Developing a survey to measure nursing students' knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study.

BACKGROUND: Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. Canada's legislation is the first to permit Nurse Practitioners (NP) to serve as independent MAiD assessors and providers. Registered Nurses' (RN) also have important roles in MAiD that include MAiD care coordination; client and family teaching and support, MAiD procedural quality; healthcare provider and public education; and bereavement care for family. Nurses have a right under the law to conscientious objection to participating in MAiD. Therefore, it is essential to prepare nurses in their entry-level education for the practice implications and moral complexities inherent in this practice. Knowing what nursing students think about MAiD is a critical first step. Therefore, the purpose of this study was to develop a survey to measure nursing students' knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context. METHODS: The design was a mixed-method, modified e-Delphi method that entailed item generation from the literature, item refinement through a 2 round survey of an expert faculty panel, and item validation through a cognitive focus group interview with nursing students. The settings were a University located in an urban area and a College located in a rural area in Western Canada. RESULTS: During phase 1, a 56-item survey was developed from existing literature that included demographic items and items designed to measure experience with death and dying (including MAiD), education and preparation, attitudes and beliefs, influences on those beliefs, and anticipated future involvement. During phase 2, an expert faculty panel reviewed, modified, and prioritized the items yielding 51 items. During phase 3, a sample of nursing students further evaluated and modified the language in the survey to aid readability and comprehension. The final survey consists of 45 items including 4 case studies. DISCUSSION: Systematic evaluation of knowledge-to-date coupled with stakeholder perspectives supports robust survey design. This study yielded a survey to assess nursing students' attitudes toward MAiD in a Canadian context. CONCLUSION: The survey is appropriate for use in education and research to measure knowledge and attitudes about MAiD among nurse trainees and can be a helpful step in preparing nursing students for entry-level practice.

Multi-disciplinary community-based group intervention for fibromyalgia: a pilot randomized controlled trial.

Fibromyalgia is characterized by widespread pain, fatigue, sleep disturbances, mood disturbances, and cognitive impairment. Most individuals with fibromyalgia experience poorly managed symptoms and increased healthcare service use. Multicomponent therapies, with a focus on nonpharmacological modalities, are increasingly supported in the literature. However, given the limited resources available, implementation in smaller communities remains a challenge. This research tested a community-based multidisciplinary group intervention for individuals diagnosed with FM living in a small urban centre. The primary outcome was perceptions of quality of care and secondary outcomes included disease-related functioning, anxious and depressive symptoms, pain beliefs, and health service utilization. A pilot randomized control trial was conducted in which 60 patients diagnosed with fibromyalgia were randomized into a 10-week community-based multidisciplinary group intervention program or usual care. Treatment components included twice-weekly exercise sessions and weekly education sessions (e.g., pain education, cognitive behavioral strategies for stress, nutrition, peer support). The trial (NCT03270449) was registered September 1 2017. Statistically significant post-intervention improvements were found in the primary outcome, perceived quality of care (Cohen's d = 0.61, 0.66 for follow up care and goal setting, respectively). Secondary outcomes showing statistically significant improvements were disease-related daily functioning (Cohen's d = 0.70), depressive symptoms (Cohen's d = 0.87), and pain beliefs (Cohen's d = 0.61, 0.67, 0.82 for harm, disability and control, respectively). No adverse events were reported. Community-based multidisciplinary group interventions for fibromyalgia show promise for improving satisfaction with quality of care, disease-related functioning, and depression, and fostering more adaptive pain beliefs.

Patient, family member and caregiver engagement in shaping policy for primary health care teams in three Canadian Provinces.

INTRODUCTION: Improving health services integration through primary health care (PHC) teams for patients with chronic conditions is essential to address their complex health needs and facilitate better health outcomes. The objective of this study was to explore if and how patients, family members, and caregivers were engaged or wanted to be engaged in developing, implementing and evaluating health policies related to PHC teams. This patient-oriented research was carried out in three provinces across Canada: British Columbia, Alberta and Ontario. METHODS: A total of 29 semi-structured interviews with patients were conducted across the three provinces and data were analysed using thematic analysis. RESULTS: Three key themes were identified: motivation for policy engagement, experiences with policy engagement and barriers to engagement in policy. The majority of participants in the study wanted to be engaged in policy processes and advocate for integrated care through PHC teams. Barriers to patient engagement in policy, such as lack of opportunities for engagement, power imbalances, tokenism, lack of accessibility of engagement opportunities and experiences of racism and discrimination were also identified. CONCLUSION: This study increases the understanding of patient, family member, and caregiver engagement in policy related to PHC team integration and the barriers that currently exist in this engagement process. This information can be used to guide decision-makers on how to improve the delivery of integrated health services through PHC teams and enhance patient, family member, and caregiver engagement in PHC policy. PATIENT OR PUBLIC CONTRIBUTION: We would like to acknowledge the contributions of our patient partners, Brenda Jagroop and Judy Birdsell, who assisted with developing and pilot testing the interview guide. Judy Birdsell also assisted with the preparation of this manuscript. This study also engaged patients, family members, and caregivers to share their experiences with engagement in PHC policy.

