Age- and sex-specific associations of frailty with mortality and healthcare utilization in community-dwelling adults from ontario, Canada.

BACKGROUND: Understanding how health trajectories are related to the likelihood of adverse outcomes and healthcare utilization is key to planning effective strategies for improving health span and the delivery of care to older adults. Frailty measures are useful tools for risk stratification in community-based and primary care settings, although their effectiveness in adults younger than 60 is not well described. METHODS: We performed a 10-year retrospective analysis of secondary data from the Ontario Health Study, which included 161,149 adults aged ≥ 18. Outcomes including all-cause mortality and hospital admissions were obtained through linkage to ICES administrative databases with a median follow-up of 7.1-years. Frailty was characterized using a 30-item frailty index. RESULTS: Frailty increased linearly with age and was higher for women at all ages. A 0.1-increase in frailty was significantly associated with mortality (HR = 1.47), the total number of outpatient (IRR = 1.35) and inpatient (IRR = 1.60) admissions over time, and length of stay (IRR = 1.12). However, with exception to length of stay, these estimates differed depending on age and sex. The hazard of death associated with frailty was greater at younger ages, particularly in women. Associations with admissions also decreased with age, similarly between sexes for outpatient visits and more so in men for inpatient. CONCLUSIONS: These findings suggest that frailty is an important health construct for both younger and older adults. Hence targeted interventions to reduce the impact of frailty before the age of 60 would likely have important economic and social implications in both the short- and long-term.

Parents' Experiences and Nurses' Perceptions of Decision-Making About Childhood Immunization.

BACKGROUND: Immunization in Canada is recommended not mandated, granting parents discretionary decision-making power regarding their child's immunization status. Uptake of childhood immunization at present falls below national targets. Nurses who interact with parents in the clinical setting may witness parents' decision-making experiences, attitudes, and opinions inclusive of vaccine hesitancy. PURPOSE: The aim of this study is to understand parents' and nurses' experiences of decision-making about childhood immunization, specifically measles-mumps-rubella and/or diphtheria-tetanus-acellular pertussis. METHODS: Thorne's interpretative description approach was used to understand parents' and nurses' experiences and perspectives about immunization. The sample was 6 nurses and 16 parents residing in northeastern Ontario. RESULTS: Common to all participants was the goal of protection. Motivated by child protection, parents carried out three broad actions, searching for information, deliberating the information and sources to determine the relative benefits and risks of immunization, and bearing responsibility for their decision to accept, delay, or decline immunization. Nurses were motivated by child protection and population health. CONCLUSION: Implications for nursing included integration of immunization competencies in nursing curricula, ongoing professional development, validation of parental actions for child protection, nurse-led education sessions, and engaging parents through social media to support access to reputable information.

Canadian community mental health workers' perceived priorities for supportive housing services in northern and rural contexts.

A relationship between mental health and supportive housing has been established, yet there exist enduring challenges in meeting the supportive housing needs of people with severe mental health problems. Furthermore, not all stakeholder viewpoints of supportive housing services are well documented in the research literature, and research has tended to focus on supportive housing provision in large, urban centres. Potentially, distinct challenges and opportunities associated with the provision of supportive housing services in smaller urban and rural communities that define the greater geographical terrain of Canada and other jurisdictions are less developed. This study describes community mental health service workers' priorities for supportive housing services. Using Q methodology, 39 statements about supportive housing services, developed from a mixed-methods parent study, were sorted by 58 service providers working in four communities in northern Ontario, Canada. Data used in this study were collected in 2010. Q analysis was used to identify correlations between service workers who held similar and different viewpoints concerning service priorities. The results yielded four discrete viewpoints about priorities for delivery of supportive housing services including: a functional system, service efficiency, individualised services and promotion of social inclusion. Common across these viewpoints was the need for concrete deliverables inclusive of financial supports and timely access to adequate housing. These findings have the potential to inform the development of housing policy in regions of low population density which address both system and individual variables.

Community reintegration of stroke survivors: the effect of a community navigation intervention.

