New Nurses' Perceptions on Transition to Practice: A Thematic Analysis.

BACKGROUND: New nurses' transition to the workforce is often described as challenging and stressful. Concerns over this transition to practice are well documented, with the hypothesis that transition experiences influence the retention of new nurses in the workforce and profession. METHODS: In a cross-sectional survey (N = 217) to assess new nurse transition in the province of Ontario, Canada, an open-ended item was included to solicit specific examples of the transition experience. The comments underwent thematic analysis to identify the facilitators and barriers of transition to practice for new nurses. RESULTS: Comments were provided by 196 respondents. Three facilitator themes (supportive teams; feeling accepted, confident, and prepared; new graduate guarantee) and four barrier themes (feeling unprepared; discouraging realities and unsupportive cultures; lacking confidence/feeling unsure; false hope) to new nurse transition emerged. CONCLUSIONS: Concerns of nursing shortages are heightened in the current COVID-19 pandemic, reinforcing the priority of retaining new nurses in the workforce. The reported themes offer insight into the contribution of a supportive work environment to new nurses' transition. The recommendations focus on aspects of supportive environments and educational strategies, including final practicums, to assist nursing students' development of self-efficacy and preparation for the workplace.

A framework for nursing practice in rural and remote Canada.

INTRODUCTION: Despite the increased understanding of Canadian rural and remote nursing practice in the past two decades, a synthesis of nursing frameworks to guide practice has been missing from the literature. In this article, the process undertaken to develop a nursing practice framework is described. The purpose of the project was to integrate existing rural and remote nursing evidence into a framework to guide rural nursing practice; inform the actions of rural communities, other health professionals, educators, policymakers and regulators; and support the health of Canadian residents who live in rural and remote areas. METHODS: Two consultants (DE, JK) worked with the Canadian Association for Rural & Remote Nursing (CARRN) Executive to plan and implement a process to develop a rural and remote nursing framework. An external advisory group, representing regulated nurses, and six expert rural nursing researchers were invited to critique project outcomes. A focused international review of the literature was conducted to determine which rural nursing frameworks existed. Electronic database platforms (ProQuest and the Cumulative Index of Allied Health Literature and Medline) were searched, with literature limited to English-only articles. Each article was analyzed to determine relevant key components and elements. RESULTS: The literature review generated 22 full-text articles that were analyzed and synthesized into five main categories: larger society/determinants of health, role of place/the rural or remote context, rural and remote peoples/communities, rural and remote nursing, and health outcomes. A draft document describing the creation of the framework and two different graphic designs of the framework were developed, then sent to the advisory group for critique. All critiques were reviewed and the document was revised as appropriate. The framework design, which used concentric circles to depict relationships between the five identified categories, was selected by a majority of the advisory group reviewers as being representative of their practice and experience. CONCLUSION: It is envisioned that, by using the framework, practicing nurses can identify the tightly woven interconnections within the rural context affecting the health of their clients. Nursing assessments and practice can then be strengthened from consideration of the framework. Nursing programs with dedicated rural nursing content potentially could incorporate the rural and remote nursing practice framework document into classroom and clinical discussions. Due to resource and time restrictions, Indigenous and Francophone nurses were not part of the framework discussions, nor were community members living in rural or remote Canada. Ongoing critique from relevant rural groups will be beneficial for future input and revisions. CARRN is developing a knowledge mobilization strategy to begin this process.

New Registered Nurse Transition to the Workforce and Intention to Leave: Testing a Theoretical Model.

