Palliative Professionals' Experiences of Receiving Gratitude: A Transformative and Protective Resource

Providing palliative care can be both challenging and rewarding. It involves emotionally demanding work and yet research shows that burnout is lower than in other fields of health care. Spontaneous expressions of gratitude from patients and family members are not uncommon and are highly valued. This study explored the experience of Spanish palliative professionals who received expressions of gratitude from their patients and families. A phenomenological approach was used to better understand the role of receiving gratitude in participants' lives. Interviews were transcribed verbatim and a phenomenological approach to analysis was undertaken using macro-thematic and micro-thematic reflection. Two team members independently engaged in this reflection with an inductive approach. The analysis was shared and discussed at periodic meetings to identify the key themes and sub-themes of the gratitude experience. Ten palliative professionals were interviewed. Participants engaged in a process of recognizing, internalizing, and treasuring the expressions of gratitude which they then used for reflection and growth. These expressions were a powerful and deeply meaningful resource that the palliative professionals revisited over time. Receiving expressions of gratitude invited a stronger sense of the value of one's self and one's work that was motivational and protective, particularly during challenging times.

Effect of "Speak Up" educational tools to engage patients in advance care planning in outpatient healthcare settings: A prospective before-after study

BACKGROUND

Tools for advance care planning (ACP) are advocated to help ensure patient values guide healthcare decisions. Evaluation of the effect of tools introduced to patients in clinical settings is needed.

OBJECTIVE

To evaluate the effect of the Canadian Speak Up Campaign tools on engagement in advance care planning (ACP), with patients attending outpatient clinics. Patient involvement: Patients were not involved in the problem definition or solution selection in this study but members of the public were involved in development of tools. The measurement of impacts involved patients.

METHODS

This was a prospective pre-post study in 15 primary care and two outpatient cancer clinics. The outcome was scores on an Advance Care Planning Engagement Survey measuring Behavior Change Process on 5-point scales and Actions (0-21-point scale) administered before and six weeks after using a tool, with reminders at two or four weeks.

RESULTS

177 of 220 patients (81%) completed the study (mean 68 years of age, 16% had cancer). Mean Behavior Change Process scores were 2.9 at baseline and 3.5 at follow-up (mean change 0.6, 95% confidence interval 0.5 to 0.7; large effect size of 0.8). Mean Action Measure score was 3.7 at baseline and 4.8 at follow-up (mean change 1.1, 95% confidence interval 0.6-1.5; small effect size of 0.2).

PRACTICAL VALUE

Publicly available ACP tools may have utility in clinical settings to initiate ACP among patients. More time and motivation may be required to stimulate changes in patient behaviors related to ACP.

People With Advanced Cancer: The Process of Living Well With Awareness of Dying

Literature suggests that it is possible to live well with advanced cancer but little is known about the process. In this article, we present a secondary analysis of experiences of living with advanced cancer (n = 22) that refines the theory of "Living Well with Chronic Illness" for a different context and population. The refined theory explains the experience of living well with advanced cancer illuminating a five-phase iterative process: struggling, accepting, living with advanced cancer, sharing the illness experience, and reconstructing life. These five phases revolve around the core concept of Awareness of Dying, which varied from awareness of the possibility of dying, to accepting the possibility of dying, to acceptance that "I am dying." Awareness of Dying led to a focus on living well with advanced cancer and movement towards living a life rather than living an illness.

Effect of an Interactive Website to Engage Patients in Advance Care Planning in Outpatient Settings

PURPOSE

Online programs may help to engage patients in advance care planning in outpatient settings. We sought to implement an online advance care planning program, PREPARE (Prepare for Your Care; http://www.prepareforyourcare.org), at home and evaluate the changes in advance care planning engagement among patients attending outpatient clinics.

METHODS

We undertook a prospective before-and-after study in 15 primary care clinics and 2 outpatient cancer centers in Canada. Patients were aged 50 years or older (primary care) or 18 years or older (cancer care) and free of cognitive impairment. They used the PREPARE website over 6 weeks, with reminders sent at 2 or 4 weeks. We used the 55-item Advance Care Planning Engagement Survey, which measures behavior change processes (knowledge, contemplation, self-efficacy, readiness) on 5-point scales and actions relating to substitute decision makers, quality of life, flexibility for the decision maker, and asking doctors questions on an overall scale from 0 to 21; higher scores indicate greater engagement.

RESULTS

In total, 315 patients were screened and 172 enrolled, of whom 75% completed the study (mean age = 65.6 years, 51% female, 35% had cancer). The mean behavior change process score was 2.9 (SD 0.8) at baseline and 3.5 (SD 0.8) at follow-up (mean change = 0.6; 95% CI, 0.49-0.73); the mean action measure score was 4.0 (SD 4.9) at baseline and 5.2 (SD 5.4) at follow-up (mean change = 1.2; 95% CI, 0.54-1.77). The effect size was moderate (0.75) for the former and small (0.23) for the latter. Findings were similar in both primary care and cancer care populations.

CONCLUSIONS

Implementation of the online PREPARE program in primary care and cancer care clinics increased advance care planning engagement among patients.

Development and Implementation of the Family Caregiver Decision Guide

Care provided by family is the backbone of palliative care in Canada. The critical roles performed by caregivers can at the same time be intensely meaningful and intensely stressful. However, experiences of caregiving can be enhanced when caregivers feel they are making informed and reflective decisions about the options available to them. With this in mind, the purpose of this five-phase research project was to create a Family Caregiver Decision Guide (FCDG). The Guide entails four steps: thinking about the current caregiving situation, imagining how the caregiving situation may change, exploring available options, and considering best options if caregiving needs change. The FCDG was based on available evidence and was developed and refined using focus groups, cognitive interviewing, and a feasibility and acceptability study. Finally, an interactive version of the Guide was created for online use ( https://www.caregiverdecisionguide.ca ). In this article, we describe the development, evaluation, and utility of the FCDG.