AIM: The overall aim of the proposed study is to examine a newly implemented navigation intervention intended to support stroke survivors' community integration during the first year following hospital discharge in four regions of Ontario, Canada. BACKGROUND: Stroke is a leading cause of disability worldwide. Stroke survivors living in the community require regular, ongoing follow-up to assess recovery, prevent deterioration and maximize health outcomes. Internationally published evidence, often conducted in large urban centres, suggests that community reintegration services are an important component of the continuum of care for stroke survivors. This evidence, however, often does not address the particular challenges inherent in smaller urban and rural contexts. DESIGN: The design of this 2-year mixed-method study will use cohort and focused ethnography. METHODS: The three stages of this study include: (1) collection of quantitative data to profile the health status, support and extent of community reintegration of stroke survivors; (2) collection of qualitative data from stroke survivors and their care partners about community reintegration and navigation; and following triangulation of findings (3) knowledge translation activities. This study was ethically approved by the academic Research Ethics Board and clinical Research Ethics Board (Sudbury, Ontario) and funded by the Ontario Stroke Network (Canada). DISCUSSION: Results will describe experiences and outcomes of a community navigation intervention. Engagement of multiple stakeholders has the potential to develop a shared understanding of community reintegration and generate evidence informed recommendations for service enhancement at critical points in stroke recovery to support survivor and community well-being.

Emergency department boarding times for patients admitted to intensive care unit: Patient and organizational influences.

INTRODUCTION: Critically ill patients can be subject to prolonged stays in the emergency department following receipt of an order to admit to an intensive care unit. The purpose of this study was to explore patient and organizational influences on the duration of boarding times for intensive care bound patients. METHODS: This exploratory descriptive study was situated in a Canadian hospital in northern Ontario. Through a six-month retrospective review of three data sources, information was collected pertaining to 16 patient and organizational variables detailing the emergency department boarding time of adults awaiting transfer to the intensive care unit. Data analysis involved descriptive and non-parametric methods. RESULTS: The majority of the 122 critically ill patients boarded in the ED were male, 55 years of age or older, arriving by ground ambulance on a weekday, and had an admitting diagnosis of trauma. The median boarding time was 34 min, with a range of 0-1549 min. Patients designated as most acute, intubated, and undergoing multiple diagnostic procedures had statistically significantly shorter boarding times. DISCUSSION: The study results provide a profile that may assist clinicians in understanding the complex and site-specific interplay of variables contributing to boarding of critically ill patients.

Third year nursing students' viewpoints about circumstances which threaten safety in the clinical setting.

BACKGROUND: Evidence emphasizes that learners, educators, clinicians, programs, and organizations share the responsibility for establishing and maintaining safety throughout undergraduate nursing education. Increased knowledge about students' perceptions of threats to safety in the clinical setting may guide educators' efforts to promote the development of safe novice practitioners while preserving patient safety. OBJECTIVE: The purpose of this study was to describe third year nursing students' viewpoints of the circumstances which threaten safety in the clinical setting. METHODS: Using Q methodology, 34 third year Bachelor of Science in Nursing students sorted 43 theoretical statement cards. Each card identified a statement describing a threat to safety in the clinical setting. These statements were generated through a review of nursing literature and consultation with experts in nursing education. Centroid factor analysis and varimax rotation identified viewpoints regarding circumstances that most threaten safety. RESULTS: Three discrete viewpoints and one consensus perspective constituted students' description of threatened safety. The discrete viewpoints were labeled lack of readiness, misdirected practices, and negation of professional boundaries. There was consensus that it is most unsafe in the clinical setting when novices fail to consolidate an integrated cognitive, behavioral, and ethical identity. This unifying perspective was labeled non-integration. CONCLUSION: Third year nursing students and their educators are encouraged to be mindful of the need to ensure readiness prior to entry into the clinical setting. In the clinical setting, the learning of prepared students must be guided by competent educators. Finally, both students and their educators must respect professional boundaries to promote safety for students and patients.

First year nursing students' viewpoints about compromised clinical safety.

