The Use of Vignettes to Improve the Validity of Qualitative Interviews for Realist Evaluation.

Although realist evaluation (RE) requires multiple data collection methods, qualitative interviews are considered most valuable and are most frequently used. The guiding principles of RE may limit the emergence of new Context-Mechanism-Outcome (CMO) configurations by evoking particular underlying mechanisms. This paper proposes a new method for conducting semi-structured interviews in the RE context by drawing on the literature and examining the ability of vignettes to explore perceptions about specific situations. Vignettes are developed based on researchers' knowledge of the setting and program theory and are updated through an iterative process throughout data collection. Interviews focus on situations illustrated in the vignette to capture variations in interviewees' perceptions. This method constrains interviewees to using retroduction to identify the hidden underlying mechanisms that link contextual elements to outcomes based on their experiences. This method allows researchers to focus on CMO configurations without evoking mechanisms, which contributes to the rigor of the method.

Comparing the implementation of advanced access strategies among primary health care providers.

The advanced access (AA) model is among the most recommended innovations for improving timely access in primary health care (PHC). Originally developed for physicians, it is now relevant to evaluate the model's implementation in more interprofessional practices. We compared AA implementation among family physicians, nurse practitioners, and nurses. A cross-sectional online open survey was completed by 514 PHC providers working in 35 university-affiliated clinics. Family physicians delegated tasks to other professionals in the team more often than nurse practitioners (p = .001) and nurses (p < .001). They also left a smaller proportion of their schedules open for urgent patient needs than did nurse practitioners (p = .015) and nurses (p < .001). Nurses created more alternatives to in-person visits than family physicians (p < .001) and coordinated health and social services more than family physicians (p = .003). During periods of absence, physicians referred patients to walk-in services for urgent needs significantly more often than nurses (p = .003), whereas nurses planned replacements between colleagues more often than physicians (p <.001). The variations among provider categories indicate that a one-size-fits-all implementation of AA principles is not recommended.

Barriers and facilitators influencing parental adherence to prevention strategies for deformational plagiocephaly: Results from a scoping review.

BACKGROUND: Deformational plagiocephaly can be prevented in many healthy infants if strategies are implemented early after birth. However, despite efforts to disseminate accurate information, parental adherence to evidence-based prevention strategies is a challenge. To date, factors - barriers and facilitators - influencing parental adherence to strategies have yet to be identified in a comprehensive manner. OBJECTIVES: This scoping review aims to identify and synthesize current evidence on barriers and facilitators impacting adherence of parents of newborns to deformational plagiocephaly prevention strategies. METHODS: This review followed the Joanna Briggs Institute (JBI) process guidelines. Seven electronic (Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, SPORTDiscus, Academic Search Complete, AMED, PsychINFO and Scopus) and two grey literature (Health Systems Evidence and Grey Literature Report) databases were searched. Studies published between 2001 and 2022 were included. The deductive thematic data analysis used was guided by the Capability, Opportunity, Motivation Behavioral Model (COM-B) of health behaviour change. RESULTS: From a total of 1172 articles, 15 met the eligibility criteria. All components of the COM-B framework were identified. Capability-psychological and opportunity-environmental factors dominated the literature, whereas capability-physical, motivation and, in particular, opportunity-social factors were understudied. The most often reported barriers were a lack of knowledge of deformational plagiocephaly and the associated prevention strategies, ambiguous or inconsistent messaging, intolerance of babies to prone positioning and a lack of time. The most frequently reported facilitators were an awareness of deformational plagiocephaly, postural asymmetry and prevention strategies, skill acquisition with practice, accurate convincing information, scheduled time and environmental organization to position the baby at home. DISCUSSION: Recommendations focused on diffusing accurate and detailed information for parents. Our review also suggests a gap regarding the comprehensive identification of factors influencing parental adherence to deformational plagiocephaly prevention strategies. Further studies exploring comprehensive opportunity-social and motivation factors influencing parental adherence to deformational plagiocephaly prevention strategies are warranted to inform prevention programmes and foster better infant outcomes.

Nursing practice and teleconsultations in a pandemic context: A mixed-methods study.

