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1.  Immigration policy and internationally educated nurses in the United States: A brief history 
Nursing outlook  2013;62(1):39-45.
Since the 1980s, U.S. policy makers have used immigration policy to influence the supply of nurses by allowing or restricting the entry of internationally educated nurses (IENs) into the U.S. workforce. The methods pursued have shifted over time from temporary visa categories in the 1980s and 1990s to permanent immigrant visas in the 2000s. The impact of policy measures adopted during nursing shortages has often been blunted by political and economic events, but the number and representation of IENs in the U.S. nursing workforce has increased substantially since the 1980s. Even as the United States seeks to increase domestic production of nurses, it remains a desirable destination for IENs and a target market for nurse-producing source countries. Hiring organizations and nurse leaders play a critical role in ensuring that the hiring and integration of IENs into U.S. health care organizations is constructive for nurses, source countries, and the U.S. health care system.
doi:10.1016/j.outlook.2013.10.012
PMCID: PMC4351994  PMID: 24345614
Immigration; International educated nurses; Policy
2.  Supporting primary health care nurse practitioners’ transition to practice 
Canadian Family Physician  2010;56(11):1176-1182.
OBJECTIVE
To examine role transition and support requirements for nurse practitioner (NP) graduates in their first year of practice from the perspectives of the NPs and coparticipants familiar with the NPs’ practices; and to make recommendations for practice, education, and policy.
DESIGN
Descriptive qualitative design informed by focused ethnography and narrative analysis using semistructured, in-depth, qualitative interviews.
SETTING
Primary health care (PHC) settings in Ontario in which NPs worked.
PARTICIPANTS
Twenty-three NPs who had graduated from the Ontario Primary Health Care Nurse Practitioner program, and 21 coparticipants including family physicians, NPs, and managers who were familiar with the NPs’ practices.
METHODS
Anglophone and francophone NPs in their first year of practice in PHC settings were contacted by e-mail or letter. Participating NPs nominated colleagues in the workplace who could comment on their practice. Interviews were conducted within the first 3 months, at 6 months, and at 12 months of the NPs’ first year of practice and were transcribed verbatim and coded. Job descriptions and organizational charts demonstrating the NPs’ organization positions were also analyzed. The researchers collaboratively analyzed the interviews using a systematic data analysis protocol.
MAIN FINDINGS
Familiarity of colleagues and employers with the NP role and scope of practice was an important element in successful NP role transition. Lack of preparation for integrating NPs into clinical settings and lack of infrastructure, orientation, mentorship, and awareness of the NP role and needs made the transition difficult for many. One-third of the NPs had changed employment, identifying interprofessional conflict or problems with acceptance of their role in new practice environments as reasons for the change.
CONCLUSION
The transition of NP graduates in Ontario was complicated by the health care environment being ill-prepared to receive them owing to rapid changes in PHC. Strategies for mentorship and for the integration of new NPs into PHC settings are available and need to be implemented by health professionals and administrators. Recommendations for family physicians to support NP graduate transition into practice are provided.
PMCID: PMC2980439  PMID: 21076001
3.  Effects of a Topically Applied Bioadhesive Berry Gel on Loss of Heterozygosity Indices in Premalignant Oral Lesions 
Purpose
The aim of this study was to assess the effects of topical application of a 10% (w/w) freeze-dried black raspberry (FBR) gel on oral intraepithelial neoplasia (IEN) variables that included histologic diagnoses and loss of heterozygosity (LOH) indices. Microsatellite instability and/or LOH at tumor suppressor gene – associated chromosomal loci have been associated with a higher risk for oral IEN progression to oral squamous cell carcinoma. Previously, our laboratories have shown that FBRs are well tolerated and possess potent antioxidant, apoptotic, and differentiation-inducing properties.
Experimental Design
Each participant with IEN served as their own internal control. Before treatment, all lesions were photographed, and lesional tissue was hemisected to obtain a pretreatment diagnosis and baseline biochemical and molecular variables. Gel dosing (0.5 g applied four times daily for 6 weeks) was initiated 1 week after the initial biopsy. Genomic DNA was isolated from laser-captured basilar and suprabasilar surface epithelial cells followed by PCR amplification using primer sets that targeted known and presumed tumor suppressor gene loci associated with INK4a/ARF, p53, and FHIT. Allelic imbalance was determined by sequence analysis using normal participant tissues to establish microsatellite marker peak patterns and allele sizes.
Results
Confirming earlier phase I data, none of the 27 participants developed FBR gel – associated toxicities. Furthermore, our results show histologic regression in a subset of patients as well as statistically significant reduction in LOH at tumor suppressor gene – associated loci.
Conclusions
These preliminary data suggest that further evaluation of berry gels for oral IEN chemoprevention is warranted.
doi:10.1158/1078-0432.CCR-07-4096
PMCID: PMC3498466  PMID: 18413833
4.  Putting the (R) Ural in Preceptorship 
Nursing Research and Practice  2012;2012:528580.
Rural nursing is recognized as a unique health care domain. Within that context, the preceptorship experience is purported to be an important approach to preparing safe and competent rural practitioners. Preceptorship is the one-to-one pairing of a nursing student with a professional nurse who assumes the mandate of teacher and role model in a designated clinical/contextual setting, in this case the rural setting. A research gap exists in the literature in which rural preceptorship is specifically explored. The purpose of this paper is to review preceptorship in relation to preparing nursing students specifically for the rural setting. Understanding how preceptorship as an educational model can prepare nursing students to transition to rural practice is an important endeavor. An authentic rural preceptorship may serve to influence the recruitment and retention needs for registered nurses in rural areas. A greater understanding of rural preceptorship serves to illustrate the appropriate support, socialization and contextual competence required to prepare nursing students for rural nursing practice. This paper's review may serve to highlight the research that currently exists related to rural preceptorship and where additional research can contribute to further understanding and development for authentic rural nursing preparation.
doi:10.1155/2012/528580
PMCID: PMC3368593  PMID: 22693664
5.  Two types of isolated epileptic nystagmus: case report 
Epileptic nystagmus (EN) is a quick, repetitive jerky movement of the eyeball caused by seizure activity, unaccompanied by other ictal phenomena rare. Here, we described two cases, one characterized by binocular and the other by monocular isolated epileptic nystagmus (IEN), and we identified the characteristics of the etiology, clinical manifestations, electroencephalogram, imaging, treatment and prognosis in epileptic nystagmus through reviewing literature. We found IEN occurs more frequently in children than in adults. Etiological factors included trauma, cerebral vascular disease, tumor, and anoxia. The frequency of IEN was high, which varied from several to hundreds of times per day, and the duration of it was usually less than 1 minute. EN and its subtypes, such as epileptic monocular nystagmus, vertical epileptic nystagmus, epileptic skew deviation, periodic alternating nystagmus, and partial oculo-clonic status, are rare. The fast phase of the nystagmus was contralateral to the epileptogenic zone in most cases. Periodic lateralized epileptiform discharges (PLEDs) is a distinct EEG pattern in EN. Our findings suggested that the occipital lobe may plays a key role in the origin of EN.
