Search

Rationale: The evidentiary standards and epistemic models of clinical care, especially those of evidence‐based medicine, are dissimilar to those used in philosophy and examination of how the two systems intersect may help clinicians make more informed treatment decisions. Aims and Objectives: This paper examines the use of ethical frameworks in routine clinical decision‐making, using the example of acute stroke treatment decisions to demonstrate that ethical evaluation is integral to clinical practice. Method: Utilising acute stroke care as a lens through which to examine the phenomenon of ethical evaluation in medical practice, we offer a philosophical analysis of the presence of ethical evaluation in medicine. Results and Conclusion: We find that the medical establishment should embrace ethical evaluation as intrinsic to medical practice and that medical training and treatment guidelines should reflect this reality. Patients deserve clarity and transparency about how physicians make determinations about their treatment, and physicians should be prepared to offer explanations for those decisions. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Occupational Therapy is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The aim of this paper is to illuminate findings of disclosure experiences for youth living with chronic illness using a non-categorical approach. The findings were derived from a larger qualitative study framed by social constructivist grounded theory that sought to understand youth's involvement in healthcare decision-making in the context of chronic illness. Fifty-four youth participated in the study, ranging from 9 to 24 years. Three main themes representing the youth's perspectives and experiences of disclosing chronic illness were identified: (1) disclosure is central to the illness experience; (2) spectrum of disclosure; and (3) navigating others' reactions to disclosure. The findings reinforce that more emphasis on decisions related to disclosing illness in research and clinical care for youth with chronic conditions is warranted. [ABSTRACT FROM AUTHOR]

Background: In this paper we assess the quality of six deliberative stakeholder consultations regarding the implementation of a precision diagnostic for life-threatening pediatric brain tumors. Decision makers who base policy recommendations on the outputs of consultative exercises can presuppose that all deliberants are well informed of the policy issue, that participation in the deliberative process was fair, and that overcoming implementation barriers will necessarily result in practice change. Additional evidence is therefore needed to substantiate the informational quality of the deliberation, measure the equality of participation and study the effects on stakeholder reasoning to appropriately guide uptake of proposed recommendation(s). Methods: Using the DeVries framework for assessing the deliberative quality, we analyzed data from 44 post-consultation evaluation surveys completed by pediatric oncology and palliative care teams at two tertiary pediatric healthcare centers in Canada. We also conducted turn-taking and word-contribution analyses from the text transcriptions of each deliberation to assess equality of participation using descriptive statistics. Results: Deliberants agreed the quality of the deliberative process was fair (median ratings ranging from 9–10 out of 10) and the opportunities to receive expert information and discuss with others about the implementation of a new LDT were helpful (9.5 out of 10). While the session improved understanding of the implementation barriers and opportunities, it had marginal effects on deliberants' reasoning about whether LDTs would change their own clinical practice (3–10 out of 10). Participation was proportionate in at least four of the six deliberations, where no deliberant took more than 20% of total turns and contributed equal to, or less than 20% of total words. Conclusion: The quality assessment we performed demonstrates high informational value and perceived fairness of two deliberative stakeholder consultations involving pediatric palliative care and oncology teams in Canada. Quality assessments can reveal how the process of deliberation unfolds, whether deliberative outputs are the result of equitable participation among deliberants and what, if any, stakeholder voices may be missing. Such assessments should be routinely reported as a condition of methodological rigor and trustworthiness of deliberative stakeholder engagement research. [ABSTRACT FROM AUTHOR]

Evidence-informed health policy making (EIHP) is becoming a necessary means to achieving health system reform. Although Canada has a rich and well documented history in the field of evidence-basedmedicine, a concerted effort to capture Canada's efforts to support EIHP in particular has yet to be realized. This paper reports on the development of EIHP in Canada, including promising approaches being used to support the use of evidence in policy making about complex health systems issues. In light of Canada's contributions, this paper suggests that scholars in Canada will continue engaging in the field of EIHP through further study of interventions underway, as well as by sharing knowledge within and beyond Canada's borders about approaches that support EIHP. [ABSTRACT FROM AUTHOR]

This paper draws on three studies conducted in Australia, Canada and Ireland which explore the factors influencing research utilisation in the child protection sector in each country. The paper recognises that research uptake is complicated by a number of factors. It also acknowledges critiques which cite the equally significant influence of ideologies, context, unpredictability, time constraints and political expediency. However, all three studies recognised the increasing importance of evidence-based practice. The methods used in the three studies were not identical but the frameworks used were sufficiently similar to enable the classification of both common and dissimilar barriers and facilitators to research use. Those which they identified were categorised into four types: individual, organisational, environmental and characteristics relating to the nature of research material. Implications were identified for policy makers, service providers and research producers. The point was made that we now live in a period where unprecedented means of knowledge transfer and exchange provide unique opportunities to improve the lives of children and families. Copyright © 2013 John Wiley & Sons, Ltd. Key Practitioner Messages Avail of opportunities to attend learning events., Draw on research findings when conducting assessments, writing reports, devising intervention plans, evaluating programmes and tendering for funding., Establish links with research centres., Become involved in the conduct of research., Support colleagues (champions) who display particular interest and motivation in the use of research evidence by recognising and/or rewarding effort., Avail of opportunities to undertake further study that includes a research component. [ABSTRACT FROM AUTHOR]

Editorial. Highlights the topics discussed at the International Conference on Treatment Decision-Making in the Clinical Encounter held in Hamilton, Ontario. Type and amount of involvement that patients want in treatment decision-making; Different physician communication styles; Different approaches to treatment decision-making; Roles of patients and physicians in treatment decision-making.

