Planning for implementation success: insights from conducting an implementation needs assessment.

AIM: The aim of this paper is to provide insights into conducting an implementation needs assessment using a case example in a less-research-intensive setting. DESIGN AND METHODS: In the case example, an implementation needs assessment was conducted, including1 an environmental scan of the organization's website and preliminary discussions with key informants to learn about the implementation context, and2 a formal analysis of the evidence-practice gap (use of sedation interruptions) deploying a chart audit methodology using legal electronic reports. RESULTS: Our needs assessment was conducted over 5 months and demonstrated how environmental scans reveal valuable information that can inform the evidence-practice gap analysis. A well-designed gap analysis, using suitable indicators of best practice, can reveal compliance rates with local protocol recommendations, even with a small sample size. In our case, compliance with the prescribed practices for sedation interruptions ranged from 65% (n=53) to as high as 84% (n=69). CONCLUSIONS: Implementation needs assessments provide valuable information that can inform implementation planning. Such assessments should include an environmental scan to understand the local context and identify both current recommended best practices and local best practices for the intervention of interest. When addressing an evidence-practice gap, analyses should quantify the difference between local practice and desired best practice. IMPACT: The insights gained from the case example presented in this paper are likely transferrable to implementation research or studies conducted in similar, less-research-intensive settings. SPANISH ABSTRACT: http://links.lww.com/IJEBH/A257.

Factors influencing nurses' use of sedation interruptions in a critical care unit: a descriptive qualitative study.

INTRODUCTION AND AIMS: This study examined critical care nurses', physicians', and allied health professionals' perceptions of factors that support, inhibit, or limit the use of sedation interruption (SI) to improve the use of this integral component of care for mechanically ventilated patients. METHOD: We conducted a theory-based, descriptive qualitative study using semi-structured interviews with critical care registered nurses, respiratory therapists, a pharmacist, and a physician in a hospital in Ontario, Canada. The interview guide and analysis were informed by the Theoretical Domains Framework and transcripts were analyzed using content analysis. RESULTS: We identified 9 facilitators and 20 barriers to SI use by nurses. Facilitators included the innovation (importance of protocols) and potential adopters (comfort with the skill). The barriers were the potential adopters' (nurses) knowledge gaps regarding the performance and goal of SI and the practice environment (lack of time, availability of extra staff, and lack of multidisciplinary rounds). CONCLUSION: This study identified facilitators and barriers to SI for mechanically ventilated patients. Implementation efforts must address barriers associated with nurses, the environment, and contextual factors. A team-based approach is essential, as the absence of interprofessional rounds is a significant barrier to the appropriate use or non-use of SI. Future research can focus on the indications, contraindications, and goals of SI, emphasizing a shared appreciation for these factors across disciplines. Nursing capacity to manage a patient waking up from sedation is necessary for point-of-care adherence; future research should focus on the best ways to do so. Implementation study designs should use theory and evidence-based determinants of SI to bridge the evidence-to-practice gap. SPANISH ABSTRACT: http://links.lww.com/IJEBH/A178.

Long-term bereavement outcomes in family members of those who died in acute care hospitals before and during the first wave of COVID-19: A cohort study.

BACKGROUND: Severe grief is highly distressing and prevalent up to 1 year post-death among people bereaved during the first wave of COVID-19, but no study has assessed changes in grief severity beyond this timeframe. AIM: Understand the trajectory of grief during the pandemic by reassessing grief symptoms in our original cohort 12-18 months post-death. DESIGN: Prospective matched cohort study. SETTINGS/PARTICIPANTS: Family members of decedents who died in an acute care hospital between November 1, 2019 and August 31, 2020 in Ottawa, Canada. Family members of patients who died of COVID (COVID +ve) were matched 2:1 with those who died of non-COVID illness (COVID -ve) during pandemic wave 1 or immediately prior to its onset (pre-COVID). Grief was assessed using the Inventory of Complicated Grief (ICG). RESULTS: Follow-up assessment was completed by 92% (111/121) of family members in the initial cohort. Mean ICG score on the 12-18-month assessment was 19.9 (SD = 11.8), and severe grief (ICG > 25) was present in 28.8% of participants. One-third (33.3%) had either a persistently high (>25) or worsening ICG score (⩾4-point increase between assessments). Using a modified Poisson regression analysis, persistently high or worsening ICG scores were associated with endotracheal intubation in the deceased, but not cause of death (COVID +ve, COVID -ve, pre-COVID) or physical presence of the family member in the final 48 h of life. CONCLUSIONS: Severe grief is a substantial source of psychological morbidity in the wake of the COVID-19 pandemic, persisting more than a year post-death. Our findings highlight an acute need for effective and scalable means of addressing severe grief.