AIM: To explore the use and implementation of teleconsultations by primary care nurses in the context of the COVID-19 pandemic. BACKGROUND: Teleconsultation use increased rapidly during the COVID-19 pandemic. Its implementation has been documented for physicians and specialists, but knowledge is still limited in nursing practice. DESIGN: A sequential mixed-methods study. METHODS: Phase 1: A cross-sectional e-survey with 98 nurses (64 nurse clinicians [NCs] and 34 nurse practitioners [NPs]) was conducted in 2020 in 48 teaching primary care clinics in Quebec (Canada). Phase 2: Semi-structured interviews with four NCs and six NPs were conducted in 2021 in three primary care clinics. This study adheres to STROBE and COREQ guidelines. RESULTS: During the pandemic, telephone was the principal teleconsultation modality used by NPs and NCs compared to other teleconsultation modalities (text messages, email and video). The only variable associated with a higher likelihood of using teleconsultations was type of professional (NCs). Video consultation was almost absent from the modalities used. The majority of participants reported several facilitators to using teleconsultations in their work (e.g. web platforms and work-family balance) and for patients (e.g. rapid access). Some barriers to utilisation were identified (e.g. lack of physical resources) for successful integration of teleconsultations at the organisational, technological and systemic levels. Participants also reported positive (e.g. assessment of cognitive deficiency) and negative (e.g. rural population) impacts of using teleconsultations during a pandemic that made the use of teleconsultations complex. CONCLUSION: This study highlights the potential for nurses to use teleconsultations in primary care practice and suggests concrete solutions to encourage their implementation after the pandemic. RELEVANCE TO CLINICAL PRACTICE: Findings emphasize the need for updated nursing education, easy-to-use technology and the strengthening of policies for the sustainable use of teleconsultations in primary health care. IMPLICATIONS FOR THE PROFESSION: This study could promote the sustainable use of teleconsultations in nursing practice. REPORTING METHOD: The study adhered to relevant EQUATOR guidelines; the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies were used for reporting. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution, as the study focused on the use of teleconsultation among health professionals, specifically primary care nurses.

Ten years later: A portrait of the implementation of the advanced access model in Quebec.

Since 2012, implementation of the advanced access model in primary care has been highly recommended across Canada to improve timely access. We present a portrait of the implementation of the advanced access model 10 years after its large-scale implementation across the province of Quebec. In total, 127 clinics participated in the study, with 999 family physicians and 107 nurse practitioners responding to the survey. Results show that opening schedules for appointments over a period of 2 to 4 weeks has largely been implemented. However, reserving consultation time for urgent or semi-urgent conditions was implemented by less than half and planning supply and demand for 20% or more of the upcoming year by fewer than one fifth of respondents. More strategies need to be put in place to react to imbalances when they occur. We demonstrate that strategies based on individual practice change are more often implemented than those requiring changes at the clinic.

Assessment tools for reflection in healthcare learners: A scoping review.

Reflection has been integrated in many healthcare educations programs to achieve deeper learning and improve professional practice. A variety of evaluation tools are used to assess reflection, but few guides are available to inform educators in their choice of a relevant evaluation tool. The aim of this paper is to identify all existing evaluation tools published along with their strengths and weaknesses. A review strategy retrieved tools available in Medline, PsychInfo, CINALH and Eric databases. The procedures outlined by Munn and colleagues were used to synthetize the information. Additionally, the reflection dimensions assessed in each tool (when sufficient information was available) were analyzed deductively, using thematic analysis according to the Killion and Todnem framework. Subthemes were identified inductively. Forty-five papers were identified, reporting on 34 different tools. The tools were based on a variety of theoretical models. Some had evidence of adequate validity and fidelity. Eleven components of reflection were identified across tools. No tool encompassed all components, but most tools included between three and five components. Context surrounding evaluation should be carefully considered when choosing an evaluation tool for reflection. There is a need for further research to validate the psychometric properties of reflection evaluation tools.

Cultural Safety as an Outcome of a Dynamic Relational Process: The Experience of Inuit in a Mainstream Residential Addiction Rehabilitation Centre in Southern Canada.