This paper considers some of the policy implications of issues raised during a conference about treatment decision-making in the clinical encounter held in Hamilton, Ontario in May 1999. Policies promoting patient participation in treatment decision-making need to be flexible enough to ensure that they are appropriate across the range of contexts in which health care decisions are made and acceptable to people with diverse preferences and abilities. They should also be formulated in consideration of other health policies and of available resources. Policies of informing people and involving them in decisions about their care are unlikely to be simple to implement. Various strategies might be needed to support them. These include the development of appropriate skills among health professionals and in the general population, the use of interventions to encourage people to play more active roles in decisions about their health care, the provision of decision aids for people facing specific decisions and the provision and accreditation of more general information resources and services. If information and other facilitators of patient participation in decision-making are seen as integral to good quality health care, then funding should be made available for them. This will, however, have opportunity costs. Policy makers’ decisions about how much health care funding should be invested in which strategies should be underpinned by good research evidence about the effects that different types of intervention have on a range of outcomes for individuals, health care systems and populations. The knowledge on which current policies are based is limited. The development of future policies will be enhanced if policy makers invest in critical conceptual thinking, reflective practice, imaginative development work and good quality evaluative research. [ABSTRACT FROM AUTHOR]

Purpose:In this paper we examine how the intersection of various social and political influences shapes discharge planning and rehabilitation practices in ways that may not meet the espoused aims of rehabilitation programs or the preferences of older adults and their families. Methods:Taking a critical bioethics perspective, we used microethnographic case study methods to examine discharge-planning processes in a well-established older adult inpatient rehabilitation setting in Canada. The data included observations of discharge-planning family conferences and semi-structured interviews conducted with older adults facing discharge, their family members and rehabilitation professionals involved in discharge planning. Results:From the time of admission, a contextual push to focus on discharge superseded program aims of providing interventions to increase older adults’ functional capabilities. Professionals’ primary commitment to safety limited consideration of discharge options and resulted in costly and potentially unnecessary recommendations for 24-hour care. The resulting “rehabilitation” stay was more akin to an extended process of “destination triage” biased towards the promotion of physical safety than optimizing functioning. Conclusions:The resulting reduction of rehabilitation into “destination triage” has significant social, financial and occupational implications for older adults and their families, and broader implications for healthcare services and overarching healthcare systems. Implications for RehabilitationCurrent trends promoting consideration of discharge planning from the point of admission and prioritizing physical safety are shifting the focus of rehabilitation away from interventions to maximize recovery of function, which are the stated aims of rehabilitation.Such practices furthermore promote assessments to determine prognosis early in the rehabilitation stay when accurate prognosis is difficult, which can lead to overly conservative recommendations for discharge from rehabilitation services, thus further negating the impact of rehabilitation.Further work is required to examine the social, occupational and functional implications of superseding rehabilitation interventions to maximize capabilities with practices that prioritize safety over quality of life for older adults and their family members. [ABSTRACT FROM PUBLISHER]

This paper explores a grey area of psychiatric practice and, as with other challenging practices, the law is called upon to navigate conflicting legal issues. In particular, this paper explores the covert administration of medication: the concealment of medication in food or drink so that it will be consumed undetected. Rights-based approaches support nuanced understanding of the practices. Few policies, protocols or guidelines govern the practice in Ontario's psychiatric settings. While covert medication is understood to have "something to do" with rights, there is confusion about how those rights play out on the ground. Institutional silences underlie and reinforce the practice. Most pressing, the covert administration of medication warrants an overt discussion, including of its impact on the rights-experience of persons in psychiatric settings. [ABSTRACT FROM AUTHOR]

Studying patients during the end of life is important, as it has the potential to lead to improvements in care for the dying. For patients who die after a controlled withdrawal of life-sustaining therapies in the intensive care unit, information about the natural history of death and the process of removing life support has additionally led to advances in practice for deceased organ donation. However, this unique population of severely critically ill and imminently dying patients has been difficult to study, largely due to assumptions made by research teams and ethics boards alike about the logistical difficulties of obtaining consent and completing research procedures before or during the process of withdrawal of life-sustaining therapies. In this paper, we describe the ethics substudy of the first prospective observational research study in Canada to obtain consent and collect clinical data on patients during the process of withdrawal of life-sustaining therapies in the intensive care unit. We describe in detail the process of protocol development, review by five institutional research ethics boards and bedside staff satisfaction with the study. We conclude that prospective research on a critically ill and imminently dying population is feasible and can be conducted in an ethical manner. Further information is needed about the experiences and motivations of families and substitute decision makers who provide consent for research on critically ill intensive care unit patients at the end of life. [ABSTRACT FROM AUTHOR]

Background. Exercise is recommended for people with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), yet there is little information to guide safe and effective mobilization and exercise for these patients. Objectives. The purpose of this study was to develop a clinical decision-making tool to guide health care professionals in the assessment, prescription, monitoring, and progression of mobilization and therapeutic exercise for patients with AECOPD. Design and Methods. A 3-round interdisciplinary Delphi panel identified and selected items based on a preselected consensus of 80%. These items were summarized in a paper-based tool titled Mobilization in Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD-Mob). Focus groups and questionnaires were subsequently used to conduct a sensibility evaluation of the tool. Results. Nine researchers, 13 clinicians, and 7 individuals with COPD identified and approved 110 parameters for safe and effective exercise in AECOPD. These parameters were grouped into 5 categories: (1) "What to Assess Prior to Mobilization," (2) "When to Consider Not Mobilizing or to Discontinue Mobilization," (3) "What to Monitor During Mobilization for Patient Safety," (4) "How to Progress Mobilization to Enhance Effectiveness," and (5) "What to Confirm Prior to Discharge." The tool was evaluated in 4 focus groups of 18 health care professionals, 90% of whom reported the tool was easy to use, was concise, and would guide a health care professional who is new to the acute care setting and working with patients with AECOPD. Limitations. The tool was developed based on published evidence and expert opinion, so the applicability of the items to patients in all settings cannot be guaranteed. The Delphi panel consisted of health care professionals from Canada, so items may not be generalizable to other jurisdictions. Conclusions. The AECOPD-Mob provides practical and concise information on safe and effective exercise for the AECOPD population for use by the new graduate or novice acute care practitioner. [ABSTRACT FROM AUTHOR]

Increases in age, acuity and co-morbidities within the population of persons with kidney disease have made it essential that renal replacement therapies and associated treatments are evidence-based, effective and consistent. Additionally, the need exists to offer treatment option advice that is transparent and unbiased, for both consumers and health care professionals. These imperatives require guidance by principles that are recommended within a uniformly accepted framework. Written in notated point-form, this paper aims to explain why guidelines are important, and to highlight the advantages of referring to clinical guidelines, through an overview of the Kidney Health Australia — Caring for Australasians with Renal Impairment (KHA-CARI) Guidelines, as they stand within local and global contexts. [ABSTRACT FROM AUTHOR]

