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Objectives: Due to the rise of the nurse practitioner (NP) role in long-term care settings, it is important to understand the underlying structures and processes that influence NP and physician care models. This scoping review aims to answer the question, "What are the structures, processes, and outcomes of care models involving NPs and physicians in long-term care (LTC) homes?" A secondary aim was to describe the structural enablers and barriers across care models., Research Design and Methods: Seven databases were searched. Studies that described NPs and physicians working in LTC were identified and included in the review. We stratified the findings by care model and synthesized using the Donabedian model, which evaluates health care quality based on 3 dimensions: structure, process, and outcome. We then categorized macro, meso, and micro structural enablers and barriers., Results: Sixty papers were included in the review. The main structural influencers within 5 care models included policies on scope of practice, clarity of role description, and workload. A limited number of papers referred to the process of enabling the development of a working relationship. Thirty-five (49%) studies described resident, staff, and health system outcomes., Conclusions and Implications: Although structural characteristics of NP and physician care models are described in-depth, there is less detail on the processes that occur within the NP and physician care models. We highlight structural barriers and enablers within the care models, allowing for recognition of the importance of organizational influence on the NP and physician relationship. Future work should focus on the processes of the relationships in the models by identifying the drivers and initiators of collaboration between NPs and physicians and how these relationships influence outcomes., Competing Interests: Disclosures The authors declare no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: To explore the Canadian first-trimester medication abortion (MA) workforce and their clinical care following the introduction of mifepristone in 2017, updated national clinical practice guidelines and government approval of nurse practitioners (NPs) as first-trimester MA providers., Study Design: We conducted a national, self-administered, cross-sectional survey of abortion providers in 2019. Our bilingual (French/English) survey collected information on demographics, abortion number, and clinical care characteristics. The true number of abortion providers is unknown thus we cannot calculate a survey response rate. To maximize identification of possibly eligible respondents, we widely distributed the survey between July and December 2020 through health professional organizations, using a modified Dillman technique. We used descriptive statistics to characterize the workforce and clinical practices., Results: Four-hundred-sixty-five clinicians responded, of whom 388 provided first-trimester MA. Physicians (n = 358) and NPs (n = 30) reported providing 13,429 first-trimester MAs in 2019 which represented 27.7% of all reported abortions in the survey. The majority of first-trimester MA respondents were primary care physicians (n = 245, 63.1%), had less than five years' experience (n = 223, 61.3%) and practiced outside of hospitals (n = 228, 66.5%). Forty-three percent (n = 165) practiced rurally, and 44.0% (n = 136) used telemedicine for some abortion care. Ninety-nine percent (n = 350) used a guideline-recommended mifepristone/misoprostol regimen while 14.5% (n = 51) sometimes used methotrexate. