Karen-Lee Miller

Neglecting the Importance of the Decision Making and Care Regimes of Personal Support Workers: A Critique of Standardization of Care Planning Through the RAI/MDS

Purpose: The Resident Assessment Instrument–Minimum Data Set (RAI/MDS) is an interdisciplinary standardized process that informs care plan development in nursing homes. This standardized process has failed to consistently result in individualized care planning, which may suggest problems with content and planning integrity. We examined the decision making and care practices of personal support workers (PSWs) in relation to the RAI/MDS standardized process. Design and Methods: This qualitative study utilized focus groups and semi-structured interviews with PSWs (n = 26) and supervisors (n = 9) in two nursing homes in central Canada. Results: PSWs evidenced unique occupational contributions to assessment via proximal familiarity and biographical information as well as to individualizing care by empathetically linking their own bodily experiences and forging bonds of fictive kinship with residents. These contributions were neither captured by RAI/MDS categories nor relayed to the interdisciplinary team. Causal factors for PSW exclusion included computerized records, low status, and poor interprofessional collaboration. Intraprofessional collaboration by PSWs aimed to compensate for exclusion and to individualize care. Implications: Exclusive institutional reliance on the RAI/MDS undermines quality care because it fails to capture residents’ preferences and excludes input by PSWs. Recommendations include incorporating PSW knowledge in care planning and documentation and examining PSWs’ nascent occupational identity and their role as interprofessional brokers in long-term care.

The impact of space and time on interprofessional teamwork in Canadian primary health care settings: implications for health care reform

Aim This paper explores the impact of space and time on interprofessional teamwork in three primary health care centres and the implications for Canadian and other primary health care reform. Background Primary health care reform in Canada has emphasized the creation of interprofessional teams for the delivery of collaborative patient-centred care. This involves the expansion and transformation of existing primary health care centres into interprofessional family health teams (FHT) promising to provide patients better access, more comprehensive care, and improved utilization of individual health professionals. Benefits for providers include improved workplace satisfaction and organizational efficiencies. Currently, there is little evidence for how effective interprofessional teamwork happens and little is known about how to create high-functioning teams in the primary health care setting. Methods We used ethnographic observations and interviews to gain a deep understanding of the nature of interprofessional teamwork. Three academic family health centres participated in a total of 139 h of observation and 37 interviews. Team members in all three centres from the disciplines of medicine, nursing, physiotherapy, occupational therapy, social work, dietetics, pharmacy, and office administration participated in this study. Findings We found that both the quantity and quality of interprofessional communication and collaboration in primary health care is significantly impacted by space and time. Across our research sites, the physical layout of clinical space and the temporal organization of clinical practice led to different approaches to, and degrees of success with, interprofessional teamwork. Varied models of interprofessional collaboration resulted when these factors came together in different ways. These findings have important implications for the transition to interprofessional family health teams in Canada and beyond.

Factors influencing exercise participation by older adults requiring chronic hemodialysis: A qualitative study

Despite the recognized health and psychosocial benefits of exercise for older adults with end-stage renal disease (ESRD), exercise participation remains poor. Previous research has attributed low levels of exercise to patient-related factors such as lack of motivation and fear of adverse consequences. This qualitative study involving focus group discussions with hemodialysis patients, nephrology nurses, and family care providers explored specific motivators and barriers to exercise participation in older adults requiring hemodialysis. Nurse participants were chosen for the health care provider focus groups because their prolonged and sustained contact with hemodialysis patients during the dialysis treatment sessions positions them well to encourage and promote exercise. Motivators to exercise included patient aspirations to exercise and their experiences of improvements from exercising, as well as the formal incorporation of exercise into the overall dialysis treatment plan. Barriers to exercise included nurses’ lack of encouragement to exercise, transportation issues, and the use of exercise equipment that precludes participation by patients who recline during dialysis and inhibits exercise encouragement by nurses due to concerns of equipment-related injury. These findings support the need for a broader recognition of the systemic factors that may impede exercise participation by older adults requiring hemodialysis. A shift is required in the culture of ESRD treatment programs towards a wellness perspective that includes expectations of exercise encouragement by the health care team and participation by patients.