Comorbidities, symptoms and end-of-life medication use in hospitalised decedents before and during the COVID-19 pandemic: a retrospective regional cohort study in Ottawa, Canada.

OBJECTIVE: To compare comorbidities, symptoms and end-of-life (EoL) palliative medication (antisecretories, opioids, antipsychotics and sedatives) use among decedents before and during the COVID-19 pandemic. DESIGN: In a retrospective cohort study, decedent records in three acute care hospitals were abstracted, generating a prepandemic (November 2019-February 2020) group (pre-COVID) and two intrapandemic (March-August 2020, wave 1) groups, one without (COVID-ve) and one with COVID-19 infection (COVID+ve). Control group decedents were matched 2:1 on age, sex and care service (medicine/intensive care unit (ICU)) with COVID+ve decedents. SETTING: Three regional acute care teaching hospitals in Ottawa, Canada PARTICIPANTS: Decedents (N=425): COVID+ve (n=85), COVID-ve (n=170) and pre-COVID (n=170). MAIN OUTCOME MEASURES: Data were abstracted regarding demographics, admission comorbidities and symptoms, and EoL medication use; opioid doses were standardised to parenteral morphine equivalent daily dose (MEDD), and the predictors of upper quartile MEDD in the last 24 hours of life were examined in multivariable logistic regression with adjusted ORs (aORs) and 95% CIs. RESULTS: The prevalence of dementia (41% vs 28% and 26%, p=0.03), breathlessness (63.5% vs 42% and 47%, p<0.01), cough (40% vs 27% and 19%, p<0.01) and fever (54% vs 9% and 13.5%) was higher in COVID+ve versus pre-COVID and COVID-ve groups, respectively. The median (IQR) of MEDD over the last 72 hours of life was 16.7 (9-36.5) vs 13.5 (5.7-21.8) and 10.5 (5.3-23.8) for COVID+ve versus pre-COVID and COVID-ve groups, respectively, (p=0.007). Male sex, COVID+ve grouping, ICU death and high-flow nasal cannula use predicted upper quartile MEDD dose, aORs (95% CIs): 1.84 (1.05 to 3.22), 2.62 (1.29 to 5.3), 5.14 (2.47 to 10.7) and 1.93 (1.05 to 3.52), respectively. COVID+ve group decedents used highest lorazepam and propofol doses. CONCLUSIONS: COVID-19 decedents, particularly those in ICU, required higher EoL opioid and sedating medication doses than matched prepandemic or intrapandemic controls. These findings should inform and guide clinical practice.

Death determination by neurologic criteria-what do families understand?

PURPOSE: Currently, there is little empirical data on family understanding about brain death and death determination. The purpose of this study was to describe family members' (FMs') understanding of brain death and the process of determining death in the context of organ donation in Canadian intensive care units (ICUs). METHODS: We conducted a qualitative study using semistructured, in-depth interviews with FMs who were asked to make an organ donation decision on behalf of adult or pediatric patients with death determination by neurologic criteria (DNC) in Canadian ICUs. RESULTS: From interviews with 179 FMs, six main themes emerged: 1) state of mind, 2) communication, 3) DNC may be counterintuitive, 4) preparation for the DNC clinical assessment, 5) DNC clinical assessment, and 6) time of death. Recommendations on how clinicians can help FMs to understand and accept DNC through communication at key moments were described including preparing FMs for death determination, allowing FMs to be present, and explaining the legal time of death, combined with multimodal strategies. For many FMs, understanding of DNC unfolded over time, facilitated with repeated encounters and explanation, rather than during a single meeting. CONCLUSION: Family members' understanding of brain death and death determination represented a journey that they reported in sequential meeting with health care providers, most notably physicians. Modifiable factors to improve communication and bereavement outcomes during DNC include attention to the state of mind of the family, pacing and repeating discussions according to families' expressed understanding, and preparing and inviting families to be present for the clinical determination including apnea testing. We have provided family-generated recommendations that are pragmatic and can be easily implemented.

RéSUMé: OBJECTIF: À l'heure actuelle, il y a peu de données empiriques sur la compréhension des familles de la mort cérébrale et de la détermination du décès. Le but de cette étude était de décrire la compréhension des membres de la famille de la mort cérébrale et du processus de détermination du décès dans le contexte du don d'organes dans les unités de soins intensifs (USI) canadiennes. MéTHODE: Nous avons mené une étude qualitative à l'aide d'entrevues semi-structurées et approfondies avec des membres de la famille à qui on a demandé de prendre une décision de don d'organes au nom de patients adultes ou pédiatriques dont le décès avait été déterminé selon des critères neurologiques (DCN) dans les unités de soins intensifs canadiennes. RéSULTATS: Sur la base d'entrevues avec 179 membres de la famille, six thèmes principaux ont émergé : 1) l'état d'esprit, 2) la communication, 3) le DCN peut être contre-intuitif, 4) la préparation à l'évaluation clinique pour un DCN, 5) l'évaluation clinique pour un DCN et 6) le moment du décès. Des recommandations sur la façon dont les cliniciens peuvent aider les membres de la famille à comprendre et à accepter un DCN par la communication à des moments clés ont été décrites, y compris la préparation des membres de la famille à la détermination du décès, l'autorisation de la présence des membres de la famille et l'explication de l'heure légale du décès, combinées à des stratégies multimodales. Pour de nombreux membres de la famille, la compréhension du DCN s'est développée au fil du temps et a été facilitée par des rencontres et des explications répétées plutôt qu'au cours d'une seule rencontre. CONCLUSION: La compréhension qu'ont les membres de la famille de la mort cérébrale et de la détermination du décès représente un parcours qu'ils ont décrit lors de rencontres successives avec des acteurs de soins de santé, et particulièrement avec des médecins. Les facteurs modifiables pour améliorer la communication et les issues du deuil pendant un DCN comprennent l'attention portée à l'état d'esprit de la famille, le rythme et la répétition des discussions en fonction de la compréhension exprimée par les familles, ainsi que la préparation et l'invitation des familles à être présentes pour la détermination clinique, y compris pendant le test d'apnée. Nous avons fourni des recommandations familiales qui sont pragmatiques et peuvent être facilement mises en œuvre.

Decisions and Decisional Needs of Canadians From all Provinces and Territories During the COVID-19 Pandemic: Population-Based Cross-sectional Surveys.

BACKGROUND: Never before COVID-19 had Canadians faced making health-related decisions in a context of significant uncertainty. However, little is known about which type of decisions and the types of difficulties that they faced. OBJECTIVE: We sought to identify the health-related decisions and decisional needs of Canadians. METHODS: Our study was codesigned by researchers and knowledge users (eg, patients, clinicians). Informed by the CHERRIES (the Checklist for Reporting Results of Internet E-Surveys) reporting guideline, we conducted 2 online surveys of random samples drawn from the Leger consumer panel of 400,000 Canadians. Eligible participants were adults (≥18 years) who received or were receiving any health services in the past 12 months for themselves (adults) or for their child (parent) or senior with cognitive impairment (caregiver). We assessed decisions and decisional needs using questions informed by the Ottawa Decision Support Framework, including decisional conflict and decision regret using the Decision Conflict Scale (DCS) and the Decision Regret Scale (DRS), respectively. Descriptive statistics were conducted for adults who had decided for themselves or on behalf of someone else. Significant decisional conflict (SDC) was defined as a total DCS score of >37.5 out of 100, and significant decision regret was defined as a total DRS score of >25 out of 100. RESULTS: From May 18 to June 4, 2021, 14,459 adults and 6542 parents/caregivers were invited to participate. The invitation view rate was 15.5% (2236/14,459) and 28.3% (1850/6542); participation rate, 69.3% (1549/2236) and 28.7% (531/1850); and completion rate, 97.3% (1507/1549) and 95.1% (505/531), respectively. The survey was completed by 1454 (97.3%) adults and 438 (95.1%) parents/caregivers in English (1598/1892, 84.5%) or French (294/1892, 15.5%). Respondents from all 10 Canadian provinces and the northern territories represented a range of ages, education levels, civil statuses, ethnicities, and annual household income. Of 1892 respondents, 541 (28.6%) self-identified as members of marginalized groups. The most frequent decisions were (adults vs parents/caregivers) as follows: COVID-19 vaccination (490/1454, 33.7%, vs 87/438, 19.9%), managing a health condition (253/1454, 17.4%, vs 47/438, 10.7%), other COVID-19 decisions (158/1454, 10.9%, vs 85/438, 19.4%), mental health care (128/1454, 8.8%, vs 27/438, 6.2%), and medication treatments (115/1454, 7.9%, vs 23/438, 5.3%). Caregivers also reported decisions about moving family members to/from nursing or retirement homes (48/438, 11.0%). Adults (323/1454, 22.2%) and parents/caregivers (95/438, 21.7%) had SDC. Factors making decisions difficult were worrying about choosing the wrong option (557/1454, 38.3%, vs 184/438, 42.0%), worrying about getting COVID-19 (506/1454, 34.8%, vs 173/438, 39.5%), public health restrictions (427/1454, 29.4%, vs 158/438, 36.1%), information overload (300/1454, 20.6%, vs 77/438, 17.6%), difficulty separating misinformation from scientific evidence (297/1454, 20.4%, vs 77/438, 17.6%), and difficulty discussing decisions with clinicians (224/1454, 15.4%, vs 51/438, 11.6%). For 1318 (90.6%) adults and 366 (83.6%) parents/caregivers who had decided, 353 (26.8%) and 125 (34.2%) had significant decision regret, respectively. In addition, 1028 (50%) respondents made their decision alone without considering the opinions of clinicians. CONCLUSIONS: During COVID-19, Canadians who responded to the survey faced several new health-related decisions. Many reported unmet decision-making needs, resulting in SDC and decision regret. Interventions can be designed to address their decisional needs and support patients facing new health-related decisions.

'They all stay with me'-An interpretive phenomenological analysis on nurses' experiences resuscitating children in community hospital emergency departments.

AIM: To understand the lived experiences of nurses resuscitating children in community hospital emergency departments. BACKGROUND: Emergency department nurses exposed to paediatric resuscitations are at a high risk of developing post-traumatic stress. This may be especially true in community hospital emergency departments, where nurses have less exposure to, knowledge about, and resources for managing these events. Interventions to proactively prevent nurse trauma in these contexts remain largely uninvestigated. To inform such interventions, a detailed understanding of the largely unknown lived experiences of these nurses is necessary. DESIGN AND METHODS: In-depth, semi-structured interviews were conducted with four registered nurses that had experienced at least one paediatric resuscitation while working in a community hospital emergency department in Ontario, Canada. Data were analysed using interpretive phenomenological analysis. Reporting follows the COREQ checklist. RESULTS: Analysis revealed three superordinate themes (i.e. 'Conceptualising Paediatric Resuscitations', 'Seeing What I See', and 'Making Sense of What I Saw') and nine corresponding subthemes. CONCLUSION: This study provides insight into the infrequent, but profound experiences of nurses resuscitating children in community hospital emergency departments. Nurses, who conceptualise these events as unnatural, emotional, and chaotic, are comforted by those who understand their experiences and are distressed by those who cannot see what they see. To reconcile what they have seen, nurses may reflect and ruminate on the event, ultimately restructuring their experiences of themselves, others, and the world to make room for a new reality where the safety of childhood is not certain. RELEVANCE TO CLINICAL PRACTICE: Our findings contribute to pragmatic recommendations for interventions to proactively prevent nurse distress in these contexts, including psychoeducation, psychological support and in-situ simulation activities. Nursing leaders should consider staff that have resuscitated children as valuable sources for information on how to improve practice settings.

A systematic review and critical appraisal of guidelines and their recommendations for sedation interruptions in adult mechanically ventilated patients.

