The effect of Mycobacterium tuberculosis treatment on thrombelastography-assessed haemostasis: a prospective cohort study.

BACKGROUND AND OBJECTIVE: Tuberculosis disease (TB) and tuberculosis infection (TBI) have been associated with increased risk of cardiovascular disease which may be connected to infection-related haemostatic changes. It is unknown if treatment of Mycobacterium tuberculosis influences haemostasis. Here, we assessed if TB or TBI treatment affects thrombelastography (TEG)-assessed haemostasis. METHODS: Individuals with TB or TBI were included from a TB outpatient clinic in Copenhagen, Denmark. Patients treated with antithrombotic medication or systemic immunosuppressants were excluded. TEG analysis was performed before and after TB/TBI treatment using the TEG®6s analyser to provide data on the reaction time of clot initiation (R) (min), the speed of clot formation (K) (min) and clot build-up (Angle) (°), maximum clot strength (MA) (mm), and clot breakdown/fibrinolysis (LY30) (%). Differences in TEG were assessed using paired t tests. RESULTS: We included eleven individuals with TB with median [interquartile range] [IQR] age 52 (Liu et al. in Medicine (United States) 95, 2016) years and mean (standard deviation) (SD) body mass index (BMI) 24.7 (6.3) kg/m2 as well as 15 individuals with TBI with median [IQR] age 49 (Wells et al. in Am J Respir Crit Care Med 204:583, 2021) years and BMI 26.0 (3.2) kg/m2. Treatment reduced MA for both TB (64.0 (6.3) vs. 57.9 (5.2) mm, p = 0.016) and TBI (61.3 (4.1) vs. 58.6 (5.0) mm, p = 0.023) whereas R, K, Angle and LY30 were unaffected. CONCLUSION: TEG analysis showed that treatments of TB and TBI were associated with reduced MA which may indicate the existence of cardiovascular benefits from therapy. TRIAL REGISTRATION: Registered at ClinicalTrials.gov 05 April 2021 with registration number NCT04830462.

Nurses' experience of handoffs on four Canadian medical and surgical units: A shared accountability for knowing and safeguarding the patient.

AIMS: To explore nurses' experience and describe how they manage various contextual factors affecting the nurse-to-nurse handoff at change of shift. DESIGN: Qualitative descriptive study. METHODS: A convenience sample of 51 nurses from four medical and surgical care units at a university-affiliated hospital in Montreal, Canada, participated in one of the 19 focus group interviews from November 2017 to January 2018. Data were analysed through a continuous and iterative process of thematic analysis. RESULTS: Analysis of the data generated a core theme of 'sharing accountability for knowing and safeguarding the patient' that is achieved through actions related to nurses' role in the exchange. Specifically, the outgoing nurse takes actions to ensure continuity of care when letting go, and the incoming nurse takes actions to provide seamless care when taking over. In both roles, nurses navigate each handoff juncture by mutually adjusting, ensuring attentiveness, managing judgements, keeping on track, and venting and debriefing. Handoff is also shaped by contextual conditions related to handoff norms and practices, the nursing environment, individual nurse attributes and patient characteristics. CONCLUSIONS: This study generated a conceptualization of nurses' roles and experience that details the relationship among the elements and conditions that shape nurse-to-nurse handoffs. IMPACT: Nursing handoff involves the communication of patient information and relational behaviours that support the exchange. Although many factors are known to influence handoffs, little was known about nurses' experience of dealing with these at the point of care. This study contributed a comprehensive conceptualization of nursing handoff that could be useful in identifying areas for quality improvement and guiding future educational efforts.

Nursing handoffs and clinical judgments regarding patient risk of deterioration: A mixed-methods study.

AIMS AND OBJECTIVES: To explore how change-of-shift handoffs relate to nurses' clinical judgments regarding patient risk of deterioration. BACKGROUND: The transfer of responsibility for patients' care comes with an exchange of information about their condition during change-of-shift handoff. However, it is unclear how this exchange affects nurses' clinical judgments regarding patient risk of deterioration. DESIGN: A sequential explanatory mixed-methods study reported according to the STROBE and COREQ guidelines. METHODS: Over four months, 62 nurses from one surgical and two medical units at a single Canadian hospital recorded their handoffs at change of shift. After each handoff, the two nurses involved each rated the patient's risk of experiencing cardiac arrest or being transferred to an intensive care unit in the next 24 hr separately. The information shared in handoffs was subjected to content analysis; code frequencies were contrasted per nurses' ratings of patient risk to identify characteristics of information that facilitated or hindered nurses' agreement. RESULTS: Out of 444 recorded handoffs, there were 125 in which at least one nurse judged that a patient was at risk of deterioration; nurses agreed in 32 cases (25.6%) and disagreed in 93 (74.4%). These handoffs generally included information on abnormal vital signs, breathing problems, chest pain, alteration of mental status or neurological symptoms. However, the quantity and seriousness of clinical cues, recent transfers from intensive care units, pain without a clear cause, signs of delirium and nurses' knowledge of patient were found to affect nurses' agreement. CONCLUSIONS: Nurses exchanged more information regarding known indicators of deterioration in handoffs when they judged that patients were at risk. Disagreements most often involved incoming nurses rating patient risk as higher. RELEVANCE TO CLINICAL PRACTICE: This study suggests a need to sensitise nurses to the impact of certain cues at report on their colleagues' subsequent clinical judgments. Low levels of agreement between nurses underscore the importance of exchanging impressions regarding the likely evolution of a patient's situation to promote continuity of care.

