Healthcare providers' perceived acceptability of a warning signs intervention for rural hospital-to-home transitional care: A cross-sectional study.

INTRODUCTION: There is a pressing need for transitional care that prepares rural dwelling medical patients to identify and respond to the signs of worsening health conditions. An evidence-based warning signs intervention has the potential to address this need. While the intervention is predominantly delivered by nurses, other healthcare providers may be required to deliver it in rural communities where human health resources are typically limited. Understanding the perspectives of other healthcare providers likely to be involved in delivering the intervention is a necessary first step to avert consequences of low acceptability, such as poor intervention implementation, uptake, and effectiveness. This study examined and compared nurses' and other healthcare providers' perceived acceptability of an evidence-based warning signs intervention proposed for rural transitional care. METHODS: A cross-sectional design was used. The convenience sample included 45 nurses and 32 other healthcare providers (e.g., physical and occupational therapists, physicians) who self-identified as delivering transitional care to patients in rural Ontario, Canada. In an online survey, participants were presented with a description of the warning signs intervention and completed established measures of intervention acceptability. The measures captured 10 intervention acceptability attributes (effectiveness, appropriateness, risk, convenience, relevance, applicability, usefulness, frequency of current use, likelihood of future use, and confidence in ability to deliver the intervention). Ratings ≥ 2 indicated acceptability. Data analysis included descriptive statistics, independent samples t-tests, as well as effect sizes to quantify the magnitude of any differences in acceptability ratings between nurses and other healthcare providers. RESULTS: Nurses and other healthcare providers rated all intervention attributes > 2, except the attributes of convenience and frequency of current use. Differences between the two groups were found for only three attributes: nurses' ratings were significantly higher than other healthcare providers on perceived applicability, frequency of current use, and the likelihood of future use of the intervention (all p's < .007; effect sizes .58 - .68, respectively). DISCUSSION: The results indicate that both participant groups had positive perspectives of the intervention on most of the attributes and suggest that initiatives to enhance the convenience of the intervention's implementation are warranted to support its widespread adoption in rural transitional care. However, the results also suggest that other healthcare providers may be less receptive to the intervention in practice. Future research is needed to explore and mitigate the possible reasons for low ratings on perceived convenience and frequency of current use of the intervention, as well as the between group differences on perceived applicability, frequency of current use, and the likelihood of future use of the intervention. CONCLUSIONS: The intervention represents a tenable option for rural transitional care in Ontario, Canada, and possibly other jurisdictions emphasizing transitional care.

Recommendations Related to Visitor and Movement Restrictions in Long-Term Care and Retirement Homes in Ontario during the COVID-19 Pandemic: Perspectives of Residents, Families, and Staff.

In Canada, long-term care and retirement home residents have experienced high rates of COVID-19 infection and death. Early efforts to protect residents included restricting all visitors as well as movement inside homes. These restrictions, however, had significant implications for residents' health and well-being. Engaging with those most affected by such restrictions can help us to better understand their experiences and address their needs. In this qualitative study, 43 residents of long-term care or retirement homes, family members and staff were interviewed and offered recommendations related to infection control, communication, social contact and connection, care needs, and policy and planning. The recommendations were examined using an ethical framework, providing potential relevance in policy development for public health crises. Our results highlight the harms of movement and visiting restrictions and call for effective, equitable, and transparent measures. The design of long-term care and retirement policies requires ongoing, meaningful engagement with those most affected.

The Impact of a Canadian Model of Aging in Place on Community Dwelling Older Adults' Experience of Physical Distancing during the COVID-19 Pandemic.

