A narrative evaluation of a community-based nurse navigation role in an urban at-risk community.

AIMS: To explore community members' stories of their experiences with a Nurse Navigator programme serving an urban neighbourhood and primary care practice to address persistent health and social barriers adversely affecting health equity and well-being. BACKGROUND: In response to striking health and social inequalities existing across neighbourhoods in a large southern city in Ontario, Canada, a pilot programme was designed to improve health and social outcomes in a specific "at-risk" neighbourhood. The programme includes nurse-led navigation support for individuals and families and networking to facilitate improved service integration at a systems level. DESIGN: A narrative inquiry approach based on the Three-Dimensional Narrative Inquiry Space method, as described by Clandinin & Connelly (Narrative inquiry: Experience and story in qualitative research, ). METHODS: A thematic analysis of nine community members' life stories from narrative semi-structured interviews (January-June 2014) in conjunction with field notes, observations and documents. Participants' life stories created a common narrative of the experience of navigation in a community setting. FINDINGS: There were four main themes: "opening the door"; "more than just a conversation"; "making connections"; and "on a new trajectory". Participants valued the development of a therapeutic relationship, which optimized social inclusion, barrier reduction and connectivity to supportive health and social services. CONCLUSIONS: The relational process of navigation as an antecedent to barrier reduction has direct implications for programme development, continuing education of navigators and quality improvement of existing navigation services. Study findings have implications for development of navigation competencies for nurses working with priority populations to address health inequities.

The Hope Research Community of Practice: Building Advanced Practice Nurses' Research Capacity.

Background Clinical nurses have multiple challenges in conducting high-quality nursing research to inform practice. Theoretically, the development of a community of practice on nursing research centered on the concept of hope is an approach that may address some of the challenges. Purpose This article describes the delivery and evaluation of a hope research community of practice (HRCoP) approach to facilitate research expertise in a group of advanced practice nurses in one hospital. It addressed the question: Does the establishment of a HRCoP for master's prepared nurses increase their confidence and competence in leading nursing research? Method Using interpretive descriptive qualitative research methodology, five participants were interviewed about their experiences within the HRCoP and facilitators engaged in participant observation. Results At 13 months, only four of the original seven participants remained in the HRCoP. While all participants discussed positive impacts of participation, they identified challenges of having protected time to complete their individual research projects, despite having administrative support to do so. Progress on individual research projects varied. Conclusion Nurse-led research remains a challenge for practicing nurses despite participating in an evidence-based HRCoP. Lessons learned from this project can be useful to other academic clinical partnerships.

The nurse as bricoleur in falls prevention: learning from a case study of the implementation of fall prevention best practices.

BACKGROUND: Falls prevention in "real-life" clinical practice is a complex undertaking. Nurses play an active and essential role in falls prevention. AIM: This discussion paper presents a picture of the nurse as a bricoleur in falls prevention, requiring knowledge in many areas and the ability to perform multiple diverse tasks. METHODS: Building on a qualitative case study with nurses at various levels in three acute care facilities, this paper posits that the concept of nurse as bricoleur has the potential to broaden our understanding of the complexity of falls prevention. FINDINGS: The nurse as bricoleur within the Promoting Action Research in Health Services framework as the provider of person- or patient-centered evidence-based care is conceptualized. Within this framework, the nurse uses his or her professional knowledge or clinical experience while considering research, local data, and information, and the patient's experience and preferences to provide this care, the bricolage. Each of these areas is discussed as well as the impact on the nurse when a fall does occur. LINKING EVIDENCE TO ACTION: Recognizing this complexity of the nurses' world has important implications for both service delivery and education, including preparation of students, and the implementation of new organizational initiatives and supports for nurses when falls do occur despite the best efforts of all involved.

Using Stake's qualitative case study approach to explore implementation of evidence-based practice.

Although the use of qualitative case study research has increased during the past decade, researchers have primarily reported on their findings, with less attention given to methods. When methods were described, they followed the principles of Yin; researchers paid less attention to the equally important work of Stake. When Stake's methods were acknowledged, researchers frequently used them along with Yin's. Concurrent application of their methods did not take into account differences in the philosophies of these two case study researchers. Yin's research is postpositivist whereas Stake's is constructivist. Thus, the philosophical assumptions they used to guide their work were different. In this article we describe how we used Stake's approach to explore the implementation of a falls-prevention best-practice guideline. We focus on our decisions and their congruence with Stake's recommendations, embed our decisions within the context of researching this phenomenon, describe rationale for our decisions, and present lessons learned.

