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Background: The expansion of the Patient-Centred Medical Home model presents a valuable opportunity to enhance the integration of team-based mental health services in primary care settings, thereby meeting the growing demand for such services. Understanding the organizational context of a Patient-Centred Medical Home is crucial for identifying the facilitators and barriers to integrating mental health care within primary care. The main objective of this paper is to present the findings related to the following research question: "What organizational features shape Family Health Teams' capacity to provide mental health services for depression and anxiety across Ontario, Canada?" Methods: Adopting a constructivist grounded theory approach, we conducted interviews with various mental health care providers, and administrators within Ontario's Family Health Teams, in addition to engaging provincial policy informants and community stakeholders. Data analysis involved a team-based approach, including code comparison and labelling, with a dedicated data analysis subcommittee convening monthly to explore coded concepts influencing contextual factors. Results: From the 96 interviews conducted, involving 82 participants, key insights emerged on the organizational contextual features considered vital in facilitating team-based mental health care in primary care settings. Five prominent themes were identified: i) mental health explicit in the organizational vision, ii) leadership driving mental health care, iii) developing a mature and stable team, iv) adequate physical space that facilitates team interaction, and v) electronic medical records to facilitate team communication. Conclusions: This study underscores the often-neglected organizational elements that influence primary care teams' capacity to deliver quality mental health care services. It highlights the significance of strong leadership complemented by effective communication and collaboration within teams to enhance their ability to provide mental health care. Strengthening relationships within primary care teams lies at the core of effective healthcare delivery and should be leveraged to improve the integration of mental health care. [ABSTRACT FROM AUTHOR]

Background: Establishing the most important outcomes for school-based speech-language therapy is essential to guide future research and program evaluation for these services. Many health disciplines have developed core outcomes sets (COS) for this purpose. A COS encompasses the most important outcomes for particular health services as identified by appropriate interested parties. These interested parties usually represent health care providers and those with the health condition. In this paper, we report the development of a guiding framework for a COS for speech-language therapy services in schools in a Canadian context. Methods: Using a group concept mapping method, we identified the outcomes for inclusion in the COS guiding framework through the elicited opinions of key interested parties: speech-language therapists, teachers, and family members of children with speech, language, and communication needs. We extracted 103 statements (potential outcomes) from a previous data set of interview transcripts. We then asked participants to sort the statements into conceptually similar groups, which were aggregated and transformed into a cluster map using multidimensional scaling followed by hierarchical cluster analysis. Participants also rated each statement on 5-point scales for importance and feasibility. We calculated mean ratings for individual statements and for all statements in a cluster, for all participants and for participant groups separately. Results: We identified seven core outcomes for school-based speech-language services in Ontario, Canada. These included: classroom-based services, a holistic approach, support for teachers, care coordination, accessible services, family supports, and student success. All outcomes were rated highly for importance. Feasibility ratings were consistently below importance ratings. All participant groups concurred that a holistic approach was the most important outcome and accessible services was the least feasible outcome to achieve. Conclusions: The seven outcomes identified in this study are recommended to guide the development of a full COS to direct future research and program evaluation for school-based speech-language services. These outcomes have not been widely included in previous research and should be incorporated into future research alongside specific intervention outcomes. Data for some outcomes may be available from non-traditional sources such as administrative data sets. Consequently, their use for program evaluations should be accompanied by appropriate institutional support to allow speech-language therapists to make meaningful use of appropriate outcomes data. [ABSTRACT FROM AUTHOR]

