Evidence-Based Decision-Making 8: A Primer on Health Policy for Researchers.

There is a growing expectation that research will be used to inform decision-making. It is important for researchers to understand how health policy is developed and the different ways they can influence the development of policy.Public policy is developed to resolve identified problems. Health policy is a subset of public policy and is typically concerned with issues related to the health of populations either from a service delivery perspective or from a broader public health and social determinants of health perspective. The policy planning algorithm is well established and follows the basic decision-making framework: problem identification, policy formulation, implementation, and evaluation. A variety of government and nongovernment stakeholders engage in complex debates to identify and resolve policy issues. In this chapter, we explore how researchers can use their research to influence the development of health policy. Knowledge translation strategies focused on communicating research to policy-makers require considerable thought and planning.

Quality improvement in curriculum development.

Purpose There is a growing emphasis on teaching patient safety principles and quality improvement (QI) processes in medical education curricula. This paper aims to present how the Faculty of Medicine at Memorial University of Newfoundland engaged medical students in quality improvement during their recent curriculum renewal process. Design/methodology/approach In the 2013-2014 academic year, the Faculty of Medicine at Memorial University of Newfoundland launched an undergraduate medical education curriculum renewal process. This presented a unique opportunity to teach quality improvement by involving students in the ongoing development and continuous improvement of their undergraduate curriculum through the implementation of quality circles and other related QI activities. Findings The authors' experience shows that implementing QI processes is beneficial in the medical education environment, particularly during times of curriculum redesign or implementation of new initiatives. Originality/value Student engagement and participation in the QI process is an excellent way to teach basic QI concepts and improve curriculum program outcomes.

An Exploration of Palliative Care Needs of People With End-Stage Renal Disease on Dialysis: Family Caregiver's Perspectives.

Patients with end-stage renal disease supported on dialysis experience high morbidity and mortality. Little is known about family caregiver experiences during the disease. Qualitative research methods were used to explore the experiences of family caregivers caring for patients receiving dialysis. In-depth, semi-structured, in-person interviews were completed with 18 family caregivers in rural and urban settings. Interviews were audiotaped, transcribed verbatim, and analyzed using thematic and descriptive analysis. Major themes identified included challenges navigating the health system, caregiver burden, perceptions of palliative care, symptom management, and decision-making. Caregiver burdens are significant including physical, emotional, social, and economic dimensions. There is a need to recognize and improve support for family caregivers and increase collaboration with nephrology and palliative care services from commencement of dialysis until death and into bereavement.

Trajectories of body mass index among Canadian seniors and associated mortality risk.

BACKGROUND: This study aims to characterize the heterogeneity in BMI trajectories and evaluate how different BMI trajectories predict mortality risk in Canadian seniors. METHODS: Data came from the Canadian National Population Health Survey (NPHS, 1994-2011) and 1480 individuals aged 65-79 years with at least four BMI records were included in this study. Group-based trajectory model was used to identify distinct subgroups of longitudinal trajectories of BMI measured over 19 years for men and women. Cox proportional hazards models were used to examine the association between BMI trajectories and mortality risks. RESULTS: Distinct trajectory patterns were found for men and women: 'Normal Weight-Down'(N-D), 'Overweight-Normal weight' (OV-N), 'Obese I-Down' (OB I-D), and 'Obese II- Down' (OB II-D) for women; and 'Normal Weight-Down' (N-D), 'Overweight-Normal weight' (OV-N), 'Overweight-Stable' (OV-S), and 'Obese-Stable' (OB-S) for men. Comparing with OV-N, men in the OV-S group had the lowest mortality risk followed by the N-D (HR = 1.66) and OB-S (HR = 1.98) groups, after adjusting for covariates. Compared with OV-N, women in the OB II-D group with three or more chronic health conditions had higher mortality risk (HR = 1.61); however, women in OB II-D had lower risk (HR = 0.56) if they had less than three conditions. CONCLUSION: The course of BMI over time in Canadian seniors appears to follow one of four different patterns depending on gender. The findings suggest that men who were overweight at age 65 and lost weight over time had the lowest mortality risk. Interestingly, obese women with decreasing BMI have different mortality risks, depending on their chronic health conditions. The findings provide new insights concerning the associations between BMI and mortality risk.

