An evaluation of the effectiveness of engaging Canadian clients as partners in in-home care.

This exploratory quasi-experimental evaluation assessed the effectiveness of the use of a concrete discussion guide to promote organisation-wide application of a partnering approach to engage older home-care clients with chronic disease/disabilities as care partners. A post-test-only design with an independent pre-test sample was used to compare selected outcomes with those of standard in-home care. The theoretically informed discussion guide portrayed how to go about the process of empowering partnering by using language and open-ended conversational leads to construct partnering, partnering effort and health as a resource for everyday living through social interaction. The discussion guide was provided to all providers for use with all clients in one home-care programme in Ontario, Canada and this organisation was compared with a similar but geographically distanced organisation, also in Ontario. Seven hundred and ninety-one randomly selected clients (mean age = 72.5 years) receiving 3+ months of in-home care for chronic conditions/disabilities from the two home-care programmes between September 2007 and May 2010 completed a researcher-administered questionnaire at either baseline, 1 year or 2 years. Instruments included the Client's Partnering Experience, Health-Promoting Partnering Effort, a modified version of Locus of Authority in Decision-Making, the Medical Outcomes Survey Self-Rated Health Scale, Health and Social Services Utilization and a modified Functional Independence Measure. Analysis of covariance revealed that the use of the concrete discussion guide to promote organisation-wide application of a partnering approach achieved significantly greater client partnering experience and health-promoting partnering effort over time than did the usual approach to in-home-care interactions. Using the discussion guide enhanced client/provider partnering, hence, interdependence, contributing positively to promoting clients' health as a resource for everyday living.

Evolving the delivery of acute care services in the home.

To serve escalating acute care caseloads, physicians affiliated with one Canadian home care program have piloted a project to integrate physician services into the home (IPSITH). This paper presents the 18-month qualitative evaluation. Phenomenological methodology and in-depth interviewing were used to construct a holistic interpretation of the implementation from the experiences of all involved: patients, family caregivers, physicians, case managers, community nurses and the project's nurse practitioner. Findings revealed the central role of the nurse practitioner, who served as a clinical expert, care coordinator and case manager. Several unsolved issues were identified: the extent to which home care is a viable alternative to hospitalization, the feasibility of physician involvement, redundancies with hospital emergency services, and the limitations of system resources for funding such services. The researchers conclude that full-scale long-term integration of physician services in the home may require macro-level decisions about system design, resource allocation, and professional regulations.

The experience of empowerment in in-home services delivery.

In-home health services strive for client-centredness, involvement, and ultimately, empowerment, but economic constraint may undermine these aims. The purpose of this study was to explore the everyday experience of in-home care, with particular attention to the enactment of empowerment in the care partnership. In-depth interviews with a maximally varied sample of clients, informal caregivers, and providers uncovered relationships largely reflecting the traditional expert model of care. Findings afford insights into the unrecognized and undervalued personal knowledge of clients, caregivers, and in-home service providers, the professional and structural hegemony and consequent disempowered group behaviour of those who share the experience of care, and the hesitance of clients to engage as equitable partners in care. Strategies to achieve empowerment approaches to in-home health services are identified.

Work in progress. Integrating physicians' services in the home.

OBJECTIVE: While increasing acuity levels and the concomitant complexity of service demand that physicians be involved in in-home care, conflicting evidence and opinions do not show how this can best be achieved. DESIGN: A phenomenologic research design was used to obtain insights into the challenges and opportunities of integrating physicians' services into the usual in-home services in London, Ont. SETTING: Home care in London, Ont. PARTICIPANTS: Twelve participants included three patients, two family caregivers, two family physicians, the program's nurse practitioner, two case managers, and two community nurses. METHOD: In-depth interviews with a maximally varied purposeful sample of patients, caregivers, and providers were analyzed using immersion and crystallization techniques. MAIN FINDINGS: Findings revealed the potential for enhanced continuity of care and interdisciplinary team functioning. Having a nurse practitioner, interdisciplinary team-building exercises and meetings, regular face-to-face contact among all providers, support for family caregivers, and 24-hour coverage for physicians were found to be essential for success. CONCLUSION: Integration of services takes time, money, and sustained commitment, particularly when undertaken in geographically isolated communities. Informed choice and a fair remuneration system remain important considerations for family physicians.

Breast cancer patients' experiences of patient-doctor communication: a working relationship.