Introduction: Cardiovascular complications can occur in oncology patients secondary to certain cancer therapies. Pharmacists are involved in the care of oncology patients who are at risk of or experiencing cardiotoxicity related to their cancer therapy. Our study aimed to understand how pharmacists in Canada care to these patients and to explore their experiences, perceptions, and challenges. Methods: Canadian pharmacists currently involved in the care of patients receiving cancer treatments and at risk of or experiencing cardiotoxicity were invited to participate in a 30-min telephone interview using an interview guide. A combination of inductive and deductive reasoning was applied using two coders who independently reviewed the transcribed interviews and identified key concepts and themes. Results: Eight pharmacists were interviewed. Perceived benefits included sharing specialized knowledge and conducting safety assessments. Perceived challenges were the lack of role recognition and resources and fractured continuity of care. Proposed future directions were to play a more substantial role in direct medication management, creation of specific guidance and tools to support the clinical decision-making process, and to understand how pharmacists at other sites were providing care through the creation of a community of practice. Conclusions: As patient-focused medication specialists, pharmacists help guide clinical decision-making, assess cardiac risk factors, and offer individualized education to meet the holistic needs of oncology patients at risk of or experiencing cardiotoxicities. The creation of a cardio-oncology community of practice may allow pharmacists with a common interest to connect, share learnings, and collaborate on how to continue to advance the delivery of care. [ABSTRACT FROM AUTHOR]

Background: We sought to identify innovative navigation programs across Canadian jurisdictions that target their services to individuals affected by life-limiting illness and their families, and articulate the principal components of these programs that enable them to address the needs of their clients who are living in the community. Methods: This realist evaluation used a two-phased approach. First, we conducted a horizon scan of innovative community-based navigation programs across Canadian jurisdictions to identify innovative community-based navigation programs that aim to address the needs of community-dwelling individuals affected by life-limiting illness. Second, we conducted semi-structured interviews with key informants from each of the selected programs. Informants included individuals responsible for managing and delivering the program and decision-makers with responsibility and/or oversight of the program. Analyses proceeded in an iterative manner, consistent with realist evaluation methods. This included iteratively developing and refining Context-Mechanism-Outcome (CMO) configurations, and developing the final program theory. Results: Twenty-seven navigation programs were identified from the horizon scan. Using specific eligibility criteria, 11 programs were selected for subsequent interviews and in-depth examination. Twenty-three participants were interviewed from these programs, which operated in five Canadian provinces. The programs represented a mixture of community (non-profit or volunteer), research-initiated, and health system programs. The final program theory was articulated as: navigation programs can improve client outcomes if they have supported and empowered staff who have the time and flexibility to personalize care to the needs of their clients. Conclusions: The findings highlight key principles (contexts and mechanisms) that enable navigation programs to develop client relationships, personalize care to client needs, and improve client outcomes. These principles include staff (or volunteer) knowledge and experience to coordinate health and social services, having a point of contact after hours, and providing staff (and volunteers) time and flexibility to develop relationships and respond to individualized client needs. These findings may be used by healthcare organizations – outside of navigation programs – to work towards more person-centred care. [ABSTRACT FROM AUTHOR]

BackgroundPatients require information to make informed decisions and consent to medical treatment. Shared decision making (SDM) is a methodology that promotes a patient-centred approach to informed consent and demonstrates respect for autonomyPurposeThe purpose of this paper is to critically review the legal and ethical issues relevant to Canadian and UK informed consent and SDM practices and how these processes relate to current palliative care practices, with a particular emphasis on radiation therapy.MethodologyA review of the English literature from 2003 to 2013 was performed using the databases PubMed (NML), OVID Medline and Google Scholar.Results and ConclusionsThe literature identifies that palliative cancer patients desire the opportunity to be involved with decision-making discussions, which has shown to increase knowledge and result in better health-related outcomes. However, ethical and legal issues regarding the practicality of including this patient population in SDM discussions raises questions about validity of consent. For SDM to be considered a valid methodology to obtain informed consent, open and honest communication between the patient and multidisciplinary team is essential. Treatment options for palliative cancer patients are often complex and SDM allows healthcare professionals and patients to exchange information and negotiate feasible treatment options based on medical expertise and patient preferences.Legal frameworks have defined current standards of practice for various healthcare professions, including radiation therapy. Radiation therapists, as members of the multidisciplinary team, are currently key contributors in providing information to patients regarding the radiotherapy process. Individuals working within advanced practice roles have the ability to develop skills once considered to be within medical domains and have begun to incorporate the delegated act of obtaining informed consent into practice which has shown to increase professional autonomy, accountability and improves patient-centred care. [ABSTRACT FROM AUTHOR]

Hermeneutics, also referred to as interpretive phenomenology, has led to important contributions to nursing research. The philosophy of Charles Taylor has been a major source in the development of contemporary hermeneutics, through his ontological and epistemological articulations of the human sciences. The aim of this paper is to demonstrate that Taylor's ideas can further enrich hermeneutic inquiry in nursing research, particularly for investigations of ethical concerns. The paper begins with an outline of Taylor's hermeneutical framework, followed by a review of his key ideas relevant for ethics research. The paper ends with a discussion of my empirical research with critically ill children in Canada and France in relation to Taylor's ideas, chiefly Social Imaginaries. I argue that Taylor's hermeneutics provides a substantive moral framework as well as a methodology for examining ethical concerns. [ABSTRACT FROM AUTHOR]

