Developing a survey to measure nursing students' knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study.

BACKGROUND: Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. Canada's legislation is the first to permit Nurse Practitioners (NP) to serve as independent MAiD assessors and providers. Registered Nurses' (RN) also have important roles in MAiD that include MAiD care coordination; client and family teaching and support, MAiD procedural quality; healthcare provider and public education; and bereavement care for family. Nurses have a right under the law to conscientious objection to participating in MAiD. Therefore, it is essential to prepare nurses in their entry-level education for the practice implications and moral complexities inherent in this practice. Knowing what nursing students think about MAiD is a critical first step. Therefore, the purpose of this study was to develop a survey to measure nursing students' knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context. METHODS: The design was a mixed-method, modified e-Delphi method that entailed item generation from the literature, item refinement through a 2 round survey of an expert faculty panel, and item validation through a cognitive focus group interview with nursing students. The settings were a University located in an urban area and a College located in a rural area in Western Canada. RESULTS: During phase 1, a 56-item survey was developed from existing literature that included demographic items and items designed to measure experience with death and dying (including MAiD), education and preparation, attitudes and beliefs, influences on those beliefs, and anticipated future involvement. During phase 2, an expert faculty panel reviewed, modified, and prioritized the items yielding 51 items. During phase 3, a sample of nursing students further evaluated and modified the language in the survey to aid readability and comprehension. The final survey consists of 45 items including 4 case studies. DISCUSSION: Systematic evaluation of knowledge-to-date coupled with stakeholder perspectives supports robust survey design. This study yielded a survey to assess nursing students' attitudes toward MAiD in a Canadian context. CONCLUSION: The survey is appropriate for use in education and research to measure knowledge and attitudes about MAiD among nurse trainees and can be a helpful step in preparing nursing students for entry-level practice.

Is parental propensity to risk associated with their child's medically-attended injuries? A cross-sectional study.

BACKGROUND: Societal expectations about safety influence parents' risk perceptions and children's risky play opportunities. This study examined parents' propensity to take risks themselves and their propensity to accept risks for their child, sex-related differences in parents' propensity to accept risks for their child, and the association between parents' propensity to accept risks for their child and that child's medically-attended injury history. METHODS: A total of 467 parents attending a pediatric hospital with their 6-12-year-old child completed a questionnaire about their risk propensity for themselves and for their child and reported their child's injury history. RESULTS: Parents' risk propensity for themselves was significantly higher than for their child, and fathers' risk propensity for themselves was higher than mothers'. Linear regressions showed that fathers reported significantly more propensity to accept risks for their child than mothers, but parents did not differentiate between their sons and daughters. A binary logistic regression showed that parents' propensity to accept risks for their child was a significant predictor of pediatric medically-attended injury. CONCLUSIONS: Parents were more comfortable in taking risks for themselves than for their child. While fathers were more comfortable with their children engaging in risks than mothers, child's sex was not related to parents' propensity to accept risks for their child. Pediatric injury was predicted by parents' propensity to accept risks for their child. Further research investigating injury type and severity related parent risk propensity is needed to determine how parents' attitudes toward risk might relate to severe injury.

"There's nothing here": Perspectives from rural parents promoting safe active recreation for children living with autism spectrum disorders.

BACKGROUND: Children with autism spectrum disorder (ASD) and their families experience challenges and barriers at multiple levels that influence their activity participation. The purpose of this study was to develop understanding about factors influencing how families can promote safe, active recreation for their children 3-12 years living with ASD across rural settings and how supports for these families can be enhanced. METHODS: This qualitative study used an interpretive descriptive approach. Twelve in-depth, semi-structured interviews with parents of children with ASD were conducted. Data was analyzed thematically. RESULTS: Four main themes emerged: 1) ASD specific child vulnerabilities impeding safe recreation. 2) Importance of safe outdoor spaces in rural settings for children with ASD. 3) Diverse parent strategies to address risks and needs. 4) Perceived needs for training of recreation providers. CONCLUSION: Findings highlight family-centred priority issues including parental safety concerns related to elopement and risk of injury linked to environmental and outdoor hazards prominent in rural settings. Autism awareness and recreational training is needed and could incorporate collaborative development of child specific safety plans to foster inclusive opportunities. Program planners can use this information to encourage policy making to aid families' safe activity participation.