OBJECTIVE: Undergraduate nursing students must uphold patient safety as a professional and moral obligation across all clinical learning experiences. This expectation commences at entry into the nursing program. As part of a larger study exploring undergraduate baccalaureate nursing students' understanding of clinical safety, this paper specifically focuses on first year students' viewpoints about unsafe clinical learning situations. METHODS: Q-methodology was used. Sixty-eight first year nursing students participated in the ranking of 43 statements indicative of unsafe clinical situations and practices. Data was entered into a Q-program for factor analysis. RESULTS: The results revealed a typology of four discrete viewpoints of unsafe clinical situations for first year students. These viewpoints included an overwhelming sense of inner discomfort, practicing contrary to conventions, lacking in professional integrity and disharmonizing relations. Overall, a consensus viewpoint described exonerating the clinical educator as not being solely responsible for clinical safety. DISCUSSION: This information may assist students and educators to cooperatively and purposefully construct a clinical learning milieu conducive to safety.

Unsafe clinical practices as perceived by final year baccalaureate nursing students: Q methodology.

BACKGROUND: Nursing education necessitates vigilance for clinical safety, a daunting challenge given the complex interchanges between students, patients and educators. As active learners, students offer a subjective understanding concerning safety in the practice milieu that merits further study. This study describes the viewpoints of senior undergraduate nursing students about compromised safety in the clinical learning environment. METHODS: Q methodology was used to systematically elicit multiple viewpoints about unsafe clinical learning from the perspective of senior students enrolled in a baccalaureate nursing program offered at multiple sites in Ontario, Canada. Across two program sites, 59 fourth year students sorted 43 theoretical statement cards, descriptive of unsafe clinical practice. Q-analysis identified similarities and differences among participant viewpoints yielding discrete and consensus perspectives. RESULTS: A total of six discrete viewpoints and two consensus perspectives were identified. The discrete viewpoints at one site were Endorsement of Uncritical Knowledge Transfer, Non-student Centered Program and Overt Patterns of Unsatisfactory Clinical Performance. In addition, a consensus perspective, labelled Contravening Practices was identified as responsible for compromised clinical safety at this site. At the other site, the discrete viewpoints were Premature and Inappropriate Clinical Progression, Non-patient Centered Practice and Negating Purposeful Interactions for Experiential Learning. There was consensus that Eroding Conventions compromised clinical safety from the perspective of students at this second site. CONCLUSIONS: Senior nursing students perceive that deficits in knowledge, patient-centered practice, professional morality and authenticity threaten safety in the clinical learning environment. In an effort to eradicate compromised safety associated with learning in the clinical milieu, students and educators must embody the ontological, epistemological and praxis fundamentals of nursing.

Stories of women involved in a postpartum depression peer support group.

Living through postpartum depression (PPD) might lead women to seek a variety of support to re-establish their well-being, including a hybrid of traditional and non-traditional services. Within this mix, some women participate in peer groups; however, there is a paucity of research regarding their subjective experiences of engaging in this type of support. The purpose of this study was to describe how women talked about living through PPD in the context of a peer support group. This focused ethnography was a component of a larger participatory action study in northern Ontario, Canada. The seven members of a 5-week peer support group described their postpartum experiences through written, visual, and spoken stories. Using structural narrative analysis, stories about recovery were identified across the data. Three groups of recovery stories were labelled as illness, mothering wisdom, and mobilizing. The findings suggested that women actively sought and established a therapeutic space for PPD recovery with peers. As such, health-care providers are encouraged to acknowledge the merits and advocate for the multiple and diverse alliances women might require to actualize recovery.

Typology of undergraduate nursing students' unsafe clinical practices: Q-methodology.

Undergraduate nursing students, as members of the health care team, must uphold patient safety as a professional and moral obligation during their clinical learning experiences. To address this imperative, in a humanistic paradigm, students engage in critical appraisal of self as a developing practitioner. Using Q-methodology, this study describes undergraduate nursing students' subjective understanding of unsafe clinical practices, and results revealed a typology of five groups of unsafe students. The results showed four discrete groups of students at risk for unsafe clinical practices-vulnerable, unprepared, unknowing, and distanced students. Overall, a consensus viewpoint described the presence of the displaced student as the greatest safety risk. Use of this typology as an assessment guide may help students and educators cooperatively create and maintain a culture of safety while developing competent novice nurses.

Implications of multiple-choice testing in nursing education.