PMCID: PMC4612972  PMID: 26550287
Epilepsy; nystagmus; electroencephalogram; etiology; clinical manifestations
6.  Pigmented squamous intraepithelial neoplasia of the esophagus 
Squamous cell carcinoma (SCC) usually lacks melanocytes within the tumor. A few reports have documented invasive SCC or SCC in situ (intraepithelial neoplasia, IEN) with melanocytic hyperplasia within the tumor, referred to as pigmented SCC, in some organs. However, case series of pigmented SCC or IEN of the esophagus have not yet been reported. This is the first study to analyze the incidence and clinicopathological features of pigmented SCC or IEN of the esophagus. We reviewed 18 surgically-resected and 122 endoscopically-resected esophageal specimens, including 79 cases of IEN. Three cases of pigmented IEN were observed in this series, and all of them were located in the middle to lower third of the esophagus. Two of 3 cases had melanocytosis in the non-neoplastic squamous epithelium around the IEN. The incidence of pigmented IEN was 2.5% of all endoscopically resected specimens and 3.8% of IEN cases. No pigmented invasive SCC was detected in both endoscopically-resected and surgically-resected specimens. The mechanism of pigmentation of esophageal IEN is unknown. However, production of melanocyte chemotactic factors by tumor cells has been demonstrated in pigmented SCC of the oral mucosa. Moreover, two of 3 cases of pigmented IEN in the present series had melanocytosis in the non-neoplastic squamous epithelium, and melanocytosis is thought to be associated with chronic esophagitis, therefore, it has been hypothesized that various stimuli can cause pigmentation in squamous epithelium. Additional studies are needed to clarify the mechanism of pigmentation in squamous IEN of the esophagus.
PMCID: PMC3759494  PMID: 24040452
Intraepithelial squamous neoplasia; squamous cell carcinoma; esophagus; melanocytes
7.  A methodological systematic review of what’s wrong with meta-ethnography reporting 
Background
Syntheses of qualitative studies can inform health policy, services and our understanding of patient experience. Meta-ethnography is a systematic seven-phase interpretive qualitative synthesis approach well-suited to producing new theories and conceptual models. However, there are concerns about the quality of meta-ethnography reporting, particularly the analysis and synthesis processes. Our aim was to investigate the application and reporting of methods in recent meta-ethnography journal papers, focusing on the analysis and synthesis process and output.
Methods
Methodological systematic review of health-related meta-ethnography journal papers published from 2012–2013. We searched six electronic databases, Google Scholar and Zetoc for papers using key terms including ‘meta-ethnography.’ Two authors independently screened papers by title and abstract with 100% agreement. We identified 32 relevant papers. Three authors independently extracted data and all authors analysed the application and reporting of methods using content analysis.
Results
Meta-ethnography was applied in diverse ways, sometimes inappropriately. In 13% of papers the approach did not suit the research aim. In 66% of papers reviewers did not follow the principles of meta-ethnography. The analytical and synthesis processes were poorly reported overall. In only 31% of papers reviewers clearly described how they analysed conceptual data from primary studies (phase 5, ‘translation’ of studies) and in only one paper (3%) reviewers explicitly described how they conducted the analytic synthesis process (phase 6). In 38% of papers we could not ascertain if reviewers had achieved any new interpretation of primary studies. In over 30% of papers seminal methodological texts which could have informed methods were not cited.
Conclusions
We believe this is the first in-depth methodological systematic review of meta-ethnography conduct and reporting. Meta-ethnography is an evolving approach. Current reporting of methods, analysis and synthesis lacks clarity and comprehensiveness. This is a major barrier to use of meta-ethnography findings that could contribute significantly to the evidence base because it makes judging their rigour and credibility difficult. To realise the high potential value of meta-ethnography for enhancing health care and understanding patient experience requires reporting that clearly conveys the methodology, analysis and findings. Tailored meta-ethnography reporting guidelines, developed through expert consensus, could improve reporting.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2288-14-119) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2288-14-119
PMCID: PMC4277825  PMID: 25407140
Meta-ethnography; Systematic review; Qualitative health research; Reporting; Qualitative synthesis; Health; Evidence-based practice
8.  Exploring the characteristics of nursing agencies in South Africa 
Global Health Action  2015;8:10.3402/gha.v8.27878.
Background
Nursing agencies are temporary employment service providers or labour brokers that supply nurses to health establishments.
Objective
This study was conducted to determine the characteristics of nursing agencies and their relationship with clients in the health sector.
Methods
During 2011, a cross-sectional national survey of 106 nursing agencies was conducted. After obtaining informed consent, telephone interviews were conducted with a representative of the selected nursing agency using a pretested structured questionnaire. Questions focused on the following: ownership, date of establishment, province of operation, distribution of clients across private and public health facilities; existence of a code of conduct; nature of the contractual relationship between nursing agencies and their clients, and numbers and cadres of nurses contracted. The survey data were analysed using STATA® 12.
Results
Fifty-two nursing agencies participated in the survey, representing a 49% response rate. The study found that 32 nursing agencies (62%) served private-sector clients only, which included private hospitals, homes for elderly people, patients in private homes, and private industry/company clinics, and only four (8%) of the agencies served the public sector only. Twenty-seven percent of nursing agencies provided services to homes for elderly individuals. Nursing agencies were more likely to have contracts with private-sector clients (84%) than with public-sector clients (16%) (p = 0.04). Although 98% of nursing agencies reported that they had a code of conduct, the proportion was higher for private-sector clients (73%) compared to public-sector clients (27%). In terms of quality checks and monitoring, 81% of agencies agreed with a statement that they checked the nursing council registration of nurses, 82% agreed with a statement that they requested certified copies of a nurse's qualifications. Only 21% indicated that they conducted reference checks of nurses with their past employers.
