Chronic obstructive pulmonary disease as disability: dilemma stories

The purpose of this work was to develop an understanding of the meaning of disability for individuals living with chronic obstructive pulmonary disease (COPD) in a Canadian midwestern community from an emic perspective. A focused ethnographic design was used. Fifteen individuals participated in interviews. Narrative analysis was used to examine the interview data. Data analysis revealed 65 dilemma stories consisting of two structural components: the impairment, and the justification/explanation of the impairment. Participants' impairment might or might not have been known to others. In both situations, individuals were faced with choices of whether to explain/justify or attempt to conceal the impairment. Participants told these dilemma stories to convey the meaning of COPD as a disability invisible to others, and at times, to themselves. The information gained from this research will serve as an essential complement to the existing knowledge about this important yet often invisible chronic illness.

First year nursing students' viewpoints about compromised clinical safety

OBJECTIVE

Undergraduate nursing students must uphold patient safety as a professional and moral obligation across all clinical learning experiences. This expectation commences at entry into the nursing program. As part of a larger study exploring undergraduate baccalaureate nursing students' understanding of clinical safety, this paper specifically focuses on first year students' viewpoints about unsafe clinical learning situations.

METHODS

Q-methodology was used. Sixty-eight first year nursing students participated in the ranking of 43 statements indicative of unsafe clinical situations and practices. Data was entered into a Q-program for factor analysis.

RESULTS

The results revealed a typology of four discrete viewpoints of unsafe clinical situations for first year students. These viewpoints included an overwhelming sense of inner discomfort, practicing contrary to conventions, lacking in professional integrity and disharmonizing relations. Overall, a consensus viewpoint described exonerating the clinical educator as not being solely responsible for clinical safety.

DISCUSSION

This information may assist students and educators to cooperatively and purposefully construct a clinical learning milieu conducive to safety.

COPD-intuition or template: nurses' stories of acute exacerbations of chronic obstructive pulmonary disease

STUDY RATIONAL: A number of nurse-researchers have examined the experience of dyspnoea reduction during non-acute phases of the chronic obstructive pulmonary disease (COPD). However, nurses working on in-patient hospital units are frequently required to care for individuals suffering from acute exacerbations of their disease (AECOPD). These critically ill individuals present at health care institutions incapacitated by severe shortness of breath/dyspnoea that is frequently refractory to treatment. To date, little is known about the nurses' understanding of the care they provide for individuals hospitalized because of these acute episodes of their chronic illness.

STUDY OBJECTIVES

The research project was undertaken, in part, to develop an understanding of nurses' experience of caregiving for individuals hospitalized for in-patient care during an AECOPD.

METHODOLOGICAL DESIGN

This focused ethnographic narrative examined the caregiving stories of 10 nurse caregivers. The 10 nurse caregivers were interviewed while caring for a patient and their family during an experience of an AECOPD characterized by incapacitating breathlessness.

RESULTS

The nurse caregivers told a number of caregiving stories that illustrated a common care template that appears to be based on intuition or pattern recognition focusing on anxiety sometimes to the exclusion of dyspnoea.

CONCLUSIONS

Analysis of these stories emphasized the need to facilitate nurses individualization of standard templates. More importantly, this analysis illustrated the critical need to develop strategies to facilitate the reshaping of inaccurate templates in the presence of new knowledge.

Stories of women involved in a postpartum depression peer support group

Living through postpartum depression (PPD) might lead women to seek a variety of support to re-establish their well-being, including a hybrid of traditional and non-traditional services. Within this mix, some women participate in peer groups; however, there is a paucity of research regarding their subjective experiences of engaging in this type of support. The purpose of this study was to describe how women talked about living through PPD in the context of a peer support group. This focused ethnography was a component of a larger participatory action study in northern Ontario, Canada. The seven members of a 5-week peer support group described their postpartum experiences through written, visual, and spoken stories. Using structural narrative analysis, stories about recovery were identified across the data. Three groups of recovery stories were labelled as illness, mothering wisdom, and mobilizing. The findings suggested that women actively sought and established a therapeutic space for PPD recovery with peers. As such, health-care providers are encouraged to acknowledge the merits and advocate for the multiple and diverse alliances women might require to actualize recovery.