Few addiction treatment options are available in Arctic Canada, leading many Inuit to seek treatment programs in southern cities. We conducted a case study to understand what contributes to a culturally safe experience for Inuit in a mainstream addiction rehabilitation centre in Southern Canada. We carried out more than 700 hours of participant observation, in addition to semi-structured interviews and member-checking activities with 20 Inuit residents, 18 staff and four managers. Data were analysed using an inductive interpretative process. Throughout their journey in the program, Inuit navigated through contrasting situations and feelings that we grouped under six broad themes: having Inuit peers, having limitations imposed on one's ways of being and doing, facing ignorance and misperceptions, having conversations and dialogue, facing language barriers and being in a supportive and caring environment. This study highlights how cultural safety varies according to people, context and time, and relates to developing trustful relationships.

Acceptability of Pediatric Telerehabilitation Interventions Provided by Physical Therapists and Occupational Therapists-A Scoping Review.

AIMS: The purpose of this scoping review was to explore the available literature and identify gaps regarding the acceptability of telerehabilitation interventions provided by pediatric physical therapists and occupational therapists. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-ScR) framework to guide this scoping review. We systematically searched eight scholarly databases (CINAHL, Medline, SPORTDiscus, AMED, APA PsychInfo, SCOPUS, PEDro, OTseeker), five gray literature databases (MedlinePlus, Gray Literature Report, OpenGrey, National Institute for Health, ProQuest Dissertation & Theses Global [PQDT]), conducted a manual search of selected references and contacted international experts. We included articles published between 2000 and 2021. Acceptability was defined in accordance with the Theoretical Framework of Acceptability of Sekhon et al. RESULTS: From a total of 1567 unique references, 123 were deemed eligible for full-text review. Eighteen studies published between 2011 and 2021 were included in this review. Even though every aspect of the Theoretical Framework of Acceptability was assessed from a variety of angles, a complete appreciation of the concept is still lacking for pediatric telerehabilitation. CONCLUSIONS: This review highlights important gaps in our knowledge regarding the acceptability of pediatric telerehabilitation interventions and supports the need for further research focusing on the subject.

Characteristics, barriers and facilitators of initiatives to develop interprofessional collaboration in rural and remote primary healthcare facilities: a scoping review.

INTRODUCTION: Despite strong evidence supporting interprofessional collaboration (IPC) and the documented need for collaborative practice in primary health care (PHC), initiatives to promote IPC in rural and remote PHC facilities have not been extensively studied. The purpose of this article is to map interprofessional education (IPE) and interprofessional practice (IPP) initiatives implemented to promote IPC in rural and remote PHC facilities, and identify barriers and facilitators to their implementation. METHODS: A scoping review was conducted. After two reviewers filtered titles and abstracts, 94 retained articles were subsequently screened. Finally, 23 articles were selected and analyzed using a directed content analysis approach in NVivo v12. RESULTS: Only 10 articles focused on the implementation of initiatives to improve IPC, while the majority reported barriers and facilitators. The most common IPE initiatives were workshops, courses, discussion groups and simulations, while IPP initiatives fell into two main categories: clinical or technological tools. Limited human resources, understanding of roles, and knowledge of context as well as traditional roles, were identified as barriers. Team size, past experience and relationships, connection to community, flexibility and openness, and financial support were facilitators to developing IPC. CONCLUSION: Deployment of IPC in rural and remote PHC facilities is critical given the various challenges faced in these clinical settings. The facilitators identified in this literature review are specific to rural and remote clinical settings and provide hope that new initiatives more tailored to rural and remote settings will be implemented and evaluated in the future to improve IPC and care delivery.

Intra- and inter-evaluator reliability of the MyotonPRO for the assessment of the viscoelastic properties of caesarean section scar and unscarred skin.

BACKGROUND: The clinical evaluation of viscoelastic properties of the Caesarean section (C-section) scar, such as stiffness and elasticity, is usually carried out using subjective scales and palpation techniques. There is currently no reliable and valid tool that objectively quantifies these properties. The MyotonPRO could fill this gap. MATERIALS AND METHODS: Nineteen healthy women aged between 21 and 40 years with C-section scars participated in this reliability study. Two points, one on the scar and one on unscarred skin, were measured four times successively with the MyotonPRO by three independent evaluators on the same day. The intra-class correlation (ICC) coefficients were estimated using a two-factor ANOVA to determine the inter- and intra-rater reliability. The capacity of the MyotonPRO to discriminate the viscoelastic properties of the C-Section scar against unscarred skin was assessed using the Wilcoxon signed rank test. RESULTS: The intra- and inter-rater reliability of the viscoelastic property measurements was good to excellent (ICC 0.99-1.00 and 0.87-0.98, respectively). There was no significant difference between C-section scar and unscarred skin in terms of elasticity (P = .737). Significant differences between C-section scars and unscarred skin tissue were observed for tone (P < .001), stiffness (P < .001), creep (P < .001), and mechanical stress relaxation time (P < .001). CONCLUSION: The MyotonPRO is a reliable tool for an objective measurement of the viscoelastic properties of the C-section scar and unscarred skin. The MyotonPRO can discriminate the viscoelastic properties of the C-section scar against the unscarred skin, for tone, stiffness, creep and relaxation times, but not for elasticity.

