Celeste Waldman

The impact of knowledge on attitudes of emergency department staff towards patients with substance related presentations: a quantitative systematic review protocol.

Center conducting the review University of Manitoba and Queens Joanna Briggs Collaboration for Patient Safety: a Collaborating Center of the Joanna Briggs Institute Review question/objective The overall objective of this systematic review is to synthesize the available evidence on the relationship between new knowledge (gained through educational interventions about substance use/abuse) and health care providers’ attitudes (measured by well validated instruments such as the Drug and Drug Problems Perceptions Questionnaire [DDPPQ], the Short Alcohol and Alcohol Problems Perception Questionnaire [SAAPPQ], etc.) towards patients with substance‐related presentations to emergency departments. The specific review question is: Among emergency department staff, does the acquisition of knowledge (on educational interventions about substance use) impact attitudes in relation to their therapeutic role towards patients with substance‐related presentations? Background Substance‐related emergency department (ED) visits are common worldwide. Estimates of cases with alcohol involvement presenting to the ED range from 6% to 45%.1 Research conducted in the UK and Australia suggests that presentations related to illicit drug use are common and have increased in recent years.2,3 In 2012, an estimated six million Canadians met the criteria for substance use disorder; alcohol was the most common substance of abuse followed by cannabis and other drugs.4 The relationship between substance use and physical injury is well documented.5,6 The risk of mortality is increased by the side effects of substances on users involved in accidents and trauma.7 Not surprisingly, substance‐related ED visits have been on the rise.8‐10 Although only 3 to 10% of overall visits are typically related to a primary entrance complaint of drug or alcohol use or abuse, studies estimate that up to 35% of ED visits may be directly or indirectly substance related.11 These reasons may range from injury resulting from accidents or violence to substance‐related illnesses.12‐14 Health care providers (i.e., typically medical and nursing staff) have often perceived substance using patients as a challenging group to manage and as adding to the workload of already busy staff.15‐17 The challenges of providing care to this patient population may be attributed to: (1) the chaotic ED environment, (2) health care providers’ lack of knowledge, experience or skill in identifying and addressing substance misuse, (3) health care providers’ lack of support structures such as sufficient time, staff and resources in working with this population, (4) health care providers’ negative attitudes towards this patient population, (5) unpleasant tasks (i.e. intoxicated patients who urinate on themselves) associated with care delivery to this patient population, (6) patients’ aggressive or violent behavior, and (7) patients’ lack of motivation to change.17‐22 Health care providers’ attitudes towards patients with substance use problems have been found to affect health care delivery.19, 22‐24 This is of concern given the research findings that suggest they generally hold negative attitudes towards this patient population.19,22,24‐26 For instance, in their study of nurses’ attitudes towards patients who use illicit drugs, Ford, Bammer and Becker25 found that only 15% of nurses gained satisfaction from caring for these patients and only 30% were motivated to care for this patient group. Researchers who have examined substance using patients’ experiences accessing health care also point to the suboptimal attitudes of health care providers towards this patient population. In the Neale, Tompkins and Sheard24 study of the barriers encountered by injecting drug users when accessing health and social care services, injecting drug users reported that they were often treated poorly or differently from other patients (i.e. sent home prematurely, not given appropriate aftercare or discharge), and made them feel not worthy of receiving help. Although the evidence relating to health care providers’ attitudes toward substance using patients comes primarily from studies conducted in mental health or primary care settings22,23, researchers who have examined ED staff attitudes towards this patient population paint a similar picture.19, 20, 27‐30 For instance, Camilli & Martins27 review of ED nurses’ attitudes toward intoxicated and psychiatric patients suggests that nurses are often frustrated when it comes to these patients as they are time consuming and offer repeat business to the ED. An ethnographic study of care delivery in an ED also points to the negative attitudes of ED staff towards this patient group. Henderson, Stacey and Dohan19 found that ED providers had interactions with substance using patients that may be considered excluding, rejecting or de‐valuing, that is, in observations and interviews, providers often spoke of this patient population as abusing the system, overusing system resources, and not caring about their own health care. Other negative attitudes of ED staff towards substance using patients found in the literature pertain to: (1) being reluctant to ask patients about substance use20,28, (2) believing little can be done in EDs to help these patients20, (2) feeling angry or professionally dissatisfied when treating this patient group29,30, (4) lacking a sense of responsibility for referring to specialist treatment20,28, and (5) believing patients lack motivation to change following interaction with medical staff.28,31 Although there is considerable evidence that indicates health care providers hold negative attitudes towards substance using patients, there are also some studies that have found positive attitudes towards this patient population. For instance, in their study of physician attitudes toward injecting drug users, Ding et al.32 found that seeing more injecting drug users was associated with more positive attitudes towards this patient population. Similarly, Kelleher & Cotters21 descriptive study of ED doctors’ and nurses’ knowledge and attitudes concerning substance use found that the ED doctors and nurses who participated in the study had positive attitudes with regards to working with substance using patients. In the majority of these studies, however, positive attitudes were reported when health care providers were professionals working in addiction services, had more experience caring for this patient population, or had more personal contact with substance using patients.21,22,32‐38 But does knowledge about substance use impact attitudes towards patients with substance‐related presentations? Providing education or experience‐based exercises may impact positively on attitudes towards substance using patients.32 Brief educational interventions, typically, informational sessions, either didactic or online, about alcohol and other drugs and how to assess and work with individuals using them, have been shown to have a positive impact on students’ attitudes, knowledge and confidence relating to substance use and substance users.39‐41 Whether ED staff attitudes towards patients with substance‐related presentations are similarly impacted by the knowledge acquired through educational interventions remains unknown. A full systematic review of the literature will answer this question. A systematic review that examines the impact of knowledge on attitudes of ED staff will inform the design of educational strategies with emergency department staff to improve attitudes towards this patient population. To confirm that no other systematic review has been published on this topic, a preliminary literature search was conducted. The following databases were searched and no current or planned review was found related to this topic: JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, PROSPERO, CINAHL, PubMed, and Scopus. Grey literature was also searched; however, no systematic review addressing the impact of knowledge on attitudes of ED staff towards patients with substance‐related presentations was located.