Comparison of risk engagement and protection survey (REPS) among mothers and fathers of children aged 6-12 years.

BACKGROUND: Parental attitudes regarding child safety and risk engagement play important roles in child injury prevention and health promotion efforts. Few studies have compared mothers' and fathers' attitudes on these topics. This study used the risk engagement and protection survey (REPS) previously validated with fathers to compare with data collected from mothers. METHODS: Multi-group confirmatory factor analysis was used with a sample of 234 mothers and 282 fathers. Eligible parents had a child 6-12 years attending a paediatric hospital for an injury-related or other reason. We tested the factor structure of the survey by examining configural, metric and scalar invariance. Following this, mothers' and fathers' mean scores on the two identified factors of child injury protection and risk engagement were compared. RESULTS: Comparing mothers' and fathers' data showed the two-factor structure of the REPS held for the mothers' data. Comparing mean scores for the two factors suggested that fathers and mothers held equivalent attitudes. For the combined sample, parent injury protection attitude scores were significantly higher for daughters versus sons. In addition, attitude scores were significantly lower for injury protection and higher for risk engagement among parents born in Canada compared with those who were not. CONCLUSIONS: The REPS allows for valid assessment of injury protection and risk engagement factors for fathers and mothers. Mothers conceptualised the two factors as distinct concepts, similar to fathers. The REPS can be used to inform parenting programme development, implementation and evaluation.

"I will go if I don't have to talk": Nursing students' perceptions of reflective, debriefing discussions and intent to participate.

BACKGROUND/OBJECTIVES: The ability to be a reflective practitioner is recognized by nursing regulatory bodies as a component of professional competence and becoming a reflective practitioner is an essential part of learning to become a nurse. In this multi-site study, we explored undergraduate nursing students' beliefs, capacities and intentions to participate in reflective, debriefing discussions facilitated by clinical instructors. At the same time, we tested the effectiveness of a period of rest and an intervention designed to refresh and inspire them. DESIGN: A randomized crossover design. SAMPLE: Our analyzed sample consisted of 106 students; 87.7% were female and 65.1% were less than 20 years old. METHOD: This study was guided by the Theory of Planned Behaviour and consisted of five steps: instrument development, recruitment, random assignment to intervention, data collection at two time points using four tools, and data analysis. One hundred and forty-one first year nursing students used a learning management system to sign up to one of 15 potential clinical groups; maximum 10 students per group. Eight groups were randomly assigned to an intervention during post-clinical discussions; seven groups participated in the usual post-clinical discussions for the same length of time. After six weeks, the groups 'crossed-over' (switched). RESULTS: Students had a negative attitude towards routine discussions that occur after clinical practice experiences which did not significantly improve despite a period of rest and an intervention. Most did not feel in control and felt social pressure to participate. Additional results revealed that most students arrived at reflective post-clinical discussions with an underlying intent not to talk. Intent to remain silent (not participate) did not significantly improve despite a period of rest and intervention. CONCLUSIONS: The context and timing of the routine discussions may dramatically influence students' decision-making regarding intent to participate. Reflective processes require time and routine reflective debriefing discussions could be delayed until later in the week after students have had a chance to absorb and assimilate their experiences.

Risk Engagement and Protection Survey (REPS): developing and validating a survey tool on fathers' attitudes towards child injury protection and risk engagement.

INTRODUCTION: Fathers play a unique role in keeping children safe from injury yet understanding of their views and attitudes towards protecting children from injury and allowing them to engage in risks is limited. The purpose of this study was to develop and validate an instrument to measure fathers' attitudes towards these two constructs. METHODS AND FINDINGS: An instrument was developed that used prior qualitative research to inform item generation. The questions were assessed for content validity with experts, then pilot-tested with fathers. The survey was completed by 302 fathers attending hospital with their child for an injury or non-injury reason. Results of confirmatory factor analysis identified eight items relating to the protection from injury factor and six items relating to the risk engagement factor. Correlation between the two factors was low, suggesting these are two independent constructs. CONCLUSIONS: The Risk Engagement and Protection Survey offers a tool for measuring attitudes and assisting with intervention strategy development in ways that reflect fathers' views and promotes a balanced view of children's needs for safety with their needs for engaging in active, healthy risk-taking.