Conclusions
Nursing agencies should enhance their quality assurance mechanisms when engaging contracted staff. Overall, the study findings suggest the need for improved governance and management of nursing agencies in South Africa.
doi:10.3402/gha.v8.27878
PMCID: PMC4430690  PMID: 25971401
nursing agency; nurses; labour broker; health workforce; South Africa
9.  The process of community health nursing clinical clerkship: A grounded theory 
Background:
The performance of the community health nurse depends on a combination of scientific and practical competencies acquired by educational experiences during the nursing course. Curriculum planners of nursing education need to understand nursing education to train professional and community-oriented nurses. The aim of this article is to explore the experiences of nursing students during their community health nursing clinical clerkship courses.
Materials and Methods:
A grounded theory approach was used to conduct this study. Twelve nursing students, 13 health-care staff members, and 10 nursing instructors were interviewed individually in 2011-2012. The interviews were tape-recorded and later transcribed verbatim. The transcriptions were analyzed using the method of Strauss and Corbin.
Results:
Ambivalence of motivation was the main category and included five subcategories: Professional identity, educational atmosphere, educational management, motivation-based approaches, and inadequate productivity. This paper presents the aspects of the community health nursing clerkship course from the viewpoint of students in areas such as the role of the community health nurse, attitude toward the course, medical orientation, prerequisite skills/knowledge, poor administrative planning, rotation of students, insufficient activity for students, passiveness, providing service to clients, responsibility, and inproductivity. These categories could explain the nature of the community health nursing clerkship of the Mashhad Faculty of Nursing and probably others in Iran.
Conclusions:
The findings revealed inadequate productivity of the community health nursing education; so, it is suggested to define a position for nurses in this setting and remove barriers and provide conditions for them to play more important roles in the promotion of community health.
PMCID: PMC3917128  PMID: 24554943
Clinical clerkship; community health; grounded theory; Iran; nursing students
10.  Programmed cell death 4 (PDCD4) expression during multistep Barrett's carcinogenesis 
Journal of Clinical Pathology  2010;63(8):692-696.
Aim
To test the contribution of programmed cell death 4 (PDCD4) tumour suppressor gene in Barrett's carcinogenesis.
Methods
PDCD4 immunohistochemical expression was assessed in 88 biopsy samples obtained from histologically proven long-segment Barrett's mucosa (BM; 25 non-intestinal columnar metaplasia, 25 intestinal metaplasia (IM), 16 low-grade intraepithelial neoplasia (LG-IEN), 12 high-grade IEN (HG-IEN) and 10 Barrett's adenocarcinoma (BAc)). As controls, 25 additional samples of native oesophageal mucosa (N) were obtained from patients with dyspepsia. To further support the data, the expression levels of miR-21, an important PDCD4 expression regulator, in 14 N, 5 HG-IEN and 11 BAc samples were determined by quantitative real-time PCR analysis.
Results
PDCD4 immunostaining decreased progressively and significantly with the progression of the phenotypic changes occurring during Barrett's carcinogenesis (p<0.001). Normal basal squamous epithelial layers featured strong PDCD4 nuclear immunoreaction (mostly coexisting with weak–moderate cytoplasmic staining). Non-intestinal columnar metaplasia and intestinal metaplasia preserved a strong nuclear immunostaining; conversely, a significant decrease in PDCD4 nuclear expression was seen in dysplastic (LG-IEN and HG-IEN) and neoplastic lesions. Weak–moderate cytoplasmic immunostaining was evident in cases of LG-IEN, while HG-IEN and BAc samples showed weak cytoplasmic or no protein expression. As expected, miR-21 expression was significantly upregulated in HG-IEN and BAc samples, consistently with PDCD4 dysregulation.
Conclusions
These data support a significant role for PDCD4 downregulation in the progression of BM to BAc, and confirm miR-21 as a negative regulator of PDCD4 in vivo. Further efforts are needed to validate PDCD4 as a potential prognostic marker in patients with Barrett's oesophagus.
doi:10.1136/jcp.2010.078253
PMCID: PMC2976066  PMID: 20702469
Barrett's oesophagus; immunohistochemistry; oesophageal cancer; PDCD4; tumour markers; tumour suppressor gene
11.  Intestinal Edema: Effect of enteral feeding on motility and gene expression 
The Journal of surgical research  2008;155(2):283-292.
Objective
Edema formation, inflammation and ileus in the intestine are commonly seen in conditions like gastroschisis, inflammatory bowel disease and cirrhosis. We hypothesized that early enteral feeding would improve intestinal transit. We also wanted to study the impact of early enteral feeding on global gene expression in the intestine.
Design
Rats were divided into Sham or Edema ± immediate enteral nutrition (IEN). At 12 hrs, small intestinal transit via FITC-Dextran and tissue water were measured. Ileum was harvested for total RNA to analyze gene expression using cDNA microarray with validation using real-time PCR. Data are expressed as mean ± SEM, n=4-6 and *, ** = p < 0.05 vs. all groups using ANOVA.
Results
IEN markedly improved intestinal transit with minimal genetic alterations in Edema animals. Major alterations in gene expression were detected in primary, cellular and macromolecular metabolic activities. Edema also altered more genes involved with the regulation of the actin cytoskeleton.
Conclusions
Intestinal edema results in impaired small intestinal transit and globally increased gene expression. Early enteral nutrition improves edema-induced impaired transit and minimizes gene transcriptional activity.
doi:10.1016/j.jss.2008.08.040
PMCID: PMC3774532  PMID: 19482297
intestinal edema; ileus; enteral feeding; micorarray
12.  Protocol-developing meta-ethnography reporting guidelines (eMERGe) 
Background
Designing and implementing high-quality health care services and interventions requires robustly synthesised evidence. Syntheses of qualitative research studies can provide evidence of patients’ experiences of health conditions; intervention feasibility, appropriateness and acceptability to patients; and advance understanding of health care issues. The unique, interpretive, theory-based meta-ethnography synthesis approach is suited to conveying patients’ views and developing theory to inform service design and delivery. However, meta-ethnography reporting is often poor quality, which discourages trust in, and use of, meta-ethnography findings. Users of evidence syntheses require reports that clearly articulate analytical processes and findings. Tailored research reporting guidelines can raise reporting standards but none exists for meta-ethnography. This study aims to create an evidence-based meta-ethnography reporting guideline articulating the methodological standards and depth of reporting required to improve reporting quality.