Enlivening a Community of Authentic Scholarship: A Faculty-Mentored Experience for Graduate Students at the 2016 Qualitative Health Research Conference

Background: Critical and engaged qualitative scholarship depends on high-quality graduate training. The need to reexamine graduate student mentorship has become particularly pressing, given the high level of mental health distress experienced by students. It is unclear whether mentorship emerging within the student–advisor relationship is sufficient to ensure comprehensive mentorship. Innovative, experiential pedagogical approaches that integrate emotional and intellectual aspects are limited but may play a vital role in mentorship. There is a critical need to develop and study creative mentorship initiatives for emerging qualitative scholars. Methods: This study used interpretive description methodology and a community of practice theoretical framework to describe a faculty-mentored experience for graduate nursing students at the 2016 Qualitative Health Research Conference (FM-QHR) hosted by the International Institute for Qualitative Methodology. Participants completed written journals elucidating their experiences throughout FM-QHR. The textual data were analyzed using a constant comparative group analysis process, leading to the development of salient and interconnected themes. Results: Six graduate students and four faculty mentors submitted journals. Three interrelated themes articulate how this FM-QHR initiative enlivened a community of authentic scholarship: Questioning the Academic Self: Unvoiced Experiences of Angst, Uncertainty, and Fear; Cocreating Authentic Community through Shared Vulnerability; and Generative and Emergent Empowerment. Conclusion: These findings provide compelling insights into the importance of assisting students to navigate the emotional experiences that are a part of qualitative graduate training. Relational, mentorship initiatives hold potential to not only alleviate emotional distress but also support student empowerment, socialization, and entrance into a community of international qualitative researchers.

Predictors of patient reluctance to wake early in the morning for bowel preparation for colonoscopy: a precolonoscopy survey in city-wide practice

Introduction  Many endoscopists do not use split-dose bowel preparation (SDBP) for morning colonoscopies. Despite SDBP being recommended practice, they believe patients will not agree to take early morning bowel preparation (BP). We assessed patients’ opinions about waking early for BP. Methods  A self-administered survey was distributed between 08/2015 and 06/2016 to patients in Winnipeg, Canada when they attended an outpatient colonoscopy. Logistic regression was performed to determine predictors of reluctance to use early morning BP. Results  Of the 1336 respondents (52 % female, median age 57 years), 33 % had used SDBP for their current colonoscopy. Of the 1336, 49 % were willing, 24 % neutral, and 27 % reluctant to do early morning BP. Predictors of reluctant versus willing were number of prior colonoscopies (OR 1.20; 95 %CI: 1.07 – 1.35), female gender (OR 1.65; 95 %CI: 1.19 – 2.29), unclear BP information (OR 1.86; 95 %CI: 1.21 – 2.85), high BP anxiety (OR 2.02; 95 %CI: 1.35 – 3.02), purpose of current colonoscopy being bowel symptoms (OR 1.40; 95 %CI: 1.00 – 1.97), use of 4 L of polyethylene glycol laxative (OR 1.45; 95 %CI: 1.02 – 2.06), not having SDBP (OR 1.96; 95 %CI: 1.31 – 2.93), and not having finished the laxative for the current colonoscopy (OR 1.66; 95 %CI: 1.01 – 2.73). Most of the same predictors were identified when reluctance was compared to willing or neutral, and in ordinal logistic regression. Conclusions  Almost three-quarters of patients do not express reluctance to get up early for BP. Among those who are reluctant, improving BP information, allaying BP-related anxiety, and use of low volume BP may increase acceptance of SDBP.

Perspectives of primary care providers and endoscopists about current practices, facilitators and barriers for preparation and follow-up of colonoscopy procedures: a qualitative study

BackgroundColonoscopy has become a common medical procedure due to increased use of colonoscopy for evaluation of symptoms, colorectal cancer screening and surveillance of people with higher risks of developing colorectal cancer. Timely access to colonoscopy is essential for diagnosis of colorectal cancer, as well as diagnosis and management of inflammatory bowel disease and gastrointestinal symptoms such as diarrhea. The purpose of this study was to obtain the perspectives of primary care providers and endoscopists about current practices, barriers and facilitators to following recommended practice for preparation and follow-up after colonoscopy. We also aimed to obtain recommendations for approaches to improve the process.MethodsSix focus groups (two with gastroenterologists, two with surgeons who perform colonoscopies and two with primary care providers) were held between October 2015 and January 2016. Analysis was performed using inductive qualitative approaches.ResultsVariations and challenges in communication for continuity of care and understanding the distribution of responsibility were identified, as were perceived benefits and challenges of a central intake system for colonoscopies. Recommendations were made to improve processes including strengthening communication and information sharing. A comprehensive quality improvement plan would facilitate implementation of recommendations.ConclusionsFindings emphasize the need for improved patient-focused information resources for each step of the colonoscopy process and improved communication among practitioners. The findings apply to other services requiring collaboration among patients, primary care providers, and medical specialists.