Background: Evidence informed decision making in health policy development and clinical practice depends on the availability of valid and reliable data. The introduction of interRAI assessment systems in many countries has provided valuable new information that can be used to support case mix based payment systems, quality monitoring, outcome measurement and care planning. The Continuing Care Reporting System (CCRS) managed by the Canadian Institute for Health Information has served as a data repository supporting national implementation of the Resident Assessment Instrument (RAI 2.0) in Canada for more than 15 years. The present paper aims to evaluate data quality for the CCRS using an approach that may be generalizable to comparable data holdings internationally. Methods: Data from the RAI 2.0 implementation in Complex Continuing Care (CCC) hospitals/units and Long Term Care (LTC) homes in Ontario were analyzed using various statistical techniques that provide evidence for trends in validity, reliability, and population attributes. Time series comparisons included evaluations of scale reliability, patterns of associations between items and scales that provide evidence about convergent validity, and measures of changes in population characteristics over time. Results: Data quality with respect to reliability, validity, completeness and freedom from logical coding errors was consistently high for the CCRS in both CCC and LTC settings. The addition of logic checks further improved data quality in both settings. The only notable change of concern was a substantial inflation in the percentage of long term care home residents qualifying for the Special Rehabilitation level of the Resource Utilization Groups (RUG-III) case mix system after the adoption of that system as part of the payment system for LTC. Conclusions: The CCRS provides a robust, high quality data source that may be used to inform policy, clinical practice and service delivery in Ontario. Only one area of concern was noted, and the statistical techniques employed here may be readily used to target organizations with data quality problems in that (or any other) area. There was also evidence that data quality was good in both CCC and LTC settings from the outset of implementation, meaning data may be used from the entire time series. The methods employed here may continue to be used to monitor data quality in this province over time and they provide a benchmark for comparisons with other jurisdictions implementing the RAI 2.0 in similar populations. [ABSTRACT FROM AUTHOR]

In this paper, we discuss a telehealth project aimed at delivering mental health crisis interventions to patients in two rural hospitals in Southern Ontario, Canada, by creating a virtual psychiatric emergency department (ED) using telehealth technology. A participatory action research approach was followed as a design framework for this project. A formal process based on Kouzes and Posner's five practices of exemplary leadership was crafted and closely followed, given the critical role of leadership necessary for the success of this project. The programme achieved its goal and was well received by patients and staff. ED physicians felt supported by the available psychiatric and mental health nursing expertise. Staff satisfaction with the protocols and processes were high, and ED physicians felt confident in the support they received during the decision-making process for appropriate disposition of the patient. [ABSTRACT FROM AUTHOR]

This study aimed to describe how occupational therapists evaluate older adults with cognitive impairments. A descriptive qualitative study design was used. Four focus groups were conducted with 16 occupational therapists working with cognitively impaired older adults in institutional and community care settings. An inductive thematic analysis of the content of the interviews was applied. Occupational therapists described a three-stage assessment process that was predominantly occupation-based, linear and iterative: (a) gathering information from the older adult, their care network and family members to plan the assessment, (b) assessing cognitive impairment and occupational performance using non-standardized observations and standardized tests, and (c) applying clinical reasoning to predict further performance issues and safety. Despite using a predominantly occupation-based assessment process, occupational therapists reported a lack confidence to predict safety. Occupational therapists may require additional knowledge, skills and tools to support them in assessing older adults with cognitive impairments. [ABSTRACT FROM AUTHOR]

As health care expenditures in Canada continue to increase annually, pressure rises to contain spending. Clinicians are partially responsible for cost containment and can help optimize spending by utilizing more cost-effective interventions. An understanding of economic evaluations, particularly cost-effectiveness analysis, will help physicians make well-informed decisions when choosing between different treatments for their patients. This paper describes different types of economic evaluations with a focus on cost-effectiveness analysis. A hypothetical study is included to illustrate how a cost-effectiveness analysis evaluation is performed. By understanding and considering the economic value of appropriate interventions, clinicians can aim to provide evidence-based care for their patients and the population as a whole. [ABSTRACT FROM AUTHOR]

The practice of covertly administering medications to patients without their consent is often discussed in the framework of legal questions around the right of patients to consent and refuse medical treatment. However, this practice also raises significant questions surrounding the professional duties and obligations of health care professionals as it relates to the decision-making process of whether to engage in the covert administration of medications. In this paper, I present an overview of the origin of those duties and obligations, and discuss how those duties and obligations when seen from different perspectives may either justify or prohibit the practice. Further, I discuss whether the duties and obligations of health care professionals as they are currently framed are suited to address the complexities of this issue both from the health care professional and patient perspectives. This analysis is conducted in the context of duties and obligations that arise from not only legal framework but also from the ethical requirements from professional codes of ethics. [ABSTRACT FROM AUTHOR]

Background: End-of-life care involves a multitude of functions delivered by a team of healthcare professionals. Family caregivers get involved in every aspect of the palliative care journey. Meeting the needs of ethnically diverse patients can be a daunting task for Western-trained healthcare professionals. Family and professional caregivers need to have a mutual understanding of perspectives and expectations to integrate family caregivers into end-of-life care. The South Asian population in Canada is fast growing, and very little is known about their understanding and expectations of end-of-life care. Methods: The purpose is to provide research-based knowledge on discordances and concordances of encounters and perceptions of end-of-life care delivery between South Asian family caregivers and palliative care health professionals. Individual interviews were conducted among seven palliative care professionals, in a tertiary care center, and seven South Asian family caregivers who have provided care, in the same inpatient center, for the same period. The constant comparison, a component of the grounded theory approach, was employed to compare the two types of caregivers' perspectives that emerged in the qualitative data. Findings: The family caregivers were divided in their perception based on death denial and acceptance. The findings weaved the discordances and concordances of meaning assigned to palliative care to the three themes that emerged: the role of the family caregiver, communication needs and challenges, and barriers to the family caregiver participation in decision-making. The discordance between professionals and family caregivers arose in the death-denial group and concorded with the death-accepted group. The findings revealed a consequence of the survival optimistic bias, as creating dissatisfaction toward the end-of-life care delivery system when the palliative care professionals prognosticate imminent end-of-life. Conclusion: The family caregivers' interactions and encounters were shaped by their acceptance or denial of the death of their family member in care. Gaining conceptual clarity on the meaning of palliative care and providing education on the process of end-of-life care delivery are crucial to integrating ethnically diverse family caregivers into the decision-making process. [ABSTRACT FROM AUTHOR]

Background Characterizing the prevalence and distribution of frailty within a population can help guide decision-making and policy development by identifying health service resource needs. Here we describe the prevalence of frailty among hospitalized older adults in New Brunswick (NB), Canada. Methods NB administrative hospital claims data were used to identify hospitalized older adults aged 65 or older between April 1, 2017 and March 31, 2019. Frailty was quantified using the Hospital Frailty Risk Score (HFRS), a validated frailty tool derived from claims data. Individuals with a HFRS ranked as intermediate or high were categorized as frail. The distribution of frailty across sex and age are described. Crude prevalence estimates and corresponding 95% confidence intervals are presented. Results A total of 55,675 older adults (52% females) were hospitalized. The overall prevalence of frailty was 21.2% (95%CI: 20.9-21.6). Prevalence increased with age: 12.7% (95%CI: 12.3-13.1) in the 65-74 age group, 24.7% (95%CI: 24.1-25.3) in the 75-84 age group and 41.6% (95%CI: 40.6-42.7) for those aged 85 and over (p<.001). Discussion/Conclusion The distribution of frailty is in line with that reported in other jurisdictions. We demonstrate the feasibility of the HFRS to identify and characterize frailty in a large sample of older adults who were hospitalized, using administrative data. [ABSTRACT FROM AUTHOR]