BACKGROUND: The transition of new nurses into practice has been identified as challenging, and new nurses report having intentions to leave (ITL) jobs. Concerns of ITL are worrisome for the nursing profession, especially when faced with the need to replace an aging nursing workforce and to maintain quality patient care. PURPOSE: Guided by components of Meleis et al.'s mid-range transition theory, the purpose of this study was to test a theoretical model linking transition and ITL, as well as the personal, community and societal conditions of transition. METHODS: A predictive, non-experimental design using cross-sectional data was employed. Ontario registered nurses, who had graduated within two years, were randomly selected to complete a mailed questionnaire in 2015 (N = 217). Structural equation modeling was undertaken to test the model. RESULTS: The new nurses reported a relatively positive transition; yet, 44% of the respondents indicated leaving their first job, and 1% departed the nursing profession. A revised model of the constructs showed a more adequate fit with the data, but overall, the hypothesized model was not supported and methodological validity of tools questioned. From the modeling, lower role stress led to a positive transition. CONCLUSIONS: Given organizational and governmental investments in orientation and transition programs, challenges in measuring transition and ITL requires additional research. Our findings highlight the value of organizations supporting new nurses by reducing role stress through reasonable workloads and expectations, which in turn contributes to a positive transition.

A population-based study of prescribing trends in a potentially vulnerable paediatric population from 1999 to 2012.

OBJECTIVES: There is a limited understanding of paediatric medication prescribing trends and patterns, thus poorly positioning decision-makers to identify quality and safety concerns related to medication use. The objective of this study was to determine overall medication prescribing trends and patterns among children receiving Ontario Drug Benefits over a thirteen-year period in the province of Ontario, Canada. METHODS: Administrative health databases housed within the Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada, were used to identify outpatient prescriptions dispensed from 1999 to 2012 through a publicly funded programme to children ≤18 years of age. Medications were classified according to the American Hospital Formulary Service Pharmacologic-Therapeutic Classification system. Descriptive statistics were used to summarize prescribing patterns. KEY FINDINGS: This study identified 457 037 children who were dispensed a new prescription between 1999 and 2012. About 56% received their first prescription before 6.5 years of age, and 85% of the children in this study were from families who received social assistance. The most commonly prescribed drugs were antiinfectives (56.1%). Prescriptions for several central nervous system agents, including antipsychotics and agents for attention-deficit/hyperactivity disorder, increased across the study period. Changes in prescribing patterns within opioids, hormones and autonomic agents were noted. The results suggest that historically, prescribing trends have shifted with public policy, pharmaceutical marketing and diagnostic patterns, thus identifying them as a possible tool to measure the impact of policydriven practice changes. Anti-infective prescribing increased markedly with the global H1N1 pandemic. Pharmaceutical marketing, formulary decisions and diagnostic trends may affect the prescribing of ADHD medications globally. The prescribing of codeine-containing products and medroxyprogesterone appeared to fluctuate in response to important publications in the medical literature, and the use of epinephrine syringes increased after public policy changes in the province of Ontario. The steady rise in the use of medications whose long-term effects in children are unknown, such as antipsychotics and proton pump inhibitors, identifies areas in need of future research. CONCLUSIONS: This study presents the first overview of Canadian prescribing trends for children, the majority of which are of low socioeconomic status and represent a potentially vulnerable population. Our analysis suggests that future research is required to determine whether prescribing trends could be used as indicators of policy effectiveness, pharmacovigilance and diagnostic trends.

A population profile of older adults with prescription encounters with nurse practitioners and family physicians in Ontario: a descriptive retrospective cohort study.

