A phenomenological analysis of medical tourism: Investigating the lived experience of returning to Canada after osseointegration abroad.

BACKGROUND: Travel out of country for medical care is increasing for many reasons including costs, wait-lists, and availability of procedures. Until 2018, when the surgery was offered in only 1 province, Canadians with amputation wanting osseointegration (OI) had to travel out of country for the surgery. The purpose of this study was to understand the lived experience of accessing health care in Canada after having a procedure performed out of country. METHODS: This is a phenomenological study of persons with amputation who had OI outside of Canada. The grand tour interview question was "What was it like travelling to another country for OI surgery and then returning to access follow-up care in Canada?" RESULTS: There were 5 participants, and 5 themes emerged: (1) lack of support from Canadian physicians; (2) exceptional support from prosthetists and other members of the health care team; (3) continued reliance on the country where the procedure was initially performed; (4) self-advocacy for access to care; and (5) benefits of travelling outweighing the problems faced. CONCLUSIONS: These themes are not unique to OI, but to medical tourism as a whole. The lack of support was countered partly by a strong sense of self-advocacy from the participants and support from other members of the health care team.

A longitudinal view of factors that influence the emotional well-being of family caregivers to individuals with heart failure.

OBJECTIVES: Caring for community-residing patients with heart failure can affect caregivers' emotional wellbeing. However, few studies have examined caregivers' well-being longitudinally, or identified factors associated with positive and negative outcomes. The objective of this longitudinal cohort study was to examine changes in caregivers' well-being over time, and to identify patient and caregiver factors associated with positive and negative outcomes. METHOD: Fifty caregiver/heart failure patient dyads were recruited from an acute care facility and followed in the community. All participants completed surveys at hospital admission and 3, 6 and 12 months later. Caregivers completed assessments of depression symptoms and positive affect and standardized measures to capture assistance provided, mastery, personal gain, social support, participation restriction, and patients' behavioral and psychological symptoms. From patients, we collected demographic characteristics and health-related quality of life. Individual Growth Curve modelling was used to analyze the data. RESULTS: Caregivers' negative and positive emotions remained stable over time. Depression symptoms were associated with higher participation restriction in caregivers. Positive affect was associated with more personal gain and more social support. Patients' health-related quality of life and their behavioral and psychological symptoms were not significantly associated with caregivers' emotional outcomes. CONCLUSION: Interventions should be offered based on caregivers' needs rather than patients' health outcomes, and should focus on fostering caregivers' feelings of personal gain, assisting them with securing social support, and engaging in valued activities.

Developing leadership capacity for guideline use: a pilot cluster randomized control trial.

SIGNIFICANCE: The importance of leadership to influence nurses' use of clinical guidelines has been well documented. However, little is known about how to develop and evaluate leadership interventions for guideline use. PURPOSE: The purpose of this study was to pilot a leadership intervention designed to influence nurses' use of guideline recommendations when caring for patients with diabetic foot ulcers in home care nursing. This paper reports on the feasibility of implementing the study protocol, the trial findings related to nursing process outcomes, and leadership behaviors. METHODS: A mixed methods pilot study was conducted with a post-only cluster randomized controlled trial and descriptive qualitative interviews. Four units were randomized to control or experimental groups. Clinical and management leadership teams participated in a 12-week leadership intervention (workshop, teleconferences). Participants received summarized chart audit data, identified goals for change, and created a team leadership action. Criteria to assess feasibility of the protocol included: design, intervention, measures, and data collection procedures. For the trial, chart audits compared differences in nursing process outcomes. PRIMARY OUTCOME: 8-item nursing assessments score. Secondary outcome: 5-item score of nursing care based on goals for change identified by intervention participants. Qualitative interviews described leadership behaviors that influenced guideline use. RESULTS: Conducting this pilot showed some aspects of the study protocol were feasible, while others require further development. Trial findings observed no significant difference in the primary outcome. A significant increase was observed in the 5-item score chosen by intervention participants (p = 0.02). In the experimental group more relations-oriented leadership behaviors, audit and feedback and reminders were described as leadership strategies. CONCLUSIONS: Findings suggest that a leadership intervention has the potential to influence nurses' use of guideline recommendations, but further work is required to refine the intervention and outcome measures. A taxonomy of leadership behaviors is proposed to inform future research.