Naturally occurring retirement communities (NORCs) are unplanned communities with a high proportion of residents aged 65 years and older. Oasis is a Canadian aging in place model that combines health and supportive community services for adults aged 65 years and older within NORCs. The aims of this study were to explore how physical distancing restrictions during the COVID-19 pandemic impacted older adults living in a NORC (Oasis members) and to investigate whether Oasis served as a context for social connection and well-being during the COVID-19 pandemic. An interpretive description methodology guided this study. Semi-structured interviews were conducted with nine Oasis members (aged 66-77 years) and two Oasis site coordinators. The Oasis members also completed a social network mapping activity guided by the hierarchical mapping technique. Three overarching themes related to the impact of physical distancing on Oasis members during the COVID-19 pandemic were identified: (1) unintended consequences of physical distancing restrictions on participants' wellbeing; (2) face-to-face interactions are important for social connection; and (3) family, friend, healthcare provider, and community support mitigated the impact of physical distancing restrictions during the COVID-19 pandemic. In addition, two of Oasis' core pillars were found to support participants: strengthening social connectivity and connection to pre-existing community services. Findings illustrate that community programs like Oasis acted as a source of resilience during the COVID-19 pandemic and advance our understanding of the impact of aging in place models on community dwelling older adults' experience of the COVID-19 pandemic.

Assessment tools for measurement of dementia-friendliness of a community: A scoping review.

BACKGROUND: A quantitative assessment of the dementia-friendliness of a community can support planning and evaluation of dementia-friendly community (DFC) initiatives, internal review, and national/international comparisons, encouraging a more systematic and strategic approach to the advancement of DFCs. However, assessment of the dementia-friendliness of a community is not always conducted and continuous improvement and evaluation of the impact of dementia-friendly initiatives are not always undertaken. A dearth of applicable evaluation tools is one reason why there is a lack of quantitative assessments of the dementia-friendliness of communities working on DFC initiatives. PURPOSE: A scoping review was conducted to identify and examine assessment tools that can be used to conduct quantitative assessments of the dementia-friendliness of a community. DESIGN AND METHODS: Peer-reviewed studies related to DFCs were identified through a search of seven electronic databases (MEDLINE, CINAHL, PsycINFO, Embase, EMCare, HealthSTAR, and AgeLine). Grey literature on DFCs was identified through a search of the World Wide Web and personal communication with community leads in Australia, Canada, New Zealand, the United Kingdom, and the United States. Characteristics of identified assessment tools were tabulated, and a narrative summary of findings was developed along with a discussion of strengths and weaknesses of identified tools. RESULTS: Forty tools that assess DFC features (built environment, dementia awareness and attitudes, and community needs) were identified. None of the identified tools were deemed comprehensive enough for the assessment of community needs of people with dementia.

Policymaker and stakeholder perspectives on access to assistive technologies in Canada: challenges and proposed solutions for enhancing equitable access.

PURPOSE: Unmet needs for assistive technologies (ATs) exist and the need for ATs is growing owing to demographic changes worldwide. Little comprehensive research has examined equity of access to ATs in Canada. Our study elucidates perspectives of policymakers and stakeholders on challenges and solutions for enhancing equitable access to ATs to advance policy discussions. METHODS: We conducted a qualitative interview study with a purposive sample of policymakers and stakeholders. Stakeholders were from non-profit organisations; private insurance companies; ageing or technology industries; and advocacy, consumer, and support groups. We used thematic analysis to develop themes that summarised and facilitated data interpretation. RESULTS: We conducted 24 interviews involving 32 participants. We present three themes: (1) User experiences, detailing challenges experienced by AT system users; (2) System characteristics: Challenges and solutions, outlining governance, financial, and delivery arrangements that create challenges for accessing AT, as well as participants' proposed solutions; and (3) Shifts in models and principles, for approaches that may foster equitable access to ATs. We consolidate results into a set of valued qualities of a system that can enhance equitable AT access, and relate results to relevant national and international activities. CONCLUSIONS: This is the most comprehensive study of Canadian policymaker and stakeholder views on AT access to date. Identified challenges and solutions point to opportunities for policy action and to support work to create a national vision for AT access that strengthens the potential for ATs to enable daily activity participation, independence, and societal inclusion of seniors and people with disabilities.IMPLICATIONS FOR REHABILITATIONAT use supports daily activity participation, independence, and societal inclusion of seniors and people with disabilities.There is an urgent need to ensure that those who need ATs have access to them, considering the benefits of their use, current unmet needs for ATs, and the anticipated demand for ATs because of the ageing population and increased prevalence of chronic disease and disability.A comprehensive understanding of policymakers' and stakeholders' perspectives on challenges and potential solutions for enhancing equitable access to ATs is critical to support development of evidence- and values-informed policies.Understanding challenges and solutions identified by diverse policymakers and stakeholders can lead to national and local opportunities for policy action and support work to create a national vision for enhancing equitable access to AT.

