Nursing care for persons with developmental disabilities: Review of literature on barriers and facilitators faced by nurses to provide care.

AIMS: To identify barriers and facilitators to nursing care of individuals with developmental disabilities (DDs). BACKGROUND: Individuals with DDs experience health disparities. Nurses, although well positioned to provide optimal care to this population, face challenges. DESIGN: Narrative review of extant published peer-reviewed literature. DATA SOURCES: Electronic databases, ProQuest and EBSCO, were searched for studies published in English between 2000 and 2019. REVIEW METHODS: Three reviewers reviewed abstracts and completed data extraction. Knowledge synthesis was completed by evaluating the 17 selected studies. RESULTS: Emerging themes were: (1) barriers and challenges to nursing interventions; (2) facilitators to nursing care; and (3) recommendations for nursing education, policy and practice. CONCLUSION: Nursing has the potential to be a key partner in supporting the health of people with DDs. IMPACT: There is a need for specific education and training, so nurses are better equipped to provide care for people with DDs.

Public health nurses' perceptions of their interactions with child protection services when supporting socioeconomically disadvantaged young mothers in British Columbia, Canada.

BACKGROUND: Children of girls and young women experiencing socioeconomic disadvantage are at risk of maltreatment and associated health and developmental problems. Nurse-Family Partnership (NFP) is an early intervention program designed to improve child and maternal health outcomes. The effectiveness of NFP is being evaluated in British Columbia (BC) through a randomized controlled trial, augmented by a process evaluation to identify influences on how NFP was implemented. OBJECTIVE: To describe how public health nurses providing NFP perceived their interactions with child protection professionals. PARTICIPANTS AND SETTING: Forty-seven public health nurses across BC. METHODS: The principles of interpretive description informed the qualitative component of the process evaluation. Data from interviews and focus groups were analyzed using the framework analysis approach. A thematic framework was generated through processes of coding, charting and mapping, with a focus on organizational and systems influences. RESULTS: Nurses' practice in supporting families often involved engagement with child protection services. Four themes about the nature of this work were identified: 1) developing a deeper understanding of the disciplinary perspectives of child protection, 2) striving for strengthened collaboration, 3) navigating change and uncertainty, and 4) responding to family and community complexity. CONCLUSIONS: Participants valued the contribution of child protection professionals and expressed willingness to collaborate to support families. However, collaboration was constrained by multiple structural barriers. Collaborative models offer possibilities for integrated practice, although can be difficult to implement within current health and child protection systems and child protection regulatory contexts.

Public Health Nurses' Professional Practices to Prevent, Recognize, and Respond to Suspected Child Maltreatment in Home Visiting: An Interpretive Descriptive Study.

The purpose of this analysis was to understand public health nurses' experiences in preventing and addressing suspected child maltreatment within the context of home visiting. The principles of interpretive description guided study decisions and data were generated from interviews with 47 public health nurses. Data were analyzed using reflexive thematic analysis. The findings highlighted that public health nurses have an important role in the primary prevention of child maltreatment. These nurses described a six-step process for managing their duty to report suspected child maltreatment within the context of nurse-client relationships. When indicators of suspected child maltreatment were present, examination of experiential practice revealed that nurses developed reporting processes that maximized child safety, highlighted maternal strengths, and created opportunities to maintain the nurse-client relationship. Even with child protection involvement, public health nurses have a central role in continuing to work with families to develop safe and competent parenting skills.

Factors obstetricians, family physicians and midwives consider when counselling women about a trial of labour after caesarean and planned repeat caesarean: a qualitative descriptive study.