Interprofessional advanced access - a quality improvement protocol for expanding access to primary care services.

BACKGROUND: The Advanced Access (AA) Model has shown considerable success in improving timely access for patients in primary care settings. As a result, a majority of family physicians have implemented AA in their organizations over the last decade. However, despite its widespread use, few professionals other than physicians and nurse practitioners have implemented the model. Among those who have integrated it to their practice, a wide variation in the level of implementation is observed, suggesting a need to support primary care teams in continuous improvement with AA implementation. This quality improvement research project aims to document and measure the processes and effects of practice facilitation, to implement and improve AA within interprofessional teams. METHODS: Five primary care teams at various levels of organizational AA implementation will take part in a quality improvement process. These teams will be followed independently over PDSA (Plan-Do-Study-Act) cycles for 18 months. Each team is responsible for setting their own objectives for improvement with respect to AA. The evaluation process consists of a mixed-methods plan, including semi-structured interviews with key members of the clinical and management teams, patient experience survey and AA-related metrics monitored from Electronic Medical Records over time. DISCUSSION: Most theories on organizational change indicate that practice facilitation should enable involvement of stakeholders in the process of change and enable improved interprofessional collaboration through a team-based approach. Improving access to primary care services is one of the top priorities of the Quebec's ministry of health and social services. This study will identify key barriers to quality improvement initiatives within primary care and help to develop successful strategies to help teams improve and broaden implementation of AA to other primary care professionals.

Communication and Interprofessional Collaboration in Primary Care: From Ideal to Reality in Practice.

To improve patient-centered care, many health care systems are mandating interprofessional collaboration (IPC). However, in many primary care contexts, IPC is still nascent and fraught with tension. Communication is thought to be a key determinant of IPC, but few studies empirically examine IP communication practices. Therefore, we report here on the qualitative portion of a mixed methods pilot study investigating observed IPC and communication in primary care clinics in Quebec, Canada. Studying actual communication practices to understand collaborative activities, we seek to investigate how the ideals of patient centeredness and clinical democracy put forward in the IP literature stack up against actual IPC practice in primary care. Qualitative data was gathered by shadowing health professionals in two primary care clinics, and analyzed through thematic coding. A typology of observed IP practices was created and compared to the continuum of interprofessional collaborative practice. Further analysis focused on how participants made sense of their collaboration, especially why, how and with whom they collaborated. Findings were grouped into three categories of communicative actions: coordinating sequential efforts; assisting others' sensemaking; and working to understand together. Implications for practice and future research are discussed.

Nurse staffing practices and adverse events in acute care hospitals: The research protocol of a multisite patient-level longitudinal study.

AIMS: We describe an innovative research protocol to: (a) examine patient-level longitudinal associations between nurse staffing practices and the risk of adverse events in acute care hospitals and; (b) determine possible thresholds for safe nurse staffing. DESIGN: A dynamic cohort of adult medical, surgical and intensive care unit patients admitted to 16 hospitals in Quebec (Canada) between January 2015-December 2019. METHODS: Patients in the cohort will be followed from admission until 30-day postdischarge to assess exposure to selected nurse staffing practices in relation to the subsequent occurrence of adverse events. Five staffing practices will be measured for each shift of an hospitalization episode, using electronic payroll data, with the following time-varying indicators: (a) nursing worked hours per patient; (b) skill mix; (c) overtime use; (d) education mix and; and (e) experience. Four high-impact adverse events, presumably associated with nurse staffing practices, will be measured from electronic health record data retrieved at the participating sites: (a) failure-to-rescue; (b) in-hospital falls; (c) hospital-acquired pneumonia and; and (d) venous thromboembolism. To examine the associations between the selected nurse staffing exposures and the risk of each adverse event, separate multivariable Cox proportional hazards frailty regression models will be fitted, while adjusting for patient, nursing unit and hospital characteristics, and for clustering. To assess for possible staffing thresholds, flexible non-linear spline functions will be fitted. Funding for the study began in October 2019 and research ethics/institutional approval was granted in February 2020. DISCUSSION: To our knowledge, this study is the first multisite patient-level longitudinal investigation of the associations between common nurse staffing practices and the risk of adverse events. It is hoped that our results will assist hospital managers in making the most effective use of the scarce nursing resources and in identifying staffing practices that minimize the occurrence of adverse events.

