The Challenges of Advance Care Planning for Acute Care Registered Nurses.

STUDY BACKGROUND: The practice of acute care nurses is shaped by organizational factors such as lack of privacy, heavy workloads, unclear roles, lack of time, and lack of specific policies and procedures. We know little about the social and organizational structures and processes that influence nurses' uptake of valuable patient-centered discussions like advance care planning (ACP). ACP is beneficial for patients, their substitute decision makers, and healthcare providers. PURPOSE: To describe the operational, organizational, and societal influences shaping nurses' ACP work in acute care settings. METHODS: This ethnographic study purposively sampled 14 registered nurses and 9 administrators who worked in two acute care hospitals in Northeastern Ontario. Methods consisted of 23 open-ended, semi-structured interviews, 20 hours of observational fieldwork, and a collection of publicly available organizational documents. Data were inductively analyzed using an iterative constant comparative approach. RESULTS: Nurses were challenged to meet multiple competing demands, leaving them to scramble to manage complex and critically ill acute care patients while also fulfilling organizational tasks aligned with funding metrics, accreditation, and strategic planning priorities. Such factors limited nurses' capacity to engage their patients in ACP. CONCLUSIONS: Acute care settings that align patient values and medical treatment need to foster ACP practices by revising organizational policies and processes to support this outcome, analyzing the tasks of healthcare providers to determine who might best address it, and budgeting how to support it with additional resources.

Re-thinking the nature of day programs for people with dementia: Implications for research.

Day programs are commonly identified in dementia strategies as a solution for keeping people with dementia home for as long as possible. Limited research evidence is available to support these policy approaches, and much of what exists demonstrates equivocal results. While key day program researchers have called for improvements in methodological and theoretical efforts, we argue that basic assumptions concerning what a day program is, and how the effects of day programs should be studied, also require reconsideration. Problematization is a systematic review strategy used to identify and critique assumptions guiding research practices and knowledge development in a field of study. The approach entails a broad overview of a field of research alongside a close reading of key texts to identify prevailing assumptions about the object of study and how it can be known. The intent is to discern how these assumptions are influencing research practices and thus knowledge development. A review of historical texts and research literature reviews was used (1) to identify trends in day program research between 1990 and 2018 and (2) to support identification of influential and typical studies for closer analysis (n = 36). The outcome of our analysis of the research literature suggests three sets of assumptions that guide much of the day program research literature: dementia is mainly treated as a problem of the individual; day programs are treated as stand-alone units of substitute care; and the space of day programs is seen as a simple background to care. We argue that the assumptions regarding care and space have narrowed the field of research and contributed to the production of equivocal findings. We suggest alternative framings of notions of care and space, informed by a Science and Technology Studies' approach to care practices, to generate knowledge about day programs that can usefully inform policy and practice.

The significance of overlooked objects: Materiality and care at home for people with dementia.

An increase in the number of older people with dementia is currently a trend around the world. In low and middle countries, effective public health services are not yet well-developed, and family care-givers may be overwhelmed by the requirements of care. This paper has two purposes: to share findings from an ethnographic study about family dementia care practices in Brazil and to draw attention to the significance of the materiality of care practices in the family context. The study was conducted in Belo Horizonte, Brazil. We describe the care trajectory of one family and, analysing data using the insights of Actor Network Theory, show the significance of objects in a networked relation of care. In particular, we show how incontinence products such as adult diapers assume different positions in the network, acting as either mediator or intermediary of care in relation to other elements of the network composed of family members and their living situation, the person with dementia herself, the doctor, and Brazilian health policies. Although the diaper is often seen as an ordinary object for care providers, its participation in a care network shapes relations, activating conflict, financial constraint, and disciplining the body of the person with dementia.

Integrating preparation for care trajectory management into nurse education: Competencies and pedagogical strategies.

