Politics, ecologies and professional regulation: The case of British Columbia's Professional Governance Act.

A variety of theories have been proposed to explain why states pass legislation to regulate professional groups, and why, more recently, they have acted to curtail professional privileges. While these theories have drawn attention to the importance of power dynamics and public protection, among other factors, the role of political interests has been downplayed. This article builds on ecological theory to argue that, with some modifications, the theory illuminates the centrality of state-profession relations and politics to regulatory change. The theory is applied to a case study of regulatory change in British Columbia, Canada impacting resources-sector professions, with particular attention to the controversies and political considerations that shaped reform. The case study suggests that when the political and professions ecologies are overlapping and symbiotic, as they were in BC, a challenge in the political ecology can implicate professions, prompting a solution that brings change within both ecologies.

Regulating for-profit virtual care in Canada: Implications for medical profession regulators and policy-makers.

For-profit virtual medical care has been expanding rapidly in Canada, creating new societal and practical challenges requiring policy and regulatory reform. We mapped the current state of regulatory policy across 10 Canadian provinces by analyzing practice standards and guidelines for virtual care from medical profession regulators. Through a comparative framework, we assessed the extent to which virtual practice policies addressed issues around mobility and licensure, equitable access, privacy, complaints, and continuity of care. We also compared these regulatory documents to the model standards from the Canadian medical regulatory consortium and considered implications for practicing in for-profit virtual environments. We found considerable variation across provincial regulatory bodies, with most existing frameworks not adequately addressing equity, access, and practitioner competency and not providing flexible, nuanced, or risk-based approaches to virtual care provision. As we compared jurisdictions, we identified gaps and leading practices to inform recommendations for professional regulators and policy-makers.

Regulating in the public interest: Lessons learned during the COVID-19 pandemic.

This article has three aims. First, to reflect on how conceptualizations of the public interest may have shifted due to COVID-19. Second, to focus on the implications of regulatory responses for the health workforce and corresponding lessons as health leaders and systems transition from pandemic response to pandemic recovery. Third, to identify how these lessons lead to potential directions for future research, connecting regulation in a whole-of-systems approach to health system safety and health workforce capacity and sustainability. Pandemic regulatory responses highlighted both strengths and limitations of regulatory structures and frameworks. The COVID-19 pandemic may have introduced new considerations around regulating in the public interest, particularly as the impact of regulatory responses on the health workforce continues to be examined. Clearly articulating practitioner practice parameters, reducing barriers to practice, and working collaboratively with stakeholders were primary aspects of regulators' pandemic responses that impacted the health workforce.

Clinic screening for adverse childhood experiences in people living with HIV to Improve Care Delivery.

Adverse childhood experiences (ACEs) are associated with negative health outcomes; however, screening for ACEs is not routinely performed among people living with HIV (PLWH). We conducted a single-center, cross-sectional pilot study to define the (1) prevalence of ACEs in PLWH and (2) acceptability of ACEs screening in routine out-patient clinical care. One hundred participants completed screening: median age of participants was 49 years (interquartile range: 38.5-59.5), 73% male, 66% Non-Hispanic Black/African American, and 47% gay/lesbian. Clinically significant ACEs score, defined as ≥4, was reported in 51%. High ACEs score was more common among participants <50 years old (64.7% vs. 36.7%; p < 0.01), but the prevalence of ACEs ≥4 did not differ by gender, race, ethnicity, or sexual orientation. Among participants with ≥4 ACEs, 44.4% screened negative on both PHQ-9 and PC-PTSD screens. The majority of participants (89%) reported a positive experience with ACEs screening. The prevalence of clinically significant ACEs in this clinic population of PLWH was more than twice that reported in the general population. Routine ACEs screening can improve delivery of trauma-informed care in the HIV primary care setting.

Patient roles in primary care interprofessional teams: a constructivist grounded theory of patient and health care provider perspectives.

Health care providers are increasingly asked to work in interprofessional teams to enhance the care provided to and health outcomes of their patients. However, there is little evidence on how to include patients in meaningful roles on these teams to support their health monitoring and management. The purpose of this study was to gain insight into roles that patients can assume within their health care teams and to understand the conditions and processes required for patient roles to be enacted. Ten patients and 10 health care providers from two Family Health Teams in Southwestern Ontario, Canada, participated in individual interviews to learn about their perspectives on patient roles in teams. Data collection and analysis strategies generated theoretical concepts, and member-checking interviews provided final feedback on the framework. This study resulted in a comprehensive framework of two roles and the conditions and processes required for patient-health care provider interactions within primary care interprofessional teams. Further researchers could use this framework to build knowledge of patient roles in interprofessional teams across varying health care settings and patient populations.

