Publications by authors named "Elizabeth Peter"

75 Publications

Post Discharge after Surgery Virtual Care with Remote Automated Monitoring Technology (PVC-RAM): protocol for a randomized controlled trial.

CMAJ Open 2021 Jan-Mar;9(1):E142-E148. Epub 2021 Mar 2.

School of Nursing (McGillion, Levesque, Lounsbury, Bird, Ouellette), McMaster University, Hamilton, Ont.; Population Health Research Institute (McGillion, Whitlock, Devereaux, Belley-Cote, Borges, Vincent, Lamy, Bangdiwala, Le Manach, Harvey, Conen), Hamilton, Ont.; Department of Anesthesiology and Perioperative Medicine (Parlow, Arellano), Queen's University, Kingston, Ont.; Department of Anesthesiology and Perioperative Medicine (Parlow, Shelley, DuMerton, Arellano), Kingston Health Sciences Centre, Kingston, Ont.; Department of Medicine (Belley-Cote, Yousef, Borges, Marcucci, Chaudhry, Haider, Guyatt, Patel, Conen, Tandon), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (Whitlock, Devereaux, Marcucci, Bangdiwala, Guyatt), McMaster University, Hamilton, Ont.; Departments of Critical Care and Anesthesiology (Jacka), University of Alberta, Edmonton, Alta.; Department of Surgery (Adili, Harlock, Simunovic, Nenshi), McMaster University, Hamilton, Ont.; St. Joseph's Healthcare Hamilton (Adili, LeBlanc, Nenshi, Tandon), Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (Lalu, McCartney, Hamilton), University of Ottawa and The Ottawa Hospital, Ottawa, Ont.; Ottawa Hospital Research Institute (Moloo, Lalu, Halman, Forster, Hamilton), Ottawa, Ont.; Department of Anesthesia and Perioperative Medicine (Sehmbi, Nagappa, Yang), Schulich School of Medicine, University of Western Ontario, London, Ont.; Department of Anesthesia and Perioperative Medicine (Sehmbi, Nagappa, Yang), London Health Sciences Centre, London, Ont.; Hamilton Health Sciences (Meyer, Paulin, Pettit, Lamy, Lounsbury, Scott, Patel, Ouellette, O'Leary), Hamilton, Ont.; Department of Anesthesia (Shanthanna, Paul, Le Manach, O'Leary), McMaster University, Hamilton, Ont.; Department of Medicine (Roshanov, Mrkobrada), Schulich School of Medicine, University of Western Ontario, London, Ont.; Department of Internal Medicine (Ofori), University of Port Harcourt, Port Harcourt, Nigeria, West Africa; Department of Medicine (Graham, Taylor), University of Alberta, Edmonton, Alta.; Department of Medicine (Halman, Forster), University of Ottawa and The Ottawa Hospital, Ottawa, Ont.; Lawrence S. Bloomberg Faculty of Nursing (Peter), University of Toronto, Toronto, Ont.; Department of Medicine (Marosi), Queen's University, Kingston, Ont.; Alberta Health Services (Deuchar), Alberta, Canada; Department of Surgery (Parry, Schlachta, Schemitsch), University of Western Ontario and London Health Sciences Centre, London, Ont.; Department of Surgery (Williams), University of Alberta, Edmonton, Alta.; Department of Oncology (Meyer), McMaster University, Hamilton, Ont.; Department of Surgery (Pichora), Queen's University and Kingston Health Sciences Centre, Kingston, Ont.; Department of Surgery (Moloo), University of Ottawa and The Ottawa Hospital, Ottawa, Ont.; The Ottawa Hospital (Waggott), Ottawa, Ont.

Background: After nonelective (i.e., semiurgent, urgent and emergent) surgeries, patients discharged from hospitals are at risk of readmissions, emergency department visits or death. During the coronavirus disease 2019 (COVID-19) pandemic, we are undertaking the Post Discharge after Surgery Virtual Care with Remote Automated Monitoring Technology (PVC-RAM) trial to determine if virtual care with remote automated monitoring (RAM) compared with standard care will increase the number of days adult patients remain alive at home after being discharged following nonelective surgery.

Methods: We are conducting a randomized controlled trial in which 900 adults who are being discharged after nonelective surgery from 8 Canadian hospitals are randomly assigned to receive virtual care with RAM or standard care. Outcome adjudicators are masked to group allocations. Patients in the experimental group learn how to use the study's tablet computer and RAM technology, which will measure their vital signs. For 30 days, patients take daily biophysical measurements and complete a recovery survey. Patients interact with nurses via the cellular modem-enabled tablet, who escalate care to preassigned and available physicians if RAM measurements exceed predetermined thresholds, patients report symptoms, a medication error is identified or the nurses have concerns they cannot resolve. The primary outcome is number of days alive at home during the 30 days after randomization.

Interpretation: This trial will inform management of patients after discharge following surgery in the COVID-19 pandemic and offer insights for management of patients who undergo nonelective surgery in a nonpandemic setting. Knowledge dissemination will be supported through an online multimedia resource centre, policy briefs, presentations, peer-reviewed journal publications and media engagement.

Trial Registration: ClinicalTrials.gov, no. NCT04344665.
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http://dx.doi.org/10.9778/cmajo.20200176DOI Listing
March 2021

The "nurse as hero" discourse in the COVID-19 pandemic: A poststructural discourse analysis.

Int J Nurs Stud 2021 Jan 26;117:103887. Epub 2021 Jan 26.

Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, Ontario M5T1P8, Canada. Electronic address:

Background: Nurses have been labelled "heroes" by politicians, the mass media, and the general public to describe their commitment to providing front-line care to people with COVID-19, despite the risks of exposure and lack of clinical resources. Few studies have examined the implications of the hero discourse to nurses' professional, social, and political identities.