Short Graphic Values History Tool for decision making during serious illness

OBJECTIVES

To develop and validate a values clarification tool, the Short Graphic Values History Tool (GVHT), designed to support person-centred decision making during serious illness.

METHODS

The development phase included input from experts and laypersons and assessed acceptability with patients/family members. In the validation phase, we recruited additional participants into a before-after study. Our primary validation hypothesis was that the tool would reduce scores on the Decisional Conflict Scale (DCS) at 1-2 weeks of follow-up. Our secondary validation hypotheses were that the tool would improve values clarity (reduce scores) more than other DCS subscales and increase engagement in advance care planning (ACP) processes related to identification and discussion of one's values.

RESULTS

In the development phase, the tool received positive overall ratings from 22 patients/family members in hospital (mean score 4.3; 1=very poor; 5=very good) and family practice (mean score 4.5) settings. In the validation phase, we enrolled 157 patients (mean age 71.8 years) from family practice, cancer clinic and hospital settings. After tool completion, decisional conflict decreased (-6.7 points, 95% CI -11.1 to -2.3, p=0.003; 0-100 scale; N=100), with the most improvement seen in the values clarity subscale (-10.0 points, 95% CI -17.3 to -2.7, p=0.008; N=100), and the ACP-Values process score increased (+0.4 points, 95% CI 0.2 to 0.6, p=0.001; 1-5 scale; N=61).

CONCLUSIONS

The Short GVHT is acceptable to end users and has some measure of validity. Further study to evaluate its impact on decision making during serious illness is warranted.

Fractured Care: A Window Into Emergency Transitions in Care for LTC Residents With Complex Health Needs

Objective: For long-term care (LTC) residents, transfers to emergency departments (EDs) can be associated with poor health outcomes. We aimed to describe characteristics of residents transferred, factors related to decisions during transfer, care received in emergency medical services (EMS), ED settings, outcomes on return to LTC, and times of transfer segments along the transition. Method: We prospectively followed 637 transitions to an ED in British Columbia and Alberta, Canada, over a 12-month period. Data were captured through an electronic Transition Tracking Tool and interviews with health care professionals. Results: Common events triggering transfer were falls (26.8%), sudden change in condition (23.5%), and shortness of breath (19.8%). Discrepancies existed between reason for transfer, EMS reported chief complaint, and ED diagnosis. Many transfers resulted in resident return directly to LTC (42.7%). Discussion: Avoidable transfers may put residents at risk of receiving inappropriate care. Standardized communication strategies to highlight changes in resident condition are warranted.

Factors Affecting Palliative Care Development in Africa: In-Country Experts' Perceptions in Seven Countries

CONTEXT

Factors contributing to and impeding palliative care (PC) development in Africa can provide insights into current strategies for advancing PC.

OBJECTIVES

To identify key factors affecting PC development in African countries from in-country PC experts' perspectives.

METHODS

About 16 PC experts from seven African countries undertook semistructured interviews on PC development in their respective countries. An interpretive description approach was adopted, with data analyzed using constant comparison.

RESULTS

Emerged themes included drivers, strengths, challenges, and aspirations for PC development in Africa. Drivers included advocates and pioneering organizations, HIV/AIDS, culture of caregiving, and the World Health Assembly PC resolution. Strengths included community health workers, the special role of nurses, diversity of services, and short training courses. Challenges included lack of PC education; lack of standardization in implementation; limited availability of and/or accessibility to morphine; poverty and disease burden; and lack of funding for PC. Aspirations included integration of PC, specialization in PC, nurse prescribing, and strong partnerships with Ministries of Health. Factors already highlighted in the literature were only briefly discussed.

CONCLUSION

The key factors underpinning PC development in the seven countries contributed to the beginnings of PC in Africa, fueled by advocates who built on existing strengths to maximize opportunities. However, the current approach is at high risk in terms of its sustainability, and strategies for maximizing existing resources and growing infrastructure support are needed moving forward.

Evaluation of an advance care planning web-based resource: applicability for cancer treatment patients

PURPOSE

The purpose of this study was to explore the acceptability, applicability, and understandability of a promising advance care planning (ACP) web-based resource for use with oncology patients, and determine whether revisions to the website would be necessary before implementation into oncology care. The resource is called PREPARE ( www.prepareforyourcare.org ) and it had not been tested for use within oncology, but had previously been shown to influence the readiness of older, community-dwelling adults to engage in ACP behaviors.

METHODS

This qualitative descriptive study included participants receiving cancer medications and one participant on watchful waiting post-chemotherapy (n = 21). Data were collected via cognitive interviewing, followed by a brief semi-structured interview to gather a meaningful account of the participants' experience with PREPARE. Content analysis resulted in a comprehensive summary of what participants liked and did not like about the resource, as well as suggestions for change.

RESULTS

Overall, participants agreed PREPARE was acceptable, applicable, and understandable for cancer patients. A small number of participants had difficulty with the life-limiting language found within the website and this requires follow-up to determine whether the language causes distress or disengagement from ACP. These findings extend our understanding of barriers to engagement in ACP that appear unique to cancer patients receiving active treatment.

CONCLUSIONS

Results indicated that PREPARE is a reflective, capacity-building ACP resource that was acceptable, applicable, and understandable for use in oncology. These findings offer direction for both research and practice.

Oncologist Experience Implementing Goals of Care Discussions in Everyday Ambulatory Oncology Practice: Implications for Education

Despite evidence that Goals of Care (GOC) discussions should occur early in the disease trajectory, the majority occur close to end of life. In a pilot, oncologists routinely initiated GOC discussions with all patients in their everyday ambulatory practice. Following the pilot, 9 of 12 eligible oncologists participated in semi-structured interviews about their experiences. Analysis resulted in the identification of seven principles of good GOC discussions embedded in the oncologists' interviews, four barriers to engaging in GOC discussions and foundational education needs. Participants believed that the appropriate trigger for a GOC discussion is a diagnosis of advanced cancer, not simply a diagnosis of cancer, and supported the importance of selective and strategic targeting of GOC discussions. The findings have informed the development of an education-based model for culture change within a province-wide cancer care system.

