Changing relationships: how does patient involvement transform professional identity? An ethnographic study

ObjectivesTo understand identity tensions experienced by health professionals when patient partners join a quality improvement committee.DesignQualitative ethnographic study based on participatory observation.SettingAn interdisciplinary quality improvement committee of a Canadian urban academic family medicine clinic with little previous experience in patient partnership.ParticipantsTwo patient partners, seven health professionals (two family physicians, two residents, one pharmacist, one nurse clinician and one nurse practitioner) and three members of the administrative team.Data collectionData collection included compiled participatory observations, logbook notes and semi-structured interviews, collected between the summer of 2017 to the summer of 2019.Data analysisGhadiri’s identity threats theoretical framework was used to analyse qualitative material and to develop conceptualising categories, using QDA Miner software (V.5.0).ResultsAll professionals with a clinical care role and patient partners (n=9) accepted to participate in the ethnographic study and semi-structured interviews (RR=100%). Transforming the ‘caregiver–patient’ relationship into a ‘colleague–colleague’ relationship generated identity upheavals among professionals. Identity tensions included competing ideals of the ‘good professional’, challenges to the impermeability of the patient and professional categories, the interweaving of symbols associated with one or the other of these identities, and the inner balance between the roles of caregiver and colleague.ConclusionThis research provides a new perspective on understanding how working in partnership with patients transform health professionals’ identity. When they are called to work with patients outside of a simple therapeutic relationship, health professionals may feel tensions between their identity as caregivers and their identity as colleague. This allows us to better understand some underlying tensions elicited by the arrival of different patient engagement initiatives (eg, professionals’ resistance to working with patients, patients’ status and remuneration, professionals’ concerns toward patient ‘representativeness’). Partnership with patients imply the construction of a new relational framework, flexible and dynamic, that takes into account this coexistence of identities.

429 What are Patient Characteristics, Nursing Interventions and Patient Outcomes for Patients with Difficulty Adapting to CPAP?

Introduction A sleep nurse clinician was added to our care team to provide situationally responsive educational, behavioral and troubleshooting interventions and case management to patients identified as high risk for untreated SDB. The objective of this study was to describe the patient characteristics, nursing interventions, and impact on CPAP usage among patients referred to the nurse-clinician. Methods Descriptive exploratory retrospective chart review was used to identify patient characteristics for all new patients referred; in-depth extraction was conducted for patients who had home CPAP for ≥ 1 month and experienced difficulty using CPAP. We examined: issues using CPAP, frequency and types of nursing contacts, nursing interventions and CPAP usage. Patient characteristics of those with difficulty adapting to CPAP were compared to those referred for assistance to obtain CPAP. Change in objective CPAP usage before vs after sleep nurse case management was determined when possible. Results 403 patients were referred, with mean (SD) age: 54.8 y (15.7), 56.1% men, RDI: 45.4 (31.4), 42.4% employed, 16.6% retired, 25% with ≥ 3 co-morbidities plus SDB. Difficulty adapting group (n = 204) had more women (p = 0.033), more employed (p = 0.03), and more insomnia (p = 0.001). CPAP issues included: mask (18%), ENT (14%), constraining beliefs (14%), access to treatment (12%), pressure intolerance (11%), comorbidities (11%), suboptimal usage (7%), insomnia (7%). Nursing contact: 74% subjects had ≤ 4 contacts (range: 1–16), 53% in-person, 25% telephone calls, 22% other. Nursing interventions were: educational (33%), troubleshooting (30%), behavioural (20%), liaison/coordination of care (13%), promoting self-management skills (3%). Preliminary mean CPAP usage (n = 18) improved by 40.0 (112.3) min and by 7.4 (31) % of nights used ≥ 4 hrs (p=NS; data extraction ongoing). Conclusion Demographic data identified women and insomnia to be significant characteristics in the difficulty adapting group. This model of care identified 2 types of interventions not previously recognized in typical interventions to promote CPAP adaptation: Liaison/coordination of care and promoting self-management skills. Some patients were able to increase their CPAP usage. Support (if any) MUHC Nursing Research Small Grants Award was supported by the Newton Foundation and the Montreal General Hospital Foundation.

Nurse Versus Clinician Symptomatic Adverse Events Assessment Based on Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE): Results of a Questionnaire-Based Study