The World Ovarian Cancer Coalition Every Woman Study: identifying challenges and opportunities to improve survival and quality of life.

INTRODUCTION: With the global incidence of ovarian cancer set to rise by 55% to 371 000 per year by 2035, current 5-year survival rates below 50%, and 15% of women with ovarian cancer dying within 2 months of diagnosis, urgent action is required to improve survival and quality of life. OBJECTIVE: To deal with the evidence gap relating to the experience of women with the disease around the globe and identify opportunities to drive progress. METHODS: The study included a review of global trends in incidence, mortality, and survival (October 2017); qualitative interviews with women and clinicians in 16 countries (December 2017); and an online survey for women available in 15 different languages (open for 2 months, March to early May 2018). Women were eligible to participate if they had been diagnosed in the previous 5 years and were proficient in one of the 15 languages offered. RESULTS: A total of 1531 women from 44 countries took part in the analysis. On average, 69.1% of women were not aware of ovarian cancer before their own diagnosis, varying from 50.9% (Hungary) to 86.4% (Brazil). A total of 78.3% of symptomatic women sought medical help, varying from 62.8% (Japan) to 87.7% (UK). Fewer than half of the women visited a doctor within 1 month (46.3%) of experiencing symptoms, varying from 38.5% (USA) to 77.3% (Germany), and a quarter of women waited 3 months or more. On average, 43.2% of women were diagnosed within 1 month of visiting a doctor, ranging from 30% (UK) to 62.3% (Italy). The average estimated time from experiencing symptoms to diagnosis was 31 weeks, but this ranged from 21.3 (Germany) to 39.7 (Brazil). Rates of post-diagnosis genetic testing ranged from 5.0% (Japan) to 79.1% (USA). Clinicians indicated that access to specialist treatment in high-volume centers varies greatly by country and region. CONCLUSION: The findings of this study identify some of the major challenges and opportunities to improve the time to diagnosis and management of women with ovarian cancer. These problems vary widely by country, and reducing the variability is an important first step towards improving outcomes for women with ovarian cancer.

How gender shapes interprofessional teamwork in the operating room: a qualitative secondary analysis.

BACKGROUND: Despite substantial implications for healthcare provider practice and patient outcomes, gender has yet to be systematically explored with regard to interprofessional operating room (OR) teamwork. We aimed to explore and describe how gender and additional social identity factors shape experiences and perceptions of teamwork in the OR. METHODS: This study was a qualitative secondary analysis of semi-structured interviews with OR team members conducted between November 2018 and July 2019. Participants were recruited across hospitals in Ontario, Canada. We conducted both purposive and snowball sampling until data saturation was reached. Transcripts were analyzed thematically by two independent research team members, moving from open to axial coding. RESULTS: Sixty-six interviews of OR healthcare professionals were completed: anesthesia (n=17), nursing (n=19), perfusion (n=2), and surgery (n=26). Traditional gender roles, norms, and stereotypes were perceived and experienced by both women and men, but with different consequences. Both women and men participants described challenges that women face in the OR, such as being perceived negatively for displaying leadership behaviours. Participants also reported that interactions and behaviours vary depending on the team gender composition, and that other social identities, such as age and race, often interact with gender. Nevertheless, participants indicated a belief that the influence of gender in the OR may be modified. CONCLUSIONS: The highly gendered reality of the OR creates an environment conducive to breakdowns in communuication and patient safety risks in addition to diminishing team morale, psychological safety, and provider well-being. Consequently, until teamwork interventions adequately account for gender, they are unlikely to be optimally effective or sustainable.

Health professional regulation in historical context: Canada, the USA and the UK (19th century to present).

BACKGROUND: There is no widespread agreement over what form healthcare professional regulation should take, and the evidence base concerning the effectiveness and fairness of regulatory systems and practices is limited. Those urging policy change argue there is a need to modernize; however, there is much we can learn from reviewing the history of healthcare professional regulation. MAIN BODY: An overview of the history of regulation in Canada, with consideration of the United States of America and the United Kingdom, is provided. Self-regulating professions emerged in the nineteenth century, influenced by a variety of stakeholders responding to local concerns for healthcare quality, access and professional training. Regulatory practices changed over the course of the twentieth and twenty-first centuries in response to changing stakeholders and shifting interests. CONCLUSIONS: Reviewing the history of healthcare professional regulation reveals lessons to inform policy in a range of settings.

Chiropody/Podiatry: Interprovincial Differences in Profession Formation.

