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Canadians are living longer with multiple complex illnesses. In turn, older adults are often in need of complex medical attention in crisis situations in acute care hospital settings. Although acute care settings are equipped with a growing variety of life saving technologies, hospitals are still the setting in which most people die. Yet, almost half of the Canadians who have been admitted to acute care centres with chronic life-limiting illnesses have not had advance care planning (ACP) conversations with their substitute decision-maker (SDM) about the personal values that bring quality to their lives. In fact, only 8% of the general Canadian population are ACP ready. Consequently, many SDMs are unprepared to make end of life (EOL) treatment decisions for their loved ones. One way to promote patient-centred care and ease the burden of in-the-moment EOL treatment decisions made by SDMs, is for nurses to engage their patients in ACP. However, very few registered nurses regularly engage their patients in ACP. The purpose of this research is to better understand the organizational factors influencing nurses’ decisions related to ACP in their hospital-based work. This ethnographic study was conducted on three acute care wards in two hospital sites located in Northern Ontario. Data collection methods included observational fieldwork, semi-structured interviews with administrators and registered nurses (n=23), and the collection of documents pertinent to the study purpose (i.e., accreditation reports, practice guidelines, etc.). Findings reveal that the work of nurses in hospital settings is embedded within a context that prioritizes patient flow, and efficiency. Consequently, hospitals often function at overcapacity, and nurses have extremely heavy workloads caring for complex patients with diagnoses that do not match the medical specialty of the units. Although participants state that they value ACP, they maintain that nurses have very little capacity to engage patients in these conversations in their practice. Findings support that expectations for hospital nurses to fully engage in ACP with their patients may be unrealistic given the context within which they work. Alternative models for considering ACP in acute care could be explored to ensure that patients with life-limiting conditions receive care that is best matched to their needs, values, and wishes. / Graduate

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This project describes the development of a curriculum for a certificate programme in Advanced Cardiac Care for Registered Nurses, developed for implementation at a large urban community college. The author describes the process of curriculum development undertaken and presents the actual curriculum designed. The implementation of one module is presented to demonstrate that the teaching of factual knowledge and skills can be integrated with the higher level skills of problem solving. An evaluation of the implementation of the module is also presented. Throughout this project emphasis is placed on educational theory and on the practising health professional as the learner. / Thesis / Master of Science (Teaching)

Background Population aging has led to an increasing number of older adults living in the community with complex care needs such as functional limitations, cognitive impairment, and multimorbidity. These individuals may need help to remain in their homes, which has created a growing demand for home care. Strategies to manage complex older adults such as home care patients safely in the community typically emphasize robust and integrated primary care. The objective of this thesis is to explore how specific measures of quality in primary care are associated with emergency department use among home care patients in Ontario. Methods I conducted four studies on varying subsets of the same population-based retrospective cohort of long-stay home care patients assessed in Ontario from 2014-2016. The first study was a descriptive examination of the entire cohort that characterized their primary care and other health system use. The second was a case-crossover study among home nursing patients examining whether access to afterhours care modifies the association between home nursing visits and same-day emergency department visits. The third study looked at physician-level provision of primary care home visits and its association with emergency department visits among home care patients with extensive functional impairments. The final study examined and compared associations between continuity of primary and specialty physician care. Results Long-stay home care patients in Ontario are high users of both primary care and the emergency department. Better access to afterhours care reduced the likelihood of an emergency department visit on the same day as a home nursing visit. Patients with extensive functional impairments whose primary care physician who provided higher levels of home visits had lower rates of emergency department use. Finally, better continuity of both primary and specialty physician care were similarly associated with lower emergency department use. Conclusion Better quality primary care integrated with other sectors of the health system is crucial to enabling home care patients to age safety in the community. Access to care is particularly important and can be improved though enhancing the availability of afterhours care and increasing the provision of home visits for those who have difficulty reaching primary care offices. Improving continuity of specialty physician care should be a health system objective alongside improving continuity of primary care. / Thesis / Doctor of Philosophy (PhD) / Older adults receiving home care are a growing population of individuals with complex care needs and high rates of emergency department use. This thesis seeks to characterize the primary care use of home care patients in Ontario and examine to what degree better quality of primary care is associated with less use of the emergency department. My findings indicate that increased access to afterhours primary care, higher levels of primary care home visits, and better continuity of both primary and specialty physician care were associated fewer emergency department visits. In conjunction with other sectors, primary care plays a central role managing older adults with complex care needs in the community. Better quality of primary care, particularly advanced access, can help keep older adults safely at home and out of hospitals as they age.

No / The community care reforms enabled some older people with severe disabilities to remain at home with domiciliary care services, as an alternative to institutional admission. This paper explores the extent to which the reforms actually enabled older people receiving domiciliary care to have greater choice and control in their daily lives than older people living in institutions. Findings are reported from a comparative study carried out in Greater Belfast, Northern Ireland, that determined the extent to which the subjective quality of life of older people--particularly autonomy--varied according to the type of setting. The older people were interviewed using a structured interview schedule and subjective autonomy was assessed using a measure of perceived choice. The measure consisted of 33 activities relating to aspects of everyday life such as what time to get up, when to see visitors or friends, and how much privacy was available. Qualitative data were also recorded which informed on the older people's perspectives on their own lives, particularly the extent to which they exercised choice on a daily basis. Two-hundred and fourteen residents in 45 residential and nursing homes were interviewed, as were 44 older people receiving domiciliary care in private households. The study found that older people living in institutions perceived themselves to have greater decisional autonomy in their everyday lives than did older people receiving domiciliary care. Indeed, it was clear that living at home did not ensure that one's decisional autonomy would be supported. However, living alone may facilitate exercising a relatively higher degree of autonomy when living at home. Whilst the community care reforms have provided some older people who have severe disabilities with the option of receiving care at home, this has not necessarily enabled them to have greater choice and control in their everyday lives than older people admitted to institutions.

No / Care homes play a major role in supporting people with dementia at the end of their lives. Seeking to understand the views of staff on the care they provide, Nicola Wheeler and Jan R Oyebode held focus groups with a range of staff in nine care homes in the West Midlands. Here they discuss their findings and implications for practice.

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No / Wound healing remains a largely overlooked area despite the perceived large numbers of people with wounds and the high costs of treatment. The lack of visibility for wounds and wound healing may in part stem from the fragmented nature of the available data on wound occurrence often limited to descriptions of specific wound types within single care settings. A survey was undertaken across all care providers serving the population of Bradford, UK to identify the number of people with wounds, the characteristics of their wounds and the allocated interventions used to prevent and heal wounds. In March 2007, 1735 completed questionnaires were returned each marking the most severe wound experienced by a patient. The overall prevalence of wounds was 3.55 people with wounds per 1000 population (prevalence 0.355% 95% CI 0.33–0.37%). Almost one third (n = 556) of the people with wounds were located in acute care settings with the remainder spread across several community locations including residential and nursing homes. The most prevalent forms of wound were acute wounds (n = 826) followed by leg ulcers (n = 482) and pressure ulcers (n = 363). A previous survey with broadly similar methodology had shown a lower prevalence of wounds (0.279% 95% CI 0.26–0.29%) with this difference perhaps explained by different data collection methodologies within the nursing home sector that resulted in a 100% return compared with 50% in the earlier survey.