The evaluation of knowledge/competence is understood as an essential component of nursing education and practice. As such, nurse educators have a plethora of existing evaluation strategies from which to choose. A common written evaluative format used across all higher education settings is multiple-choice testing. This evaluation approach is accepted as a 'user-friendly' strategy to assess knowledge. Researchers from the disciplines of psychology and education have long been concerned with the consequences of multiple-choice testing on learning outcomes, a discussion that is essentially absent from the nursing literature. The purpose of this paper is to address the professional implications of multiple-choice testing in nursing. The potential knowledge consequences for nurse-learners, and by extension the provision of care to healthcare recipients, resultant from use of this testing modality are addressed within the context of the implementation of best practice guidelines in a long-term care home in a mid-sized rural and northern Canadian community with both regulated and non-regulated care providers.

Mothers with serious mental illness: their experience of "hitting bottom".

This study sought to understand the experience of "hitting bottom" from the perspective of 32 mothers with serious mental illness. Secondary narrative analysis of 173 stories about experiences related to hitting bottom were identified. Enactment of their perceived mothering roles and responsibilities was compromised when confronted by the worst of illness. Subsequent to women's descent to bottom was their need for a timely and safe exit from bottom. An intense experience in bottom further jeopardized their parenting and treatment self-determination and, for some, their potential for survival. The results suggest that prevention of bottom is feasible with early assessment of the diverse issues contributing to mothers' vulnerabilities. Interventions to lessen their pain may circumvent bottom experiences. Healing necessitates purposeful approaches to minimize the private and public trauma of bottom experiences, nurture growth towards a future, and establish resources to actualize such a life.

Chronic obstructive pulmonary disease as disability: dilemma stories.

The purpose of this work was to develop an understanding of the meaning of disability for individuals living with chronic obstructive pulmonary disease (COPD) in a Canadian midwestern community from an emic perspective. A focused ethnographic design was used. Fifteen individuals participated in interviews. Narrative analysis was used to examine the interview data. Data analysis revealed 65 dilemma stories consisting of two structural components: the impairment, and the justification/explanation of the impairment. Participants' impairment might or might not have been known to others. In both situations, individuals were faced with choices of whether to explain/justify or attempt to conceal the impairment. Participants told these dilemma stories to convey the meaning of COPD as a disability invisible to others, and at times, to themselves. The information gained from this research will serve as an essential complement to the existing knowledge about this important yet often invisible chronic illness.

Preceptor preparation: an investment in the future generation of nurses.

Nurse preceptors fulfill a primary role in the success of preceptorship experiences during the education of student nurses in their final year of study. Evidence suggests that this success depends greatly on adequate preceptor role preparation and support. The purposes of this qualitative, descriptive study were to explore and describe preceptor role support and development within the context of a rural and northern mid-sized Canadian community. More specifically, in this study the following are described: preceptors' (a) perception of past role preparation and current role support; (b) use and evaluation of the existing print-based fourth-year Preceptor Resource Manual (PRM); (c) perception of role support facilitators and barriers; and (d) recommendations for improvements to preceptor role preparation and support. Data were collected through individual and group interviews. Through content analysis four major themes emerged: accessible resources, role complexity, partners in precepting, and role development.

The novice objective structured clinical evaluation tool: psychometric testing.

AIM: This paper is a report of a study of the psychometric properties of the Novice Objective Structured Clinical Evaluation Tool. BACKGROUND: A collaborative undergraduate nursing programme is currently using an objective structured clinical evaluation at the conclusion of the first nursing clinical course to determine student competence as a component of quality and safety education. However, the reliability and validity of the assessment tool has not been established. METHODS: Psychometric testing was conducted with a convenience sample of 565 nursing students. Data were collected during three consecutive years from 2002 to 2004. Exploratory factor analysis and reliability testing were conducted on this 25-item tool. RESULTS: Principal axis factoring method identified two factors through the orthogonal, oblimin and promax rotations: Factor 1 Safety and Factor 2, Anticipation. Spearman-Brown's result for Factor 1 was 0·93 and for Factor 2 was 0·77. Cronbach's alpha was.94 for Factor 1 and 0·71 for Factor 2. CONCLUSION: The tool was found to have adequate construct validity and reliability. Its stability should be tested by conducting test-retest analysis. Equivalency dimensions of reliability should be evaluated by looking at interrater reliability. This tool shows merit for assessing elements of quality and safety education.

