Jan Angus

Factors influencing participation in cardiac rehabilitation programmes after referral and initial attendance: qualitative systematic review and meta-synthesis

Background: Greater participation in cardiac rehabilitation improves morbidity and mortality in people with coronary heart disease, but little is understood of patients’ decisions to participate. Methods: To develop interventions aimed at increasing completion of programmes, we conducted a qualitative systematic review and meta-synthesis to explore the complex factors and processes influencing participation in cardiac rehabilitation programmes after referral and initial access. To be included in the review, studies had to contain a qualitative research component, population specific data on programme participation in adults >18 years, and be published ≥1995 as full articles or theses. Ten databases were searched (31 October 2011) using 100+ search terms. Results: Of 2264 citations identified, 62 studies were included involving: 1646 patients (57% female; mean age 64.2), 143 caregivers, and 79 professionals. Patients’ participation was most strongly influenced by perceptions of the nature, suitability and scheduling of programmes, social comparisons made possible by programmes, and the degree to which programmes, providers, and programme users met expectations. Women’s experiences of these factors rendered them less likely to complete. Comparatively, perceptions of programme benefits had little influence on participation. Conclusions: Factors reducing participation in programmes are varied but amenable to intervention. Participation should be viewed as a ‘consumer behaviour’ and interventions should mobilize family support, promote ‘patient friendly’ scheduling, and actively harness the social, identity-related, and experiential aspects of participation.

Factors influencing referral to cardiac rehabilitation and secondary prevention programs: a systematic review.

Background: Referral to cardiac rehabilitation and secondary prevention programs remains very low, despite evidence suggesting strong clinical efficacy. To develop evidence-based interventions to promote referral, the complex factors and processes influencing referral need to be better understood. Design: We performed a systematic review using qualitative meta-synthesis. Methods: A comprehensive search of 11 databases was conducted. To be included, studies had to contain a qualitative research component wholly or in a mixed method design. Population specific data or themes had to be extractable for referral to programs. Studies had to contain extractable data from adults >18 years and published as full papers or theses during or after 1995. Results: A total of 2620 articles were retrieved: out of 1687 studies examined, 87 studies contained data pertaining to decisions to participate in programs, 34 of which included data on referral. Healthcare professional, system and patient factors influenced referrals. The main professional barriers were low knowledge or scepticism about benefits, an over-reliance on physicians as gatekeepers and judgments that patients were not likely to participate. Systems factors related to territory, remuneration and insufficient time and workload capacity. Patients had limited knowledge of programs and saw physicians as key elements of referral but found the process of attaining a referral confusing and challenging. Conclusions: The greatest increases in patient referral to programs could be achieved by allowing referral from non-physicians or alternatively, automatic referral to a choice of hospital or home-based programs. All referring health professionals should receive educational outreach visits or workshops around the ethical and clinical aspects of programs.

Media Portrayal of Nurses' Perspectives and Concerns in the SARS Crisis in Toronto

Purpose: To describe nursing work life issues as portrayed in the media during the SARS crisis in Toronto. Methods: Content analysis of local and national news media documents in Canada. Media articles were sorted and classified by topic, and themes were identified. Findings: Themes were: (a) changing schemas of nursing practice: the new normal; (b) barriers to relational nursing work; (c) work life concerns: retention and recruitment; (d) nursing virtue: nurses as heroes and professionals; (e) paradoxical responses to nurses from the community; and (f) leadership in nursing during the SARS crisis. Conclusions: This analysis enhanced understanding of how nurses are portrayed in the media, but it indicated the significance of quality of work life and issues about work‐home life. Some descriptions of the care and caring of nurses have made nursing seem like an important and influential profession to potential applicants who might previously have dismissed nursing as a career.

Studying delays in breast cancer diagnosis and treatment: critical realism as a new foundation for inquiry.

PURPOSE/OBJECTIVES To examine how delays in breast cancer care currently are conceptualized and to introduce philosophical and theoretical tenets of critical realism as an alternative approach. DATA SOURCES Health and social sciences literature. DATA SYNTHESIS Diagnostic and treatment delays in breast cancer most frequently are conceptualized as patient, provider, or system related. The approach has limited utility in guiding explanatory analysis because it does not acknowledge the social context in which the delays occur. The philosophical tenets of critical realism and two related theoretical approaches are an alternative. They illustrate how an individuals biologic, social, and material resources may undermine or support structural inequities in access to breast cancer care. CONCLUSIONS Critical realism provides a useful framework for analysis of links between social inequalities and delays in breast cancer diagnosis and treatment. IMPLICATIONS FOR NURSING Access to breast cancer care could be better understood and conceptualized by basing future research and theoretical endeavors on a critical realist perspective.