Uncertainty and alternate level of care: a narrative study of the older patient and family caregiver experience.

Older adults in Canada who have multiple illnesses and are awaiting placement in long-term care are greatly impacted by alternate level of care (ALC). The purpose of this narrative study was to record the experiences of hospitalized older adults and their family caregivers after the patient is designated as requiring ALC. The researchers conducted 21 interviews with 5 older patients and 4 of their family caregivers. The interviews were transformed into stories summarizing the participants' experiences and analyzed for common themes. An overall finding was that uncertainty is integral to the experience of ALC as expressed under 3 themes: I never thought I'd end up like this, I don't know, and waiting. To improve the ALC experience, comprehensive strategies should be developed at the individual, organizational, and structural level to better manage uncertainty while seeking to reduce the occurrence of ALC among older patients.

The real world journey of implementing fall prevention best practices in three acute care hospitals: a case study.

BACKGROUND: Globally, falls are the second leading cause of unintentional injury. In Canada, falls that occur in hospitals have been ranked second as an area of patient safety concern. Many Canadian hospitals seeking to achieve patient safety, accreditation and resource containment goals are implementing evidence-based practices in fall prevention. However, best practices are reported to be only variably effective in reducing hospital fall rates, indicating a potential gap in our understanding of the implementation process. This study was designed to provide insight into the real world of implementation of best practices in fall prevention in acute care Canadian hospitals. APPROACH: Using case study methodology, ninety-five administrative and point-of-care nurses at three hospitals participated in interviews or focus groups and provided documents and artifacts that described their implementation of a falls prevention guideline. FINDINGS AND IMPLICATIONS: Four recommendations with potential to guide others in fall prevention were identified: (1) the need to listen to and recognize the expertise and clinical realities of staff, (2) the importance of keeping the implementation process simple, (3) the need to recognize that what seems simple becomes complex when meeting individual patient needs, and (4) the need to view the process as one of continuous quality improvement.

Recovery-oriented service provision and clinical outcomes in assertive community treatment.

OBJECTIVE: While the term "recovery" is routinely referenced in clinical services and health policy, few studies have examined the relationship between recovery-oriented service provision and client outcomes. The present study was designed to examine the relationship between recovery-orientation of service provision for persons with severe mental illnesses and outcomes in Assertive Community Treatment (ACT). METHODS: Client, family, staff, and manager ratings of service recovery-orientation and outcomes across a range of service utilization and community functioning indicators were examined among 67 ACT teams in Ontario, Canada. RESULTS: Significant associations were found between ratings of recovery-oriented service provision and better outcomes in the domains of legal involvement, hospitalization days, education involvement, and employment. Results were not uniformly positive or consistent, however, across stakeholder Recovery Self-Assessment (RSA) ratings or outcomes. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These findings provide some preliminary support for an association between recovery-oriented service delivery for persons with severe mental illnesses and better outcomes. In line with the current practice commentary, this association would suggest the importance of evaluating and cultivating recovery-oriented values and practices in ACT contexts. This is a particularly salient point given that ACT standards minimally address key domains of recovery-oriented service provision. Further study is required, however, to determine if these findings apply to the implementation of ACT in other jurisdictions or generalize to other community support programs.

Transformative learning through a research practicum for undergraduate nursing students.

In their final year of a Bachelor of Science in Nursing (BScN) program, students are required to take a research practicum related to clinical practice in a new or ongoing research project, supervised by nursing faculty. This course is designed to enhance students' understanding of the research process. The student's potential role as a research collaborator is emphasized. Involvement in an interdisciplinary narrative study with formerly homeless individuals challenged by severe alcohol dependence, in general poor health and living in a harm reduction environment, transformed students' values, assumptions, and beliefs. Not only did students gain confidence in their beginning skills as potential research collaborators, but they also felt that their future practice would be enhanced by new perspectives gained by studying a marginalized and stigmatized group, thus enabling them to appreciate cultural diversity and improve their competence.

Fidelity and recovery-orientation in assertive community treatment.