Objective: To critically examine the effects of the hero discourse on nurses who are contending with the ongoing COVID-19 crisis and to consider the political, social, cultural, and professional impact of this discourse on nursing work.

Methods: A poststructural discourse analysis, employing the theoretical ideas of truth, power, knowledge, subjectivity, and normalization, was conducted to explore the mass media's constructions of nurse as hero in the contexts of COVID-19. Media electronic databases were searched between March 1, 2020 to August 1, 2020 to locate newspaper and magazine articles, corporate advertisements, videos, social media postings, and institutional/corporate websites.

Setting: Data sources included English language media accounts that originated from Canada, the USA, and the UK.

Results: Three main elements of the hero discourse include: 1. Nurses as a "necessary sacrifice" - portraying nurses as selfless, sacrificing, and outstanding moral subjects for practicing on the front-line without adequate protective gear and other clinical resources; 2. Nurses as "model citizens" - positioning nurses as compliant, hardworking, and obedient subjects in contrast to harmful individuals and groups that ignore or resist COVID-19 public health measures. 3. Heroism itself as the reward for nurses - characterizing hero worship as a fitting reward for nurses who were unappreciated pre-pandemic, as opposed to supporting long-term policy change, and highlighting how heroism reconfigures nursing work from the mundane and ordinary to the exciting and impactful.

Conclusions: The hero discourse is not a neutral expression of appreciation and sentimentality, but rather a tool employed to accomplish multiple aims such as the normalization of nurses' exposure to risk, the enforcement of model citizenship, and the preservation of existing power relationships that limit the ability of front-line nurses to determine the conditions of their work. Our study has implications for approaching the collective political response of nursing in the ongoing COVID-19 crisis and formalizing the ongoing emotional, psychological, ethical, and practice supports of nurses as the pandemic continues.
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http://dx.doi.org/10.1016/j.ijnurstu.2021.103887DOI Listing
January 2021

Pedagogical practices that influence professional identity formation in baccalaureate nursing education: A scoping review.

Nurse Educ Today 2020 Oct 27;93:104516. Epub 2020 Jun 27.

Office of the Vice-President & Provost, University of Toronto, 27 King's College Circle, Simcoe Hall, Suite 225, Toronto, ON M5S 1A1, Canada. Electronic address:

Objectives: The purpose of this review was to identify pedagogical practices that contribute to professional identity formation in undergraduate nursing education and to map the components of professional identity described within these practices.

Design: A scoping review using a six-stage methodological framework was used to capture a range of evidence describing how professional identity has been conceptualized and integrated into nursing curriculum.

Data Sources: Databases searched included: Ovid MEDLINE: Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE® Daily and Ovid MEDLINE® 1946-Present, EBSCO CINAHL (1981 to present), OVID PsycINFO (1806 to Present), ProQuest ERIC, ASSIA, and Sociological Abstracts. Additional studies were identified by scanning the reference lists of relevant articles.

Review Methods: The study team collaboratively designed the data charting table and two coauthors independently screened the studies using Covidence software. Qualitative content analysis was used to categorize learning outcomes into five components of professional identity that were associated with pedagogical practices identified in the studies.

Results: A total of 114 peer-reviewed journal articles were initially charted. Articles were categorized as intervention studies (46, 40%), perspective studies (40, 35%), theoretical papers (17, 15%), or reviews (11, 10%). To ensure feasibility in collating and reporting the results, the review focused on the 46 empirical intervention studies that described associations between pedagogical practices and professional identity formation learning outcomes for students.

Conclusions: This scoping review illustrates the range of contexts in which nursing students learn, the multidimensional nature of identity formation, as well as the breadth of pedagogical practices and learning outcomes that guide course design. The results can be used to inform future curriculum planning and to identify focused research questions to extend our understanding of evidence-based teaching practices supporting professional identity formation.
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http://dx.doi.org/10.1016/j.nedt.2020.104516DOI Listing
October 2020

Relational influences on experiences with assisted dying: A scoping review.

Nurs Ethics 2020 Nov 21;27(7):1501-1516. Epub 2020 May 21.

7938University of Toronto, Canada.

Background: Family members and healthcare providers play an integral role in a person's assisted dying journey. Their own needs during the assisted dying journey are often, however, unrecognized and underrepresented in policies and guidelines. Circumstances under which people choose assisted dying, and relational contexts such as the sociopolitical environment, may influence the experiences of family members and healthcare providers.

Ethical Considerations: Ethics approval was not required to conduct this review.

Aim: This scoping review aims to identify the relational influences on the experiences of family members and healthcare providers of adults who underwent assisted dying and of those unable to access assisted dying due to the loss of capacity to consent.

Methods: A literature search was conducted in four databases, including MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. The search retrieved 12,074 articles, a number narrowed down to 172 articles for full-text screening. Thirty-six articles met the established inclusion criteria. A feminist relational framework guided the data analysis.

Results: Five key themes on the influences of family members' and healthcare providers' experiences throughout the assisted dying process were synthesized from the data. They include (1) relationships as central to beginning the process, (2) social and political influences on decision making, (3) complex roles and responsibilities of family members and healthcare providers, (4) a unique experience of death, and (5) varying experiences following death.

Conclusion: The feminist relational lens, used to guide analysis, shed light on the effect of the sociopolitical influences and the relationships among patients, families, and healthcare providers on each other's experiences. Addressing the needs of the family members and healthcare providers is vital to improving the assisted dying process. Including families' and healthcare providers' needs within institutional policies and enhancing collaboration and communication among those involved could improve the overall experience.
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http://dx.doi.org/10.1177/0969733020921493DOI Listing
November 2020

Management of bed availability in intensive care in the context of hospitalization by court order.

