Exploration of difficulty accessing the mouths of intubated and mechanically ventilated adults for oral care: A video and photographic elicitation study.

AIM: To explore descriptors of difficulty accessing the mouths of intubated and mechanically ventilated adults for oral care, consequences, modifiable antecedents and recommendations for improving care delivery. BACKGROUND: Nurses report oral access and care delivery difficulty in most mechanically ventilated patients. DESIGN: A prospective qualitative descriptive design. METHODS: Data were collected using video and photographic elicitation interviews focused on delivery of oral care. Directed content analysis was used to explore descriptive categories. Reporting used the SRQR guidelines. SETTING AND PARTICIPANTS: A university-affiliated hospital in Toronto, Canada. Participants included clinicians experienced in accessing the oral space of adults representing nursing, medicine, dentistry and allied health professionals. FINDINGS: We recruited 18 participants; 9 representing critical care and 9 other specialties frequently accessing the mouth, that is dentistry. Descriptors for observed difficulty accessing the oral cavity were "oral crowding with tubes" and "aversive patient responses", which were considered to result in insufficient oral care. Participants perceived aversive patient responses (e.g. biting, turning head side to side, gagging, coughing) as a consequence of forced introduction of instruments inside a crowded mouth. A key finding identified by participants was the observation of substantial procedural pain during oral care interventions. Potentially modifiable antecedents to difficult oral care delivery identified were procedural pain, oral health deterioration (e.g. xerostomia) and lack of interprofessional team problem-solving. Recommendations to address these antecedents included patient preparation for oral care through verbal and nonverbal cueing, pharmacological and nonpharmacological strategies, and ICU interprofessional education. CONCLUSIONS: Oral care in mechanically ventilated adults is complex and painful. Visual research methods offer important advantages for oral care exploration including its ability to reveal less visible aspects of the nurse-patient encounter, thereby enabling novel insights and care. RELEVANCE FOR CLINICAL PRACTICE: Interprofessional education and training in oral health and care interventions tailored to mechanically ventilated patients are recommended.

"It's Hard Work": A Feminist Political Economy Approach to Reconceptualizing "Work" in the Cancer Context.

Within mainstream cancer literature, policy documents, and clinical practice, "work" is typically characterized as being synonymous with paid employment, and the problem of work is situated within the "return to work" discourse. The work that patients perform in managing their health, care, and everyday life at times of illness, however, is largely overlooked and unsupported. Drawing on feminist political economy theory, we report on a qualitative study of 12 women living with cancer. Major findings show that the work of patienthood cut across multiple fields of practice and included both paid and unpaid labor. The most prevalent types of work included illness work, body work, identity work, everyday work, paid employment and/or the work of maintaining income, and coordination work. The findings of this study disrupt popular conceptualizations of work and illuminate the nuanced and often invisible work that cancer patients may encounter, and the health consequences and inequities therein.

"I Want to Help, but What Do You Do in a Situation Like That?" Health Care Providers' Qualitative Perspectives on Working with Disabled Women in Breast Cancer Screening.

BACKGROUND: Disabled women find that social and physical discomforts during encounters with health providers pose barriers to breast cancer screening. We studied providers' perspectives and learning needs related to this problem in order to develop a disability education initiative. DESIGN: This was a descriptive qualitative study with focus group methods. Participants were recruited from staff of a joint Department of Medical Imaging at three academic teaching hospitals in Toronto, Canada. Seven focus groups were held with 43 clerical staff, mammography technologists, and radiologists. RESULTS: Participants reported that they aimed to provide positive breast screening experiences for disabled women but expressed uncertainty about respectful and appropriate communication with disabled women. Novel situations with disabled women were challenging and, without formal disability education, most relied on experiential learning. CONCLUSIONS: Our study elicited important information about the concerns and learning needs of health professionals who provide breast screening services to disabled women. This information supported development of a disability education curriculum for these providers.

Gender matters in cardiac rehabilitation and diabetes: Using Bourdieu's concepts.