The interactions of Canadian ethics consultants with health care managers and governing boards during times of crisis.

BACKGROUND: Health care organizations can be very complex, and are often the setting for crisis situations. In recent years, Canadian health care organizations have faced large-scale systemic medical errors, a nation-wide generic injectable drug shortage, iatrogenic infectious disease outbreaks, and myriad other crises. These situations often have an ethical component that ethics consultants may be able to address. Organizational leaders such as health care managers and governing boards have responsibilities to oversee and direct the response to crisis situations. This study investigates the nature and degree of involvement of Canadian ethics consultants in such situations. METHODS: This qualitative study used semi-structured interviews with Canadian ethics consultants to investigate the nature of their interactions with upper-level managers and governing board members in health care organizations, particularly in times of organizational crisis. We used a purposive sampling technique to identify and recruit ethics consultants throughout Canada. RESULTS: We found variability in the interactions between ethics consultants and upper-level managers and governing boards. Some ethics consultants we interviewed did not participate in managing organizational crisis situations. Most ethics consultants reported that they had assisted in the management of some crises and that their participation was usually initiated by managers. Some ethics consultants reported the ability to bring issues to the attention of upper-level managers and indirectly to their governing boards. The interactions between managers and ethics consultants were characterized by varying degrees of collegiality. Ethics consultants reported participating in or chairing working groups, participating in incident management teams, and developing decision-making frameworks. CONCLUSIONS: Canadian ethics consultants tend to believe that they have valuable skills to offer in the management of organizational crisis situations. Most of the ethics consultants we interviewed believed that they play an important role in this regard.

Leadership training for undergraduate medical students.

Purpose Physicians play an important leadership role in the management and governance of the healthcare system. Yet, many physicians lack formal management and leadership training to prepare them for this challenging role. This Viewpoint article argues that leadership concepts need to be introduced to undergraduate medical students early and throughout their medical education. Design/methodology/approach Leadership is an integral part of medical practice. The recent inclusion of "Leader" competency in the CanMEDS 2015 represents a subtle but important shift from the previous "manager" competency. Providing medical students with the basics of leadership concepts early in their medical education allows them to integrate leadership principles into their professional practice. Findings The Faculty of Medicine at the Memorial University of Newfoundland (MUN) has developed an eight-module, fully online Physician Leadership Certificate for their undergraduate medical education program. This program is cited as an example of an undergraduate medical curriculum that offers leadership training throughout the 4 years of the MD program. Originality/value There are a number of continuing professional development opportunities for physicians in the area of management and leadership. This Viewpoint article challenges undergraduate medical education programs to develop and integrate leadership training in their curricula.

Negotiation, Mediation and Communication between Cultures: End-of-Life Care for South Asian Immigrants in Canada from the Perspective of Family Caregivers.

In the present study, we explored family caregivers' experiences in providing end-of-life care for terminally ill South Asian immigrants. We employed qualitative methods and. in-depth interviews were conducted with seven family caregivers living in Nova Scotia, Canada. Interview data were validated, coded and organized for themes. Three major themes identified in the data illustrated (a) how South Asian caregivers experienced clashes between biomedical and ethno-cultural realms of care that led to cultural insensitivity, (b) how family members acted as mediators, and (c) how communication issues that challenged cultural sensitivity were handled. Findings provide directions for culturally sensitive end-of-life care planning.

The use of Ethics Decision-Making Frameworks by Canadian Ethics Consultants: A Qualitative Study.

In this study, Canadian healthcare ethics consultants describe their use of ethics decision-making frameworks. Our research finds that ethics consultants in Canada use multi-purpose ethics decision-making frameworks, as well as targeted frameworks that focus on reaching an ethical resolution to a particular healthcare issue, such as adverse event reporting, or difficult triage scenarios. Several interviewees mention the influence that the accreditation process in Canadian healthcare organizations has on the adoption and use of such frameworks. Some of the ethics consultants we interviewed also report on their reluctance to use these tools. Limited empirical work has been done previously on the use of ethics decision-making frameworks. This study begins to fill this gap in our understanding of the work of healthcare ethics consultants.