Background: There has been a significant uptake in the use of telepractice during the coronavirus SARS‐CoV‐2 (COVID‐19) pandemic. This study explored the experiences of speech and language therapists (SLTs), assistants (SLTAs) and parents with telepractice during the COVID‐19 pandemic. Aims: (1) To identify factors that influenced success of telepractice; and (2) to describe clinicians' and parents' preferences for the future mode of service delivery for preschoolers with communication disorders. Methods & Procedures: The study was conducted in partnership with one publicly funded programme in Ontario, Canada, that offered services to preschoolers with speech, language and communication needs at no cost. SLTs (N = 13), assistants (N = 3) and parents (N = 13) shared their experiences and perspectives during semi‐structured videoconference interviews. Outcomes & Results: Factors that influenced the success of telepractice were reported in three categories: the setting (i.e., where and how telepractice was being delivered); the nature of telepractice (i.e., the services that were provided via telepractice); and the individuals (i.e., who was involved in telepractice). These factors were reported to interact with each other. As the needs for each child and family are unique, parents and clinicians reported a preference for a hybrid and flexible service delivery model in the future. Conclusions & Implications: The themes identified in this study can be used by clinicians and managers to consider factors that influence the success of telepractice for children and families. WHAT THIS PAPER ADDS: What is already known on the subject?: Studies conducted before the COVID‐19 pandemic showed that telepractice was an effective and acceptable service approach. However, some clinicians and parents reported wanting to resume in‐person visits. The provision of telepractice services to families with children with communication disorders increased significantly during COVID‐19. What this paper adds to existing knowledge?: Parents and clinicians shared factors that influenced the success of telepractice during semi‐structured interviews. Factors were identified in three categories: the setting (i.e., where and how telepractice was being delivered); the nature of telepractice (i.e., the services that were provided via telepractice); and the individuals (i.e., who were involved in telepractice). As each child's and family's needs are unique, parents and clinicians reported a preference for a hybrid and flexible service delivery model in the future. What are the potential or actual clinical implications of this work?: SLTs and SLT managers can use the factors identified to discuss with parents and decide whether telepractice may be well suited to the needs of each child and family. [ABSTRACT FROM AUTHOR]

Background: Many family medicine residency graduates indicate a desire to provide obstetric care, but a low proportion of family physicians (FPs) provide obstetric care within their practice. This suggests personal preference alone may not account for the low proportion of FPs who ultimately provide full obstetric care. If decisionmakers plan to augment the number of FPs providing obstetric care, barriers to the provision of such care must first be identified. Within this paper, we explore the perspectives of both family practice residents and early-career FPs on the factors that shaped their decision to provide obstetric care.Methods: In this qualitative study, we analyzed a subset of interview data from three Canadian provinces: British Columbia, Ontario, and Nova Scotia (n = 18 family practice residents; n = 39 early-career FPs). We used thematic analysis to analyze data relevant to obstetric care practice, applying the socio-ecological model and comparing themes across participant types, gender, and province.Results: Participants described influences affecting their decision about providing obstetric care. Key influencing factors aligned with the levels of the socio-ecological model of public policy (i.e., liability), community (i.e., community needs), organizational (e.g., obstetric care trade-offs, working in teams, sufficient exposure in training), interpersonal practice preferences (i.e., impact on family life, negative interactions with other healthcare professionals), and individual factors (i.e., defining comprehensive care as "everything but obstetrics"). Many participants were interested in providing obstetric care within their practice but did not provide such care. Participants' decision-making around providing or not providing obstetric care included considerations of personal preferences and outside influences.Conclusions: Individual-level factors alone do not account for the decrease in the type and amount of obstetric care offered by FPs. Instead, FPs' choice to provide or not provide obstetric care is influenced by factors at higher levels of the socio-ecological model. Policymakers who want to encourage obstetric practice by FPs should implement interventions at the public policy, community, organizational, interpersonal, and individual levels. [ABSTRACT FROM AUTHOR]

Background: Health and social service providers receive limited education on recognizing and responding to family violence. With adequate education, providers could be prepared to identify individuals subjected to family violence and help reduce the risk of associated impairment. Informed by the Active Implementation Frameworks, our research will determine the scope of strategies needed for the uptake and sustainability of educational interventions focused on family violence for providers. It will also determine the acceptability, feasibility, and proof-of-concept for a new educational intervention, called VEGA (Violence, Evidence, Guidance, Action), for developing and improving primary care provider knowledge and skills in family violence. Methods: This paper details the protocol for the Researching the Impact of Service provider Education (RISE) Project. The RISE Project follows a sequential multiphase mixed method research design; qualitative and quantitative data are being collected and integrated over three conceptually and methodologically linked research phases. Activities primarily occur in Ontario, Alberta, and Quebec. Phase 1 uses a sequential exploratory mixed method research design to characterize the scope and salience of learning and implementation needs and preferences for family violence education. Phase 2 will use an embedded mixed method research design to determine whether VEGA technology supports providers to achieve their family violence learning goals with effectiveness, efficiency, and satisfaction. Phase 3 will use a concurrent mixed method research design to determine acceptability, feasibility, and proof-of-concept for evaluating whether VEGA improves primary care providers' knowledge and skills in family violence. This final phase will provide information on implementation strategies for family violence education in the "real world." It will also generate data on provider recruitment, retention, and data completeness, as well as exploratory estimates of the effect for provider outcome measures proposed for a randomized controlled trial. Discussion: The RISE Project comprehensively integrates an implementation approach to improve family violence education for the health and social service professions. It will provide important information about factors that could influence the uptake and effectiveness of a health profession's educational intervention into the real world, as well as provide foundational evidence concerning the tenability of using a randomized controlled trial to evaluate the impact of VEGA in primary care settings. [ABSTRACT FROM AUTHOR]

