"And this is the life jacket, the lifeline they've been wanting": Participant perspectives on navigating challenges and successes of prescribed safer supply.

BACKGROUND: In 2021, 43% of drug toxicity deaths in Ontario were reported by public health units serving medium-sized urban and rural communities. Safer supply programs (SSPs) have been primarily established in large urban centres. Given this, the current study is based on an evaluation of a SSP based in a medium-sized urban centre with a large catchment area that includes rural and Indigenous communities. The aim of this research paper is to understand the challenges and successes of the nurse practitioner-led SSP from the perspective of program participants. METHODS: Interpretive description was used to understand the experiences of 14 participants accessing a SSP. Each participant was interviewed using a semi-structured approach, and 13 of the interviewees also completed surveys accessed through Qualtrics. An iterative process using NVivo software was used to code interviews, and a constant comparative data analysis approach was used to refine and categorize codes to themes. FINDINGS: Three overarching themes were the result of this analysis: feeling better, renewed hope, and safety. These three themes capture the experiences of participants in the SSP, including both the challenges and successes they faced. CONCLUSION: The findings and subsequent discussion focus on both the key best practices of the program, and areas for future development and improvement. Despite barriers to services, prescribed SSPs are improving the lives of people who use drugs, and the current outcomes align with reports and evaluations from other SSPs across Canada.

Developing guideline-based quality indicators: assessing gaps in pain management practice.

AIM: In this article, the authors discuss a multiphase approach for developing quality indicators based on pain practice guidelines, and the challenges associated with the process. The presentation is based on previously published reporting standards for guideline-based quality indicators. METHODS: The following steps of the indicator development process were undertaken: topic selection; guideline selection; extraction of recommendations; quality indicator selection and practice test. RESULTS: Eleven practice guidelines were reviewed for quality, and three high-quality guidelines were compared for pertinent recommendations. From these three guidelines, 12 recommendations were extracted and judged appropriate to examine the practice gap for nursing students and clinicians on an oncology and palliative care unit. Quality indicators were then identified by a consensus process, resulting in 24 discrete indicators that were included in the practice test. CONCLUSION: Quality indicators can be used to examine gaps in pain management practice, and to evaluate change after guideline implementation. However, their development can be challenging, and guideline developers could facilitate uptake of guidelines by including clear, relevant quality indicators as part of guideline creation and presentation.

Transition to NCLEX-RN: Reflections from a CASN Past President.

Each president of CASN has one "issue" on which he or she focuses most during the presidency - for me, it was the NCLEX. Canadian nursing graduates first wrote the NCLEX for entry to practice in 2015. Failure rates were significantly higher than for the previous exam - the CRNE. Although the pass rates have improved, this is likely a result of better practice for writing this type of test. Apprehensions remain about the negative impact of the Americanization of our Canadian nursing curriculum and the damage that this examination appears to be doing to present and future francophone nurses.

Factors influencing adherence to regular exercise in middle-aged women: a qualitative study to inform clinical practice.

BACKGROUND: About half of women decrease their regular exercise during middle age. Concurrently, they experience a reduction in basal metabolic rate and loss of lean muscle as they transition to menopause. The combined effects place these women at increased risk for body weight gain and associated co-morbidities. Further research is required to better assess their barriers to regular exercise and to develop more applied knowledge aimed to improve the applicability of clinical interventions aimed at this population. The main aim of this study was to identify enablers and barriers influencing adherence to regular exercise in middle-aged women who exercise. METHODS: An interpretive description qualitative study was conducted using individual interviews. The two key questions were focused on planning to engage in physical activity and succeeding or planning to engage in physical activity and not succeeding. Inductive content analysis was used. RESULTS: Fifty-three women interviewed were aged 40-62 years and experiencing mild to moderate menopausal symptoms. Six broad themes influencing adhering to regular exercise were: routine, intrinsic motivation, biophysical issues, psychosocial commitments, environmental factors, and resources. Common sub-themes were identified as enabling factors: daily structure that incorporated physical activity (broad theme routine), anticipated positive feelings associated with physical activity (intrinsic), and accountability to others (psychosocial). Other common sub-themes identified as barriers were disruptions in daily structure (routine), competing demands (routine) and self-sacrifice (psychosocial). CONCLUSIONS: The most common barrier middle-aged women describe as interfering with adhering to regular exercise was attributable to the demands of this life stage at home and with others. Lack of time and menopausal symptoms were not identified as the common barriers. To support women to adhere to regular exercise, healthcare professionals should consider a narrative approach to assessing barriers and focus on enablers to overcoming identified barriers.

Effect of nurse practitioner and pharmacist counseling on inappropriate medication use in family practice.