Community stakeholder-driven technology solutions towards rural health equity: A concept mapping study in Western Canada.

BACKGROUND: Technology holds great potential for promoting health equity for rural populations, who have more chronic illnesses than their urban counterparts but less access to services. Yet, more participatory research approaches are needed to gather community-driven health technology solutions. The purpose was to collaboratively identify and prioritize action strategies for using technology to promote rural health equity through community stakeholder engagement. METHODS: Concept mapping, a quantitative statistical technique, embedded within a qualitative approach, was used to identify and integrate technological solutions towards rural health equity from community stakeholders in three steps: (1) idea generation; (2) sorting and rating feasibility/importance and (3) group interpretation. Purposeful recruitment strategies were used to recruit key stakeholders and organizational representatives from targeted rural communities. RESULTS: Overall, 34 rural community stakeholders from western Canada (76% female, mean age = 55.4 years) participated in the concept mapping process. In Step 1, 84 ideas were generated that were reduced to a pool of 30. Multidimensional scaling and cluster analysis resulted in a six-cluster map representing how technological solutions can contribute toward rural health equity. The clusters of ideas included technological solutions and applications, but also ideas to make health care more accessible regardless of location, training and support in the use of technology, ensuring digital tools are simplified for ease of use, technologies to support collaboration among healthcare professionals and ideas for overcoming challenges to data sharing across health systems/networks. Each cluster included ideas that were rated as equally important and feasible. Key themes included organizational and individual-level solutions and connecting patients to newly developed technologies. CONCLUSIONS: Overall, the grouping of solutions revealed that technological applications require not only access but also support and collaboration. Concept mapping is a tool that can engage rural community stakeholders in the identification of technological solutions for promoting rural health equity. PATIENT OR PUBLIC CONTRIBUTION: Rural community stakeholders were involved in the generation and interpretation of technological solutions towards rural health equity in a three-step process: (1) individual brainstorming of ideas, (2) sorting and rating all ideas generated and (3) collective interpretation and group consensus on final results.

Living as older adults with mental health concerns in rural British Columbia: A photovoice study.

OBJECTIVES: The purpose of this study was to understand the mental health experiences of adults 50 years of age and older living in a rural community in British Columbia. METHODS: This study used critical social theory and interpretive description. Purposive sampling was used to recruit 8 adults aged 50 years and older. Participants used digital cameras and spent up to five weeks taking photos of representations of their life as an older adult with a mental health concern in a rural community. Semi-structured interviews were used to explore participants' reasons for taking various photos, unveiling their experiences. Constant comparison was used to analyze the data. RESULTS: Four key themes were identified: mental wellbeing (hope, spirituality, and gratitude; nature and losses); stigma; services and supports; and environment. CONCLUSION: There is a significant need for more health care providers for rural older adults' mental health. Additionally, there is a need for integrated services and peer-led supports to address the needs of this population.

Legal Privilege Legislation: Consequences for Patient Safety.

Increasing awareness of the extent of preventable harm from healthcare has led to efforts to improve patient safety through a variety of efforts, including legislation. Extending legal privilege to quality and safety reviews leads to further harm for many patients, families and healthcare providers. The intentional isolation, silencing and exclusion after the incident undermines trust, prevents learning and impedes an opportunity to heal and recover for all those directly involved. Our case study examines Section 51 of British Columbia's Evidence Act (1996) and concludes that amending this legislation is an urgent and necessary step toward trauma-informed care.

Using the Awareness, Motivation, Skills, and Opportunity Framework for Health Promotion in a Primary Care Network.