Experiences of a home-based fall prevention exercise program among older adults with chronic lung disease.

BACKGROUND: Individuals with chronic obstructive pulmonary disease (COPD) often have mobility limitations; these may include challenges with balance and being at high risk of falling. Risk of falling can be reduced through exercise programs targeting balance; however, older adults with COPD may experience many barriers to exercise adherence. In this paper we present qualitative findings about the feasibility of a six-month home-based fall-prevention exercise program for older adults with COPD. The aim of the study is to describe the experiences of older adults with COPD who participated in a home-based fall prevention exercise program in order to determine their perceived facilitators and barriers to participation. METHODS: 15 participants with COPD who had completed the six-month home-based program participated in one-on-one semi-structured interviews over the phone. Interpretive description methodology and thematic analysis were used. RESULTS: Two major themes emerged with respect to participants' perspectives of the intervention and facilitators and barriers to participation: program personalization based on each individual's characteristics, lifestyles, and preferences; and self-motivation and support from family, friends, and healthcare providers. CONCLUSIONS: Fall prevention exercise programs that are personalized and focus on providing support for older adults with COPD may help to improve adherence and reduce participants' risk of falling.Implications for rehabilitationIndividuals with COPD often have balance problems and a high risk of falling.Fall prevention programs can improve balance, but adherence is a commonly cited challenge.Patient experiences suggest that fall prevention programs should be personalized and incorporate social support to improve adherence to fall prevention exercises.

Art Activities in Long-Term Care: A Scoping Review.

Background: Outcomes of using art in therapy overlap with goals of occupational therapy with older adults in long-term care, which include improving and maintaining health and well-being through engagement in occupations. There is a lack of evidence about how art activities could complement or inform occupational therapy. Purpose: The purpose of this scoping review is to map existing literature about how art activities are used in long-term care. Methods: Six electronic databases were searched. Fourteen studies met inclusion criteria and were analyzed to identify patterns and discrepancies. Findings: The analysis suggests art activities can contribute to well-being by improving mood, promoting communication and reminiscence, and supporting the development and deepening of social relationships. Implications: Occupational therapists should consider incorporating art activities as these offer therapeutic benefits and can be adapted to individual strengths and preferred type and level of participation.

Ethical Tensions in Occupational Therapy Practice: Conflicts and Competing Allegiances.

BACKGROUND.: Ethical tensions inevitably arise in practice in light of diverse agendas embedded in practice contexts. Such tensions can contribute to moral distress and lead to professional burnout and attrition. Despite potentially serious implications, little work has been done to examine how various allegiances in occupational therapy practice can set up ethical tensions. PURPOSE.: In this article, we present findings of an exploratory study examining conflicting allegiances in occupational therapy. METHOD.: Using collective case study methodology, we examined ethical tensions reported by seven occupational therapists practicing in different settings in Southwestern Ontario. FINDINGS.: Ethical tensions were seen to arise in ways that highlighted competing allegiances to participants' own values, clients, others in the context, colleagues, employers, and regulatory colleges. IMPLICATIONS.: The findings open a discussion informing how practice settings can better facilitate practice directed at responding to client needs while also meeting the various demands imposed on occupational therapists.

Optimizing hospital-to-home transitions for older persons in rural communities: a participatory, multimethod study protocol.

