Exploring implementation processes of a parent-targeted educational video for improving newborn pain treatment: A sequential exploratory mixed-methods study

Despite known analgesic effects of breastfeeding (BF), skin-to-skin care (SSC), and sweet solutions (sucrose) for newborns, these interventions remain underutilized. Our team produced a five-minute parent-targeted video (BSweet2Babies) demonstrating BF, SSC, and sucrose during newborn blood sampling. We conducted a sequential exploratory mixed-methods study with eight maternal-newborn units across Ontario, Canada to identify barriers and facilitators to implementing the video and the three pain management strategies.Over a 6-month period, data collection included 15 telephone interviews, two email communications, and three community of practice teleconferences with the participating sites (n = 8). We used the Theoretical Domains Framework as the coding matrix. Participants discussed integrating the video in prenatal education and the importance of involving leadership when planning for practice change. Key barriers included lack of comfort with parental presence, perception of high complexity of the strategies, short postpartum stays, competing priorities, and interprofessional challenges. Key facilitators included alignment with the Baby-Friendly Hospital Initiative, modeling by Lactation Consultants, and frequent reminders.

Association between maternal marginalization and infants born with congenital heart disease in Ontario Canada

BACKGROUND

This study aims to evaluate the impact of socioeconomic status (SES) on the risk of congenital heart disease (CHD) since previous studies have yielded inconsistent results.

METHODS

We conducted a population-based retrospective cohort study, including all singleton live and still births in Ontario hospitals from April 1, 2012, to March 31, 2018. We used linked records from the Better Outcomes Registry & Network Information System, the Canadian Institute for Health Information databases, and the Ontario Marginalization Index (ON_Marg). ON_Marg was estimated at a dissemination area level using Canadian Census 2016 data and categorized into quintiles. Multivariable logistic regression models were performed to examine the relationships between four ON_Marg indices (material deprivation, dependency, ethnic concentration, residential instability), as proxies for maternal SES and the risk of infant CHD. We adjusted for maternal age at birth, assisted reproductive technology, obesity, pre-existing health conditions, substance use during pregnancy, mental health conditions before and during pregnancy, rural residence, and infant's sex in the analysis.

RESULTS

Among the cohort of 776,799 singletons, 9,359 infants had a diagnosis of CHD. Of those, 3,069 were severe CHD and 493 cases were single ventricle CHD. The prevalence of all infant CHD types was higher for males relative to females. Compared to mothers living in neighbourhoods with the lowest material deprivation, mothers with highest material deprivation had a 27% (adjusted OR = 1.27; 95% CI: 1.18-1.37) higher odds of having an infant diagnosed with CHD. Mothers living in neighbourhoods with the highest minority ethnic and immigrant concentration tend to have infants with 11% lower odds of CHD (adjusted OR = 0.89; 95% CI: 0.82-0.97) as compared to those living in the least ethnically diverse communities. Maternal dependency and residential stability quintiles were not significantly associated with the risk of CHD.

CONCLUSION

Higher maternal material deprivation was associated with increasing odds of infant CHD, whereas neighbourhood minority ethnic concentration was inversely associated with the odds of infant CHD. Our study further confirms that poverty is associated with CHD development. Future investigations might focus on the causal pathways between social deprivation, immigrant status, ethnicity, and the risk of infant CHD.

Barriers and facilitators to program directors' use of the medical education literature: a qualitative study

BACKGROUND

It is unclear how often frontline clinical teachers are using this literature and its evidence base in teaching and assessment. Our study purpose was to examine postgraduate program director perspectives on the utilization and integration of evidence-based medical education literature in their teaching and assessment practices.

METHODS

The authors conducted semi-structured telephone interviews with a convenience sample of current and former program directors from across Canada. Interviews were transcribed and analyzed inductively to distil pertinent themes.