Body Mass Index Trajectories among Middle-Aged and Elderly Canadians and Associated Health Outcomes.

BACKGROUND: Whether there is heterogeneity in the development of BMI from middle-age onward is still unknown. The primary aim of this study is to analyze long-term obesity and how BMI trajectories are associated with health outcomes in midlife. METHODS: Latent Class Growth Modelling was used to capture the changes in BMI over time. In this study, 3070 individuals from the National Population Health Survey (NPHS), aged 40-55 years at baseline, were included. RESULTS: Four BMI trajectory groups, "Normal-Stable" (N-S), "Overweight-Stable" (OV-S), "Obese I-Stable" (OB I-S), and "Obese II-Stable" (OB II-S), were identified. Men, persons of White ancestry, and individuals who had no postsecondary education had higher odds of being in the latter three groups. Moreover, members of the OV-S, OB I-S, and OB II-S groups experienced more asthma, arthritis, hypertension, diabetes, heart disease, cognitive impairment, and reduced self-rated overall health. Individuals in the OB II-S group were at greater risk for back problems, chronic bronchitis or emphysema, and emotional issues when compared to the N-S group. CONCLUSION: Understanding different BMI trajectories is important in order to identify people who are at the highest risk of developing comorbidities due to obesity and to establish programs to intervene appropriately.

Models of Ethics Consultation Used by Canadian Ethics Consultants: A Qualitative Study.

This article describes a qualitative study of models of ethics consultation used by ethics consultants in Canada. We found four different models used by Canadian ethics consultants whom we interviewed, and one sub-variant. We describe (1) the lone ethics consultant model, (1a) the hub-and-spokes sub-variant of this model; (2) the ethics committee model; (3) the capacity-building model; and (4) the facilitated model. Previous empirical studies of ethics consultation describe only two or three of these models.

Developing a Physician Management & Leadership Program (PMLP) in Newfoundland and Labrador.

PURPOSE: This article aims to document the process the province of Newfoundland and Labrador used to develop an innovative Physician Management and Leadership Program (PMLP). The PMLP is a collaborative initiative among Memorial University (Faculty of Medicine and Faculty of Business), the Government of Newfoundland and Labrador, and the Regional Health Authorities. As challenges facing health-care systems become more complex there is a growing need for management and leadership training for physicians. DESIGN/METHODOLOGY/APPROACH: Memorial University Faculty of Medicine and the Gardiner Centre in the Faculty of Business in partnership with Regional Health Authorities and the Government of Newfoundland and Labrador identified the need for a leadership and management education program for physician leaders. A provincial needs assessment of physician leaders was conducted to identify educational needs to fill this identified gap. A Steering Committee was formed to guide the design and implementation and monitor delivery of the 10 module Physician Management and Leadership Program (PMLP). FINDINGS: Designing management and leadership education programs to serve physicians who practice in a large, predominately rural geographic area can be challenging and requires efficient use of available resources and technology. ORIGINALITY/VALUE: While there are many physician management and leadership programs available in Canada and abroad, the PMLP was designed to meet the specific educational needs of physician leaders in Newfoundland and Labrador.

Evidence-based decision-making 8: Health policy, a primer for researchers.

There is a growing expectation that research will be used to inform decision-making. It is important for researchers to understand how health policy is developed and the different ways they can influence the development of policy. Public policy is developed to resolve identified problems. Health policy is a subset of public policy and is typically concerned with issues related to the health of populations either from a service delivery perspective or from a broader public health and social determinants of health perspective. The policy planning algorithm is well established and follows the basic decision-making framework: assessment, planning, implementation, and evaluation. A variety of government and nongovernment stakeholders engage in complex debates to identify and resolve policy issues. In this chapter we explore how researchers can use their research to influence the development of health policy. Knowledge translation strategies focused on communicating research to policy-makers require considerable thought and planning.

Awareness of palliative care and end-of-life options among African Canadians in Nova Scotia.