OBJECTIVE: To measure the effect of nurse practitioner and pharmacist consultations on the appropriate use of medications by patients. DESIGN: We studied patients in the intervention arm of a randomized controlled trial. The main trial intervention was provision of multidisciplinary team care and the main outcome was quality and processes of care for chronic disease management. SETTING: Patients were recruited from a single publicly funded family health network practice of 8 family physicians and associated staff serving 10 000 patients in a rural area near Ottawa, Ont. PARTICIPANTS: A total of 120 patients 50 years of age or older who were on the practice roster and who were considered by their family physicians to be at risk of experiencing adverse health outcomes. INTERVENTION: A pharmacist and 1 of 3 nurse practitioners visited each patient at his or her home, conducted a comprehensive medication review, and developed a tailored plan to optimize medication use. The plan was developed in consultation with the patient and the patient's doctor. We assessed medication appropriateness at the study baseline and again 12 to 18 months later. MAIN OUTCOME MEASURES: We used the medication appropriateness index to assess medication use. We examined associations between personal characteristics and inappropriate use at baseline and with improvements in medication use at the follow-up assessment. We recorded all drug problems encountered during the trial. RESULTS: At baseline, 27.2% of medications were inappropriate in some way and 77.7% of patients were receiving at least 1 medication that was inappropriate in some way. At the follow-up assessments these percentages had dropped to 8.9% and 38.6%, respectively (P < .001). Patient characteristics that were associated with receiving inappropriate medication at baseline were being older than 80 years of age (odds ratio [OR] = 5.00, 95% CI 1.19 to 20.50), receiving more than 4 medications (OR = 6.64, 95% CI 2.54 to 17.4), and not having a university-level education (OR = 4.55, 95% CI 1.69 to 12.50). CONCLUSION: We observed large improvements in the appropriate use of medications during this trial. This might provide a mechanism to explain some of the reductions in mortality and morbidity observed in other trials of counseling and advice provided by pharmacists and nurses. TRIAL REGISTRATION NUMBER: NCT00238836 (ClinicalTrials.gov).

Cold therapy for the management of pain associated with deep breathing and coughing post-cardiac surgery.

BACKGROUND: Coughing has been identified as the most painful experience post cardiac surgery. METHODS: Participants (n = 32), in a randomized crossover trial, applied a frozen gel pack to their sternal incision dressing before performing deep breathing and coughing (DB & C) exercises. Pain scores from 0 to 10 at rest were compared with pain scores post DB & C with and without the gel pack. Participants were also asked to describe their sensations with the frozen gel pack, as well as their preferences for gel pack application. RESULTS: The repeated measures analysis of variance revealed a significant reduction in pain scores between pre- and post-application of the gel pack (F = 28.69, p < .001). There were 22 (69%) participants who preferred the application of the gel pack compared with no gel pack. All 32 (100%) participants would reapply the gel pack in the future. CONCLUSION: This study demonstrates that cold therapy can be used to manage sternal incisional pain when DB & C.

Evaluation of a natural health product decision aid: a tool for middle aged women considering menopausal symptom relief.

OBJECTIVE: To evaluate the effectiveness of a self-administered decision aid for menopausal women facing decisions about natural health products. STUDY DESIGN: This pre-/post-test study included peri- or post-menopausal women, aged 45-64 considering the use of a natural health product for management of menopausal symptoms. They were recruited from a Women's Health Center. OUTCOME MEASURES: The primary outcome was decisional conflict and secondary outcomes included knowledge, strength of values, and decision preference. RESULTS: Of 24 women, the typical participant was 50-64 years of age, Caucasian, married, and well educated. Compared to baseline, after using the decision aid, women's total decisional conflict was reduced from 63% to 24% (p<0.001) and knowledge improved from 76% to 87% (p=0.001). Of the 24 women, 10 were unsure of their choice at baseline and 3-post use of the decision aid (p=0.015). There was a trend for women preferring natural health products (n=12) to be more likely to rate the non-chemical aspect as important and the cost of the natural health product as less important; women who preferred not to take natural health products (n=3) rated the non-chemical aspect as less important and the costs as more important. CONCLUSIONS: The natural health product decision aid improved the quality of decisions by enhancing knowledge and reducing decisional conflict. As well, women were more likely to make a choice that was consistent with their values.

Cultural syndromes and age moderate the emotional impact of illness intrusiveness in rheumatoid arthritis.

