The relationship between patient experience and real-world digital health access in primary care: A population-based cross-sectional study.

Implementing digital health technologies in primary care is anticipated to improve patient experience. We examined the relationships between patient experience and digital health access in primary care settings in Ontario, Canada. We conducted a retrospective cross-sectional study using patient responses to the Health Care Experience Survey linked to health and administrative data between April 2019-February 2020. We measured patient experience by summarizing HCES questions. We used multivariable logistic regression stratified by the number of primary care visits to investigate associations between patient experience with digital health access and moderating variables. Our cohort included 2,692 Ontario adults, of which 63.0% accessed telehealth, 2.6% viewed medical records online, and 3.6% booked appointments online. Although patients reported overwhelmingly positive experiences, we found no consistent relationship with digital health access. Online appointment booking access was associated with lower odds of poor experience for patients with three or more primary care visits in the past 12 months (adjusted odds ratio 0.16, 95% CI 0.02-0.56). Younger age, tight financial circumstances, English as a second language, and knowing their primary care provider for fewer years had greater odds of poor patient experience. In 2019/2020, we found limited uptake of digital health in primary care and no clear association between real-world digital health adoption and patient experience in Ontario. Our findings provide an essential context for ensuing rapid shifts in digital health adoption during the COVID-19 pandemic, serving as a baseline to reexamine subsequent improvements in patient experience.

Crisis leadership behaviors in healthcare: survey validation and influence on staff outcomes in primary care clinics during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic triggered an unprecedented transition from in-person to virtual delivery of primary health care services. Leaders were at the helm of the rapid changes required to make this happen, yet outcomes of leaders' behaviours were largely unexplored. This study (1) develops and validates the Crisis Leadership and Staff Outcomes (CLSO) Survey and (2) investigates the leadership behaviours exhibited during the transition to virtual care and their influence on select staff outcomes in primary care. METHODS: We tested the CLSO Survey amongst leaders and staff from four Community Health Centres in Ontario, Canada. The CLSO Survey measures a range of crisis leadership behaviors, such as showing empathy and promoting learning and psychological safety, as well as perceived staff outcomes in four areas: innovation, teamwork, feedback, and commitment to change. We conducted an exploratory factor analysis to investigate factor structure and construct validity. We report on the scale's internal consistency through Cronbach's alpha, and associations between leadership scales and staff outcomes through odds ratios. RESULTS: There were 78 staff and 21 middle and senior leaders who completed the survey. A 4-factor model emerged, comprised of the leadership behaviors of (1) "task-oriented leadership" and (2) "person-oriented leadership", and select staff outcomes of (3) "commitment to sustaining change" and (4) "performance self-evaluation". Scales exhibited strong construct and internal validity. Task- and person-oriented leadership behaviours positively related to the two staff outcomes. CONCLUSION: The CLSO Survey is a reliable measure of leadership behaviours and select staff outcomes. Our results suggest that crisis leadership is multifaceted and both person-oriented and task-oriented leadership behaviours are critical during a crisis to improve perceived staff performance and commitment to change.

Preexisting Diabetes Mellitus and All-Cause Mortality in Adult Patients With Sepsis: A Population-Based Cohort Study.

OBJECTIVES: We assessed the association of preexisting diabetes mellitus with all-cause mortality and organ support receipt in adult patients with sepsis. DESIGN: Population-based cohort study. SETTING: Ontario, Canada (2008-2019). POPULATION: Adult patients (18 yr old or older) with a first sepsis-related hospitalization episode. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The main exposure of interest was preexisting diabetes (either type 1 or 2). The primary outcome was all-cause mortality by 90 days; secondary outcomes included receipt of invasive mechanical ventilation and new renal replacement therapy. We report adjusted (for baseline characteristics using standardization) risk ratios (RRs) alongside 95% CIs. A main secondary analysis evaluated the potential mediation by prior metformin use of the association between preexisting diabetes and all-cause mortality following sepsis. Overall, 503,455 adults with a first sepsis-related hospitalization episode were included; 36% had preexisting diabetes. Mean age was 73 years, and 54% of the cohort were females. Preexisting diabetes was associated with a lower adjusted risk of all-cause mortality at 90 days (RR, 0.81; 95% CI, 0.80-0.82). Preexisting diabetes was associated with an increased risk of new renal replacement therapy (RR, 1.53; 95% CI, 1.46-1.60) but not invasive mechanical ventilation (RR, 1.03; 95% CI, 1.00-1.05). Overall, 21% (95% CI, 19-28) of the association between preexisting diabetes and reduced risk of all-cause mortality was mediated by prior metformin use. CONCLUSIONS: Preexisting diabetes is associated with a lower risk of all-cause mortality and higher risk of new renal replacement therapy among adult patients with sepsis. Future studies should evaluate the underlying mechanisms of these associations.