Nurses make an important contribution to the organisation and coordination of patient care but receive little formal educational preparation for this work. This paper builds on Allen's care trajectory management framework to specify evidence-based and theoretically informed competencies for this component of the nursing role and proposes how these might be incorporated into nursing curricula. This is necessary so that at the point of registration nurses have the expertise to realise their potential as both providers and organisers of patient care and are better able to articulate and develop this aspect of nursing practice.

The Drive towards Sustainable Health Systems Needs an Alignment: Where are the Innovations in Health Systems Planning?

Clarifying the healthcare innovation agenda is critical in order to advance the impact of system innovations. As part of this agenda-setting it is important to address the four conditions within which innovations can enhance system sustainability: 1) the innovation agenda reflects and is aligned with healthcare objectives and policy; 2) planning methodologies for services, workforce and funding are aligned with healthcare objectives and policy; 3) innovations in services are accommodated in systems through innovations in policy, planning and funding; and 4) innovations are systematically monitored and evaluated. In order to illustrate these conditions, the authors present a case study of an evaluation of one Canadian Health Authority's efforts to transform healthcare delivery. This case study reveals that aligning innovations in policy, planning, funding and health services is critical to transforming health systems and that, in the absence of such alignment, sustainable health systems are difficult to achieve.

Caregiving for the Elderly Person: Discourses Embedded in the Brazilian Practical Guide for the Caregiver.

It is estimated that in 2025, Brazil will have the sixth largest elderly population in the world. Beyond the economic consequences of this projection, this changing demographic portends significant changes in the social realm. The aim of this study was to review and consider a range of government documents, developed during the past thirty years and directed toward elderly Brazilian citizens, to explore the ways that caregivers of older persons are positioned in daily care practices through the discourses such documents deploy. The analysis draws on Foucault's genealogical approach, and begins with a review of the historicity of policies, regulations, and legislation related to older people, followed by an analysis of the discourses embedded in the Practical Guide for the Caregiver, a document created by the Brazilian Ministry of Health to provide guidance to informal caregivers in the actual provision of care to elders. The analysis shows that throughout the Guide, caregivers are portrayed as multifaceted subjects; yet at the same time, three primary positionings for the caregiver and her or his work are emphasized: the almost-angel, the almost-healthcare professional, and the almost-household professional.

Nursing with care: a meditation in three voices (in memoriam John S. Drummond).

This paper is a written version of a talk given at the 19th International Philosophy of Nursing conference to honour the contributions of Dr. John S. Drummond, nurse and philosopher, to an ongoing and collective project we could call 'thinking nursing'. Over the course of his career, John Drummond published a series of essays, building on his reading of the works of continental philosophers such as Nietzsche, Lyotard or Deleuze, that draw us to nursing as a matter of concern, and that through their incisive analyses, help us to pay attention to the changes that are going on with nursing now. Though this essay began as a way to mark the death of John Drummond, and to pay tribute to his work, we also find that our return to his texts is like other experiences of return - the pleasure of experiencing something anew, as if for the first time.

The 'right' place to care for older people: home or institution?

In 2008, the Minister of Health for Iceland issued a new regulation intended to govern assessment practices related to placement in nursing homes. One of the aims of the regulation was to ensure that those with the most severe need would have priority. This would be achieved, in part, by requiring older people to exhaust all available community-based service options before an assessment for placement would even take place. The new regulation was received with some hostility and criticism on the part of older people and their relatives, who described the changed expectations as 'abandonment' by the authorities. We present our analysis of these changes by examining how older people and families are reconfigured through the new policy and argue that this 'new' practice of de-institutionalization is underpinned by a shifting epistemic and normative context that is working to create a new identity and a different way of life in advanced age in Iceland. The analysis has implications for other nations as well, as much policy related to older people is broadly informed by this idea that 'home is best', that is, the idea that more care simply needs to happen outside of institutional settings.

Implications of early workplace experiences on continuing interprofessional education for physicians and nurses.