Measuring Advance Care Planning: Optimizing the Advance Care Planning Engagement Survey

CONTEXT

A validated 82-item Advance Care Planning (ACP) Engagement Survey measures a broad range of behaviors. However, concise surveys are needed.

OBJECTIVES

The objective of this study was to validate shorter versions of the survey.

METHODS

The survey included 57 process (e.g., readiness) and 25 action items (e.g., discussions). For item reduction, we systematically eliminated questions based on face validity, item nonresponse, redundancy, ceiling effects, and factor analysis. We assessed internal consistency (Cronbach's alpha) and construct validity with cross-sectional correlations and the ability of the progressively shorter survey versions to detect change one week after exposure to an ACP intervention (Pearson correlation coefficients).

RESULTS

Five hundred one participants (four Canadian and three US sites) were included in item reduction (mean age 69 years [±10], 41% nonwhite). Because of high correlations between readiness and action items, all action items were removed. Because of high correlations and ceiling effects, two process items were removed. Successive factor analysis then created 55-, 34-, 15-, nine-, and four-item versions; 664 participants (from three US ACP clinical trials) were included in validity analysis (age 65 years [±8], 72% nonwhite, 34% Spanish speaking). Cronbach's alphas were high for all versions (four items 0.84-55 items 0.97). Compared with the original survey, cross-sectional correlations were high (four items 0.85; 55 items 0.97) as were delta correlations (four items 0.68; 55 items 0.93).

CONCLUSION

Shorter versions of the ACP Engagement Survey are valid, internally consistent, and able to detect change across a broad range of ACP behaviors for English and Spanish speakers. Shorter ACP surveys can efficiently measure broad ACP behaviors in research and clinical settings.

Families Living Well With Chronic Illness: The Healing Process of Moving On

Chronic illness is a global issue of escalating importance. While prevention, control, and management of chronic disease are imperative, it is also critical to shift our focus away from illness and toward living. In particular, attention needs to focus on living well despite illness. This article reports a grounded theory study with 43 members from 17 families who perceived they were managing well with serious chronic illnesses. The theory that captures the circular, iterative healing process of moving on is comprised of five phases: the fight, accepting, living with the chronic illness, sharing the experience, and reconstructing life. Families moved on through the process and moved on over time toward healing where they lived well alongside chronic illness. Family issues associated with each phase are identified as well as implications for health care providers. The theory provides a way of conceptualizing wellness in illness that supports patient- and family-centered care.

Caring at home until death: enabled determination

PURPOSE

The importance of family caregivers in providing palliative care at home and in supporting a home death is well supported. Gaining a better understanding of what enables palliative family caregivers to continue caring at home for their family members until death is critical to providing direction for more effective support. The purpose of the study was to describe the experiences of bereaved family caregivers whose terminally ill family members with advanced cancer were successful in achieving a desired home death.

METHOD

A qualitative interpretive descriptive approach was used. Data were collected using semi-structured, audio-recorded interviews conducted in-person or via telephone in addition to field notes and reflective journaling. The study took place in British Columbia, Canada, and included 29 bereaved adult family caregivers who had provided care for a family member with advanced cancer and experienced a home death.

RESULTS

Four themes captured the experience of caring at home until death: context of providing care, supportive antecedents to providing care, determination to provide care at home, and enabled determination. Factors that enabled determination to achieve a home death included initiation of formal palliative care, asking for and receiving help, augmented care, relief or respite, and making the healthcare system work for the ill person.

CONCLUSIONS

Clarifying caregiving goals and supporting the factors that enable caregiver determination appear to be critical in enhancing the likelihood of a desired home death.

Trust, Health Care Relationships, and Chronic Illness: A Theoretical Coalescence

Trust in health care relationships is a key ingredient of effective, high-quality care. Although the indirect influence of trust on health outcomes has long been recognized, recent research has shown that trust has a direct effect on outcomes of care. Trust is important. However, the research on trust is disparate, organized around differing definitions, and primarily focused on patients' trust in physicians. Morse's method of theoretical coalescence was used to further develop and elaborate a grounded theory of the evolution of trust in health care relationships, in the context of chronic illness. This middle-range theory offers a clear conceptual framework for organizing and relating disparate studies, explaining the findings of different studies at a higher conceptual level, and identifying gaps in research and understanding. In addition, the grounded theory is relevant to practice.

Measuring engagement in advance care planning: a cross-sectional multicentre feasibility study

OBJECTIVES

To assess the feasibility, acceptability and clinical sensibility of a novel survey, the advance care planning (ACP) Engagement Survey, in various healthcare settings.

SETTING

A target sample of 50 patients from each of primary care, hospital, cancer care and dialysis care settings.

PARTICIPANTS

A convenience sample of patients without cognitive impairment who could speak and read English was recruited. Patients 50 and older were eligible in primary care; patients 80 and older or 55 and older with clinical markers of advanced chronic disease were recruited in hospital; patients aged 19 and older were recruited in cancer and renal dialysis centres.

OUTCOMES

We assessed feasibility, acceptability and clinical sensibility of the ACP Engagement Survey using a 6-point scale. The ACP Engagement Survey measures ACP processes (knowledge, contemplation, self-efficacy and readiness) on 5-point Likert scales and actions (yes/no).

RESULTS

196 patients (38-96 years old, 50.5% women) participated. Mean (±SD) time to administer was 48.8±19.6 min. Mean acceptability scores ranged from 3.2±1.3 in hospital to 4.7±0.9 in primary care, and mean relevance ranged from 3.5±1.0 in hospital to 4.9±0.9 in dialysis centres (p<0.001 for both). The mean process score was 3.1±0.6 and the mean action score was 11.2±5.6 (of a possible 25).

CONCLUSIONS

The ACP Engagement Survey demonstrated feasibility and acceptability in outpatient settings but was less feasible and acceptable among hospitalised patients due to length. A shorter version may improve feasibility. Engagement in ACP was low to moderate.