Among Indigenous Peoples in Canada and around the world, the health impacts of COVID-19 have been measured largely through biological, social, and psychological impacts. Our study draws from a relational concept of health to examine two objectives: (1) how social distancing protocols have shaped Indigenous connections with self, family, wider community, and nature; and (2) what these changing relationships mean for perceptions of Indigenous health. Carried out by an Indigenous team of scholtives ars, community activists, and students, this research draws from a decolonizing methodology and qualitative interviews (n = 16) with Indigenous health and social care providers in urban and reserve settings. Our results illustrate a considerable decline in interpersonal connections--such as with family, community organizations, and larger social networks--as a result of social distancing. Among those already vulnerable, underlying health, social, and economic inequities have been exacerbated. While the health impacts of COVID-19 have been overwhelmingly negative, participants noted the importance of this time for self-reflection and reconnection of human-kind with Mother Earth. This paper offers an alternative perspective to popularized views of Indigenous experiences of COVID-19 as they relate to vulnerability and resilience. [ABSTRACT FROM AUTHOR]

Objectives This scoping review aims to systematically map the empirical evidence on publicly funded medication reviews provided by community pharmacists in Canada and identify gaps that could inform future research directions. Methods We used a scoping review framework and PRISMA guidelines for Scoping Reviews to conduct the study. Three electronic databases were searched for papers published between January 2000 until August 2020. Data was charted on study characteristics, and a thematic synthesis was performed. Key findings Of 41 original studies included, most were conducted in Ontario (n = 21). Majority of the studies employed quantitative designs (70%). Five major themes identified were program uptake, patient health outcomes, stakeholder beliefs and attitudes, processes and collaboration and pharmacy workplace culture, which varied considerably. At the individual, organizational and policy levels, many factors were interrelated and influenced the implementation of reimbursed medication reviews by community pharmacists. Gaps in eligibility policy highlighted some patients who may have complex needs are excluded. Variation in clinical outcomes may relate to different types of medication review and pharmacist practice across Canada. Few researchers evaluated eligibility criteria, the impact of policy changes, strategies to engage patients and healthcare professionals, patient–pharmacist communication or compared practice models of medication reviews. About 12% of the research applied a theoretical framework. Summary Publicly funded medication reviews in Canadian community pharmacies reduce medication-related problems and potentially improve patient health outcomes. Future research and policies could consider addressing barriers and exploring models for sustainable delivery of high-quality medication reviews internationally. [ABSTRACT FROM AUTHOR]

Background: There is a growing number of older adults with cognitive impairment (CI) that require inpatient rehabilitation, and as such patient centred rehabilitation models have been developed. However, implementing evidence-based models without attending to the fit of the model to the new context could lead to an unsuccessful outcome. Researchers collaborated with administrators and staff in one rural site to adapt a patient centred rehabilitation model of care in the Canadian province of Ontario. This paper reports on the contextual factors that influenced the implementation of the model of care.Methods: The study takes a case study approach. One rural facility was purposefully selected for its interest in offering rehabilitation to persons with CI. Four focus group discussions were conducted to explore healthcare professionals' perceptions on the contextual factors that could affect the implementation of the rehabilitation model of care in the facility. Twenty-seven professionals with various backgrounds were purposively sampled using a maximum diversity sampling strategy. A hybrid inductive-deductive approach was used to analyze the data using the Context and Implementation of Complex Interventions (CICI) Framework.Results: Across the domains of the CICI framework, three domains (political, epidemiological, and geographical) and seven corresponding sub-domains of the context were found to have a major influence on the implementation process. Key elements within the political domain included effective teamwork, facilitation, adequate resources, effective communication strategies, and a vision for change. Within the epidemiological domain, a key element was knowing how to tailor rehabilitation approaches for persons with CI. Infrastructure, an aspect of the geographical domain, focused on the facility's physical layout that required attention.Conclusions: The CICI framework was a useful guide to identify key factors within the context that existed and were required to fully support the implementation of the model of care in a new environment. The findings suggest that when implementing a new program of care, strong consideration should be paid to the political, epidemiological, and geographical domains of the context and how they interact and influence one another. [ABSTRACT FROM AUTHOR]