Formative experiences, identities and collaborative strategies of nurses and physicians need to be appreciated to develop transformative interprofessional education for them. This article develops the collaborative profiles of recently graduated physicians and nurses based on a phenomenological study conducted at tertiary training hospitals in Canada and the United Kingdom. Recent nursing and medical graduates were interviewed to study the impact of undergraduate professional education on their ability to practice collaboratively in the workplace. The impact of undergraduate professional education on teamwork was found to be diluted by internal contradictions and overshadowed by the demands and contingencies of the workplace reported here. Initiation into the workplace was frequently precipitous and for residents the workplace environment was fluid and repeatedly new, as they rotated through various disciplines in the hospital. In busy wards, interdependent but competing priorities led to the development of adversarial uniprofessional identities and derogatory stereotyping of the other. Both groups were overwhelmed by high workload, unpreparedness and responsibility. Cross generational and gender based interactions also provoked resentment. Over time collaborative attitudes became blunted and interprofessional identities were renegotiated. Continuing interprofessional education, for recent graduates that prioritises problem areas, alongside appropriate structural changes could potentially transform the prevalent culture and impact teamwork downstream.

Theorizing accommodation in supportive home care for older people.

This paper examines the issue of what thinking is necessary in order to advance a notion of accommodation in the organization and provision of supportive home care for older people. Accommodation in this context is understood as responsiveness to the singularity of older adults, and we consider how this idea might be used to support opportunities for (independent) living for elders as they age and become frailer. To elaborate the question we draw on examples from our empirical work - ethnographic studies of home care practice undertaken in Canada and Iceland - and consider these examples in light of critical philosophical and social theory, particularly Agamben's (1993) work, The Coming Community. This is a relevant frame through which to consider the potential for the accommodation of the unique needs of older adults in home care because it helps us to problematize the systems through which care is accomplished and the current, dominant terms of relations between individuals and collectives. We argue that giving substance to a notion of accommodation contributes an important dimension to aligned ideas, such as patient-centeredness in care, by working to shift the intentionality of these practices. That is, accommodation, as an orientation to care practices, contests the organizational impulse to carry on in the usual way.

Redesigning care delivery in British Columbia.

Phase 1 of this initiative was designed to examine the current state of practice in acute care and to provide administrators with research evidence for identifying areas for improvement. Data were collected through observational research using function analysis augmented by a staff survey and interviews. Data were collected from 17 acute care sites across Vancouver Island and the Mainland of British Columbia involving four health authorities.

Means without ends: justifying supportive home care for frail older people in Canada, 1990-2010.

The challenges associated with ageing populations are very much on the policy and research agenda of many nations, with significant discussions focused on establishing appropriate, acceptable parameters of home care for those who are older and frail. This paper develops an analysis of changing justifications of home care in Canada (1990-2010) through examination of governmental and non-governmental home care policy documents and position papers, as well as observations from recent fieldwork in home care. Boltanski and Thévenot's sociology of justification provides a framework for analysis of these situations where competing and irreducible pluralities of goods complicate discussions of the 'right' way to proceed.

An exploration of empowerment discourse within home-care nurses' accounts of practice.

In this study, we explore how client and family caregiver 'empowerment' is interpreted by home-care nurses talking about their practice with palliative (and to a lesser extent, non-palliative) clients and families. We draw on secondary analysis of qualitative data collected through in-person interviews with 27 home-care nurses from a western Canadian health authority. First, we illustrate how the practice ideal of empowerment, in the sense of 'respecting autonomy and choices', can be understood as reflecting home-care nurses' needs to mitigate the emotional impact of feeling unable to effectively help palliative clients/families. Then, we illustrate how the practice ideal of empowerment, in the sense of 'promoting independence', can be understood to accomplish the need to shift responsibility for particular care tasks to clients and family members. Lastly, home-care nurses, talk about 'promoting choices' is also investigated. 'Choice' was framed narrowly with respect to allowing palliative clients and families to determine visit time and frequency. Findings are discussed in relation to the concept of 'responsibilization'.