RESULTS

In 2017, 11 former and current program directors participated in interviews. Major themes uncovered included the desire for time-efficient and easily adaptable teaching and assessment tools. Participants reported insufficient time to examine the medical education literature, and preferred that it be 'synthesized for them'. (i.e., Best evidence guidelines). Participants recognised continuing professional development and peer to peer sharing as useful means of education about evidence-based tools. Barriers to the integration of the literature in practice included inadequate time, lack of financial compensation for teaching and assessment, and the perception that teaching and assessment of trainees was not valued in academic promotion.

DISCUSSION

Faculty development offices should consider the time constraints of clinical teachers when planning programming on teaching and assessment. To enhance uptake, medical education publications need to consider approaches that best meet the needs of a targeted audiences, including frontline clinical teachers. This may involve novel methods and formats that render evidence and findings from their studies more easily 'digestible' by clinical teachers to narrow the knowledge to practice gap.

A Quality Improvement Project on Pain Management at a Tertiary Pediatric Hospital

To assess and improve pain management practices for hospitalized children in an urban tertiary pediatric teaching hospital.

METHODS

Health Quality Ontario Quality Improvement (QI) framework informed this study. A pre (T1) - post (T2) intervention assessment included chart reviews and children/caregiver surveys to ascertain pain management practices. Information on self-reported pain intensity, painful procedures, pain treatment and satisfaction were obtained from children/caregivers. Documented pain assessment, pain scores, and pharmacological/non-pharmacological pain treatments were collected by chart review. T1 data was fed back to pediatric units to inform their decisions and pain management targets.

RESULTS

At T1, 51 (58% of eligible participants) children/caregivers participated. At T2, 86 (97%) chart reviews and 51 (54%) children/caregivers surveys were completed. Most children/caregivers at T1 (78%) and T2 (80%) reported moderate to severe pain during their hospitalization. A mean of 2.6 painful procedures were documented in the previous 24 h, with the most common being needle-related procedures at both T1 and T2. Pain management strategies were infrequently used during needle-related procedures at both time points.

CONCLUSION

No improvements in pain management as measured by the T1 and T2 data occurred. Findings informed further pain management initiatives in the participating hospital.

Using behavioral theory and shared decision-making to understand clinical trial recruitment: interviews with trial recruiters

BACKGROUND

Clinical trial recruitment is a continuing challenge for medical researchers. Previous efforts to improve study recruitment have rarely been informed by theories of human decision making and behavior change. We investigate the trial recruitment strategies reported by study recruiters, guided by two influential theoretical frameworks: shared decision-making (SDM) and the Theoretical Domains Framework (TDF) in order to explore the utility of these frameworks in trial recruitment.

METHODS

We interviewed all nine active study recruiters from a multi-site, open-label pilot trial assessing the feasibility of a large-scale randomized trial. Recruiters were primarily nurses or master's-level research assistants with a range of 3 to 30 years of experience. The semi-structured interviews included questions about the typical recruitment encounter, questions concerning the main components of SDM (e.g. verifying understanding, directive vs. non-directive style), and questions investigating the barriers to and drivers of their recruitment activities, based on the TDF. We used directed content analysis to code quotations into TDF domains, followed by inductive thematic analysis to code quotations into sub-themes within domains and overarching themes across TDF domains. Responses to questions related to SDM were aggregated according to level of endorsement and informed the thematic analysis.

RESULTS

The analysis helped to identify 28 sub-themes across 11 domains. The sub-themes were organized into six overarching themes: coordinating between people, providing guidance to recruiters about challenges, providing resources to recruiters, optimizing study flow, guiding the recruitment decision, and emphasizing the benefits to participation. The SDM analysis revealed recruiters were able to view recruitment interactions as successful even when enrollment did not proceed, and most recruiters took a non-directive (i.e. providing patients with balanced information on available options) or mixed approach over a directive approach (i.e. focus on enrolling patient in study). Most of the core SDM constructs were frequently endorsed.

CONCLUSIONS

Identified sub-themes can be linked to TDF domains for which effective behavior change interventions are known, yielding interventions that can be evaluated as to whether they improve recruitment. Despite having no formal training in shared decision-making, study recruiters reported practices consistent with many elements of SDM. The development of SDM training materials specific to trial recruitment could improve the informed decision-making process for patients.