Implementation and adaptation of a hub-based psychiatric and primary care program: A qualitative descriptive analysis of The Seamless Care Optimizing the Patient Experience (SCOPE) Mental Health program.

BACKGROUND: The Seamless Care Optimizing the Patient Experience (SCOPE)-Mental Health program is a comprehensive case management and psychiatric care initiative that supports primary care physicians in independent medical practices. This program offers a range of services that aims to enhance primary care capacity for mental health and provide accessible clinical care for patients. With its flexible hub-based approach, this program allows participating sites to tailor their implementation based on their available resources and specific needs within their community. OBJECTIVES: The aim of this quality improvement initiative was to investigate the evolution of this collaborative mental health model, focusing on specific site adaptations, local implementation challenges, and opportunities for ongoing development and sustainability across SCOPE sites in the Greater Toronto Area. METHOD: This evaluation employed a qualitative descriptive design where semi-structured interviews, guided by the Reach Effectiveness Adoption, Implementation, and Maintenance framework were conducted with staff from all 8 SCOPE-Mental Health sites. Site representatives were interviewed virtually between March and July 2023 and data were analyzed using qualitative content analysis. FINDINGS: The SCOPE-Mental Health model permits flexibility through specific local adaptations led by community need that leverage existing assets either at the site or within the individual community. Adoption by primary care physicians was crucial to program success and facilitated efficiency and interprofessional collaboration. Maintenance efforts included pathway refinement, and marketing and funding considerations. Challenges to program development included continuity of staff, physician compensation issues, and electronic health record interoperability. The SCOPE-Mental Health program fosters linkages among unaffiliated primary care offices, hospitals, and community-based resources to improve mental health care. Key recommendations include advocating for sustainable funding and facilitated mechanisms for psychiatric consultations. CONCLUSIONS: This initiative offers valuable insights for healthcare organizations seeking to develop similar programs, emphasizing the need for tailored approaches and ongoing evaluation to ensure a lasting impact in underserved communities.

Professional identity work of nurse practitioners and family physicians in primary care in Quebec and Ontario - a study protocol.

BACKGROUND: Solo medical practices in primary healthcare delivery have been abandoned in favor of interdisciplinary teamwork in most Western countries. Dynamics in interdisciplinary teams might however be particularly difficult when two or more autonomous health professionals develop similar roles at the practice level. This is the case of family physicians (FPs) and nurse practitioners (NPs), due to the fact that the latter might accomplish not only the traditional role proper to a nurse, but also several medical activities such as requesting diagnostic exams and prescribing medical treatments. The tensions that this overlap might generate and their implications in regard of the development of professional identities, and consequently of the quality of health care delivered, have been suggested, but rarely examined empirically. The goal of this study is to examine identity work, i.e., the processes of (re)construction of professional identities, of NPs and FPs working together in primary care interdisciplinary teams. METHODS: A longitudinal, interpretive, and comparative multiple (n = 2) case study is proposed. Identity work theory in organizations is adopted as theoretical perspective. Cases are urban primary care multidisciplinary teams from two different Canadian provinces: Quebec and Ontario. Participants are NPs, FPs, managers, and patients. Data gathering involves audio-diaries, individual semi-structured and focus group interviews, observations, and archival material. Narrative and metaphor techniques are adopted for analyzing data collected. Within- and cross-case analysis will be performed. DISCUSSION: For practice, the results of this investigation will: (a) be instrumental for clinicians, primary care managers, and policy decision-makers responsible for the implementation of interdisciplinary teamwork in primary healthcare delivery to improve decision-making processes and primary care team performance over time; (b) inform continuing interdisciplinary professional development educational initiatives that support competency in health professionals' identity construction in interdisciplinary primary care organizations. For research, the project will contribute to enriching theory about identity construction dynamics in health professions, both in the fields of health services and primary care education research.

A population-based analysis of the management of symptoms of depression among patients with stage IV non-small cell lung cancer (NSCLC) in Ontario, Canada.