BACKGROUND: Repeat caesarean sections (CSs) are major contributors to the high rate of CS in Canada and globally. Women's decisions to have a planned repeat CS (PRCS) or a trial of labour after CS (TOLAC) are influenced by their maternity care providers. This study explored factors maternity care providers consider when counselling pregnant women with a previous CS, eligible for a TOLAC, about delivery method. METHODS: A qualitative descriptive design was implemented. Semi-structured, one-to-one in-depth telephone interviews were conducted with 39 maternity care providers in Ontario, Canada. Participants were recruited at 2 maternity care conferences and with the use of snowball sampling. Interviews were audio recorded and transcribed verbatim. Data were uploaded into the data management software, NVIVO 10.0 and analyzed using qualitative content analysis. RESULTS: Participants consisted of 12 obstetricians, 13 family physicians and 14 midwives. Emergent themes, reflecting the factors maternity care providers considered when counselling on mode of delivery, were organized under the categories clinical/patient factors, health system factors and provider preferences. Maternity care providers considered clinical/patient factors, including women's choice … with conditions, their assessment of women's chances of a successful TOLAC, their perception of women's risk tolerance, women's preferred delivery method, and their perception of women's beliefs and attitudes about childbirth. Additionally, providers considered health system factors which included colleague support for TOLAC and time needed to mount an emergency CS. Finally, provider factors emerged as considerations when counselling. They included provider preference for PRCS or TOLAC, provider scope of practice, financial incentives and convenience related to PRCS, past experiences with TOLAC and PRCS and providers' perspectives on risk of TOLAC. CONCLUSION: The findings highlight the multiplicity of factors maternity care providers consider when counselling women. Effectively addressing clinical, health care system and personal factors that influence counselling may help decrease non-medically indicated PRCS.

Supporting sexual adjustment from the perspective of men living with spinal cord injury.

STUDY DESIGN: Descriptive phenomenological approach. OBJECTIVES: This study explored the lived experience of sexuality for men after spinal cord injury (SCI) and described the current state of tools and resources available to assist with sexual adjustment from the perspective of men living with SCI. SETTING: Men living in the community in Ontario, Canada. METHODS: Six men (age 24-49 years) with complete or incomplete SCI (C4-T12; <1-29 years post injury) participated in one individual, in-depth, standardized, open-ended interview (68-101 min). Analysis was conducted using Giorgi's method, and involved within case analysis followed by cross-case analysis. RESULTS: All participants reported that resources available to support sexual adjustment after SCI were inadequate, and the majority of men felt their healthcare providers lacked knowledge regarding, and comfort discussing sexuality after SCI. Men reported sexuality was not a priority of the rehabilitation centers and felt that healthcare providers did not understand the importance of addressing sexuality. Existing resources were described as too clinical and not necessarily relevant given changes in sensation and mobility post injury. Participants provided recommendations for the effective delivery of relevant sexual education information. CONCLUSIONS: To improve quality of life for men after SCI, suitable resources must be available to support sexual rehabilitation post injury. Future research should focus on developing strategies to facilitate discussions about sexuality between individuals with SCI and healthcare providers, and on developing resources that are effective and relevant for these men.

The Angle Labor Pain Questionnaire: Reliability, Validity, Sensitivity to Change, and Responsiveness During Early Active Labor Without Pain Relief.

OBJECTIVES: The Angle Labor Pain Questionnaire (A-LPQ) is a new, condition-specific, multidimensional psychometric instrument that measures the most important dimensions of women's childbirth pain experiences using 5 subscales: The Enormity of the Pain, Fear/Anxiety, Uterine Contraction Pain, Birthing Pain, and Back Pain/Long Haul. This study assessed the A-LPQ's test-retest reliability during early active labor without pain relief. METHODS: Two versions of the A-LPQ were randomly administered to laboring women during 2 test sessions separated by a 20-minute window. Participants were of mixed parity, contracting ≥3 minutes apart, cervical dilation ≤6 cm, and without pain relief. Changes in pain were rated using the Patient Global Impression of Change Scale. Overall pain intensity and pain coping were rated using the Numeric Rating Scale (NRS) and the Verbal Rating Scale (VRS) and the Pain Mastery Scale (PMS) respectively. A-LPQ test-retest reliability (primary outcome), Cronbach's α, and concurrent validity with NRS, VRS, and PMS scores were assessed (n=104). Responsiveness was assessed in 55 women who reported changes in pain. RESULTS: A-LPQ summary and subscale scores demonstrated good test-retest reliability (ICCs, 0.96 to 0.89), trivial to moderate sensitivity to change, and high responsiveness to minimal changes in pain (0.85 to 1.50). Cronbach's α for A-LPQ summary scores was excellent (0.94) and ranged from 0.72 to 0.94 for subscales. Concurrent validity was supported by moderate to strong correlations with NRS and VRS scores for overall pain intensity and PMS scores for pain coping. DISCUSSION: Findings support A-LPQ use for assessing women's childbirth pain experiences.