OBJECTIVE: The objectives of the review were to (i) assess the methodological quality of all accessible and published guidelines and care bundles that offer a recommendation related to sedation interruptions, using the AGREE-II instrument, to (ii) determine what is the recommended best practice for sedation interruptions from the available guidelines, and then to have (iii) a closer inspection of the overall credibility and applicability of the recommendations using the AGREE-REX instrument. This review will benefit the outcomes of critically ill patients and the multidisciplinary team responsible for the care of mechanically ventilated adults with continuous medication infusions by providing a synthesis of the recommended action(s), actor(s), contextual information, target(s), and timing related to sedation interruptions from current best practice. REVIEW METHOD USED: We conducted a systematic review. DATA SOURCES: We applied a peer-reviewed search strategy to four electronic databases from 2010 to November 2021-MEDLINE, CINAHL, Embase, and The Cochrane Database of Systematic Reviews-and included grey literature. REVIEW METHOD: Findings are reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses checklist. We assessed overall quality using the validated Appraisal of Guidelines for Research and Evaluation II and AGREE Recommendation Excellence tools. RESULTS: We identified 11 clinical practice guidelines and care bundles comprising 15 recommendations related to sedation interruption. There are three key findings: (i) deficiencies exist with the methodological quality of included guidelines, (ii) sedation interruption is recommended practice for the care of adult mechanically ventilated patients, and (iii) the current evidence is of low quality, which impacts overall credibility and applicability of the recommendations. CONCLUSIONS: Sedation interruptions are currently best practice for adult mechanically ventilated patients; however, the available guidelines and recommendations have several deficiencies. Future research is needed to further understand the role of the nurse and other actors to enact this practice.

The experiences of family members of deceased organ donors and suggestions to improve the donation process: a qualitative study.

BACKGROUND: Decisions about organ donation are stressful for family members of potential organ donors. We sought to comprehensively explore the donation process from interviews conducted with family members of patients admitted to pediatric and adult intensive care units in Canada. METHODS: We conducted a qualitative study using semistructured, in-depth interviews with 271 family members asked to make an organ donation decision. We recruited participants from all provinces with an organ donation organization (n = 10), and analyzed themes using a modified grounded theory approach. On the basis of these interviews, suggestions were made by researchers and family members on how to improve the process of organ donation. RESULTS: We identified 3 main themes and 9 subthemes. Families need more comprehensive support around the time of donation, including having access to someone with shared experiences, support during specific moments as needed and better support during critical transitions (e.g., when the donor body goes to the operating room). The theme of better connection to recipient(s) included receiving information about the donation surgery (e.g., which organs were recovered), establishing connection with recipients (e.g., via social networks or letters) and planned encounters. Support after donation, such as updates on organ transplantation, early mental health checks and continued connection to donor organizations, could be improved. We derived 20 suggestions for improving the organ donation process, derived from interviews with family members of pediatric and adult organ donors. INTERPRETATION: We found gaps in family support during end-of-life and donation care. Feelings of abandonment, lack of support and poor-to-little follow-up provide the empirical findings needed for hospitals and organ donor organizations to provide better support to donor families.

Bereavement outcomes in family members of those who died in acute care hospitals before and during the first wave of COVID-19: A cohort study.

BACKGROUND: The COVID-19 pandemic has caused millions of deaths worldwide, leading to symptoms of grief among the bereaved. Neither the burden of severe grief nor its predictors are fully known within the context of the pandemic. AIM: To determine the prevalence and predictors of severe grief in family members who were bereaved early in the COVID-19 pandemic. DESIGN: Prospective, matched cohort study. SETTING/PARTICIPANTS: Family members of people who died in an acute hospital in Ottawa, Canada between November 1, 2019 and August 31, 2020. We matched relatives of patients who died of COVID (COVID +ve) with those who died of non-COVID illness either during wave 1 of the pandemic (COVID -ve) or immediately prior to its onset (pre-COVID). We abstracted decedents' medical records, contacted family members >6 months post loss, and assessed grief symptoms using the Inventory of Complicated Grief-revised. RESULTS: We abstracted data for 425 decedents (85 COVID +ve, 170 COVID -ve, and 170 pre-COVID), and 110 of 165 contacted family members (67%) consented to participate. Pre-COVID family members were physically present more in the last 48 h of life; the COVID +ve cohort were more present virtually. Overall, 35 family members (28.9%) had severe grief symptoms, and the prevalence was similar among the cohorts (p = 0.91). Grief severity was not correlated with demographic factors, physical presence in the final 48 h of life, intubation, or relationship with the deceased. CONCLUSION: Severe grief is common among family members bereaved during the COVID-19 pandemic, regardless of the cause or circumstances of death, and even if their loss took place before the onset of the pandemic. This suggests that aspects of the pandemic itself contribute to severe grief, and factors that normally mitigate grief may not be as effective.

Comparative end-of-life communication and support in hospitalised decedents before and during the COVID-19 pandemic: a retrospective regional cohort study in Ottawa, Canada.