Intentional partnering: a grounded theory study on developing effective partnerships among nurse and physician managers as they co-lead in an evolving healthcare system.

AIM: The aim of this study was to describe the process of how nurse and physician managers in formalized dyads work together to address clinical management issues in the surgical division of one hospital setting. BACKGROUND: Nurse and physician managers are uniquely positioned to co-lead and transform healthcare delivery. However, little is known about how this management dyad functions in the healthcare setting. DESIGN: A constructivist grounded theory approach was used to investigate the process of how nurse and physician managers work together in formalized dyads in an urban Canadian university affiliated teaching hospital. METHODS: Data collection occurred from September 2013-August 2014. Data included participant observation (n = 142 hours) and intensive interviews (n = 36) with nurse-physician manager dyads (12 nurses, 9 physicians) collected in a surgical department. Theoretical sampling was used to elaborate on properties of emerging concepts and categories. RESULTS/FINDINGS: A substantive theory on 'intentional partnering' was generated. Nurses' and physicians' professional agendas, which included their interests and purposes for working with each other served as the starting point of 'intentional partnering'. The theory explains how nurse and physician managers align their professional agendas through the processes of 'accepting mutual necessity', 'daring to risk (together)' and 'constructing a shared responsibility'. Being credible, earning trust and safeguarding respect were fundamental to communicating effectively. CONCLUSION: Intentional partnering elucidates the relational components of working together and the strategizing that occurs as each partner deliberates on what he or she is willing to accept, risk and put into place to reap the benefits of collaborating.

Educational interventions to enhance competencies for interprofessional collaboration among nurse and physician managers: An integrative review.

Collaborative leadership and management structures are critical to transforming care delivery. Both nurse and physician managers are uniquely positioned to co-lead. However, little is known on how to prepare and support individuals for these co-leader arrangements. The re-design of healthcare professional education focuses on interprofessional collaboration, mutual learning, and a competency-based approach. While competencies for interprofessional collaboration have been delineated, competencies for collaborative management practice have yet to be addressed. An integrative review of empirical studies on existing educational interventions was conducted to critically appraise and synthesise the results regarding collaborative competence among nurse and physician leaders. We reviewed how these interventions have been designed, implemented, and evaluated within workplace settings in order to inform our understanding of what components are effective or ineffective for the future development of an educational programme. This review reports on key characteristics of nine empirical studies and emphasises that: a uniprofessional approach to leadership development is predominant within educational programmes and that the assessment of shared learning experiences are not addressed; there are inconsistency in terms used to describe competencies by individual researchers and limitations within the competency frameworks used in the studies reviewed; and there is a lack of suitable instruments available to assess whether competencies have been achieved through the educational programmes. None of the studies discussed the process of how individuals learned specific competencies or whether learning outcome were achieved. Educational programmes were developed based on a perceived lack of leadership preparation and orientation programmes for leaders in formal management positions and used multiple interventions. Only two of the programmes involved organisational or systems level competencies. Interprofessional co-leading requires enhanced capabilities and capacity for managers. There is a need for developing an in-action education intervention that addresses the unique learning needs of co-leader arrangements particularly among nurses and physicians who are new to their role.

Evaluation of the effectiveness of a Strengths-Based Nursing and Healthcare Leadership program aimed at building leadership capacity: A concurrent mixed-methods study.

