Publications by authors named "Sandra LeFort"

35 Publications

A Canadian Survey of Self-Management Strategies and Satisfaction with Ability to Control Pain: Comparison of Community Dwelling Adults with Neuropathic Pain versus Adults with Non-neuropathic Chronic Pain.

Pain Manag Nurs 2018 08 2;19(4):377-390. Epub 2018 Mar 2.

School of Nursing & Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada. Electronic address:

Background: Individuals with chronic pain with neuropathic characteristics (CPNC) describe a different pain experience compared with those with chronic pain without neuropathic characteristics (CP).

Aims: The aim of this study was to describe and compare pain, self-management strategies, and satisfaction with ability to control pain between adults with CPNC versus CP.

Participants: Seven hundred and ten community-dwelling adults with chronic pain participated in a cross-sectional survey.

Methods: CPNC was defined as a score ≥12 on the Self-Report Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale. Self-management and pain control was compared between participants with CPNC and CP using frequency, percent, relative risk (RR), odds ratios (ORs), and 95% confidence intervals (CIs).

Results: Participants with CPNC (188/710) reported lower socioeconomic status, poorer general health, and more intense, frequent, and widespread pain. They were more likely to use prescription medications to manage pain (adjusted OR = 2.25, CI = 1.47-3.42). They were more likely to use potentially negative strategies to ease the emotional burden of living with chronic pain, including substance use (adjusted OR = 1.58, CI = 1.06-2.35), denial (adjusted OR = 2.21, CI = 1.49-3.28), and behavioral disengagement (adjusted OR = 1.68, CI = 1.16-2.45), and they were more likely to be completely dissatisfied with their ability to control pain (RR = 1.77, CI = 1.21-2.58).

Conclusions: Individuals with CPNC have distinct pain and self-management experiences compared with those with CP that may lead to negative coping strategies and dissatisfaction with ability to control pain. Therefore, self-management assessment and support should be tailored by pain condition.
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http://dx.doi.org/10.1016/j.pmn.2017.10.016DOI Listing
August 2018

Self-management of cardiac pain in women: an evidence map.

BMJ Open 2017 Nov 25;7(11):e018549. Epub 2017 Nov 25.

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

Objective: To describe the current evidence related to the self-management of cardiac pain in women using the process and methodology of evidence mapping.

Design And Setting: Literature search for studies that describe the self-management of cardiac pain in women greater than 18 years of age, managed in community, primary care or outpatient settings, published in English or a Scandinavian language between 1 January 1990 and 24 June 2016 using AMED, CINAHL, ERIC, EMBASE, MEDLINE, Proquest, PsychInfo, the Cochrane Library, Scopus, Swemed+, Web of Science, the Clinical Trials Registry, International Register of Controlled Trials, MetaRegister of Controlled Trials, theses and dissertations, published conference abstracts and relevant websites using GreyNet International, ISI proceedings, BIOSIS and Conference papers index. Two independent reviewers screened using predefined eligibility criteria. Included articles were classified according to study design, pain category, publication year, sample size, per cent women and mean age.

Interventions: Self-management interventions for cardiac pain or non-intervention studies that described views and perspectives of women who self-managed cardiac pain.

Primary And Secondary Outcomes Measures: Outcomes included those related to knowledge, self-efficacy, function and health-related quality of life.

Results: The literature search identified 5940 unique articles, of which 220 were included in the evidence map. Only 22% (n=49) were intervention studies. Sixty-nine per cent (n=151) of the studies described cardiac pain related to obstructive coronary artery disease (CAD), 2% (n=5) non-obstructive CAD and 15% (n=34) postpercutaneous coronary intervention/cardiac surgery. Most were published after 2000, the median sample size was 90 with 25%-100% women and the mean age was 63 years.

Conclusions: Our evidence map suggests that while much is known about the differing presentations of obstructive cardiac pain in middle-aged women, little research focused on young and old women, non-obstructive cardiac pain or self-management interventions to assist women to manage cardiac pain.

Prospero Registration Number: CRD42016042806.
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http://dx.doi.org/10.1136/bmjopen-2017-018549DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5719283PMC
November 2017

What Are the Barriers and Facilitators for the Self-Management of Chronic Pain with and without Neuropathic Characteristics?

Pain Manag Nurs 2017 10 9;18(5):295-308. Epub 2017 Jun 9.

School of Nursing, Queen's University, Kingston, Ontario, Canada; Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Kingston, Ontario, Canada. Electronic address:

Chronic pain requires affected individuals to self-manage their health. This study compared barriers and facilitators of self-management in two groups of people with chronic pain: those with and without neuropathic characteristics. A cross-sectional survey study of community-dwelling Canadians was conducted. The sample (n = 710) included randomly selected participants who reported chronic pain. The Self-Report Leeds Assessment of Neuropathic Symptoms and Signs was used to screen for neuropathic characteristics. Barriers and facilitators of self-management included self-efficacy (Pain Self-Efficacy Questionnaire), depression (Patient Health Questionnaire 9), social support and relationship with health care provider (Chronic Illness Resources Survey), and pain intensity (numeric rating scale). Participants were asked which factors they felt made pain management easier or harder. Statistical analyses included frequency, percent, relative risk (RR), and 95% confidence intervals (CI). Self-confidence to manage pain was the most commonly perceived self-management barrier/facilitator by both groups; however, participants with neuropathic characteristics (n = 188) were more likely to report low self-efficacy than those without neuropathic characteristics (n = 522) (RR = 2.1, CI = 1.62-2.72, ref = high self-efficacy). Participants with neuropathic characteristics were also more likely to screen positive for depression (RR = 2.30, CI = 1.73-3.06, ref = no/mild depression). There were no group differences in social support and relationship with health professional, but 40.8% felt they were not involved as equal partners in decision making and goal setting related to their care. Health professionals should consider collaborative decision making when seeking to support self-management abilities. Addressing low self-efficacy and depression may be especially important for supporting self-management by individuals with neuropathic characteristics.
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http://dx.doi.org/10.1016/j.pmn.2017.04.006DOI Listing
October 2017

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

Standardized Discharge Information After Short-Stay Hysterectomy and Relationships With Self-Care Confidence, Perceived Recovery, and Satisfaction.

J Obstet Gynecol Neonatal Nurs 2016 Sep-Oct;45(5):e41-54. Epub 2016 Jul 26.

We report on the development and investigation of standardized, nurse-delivered discharge information to women after same-day hysterectomy, including the relationships among discharge information, self-care confidence, perceived recovery, and satisfaction. Fifty-one women reported high levels of self-care confidence and various levels of perceived recovery 48 to 72 hours after surgery. They were satisfied to highly satisfied with their experiences and with the discharge information provided. The important role of standardized patient discharge information is highlighted.
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http://dx.doi.org/10.1016/j.jogn.2016.05.003DOI Listing
April 2018

Validity of the Child Facial Coding System for the Assessment of Acute Pain in Children With Cerebral Palsy.

J Child Neurol 2016 Apr 9;31(5):597-602. Epub 2015 Sep 9.

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.

The purpose of the current study was to examine the concurrent and discriminant validity of the Child Facial Coding System for children with cerebral palsy. Eighty-five children (mean = 8.35 years, SD = 4.72 years) were videotaped during a passive joint stretch with their physiotherapist and during 3 time segments: baseline, passive joint stretch, and recovery. Children's pain responses were rated from videotape using the Numerical Rating Scale and Child Facial Coding System. Results indicated that Child Facial Coding System scores during the passive joint stretch significantly correlated with Numerical Rating Scale scores (r = .72, P < .01). Child Facial Coding System scores were also significantly higher during the passive joint stretch than the baseline and recovery segments (P < .001). Facial activity was not significantly correlated with the developmental measures. These findings suggest that the Child Facial Coding System is a valid method of identifying pain in children with cerebral palsy.
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http://dx.doi.org/10.1177/0883073815604228DOI Listing
April 2016

A comparison of observers' and self-report pain ratings for children with cerebral palsy.

J Dev Behav Pediatr 2015 Jan;36(1):14-23

*Department of Psychology, Memorial University of Newfoundland, St. John's, NL, Canada; †School of Nursing, Memorial University of Newfoundland, St. John's, NL, Canada; ‡Janeway Children's Hospital and Rehabilitation Center, St. John's, NL, Canada; §Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.

Objectives: This study aimed to examine (1) the relationship between children's self-reports of pain and their different care providers' pain ratings, (2) the relationship between different care providers' ratings of pain in children with cerebral palsy (CP), and (3) whether the child's level of disability influences care providers' pain ratings.

Methods: Sixty-three children with CP were separated into 2 groups according to whether they were able to pass a self-report training task. Pain was rated using a Numerical Rating Scale and the Non-Communicating Children's Pain Checklist-Postoperative Version (NCCPC-PV). Children were observed during their regular physiotherapy sessions at 3 separate time segments (Baseline, Stretch Procedure, and Recovery).

Results: As anticipated, results showed that all observers reported significantly higher pain scores during a physiotherapy stretching procedure than the baseline and recovery segments. Observers' NCCPC-PV scores were significantly higher during the stretch procedure for the children who did not pass the self-report training task. Findings also indicated that parents tended to report significantly lower pain scores compared with both their children and other observers.

Conclusions: The findings bring into question the accuracy of single-observer pain ratings for children with CP and possess implications for the management of pain in children with CP.
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http://dx.doi.org/10.1097/DBP.0000000000000118DOI Listing
January 2015

Self-management interventions for chronic pain.

Pain Manag 2013 May;3(3):211-22

School of Nursing, Queen's University, Cataraqui Building, 92 Barrie Street, Kingston, ON, K7L 3N6, Canada.

SUMMARY Individuals living with chronic pain face daily challenges of managing symptoms, modifying roles and responsibilities, and coping with the negative emotional consequences of pain. Self-management interventions teach a variety of strategies to meet these challenges and build participants' self-efficacy for their use. These interventions have been delivered in individual, group and online formats for a variety of different pain conditions. The evidence supports the efficacy of self-management interventions in improving pain, mental health and health-related quality of life outcomes. Acceptance of the chronic nature of their pain is a necessary step before individuals are ready to self-manage. Clinicians can play a critical role in supporting self-management through answering questions, providing advice, addressing barriers and facilitators, and encouraging self-management efforts.
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http://dx.doi.org/10.2217/pmt.13.9DOI Listing
May 2013

The Canadian STOP-PAIN project: the burden of chronic pain-does sex really matter?