Identification of facilitators and barriers to the role of a mentor in the clinical setting.

Clinical mentors are integral to the education of health care professionals. In Northeastern Ontario, Canada, clinical mentors can take a variety of forms. Examples include preceptors who are employees in a clinical setting working with an individual student for a specific period of time, clinical educators, individuals contracted to take a group of students in acute care settings, and faculty advisors, who facilitate students' community placements. An internet survey exploring the preparation and support of clinical mentors was delivered to clinical mentors from a variety of health disciplines. Part of the survey was based on the concept of self-efficacy which assessed participants' confidence levels with the various aspects of the clinical mentor role. Participants also reported on supports and barriers to their role as clinical mentors. Findings indicate that clinical mentors across all the health disciplines are not always confident in the delivery of clinical education, most specifically with adapting teaching style and assisting the student to apply research to practice. Consistency of results of the survey speaks to the potential value for a collaborative, interprofessional approach to the orientation and support of clinical mentors in a variety of health discipline education programs.

Representations of disability in nursing and healthcare literature: an integrative review.

AIM: This paper is a report of an integrative review to explore the way in which disability has been considered in the multidisciplinary health and nursing literature. BACKGROUND: In the multidisciplinary health and nursing literature, two ways are presented in which disability can be understood: the traditional, functional perspective and a more contemporary, social perspective. DATA SOURCES: Computerized databases of the CINAHL, Proquest Nursing and Allied Health Sources, EBSCO and Evidence Based Medicine Reviews Multifile and Cochrane databases were conducted for papers published in English in the period 1963-2007 using the keywords 'models of disability', 'disability and nursing research' and 'theories of disability'. METHODS: An integrative review was performed and, of the 11,578 papers identified, 65 were included. RESULTS: The concept of functional disability refers to an individual who is physically 'disabled' and unable to perform expected roles. The concepts of social stigmatization and normalcy are associated with functional disability. In contrast, social disability concerns functional limitations within an individual's experience of living with disability, examining how socially constructed barriers actually 'disable' people. Conventionally, disability research has been conducted from an etic perspective. Researchers contend that a shift towards an understanding from the emic perspective is needed for disability research to be emancipatory. CONCLUSION: Adoption of a social perspective is necessary to inform an understanding of disability that addresses stigmatization and oppression. Research-informed nursing practice, complemented by supportive health and social policies, could transform the experience of living with disability.

COPD-intuition or template: nurses' stories of acute exacerbations of chronic obstructive pulmonary disease.

UNLABELLED: STUDY RATIONAL: A number of nurse-researchers have examined the experience of dyspnoea reduction during non-acute phases of the chronic obstructive pulmonary disease (COPD). However, nurses working on in-patient hospital units are frequently required to care for individuals suffering from acute exacerbations of their disease (AECOPD). These critically ill individuals present at health care institutions incapacitated by severe shortness of breath/dyspnoea that is frequently refractory to treatment. To date, little is known about the nurses' understanding of the care they provide for individuals hospitalized because of these acute episodes of their chronic illness. STUDY OBJECTIVES: The research project was undertaken, in part, to develop an understanding of nurses' experience of caregiving for individuals hospitalized for in-patient care during an AECOPD. METHODOLOGICAL DESIGN: This focused ethnographic narrative examined the caregiving stories of 10 nurse caregivers. The 10 nurse caregivers were interviewed while caring for a patient and their family during an experience of an AECOPD characterized by incapacitating breathlessness. RESULTS: The nurse caregivers told a number of caregiving stories that illustrated a common care template that appears to be based on intuition or pattern recognition focusing on anxiety sometimes to the exclusion of dyspnoea. CONCLUSIONS: Analysis of these stories emphasized the need to facilitate nurses individualization of standard templates. More importantly, this analysis illustrated the critical need to develop strategies to facilitate the reshaping of inaccurate templates in the presence of new knowledge.