A Motivational, Gender-Sensitive Smoking Cessation Resource for Family Members of Patients With Lung Cancer

PURPOSE/OBJECTIVES

To gather feedback on an innovative gender-sensitive booklet that draws on emotional connections and relationship factors to motivate smoking cessation.

RESEARCH APPROACH

Qualitative, descriptive.

SETTING

Six provinces in Canada.

PARTICIPANTS

30 family members of patients with lung cancer who were currently smoking or had recently quit.

METHODOLOGIC APPROACH

Parallel booklets for women and men were developed using language and images to emphasize family relationships and gender considerations to motivate smoking cessation. Participants were provided with the women's and men's versions of the resource, and they were asked to review the gender-specific version of the booklet that was relevant to them. Semistructured telephone interviews were conducted, and transcriptions were analyzed for themes.

FINDINGS

Three themes were evident in the data, including "new perspectives.

CONCLUSIONS

A gender-sensitive approach that focuses on relationship factors represents an acceptable way to engage relatives of patients with lung cancer in discussions to support smoking cessation.

INTERPRETATION

Approaches to supporting smoking cessation among relatives of patients diagnosed with lung cancer should draw on positive relationship bonds and caring connections to motivate cessation.

Feasibility of a rural palliative supportive service

INTRODUCTION

Healthcare models for the delivery of palliative care to rural populations encounter common challenges: service gaps, the cost of the service in relation to the population, sustainability, and difficulty in demonstrating improvements in outcomes. Although it is widely agreed that a community capacity-building approach to rural palliative care is essential, how that approach can be achieved, evaluated and sustained remains in question. The purpose of this community-based research project is to test the feasibility and identify potential outcomes of implementing a rural palliative supportive service (RPaSS) for older adults living with life-limiting chronic illness and their family caregiver in the community. This paper reports on the feasibility aspects of the study.

METHODS

RPaSS is being conducted in two co-located rural communities with populations of approximately 10 000 and no specialized palliative services. Participants living with life-limiting chronic illness and their family caregivers are visited bi-weekly in the home by a nurse coordinator who facilitates symptom management, teaching, referrals, psychosocial and spiritual support, advance care planning, community support for practical tasks, and telephone-based support for individuals who must commute outside of the rural community for care. Mixed-method collection strategies are used to collect data on visit patterns; healthcare utilization; family caregiver needs; and participant needs, functional performance and quality of life.

RESULTS

A community-based advisory committee worked with the investigative team over a 1-year period to plan RPaSS, negotiating the best fit between research methods and the needs of the community. Recruitment took longer than anticipated with service capacity being reached at 8 months. Estimated service capacity of one nurse coordinator, based on bi-weekly visits, is 25 participants and their family caregivers. A total of 393 in-person visits and 53 telephone visits were conducted between January 2013 and May 2014. Scheduled in-person visit duration showed a mean of 67 minutes. During this same time period only 19 scheduled visits were declined, and there was no study attrition except through death, indicating a high degree of acceptability of the intervention. The primary needs that were addressed during these visits have been related to chronic disease management, and the attending physical symptoms were addressed through teaching and support. The use of structured quality of life and family caregiver needs assessments has been useful in facilitating communication, although some participants experienced the nature of the questions as too personal in the early stages of the relationship with the nurse coordinator.

CONCLUSIONS

Findings from this study illustrate the feasibility of providing home-based services for rural older adults living with life-limiting chronic illness. The RPaSS model has the potential to smooth transitions and enhance quality of life along the disease trajectory and across locations of care by providing a consistent source of support and education. This type of continuity has the potential to foster the patient- and family-centered approach to care that is the ideal of a palliative approach. Further, the use of a rural community capacity-building approach may contribute to sustainability, which is a particularly important part of rural health service delivery.

Gender, smoking and tobacco reduction and cessation: a scoping review

Considerations of how gender-related factors influence smoking first appeared over 20 years ago in the work of critical and feminist scholars. This scholarship highlighted the need to consider the social and cultural context of women's tobacco use and the relationships between smoking and gender inequity. Parallel research on men's smoking and masculinities has only recently emerged with some attention being given to gender influences on men's tobacco use. Since that time, a multidisciplinary literature addressing women and men's tobacco use has spanned the social, psychological and medical sciences. To incorporate these gender-related factors into tobacco reduction and cessation interventions, our research team identified the need to clarify the current theoretical and methodological interpretations of gender within the context of tobacco research. To address this need a scoping review of the published literature was conducted focussing on tobacco reduction and cessation from the perspective of three aspects of gender: gender roles, gender identities, and gender relations. Findings of the review indicate that there is a need for greater clarity on how researchers define and conceptualize gender and its significance for tobacco control. Patterns and anomalies in the literature are described to guide the future development of interventions that are gender-sensitive and gender-specific. Three principles for including gender-related factors in tobacco reduction and cessation interventions were identified: a) the need to build upon solid conceptualizations of gender, b) the importance of including components that comprehensively address gender-related influences, and c) the importance of promoting gender equity and healthy gender norms, roles and relations.

The Male Face of Caregiving

The purpose of this scoping review was to examine the empirical evidence published since 2007 on men as family caregivers of persons with dementia. Searches were conducted on Academic Search Complete, Ageline, CINAHL, Embase, Medline, PsychINFO, Social Work Abstracts, and Web of Science using database-specific controlled (i.e., MeSH terms) vocabulary related to dementia, men, and caregiving. Studies published in English between 2007 and 2012 that provided evidence of the experiences of male family caregivers of persons with dementia were included in the review. A total of 30 articles were selected for inclusion. Studies were grouped into three major themes for review: men’s experiences of caregiving, relational factors, and outcomes of caregiving. The reviewed studies build on and support previous findings related to stress, burden, accessing services, and the importance of relational factors to men’s caregiving experiences. However, there is a need for a framework that explains these findings in relation to masculinities. Such a framework would provide the necessary unifying context for a more powerful explanatory account. Furthermore, there appears to be the potential for great benefit in fully linking men’s caregiver research to men’s health issues as a means to articulate strategies to sustain the health and well-being of men caregivers. This seems especially relevant in light of the closing gender gap in life expectancy, which will ultimately see many men providing direct care to their partners.