Methods/design
The mixed-methods design of this National Institute of Health Research-funded study (http://www.stir.ac.uk/emerge/) follows good practice in research reporting guideline development comprising: (1) a methodological systematic review (PROSPERO registration: CRD42015024709) to identify recommendations and guidance in conducting/reporting meta-ethnography; (2) a review and audit of published meta-ethnographies to identify good practice principles and develop standards in conduct/reporting; (3) an online workshop and Delphi studies to agree guideline content with 45 international qualitative synthesis experts and 45 other stakeholders including patients; (4) development and wide dissemination of the guideline and its accompanying detailed explanatory document, a report template for National Institute of Health Research commissioned meta-ethnographies, and training materials on guideline use.
Discussion
Meta-ethnography, devised in the field of education, is now used widely in other disciplines. Methodological advances relevant to meta-ethnography conduct exist. The extent of discipline-specific adaptations of meta-ethnography and the fit of any adaptions with the underpinning philosophy of meta-ethnography require investigation. Well-reported meta-ethnography findings could inform clinical decision-making. A bespoke meta-ethnography reporting guideline is needed to improve reporting quality, but to be effective potential users must know it exists, trust it and use it. Therefore, a rigorous study has been designed to develop and promote a guideline. By raising reporting quality, the guideline will maximise the likelihood that high-quality meta-ethnographies will contribute robust evidence to improve health care and patient outcomes.
doi:10.1186/s12874-015-0068-0
PMCID: PMC4660777  PMID: 26606922
Reporting guideline; Meta-ethnography; Qualitative review or synthesis; Qualitative research; Evidence-based practice; Systematic review
13.  Applying a typology of health worker migration to non-EU migrant doctors in Ireland 
Background
Research on health worker migration in the Irish context has categorized migrant health workers by country or region of training (for example, non-EU nurses or doctors) or recruitment mechanism (for example, actively recruited nurses). This paper applies a new typology of health worker migrants – livelihood, career-oriented, backpacker, commuter, undocumented and returner migrants (European Observatory on Health Systems and Policies and WHO, vol. 2:129-152, 2014) – to the experiences of non-EU migrant doctors in Ireland and tests its utility for understanding health worker migration internationally.
Methods
The paper draws on quantitative survey (N = 366) and qualitative interview (N = 37) data collected from non-EU migrant doctors in Ireland between 2011 and 2013.
Results
Categorizing non-EU migrant doctors in Ireland according to the typology (European Observatory on Health Systems and Policies and WHO, vol. 2:129-152, 2014) offers insight into their differing motivations, particularly on arrival. Findings suggest that the career-oriented migrant is the most common type of doctor among non-EU migrant doctor respondents, accounting for 60 % (N = 220) of quantitative and 54 % (N = 20) of qualitative respondents. The authors propose a modification to the typology via the addition of two additional categories – the family migrant and the safety and security migrant.
Conclusions
Employing a typology of health worker migration can facilitate a more comprehensive understanding of the migrant medical workforce, a necessary prerequisite for the development of useful policy tools (European Observatory on Health Systems and Policies and WHO, vol. 2:129-152, 2014). The findings indicate that there is some fluidity between categories, as health worker motivations change over time. This indicates the potential for policy levers to influence migrant health worker decision-making, if they are sufficiently “tuned in” to migrant health worker motivation.
doi:10.1186/s12960-015-0042-2
PMCID: PMC4488134  PMID: 26111814
Doctor migration; Migration typology; Medical workforce planning; Health workforce planning; Health human resources for health
14.  Adolescent Work Experience and Self-efficacy 
Purpose of this paper
To assess the relationship between high school work experiences and self-efficacy.
Design/methodology/approach
OLS regressions are applied to longitudinal data from the Youth Development Study to examine work experiences and self-efficacy.
Findings
The analyses indicate that employment fosters self-efficacy in multiple realms, Occasional and sporadic workers exhibit less self-efficacy than steady workers. Supervisory support may be especially important in enhancing adolescents’ confidence as they anticipate their future family lives, community participation, personal health, and economic achievements.
Research limitations/Implications
This research includes only a small set of the work dimensions that may be important for adolescents. Ethnography and in-depth interviews are recommended to further explore the subjective and emotional dimensions of youth work experiences.
Practical implications
In developing policies and guidance, educators, parents, and employers should be aware that steady employment and supervisory support enhance the development of adolescent self-efficacy.
Original value of paper
This paper finds evidence that adolescent work experiences spill over to influence youth’s developing confidence in the realms of family life, community and personal health. It also suggests that sporadic and occasional work patterns can impair the development of self-efficacy in adolescence.
doi:10.1108/01443330910947534
PMCID: PMC2742471  PMID: 19750144
self-efficacy; adolescence; employment; work quality
15.  The role and significance of nurses in managing transitions to palliative care: a qualitative study 
BMJ Open  2014;4(9):e006026.
Objectives
Nurses are generally present, and often influential, in supporting patient and family acceptance of medical futility and in assisting doctors in negotiating referral to palliative care. Yet the specificities of the nursing role and how nurses may contribute to timely and effective referrals is not well understood. This study aimed to systematically explore hospital-based nurses’ accounts of the transition to palliative care, and the potential role of nurses in facilitating more effective palliative care transitions.
Design
Qualitative study using semistructured interviews.
Setting
Two health services with public as well as private clinical environments in a major metropolitan area of Australia.
Participants
Hospital-based nurses (n=20) who regularly work with patients at the point of referral and in managing transitions to palliative care.
Results
Four significant themes emerged from thematic analysis. These include: (1) professional dynamics and the roles played by nurses in initiating the transition to palliative care; (2) the value of nurses’ informal interactions in timely and effective transitions; (3) the emerging challenge of managing task-oriented nursing versus intense emotional nursing work at the point of medical futility and (4) the emotional burden experienced by nurses within this clinical context. Nurses self-reported occupying critical albeit complex roles in the management of medical futility and the transition to palliative care. They reported experiencing significant emotional burden in balancing interpersonal and interprofessional relationships during this time.