Rev Lat Am Enfermagem 2020 11;28:e3271. Epub 2020 May 11.

Departamento de Enfermagem, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.

Objective: to identify, from the nurse perspective, situations that interfere with the availability of beds in the intensive care unit in the context of hospitalization by court order.

Method: qualitative exploratory, analytical research carried out with 42 nurses working in adult intensive care. The selection took place by non-probabilistic snowball sampling. Data collected by interview and analyzed using the Discursive Textual Analysis technique.

Results: three categories were analyzed, entitled deficiency of physical structure and human resources; Lack of clear policies and criteria for patient admission and inadequate discharge from the intensive care unit. In situations of hospitalization by court order, there is a change in the criteria for the allocation of intensive care beds, due to the credibility of professionals, threats of medico-legal processes by family members and judicial imposition on institutions and health professionals.

Conclusion: nurses defend the needs of the patients, too, with actions that can positively impact the availability of intensive care beds and adequate care infrastructure.
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http://dx.doi.org/10.1590/1518-8345.3420.3271DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7217627PMC
June 2020

Postoperative Remote Automated Monitoring and Virtual Hospital-to-Home Care System Following Cardiac and Major Vascular Surgery: User Testing Study.

J Med Internet Res 2020 03 18;22(3):e15548. Epub 2020 Mar 18.

Population Health Research Institute, Hamilton, ON, Canada.

Background: Cardiac and major vascular surgeries are common surgical procedures associated with high rates of postsurgical complications and related hospital readmission. In-hospital remote automated monitoring (RAM) and virtual hospital-to-home patient care systems have major potential to improve patient outcomes following cardiac and major vascular surgery. However, the science of deploying and evaluating these systems is complex and subject to risk of implementation failure.

Objective: As a precursor to a randomized controlled trial (RCT), this user testing study aimed to examine user performance and acceptance of a RAM and virtual hospital-to-home care intervention, using Philip's Guardian and Electronic Transition to Ambulatory Care (eTrAC) technologies, respectively.

Methods: Nurses and patients participated in systems training and individual case-based user testing at two participating sites in Canada and the United Kingdom. Participants were video recorded and asked to think aloud while completing required user tasks and while being rated on user performance. Feedback was also solicited about the user experience, including user satisfaction and acceptance, through use of the Net Promoter Scale (NPS) survey and debrief interviews.

Results: A total of 37 participants (26 nurses and 11 patients) completed user testing. The majority of nurse and patient participants were able to complete most required tasks independently, demonstrating comprehension and retention of required Guardian and eTrAC system workflows. Tasks which required additional prompting by the facilitator, for some, were related to the use of system features that enable continuous transmission of patient vital signs (eg, pairing wireless sensors to the patient) and assigning remote patient monitoring protocols. NPS scores by user group (nurses using Guardian: mean 8.8, SD 0.89; nurses using eTrAC: mean 7.7, SD 1.4; patients using eTrAC: mean 9.2, SD 0.75), overall NPS scores, and participant debrief interviews indicated nurse and patient satisfaction and acceptance of the Guardian and eTrAC systems. Both user groups stressed the need for additional opportunities to practice in order to become comfortable and proficient in the use of these systems.

Conclusions: User testing indicated a high degree of user acceptance of Philips' Guardian and eTrAC systems among nurses and patients. Key insights were provided that informed refinement of clinical workflow training and systems implementation. These results were used to optimize workflows before the launch of an international RCT of in-hospital RAM and virtual hospital-to-home care for patients undergoing cardiac and major vascular surgery.
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http://dx.doi.org/10.2196/15548DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7113803PMC
March 2020

Recognizing the Role of Research Assistants in the Protection of Participants in Vulnerable Circumstances.

J Empir Res Hum Res Ethics 2020 07 30;15(3):143-152. Epub 2019 Aug 30.

University of Toronto, Ontario, Canada.

Little is known about how research assistants (RAs) protect participants in vulnerable circumstances. Using a critical qualitative method informed by feminist ethics, we ran five focus groups with experienced RAs. We identified two themes: (a) expressing moral competencies (subthemes: recognizing power, privilege, and vulnerability; adapting processes and providing support; understanding the sources of moral competencies) and (b) negotiating and making transparent roles and responsibilities (subthemes: separating responsibilities as a clinician from those of an RA; critically reflecting on the shared responsibilities of principal investigators and RAs; and identifying the role of the Research Ethics Committee). Although RAs possess a variety of moral competencies and have an important role in protecting research participants in vulnerable circumstances, that role is largely unrecognized.
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http://dx.doi.org/10.1177/1556264619872366DOI Listing
July 2020

The medicalisation of the dying self: The search for life extension in advanced cancer.

Nurs Inq 2020 01 9;27(1):e12316. Epub 2019 Aug 9.

Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.

Although many studies have previously examined medicalisation, we add a new dimension to the concept as we explore how contemporary oncological medicine shapes the dying self as predominantly medical. Through an analysis of multiple case studies collected within a comprehensive cancer centre in Ontario, Canada, we examine how people with late-stage cancer and their healthcare providers enacted the process of medicalisation through engaging in the search for oncological treatments, such as experimental drug trials, despite the incurability of their disease. The seven cases included 20 interviews with patients, family, physicians and nurses, the analysis of 30 documents and 5 hr of field observation. A poststructural perspective informed our study. We propose that searching for life extension enacts medicalisation by shaping the dying person afflicted with terminal cancer into new medical subjectivities that are knowledgeable, active, entrepreneurial and curative. Participants initially took up medical thinking from the formal oncology system, but then began to apply and internalise medical rationalities to alter their personhood, thereby generating new curative possibilities for themselves. For people seeking life extension, the embodied and day-to-day experiences of suffering and being close to death became expressed and moderated in fundamentally medicalised terms.
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http://dx.doi.org/10.1111/nin.12316DOI Listing
January 2020

Advance care planning with chronically ill patients: A relational autonomy approach.