The regulation of foot health care professionals varies across provinces in Canada. In Ontario, the regulated health profession is chiropody. Chiropodists are foot specialists with a limited scope of practice. In contrast, British Columbia and five other provinces regulate podiatrists, who are highly trained foot physicians with an extensive scope of practice. This article explores the history of chiropody/podiatry in Ontario and British Columbia from the early 1900s through the 1980s in order to understand how professional development in this field took such divergent paths within Canada. In so doing, it not only sheds light on a health practice that has received little scholarly attention, but it also highlights the centrality of inter-professional conflict and state actors' agendas to professional regulatory outcomes.

Performance of an Human Papillomavirus Test in Samples From Women With Histolopathologically Confirmed Invasive Cervical Cancer.

BACKGROUND: High-risk human papillomavirus (hrHPV) is now recognized as a single, necessary cause of cancer of the cervix. Although Pap tests have been central to cervical cancer screening programs for more than 50 years, tests that detect infection with these hrHPV genotypes are now being used increasingly in cervical cancer screening programs. OBJECTIVE: The aim of the study was to determine the sensitivity of an HPV test to detect cervical cancer. MATERIALS AND METHODS: Fifty successive cervical samples from women diagnosed with invasive cervical cancer were tested using a molecular HPV DNA test. Thereafter, the residual sample was further tested with a different HPV genotyping test (capable of detecting 27 low- and high-risk types of HPV) and a nucleic acid hybridization test (capable of detecting 13 high-risk types of HPV). RESULTS: Of the 50 women tested, the first HPV test was positive in 47 cases. Of the 3 negative cases, all were negative by second polymerase chain reaction-based test and 2 were negative by the nucleic acid hybridization test. Human immunodeficiency virus status was positive in 14 women, the majority of whom were positive for HPV 16 (n = 8) and 1 was HPV negative. Most women were diagnosed with having stage II cervical cancer or higher. CONCLUSIONS: With a sensitivity of 94% of the first HPV test, 6 of 100 cervical cancers will be missed if this was the only test used in a population screening program. The missed cancers were however all clinically detectable.

Multimodal functional and structural neuroimaging investigation of major depressive disorder following treatment with duloxetine.

BACKGROUND: Longitudinal neuroimaging studies of major depressive disorder (MDD) have most commonly assessed the effects of antidepressants from the serotonin reuptake inhibitor class and usually reporting a single measure. Multimodal neuroimaging assessments were acquired from MDD patients during an acute depressive episode with serial measures during a 12-week treatment with the serotonin-norepinephrine reuptake inhibitor (SNRI) duloxetine. METHODS: Participants were medication-free MDD patients (n = 32; mean age 40.2 years) in an acute depressive episode and healthy controls matched for age, gender, and IQ (n = 25; mean age 38.8 years). MDD patients received treatment with duloxetine 60 mg daily for 12 weeks with an optional dose increase to 120 mg daily after 8 weeks. All participants had serial imaging at weeks 0, 1, 8, and 12 on a 3 Tesla magnetic resonance imaging (MRI) scanner. Neuroimaging tasks included emotional facial processing, negative attentional bias (emotional Stroop), resting state functional MRI and structural MRI. RESULTS: A significant group by time interaction was identified in the anterior default mode network in which MDD patients showed increased connectivity with treatment, while there were no significant changes in healthy participants. In the emotional Stroop task, increased posterior cingulate activation in MDD patients normalized following treatment. No significant group by time effects were observed for happy or sad facial processing, including in amygdala responsiveness, or in regional cerebral volumes. Reduced baseline resting state connectivity within the orbitofrontal component of the default mode network was predictive of clinical response. An early increase in hippocampal volume was predictive of clinical response. CONCLUSIONS: Baseline resting state functional connectivity was predictive of subsequent clinical response. Complementary effects of treatment were observed from the functional neuroimaging correlates of affective facial expressions, negative attentional bias, and resting state. No significant effects were observed in affective facial processing, while the interaction effect in negative attentional bias and individual group effects in resting state connectivity could be related to the SNRI class of antidepressant medication. The specificity of the observed effects to SNRI pharmacological treatments requires further investigation. TRIAL REGISTRATION: Registered at clinicaltrials.gov ( NCT01051466 ).

The metamorphosis of a collaborative team: from creation to operation.

This paper reports on the process of developing a community-based interprofessional team to provide diabetes related foot ulcer care. A new interprofessional team was formed in a local community, and the process of building a successful team was examined by the adoption of an exploratory qualitative case study approach that gathered a series of one-on-one interviews with participants at three points in time - prior to the team's formation, two months into the team's operation, and finally seven months later - shortly before the team and its clinic closed. Interviews were also conducted with a small sample of the team's patients. The factors linked to the successes and challenges of building a care team in a community setting are explored. Informants highlighted the value of regular team meetings, role clarity, and a commitment to patient-centered care. However effective collaboration was not sufficient to maintain the team in the face of poor institutional and government support.