BACKGROUND: Transitional care involves time-limited interventions focusing on the continuity of care from hospital to home, to optimize patient functioning and management. Providing interventions, as part of transitional care, that optimize the functioning of older people with dementia is critical due to the small window of opportunity in which they can return to their baseline levels of functioning. Yet prior research on transitional care has not included interventions focused on functioning and did not target older people with dementia in rural communities, limiting the applicability of transitional care to this population. Accordingly, the goal of this study is to align hospital-to-home transitional care with the function-related needs of older people with dementia and their family-caregivers in rural communities. METHODS: In this multimethod study, two phases of activities are planned in rural Ontario and Nova Scotia. In phase I, a purposive sample of 15-20 people with dementia and 15-20 family-caregivers in each province will rate the acceptability of six evidence-based interventions and participate in semi-structured interviews to explore the interventions' acceptability and, where relevant, how to improve their acceptability. Acceptable interventions will be further examined in phase II, in which a purposive sample of healthcare providers, stratified by employment location (hospital vs. homecare) and role (clinician vs. decision-maker), will (1) rate the acceptability of the interventions and (2) participate in semi-structured focus group discussions on the facilitators and barriers to delivering the interventions, and suggestions to enable their incorporation into rural transitional care. Two to three focus groups per stratum (8-10 healthcare providers per focus group) will be held for a total of 8-12 focus groups per province. Data analysis will involve qualitative content analysis of interview and focus group discussions and descriptive statistics of intervention acceptability ratings. DISCUSSION: Findings will (1) include a set of acceptable interventions for rural transitional care that promote older patients' functioning and family-caregivers' ability to support patients' functioning, (2) identify resources needed to incorporate the interventions into rural transitional care, and (3) provide high-quality evidence to inform new transitional care practices and policies and guide future research.

Collaborating with healthcare providers to understand their perspectives on a hospital-to-home warning signs intervention for rural transitional care: protocol of a multimethod descriptive study.

INTRODUCTION: This study builds on our prior research, which identified that older rural patients and families (1) view preparation for detecting and responding to worsening health conditions as their most pressing unmet transitional care (TC) need and (2) perceive an evidence-based intervention, preparing them to detect and respond to warning signs of worsening health conditions, as highly likely to meet this need. Yet, what healthcare providers need to implement a warning signs intervention in rural TC is unclear. The objectives of this study are (1) to examine healthcare providers' perspectives on the acceptability of a warning signs intervention and (2) to identify barriers and facilitators to healthcare providers' provision of the intervention in rural communities. METHODS AND ANALYSIS: This multimethod descriptive study uses a community-based, participatory research approach. We will examine healthcare providers' perspectives on a warning signs intervention. A purposive, criterion-based sample of healthcare providers stratified by professional designation (three strata: nurses, physicians and allied healthcare professionals) in two regions (Southwestern and Northeastern Ontario, Canada) will (1) rate the acceptability of the intervention and (2) participate in small (n=4-6 healthcare providers), semistructured telephone focus group discussions on barriers and facilitators to delivering the intervention in rural communities. Two to three focus groups per stratum will be held in each region for a total of 12-18 focus groups. Data will be analysed using conventional qualitative content analysis and descriptive statistics. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Office of Research Ethics at York University and the Health Sciences North Research Ethics Board. Findings will be communicated through plain language summary and policy briefs, press releases, manuscripts and conferences.

Engaging older adults in discharge planning: case studies illuminating approaches adopted by family members that promote relational autonomy.

Background: Discharge decisions have significant implications for older adults and their involved family members. Evidence of older adult and family members' engagement in discharge decision-making, however, varies widely. Some recent work shows assumed associations between ageing, diminished participation in healthcare decision-making and increased reliance on family members. Other research suggests that family members adopt strategies to promote older adults' participation in decision-making. Relational autonomy theory suggests that individuals have differing levels of autonomy and that individuals' agency can be supported (or marginalized) by others.Purpose: Using three case studies, we examine traditional and relational conceptions of autonomy and explore how relational approaches could inform healthcare practice.Methods: Taking a critical feminist bioethics perspective, we present a secondary analysis of three microethnographic case studies focused on discharge planning with older adults in one Canadian inpatient rehabilitation setting. The data consist of observations of discharge planning family conferences and semi-structured interviews with older adults and family members.Results: Tensions between older adults' wishes to return home and their diminished participation in discharge decisions, and family members' assumption of a primary role in discharge decision-making and their wish for the older adult to move to a supported setting were apparent. To reconcile these tensions, the older adults' family members in these cases employed strategies to promote older adults' participation in decision-making that were consistent with relational autonomy theory.Conclusion and implications for practice: The analysis suggests that older adults' participation in discharge decision-making processes could be better promoted through relational approaches.Implications for rehabilitation • Adopting an approach guided by relational autonomy might better enable patients to participate in decision-making than would an approach guided by traditional conceptions of autonomy. • Rehabilitation professionals could seek assistance from family members and guide them toward collaborative partnerships. • A range of strategies may be employed to customize relational approaches to enhance autonomy: • having several different conversations with patients to enable multiple chances to contribute knowledge and views; • involving family members or taking the time to explain information several different times and in diverse manners; • showing patients videos or photos of discharge locations; • exploring a breadth of potential discharge options; • accompanying patients to visit different options in person; and • getting patients in touch with individuals who have made similar choices. • It is recognized that taking a relational approach might be time-consuming and that practice contexts may not be conducive to such practice.