Identification of facilitators and barriers to the role of a mentor in the clinical setting

Clinical mentors are integral to the education of health care professionals. In Northeastern Ontario, Canada, clinical mentors can take a variety of forms. Examples include preceptors who are employees in a clinical setting working with an individual student for a specific period of time, clinical educators, individuals contracted to take a group of students in acute care settings, and faculty advisors, who facilitate students' community placements. An internet survey exploring the preparation and support of clinical mentors was delivered to clinical mentors from a variety of health disciplines. Part of the survey was based on the concept of self-efficacy which assessed participants' confidence levels with the various aspects of the clinical mentor role. Participants also reported on supports and barriers to their role as clinical mentors. Findings indicate that clinical mentors across all the health disciplines are not always confident in the delivery of clinical education, most specifically with adapting teaching style and assisting the student to apply research to practice. Consistency of results of the survey speaks to the potential value for a collaborative, interprofessional approach to the orientation and support of clinical mentors in a variety of health discipline education programs.

Third year nursing students' viewpoints about circumstances which threaten safety in the clinical setting

BACKGROUND

Evidence emphasizes that learners, educators, clinicians, programs, and organizations share the responsibility for establishing and maintaining safety throughout undergraduate nursing education. Increased knowledge about students' perceptions of threats to safety in the clinical setting may guide educators' efforts to promote the development of safe novice practitioners while preserving patient safety.

OBJECTIVE

The purpose of this study was to describe third year nursing students' viewpoints of the circumstances which threaten safety in the clinical setting.

METHODS

Using Q methodology, 34 third year Bachelor of Science in Nursing students sorted 43 theoretical statement cards. Each card identified a statement describing a threat to safety in the clinical setting. These statements were generated through a review of nursing literature and consultation with experts in nursing education. Centroid factor analysis and varimax rotation identified viewpoints regarding circumstances that most threaten safety.

RESULTS

Three discrete viewpoints and one consensus perspective constituted students' description of threatened safety. The discrete viewpoints were labeled lack of readiness, misdirected practices, and negation of professional boundaries. There was consensus that it is most unsafe in the clinical setting when novices fail to consolidate an integrated cognitive, behavioral, and ethical identity. This unifying perspective was labeled non-integration.

CONCLUSION

Third year nursing students and their educators are encouraged to be mindful of the need to ensure readiness prior to entry into the clinical setting. In the clinical setting, the learning of prepared students must be guided by competent educators. Finally, both students and their educators must respect professional boundaries to promote safety for students and patients.

Unsafe clinical practices as perceived by final year baccalaureate nursing students: Q methodology

Background

Nursing education necessitates vigilance for clinical safety, a daunting challenge given the complex interchanges between students, patients and educators. As active learners, students offer a subjective understanding concerning safety in the practice milieu that merits further study. This study describes the viewpoints of senior undergraduate nursing students about compromised safety in the clinical learning environment.

Methods

Q methodology was used to systematically elicit multiple viewpoints about unsafe clinical learning from the perspective of senior students enrolled in a baccalaureate nursing program offered at multiple sites in Ontario, Canada. Across two program sites, 59 fourth year students sorted 43 theoretical statement cards, descriptive of unsafe clinical practice. Q-analysis identified similarities and differences among participant viewpoints yielding discrete and consensus perspectives.

Results

A total of six discrete viewpoints and two consensus perspectives were identified. The discrete viewpoints at one site were Endorsement of Uncritical Knowledge Transfer, Non-student Centered Program and Overt Patterns of Unsatisfactory Clinical Performance. In addition, a consensus perspective, labelled Contravening Practices was identified as responsible for compromised clinical safety at this site. At the other site, the discrete viewpoints were Premature and Inappropriate Clinical Progression, Non-patient Centered Practice and Negating Purposeful Interactions for Experiential Learning. There was consensus that Eroding Conventions compromised clinical safety from the perspective of students at this second site.

Conclusions

Senior nursing students perceive that deficits in knowledge, patient-centered practice, professional morality and authenticity threaten safety in the clinical learning environment. In an effort to eradicate compromised safety associated with learning in the clinical milieu, students and educators must embody the ontological, epistemological and praxis fundamentals of nursing.