BACKGROUND: Habitual practices are challenged by chronic illness. Cardiac rehabilitation (CR) involves changes to habits of diet, activity and tobacco use, and although it is effective for people with diabetes and cardiovascular disease (CVD), some participants are reportedly less likely to complete programs and adopt new health related practices. Within the first three months of enrolling in CR, attrition rates are highest for women and for people with diabetes. Previous studies and reviews indicate that altering habits is very difficult, and the social significance of such change requires further study. PURPOSE: The purpose of the study was to use Bourdieu's concepts of habitus, capital and field to analyse the complexities of adopting new health practices within the first three months after enrolling in a CR program. We were particularly interested in gender issues. METHODS: Thirty-two men and women with diabetes and CVD were each interviewed twice within the first three months of their enrolment in one of three CR programs in Toronto, Canada. RESULTS: Attention to CR goals was not always the primary consideration for study participants. Instead, a central concern was to restore social dignity within other fields of activity, including family, friendships, and employment. Thus, study participants evolved improvised tactical approaches that combined both physical and social rehabilitation. These improvised tactics were socially embedded and blended new cultural capital with existing (often gendered) cultural capital and included: concealment, mobilizing cooperation, re-positioning, and push-back. CONCLUSIONS: Our findings suggest that success in CR requires certain baseline levels of capital - including embodied, often gendered, cultural capital - and that efforts to follow CR recommendations may alter social positioning.

Transitions to End-of-Life Care for Patients With Chronic Critical Illness: A Meta-Synthesis.

BACKGROUND: Adults with chronic critical illness (CCI) frequently experience a terminal trajectory but receive varying degrees of palliation and end-of-life care (EOLC) in intensive care units (ICUs). Why palliation (over curative treatment) is not augmented earlier for patients with CCI in ICU is not well understood. PURPOSE: To identify the social structures that contribute to timely, context-dependent decisions for transition from acute care to EOLC for patients with CCI and their families. METHODS: We conducted a meta-synthesis of qualitative and/or mixed-method studies that recruited adults with CCI, their families or close friends, and/or health-care providers (HCPs) in an ICU environment. RESULTS: Five studies reported data from 83 patients, 109 family members, and 57 HCPs across 5 institutions in Canada and the United States. Overall, we found that morally ambiguous social expectations of treatment tended to lock in HCPs to focus on prescriptive work of preserving life, despite pathways that could "open" access to augmenting palliation and EOLC. This process limited space for families' reflexivity and reappraisal of CCI as a phase liminal to active dying. Notably, EOLC mechanisms were informal and less visible. CONCLUSION: The management of dying is one of the central tenets of ICU care. Our findings suggest that patients and families need help in negotiating meanings of this situation and in using mechanisms that allow reappraisal and permit understanding of CCI as a phase liminal to dying. Moreover, these mechanisms may paradoxically reduce the ambiguity of patients' future, allowing them to live more fully in the present.

Ethnographic Investigation of Oral Care in the Intensive Care Unit.

BACKGROUND: Oral care plays a clear and important role in the prevention of ventilator-associated pneumonia. However, few studies have explored the actual work of oral care by nurses in the intensive care unit. OBJECTIVE: To explore intensive care nurses' knowledge of and experiences with the delivery of oral care to reveal less visible aspects of this work. METHODS: In an institutional ethnography, go-along and semistructured interview methods were used to explore the oral care practices and perspectives of 12 bedside nurses and 12 interprofessional (intensivist, allied health, and management) participants in an intensive care unit at a large urban teaching hospital in Ontario, Canada. RESULTS: Nurses described how obstacles frequently inhibited the delivery of oral care. Technical barriers included oral crowding with tubes and aversive responses by patients, such as biting. Contextual impediments to oral care included time constraints, lack of training, and limited opportunities for interprofessional collaboration. A key discovery was the presence of an informal unit-based nursing curriculum, whereby nurses acquired strategies to overcome barriers to oral care. Although the nurses did extensive problem solving in providing oral care, the interprofessional participants had limited knowledge of how oral care was accomplished. CONCLUSION: These data suggest the complexity of performing oral care in intensive care is underestimated and perhaps undervalued. Future research is needed to address technical and contextual barriers to optimize current guideline expectations for the provision of regular and effective oral care.

A secondary meta-synthesis of qualitative studies of gender and access to cardiac rehabilitation.