Ethical questions identified in a study of local and expatriate responders' perspectives of vulnerability in the 2010 Haiti earthquake.

BACKGROUND: Situations of disaster that prompt international humanitarian responses are rife with ethical tensions. The 2010 Haiti earthquake caused great destruction and prompted a massive humanitarian response. The widespread needs experienced by the population and the scale of the response inevitably rendered priority-setting difficult, and gave rise to ethical challenges. PURPOSE: This paper presents four ethical questions identified in the analysis of a study on vulnerability and equity in the humanitarian response to the 2010 Haiti earthquake. METHODS: Using interpretive description methodology, the interdisciplinary research team analysed 24 semi-structured in-depth interviews conducted with expatriate and Haitian health workers and decision-makers involved in the response. RESULTS: Ethical questions identified through the analysis were: (1) How should limited resources be allocated in situations of widespread vulnerability and elevated needs? (2) At what point does it become ethically problematic to expend (considerable) resources to sustain expatriate disaster responders? (3) How ought rapid and reactive interventions be balanced with more deliberated and coordinated approaches? (4) What trade-offs are justified when interventions to address acute needs could contribute to long-term vulnerabilities? DISCUSSION: The questions arise in light of an immense gap between available resources and widespread and elevated needs. This gap is likely unavoidable in large-scale crises and may be a source of ethical distress for both local and international responders. The analysis of ethical questions associated with crisis response can advance discussions about how relief efforts can best be designed and implemented to minimise ethical distress and improve assistance to local populations.

Rehabilitation as "destination triage": a critical examination of discharge planning.

PURPOSE: In this paper we examine how the intersection of various social and political influences shapes discharge planning and rehabilitation practices in ways that may not meet the espoused aims of rehabilitation programs or the preferences of older adults and their families. METHODS: Taking a critical bioethics perspective, we used microethnographic case study methods to examine discharge-planning processes in a well-established older adult inpatient rehabilitation setting in Canada. The data included observations of discharge-planning family conferences and semi-structured interviews conducted with older adults facing discharge, their family members and rehabilitation professionals involved in discharge planning. RESULTS: From the time of admission, a contextual push to focus on discharge superseded program aims of providing interventions to increase older adults' functional capabilities. Professionals' primary commitment to safety limited consideration of discharge options and resulted in costly and potentially unnecessary recommendations for 24-hour care. The resulting "rehabilitation" stay was more akin to an extended process of "destination triage" biased towards the promotion of physical safety than optimizing functioning. CONCLUSIONS: The resulting reduction of rehabilitation into "destination triage" has significant social, financial and occupational implications for older adults and their families, and broader implications for healthcare services and overarching healthcare systems. Implications for Rehabilitation Current trends promoting consideration of discharge planning from the point of admission and prioritizing physical safety are shifting the focus of rehabilitation away from interventions to maximize recovery of function, which are the stated aims of rehabilitation. Such practices furthermore promote assessments to determine prognosis early in the rehabilitation stay when accurate prognosis is difficult, which can lead to overly conservative recommendations for discharge from rehabilitation services, thus further negating the impact of rehabilitation. Further work is required to examine the social, occupational and functional implications of superseding rehabilitation interventions to maximize capabilities with practices that prioritize safety over quality of life for older adults and their family members.

Understanding and Addressing Vulnerability Following the 2010 Haiti Earthquake: Applying a Feminist Lens to Examine Perspectives of Haitian and Expatriate Health Care Providers and Decision-Makers.

