates in the communities they serve. Partnered efforts between workers, unions and agency leadership with public health experts to address concerns are required.

Understanding the behavioural determinants of opioid prescribing among family physicians: a qualitative study.

BACKGROUND: Longstanding variation in the views of family physicians (FPs) on the role of opioids seems to translate into widely varying prescribing rates. Improvement interventions are unlikely to achieve change if they do not understand and explicitly target the factors that determine physician prescribing behaviour. The aim of this work was to understand (1) the perspectives of FPs as it relates to opioid prescribing, and (2) the perceived barriers and enablers to guideline-adherent opioid prescribing and management of chronic non-cancer pain. METHODS: A qualitative study involving one-on-one, semi-structured interviews with a sample of FPs in Ontario, Canada. Interviews were analyzed using a directed content analysis informed by the Theoretical Domains Framework. A framework approach was used to explore interaction across behavioural determinants (factors influencing behaviour) as well as demographic sources of variation. The behaviour of interest for the current study was the prescribing of opioid medications (including initiation, renewal, and dose reduction) for patients with chronic, non-cancer pain. Associated issues in the overall management of such patients were also explored. RESULTS: Interviews were conducted with 22 FPs. Behavioural determinants interacted with one another to influence FPs prescribing behavior. The TDF domain Beliefs about Consequences played a central role in explaining physician prescribing behaviours as they related to the management of chronic non-cancer pain. Individual beliefs about prescribing consequences and patient behaviour interacted with prescriber beliefs about capabilities and perceptions of the FP's professional role to influence prescriber behaviour. Emotion and the environmental context influenced the impact of these determinants on opioid prescribing and the management of chronic non-cancer pain. CONCLUSIONS: FPs face a wide range of complex (and often interacting) challenges when prescribing opioid therapy to their patients. Solution-based strategies should target these determinants directly using evidence-based strategies that move beyond guideline dissemination and general education. Shared decision-making strategies and patient-facing decision aids are likely to decrease the tension experienced in challenging conversations.

Understanding the impact of accreditation on quality in healthcare: A grounded theory approach.

OBJECTIVE: To explore how organizations respond to and interact with the accreditation process and the actual and potential mechanisms through which accreditation may influence quality. DESIGN: Qualitative grounded theory study. SETTING: Organizations who had participated in Accreditation Canada's Qmentum program during January 2014-June 2016. PARTICIPANTS: Individuals who had coordinated the accreditation process or were involved in managing or promoting quality. RESULTS: The accreditation process is largely viewed as a quality assurance process, which often feeds in to quality improvement activities if the feedback aligns with organizational priorities. Three key stages are required for accreditation to impact quality: coherence, organizational buy-in and organizational action. These stages map to constructs outlined in Normalization Process Theory. Coherence is established when an organization and its staff perceive that accreditation aligns with the organization's beliefs, context and model of service delivery. Organizational buy-in is established when there is both a conceptual champion and an operational champion, and is influenced by both internal and external contextual factors. Quality improvement action occurs when organizations take purposeful action in response to observations, feedback or self-reflection resulting from the accreditation process. CONCLUSIONS: The accreditation process has the potential to influence quality through a series of three mechanisms: coherence, organizational buy-in and collective quality improvement action. Internal and external contextual factors, including individual characteristics, influence an organization's experience of accreditation.

Testing e-mail content to encourage physicians to access an audit and feedback tool: a factorial randomized experiment.

Background: In Ontario, an online audit and feedback tool that provides primary care physicians with detailed information about patients who are overdue for cancer screening is underused. In the present study, we aimed to examine the effect of messages operationalizing 3 behaviour change techniques on access to the audit and feedback tool and on cancer screening rates. Methods: During May-September 2017, a pragmatic 2×2×2 factorial experiment tested 3 behaviour change techniques: anticipated regret, material incentive, and problem-solving. Outcomes were assessed using routinely collected administrative data. A qualitative process evaluation explored how and why the e-mail messages did or did not support Screening Activity Report access. Results: Of 5449 primary care physicians randomly allocated to 1 of 8 e-mail messages, fewer than half opened the messages and fewer than 1 in 10 clicked through the messages. Messages with problem-solving content were associated with a 12.9% relative reduction in access to the tool (risk ratio: 0.871; 95% confidence interval: 0.791 to 0.958; p = 0.005), but a 0.3% increase in cervical cancer screening (rate ratio: 1.003; 95% confidence interval: 1.001 to 1.006; p = 0.003). If true, that association would represent 7568 more patients being screened. No other significant effects were observed. Conclusions: For audit and feedback to work, recipients must engage with the data; for e-mail messages to prompt activity, recipients must open and review the message content. This large factorial experiment demonstrated that small changes in the content of such e-mail messages might influence clinical behaviour. Future research should focus on strategies to make cancer screening more user-centred.

Improving the appropriateness of antipsychotic prescribing in nursing homes: a mixed-methods process evaluation of an academic detailing intervention.

BACKGROUND: In 2014, nursing home administration and government officials were facing increasing public and media scrutiny around the variation of antipsychotic medication (APM) prescribing across Ontario nursing homes. In response, policy makers partnered to test an academic detailing (AD) intervention to address appropriate prescribing of APM in nursing homes in a cluster-randomized trial. This mixed-methods study aimed to explore how and why the AD intervention may have resulted in changes in the nursing home context. The objectives were to understand how the intervention was implemented, explore contextual factors associated with implementation, and examine impact of the intervention on prescribing. METHODS: Administrative data for the primary outcome of the full randomized trial will not be available for a minimum of 1 year. Therefore, this paper reports the findings of a planned, quantitative interim trial analysis assessed mean APM dose and prescribing prevalence at baseline and 3 and 6 months across 40 nursing homes (18 intervention, 22 control). Patient-level administrative data regarding prescribing were analyzed using generalized linear mixed effects regression. Semi-structured interviews were conducted with nursing home staff from the intervention group to explore opinions and experiences of the AD intervention. Interviews were analyzed using the framework method, with constructs from the Consolidated Framework for Implementation Research (CFIR) applied as pre-defined deductive codes. Open coding was applied when emerging themes did not align with CFIR constructs. Qualitative and quantitative findings were triangulated to examine points of divergence to understand how the intervention may work and to identify areas for future opportunities and areas for improvement. RESULTS: No significant differences were observed in prescribing outcomes. A total of 22 interviews were conducted, including four academic detailers and 18 nursing home staff. Constructs within the CFIR domains of Outer Setting, Inner Setting, and Characteristics of Individuals presented barriers to antipsychotic prescribing. Intervention Source, Evidence Strength and Quality, and Adaptability explained participant engagement in the AD intervention; nursing homes that exhibited a Tension for Change and Leadership Engagement reported positive changes in processes and communication. CONCLUSIONS: Participants described their experiences with the intervention against the backdrop of a range of factors that influence APM prescribing in nursing homes that exist at the system, facility, provider, and resident levels. In this context, the perceived credibility and flexibility of the intervention were critical features that explained engagement with and potential impact of the intervention. Development of a common language across the team to enable communication was reported as a proximal outcome that may eventually have an effect on APM prescribing rates. Process evaluations may be useful during early stages of evaluation to understand how the intervention is working and how it might work better. Qualitative results suggest the lack of early changes observed in prescribing may reflect the number of upstream factors that need to change for APM rates to decrease. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02604056.