Performance of the Angle Labor Pain Questionnaire During Initiation of Epidural Analgesia in Early Active Labor.

BACKGROUND: The Angle Labor Pain Questionnaire (A-LPQ) is a new, 22-item multidimensional psychometric questionnaire that measures the 5 most important dimensions of women's childbirth pain experiences using 5 subscales: The Enormity of the Pain, Fear/Anxiety, Uterine Contraction Pain, Birthing Pain, and Back Pain/Long Haul. Previous work showed that the A-LPQ has overall good psychometric properties and performance during early active labor in women without pain relief. The current study assessed the tool's sensitivity to change during initiation of labor epidural analgesia with the standardized response mean (SRM, primary outcome). METHODS: Two versions of the A-LPQ were administered once, in each of 2 test sessions, by the same trained interviewer during early active labor. The sequence of administration was randomized (ie, standard question order version [Test 1] followed by mixed version [Test 2] or vice versa). Test 1 was completed before epidural insertion; Test 2 commenced 20 to 30 minutes after the test dose. Providers assessed/treated pain independently of the study. Sensitivity to change was assessed using SRMs, Cohen's d, and paired t tests. Overall pain intensity was concurrently examined using Numeric Rating Scale and the Verbal Rating Scale (VRS); coping was assessed with the Pain Mastery Scale. Changes in pain were measured with the Patient Global Impression of Change Scale. Internal consistency was assessed with Cronbach's α. Concurrent validity with other tools was assessed using Spearman's rank correlation coefficient. RESULTS: A total of 51 complete datasets were analyzed. Most women reported moderate (63%, 32/51) or severe (18%, 9/51) baseline pain on VRS scores during Test 1; 29% (15/51) reported mild pain, and 6% (3/51) reported moderate pain during Test 2. Approximately 90% (46/51) of women reported much or very much improved pain at the end of testing. Cronbach's α for A-LPQ summary scores was excellent (0.94) and ranged from 0.78 (acceptable) to 0.92 (excellent) for subscales (Test 1). Large SRMs were found for A-LPQ summary scores (1.6, 95% CI: 1.2, 2.1) and all subscales except the Birthing Pain subscale (moderate, 0.60, 95% CI: 0.23, 0.97). Significant (P < .001) differences were found between A-LPQ summary scores and between all subscales on paired t tests. Correlations between A-LPQ summary and Numeric Rating Scale scores (overall pain intensity) were strong (ρ > 0.73), correlations were moderate (ρ > 0.5) with VRS scores and coping scores (ρ > 0.67). CONCLUSIONS: Findings support A-LPQ use for measurement of women's childbirth pain experiences during initiation of labor epidural analgesia during early active labor. Combined with our previous work, they also support the use of the A-LPQ in late labor and at delivery.

Key issues and barriers to obstetrical anesthesia care in Ontario community hospitals with fewer than 2,000 deliveries annually.