Mothers with serious mental illness: their experience of "hitting bottom"

This study sought to understand the experience of “hitting bottom” from the perspective of 32 mothers with serious mental illness. Secondary narrative analysis of 173 stories about experiences related to hitting bottom were identified. Enactment of their perceived mothering roles and responsibilities was compromised when confronted by the worst of illness. Subsequent to women's descent to bottom was their need for a timely and safe exit from bottom. An intense experience in bottom further jeopardized their parenting and treatment self-determination and, for some, their potential for survival. The results suggest that prevention of bottom is feasible with early assessment of the diverse issues contributing to mothers' vulnerabilities. Interventions to lessen their pain may circumvent bottom experiences. Healing necessitates purposeful approaches to minimize the private and public trauma of bottom experiences, nurture growth towards a future, and establish resources to actualize such a life.

Representations of disability in nursing and healthcare literature: an integrative review

AIM

This paper is a report of an integrative review to explore the way in which disability has been considered in the multidisciplinary health and nursing literature.

BACKGROUND

In the multidisciplinary health and nursing literature, two ways are presented in which disability can be understood: the traditional, functional perspective and a more contemporary, social perspective.

DATA SOURCES

Computerized databases of the CINAHL, Proquest Nursing and Allied Health Sources, EBSCO and Evidence Based Medicine Reviews Multifile and Cochrane databases were conducted for papers published in English in the period 1963-2007 using the keywords 'models of disability', 'disability and nursing research' and 'theories of disability'.

METHODS

An integrative review was performed and, of the 11,578 papers identified, 65 were included.

RESULTS

The concept of functional disability refers to an individual who is physically 'disabled' and unable to perform expected roles. The concepts of social stigmatization and normalcy are associated with functional disability. In contrast, social disability concerns functional limitations within an individual's experience of living with disability, examining how socially constructed barriers actually 'disable' people. Conventionally, disability research has been conducted from an etic perspective. Researchers contend that a shift towards an understanding from the emic perspective is needed for disability research to be emancipatory.

CONCLUSION

Adoption of a social perspective is necessary to inform an understanding of disability that addresses stigmatization and oppression. Research-informed nursing practice, complemented by supportive health and social policies, could transform the experience of living with disability.

Typology of undergraduate nursing students' unsafe clinical practices: Q-methodology

Undergraduate nursing students, as members of the health care team, must uphold patient safety as a professional and moral obligation during their clinical learning experiences. To address this imperative, in a humanistic paradigm, students engage in critical appraisal of self as a developing practitioner. Using Q-methodology, this study describes undergraduate nursing students' subjective understanding of unsafe clinical practices, and results revealed a typology of five groups of unsafe students. The results showed four discrete groups of students at risk for unsafe clinical practices-vulnerable, unprepared, unknowing, and distanced students. Overall, a consensus viewpoint described the presence of the displaced student as the greatest safety risk. Use of this typology as an assessment guide may help students and educators cooperatively create and maintain a culture of safety while developing competent novice nurses.

Implications of multiple-choice testing in nursing education

The evaluation of knowledge/competence is understood as an essential component of nursing education and practice. As such, nurse educators have a plethora of existing evaluation strategies from which to choose. A common written evaluative format used across all higher education settings is multiple-choice testing. This evaluation approach is accepted as a 'user-friendly' strategy to assess knowledge. Researchers from the disciplines of psychology and education have long been concerned with the consequences of multiple-choice testing on learning outcomes, a discussion that is essentially absent from the nursing literature. The purpose of this paper is to address the professional implications of multiple-choice testing in nursing. The potential knowledge consequences for nurse-learners, and by extension the provision of care to healthcare recipients, resultant from use of this testing modality are addressed within the context of the implementation of best practice guidelines in a long-term care home in a mid-sized rural and northern Canadian community with both regulated and non-regulated care providers.

Parents' Experiences and Nurses' Perceptions of Decision-Making About Childhood Immunization

BACKGROUND

Immunization in Canada is recommended not mandated, granting parents discretionary decision-making power regarding their child's immunization status. Uptake of childhood immunization at present falls below national targets. Nurses who interact with parents in the clinical setting may witness parents' decision-making experiences, attitudes, and opinions inclusive of vaccine hesitancy.