BACKGROUND: Compared with patients in family physician practices, there is a poor understanding at a population level of patients in nurse practitioner practices. The study aim was to use Ontario administrative databases to identify the sociodemographic characteristics and comorbidities of patients aged 65 years and older who were prescribed medications by nurse practitioners and family physicians between 2000 and 2015. METHODS: This population-based descriptive retrospective cohort study included patients 65 years of age and older with Ontario Health Insurance Plan eligibility and at least 1 prescription encounter with a nurse practitioner or family physician during the study period. Prescription identification of patients permitted their characterization by age, sex, geographical location, rurality, neighbourhood income and comorbidities. Patients were categorized into 3 provider groups on the basis of the percentage of prescription encounters with nurse practitioners versus family physicians. RESULTS: In 2015, patients in the study cohort with prescriptions by nurse practitioners (n = 25 220) were younger than those with prescriptions by family physicians (40.3% were aged 65-69 yr) and they were more likely to be residents of low-income neighbourhoods (44.0% were in the lowest 2 neighbourhood income quintiles) and to be living outside of central Ontario. In contrast, patients who received prescriptions from family physicians (n = 1 952 904) tended to be older (26.8% were aged ≥ 80 yr), to have higher incomes (21.1% were in the highest neighbourhood income quintile) and to live in urban areas (86.5%). Mean Elixhauser Comorbidity Index scores were consistently lower among patients cared for by nurse practitioners than among those predominantly seen by family physicians (1.30 v. 2.04). The most prevalent conditions were hypertension and diabetes, regardless of provider. INTERPRETATION: The patient characteristic with the highest variability between providers was geographic residence in the province. Elucidating patterns of care is critical for primary care policy and our results provide baseline data for future health care planning.

Measures of movement and mobility used in clinical practice and research: a scoping review protocol.

REVIEW QUESTION: The first objective of this scoping review is to identify all tools designed to measure movement or mobility in adults. The second objective is to compare the tools to the conceptual definitions of movement and mobility by mapping them against the International Classification of Functioning, Disability and Health (ICF).The specific questions that will be answered for each tool by the mapping are.

Team composition and chronic disease management within primary healthcare practices in eastern Ontario: an application of the Measuring Organizational Attributes of Primary Health Care Survey.

BACKGROUND: Various organizational-level attributes are being implemented in primary healthcare to improve healthcare delivery. There is a need to describe the distribution and nature of these attributes and explore differences across practices.AimThe aim of this study was to better understand organizational attributes of primary care teams, focusing specifically on team composition, nursing roles, and strategies that support chronic disease management. METHODS: We employed a cross-sectional survey design. Team composition, nursing roles, availability of health services, and chronic disease management activities were described using the 'Measuring Organizational Attributes of Primary Health Care Survey.'FindingsA total of 76% (n=26 out of 34) of practice locations completed the survey, including family health teams (FHT; n=21) and community health centers (CHC; n=4). Nurse practitioners (NPs) and registered nurses (RNs) were the most common non-physician providers, and CHCs had a greater proportion of non-physician providers than FHTs. There was overlap in roles performed by NPs and RNs, and registered practical nurses engaged in fewer roles compared with NPs and RNs. A greater proportion of FHTs had systematic chronic disease management services for hypertension, depression and Alzheimer's disease compared with CHC practices. The 'Measuring Organizational Attributes of Primary Health Care Survey' was a useful tool to highlight variability in organizational attributes across PHC practices. Nurses are prominent within PHC practices, engaging in a wide range of roles related to chronic disease management, suggesting a need to better understand their contributions to patient care to optimize their roles.

Patient safety in practical nurses' education: A cross-sectional survey of newly registered practical nurses in Canada.

BACKGROUND: Practical nurses have experienced an increasing scope of practice, including an expectation to care for complex patients and function on interdisciplinary teams. Little is known about the degree to which patient safety principles are addressed in practical nursing education. PURPOSE: To examine self-reported patient safety competencies of practical nurses. DESIGN: A cross-sectional online survey (July 2014) and face-to-face interviews (June 2015). SETTING: Ontario, Canada. PARTICIPANTS: Survey participants were practical nurses newly registered with the College of Nurses of Ontario between January 2012 and December 2013. Interview participants were faculty and students in a practical nursing program in Ontario. METHODS: Survey respondents completed the Health Professional Education in Patient Safety Survey online. Self-reported competencies in various patient safety domains were compared between classroom and clinical settings. Faculty members were interviewed about educational preparation of practical nurses and students were interviewed to provide insight into interpretation of survey questions. RESULTS: The survey response rate was 28.4% (n=1104/3883). Mean domain scores indicated a high level of confidence in patient safety competence (<4.0/5.0). Confidence was highest in respondents registered with the College of Nurses of Ontario >2years and in those who obtained their education outside of Canada. Faculty believed their approach to teaching and learning instilled a deep understanding of the limits to practical nurse autonomous practice. CONCLUSIONS: Practical nurses were confident in what they learned about patient safety in their educational programs. The high degree of patient safety competence may be a true reflection of practical nurses understanding of, and comfort with, the limits of their knowledge and, ultimately, the limits of their individual autonomous practice. Further exploration as to whether the questionnaire requires additional modification for use with practical nurse populations is warranted. However, this study provides the first examination of practical nurses' perspectives and perceptions about patient safety education.