Program assessment framework for a rural palliative supportive service

Although there are a number of quality frameworks available for evaluating palliative services, it is necessary to adapt these frameworks to models of care designed for the rural context. The purpose of this paper was to describe the development of a program assessment framework for evaluating a rural palliative supportive service as part of a community-based research project designed to enhance the quality of care for patients and families living with life-limiting chronic illness. A review of key documents from electronic databases and grey literature resulted in the identification of general principles for high-quality palliative care in rural contexts. These principles were then adapted to provide an assessment framework for the evaluation of the rural palliative supportive service. This framework was evaluated and refined using a community-based advisory committee guiding the development of the service. The resulting program assessment framework includes 48 criteria organized under seven themes: embedded within community; palliative care is timely, comprehensive, and continuous; access to palliative care education and experts; effective teamwork and communication; family partnerships; policies and services that support rural capacity and values; and systematic approach for measuring and improving outcomes of care. It is important to identify essential elements for assessing the quality of services designed to improve rural palliative care, taking into account the strengths of rural communities and addressing common challenges. The program assessment framework has potential to increase the likelihood of desired outcomes in palliative care provisions in rural settings and requires further validation.

Older Persons' Transitions in Care (OPTIC): a study protocol

BACKGROUND

Changes in health status, triggered by events such as infections, falls, and geriatric syndromes, are common among nursing home (NH) residents and necessitate transitions between NHs and Emergency Departments (EDs). During transitions, residents frequently experience care that is delayed, unnecessary, not evidence-based, potentially unsafe, and fragmented. Furthermore, a high proportion of residents and their family caregivers report substantial unmet needs during transitions. This study is part of a program of research whose overall aim is to improve quality of care for frail older adults who reside in NHs. The purpose of this study is to identify successful transitions from multiple perspectives and to identify organizational and individual factors related to transition success, in order to inform improvements in care for frail elderly NH residents during transitions to and from acute care. Specific objectives are to: 1. define successful and unsuccessful elements of transitions from multiple perspectives; 2. develop and test a practical tool to assess transition success; 3. assess transition processes in a discrete set of transfers in two study sites over a one year period; 4. assess the influence of organizational factors in key practice locations, e.g., NHs, emergency medical services (EMS), and EDs, on transition success; and 5. identify opportunities for evidence-informed management and quality improvement decisions related to the management of NH - ED transitions.

METHODS/DESIGN

This is a mixed-methods observational study incorporating an integrated knowledge translation (IKT) approach. It uses data from multiple levels (facility, care unit, individual) and sources (healthcare providers, residents, health records, and administrative databases).

DISCUSSION

Key to study success is operationalizing the IKT approach by using a partnership model in which the OPTIC governance structure provides for team decision-makers and researchers to participate equally in developing study goals, design, data collection, analysis and implications of findings. As preliminary and ongoing study findings are developed, their implications for practice and policy in study settings will be discussed by the research team and shared with study site administrators and staff. The study is designed to investigate the complexities of transitions and to enhance the potential for successful and sustained improvement of these transitions.

Supporting rural family palliative caregivers

There is urgent need to effectively support the well-being of rural palliative family caregivers (FCGs). A mixed method study was conducted with 23 FCGs. Data collection included completion of an assessment questionnaire and semistructured interviews. The most prevalent needs identified by questionnaire were caring for the patient's pain, fatigue, body, and nourishment; FCG's fatigue and need for respite. Yet few FCGs wanted more attention to these needs by healthcare providers. FCGs resisted considering their own personal needs. Instead, they focused on needs related to providing care including to be(come) a palliative caregiver, be skilled and know more, navigate competing wishes, needs, demands, and priorities, and for "an extra pair of hands." Gaps in rural palliative services contributed to low expectations for assistance; reluctance to seek assistance was influenced by FCGs' resourcefulness and independence. Findings suggest that supporting FCGs will most likely be successful when framed in relation to their caregiving role.

Stakeholder perspectives on transitions of nursing home residents to hospital emergency departments and back in two Canadian provinces

Major gaps exist in our understanding of transitions in care for older persons living in nursing homes. The purpose of the study was to identify key elements, from multiple stakeholder perspectives, that influence the success of transitions experienced by nursing home residents when they required transfer to a hospital emergency department. This interpretive descriptive study was conducted in two cities in the Canadian provinces of British Columbia and Alberta. Data were collected from 71 participants via focus groups and individual interviews with nursing home residents, family members, and professional healthcare providers working in nursing homes, emergency departments, and emergency medical services. Transcripts were analyzed using constant comparison. The elements contributing to the success of transitions reflected a patient- and family-centered approach to care. Transitions were influenced by the complex interplay of multiple elements that included: knowing the resident; critical geriatric knowledge and skilled assessment; positive relationships; effective communication; and timeliness. When one or more of the elements was absent or compromised, the success of the transition was also compromised. There was consistency about the importance of all the identified elements across all stakeholder groups whether they are residents, family members, or health professionals in nursing homes, emergency departments or emergency medical services. Aspects of many of these elements are modifiable and suggest viable targets for interventions aimed at improving the success of transitions for this vulnerable population.

Gamma-aminobutyric acid (GABA)-B receptor 1 in cerebellar cortex of essential tremor

Some reports suggest cerebellar dysfunction as the basis of essential tremor (ET). Several drugs with the action of gamma-aminobutyric acid (GABA) are known to improve ET. Autopsy studies were performed on brains from nine former patients followed at the Movement Disorders Clinic Saskatchewan, Canada, and compared with five normal control brains. We aimed to measure the concentration of GABA B receptor 1 (GBR1) in the brains of patients who had had ET and to compare them to the GABA concentration in brains of controls. Western blot was used to determine the expression of GBR1 in cerebellar cortex tissue. We found that compared to the controls, the ET brains had three different patterns of GBR1 protein concentration--two with high, four comparable, and three with marginally low levels. There was no association between the age of onset, severity or duration of tremor, the response to alcohol or other drugs and GBR1 level. Thus, we conclude that our study does not support that GBR1 is involved in ET. Further studies are needed to verify these results.