AIMS: To discuss issues in the theorization and study of gender observed during a qualitative meta-synthesis of influences on uptake of secondary prevention and cardiac rehabilitation services. BACKGROUND: Women and men can equally benefit from secondary prevention/cardiac rehabilitation and there is a need to understand gender barriers to uptake. DESIGN: Meta-method analysis secondary to meta-synthesis. For the meta-synthesis, a systematic search was performed to identify and retrieve studies published as full papers during or after 1995 and contained: a qualitative research component wholly or in a mixed method design, extractable population specific data or themes for referral to secondary prevention programmes and adults ≥18 years. DATA SOURCES: Databases searched between January 1995-31 October 2011 included: CSA Sociological Abstracts, EBSCOhost CINAHL, EBSCOhost Gender Studies, EBSCOhost Health Source Nursing: Academic Edition, EBSCOhost SPORTDiscus, EBSCOhost SocINDEX. REVIEW METHODS: Studies were reviewed against inclusion/exclusion criteria. Included studies were subject to quality appraisal and standardized data extraction. RESULTS: Of 2264 screened articles, 69 were included in the meta-method analysis. Only four studies defined gender or used gender theories. Findings were mostly presented as inherently the characteristic of gendered worldviews of participants. The major themes suggest a mismatch between secondary prevention/cardiac rehabilitation services and consumers' needs, which are usually portrayed as differing according to gender but may also be subject to intersecting influences such as age or socioeconomic status. CONCLUSION: There is a persistent lack of theoretically informed gender analysis in qualitative literature in this field. Theory-driven gender analysis will improve the conceptual clarity of the evidence base for gender-sensitive cardiac rehabilitation programme development.

"I'm No Superman": Understanding Diabetic Men, Masculinity, and Cardiac Rehabilitation.

Exercise-based cardiac rehabilitation (CR) programs help patients with coronary heart disease (CHD) reduce their risk of recurrent cardiac illness, disability, and death. However, men with CHD and Type 2 diabetes mellitus (T2DM) demonstrate lower attendance and completion of CR despite having a poor prognosis. Drawing on gender and masculinity theory, we report on a qualitative study of 16 Canadian diabetic men recently enrolled in CR. Major findings reflect two discursive positions men assumed to regain a sense of competency lost in illness: (a) working with the experts, or (b) rejection of biomedical knowledge. These positions underscore the varied and sometimes contradictory responses of seriously ill men to health guidance. Findings emphasize the priority given to the rehabilitation of a positive masculine identity. The analysis argues that gender, age, and employment status are powerful mechanisms of variable CR participation.

Patient-centered care or cultural competence: negotiating palliative care at home for Chinese Canadian immigrants.

The literature about Chinese attitudes toward death and dying contains frequent references to strong taboos against open discussion about death; consequently, there is an assumption that dying at home is not the preferred option. This focused ethnographic study examined the palliative home care experiences of 4 Chinese immigrants with terminal cancer, their family caregivers, and home care nurses and key informant interviews with 11 health care providers. Three main themes emerged: (1) the many facets of taboo; (2) discursive tensions between patient-centered care and cultural competence; and (3) rethinking language barriers. Thus, training on cultural competence needs to move away from models that portray cultural beliefs as shared, fixed patterns, and take into account the complicated reality of everyday care provision at end of life in the home.

Women's strategies to achieve access to healthcare in Ontario, Canada: a meta-synthesis.

As part of a mixed methods study on women's access to the healthcare system in Ontario, Canada, we undertook a qualitative meta-synthesis to better understand the contextual conditions under which women access healthcare. An earlier phase of the synthesis demonstrated a series of factors that complicate women's access to healthcare in Ontario. Here, we consider women's agency in responding to these factors. We used meta-study methods to synthesise findings from qualitative studies published between January 2002 and December 2010. Studies were identified by searches of numerous databases, including CINAHL, MEDLINE, Scopus, Gender Studies Database and LGBT Life. Inclusion criteria included use of a qualitative research design; published in a peer-reviewed journal during the specified time period; included a sample at least partially recruited in Ontario; included distinct findings for women participants; and in English language. Studies were included in the final sample after appraisals using a qualitative research appraisal tool. We found that women utilised a spectrum of responses to forces limiting access to healthcare: mobilising financial, social and interpersonal resources; living out shortfalls by making do, doing without, and emotional self-management; and avoiding illness and maintaining health. Across the studies, women described their efforts to overcome challenges to accessing healthcare. However, there were evident limits to women's agency and many of their strategies represented temporary measures rather than viable long-term solutions. While women can be resourceful and resilient in overcoming access disparities, systemic problems still need to be addressed. Women need to be involved in designing and implementing interventions to improve access to healthcare, and to address the root problems of these issues.