PURPOSE: Patients with lung cancer can experience significant psychological morbidities including depression. We characterize patterns and factors associated with interventions for symptoms of depression in stage IV non-small cell lung cancer (NSCLC). METHODS: We conducted a population-based cohort study using health services administrative data in Ontario, Canada of stage IV NSCLC diagnosed from January 2007 to September 2018. A positive symptom of depression score was defined by reporting at least one ESAS (Edmonton Symptom Assessment System) depression score ≥ 2 following diagnosis until the end of follow-up (September 2019). Patient factors included age, sex, comorbidity burden, rurality of residence, and neighbourhood income quintile. Interventions included psychiatry assessment, psychology referral, social work referral and anti-depressant medical therapy (for patients ≥ 65 years with universal drug coverage). Multivariable modified Poisson regression models were used to examine the association between patient factors and intervention use for patients who reported symptoms of depression. RESULTS: In the cohort of 13,159 patients with stage IV NSCLC lung cancer, symptoms of depression were prevalent (71.4%, n = 9,397). Patients who reported symptoms of depression were more likely to receive psychiatry assessment/psychology referral (7.8% vs 3.5%; SD [standardized difference] 0.19), social work referral (17.4% vs 11.9%; SD 0.16) and anti-depressant prescriptions (23.8% vs 13.8%; SD 0.26) when compared to patients who did not report symptoms of depression respectively. In multivariable analyses, older patients were less likely to receive any intervention. Females were more likely to obtain a psychiatry assessment/psychology referral or social work referral. In addition, patients from non-major urban or rural residences were less likely to receive psychiatry assessment/psychology referral or social work referral, however patients from rural residences were more likely to be prescribed anti-depressants. CONCLUSIONS: There is high prevalence of symptoms of depression in stage IV NSCLC. We identify patient populations, including older patients and rural patients, who are less likely to receive interventions that will help identifying and screening for symptoms of depression.

Workshop report - interdisciplinary metabolomic epidemiology: the pathway to clinical translation.

Metabolomic epidemiology studies are complex and require a broad array of domain expertise. Although many metabolite-phenotype associations have been identified; to date, few findings have been translated to the clinic. Bridging this gap requires understanding of both the underlying biology of these associations and their potential clinical implications, necessitating an interdisciplinary team approach. To address this need in metabolomic epidemiology, a workshop was held at Metabolomics 2023 in Niagara Falls, Ontario, Canada that highlighted the domain expertise needed to effectively conduct these studies -- biochemistry, clinical science, epidemiology, and assay development for biomarker validation -- and emphasized the role of interdisciplinary teams to move findings towards clinical translation.

Transform[ing] heart failure professionals with Indigenous land-based cultural safety in Ontario, Canada.

Cardiovascular disease is a leading cause of death worldwide, with disproportionate impacts on Indigenous Peoples in Canada. In Spring 2022, a land-based learning program was piloted and evaluated as an Indigenous cultural safety training for professionals at a cardiac care centre and university in a large urban city. Baseline and endline surveys showed an increase in knowledge of Indigenous histories, cultures, and practices; increased reflection on positionality and intention to create change; and strengthened relationships with the land. Future work should explore the long-term effects of land-based cultural safety training on participant behaviours, and health outcomes for Indigenous Peoples.

Identification of environmental and methodological factors driving variability of Pepper Mild Mottle Virus (PMMoV) across three wastewater treatment plants in the City of Toronto.

PMMoV has been widely used to normalize the concentration of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA, influenza, and respiratory syncytial virus (RSV) to account for variations in the fecal content of wastewater. PMMoV is also used as an internal RNA recovery control for wastewater-based epidemiology (WBE) tests. While potentially useful for the interpretation of WBE data, previous studies have suggested that PMMoV concentration can be affected by various physico-chemical characteristics of wastewater. There is also the possibility that laboratory methods, particularly the variability in centrifugation steps to remove supernatant from pellets can cause PMMoV variability. The goal of this study is to improve our understanding of the main drivers of PMMoV variability by assessing the relationship between PMMoV concentration, the physico-chemical characteristics of wastewater, and the methodological approach for concentrating wastewater samples. We analyzed 24-hour composite wastewater samples collected from the influent stream of three wastewater treatment plants (WWTPs) located in the City of Toronto, Ontario, Canada. Samples were collected 3 to 5 times per week starting from the beginning of March 2021 to mid-July 2023. The influent flow rate was used to partition the data into wet and dry weather conditions. Physico-chemical characteristics (e.g., total suspended solids (TSS), biological oxygen demand (BOD), alkalinity, electrical conductivity (EC), and ammonia (NH3)) of the raw wastewater were measured, and PMMoV was quantified. Spatial and temporal variability of PMMoV was observed throughout the study period. PMMoV concentration was significantly higher during dry weather conditions. Multiple linear regression analysis demonstrates that the number and type of physico-chemical parameters that drive PMMoV variability are site-specific, but overall BOD and alkalinity were the most important predictors. Differences in PMMoV concentration for a single WWTP between two different laboratory methods, along with a weak correlation between pellet mass and TSS using one method may indicate that differences in sample concentration and subjective subsampling bias could alter viral recovery and introduce variability to the data.