OBJECTIVE: To compare end-of-life in-person family presence, patient-family communication and healthcare team-family communication encounters in hospitalised decedents before and during the COVID-19 pandemic. DESIGN: In a regional multicentre retrospective cohort study, electronic health record data were abstracted for a prepandemic group (pre-COVID) and two intrapandemic (March-August 2020, wave 1) groups, one COVID-19 free (COVID-ve) and one with COVID-19 infection (COVID+ve). Pre-COVID and COVID-ve groups were matched 2:1 (age, sex and care service) with the COVID+ve group. SETTING: One quaternary and two tertiary adult, acute care hospitals in Ottawa, Canada. PARTICIPANTS: Decedents (n=425): COVID+ve (n=85), COVID-ve (n=170) and pre-COVID (n=170). MAIN OUTCOME MEASURES: End-of-life (last 48 hours) in-person family presence and virtual (video) patient-family communication, and end-of-life (last 5 days) virtual team-family communication encounter occurrences were examined using logistic regression with ORs and 95% CIs. End-of-life (last 5 days) rates of in-person and telephone team-family communication encounters were examined using mixed-effects negative binomial models with incidence rate ratios (IRRs) and 95% CIs. RESULTS: End-of-life in-person family presence decreased progressively across pre-COVID (90.6%), COVID-ve (79.4%) and COVID+ve (47.1%) groups: adjusted ORs=0.38 (0.2-0.73) and 0.09 (0.04-0.17) for COVID-ve and COVID+ve groups, respectively. COVID-ve and COVID+ve groups had reduced in-person but increased telephone team-family communication encounters: IRRs=0.76 (0.64-0.9) and 0.61 (0.47-0.79) for in-person, and IRRs=2.6 (2.1-3.3) and 4.8 (3.7-6.1) for telephone communications, respectively. Virtual team-family communication encounters occurred in 17/85 (20%) and 10/170 (5.9%) of the COVID+ve and COVID-ve groups, respectively: adjusted OR=3.68 (1.51-8.95). CONCLUSIONS: In hospitalised COVID-19 pandemic wave 1 decedents, in-person family presence and in-person team-family communication encounters decreased at end of life, particularly in the COVID+ve group; virtual modalities were adopted for communication, and telephone use increased in team-family communication encounters. The implications of these communication changes for the patient, family and healthcare team warrant further study.

ICU Clinicians' Experiences of Terminal Weaning and Extubation.

CONTEXT: Aside from spontaneous death, a majority of ICU deaths occur after a decision to either withhold or withdraw life-sustaining measures, including withdrawal of ventilatory support. While terminal weaning or terminal extubation are both used, the lack of evidence on the superiority of one method over the other can create challenges for ICU clinicians. There is a need to explore clinicians' experiences related to terminal weaning/extubation to understand their decision-making processes as well as the context and mechanisms that guide this process. OBJECTIVES: This study aimed to explore ICU clinicians'experiences of Terminal Weaning of Mechanical Ventilation (TWMV) in order to better understand the process, and clinicians' feelings about the process. METHODS: This study used an exploratory descriptive qualitative design. Data were collected via semi-structured, face-to-face interviews with 20 ICU clinicians. An inductive, data driven thematic analysis approach was used for data analysis. RESULTS: Analysis of the data resulted in four themes: Fine-tuning the Process of TWMV; Focusing on the Family; Ensuring Patient-Centered Care; and Impact on Health care Clinicians and Support Needs. CONCLUSION: The identified themes provide insight into the complexity of the withdrawal of mechanical ventilation within the context of end-of-life care in the ICU. The themes highlight the need for clear communication of a TWMV plan between clinicians to avoid conflict during the process, ensuring medication is in place for potential distressing symptoms, incorporating patient and family wishes in planning, supporting the family during the process, and training and support for clinicians.

NCLEX-RN© preparation resources available online in French: An integrative review.

