Helping the helpers: Understanding information and support needs of caregivers in underserved communities.

Informal caregivers caring for patients at the end of life in rural geographic areas may have inadequate support due to insufficient community-based palliative care services. We conducted a parallel mixed-methods study to understand informal caregivers' unmet supportive, educational, and informational needs living in rural areas with limited community-based palliative care services. Forty-four caregivers of loved ones that died at home between December 2017 and September 2020 completed the Carer Support Needs Assessment Tool (CSNAT) and 14 caregivers were interviewed. Using a parallel mixed analysis, results showed that caregiver distress was associated with unmet information needs about how to accurately assess and manage pain levels and identify signs and symptoms of end-of-life. Caregivers needed more support related to available, knowledgeable, and well-trained home health care providers, accessible equipment, 24-hour respite care, accessible grief counseling, and a central triage contact number for community support.

Practitioner Experience With Mistreated Older Adults Who Have Dementia: Understanding Contextual Influences and Consequences.

Studies of mistreatment of older adults have revealed alarmingly higher prevalence rates of mistreatment of those who have dementia. When the mistreatment occurs within the context of the home and is perpetrated by a family caregiver, it may remain hidden and only be discovered by the health and social service practitioners who have access to the home. Understanding the contexts within which this mistreatment occurs, and the influence of these contexts on the experience of these practitioners as well as on the resulting outcomes for mistreated older adults, has received little attention in the literature. This qualitative study, framed by critical social theory, aimed to answer the following research question: What are the contextual influences on practitioner experience with mistreatment of older adults with dementia by a caregiver within the home? Specifically, this study explored contextual influences within a Canadian province, where there is neither specific adult protective legislation nor infrastructure when mistreatment occurs within the home. Data were collected via semi-structured interviews, journals, and focus groups with 51 practitioners from various disciplines providing services to mistreated older adults with dementia in their homes. Theoretical thematic analysis led to the discovery of five contextual themes influencing the experience: the privileged burden of seeing behind closed doors; a domestic problem within a societal context; interprofessional challenges; a history of stagnation, losses, and systems failure; and a legislative complexity and oppression. Understanding these contextual influences is crucial to supporting practitioners, who, although entrusted to protect mistreated older adults, describe powerlessness within current contexts. This understanding is needed to improve outcomes for mistreated older adults with dementia.

Practitioner Empowerment, Older Adult Mistreatment, and Dementia.

Although some studies have revealed practitioner disempowerment in cases of older adult mistreatment, this experience is poorly understood. In addition, dementia and contextual influences further complicate cases; yet,  little is known about the experience of practitioners with this complexity. This critical inquiry, based on Critical social theory, critical consciousness, and professional agency, aimed to address these gaps. Fifty-one practitioners from diverse health care and social service disciplines from rural and urban communities in Northeastern Ontario participated in interviews, journals, and focus groups. Analysis of data revealed the need for empowerment within a perpetual cycle of non-resolution, to refocus on legal clarity and intervention versus the current legal complexity and education focus, and to develop adequate infrastructure to support interprofessional efforts. The infusion of this knowledge into policy, practice, and research has great potential to improve outcomes for older adults with dementia who are mistreated in their homes.

Midwives' integration of post abortion manual vacuum aspiration in the Democratic Republic of Congo: a mixed methods case study & positive deviance assessment.