The traumas of diagnosis and treatment for breast cancer are well researched and generally addressed in care. While women with breast cancer continue to identify the need for better communication with physicians, studies to date have not investigated how the process of communication between physicians and women with breast cancer actually unfolds. This phenomenological study therefore explored how women with breast cancer experience patient-physician communication to gain a greater understanding of effective approaches. Interviews of a purposeful sample of 11 women within 6 months of initial diagnosis or recurrence of breast cancer were audiotaped, transcribed verbatim and analyzed using inductive interpretation. Themes and patterns of positive and negative experiences emerged. All experiences began with the woman's feeling of vulnerability. In positive experiences, information sharing and relationship building were inextricably linked components of a working relationship which was at the same time affective, behavioural and instrumental. This experience, in turn, influenced the woman's experience of control and mastery of the illness experience, and their experience of learning to live with breast cancer. Findings illuminate the importance of comprehensively patient-centred, working relationships. Several specific techniques to enhance effective communication are identified.

Case management approaches for in-home care.

Restructuring healthcare delivery systems within limited budgets presents multiple management challenges. As hospitals have downsized, the demand for in-home services has increased. The involvement of multiple provider agencies and professionals has heightened duplication and fragmentation of services and has complicated the need to develop client-focused, evidence-based approaches. In response to these challenges, community-based case management has burgeoned.

The effects of family nursing and family medicine clinical rotations on nursing and medical students' self-efficacy for health promotion counseling.

The effects of community-based family nursing and medicine clinical rotations on students' confidence in their knowledge and ability to counsel clients in selected health promotion areas were examined from the perspective of Bandura's (1986) self-efficacy theory. Nursing students (n=66) enrolled in a community family nursing course and medical students (n=71) enrolled in a 6-week family practice clerkship rotation completed questionnaires at three points: prior to, at completion of, and 3 months following their clinical rotations. Nursing and medical students' self-efficacy levels at pretest were similar. At-posttest, nursing students' self-efficacy was significantly higher than that of the medical students. This difference was sustained at 3 months follow up. Students' conception of health (clinical vs. nonclinical) did not have an effect on posttest self-efficacy levels. Self-efficacy scores accounted for 63% of the variance in the nursing students' self-reported use of health promotion principles in their daily practice; but only 11% of the variance in medical students' daily practice. The results of this exploratory study provide information to guide theory-informed curricular decisions to design clinical learning activities that foster the development of health promotion counseling skills in both nursing and medical students.

Mother-loss: recreating relationship and meaning.

The purpose of this investigation was to describe adult women's experiences in losing their mother. Using an interpretive phenomenological frame of inquiry, 5 women were purposively selected to share their loss experience. Memories of the mother-daughter relationship were explored, and the meanings the daughters attached to their loss described, in written narratives, 2 in-depth interviews, and 1 group session. Seven themes emerged: Recalling, Holding On, Saying Goodbye, Longings of the Heart, Shifting Patterns of Relationship, Recreating the Dialogue, and Honouring Our Mothers/Ourselves. The loss of one's mother represents the loss of one's first intimate relationship, a relationship that has a unique meaning for daughters because their personal development is profoundly and uniquely shaped by it. This potentially pervasive and transforming life experience is best understood from an in-depth exploration and understanding of the nature of the mother-daughter relationship. Nurses who come to understand the dynamic interaction of grief and development through women's experience of mother-loss can more successfully offer their presence, their understanding of the complexity of the mother-daughter relationship, and their skills in bereavement care to facilitate healing and to promote health and personal growth.

Using the patient-centered method to achieve excellence in care for women with breast cancer.

The diagnosis of breast cancer remains one of the most threatening and emotionally debilitating diagnoses given to patients. Breast cancer elicits fears of loss of ability, control, hope, and at worst--loss of life. Patients and their families, devastated by the diagnosis of cancer, often feel unsupported or dismissed by their health care providers. Using the example of breast cancer, this paper describes how the application of the patient-centred clinical method can assist physicians in caring for patients diagnosed with breast cancer. Composite cases and quotes drawn from qualitative research studies with breast cancer patients are used to illustrate the application of the patient-centred clinical method.

Bridging town and gown: building research partnerships between community-based professional providers and academia.

Strategic research partnerships between community-based professionals and academic researchers are increasingly recognized as a means of evolving evidence-based practice and policy directions in health services delivery. Many barriers impede collaboration, however, and information on how to successfully implement collaborative partnerships is scattered, leaving much to trial and error. This article describes the process of achieving a successful research partnership among community-based home care professionals and academic researchers during a 6-year period of collaboration. The case illustration portrays how to identify and motivate the right research partners, how to mobilize resources, how to sustain an effective partnership process during the lengthy time commitments required to complete research, and how to ensure the experience of return on investment of time, energy, and resources in the partnership process. As measured by the outcomes of their collaborative research experience, the authors conclude that the benefits of bridging town and gown greatly outweigh the challenges of research partnerships.