PURPOSE

The aim of this study is to understand parents' and nurses' experiences of decision-making about childhood immunization, specifically measles-mumps-rubella and/or diphtheria-tetanus-acellular pertussis.

METHODS

Thorne's interpretative description approach was used to understand parents' and nurses' experiences and perspectives about immunization. The sample was 6 nurses and 16 parents residing in northeastern Ontario.

RESULTS

Common to all participants was the goal of protection. Motivated by child protection, parents carried out three broad actions, searching for information, deliberating the information and sources to determine the relative benefits and risks of immunization, and bearing responsibility for their decision to accept, delay, or decline immunization. Nurses were motivated by child protection and population health.

CONCLUSION

Implications for nursing included integration of immunization competencies in nursing curricula, ongoing professional development, validation of parental actions for child protection, nurse-led education sessions, and engaging parents through social media to support access to reputable information.

Community reintegration of stroke survivors: the effect of a community navigation intervention

AIM

The overall aim of the proposed study is to examine a newly implemented navigation intervention intended to support stroke survivors' community integration during the first year following hospital discharge in four regions of Ontario, Canada.

BACKGROUND

Stroke is a leading cause of disability worldwide. Stroke survivors living in the community require regular, ongoing follow-up to assess recovery, prevent deterioration and maximize health outcomes. Internationally published evidence, often conducted in large urban centres, suggests that community reintegration services are an important component of the continuum of care for stroke survivors. This evidence, however, often does not address the particular challenges inherent in smaller urban and rural contexts.

DESIGN

The design of this 2-year mixed-method study will use cohort and focused ethnography.

METHODS

The three stages of this study include: (1) collection of quantitative data to profile the health status, support and extent of community reintegration of stroke survivors; (2) collection of qualitative data from stroke survivors and their care partners about community reintegration and navigation; and following triangulation of findings (3) knowledge translation activities. This study was ethically approved by the academic Research Ethics Board and clinical Research Ethics Board (Sudbury, Ontario) and funded by the Ontario Stroke Network (Canada).

DISCUSSION

Results will describe experiences and outcomes of a community navigation intervention. Engagement of multiple stakeholders has the potential to develop a shared understanding of community reintegration and generate evidence informed recommendations for service enhancement at critical points in stroke recovery to support survivor and community well-being.

Emergency department boarding times for patients admitted to intensive care unit: Patient and organizational influences

INTRODUCTION

Critically ill patients can be subject to prolonged stays in the emergency department following receipt of an order to admit to an intensive care unit. The purpose of this study was to explore patient and organizational influences on the duration of boarding times for intensive care bound patients.

METHODS

This exploratory descriptive study was situated in a Canadian hospital in northern Ontario. Through a six-month retrospective review of three data sources, information was collected pertaining to 16 patient and organizational variables detailing the emergency department boarding time of adults awaiting transfer to the intensive care unit. Data analysis involved descriptive and non-parametric methods.

RESULTS

The majority of the 122 critically ill patients boarded in the ED were male, 55 years of age or older, arriving by ground ambulance on a weekday, and had an admitting diagnosis of trauma. The median boarding time was 34 min, with a range of 0-1549 min. Patients designated as most acute, intubated, and undergoing multiple diagnostic procedures had statistically significantly shorter boarding times.

DISCUSSION

The study results provide a profile that may assist clinicians in understanding the complex and site-specific interplay of variables contributing to boarding of critically ill patients.

Healthcare Providers' Experiences as Arts-Based Research Participants: "I Created My Story About Disability and Difference, Now What?"

Little is known about the experiences of healthcare providers as research participants in qualitative studies employing methods that encourage disclosure of their own disabilities. In this paper, we describe the experiences and implications of creating personal stories of disability and difference for healthcare provider participants in an arts-based study. The study design is a supplementary secondary analysis of a subset of data from a larger study focused on transforming negative concepts of disability and difference entitled, Mobilizing New Meanings of Disability and Difference: Using Arts-Based Approaches to Advance Healthcare Inclusion for Women with Disabilities. This supplementary study explores the experiences and perspectives of 17 healthcare provider participants who completed semi-structured interviews following creation of a multi-media story about their experience of disability or difference. Using creative non-fiction methods, two narrative streams are identified about healthcare provider experiences and the impacts of participating. The first addresses shared positive experiences about the research. The second entails more ambivalent reflections on their involvement as participants. The tension between the two experiences generates considerations to forward a mutually beneficial alliance to disrupt ableist understandings in healthcare and reveals new meanings of disability that are agential and integral to the stories and storytellers themselves.