AIM: This review describes the availability of online French NCLEX-RN© preparation resources for candidates BACKGROUND: One entry to practice requirement for Canadian nurses is to successfully pass a licensing exam upon graduation from their educational program. In 2015, the American NCLEX-RN© replaced the Canadian entry to practice licensing examination which was offered in Canada's two official languages: English and French. The NCLEX-RN© was developed in English and later translated to French. Since its implementation, Francophone candidates and educators in Canada have reported a lack of preparatory resources available in their language and have had substantial lower NCLEX-RN© pass rates, consistently below 50% METHODS: An integrative review using Whittemore and Knafl's framework was conducted between February and May 2019, and updated in September 2020, through online searches of CINAHL, PubMed, Science Direct and Google Scholar databases. Grey literature was included from 2012 onwards. Results are presented narratively. RESULTS: A total of 17 French language preparatory resources were found. These resources were categorised into four main groups: (1) What is the NCLEX-RN© ?; (2) What do I need to do prior to writing the NCLEX-RN© ?; (3) What is assessed through the NCLEX-RN© ? and finally, (4) How can I practice before taking the NCLEX-RN© ? CONCLUSION: Limited French-language NCLEX-RN© preparatory resources exist for Francophone candidates. Furthermore, practice questions in French are few compared to what is available in English IMPLICATIONS FOR NURSING AND NURSING POLICY: Other countries may consider implementing an entry to practice exam such as the NCLEX-RN© because of its availability in both the French and English language, as well as the possibility of translating the exam to other languages, creating a potential market for this test around the globe. The lack of preparatory resources in French is a major concern to Francophone candidates undertaking such a high-stakes examination in their language. Nursing stakeholders and policy leaders should acknowledge that such gaps place Francophone writers in a disadvantaged position in comparison to their Anglophone counterparts.

Part 2: New Graduate Nurse Transition Into the Intensive Care Unit: Summative Insights From a Longitudinal Mixed-Methods Study.

BACKGROUND AND PURPOSE: To address the nursing shortage, it is increasingly common for hospitals to hire new graduate nurses into intensive care units (ICU). New graduates in intensive care likely experience needs beyond those of their peers outside of critical care contexts. Yet, relatively little is known about the experiences of this unique population. The purpose of this study was to explore the transition experience of a cohort of new graduate nurses in the ICU over a 2-year period. METHODS: A longitudinal mixed-methods convergent design using a purposive and convenience sample of new graduate nurses working in an ICU. Surveys were administered and in-depth qualitative interviews were conducted at four points in time over a 2-year period. RESULTS: Participants identified a number of skills that remained difficult, as well as less comfort in performing a number of nursing interventions, over the four time points. In addition, they highlighted a decline in their perception of receiving encouragement and feedback from their manager. Participants identified that a lack of confidence was a barrier to transition and that improved orientation and work environment could further support them in their journey. Certain aspects of their work environment, such as peer support, were identified as most satisfying, whereas the environment and system were least satisfying. IMPLICATIONS FOR PRACTICE: The results provide a greater understanding of the transition experienced by new graduate nurses in the ICU. In addition, the results may provide the ICU leadership team with potential areas to further support the transition of new graduates within this critical care environment.

Engaging in resuscitation status conversations in psychiatry: A qualitative study of nurses' perspectives.

WHAT IS KNOWN ON THE SUBJECT?: Discussion and documentation of a patient's resuscitation status are essential aspects of any hospital admission, and yet, they seldomly occur in psychiatry. Nurses play an important role in resuscitation status determination by being an information broker, supporter and advocate. Persons with mental illness may be competent to engage in the determination of their resuscitation status and deserve the same respect and autonomy as other patients during this process. There are no published qualitative studies exploring healthcare providers experiences in initiating resuscitation status conversations in the psychiatric setting. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: An in-depth qualitative understanding of the complexity of resuscitation status determination in psychiatry. The shared experiences of nurses enacting their role in resuscitation status determination with patients admitted to psychiatry. The challenges of implementing a 'one-size fits all' approach to resuscitation status policies, and the ways in which depression and/or suicidal ideation influence the process. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Role clarity and improved communication between providers about resuscitation status determination in psychiatry are needed. Hospital policies for resuscitation status determination must account for the psychiatric context to ensure patients' goals of care are known and upheld. Nurses working in psychiatry should initiate and more readily engage in resuscitation status conversations. ABSTRACT: Introduction Patients with mental illness experience stigma and marginalization, which affects the quality of their health care. In most settings, end-of-life decisions, including goals of care, must be discussed with all patients upon hospital admission, including determining cardiopulmonary resuscitation preferences in the event of a medical emergency. Despite this requirement, these conversations do not routinely occur in inpatient psychiatry. By default, patients become a 'full code status', mandating life-sustaining interventions. Aim To explore how and why resuscitation status conversations occur, or do not occur, in inpatient psychiatry from the perspectives of healthcare providers. Method Qualitative descriptive study using focus groups with nurses working in psychiatry. Results Nurses' experiences with initiating and engaging in resuscitation status conversations related to Working in Psychiatry, which represents the current practices and the participants' views of the nursing role; Caring for Psychiatric Patients, which describes how fluctuating competency and suicidality influence determination; and The Influence of Physical Health Status, which details how differences in physical health status affect how healthcare providers engage in resuscitation status determination. Discussion Although the importance of completing resuscitation status conversations with patients admitted to psychiatry was expressed by participants, they seldomly occur. There is ambiguity about when and how to determine patient wishes. Implications for practice Tailored strategies are needed to ensure patients' rights to self-determination are upheld when they are admitted to psychiatry. Nurses working in this setting would benefit from education, training and support to adequately initiate and engage in these conversations.

