Shared Decision-Making for Patients Using Cannabis for Pain Symptom Management in the United States

ObjectivesGaps in research evidence and inconsistent policies regarding use of cannabis for pain and associated symptoms result in confusion for healthcare providers and patients. The objective of this review was to synthesize information on cannabis use for pain with legal and policy implications to create a shared decision-making model that can be used to guide patient care interactions.ApproachCurrent cannabis policies, state laws, research, and patient care practices related to medical and recreational cannabis in the United States were reviewed, along with best practices in shared decision-making. Reviewed literature was then synthesized to create a model that can be used by registered nurses and others to address cannabis use, where legal, for pain and related symptoms.Result and conclusionsCannabis is a legal option for many patients with pain. To minimize harms and optimize benefits, nurses can play a key role when authorized by law in assisting with decision-making surrounding cannabis use.     

Examining the implementation of collaborative competencies in a critical care setting: Key challenges for enacting competency-based education

Interprofessional collaboration is recognised as an important factor in improving patient care in intensive care units (ICUs). Competency frameworks, and more specifically interprofessional competency frameworks, are a key strategy being used to support the development of attitudes, knowledge, skills, and behaviours needed for an interprofessional approach to care. However, evidence for the application of competencies is limited. This study aimed to extend our empirically based understanding of the significance of interprofessional competencies to actual clinical practice in an ICU. An ethnographic approach was employed to obtain an in-depth insight into healthcare providers’ perspectives, behaviours, and interactions of interprofessional collaboration in a medical surgical ICU in a community teaching hospital in Canada. Approximately 160 hours of observations were undertaken and 24 semi-structured interviews with healthcare workers were conducted over a period of 6 months. Data were analysed using a directed content approach where two national competency frameworks were used to help generate an understanding of the practice of interprofessional collaboration. Healthcare professionals demonstrated numerous instances of interprofessional communication, role understandings, and teamwork in the ICU setting, which supported a number of key collaborative competencies. However, organisational factors such as pressures for discharge and patient flow, staffing, and lack of prioritisation for interprofessional learning undermined competencies designed to improve collaboration and teamwork. The findings demonstrate that interprofessional competencies can play an important role in promoting knowledge, attitudes, skills, and behaviours needed. However, competencies that promote interprofessional collaboration are dependent on a range of contextual factors that enable (or impede) individuals to actually enact these competencies.     

Paternalism in nursing and healthcare: central issues and their relation to theory

Paternalistic practices, wherein providers confer a treatment or service upon a person or persons without their consent, ostensibly by reason of their limited autonomy or diminished capacity, are widespread in healthcare and in societies around the world. In the United States, paternalism in health and human services is widespread and probably increasing with newly emergent forms. Numerous issues surround paternalistic practices. In this column, the author examines these issues in relation to theory development in healthcare and nursing as well as theory as a guide to practice. It is suggested that scientific and ethical knowing are not separate but must be united in theoretical structures that include both in unity, along with an appreciation of the infinite complexity of life as it is humanly lived. It is also suggested that nursing's unique theory base of frameworks that honor human dignity and focus on human experience offers an opportunity for leadership in further developing theoretical frameworks that transcend paternalistic practices.     

Engaging the Transgender Community to Improve Medical Education and Prioritize Healthcare Initiatives