Can we move beyond burden and burnout to support the health and wellness of family caregivers to persons with dementia? Evidence from British Columbia, Canada

After more than a decade of concerted effort by policy-makers in Canada and elsewhere to encourage older adults to age at home, there is recognition that the ageing-in-place movement has had unintended negative consequences for family members who care for seniors. This paper outlines findings of a qualitative descriptive study to investigate the health and wellness and support needs of family caregivers to persons with dementia in the Canadian policy environment. Focus groups were conducted in 2010 with 23 caregivers and the health professionals who support them in three communities in the Southern Interior of British Columbia. Thematic analysis guided by the constant comparison technique revealed two overarching themes: (1) forgotten: abandoned to care alone and indefinitely captures the perceived consequences of caregivers' failed efforts to receive recognition and adequate services to support their care-giving and (2) unrealistic expectations for caregiver self-care relates to the burden of expectations for caregivers to look after themselves. Although understanding about the concepts of caregiver burden and burnout is now quite developed, the broader sociopolitical context giving rise to these negative consequences for caregivers to individuals with dementia has not improved. If anything, the Canadian homecare policy environment has placed caregivers in more desperate circumstances. A fundamental re-orientation towards caregivers and caregiver supports is necessary, beginning with viewing caregivers as a critical health human resource in a system that depends on their contributions in order to function. This re-orientation can create a space for providing caregivers with preventive supports, rather than resorting to costly patient care for caregivers who have reached the point of burnout and care recipients who have been institutionalised.

Gender relations and health research: a review of current practices

Introduction

The importance of gender in understanding health practices and illness experiences is increasingly recognized, and key to this work is a better understanding of the application of gender relations. The influence of masculinities and femininities, and the interplay within and between them manifests within relations and interactions among couples, family members and peers to influence health behaviours and outcomes.

Methods

To explore how conceptualizations of gender relations have been integrated in health research a scoping review of the existing literature was conducted. The key terms gender relations, gender interactions, relations gender, partner communication, femininities and masculinities were used to search online databases.

Results

Through analysis of this literature we identified two main ways gender relations were integrated in health research: a) as emergent findings; and b) as a basis for research design. In the latter, gender relations are included in conceptual frameworks, guide data collection and are used to direct data analysis.

Conclusions

Current uses of gender relations are typically positioned within intimate heterosexual couples whereby single narratives (i.e., either men or women) are used to explore the influence and/or impact of intimate partner gender relations on health and illness issues. Recommendations for advancing gender relations and health research are discussed. This research has the potential to reduce gender inequities in health.

Validating the CANRISK prognostic model for assessing diabetes risk in Canada's multi-ethnic population

INTRODUCTION

Despite high rates of undiagnosed diabetes and prediabetes, suitable risk assessment tools for estimating personal diabetes risk in Canada are currently lacking.

METHODS

We conducted a cross-sectional screening study that evaluated the accuracy and discrimination of the new Canadian Diabetes Risk Assessment Questionnaire (CANRISK) for detecting diabetes and prediabetes (dysglycemia) in 6223 adults of various ethnicities. All participants had their glycemic status confirmed with the oral glucose tolerance test (OGTT). We developed electronic and paper-based CANRISK scores using logistic regression, and then validated them against reference standard blood tests using test-set methods. We used area under the curve (AUC) summary statistics from receiver operating characteristic (ROC) analyses to compare CANRISK with other alternative risk-scoring models in terms of their ability to discern true dysglycemia.

RESULTS

The AUC for electronic and paper-based CANRISK scores were 0.75 (95% CI: 0.73-0.78) and 0.75 (95% CI: 0.73-0.78) respectively, as compared with 0.66 (95% CI: 0.63-0.69) for the Finnish FINDRISC score and 0.69 (95% CI: 0.66-0.72) for a simple Obesity model that included age, BMI, waist circumference and sex.

CONCLUSION

CANRISK is a statistically valid tool that may be suitable for assessing diabetes risk in Canada's multi-ethnic population. CANRISK was significantly more accurate than both the FINDRISC score and the simple Obesity model.

Be known, be available, be mutual: a qualitative ethical analysis of social values in rural palliative care

Background

Although attention to healthcare ethics in rural areas has increased, specific focus on rural palliative care is still largely under-studied and under-theorized. The purpose of this study was to gain a deeper understanding of the values informing good palliative care from rural individuals' perspectives.

Methods

We conducted a qualitative ethnographic study in four rural communities in Western Canada. Each community had a population of 10, 000 or less and was located at least a three hour travelling distance by car from a specialist palliative care treatment centre. Data were collected over a 2-year period and included 95 interviews, 51 days of field work and 74 hours of direct participant observation where the researchers accompanied rural healthcare providers. Data were analyzed inductively to identify the most prevalent thematic values, and then coded using NVivo.

Results

This study illuminated the core values of knowing and being known, being present and available, and community and mutuality that provide the foundation for ethically good rural palliative care. These values were congruent across the study communities and across the stakeholders involved in rural palliative care. Although these were highly prized values, each came with a corresponding ethical tension. Being known often resulted in a loss of privacy. Being available and present created a high degree of expectation and potential caregiver strain. The values of community and mutuality created entitlement issues, presenting daunting challenges for coordinated change.

Conclusions

The values identified in this study offer the opportunity to better understand common ethical tensions that arise in rural healthcare and key differences between rural and urban palliative care. In particular, these values shed light on problematic health system and health policy changes. When initiatives violate deeply held values and hard won rural capacity to address the needs of their dying members is undermined, there are long lasting negative consequences. The social fabric of rural life is frayed. These findings offer one way to re-conceptualize healthcare decision making through consideration of critical values to support ethically good palliative care in rural settings.