Objective: It is essential that the embedded process of rural case selection be highlighted and documented to provide reassurance of rigour across rural surgical services supported by generalist surgeons, general practitioners with enhanced surgical skills and general practitioner anaesthetists. This enables feedback and improves the triage and case selection process to ensure the highest quality outcomes. Therefore, this research aims to explore participants' rational criteria for decision making around rural case selection. Design: Participants participated in a series of semi‐structured in‐depth interviews which were coded and underwent thematic analysis. Setting: Six community hospitals in British Columbia, Canada. Participants: General practitioners with enhanced surgical skills, general practitioner anaesthetists, local maternity care providers, and specialists. Results: Based on participant accounts, rural surgical and obstetrical decision‐making processes for local patient selection or regional referral had five major components: (1) Clinical Factors, (2) Physician Factors, (3) Patient Factors, (4) Consensus Between Providers and (5) the Availability of Local Resources. Conclusion: Decision‐making processes around rural surgical and obstetrical patient selection are complex and require comprehensive understanding of local capacity and resources. Current policies and guidelines fail to consider the varying capacities of each rural site and should be hospital specific. [ABSTRACT FROM AUTHOR]

Background: Examining the emerging body of evidence investigating what drives physiotherapist's clinical decisions in the management of low back pain can guide future research into identifying barriers and facilitators of their adherence to evidence recommended interventions. Objective: To establish the body of evidence regarding factors that improve or hinder physiotherapists' adherence to high‐value interventions on the management of non‐specific low back pain. Design: Scoping review. Methods: We conducted a Scoping review by searching MEDLINE, CINAHL, and SPORTDiscus databases on 13 February 2021. Two reviewers independently screened the retrieved literature and selected articles for inclusion. We included quantitative research that investigated an association between physiotherapists' personal characteristics or setting related characteristics with their clinical management of patients with non‐specific low back pain. Results: Twelve studies reported in 13 publications were included. The majority of the studies were conducted in high‐income countries including, the United States, Canada and UK. Twenty‐six factors were investigated as potentially influencing physiotherapists' adherence to high value interventions in low back pain management. The most commonly examined physiotherapists' attributes were educational qualification that is postgraduate or certification course (58%, N = 7 studies), years of experience (41%, N = 5 studies), and beliefs and attitude about low back pain (41%, N = 5 studies). Work setting (N = 4) and workload (N = 3) were frequently investigated setting related factors. Conclusion: Currently, there is limited evidence available to understand determinants controlling practice behaviours of physiotherapists' management of nonspecific low back pain. Future researches conceptualized within contemporary theories of clinician behaviour change and models of knowledge translation are needed. [ABSTRACT FROM AUTHOR]

Aims and objectives: To understand how acute care nurses make decisions about administering "as‐needed" (PRN) psychotropic medications to hospitalised people with dementia (PWD). Background: Behavioural and psychological symptoms of dementia occur in approximately 75% of PWD admitted to acute care. Despite this, few studies provide insight into the use and prevalence of psychotropic use in acute care. Design: A qualitative descriptive design was used to explore acute care nurses' decision‐making about PRN psychotropic medication administration to PWD. Methods: Semi‐structured interviews were conducted with eight nurses from three acute care medical units in a large tertiary hospital in Western Canada. Conventional content analysis was used to develop three themes that reflect nurses' decision‐making related to administering PRNs to hospitalised PWD. COREQ guidelines were followed. Results: Three themes of legitimising control, making the patient fit and future telling were developed. Legitimising control involved medicating undesirable behaviours to promote the nurses' perceptions of safety. Making the patient fit involved maintaining routine and order. Future telling involved pre‐emptively medicating to prevent undesirable behaviours from escalating. Nurses provided little to no mention of assessing for physical causes contributing to behaviours. PRNs were seen as a reasonable alternative to physical restraints and were frequently used. Additionally, organisational and unit routines greatly influenced nurses' decision‐making. Conclusions: These findings provide an initial understanding of how nurses make decisions to administer PRN medications to hospitalised older people and may inform prescribing practices. There were novel findings about the lack of assessment prior to PRN administration, and the nurses' collective response in decision‐making. More research is needed to better understand the complexities of nurses' decision‐making, to assist in the development of interventions for nursing practice. [ABSTRACT FROM AUTHOR]

Ethical or legal errors related to the consent pathway for incapable patients are an everyday reality. Quality improvements in communication or palliative care have been attempted, but little attention has been given to meeting basic legal and ethical obligations. In this paper, the authors share lessons learned during two years of implementing the Checklist for meeting Ethical and Legal Obligations (ChELO) in the intensive care unit of a large community hospital in Ontario. We use a case-based approach to demonstrate the need for our intervention, our use of positive deviance in a change strategy, and the effectiveness of the checklist itself. Through stories, we show common ethical and legal errors related to the consent pathway and how we were able to resolve them with this innovative tool. [ABSTRACT FROM AUTHOR]