Phenomenon: Transgender patients experience discrimination, limited access to care, and inadequate provider knowledge in healthcare settings. Medical education to address transgender-specific disparities is lacking. Research that engages transgender community members may help address health disparities by empowering patients, increasing trust, and informing medical curricula to increase competence. Approach: A 2015 Community Forum on Transgender Health Care was hosted at the University of Louisville School of Medicine, which included healthcare professionals and transgender community members to facilitate dialogue among mixed-participant groups using a World Café model. Fifty-nine participants discussed the status of transgender healthcare and made recommendations for local improvements. A follow-up survey was administered to 100 individuals, including forum participants and their referrals. The forum discussion and survey responses were analyzed to determine common perceptions of transgender healthcare, priorities for improvement interventions, and themes to inform curriculum. Findings: The community forum discussion showed that local transgender care is overwhelmingly underdeveloped and unresponsive to the needs of the transgender community. The follow-up survey revealed that priorities to improve transgender care included a multidisciplinary clinic for lesbian, gay, bisexual, and transgender (LGBT) patients, an LGBT-friendly network of physicians, and more training for providers and support staff. This mutually constructive engagement experience influenced reform in undergraduate curricula and continuing education opportunities. Insights: Community engagement in healthcare disparities research can cultivate improbable discussions, yield innovative insight from marginalized populations, and build relationships with community members for future collaborations and interventions. Societal acceptance of transgender identities, which could be promoted through healthcare providers, could stimulate significant progress in transgender healthcare. Supplemental educational interventions for practicing physicians will improve the current conditions of transgender healthcare, but a comprehensive medical school curriculum specifically for transgender health that includes interactions between the transgender community and medical students could be particularly impactful.     

Telenursing and home healthcare. the many facets of technology

Telenursing was instituted as an effective mode for providing care to patients geographically distant from healthcare providers. Using telecommunications and information technology, nursing care is provided remotely to individuals. Nurses recognize the value of telecare and telehomecare as essential components of telenursing that give patients easy access to high-quality care and eliminate costs and difficulties associated with travel to healthcare facilities. Patient satisfaction with telenursing is related to prompt quality care from professional nurses. Telenursing continues to grow as a valuable method for providing nursing care, especially in home healthcare.     

Evidence-based nursing care for patients with heart failure

There is a gap between the evidence that supports treatments used in heart failure and day-to-day patient care. Clinical practice guidelines are evidence-based and suggest best practices; however, healthcare providers, patient and system factors complicate the diagnosis and must be addressed. Performance measures specific to nursing can be derived from the guidelines to guide practice and increase high-quality care. Innovative practice improvement programs, clinical leaders, and system tools are needed to close the gap. Nurses can facilitate processes that advance care planning and promote effective care delivery as part of a multidisciplinary team of healthcare providers.     

Social support for breast cancer management among Portuguese-speaking immigrant women

Breast cancer is one of the most commonly diagnosed types of cancer among women in Canada. Much health sciences research has examined this topic. The importance of formal and informal social support in managing breast cancer has received particular attention, but research with immigrant women has been limited. This article presents the findings of an applied ethnographic study conducted in Toronto, Canada, with 12 Portuguese-speaking women from Brazil, Portugal, and Angola about their need for, access to, and use of social support in the management of breast cancer. The key findings pertain to cancer-related fears and stigma that restrict access to and use of informal social support, barriers to obtaining formal social support, and women's resilience in the context of limited informal and formal social support. Implications for healthcare providers are presented at micro, meso, and macro levels.     

Providing high-quality care in primary care settings: How to make trade-offs

Objective

To gain a deeper understanding of how primary care (PC) practices belonging to different models manage resources to provide high-quality care.

Design

Multiple-case study embedded in a cross-sectional study of a random sample of 37 practices.

Setting

Three regions of Quebec.

Participants

Health care professionals and staff of 5 PC practices.

Methods

Five cases showing above-average results on quality-of-care indicators were purposefully selected to contrast on region, practice size, and PC model. Data were collected using an organizational questionnaire; the Team Climate Inventory, which was completed by health care professionals and staff; and 33 individual interviews. Detailed case histories were written and thematic analysis was performed.

Main findings

The core common feature of these practices was their ongoing effort to make trade-offs to deliver services that met their vision of high-quality care. These compromises involved the same 3 areas, but to varying degrees depending on clinic characteristics: developing a shared vision of high-quality care; aligning resource use with that vision; and balancing professional aspirations and population needs. The leadership of the physician lead was crucial. The external environment was perceived as a source of pressure and dilemmas rather than as a source of support in these matters.