Exploring how IBCLCs manage ethical dilemmas: a qualitative study.

BACKGROUND: Professional health care practice should be based on ethical decisions and actions. When there are competing ethical standards or principles, one must choose between two or more competing options. This study explores ethical dilemmas experienced by International Board Certified Lactation Consultants. METHODS: The investigator interviewed seven International Board Certified Lactation Consultants and analyzed the interviews using qualitative research methods. RESULTS: "Staying Mother-Centred" emerged as the overall theme. It encompassed six categories that emerged as steps in managing ethical dilemmas: 1) recognizing the dilemma; 2) identifying context; 3) determining choices; 4) strategies used; 5) results and choices the mother made; and 6) follow-up. The category, "Strategies used", was further analyzed and six sub-themes emerged: building trust; diffusing situations; empowering mothers; finding balance; providing information; and setting priorities. CONCLUSIONS: This study provides a framework for understanding how International Board Certified Lactation Consultants manage ethical dilemmas. Although the details of their stories changed, the essence of the experience remained quite constant with the participants making choices and acting to support the mothers. The framework could be the used for further research or to develop tools to support IBCLCs as they manage ethical dilemmas and to strengthen the profession with a firm ethics foundation.

Impacting Canadian public health nurses' job satisfaction.

OBJECTIVE: Workforce recruitment and retention challenges are being experienced in public health as in other Canadian health sectors. While there are many nurses working in public health, little research has been done about their job satisfaction. Job satisfaction is linked to recruitment, retention and positive client outcomes. The purpose of this research was to examine the relationships between three modifiable work environment factors (autonomy, control-over-practice, and workload) and Canadian public health nurses' (PHNs) job satisfaction. METHODS: Data were from the 2005 National Survey of the Work and Health of Nurses (response rate, 79.7%; 18,676 nurses). Bivariate and multivariate logistic regression analyses were used for this secondary analysis. Findings were discussed with practicing PHNs, policy-makers and researchers from across Canada at a knowledge translation (KT) 'Think-Tank'. RESULTS: Among the 271 PHNs, 53.5% reported being 'very satisfied' with their jobs. The interaction between autonomy and workload was a significant predictor of PHNs' job satisfaction, (OR 0.97, 95% CI 0.96-0.99, p < 0.01) as was the interaction between age and workload (OR 1.01, 95% CI 1.00-1.01, p < 0.01). Think-Tank participants selected priority areas for application to public health practice, management and research. CONCLUSION: Despite being an important practice factor, this is the first study to reveal the negative influence of PHNs' autonomy when in interaction with an excessive workload. Significant workload findings and the presence of generational differences suggest the need for development of workload measurement tools and public health human resource strategies tailored to a multi-generational workforce.

Iatrogenic newborn weight loss: knowledge translation using a study protocol for your maternity setting.

BACKGROUND: In our original study of newborn weight loss, we determined there were positive correlations among newborn weight loss, neonatal output, and the IV fluids mothers received before their babies' birth. Basically, an increase in maternal IV fluids is correlated to an increase in neonatal output and newborn weight loss. When assessing newborn weight change, our recommendation is to change baseline from birth weight to a weight measured at 24 hours. The purpose of this paper is to provide a protocol for clinicians to collect and analyze data from their own maternity site to determine if the newborns experience such an iatrogenic weight loss and to make decisions about how to assess newborn weight changes. METHODS: We recommend a prospective observational study with data collected about maternal fluids, neonatal output, and newborn weight measurements. The methods we suggest include specifics about recruitment, data collection, and data analysis. DISCUSSION: Quality assurance and research ethics considerations are described. We also share practical information that we learned from our original study. Ultimately, to encourage knowledge translation and research uptake, we provide a protocol and sound advice to do a research study in your maternity setting.

An observational study of associations among maternal fluids during parturition, neonatal output, and breastfed newborn weight loss.