Diabetes care and mental illness: the social organization of food in a residential care facility.

OBJECTIVE: To explore the social organization of food provision and dietary intake in seriously mentally ill people with diabetes who reside in a for-profit group home. METHODS: Institutional ethnography was used to explore diabetes-related care practices among 26 women in a rural residential care facility in southern Ontario. Semi-structured, in-depth interviews were conducted with residents with diabetes, care providers, field workers, and health professionals. Observations and document analysis were also used to understand the lack of congruence between diabetes guidelines and the possibilities for diabetes management within the confines of group home care. RESULTS: Although it was mandated in group home guidelines that "Health Canada's Eating Well with Canada's Food Guide" (2007) be followed, menus were planned within the context of a limited food budget of approximately $1.91 per day per resident. Group home policies regulated systems of safety, reporting, and financial accountability, but not health promotion. Inspections carried out by the Public Health Department focused primarily on food safety during handling, preparation, and storage, and compliance to regulations regarding environmental cleanliness and infection control. CONCLUSION: Resource rationing found in group home care exacerbates illness in an already marginalized group. Financial support is required to enable provision of healthy food choices, including dairy products, fresh fruits, and vegetables. Additional support is required for care of co-morbid conditions such as diabetes for associated food costs and education to improve outcomes. Group home policies must take into consideration health threats to this population and give primacy to health promotion and illness prevention.

Maintaining distance from a necessary intrusion: a postcolonial perspective on dying at home for Chinese immigrants in Toronto, Canada.

PURPOSE: The purpose of this study was to describe and examine how meanings of home condition negotiations of care for Chinese immigrants with advanced cancer receiving palliative home care in Toronto, Canada. METHOD: This focused ethnographic study drew on the tenets of postcolonial theory to examine the social and material circumstances associated with dying at home for Chinese immigrants. Eleven key informants were recruited, in addition to 4 cases comprised of a Chinese immigrant care recipient, primary family caregiver, and home visiting nurse. Individual, open-ended interviews were conducted with each participant, along with observations of home visits. RESULTS: Palliative care was not viewed strictly as an intrusion that was thrust upon the home without permission or invitation, but an insertion into the routines of the home that was necessary because care recipients recognized the need for palliative care providers to help navigate the system and negotiate dying at home. Consequently, care recipients and family caregivers also sought to minimize the intrusions of palliative care by preserving everyday routines and engaging with family and friends. CONCLUSIONS: Although the study was focused on Chinese immigrants, the findings resonate with and speak more broadly to the contextual, systemic, social, and material circumstances associated with dying at home for immigrants with advanced cancer. Nurses providing palliative home care to immigrants may begin to critically examine assumptions of "cultural" beliefs about cancer and end-of-life care and look beyond identifying ethno-specific practices, but come to recognize how nurses are implicated in a culture of palliative care.

Factors influencing participation in cardiac rehabilitation programmes after referral and initial attendance: qualitative systematic review and meta-synthesis.

BACKGROUND: Greater participation in cardiac rehabilitation improves morbidity and mortality in people with coronary heart disease, but little is understood of patients' decisions to participate. METHODS: To develop interventions aimed at increasing completion of programmes, we conducted a qualitative systematic review and meta-synthesis to explore the complex factors and processes influencing participation in cardiac rehabilitation programmes after referral and initial access. To be included in the review, studies had to contain a qualitative research component, population specific data on programme participation in adults >18 years, and be published ≥1995 as full articles or theses. Ten databases were searched (31 October 2011) using 100+ search terms. RESULTS: Of 2264 citations identified, 62 studies were included involving: 1646 patients (57% female; mean age 64.2), 143 caregivers, and 79 professionals. Patients' participation was most strongly influenced by perceptions of the nature, suitability and scheduling of programmes, social comparisons made possible by programmes, and the degree to which programmes, providers, and programme users met expectations. Women's experiences of these factors rendered them less likely to complete. Comparatively, perceptions of programme benefits had little influence on participation. CONCLUSIONS: Factors reducing participation in programmes are varied but amenable to intervention. Participation should be viewed as a 'consumer behaviour' and interventions should mobilize family support, promote 'patient friendly' scheduling, and actively harness the social, identity-related, and experiential aspects of participation.

