Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

PURPOSE: To develop an evidence-based guideline for the management of grades I-III neck pain and associated disorders (NAD). METHODS: This guideline is based on recent systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (obtained from qualitative research) when formulating recommendations. Target audience includes clinicians; target population is adults with grades I-III NAD <6 months duration. RECOMMENDATION 1: Clinicians should rule out major structural or other pathologies as the cause of NAD. Once major pathology has been ruled out, clinicians should classify NAD as grade I, II, or III. RECOMMENDATION 2: Clinicians should assess prognostic factors for delayed recovery from NAD. RECOMMENDATION 3: Clinicians should educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I-III and the importance of maintaining activity and movement. Patients with worsening symptoms and those who develop new physical or psychological symptoms should be referred to a physician for further evaluation at any time during their care. RECOMMENDATION 4: For NAD grades I-II ≤3 months duration, clinicians may consider structured patient education in combination with: range of motion exercise, multimodal care (range of motion exercise with manipulation or mobilization), or muscle relaxants. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, strain-counterstrain therapy, relaxation massage, cervical collar, electroacupuncture, electrotherapy, or clinic-based heat. RECOMMENDATION 5: For NAD grades I-II >3 months duration, clinicians may consider structured patient education in combination with: range of motion and strengthening exercises, qigong, yoga, multimodal care (exercise with manipulation or mobilization), clinical massage, low-level laser therapy, or non-steroidal anti-inflammatory drugs. In view of evidence of no effectiveness, clinicians should not offer strengthening exercises alone, strain-counterstrain therapy, relaxation massage, relaxation therapy for pain or disability, electrotherapy, shortwave diathermy, clinic-based heat, electroacupuncture, or botulinum toxin injections. RECOMMENDATION 6: For NAD grade III ≤3 months duration, clinicians may consider supervised strengthening exercises in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, cervical collar, low-level laser therapy, or traction. RECOMMENDATION 7: For NAD grade III >3 months duration, clinicians should not offer a cervical collar. Patients who continue to experience neurological signs and disability more than 3 months after injury should be referred to a physician for investigation and management. RECOMMENDATION 8: Clinicians should reassess the patient at every visit to determine if additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged.

Narrative Inquiry: Experience matters.

Narrative Inquiry is a research methodology that we adapted over the past two decades from Canadian higher education and curriculum studies to nursing research, education, and health-care practice. The Narrative Inquiry we use originated from Connelly and Clandinin in the 1990s, and rests on John Dewey's philosophy that experience is relational, temporal, and situational, and as such, if intentionally explored, has the potential to be educational. More specifically, it is only when experience is reflected upon and reconstructed that it has the potential to reveal the construction of identity, knowledge, and the humanness of care. Congruent with the expectation that nurses are reflective practitioners and knowledge-makers, Narrative Inquiry provides a means to enhance, not only quality of care, but quality of experience of those in our care: in education, our students, and in practice, our patients. In this article, we explicate how Narrative Inquiry may be lived in health-care education and practice, with a primary focus on nursing. We illuminate how we support our graduate students, the next generation of narrative inquirers, through a Narrative Inquiry Works-in-Progress group.

Patients' Experiences With Vehicle Collision to Inform the Development of Clinical Practice Guidelines: A Narrative Inquiry.

OBJECTIVE: The purpose of this narrative inquiry was to explore the experiences of persons who were injured in traffic collisions and seek their recommendations for the development of clinical practice guideline (CPG) for the management of minor traffic injuries. METHODS: Patients receiving care for traffic injuries were recruited from 4 clinics in Ontario, Canada resulting in 11 adult participants (5 men, 6 women). Eight were injured while driving cars, 1 was injured on a motorcycle, 2 were pedestrians, and none caused the collision. Using narrative inquiry methodology, initial interviews were audiotaped, and follow-up interviews were held within 2 weeks to extend the story of experience created from the first interview. Narrative plotlines across the 11 stories were identified, and a composite story inclusive of all recommendations was developed by the authors. The research findings and composite narrative were used to inform the CPG Expert Panel in the development of new CPGs. RESULTS: Four recommended directions were identified from the narrative inquiry process and applied. First, terminology that caused stigma was a concern. This resulted in modified language ("injured persons") being adopted by the Expert Panel, and a new nomenclature categorizing layers of injury was identified. Second, participants valued being engaged as partners with health care practitioners. This resulted in inclusion of shared decision-making as a foundational recommendation connecting CPGs and care planning. Third, emotional distress was recognized as a factor in recovery. Therefore, the importance of early detection and the ongoing evaluation of risk factors for delayed recovery were included in all CPGs. Fourth, participants shared that they were unfamiliar with the health care system and insurance industry before their accident. Thus, repeatedly orienting injured persons to the system was advised. CONCLUSION: A narrative inquiry of 11 patients' experiences with traffic collision and their recommendations for clinical guidelines informed the Ontario Protocol for Traffic Injury Management Collaboration in the development of new Minor Injury Guidelines. The values and findings of the qualitative inquiry were interwoven into each clinical pathway and embedded within the final guideline report submitted to government.