Research has demonstrated the benefits of mental healthcare interventions that ensure a safe transition of clients throughout the discharge and community integration process. This paper reports on qualitative data from focus groups with health professionals collected as part of a larger a mixed method study designed to examine the effectiveness and sustainability of implementing the transitional discharge model. Data collection involved two sets of focus groups, which were held at six months and one‐year post‐implementation. There were 216 health professional participants from nine (9) hospitals across the Province of Ontario, Canada. Data analysis used a four‐step ethnographic framework by Leininger (1985) to identify descriptors and recurrent and major themes. The study identified four major themes, including healthcare professionals' roles and positive experiences in implementing the transitional discharge model; perceived benefits of the model; challenges to implementing the model; and suggestions for sustaining the model's implementation. Healthcare professionals felt that the implementation of the transitional discharge model has the potential for increasing their awareness of the process of clients' integration, serving as a framework for discharge planning, and reducing hospital readmissions. The study findings may provide healthcare providers with information on pragmatic ways to plan clients' discharge, to bridge the gap between hospital and community care, and to positively impact client health outcomes. [ABSTRACT FROM AUTHOR]

Background: Many countries are engaged in primary care reforms to support older adults who are living longer in the community. Health Teams Advancing Patient Experience: Strengthening Quality [Health TAPESTRY] is a primary care intervention aimed at supporting older adults that involves trained volunteers, interprofessional teams, technology, and system navigation. This paper examines implementation of Health TAPESTRY in relation to interprofessional teamwork including volunteers. Methods: This study applied Normalization Process Theory (NPT) and used a descriptive qualitative approach [1] embedded in a mixed-methods, pragmatic randomized controlled trial. It was situated in two primary care practice sites in a large urban setting in Ontario, Canada. Focus groups and interviews were conducted with primary care providers, clinical managers, administrative assistants, volunteers, and a volunteer coordinator. Data was collected at 4 months (June–July 2015) and 12 months (February–March 2016) after intervention start-up. Patients were interviewed at the end of the six-month intervention. Field notes were taken at weekly huddle meetings. Results: Overall, 84 participants were included in 17 focus groups and 13 interviews; 24 field notes were collected. Themes were organized under four NPT constructs of implementation: 1) Coherence- (making sense/understanding of the program's purpose/value) generating comprehensive assessments of older adults; strengthening health promotion, disease prevention, and self-management; enhancing patient-focused care; strengthening interprofessional care delivery; improving coordination of health and community services. 2) Cognitive Participation- (enrolment/buy-in) tackling new ways of working; attaining role clarity. 3) Collective Action- (enactment/operationalizing) changing team processes; reconfiguring resources. 4) Reflective Monitoring- (appraisal) improving teamwork and collaboration; reconfiguring roles and processes. Conclusions: This study contributes key strategies for effective implementation of interventions involving interprofessional primary care teams. Findings indicate that regular communication among all team members, the development of procedures and/or protocols to support team processes, and ongoing review and feedback are critical to implementation of innovations involving primary care teams. Trial registration: ClinicalTrials.gov, no. NCT02283723 November 5, 2014. Prospectively registered. [ABSTRACT FROM AUTHOR]

This paper describes findings from an institutional ethnography that arose out of the concerns of women living with HIV in Ontario, Canada, regarding the disclosure of their HIV status while accessing perinatal care. The enquiry traces the connections between women's experiences of perinatal care, the activities of healthcare providers delivering such care and the ruling relations that organise women's experiences and healthcare providers' activities. Focusing on HIV disclosure as a concern expressed by women, the findings make visible the day-to-day, routinised practices of healthcare providers working in perinatal care for women living with HIV, as well as the ideological discourses of 'fear of contagion' and 'AIDS hysteria' that contributed to producing the kinds of care experiences that were articulated by women. Opportunities to strengthen perinatal care policies and practices for women living with HIV are discussed. [ABSTRACT FROM AUTHOR]