Purpose. To use the Awareness, Motivation, Skills, and Opportunity (AMSO) framework as a foundation for service delivery in a primary care network (PCN). Method. The AMSO framework (awareness, motivation, skills, opportunity) was integrated into PCN program design: Health Basics (8 weeks with monthly follow-up) focused on healthy living and Happiness Basics (6 weeks) used positive psychology. Evaluation included quality of life (QofL) and participant experience; weight, body mass index, and waist circumference were included for Health Basics. Data were analyzed using descriptive statistics, paired t tests, and thematic analysis. Setting. PCN in western Canada with midsized urban center and surrounding areas. Participants. Health Basics-adults with or at risk for chronic disease (n = 103). Happiness Basics-adults with depression, languishing, or flourishing (n = 124). Results. Changes were evident in weight loss, body mass index, waist circumference, and QofL (p < .05) for Health Basics participants. The participants also reported being more active, eating healthier, having a more positive mind-set, and having confidence in making lifestyle changes. Happiness Basics participants' QofL improved in all domains (p < .05) except the physical summary score (p = .079). Happiness participants described positive experiences and learned new skills. Conclusion. The AMSO framework was successfully implemented in our PCN. Recommendations are included to improve program effectiveness and use.

Health in All Policies utilization by municipal governments: scoping review.

The aim of this scoping review was to examine the utilization of a Health in All Policies (HiAP) approach in municipal government settings. Specific objectives included: to review peer reviewed and grey literature, to identify common themes from the literature, and to highlight gaps in the evidence base for HiAP. An iterative scoping review method was used. Documents were identified through searches of academic databases, reference lists and journal indices, and the World Wide Web. Included documents focused on HiAP in the local or municipal government context, published in English, between 2006 and 2015. Data were extracted and analyzed using descriptive statistics and a narrative thematic method. As of June 2015, 26 documents met the inclusion criteria. A lack of research studies examining HiAP in the municipal government context was identified. Three broad themes were abstracted from analysis of the documents: the conceptualization of HiAP, the adoption of HiAP, and the implementation of HiAP. The focus on a HiAP approach at the municipal level of government is growing. A majority of the existing documents provide narrative evidence and recommendations for implementing a HiAP approach at the municipal level. Research is needed in the areas of conceptualization, implementation, adoption and evaluation of a HiAP approach in municipal settings.

The Cedar Project: Using Indigenous-specific determinants of health to predict substance use among young pregnant-involved Indigenous women in Canada.

BACKGROUND: Indigenous women in Canada have been hyper-visible in research, policy and intervention related to substance use during pregnancy; however, little is known about how the social determinants of health and substance use prior to, during, and after pregnancy intersect. The objectives of this study were to describe the social contexts of pregnant-involved young Indigenous women who use substances and to explore if an Indigenous-Specific Determinants of Health Model can predict substance use among this population. METHODS: Using descriptive statistics and hierarchical logistic regression guided by mediation analysis, the social contexts of pregnant-involved young Indigenous women who use illicit drugs' lives were explored and the Integrated Life Course and Social Determinants Model of Aboriginal Health's ability to predict heavy versus light substance use in this group was tested (N = 291). RESULTS: Important distal determinants of substance use were identified including residential school histories, as well as protective factors, such as sex abuse reporting and empirical evidence for including Indigenous-specific determinants of health as important considerations in understanding young Indigenous women's experiences with pregnancy and substance use was provided. CONCLUSIONS: This analysis provided important insight into the social contexts of women who have experiences with pregnancy as well as drug and/or alcohol use and highlighted the need to include Indigenous-specific determinants of health when examining young Indigenous women's social, political and historical contexts in relation to their experiences with pregnancy and substance use.

Correction to: The Cedar Project: Using Indigenous-specific determinants of health to predict substance use among young pregnant-involved Indigenous women in Canada.

After publication of the original article (1) it was noted that the title of this manuscript was incorrect. The title presently reads "The cedar project: using indigenous-specific determinants of health to predict substance use among young pregnant-involved aboriginal women" but should read "The Cedar Project: Using Indigenous-specific determinants of health to predict substance use among young pregnant-involved Indigenous women in Canada".

Researching safety culture: deliberative dialogue with a restorative lens.