Advance care planning: re-visioning our ethical approach

This qualitative study explored the applicability and usefulness of a promising advance care planning (ACP) intervention and examined the ACP process. Nine dyads (patients newly diagnosed with advanced lung cancer and a family member) participated in the ACP intervention, with evaluative interviews at 3 and 6 months after the intervention. All interviews were recorded, transcribed verbatim, and analyzed using constant comparison. The process was found not to be one of preparing a substitute decision-maker to speak for oneself and direct health care at a time when one is incapacitated; rather, the families engaged in a deeply relational process where meaning, values, and preferences were negotiated in conversation. ACP is theoretically rooted in a traditional notion of patient autonomy that is not aligned with the relational process that unfolded in this study. An approach that embraces relational autonomy is more congruent and provides a stronger foundation for meeting the needs of families.

Issues in rural palliative care: views from the countryside

CONTEXT

Growing concern exists among health professionals over the dilemma of providing necessary health care for Canada's aging population. Hospice palliative services are an essential need in both urban and rural settings. Rural communities, in particular, are vulnerable to receiving inadequate services due to their geographic isolation.

PURPOSE

To better understand experiences and issues related to rural palliative care.

METHODS

Focus groups were held for health professionals, family members and volunteers in 3 rural British Columbia communities. A coding schema was developed and the data were then thematically analyzed using a constant comparison technique.

FINDINGS

Three themes in rural palliative care were established: nature of palliative health care services, nature of rural relationships, and competencies required for rural palliative care. Findings indicated that the diversity in rural communities requires tailored approaches to palliative care that consider the geographic, cultural and health aspects of residents in order to optimize care.

CONCLUSION

Tailored approaches to palliative care developed in conjunction with rural communities are needed in order to optimize care.

A home away from home: The meaning of home according to families of residents with dementia

This study sought to understand the ways in which family caregivers to institutionalized relatives with dementia perceived and experienced the relocation of their relative to a more home-like setting of care. Twenty-nine family members were interviewed through focus groups and individual interviews following the closing of two traditional care facilities and the subsequent migration of all residents to dementia cottages. Questions focused on the assessment and evaluation of quality of care. Results of this qualitative study pointed to the centrality of relationships in creating a truly homelike environment, in addition to what constitutes effective relational practice from the family perspective. We argue that the creation of a meaningful home for persons with dementia must encompass a relational orientation, both philosophically and in practice, that is inclusive of resident, staff, and family.

"Just because you've got lung cancer doesn't mean I will": lung cancer, smoking, and family dynamics

Although individuals who are diagnosed with smoking-related disorders are offered smoking cessation programs, little attention has been directed toward reducing tobacco use among healthy relatives who smoke. The purpose of this article is to report smoking relatives' responses to a family member's diagnosis of lung disease, their constructions of smoking in this context, and their interaction patterns with the patient. Interviews with 11 family members where there was a diagnosis of lung cancer and 3 family members where there was another serious smoking-related diagnosis were analyzed. Family members used two strategies to support their continued smoking: distancing themselves from the diagnosis and taking the position that smoking cessation needed to be internally motivated by the "right reason" and initiated at the "right time" to anticipate success. The few participants who chose to quit, did so in support of their ill family member. The findings provide direction for intervening with family members who smoke.

Impacts on non-human biota from a generic geological disposal facility for radioactive waste: some key assessment issues

This paper provides an overview of key issues associated with the application of currently available biota dose assessment methods to consideration of potential environmental impacts from geological disposal facilities. It explores philosophical, methodological and practical assessment issues and reviews the implications of test assessment results in the context of recent and on-going challenges and debates.

Experiences of rural family caregivers who assist with commuting for palliative care

Commuting for advanced cancer care is an important option for rural patients who require palliative treatment.The purpose of this qualitative descriptive study was to investigate the experiences of rural family palliative caregivers (FPCs) who supported advanced cancer patients receiving palliative treatment at a regional cancer centre. Semi-structured interviews were conducted with 15 FPCs (27-73 years of age) who commuted with family members. Rural life, the multiple responsibilities borne by FPCs, the availability of support networks, and the culture of the regional cancer centre were all relevant contextual factors.The dedication of FPCs to making the commuting experience as positive as possible for the patient was the central theme. Subthemes were planning ahead to prepare for all possibilities, experiences on the road, the toll of commuting on FPCs, and making the best of it. The authors offer recommendations for self-care, nursing practice, and future research.

Samplers for evaluation and quantification of ultra-low volume space sprays

A field study was conducted to explore the suitability of 5 pesticide deposition samplers for airborne spray and ground deposits from ultra-low-volume (ULV) space sprays. Samplers included horizontally stretched stationary cotton ribbons at 2 heights, rotating ribbon, rotating Teflon slides, and filter paper. Slides were also used for droplet-size analysis. A set of 7 samplers of each type was placed at 1, 7, 15, 25, 40, 65, and 90 m from the spray line along the spray swath. Water and BVA13 oil with fluorescent dyes as tracers were sprayed with the use of a truck-mounted ULV sprayer at dusk and dawn. Results suggest that the horizontal and rotating cotton ribbons are best for quantification of airborne spray and filter paper is best for ground deposition collection. The rotating slide samplers only detected the BVA13 oil-based sprays.

Canopy penetration and deposition of barrier sprays from electrostatic and conventional sprayers

An experimental study was conducted to investigate the usefulness of electrostatic and conventional sprayers for barrier applications. Two conventional and three electrostatic sprayers were used in the study. Usefulness of the sprayers was rated based on penetration of spray into and deposition onto 2 sides of leaves on natural vegetation. Bifenthrin (Talstar adulticide) was applied at labeled rate, fluorescent dye was added to the tank mix as tracer, and all sprayers applied the dye and insecticide at the same rate. The results indicated that sprayers producing larger droplets produced significantly higher deposition on vegetation in barrier applications than the sprayers producing smaller droplets. Sprayers with higher air velocity at the nozzle discharge proved significantly better for barrier sprays than the sprayers with lower air velocity. Electrostatic sprayers did not show any improvement in deposition on vegetation or in penetration into vegetation over the conventional sprayers. There was no difference in deposition between truck-mounted and backpack sprayers.