Conclusions
The results suggest that nurses may be utilised in a more formalised and systematic fashion in the context of managing medical futility and the need to topicalise the transition, with the focus shifted away from medical referrals towards more team-based and patient-centred timely transitions. Further research focused on the experiences of doctors, allied health professionals, patients and families is required to provide a broader interdisciplinary understanding of futility and contributions to the negotiation of palliative care.
doi:10.1136/bmjopen-2014-006026
PMCID: PMC4179576  PMID: 25270859
QUALITATIVE RESEARCH; PALLIATIVE CARE
16.  Nurse-patient communication in primary care diabetes management: an exploratory study 
BMC Nursing  2013;12:20.
Background
Diabetes is a major health issue for individuals and for health services. There is a considerable literature on the management of diabetes and also on communication in primary care consultations. However, few studies combine these two topics and specifically in relation to nurse communication. This paper describes the nature of nurse-patient communication in diabetes management.
Methods
Thirty-five primary health care consultations involving 18 patients and 10 nurses were video-recorded as part of a larger multi-site study tracking health care interactions between health professionals and patients who were newly diagnosed with Type 2 diabetes. Patients and nurses were interviewed separately at the end of the 6-month study period and asked to describe their experience of managing diabetes. The analysis used ethnography and interaction analysis.
In addition to analysis of the recorded consultations and interviews, the number of consultations for each patient and total time spent with nurses and other health professionals were quantified and compared.
Results
This study showed that initial consultations with nurses often incorporated completion of extensive checklists, physical examination, referral to other health professionals and distribution of written material, and were typically longer than consultations with other health professionals. The consultations were driven more by the nurses’ clinical agenda than by what the patient already knew or wanted to know. Interactional analysis showed that protocols and checklists both help and hinder the communication process. This contradictory outcome was also evident at a health systems level: although organisational targets may have been met, the patient did not always feel that their priorities were attended to. Both nurses and patients reported a sense of being overwhelmed arising from the sheer volume of information exchanged along with a mismatch in expectations.
Conclusions
Conscientious nursing work was evident but at times misdirected in terms of optimal use of time. The misalignment of patient expectations and clinical protocols highlights a common dilemma in clinical practice and raises questions about the best ways to balance the needs of individuals with the needs of a health system. Video- recording can be a powerful tool for reflection and peer review.
doi:10.1186/1472-6955-12-20
PMCID: PMC3856446  PMID: 24028348
17.  Community health nurses’ learning needs in relation to the Canadian community health nursing standards of practice: results from a Canadian survey 
BMC Nursing  2014;13:31.
Background
Canadian Community health nurses (CHNs) work in diverse urban, rural, and remote settings such as: public health units/departments, home health, community health facilities, family practices, and other community-based settings. Research into specific learning needs of practicing CHNs is sparsely reported. This paper examines Canadian CHNs learning needs in relation to the 2008 Canadian Community Health Nursing Standards of Practice (CCHN Standards). It answers: What are the learning needs of CHNs in Canada in relation to the CCHN Standards? What are differences in CHNs’ learning needs by: province and territory in Canada, work setting (home health, public health and other community health settings) and years of nursing practice?
Methods
Between late 2008 and early 2009 a national survey was conducted to identify learning needs of CHNs based on the CCHN Standards using a validated tool.
Results
Results indicated that CHNs had learning needs on 25 of 88 items (28.4%), suggesting CHNs have confidence in most CCHN Standards. Three items had the highest learning needs with mean scores > 0.60: two related to epidemiology (means 0.62 and 0.75); and one to informatics (application of information and communication technology) (mean = 0.73). Public health nurses had a greater need to know about “…evaluating population health promotion programs systematically” compared to home health nurses (mean 0.66 vs. 0.39, p <0.010). Nurses with under two years experience had a greater need to learn “… advocating for healthy public policy…” than their more experienced peers (p = 0.0029). Also, NPs had a greater need to learn about “…using community development principles when engaging the individual/community in a consultative process” compared to RNs (p = 0.05). Many nurses were unsure if they applied foundational theoretical frameworks (i.e., the Ottawa Charter of Health Promotion, the Jakarta Declaration, and the Population Health Promotion Model) in practice.
Conclusions
CHN educators and practice leaders need to consider these results in determining where to strengthen content in graduate and undergraduate nursing programs, as well as professional development programs. For practicing CHNs educational content should be tailored based on learner’s years of experience in the community and their employment sector.
doi:10.1186/1472-6955-13-31
PMCID: PMC4209163  PMID: 25349531
Community health nursing; Learning needs; Standards of practice; Professional education; Continuing education; Undergraduate education; Nursing education
18.  Sociocultural and linguistic boundaries influencing intercultural communication between nurses and Moroccan patients in southern Spain: a focused ethnography 
BMC Nursing  2013;12:14.
Background
During the last 25 years, cultural diversity has increased substantially with global migration. In more recent years this has become highly evident in the south of Spain with its steadily increasing Moroccan population. The accompanying differences in ethnocultural values and traditions between the host and newcomer populations may greatly impact healthcare interactions and thus also effective provision of care. This landscape provides for excellent exploration of intercultural communication in healthcare settings and elucidation of possible ways to overcome existing barriers to provision of culturally competent care by nurses. This study aimed to ascertain how nurses perceive their intercultural communication with Moroccan patients and what barriers are evident which may be preventing effective communication and care.
Methods
A focused ethnography was conducted with semi-structured interviews of 32 nurses in three public hospitals in southern Spain. Interviews were audio-recorded and transcribed verbatim before undergoing translation and back-translation between Spanish and English. Data was managed, classified and ordered with the aid of AQUAD.6 (Günter L. Huber, Tübingen, Germany) qualitative data analysis software.
Results
As an important dimension of cultural competence, findings from the interviews with nurses in this study were interpreted within the framework of intercultural communication. Various barriers, for which we have termed “boundaries”, seem to exist preventing effective communication between nurses and their patients. The substantial language barrier seems to negatively affect communication. Relations between the nurses and their Moroccan patients are also marked by prejudices and social stereotypes which likely compromise the provision of culturally appropriate care.