OBJECTIVE: The authors investigated cultural syndromes (multidimensional vectors comprising culturally based attitudes, values, and beliefs) and age as moderators of the emotional impact of illness intrusiveness--illness-induced lifestyle disruptions--in rheumatoid arthritis (RA) and examined illness intrusiveness effects in total and separately for three life domains (relationships and personal development, intimacy, and instrumental). RESEARCH METHOD/DESIGN: People with RA (n = 105) completed the Illness Intrusiveness Ratings, Individualism-Collectivism, and Center for Epidemiologic Studies--Depression scales in a one-on-one interview. RESULTS: Controlling for disease and background characteristics, the association between illness intrusiveness (total score and the Relationships and Personal Development subscale) and distress was inverse when young adults with RA endorsed high horizontal individualism. Illness intrusiveness into intimacy was associated with increased distress, and this intensified when respondents endorsed high vertical individualism, horizontal collectivism, vertical collectivism, or low horizontal individualism. The negative emotional impact of illness intrusiveness into intimacy diminished with increasing age. CONCLUSION: Given an aging and increasingly pluralistic society, diversity can no longer be ignored in addressing the psychosocial impact of chronic, disabling disease.

Fatigue and physical activity in older patients with cancer: a six-month follow-up study.

PURPOSE/OBJECTIVES: To determine the relationship between fatigue and physical activity in older patients with cancer. DESIGN: Targeted analysis using data from a prospective longitudinal study. SETTING: A cancer care facility in southeastern Ontario, Canada. SAMPLE: 440 patients, aged 65 years and older, seeking consultation for cancer treatment at a regional cancer clinic for lymphoma or leukemia or lung, breast, genitourinary, head or neck, gastrointestinal, or skin cancers. METHODS: Self-report questionnaires were mailed to consenting participants and completed at baseline and three and six months after consultation for cancer treatment. MAIN RESEARCH VARIABLES: Participants rated fatigue and physical activity and reported comorbidities and personal demographic characteristics. Clinical measures of disease and treatment factors were obtained through chart abstraction. FINDINGS: Fatigue was the most prevalent symptom reported. Higher fatigue was associated with lower physical activity levels. Physical activity level significantly predicted fatigue level, regardless of age. CONCLUSIONS: Physical activity level is a modifiable factor significantly predicting cancer-related fatigue at three and six months following consultation for cancer treatment. The results suggest that physical activity may reduce fatigue in older patients with cancer. IMPLICATIONS FOR NURSING: Physical activity interventions should be developed and tested in older patients with cancer.

A mixed methods pilot study with a cluster randomized control trial to evaluate the impact of a leadership intervention on guideline implementation in home care nursing.

BACKGROUND: Foot ulcers are a significant problem for people with diabetes. Comprehensive assessments of risk factors associated with diabetic foot ulcer are recommended in clinical guidelines to decrease complications such as prolonged healing, gangrene and amputations, and to promote effective management. However, the translation of clinical guidelines into nursing practice remains fragmented and inconsistent, and a recent homecare chart audit showed less than half the recommended risk factors for diabetic foot ulcers were assessed, and peripheral neuropathy (the most significant predictor of complications) was not assessed at all. Strong leadership is consistently described as significant to successfully transfer guidelines into practice. Limited research exists however regarding which leadership behaviours facilitate and support implementation in nursing. The purpose of this pilot study is to evaluate the impact of a leadership intervention in community nursing on implementing recommendations from a clinical guideline on the nursing assessment and management of diabetic foot ulcers. METHODS: Two phase mixed methods design is proposed (ISRCTN 12345678). Phase I: Descriptive qualitative to understand barriers to implementing the guideline recommendations, and to inform the intervention. Phase II: Matched pair cluster randomized controlled trial (n = 4 centers) will evaluate differences in outcomes between two implementation strategies. PRIMARY OUTCOME: Nursing assessments of client risk factors, a composite score of 8 items based on Diabetes/Foot Ulcer guideline recommendations. INTERVENTION: In addition to the organization's 'usual' implementation strategy, a 12 week leadership strategy will be offered to managerial and clinical leaders consisting of: a) printed materials, b) one day interactive workshop to develop a leadership action plan tailored to barriers to support implementation; c) three post-workshop teleconferences. DISCUSSION: This study will provide vital information on which leadership strategies are well received to facilitate and support guideline implementation. The anticipated outcomes will provide information to assist with effective management of foot ulcers for people with diabetes. By tracking clinical outcomes associated with guideline implementation, health care administrators will be better informed to influence organizational and policy decision-making to support evidence-based quality care. Findings will be useful to inform the design of future multi-centered trials on various clinical topics to enhance knowledge translation for positive outcomes.

A commentary on access to cardiovascular services: nursing roles and initiatives.

The Canadian Council of Cardiovascular Nurses (CCCN) applauds the work done by the Canadian Cardiovascular Society in setting benchmarks for wait times. The Canadian Cardiovascular Society is to be commended for developing the benchmark documents, as well as for establishing strategies for systematic dissemination to increase awareness, advocacy and implementation of the benchmarks across Canada. Quality nursing care, as defined within the CCCN framework, includes working with health teams to ensure that patients have timely access to specialized personnel, tests and procedures as required to prevent disease, promote health, address acute and episodic interventions, and to provide rehabilitative and palliative services, depending on patient need. To extend the access to care discussion, the CCCN suggests that further engagement of all stakeholders, especially clients/patients, is needed to find solutions to wait times and define benchmarks. In addition, preventing heart disease and promoting 'health care' should be recognized and acted on as central to reducing wait times for cardiovascular care. Finally, access to cardiovascular services will be more efficient when the first point of care is broadened to include nurses and other health care professionals. Nurses occupy creative, cost-effective roles directly aimed at reducing wait times and improving care while patients wait. The expanded role of interprofessional education and health care teams, as well as the inclusion of patients and families in program improvement, are solutions that the CCCN suggests may contribute to improved access to cardiovascular care and a sustainable health care system in Canada.