There has been increasing commentary about the degree to which Assertive Community Treatment (ACT) teams provide recovery-oriented services, often centered around the question of the use of coercion. The present study was designed to contribute to this discussion through an examination of recovery-oriented service provision and ACT fidelity among 67 teams in the province of Ontario, Canada. The findings indicated a moderate to high degree of recovery orientation in service provision, with no significant relationship between ACT fidelity and consumer and family/key support ratings of recovery orientation. A significant relationship was found, however, between the 'nature of services' domain of the Dartmouth Assertive Community Treatment Scale (DACTS) and ratings of recovery orientation provided by staff and ACT coordinators. These findings extend the existing dialogue regarding the evaluation of ACT intervention process factors and indicate that current measures of fidelity may not be adequately addressing dimensions of recovery-oriented service provision.

Implementing program-wide awareness about recovery in a large mental health and addictions program.

St. Joseph's Healthcare Hamilton conceptualized a multi-step plan for implementing a recovery oriented service delivery approach within their Mental Health and Addictions Program. This brief report discusses the first phase of this plan which included building awareness of recovery utilizing Anthony's (2000) system standards to develop a needs assessment for managers and senior team members. The survey had three purposes: to increase managers' awareness about recovery; to allow managers to express concerns that they had with this paradigm; and to afford managers an opportunity to explore the ways in which their service was and was not operating in a recovery oriented way. Initiatives designed to build awareness throughout the program are discussed.

The development of an assessment and intervention falls guide for older hospitalized adults with cardiac conditions.

BACKGROUND: Older patients with chronic cardiac conditions are more vulnerable to falls and injuries. Cardiovascular conditions, prevalent in older people, are also the frequent cause of potentially harmful fall injuries among this group. The need to identify the fall risk-related factors that cluster with arrhythmia and syncope is relevant as it will potentially reduce patients' risk for falls and fall injuries. AIM: The paper describes the process taken to design, develop and implement a practice-change initiative that specifically focuses on cardiac-related falls and injuries. PROCESS: A review of best practice guidelines, related studies and patients' profiles from chart audits were utilized to obtain evidence-based information to develop this assessment and intervention falls guide. Prior to the development of this guide, the charts of six patients were reviewed to assess specific data including age, history of falls, type of injury, cognitive function and underlying medical conditions. The developed Assessment and intervention falls guide was utilized with seven patients in the Cardiology Unit who were admitted with diagnosis of syncope and atrial fibrillation to assess their risk for falls. CONCLUSION: The project demonstrated an evidence-informed process that was used to design and implement this assessment tool and a change in nursing practice. It also provided information about the prevalence of cardiac-related risk fall factors that were utilized in the development of this Assessment and Intervention Falls Guide for elderly people.

A narrative framework for understanding experiences of people with severe mental illnesses.

This article discusses the value of a narrative approach to understand the experiences of people with severe mental illnesses and the systems around them, and the importance of narrative in the patient-practitioner relationship. These are important concepts in the shift to recovery-oriented systems. People lead storied lives which provide coherence and meaning, but that story has the potential to be change. Both consumers and practitioners have stories, and it is the shared decision-making between them that can lead to recovery. Narratives can be illness narratives, initiated by an illness and the search for meaning in it, or counterstories which are inherently political. The article identifies a Framework for Understanding Stories as a means for listening to and understanding stories at multiple levels. It can be useful for nurses to understand complexity and multilevel aspects of an individual's experience. Although people tell their own individual stories, they compose them by adapting narrative types, which a culture makes available. Programs tells a story and provide an important context for both consumers and practitioners. Dominant societal narratives provide an overall context which can be empowering or disempowering for programs, consumers and practitioners. Thus, as the recovery paradigm has become more prominent, people with mental illnesses have increasingly talked and written about recovery.

Understanding those who seek frequent psychiatric hospitalizations.

In the period after deinstitutionalization, there has been a rise in hospital readmission rates. It is estimated that the readmission rate for individuals who are frequent users of psychiatric inpatient services is approximately 40% to 50% within 1 year of hospital discharge. Attempts to determine predictors of recidivism have identified multiple variables, some of which are mutually contradictory. Furthermore, comparison among studies is difficult given methodological and theoretical limitations. Despite such issues, however, one consistent predictor of frequent rehospitalization is a person's history of past psychiatric hospital admissions. It seems that those who have shown a pattern of seeking inpatient services in the past tend to repeat this treatment-seeking behavior. The aim of this report is to critically examine some of the predictors of rehospitalization. A better understanding of those who engage in the persistent pattern of seeking inpatient services may assist nurses in planning care that is more suited for their needs.