Association between registered nurse staffing and management outcomes of patients with type 2 diabetes within primary care: a cross-sectional linkage study.

BACKGROUND: As the organization of primary care continues to evolve toward more interdisciplinary team structures, demonstrating effectiveness of care delivery is becoming important, particularly for nonphysician providers. Nurses are the most common nonphysician provider within primary care. The purpose of this study was to examine the relation between primary care delivery models that incorporate registered nurses and clinical outcomes of patients with type 2 diabetes. METHODS: Patient data from the Canadian Primary Care Sentinel Surveillance Network were matched with survey data from 15 Family Health Team practices in southeastern Ontario. Included patients were adults with type 2 diabetes mellitus who had at least 1 primary care encounter at a Family Health Team practice that completed the organizational survey between Apr. 1, 2013, and Mar. 31, 2014. The clinical outcomes explored included hemoglobin A1c, fasting plasma glucose, blood pressure, low-density lipoprotein cholesterol and urine albumin:creatinine ratio. RESULTS: Of the 15 practices, 13 (86.7%) had at least 1 registered nurse. The presence of 1 or more registered nurses in the practice was associated with increased odds of patients' having their hemoglobin A1c, fasting plasma glucose, blood pressure and low-density lipoprotein cholesterol values meet recommended targets. Practices with the lowest ratios of patients with diabetes to registered nurse had a significantly greater proportion of patients with hemoglobin A1c and fasting plasma glucose values on target than did practices with the highest ratios of patients to registered nurse (p < 0.01 and p = 0.03, respectively). INTERPRETATION: The findings suggest that registered nurse staffing within primary care practice teams contributes to better diabetic care, as measured by diabetes management indicators. This study sets the groundwork for further exploration of nursing and organizational contributions to patient care in the primary care setting.

Trends in nurse practitioners' prescribing to older adults in Ontario, 2000-2010: a retrospective cohort study.

BACKGROUND: Nurse prescribing is a practice that has evolved and will continue to evolve in response to emerging trends, particularly in primary care. The goal of this study was to describe the trends and patterns in medication prescription to adults 65 years of age or older in Ontario by nurse practitioners over a 10-year period. METHODS: We conducted a population-based descriptive retrospective cohort study. All nurse practitioners registered in the Corporate Provider Database between Jan. 1, 2000, and Dec. 31, 2010, were identified. We identified actively prescribing nurse practitioners through linkage of dispensed medications to people aged 65 years or older from the Ontario Drug Benefit database. For comparison, all prescription medications dispensed by family physicians to a similar group were identified. Geographic location was determined based on site of nurse practitioner practice. RESULTS: The number and proportion of actively prescribing nurse practitioners prescribing to older adults increased during the study period, from 44/340 (12.9%) to 888/1423 (62.4%). The number and proportion of medications dispensed for chronic conditions by nurse practitioners increased: in 2010, 9 of the 10 top medications dispensed were for chronic conditions. There was substantial variation in the proportion of nurse practitioners dispensing medication to older adults across provincial Local Health Integration Networks. INTERPRETATION: Prescribing by nurse practitioners to older adults, particularly of medications related to chronic conditions, increased between 2000 and 2010. The integration of nurse practitioners into primary care has not been consistent across the province and has not occurred in relation to population changes and perhaps population needs.