Abstract NS16: What’s Important for Post-Stroke Community Re-integration? Viewpoints of Stroke Survivors and Service Providers in Ontario, Canada

Background: Stroke is a leading cause of disability worldwide. Stroke survivors living in the community require regular, ongoing, and coordinated services to prevent deterioration and maximize health outcomes. Published evidence, often conducted in large urban centres, suggests that community reintegration services are an important component of care for stroke survivors. This evidence, however, often does not address the particular challenges inherent in servicing stroke survivors who reside in smaller urban and rural contexts.

Purpose: The purpose of this study was to gain an understanding of the priorities that are needed to support stroke recovery and community reintegration from the perspectives of survivors and service providers living in four geographic districts in Northeastern Ontario, Canada.

Methods: Using Q methodology, 45 service providers, and 43 stroke survivors and their family caregivers ranked 30 theoretical statement cards. Each card identified a feature specific to stroke recovery, community navigation and community reintegration. These statements were generated through a review of health care literature and qualitative data collected from interviews with stroke survivors. Q analysis of the priority ranked statements involved centroid factor analysis and varimax rotation.

Results: The three discrete viewpoints of survivors were Role of Skilled Navigators, Survivors as Co-navigators, and Striving for Well-being. The survivors’ consensus perspective, labelled Quality Service, identified the importance of timeliness and appropriateness of service. The three discrete viewpoints for service providers were Role of Skilled Navigators, Survivor-centered Practices, and Optimizing Survivors’ Resources. The consensus perspective of service providers was labelled Involvement of Family Carers. Findings were consistent across all 4 geographic districts.

Conclusion: This research suggests that survivors’ and providers’ conceptualized role of community navigators is focused on building upon the strengths and capacity of survivors through cooperative inquiry with multiple stakeholders. A time-sensitive, appropriate, and family involved service structure supports survivor-centric community reintegration.

Canadian community mental health workers' perceived priorities for supportive housing services in northern and rural contexts

A relationship between mental health and supportive housing has been established, yet there exist enduring challenges in meeting the supportive housing needs of people with severe mental health problems. Furthermore, not all stakeholder viewpoints of supportive housing services are well documented in the research literature, and research has tended to focus on supportive housing provision in large, urban centres. Potentially, distinct challenges and opportunities associated with the provision of supportive housing services in smaller urban and rural communities that define the greater geographical terrain of Canada and other jurisdictions are less developed. This study describes community mental health service workers' priorities for supportive housing services. Using Q methodology, 39 statements about supportive housing services, developed from a mixed-methods parent study, were sorted by 58 service providers working in four communities in northern Ontario, Canada. Data used in this study were collected in 2010. Q analysis was used to identify correlations between service workers who held similar and different viewpoints concerning service priorities. The results yielded four discrete viewpoints about priorities for delivery of supportive housing services including: a functional system, service efficiency, individualised services and promotion of social inclusion. Common across these viewpoints was the need for concrete deliverables inclusive of financial supports and timely access to adequate housing. These findings have the potential to inform the development of housing policy in regions of low population density which address both system and individual variables.

Age- and sex-specific associations of frailty with mortality and healthcare utilization in community-dwelling adults from ontario, Canada

BACKGROUND

Understanding how health trajectories are related to the likelihood of adverse outcomes and healthcare utilization is key to planning effective strategies for improving health span and the delivery of care to older adults. Frailty measures are useful tools for risk stratification in community-based and primary care settings, although their effectiveness in adults younger than 60 is not well described.

METHODS

We performed a 10-year retrospective analysis of secondary data from the Ontario Health Study, which included 161,149 adults aged ≥ 18. Outcomes including all-cause mortality and hospital admissions were obtained through linkage to ICES administrative databases with a median follow-up of 7.1-years. Frailty was characterized using a 30-item frailty index.