Vulnerability is a central concept in humanitarian aid. Discussions of vulnerability in disaster response literature and guidelines for humanitarian aid range from considerations of a universal human vulnerability, to more nuanced examinations of how particular characteristics render individuals more or less at risk. Despite its frequent use, there is a lack of clarity about how vulnerability is conceptualized and how it informs operational priorities in humanitarian assistance. Guided by interpretive description methodology, we draw on the feminist taxonomy of vulnerability presented by Mackenzie, Rogers and Dodds (2014) to examine perspectives of 24 expatriate and Haitian decision-makers and health professionals interviewed between May 2012 and March 2013. The analysis explores concepts of vulnerability and equity in relation to the humanitarian response following the 2010 earthquake in Haiti. Participants' conceptualizations of vulnerability included consideration for inherent vulnerabilities related to individual characteristics (e.g. being a woman or disabled) and situational vulnerabilities related to particular circumstances such as having less access to health care resources or basic necessities. Participants recognized that vulnerabilities could be exacerbated by socio-political structures but felt ill-equipped to address these. The use of the taxonomy and a set of questions inspired by Hurst's (2008) approach to identifying and reducing vulnerability can guide the analysis of varied sources of vulnerability and open discussions about how and by whom vulnerabilities should be addressed in humanitarian responses. More research is required to inform how humanitarian responders could balance addressing acute vulnerability with consideration of systemic and pre-existing circumstances that underlie much of the vulnerability experienced following an acute disaster.

Ethical Tensions Related to Systemic Constraints: Occupational Alienation in Occupational Therapy Practice.

Ethical tensions arise daily in health care practice and are frequently related to health care system structures or policies. Collective case study methodology was adopted to examine ethical tensions reported by occupational therapists practicing in different settings in Southwestern Ontario, Canada. Inductive analysis involving multiple layers of coding was conducted. This article focuses on tensions related to systemic constraints. Participants reported ethical tensions related to balancing client priorities with those of health care services. Four themes related to systemic constraints were identified including imposed practices, ineffective processes, resource limitations, and lack of services. Therapists' aims could be seen to align with an "ethic of care" and were seen to be in tension in light of systemic constraints. The findings raise issues related to occupational justice, particularly related to occupational alienation in occupational therapy practice, and open conversations related to neoliberalist health care agendas.

Ethics teaching in rehabilitation: results of a pan-Canadian workshop with occupational and physical therapy educators.

PURPOSE: Ethical practice is an essential competency for occupational and physical therapists. However, rehabilitation educators have few points of reference for choosing appropriate pedagogical and evaluation methods related to ethics. The objectives of this study were to: (1) identify priority content to cover in ethics teaching in occupational therapy (OT) and physical therapy (PT) programmes and (2) explore useful and innovative teaching and evaluation methods. METHOD: Data for this qualitative descriptive study were collected during a 1-d knowledge exchange workshop focused on ethics teaching in rehabilitation. RESULTS: Twenty-three educators from 11 OT and 11 PT Canadian programmes participated in the workshop. They highlighted the importance of teaching foundational theoretical/philosophical approaches and grounding this teaching in concrete examples drawn from rehabilitation practice. A wide range of teaching methods was identified, such as videos, blogs, game-based simulations and role-play. For evaluation, participants used written assignments, exams, objective structured clinical examinations and reflective journals. The inclusion of opportunities for student self-evaluation was viewed as important. CONCLUSION: The CREW Day provided ethics educators the opportunity to share knowledge and begin creating a community of practice. This space for dialogue could be expanded to international rehabilitation ethics educators, to facilitate a broader network for sharing of tacit and experiential knowledge. Implications for Rehabilitation According to the study participants, rehabilitation ethics education should include learning about foundational knowledge related to ethical theory; be grounded in examples and cases drawn from clinical rehabilitation practice; and contribute to building professional competencies such as self-knowledge and critical thinking in students. Regardless of the methods used by occupational therapy (OT) and physical therapy (PT) educators for teaching and evaluation, the value of creating spaces that support open discussion for students (e.g. protected discussion time in class, peer-discussions with the help of a facilitator, use of a web discussion forum) was consistently identified as an important facet. Educators from OT and PT programmes should work with various professionals involved in OT and PT student training across the curricula (e.g. clinical preceptors, other educators) to extend discussions of how ethics can be better integrated into the curriculum outside of sessions specifically focused on ethics. The CREW Day workshop was the first opportunity for Canadian rehabilitation ethics educators to meet and discuss their approaches to teaching and evaluating ethics for OT and PT students. Including international rehabilitation ethics educators in this dialogue could positively expand on this initial dialogue by facilitating the sharing of tacit and experiential knowledge amongst a larger and more diverse group of ethics educators.