A shifting terrain: Understanding the perspectives of walk-in physicians on their roles amid worsening primary care access in Ontario, Canada.

BACKGROUND: High-quality primary care is associated with better health outcomes and more efficient and equitable health system performance. However, the rate of primary care attachment is falling, and timely access to primary care is worsening, driving many patients to use walk-in clinics for their comprehensive primary care needs. This study sought to explore the experiences and perceived roles and responsibilities of walk-in physicians in this current climate. Methods: Qualitative interviews were conducted with nineteen physicians currently providing walk-in care in Ontario, Canada between May and December 2022. RESULTS: Limited capacity for continuity and comprehensiveness of care were identified as major sources of professional tension for walk-in physicians. Divergent perspectives on their roles were anchored in how physicians viewed their professional identity. Some saw providing continuous and comprehensive care as an infringement on their professional role; others saw their professional role as more flexible and responsive to population needs. Regardless of their professional identity, participants reported feeling ill-equipped to manage the swell of unattached patients, citing a lack of time, resources, connectivity to the system, and remuneration flexibility. Conclusions: As practice demands of walk-in clinics change, an evolution in the professional roles and responsibilities of walk-in physicians follows. However, the resources, structure, and incentives of walk-in care have not evolved to reflect this, leaving physicians to set their own professional boundaries with patients. This results in increasing variations in care and confusion across the primary care sector around who is responsible for what, when, and how.

Professional regulation in the digital era: A qualitative case study of three professions in Ontario, Canada.

Technology is transforming service delivery and practice in many regulated professions, altering required skills, scopes of practice, and the organization of professional work. Professional regulators face considerable pressure to facilitate technology-enabled work while adapting to digital changes in their practices and procedures. However, our understanding of how regulators are responding to technology-driven risks and the impact of technology on regulatory policy is limited. To examine the impact of technology and digitalization on regulation, we conducted an exploratory case study of the regulatory bodies for nursing, law, and social work in Ontario, Canada. Data were collected over two phases. First, we collected documents from the regulators' websites and regulatory consortiums. Second, we conducted key informant interviews with two representatives from each regulator. Data were thematically analyzed to explore the impact of technological change on regulatory activities and policies and to compare how regulatory structure and field shape this impact. Five themes were identified in our analysis: balancing efficiency potential with risks of certain technological advances; the potential for improving regulation through data analytics; considering how to regulate a technologically competent workforce; recalibrating pandemic emergency measures involving technology; and contemplating the future of technology on regulatory policy and practice. Regulators face ongoing challenges with providing equity-based approaches to regulating virtual practice, ensuring practitioners are technologically competent, and leveraging regulatory data to inform decision-making. Policymakers and regulators across Canada and internationally should prioritize risk-balanced policies, guidelines, and practice standards to support professional practice in the digital era.

Mode of delivery and birth outcomes before and during COVID-19 -A population-based study in Ontario, Canada.