Undergraduate baccalaureate nursing students' self-reported confidence in learning about patient safety in the classroom and clinical settings: an annual cross-sectional study (2010-2013).

BACKGROUND: Given the increasing incidence of adverse events and medication errors in healthcare settings, a greater emphasis is being placed on the integration of patient safety competencies into health professional education. Nurses play an important role in preventing and minimizing harm in the healthcare setting. Although patient safety concepts are generally incorporated within many undergraduate nursing programs, the level of students' confidence in learning about patient safety remains unclear. OBJECTIVES: Self-reported patient safety competence has been operationalized as confidence in learning about various dimensions of patient safety. The present study explores nursing students' self-reported confidence in learning about patient safety during their undergraduate baccalaureate nursing program. DESIGN: Cross-sectional study with a nested cohort component conducted annually from 2010 to 2013. SETTING AND PARTICIPANTS: Participants were recruited from one Canadian university with a four-year baccalaureate of nursing science program. All students enrolled in the program were eligible to participate. METHODS: The Health Professional Education in Patient Safety Survey was administered annually. The Health Professional Education in Patient Safety Survey captures how the six dimensions of the Canadian Patient Safety Institute Safety Competencies Framework and broader patient safety issues are addressed in health professional education, as well as respondents' self-reported comfort in speaking up about patient safety issues. RESULTS: In general, nursing students were relatively confident in what they were learning about the clinical dimensions of patient safety, but they were less confident about the sociocultural aspects of patient safety. Confidence in what they were learning in the clinical setting about working in teams, managing adverse events and responding to adverse events declined in upper years. The majority of students did not feel comfortable speaking up about patient safety issues. The nested cohort analysis confirmed these findings. In particular, confidence in acquiring basic clinical skills, learning about adverse events, and managing safety risks improved between Year 1 and Year 2, and confidence in managing safety risks declined in upper years. CONCLUSIONS: These findings suggest nursing students are confident in what they are learning about clinical aspects of patient safety, however, their confidence in learning about sociocultural aspects declines as they are increasingly exposed to the clinical environment. This suggests a need to address the impact of the practice environment on nursing students' confidence in what they are learning about patient safety.

Self-reported patient safety competence among Canadian medical students and postgraduate trainees: a cross-sectional survey.

BACKGROUND: Quality and patient safety (PS) are critical components of medical education. This study reports on the self-reported PS competence of medical students and postgraduate trainees. METHODS: The Health Professional Education in Patient Safety Survey was administered to medical students and postgraduate trainees in January 2012. PS dimension scores were compared across learning settings (classroom and clinical) and year in programme. RESULTS: Sixty-three percent (255/406) of medical students and 32% (141/436) of postgraduate trainees responded. In general, both groups were most confident in their learning of clinical safety skills (eg, hand hygiene) and least confident in learning about sociocultural aspects of safety (eg, understanding human factors). Medical students' confidence in most aspects of safety improved with years of training. For some of the more intangible dimensions (teamwork and culture), medical students in their final year had lower scores than students in earlier years. Thirty-eight percent of medical students felt they could approach someone engaging in unsafe practice, and the majority of medical students (85%) and postgraduate trainees (78%) agreed it was difficult to question authority. CONCLUSIONS: Our results suggest the need to improve the overall content, structure and integration of PS concepts in both classroom and clinical learning environments. Decreased confidence in sociocultural aspects of PS among medical students in the final year of training may indicate that culture in clinical settings negatively affects students' perceived PS competence. Alternatively, as medical students spend more time in the clinical setting, they may develop a clearer sense of what they do not know.

Social support needs of families: the context of rheumatoid arthritis.