Background: Over the last three decades, there has been worldwide recognition of peer support contributions to improve mental healthcare provision. However, in the current literature, little attention has been paid to exploring perspectives of peer supporters on their involvement in mental health services provision. The purpose of the present study was to examine peer supporters' perspectives on the implementation of a transitional discharge model (TDM), an intervention for the community integration of people with mental illness. Methods: This paper represents ethnographic qualitative data collected as part of a study that used mixed methods to evaluate the implementation of TDM across nine hospitals from the Province of Ontario, in Canada. The study involved a sample of 66 peer supporters, who were recruited from participating Consumer/Survivor Initiative Organizations and Peer Support Programs. The study collected data using two sets of focus groups, which were held at 6 months and 1-year post implementation. Data analysis used an ethnography model of qualitative analysis. Results: Peer supporters expressed that their involvement in mental healthcare enhanced clients' autonomy and hope about their recovery, as well as established a safety net and reduced hospital readmissions. Peer supporters articulated that they assumed several roles to facilitate clients' transition from hospital to the community. These roles included: assisting clients in building their capacity and developing healthy routines; attending regular on-ward and community meetings; accompanying clients to their appointments; and working with clients to set goals for their recovery. The study showed hindrances to effective implementation of peer support programs, such as a lack of understanding and appreciation of peer supporter roles, lack of careful allocation of peer supporters to clients, and an absence of appropriate protocols for ensuring the safety and supervision of the peer supporters. Conclusions: Results of the TDM implementation demonstrated that involving peer supporters in mental healthcare delivery may benefit clients by enhancing autonomy and hope about their recovery, as well as establishing a safety net and reducing hospital readmissions. Results from the study have the potential to inform healthcare professionals and managers of strategies for developing effective peer support programs. [ABSTRACT FROM AUTHOR]

Primary care is the level of a health system that provides first point of access to health care services for all health-related needs and problems, providing person-focused care over time in a continuous and coordinated fashion (Primary Healthcare Planning Group [48]; Aggarwal and Hutchison [1]; Health Canada [20]). This paper undertakes a comprehensive examination of how primary care services are distributed across Southwestern Ontario (SWO), with a particular focus on understanding how the distribution is meeting the primary care needs of the senior population (i.e., people aged 65 years and older) and populations living in different geographic settings (i.e., the urban-rural continuum). PCPs were included in our research database if they were physicians or NPs that have a comprehensive primary care practice and have a roster of enrolled patients for whom they provide ongoing primary care (as of July 2015). Despite the high PCP-to-population ratios, the number of PCPs actually providing care in these rural and small population centre communities away from metropolitan influence zones is overestimated, as many PCPs provide other health services (e.g., emergency room doctors, specialists, service to long-term care). [Extracted from the article]

Floating Catchment Area (FCA) methods are a popular tool to investigate accessibility to public facilities, in particular health care services. FCA approaches are attractive because, unlike other accessibility measures, they take into account the potential for congestion of facilities. This is done by 1) considering the population within the catchment area of a facility to calculate a variable that measures level of service, and then 2) aggregating the level of service by population centers subject to catchment area constraints. In this paper we discuss an effect of FCA approaches, an artifact that we term demand and level of service inflation. These artifacts are present in previous implementations of FCA methods. We argue that inflation makes interpretation of estimates of accessibility difficult, which has possible deleterious consequences for decision making. Next, we propose a simple and intuitive approach to proportionally allocate demandand and level of service in FCA calculations. The approach is based on a standardization of the impedance matrix, similar to approaches popular in the spatial statistics and econometrics literature. The result is a more intiuitive measure of accessibility that 1) provides a local version of the provider-to-population ratio; and 2) preserves the level of demand and the level of supply in a system. We illustrate the relevant issues with some examples, and then empirically by means of a case study of accessibility to family physicians in the Hamilton Census Metropolitan Area (CMA), in Ontario, Canada. Results indicate that demand and supply inflation/deflation affect the interpretation of accessibility analysis using existing FCA methods, and that the proposed adjustment can lead to more intuitive results. [ABSTRACT FROM AUTHOR]

Abstract The disproportionate concentration of healthcare professionals in urban areas is a concern in many countries, including Canada. A need to address this rural care gap has driven a large number of government led initiatives worldwide over the years. This paper presents a model that can be used as a tool to examine the efficacy of such policies on the workforce distribution in the long term. A small system dynamics model is employed to simulate the current and future distribution of general physicians at a jurisdictional level. The model represents the transition of general practitioners to provide insight into the dynamics of care provision over time. The movement, and competition, between rural and urban areas is modeled to enable detailed exploration of the ability for proposed measures to alleviate the care gap in the future. Among the tested policies are such commonly used initiatives as financial incentives to rural professionals, promotion of medical education in rural areas, expansion of rural education programs and the engagement of international medical graduates etc. We demonstrate how the model can be used as a tool to determine an efficient and well-chosen combination of policies which can help alleviate the rural care gap in the future, given that some policies are more effective than others alone but also combined with other initiatives. The presented small system dynamics model is tested on Canada's reality, but its simple nature lends itself to easy application to other countries that experience a similar problem. Highlights • A small system dynamics model is used to simulate the current and future distribution of general physicians. • The model provides a tool to explore the efficacy of policies employed to alleviate the rural care gap in the future. • Careful selection and combination of policies offers potential to improve rural areas underserved by general practitioners. [ABSTRACT FROM AUTHOR]

