The impact of funding models on the integration of Ontario midwives: a qualitative study.

BACKGROUND: Nearly 30 years post legalisation and introduction, midwifery is still not optimally integrated within the health system of Canada's largest province, Ontario. Funding models have been identified as one of the main barriers. METHODS: Using a constructivist perspective, we conducted a qualitative descriptive study to examine how antepartum, intrapartum, and postpartum funding arrangements in Ontario impact midwifery integration. We conceptualized optimal 'integration' as circumstances in which midwives' knowledge, skills, and model of care are broadly respected and fully utilized, interprofessional collaboration and referral support the best possible care for patients, and midwives feel a sense of belonging within hospitals and the greater health system. We collected data through semi-structured telephone interviews with midwives, obstetricians, family physicians, and nurses. The data was examined using thematic analysis. RESULTS: We interviewed 20 participants, including 5 obstetricians, 5 family physicians, 5 midwives, 4 nurses, and 1 policy expert. We found that while course-of-care-based midwifery funding is perceived to support high levels of midwifery client satisfaction and excellent clinical outcomes, it lacks flexibility. This limits opportunities for interprofessional collaboration and for midwives to use their knowledge and skills to respond to health system gaps. The physician fee-for-service funding model creates competition for births, has unintended consequences that limit midwives' scope and access to hospital privileges, and fails to appropriately compensate physician consultants, particularly as midwifery volumes grow. Siloing of midwifery funding from hospital funding further restricts innovative contributions from midwives to respond to community healthcare needs. CONCLUSIONS: Significant policy changes, such as adequate remuneration for consultants, possibly including salary-based physician funding; flexibility to compensate midwives for care beyond the existing course of care model; and a clearly articulated health human resource plan for sexual and reproductive care are needed to improve midwifery integration.

An observational cohort study comparing ibuprofen and oxycodone in children with fractures.

OBJECTIVE: To compare the effectiveness and safety of prescribing ibuprofen and oxycodone for at-home management of children's fracture pain. METHODS: A prospective observational cohort was conducted at the Stollery Children's Hospital pediatric emergency department (June 2010-July 2014). Children aged 4-16 years with an isolated fracture discharged home with advice to use either ibuprofen or oxycodone were recruited. RESULTS: A cohort of 329 children (n = 217 ibuprofen, n = 112 oxycodone) were included. Mean age was 11.1 years (SD 3.5); 68% (223/329) were male. Fracture distribution included 80.5% (264/329) upper limb with 34.3% (113/329) requiring fracture reduction. The mean reduction in Faces Pain Score-Revised score (maximum pain-post-treatment pain) for Day 1 was 3.6 (SD 1.9) (ibuprofen) and 3.8 (SD 2.1) (oxycodone) (p = 0.50); Day 2 was 3.6 (SD 1.8) (ibuprofen) and 3.7 (SD 1.6) (oxycodone) (p = 0.56); Day 3 was 3.7 (SD 1.7) (ibuprofen) and 3.3 (SD 1.7) (oxycodone) (p = 0.24). Children prescribed ibuprofen (51.2%, 109/213) experienced less adverse events compared to those prescribed oxycodone (70.5% 79/112) on Day 1 (p = 0.001). Children prescribed ibuprofen (71.8%, 150/209) had their function (eat, play, school, sleep) affected less than those prescribed oxycodone (83.0%, 93/112) (p = 0.03) on Day 1. CONCLUSION: Children prescribed ibuprofen or oxycodone experienced similar analgesic effectiveness for at-home fracture pain. Oxycodone prescribing was associated with more adverse events and negatively impacted function. Oxycodone use does not appear to confer any benefit over ibuprofen for pain relief and has a negative adverse effect profile. Ibuprofen appears to be a safe option for fracture-related pain.

Comparison of two vitamin D supplementation strategies in children with sickle cell disease: a randomized controlled trial.