Course in Parkinson disease subtypes: A 39-year clinicopathologic study

BACKGROUND

Individual variations in the course of Lewy body Parkinson disease (PD) are well known. Patients have been classified into different clinical subtypes to identify differences in the course among the subgroups. Several studies indicate that the outcome is more favorable in tremor dominant (TD) cases but others report no difference. A majority of progression studies are based on cross-sectional single point data or short-term clinical observations. The lack of longitudinally followed autopsy-confirmed PD cohort remains a major weakness in the literature. Biochemical studies of brain indicate most pronounced abnormalities in akinetic/rigid (AR) and the least in TD cases. We postulate that PD course in these subtypes is concordant with the biochemical findings.

OBJECTIVE

To compare the course in TD, mixed (MX), and AR subtypes of PD.

METHODS

Longitudinal clinical follow-up and autopsy studies were performed on 166 patients with PD over 39 years (1968-2006). Patients were classified into TD, AR, and MX based on the entire clinical course. Only the pathologically confirmed PD cases were included.

RESULTS

Sixty-six percent of cases had MX, 26% AR, and 8% TD profile. The age at onset was younger (p < 0.001) and progression to Hoehn & Yahr stage 4 was slower (p = 0.016) in the TD cases. Dementia was most common in AR (p = 0.039) and the least common in TD. In general, the course was most favorable in TD, followed by MX and AR subgroups.

CONCLUSION

The three subtypes of Parkinson disease have different courses which are concordant with the differences in brain biochemical abnormalities.

Continued family smoking after lung cancer diagnosis: the patient's perspective

PURPOSE/OBJECTIVES

To explore the influence of lung cancer diagnosis on interpersonal dynamics in families in which one or more members continue to smoke following diagnosis.

RESEARCH APPROACH

Descriptive, qualitative.

SETTING

Three cancer care sites in western Canada.

PARTICIPANTS

16 participants from 8 family dyads.

METHODOLOGIC APPROACH

Patients with lung cancer receiving treatment and immediate family members were recruited to participate in individual or conjoint semistructured interviews. Thematic analysis was conducted on transcribed interviews.

MAIN RESEARCH VARIABLES

Intrafamily interaction patterns, smoking and smoking cessation, lung cancer diagnosis.

FINDINGS

Following diagnosis, patients with lung cancer experienced considerable distress as they struggled to understand family members' continued smoking. Patient orientations to family members who smoked included preserving relationships (maintaining harmony and connection with family members took priority over directly intervening with smokers) and risking relationships (patients repeatedly confronted family members about continued smoking to influence their cessation despite the impact on relationships). Neither pattern was successful in engaging relatives in smoking reduction or cessation, and the risking relationships approach resulted in conflict and strained family relationships.

CONCLUSIONS

The findings provide additional support for examining family dynamics related to tobacco reduction and cessation as well as directions for future research.

INTERPRETATION

Nurses should encourage tobacco reduction as a supportive intervention for patients with lung cancer and their families to eliminate smoking-related distress.

Rural Palliative Care: A Comprehensive Review

Abstract Background: Access to integrated, palliative care regardless of location of residence is a palliative care standard yet we know such access is limited for those living in rural and remote settings. As a beginning step in the development of research aimed at informing policy and program development, a comprehensive review of the state of knowledge regarding palliative care in rural contexts is required. Purpose: To identify, evaluate and synthesize the published literature on rural palliative care. Design: Comprehensive review. Methods: Computer searches were conducted on PubBMed, ISI Web of Science, PsycInfo, CINAHL, and Ageline using the search terms palliative care, hospice, terminal care, end-of-life care, end-of-life, and rural or remote. Results: One hundred fifty-eight studies were retrieved. After screening using relevance and quality criteria, 79 studies were included in the review. Studies were grouped by subject matter into one of three categories: patient and caregiver perspectives; professional attitudes, knowledge and practice issues; and health care services. Conclusion: The body of research literature is small and eclectic, which means there is little strong evidence to inform palliative policy and service development in rural settings. Coordinated programs of research are clearly required to develop a body of knowledge that is adequate to support effective service and policy development.

Rural-urban differences in the effects on mental well-being of caring for people with stroke or dementia

BACKGROUND

Rural and urban differences in the effects of care-giving are not well documented. This paper reports data on 122 carers for people with stroke or dementia living in rural and urban settings in Wales.

METHOD

Carers completed a postal questionnaire, including the SF-12v2 Health Survey. Definitions of rural and urban were based on the Urban/Rural Indicator from the Office of National Statistics (ONS) All Fields Postcode Directory 2004.

RESULTS

Carers' mean Mental Component Summary (MCS) score (adjusted for age and sex) was one standard deviation below the population mean (-12.03). Male carers living in urban areas reported better mental health than male carers in rural areas (p<0.05) and female carers in both settings (p<0.05). A full model and a parsimonious model were developed, using MCS scores as outcome variables. In the full model sitting service provision in rural and urban locations was linked to better carer mental health, while support from friends and family was linked to better mental health for urban carers only.

CONCLUSION

Our findings indicate the existence of both gender and location differences in carer experiences.

Parkinsonism, Lrrk2 G2019S, and tau neuropathology

Lrrk2 G2019S is predominantly associated with alpha-synuclein-immunopositive Lewy body pathology. We have identified Family SK where Lrrk2 G2019S segregates with slowly progressive parkinsonism and the affected proband has tau-immunopositive neurofibrillary tangle pathology. Thus alpha-synucleinopathy and tauopathy, the predominant pathologies associated with parkinsonism, may be alternate outcomes of the same underlying genetic cause. Intriguingly, we observe no evidence of a direct interaction between either the tau or alpha-synuclein protein with Lrrk2.