Rehabilitation clinicians need information about patient activities in the home/community to inform care. Despite active efforts to develop technologies that can meet this need, clinicians' perspectives regarding how information is collected and used in outpatient rehabilitation have not been comprehensively described. Therefore, we aimed to describe: (1) what data pertaining to a patient's health, function and activity in their home/community are currently collected in outpatient rehabilitation, (2) how these data can impact clinical decisions, and (3) what challenges clinicians encounter when they manage the care of outpatients based on this information. Eight clinicians working in outpatient rehabilitation programs completed qualitative interviews that were analyzed using an inductive thematic analysis. Four themes were identified: "Nature of data about a patient's health, function and activity in the home/community and how it is collected by clinicians," "Value of data from the home/community," "Perceived drawbacks of current data collection methods," and "Improving data collection to understand patient trajectory." Clinicians described the importance of understanding patient activities in the home/community, but perspectives varied regarding the suitability of current methods. These perceptions may inform the design of solutions to bridge the gap between the clinic and the community in outpatient rehabilitation. Clinical decision-making in outpatient rehabilitation is guided by verbal and written reports about a patient's health and function in the community and adherence to treatment plans. Differing perceptions on the suitability of current data collection methods indicate that the development of new solutions, such as rehabilitation technologies, needs to carefully consider clinician workflows and what data are perceived as meaningful. Potentially impactful directions for new solutions include providing well validated data on adherence, movement quality, or longitudinal progression, presented in formats that match clinical decision criteria. [ABSTRACT FROM AUTHOR]

The process of applying new scientific knowledge to clinical decision-making is critical for the provision of optimal healthcare delivery; however, this process is often slow or inconsistent. Knowledge mobilization is the iterative and bidirectional process that involves the generation, dissemination, and translation of knowledge between researchers and knowledge users. Incorporation and application of knowledge mobilization in health care is being increasingly recognized across all fields, including naturopathic medicine. This review explores generally employed knowledge mobilization approaches. Additionally, it summarizes the knowledge mobilization strategies currently being used by the Canadian naturopathic profession and makes recommendations on the strategies which might be used in the future to bridge the gap between research evidence and clinical practice. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to look at the effects of exercise in the treatment and prevention of osteoporosis in athletes of all age groups. Recommendations for exercise programs will be discussed as a tool to improve bone health. Medical management of osteoporosis will be reviewed mainly as it pertains to postmenopausal women. [ABSTRACT FROM AUTHOR]

Abstract: International policies regulating clinical ethics committees'' (CEC) roles are non-existent. Nonetheless, CECs have established themselves in several countries and there exist striking differences in the way these work. This international practice variation stems from the ways CECs developed, within particular legal, political, social and professional contexts. National guidelines and normative documents have been published in many countries regarding CECs. To better understand CECs'' evolution and differences in various countries, we reviewed guidelines, position statements and normative papers which describe and frame the development of CECs in the United States, the United Kingdom, Canada and France. Systematic content analysis addressed guideline development, CECs'' roles, consultation methods and CEC members'' education requirements. Differing contexts informed the ways in which guidelines were developed. American CECs, established within a strongly litigious context are perceived to play strong decision-making roles, whereas British CECs, encouraged by clinicians, endorse a more supportive model. Canadian guidelines focus on the role of the ethicist, while the French model is interested in a theoretical interdisciplinary approach. This analysis shows important challenges facing the implementation of accountable CECs in different contexts and can help inform future policy development. [Copyright &y& Elsevier]

This article provides a comprehensive summary of clinical librarian service models in the US, Canada, and the UK from a cross-sectional study. An online survey received 182 responses from clinical librarians in hospital (62%), academic (26%), and other (10%) libraries. These clinical librarians shared the services they provide, patrons they work with, and their perceptions of the value they add to clinical environments. Overall, this study quantifies the services offered most frequently by clinical librarians, the services felt to be most valuable, and the variety of health care clientele whom clinical librarians serve. These findings have implications for current clinical librarians, libraries and health care institutions, and for those who may become clinical librarians in the future. [ABSTRACT FROM AUTHOR]

Background/Objectives: As the elderly population and associated number of persons with dementia increase, so does the need for decision‐making capacity assessments (DMCAs). Many healthcare professionals (HCPs), however, do not feel prepared to conduct DMCAs. We have provided 4‐h DMCA workshops to HCPs since 2006 and offered physicians either a 3‐h or 2‐day DMCA workshop from 2013 to present. We evaluated the effectiveness of the workshops on self‐reported key concepts of capacity. Design Pre‐/post‐test design. Setting: DMCA workshops for physicians across Canada and HCPs within Alberta. Participants: Two hundred and eighty‐one physicians and 835 HCPs. Measurements Pre‐/post‐workshop ratings on level of comfort with and understanding of 15 core DMCA concepts using 4‐point Likert‐type items. Results: For the DMCA workshops among physicians, ten 3‐h workshops were held in 2014–2015 with 166 participants and seven 2‐day workshops, between 2014 and 2018, with 115 participants. With respect to the self‐report on core DMCA concepts, at least 62.7% (range: 62.7%–89.6%) of physician participants had higher post‐workshop ratings (sign test; p < 0.001) than pre‐workshop ratings for all core DMCA concepts. For the DMCA workshops among HCPs, 4‐h workshops were delivered to 835 HCP participants from 2008 to 2012. At least 49.6% of participants (range: 49.6%–78.9%) had increased post‐workshop ratings (sign test; p < 0.001) for all level of comfort items with and understanding of core DMCA concepts. Conclusion: There is a need for DMCA training for physicians and HCPs. The content and method of the workshops are effective at enhancing self‐reported level of comfort with and understanding of core DMCA concepts. [ABSTRACT FROM AUTHOR]

Continuous delivery of oxygen therapy has been observed to improve healing for individuals with an advanced diabetic foot ulcer (DFU). However, this intervention requires the purchasing of an oxygen delivery device and moist dressings. It is unknown whether this upfront financial investment represents good value for money. Thus the aim of this project is to evaluate the cost‐effectiveness of treating advanced DFU using continuous delivery of oxygen compared with negative pressure wound therapy from the perspective of the public health care payer in Ontario, Canada. A microsimulation model was constructed with inputs from peer‐reviewed journal publications and publicly available reports. The 5‐year costs and quality‐adjusted life‐years were compared between treatment and comparator. Sensitivity analyses were conducted to evaluate the robustness of results. The model predicted that continuous delivery of oxygen would cost $4800 less compared with negative pressure wound therapy and increased quality‐adjusted life years by 0.025. Lower cost and improved outcomes were observed in most scenario analyses. The results of this economic evaluation suggest that CDO therapy may reduce health care economic burden with a modest increase in quality of life outcomes. Health care decision‐makers should consider the inclusion of CDO for the treatment of DFU. [ABSTRACT FROM AUTHOR]

The article offers information on the resources of the review articles about the program "Evidence Based Reviews in Surgery" sponsored by the Canadian Association of General Surgeons and the American College of Surgeons and supported by several companies. The program investigated the effect of a decision aid for the decision making of patients with breast cancer. The objective of the program is to improve the critical appraisal skills of practicing surgeons.