Previously, we showed that nearly 70% of children followed in our sickle cell disease (SCD) clinic were vitamin D- deficient and had low vitamin intake with poor use of supplements. We compared the change in serum 25-hydroxyvitamin D [25(OH)D], safety and clinical impact of two vitamin D supplementation regimens in children with SCD. Children (5-17 years, all genotypes) were randomized to a single bolus of vitamin D3 (300 000 IU; n = 18) or placebo (n = 20). All children received a prescription for daily 1 000 IU vitamin D3 . Serum 25(OH)D and calcium, urinary calcium/creatinine ratio, musculoskeletal pain, quality of life, haematology and bone markers were assessed at baseline and three months post intervention. Bolus administration led to a greater rise in 25(OH)D levels from baseline compared to placebo (20 ± 16 nmol/l vs. 2 ± 19 nmol/l; P = 0·003) and correction of vitamin D deficiency. No hypercalcaemia nor hypercalciuria occurred during the study, but more children in the bolus group experienced gastrointestinal symptoms within the first month (P = 0·04). There were no differences between groups for other outcomes. The use of a high-dose vitamin D bolus combined with daily 1 000 IU vitamin D3 was more efficient in raising 25(OH)D levels than daily supplementation alone in children with SCD.

Virtual reality hand therapy: A new tool for nonopioid analgesia for acute procedural pain, hand rehabilitation, and VR embodiment therapy for phantom limb pain.

INTRODUCTION: Affordable virtual reality (VR) technology is now widely available. Billions of dollars are currently being invested into improving and mass producing VR and augmented reality products. PURPOSE OF THE STUDY: The purpose of the present study is to explore the potential of immersive VR to make physical therapy/occupational therapy less painful, more fun, and to help motivate patients to cooperate with their hand therapist. DISCUSSION: The following topics are covered: a) psychological influences on pain perception, b) the logic of how VR analgesia works, c) evidence for reduction of acute procedural pain during hand therapy, d) recent major advances in VR technology, and e) future directions-immersive VR embodiment therapy for phantom limb (chronic) pain. CONCLUSION: VR hand therapy has potential for a wide range of patient populations needing hand therapy, including acute pain and potentially chronic pain patients. Being in VR helps reduce the patients' pain, making it less painful for patients to move their hand/fingers during hand therapy, and gamified VR can help motivate the patient to perform therapeutic hand exercises, and make hand therapy more fun. In addition, VR camera-based hand tracking technology may be used to help therapists monitor how well patients are doing their hand therapy exercises, and to quantify whether adherence to treatment increases long-term functionality. Additional research and development into using VR as a tool for hand therapist is recommended for both acute pain and persistent pain patient populations.

A cluster randomized clinical trial to evaluate the effectiveness of the Implementation of Infant Pain Practice Change (ImPaC) Resource to improve pain practices in hospitalized infants: a study protocol.

BACKGROUND: Hospitalized infants undergo multiple painful procedures daily. Despite the significant evidence, procedural pain assessment and management continues to be suboptimal. Repetitive and untreated pain at this vital developmental juncture is associated with negative behavioral and neurodevelopmental consequences. To address this knowledge to practice gap, we developed the web-based Implementation of Infant Pain Practice Change (ImPaC) Resource to guide change in healthcare professionals' pain practice behaviors. This protocol describes the evaluation of the intervention effectiveness and implementation of the Resource and how organizational context influences outcomes. METHODS: An effectiveness-implementation hybrid type 1 design, blending a cluster randomized clinical trial and a mixed-methods implementation study will be used. Eighteen Neonatal Intensive Care Units (NICUs) across Canada will be randomized to intervention (INT) or standard practice (SP) groups. NICUs in the INT group will receive the Resource for six months; those in the SP group will continue with practice as usual and will be offered the Resource after a six-month waiting period. Data analysts will be blinded to group allocation. To address the intervention effectiveness, the INT and SP groups will be compared on clinical outcomes including the proportion of infants who have procedural pain assessed and managed, and the frequency and nature of painful procedures. Data will be collected at baseline (before randomization) and at completion of the intervention (six months). Implementation outcomes (feasibility, fidelity, implementation cost, and reach) will be measured at completion of the intervention. Sustainability will be assessed at six and 12 months following the intervention. Organizational context will be assessed to examine its influence on intervention and implementation outcomes. DISCUSSION: This mixed-methods study aims to determine the effectiveness and the implementation of a multifaceted online strategy for changing healthcare professionals' pain practices for hospitalized infants. Implementation strategies that are easily and effectively implemented are important for sustained change. The results will inform healthcare professionals and decision-makers on how to address the challenges of implementing the Resource within various organizational contexts. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03825822. Registered 31 January 2019.