There is lack of clarity on whether pregnancies during COVID-19 resulted in poorer mode of delivery and birth outcomes in Ontario, Canada. We aimed to compare mode of delivery (C-section), birth (low birthweight, preterm birth, NICU admission), and health services use (HSU, hospitalizations, ED visits, physician visits) outcomes in pregnant Ontario women before and during COVID-19 (pandemic periods). We further stratified for pre-existing chronic diseases (asthma, eczema, allergic rhinitis, diabetes, hypertension). Deliveries before (Jun 2018-Feb 2020) and during (Jul 2020-Mar 2022) pandemic were from health administrative data. We used multivariable logistic regression analyses to estimate adjusted odds ratios (aOR) of delivery and birth outcomes, and negative binomial regression for adjusted rate ratios (aRR) of HSU. We compared outcomes between pre-pandemic and pandemic periods. Possible interactions between study periods and covariates were also examined. 323,359 deliveries were included (50% during pandemic). One in 5 (18.3%) women who delivered during the pandemic had not received any COVID-19 vaccine, while one in 20 women (5.2%) lab-tested positive for COVID-19. The odds of C-section delivery during the pandemic was 9% higher (aOR = 1.09, 95% CI: 1.08-1.11) than pre-pandemic. The odds of preterm birth and NICU admission were 15% (aOR = 0.85, 95% CI: 0.82-0.87) and 10% lower (aOR = 0.90, 95% CI: 0.88-0.92), respectively, during COVID-19. There was a 17% reduction in ED visits but a 16% increase in physician visits during the pandemic (aRR = 0.83, 95% CI: 0.81-0.84 and aRR = 1.16, 95% CI: 1.16-1.17, respectively). These aORs and aRRs were significantly higher in women with pre-existing chronic conditions. During the pandemic, healthcare utilization, especially ED visits (aRR = 0.83), in pregnant women was lower compared to before. Ensuring ongoing prenatal care during the pandemic may reduce risks of adverse mode of delivery and the need for acute care during pregnancy.

Does proximity to a fertility centre increase the chance of achieving pregnancy in Northeastern Ontario?

INTRODUCTION: Northern Ontario has a population of approximately 800,000 people distributed over 806,707 km2. Before 2018, the only fertility treatment centre in Northern Ontario was located in Thunder Bay; many patients travelled south for care. In 2018, the Northeastern Ontario Women's Health Network (NEOWHN) opened in Sudbury, providing fertility treatments to people living in Northeastern Ontario. The goal of this study was to determine if proximity to this new fertility centre increases one's chance of achieving pregnancy when undergoing fertility treatment. Secondary outcomes included the quantity and types of fertility investigations and treatments completed by patients. MATERIALS AND METHODS: A retrospective chart review was performed for all patients seeking fertility treatment at NEOWHN between January 2019 and December 2020. Traveling >100 km to access healthcare was considered to be a clinically significant determinant of health. RESULTS: Seven hundred and 5 patients were seen in consultation for fertility services at NEOWHN during the study period. One hundred eighty-one of 478 (37.9%) patients living <100 km from NEOWHN achieved pregnancy compared to 39 of 227 (17.2%) patients living >100 km from NEOWHN (P < 0.01). CONCLUSION: Living in proximity (<100 km) to NEOWHN increased the likelihood that individuals in Northeastern Ontario would seek fertility services and would achieve pregnancy. Financial constraints and inaccessibility likely play a role in this, but further studies are needed to explain this difference. INTRODUCTION: Le Nord de l'Ontario compte une population d'environ 800,000 personnes réparties sur 806,707 km2. Avant 2018, le seul centre de traitement de la fertilité du Nord de l'Ontario était situé à Thunder Bay; de nombreux patients SE rendaient dans le sud pour recevoir des soins. En 2018, le Northeastern Ontario Women's Health Network (NEOWHN-le Réseau de santé des femmes du Nord-Est de l'Ontario) a ouvert ses portes à Sudbury, offrant des traitements de fertilité aux personnes vivant dans le Nord-Est de l'Ontario. L'objectif de cette étude était de déterminer si la proximité de ce nouveau centre de fertilité augmente les chances d'obtenir une grossesse lors d'un traitement de fertilité. Les résultats secondaires comprenaient la quantité et les types d'examens et de traitements de fertilité effectués par les patients. MTHODES: Une étude rétrospective des dossiers a été réalisée pour tous les patients cherchant un traitement de fertilité au NEOWHN entre janvier 2019 et décembre 2020. Le fait de voyager >100 km pour accéder aux soins de santé a été considéré comme un déterminant de la santé cliniquement significatif. RSULTATS: Seven hundred and 5 patients ont été vus en consultation pour des services de fertilité au NEOWHN pendant la période d'étude. One hundred eighty-one des 478 (37.9%) patientes vivant à moins de 100 km du NEOWHN ont obtenu une grossesse, contre 39 des 227 (17.2%) patientes vivant à plus de 100 km du NEOWHN (P < 0.01). CONCLUSION: Le fait de vivre à proximité (<100 km) du NEOWHN augmente la probabilité que les habitants du Nord-Est de l'Ontario aient recours à des services de fertilité et obtiennent une grossesse. Les contraintes financières et l'inaccessibilité jouent probablement un rôle à cet égard, mais d'autres études sont nécessaires pour expliquer cette différence.