RESULTS

Frailty increased linearly with age and was higher for women at all ages. A 0.1-increase in frailty was significantly associated with mortality (HR = 1.47), the total number of outpatient (IRR = 1.35) and inpatient (IRR = 1.60) admissions over time, and length of stay (IRR = 1.12). However, with exception to length of stay, these estimates differed depending on age and sex. The hazard of death associated with frailty was greater at younger ages, particularly in women. Associations with admissions also decreased with age, similarly between sexes for outpatient visits and more so in men for inpatient.

CONCLUSIONS

These findings suggest that frailty is an important health construct for both younger and older adults. Hence targeted interventions to reduce the impact of frailty before the age of 60 would likely have important economic and social implications in both the short- and long-term.

Indigenous Fathering and Wellbeing: Kinship and Decolonial Approaches to Health Research

In the past decade, Canadian statistics indicate that fathering nurtures family wellbeing which ultimately fosters community growth. The wellbeing of Indigenous men, shaped by determinants of health and culture-based perspectives, is challenged by ongoing settler colonialism. In particular to Indigenous men living with children in their homes, less is known about their strengths as nurturers. For the purpose of this study, based on Indigenist, decolonizing theories, 'father' is not conceived as the head of household. An alternative to the heteropatriarchal model is the kinship orientation of Indigenous fathering and as such, father refers to uncle, grandfather, traditional Clan leader, adoptive parent, and so on. This study's secondary quantitative analysis  compared health and social characteristics of three cohorts of Indigenous adult men who identify as residing with children. Based on an extracted subset of variables from the 2012 Aboriginal Peoples Survey, results showed many significance comparisons among First Nations, Metis and Inuit men. Across health and social domains, multiple and decolonial supports are needed for Indigenous fathering to flourish.

Priorities for Supportive Housing Services: Perspectives of People With Mental Illness in Northeastern Ontario

Background

Accessible, appropriate, and affordable housing is recognized as essential for the well-being of all Canadians. Securing and maintaining housing tenure for individuals living with chronic health and social challenges can be compromised without appropriate services. There has been limited research into the priorities to enhance supportive housing services from the perspective of individuals living with mental illness in smaller urban and rural communities.

Purpose

The purpose was to describe the priorities for supportive housing from the viewpoints of tenants recovering from mental illness in northeastern Ontario.

Methods

This descriptive study used Q methodology to engage 52 adults regarding their impressions about enhancing supportive housing services. Participants ranked 39 housing and support priority statements on a nine-point Likert-type scale.

Results

Four discrete viewpoints about priorities for supportive housing were building a home, letting others in, moving outside the walls, and accessing personalized services. Common across these viewpoints was the need to increase financial assistance offered through existing programs.

Conclusions

Fostering individual pathways to recovery involves mitigating health and social disparities, relative to supportive housing, one size does not fit all. Service providers and decision makers are compelled to situate each individual within an evidence-informed supportive housing system for citizenship.

Self-perceived Mental Health of Older Adults in Canada

Background: In the past decade, statistics indicate that over 80% of the six million Canadians aged 65 or older resided in non-institutional settings. To sustain their health in the community, there is national evidence about the interplay among alterations in physical, emotional, cognitive, social, cultural, and geographical factors. Although much is known about mental health challenges of this population, less is known about determinants of self-perceived mental health. Aim: The primary aim of this study was to determine personal and external variables that are associated with self-perceived mental health in two groups of community dwelling Canadians aged 65 to 79 and those aged 80 and older. Methods: The study design was a secondary analysis of Canadian Community Health Survey (2014) public use micro-data file. A sub-set of health, determinants of health, and health system utilization variables were extracted for 19,502 community-dwelling older adults residing in ten provinces and three territories. Results: Self-perceived mental health was significantly associated with several personal and external variables relative to age group. For both age groups, a positive perception of mental health was predicated on self-perceived physical health, emotional functioning, general life satisfaction, sense of belonging and income. Conclusion: Findings support the potential for innovative interdisciplinary models to optimize older adults' mental health for living independently.