Background: This study reports on physicians’ experiences with chronic pain management. For over a decade prescription opioids have been a primary treatment for chronic pain in North America. However, the current opioid epidemic has complicated long-standing practices for chronic pain management which historically involved prescribing pain medication. Caring for patients with chronic pain occurs within a context in which a growing proportion of patients suffer from chronic rather than acute conditions alongside rising social inequities. Methods: Our team undertook an ethnographic approach known as institutional ethnography in the province of Ontario, Canada in order to explore the social organization of chronic pain management from the standpoint of primary care physicians. This paper reports on a subset of this study data, specifically interviews with 19 primary care clinicians and 8 nurses supplemented by 40 hours of observations. The clinicians in our sample were largely primary care physicians and nurses working in urban, rural and Northern settings. Findings: In their reflections on providing care for patients with chronic pain, many providers describe being most challenged by the work involved in helping patients who also struggled with poverty, mental health and addiction. These frustrations were often complicated by concerns that they could lose their license for inappropriate prescribing, thus shifting their work from providing treatment and care to policing their patients for malingering and opioid abuse. Interpretation: Our findings show that care providers find the treatment of patients with chronic pain–especially those patients also experiencing poverty–to be challenging at best, and at worst frustrating and overwhelming. In many instances, their narratives suggested experiences of depersonalization, loss of job satisfaction and emotional exhaustion in relation to providing care for these patients, key dimensions of burnout. In essence, the work that they performed in relation to their patients’ social rather than medical needs seems to contribute to these experiences. Their experiences were further exacerbated by the fact that restricting and reducing opioid dosing in patients with chronic pain has become a major focus of care provision. [ABSTRACT FROM AUTHOR]

As a term used in nursing and other health professions to describe when one is prevented by institutional constraints from pursuing the right course of action, moral distress has gained traction to examine the effects of restructuring on health and social care providers. Using a critical narrative methodology, this paper presents the counter-stories of nine pediatric oncology nurses in Ontario, Canada, whose stories illustrate the embeddedness of their caregiving and moral distress within institutional contexts that leave them stretched thin amongst multiple caregiving and administrative demands, and that limit their capacities to be the nurses they want to be. Informed by feminist philosophical theorizations of moral distress, we elucidate how the nurses' counter-stories: (i) re-locate the sources of their moral distress within institutional constraints that fracture their moral identities and moral relationships, and (ii) dis-locate dominant narratives of technological cure by ascribing value and meaning to the relational care through which they sustain moral responsibilities with patients and their families. By making visible the relational care that they find meaningful and that brings them in proximity to patients and families, these counter-stories assist nurses in restoring their damaged moral identities. This study demonstrates the power of identifying and mobilizing counter-stories in tracing and critically examining the conditions that structure nurses' experiences of moral distress. The findings add theoretical and empirical depth to contemporary understandings of moral distress and complement ongoing public discussion of burnout among nurses and other health care workers during the COVID-19 pandemic. These counter-narratives may act as resources for resistance among nurses, help to reduce the distance between management and health care workers, and catalyze changes in policy and practice so that nurses, and the full scope of their caregiving, are valued. • Counter-stories challenge dominant constructions of healthcare and caregiving. • Moral distress is embedded in institutional constraints that fracture moral identities. • Nurses' counter-stories assign meaning to relational care and moral responsibilities. • Nurses' fractured moral identities are restored through counter-stories. • Counter-stories act as narrative resources for resistance and resilience among nurses. [ABSTRACT FROM AUTHOR]

Patient safety has been presented as a unifying concern across the health professions. This conceptual connection has been accompanied with efforts towards standardized, interprofessional safety competencies, as well as increased attention towards interprofessional education for systems improvement. Despite numerous program initiatives and research endeavors, progress towards improving patient safety in hospitals is viewed as disappointingly slow. This paper adds to a body of literature that suggests patient safety remains a difficult problem to solve because safety is not simply a technical issue, but is a practice embedded in organizational and professional contexts. In this paper, we explore the differences between the professions, as different professional groups intersect with the ways patient safety is thought about, talked about, and known about in an acute care hospital in Canada. We draw on findings from a critical discourse analysis of documents related to patient safety, as well as transcripts from interviews from (a) formal health care leaders and (b) practicing clinicians from medicine, nursing, occupational therapy, physiotherapy, and social work. This analysis suggests implications for the way different professions may or may not work with one another in the service of patient safety. [ABSTRACT FROM AUTHOR]