Clinical reasoning (CR) is the cognitive process that therapists use to plan, direct, perform and reflect on client care. Linked to intervention efficiency and quality, CR is a core competency that occurs within an institutional context (legal, regulatory, administrative and organisational elements). Because this context can shape how community therapists think about their clients' care, its involvement in their CR could have a major impact on the interventions delivered. However, little is known about this involvement. Our study thus aimed to describe the elements of the institutional context involved in community therapists' CR. From March 2012 to June 2014, we conducted an institutional ethnography (IE) inquiry in three Health and Social Services Centres in Québec (Canada). We observed participants and conducted semi‐structured interviews with 10 occupational therapists. We also interviewed 12 secondary key informants (colleagues and managers) and collected administrative documents (n = 50). We analysed data using the IE process. Of the 13 elements of the institutional context identified, we found that four are almost constantly involved in participants' CR. These four elements, that is, institutional procedures, organisation's basket of services, occupational therapists' mandate and wait times for their services, restrictively shape CR. Specifically, occupational therapists restrict their representation of the client's situation and exploration of potential solutions to what is possible within the bounds of these four elements. In light of such restrictions on the way they think about their clients' care, therapists should pay close attention to the elements of their own institutional context and how they are involved in their CR. Because of its potentially important impact on the future of professions (e.g. further restrictions on professionals' role, reduced contribution to population health and well‐being), this involvement of the institutional context in CR concerns all professionals, be they clinicians, educators, researchers or regulatory college officers. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the association between dentists' geographic density and perceptions of market competition with clinical decision‐making among a representative sample of dentists in Ontario, Canada's most populated province. Methods: Competition was quantified using dentist density, defined as the number of dental clinics lying within a one kilometre radius around the respondents' clinic address and by self‐reported perceived pressure from other dental clinics. The outcome (clinical decision‐making or treatment intensity) was measured using a set of clinical scenarios, which categorized dentists as either relatively aggressive or conservative. Associations were assessed using bivariate analysis and logistic and linear regression. Results: Dentists who perceived large competitive pressure from other dentists (OR = 1.63, 95% CI: 1.07‐2.49) were relatively more aggressive in their treatment choices. Interestingly, dentists located in very low dentist density areas (OR = 1.31, 95% CI: 1.03‐1.68) were also relatively more aggressive in their treatment choices. Conclusion: This study is the first to explore the impact of competition on the clinical decision‐making of dentists in a Canadian context. It presents a valuable addition to the competition literature and helps to understand current dynamics in the Canadian dental care market. [ABSTRACT FROM AUTHOR]

Copyright of Physiotherapy Canada is the property of University of Toronto Press and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background Unlike some other safety critical professions, there is no mandatory age of retirement for doctors, including surgeons. Medical regulators in Australia are implementing additional checks on doctors from the age of 70. We describe expert opinions on assuring performance and supporting career transitions among older surgeons. Methods In this qualitative study, experts in four countries were purposively selected for their expertise in surgical governance. Experts responded to interviews (Australia, New Zealand and UK) or a survey (Canada). A tiered framework of interventions was developed by integrating findings with previous literature and responsive regulation theory. Results 52 experts participated. Participants valued the contribution of senior surgeons, while acknowledging that age- related changes can affect performance. Participants perceived that identity, relationships and finances influence retirement decisions. Experts were divided on the need for age- specific testing, with some favouring whole- of- career approaches to assuring safe care. A lack of validated tools for assessing performance of older surgeons was highlighted. Participants identified three options for addressing performance concerns-- remediate, restrict or retire--and emphasised the need for co- ordinated and timely responses. Conclusion Experts perceive the need for a staged approach to assessing the performance of older surgeons and tailoring interventions. Most older surgeons are seen to make decisions around career transitions with self- awareness and concern for patient safety. Some older surgeons may benefit from additional guidance and support from employers and professional colleges. A few poorly performing older surgeons, who are recalcitrant or lack insight, require regulatory action to protect patient safety. Developing robust processes to assess performance, remediate deficits and adjust scopes of practice could help to support safe career transitions at any age. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Program Evaluation is the property of University of Toronto Press and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective: This study examined accessibility of communication tools in the workplace, use of education to update nursing knowledge, and use of information to make specific decisions in practice among registered nurses (RNs) and licensed practical nurses (LPNs) in rural and remote communities in Canada. Methods: Data were analyzed from the cross-sectional survey, "Nursing Practice in Rural and Remote Canada II," of regulated nurses practicing in all provinces and territories of Canada. Data were collected from April 2014 to August 2015. Results: The survey was completed by 3,822 of 9,622 nurses (40% response), and the present analysis was conducted with a subsample of 2,827 nurses. High-speed Internet was the most accessible communication tool, and nurses used "online/electronic education" more often than "in-person education" to update their nursing knowledge. Internet searches were used more often than several other online/electronic sources to inform decision making. Compared to LPNs, RNs reported greater workplace access to most communication tools and greater use of online/electronic education as well as information sources in online/electronic and print formats. Compared to nurses in community-based health care and hospital settings, nurses in long-term care settings reported lower access to most communication tools, lower use of online/electronic and in-person education, and lower use of online/electronic information. Conclusions: Access to continuing education and up-to-date information is important for effective patient care. This study points to a need for further research on the continuing education and information needs of rural and remote RNs and LPNs, and on their capacity to incorporate and apply new knowledge in practice. [ABSTRACT FROM AUTHOR]