Developing a tool to measure contributions to medication-related processes in family practice.

Successful team care requires a shared understanding of roles and expertise. This paper describes the development and preliminary exploration of the psychometric properties of a tool designed to measure contributions to family practice medication-related processes. Our team identified medication-related processes commonly occurring in family practice. We assessed clinical appropriateness using a sensibility questionnaire and pilot-tested with 11 pharmacists, nurses and physicians. We performed a simulated exercise to group the processes and assessed the internal consistency of the groupings using Cronbach's alpha coefficient. We examined test-retest reliability using intra-class coefficient (ICC). Following three revisions, the final Medication Use Processes Matrix (MUPM) included 22 medication-related processes and scale descriptors reflecting contribution to each process. Mean sensibility ratings were high for each component. We developed five theoretical groupings (diagnosis & prescribing, monitoring, administrative/documentation, education, medication review) and found their overall internal consistency was good (alpha > 0.80). The test-retest reliability was strong (ICC > 0.80). Preliminary validation showed significant differences in how health professionals view interprofessional contributions toward medication-related processes. Interprofessional care requires a negotiated understanding of processes and contributions. The MUPM provides an explicit description of medication-related processes in primary care, measures perceived contributions and emerges as a new tool to measure collaborative care in family practices.

Fatigue and physical activity in older adults with cancer: a systematic review of the literature.

Cancer is a disease predominantly affecting older adults. Cancer fatigue is the most common and often most distressing symptom associated with cancer and its treatment, often persisting months to years after treatment. Untreated cancer fatigue may lead to significant reductions in physical activity, physical functioning, and quality of life and may interfere with patients' adherence to cancer treatment. Physical activity has the strongest supporting evidence as an intervention to reduce cancer fatigue, maintain physical function, and optimize quality of life. This article reviews the literature related to fatigue and physical activity in older adults with cancer. Nine experimental and 10 observational studies that enrolled subjects 65 years or older were synthesized in the review and provided evidence that physical activity may be an effective intervention for cancer fatigue in older adults. The generalizability of the findings to older adults was limited by the poor representation of this age group in the studies. Few studies provided an analysis of age-related effects of physical activity on fatigue, physical function, and quality of life.

Positron emission tomography: a study of PET test-related anxiety.

The objective of this study was to determine whether sending an information pamphlet to patients scheduled for a PET test two weeks prior to the appointment date significantly reduced patient anxiety and increased patient knowledge about the test. This study was conducted as a randomized controlled trial in which patients were randomly allocated to receive a mailed information pamphlet (intervention) or no mailed pamphlet two weeks prior to the appointment (usual care). The results of this study suggested that sending information pamphlets to patients scheduled for PET scans did not decrease pre-test levels of patient anxiety or result in increased patient knowledge about test preparation and procedures.

The efficacy of calcium carbonate in the treatment of protease inhibitor-induced persistent diarrhea in HIV-infected patients.

BACKGROUND: Although some evidence exists to support the practice of using calcium carbonate to treat nelfinavir-induced diarrhea, there is a lack of data supporting the role of calcium in diarrhea induced by other protease inhibitors (PIs). PURPOSE: The objective of this prospective open-label study is to evaluate the efficacy of calcium carbonate in the treatment of PI-induced persistent diarrhea in HIV-infected patients. METHOD: Along with dietary advice, patients were asked to take oral calcium carbonate 500 mg twice daily for 2 weeks. Visual Analog Scale (VAS) and the National Cancer Institute of Canada (NCIC) scale were used to assess the severity of diarrhea. Data were analyzed using paired t tests to test for differences in VAS and NCIC scores between baseline and 14 days. Pearson correlation was used to explore the relationships between change in diarrhea and patient baseline factors. RESULTS: At day 0, the mean VAS +/- standard deviation was 6.6 +/- 2.1 and decreased to 5.3 +/- 1.9 (p=.01) after 14 days. At day 0, the mean NCIC score was 1.9 +/- 0.8 and decreased to 1.2 +/- 0.9 (p=.005) after 14 days. No baseline patient factors predicted change in NCIC or VAS grade. CONCLUSION: Calcium carbonate is associated with a reduction of diarrhea in individuals with diarrhea induced by PI.