AIM: The present study aimed to describe the experience of family members who provide social support to their relative with rheumatoid arthritis (RA), and explore the forms of support that they require. BACKGROUND: The psychosocial effects and changes that family members experience with their relative's illness can pose considerable challenge for the family unit. METHODS: The study used a descriptive qualitative design. A semi-structured interview guide was used to interview seven participants. Qualitative direct content analysis was used to analyze the data. RESULTS: Five themes emerged from the data analysis: effect of the disease; reshaping the relationship; provider of support; social support needs of family members; and, finding balance and coping. CONCLUSIONS: Family members of people with RA require social support to achieve balance and cope with the chronicity and disability of RA. Nurses should tailor nursing interventions to provide emotional support, informational support, and guidance to families.

Identification, summary and comparison of tools used to measure organizational attributes associated with chronic disease management within primary care settings.

RATIONALE, AIMS AND OBJECTIVES: Given the increasing emphasis being placed on managing patients with chronic diseases within primary care, there is a need to better understand which primary care organizational attributes affect the quality of care that patients with chronic diseases receive. This study aimed to identify, summarize and compare data collection tools that describe and measure organizational attributes used within the primary care setting worldwide. METHODS: Systematic search and review methodology consisting of a comprehensive and exhaustive search that is based on a broad question to identify the best available evidence was employed. RESULTS: A total of 30 organizational attribute data collection tools that have been used within the primary care setting were identified. The tools varied with respect to overall focus and level of organizational detail captured, theoretical foundations, administration and completion methods, types of questions asked, and the extent to which psychometric property testing had been performed. The tools utilized within the Quality and Costs of Primary Care in Europe study and the Canadian Primary Health Care Practice-Based Surveys were the most recently developed tools. Furthermore, of the 30 tools reviewed, the Canadian Primary Health Care Practice-Based Surveys collected the most information on organizational attributes. CONCLUSIONS: There is a need to collect primary care organizational attribute information at a national level to better understand factors affecting the quality of chronic disease prevention and management across a given country. The data collection tools identified in this review can be used to establish data collection strategies to collect this important information.

Nursing contributions to chronic disease management in primary care.

BACKGROUND: As the prevalence of chronic diseases continues to increase, emphasis is being placed on the development of primary care strategies that enhance healthcare delivery. Innovations include interprofessional healthcare teams and chronic disease management strategies. OBJECTIVE: To determine the roles of nurses working in primary care settings in Ontario and the extent to which chronic disease management strategies have been implemented. METHODS: We conducted a cross-sectional survey of a random sample of primary care nurses, including registered practical nurses, registered nurses, and nurse practitioners, in Ontario between May and July 2011. RESULTS: Nurses in primary care reported engaging in chronic disease management activities but to different extents depending on their regulatory designation (licensure category). Chronic disease management strategy implementation was not uniform across primary care practices where the nurses worked. CONCLUSIONS: There is the potential to optimize and standardize the nursing role within primary care and improve the implementation of chronic disease management strategies.

Canadian home care policy and practice in rural and remote settings: challenges and solutions.

With the aging of the population, especially in Canadian rural areas, providing home care services will be particularly challenging as care is needed by increasingly vulnerable rural older adults in increasingly vulnerable rural settings with fewer services, supports, and caregivers. The purpose of this paper is to present examples of the federal (e.g., First Nations and Inuit Home and Community Care) and provincial (e.g., Ontario's Community Care Access Centres) home care policy context in which Canadian home care is provided, to identify the challenges faced by home care providers in meeting the needs of rural residents, and to offer solutions to these challenges. The most pressing challenges in aging rural settings are to ensure effective access to quality health care services and to address the shortage of home care providers, especially registered nurses. Provincial and federal home care models would be enhanced by an integrative model of continuing care and a national home care framework that would address the broader funding and human resource issues. Other uniquely rural recruitment and retention strategies are suggested such as maximizing the "fit" between the home care provider's attributes and the needs and expectations of the rural community. Sufficient public funding and resources for rural and remote home care programs are needed to develop and implement (1) the expanded role of case managers; (2) health care teams that include both professionals and paraprofessionals; (3) standardized assessment tools and reporting systems; (4) innovative use and training in the use of technology; and (5) partnerships that optimize resources and build support networks for rural home care providers, clients, and family and friend caregivers.