Safety culture is a key component of patient safety. Many patient safety strategies in health care have been adapted from high-reliability organizations (HRO) such as aviation. However, to date, attempts to transform the cultures of health care settings through HRO approaches have had mixed results. We propose a methodological approach for safety culture research, which integrates the theory and practice of restoration science with the principles and methods of deliberative dialogue to support active engagement in critical reflection and collective debate. Our aim is to describe how these two innovative approaches in health services research can be used together to provide a comprehensive effective method to study and implement change in safety culture. Restorative research in health care integrates socio-ecological theory of complex adaptive systems concepts with collaborative, place-sensitive study of local practice contexts. Deliberative dialogue brings together all stakeholders to collectively develop solutions on an issue to facilitate change. Together these approaches can be used to actively engage people in the study of safety culture to gain a better understanding of its elements. More importantly, we argue that the synergistic use of these approaches offers enhanced potential to move health care professionals towards actionable strategies to improve patient safety within today's complex health care systems.

Understanding the Life Histories of Pregnant-Involved Young Aboriginal Women With Substance Use Experiences in Three Canadian Cities.

Despite attention paid to substance use during pregnancy, understandings of young Aboriginal women's experiences based on their perspectives have been virtually absent in the published literature. This study's objective was to understand the life experiences of pregnant-involved young Aboriginal women with alcohol and drugs. Semi-structured interviews to gather life histories were conducted with 23 young Aboriginal women who had experiences with pregnancy, and alcohol and drug use. Transcribed interviews were analyzed for themes to describe the social and historical contexts of women's experiences and their self-representations. The findings detail women's strategies for survival, inner strength, and capacities for love, healing, and resilience. Themes included the following: intersectional identities, life histories of trauma (abuse, violence, and neglect; intergenerational trauma; separations and connections), the ever-presence of alcohol and drugs, and the highs and lows of pregnancy and mothering. The findings have implications for guiding policy and interventions for supporting women and their families.

The evolving role of nurses in primary care medical settings.

The role of nurses in primary care is understudied. The purpose of this study was to describe the current registered nurse (RN) role in three Primary Care Networks (PCNs) in western Canada and to identify opportunities for optimal utilization of RNs in these settings. Case study methodology included interviews and document review. Although the RN role evolved during the study, most RNs focused on chronic disease management. Role ambiguity was evident between nurses and with interprofessional team members. Relationships of RNs to other providers, particularly physicians, impacted the enactment of the nursing role. Other barriers to role enactment included physician fee-for-service remuneration, management structures and processes, lack of access to electronic medical records and lack of previous opportunities to apply primary health-care education in the practice setting. Further work is needed to optimize the RN role in primary care to ensure maximum impact for patients, providers and the health system overall.

Grappling With the Inclusion of Patients and the Public in Consensus Building: A Commentary on Inclusion, Safety, and Accessibility; Comment on "Evaluating Public Participation in a Deliberative Dialogue: A Single Case Study".

Deliberative dialogue (DD) may be relatively new in health research but has a rich history in fostering public engagement in political issues. Dialogic approaches are future-facing, comprising structured discussions and consensus building activities geared to the collective identification of actionable and contextualized solutions. Relying heavily on a need for coproduction and shared leadership, these approaches seek to garner meaningful collaborations between researchers and knowledge users, such as healthcare providers, decision-makers, patients, and the public. In this commentary, we explore some of the challenges, successes, and opportunities arising from public engagement in DD, drawing also upon insights gleaned from our own research, along with the case study presented by Scurr and colleagues. Specifically, we seek to expand discussions related to inclusion, power, and accessibility in DD, highlight the need for scholarship that addresses the epistemic, methodological, and practical aspects of patient and public engagement within dialogic methods, and identify promising practices.

Co-designing action-oriented mental health conversations between care providers and ageing Canadians in the community: a participatory mixed-methods study protocol.