Structuring communication relationships for interprofessional teamwork (SCRIPT): A Canadian initiative aimed at improving patient-centred care

There is a growing movement in health care that advocates the use of interprofessional education to help deliver collaborative patient-centred care (Oandasan et al., 2004). For example, the Romanow Commission (2002) and the First Ministers’ Accord (Health Canada 2003) both stress the need for collaborative practice to help ensure that the quality of health care delivered to Canadians can be enhanced. Both reports identified that introducing interprofessional education within the health professional education system was the key to achieving this aim. Evidence of the effectiveness of interprofessional education suggests that it can generate a number of positive outcomes for professionals and for patients (Barr et al., 2005). However, at present, this evidence base is generally weak and fragmentary in nature (Zwarenstein & Reeves, 2006). To help generate a more informed understanding of interprofessional education and its potential impact on collaborative relationships and the delivery of patient care, the Canadian federal government has recently funded eleven projects across the country. This paper describes one of these projects based at the University of Toronto. The project involves the development of an intervention designed to improve interprofessional collaboration across three separate clinical settings: general internal medicine (GIM); primary care; and rehabilitation and complex continuing care. Each of these settings was selected as they represent key trajectories along which patients travel while receiving care in the Toronto Academic Health Science Network (TAHSN), the network of partnerships between the University of Toronto and its fully affiliated health services’ institutes. Journal of Interprofessional Care, January 2007; 21(1): 111 – 114

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.

Improving Client-Centered Brain Injury Rehabilitation Through Research-Based Theater

Traumatic brain injury often results in physical, behavioral, and cognitive impairments perceived by health care practitioners to limit or exclude clients’ full participation in treatment decision making. We used qualitative methods to evaluate the short- and long-term impact of “After the Crash: A Play About Brain Injury,” a research-based drama designed to teach client-centered care principles to brain injury rehabilitation staff. We conducted interviews and observations with staff of two inpatient neurorehabilitation units in Ontario, Canada. Findings demonstrate the effectiveness of the play in influencing practice through the avoidance of medical jargon to improve clients’ understanding and participation in treatment; newfound appreciation for clients’ needs for emotional expression and sexual intimacy; increased involvement of family caregivers; and avoidance of staff discussions as if clients were unaware. These findings suggest that research-based drama can effect reflexivity, empathy, and practice change to facilitate a client-centered culture of practice in brain injury rehabilitation.

Interprofessional information work: Innovations in the use of the chart on internal medicine teams

An abundance of evidence suggests that communication in interprofessional healthcare teams is a complex endeavour. Even relatively simple communication processes involving information work – the gathering, storage, retrieval and discussion of patient information – may be fraught with pitfalls, and yet teams manage to conduct their daily information work, often with a high degree of effectiveness. In this article, we explore one commonplace dimension of information work – the use of patient charts to foster collaborative decision-making and care enactment – towards building an elaborated understanding of how teams innovate in the face of daily complexities in their information work processes. Drawing on results from an ethnographic study of team communication in two internal medicine inpatient wards, we describe the nature and use of patient charts, analyze recurrent problems, and explore adaptive strategies for carrying on team information work in the face of daily barriers.

Presence redefined: The reciprocal nature of engagement between elder-clowns and persons with dementia

Elder-clowns are a recent innovation in arts-based approaches to person-centred dementia care. They use improvisation, humour, and empathy, as well as song, dance, and music. We examined elder-clown practice and techniques through a 12-week programme with 23 long-term care residents with moderate to severe dementia in Ontario, Canada. Analysis was based on qualitative interviews and ethnographic observations of video-recorded clown-resident interactions and practice reflections. Findings highlight the reciprocal nature of clown-resident engagement and the capacity of residents to initiate as well as respond to verbal and embodied engagement. Termed relational presence, this was achieved and experienced through affective relationality, reciprocal playfulness, and coconstructed imagination. These results highlight the often overlooked capacity of individuals living with dementia to be deliberately funny, playful, and imaginative. Relational presence offers an important perspective with which to rethink care relationships between individuals living with dementia and long-term care staff.

Citizenship, human rights, and dementia: Towards a new embodied relational ethic of sexuality

Sexual citizenship and sexual rights scholarship have made important contributions to broadening citizenship and more fully accommodating rights related to sexuality. However, this scholarship has concentrated primarily on the sexuality and intimacy-related needs of younger people and those who are not cognitively impaired. Consequently, it has inadvertently served to marginalize persons living with dementia who reside in long-term residential care settings. We argue that supporting sexual rights for persons with dementia requires a particular human rights ontology for citizenship—one that recognizes that corporeality is a fundamental source of self-expression, interdependence, and reciprocal engagement. This is an ontology that underpins our model of relational citizenship and that grounds our articulation of an ethic of embodied relational sexuality. In our view, this ethic offers important direction for the development of policy, legislation, and clinical guidelines to support sexual rights for persons with dementia in long-term residential care.

Elder‐Clowning in Long‐Term Dementia Care: Results of a Pilot Study

To assess the effects of elder‐clowning on moderate to severe behavioral and psychological symptoms of dementia (BPSD) in nursing home residents with dementia, primarily of the Alzheimers type.