PURPOSE: Lack of the availability of anesthesia services may be a factor in the closure of maternity services in rural Canada, limiting the capacity for Cesarean delivery and intensifying the urbanization of maternity care. Unlike other professions involved in maternal newborn care, health services research in obstetrical anesthesia is virtually non-existent. This study explored barriers physicians encountered in providing obstetrical anesthesia care in Ontario community hospitals experiencing low volumes (fewer than 2,000) deliveries per annum (PA). Solutions proposed by a mixed focus group of academic and community hospital leaders were also described. METHODS: Following Research Ethics Board approval, the authors performed a secondary analysis of qualitative data from 18 anesthesiologists and family practitioner (FP/GP) anesthetists who had participated in a larger provincial study that was also conducted by the authors. Participants were leaders from community hospitals with fewer than 2000 deliveries PA and university-based teaching programs from across Ontario. Fourteen community physicians participated in focus groups that explored key issues and barriers to care and their potential solutions. A final group of eight academic and community physician key informants further explored solutions. FINDINGS: Three themes emerged: Obstetrical Anesthesia in the "Periphery", "Key Issues and Barriers to Obstetrical Anesthesia Care", and "A Multi-faceted but Context-Specific Solution is Required." The physicians identified barriers within the greater context of those encountered during the provision of anesthesia services in the periphery, including lack of time, need for continuing medical education (CME), need for hospital infrastructure support to develop and implement best practice protocols, and need for resources and anesthesia mentorship supports from the system. Difficulties were greatest for FP/GP anesthetists in rural communities who described lack of locums, need for relevant CME, and worsening physician shortages threatening provision of services in some rural hospitals. Family practitioner anesthetist multi-taskers were described as the best solution to the provider shortage in rural communities. Participants described the need for increased numbers of FP/GP anesthetists and the development of formal funded networks for knowledge transfer between academic and community hospitals as a mechanism to provide supports. CONCLUSIONS: Physicians in community hospitals face significant barriers in the provision of obstetrical anesthesia care. These are greatest among FP/GP anesthetists and in rural hospitals where physician shortages and lack of supports threaten provision of services in some hospitals. Local context-specific and systems-level solutions are required.

The experiences of socioeconomically disadvantaged postpartum women in the first 4 weeks at home.

We used a qualitative descriptive approach to explore and describe the situated experiences of socioeconomically disadvantaged (SED) postpartum women in the first 4 weeks after hospital discharge. Qualitative content analysis was used to analyze the data from in-depth interviews with 24 SED postpartum women. Two intertwining, overarching themes emerged: (a) the ongoing burden of their day-to-day lives, with subthemes of poverty and material deprivation, stigmatization through living publicly examined lives, and precarious social support; and (b) the ongoing struggles to adjust to changes that came with the baby's arrival, with subthemes of "the first weeks were hard," "feeling out of control," "absence of help at home," "complex relationship with the baby's father," and "health and well-being." Knowledge of SED women's situated experiences is vital to the development of health policies and services that will truly meet their needs.

Urban women's socioeconomic status, health service needs and utilization in the four weeks after postpartum hospital discharge: findings of a Canadian cross-sectional survey.

BACKGROUND: Postpartum women who experience socioeconomic disadvantage are at higher risk for poor health outcomes than more advantaged postpartum women, and may benefit from access to community based postpartum health services. This study examined socioeconomically disadvantaged (SED) postpartum women's health, and health service needs and utilization patterns in the first four weeks post hospital discharge, and compared them to more socioeconomically advantaged (SEA) postpartum women's health, health service needs and utilization patterns. METHODS: Data collected as part of a large Ontario cross-sectional mother-infant survey were analyzed. Women (N = 1000) who had uncomplicated vaginal births of single 'at-term' infants at four hospitals in two large southern Ontario, Canada cities were stratified into SED and SEA groups based on income, social support and a universally administered hospital postpartum risk screen. Participants completed a self-administered questionnaire before hospital discharge and a telephone interview four weeks after discharge. Main outcome measures were self-reported health status, symptoms of postpartum depression, postpartum service needs and health service use. RESULTS: When compared to the SEA women, the SED women were more likely to be discharged from hospital within the first 24 hours after giving birth [OR 1.49, 95% CI (1.01-2.18)], less likely to report very good or excellent health [OR 0.48, 95% CI (0.35-0.67)], and had higher rates of symptoms of postpartum depression [OR 2.7, 95% CI(1.64-4.4)]. No differences were found between groups in relation to self reported need for and ability to access services for physical and mental health needs, or in use of physicians, walk-in clinics and emergency departments. The SED group were more likely to accept public health nurse home visits [OR 2.24, 95% CI(1.47-3.40)]. CONCLUSION: Although SED women experienced poorer mental and overall health they reported similar health service needs and utilization patterns to more SEA women. The results can assist policy makers, health service planners and providers to develop and implement necessary and accessible services. Further research is needed to evaluate SED postpartum women's health service needs and barriers to service use.