Background: Targeted interventions have been found effective for developing leadership practices in nurses. However, to date, no leadership training program based on the Strengths-Based Nursing and Healthcare Leadership approach exists. Objectives: Demonstrate the effectiveness of a Strengths-Based Nursing and Healthcare Leadership 6-month program designed for nurse and healthcare leaders on leadership capacity and psychological outcomes. Design: Concurrent mixed-methods with nurse and healthcare leaders from five healthcare organisations in Quebec and Ontario (Canada). Settings: Participants were recruited from five Canadian health care organizations: two in Toronto (Ontario) and three in Montreal (Quebec). Participants: A total of 50 nurse leaders and healthcare leaders were included in the quantitative component, and 22 (20 nurse leaders and two healthcare leaders) participated in the qualitative individual interviews. Methods: Quantitative and qualitative (interviews) methods were used. Quantitative data (pre-post surveys) were collected from the participants before their participation in the program (Time 0), as well as after the completion of the program (Time 1). Qualitative data (individual interviews) were collected from participants at the end of the program (Time 1). Analysis was conducted using descriptive statistics, paired-sample t-tests, and thematic analysis. Results: Quantitative results suggest a significant improvement in terms of leadership capabilities, work satisfaction, and reduction in perceived stress among participants. Three themes emerged from the qualitative data analysis: 1) focus on people's strengths, 2) structure and language based on Strengths-Based Nursing and Healthcare values, and 3) building support networks. Conclusions: The Strengths-Based Nursing and Healthcare Leadership program developed to build the leadership capabilities of nurse and healthcare leaders was found to be effective. The positive impact of the 6-month program was demonstrated. It was also shown that the leadership program can help improve the leadership competencies, well-being, and work satisfaction of participating nurses and healthcare leaders. Implication: This study reinforces the importance of working with educational, research, and healthcare organizations to establish leadership development programs and mentorship opportunities. Future leadership training should use a Strengths-Based Nursing and Healthcare Leadership lens when tackling leadership and stress in the workplace.

Nursing leaders' perceptions of the impact of the Strengths-Based Nursing and Healthcare Leadership program three months post training.

Background: Development of nursing leadership is necessary to ensure that nurse leaders of the future are well-equipped to tackle the challenges of a burdened healthcare system. In this context, the Strengths-Based Nursing and Healthcare Leadership program was delivered to 121 participants from 5 organizations in Canada in 2021 and 2022. To date, no study used a qualitative approach to explore nursing leaders' perceptions of a leadership Strengths-Based Nursing and Healthcare Leadership program three months post training. Objective: To describe nursing leaders' perceptions of the impact of the Strengths-Based Nursing and Healthcare Leadership program three months post training. Methods: Qualitative descriptive design was used with individual semi-structured interviews. A convenient sample of nurse leaders (n = 20) who had participated in the leadership program were recruited for an individual interview three months post training. The data generated by interviews were analyzed using a method of thematic content analysis. Results: Three themes emerged from the qualitative data analysis related to the leadership program that stayed with participants three months post training: 1) mentorship: a lasting relationship, 2) human connections through Story-sharing, and 3) focus on strengths. Two other themes emerged related to the changes that they have made since attending the program: 1) seeking out different perspectives to work better as a team and 2) create a positive work environment and to show appreciation for their staff. Conclusion: The present study offers evidence of the impact of the Strengths-Based Nursing and Healthcare Leadership program three months post training. Implication: This study reinforces the importance of training using a Strengths-Based Nursing and Healthcare Leadership lens when tackling leadership.

Improving qualitative interviews with newly arrived migrant women.

There is a paucity of literature on how to conduct research with migrants, particularly those who do not speak the host country language, those who are newly arrived, and those who have a precarious immigration status. In qualitative research, interviewing is a common method for obtaining rich data and participants' points of view. Gathering and presenting all perspectives when interviewing vulnerable migrant women on health-seeking behaviors is challenging. In this article, we explore the process of developing and implementing a data collection plan and an interview guide for a study carried out with migrant women to explore the inhibitors/facilitators for following through on professional referrals for postbirth care. Adaptability and careful attention to multiple factors throughout the process are essential to maximizing participation and enhancing the trustworthiness of the data. Appropriate health policy and care delivery can only originate from health research with diverse migrant populations.

Nurses' judgments of patient risk of deterioration at change-of-shift handoff: Agreement between nurses and comparison with early warning scores.

BACKGROUND: Nurses begin forming judgments regarding patients' clinical stability during change-of-shift handoffs. OBJECTIVES: To examine the agreement between incoming and outgoing nurses' judgments of deterioration risk following handoff and compare these judgments to commonly used early warning scores (MEWS, NEWS, ViEWS). METHODS: Following handoffs on three medical/surgical units, nurses completed the Patient Acuity Rating. Nurse ratings were compared with computed early warning scores based on clinical data. In follow-up interviews, nurses were invited to describe their experiences of using the rating scale. RESULTS: Sixty-two nurses carried out 444 handoffs for 158 patients. While the agreement between incoming and outgoing nurses was fair, correlations with early warning scores were low. Nurses struggled with predicting risk and used their impressions of differential risk across all the patients to whom they had been assigned to arrive at their ratings. CONCLUSION: Nurses shared information that influenced their clinical judgments at handoff; not all of these cues may necessarily be captured in early warning scores.

Mothers' experiences with breastfeeding management and support: a quality improvement study.