Varying perceptions of the role of "nurse as teacher" for medical trainees: A qualitative study

INTRODUCTION

The informal curriculum-an essential complement to the formal curriculum-is delivered to medical trainees through learning outside the classroom. We sought to explore nurse-mediated aspects of trainee education in the informal curriculum in obstetrics and gynecology (OBGYN), as well as nursing perceptions of their role in medical trainee education.

METHODS

Naturalistic, non-participant observations (40 h) were performed on a tertiary care birthing unit (BU) to document teaching and learning interactions. Insights gleaned from observations informed subsequent semi-structured interviews with BU nurses (n = 10) and focus group discussions with third-year medical students who had completed an OBGYN rotation (n = 10). Thematic analysis was conducted across data sets.

RESULTS

Conceptions of nurse-mediated education differed considerably between nurses and trainees. Nurses were widely acknowledged as gatekeepers and patient advocates by both groups, although this role was sometimes perceived by trainees as impacting on learning. Interest and engagement were noted as mediators of teaching, with enhanced access to educational opportunities reported by trainees who modelled openness and enthusiasm for learning. Nurse-driven education was frequently tailored to the learner's level, with nurses feeling well positioned to share procedural knowledge or hard skills, soft skills (i.e. bedside manners), and clinical insights gained from bedside practice.

DISCUSSION

Nurses are instrumental in the education of medical trainees; however, divergence was noted in how this role is enacted in practice. Given the valuable teaching resource BU nurses present, more emphasis should be placed on interprofessional co-learning and the actualization of this role within the informal curriculum.

Neighbourhood maternal socioeconomic status indicators and risk of congenital heart disease

BACKGROUND

This study aimed to examine the relationships between various maternal socioeconomic status (SES) indicators and the risk of congenital heart disease (CHD).

METHODS

This was a population-based retrospective cohort study, including all singleton stillbirths and live births in Ontario hospitals from April 1, 2012 to March 31, 2018. Multivariable logistic regression models were performed to examine the relationships between maternal neighbourhood household income, poverty, education level, employment and unemployment status, immigration and minority status, and population density and the risk of CHD. All SES variables were estimated at a dissemination area level and categorized into quintiles. Adjustments were made for maternal age at birth, assisted reproductive technology, obesity, pre-existing maternal health conditions, substance use during pregnancy, rural or urban residence, and infant's sex.

RESULTS

Of 804,292 singletons, 9731 (1.21%) infants with CHD were identified. Compared to infants whose mothers lived in the highest income neighbourhoods, infants whose mothers lived in the lowest income neighbourhoods had higher likelihood of developing CHD (adjusted OR: 1.29, 95% CI: 1.20-1.38). Compared to infants whose mothers lived in the neighbourhoods with the highest percentage of people with a university or higher degree, infants whose mothers lived in the neighbourhoods with the lowest percentage of people with university or higher degree had higher chance of CHD (adjusted OR: 1.34, 95% CI: 1.24-1.44). Compared to infants whose mothers lived in the neighbourhoods with the highest employment rate, the odds of infants whose mothers resided in areas with the lowest employment having CHD was 18% higher (adjusted OR: 1.18, 95% CI: 1.10-1.26). Compared to infants whose mothers lived in the neighbourhoods with the lowest proportion of immigrants or minorities, infants whose mothers resided in areas with the highest proportions of immigrants or minorities had 18% lower odds (adjusted OR: 0.82, 95% CI: 0.77-0.88) and 16% lower odds (adjusted OR: 0.84, 95% CI: 0.78-0.91) of CHD, respectively.

CONCLUSION

Lower maternal neighbourhood household income, poverty, lower educational level and unemployment status had positive associations with CHD, highlighting a significant social inequity in Ontario. The findings of lower CHD risk in immigrant and minority neighbourhoods require further investigation.