Conclusions
The language barrier may compromise nursing care delivery and could be readily overcome by implementation of professional interpretation within the hospital settings. Moreover, it is essential that the nurses of southern Spain are educated in the provision of culturally appropriate and sensitive care.
doi:10.1186/1472-6955-12-14
PMCID: PMC3669007  PMID: 23705680
Intercultural communication; Cultural competency in nursing; Immigration in Spain; Moroccan immigrants
19.  A Comprehensive Medical Education Program Response to Rural Primary Care Needs 
This article presents the characteristics and results of the Rural Medical Education (RMED) Program which addresses medical workforce needs focused on reducing rural health disparities. The program is comprehensive in implementing a system of recruitment of candidates from rural backgrounds, offering a rural-focused curriculum, and instituting evaluative components to track outcomes. Distinctive program features include a Recruitment and Retention Committee of rural community members; special rural-focused topics and events during the first three years of undergraduate medical education; and a required fourth-year, 16-week rural preceptorship through which students work with primary care physicians and conduct community-oriented primary care projects.
Since 1993, 216 students have matriculated. More than three quarters of candidates interviewed received offers into the program (overall acceptance rate of 75%). Comparisons between RMED and all other students on composite MCAT scores and United States Medical Licensing Examination (USMLE) Part 1 scores show a slightly lower MCAT average for RMED students, but USMLE scores are equal to those of non-RMED students. To date, 159 students have graduated, with 76% entering primary care residencies; 103 are currently in practice, with 64.4% in primary care practice in small towns and/or rural communities. RMED Program outcomes compare favorably with those of other rural medical education programs.
RMED can serve as a model at many levels, including recruitment, collaboration, curriculum, and retention. Future challenges for program development and disparity reduction include recruiting students from the growing number of rural minority populations, expanding the number of program slots, and integrating the program with other health professions to address the needs of rural populations.
doi:10.1097/ACM.0b013e3181850a02
PMCID: PMC3740530  PMID: 18820528
20.  'One patient amongst many': a qualitative analysis of intensive care unit patients' experiences of transferring to the general ward 
Critical Care  2008;12(1):R21.
Introduction
Many patients experience 'relocation stress' when they are transferred from an intensive care unit (ICU) to step-down (high dependency) or general ward care, and much has been written about the psychological causes. This qualitative analysis of in-depth, narrative interviews with former ICU patients explores and examines patients' accounts in order to identify additional causes of relocation stress.
Methods
Forty former ICU patients were recruited throughout the UK, using maximum variation sampling, to achieve a broad range of experiences of intensive care. Interviews in people's homes were recorded on video and audio equipment as part of a study for the Database of Personal Experiences of Health and Illness (DIPEx) web resource. All interviews were transcribed, checked and returned to respondents. For this report, a qualitative thematic analysis was used to explore experiences of transfer.
Results
We found that most people experienced relocation distress not only because of physical and emotional difficulties relating to their illness and treatment and the inevitable anxiety resulting from leaving a protected environment, but also from concrete, practical causes. These included specific concerns about communication, feeding, nursing care and support, as well as ward organization and environment. Written excerpts from the interviews and two video excerpts taken from the DIPEx website illustrate our findings.
Conclusion
We conclude that there are several aspects of care that deserve further examination by researchers and service providers, and that not all of the factors associated with relocation stress should be seen as an inevitable consequence of the psychological adjustment involved in transfer from an ICU.
doi:10.1186/cc6795
PMCID: PMC2374598  PMID: 18294370
21.  Registered nurses in Israel - workforce employment characteristics and projected supply 
Background
Surveys of nursing supplies around the world have furnished a better understanding of the structure of the workforce, helped identify shortages, and plan professional training. This study aimed to examine the employment and workforce characteristics of registered nurses and the projected supply in Israel as a tool for planning.
Methods
1. A survey of a national sample of 10% of the RNs of working age (3,200 nurses). 2. Analysis of administrative data from the Ministry of Health' Nursing Division and the Central Bureau of Statistics.
Results
Most registered nurses are employed (89%) - 67% work full time. The workforce is mature (45% are above 45), trained (55% qualified beyond the basic course, 48% hold a BA, 18% hold an MA or PhD), and stable: few quit the profession altogether. The likelihood of "survival" in the profession after 10 years is 93%; after 20 years - 88%. 23% have made some transition in the last 10 years (most - a single transition). Most of the transitions are from hospital to community work. Supply projections show a decrease in the total number of RNs in the nursing workforce from 28,500 in 2008 to 21,201 in 2028 - i.e., of 25% by the end of the period. As for the ratio per 1,000 population, the drop is from 4 registered nurses/1,000 in 2008 to 2/1,000 in 2028.
Conclusions
The study findings provide more rigorous projections of supply than in the past on the declining rates of the nursing workforce in the coming decades, and contribute to decision making about the scope of training and recruitment. The study also points to the implications for policy decisions regarding the findings that the young nursing workforce is less stable, that there are advantages to recruiting a more mature workforce, and that post-basic education is connected with workforce stability.
doi:10.1186/2045-4015-1-11
PMCID: PMC3424825  PMID: 22913612
22.  Supporting work practices through telehealth: impact on nurses in peripheral regions 
Background
In Canada, workforce shortages in the health care sector constrain the ability of the health care system to meet the needs of its population and of its health care professionals. This issue is of particular importance in peripheral regions of Quebec, where significant inequalities in workforce distribution between regions has lead to acute nursing shortages and increased workloads. Information and communication technologies (ICTs) are innovative solutions that can be used to develop strategies to optimise the use of available resources and to design new nursing work practices. However, current knowledge is still limited about the real impact of ICTs on nursing recruitment and retention. Our aim is to better understand how work practice reorganization, supported by ICTs, and particularly by telehealth, may influence professional, educational, and organizational factors relating to Quebec nurses, notably those working in peripheral regions.
Methods/Design
First, we will conduct a descriptive study on the issue of nursing recruitment. Stratified sampling will be used to select approximately twenty innovative projects relating to the reorganization of work practices based upon ICTs. Semi-structured interviews with key informants will determine professional, educational, and organizational recruitment factors. The results will be used to create a questionnaire which, using a convenience sampling method, will be mailed to 600 third year students and recent graduates of two Quebec university nursing faculties. Descriptive, correlation, and hierarchical regression analyses will be performed to identify factors influencing nursing graduates' intentions to practice in peripheral regions. Secondly, we will conduct five case studies pertaining to the issue of nursing retention. Five ICT projects in semi-urban, rural, and isolated regions have been identified. Qualitative data will be collected through field observation and approximately fifty semi-structured interviews with key stakeholders.