Clin J Pain 2014 May;30(5):443-52

*Department of Psychology, Université du Québec à Montréal †Centre de Recherche ‡‡Clinique de la douleur du, Centre Hospitalier de l'Université de Montréal Departments of ‡Family Medicine and Emergency #Anaesthesiology, Faculty of Medicine, Université de Montréal §Research Centre of the Montreal Heart Institute ¶¶Montreal Heart Institute, Coordinating Center ∥∥∥Pain Centre, McGill University Health Centre, Montréal, QC ∥Department of Health Policy, Management, and Evaluation, University of Toronto ¶Institute for Clinical Evaluative Sciences ∥∥Wasser Pain Management Clinic, Mount Sinai Hospital, Toronto **Department of Anesthesia and Perioperative Medicine, University of Western Ontario †††London Health Sciences Centre, London, ON ††Calgary Chronic Pain Program, Alberta Health Sciences, Calgary §§§Multidisciplinary Chronic Pain Centre, University of Alberta, Edmonton, AB §§Pain Management Unit, Queen Elizabeth II Health Sciences Centre, Halifax, NS ##Health Sciences Centre Pain Clinic, University of Manitoba, Winnipeg, MB ***School of Nursing, Memorial University of Newfoundland, St-John's, NF ‡‡‡St-Paul's Hospital Pain Centre, Vancouver, BC, Canada.

Objectives: The Canadian STOP-PAIN Project assessed the human and economic burden of chronic pain (CP) in individuals on waitlists of Canadian multidisciplinary pain treatment facilities. This article focuses on sex differences. Objectives were to (1) determine the pain characteristics and related biopsychosocial factors that best differentiated women and men with CP; and (2) examine whether public and private costs associated with CP differed according to sex.

Materials And Methods: Sample consisted of 441 women and 287 men who were evaluated using self-administered questionnaires and a structured interview protocol. A subsample (233 women and 137 men) recorded all pain-related expenditures in a comprehensive diary over 3 months.

Results: Results revealed that the burden of illness associated with CP was comparable in both sexes for average and worst pain intensity, pain impact on daily living, quality of life, and psychological well-being. The same was true for pain-related costs. The results of a hierarchical logistic regression analysis, in which sex was treated as the dependent variable, showed that factors that differentiated men and women were: work status, certain circumstances surrounding pain onset, present pain intensity, intake of particular types of pain medication, use of certain pain management strategies, pain beliefs, and utilization of particular health care resources.

Discussion: This study suggests that women and men who are referred to multidisciplinary pain treatment facilities do not differ significantly in terms of their pain-related experience. However, the aspects that differ may warrant further clinical attention when assessing and managing pain.
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http://dx.doi.org/10.1097/AJP.0b013e3182a0de5eDOI Listing
May 2014

Evaluation of chronic pain-related information available to consumers on the Internet.

Pain Med 2013 Jun 8;14(6):855-64. Epub 2013 Apr 8.

Department of Psychology, University of New Brunswick, Fredericton, New Brunswick, Canada.

Objective: Recent surveys suggest more than one third of patients utilize the Internet to seek information about chronic pain (CP) and that 60% of patients feel more confident in the information provided online than provided by their physician. Unfortunately, the quality of online information is questionable. For example, some Websites make unsubstantiated claims while others may have covert motives (i.e., product advertisement). This article presents two studies that utilized a well-validated tool to evaluate the quality of online CP-related information.

Design: A Website search was conducted by entering the most commonly used pain-related search terms into the three most commonly used search engines in North America. In study 1, the first 50 Websites from each search were evaluated using a consumer-focused evaluation tool-the DISCERN. In study 2, 21 clients with CP used the DISCERN to rate a random selection of Websites from among the 10 highest scoring and five lower scoring sites from Study 1, and answered open-ended questions regarding the DISCERN and Websites.

Results: Ratings indicated that Websites ranged substantially in quality, with many providing incomplete and incorrect information, and others providing accurate and detailed information. The majority of the Websites provided low-quality information. Client ratings of the Websites were consistent with those of the researchers.

Conclusions: Overall, these findings speak to the risks associated with clients making CP-related treatment choices based on information obtained online without first evaluating the Website.
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http://dx.doi.org/10.1111/pme.12087DOI Listing
June 2013

Designing strategies to implement research-based policies and procedures: a set of recommendations for nurse leaders based on the PARiHS framework.

J Nurs Adm 2012 May;42(5):293-7

Ottawa Hospital Research Institute, Ottawa, ON, Canada.

Organizational policies and procedures are one vehicle for translating research into nursing practice and improving quality and patient and organizational outcomes. However, their existence alone is not sufficient to ensure use. In this article, we describe the Promoting Action on Research Implementation in Health Services framework and how nurse leaders can use the framework to support the implementation of research-based policies and procedures.
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http://dx.doi.org/10.1097/NNA.0b013e318253565fDOI Listing
May 2012

Ethical conflicts with hospitals: the perspective of nurses and physicians.