The effectiveness of exercise for the management of musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.

OBJECTIVE: The purpose of this systematic review was to evaluate the effectiveness of exercise compared to other interventions, placebo/sham intervention, or no intervention in improving self-rated recovery, functional recovery, clinical, and/or administrative outcomes in individuals with musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand. METHODS: We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers independently screened studies for relevance and assessed the risk of bias using the Scottish Intercollegiate Guidelines Network criteria. We synthesized the evidence using the best evidence synthesis methodology. RESULTS: We identified 5 studies with a low risk of bias. Our review suggests that, for patients with persistent lateral epicondylitis, (1) adding concentric or eccentric strengthening exercises to home stretching exercises provides no additional benefits; (2) a home program of either eccentric or concentric strengthening exercises leads to similar outcomes; (3) home wrist extensor strengthening exercises lead to greater short-term improvements in pain reduction compared to "wait and see"; and (4) clinic-based, supervised exercise may be more beneficial than home exercises with minimal improvements in pain and function. For hand pain of variable duration, supervised progressive strength training added to advice to continue normal physical activity provides no additional benefits. CONCLUSION: The relative effectiveness of stretching vs strengthening for the wrist extensors remains unknown for the management of persistent lateral epicondylitis. The current evidence shows that the addition of supervised progressive strength training does not provide further benefits over advice to continue normal physical activity for hand pain of variable duration.

Paradox of a graduate human science curriculum experienced online: a faculty perspective.

BACKGROUND: Program evaluation contributes to evidence-based nursing education. Exploring graduate faculty experience with developing and teaching an online master's of science in nursing program contributes to building a science of nursing education. METHODS: A multimodal methodology for conducting a program evaluation is participatory and demonstrates both formative (improve the quality of the program) and summative (determine the worth of the program) components. Faculty participated through questionnaires, journals, and focus groups. RESULTS: In the context of a philosophy that values understanding lived experience as foundational for nursing, faculty are teaching in an environment that is disembodied, technology based, and at a distance. Faculty relationships with students reveal emerging curricular issues. CONCLUSIONS: Research into the intersection of pedagogy and technology reveals similarities with contemporary literature and many lived paradoxes to be accounted for in evaluation of graduate nursing education.

Thinking narratively: artificial persons in nursing and healthcare.

Positioned within my research program that explores nurses' experience and construction of their daily praxis, I think narratively about how to stay in my work as a nurse-teacher, how students enter the profession and how registered nurses stay in nursing practice. I present co-participants' stories (all names are pseudonyms except for the author's "I") that reveal how a nurse is often in between autobiographically informed actions and the certainty of institutional roles that shape us into artificial persons. I explore the nature of the relationship between nurses, their professional roles and a primary accountability to people who happen to be patients - or students. This paper has implications for retention of nurses in practice and in education within the context of a global shortage of nurses. Further inquiry is invited in relation to our ability to shape social situations towards health. When narrative inquiry is working, people are drawn into their own experience and can discern new plotlines for relationships and possibilities for action within their social environments.

Experiencing nursing education research: narrative inquiry and interpretive phenomenology.

Narrative inquiry is emerging from higher education curriculum studies into nursing, and interpretive phenomenology is established in nursing education research. These two research methods are compared by subject matter, agent, method, data and outcome, using examples from nursing education research. This comparison facilitates a researcher's choice of method by showing what is revealed by each type of inquiry and how they differ.

The effectiveness of structured patient education for the management of musculoskeletal disorders and injuries of the extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

PURPOSE: To determine the effectiveness of structured patient education for the management of musculoskeletal disorders and injuries of the extremities. METHODS: We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from January 1, 1990 to March 14, 2015. Paired reviewers independently screened titles and abstracts for eligibility. The internal validity of studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Results from studies with a low risk of bias were synthesized using the best-evidence synthesis methodology. RESULTS: We identified two randomized trials with a low risk of bias. Our review suggests that: 1) multimodal care and corticosteroid injections lead to faster pain relief and improvement than reassurance and advice in the short-term and similar outcomes in the long-term for patients with persistent lateral epicondylitis; and 2) providing health education material alone may be less effective than multimodal care for the management of persistent patellofemoral pain syndrome. CONCLUSION: Our systematic search of the literature demonstrates that little is known about the effectiveness of structured patient education for the management of musculoskeletal disorders and injuries of the extremities. Two studies suggest that when used alone, structured patient education may be less effective than other interventions used to manage persistent lateral epicondylitis and persistent patellofemoral syndrome.