Group transdiagnostic cognitive-behavior therapy for anxiety disorders: a pragmatic randomized clinical trial.

BACKGROUND: Transdiagnostic group cognitive-behavioral therapy (tCBT) is a delivery model that could help overcome barriers to large-scale implementation of evidence-based psychotherapy for anxiety disorders. The aim of this study was to assess the effectiveness of combining group tCBT with treatment-as-usual (TAU), compared to TAU, for the treatment of anxiety disorders in community-based mental health care. METHODS: In a multicenter single-blind, two-arm pragmatic superiority randomized trial, we recruited participants aged 18-65 who met DSM-5 criteria for principal diagnoses of generalized anxiety disorder, social anxiety disorder, panic disorder, or agoraphobia. Group tCBT consisted of 12 weekly 2 h sessions. There were no restrictions for TAU. The primary outcome measures were the Beck Anxiety Inventory (BAI) and clinician severity rating from the Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5) for the principal anxiety disorder at post-treatment, with intention-to-treat analysis. RESULTS: A total of 231 participants were randomized to either tCBT + TAU (117) or TAU (114), with outcome data available for, respectively, 95 and 106. Results of the mixed-effects regression models showed superior improvement at post-treatment for participants in tCBT + TAU, compared to TAU, for BAI [p < 0.001; unadjusted post-treatment mean (s.d.): 13.20 (9.13) v. 20.85 (10.96), Cohen's d = 0.76] and ADIS-5 [p < 0.001; 3.27 (2.19) v. 4.93 (2.00), Cohen's d = 0.79]. CONCLUSIONS: Our findings suggest that the addition of group tCBT into usual care can reduce symptom severity in patients with anxiety disorders, and support tCBT dissemination in routine community-based care.

Implementing a fracture follow-up liaison service: perspective of key stakeholders.

Fracture liaison services (FLS) have been shown to prevent efficiently subsequent fragility fractures (FF). However, very few studies have examined their implementation in depth. The purpose of this research was to identify factors influencing the implementation of a FLS at three sites in Quebec, Canada. From 2013 to 2015, individual and group interviews focused on experiences of FLS stakeholders, including implementation committee members, coordinators, and orthopaedic surgeons and their teams. Emerging key implementation factors were triangulated with the FLS patients' clinico-administrative data. The Consolidated Framework for Implementation Research guided the analysis of perceived factors influencing four intervention outputs: investigation of FF risk (using the FRAX score), communication with the participant primary care provider, initiation of anti-osteoporosis medications (when relevant), and referral to organized fall prevention activities (either governmental or community based). Among the 454 FLS patients recruited to the intervention group, 83% were investigated for FF risk, communication with the primary care provider was established for 98% of the participants, 54% initiated medication, and 35% were referred to organized fall prevention activities. Challenges related to restricted rights to prescribe medication and access to organized fall prevention activities were reported. FLS coordinator characteristics to overcome those challenges included self-efficacy beliefs, knowledge of community resources, and professional background. This study highlighted the importance of enabling access to services for subsequent FF prevention, consolidating the coordinator's role to facilitate a more integrated intervention, and involving local leaders to promote the successful implementation of the FLS.

Evaluation of the implementation and associated effects of advanced access in university family medicine groups: a study protocol.