Professional regulation in the digital era: A qualitative case study of three professions in Ontario, Canada.

Technology is transforming service delivery and practice in many regulated professions, altering required skills, scopes of practice, and the organization of professional work. Professional regulators face considerable pressure to facilitate technology-enabled work while adapting to digital changes in their practices and procedures. However, our understanding of how regulators are responding to technology-driven risks and the impact of technology on regulatory policy is limited. To examine the impact of technology and digitalization on regulation, we conducted an exploratory case study of the regulatory bodies for nursing, law, and social work in Ontario, Canada. Data were collected over two phases. First, we collected documents from the regulators' websites and regulatory consortiums. Second, we conducted key informant interviews with two representatives from each regulator. Data were thematically analyzed to explore the impact of technological change on regulatory activities and policies and to compare how regulatory structure and field shape this impact. Five themes were identified in our analysis: balancing efficiency potential with risks of certain technological advances; the potential for improving regulation through data analytics; considering how to regulate a technologically competent workforce; recalibrating pandemic emergency measures involving technology; and contemplating the future of technology on regulatory policy and practice. Regulators face ongoing challenges with providing equity-based approaches to regulating virtual practice, ensuring practitioners are technologically competent, and leveraging regulatory data to inform decision-making. Policymakers and regulators across Canada and internationally should prioritize risk-balanced policies, guidelines, and practice standards to support professional practice in the digital era.

Virtual care during COVID-19: The perspectives of older adults and their healthcare providers in a cardiac rehabilitation setting.

The present study aimed to explore the perspectives of older adults and health providers on cardiac rehabilitation care provided virtually during COVID-19. A qualitative exploratory methodology was used. Semi-structured interviews were conducted with 15 older adults and 6 healthcare providers. Five themes emerged from the data: (1) Lack of emotional intimacy when receiving virtual care, (2) Inadequacy of virtual platforms, (3) Saving time with virtual care, (4) Virtual care facilitated accessibility, and (5) Loss of connections with patients and colleagues. Given that virtual care continues to be implemented, and in some instances touted as an optimal option for the delivery of cardiac rehabilitation, it is critical to address the needs of older adults living with cardiovascular disease and their healthcare providers. This is particularly crucial related to issues accessing and using technology, as well as older adults' need to build trust and emotional connection with their providers.

The every woman study™ low- and middle-income countries edition protocol: A multi-country observational study to assess opportunities and challenges to improving survival and quality of life for women with ovarian cancer.

BACKGROUND: Ovarian cancer is a challenging disease to diagnose and treat effectively with five-year survival rates below 50%. Previous patient experience research in high-income countries highlighted common challenges and opportunities to improve survival and quality of life for women affected by ovarian cancer. However, no comparable data exist for low-and middle-income countries, where 70% of women with the disease live. This study aims to address this evidence gap. METHODS: This is an observational multi-country study set in low- and middle-income countries. We aim to recruit over 2000 women diagnosed with ovarian cancer across multiple hospitals in 24 countries in Asia, Africa and South America. Country sample sizes have been calculated (n = 70-96 participants /country), taking account of varying national five-year disease prevalence rates. Women within five years of their diagnosis, who are in contact with participating hospitals, are invited to take part in the study. A questionnaire has been adapted from a tool previously used in high-income countries. It comprises 57 multiple choice and two open-ended questions designed to collect information on demographics, women's knowledge of ovarian cancer, route to diagnosis, access to treatments, surgery and genetic testing, support needs, the impact of the disease on women and their families, and their priorities for action. The questionnaire has been designed in English, translated into local languages and tested according to local ethics requirements. Questionnaires will be administered by a trained member of the clinical team. CONCLUSION: This study will inform further research, advocacy, and action in low- and middle-income countries based on tailored approaches to the national, regional and global challenges and opportunities. In addition, participating countries can choose to repeat the study to track progress and the protocol can be adapted for other countries and other diseases.

Protecting the public interest while regulating health professionals providing virtual care: A scoping review.