BACKGROUND: Newborn weight measurements are used as a key indicator of breastfeeding adequacy. The purpose of this study was to explore non-feeding factors that might be related to newborn weight loss. The relationship between the intravenous fluids women receive during parturition (the act of giving birth, including time in labour or prior to a caesarean section) and their newborn's weight loss during the first 72 hours postpartum was the primary interest. METHODS: In this observational cohort study, we collected data about maternal oral and IV fluids during labour or before a caesarean section. Participants (n = 109) weighed their newborns every 12 hours for the first three days then daily to Day 14, and they weighed neonatal output (voids and stools) for three days. RESULTS: At 60 hours (nadir), mean newborn weight loss was 6.57% (SD 2.51; n = 96, range 1.83-13.06%). When groups, based on maternal fluids, were compared (≤1200 mls [n = 21] versus > 1200 [n = 53]), newborns lost 5.51% versus 6.93% (p = 0.03), respectively. For the first 24 hours, bivariate analyses show positive relationships between a) neonatal output and percentage of newborn weight lost (r(96) = 0.493, p < 0.001); and b) maternal IV fluids (final 2 hours) and neonatal output (r(42) = 0.383, p = 0.012). At 72 hours, there was a positive correlation between grams of weight lost and all maternal fluids (r(75) = 0.309, p = 0.007). CONCLUSIONS: Timing and amounts of maternal IV fluids appear correlated to neonatal output and newborn weight loss. Neonates appear to experience diuresis and correct their fluid status in the first 24 hours. We recommend a measurement at 24 hours, instead of birth weight, for baseline when assessing weight change. Because practices can differ between maternity settings, we further suggest that clinicians should collect and analyze data from dyads in their care to determine an optimal baseline measurement.

Lactation and breastfeeding research studies: who should provide consent for the neonate?

Research ethics guidelines do not provide sufficient direction for breastfeeding and human lactation studies. This article presents the principles of consent for research studies and discusses rationales for who should consent for infants in lactation and breastfeeding research studies.

Telehome monitoring in patients with cardiac disease who are at high risk of readmission.

Patients with chronic conditions are heavy users of the health care system. There are opportunities for significant savings and improvements to patient care if patients can be maintained in their homes. A randomized control trial tested the impact of 3 months of telehome monitoring on hospital readmission, quality of life, and functional status in patients with heart failure or angina. The intervention consisted of video conferencing and phone line transmission of weight, blood pressure, and electrocardiograms. Telehome monitoring significantly reduced the number of hospital readmissions and days spent in the hospital for patients with angina and improved quality of life and functional status in patients with heart failure or angina. Patients found the technology easy to use and expressed high levels of satisfaction. Telehealth technologies are a viable means of providing home monitoring to patients with heart disease at high risk of hospital readmission to improve their self-care abilities.

Physiological weight loss in the breastfed neonate: a systematic review.

BACKGROUND: Healthy, full-term, exclusively breastfed infants are expected to lose weight in the first days following birth. There are conflicting opinions about what constitutes a normal neonatal weight loss, and about when interventions such as supplemental feedings should be considered. OBJECTIVE: To establish the reference weight loss for the first 2 weeks following birth by conducting a systematic review of studies reporting birth weights of exclusively breastfed neonates. METHODS: We searched 5 electronic databases from June 2006 to June 2007: the Cochrane Database of Systematic Reviews; MEDLINE (from 1950); CINAHL (from 1982); EMBASE (from 1980); and Ovid HealthSTAR (from 1999). We included primary research studies with weight loss data for healthy, full-term, exclusively breastfed neonates in the first 2 weeks following birth. RESULTS: Eleven studies met the inclusion criteria. Definitions, types of measurements, and reporting styles varied among studies. In most studies, daily weights were not measured and measurements did not continue for 2 weeks. Mean weight loss ranged from 5.7% to 6.6%, with standard deviations around 2%. Median percentage weight loss ranged from 3.2 to 8.3, with the majority around 6%. The majority of infants in these 11 studies regained their birth weight within the first 2 weeks postpartum. The second and third days following birth appear to be the days of maximum weight loss. DISCUSSION: Methods used to report weight loss were inconsistent, using either an average of single lowest weights or a combination of weight losses. The 7% maximum allowable weight loss recommended in 4 clinical practice guidelines appears to be based on mean weight loss and does not account for standard deviation. Further research is needed to understand the causes of neonatal weight loss and its implications for morbidity and mortality.