Choosing nursing as a career: a narrative analysis of Millennial nurses' career choice of virtue.

The growth and sustainability of the nursing profession depends on the ability to recruit and retain the upcoming generation of professionals. Understanding the career choice experiences and professional expectations of Millennial nurses (born 1980 or after) is a critical component of recruitment and retention strategies. This study utilized Polkinghorne's interpretive, narrative approach to understand how Millennial nurses explain, account for and make sense of their choice of nursing as a career. The positioning of nursing as a virtuous choice was both temporally and contextually influenced. The decision to enter the profession was initially emplotted around a traditional understanding of nursing as a virtuous profession: altruistic, noble, caring and compassionate. The centricity of virtues depicts one-dimensional understanding of the nursing profession that alone could prove dissatisfying to a generation of professionals who have many career choices available to them. The narratives reveal how participants' perceptions and expectations remain influenced by a stereotypical understanding of nursing, an image that remains prevalent in society and which holds implications for the future recruitment, socialization and retention strategies for upcoming and future generations of nurses.

Beyond barriers in studying disparities in women's access to health services in Ontario, Canada: a qualitative metasynthesis.

Women live within complex and differing social, economic, and environmental circumstances that influence options to seek health care. In this article we report on a metasynthesis of qualitative research concerning access disparities for women in the Canadian province of Ontario, where there is a publicly funded health care system. We took a metastudy approach to analysis of results from 35 relevant qualitative articles to understand the conditions and conceptualizations of women's inequitable access to health care. The articles' authors attributed access disparities to myriad barriers. We focused our analysis on these barriers to understand the contributing social and political forces. We found that four major, sometimes countervailing, forces shaped access to health care: (a) contextual conditions, (b) constraints, (c) barriers, and (d) deterrents. Complex convergences of these forces acted to push, pull, obstruct, and/or repel women as they sought health care, resulting in different patterns of inequitable access.

Exploring ways to overcome barriers to mammography uptake and retention among South Asian immigrant women.

South Asians comprise one of the fastest growing immigrant groups in North America. Evidence indicates that South Asian (SA) immigrant women are vulnerable to low rates of breast cancer screening. Yet, there is a dearth of knowledge pertaining to socioculturally tailored strategies to guide the uptake of screening mammography in the SA community. In 2010, the authors conducted semi-structured focus groups (FG) to elicit perspectives of health and social service professionals on possible solutions to barriers identified by SA immigrant women in a recent study conducted in the Greater Toronto Area. Thirty-five health and social services staff members participated in five FG. The discussions were audio taped and detailed field notes were taken. All collected data were transcribed verbatim and thematic analysis was conducted using techniques of constant comparison within and across the group discussions. Three dominant themes were identified: (i) 'Target and Tailor' focused on awareness raising through multiple direct and indirect modes or approaches with underlying shared processes of involving men and the whole family, use of first language and learning from peers; (ii) 'Enhancing Access to Services' included a focus on 'adding ancillary services' and 'reinforcement of existing services' including expansion to a one-stop model; and (iii) 'Meta-Characteristics' centred on providing 'multi-pronged' approaches to reach the community, and 'sustainability' of initiatives by addressing structural barriers of adequate funding, healthcare provider mix, inter-sectoral collaboration and community voice. The findings simultaneously shed light on the grassroot practical strategies and the system level changes to develop efficient programmes for the uptake of mammography among SA immigrant women. The parallel focus on the 'Target and Tailor' and 'Enhancing Access to Services' calls for co-ordination at the policy level so that multiple sectors work jointly to streamline resources, or meta-characteristics.