Barriers and facilitators to seniors' independence. Perceptions of seniors, caregivers, and health care providers.

OBJECTIVE: To identify barriers and facilitators to independence as perceived by seniors with chronic health problems and their caregivers. In particular, researchers sought insights into seniors' experience of medical, home-based, and public health services. DESIGN: This study used the qualitative method of focus groups. SETTING: London, Ont, and surrounding area. PARTICIPANTS: Seniors with chronic health problems and informal and formal caregivers were purposefully selected to participate. METHOD: Seven focus groups composed of seniors, informal caregivers, and health care providers representing each of the three primary care areas (medical, home-based, and public health) explored the barriers and facilitators to seniors' independence. MAIN FINDINGS: Four main themes characterized the barriers and facilitators to seniors' independence: attitudes and attributes, service accessibility, communication and coordination, and continuity of care. CONCLUSIONS: Knowledge of barriers and facilitators to seniors' independence in the context of the health care system provides insight into how seniors can be empowered to remain independent. Health care providers need to communicate better, to foster more positive attitudes toward aging, and to participate in refining service access, coordination of services, and continuity of care.

Cancer in remission. Challenge in collaboration for family physicians and oncologists.

OBJECTIVE: To explore oncologists' perspectives on the process of cancer patient follow up and to identify what oncologists need from family physicians during the remission stage of cancer disease. DESIGN: Qualitative study with in-depth interviews. SETTING: Regional cancer centre serving a catchment area of 1.4 million people. PARTICIPANTS: A purposive sample of 10 oncologists. One was unable to participate because of sabbatical leave. The nine who participated represented both radiation and medical oncology. Oncologists who had practised at the cancer centre for less than 2 years were excluded from the study. MAIN OUTCOME MEASURES: Existing barriers to communication and collaboration between oncologists and family physicians in cancer patient follow up. RESULTS: Oncologists described roles for themselves in reassuring patients, detecting recurrence, monitoring toxicity of treatment, and gathering data for clinical trials. Collaboration with family physicians in the remission phase was identified as desirable but inhibited by variable and unpredictable interest, poor communication with family physicians, and patients' own preferences for follow up. Oncologists perceived the cancer system structure as a "black box" within which multidisciplinary teams worked well but seldom included family physicians. Oncologists expressed a need to see healthy patients and to have more understanding and support from family physicians, preferably through sharing follow-up care. Developing dialogue and a more collaborative approach were suggested. CONCLUSIONS: Family physicians should maintain a role in remission follow-up. However, a more collaborative approach with oncologists is warranted. Communication barriers, patient preferences, and misperceptions between groups must be addressed before roles are redefined.

Considering nursing resource as "caring time'.

The present constrained economic climate faced by health care agencies underscores the need for nurse administrators to have an in-depth appreciation of how nursing services are being used. The purpose of this investigation was to increase the understanding of nursing as a resource. Using phenomenological research methodology, the investigator purposefully selected six patients and a chain sample of 14 professionals responsible for their care, including nurses, nurse managers and physicians. Data collection methods included in-depth interviews, document reviews, and participant observation. The inductive interpretation depicts the nature of nursing resource to be "caring time'. Caring was understood primarily in terms of time and was experienced by all participants as "spending time'. Caring time was spent through "being with' and "doing to/doing for' the patient. Study participants experienced tension with regard to how best to spend precious "caring time'. Nursing resource was inextricably linked to both quantitative and qualitative expressions of nursing, and "being with' patients was a highly valued, under-allocated, and unintentionally provided component of nursing resource. The researcher concluded that nursing administrators, nurse managers and practitioners all have leadership roles to play in achieving recognition, allocation and promotion of caring time within their agencies.

Creating health with chronic illness.

Within the current context of health care, health promotion for individuals with chronic illness often reflects the priorities of disease-specific preventive care needs and related physical, social, emotional, and spiritual well-being. This article reports a phenomenological study of how older people with chronic illness experience health and health promotion and illuminates a different perspective of health resources and strategies. The findings have profound implications for nursing practice and theory, suggesting the need for restructuring work assignments and refocusing nursing care more clearly away from the medical model.

Evolving an empowering approach to continuous quality improvement in home care.