Conclusion

Irrespective of their models, PC practices’ pursuit of high-quality care is based on a vision in which accessibility is a key component, balanced by appropriate management of available resources and of external environment expectations. Current PC reforms often create tensions rather than support PC practices in their pursuit of high-quality care.     

Using cost-analysis techniques to measure the value of nurse practitioner care

Nurse practitioners are in a unique position to deliver high-quality care to a variety of populations and are being utilized in many countries worldwide. Although certain aspects of the nurse practitioner role may differ from country to country, limited financial support and competition for access to patients make it incumbent on nurse practitioners to document the cost-effectiveness of their care. Cost analysis, a business tool that can be used by any practitioner in any health care system, was used to examine business practices of an academic-based nurse-managed centre. In order for this tool to be effective, nurse practitioners must become comfortable with using cost-analysis techniques in their practices. Linking outcome data with cost data was found to be one method for explicating the value of nurse practitioner practice. Nurse practitioners must also recognize that they are competing with primary-care physician practices and other primary health-care practices. It is vital for nurse practitioners to document both the quality and the costs of their care in order to compete with physicians and other health care providers, in order to influence policy and other health-care decision makers.     

Healthcare provider perceptions of the role of interprofessional care in access to and outcomes of primary care in an underserved area

To meet the needs of an aging population who often have multiple chronic conditions, interprofessional care is increasingly adopted by patient-centred medical homes and Accountable Care Organisations to improve patient care coordination and decrease costs in the United States, especially in underserved areas with primary care workforce shortages. In this cross-sectional survey across multiple clinical settings in an underserved area, healthcare providers perceived overall outcomes associated with interprofessional care teams as positive. This included healthcare providers’ beliefs that interprofessional care teams improved patient outcomes, increased clinic efficiency, and enhanced care coordination and patient follow-up. Teams with primary care physician available each day were perceived as better able to coordinate care and follow up with patients (p = .031), while teams that included clinical pharmacists were perceived as preventing medication-associated problems (p < .0001). Healthcare providers perceived the interprofessional care model as a useful strategy to improve various outcomes across different clinical settings in the context of a shortage of primary care physicians.     

An exploration of youth and parents' experiences of child mental health service access

Youth experience an increased prevalence of mental health issues, while access to timely and quality services remains problematic. This study examined the experiences of adolescents and their parents surrounding mental health care access. A 4-month focused ethnography was conducted at a mental health clinic for adolescents experiencing difficulties with emotional regulation. Findings revealed major barriers to service access, including a lack of knowledge, information, and guidance, long wait times, and stigma. Facilitators to access included social support, having a contact person, and good rapport with healthcare providers. The study highlights the importance of timely mental health service access for adolescents and provides insights for the improvement of service accessibility.     

Remote nursing certified practice: viewing nursing and nurse practitioner practice through a social justice lens

Remote Nursing Certified Practice (RNCP) was introduced in 2010 to regulate nursing practice in remote, largely First Nations communities in British Columbia, Canada. These are communities that often experience profound health and health-care inequities. Typically nurses are the main health-care providers. Using a critical social justice lens, the authors explore the clinical and ethical implications of RNCP in terms of access to equitable, high-quality primary health care.They examine the fit between the level and scope of health services provided by registered nurses working under RNCP and the health needs of remote First Nations communities. In doing so, they draw comparisons between nurse practitioners (NPs) and outpost nurses working in NP roles who historically were employed to provide health care in these communities.The authors conclude by calling for nursing regulations that support equitable, high-quality primary care for all British Columbians.     