Mouth care for orally intubated patients: a critical ethnographic review of the nursing literature.

OBJECTIVES: The aim of this critical ethnographic literature review was to explore the evolution of nursing discourse in oral hygiene for intubated and mechanically ventilated patients. METHODS: The online databases CINAHL and MEDLINE were searched for nurse-authored English language articles published between 1960 and 2011 in peer-reviewed journals. Articles that did not discuss oral problems or related care for intubated adult patients were excluded. Articles that met the inclusion criteria were chronologically reviewed to trace changes in language and focus over time. RESULTS: A total of 469 articles were identified, and 84 papers met all of the inclusion criteria. These articles presented an increasingly scientific and evaluative nursing discourse. Oral care originally focused on patient comfort within the literature; now it is emphasized as an infection control practice for the prevention of ventilator-associated pneumonia (VAP). Despite concern for its neglected application, the literature does not sufficiently address mouth care's practical accomplishment. CONCLUSIONS: Mouth care for orally intubated patients is both a science and practice. However, the nursing literature now emphasises a scientific discourse of infection prevention. Inattention to the social and technical complexities of practice may inhibit how nurses learn, discuss and effectively perform this critical aspect of patient care.

A qualitative systematic review of influences on attendance at cardiac rehabilitation programs after referral.

BACKGROUND: Cardiac rehabilitation and secondary prevention programs can prevent heart disease in high-risk populations. However, up to half of all patients referred to these programs do not subsequently participate. Although age, sex, and social factors are common predictors of attendance, to increase attendance rates after referral, the complex range of factors and processes influencing attendance needs to be better understood. METHODS: A systematic review using qualitative meta-synthesis was conducted. Ten databases were systematically searched using 100+ search terms until October 31, 2011. To be included, studies had to contain a qualitative research component and population-specific primary data pertaining to program attendance after referral for adults older than 18 years and be published as full articles in or after 1995. RESULTS: Ninety studies were included (2010 patients, 120 caregivers, 312 professionals). Personal and contextual barriers and facilitators were intricately linked and consistently influenced patients' decisions to attend. The main personal factors affecting attendance after referral included patients' knowledge of services, patient identity, perceptions of heart disease, and financial or occupational constraints. These were consistently derived from social as opposed to clinical sources. Contextual factors also influenced patient attendance, including family and, less commonly, health professionals. Regardless of the perceived severity of heart disease, patients could view risk as inherently uncontrollable and any attempts to manage risk as futile. CONCLUSIONS: Decisions to attend programs are influenced more by social factors than by health professional advice or clinical information. Interventions to increase patient attendance should involve patients and their families and harness social mechanisms.

"I can't just follow any particular textbook": immigrants in cardiac rehabilitation.

AIM: The study purpose was to examine how and under what circumstances immigrants combine diabetes self-care with cardiac rehabilitation recommendations. BACKGROUND: Cardiac rehabilitation can improve and lengthen life in people with coronary heart disease as it promotes healthy physical and psychosocial behaviours and outcomes. This study is the first to examine the convergence of two common issues on participation: (1) the problems posed when cardiac rehabilitation patients must also contend with type II diabetes and (2) the experiences of immigrants in cardiac rehabilitation. DESIGN: A critical ethnographic approach was employed. METHODS: Two in depth interviews were conducted with 18 immigrants (eight men, ten women) enrolled in cardiac rehabilitation. Data were collected from 2008-2010. FINDINGS: Threaded throughout immigrant participants' descriptions were biographical accounts of crossing geographical borders, establishing a sense of belonging in their adopted country and trying to feel 'at home' in cardiac rehabilitation. Participants described creative hybridization of transnationally informed knowledges and particularized practices to manage diabetes self-care and to reduce cardiac risk. Participants judiciously considered, assessed and blended knowledges from cardiac rehabilitation, experience with their own bodies and general 'wisdoms' passed on within their own and other immigrant communities. CONCLUSION: These findings suggest that migration constitutes an important social positioning that contextualizes individual efforts to activate diabetes self-care and cardiac rehabilitation. Support to immigrants may improve when nurses recognize the significance of such experiences. Efforts are needed in practice and research to recognize and explore immigrants' creative efforts to engage in cardiac rehabilitation.