Therapeutic benefit of preventive telehealth counseling in the Community Outreach Heart Health and Risk Reduction Trial.

We evaluated whether telehealth counseling augments lifestyle change and risk factor decrease in subjects at high risk for primary or secondary cardiovascular events compared to a recommended guideline for brief preventive counseling. Subjects at high risk or with coronary heart disease (35 to 74 years of age, n = 680) were randomized to active control (risk factor feedback, brief advice, handouts) or telehealth lifestyle counseling (active control plus 6 weekly 1-hour teleconferenced sessions to groups of 4 to 8 subjects). Primary outcome was questionnaire assessment of adherence to daily exercise/physical activity and diet (daily vegetable and fruit intake and restriction of fat and salt) after treatment and at 6-month follow-up. Secondary outcomes were systolic and diastolic blood pressures, ratio of total to high-density lipoprotein cholesterol, and 10-year absolute risk for coronary disease. After treatment and at 6-month follow-up, adherence increased for telehealth versus control in exercise (29.3% and 18.4% vs 2.5% and 9.3%, respectively, odds ratio 1.60, 95% confidence interval 1.2 to 2.1) and diet (37.1% and 38.1% vs 16.7% and 33.3%, respectively, odds ratio 1.41, 95% confidence interval 1.1 to 1.9). Telehealth versus control had greater 6-month decreases in blood pressure (mean ± SE, systolic -4.8 ± 0.8 vs -2.8 ± 0.9 mm Hg, p = 0.04; diastolic -2.7 ± 0.5 vs -1.5 ± 0.6 mm Hg, p = 0.04). Decreases in cholesterol ratio and 10-year absolute risk were significant for the 2 groups. In conclusion, telehealth counseling augments therapeutic lifestyle change in subjects at high risk for cardiovascular events compared to a recommended guideline for brief preventive counseling.

Access to Cancer Screening for Women with Mobility Disabilities

Women with mobility disabilities are less likely to access cancer screening, even when they have a primary care provider. The Gateways to Cancer Screening project was initiated to document the challenges for women with disabilities in their access and experiences of screening for breast, cervical and colorectal cancer. The study followed the tenets of participatory action research. Five peer-led focus groups were held with 24 women with mobility disabilities. Study participants identified multiple and interacting institutional barriers to cancer screening. Their discussions highlighted the complex work of (1) arranging and attending health-related appointments, (2) confronting normative assumptions about womens bodies and (3) securing reliable health care and information. These overlapping, mutually reinforcing issues interact to shape how women with disabilities access and experience cancer screening. We explore implications for redesign of cancer screening services and education of health providers, providing specific recommendations suggested by our participants and the findings.

Respect in forensic psychiatric nurse-patient relationships: a practical compromise.

Abstract The context of forensic psychiatric nursing is distinct from other psychiatric settings as, it involves placement of patients in secure environments with restrictions determined by the courts. Previous literature has identified that nurses morally struggle with respecting patients who have committed heinous offences, which can lead to the patient being depersonalized and dehumanized. Although respect is fundamental to ethical nursing practice, it has not been adequately explored conceptually or empirically. As a result, little knowledge exists that identifies how nurses develop, maintain, and express respect for patients. The purpose of this study is to analyze the concept of respect systematically, from a forensic psychiatric nurses perspective using the qualitative methodology of focused ethnography. Forensic psychiatric nurses were recruited from two medium secure forensic rehabilitation units. In the first interview, 13 registered nurses (RNs) and two registered practical nurses (RPNs) participated, and although all informants were invited to the second interview, six RNs were lost to follow‐up. Despite this loss, saturation was achieved and the data were interpreted through a feminist philosophical lens. Respect was influenced by factors categorized into four themes: (1) emotive—cognitive reactions, (2) nonjudgmental approach, (3) social identity and power, and (4) context. The data from the themes indicate that forensic psychiatric nurses strike a practical compromise, in their understanding and enactment of respect in therapeutic relationships with forensic psychiatric patients.

Mouth care for orally intubated patients: A critical ethnographic review of the nursing literature

OBJECTIVES The aim of this critical ethnographic literature review was to explore the evolution of nursing discourse in oral hygiene for intubated and mechanically ventilated patients. METHODS The online databases CINAHL and MEDLINE were searched for nurse-authored English language articles published between 1960 and 2011 in peer-reviewed journals. Articles that did not discuss oral problems or related care for intubated adult patients were excluded. Articles that met the inclusion criteria were chronologically reviewed to trace changes in language and focus over time. RESULTS A total of 469 articles were identified, and 84 papers met all of the inclusion criteria. These articles presented an increasingly scientific and evaluative nursing discourse. Oral care originally focused on patient comfort within the literature; now it is emphasized as an infection control practice for the prevention of ventilator-associated pneumonia (VAP). Despite concern for its neglected application, the literature does not sufficiently address mouth cares practical accomplishment. CONCLUSIONS Mouth care for orally intubated patients is both a science and practice. However, the nursing literature now emphasises a scientific discourse of infection prevention. Inattention to the social and technical complexities of practice may inhibit how nurses learn, discuss and effectively perform this critical aspect of patient care.