Medical cannabis education among healthcare trainees: A scoping review

ObjectivesIt has been previously demonstrated that healthcare professionals would like additional education on medical cannabis. However, there has not yet been a review of the status of medical cannabis curriculum for medical and allied healthcare trainees worldwide, even though future healthcare workers will be placed on the forefront of patient care and must be prepared to counsel patients. This study was designed to address this gap in knowledge.DesignA search syntax was generated and databases PubMed, ERIC, CINAHL, and Web of Science were searched for relevant articles. A grey literature search of Google Scholar, MedEd, Medline, and the Proquest Dissertations and Theses section was also performed. All titles and abstracts were screened. Selected articles were subsequently screened using predetermined inclusion and exclusion criteria.ResultsAllied healthcare trainees lacked sufficient knowledge about medical cannabis and did not feel prepared to counsel patients on this subject. Additionally, they expressed a growing interest in medical cannabis and would like more standardized education on the topic. Finally, faculty and deans in various institutions agreed on the need to educate students on the subject, and aimed to implement courses on medical cannabis or expand their existing curricula.ConclusionsWhile the medical cannabis landscape is developing, medical and allied health students are not properly educated and knowledgeable on this emerging field of clinical care. The findings suggest that the implementation of competencies-based curricula on medical cannabis is essential for medical and allied healthcare trainees to have the appropriate level of knowledge to counsel and educate their patients.     

Putting the ‘patient’ back into patient-centred care: An education perspective

Patient-centred care is a value espoused by most healthcare systems and a concept taught in nursing education programs as a fundamental concept of patient care. In this study, we focused on the patient's experience of patient-centredness, interviewing eighteen patients and eight family members about their experiences as patients on an in-patient acute care medical unit in a large hospital in Canada. Approximately half of the patients expressed satisfaction with their experiences and their involvement in decisions about their healthcare. The remainder expressed concerns about their care that jeopardized their experiences of patient-centredness. These areas concerned issues of communication with and among healthcare professionals, relationships with these care providers, trust and respect in the professional relationships, and general satisfaction with care. Participants provided advice to professional students about ways to interact more effectively with their patients to establish caring, empathetic, patient-centred relationships as the basis for care. We address patient recommendations to support learner understanding of the patient experience both in classrooms and clinical experiences throughout educational programs as a means to enhance their patient-centredness.     

Kangaroo mother care: A literature review of barriers and facilitators to implementation in the neonatal intensive care unit

Kangaroo mother care (KMC) is a cost-effective, natural, safe, and evidence-based intervention that improves maternal-infant bonding, increases breastfeeding rates, and decreases the risk of mortality and morbidity in preterm infants. Although KMC is recommended to be the standard of care for preterm infants, there are significant implementation barriers. This literature review critically analyzes the barriers and facilitators to implementation from three health care system components: (1) health care facilities, (2) health care providers, and (3) parents. One independent author included 17 research-based articles from 2014 to 2021. Overarching themes identified were: availability of protocols, policies, and guidelines; access to training and support; access to resources; buy-in; and medical concerns. Recommendations to overcome barriers and increase uptake are: develop and disseminate KMC protocols, policies, and guidelines; provide quality training and support to health care providers; provide quality education and socio-cultural support to parents; and allocate resources to support KMC.     

Nurse‐Managed Free Clinic Fosters Care Connection for Homeless Population

The goal of this article is to demystify the process that healthcare providers must follow when working with homeless patients who sustain injuries or exhibit illnesses that necessitate rehabilitation care. Observations made over a period of more than 12 years at an inner‐city medical/psychiatric nurse‐managed free clinic that delivers cutting‐edge services and educates multidisciplinary students to care for disenfranchised populations led the author to several conclusions: homeless people frequently lose their identity as individuals when facing healthcare providers; previous negative perceptions of homelessness can turn positive when care providers meet these patients on a person‐to‐person level; the concept of health and rehabilitation must be clearly understood in the same way by both providers and patients for nursing goals to be realistic and achievable; and a collaborative relationship must be formed between nurses and patients.     