The purpose of this study was to examine the experiences on mothers with regard to the breastfeeding support and management provided by healthcare professionals on an acute care postpartum unit in a multiethnic obstetrical referral center in Montreal, Canada. The study survey was largely based on the UNICEF/World Health Organization's (1998) ten steps to successful breastfeeding. The convenience sample included 60 recently-delivered mothers. Findings indicated that primiparous women and women who delivered by caesarean section consistently received more information about breastfeeding management than multiparous women and women who delivered vaginally. However, the study does suggest that all women, regardless of parity or type of delivery, have information and support needs related to breastfeeding. A total of 29 mothers (67%), who intended to breastfeed exclusively, supplemented with artificial baby milk. Of these mothers, 16 (55%) stated 'milk insufficiency' as their primary reasons for supplementing. Overall, respondents perceived healthcare professionals to be encouraging of breastfeeding, and 48 mothers (80%) were 'moderately' to 'very' satisfied with the breastfeeding education and support received. These findings suggest that overall adherence to breastfeeding best practices in the current study hospital are below targets set by the World Health Organization for 'Baby Friendly' status. Results from the study can be used to target areas for improvement.

Toward Resilient Nurse Leaders: The Leadership-In-Action Program in Nursing (LEAP-IN).

Leadership is a critical component of health system performance. This paper describes a tailored leadership development program for nurse managers in an academic health network in Montreal, Canada, developed in collaboration with a university school of continuing studies. This program is aimed toward strengthening individual leadership competencies and developing a resilient nursing leadership community of practice. In total, 26 nurse managers across the health network participated in the program. Senior nurse directors participated by facilitating group discussions with the nurse managers. Program content was developed through a participative process and in direct response to senior leadership participation through online surveys, interviews and focus groups. An experiential learning approach was used to analyze incidents, explore problems and develop projects specific to the learners' context. The present paper describes the development of this program, outlines plans for evaluation and discusses the lessons learned throughout this process.

Acceptability and feasibility of recruitment and data collection in a field study of hospital nurses' handoffs using mobile devices.

BACKGROUND: The portability and multiple functionalities of mobile devices make them well suited for collecting field data for naturalistic research, which is often beset with complexities in recruitment and logistics. This paper describes the implementation of a research protocol using mobile devices to study nurses' exchanges of patient information at change of shift. METHODS: Nurses from three medical and surgical units of an acute care teaching hospital in Montreal, Canada, were invited to participate. On 10 selected days, participants were asked to record their handoffs using mobile devices and to complete paper questionnaires regarding these exchanges. Nurse acceptance of mobile devices was assessed using a 30-item technology acceptance questionnaire and focus group interviews. The principal feasibility indicator was whether or not 80 complete handoffs could be collected on each unit. RESULTS: From October to December 2017, 63 of 108 eligible nurses completed the study. Results suggest that the use of mobile devices was acceptable to nurses, who felt that the devices were easy to use but did not improve their job performance. The principal feasibility criterion was met, with complete data collected for 176, 84, and 170 of the eligible handoffs on each unit (81% of eligible handoffs). The research protocol was acceptable to nurses, who felt the study's demands did not interfere with their clinical work. CONCLUSIONS: The research protocol involving mobile devices was feasible and acceptable to nurses. Nurses felt the research protocol, including the use of mobile devices, required minimal investment of time and effort. This suggests that their decision to participate in research involving mobile devices was based on their perception that the study protocol and the use of the device would not be demanding. Further work is needed to determine if studies involving more sophisticated and possibly more demanding technology would be equally feasible and acceptable to nurses.

Developing an interprofessional care plan for an older adult woman with breast cancer: from multiple voices to a shared vision.

Interprofessional collaboration is central to quality patient care; however, little is known about developing interprofessional care plans, particularly in oncology. This article describes the development of an interprofessional care plan for an older adult woman with breast cancer. Two collaborative expert workshops were used; 15 clinical experts reviewed an online patient case and were asked to prepare a uniprofessional care plan. In workshop 1, participants worked from a draft interprofessional care plan, synthesized from the uniprofessional care plans by research associates, to arrive at consensus on an ideal interprofessional care plan. Using qualitative inductive content analysis of workshop transcripts, specific changes and overall key principles were identified and used to revise the draft plan. Based on these findings, a generalized interprofessional care plan/oncology model was developed. Revisions and proposed model were validated through consensus by participants during workshop 2. Participants highlighted the iterative, cyclical, and multilayered nature of patient care experiences; the importance of central patient profiles, which are contributed to and validated by all healthcare professionals; and the importance of assessing patient understanding. Participation of a patient representative provided an invaluable contribution. The process and model provide a unique framework for interprofessional care plan development in other settings and patient populations.