OBJECTIF: Déterminer l'efficacité d'une éducation des patients structurée aux fins de la prise en charge des troubles musculo-squelettiques et des lésions des extrémités. MÉTHODES: Nous avons consulté MEDLINE, EMBASE, CINAHL, PsycINFO et le Cochrane Central Register of Controlled Trials du 1er janvier 1990 au 14 mars 2015 aux fins de recherche. Les examinateurs appariés ont trié de façon indépendante les titres et résumés afin d'évaluer leur admissibilité. La validité interne des études a été évaluée à l'aide des critères du Scottish Intercollegiate Guidelines Network (SIGN). Les résultats des études présentant un faible risque de biais ont été synthétisés à l'aide de la méthodologie de la synthèse des meilleures données probantes. RÉSULTATS: Nous avons identifié deux essais randomisés présentant un faible risque de biais. Notre examen suggère ce qui suit : 1) les soins multimodaux et les injections corticostéroïdes entraînent un soulagement de la douleur et une amélioration plus rapides que la rassurance et les conseils à court terme, et conduisent à des résultats similaires à long terme chez les patients souffrant d'épicondylite latérale persistante; et 2) fournir uniquement des documents d'éducation à la santé peut être moins efficace que les soins multimodaux pour la prise en charge du syndrome fémoro-rotulien douloureux persistant. CONCLUSION: Nos recherches systématiques de la littérature démontrent que les connaissances au sujet de l'efficacité de l'éducation des patients structurée aux fins de la prise en charge des troubles musculo-squelettiques et des lésions des extrémités sont limitées. Deux études suggèrent que lorsqu'elle est utilisée seule, l'éducation des patients structurée peut être moins efficace que les autres interventions utilisées pour prendre en charge l'épicondylite latérale persistante et le syndrome fémoro-rotulien de durée variable.

How nurses are conceptualized in healthcare reform literature.

Nurse coping, empowerment and job satisfaction are conceptualized as modifiable from organizational and psychological perspectives. Questions about what stories nurses tell themselves to live by and to shape healthcare reform have not been part of thinking about the impact of restructuring on nurses.

Opening the black-box of person-centred care: An arts-informed narrative inquiry into mental health education and practice.

BACKGROUND: Nursing education has a history of encouraging students to know their patients and to negotiate the in-between of art/science, person/profession, and intuition/evidence. Nurse-teachers know that students may abandon some values and practices when they encounter practice environments that are complex and have competing agendas. We are concerned that nursing knowledge is black-boxed, invisible and taken-for-granted, in healthcare settings. OBJECTIVES: Our research explores how nursing students and nurses are constructing and enacting person-centred care in mental health education and practice. We want to understand the nursing standpoint on this significant ontological issue and to make nursing knowledge construction and utilization visible; illuminating how person-centred theory emerges from practice. DESIGN: The process involved four 3-hour group meetings and an individual follow-up telephone conversation. SETTINGS: Students and nurses met at a tertiary-care mental health organization. PARTICIPANTS: Fourteen nurses (Registered Nurses and Registered Practical Nurses) and nursing students (Bachelor of Science in Nursing and Practical Nursing) participated in our inquiry. METHODS: We used arts-informed narrative inquiry to explore experience through the arts such as metaphor, collage, poems, letters, and group conversations. RESULTS: The black-box is opened as the inquiry reveals how nursing knowledge is constructed, assumptions are challenged and new practices emerge. CONCLUSIONS: Our research is significant for education and for practice and is transferable to other populations and settings. Nurses are affirmed in person-centred values and practices that include partnership with those in their care, role modeling for colleagues and mentoring students and new nurses. Students participate in transferring their learning from school to practice, in the company of experienced colleagues; together they open the black-box to show how nurses conceptualize and enact person-centred care.

Patterns of inquiry: curriculum as life experience.

Readers are invited to be actors in a text-based theatre, drawn into the stories with their own experiences and discerning patterns that reveal a narrative unity. I show how curriculum-building is inclusive of a teacher's autobiography, as well as the theoretical/philosophical commitments significant for teaching-learning. This is accomplished through thinking narratively about an experience with my Dad in the healthcare system while simultaneously teaching theory-guided nursing in higher education. Health as expanding consciousness is revealed through a research-as-praxis process that is the content for inquiry.

Narrative inquiry in a nursing practicum.

One approach to creating research-based nursing education is to think and write narratively about the daily life of a BScN program student and her teacher in diverse settings and over time. Gail, as a nurse-teacher, and Faith, as a nursing student and now Public Health Nurse, reconstruct their teaching-learning experiences in an integrated practicum in maternal-child health services as a narrative inquiry. After presenting this reconstruction of experience at a conference on maternal scholarship, further inquiry into their experiences shows how narrative inquiry matters to construction of nursing praxis and to life-long learning as a nurse. Teaching-learning relationships are seen as a template for a student's connections to people experiencing nursing care and to other clinicians. Construction of stories to live by that take into account becoming a nurse, constructing knowledge and enacting caring-healing nursing practices is illuminated through narrative inquiry.