Nurs Ethics 2011 Nov 5;18(6):756-66. Epub 2011 Oct 5.

School of Nursing,Memorial University of Newfoundland, St. John’s, Newfoundland, Canada.

Nurses and physicians may experience ethical conflict when there is a difference between their own values, their professional values or the values of their organization. The distribution of limited health care resources can be a major source of ethical conflict. Relatively few studies have examined nurses' and physicians' ethical conflict with organizations. This study examined the research question 'What are the organizational ethical conflicts that hospital nurses and physicians experience in their practice?' We interviewed 34 registered nurses, 10 nurse managers, and 31 physicians as part of a larger study, and asked them to describe their ethical conflicts with organizations. Through content analysis, we identified themes of nurses' and physicians' ethical conflict with organizations and compared the themes for nurses with those for physicians.
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http://dx.doi.org/10.1177/0969733011401121DOI Listing
November 2011

Barriers and facilitators to consulting hospital clinical ethics committees.

Nurs Ethics 2011 Nov 6;18(6):767-80. Epub 2011 Jun 6.

School of Nursing, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada.

Hospitals in many countries have had clinical ethics committees for over 20 years. Despite this, there has been little research to evaluate these committees and growing evidence that they are underutilized. To address this gap, we investigated the question 'What are the barriers and facilitators nurses and physicians perceive in consulting their hospital ethics committee?' Thirty-four nurses, 10 nurse managers and 31 physicians working at four Canadian hospitals were interviewed using a semi-structured interview guide as part of a larger investigation. We used content analysis of the interview data related to barriers and facilitators to use of hospital ethics committees to identify nine categories of barriers and nine categories of facilitators. These categories as well as their subcategories are discussed and those specific to nurses or physicians are identified. The need to increase health professionals' use of clinical ethics committees through reducing barriers and maximizing facilitators is discussed.
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http://dx.doi.org/10.1177/0969733011403808DOI Listing
November 2011

The functioning of hospital ethics committees: a multiple-case study of four Canadian committees.

HEC Forum 2011 Sep;23(3):225-38

School of Nursing, Memorial University of Newfoundland, St. John's, Newfoundland, Canada.

A multiple-case study of four hospital ethics committees in Canada was conducted and data collected included interviews with key informants, observation of committee meetings and ethics-related hospital documents, such as policies and committee minutes. We compared the hospital committees in terms of their structure, functioning and perceptions of key informants and found variation in the dimensions of empowerment, organizational culture of ethics, breadth of ethics mandate, achievements, dynamism, and expertise.
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http://dx.doi.org/10.1007/s10730-011-9151-zDOI Listing
September 2011

Clinical ethical conflicts of nurses and physicians.

Nurs Ethics 2011 Jan;18(1):9-19

Memorial University of Newfoundland, St John’s, Newfoundland, Canada.

Much of the literature on clinical ethical conflict has been specific to a specialty area or a particular patient group, as well as to a single profession. This study identifies themes of hospital nurses' and physicians' clinical ethical conflicts that cut across the spectrum of clinical specialty areas, and compares the themes identified by nurses with those identified by physicians. We interviewed 34 clinical nurses, 10 nurse managers and 31 physicians working at four different Canadian hospitals as part of a larger study on clinical ethics committees and nurses' and physicians' use of these committees. We describe nine themes of clinical ethical conflict that were common to both hospital nurses and physicians, and three themes that were specific to physicians. Following this, we suggest reasons for differences in nurses' and physicians' ethical conflicts and discuss implications for practice and research.
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http://dx.doi.org/10.1177/0969733010385532DOI Listing
January 2011

The Canadian STOP-PAIN project - Part 2: What is the cost of pain for patients on waitlists of multidisciplinary pain treatment facilities?

Can J Anaesth 2010 Jun 23;57(6):549-58. Epub 2010 Apr 23.

Department of Health Policy, Management and Evaluation, University of Toronto, ON, Canada.

Purpose: The Canadian STOP-PAIN Project was designed to document the human and economic burden of chronic pain in individuals on waitlists of Multidisciplinary Pain Treatment Facilities (MPTF). This paper describes the societal costs of their pain.

Methods: A subgroup of 370 patients was selected randomly from The Canadian STOP-PAIN Project. Participants completed a self-administered costing tool (the Ambulatory and Home Care Record) on a daily basis for three months. They provided information about publicly financed resources, such as health care professional consultations and diagnostic tests as well as privately financed costs, including out-of-pocket expenditures and time devoted to seeking, receiving, and providing care. To determine the cost of care, resources were valued using various costing methods, and multivariate linear regression was used to predict total cost.

Results: Overall, the median monthly cost of care was $1,462 (CDN) per study participant. Ninety-five percent of the total expenditures were privately financed. The final regression model consisted of the following determinants: educational level, employment status, province, pain duration, depression, and health-related quality of life. This model accounted for 35% of the variance in total expenditure (P < 0.001).

Conclusion: The economic burden of chronic pain is substantial in patients on waitlists of MPTFs. Consequently, it is essential to consider this burden when making decisions regarding resource allocation and waitlist assignment for a MPTF. Resource allocation decision-making should include the economic implications of having patients wait for an assessment and for care.
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http://dx.doi.org/10.1007/s12630-010-9306-4DOI Listing
June 2010

The Canadian STOP-PAIN project - Part 1: Who are the patients on the waitlists of multidisciplinary pain treatment facilities?