Haitian and international responders' and decision-makers' perspectives regarding disability and the response to the 2010 Haiti earthquake.

BACKGROUND: Following disasters, persons with disabilities (PWD) are especially vulnerable to harm, yet they have commonly been excluded from disaster planning, and their needs have been poorly addressed during disaster relief. Following the 2010 Haiti earthquake, thousands of individuals experienced acute injuries. Many more individuals with preexisting disabilities experienced heightened vulnerability related to considerations including safety, access to services, and meeting basic needs. OBJECTIVE: The objective of this research was to better understand the perceptions of responders and decision-makers regarding disability and efforts to address the needs of PWD following the 2010 earthquake. DESIGN: We conducted a qualitative study using interpretive description methodology and semistructured interviews with 14 Haitian and 10 international participants who were involved in the earthquake response. RESULTS: Participants identified PWD as being among the most vulnerable individuals following the earthquake. Though some forms of disability received considerable attention in aid efforts, the needs of other PWD did not. Several factors were identified as challenges for efforts to address the needs of PWD including lack of coordination and information sharing, the involvement of multiple aid sectors, perceptions that this should be the responsibility of specialized organizations, and the need to prioritize limited resources. Participants also reported shifts in local social views related to disability following the earthquake. CONCLUSIONS: Addressing the needs of PWD following a disaster is a crucial population health challenge and raises questions related to equity and responsibility for non-governmental organizations, governments, and local communities.

Thinking critically about client-centred practice and occupational possibilities across the life-span.

BACKGROUND: Client-centred occupational therapy practice is tacitly guided by prevailing social values and beliefs about what are "normal" occupational possibilities. These values and beliefs privilege some occupations and negate others. AIM: This study aims to identify and problematize assumptions regarding the value of approximating normal occupational possibilities, showing how these assumptions influence and may diminish client-centred practice. METHODS: Using empirical research examples it demonstrates how occupational therapists and clients are immersed in contexts that shape values and beliefs about what are considered "normal" occupations and how these taken-for-granted values structure occupational therapy practice. CONCLUSION: Critique of client-centred practice requires conscious reflexivity, interrogating our own and our clients' predispositions to value some occupations over others. Engaging in critical reflexivity can help therapists develop new perspectives of how client-centred practice can be applied that includes enabling possibilities for occupations that would be missed altogether in the pursuit of "normal'.

Contradictions in client-centred discharge planning: through the lens of relational autonomy.

BACKGROUND: While client-centred practice has received wide support, it remains difficult to apply in many practice settings. Identified barriers include constraints on time, resources, and services imposed by healthcare policies. Healthcare professionals' prioritizing of client safety over (other) interests that clients may name may further restrict the application of client-centred practice. Discharge planning is one area where such considerations can conflict. AIM: This paper presents a secondary analysis of data examining the process of discharge in one Canadian rehabilitation setting. It examines how discourses of client-centred practice and of prioritizing safety were reflected in discharge planning with older adults and considers the implications of potential conflicts between these discourses. METHOD: Taking a critical bioethics perspective informed by relational autonomy theory, microethnographic case studies were used to examine discharge planning from the perspectives of older adult clients and healthcare professionals. RESULTS: Healthcare professionals interpreted client-centred practice to require abiding by client wishes, as long as this was safe; furthermore prioritizing safety took precedence over other considerations in discharge planning. CONCLUSION AND SIGNIFICANCE: Client-centred practice was not promoted in discharge planning processes in the research setting. Applying a relational autonomy lens to practice could promote approaches that better facilitate client-centred practice.