Discussion
Data from both parts of this research project will be jointly analysed using triangulation of researchers, theoretical approaches, methods, and results. Continuous exchanges with decision makers and periodic knowledge transfer activities are planned to facilitate the dissemination and utilization of research results in policies regarding the nursing recruitment and retention.
doi:10.1186/1472-6963-11-27
PMCID: PMC3040127  PMID: 21294882
23.  Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors 
Executive Summary
In early August 2007, the Medical Advisory Secretariat began work on the Aging in the Community project, an evidence-based review of the literature surrounding healthy aging in the community. The Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the ministry’s newly released Aging at Home Strategy.
After a broad literature review and consultation with experts, the secretariat identified 4 key areas that strongly predict an elderly person’s transition from independent community living to a long-term care home. Evidence-based analyses have been prepared for each of these 4 areas: falls and fall-related injuries, urinary incontinence, dementia, and social isolation. For the first area, falls and fall-related injuries, an economic model is described in a separate report.
Please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html, to review these titles within the Aging in the Community series.
Aging in the Community: Summary of Evidence-Based Analyses
Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors: An Evidence-Based Analysis
Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors: An Evidence-Based Analysis
Caregiver- and Patient-Directed Interventions for Dementia: An Evidence-Based Analysis
Social Isolation in Community-Dwelling Seniors: An Evidence-Based Analysis
The Falls/Fractures Economic Model in Ontario Residents Aged 65 Years and Over (FEMOR)
Objective
To assess the effectiveness of behavioural interventions for the treatment and management of urinary incontinence (UI) in community-dwelling seniors.
Clinical Need: Target Population and Condition
Urinary incontinence defined as “the complaint of any involuntary leakage of urine” was identified as 1 of the key predictors in a senior’s transition from independent community living to admission to a long-term care (LTC) home. Urinary incontinence is a health problem that affects a substantial proportion of Ontario’s community-dwelling seniors (and indirectly affects caregivers), impacting their health, functioning, well-being and quality of life. Based on Canadian studies, prevalence estimates range from 9% to 30% for senior men and nearly double from 19% to 55% for senior women. The direct and indirect costs associated with UI are substantial. It is estimated that the total annual costs in Canada are $1.5 billion (Cdn), and that each year a senior living at home will spend $1,000 to $1,500 on incontinence supplies.
Interventions to treat and manage UI can be classified into broad categories which include lifestyle modification, behavioural techniques, medications, devices (e.g., continence pessaries), surgical interventions and adjunctive measures (e.g., absorbent products).
The focus of this review is behavioural interventions, since they are commonly the first line of treatment considered in seniors given that they are the least invasive options with no reported side effects, do not limit future treatment options, and can be applied in combination with other therapies. In addition, many seniors would not be ideal candidates for other types of interventions involving more risk, such as surgical measures.
Note: It is recognized that the terms “senior” and “elderly” carry a range of meanings for different audiences; this report generally uses the former, but the terms are treated here as essentially interchangeable.
Description of Technology/Therapy
Behavioural interventions can be divided into 2 categories according to the target population: caregiver-dependent techniques and patient-directed techniques. Caregiver-dependent techniques (also known as toileting assistance) are targeted at medically complex, frail individuals living at home with the assistance of a caregiver, who tends to be a family member. These seniors may also have cognitive deficits and/or motor deficits. A health care professional trains the senior’s caregiver to deliver an intervention such as prompted voiding, habit retraining, or timed voiding. The health care professional who trains the caregiver is commonly a nurse or a nurse with advanced training in the management of UI, such as a nurse continence advisor (NCA) or a clinical nurse specialist (CNS).
The second category of behavioural interventions consists of patient-directed techniques targeted towards mobile, motivated seniors. Seniors in this population are cognitively able, free from any major physical deficits, and motivated to regain and/or improve their continence. A nurse or a nurse with advanced training in UI management, such as an NCA or CNS, delivers the patient-directed techniques. These are often provided as multicomponent interventions including a combination of bladder training techniques, pelvic floor muscle training (PFMT), education on bladder control strategies, and self-monitoring. Pelvic floor muscle training, defined as a program of repeated pelvic floor muscle contractions taught and supervised by a health care professional, may be employed as part of a multicomponent intervention or in isolation.
Education is a large component of both caregiver-dependent and patient-directed behavioural interventions, and patient and/or caregiver involvement as well as continued practice strongly affect the success of treatment. Incontinence products, which include a large variety of pads and devices for effective containment of urine, may be used in conjunction with behavioural techniques at any point in the patient’s management.
Evidence-Based Analysis Methods
A comprehensive search strategy was used to identify systematic reviews and randomized controlled trials that examined the effectiveness, safety, and cost-effectiveness of caregiver-dependent and patient-directed behavioural interventions for the treatment of UI in community-dwelling seniors (see Appendix 1).
Research Questions
Are caregiver-dependent behavioural interventions effective in improving UI in medically complex, frail community-dwelling seniors with/without cognitive deficits and/or motor deficits?
Are patient-directed behavioural interventions effective in improving UI in mobile, motivated community-dwelling seniors?
Are behavioural interventions delivered by NCAs or CNSs in a clinic setting effective in improving incontinence outcomes in community-dwelling seniors?
Assessment of Quality of Evidence
The quality of the evidence was assessed as high, moderate, low, or very low according to the GRADE methodology and GRADE Working Group. As per GRADE the following definitions apply:
Summary of Findings
Executive Summary Table 1 summarizes the results of the analysis.
The available evidence was limited by considerable variation in study populations and in the type and severity of UI for studies examining both caregiver-directed and patient-directed interventions. The UI literature frequently is limited to reporting subjective outcome measures such as patient observations and symptoms. The primary outcome of interest, admission to a LTC home, was not reported in the UI literature. The number of eligible studies was low, and there were limited data on long-term follow-up.
Summary of Evidence on Behavioural Interventions for the Treatment of Urinary Incontinence in Community-Dwelling Seniors
Prompted voiding
Habit retraining
Timed voiding
Bladder training
PFMT (with or without biofeedback)
Bladder control strategies
Education
Self-monitoring
CI refers to confidence interval; CNS, clinical nurse specialist; NCA, nurse continence advisor; PFMT, pelvic floor muscle training; RCT, randomized controlled trial; WMD, weighted mean difference; UI, urinary incontinence.