Can J Anaesth 2010 Jun;57(6):539-48

Centre de recherche du Centre hospitalier de l'Université de Montréal, QC, Canada.

Purpose: The Canadian STOP-PAIN Project assessed the human and economic burden of chronic pain in individuals on waitlists of Multidisciplinary Pain Treatment Facilities (MPTF). This article presents the patients' bio-psycho-social profile.

Methods: A sample of 728 patients was recruited from waitlists of eight university-affiliated MPTFs across Canada. Subjects completed validated questionnaires to: 1) assess the characteristics and impact of their pain; and 2) evaluate their emotional functioning and quality of life (QoL). Follow-up questionnaires were completed by a subgroup of 271 patients three months later.

Results: Close to 2/3 of the participants reported severe pain (> or = 7/10) that interfered substantially with various aspects of their daily living and QoL. Severe or extremely severe levels of depression were common (50.0%) along with suicidal ideation (34.6%). Patients aged > 60 yr were twice as likely to experience severe pain (> or = 7/10) as their younger counterparts (P = 0.002). Patients with frequent sleep problems were more at risk of reporting severe pain (P < or = 0.003). Intense pain was also associated with a greater tendency to catastrophize (P < 0.0001) severe depressive symptoms (P = 0.003) and higher anger levels (P = 0.016). Small but statistically significant changes in pain intensity and emotional distress were observed over a three-month wait time (all P < 0.05).

Conclusion: This study highlights the severe impairment that patients experience waiting for treatment in MPTFs. Knowing that current facilities cannot meet the clinical demand, it is clear that effective prevention/treatment strategies are needed earlier in primary and secondary care settings to minimize suffering and chronicity.
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http://dx.doi.org/10.1007/s12630-010-9305-5DOI Listing
June 2010

Evolution of hospital clinical ethics committees in Canada.

J Med Ethics 2010 Mar;36(3):132-7

School of Nursing, Memorial University of Newfoundland, St John's NL A1B 3V6, Canada.

To investigate the current status of hospital clinical ethics committees (CEC) and how they have evolved in Canada over the past 20 years, this paper presents an overview of the findings from a 2008 survey and compares these findings with two previous Canadian surveys conducted in 1989 and 1984. All Canadian hospitals over 100 beds, of which at least some were acute care, were surveyed to determine the structure of CEC, how they function, the perceived achievements of these committees and opinions about areas with which CEC should be involved. The percentage of hospitals with CEC in our sample was found to be 85% compared with 58% and 18% in 1989 and 1984, respectively. The wide variation in the size of committees and the composition of their membership has continued. Meetings of CEC have become more regularised and formalised over time. CEC continue to be predominately advisory in their nature, and by 2008 there was a shift in the priority of the activities of CEC to meeting ethics education needs and providing counselling and support with less emphasis on advising about policy and procedures. More research is needed on how best to define what the scope of activities of CEC should be in order to meet the needs of hospitals in Canada and elsewhere. More research also is needed on the actual outcomes to patients, families, health professionals and organisations from the work of these committees in order to support the considerable time committee members devote to this endeavour.
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http://dx.doi.org/10.1136/jme.2009.032607DOI Listing
March 2010

Role of health care professionals in multidisciplinary pain treatment facilities in Canada.

Pain Res Manag 2008 Nov-Dec;13(6):484-8

Wasser Pain Management Centre, Mount Sinai Hospital, Department of Anesthesiology, University of Toronto, Toronto, Ontario, Canada.

Purpose: To examine the role of health care professionals in multidisciplinary pain treatment facilities (MPTF) for the treatment of chronic pain across Canada.

Methods: MPTF were defined as clinics that advertised specialized multidisciplinary services for the diagnosis and management of chronic pain, and had staff from a minimum of three different health care disciplines (including at least one medical specialty) available and integrated within the facility. Administrative leaders at eligible MPTF were asked to complete a detailed questionnaire on their infrastructure as well as clinical, research, teaching and administrative activities.

Results: A total of 102 MPTF returned the questionnaires. General practitioners, anesthesiologists and physiatrists were the most common types of physicians integrated in the MPTF (56%, 51% and 32%, respectively). Physiotherapists, psychologists and nurses were the most common nonphysician professionals working within these MPTF (75%, 68% and 57%, respectively), but 33% to 56% of them were part-time staff. Only 77% of the MPTF held regular interdisciplinary meetings to discuss patient management, and 32% were staffed with either a psychologist or psychiatrist. The three most frequent services provided by physiotherapists were patient assessment, individual physiotherapy or exercise, and transcutaneous electrical nerve stimulation. The three most common services provided by psychologists were individual counselling, cognitive behavioural therapy and psychodynamic therapy. The major roles of nurses were patient assessment, assisting in interventional procedures and patient education.

Conclusion: Different health care professionals play a variety of important roles in MPTF in Canada. However, few of them are involved on a full-time basis and the extent to which pain is assessed and treated in a truly multidisciplinary manner is questionable.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2799317PMC
http://dx.doi.org/10.1155/2008/726804DOI Listing
April 2009

Cost of illness for chronic stable angina patients enrolled in a self-management education trial.