Pathways to breast cancer diagnosis and treatment: exploring the social relations of diagnostic delay

De acuerdo a los estudios epidemiologicos, la falta de equidad en el acceso a los servicios de cuidado y tratamiento del cancer de mama se acompana de variables tales como renta, edad, nivel de estudios, etnia y lugar de residencia. Estas variables corresponden a patrones estructurales favorecidos o desfavorecidos, que pueden por tanto facilitar o limitar el tiempo de acceso a dichos servicios. El objetivo de este estudio fue el de comprender la complejidad de las trayectorias de las mujeres hacia el diagnostico. Treinta y cinco mujeres con experiencias diversas y con sintomas de cancer de mama clinicamente detectables en el momento del diagnostico, participaron en entrevistas parcialmente estructuradas. Todas ellas recibian y/o habian completado su tratamiento en el momento de su participacion. Los datos fueron analizados mediante el empleo de estrategias de induccion, comparacion y abduccion. Las participantes describieron una amplia variedad de actividades involucradas en la busqueda de atencion de salud para el cancer de mama. Los hallazgos ilustran como las relaciones sociales del cuidado en salud pueden constituir barreras al diagnostico en un tiempo adecuado, mas alla de lo que lo puedan ser el retraso por parte de la paciente o del profesional. Se ilustra ademas como los diversos contextos sociales y materiales de las mujeres generan oportunidades y barreras de acceso a dichos cuidados.De acuerdo a los estudios epidemiologicos, la falta de equidad en el acceso a los servicios de cuidado y tratamiento del cancer de mama se acompana de variables tales como renta, edad, nivel de estudios, etnia y lugar de residencia. Estas variables corresponden a patrones estructurales favorecidos o desfavorecidos, que pueden por tanto facilitar o limitar el tiempo de acceso a dichos servicios. El objetivo de este estudio fue el de comprender la complejidad de las trayectorias de las mujeres hacia el diagnostico. Treinta y cinco mujeres con experiencias diversas y con sintomas de cancer de mama clinicamente detectables en el momento del diagnostico, participaron en entrevistas parcialmente estructuradas. Todas ellas recibian y/o habian completado su tratamiento en el momento de su participacion. Los datos fueron analizados mediante el empleo de estrategias de induccion, comparacion y abduccion. Las participantes describieron una amplia variedad de actividades involucradas en la busqueda de atencion de salud para el cancer de mama. Los hallazgos ilustran como las relaciones sociales del cuidado en salud pueden constituir barreras al diagnostico en un tiempo adecuado, mas alla de lo que lo puedan ser el retraso por parte de la paciente o del profesional. Se ilustra ademas como los diversos contextos sociales y materiales de las mujeres generan oportunidades y barreras de acceso a dichos cuidados.

Context and cardiovascular risk modification in two regions of Ontario, Canada: a photo elicitation study.

Cardiovascular diseases, which include coronary heart diseases (CHD), remain the leading cause of death in Canada and other industrialized countries. This qualitative study used photo-elicitation, focus groups and in-depth interviews to understand health behaviour change from the perspectives of 38 people who were aware of their high risk for CHD and had received information about cardiovascular risk modification while participating in a larger intervention study. Participants were drawn from two selected regions: Sudbury and District (northern Ontario) and the Greater Toronto Area (southern Ontario). Analysis drew on concepts of place and space to capture the complex interplay between geographic location, sociodemographic position, and people’s efforts to understand and modify their risk for CHD. Three major sites of difference and ambiguity emerged: 1) place and access to health resources; 2) time and food culture; and 3) itineraries or travels through multiple locations. All participants reported difficulties in learning and adhering to new lifestyle patterns, but access to supportive health resources was different in the two regions. Even within regions, subgroups experienced different patterns of constraint and advantage. In each region, “fast” food and traditional foods were entrenched within different temporal and social meanings. Finally, different and shifting strategies for risk modification were required at various points during daily and seasonal travels through neighbourhoods, to workplaces, or on vacation. Thus health education for CHD risk modification should be place-specific and tailored to the needs and resources of specific communities.