Barriers and Enablers to Enacting Child and Youth Related Injury Prevention Legislation in Canada.

Injury prevention policy is crucial for the safety of Canada's children; however legislation is not adopted uniformly across the country. This study aimed to identify key barriers and enablers to enacting injury prevention legislation. Purposive snowball sampling identified individuals involved in injury prevention throughout Canada. An online survey asked respondents to identify policies that were relevant to them, and whether legislation existed in their province. Respondents rated the importance of barriers or enablers using a 5-point Likert type scale and included open-ended comments. Fifty-seven respondents identified the most common injury topics: bicycle helmets (44, 77%), cell phone-distracted driving (36, 63%), booster seats (28, 49%), ski helmets (24, 42%), and graduated driver's licensing (21, 37%). The top enablers were research/surveillance, managerial/political support and professional group consultation, with much variability between injury topics. Open-ended comments emphasized the importance of a united opinion as an enabler and barriers included costs of protective equipment and inadequate enforcement of legislation. The results highlighted the importance of strategies that include research, management and community collaboration and that injury prevention topics should be addressed individually as information may be lost if topics are considered together. Findings can inform the process of turning injury prevention evidence into action.

Safety-Related Concerns of Parents for Children with Disabilities and Chronic Conditions.

OBJECTIVE: The aim of this study was to explore the safety-related concerns of parents of children with a variety of disabilities and chronic conditions. We sought to examine concerns common to parents as they related to their children's delayed development, behavioral difficulties, and chronic conditions. METHOD: A qualitative approach guided by grounded theory was used. Participants included parents of children between 1 and 5 years with a disability or chronic condition who resided in British Columbia, Canada. Data were collected using in-depth in-person interviews and analysis conducted using constant comparative methods. RESULTS: Three themes were identified that reflected parental safety concerns. These included concerns about: (1) Child's level of understanding about danger; (2) Child interactions with physical environment (concerns about child movement, concerns about ingestions); (3) Child interactions with social environment. Difficult-to-manage behaviors and cognitive limitations exacerbated parents' safety concerns. Parents were found to share safety concerns about movement and ingestions across a range of types of child health conditions. CONCLUSION: For themes of child movement and child ingestions, findings supported the utility of a noncategorical approach for the design of injury prevention strategies for these types of concerns. Parent concerns about child lack of understanding about risk and social safety concerns were linked to a smaller number of conditions and supported a more tailored approach. Flexible approaches may be needed that can offer both generic and specific information and to meet the needs of parents and clinicians.

The combined impact of adherence to five lifestyle factors on all-cause, cancer and cardiovascular mortality: a prospective cohort study among Danish men and women.

Individual lifestyle factors have been associated with lifestyle diseases and premature mortality by an accumulating body of evidence. The impact of a combination of lifestyle factors on mortality has been investigated in several studies, but few have applied a simple index taking national guidelines into account. The objective of the present prospective cohort study was to investigate the combined impact of adherence to five lifestyle factors (smoking, alcohol intake, physical activity, waist circumference and diet) on all-cause, cancer and cardiovascular mortality based on international and national health recommendations. A Cox proportional hazards model was used to estimate hazard ratios (HR) with 95 % CI. During a median follow-up of 14 years, 3941 men and 2827 women died. Among men, adherence to one additional health recommendation was associated with an adjusted HR of 0·73 (95 % CI 0·71, 0·75) for all-cause mortality, 0·74 (95 % CI 0·71, 0·78) for cancer mortality and 0·70 (95 % CI 0·65, 0·75) for cardiovascular mortality. Among women, the corresponding HR was 0·72 (95 % CI 0·70, 0·75) for all-cause mortality, 0·76 (95 % CI 0·73, 0·80) for cancer mortality and 0·63 (95 % CI 0·57, 0·70) for cardiovascular mortality. In the present study, adherence to merely one additional health recommendation had a protective effect on mortality risk, indicating a huge potential in enhancing healthy lifestyle behaviours of the population.