Nurs Ethics 2020 Mar 23;27(2):360-371. Epub 2019 May 23.

University of Toronto, Canada.

Advance care planning is a process that encourages people to identify their values, to reflect upon the meanings and consequences of serious illness, to define goals and preferences for future medical treatment and care, and to discuss these goals with family and health-care providers. Advance care planning is especially important for those who are chronically ill, as patients and their families face a variety of complex healthcare decisions. Participating in advance care planning has been associated with improved outcomes; yet, despite over 25 years of public awareness campaigns, research, and interventions developed to increase participation, advance care planning completion rates for people with chronic illnesses are no different than those in the general public (approximately 25%). Advance care planning has traditionally used an individualistic approach to autonomy, which puts forward an understanding of agents as independent, rational and self-interested persons. Because this individualistic approach has been largely unsuccessful in improving advance care planning uptake, a re-examination of the philosophical underpinnings of this practice and an exploration of alternative frameworks is warranted. In offering this exploration, we briefly outline two current perspectives on autonomy: the individualistic view and the relational view as articulated by feminist philosophers. Using a critical examination of the theoretical and empirical work on this topic, we argue that the individualistic view of autonomy does not sufficiently capture the relational and social complexities of the decision-making process of advance care planning. To offer a counterpoint, we examine the relational view of autonomy and suggest that this perspective is better aligned with the process of advance care planning. Specifically, we demonstrate that a relational model of autonomy is well suited to exploring advance care planning for four main reasons: (1) it recognizes the importance of relationships, (2) it reflects the fluctuating nature of autonomy in chronic illness, (3) it recognizes vulnerability, and (4) it is consonant with empirical work examining the advance care planning process.
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http://dx.doi.org/10.1177/0969733019848031DOI Listing
March 2020

The advocacy role of nurses in cardiopulmonary resuscitation.

Nurs Ethics 2020 Mar 21;27(2):333-347. Epub 2019 May 21.

University of Toronto, Canada.

Background: The decision whether to initiate cardiopulmonary resuscitation may sometimes be ethically complex. While studies have addressed some of these issues, along with the role of nurses in cardiopulmonary resuscitation, most have not considered the importance of nurses acting as advocates for their patients with respect to cardiopulmonary resuscitation.

Research Objective: To explore what the nurse's advocacy role is in cardiopulmonary resuscitation from the perspective of patients, relatives, and health professionals in the Basque Country (Spain).

Research Design: An exploratory critical qualitative study was conducted from October 2015 to March 2016. Thematic analysis was used to analyse the data.

Participants: Four discussion groups were held: one with patients and relatives (n = 8), two with nurses (n = 7 and n = 6, respectively), and one with physicians (n = 5).

Ethical Considerations: Approval was obtained from the Basque Country Clinical Research Ethics Committee.

Findings: Three significant themes were identified: (a) accompanying patients during end of life in a context of medical dominance, (b) maintaining the pact of silence, and (c) yielding to legal uncertainty and concerns.

Discussion: The values and beliefs of the actors involved, as well as pre-established social and institutional rules reduced nurses' advocacy to that of intermediaries between the physician and the family within the hospital environment. On the contrary, in primary health care, nurses participated more actively within the interdisciplinary team.

Conclusion: This study provides key information for the improvement and empowerment for ethical nursing practice in a cardiac arrest, and provides the perspective of patients and relatives, nurses and physicians.
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http://dx.doi.org/10.1177/0969733019843634DOI Listing
March 2020

Invisibility of the self: Reaching for the telos of nursing within a context of moral distress.

Nurs Inq 2019 01 9;26(1):e12269. Epub 2018 Nov 9.

Nursing School, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.

Many studies have examined clinical and institutional moral problems in the practice of nurses that have led to the experience of moral distress. The causes and implications of moral distress in nurses, however, have not been understood in terms of their implications from the perspective of virtue ethics. This paper analyzes how nurses reach for the telos of their practice, within a context of moral distress. A qualitative case study was carried out in a private hospital in Brazil. Observation and semi-semistructured interviews were conducted with 13 nurse participants. With the aid of ATLAS.ti software, the data were analyzed by using thematic content analysis using virtue ethics to theorize the findings. These nurses experienced a loss of their nursing identity as they encountered an ambiguous telos and the domination of institutional values. In their reach for the telos of their practice, nurses found an environment permeated by ethical challenges, which not only created moral distress but also created professional invisibility, a phenomenon referred to as 'invisibility of the self'.
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http://dx.doi.org/10.1111/nin.12269DOI Listing
January 2019

Immediate Staff Debriefing Following Seclusion or Restraint Use in Inpatient Mental Health Settings: A Scoping Review.

Clin Nurs Res 2020 09 27;29(7):479-495. Epub 2018 Jul 27.

University of Toronto, Ontario, Canada.