BACKGROUND: Timely access in primary health care is one of the key issues facing health systems. Among many interventions developed around the world, advanced access is the most highly recommended intervention designed specifically to improve timely access in primary care settings. Based on greater accessibility linked with patients' relational continuity and informational continuity with a primary care professional or team, this organizational model aims to ensure that patients obtain access to healthcare services at a time and date convenient for them when needed regardless of urgency of demand. Its implementation requires a major organizational change based on reorganizing the practices of all the administrative staff and health professionals. In recent years, advanced access has largely been implemented in primary care organizations. However, despite its wide dissemination, we observe considerable variation in the implementation of the five guiding principles of this model across organizations, as well as among professionals working within the same organization. The main objective of this study is to assess the variation in the implementation of the five guiding principles of advanced access in teaching primary healthcare clinics across Quebec and to better understand the influence of the contextual factors on this variation and on outcomes. METHODS: This study will be based on an explanatory sequential design that includes 1) a quantitative survey conducted in 47 teaching primary healthcare clinics, and 2) a multiple case study using mixed data, contrasted cases (n = 4), representing various implementation profiles and geographical contexts. For each case, semi-structured interviews and focus group will be conducted with professionals and patients. Impact analyses will also be conducted in the four selected clinics using data retrieved from the electronic medical records. DISCUSSION: This study is important in social and political context marked by accessibility issues to primary care services. This research is highly relevant in a context of massive media coverage on timely access to primary healthcare and a large-scale implementation of advanced access across Quebec. This study will likely generate useful lessons and support evidence-based practices to refine and adapt the advanced access model to ensure successful implementation in various clinical contexts facing different challenges.

Evaluating implementation and impact of a provincial quality improvement collaborative for the management of chronic diseases in primary care: the COMPAS+ study protocol.

BACKGROUND: Chronic conditions such as diabetes and chronic obstructive pulmonary disease (COPD) are common and burdensome diseases primarily managed in primary care. Yet, evidence points to suboptimal quality of care for these conditions in primary care settings. Quality improvement collaboratives (QICs) are organized, multifaceted interventions that can be effective in improving chronic disease care processes and outcomes. In Quebec, Canada, the Institut national d'excellence en santé et en services sociaux (INESSS) has developed a large-scale QIC province-wide program called COMPAS+ that aims to improve the prevention and management of chronic diseases in primary care. This paper describes the protocol for our study, which aims to evaluate implementation and impact of COMPAS+ QICs on the prevention and management of targeted chronic diseases like diabetes and COPD. METHODS: This is a mixed-methods, integrated knowledge translation study. The quantitative component involves a controlled interrupted time series involving nine large integrated health centres in the province. Study sites will receive one of two interventions: the multifaceted COMPAS+ intervention (experimental condition) or a feedback only intervention (control condition). For the qualitative component, a multiple case study approach will be used to achieve an in-depth understanding of individual, team, organizational and contextual factors influencing implementation and effectiveness of the COMPAS+ QICs. DISCUSSION: COMPAS+ is a QI program that is unique in Canada due to its integration within the governance of the Quebec healthcare system and its capacity to reach many primary care providers and people living with chronic diseases across the province. We anticipate that this study will address several important gaps in knowledge related to large-scale QIC projects and generate strong and useful evidence (e.g., on leadership, organizational capacity, patient involvement, and implementation) having the potential to influence the design and optimisation of future QICs in Canada and internationally.

Understanding parental concerns related to their child's development and factors influencing their decisions to seek help from health care professionals: Results of a qualitative study.

BACKGROUND: Early identification of children at risk of developmental delay is crucial to promote healthy development. Assessing parental concerns about development is often part of identification processes. However, we currently do not understand well how and why parents become concerned and how and why they access early identification and intervention services. The purpose of this study was to explore parental perceptions about their child's development and the factors influencing their reported professional help-seeking behaviours. METHODS: This exploratory study was part of a larger study describing child development in children aged 2-5 in a small Canadian city. We conducted semistructured interviews with 16 parents whose children were at risk of developmental delay to examine their perceptions of their child's development, their use of community services promoting development, and their recommendations to optimize those services. RESULTS: Four themes were identified: (a) Vision of child development influencing help-seeking behaviours: Natural or Supported?, (b) Internal and external sources contributing to parents' level of developmental concern, (c) Using internal resources and struggling to access external resources, and (d) Satisfaction with services accessed and recommendations to access more support. Parents' vision of child development along with sources of parental concern appeared to influence the level of concern, enhancing our understanding of how parents become concerned. The level of concern and parents' knowledge and perceived access to resources seemed to influence their decision whether or not to consult health care professionals. Parents provided many suggestions to improve services to promote child development and support families. DISCUSSION: Results highlight the importance of supporting parents in recognizing if their child is at risk of delay and increasing awareness of available resources. It appears particularly important to ensure that health care professionals and community-based support services are accessible to provide parents with the support they need, especially when they have concerns.