PURPOSE: To assess, using qualitative methods, the knowledge African Canadians living in Nova Scotia have regarding their options for palliative and end-of-life (EOL) care. DESIGN: This project engaged caregivers in a Black community in Nova Scotia, Canada, in an exploration of palliative and EOL care. A group of six caregivers who cared for someone who had died were recruited through purposive sampling. The caregivers met three times to (1) discuss their experiences, (2) receive a presentation from the palliative care service, and (3) discuss whether those services would be beneficial. This was followed by a community meeting to discuss the findings. FINDINGS: Knowledge of options for palliative care services is limited. Family centered care may be a reason why "system" is generally not aware of the EOL experiences of African Nova Scotians. DISCUSSION: Information about palliative care services is not filtering down to the community in a way that is meaningful to families. Families tend to self-select services that assist them in providing care in the home setting. There is a need to engage Black communities and palliative care services in developing culturally appropriate services.

Palliative and end-of-life care in Newfoundland's deaf community.

The deaf community is a distinct cultural and linguistic community (the uppercase D is a cultural identification). Compared to the general population, the deaf community, as a social group, experiences poorer health status. Deaf people seek care less frequently than the general population and have fewer interactions with the health system. Their encounters with the health system are often characterized by communication difficulties, fear, mistrust, and frustration. Qualitative research was used to explore the experiences of family caregivers who provided end-of-life care for a deaf person. Key findings indicate that the deaf community has limited understanding of their options for palliative and end-of-life care. Communication and health literacy are key barriers to accessing appropriate end-of-life care. Pain and symptom management, consideration of physical environments, and limited access to bereavement care are common issues faced by deaf people when caring for loved ones at the end of life.

Quality of work life of novice nurses: a qualitative exploration.

This qualitative research study examines factors influencing the quality of work life of novice nurses (less than 2 years' experience) in the Eastern Regional Health Authority in St. John's, Newfoundland and Labrador, Canada. Although novice nurses are highly motivated to provide quality patient care, they encounter many sources of stress, including "difficult personalities," inadequate orientation and mentoring, and horizontal violence from nursing and medical colleagues. These stressors are compounded by staffing shortages and heavy workloads. Supportive mentoring and adequate orientation are key factors to successful transition.

Research to Action: an evaluation.

The evaluation of the Research to Action project was conducted using an Outcome Mapping (OM) methodology (Earl et al. 2001) with a mixed-methods, repeat survey (before/after) study design. This design uses concurrent measurement of process and outcome indicators at baseline and follow-up. The RTA project proved effective at improving work environments and thereby promoting the retention and recruitment of nurses. Nurses involved in the RTA initiatives had a higher perception of leadership and support in their units, improved job satisfaction, increased empowerment and occupational commitment, and a greater intention to stay on the job.The pilot projects were most successful when there were clearly stated objectives, buy-in from nurses, support from the steering committee and management, and adequate communication among stakeholders. Committed coordination and leadership, both locally and nationally, were central to success.Considerable evidence has documented the challenges facing Canada's nursing human resources and their workplaces, such as high levels of turnover, excessive use of overtime and persistent shortages. There is a growing imperative to translate this research into action, and much of the available evidence presents viable policy alternatives for consideration. For example, a recent national synthesis report (Maddalena and Crupi 2008) recommended that, in consultation with stakeholders, processes should be put in place to share knowledge and best practices in nursing management, practice, staffing models and innovations in workplace health and well-being.Nurses across the country report a desire to be more involved in decisions affecting them and their patients (Wortsman and Janowitz 2006). A recent study on the shortage of registered nurses in Canada (Tomblin Murphy et al. 2009) highlighted the need for collaboration among governments, employers, unions and other stakeholders to improve working conditions for nurses. Another report notes the potential benefits of reduced turnover among nurses, the cost of which has been identified as a major burden on the Canadian healthcare system (O'Brien-Pallas et al. 2010). One of the goals of the pan-Canadian framework for health human resources (HHR) planning adopted by the Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources is to enhance all jurisdictions' capacity to build and maintain a sustainable workforce in healthy, safe work environments (ACHDHR 2005).Within this context, Health Canada's Office of Nursing Policy provided funding to the Canadian Federation of Nurses Unions (CFNU) and partner agencies in October 2008 to develop pilot projects across the country aimed at improving nurse retention and recruitment through various workplace improvement schemes. Each of the provincial partners contributed funds, in-kind support or both to the projects. The initiative was entitled Research to Action: Applied Workplace Solutions for Nurses (RTA). A national steering committee including representation from unions, governments and employers, each pilot project, CFNU and its national partners ­ the Canadian Nurses Association, the Canadian Healthcare Association and the Dietitians of Canada ­ was formed to oversee the development of 10 pilot projects. There was one project in each of Newfoundland and Labrador, Nova Scotia, New Brunswick, Prince Edward Island, Ontario, Manitoba, Saskatchewan, Alberta, British Columbia and Nunavut. The pilot projects, led by their own steering committees, focused on various aspects of nursing practice identified as particularly relevant to each jurisdiction, with a specific emphasis on improving the work life of nurses and transforming research knowledge into practice. The goals of the RTA initiative were to promote high-quality workplace environments, improve the retention and recruitment of nurses (RNs and LPNs), enhance the quality of patient care and engage stakeholders in collaborative partnerships. The first project began in May 2009 and the last project was completed in March 2011.