The aim of this scoping review is to synthesize the academic and gray literature on the use of immediate staff debriefing following seclusion or restraint events in inpatient mental health settings. Multiple electronic databases were searched to identify literature on the topic of immediate staff debriefing. The analysis identified several core components of immediate staff debriefing: terminology, type, critical reflection, iterative process, training, documentation, and monitoring. While these components were regarded as vital to the implementation of debriefing, they remain inconsistently described in the literature. Immediate staff debriefing is an important intervention not only to prevent future episodes of seclusion and restraint use, but as a forum for staff to support each other emotionally and psychologically after a potentially distressing event. The core components identified in this review should be incorporated into the organization's policies, practice guidelines, and training modules to ensure consistent conceptualization and implementation of the debriefing process.
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http://dx.doi.org/10.1177/1054773818791085DOI Listing
September 2020

Postoperative Remote Automated Monitoring: Need for and State of the Science.

Can J Cardiol 2018 07 25;34(7):850-862. Epub 2018 Apr 25.

McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.

Worldwide, more than 230 million adults have major noncardiac surgery each year. Although surgery can improve quality and duration of life, it can also precipitate major complications. Moreover, a substantial proportion of deaths occur after discharge. Current systems for monitoring patients postoperatively, on surgical wards and after transition to home, are inadequate. On the surgical ward, vital signs evaluation usually occurs only every 4-8 hours. Reduced in-hospital ward monitoring, followed by no vital signs monitoring at home, leads to thousands of cases of undetected/delayed detection of hemodynamic compromise. In this article we review work to date on postoperative remote automated monitoring on surgical wards and strategy for advancing this field. Key considerations for overcoming current barriers to implementing remote automated monitoring in Canada are also presented.
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http://dx.doi.org/10.1016/j.cjca.2018.04.021DOI Listing
July 2018

[Presence of relatives during cardiopulmonary resuscitation: Perspectives of health professionals, patients and family in the Basque Country].

Aten Primaria 2019 05 20;51(5):269-277. Epub 2018 Mar 20.

Centro de Investigación Biomédica en Red en Fragilidad y Envejecimiento Saludable (CIBERFES), Madrid, España; Grup d'Estudis sobre Societat, Salut, Educació i Cultura (GESEC), Facultad de Enfermería y Fisioterapia, Universidad de Lleida, Lleida, España; Grup de Recerca en Cures de la Salut (GRECS), Instituto de Investigación Biomédica de Lleida, Lleida, España.

Objective: To determine the perception of nurses, doctors, patients and family or relatives being present during cardiopulmonary resuscitation (CPR) in adult patients.

Design: A qualitative exploratory study and thematic analysis were developed. SITE: Primary Care, Hospital Care and Emergency Service of the Basque Health Service.

Participants: The selection of the participants was made through intentional sampling. Four focus groups were developed: one of patients and family, 2 of nurses, and one of physicians.

Method: Thematic analysis was performed. Triangulation techniques were used between investigators and investigator-participant member. The Open code 4.1 statistics software was used.

Results: Three significant categories were identified: the impact on the family; the weight of ethical and legal responsibility; power, place of death, and cultural assumptions.

Conclusions: CPR is a social construct influenced by values which are situated in specific socio-cultural contexts. In this study, patients and family members describe the fear and resistance to being present during CPR. Health professionals consider that their decision is complex, and each case must be assessed independently, and patients and relatives must be integrated into decision-making. Future research should explore in greater depth the subjective experience of relatives who have witnessed CPR and the impact of contextual and sociocultural elements from the perspectives of relatives.
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http://dx.doi.org/10.1016/j.aprim.2017.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6837081PMC
May 2019

Pharmacists as vaccinators: An analysis of their experiences and perceptions of their new role.

Hum Vaccin Immunother 2018 02 19;14(2):471-477. Epub 2017 Dec 19.

g Leslie Dan Faculty of Pharmacy , Univeristy of Toronto , Toronto , Ontario , Canada.

Objectives: In 2012, Ontario pharmacists were granted immunization privileges to administer influenza vaccines to the public. This study explored the experiences and practices of pharmacist vaccinators and the impact of vaccination pain on their practice.

Methods: Semi-structured interviews were conducted with 12 pharmacists in the Greater Toronto Area. Transcribed interview data were coded and analyzed via thematic analysis.

Key Findings: Data analysis revealed 4 main themes: 1) expanded scope of practice as an enhancement and challenge to relationships; 2) professional satisfaction and workload demands; 3) knowledge and attitudes regarding pain and fear; 4) practices regarding pain and fear management. Pharmacists reported satisfaction in their new role, despite the associated increased workload. Pharmacists felt that vaccination pain was not a key consideration when administering vaccines and that pain management was generally not necessary. Fear was identified as more important than pain and vaccinating children was challenging and time intensive. Pharmacists' main focus was on injection techniques in managing pain.

Conclusion: These findings suggest that pharmacists are accepting of their role as vaccinators but more research is needed to examine impact on workload and pharmacist knowledge and perceptions of injection-related pain and fear.
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http://dx.doi.org/10.1080/21645515.2017.1403695DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5806653PMC
February 2018

Instrumentalisation of the health system: An examination of the impact on nursing practice and patient autonomy.

Nurs Inq 2018 01 4;25(1). Epub 2017 Jun 4.

Balearic Islands Health System, Mallorca, Spain.

Most current management systems of healthcare institutions correspond to a model of market ethics with its demands of competitiveness. This approach has been called managerialism and is couched in terms of much-needed efficiencies and effective management of budgetary constraints. The aim of this study was to analyse the decision-making of nurses through the impact of health institution management models on clinical practice. Based on Foucault's ethical theory, a qualitative study was conducted through a discourse analysis of the nursing records in a hospital unit. The results revealed that the health institution standardises health care practice, which has an impact on professional and patient autonomy as it pertains to decision-making. The results of this research indicate that resistance strategies in the internal structures of health organisations can replace the normalisation and instrumentalisation of professional practice aimed at promoting patient self-determination.
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http://dx.doi.org/10.1111/nin.12201DOI Listing
January 2018

Recognizing Risk and Vulnerability in Research Ethics: Imagining the "What Ifs?"