Introduction: Co-design methods are increasingly employed to solve complex problems in health care in Australia and globally (1, 2, 3). Despite the proliferation of services developed through co-design methods, the term 'co-design' is used to describe a wide range of processes and practices with varying degrees of stakeholder engagement. In addition, studies often fail to explicate how existing research evidence, practice knowledge and lived experience come together in the co-design process. In this paper, we present our lessons from co-designing a Child and Family Hub in Wyndham Vale, a low socio-demographic and culturally diverse area of Western Melbourne, Australia. Aims Objectives Theory or Methods: The Child and Family Hub model was co-designed through a 10-week series of workshops and consultations with intersectoral practitioners and families. The process focused on the client journey through the Hub and the workforce infrastructure required for its implementation. A core team of seven stakeholders worked through the British Design Council's Double Diamond humancentred design process (4). The findings of evidence reviews, individual interviews and group discussions were incorporated into the 'Discover' and 'Define' stages. Prototypes were 'Developed' and iteratively tested with over 100 families and 30 practitioners. The workshops were evaluated using the Public and Patient Engagement Evaluation Tool. Highlights or Results or Key Findings: Strategies to create a common language and understanding of 'adversity', 'child mental health' and 'co-design' served as a crucial foundation for the process. Stakeholder engagement preceding, during and following the co-design process was important for generating trust in and local ownership of the Hub model. These engagement activities included mechanisms to tap into a diverse range of community and practitioner voices and experiences. Client personas were effective for incorporating research findings into the process and generating empathy for clients who will use the Hub. The evaluation outcomes and team reflections on the process highlighted the transformative potential of bringing community and practitioners together to generate mutual learning. Balancing the time commitment of core team members with the need to undertake user testing was a key challenge. Clearly articulating the parameters and fixed inputs to the co-design process based on the research evidence was also required to effectively manage stakeholder expectations. Conclusions: The Child and Family Hub model was successfully co-designed in partnership with families, intersectoral practitioners and community members with a key focus on the client journey and workforce infrastructure necessary to support families with children 0-8 years experiencing adversity as they navigate the health and social care systems. Implications for applicability/transferability sustainability and limitations: While this study was conducted in one metropolitan area of Australia, the key lessons related to language, stakeholder engagement, team composition and feasibility are useful for informing future research and service design with families experiencing adversity. The next phase of the project tests and evaluates the impact of the Hub. [ABSTRACT FROM AUTHOR]

Introduction: Persons living with dementia (PLWD), caregivers and care providers know the dementia journey is full of changes - in mental and physical function, care settings, care providers, and roles of caregivers and care providers in providing the "clinical" versus the more "emotional, relational" care. While "person-centred care" tools, practices and approaches are available for providers and PLWD to work together better, there are fewer tools to help caregivers and providers communicate and share their knowledge, progress and activities better so they are working better together at all times, and particular during these changes. Aims Objectives Theory or Methods: This study evolved over time using our Participatory Research to Action framework. After a specific need was identified by PLWD and caregivers in a focus group, we held six sessions with different caregivers and providers to co-design a prototype tool to help caregivers and care providers work together better. Next, multiple co-design workshops with different communities identified prototype elements that were not relevant and how they should be changed. Each workshop was tailored in collaboration with community representatives. Highlights or Results or Key Findings: Guided by caregivers and providers from long-term care homes and home care, a prototype tool, Our Dementia Journey Journal, was produced on paper and in an online app to respond to the identified need. We then engaged with PLWD and their caregivers in diverse communities across Canada, including First Nations communities, to see how the prototype would need to be adapted to be culturally, linguistically and geographically relevant and useful. Overall, we heard that the essential components of the prototype Journal, adapted to local needs, will be helpful to improve the care of persons living with dementia by improving caregiver-care provider relationships and shared knowledge through various changes over time. The Journal includes basic information about dementia and links to online resources, tools for encouraging exchange of questions and answers, opportunities to record changes in wellbeing of caregivers and the emotional journey of the potential Journal users surrounding a PLWD. Conclusions: Through iterations in serial co-design sessions with caregivers and providers, we identified core elements of a tool they believe will improve their partnerships over the dementia journey with its multifaceted changes, and the necessary adaptations to make it culturally, linguistically and geographical relevant. Implications for applicability/transferability sustainability and limitations: We have information about the different versions of Our Dementia Journey Journal to meet the needs of caregivers and providers in rural, remote, suburban, urban, francophone and First Nations communities. These various versions will now be distributed for use and evaluation of their impact on caregiver-provider relationships. [ABSTRACT FROM AUTHOR]