Objectives: This qualitative study describes the social processes of evidence interpretation employed by Clinical Competency Committees (CCCs), explicating how they interpret, grapple with and weigh assessment data. Methods: Over 8 months, two researchers observed 10 CCC meetings across four postgraduate programmes at a Canadian medical school, spanning over 25 hours and 100 individual decisions. After each CCC meeting, a semi‐structured interview was conducted with one member. Following constructivist grounded theory methodology, data collection and inductive analysis were conducted iteratively. Results: Members of the CCCs held an assumption that they would be presented with high‐quality assessment data that would enable them to make systematic and transparent decisions. This assumption was frequently challenged by the discovery of what we have termed 'problematic evidence' (evidence that CCC members struggled to meaningful interpret) within the catalogue of learner data. When CCCs were confronted with 'problematic evidence', they engaged in lengthy, effortful discussions aided by contextual data in order to make meaning of the evidence in question. This process of effortful discussion enabled CCCs to arrive at progression decisions that were informed by, rather than ignored, problematic evidence. Conclusions: Small groups involved in the review of trainee assessment data should be prepared to encounter evidence that is uncertain, absent, incomplete, or otherwise difficult to interpret, and should openly discuss strategies for addressing these challenges. The answer to the problem of effortful processes of data interpretation and problematic evidence is not as simple as generating more data with strong psychometric properties. Rather, it involves grappling with the discrepancies between our interpretive frameworks and the inescapably subjective nature of assessment data and judgement. The authors of this qualitative study illustrate the processes of evidence interpretation Clinical Competency Committees (CCCs) use to grapple with and weigh assessment data. [ABSTRACT FROM AUTHOR]

Aims and objectives: To empirically test a conceptual model of confidence and competence in rural and remote nursing practice. Background: The levels of competence and confidence of nurses practising in rural settings have been highlighted as essential to the quality of health outcomes for rural peoples. However, there is limited research exploring these constructs in the context of rural/remote nursing practice. Design: Structural equation modelling was used to verify the conceptual model with data from the cross‐sectional pan‐Canadian Nursing Practice in Rural and Remote Canada II Survey. The STROBE guidelines for cross‐sectional research were followed in the design/reporting of this analysis. The sample consisted of 2,065 registered nurses and nurse practitioners who were working in direct rural/remote nursing practice. Results: The maximum likelihood ratio χ2 = 0.0822, df = 2, p = 0.959 indicated model fit, with final model estimates explaining 53% of the variance in work confidence and 17% of the variance in work competence. The model also accounted for 40% of the variance in work engagement, 39% of the variance in burnout and 15% of the variance in perceived stress. The complexity of competence and confidence in rural nursing practice was evident, being influenced by nursing experience in rural settings, rural work environment characteristics, community factors and indicators of professional well‐being. Conclusions: The factors influencing nurses' competence and confidence in rural/remote nursing practice are more complex than previously understood. Our model, created and tested using structural equation modelling, merits further research, to extend our understanding of how nurses can be prepared and supported for practice in rural and remote settings. Relevance to clinical practice: This study highlights the importance of supporting new nurses' exposure to rural nursing experiences, reducing professional isolation and improving decision‐making support for those who are working at a greater distance from colleagues and/or those with fewer opportunities for interprofessional collaboration. [ABSTRACT FROM AUTHOR]

Background: Patient engagement (PE), patients' meaningful involvement in research through partnerships and sensitivity to their expertise, is receiving attention. However, PE initiatives are poorly reported and little is known about patients' perspective on PE. Objective: To document and evaluate the first phase (22 months) of a PE Project for the I‐Score Study which is developing a patient‐reported measure of HIV treatment adherence barriers, we describe the nature of PE conducted, determine the level of PE achieved and present its impacts from the engaged patients' perspective. Setting and participants: A Montreal‐based committee of ten people with HIV was recruited from community and clinical settings and participated in: I‐Score study decision making, knowledge dissemination, research on the experience of people with HIV and the PE project's evaluation. Methods: The evaluation followed a convergent parallel mixed‐methods design. Data collection included participant observation, a satisfaction survey and meeting minutes/transcriptions. Analysis entailed reporting PE activities, generating descriptive statistics and thematically analysing qualitative material. Results: PE consisted of twelve meetings, including two focus groups (needs assessment), in addition to four knowledge dissemination activities. PE levels showed an increase: the first four regular meetings entailed information/consultation, while subsequent meetings reached implication/collaboration. Regarding impacts, patients indicated high and stable satisfaction rates (M = 4.4/5; SD = 0.76). Furthermore, thematic analysis identified "positive interactions," "co‐learning," "self‐determination," and "the collective management of confidentiality" as important PE impacts for engaged patients. Conclusion: This PE Project evaluation highlighted growing engagement levels, high satisfaction rates and the importance of a patient‐centric approach to PE. [ABSTRACT FROM AUTHOR]

Our aim is to develop a robust socio‐geographical transferable theory outlining the basic social process used by members of an interprofessional health care team when making decisions around wound care management. Using a qualitative multigrounded theory approach, three focus groups were held at the Royal Victoria Regional Health Centre in Barrie, Ontario, Canada, comprised of 13 clinicians who participate in wound care decision‐making. Data were analysed using an approach developed for multigrounded theory. A Critical Realist theoretical lens was applied to data analysis in the development of conclusions. Ten categories were identified before thematic saturation. Category interactions developed a perceived basic social process outlining how interprofessional clinicians determine how they approach wound care decisions: patient factors, scope of practice, equipment and supplies, internal clinician factors, knowledge and education, interprofessional team, assessment, wound care specialist consultation, and care plan, as well as documentation and communication. Understanding how wound care decision‐making is determined by interprofessional health care providers will assist clinical leaders and policy makers in creating a foundation for determining resource allocation, allowing clinicians to use evidence‐based practice to improve patient and clinician satisfaction, wound healing time, decrease costs, and prevent wound recurrence. [ABSTRACT FROM AUTHOR]

In Canada, limited resources and increasing demand place pressure on the public healthcare system, something that is likely to increase. In this context, wait lists in outpatient physiotherapy departments (OPD) will get longer, system inefficiencies will arise, and frustrations and ethical concerns will be experienced by patients and staff. To better understand the perceptions of OPD staff regarding priority setting, treatment frequency, treatment duration, and wait list management strategies, we conducted an Interpretive Description study involving semi-structured interviews in three OPDs in Montreal. Participants discussed factors that influenced their decision making about who was prioritized to receive care, strategies that were used to respond to an imbalance between needs and resources in the OPDs and procedures to manage wait lists to help improve access to care. While clinical needs are central in approaches to prioritization, other non-clinical factors relating to the patient, the physiotherapist, and the institution also influence decisions. We examine these findings through the lens of complexity theory, providing insight into opportunities and obstacles for the implementation of management strategies in OPDs. These strategies will need to be carefully evaluated in order to create evidence-based guidelines for wait list management in other settings. [ABSTRACT FROM AUTHOR]