Understanding barriers to emergency care in low-income countries: view from the front line

INTRODUCTION: Morbidity and mortality due to acute but treatable conditions remain high in the developing world, as many significant barriers exist to providing emergency medical care.This study investigates these barriers in a rural region of Ethiopia. HYPOTHESIS: The limited capacity of frontline healthcare workers to diagnose and treat acute medical and surgical conditions represents a major barrier to the provision of emergency care in rural Ethiopia. METHODS: Health providers at a convenience sample of 16 rural health centers in the state of Tigray, Ethiopia completed a questionnaire designed to assess the availability of diagnostic and treatment modalities, the proximity and methods of transportation to referral facilities, and health providers' level of comfort in diagnosing and treating a variety of representative emergency medical conditions. RESULTS: Thirteen (81%) providers had only a very basic level of medical training, and seven (44%) lacked access to any diagnostic equipment. While most providers could offer oral rehydration solution (ORS), anti-pyretic medications, and antibiotics, none of the providers could offer blood transfusions or any form of surgery. Ten (63%) respondents stated that their patients had to travel >10 km from the health center to a referral hospital, with only a minority of patients having access to motorized transport. For the seven emergency conditions assessed, a majority of providers felt comfortable diagnosing these conditions, though fewer felt comfortable treating them. CONCLUSION: There is a significant need for both health worker training and improvements in transportation infrastructure in order to increase access to emergency medical care in rural areas of the developing world. Low-cost interventions that improve human capacity in a context-appropriate manner are warranted as transportation and hospital network capacity expansions are considered.     

Women's stories of their experiences as overweight patients

Title. Women’s stories of their experiences as overweight patients. Aim. This paper is a report of a study to illuminate the meaning of women’s experiences as overweight patients in their encounters with healthcare services and healthcare providers. Background. Overweight and obesity are increasingly important issues for women’s health internationally. Overweight or obese women may delay or avoid health care if care providers have previously reacted negatively to them based on weight. However, studies focusing on the meaning of women’s experiences as overweight patients and as recipients of healthcare services are lacking. Method. A hermeneutic phenomenological approach was used. Face‐to‐face interviews were conducted in the United States of America in 2007 with eight women volunteers who self‐identified as being overweight patients. The framework of van Manen’s lifeworld existentials of lived space, lived body, lived time and lived relation‐guided reflection for data analysis. Findings. The essence of women’s experiences was a battle to fit into the world of healthcare services. Four major themes were identified. ‘ Struggling to fit in ’ consisted of trying to fit into limited physical space (examination rooms, equipment), limited time, and limited satisfaction and support in relationships with healthcare providers. ‘ Being dismissed ’ consisted of demeaning and embarrassing interactions with providers. ‘ Feeling not quite human ’ involved the stigma of being different because of body size. ‘ Refusing to give up ’ consisted of persistence in seeking support and advice from professionals despite negative past experiences. Conclusion. Awareness of these findings could reform understanding of women’s experiences as overweight patients and raise the consciousness of nurses worldwide to develop sensitive communication strategies and healthcare environments that support holistic care.     

Health and Psychiatric Disparities in Children with Cognitive and Developmental Delays: Implications for Health Policy in Quebec

Background Previous research on psychiatric and health disparities according to level of cognitive functioning has focused on adults within an American healthcare context. The current study compares children with and without cognitive and developmental delays in Quebec, Canada, using physician billing data from a longitudinal study of low‐income, francophone families. Canada is an ideal context for studying medical billing data as its equal access healthcare system removes many socioeconomic biases. Methods A large sample (n = 1050) of children is used to describe psychiatric and health disparities, as well as differences in Ambulatory Care Sensitive (ACS) conditions and primary healthcare, between children with (n = 107) and without (n = 943) diagnoses in their billing history indicative of delays. Results The findings demonstrated a relatively high level of psychiatric diagnoses for children with delays. However, no difference was found between children with and without delays in regard to emergency room visits and hospitalizations for ACS conditions and primary healthcare. Conclusions The findings suggest that, within a universal healthcare system, disparities in primary healthcare may not emerge until adulthood in individuals with delay status.