J Empir Res Hum Res Ethics 2017 04 14;12(2):107-116. Epub 2017 Mar 14.

1 University of Toronto, Ontario, Canada.

Research ethics committees (RECs) may misunderstand the vulnerability of participants, given their distance from the field. What RECs identify as the vulnerabilities that were not adequately recognized in protocols and how they attempt to protect the perceived vulnerability of participants and mitigate risks were examined using the response letters sent to researchers by three university-based RECs. Using a critical qualitative method informed by feminist ethics, we identified an overarching theme of recognizing and responding to cascading vulnerabilities and four subthemes: identifying vulnerable groups, recognizing potentially risky research, imagining the "what ifs," and mitigating perceived risks. An ethics approach that is up-close, as opposed to distant, is needed to foster closer relationships among participants, researchers, and RECs and to understand participant vulnerability and strength better.
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http://dx.doi.org/10.1177/1556264617696920DOI Listing
April 2017

Examining the relationship between therapeutic self-care and adverse events for home care clients in Ontario, Canada: a retrospective cohort study.

BMC Health Serv Res 2017 03 14;17(1):206. Epub 2017 Mar 14.

Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada.

Background: In an era of a rapidly aging population who requires home care services, clients must possess or develop therapeutic self-care ability in order to manage their health conditions safely in their homes. Therapeutic self-care is the ability to take medications as prescribed and to recognize and manage symptoms that may be experienced, such as pain. The purpose of this research study was to investigate whether therapeutic self-care ability explained variation in the frequency and types of adverse events experienced by home care clients.

Methods: A retrospective cohort design was used, utilizing secondary databases available for Ontario home care clients from the years 2010 to 2012. The data were derived from (1) Health Outcomes for Better Information and Care; (2) Resident Assessment Instrument-Home Care; (3) National Ambulatory Care Reporting System; and (4) Discharge Abstract Database. Descriptive analysis was used to identify the types and prevalence of adverse events experienced by home care clients. Logistic regression analysis was used to examine the association between therapeutic self-care ability and the occurrence of adverse events in home care.

Results: The results indicated that low therapeutic self-care ability was associated with an increase in adverse events. In particular, logistic regression results indicated that low therapeutic self-care ability was associated with an increase in clients experiencing: (1) unplanned hospital visits; (2) a decline in activities of daily living; (3) falls; (4) unintended weight loss, and (5) non-compliance with medication.

Conclusions: This study advances the understanding about the role of therapeutic self-care ability in supporting the safety of home care clients. High levels of therapeutic self-care ability can be a protective factor against the occurrence of adverse events among home care clients. A clear understanding of the nature of the relationship between therapeutic self-care ability and adverse events helps to pinpoint the areas of home care service delivery required to improve clients' health and functioning. Such knowledge is vital for informing health care leaders about effective strategies that promote therapeutic self-care, as well as providing evidence for policy formulation in relation to risk mitigation in home care.
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http://dx.doi.org/10.1186/s12913-017-2103-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5351056PMC
March 2017

Harm Reduction and Tensions in Trust and Distrust in a Mental Health Service: A Qualitative Approach.

Subst Abuse Treat Prev Policy 2017 03 8;12(1):12. Epub 2017 Mar 8.

School of Public Health, University of Sao Paulo, São Paulo, Brazil.

Background: People seeking care for substance use (PSCSU) experience deep social and health inequities. Harm reduction can be a moral imperative to approach these persons. The purpose of this study was to explore relationships among users, health care providers, relatives, and society regarding harm reduction in mental health care, using a trust approach rooted in feminist ethics.

Methods: A qualitative study was conducted in a mental health service for PSCSU, and included fifteen participants who were health care providers, users, and their relatives. Individual in-depth and group interviews, participant observation, and a review of patients' records and service reports were conducted.

Results: Three nested levels of (dis)trust were identified: (dis)trust in the treatment, (dis)trust in the user, and self-(dis)trust of the user, revealing the interconnections among different layers of trust. (Dis)trust at each level can amplify or decrease the potential for a positive therapeutic response in users, their relatives' support, and how professionals act and build innovations in care. Distrust was more abundant than trust in participants' reports, revealing the fragility of trust and the focus on abstinence within this setting.

Conclusion: The mismatch between wants and needs of users and the expectations and requirements of a society and mental health care system based on a logic of "fixing" has contributed to distrust and stigma. Therefore, we recommend policies that increase the investment in harm reduction education and practice that target service providers, PSCSU, and society to change the context of distrust identified.
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http://dx.doi.org/10.1186/s13011-017-0098-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5341417PMC
March 2017

A very human being: Sister Marie Simone Roach, 1922-2016.

Nurs Inq 2016 12 28;23(4):283-289. Epub 2016 Oct 28.

Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.

Sister (Sr.) Marie Simone Roach, of the Sisters of St. Martha of Antigonish, Nova Scotia, died at the Motherhouse on 2 July 2016 at the age of 93, leaving behind a rich legacy of theoretical and practical work in the areas of care, caring and nursing ethics. She was a humble soul whose deep and scholarly thinking thrust her onto the global nursing stage where she will forever be tied to a central concept in nursing, caring, through her Six Cs of Caring model. In Canada, she was the lead architect of the Canadian Nurses Association's first code of ethics, and her influence on revisions to it is still profound more than 35 years later. In this paper, four global scholars in nursing and ethics are invited to reflect on Sr. Simone's contribution to nursing and health-care, and we link her work to nursing and health-care going forward.
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http://dx.doi.org/10.1111/nin.12168DOI Listing
December 2016

Fostering Nurses' Moral Agency and Moral Identity: The Importance of Moral Community.