Access to genetic testing and genetic counseling in vulnerable populations: the d/Deaf and hard of hearing population.

Genetic testing holds great potential for preventing morbidities and mortalities for a number of diseases through early detection and effective intervention. As the number of genetic tests expand, so will public demand for these services. Therefore, it is essential to evaluate access to genetic testing and genetic services to ensure that all Canadians, including vulnerable groups, have equitable access to all forms of health care, in keeping with the mandate of the Canadian Health Act. The purpose of this paper is to examine the literature to determine if and how the Deaf community, as a vulnerable group, is at an increased risk of inequitable access to genetic services in Canada and to discuss how those who are deaf and hard of hearing are subject to the same risks. First, we define vulnerability and describe why the Deaf community, as a social group, can be considered a vulnerable group, followed by a description of the benefits of genetic testing. Second, we describe the barriers to accessing genetic testing, and how the d/Deaf and hard of hearing population experience additional barriers. Third, we examine the difficulties incorporating genetic testing into medical practice, and how this creates additional barriers to those already at risk. Finally, we discuss the steps necessary to promote equitable access to genetic testing among the d/Deaf and hard of hearing populations within Canada, and provide recommendations for further research in this topic area. Lastly, we comment on how barriers to genetic testing vary among the d/Deaf and hard of hearing is dependent upon the type of health care system available (whether public or private).

Cancer care experiences and the use of complementary and alternative medicine at end of life in Nova Scotia's Black Communities.

PURPOSE: This qualitative study examines the meanings that African Canadians living in Nova Scotia, Canada, ascribe to their experiences with cancer, family caregiving, and their use of complementary and alternative medicine (CAM) at end of life. DESIGN: Case study methodology using in-depth interviews were used to examine the experiences of caregivers of decedents who died from cancer in three families. FINDINGS: For many African Canadians end of life is characterized by care provided by family and friends in the home setting, community involvement, a focus on spirituality, and an avoidance of institutionalized health services. Caregivers and their families experience multiple challenges (and multiple demands). There is evidence to suggest that the use of CAM and home remedies at end of life are common. DISCUSSION: The delivery of palliative care to African Canadian families should consider and support their preference to provide end-of-life care in the home setting.

Cultural competence and holistic practice: implications for nursing education, practice, and research.

Western society is becoming increasingly diverse in its cultural, ethnic, linguistic, and religious composition and this has implications for nursing education, practice, and research. Although the healthcare setting is becoming increasingly multicultural, nurses often lack "cultural competence." Incorporating cultural competence in nursing curricula, organizational policy, and research programs will help prepare nurses for multicultural practice environments.

A practical approach to ethical decision-making.

PURPOSE: The purpose of this paper is to provide a practical approach to ethical decision-making for executives working in the healthcare setting. DESIGN/METHODOLOGY/APPROACH: A nine step decision-making algorithm is presented to serve as a guide for identifying and resolving complex ethical problems. FINDINGS: While decision-making frameworks are not new to the management literature, this practical approach outlines a coherent and logical means by which executives can articulate a management problem. ORIGINALITY/VALUE: Identifies and evaluates potential solutions for consideration, plans an approach to implementing the desired solution, and evaluates the impact of their decision.