BACKGROUND: Despite a recognized need for midwives to provide post abortion care, there exist barriers preventing them from integrating lifesaving skills such as manual vacuum aspiration (MVA) into practice. This collaborative research with the Professional Association of Congolese Midwives (SCOSAF), sought to understand how certain midwives in the Democratic Republic of Congo (DRC) have overcome barriers to successfully integrate MVA for post abortion care. Specifically, in order to provide locally-driven solutions to the problem of inadequate post abortion care in the DRC, this study aimed to identify examples of positive deviance, or midwives who had successfully integrated MVA in complex working environments following an in-service training facilitated by their midwifery association, SCOSAF. METHODS: Creswell's mixed method comparative case study design was used to identify positive deviant midwives who had practiced MVA one or more times post training and to explore their strategies and enabling factors. Other midwives who had not practiced MVA post training permitted for a comparison gro cup and further interpretations. Sources of data included a sequential survey and semi-structured interviews. RESULTS: All 102 midwives invited to be surveyed were recruited and 34% reported practicing MVA post training (positive deviant midwives). No statistical significance was found between the two groups' demographics and practice facility type. Overall, both groups had positive attitudes regarding midwifery-led MVA and legalization of abortion. Positive deviant midwives demonstrated and described more confidence and competence to practice and teach MVA. They were more likely to identify as teachers and overcome interprofessional barriers by teaching MVA to physicians, medical students and other midwives and position themselves as experts during post abortion emergencies. CONCLUSION: Results provided important insight to midwives' integration of post abortion care in Kinshasa. Strategies used by positive deviant midwives in emergencies allowed them to navigate challenging contexts in order to practice MVA, while simultaneously increasing the credibility of their profession and the dissemination of evidenced-based MVA practice. Programs designed to work with and promote positive deviant midwives as knowledge brokers could be tested for their overall impact on the diffusion of midwifery-led MVA to improve access to safe, respectful reproductive care.

Mistreated older adults with dementia in the home: practitioner experience and unattainable professional agency.

The experience of practitioners who encounter mistreatment of an older adult with dementia by a caregiver in the home has received little attention in the literature. A critical research methodology aimed to understand the experience of professional agency, the ability to control outcomes and act in a meaningful way, of health and social service practitioners when encountering these cases in the home. Fifty-one practitioners from urban, rural and Northeastern communities in Ontario participated in semi-structured interviews, reflective journals, as well as focus group discussions. Theoretical thematic analysis of data led to the discovery of five themes: weathering the storm to realization; cognitive uncertainty; emotional upheaval; one's inability to resolve the mistreatment; and the double-edge sword of self-reflection. Understanding this experience is an essential step toward improving practice and policy, and achieving positive outcomes for the mistreated older adult with dementia and their caregiver within the home.

Health Care Students' Attitudes About Alcohol Consumption During Pregnancy: Responses to Narrative Vignettes.

This article explores medical, midwifery, and nurse practitioner students' attitudes about women who may consume alcohol throughout their pregnancies. Twenty-one health care students responded to a scenario-based vignette addressing alcohol consumption during pregnancy, as well as a semistructured interview, which were analyzed using Braun and Clarke's thematic analysis approach. Two primary themes related to students' attitudes concerning alcohol consumption during pregnancy were identified: (a) divergent recommendations for different women, based on perceptions of their level of education, culture/ethnicity, and ability to stop drinking; and (b) understanding the social determinants of health, including the normalization of women's alcohol consumption and potential partner violence. Health care professionals in training need further education about the risks of alcohol consumption during pregnancy and fetal alcohol spectrum disorder (FASD). In addition, health care students need training in how to engage in reflective practice to identify their own stereotypical beliefs and attitudes and how these attitudes may affect their practice.

"No Alcohol Is Recommended, But . . .": Health Care Students' Attitudes About Alcohol Consumption During Pregnancy.

Canadian findings suggest that health care providers require further training and education to support their work preventing fetal alcohol spectrum disorder (FASD). However, the knowledge and training of health care students in relation to FASD remains largely unexplored. The purpose of this study was to understand the attitudes and beliefs of health care students about alcohol use during pregnancy. Twenty-one health care students participated in a scenario-based vignette about alcohol consumption during pregnancy. Although almost all students recognized that no alcohol consumption during pregnancy is the safest recommendation, many students recounted that this advice is not always conveyed during encounters with their pregnant patients. Three primary themes related to students' attitudes concerning alcohol use during pregnancy were identified. Health care professionals in training need further education about the risks of alcohol consumption during pregnancy and the potential health outcomes associated with prenatal alcohol exposure.