Association between immigration status and total knee arthroplasty outcomes in Ontario, Canada: a population-based matched cohort study.

BACKGROUND: Immigrants and refugees face unique challenges navigating the health care system to manage severe arthritis, because of unfamiliarity, lack of awareness of surgical options, or access. The purpose of this study was to assess total knee arthroplasty (TKA) uptake, surgical outcomes, and hospital utilization among immigrants and refugees compared with Canadian-born patients. METHODS: We included all adults undergoing primary TKA from January 2011 to December 2020 in Ontario. Cohorts were defined as Canadian-born or immigrants and refugees. We assessed change in yearly TKA utilization for trend. We compared differences in 1-year revision, infection rates, 30-day venous thromboembolism (VTE), presentation to emergency department, and hospital readmission between matched Canadian-born and immigrant and refugee groups. RESULTS: We included 158 031 TKA procedures. A total of 11 973 (7.6%) patients were in the immigrant and refugee group, and 146 058 (92.4%) patients were in the Canadian-born group. The proportion of TKAs in Ontario performed among immigrants and refugees nearly doubled over the 10-year study period (p < 0.001). After matching, immigrants were at relatively lower risk of 1-year revision (0.9% v. 1.6%, p < 0.001), infection (p < 0.001), death (p = 0.004), and surgical complications (p < 0.001). No differences were observed in rates of 30-day VTE or length of hospital stay. Immigrants were more likely to be discharged to rehabilitation (p < 0.001) and less likely to present to the emergency department (p < 0.001) than Canadian-born patients. CONCLUSION: Compared with Canadian-born patients, immigrants and refugees have favourable surgical outcomes and similar rates of resource utilization after TKA. We observed an underutilization of these procedures in Ontario relative to their proportion of the population. This may reflect differences in perceptions of chronic pain or barriers accessing arthroplasty.

Bridging Educational Grant in Nursing (BEGIN) students' intentions for retention in long-term, home and community care: A survey protocol.

INTRODUCTION: Retention of nurses in long-term care (LTC) and home and community care (HCC) settings is a growing concern. Previous evidence underscores factors which contribute to nurses' intentions for retention in these sectors. However, perspectives of nursing students preparing to enter the workforce, and their intentions for short-term and long-term retention, remain unknown. This study aims to explore relationships between short-term and long-term intentions for retention with psychological empowerment, work engagement, career commitment, burnout, prosocial motivation, self-care and personal resilience among students enrolled in nursing educational bridging programs supported by the Bridging Educational Grant in Nursing (BEGIN) program in Ontario, Canada. METHODS AND ANALYSIS: This cross-sectional design study will use an open online survey to investigate perspectives of current nursing students enrolled in educational bridging programs on factors relating to psychological empowerment, work engagement, career commitment, resilience, burnout, prosocial motivation, self-care and intentions for retention. Additionally, the survey will collect demographic information, including age, gender, ethnicity, citizenship, income, family status, nursing role, and years of employment and/or education. Open-ended questions will elicit participants' perspectives on financial considerations for career planning and other factors impacting intentions for retention. Descriptive data will be presented for contextualisation of participants' demographic characteristics to enhance generalisability of the cohort. Descriptive statistics will be used to summarise participants' scores on various assessment measures, as well as their short-term and long-term intentions for retention in LTC and HCC after completion of BEGIN. A Pearson's product moment r correlation will determine relationships between intentions for retention and other measures, and linear regression will determine whether any potential correlations can be explained by regression. ETHICS AND DISSEMINATION: This research protocol received ethical approval from a research-intensive university research ethics board (#123211). Findings will be disseminated to nursing knowledge users in LTC and HCC through publications, conferences, social media and newsletters.

Digital Interventions to Understand and Mitigate Stress Response: Protocol for Process and Content Evaluation of a Cohort Study.