Technology is transforming service delivery in many health professions, particularly with the rapid shift to virtual care during the COVID-19 pandemic. Health profession regulators must navigate legal and ethical complexities to facilitate virtual care while upholding their mandate to protect the public interest. The objectives of this scoping review were to examine how the public interest is protected when regulating health professionals who provide virtual care, discuss policy and practice implications of virtual care, and make recommendations for future research. We searched six multidisciplinary databases for academic literature published in English between January 2015 and May 2021. We also searched specific databases and websites for relevant grey literature. After screening, 59 academic articles and 18 grey literature sources were included for analysis. We identified five key findings: the public interest when regulating health professionals providing virtual care was only implicitly considered in most of the literature; when the public interest was discussed, the dimension of access was emphasized; criticism in the literature focused on social ideologies driving regulation that may inhibit more widespread use of virtual care; subnational licensure was viewed as a barrier; and the demand for virtual care during COVID-19 catalyzed licensure and scope of practice changes. Overall, virtual care introduces new areas of risk, potential harm, and inequity that health profession regulators need to address as technology continues to evolve. Regulators have an essential role in providing clear standards and guidelines around virtual care, including what is required for competent practice. There are indications that the public interest concept is evolving in relation to virtual care as regulators continue to balance public safety, equitable access to services, and economic competitiveness.

Protecting the public interest when regulating health professionals providing virtual care: a scoping review protocol.

BACKGROUND: Virtual care is transforming the nature of healthcare, particularly with the accelerated shift to telehealth and virtual care during the COVID-19 pandemic. Health profession regulators face intense pressures to safely facilitate this type of healthcare while upholding their legislative mandate to protect the public. Challenges for health profession regulators have included providing practice guidance for virtual care, changing entry-to-practice requirements to include digital competencies, facilitating interjurisdictional virtual care through licensure and liability insurance requirements, and adapting disciplinary procedures. This scoping review will examine the literature on how the public interest is protected when regulating health professionals providing virtual care. METHODS: This review will follow the Joanna Briggs Institute (JBI) scoping review methodology. Academic and grey literature will be retrieved from health sciences, social sciences, and legal databases using a comprehensive search strategy underpinned by Population-Concept-Context (PCC) inclusion criteria. Articles published in English since January 2015 will be considered for inclusion. Two reviewers will independently screen titles and abstracts and full-text sources against specific inclusion and exclusion criteria. Discrepancies will be resolved through discussion or by a third reviewer. One research team member will extract relevant data from the selected documents and a second will validate the extractions. DISCUSSION: Results will be presented in a descriptive synthesis that highlights implications for regulatory policy and professional practice, as well as study limitations and knowledge gaps that warrant further research. Given the rapid expansion of virtual care provision by regulated health professionals in response to the COVID-19 pandemic, mapping the literature on how the public interest is protected in this rapidly evolving digital health sector may help inform future regulatory reform and innovation. SYSTEMATIC REVIEW REGISTRATION: This protocol is registered with the Open Science Framework ( https://doi.org/10.17605/OSF.IO/BD2ZX ).

Transitional Care from Hospital to Cardiac Rehabilitation During COVID-19: The Perspectives of Older Adults and Their Healthcare Providers.

Transitional care to cardiac rehabilitation during the pandemic was a complex process for older adults, with additional challenges for decision-making and participation. This study aimed to explore the perspectives of older adults and health providers on transitional care from the hospital to cardiac rehabilitation, focusing on patient participation in decision-making. A qualitative exploratory design was used. Semi-structured interviews were conducted with 15 older adults and 6 healthcare providers. Document analysis and reflexive journaling were used to support triangulation of findings. Six themes emerged from the data, related to insufficient follow-up from providers, the importance of patients' emotional and psychological health and the support provided by family members, the need for information tailored to patients' needs and spaces for participation in decision-making, as well as challenges during COVID-19, including delayed medical procedures, rushed discharge and isolating hospital stays. The findings of this study indicated a number of potential gaps in the provision of transitional care services as reported by older adults who had a cardiovascular event, often during the first few weeks post hospital discharge.

"The workload is staggering": Changing working conditions of stay-at-home mothers under COVID-19 lockdowns.

The COVID-19 pandemic has drawn attention to the home as a work environment, but the focus has centered on the experiences of paid workers. Stay-at-home mothers (SAHMs), for whom the home was already a workplace, have received little attention. This article explores how pandemic-induced lockdowns impacted SAHMs' working conditions and their experiences of childrearing. Combining a Marxist-feminist conceptualization of domestic labor with a labor process framework, we performed a qualitative content analysis of vignettes SAHMs shared about their day-to-day domestic labor in an online mothering community. Our findings show that, under lockdown conditions, the primacy given to partners' paid work combined with children's increased demands for care and attention reduced SAHMs work autonomy and exacerbated gender inequalities in the home. Combining labor process theory with literature on motherwork illuminates the home as a gendered work environment and enhances understanding of how changing conditions of domestic labor can intensify gender inequalities (and workers' awareness of them) that typically remain "hidden in the household."