Hastings Cent Rep 2016 09;46 Suppl 1:S18-21

It may be the case that the most challenging moral problem of the twenty-first century will be the relationship between the individual moral agent and the practices and institutions in which the moral agent is embedded. In this paper, we continue the efforts that one of us, Joan Liaschenko, first called for in 1993, that of using feminist ethics as a lens for viewing the relationship between individual nurses as moral agents and the highly complex institutions in which they do the work of nursing. Feminist ethics, with its emphasis on the inextricable relationship between ethics and politics, provides a useful lens to understand the work of nurses in context. Using Margaret Urban Walker's and Hilde Lindemann's concepts of identity, relationships, values, and moral agency, we argue that health care institutions can be moral communities and profoundly affect the work and identity and, therefore, the moral agency of all who work within those structures, including nurses. Nurses are not only shaped by these organizations but also have the power to shape them. Because moral agency is intimately connected to one's identity, moral identity work is essential for nurses to exercise their moral agency and to foster moral community in health care organizations. We first provide a brief history of nursing's morally problematic relationship with institutions and examine the impact institutional master narratives and corporatism exert today on nurses' moral identities and agency. We close by emphasizing the significance of ongoing dialogue in creating and sustaining moral communities, repairing moral identities, and strengthening moral agency.
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http://dx.doi.org/10.1002/hast.626DOI Listing
September 2016

Technology-Enabled Remote Monitoring and Self-Management - Vision for Patient Empowerment Following Cardiac and Vascular Surgery: User Testing and Randomized Controlled Trial Protocol.

JMIR Res Protoc 2016 Aug 1;5(3):e149. Epub 2016 Aug 1.

McMaster University, Hamiltion, ON, Canada.

Background: Tens of thousands of cardiac and vascular surgeries (CaVS) are performed on seniors in Canada and the United Kingdom each year to improve survival, relieve disease symptoms, and improve health-related quality of life (HRQL). However, chronic postsurgical pain (CPSP), undetected or delayed detection of hemodynamic compromise, complications, and related poor functional status are major problems for substantial numbers of patients during the recovery process. To tackle this problem, we aim to refine and test the effectiveness of an eHealth-enabled service delivery intervention, TecHnology-Enabled remote monitoring and Self-MAnagemenT-VIsion for patient EmpoWerment following Cardiac and VasculaR surgery (THE SMArTVIEW, CoVeRed), which combines remote monitoring, education, and self-management training to optimize recovery outcomes and experience of seniors undergoing CaVS in Canada and the United Kingdom.

Objective: Our objectives are to (1) refine SMArTVIEW via high-fidelity user testing and (2) examine the effectiveness of SMArTVIEW via a randomized controlled trial (RCT).

Methods: CaVS patients and clinicians will engage in two cycles of focus groups and usability testing at each site; feedback will be elicited about expectations and experience of SMArTVIEW, in context. The data will be used to refine the SMArTVIEW eHealth delivery program. Upon transfer to the surgical ward (ie, post-intensive care unit [ICU]), 256 CaVS patients will be reassessed postoperatively and randomly allocated via an interactive Web randomization system to the intervention group or usual care. The SMArTVIEW intervention will run from surgical ward day 2 until 8 weeks following surgery. Outcome assessments will occur on postoperative day 30; at week 8; and at 3, 6, 9, and 12 months. The primary outcome is worst postop pain intensity upon movement in the previous 24 hours (Brief Pain Inventory-Short Form), averaged across the previous 14 days. Secondary outcomes include a composite of postoperative complications related to hemodynamic compromise-death, myocardial infarction, and nonfatal stroke- all-cause mortality and surgical site infections, functional status (Medical Outcomes Study Short Form-12), depressive symptoms (Geriatric Depression Scale), health service utilization-related costs (health service utilization data from the Institute for Clinical Evaluative Sciences data repository), and patient-level cost of recovery (Ambulatory Home Care Record). A linear mixed model will be used to assess the effects of the intervention on the primary outcome, with an a priori contrast of weekly average worst pain intensity upon movement to evaluate the primary endpoint of pain at 8 weeks postoperation. We will also examine the incremental cost of the intervention compared to usual care using a regression model to estimate the difference in expected health care costs between groups.

Results: Study start-up is underway and usability testing is scheduled to begin in the fall of 2016.

Conclusions: Given our experience, dedicated industry partners, and related RCT infrastructure, we are confident we can make a lasting contribution to improving the care of seniors who undergo CaVS.
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http://dx.doi.org/10.2196/resprot.5763DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4999307PMC
August 2016

Nurses' narratives of moral identity: Making a difference and reciprocal holding.

Nurs Ethics 2018 May 24;25(3):324-334. Epub 2016 May 24.

University of Minnesota, USA.

Background: Explicating nurses' moral identities is important given the powerful influence moral identity has on the capacity to exercise moral agency.

Research Objectives: The purpose of this study was to explore how nurses narrate their moral identity through their understanding of their work. An additional purpose was to understand how these moral identities are held in the social space that nurses occupy.

Research Design: The Registered Nurse Journal, a bimonthly publication of the Registered Nurses' Association of Ontario, Canada, features a regular column entitled, 'In the End … What Nursing Means to Me …' These short narratives generally include a story of an important moment in the careers of the authors that defined their identities as nurses. All 29 narratives published before June 2015 were analysed using a critical narrative approach, informed by the work of Margaret Urban Walker and Hilde Lindemann, to identify a typology of moral identity. Ethical considerations: Ethics approval was not required because the narratives are publicly available.