Background: In 2014, nursing home administration and government officials were facing increasing public and media scrutiny around the variation of antipsychotic medication (APM) prescribing across Ontario nursing homes. In response, policy makers partnered to test an academic detailing (AD) intervention to address appropriate prescribing of APM in nursing homes in a cluster-randomized trial. This mixed-methods study aimed to explore how and why the AD intervention may have resulted in changes in the nursing home context. The objectives were to understand how the intervention was implemented, explore contextual factors associated with implementation, and examine impact of the intervention on prescribing.Methods: Administrative data for the primary outcome of the full randomized trial will not be available for a minimum of 1 year. Therefore, this paper reports the findings of a planned, quantitative interim trial analysis assessed mean APM dose and prescribing prevalence at baseline and 3 and 6 months across 40 nursing homes (18 intervention, 22 control). Patient-level administrative data regarding prescribing were analyzed using generalized linear mixed effects regression. Semi-structured interviews were conducted with nursing home staff from the intervention group to explore opinions and experiences of the AD intervention. Interviews were analyzed using the framework method, with constructs from the Consolidated Framework for Implementation Research (CFIR) applied as pre-defined deductive codes. Open coding was applied when emerging themes did not align with CFIR constructs. Qualitative and quantitative findings were triangulated to examine points of divergence to understand how the intervention may work and to identify areas for future opportunities and areas for improvement.Results: No significant differences were observed in prescribing outcomes. A total of 22 interviews were conducted, including four academic detailers and 18 nursing home staff. Constructs within the CFIR domains of Outer Setting, Inner Setting, and Characteristics of Individuals presented barriers to antipsychotic prescribing. Intervention Source, Evidence Strength and Quality, and Adaptability explained participant engagement in the AD intervention; nursing homes that exhibited a Tension for Change and Leadership Engagement reported positive changes in processes and communication.Conclusions: Participants described their experiences with the intervention against the backdrop of a range of factors that influence APM prescribing in nursing homes that exist at the system, facility, provider, and resident levels. In this context, the perceived credibility and flexibility of the intervention were critical features that explained engagement with and potential impact of the intervention. Development of a common language across the team to enable communication was reported as a proximal outcome that may eventually have an effect on APM prescribing rates. Process evaluations may be useful during early stages of evaluation to understand how the intervention is working and how it might work better. Qualitative results suggest the lack of early changes observed in prescribing may reflect the number of upstream factors that need to change for APM rates to decrease.Trial Registration: ClinicalTrials.gov, NCT02604056. [ABSTRACT FROM AUTHOR]

Sexuality is an aspect of health and development that is often overlooked among people with physical disabilities, particularly adolescents. Studies have demonstrated that youth with physical disabilities show considerably lower levels of sexual knowledge and receive inadequate sex education compared to their peers without such disabilities. The data for this paper are part of a qualitative study that explored the experiences, barriers and challenges associated with sex education for youth with physical disabilities from the perspectives of young people themselves, their parents and the health professionals who work with them. The findings from this study highlight the tendency for parents, educators and health professionals to place the responsibility of delivering sex education to young people with physical disabilities on someone else who they believe to be more appropriately qualified to handle these types of situations. As a result, the findings illustrate that adolescents with physical disabilities do not always receive the necessary combination of comprehensive sex education within school environments, specialized information from health professionals, and informal sex education from family and peers that they require in order to gain the knowledge and skills needed to understand their own sexual capabilities and make informed decisions about their sexual health and intimate relationships. [ABSTRACT FROM AUTHOR]

This paper reports on the process of developing a community-based interprofessional team to provide diabetes related foot ulcer care. A new interprofessional team was formed in a local community, and the process of building a successful team was examined by the adoption of an exploratory qualitative case study approach that gathered a series of one-on-one interviews with participants at three points in time - prior to the team's formation, two months into the team's operation, and finally seven months later - shortly before the team and its clinic closed. Interviews were also conducted with a small sample of the team's patients. The factors linked to the successes and challenges of building a care team in a community setting are explored. Informants highlighted the value of regular team meetings, role clarity, and a commitment to patient-centered care. However effective collaboration was not sufficient to maintain the team in the face of poor institutional and government support. [ABSTRACT FROM AUTHOR]