Factors influencing oral care in intubated intensive care patients.

BACKGROUND: The practice of oral care in intensive care settings remains inconsistent among intubated patients, yet these patients are at high risk of developing ventilator-associated pneumonia. Therefore, it is important to adopt safe professional behaviour based on clinical practice guidelines. This study was based on Ajzen's (1985) theory of planned behavior, a conceptual framework that allows a better understanding of how internal and external factors influence behaviour adoption. AIMS AND OBJECTIVES: To study influential factors in how nurses practice oral care with intubated clients in intensive care settings, referring to the theory of planned behavior (TPB) constructs. DESIGN: A cross-sectional descriptive correlational design was conducted through a provincial postal survey in Quebec, Canada. METHODS: A questionnaire was completed by 375 nurses working in intensive care units (ICUs). RESULTS: Perceived behavioural control and attitude were the most important determinants in the level of intention to engage in oral care. Knowledge, available human and material resources, and number of years of experience in critical care nursing also seemed to be significant influencing factors. CONCLUSIONS: This study improved our understanding of the factors influencing the practice of oral care in intubated patients in the ICU, relying on TPB as an explanatory framework. It would be important to continue to study this professional behaviour and to work in collaboration with health care facilities to promote the importance of oral care as an imperative for the safety and quality of health care. RELEVANCE TO CLINICAL PRACTICE: The results of this study represent a solid foundation for advancing continuing education programmes and intensive care orientation programmes tailored to the needs of nurses.

Validation of the Adolescent Pediatric Pain Tool for the Multidimensional Measurement of Pain in Children and Adolescents Diagnosed with Osteogenesis Imperfecta.

Background: The Adolescent Pediatric Pain Tool (APPT) is a self-reported, multidimensional assessment of pain location, intensity, and quality in children and adolescents. Yet, it has not been validated for use in children and adolescents with osteogenesis imperfecta (OI). Aims: This study aimed to validate and evaluate the feasibility of the APPT for pain assessment in children and adolescents with OI. Methods: A prospective observational study was conducted at a university-affiliated pediatric hospital in Canada. Thirty-three children and adolescents with OI participated by completing the APPT pre-bisphosphonate intravenous infusion and 1 week post-bisphosphonate intravenous infusion. Main outcomes were internal consistency, convergent and discriminative validity, and feasibility. Results: The Kuder-Richardson test of internal consistency was 0.863, 0.661, and 0.729 for the Sensory, Affective, and Evaluative subscales, respectively. For the entire pain quality scale, the Cronbach's alpha was 0.835. Regarding convergent validity, a moderate correlation was observed between the ratings on the pain intensity scale and the Faces Pain Scale-Revised (Spearman's rho = 0.711). Patients for whom pain was a problem reported higher pain intensity (Mann Whitney U = 41.50, P = 0.032) and more pain quality descriptors (Mann Whitney U = 45.50, P = 0.020) and painful body areas (Mann-Whitney U = 25.50, P = 0.001) than those for whom it was not (Mann-Whitney U, P < 0.05). In terms of feasibility, completing the tool may require a considerable time commitment and assistance from a clinician or parent, especially if the patient is experiencing pain and provides detailed pain location and quality information by completing the APPT. Conclusions: This study suggests that the APPT is valid for the multidimensional assessment of pain in children and adolescents with OI, but feasibility needs to be enhanced.