Can J Cardiol 2008 Oct;24(10):759-64

Faculty of Nursing, University of Toronto, Toronto, Canada.

Background: Chronic stable angina (CSA) is a major debilitating health problem in Canada. A paucity of relevant cardiovascular data sets has precluded a detailed examination of the impact of interventions on CSA-related costs and its broader economic burden.

Objectives: As part of a larger clinical trial, the authors sought to determine the short-term impact of a standardized self-management training program on CSA-related costs. A secondary objective was to estimate the total annualized cost of CSA per patient from a societal perspective.

Methods: Pre- and three-month post-test cost data were collected on 117 participants using the Ambulatory Home Care Record. Mean annualized direct, indirect and system-related CSA costs (2003 to 2005) were estimated; total per-patient CSA costs from a societal perspective were calculated as the sum of these costs.

Results: The mean (+/- SD) age of participants was 68+/-11 years; 80% were male. The program did not impact costs in the short-term. Direct annual out-of-pocket costs, including money paid for health care, travel to appointments, medication, equipment and home support totaled $3,267. Indirect costs, reflecting the value of all unpaid time spent by those engaged in angina-related care, were $12,963. System costs, including costs paid by public and private insurers, were $2,979. Total estimated annual CSA costs from a societal perspective were $19,209 per patient.

Conclusions: These data suggest that CSA imposes a major economic burden, comparable with other prevalent conditions such as chronic noncancer pain. Advancements in self-management training research are needed to help reduce the economic burden of CSA in Canada.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2643155PMC
http://dx.doi.org/10.1016/s0828-282x(08)70680-9DOI Listing
October 2008

Therapeutic Interactive Voice Response enhanced CBT gains in chronic pain.

Authors:
Sandra M Lefort

Evid Based Nurs 2008 Jul;11(3):79

School of Nursing, Memorial University of Newfoundland, St John's, Newfoundland & Labrador, Canada.

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http://dx.doi.org/10.1136/ebn.11.3.79DOI Listing
July 2008

Randomized controlled trial of a psychoeducation program for the self-management of chronic cardiac pain.

J Pain Symptom Manage 2008 Aug 18;36(2):126-40. Epub 2008 Apr 18.

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

Cardiac pain arising from chronic stable angina (CSA) is a cardinal symptom of coronary artery disease and has a major negative impact on health-related quality of life (HRQL), including pain, poor general health status, and inability to self-manage. Current secondary prevention approaches lack adequate scope to address CSA as a multidimensional ischemic and persistent pain problem. This trial evaluated the impact of a low-cost six-week angina psychoeducation program, entitled The Chronic Angina Self-Management Program (CASMP), on HRQL, self-efficacy, and resourcefulness to self-manage anginal pain. One hundred thirty participants were randomized to the CASMP or three-month wait-list usual care; 117 completed the study. Measures were taken at baseline and three months. General HRQL was measured using the Medical Outcomes Study 36-Item Short Form and the disease-specific Seattle Angina Questionnaire (SAQ). Self-efficacy and resourcefulness were measured using the Self-Efficacy Scale and the Self-Control Schedule, respectively. The mean age of participants was 68 years, 80% were male. Analysis of variance of change scores yielded significant improvements in treatment group physical functioning [F=11.75(1,114), P<0.001] and general health [F=10.94(1,114), P=0.001] aspects of generic HRQL. Angina frequency [F=5.57(1,115), P=0.02], angina stability [F=7.37(1,115), P=0.001], and self-efficacy to manage disease [F=8.45(1,115), P=0.004] were also significantly improved at three months. The CASMP did not impact resourcefulness. These data indicate that the CASMP was effective for improving physical functioning, general health, anginal pain symptoms, and self-efficacy to manage pain at three months and provide a basis for long-term evaluation of the program.
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http://dx.doi.org/10.1016/j.jpainsymman.2007.09.015DOI Listing
August 2008

A responsive evaluation of an Aboriginal nursing education access program.

Nurse Educ 2008 Jan-Feb;33(1):13-7

Centre for Collaborative Health Professional Education, Faculty of Medicine, Health Sciences Centre, St John's, NL, Canada.

Nursing education access programs have been introduced in a number of countries to address the shortage of healthcare providers of Aboriginal descent. An evaluation study of a nursing education access program in Labrador, Canada, was undertaken using a Responsive Evaluation approach. Interviews and focus groups with program stakeholders were conducted. Program effectiveness was influenced by culturally relevant curriculum, experiential and authentic learning opportunities, academic and social support, and the need for partnership building between stakeholders. The authors report key findings resulting from the Responsive Evaluation.
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http://dx.doi.org/10.1097/01.NNE.0000299496.23119.68DOI Listing
March 2008

Dedicated multidisciplinary pain management centres for children in Canada: the current status.

Can J Anaesth 2007 Dec;54(12):985-91

Wasser Pain Management Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario.

Purpose: The objective of this study was to examine the services currently offered by multidisciplinary pain treatment facilities (MPTFs) dedicated for pediatric chronic pain management across Canada.