New graduate nurses and dementia care in acute care: A qualitative study.

With the increasing older adult population, new graduate nurses will be providing care for patients with dementia more frequently. The purpose of this qualitative study was to explore the experiences of new graduate nurses when providing care for patients with dementia in acute care environments. We conducted semi-structured interviews with eleven new graduate nurses in Ontario, Canada. Three themes emerged from the thematic analysis: (1) building of vision and values; (2) clashing of vision and values; and (3) making do with what you have. Barriers to providing dementia care in acute care were similar to barriers experienced by non- new graduate nurses reported in the literature, such as challenges with responsive behaviours, maintaining safety and providing psychosocial care. Facilitators identified were supportive colleagues and early exposure to dementia care.

The effect of COVID-19 pandemic on the mental health of Canadian critical care nurses providing patient care during the early phase pandemic: A mixed method study.

BACKGROUND: Healthcare workers have historically experienced symptoms of post-traumatic stress disorder, depression and anxiety with previous infectious outbreaks. It is unknown if critical care nurses have similar experiences. OBJECTIVES: The study aimed to examine the mental health of Critical Care Registered Nurses providing direct patient care during the initial phase of the COVID-19 pandemic in Canada. DESIGN: This was a convergent parallel mixed method study utilizing validated questionnaires and semi-structured qualitative interviews. SETTING: Critical care units in a single large 650 bed academic teaching hospital in western Canada. The critical care units serve a general mixed medical - surgical adult patient population. PARTICIPANTS: Critical Care Registered Nurses providing direct patient care in the intensive care and high acuity units at the designated site. METHODS: 109 participants completed two self-reported validated surveys, the Impact of Events Scale - Revised and the Depression, Anxiety and Stress Scale. 15 participants completed one-on-one semi-structured interviews that were analyzed using inductive thematic analysis. RESULTS: In the surveys, the participants reported clinical concern for (23%), probable (13%) and significant (38%) symptoms of post-traumatic stress disorder, as well as mild to severe depression (57%), anxiety (67%) and stress (54%). In the interviews, psychological distress was described as anxiety, worry, distress and fear related to: 1) rapidly changing policy and information, 2) overwhelming and unclear communication, 3) meeting patient care needs in new ways while staying safe, and 4) managing home and personal commitments to self and family. CONCLUSIONS: Critical care nurses experienced psychological distress associated with providing care to COVID-19 patients during the early phases of the pandemic.

Violence and Health Promotion Among First Nations, Métis, and Inuit Women: A Systematic Review of Qualitative Research.

Indigenous women experience a disproportionate burden of intimate partner violence (IPV) compared to other women in post-colonial countries such as Canada. Intersections between IPV and other forms of structural violence including racism and gender-based discrimination create a dangerous milieu where 'help seeking' may be deterred and poor health outcomes occur. The aim of this review was to explore the perspectives of First Nations, Métis and Inuit (FNMI) women living in Canada about how violence influenced their health and wellbeing. This systematic review of qualitative research used thematic analysis to produce a configurative synthesis. A comprehensive search of electronic databases was conducted. Two reviewers screened studies for relevance and congruence with eligibility criteria. Sixteen studies were included in the review. Four themes with subthemes emerged: 1) ruptured connections between family and home, 2) that emptiness… my spirit being removed, 3) seeking help and being unheard, and 4) a core no one can touch. Together these themes form complex pathways that influenced health among women exposed to violence. Findings from this review highlight the need for collaboration with FNMI women and their communities to prevent IPV and ensure access to trauma and violence informed care (TVIC). The strength and resiliency of FNMI women is fundamental to healing from violence. Working with FNMI women and their communities to build effective interventions and promote culturally meaningful care will be important directions for researchers and policy makers.