Low-Income Mothers' Descriptions of Children's Injury-Related Events: A Discourse Analysis.

The purpose of this study was to examine how mothers with young children who were living in low-income households used discursive strategies to explain their children's injury and near-miss events. In-person interviews were conducted with 17 mothers and a discourse analytic approach was used to analyze the data. Mothers used a variety of discursive strategies to explain injury events including minimizing the nature of events and expressing tensions between responsibility and resistance. Mothers also described challenges related to predicting children's behavior and dealing with competing demands. These discursive strategies reflected how societal expectations that mothers are held to in terms of keeping children safe conflicted at times with the constraints experienced by mothers living in economically challenging situations. The findings can be used to inform the design of injury prevention strategies that are sensitive to experiences of mothers of young children who are living with economic challenges.

Fathers' views on their financial situations, father-child activities, and preventing child injuries.

Unintentional injuries are a leading public health problem for children, particularly among those living at lower socioeconomic levels. Parents play an important preventive role, and the aim of this study was to examine fathers' views on the role of their family financial situation in preventing children's injuries. In-depth interviews were conducted with 15 fathers of children 2 to 7 years living in western Canada. Questions solicited fathers' views about their financial situation and their child injury prevention efforts. Data analysis was underpinned by masculinity theory and guided by constant comparative grounded theory methods. Findings included that fathers living with fewer financial limitations emphasized use of safety equipment and aligned themselves with provider and protector masculine ideals. Fathers with moderate financial constraint described more child-centered safety efforts and efforts to manage finances. Those facing greatest constraint demonstrated aspects of marginalized masculinities, whereby they acknowledged their economic provider limitations while strongly aligning with the protector role. These findings hold relevance for development of interventions aimed at reducing child injury risk inequities. Taking into account how masculinities may shape their beliefs and practices can inform design of father-centered interventions for men living at different points on the socioeconomic spectrum.

Heterosexual gender relations in and around childhood risk and safety.

Injuries are a leading cause of child death, and safety interventions frequently target mothers. Fathers are largely ignored despite their increasing childcare involvement. In our qualitative study with 18 Canadian heterosexual couples parenting children 2 to 7 years old, we examined dyadic decision making and negotiations related to child safety and risk engagement in recreational activities. Parents viewed recreation as an important component of men's childcare, but women remained burdened with mundane tasks. Most couples perceived men as being more comfortable with risk than women, and three negotiation patterns emerged: fathers as risk experts; mothers countering fathers' risk; and fathers acknowledging mothers' safety concerns but persisting in risk activities. Our findings suggest that contemporary involved fathering practices privilege men in the outdoors and can erode women's control for protecting children from unintentional injury. We recommend promoting involved fathering that empowers both parents and developing injury-prevention strategies incorporating both fathers' and mothers' perspectives.

Men on fathering in the context of children's unintentional injury prevention.

Injuries are a leading cause of death for children, and parental safety behaviors are fundamental to child injury prevention. Fathers' perspectives are largely absent. Our novel research connects masculinities, fathering, and childhood injury. Sixteen fathers of children aged 2 to 7 years in two Canadian urban settings participated in photo-elicitation interviews detailing activities they enjoyed with their children and concerns regarding child safety. Participants described how elements of risk, protection, and emotional connection influenced their approach to fathering as it related to injury prevention. Most men considered engaging children in risk as key to facilitating development and described strategies for protecting their children while engaging in risk. Many men identified how the presence of an emotional connection to their children allowed them to gauge optimal levels of risk and protection. There exists a tremendous opportunity to work with fathers to assist in their efforts to keep their children safe.

Unheard voices: a qualitative exploration of fathers' access of child safety information.