Methods: A MPTF was defined as a clinic that advertised specialized multidisciplinary services for the diagnosis and management of chronic pain and had a minimum of three different health care disciplines (including at least one medical speciality) available and integrated within the facility. The search method was previously described in an accompanying article. Designated investigators were responsible for confirming and supplementing MPTFs from the preliminary list in their respective provinces. Administrative leads at each eligible MPTF were asked to complete a detailed questionnaire on their infrastructure, clinical, research, teaching and administrative activities. Only MPTFs dedicated to pediatric populations were included.

Results: Only five centres surveyed had dedicated pediatric MPTFs, all located in major cities in five different provinces. While the median wait time was four weeks, it could be as long as nine months in one MPTF. Headache and neuropathic pain were the most commonly treated pain syndromes. All MPTFs included physicians, nurses and psychologists, and used a rehabilitation model that incorporated a wide variety of pharmacological, psychological and physical therapies. All centres provided training for medical and other healthcare professionals, and three of the five centres conducted research. Government funding was the major source of funding for patient services and overhead costs.

Conclusions: There are very few pediatric MPTFs in Canada. These facilities exist in five of ten provinces, each within large urban centres. Limited accessibility leads to variable and prolonged wait times for pediatric patients suffering from chronic pain.
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http://dx.doi.org/10.1007/BF03016632DOI Listing
December 2007

Challenges in accessing multidisciplinary pain treatment facilities in Canada.

Can J Anaesth 2007 Dec;54(12):977-84

Wasser Pain Management Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario.

Purpose: The objective of this survey was to examine the services offered by multidisciplinary pain treatment facilities (MPTFs) across Canada and to compare access to care at these MPTFs.

Methods: A MPTF was defined as a clinic that advertised specialized multidisciplinary services for the diagnosis and management of patients with chronic pain, having a minimum of three different health care disciplines (including at least one medical speciality) available and integrated within the facility. The search method included approaching all hospital and rehabilitation centre administrators in Canada, the Insurance Bureau of Canada, the Workplace Safety and Insurance Board or similar body in each province. Designated investigators were responsible for confirming and supplementing MPTFs from the preliminary list for each province. Administrative leads at each eligible MPTF were asked to complete a detailed questionnaire regarding their MPTF infrastructure, clinical, research, teaching and administrative activities.

Results: Completed survey forms were received from 102 MPTFs (response rate 85%) with 80% concentrated in major cities, and none in Prince Edward Island and the Territories. The MPTFs offer a wide variety of treatments including non-pharmacological modalities such as interventional, physical and psychological therapy. The median wait time for a first appointment in public MPTFs is six months, which is approximately 12 times longer than non-public MPTFs. Eighteen pain fellowship programs exist in Canadian MPTFs and 64% engage in some form of research activities

Conclusion: Canadian MPTFs are unable to meet clinical demands of patients suffering from chronic pain, both in terms of regional accessibility and reasonable wait time for patients' first appointment.
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http://dx.doi.org/10.1007/BF03016631DOI Listing
December 2007

Positive shifts in the perceived meaning of cardiac pain following a psychoeducation program for chronic stable angina.

Can J Nurs Res 2007 Jun;39(2):48-65

Lawrence Bloomberg Faculty of Nursing, University of Toronto, Ontario, Canada.

This study examined the meaning of cardiac pain for chronic stable angina (CSA) patients who participated in a standardized angina psychoeducation program. The patients documented what angina meant to them at sessions 1 and 6 of a 6-week standardized psychoeducation program aimed at enhancing CSA self-management. At session 1, angina was described as a major negative life change characterized by fear, frustration, limitations, and anger. At session 6, angina signified a broad and ongoing pain problem requiring continual self-management in order to maximize quality of life. The findings suggest that the perceived meaning of angina as a burdensome and debilitating life change shifts, during psychoeducation, to one of angina as a broad pain problem requiring ongoing self-management in order to preserve life goals and functioning. How such perceptual shifts in the meaning of cardiac pain might contribute to the overall effectiveness of psychoedcuation warrants further investigation.
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June 2007

Exploring the role of organizational policies and procedures in promoting research utilization in registered nurses.

Implement Sci 2007 Jun 5;2:17. Epub 2007 Jun 5.

Knowledge Utilization Studies Program, Faculty of Nursing, University of Alberta, Edmonton, Alberta T6G 0P2, Canada.

Background: Policies and procedures (P&Ps) have been suggested as one possible strategy for moving research evidence into practice among nursing staff in hospitals. Research in the area of P&Ps is limited, however. This paper explores: 1) nurses' use of eight specific research-based practices (RBPs) and RBP overall, 2) nurses' use and understanding of P&Ps, and 3) the role of P&Ps in promoting research utilization.

Methods: Staff nurses from the eight health regions governing acute care services across the Canadian province of Newfoundland and Labrador completed an anonymous questionnaire regarding their use of eight RBPs and associated P&Ps. Data were also obtained from authorities in six of the eight regions about existing relevant P&Ps. We used descriptive statistics and multivariate regression analysis to assess the relationship between key independent variables and self-reported use of RBP.