Exploring the issue of failure to fail in a nursing program.

A study using a qualitative descriptive design was undertaken to explore the issue of "failure to fail" in a nursing program. Individual in-depth interviews were conducted with nursing university faculty members, preceptors, and faculty advisors (n=13). Content analysis was used to analyze the data. Results indicate that: (a) failing a student is a difficult process; (b) both academic and emotional support are required for students and preceptors and faculty advisors; (c) there are consequences for programs, faculty, and students when a student has failed a placement; (d) at times, personal, professional, and structural reasons exist for failing to fail a student; and (e) the reputation of the professional program can be diminished as a result of failing to fail a student. Recommendations for improving assessment, evaluation, and intervention with a failing student include documentation, communication, and support. These findings have implications for improving the quality of clinical experiences.

Older adult mistreatment risk screening: contribution to the validation of a screening tool in a domestic setting.

ABSTRACTThe hidden nature of older adult mistreatment renders its detection in the domestic setting particularly challenging. A validated screening instrument that can provide a systematic assessment of risk factors can facilitate this detection. One such instrument, the "expanded Indicators of Abuse" tool, has been previously validated in the Hebrew language in a hospital setting. The present study has contributed to the validation of the "e-IOA" in an English-speaking community setting in Ontario, Canada. It consisted of two phases: (a) a content validity review and adaptation of the instrument by experts throughout Ontario, and (b) an inter-rater reliability assessment by home visiting nurses. The adaptation, the "Mistreatment of Older Adult Risk Factors" tool, offers a comprehensive tool for screening in the home setting. This instrument is significant to professional practice as practitioners working with older adults will be better equipped to assess for risk of mistreatment.

Context and cardiovascular risk modification in two regions of Ontario, Canada: a photo elicitation study.

Cardiovascular diseases, which include coronary heart diseases (CHD), remain the leading cause of death in Canada and other industrialized countries. This qualitative study used photo-elicitation, focus groups and in-depth interviews to understand health behaviour change from the perspectives of 38 people who were aware of their high risk for CHD and had received information about cardiovascular risk modification while participating in a larger intervention study. Participants were drawn from two selected regions: Sudbury and District (northern Ontario) and the Greater Toronto Area (southern Ontario). Analysis drew on concepts of place and space to capture the complex interplay between geographic location, sociodemographic position, and people's efforts to understand and modify their risk for CHD. Three major sites of difference and ambiguity emerged: 1) place and access to health resources; 2) time and food culture; and 3) itineraries or travels through multiple locations. All participants reported difficulties in learning and adhering to new lifestyle patterns, but access to supportive health resources was different in the two regions. Even within regions, subgroups experienced different patterns of constraint and advantage. In each region, "fast" food and traditional foods were entrenched within different temporal and social meanings. Finally, different and shifting strategies for risk modification were required at various points during daily and seasonal travels through neighbourhoods, to workplaces, or on vacation. Thus health education for CHD risk modification should be place-specific and tailored to the needs and resources of specific communities.

Practical issues in using a card sort in a study of non-support and family caregiving.

The authors successfully used the card sort data collection technique with 17 female family caregivers in a large ethnographic study of non-support. In this article, they describe the practical issues they addressed. Initially, they developed strategies to construct meaningful statements that reflected key themes and were manageable in an interview. Later, to address challenges for participants, they developed approaches to assist women in moving beyond their own experience, dealing with test anxiety, and anticipating an emotional response. To facilitate effective data collection, they made detailed arrangements in advance, collected "talk aloud" data that captured women's decisions, and maintained accurate records. The women felt validated in their caregiving roles, as the card statements reflected their experience and rich data was elicited. The card sort exercise contributed information about variability in the meaning of similar interactions for different women and a beginning understanding of the criteria women used to make decisions.