To gain an understanding about fathers' perspectives and practices related to accessing information on childhood safety. Qualitative interviews were carried out with 32 fathers of children aged 2-7 years in British Columbia, Canada. Interview questions investigated whether fathers accessed information on child safety issues, the type of information they searched for, and the resources they used. Transcripts were examined using thematic content analysis. Fathers reported varied processes for searching for information and emphasized a need for credible, synthesized information. The internet was the source of child safety information fathers mentioned most frequently. Published information, resources from community organizations including general, educational and health organizations and access to personal connections were also seen as important. Fathers' involvement in childcare is growing and they play a significant role in ensuring children's safety. Increasing fathers' knowledge on safety related practices can contribute to a reduction in childhood injuries. The results of this study provide an in-depth exploration of fathers' perspectives and practices that can inform the design of materials and dissemination strategies to help increase and optimize access to safety information.

Risky play and children's safety: balancing priorities for optimal child development.

Injury prevention plays a key role in keeping children safe, but emerging research suggests that imposing too many restrictions on children's outdoor risky play hinders their development. We explore the relationship between child development, play, and conceptions of risk taking with the aim of informing child injury prevention. Generational trends indicate children's diminishing engagement in outdoor play is influenced by parental and societal concerns. We outline the importance of play as a necessary ingredient for healthy child development and review the evidence for arguments supporting the need for outdoor risky play, including: (1) children have a natural propensity towards risky play; and, (2) keeping children safe involves letting them take and manage risks. Literature from many disciplines supports the notion that safety efforts should be balanced with opportunities for child development through outdoor risky play. New avenues for investigation and action are emerging seeking optimal strategies for keeping children "as safe as necessary," not "as safe as possible." This paradigm shift represents a potential for epistemological growth as well as cross-disciplinary collaboration to foster optimal child development while preserving children's safety.

Aboriginal community-centered injury surveillance: a community-based participatory process evaluation.

While injuries are a leading health concern for Aboriginal populations, injury rates and types vary substantially across bands. The uniqueness of Aboriginal communities highlights the importance of collecting community-level injury surveillance data to assist with identifying local injury patterns, setting priorities for action and evaluating programs. Secwepemc First Nations communities in British Columbia, Canada, implemented the Injury Surveillance Project using the Aboriginal Community-Centered Injury Surveillance System. This paper presents findings from a community-based participatory process evaluation of the Injury Surveillance Project. Qualitative data collection methods were informed by OCAP (Ownership, Control, Access, and Possession) principles and included focus groups, interviews and document review. Results focused on lessons learned through the planning, implementation and management of the Injury Surveillance Project identifying lessons related to: project leadership and staff, training, project funding, initial project outcomes, and community readiness. Key findings included the central importance of a community-based and paced approach guided by OCAP principles, the key role of leadership and project champions, and the strongly collaborative relationships between the project communities. Findings may assist with successful implementation of community-based health surveillance in other settings and with other health issues and illustrate another path to self-determination for Aboriginal communities. The evaluation methods represent an example of a collaborative community-driven approach guided by OCAP principles necessary for work with Aboriginal communities.

Striking a balance between risk and protection: fathers' attitudes and practices toward child injury prevention.

OBJECTIVES: To gain understanding of fathers' attitudes, decisions, and practices regarding the level of risk they are willing to expose their children to and the level of protection they feel is necessary. METHODS: Interviews were conducted with a diverse sample of 32 fathers of children aged 2 to 7 years in British Columbia. Questions addressed fathers' roles and typical activities with their children, child safety concerns and practices. Grounded theory methods guided data analysis. RESULTS: Fathers believed a central aspect of their role involved actively exploring the world with their children through physical and play-based activities. Fathers made decisions about the appropriateness of activities, striking a balance between protecting their child and exposing them to risk and new experiences. Most fathers placed high value on providing their children with risk-taking opportunities and discussed many positive aspects of risk and experiencing minor injuries. The potential for serious injury was considered in weighing decisions regarding risk engagement. A theoretical model outlining 4 decision-making characteristics for striking a balance is proposed. CONCLUSION: Injury prevention interventions can benefit from understanding the meanings and priorities fathers hold about their children's safety, creating programs that resonate with fathers to increase relevance. To maximize success, messaging should consider fathers' decision-making characteristics, incorporate the importance of healthy risk taking for child development, and teach fathers how to minimize likelihood of injury in the context of being active and taking risks with their child.

Differences in cortical and pituitary activity in response to hypoglycaemia and cognitive testing in healthy men with different basal activity of the renin-angiotensin system.