Background: Monitoring adverse Events (AEs) is a standard practice for clinician to assess the overall effect of anti-cancer treatment on patients. However, studies have found clinicians have difficulty in capturing nuance aspects of patient-centered AEs. We aimed to explore the differences between nurses and clinicians in term of subjective AEs assessment and discuss the nurses’ role in subjective AEs assessment.Methods: From April and July, 2020, a questionnaires based study was conducted in Day Chemotherapy ward of Breast Center in Hebei Cancer Hospital. Six common subjective AEs were assessed by nurses and clinicians utilizing Common Terminology Criteria for Adverse Events (CTCAE). Patients needed to self-report their own subject AEs by filling up a Simplified Chinese version of PRO-CTCAE containing the same AEs. Results from the three different pairs (Nurse/Patient, Nurse/ Clinician, and Clinician/Patient) were collected and analyzed. Chi-square test and kappa coefficient were utilized to analysis the differences and consistency among different pairs.Results: of 417 patients were asked to participate in the study, 384 pairs surveys were collected. Nurses detected more AEs than clinicians, and the differences were statistically significant (P＜0.00). Nurse/patient pair scored the highest agreement in terms of reporting rate and toxicity grade for most of AEs except the toxicity grade for the frequency of vomiting and pain which were as consistent as nurse/clinician.Conclusions: The results of this study support nurses can be successfully enrolled in the assessment of subjective AEs because of the greater ability to elicit more patient-centered information than clinicians.

Improving the wait time to triage at the emergency department

Triaging of patients at the emergency department (ED) is one of the key steps prior to initiation of doctor consult. To improve the overall wait time to consultation, we have identified the need to reduce the wait time to triage for ED patients. We seek to determine if the implementation of a series of plan, do, study, act (PDSA) cycles would improve the wait time to triage within 1 year. The interventions related to the PDSA cycles include the refining of triage criteria, ‘eyeball’ triage by senior nurses to facilitate direct bedding of patients, formation of a triage nurse clinician role, and a needs analysis of required nursing manpower. The baseline period for this study was from January 2017 to April 2017, with the results following implementation of the respective PDSA cycles sequentially tracked from May 2017 to March 2019. There was an improvement in the wait time to triage from a baseline duration of 18 min to the postimplementation period duration of 13 min, with a 25% decrease in variance from 16 to 12 min. The improvements were sustained. Strategies to further reduce wait time to triage at the ED are discussed. We also highlight the importance of adequate triage manpower, data-driven decision making and continued engagement of stakeholders in enabling positive outcomes from this quality improvement effort.

Walking Interviews and Wandering Behavior: Ethical Insights and Methodological Outcomes While Exploring the Perspectives of Older Adults Living With Dementia

While the use of walking interviews is not new in health care research, this method has not been used to study the wandering behavior of older adults living with dementia in long-term care (LTC) homes. The aim of this article is to describe ethical insights and consequential methodological outcomes when walking interviews were used as a means of exploring the perspectives of older adults living with mild to moderate dementia. We suggest that our use of walking interviews with older adults who presented with wandering behavior respected participants’ agency and, at times, placed the first author in the situation of “ethical vulnerability” in the roles of researcher and clinician. The first author, an experienced nurse clinician, walked with eight participants while interviewing them about why they walk and their intended destinations. Walking interviews provided the opportunity not only to interview participants but also to observe their walking behavior and interaction with others in the LTC home. Walking interviews with older adults living with dementia who are highly mobile in the LTC home acknowledge the primacy of the research participant and the researcher as learner.

Becoming a Transformative Nurse Educator: Finding Safety and Authenticity

The study purpose was to evaluate and strengthen this program’s nursing education curriculum to better prepare and develop future nurse faculty. As the dire nursing faculty shortage increases, the transition of expert nurse clinician to novice educator is receiving more attention. In order to prepare, recruit, and retain the nursing faculty needed to meet the growing nurse shortage, understanding what nurse educators need in order to be successful is essential. Fourteen participants from four focus groups of nurse educators shared stories about their role transition. Two administrators were interviewed to determine what they identified as crucial in hiring new nurse educators. Interpretive analysis focused on identification of themes and possible paradigm cases. Themes that emerged included: a) culture of academia surprises, b) exciting “Aha!” moments, and c) Safety with a capital “S”. These findings were used to strategically revise the entire nurse educator curriculum.

Inter-Rater Reliability of the Retrospectively Assigned Clinical Frailty Scale Score in a Geriatric Outreach Population

BackgroundFrailty, a common clinical syndrome in older adults associated with increased risk of poor health outcomes, has been retrospectively calculated in previous publications; however, the reliability of retrospectively assigned frailty scores has not been established. The aim of this study was to see if frailty scores, based on chart review data, agreed with clinician-determined scores based on a comprehensive geriatric assessment.MethodsPer standard practice, all patients seen by one nurse clinician (JW) from the Southwestern Ontario Regional Geriatric Program, a tertiary care-based outreach service, between August 15, 2013 and December 31, 2015 received a comprehensive geriatric assessment which included the assignment of an interview-based Clinical Frailty Scale score (CFS-I). Subsequently, a medical student researcher (JD), blinded to the CFS-I, assigned each consenting patient a frailty score based on chart review data (CFS-C). The inter-rater reliability of the CFS-I and CFS-C was then determined.ResultsOf the 41 consented patients, 39 had both a CFS-I and CFSC score. The median CFS score was 6, indicating patients were moderately frail and required assistance for some basic activities of daily living. Cohen’s kappa coefficient was 0.64, indicating substantial agreement.ConclusionCFS scores can be reliably assigned retrospectively, thereby strengthening the utility of this measure.