Contexte: L'outil d'évaluation de la douleur des adolescents en pédiatrie (APPT) est une évaluation multidimensionnelle auto-déclarée de l'emplacement, de l'intensité et de la qualité de la douleur chez les enfants et les adolescents. Toutefois, l'utilisation de cet outil auprès des enfants et des adolescents souffrant d'ostéogénèse imparfaite n'a pas encore été validée.But: Cette étude avait pour but de valider et d'évaluer la faisabilité de l'APPT pour l'évaluation de la douleur dans cette population.Méthodes: Une étude observationnelle prospective a été menée dans un centre hospitalier universitaire à vocation pédiatrique au Canada. Trente-trois enfants et adolescents atteints d'ostéogénèse imparfaite ont participé à cette étude en répondant à l'APPT avant l'infusion intraveineuse de bisphosphonate et une semaine après celle-ci. Les principaux résultats étaient la cohérence interne, la validation convergente et discriminante, et la faisabilité.Résultats: Le résultat du test de Kuder-Richardson pour mesurer la cohérence interne était de 0,863 pour le sensoriel, 0,661 pour l'affectif et 0,729 pour les sous-échelles d'évaluation. Pour l'échelle de qualité de la douleur au complet, l'indice alpha de Cronbach était de 0,835. En ce qui concerne la validation convergente, une corrélation modérée a été observée entre les scores obtenus à l'échelle d'intensité de la douleur et le FPS-R (Rho de Spearman= 0,711). Les patients pour lesquels la douleur était problématique ont fait état d'une intensité de la douleur plus élevée, ont eu recours à un plus grand nombre de descripteurs de la qualité de la douleur et ont identifié davantage de parties du corps douloureuses que ceux pour lesquels la douleur n'était pas problématique (Mann-Whitney U, p < 0,05). En ce qui concerne la faisabilité, le temps requis pour répondre au questionnaire peut être considérable et l'aide d'un clinicien ou d'un parent peut être nécessaire, particulièrement si le patient ressent de la douleur et donne de l'information détaillée sur la localisation et la qualité de la douleur en répondant à l'APPT.Conclusions: Selon cette étude, l'APPT est valide pour l'évaluation multidimensionnelle de la douleur chez les enfants et les adolescens souffrant d'oastéogénèse imparfaite, mais sa faisabilité doit être améliorée.

Projector-based virtual reality dome environment for procedural pain and anxiety in young children with burn injuries: a pilot study.

BACKGROUND: Virtual reality (VR) is a non-pharmacological method to distract from pain during painful procedures. However, it was never tested in young children with burn injuries undergoing wound care. AIM: We aimed to assess the feasibility and acceptability of the study process and the use of VR for procedural pain management. METHODS: From June 2016 to January 2017, we recruited children from 2 months to 10 years of age with burn injuries requiring a hydrotherapy session in a pediatric university teaching hospital in Montreal. Each child received the projector-based VR intervention in addition to the standard pharmacological treatment. Data on intervention and study feasibility and acceptability in addition to measures on pain (Face, Legs, Activity, Cry, Consolability scale), baseline (Modified Smith Scale) and procedural (Procedure Behavior Check List) anxiety, comfort (OCCEB-BECCO [behavioral observational scale of comfort level for child burn victims]), and sedation (Ramsay Sedation Scale) were collected before, during, and after the procedure. Data analyses included descriptive and non-parametric inferential statistics. RESULTS: We recruited 15 children with a mean age of 2.2±2.1 years and a mean total body surface area of 5% (±4). Mean pain score during the procedure was low (2.9/10, ±3), as was the discomfort level (2.9/10, ±2.8). Most children were cooperative, oriented, and calm. Assessing anxiety was not feasible with our sample of participants. The prototype did not interfere with the procedure and was considered useful for procedural pain management by most health care professionals. CONCLUSION: The projector-based VR is a feasible and acceptable intervention for procedural pain management in young children with burn injuries. A larger trial with a control group is required to assess its efficacy.