INTRODUCTION: The mental health of ageing Canadians is a growing concern, particularly post-pandemic. Older adults face systemic ageism and mental health stigma as pervasive barriers to seeking needed mental health support, care and treatment within health and social care systems. These barriers are exacerbated when service providers focus on physical healthcare needs or lack the skills and confidence to talk about and/or address mental health during routine visits. This study aims to co-design and test an evidence-based approach to mental health conversations at the point-of-care in home and community settings with older adults, family and friend caregivers and health and social care providers that could facilitate help-seeking activities and care access. METHODS AND ANALYSIS: A participatory mixed-methods study design will be applied, guided by a Working Group of experts-by-experience (n=30). Phase 1 engages ageing Canadians in four online workshops (n=60) and a national survey (n=1000) to adapt an evidence-based visual model of mental health for use with older adults in home and community care. Phase 2 includes six co-design workshops with community providers (n=90) in rural and urban sites across three Canadian provinces to co-design tools, resources and processes for enabling the use of the adapted model as a conversation guide. Phase 3 involves pilot and feasibility testing the co-designed conversations with older adult clients of providers from Phase 2 (n=180). ETHICS AND DISSEMINATION: Phases 1 and 2 of this study have received ethics clearance at the University of Waterloo (ORE #44187), University of British Columbia (#H22-02306) and St. Francis Xavier University (#26075). While an overview of Phase 3 is included, details will rely on Phase 2 outcomes. Knowledge mobilisation activities will include peer-reviewed publications, conference presentations, webinars, newsletters, infographics and policy briefs. Interested audiences may include community organisations, policy and decision-makers and health and social care providers.

Care Transition From the Perspectives of Oncological Patients and the Multiprofessional Care Team: A Mixed Methods Study.

BACKGROUND: Integration into the health system is essential for safe care and efficient use of resources. OBJECTIVES: The aims of this study were to analyze the transition of care from the perspective of adult patients with neoplasia of the digestive tract and the multiprofessional care team, identify factors that influence the transition of care, and, collectively with professionals, create actions to improve the transition of care at the study site. METHODS: The Care Transitions Measure-15 was administered in a mixed methods study, with a QUAN→QUAL sequential explanatory approach. The principles of deliberative dialogue were used as a knowledge translation strategy, and data integration was carried out. RESULTS: The average score of the Care Transitions Measure-15 considered satisfactory was 74.3. The care plan factor had an unsatisfactory score of 66. Strategies to improve the care transition were listed by the focus group participants, such as supplementary care protocol for patients with neoplasms of the digestive tract, and providing a single discharge plan containing all information relevant to the treatment and continuity of patient care. CONCLUSION: The low score for the care plan factor indicates weakness in the care transition. IMPLICATIONS FOR PRACTICE: The integrated analysis results indicated that the care transition can be improved by an educational process during discharge planning, implementation of protocols for patients with neoplasia of the digestive tract, and identification of a reference caregiver to help patients navigate the healthcare system.

Can Answers to the Health Workforce Crisis Be Found in Equity-Informed Digital Health?

In this paper, we describe current pressures on health human resources (HHRs) in the Canadian context and related factors that impact equity-deserving communities/populations. We explore issues of HHR challenges in rural, remote and urban underserved contexts and explore the associated benefits and challenges of incorporating digital health (DH). We present examples and evidence of integrating hybrid models of care as a means of supporting HHRs via DH in the publicly funded health system.

Relational Work Is the Work: Virtual Healthcare Transformation for Rural, Remote and First Nations Communities in British Columbia.

The healthcare crisis across unceded First Nations' territories in rural, remote and Indigenous communities in British Columbia (BC) is marked by persistent barriers to accessing care and support close to home. This commentary describes an exceptional story of how technology, trusted partnerships and relationships came together to create an innovative suite of virtual care programs called "Real-Time Virtual Support" (RTVS). We describe key approaches, learnings and future considerations to improve the equity of healthcare delivery for rural, remote and First Nations communities. The key lessons include the following: (1) moving beyond a biomedical model - the collaboration framework for health service design incorporated First Nations' perspective on health and wellness; (2) relational work is the work - the RTVS collaboration was grounded in building connections and relationships to prioritize cultivating trust in the partnership over specific outputs; and (3) aligning to the core values of co-creation - working from a commitment to do things differently and applying an inclusive approach of engagement to integrate perspectives across different sectors and interest groups.

Intersections between interprofessional practice, cultural competency and primary healthcare.

The concepts of interprofessional collaborative practice (IPCP), cultural competency and primary healthcare (PHC) appear to be linked in theory and practice. This discussion article provides arguments explicating the potential linkages between IPCP and cultural competency. We argue that cultural competency is an important component of IPCP both for relationships with patients and/or communities in which providers work and between team members. Organizational structures also play an important role in facilitating IPCP and cultural competency. The integration of both IPCP and cultural competency has the potential to enhance positive health outcomes. Furthermore, we argue IPCP and cultural competency have important implications for PHC service design, given interprofessional teams are a key component of PHC systems. Linking these concepts in providing PHC services can be essential for impacting outcomes at all levels of primary healthcare, including patient, provider and systems.