The use of meta-synthesis in cardiovascular nursing research.

Guidelines for critiquing systematic reviews and meta-syntheses are presented in Polit and Beck's (2008) most recent research text. These have been loosely used to review the two study examples. Although the study by Lefler and Bondy (2004) is titled a meta-synthesis, it is clearly an integrative review and, thus, helps to illustrate the similarities and differences between these two approaches. The Paterson study (2001) suffers, as many qualitative reports do, from a restriction on length, making it difficult to completely assess all aspects of the study. Having said this, the purpose of Paterson's study could have been stated more clearly and the search strategy and inclusion/exclusion criteria could have been more explicit. In both reviews, issues of quality appraisal should have been dealt with in more detail, or reasons for not undertaking a quality appraisal discussed. While Paterson discusses at length the "state of the knowledge" in meta-synthesis, her description of the actual analysis done was very brief. Neither of the studies specifically addressed issues of rigour and Lefler and Bondy only briefly discussed study limitations. No limitations were discussed in the Paterson paper (2001). There are limitations to all research studies and it is important to interpret a study's findings while acknowledging how the limitations affect their interpretation. Lefler and Bondy identify three types of factors that may delay treatment-seeking in women who have had a myocardial infarction and have suggested further research that should be undertaken. Paterson (2001) has proposed a model of chronic illness that can assist nurses in supporting patients with chronic illness. Two studies of potential interest to cardiovascular nurses have been used to illustrate a relatively new research method -- meta-synthesis. Although there are still many methodological questions, the body of knowledge about meta-synthesis is sufficiently developed and documented to permit both novice and experienced researchers to undertake one. Meta-synthesis is an important way of making the large body of qualitative nursing research available to practising nurses and policymakers, as well as generating higher levels of understanding about phenomena of interest to nursing science.

Randomized controlled trial to determine effects of prenatal breastfeeding workshop on maternal breastfeeding self-efficacy and breastfeeding duration.

OBJECTIVE: To determine the effects of a prenatal breastfeeding workshop on maternal breastfeeding self-efficacy and breastfeeding duration. DESIGN: Randomized controlled trial. SETTING: Large tertiary hospital in Ontario, Canada. PARTICIPANTS: 110 primiparous women expecting a single child, an uncomplicated birth, and planning to breastfeed. INTERVENTION: 2.5-hour prenatal breastfeeding workshop based on adult learning principles and self-efficacy theory. MAIN OUTCOME MEASURE: Maternal breastfeeding self-efficacy and the numbers of days and amount of breastfeeding were measured at four and eight weeks postpartum. RESULTS/DATA ANALYSIS: Over time, maternal breastfeeding self-efficacy scores increased in both groups. Women who attended the workshop had higher self-efficacy scores and a higher proportion were exclusively breastfeeding compared to women who did not attend the workshop. There was little difference in the average number of days of breastfeeding, but the intervention group had less weaning. CONCLUSIONS: The workshop increased maternal breastfeeding self-efficacy and exclusive breastfeeding.

Gender of the care environment: influence on recovery in women with heart disease.

UNLABELLED: Women experience higher levels of distress than men (depression, anxiety, poor quality of life) after a first myocardial infarction. Sex differences in distress are not present in predominantly female diseases such as arthritis. This study explored the possibility that the predominantly male treatment environment for heart disease accounted for some of the sex differences in distress. METHODS: Men and women who had experienced a first-MI were asked to complete the Bem Sex Role Inventory (BSRI), a modified version of the Moos Ward Atmosphere Scale (WAS) and measures of illness intrusiveness, depression, anxiety and quality of life. Gender syntony was defined as a match between patient gender (BSRI) and the perceived gender of the treatment environment (WAS). RESULTS: Women experienced higher levels of distress than men and were more likely to experience discordance between their gender and the perceived gender of the care environment (73% of women versus 32% of men). The presence of gender dystony (a mismatch between gender and treatment environment) was related to higher levels of illness intrusiveness and overall distress. CONCLUSIONS: Modification of the heart disease treatment environment so that it better meets the needs of women may reduce sex differences in distress.