BACKGROUND: Staffing and resource shortages, especially during the COVID-19 pandemic, have increased stress levels among health care workers. Many health care workers have reported feeling unable to maintain the quality of care expected within their profession, which, at times, may lead to moral distress and moral injury. Currently, interventions for moral distress and moral injury are limited. OBJECTIVE: This study has the following aims: (1) to characterize and reduce stress and moral distress related to decision-making in morally complex situations using a virtual reality (VR) scenario and a didactic intervention; (2) to identify features contributing to mental health outcomes using wearable, physiological, and self-reported questionnaire data; and (3) to create a personal digital phenotype profile that characterizes stress and moral distress at the individual level. METHODS: This will be a single cohort, pre- and posttest study of 100 nursing professionals in Ontario, Canada. Participants will undergo a VR simulation that requires them to make morally complex decisions related to patient care, which will be administered before and after an educational video on techniques to mitigate distress. During the VR session, participants will complete questionnaires measuring their distress and moral distress, and physiological data (electrocardiogram, electrodermal activity, plethysmography, and respiration) will be collected to assess their stress response. In a subsequent 12-week follow-up period, participants will complete regular assessments measuring clinical outcomes, including distress, moral distress, anxiety, depression, and loneliness. A wearable device will also be used to collect continuous data for 2 weeks before, throughout, and for 12 weeks after the VR session. A pre-post comparison will be conducted to analyze the effects of the VR intervention, and machine learning will be used to create a personal digital phenotype profile for each participant using the physiological, wearable, and self-reported data. Finally, thematic analysis of post-VR debriefing sessions and exit interviews will examine reoccurring codes and overarching themes expressed across participants' experiences. RESULTS: The study was funded in 2022 and received research ethics board approval in April 2023. The study is ongoing. CONCLUSIONS: It is expected that the VR scenario will elicit stress and moral distress. Additionally, the didactic intervention is anticipated to improve understanding of and decrease feelings of stress and moral distress. Models of digital phenotypes developed and integrated with wearables could allow for the prediction of risk and the assessment of treatment responses in individuals experiencing moral distress in real-time and naturalistic contexts. This paradigm could also be used in other populations prone to moral distress and injury, such as military and public safety personnel. TRIAL REGISTRATION: ClinicalTrials.gov NCT05923398; https://clinicaltrials.gov/study/NCT05923398. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/54180.

Effect of neurosurgical residency programs on neurosurgical patient outcomes in a single health care system: a cohort study.

BACKGROUND: The evidence on the benefits and drawbacks of involving neurosurgical residents in the care of patients who undergo neurosurgical procedures is heterogeneous. We assessed the effect of neurosurgical residency programs on the outcomes of such patients in a large single-payer public health care system. METHODS: Ten population-based cohorts of adult patients in Ontario who received neurosurgical care from 2013 to 2017 were identified on the basis of procedural codes, and the cohorts were followed in administrative health data sources. Patient outcomes by the status of the treating hospital (with or without a neurosurgical residency program) within each cohort were compared with models adjusted for a priori confounders and with adjusted multilevel models (MLMs) to also account for hospital-level factors. RESULTS: A total of 46 608 neurosurgical procedures were included. Operative time was 8%-30% longer in hospitals with neurosurgical residency programs in 9 out of 10 cohorts. Thirty-day mortality was lower in hospitals with neurosurgical residency programs for aneurysm repair (odds ratio [OR] 0.30, 95% confidence interval [CI] 0.20-0.44), cerebrospinal fluid shunting (OR 0.52, 95% CI 0.34-0.79), intracerebral hemorrhage evacuation (OR 0.66, 95% CI 0.52-0.84), and posterior lumbar decompression (OR 0.32, 95% CI 0.15-0.65) in adjusted models. The mortality rates remained significantly different only for aneurysm repair (OR 0.19, 95% CI 0.05-0.69) and cerebrospinal shunting (OR 0.42, 95% CI 0.21-0.85) in MLMs. Length of stay was mostly shorter in hospitals with neurosurgical residents, but this finding did not persist in MLMs. Thirty-day reoperation rates did not differ between hospital types in MLMs. For 30-day readmission rates, only extracerebral hematoma decompression was significant in MLMs (OR 1.41, 95% CI 1.07-1.87). CONCLUSION: Hospitals with neurosurgical residents had longer operative times with similar to better outcomes. Most, but not all, of the differences between hospitals with and without residency programs were explained by hospital-level variables rather than direct effects of residents.

The Ottawa resident observation form for nurses (O-RON): evaluation of an assessment tool's psychometric properties in different specialties.