Theory suggests that in an "empowering" organization all individuals assume genuine decision-making roles and control over their work. Unfortunately, many organizations actually stifle empowerment through creating new bureaucratic barriers as they implement structures to deploy quality management principles. The Oxford County Home Care Program describes how it redesigned its organizational structure to facilitate empowerment.

Managing patient discharge to home: the challenges of achieving quality of care.

Discharging older patients from hospital to care at home presents considerable challenges for those concerned about the current mandate of quality management. A great many professionals with different priorities and organizational commitments are involved. The policies and procedures of at least two agencies, a hospital and a home care agency, play a role in shaping the whole process. The purpose of this study was to explore and describe factors other than medical condition and treatment which shaped the quality of the discharge experiences of older patients. Qualitative research methodology was used to document the discharge process from the perspective of 12 rural and nine urban patients, and a purposeful sample of 22 family caregivers and 117 professionals involved in their care. As well, 24 agency administrators with an overview of related policies and procedures provided data. Findings provide an in-depth description of the different implementation approaches and related quality issues in rural and urban settings. Quality management was undermined by role confusion, compromised and overly zealous pursuit of efficiency, fragmented work, variable physician practice style, and communication and coordination problems. Several readily implemented solutions to these problems are recommended. The implications of the more difficult leadership challenges related to achieving reasonable efficiency and maintaining a humane orientation in the complex care system are addressed.

Keeping it secret: the costs and benefits of nursing's hidden work in discharging patients.

Workload analysts and nursing theorists alike continue their attempts to capture the hidden work of nursing, with varying degrees of success. An interpretative study of the process of discharging patients from hospital to care at home led to a new understanding of the context-related work which nurses do. Three components of context-related work were identified: working with the characteristics of bureaucracy; compensating for bureaucracy on behalf of the health care team; and providing leadership which ensured effective care from others. All constituted invaluable yet obscured and unrecognized components of nursing's indirect contribution to patient care. The costs to keeping this work 'secret' were readily apparent. The understanding derived from this research affords new insights into why nursing has kept this hidden work secret. These insights, in turn, help identify potential solutions for consideration by all concerned about nursing's professional role, status and identity.

A new perspective on threatened autonomy in elderly persons: the disempowering process.

This study explored factors other than medical condition and treatments which contributed to the discharge experiences of 12 rural and 9 urban patients. Interpretive research methodology included document review, observation and in-depth interviews of all key participants. The purposefully selected sample consisted of a total of 21 patients, 22 informal caregivers, and 117 professionals involved in the hospital and/or home setting. Findings document a new perspective on how patients and professionals together contribute to the patient's threatened autonomy. Lack of clarity about goals, aspirations, and purpose in life and a generally negative frame of mind in the elderly combine with professional practice approaches to create a disempowering process. Faced with the biomedical orientation and paternalism of professionals, patients with a positive mindset and sense of direction and purpose in life did not experience threat to their autonomy. The researchers conclude that empowerment strategies must encompass a patient-centred approach, which includes an understanding of the patient's mindset, goals, aspirations, and sense of purpose within a larger life context. This consideration is essential to enable elderly patients to maintain autonomy despite continued health care requirements.

The challenging experience of palliative care support-team nursing.

The purpose of this study was to document the experience of palliative care nursing as a part of a multidisciplinary support team. Data were obtained from two palliative care support-team nurses. Each nurse privately recorded on audiotape any reflections about particularly meaningful aspects of her daily work experience; in-depth interviews with the two nurses together also were used for data collection. Inductive analysis elicited previously identified dimensions of palliative care nursing, including the support and coordination functions provided to other health professionals. The palliative care support-team experience included many challenges associated with the ultimate outcome of death; restricted and unpredictable time frames; and greater demands for human resources, psychosocial-care skills, and interdisciplinary, family-oriented care. These factors appeared to interact with the nurses' commitment by escalating their drive to serve others and creating both internal and external conflicts. The nurses expended considerable energy in role adaptation and in intrapersonal and interprofessional conflict management. This effort emerged as being vital to the nurses preserving their own integrity, both personally and professionally. The findings of this study may help all professionals who provide palliative care to better understand the nature of their work, themselves, and each other. Strategies to promote understanding may help to reduce the amount of time and energy that professionals must dedicate to preservation of integrity.

Health promotion. Strategies for family physicians.

The current emphasis on health promotion raises questions among experienced health professionals. Many wonder whether such care differs from what we have always done and have doubts about cost effectiveness and government motives. This paper explores the latest meaning of the term health promotion, the evolution of strategies to promote health, and the implications of these strategies for practising family medicine.