Changing nursing practice within primary health care innovations: the case of advanced access model.

BACKGROUND: The advanced access (AA) model has attracted much interest across Canada and worldwide as a means of ensuring timely access to health care. While nurses contribute significantly to improving access in primary healthcare, little is known about the practice changes involved in this innovative model. This study explores the experience of nurse practitioners and registered nurses with implementation of the AA model, and identifies factors that facilitate or impede change. METHODS: We used a longitudinal qualitative approach, nested within a multiple case study conducted in four university family medicine groups in Quebec that were early adopters of AA. We conducted semi-structured interviews with two types of purposively selected nurses: nurse practitioners (NPs) (n = 6) and registered nurses (RNs) (n = 5). Each nurse was interviewed twice over a 14-month period. One NP was replaced by another during the second interviews. Data were analyzed using thematic analysis based on two principles of AA and the Niezen & Mathijssen Network Model (2014). RESULTS: Over time, RNs were not able to review the appointment system according to the AA philosophy. Half of NPs managed to operate according to AA. Regarding collaborative practice, RNs were still struggling to participate in team-based care. NPs were providing independent and collaborative patient care in both consultative and joint practice, and were assuming leadership in managing patients with acute and chronic diseases. Thematic analysis revealed influential factors at the institutional, organizational, professional, individual and patient level, which acted mainly as facilitators for NPs and barriers for RNs. These factors were: 1) policy and legislation; 2) organizational policy support (leadership and strategies to support nurses' practice change); facility and employment arrangements (supply and availability of human resources); Inter-professional collegiality; 3) professional boundaries; 4) knowledge and capabilities; and 5) patient perceptions. CONCLUSIONS: Our findings suggest that healthcare decision-makers and organizations need to redefine the boundaries of each category of nursing practice within AA, and create an optimal professional and organizational context that supports practice transformation. They highlight the need to structure teamwork efficiently, and integrate and maximize nurses' capacities within the team throughout AA implementation in order to reduce waiting times.

Service Preferences of Parents of Children With Mild Bilateral or Unilateral Hearing Loss: A Conjoint Analysis Study.

OBJECTIVE: Universal newborn hearing screening results in substantially more children with mild bilateral and unilateral hearing loss identified in the early years of life. While intervention services for children with moderate loss and greater are generally well-established, considerable uncertainty and variation surrounds the need for intervention services for children with milder losses. This study was undertaken with parents of young children with permanent mild bilateral and unilateral hearing loss to examine their preferences for characteristics associated with intervention services. DESIGN: Conjoint analysis, a preference-based technique, was employed to study parents' strength of preferences. Using a cross-sectional survey that consisted of eight hypothetical clinic scenarios, we invited parents to make a discrete choice (to select one of two or more different services) between available services with different characteristics. The survey was informed by qualitative interviews conducted for this purpose. The questionnaire was administered to parents receiving intervention services in the province of Ontario, Canada, who were enrolled in a mixed-methods longitudinal study examining outcomes in early-identified children with mild bilateral/unilateral hearing loss. Data were analyzed using a generalized linear model (probit link) to identify attributes of interest for the respondents. Characteristics of the children were entered into the model to control for differences in age of diagnosis, sex, laterality of hearing loss, and hearing aid use. RESULTS: A total of 51 of 62 invited parents completed the questionnaire. All four attributes of care that were included in the survey were found to be statistically significant, that is, parents valued support for amplification, support for speech-language development, emotional support, and communication from professionals. Analysis showed greater preference for enhanced levels relating to support for speech-language development than for support for amplification. Preference for attributes relating to emotional support and communication were also greater than for support for amplification use. CONCLUSIONS: Conjoint analysis was used to quantify parents' preferences for service attributes. Parents' values provide insights into the aspects of a service model that should receive consideration in the development of intervention programs for young children with mild bilateral or unilateral hearing loss and their families. Although parents of young children with mild bilateral or unilateral hearing loss valued several components of care, they indicated a clear preference for speech-language support compared with support for amplification use.