Findings: Two narrative types were identified that represent the moral identities of nurses as expressed through their work: (1) making a difference in the lives of individuals and communities and (2) holding the identities of vulnerable individuals.

Discussion: Nurses' moral identities became evident when they could see improvement in the health of patients or communities or when they could maintain the identity of their patients despite the disruptive forces of illness and hospitalization. In reciprocal fashion, the responses of their patients, including expressions of gratitude, served to hold the moral identities of these nurses.

Conclusion: Ultimately, the sustainability of nurses' moral identities may be dependent on the recognition of their own needs for professional satisfaction and care in ways that go beyond the kind of acknowledgement that patients can offer.
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http://dx.doi.org/10.1177/0969733016648206DOI Listing
May 2018

Development and Psychometric Testing of the Humanistic Nurse-Patient Scale.

Can J Aging 2016 Mar 16;35(1):1-13. Epub 2016 Feb 16.

Lawrence S. Bloomberg Faculty of Nursing,University of Toronto.

Quality of life and well-being of older patients in chronic care facilities is often determined by their relationships with nurses. The authors developed and tested a scale to assess patients' views of what matters most when relating to nurses. Based on the humanistic nursing theory by Paterson and Zderad (1988), 69 items were created and tested with a sample of 40 patients, resulting in refinement of a scale with 24 items. This scale was factor analysed on responses from 249 patients residing in five facilities in Ontario, Canada. The Humanistic Relationship Importance Scale demonstrated strong internal consistency, stability, and reliability with a five-factor solution (α = .87). Construct validity was supported through factual identification. This scale is a valid measure of patients' perspectives of a nurse-patient relationship in chronic care and can be used to measure health professionals' relationships with their older patients and evaluate interventions to enhance relational care.
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http://dx.doi.org/10.1017/S0714980815000604DOI Listing
March 2016

The ethics in qualitative health research: special considerations.

Authors:
Elizabeth Peter

Cien Saude Colet 2015 Sep;20(9):2625-30

Lawrence S. Bloomberg Faculty of Nursing, Joint Centre for Bioethics, University of Toronto, Toronto, ON, CA,

A sound knowledge of the nature of qualitative research, along with an appreciation of some special ethical considerations, is needed for rigorous reviews to be conducted. The overall character of qualitative research is described with an emphasis on the tendency of qualitative researchers to explore sensitive topics using theoretically informed methods. A number of specific features of qualitative that require additional ethical attention and awareness are also examined including the following: 1) participants are frequently quite vulnerable and require protection because the data collection methods, such as in-depth interviews, can delve into personally and politically charged matters; 2) naturalistic observation can raise concerns regarding privacy and consent; 3) the potential for the identifiability of the results of this research may require extra efforts to maintain confidentiality. Ultimately, Reseach Ethics Committee members must be knowledgeable about qualitative approaches to be able to assess the potential harms and benefits in a protocol carefully. Without this knowledge gaining ethics approval can be overly difficult for researchers and the best practices for protecting human participants can be overlooked.
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http://dx.doi.org/10.1590/1413-81232015209.06762015DOI Listing
September 2015

Rethinking Case Study Methodology in Poststructural Research.

Can J Nurs Res 2015 Mar;47(1):97-114

Royal Bank of Canada Chair of Oncology Nursing Research, Princess Margaret Cancer Centre, Toronto.

Little consideration has been given to how case study might be used in poststructural research to explore power relations that constitute a phenomenon. Many case study scholars, most notably Robert Yin, adopt a postpositivist perspective that assumes the "truth" can be accessed through applying prescriptive and rigid research techniques. Using a discussion of Michel Foucault's key theoretical ideas and the insights gained through a Foucauldian case study of people with advanced cancer who continue to receive curative treatment, the authors argue for the expansion of case study in poststructural inquiry. They propose that the use of poststructuralist case study is valuable because of the flexibility and comprehensiveness of the methodology, which allows for the exploration of a deeper understanding of the broader discourses that shape a phenomenon, as well as how power/knowledge relations shape the behaviours and perceptions of people. They also introduce the reflexive implications of poststructural case study research.
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http://dx.doi.org/10.1177/084456211504700107DOI Listing
March 2015

The "Conflicted Dying": The Active Search for Life Extension in Advanced Cancer Through Biomedical Treatment.

Qual Health Res 2016 Mar 23;26(4):555-67. Epub 2015 Feb 23.

University of Toronto, Toronto, Ontario, Canada Princess Margaret Cancer Center, Toronto, Ontario, Canada.

Using a poststructural perspective, we examine the subjectivities that are produced when advanced cancer patients seek life extension through biomedical treatments. Seven case studies were developed that included 20 interviews with patients, family, nurses, and physicians recruited from a tertiary hospital in Canada, 30 documents, and 5 hours of participant observation. We identify seven types of subjectivity: (a) the Desperate Subject, (b) the Cancer Expert Subject, (c) the Proactive Subject, (d) the Productive Subject, (e) the Mistrusting Subject, (f) the Model Patient Subject, and (g) the Suffering Subject. We characterize the "conflicted dying," a contemporary figure who holds multiple perspectives about seeking curative treatment despite the acknowledgment of death. Using active strategies to gain access to treatment, this figure resists traditional arrangements of power/knowledge established by health care providers. We suggest that the search for life extension is a process of shaping the self to fit certain aesthetical traits associated with surviving cancer.
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http://dx.doi.org/10.1177/1049732315572772DOI Listing
March 2016