Economic Analysis
A budget impact analysis was conducted to forecast costs for caregiver-dependent and patient-directed multicomponent behavioural techniques delivered by NCAs, and PFMT alone delivered by physiotherapists. All costs are reported in 2008 Canadian dollars. Based on epidemiological data, published medical literature and clinical expert opinion, the annual cost of caregiver-dependent behavioural techniques was estimated to be $9.2 M, while the annual costs of patient-directed behavioural techniques delivered by either an NCA or physiotherapist were estimated to be $25.5 M and $36.1 M, respectively. Estimates will vary if the underlying assumptions are changed.
Currently, the province of Ontario absorbs the cost of NCAs (available through the 42 Community Care Access Centres across the province) in the home setting. The 2007 Incontinence Care in the Community Report estimated that the total cost being absorbed by the public system of providing continence care in the home is $19.5 M in Ontario. This cost estimate included resources such as personnel, communication with physicians, record keeping and product costs. Clinic costs were not included in this estimation because currently these come out of the global budget of the respective hospital and very few continence clinics actually exist in the province. The budget impact analysis factored in a cost for the clinic setting, assuming that the public system would absorb the cost with this new model of community care.
Considerations for Ontario Health System
An expert panel on aging in the community met on 3 occasions from January to May 2008, and in part, discussed treatment of UI in seniors in Ontario with a focus on caregiver-dependent and patient-directed behavioural interventions. In particular, the panel discussed how treatment for UI is made available to seniors in Ontario and who provides the service. Some of the major themes arising from the discussions included:
Services/interventions that currently exist in Ontario offering behavioural interventions to treat UI are not consistent. There is a lack of consistency in how seniors access services for treatment of UI, who manages patients and what treatment patients receive.
Help-seeking behaviours are important to consider when designing optimal service delivery methods.
There is considerable social stigma associated with UI and therefore there is a need for public education and an awareness campaign.
The cost of incontinent supplies and the availability of NCAs were highlighted.
Conclusions
There is moderate-quality evidence that the following interventions are effective in improving UI in mobile motivated seniors:
Multicomponent behavioural interventions including a combination of bladder training techniques, PFMT (with or without biofeedback), education on bladder control strategies and self-monitoring techniques.
Pelvic floor muscle training alone.
There is moderate quality evidence that when behavioural interventions are led by NCAs or CNSs in a clinic setting, they are effective in improving UI in seniors.
There is limited low-quality evidence that prompted voiding may be effective in medically complex, frail seniors with motivated caregivers.
There is insufficient evidence for the following interventions in medically complex, frail seniors with motivated caregivers:
habit retraining, and
timed voiding.
PMCID: PMC3377527  PMID: 23074508
24.  Liver–Intestine-Cadherin Is a Sensitive Marker of Intestinal Differentiation During Barrett’s Carcinogenesis 
Digestive Diseases and Sciences  2012;58(3):699-705.
Background
Histopathologic differentiation between the stages of Barrett’s carcinogenesis is often challenging. Liver–intestine (LI)-cadherin, an intestine-specific marker, is involved in intestinal metaplasia development in gastric and colon cancers and could be of value in diagnosis and differentiation.
Aims
To examine the expression of LI-cadherin in the sequence of Barrett’s carcinogenesis and to evaluate its association with clinicopathological data.
Methods
LI-cadherin expression was immunohistologically investigated, by use of anti-CDH17 antibody, in gastric mucosa (GM) biopsies taken from the cardia (n = 9), in Barrett’s esophagus (BE) without intraepithelial neoplasia (without IEN) (n = 9) and BE with low-grade IEN (n = 11), and in esophageal adenocarcinoma (ADC) (n = 13).
Results
The immunoreactivity score was highest in adenocarcinoma (mean IRS = 4.0), and dropped gradually from BE with IEN and BE without IEN (mean IRS = 2.0) to cardia mucosa (IRS = 0). Similarly, the intensity of staining and the percentage of positive cells increased during the sequential stages of BE carcinogenesis. Comparative analysis showed that LI-cadherin expression was significantly different between cardiac epithelium and ADC. Also, percentage of positive cells in GM was significantly different from that in BE with IEN. LI-cadherin IRS was lower for tumors with poor differentiation than for moderately differentiated tumors, but the difference was not statistically significant.
Conclusions
LI-cadherin is a sensitive marker of intestinal metaplasia and can be helpful for early histologic diagnosis of Barrett’s esophagus; it is, however, not significantly different between BE with and without IEN, and cannot be used to distinguish between these.
doi:10.1007/s10620-012-2425-8
PMCID: PMC3616226  PMID: 23053896
LI-cadherin; Barrett’s esophagus; Esophageal adenocarcinoma; Intestinal metaplasia; Intraepithelial neoplasia
25.  Intense parenting: a qualitative study detailing the experiences of parenting children with complex care needs 
BMC Pediatrics  2015;15:197.
Background
Increased numbers of children with chronic illnesses and/or disabilities who have complex care needs are living at home. Along with the transfer of care to the home setting, parents assume the primary responsibility of their child’s complex care needs. Accordingly, it becomes even more important to understand the evolving roles and challenges faced by parents of children with complex care needs in order to better support them. The aim of this paper is to present research findings that add to our understanding of the roles parents assume in parenting their children with complex care needs.
Methods
To arrive at a detailed and accurate understanding of families’ perspectives and experiences, the qualitative research design of ethnography was used. In total, 68 parents from 40 families were recruited. Data collection strategies included ethnographic methods of interviewing and photovoice. Several levels of analysis generated a sociocultural theme with subthemes representing how parents experienced raising children with complex care needs within the context of their life situations.
Results
Intense parenting as the overarching theme refers to the extra efforts parents had to commit to in raising their children with complex care needs. Parenting was described as labour-intensive, requiring a readiness to provide care at any time. This left parents with minimal time for addressing any needs and tasks not associated with caring for their child. The main theme is supported by four sub-themes: 1) the good parent; 2) more than a nurse; 3) there’s just not enough; 4) it takes a toll on the health of parents.
Conclusions
Overall, parents of children with complex care needs take on more roles as well as work more intensely at these roles than parents of healthy children. This, in turn, has led to the need for additional supports and resources for parents. However, to date, parents of children with complex care needs are still lacking adequate services and supports necessary to help them in their role of intense parenting. The findings sensitize professionals to the issues confronted by parents caring for children with complex care needs. Implications for further research and clinical practice are discussed.
doi:10.1186/s12887-015-0514-5
PMCID: PMC4660805  PMID: 26611116
Parents; Children; Complex care needs; Qualitative research; Photovoice

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