Results: Use of the eight RBPs ranged from 7.8% to 88.6%, depending on the practice. Nurses ranked P&P manuals as their number one source of practice knowledge. Most respondents (84.8%) reported that the main reason they consult the P&P manual is to confirm they are practicing according to agency rules. Multivariate regression analysis identified three significant predictors of being a user versus non-user of RBP overall: awareness, awareness by regular use, and persuasion. Six significant predictors of being a consistent versus less consistent user of RBP overall were also identified: perception of P&P existence, unit, nursing experience, personal experience as a source of practice knowledge, number of existing research-based P&Ps, and lack of time as a barrier to consulting P&P manuals.

Conclusion: Findings suggest that nurses use P&Ps to guide their practice. However, the mere existence of P&Ps is not sufficient to translate research into nursing practice. Individual and organizational factors related to nurses' understanding and use of P&Ps also play key roles. Thus, moving research evidence into practice will require careful interplay between the organization and the individual. P&Ps may be the interface through which this occurs.
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http://dx.doi.org/10.1186/1748-5908-2-17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1904235PMC
June 2007

The impact of organizational culture on clinical managers' organizational commitment and turnover intentions.

J Nurs Adm 2007 May;37(5):235-42

School of Nursing and Clinical Epidemiology, Memorial University of Newfoundland, St. John's, NL, Canada.

Objectives: The purpose was to investigate managers' perceptions of organizational culture and attitudinal and behavioral reactions during and after restructuring, and to test a model linking culture to outcome.

Background: Healthcare reform has altered the work environment, but few studies have documented the impact of system changes on managers responsible for clinical services.

Methods: Survey data were collected from clinical managers (N = 104; 99) employed by 3 institutional boards in Newfoundland and Labrador in 2000 and 2002. Response rates were 57.6% and 47.7%, respectively.

Results: For both periods, most variable ratings were in the low range and depicted moderately, positive intercorrelations. Select culture variables, trust, and job satisfaction emerged as significant predictors of commitment. Although culture and trust exerted inconsistent effects on intent, satisfaction remained a predictor over time.

Conclusion: The findings support the negative impact of reform on clinical managers, and the strong link between positive ratings of culture, trust, and satisfaction, and greater commitment and intent to stay. Greater attention should focus on promoting more positive cultures and work-related attitudes, and less turnover intentions.
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http://dx.doi.org/10.1097/01.NNA.0000269741.32513.7fDOI Listing
May 2007

Predictors of registered nurses' organizational commitment and intent to stay.

Health Care Manage Rev 2007 Apr-Jun;32(2):119-27

Clinical Epidemiology Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada.

Background: Health care reform has significantly altered employment relations. Research findings suggest that the presence or absence of supportive work environments helps explain the differences observed in employee attitudes and turnover intentions.

Purposes: The purposes of this study were to examine frontline registered nurses' (RNs') perceptions of organizational culture and attitudes and behaviors and test a model linking culture to outcome (organizational commitment and intent to stay).

Methodology: A non-experimental predictive survey design was used to test the model in a sample (N = 343) of acute care RNs employed in one Canadian province. Data were collected with the following scales: Emotional Climate, Practice Issues, Collaborative Relations, Psychological Contract Violation, General Job Satisfaction, Organizational Commitment Questionnaire, and Intent to Stay.

Findings: The response rate was 29.4%. Most respondents were middle aged and diploma prepared, were in their current positions for 5 years or more, had 10 or more years of nursing experience, and worked full time. Despite moderate levels of job satisfaction, RNs held negative perceptions of culture (emotional climate, practice-related issues, and collaborative relations), trust, and commitment and were unlikely to stay with current employers. Structural equation modeling provided support for the impact of culture, trust, and satisfaction on commitment and partial support for intent to stay, explaining 45 and 31% of the variance, respectively.

Practice Implications: The development and implementation of policies and interventions aimed at creating more supportive work environments and greater trust in employers and job satisfaction have merit. The most obvious benefit from such strategic interventions is the potential for improving RNs' organizational commitment and reducing turnover intentions.
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http://dx.doi.org/10.1097/01.HMR.0000267788.79190.f4DOI Listing
July 2007

Processes of care: comparison between nurse practitioners and physician residents in acute care.

Nurs Leadersh (Tor Ont) 2006 Mar;19(1):69-85

Faculty of Nursing, University of Toronto, ON.

The purpose of this study was to compare the processes of care (performance of role functions, provision of comprehensive care, coordination of services) of acute care nurse practitioners (ACNPs) and physician residents (PRs) assigned to various medical and surgical programs in acute care settings. A cross-sectional comparative design was used. ACNPs (n = 31) and PRs (n = 10) completed the study questionnaire within two weeks of consenting. Patients who received ACNP care (n = 320) and those who received PR care (n = 46) completed the questionnaire within one week of discharge. The results indicate that ACNPs engaged in management and informal coordination activities more than PRs did, while PRs engaged in more formal coordination activities compared to ACNPs. ACNPs encouraged more patient participation in care and provided more patient education than PRs. These findings, which reflect differences in the processes used by ACNPs and PRs to provide care to patients, could influence the quality and cost outcomes expected of these two groups of healthcare providers.
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http://dx.doi.org/10.12927/cjnl.2006.18050DOI Listing
March 2006