Home care nurses' decisions about the need for and amount of service at the end of life.

AIMS: We explore home care nurse decision-making about the need for and amount of service by clients and families at the end of life. We identify factors nurses refer to when describing these decisions, situated within contextual features of nursing practice. BACKGROUND: Home care nurses are often responsible for decisions which have an impact on the access of clients and families to services at the end of life. Understanding how these decisions, are made, factors that are considered, and contextual influences is critical for improving access and enhancing care. METHODS: Qualitative data were collected between 2006 and 2008 from two samples of home care nurses: the first group (n = 29) recorded narrative descriptions of decisions made during visits to families. The second group (n = 27) completed in-person interviews focusing on access to care and their interactions with clients and families. Data were analysed with thematic coding and constant comparison. FINDINGS: Participants described assessing client and family needs and capacity. These assessments, at times integrated with considerations about relationships with clients and families, inform predictive judgements about future visits; these judgments are integrated with workload and home health resource considerations. In describing decisions, participants referred to concepts such as expertise, practice ideals and approaches to care. CONCLUSION: Findings highlight the role of considerations of family caregiver capacity, the influence of relationships and the importance of the context of practice, as part of a complete understanding of the complexity of access to care at the end of life.

Articulating the role of relationships in access to home care nursing at the end of life.

In this article, we draw on data collected from two samples of home care nurses to examine how relationships between nurses and family caregivers intersected with access to palliative home care nursing services. Participants referred to relationships as important for their practical benefits and for access to care: good relationships enhanced the nurse's ability to assess clients and families and fostered the family's trust in the nurse's care. Although emphasizing the need to build and maintain relationships (often requiring time), participants simultaneously referred to beliefs about the need to control the personal emotions invoked in relationships so as to ensure appropriate access for clients and families. Future research should further explore how the organizational and resource context, and the culture of palliative care, shape nurses' beliefs about relationships in their practice, the nature and types of relationships that can develop, and both client and family caregivers' access to care.

The power and politics of collaboration in nurse practitioner role development.

This health services study employed participatory action research to engage nurse practitioners (NPs) from two health authorities in British Columbia, Canada, to examine the research question: How does collaboration advance NP role integration within primary health-care? The inquiry was significant and timely because the NP role was recently introduced into the province, supported by passage of legislation and regulation and introduction of graduate education programs. In separate and concurrent inquiry groups, the NPs discussed their practice patterns, role development progress and understanding of collaboration and role integration. The inquiry revealed the political nature of the NP role and the extent to which NPs relied on collaborative relations at all levels of the health system to advance role integration. Given that NP role development is still at an early stage in this province, as well as other provinces in Canada, this study provides important insights into the power and politics of role development, and offers direction for future role advancement.

The BC Educator Pathway Collaborative Framework: creating the foundation for nursing education capacity.

This paper describes the conceptual structure and organizational framework of the Educator Pathway Project (EPP), which is a unique collaborative capacity-building project creating infrastructure for integrating nursing practice learning and development throughout the service and education sectors in British Columbia. Since 2005, two major health authorities, two universities and the provincial nurses' bargaining association have been engaged in an intensive and dynamic partnership to conceptualize and fundamentally change intersectoral directions and possibilities. This unique initiative has required considerable investment and commitment among all partner organizations, resulting in a clear, shared vision of systemwide support of nursing. With the EPP now in its final year of funding, we are beginning to document its elements and interpret its significant impact on nurses and their workplaces across the regions. In this paper, we describe the overall program design, explain the collaborative partnership mechanisms through which we have been implementing the project and articulate a range of processes through which we are working together to enact significant system-level adjustments aimed at a genuine practice-education continuum. As part of sustaining a strong nursing workforce, we believe that nursing practice and education leaders across Canada are ready to employ this kind of creative approach towards realizing our common goals.