INTRODUCTION: High renin-angiotensin system (RAS) activity has been associated with a high risk of severe hypoglycaemia in patients with type 1 diabetes and with cognitive deterioration during experimental hypoglycaemia in healthy subjects. The aim of this study was to describe possible differences in cerebral activity during hypoglycaemia and cognitive testing in two groups of healthy men with different basal RAS activity. METHODS: Ten healthy men with high RAS activity and 10 with low activity underwent six oxygen-15-labelled water positron emission tomography scans: twice during normoglycaemia, twice during insulin-induced hypoglycaemia and twice during post-hypoglycaemia. During the scans, the subjects performed a computer-based reaction time test. RESULTS: Occipital areas were consistently more activated in the low RAS group than in the high RAS group throughout all three conditions. During normoglycaemia, the frontal region was more activated in the low RAS group than in the high RAS group. During hypoglycaemia, the high RAS group was more activated in the pituitary gland than the low RAS group. CONCLUSION: Basal RAS activity influenced cerebral activity. Low RAS was associated with more pronounced cortical activation in all glycaemic conditions. High RAS was associated with pituitary activation during hypoglycaemia and post-hypoglycaemia, and this was associated with a greater growth hormone response.

Association between regional cerebral blood flow during hypoglycemia and genetic and phenotypic traits of the renin-angiotensin system.

The risk of severe hypoglycemia in patients with type I diabetes and high basal activity in the renin-angiotensin system (RAS) is significantly higher than in patients with low basal RAS activity. In healthy men, we tested the hypothesis that differences in spontaneous RAS activity are associated with differences in cerebral activity responses during mild hypoglycemia. A total of 10 healthy men with high and 10 with low spontaneous RAS activity were selected. An H(2)(15)O-PET (H(2)(15)O-positron emission tomography) study was conducted with a series of six scans, i.e., two during normoglycemia, two during hypoglycemia, and two after hypoglycemia. The mean plasma glucose concentration was similar in both the groups (i.e., 2.1 mmol/L (s.d.: 0.4) in the low RAS group and 2.2 mmol/L (s.d.: 0.4) in the high RAS group (P=0.47)). The high RAS group has lower cerebral activity in the frontal area and a higher cerebral activity in the entorhinal area that expanded to include the parahippocampal gyrus after hypoglycemia. Our findings suggest that the high RAS group to a lesser extent than the low RAS group activates areas involving executive function that may explain the correlation between high basal RAS activity and risk of severe hypoglycemia in type I diabetes.

Changes of cognition and regional cerebral activity during acute hypoglycemia in normal subjects: A H2 15O positron emission tomographic study.

Blurred vision and cognitive difficulties are prominent symptoms during acute insulin-induced hypoglycemia. Our hypothesis was that changes in cerebral activity reflect these symptoms. Positron emission tomography (PET) with oxygen-15-labelled water was used to measure relative changes in regional cerebral blood flow (rCBF) as a marker of cerebral activity. Hypoglycemia was induced by intravenous insulin infusion in 19 healthy men performing two different cognitive tasks of varying complexity. The hypoglycemic stimulus [plasma glucose 2.2 mmol/liter (0.4)] produced a significant hormonal counterregulatory response. During the low cognitive load, rCBF decreased in response to hypoglycemia in a large bilateral area in the posterior part of the temporal lobe, and rCBF increased bilaterally in the anterior cingulate gyrus, the right frontal gyrus, the fusiform gyrus, thalamus, and the left inferior part of the frontal gyrus. During the high cognitive load, rCBF decreased bilaterally in a large region in the posterior part of the temporal gyrus and increased in the left and right anterior cingulate gyrus, left and right frontal gyrus, right parahippocampal and lingual gyrus, and left superior temporal gyrus. Visual impairment during hypoglycemia was associated with deactivation in the ventral visual stream. The anterior cingulate gyrus was activated during hypoglycemia in a load-dependent manner. Areas on the frontal convexity were differentially activated in response to the cognitive load during hypoglycemia. Our findings suggest that hypoglycemia induces changes in sensory processing in a cognition-independent manner, whereas activation of areas of higher order functions is influenced by cognitive load as well as hypoglycemia.