BACKGROUND: Workplace-based assessment (WBA) used in post-graduate medical education relies on physician supervisors' feedback. However, in a training environment where supervisors are unavailable to assess certain aspects of a resident's performance, nurses are well-positioned to do so. The Ottawa Resident Observation Form for Nurses (O-RON) was developed to capture nurses' assessment of trainee performance and results have demonstrated strong evidence for validity in Orthopedic Surgery. However, different clinical settings may impact a tool's performance. This project studied the use of the O-RON in three different specialties at the University of Ottawa. METHODS: O-RON forms were distributed on Internal Medicine, General Surgery, and Obstetrical wards at the University of Ottawa over nine months. Validity evidence related to quantitative data was collected. Exit interviews with nurse managers were performed and content was thematically analyzed. RESULTS: 179 O-RONs were completed on 30 residents. With four forms per resident, the ORON's reliability was 0.82. Global judgement response and frequency of concerns was correlated (r = 0.627, P < 0.001). CONCLUSIONS: Consistent with the original study, the findings demonstrated strong evidence for validity. However, the number of forms collected was less than expected. Exit interviews identified factors impacting form completion, which included clinical workloads and interprofessional dynamics.

Adverse childhood events and self-harming behaviours among individuals in Ontario forensic system: the mediating role of psychopathy.

BACKGROUND: Adverse childhood events (ACEs), psychopathy, and self-harming behaviours are prevalent among individuals in the forensic psychiatry system. While existing literature suggests that ACEs, self-harm, and psychopathy are interrelated, little is known about the interplay of psychopathic traits in this relationship. The present study aimed to determine the mediating role of psychopathy in the relationship between ACEs and self-harming behaviours in forensic patients. METHODS: This was a retrospective study of patients under the Ontario Review Board (ORB) between 2014 and 2015. In the analysis, we included patients with complete data on ACEs, self-harming behaviours, and a Psychopathy Checklist-Revised (PCL-R) score - a measure of psychopathic traits and their severity conducted during the reporting period. Mediation analysis was based on the Baron and Kenny approach, and sensitivity analysis was performed based on the types of ACEs. RESULTS: ​​​The sample population (n = 593) was made up of adults, with a mean age of 41.21 (± 12.35) years and were predominantly males (92.37%). While there was a partial mediating effect of psychopathy on the relationship between ACEs and incidents of self-harming behaviours in the past year, the mediation was complete in the relationship between ACEs and a lifetime history of self-harming behaviours. Following sensitivity analysis based on the types of ACE, the mediating effects were more attributed to specific ACEs, especially having experienced child abuse or having an incarcerated household member before 18 years. CONCLUSION: Among forensic patients in Ontario, psychopathy mediates​ ​the relationship between experiencing ACEs and engaging in self-harming behaviours. Effective intervention to mitigate self-harming behaviours in this population should consider the potential role of psychopathy, especially among individuals who have experienced ACEs involving a history of child abuse and a family who was incarcerated.

Predicting CBT modality, treatment participation, and reliable improvements for individuals with anxiety and depression in a specialized mental health centre: a retrospective population-based cohort study.

BACKGROUND: Cognitive Behaviour Therapy (CBT) is one of the most successful therapeutic approaches for treating anxiety and depression. Clinical trials show that for some clients, internet-based CBT (eCBT) is as effective as other CBT delivery modes. However, the fidelity of these effects may be weakened in real-world settings where clients and providers have the freedom to choose a CBT delivery mode and switch treatments at any time. The purpose of this study is to measure the CBT attendance rate and identify client-level characteristics associated with delivery mode selection and having reliable and clinically significant improvement (RCSI) of treatment in each delivery mode in a real-world CBT outpatient program. METHODS: This is a retrospective cohort analysis of electronic medical records collected between May 1, 2019, and March 31, 2022, at Ontario Shores Centre for Mental Health Sciences. Regression models were used to investigate the impact of individual client characteristics on participation and achieving RCSI of different CBT delivery modes. RESULTS: Our data show a high attendance rate for two and more CBT sessions across all modalities (98% of electronic, 94% of group, 100% of individual, and 99% of mixed CBT). Individuals were more likely to enter mixed and group CBT modality if they were younger, reported being employed, and reported higher depression severity at the baseline. Among the four modalities of CBT delivery, group CBT clients were least likely to have RCSI. Of those who started sessions, clients were significantly more likely to experience RCSI on the Patient Health Questionnaire (PHQ)-9 and the Generalized Anxiety Disorder (GAD)-7 if they were employed, reported more severe symptoms at baseline, and were living in the most deprived neighborhoods. CONCLUSIONS: This study will contribute to the body of knowledge about the implementation and treatment planning of different CBT delivery modes in real-world settings. With the changing clinical environment, it is possible to advocate for the adoption of the eCBT intervention to improve therapy practices and achieve better treatment success. The findings can help guide future CBT program planning based on client socio-demographic characteristics, allowing the optimal therapy type to be targeted to the right client at the right time.