A Randomized Controlled Trial Evaluating the Efficacy of Oral Sucrose in Infants 1 to 3 Months Old Needing Intravenous Cannulation.

OBJECTIVES: The objective was to compare the efficacy of an oral sucrose versus placebo in reducing pain in infants 1 to 3 months of age during intravenous (IV) cannulation in the emergency department. METHODS: A randomized, double-blind, placebo clinical trial was conducted. Participants were randomly allocated to receive 2 mL of an oral 88% sucrose solution or 2 mL of a placebo solution orally. The outcome measure were mean difference in pain score at 1 minute post-IV cannulation assessed by the Face, Legs, Activity, Cry, and Consolability Pain Scale (FLACC) and the Neonatal Infant Pain Scale (NIPS), crying time, and variations in heart rate. RESULTS: Eighty-seven participants completed the study, 45 in the sucrose group and 42 in the placebo group. There was no statistical difference in variations in both the FLACC score (p = 0.49) and the NIPS score (p = 0.36) between the two groups as per the Mann-Whitney U-test. With the same test, median crying times following IV cannulation were statistically significantly different between both groups (17 seconds in the sucrose group vs. 41 seconds in the placebo group, p = 0.04). Mean changes in heart rate 1 minute after IV cannulation were similar in both groups (16 ± 4 beats/min for sucrose vs. 18 ± 4 beats/min for placebo, p = 0.74). Side effects were similar for both groups and no adverse events were reported. CONCLUSIONS: Administration of an oral sucrose solution in infants 1 to 3 months of age during IV cannulation did not lead to statistically significant changes in pain scores. However, the cry time was significantly reduced.

Usability testing of an online self-management program for adolescents with cancer.

The objective of this study was to explore the usability of a bilingual (English and French) Internet-based self-management program for adolescents with cancer and their parents and refine the Internet program. A qualitative study design with semistructured, audio-taped interviews and observation was undertaken with 4 iterative cycles. A purposive sample of English-speaking and French-speaking adolescents with cancer and one of their parents/caregivers was recruited. Adolescents and parents provided similar feedback on how to improve the usability of the Internet program. Most changes to the website were completed after the initial cycles of English and French testing. Both groups also found information presented on the website to be appropriate, credible, and relevant to their experiences of going through cancer. Participants reported the program would have been extremely helpful when they were first diagnosed with cancer. Usability testing uncovered some issues that affected the usability of the website that led to refinements in the online program.

Pain management interventions with parents in the emergency department: a randomized trial.

AIM: This paper is a report of the efficacy of a parental educational intervention on children's pain intensity and experience of pain-related unpleasantness at 24 hours post-discharge from the emergency department, and on parents' beliefs about pain. BACKGROUND: Parents' misbeliefs about pain management may inhibit them from managing their child's pain appropriately. Educating parents about pain management may increase their knowledge, dispel myths and help decrease children's pain intensity and unpleasantness related to pain following a visit to an emergency department. METHOD: A randomized design was adopted with samples of parent/child dyads. The experimental group received a bookmark, booklet on pain management and pain scale. The control group only received a pain scale. Pain intensity and unpleasantness were measured at triage and 24 hours after discharge from the emergency department. Parents' beliefs were measured with the Pain Belief Questionnaire. Data were collected from November 2005 to May 2006. RESULTS: Samples of 98 (experimental) and 97 (control) children/parents were recruited. No statistically significant differences were found between both groups regarding pain intensity and unpleasantness, at triage and 24 hours post-discharge. Results for the Pain Belief Questionnaire were similar between the groups (t = 1·751, P = 0·082). CONCLUSION: The interventions were not effective to reduce pain and unpleasantness related to pain, as well as to improve pain beliefs of parents. Other interventions, such as having parents participate actively in their child's pain management, might be more effective than a passive educational intervention.

The effect of music on parental participation during pediatric laceration repair.

The purpose of this quasi-experimental study was to test an intervention on the use of music during simple laceration repair to promote parent-led distraction in children aged 1 to 5. Children's songs were broadcast via speakers during laceration repair and parents were encouraged to participate in distracting their child. The proportion of parental participation was determined. Laceration procedures were videotaped and objectively scored using the Procedure Behavior Check List. A total of 57 children participated in the study. There was no difference in parental involvement between the control and intervention groups. When age, sex, and condition were controlled for, distress scores were significantly higher if the father was present in the procedure room than if only the mother was present (43.68 vs. 23.39, t(54) 4.296, p = < 0.001). It was concluded that distress varies with the age of the child and the parent who is present during the procedure. Providing music during simple laceration repair did not increase the proportion of parents who were involved in distraction.

Theoretical, psychometric, and pragmatic issues in pain measurement.

Measurement is essential to nursing practice and research, and adequate tool selection is crucial for both. The present paper seeks to provide an overview of key issues to consider in tool development, selection, and psychometric testing using the concept of pain. Both the classic and the contemporary approaches to validity are described and compared. Although sharing similar features, the contemporary approach seems more encompassing, because it considers measurement purposes, participants' characteristics, and conditions under which instruments are used. Strategies pertaining to reliability and validity testing are discussed and illustrated with specific pain assessment measures, including pain intensity scales, multidimensional questionnaires, and other behavioral tools. Depending on measurement purposes, the more appropriate strategies are highlighted. Cultural issues in pain measurement as well as pragmatic criteria for measure selection also are discussed.

[Validity 'and Utilities' clinic of a grid observation (PACSLAC-F) to evaluate the pain in seniors with dementia's living in the Long-Term Care ]. / Validité et utilité clinique d'une grille d'observation (PACSLAC-F) pour évaluer la douleur chez des aînés atteints de démence vivant en milieu de soins de longue durée.

This study presents the validation of the French Canadian version (PACLSAC-F) of the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC). Unlike the published validation of the English version of the PACSLAC, which was validated retrospectively, the French version was validated prospectively. The PACSLAC-F was completed by nurses working in long-term care facilities after observing 86 seniors, with severe cognitive impairment, in calm, painful or distressing but non-painful situations. The test-retest and inter-observer reliability, the internal consistency, and the discriminent validity were found to be satisfactory. To evaluate the convergent validity with the DOLOPLUS-2 and the clinical relevance of the PACSLAC, it was also completed by nurses during their work shift, with 26 additional patients, for three days per week during a period of four weeks. These results encourage us to test the PACSLAC in a comprehensive program of pain management targeting this population.

Quality of life before and after heart valve surgery is influenced by gender and type of valve.

BACKGROUND: Quality of life (QoL) in valvular surgery may differ according to the underlying pathology and surgical technique used. METHOD: 82 adults undergoing their first elective surgery for valve repair (VP; n = 9) or valve replacement (VR) with a mechanical valve (MVR; n = 57) or bioprosthesis (BVR; n = 16) were assessed before surgery and three months afterwards. DEPENDENT VARIABLES: delta scores (postoperative-preoperative) on QoL measures (Quality of Life Systemic Inventory (QLSI) and SF-36). ANALYSES: Paired t tests and ANCOVAs with age and preoperative QoL scores as covariates. RESULTS: QoL improves after surgery according to most subscales. According to group comparisons, patients with an MVR improve more than those with a BVR on the mental health subscale. In physical roles, patients with an MVR improve while those with a BVR deteriorate. In emotional roles, patients with a VR improve while those with a VP deteriorate. However, they are similar on all other subscales. Women improve more than men on leisure, affectivity and social functioning while the opposite holds true for mental health. CONCLUSION: QoL improves after surgery. However, significant differences between groups are small because of a lack of statistical power.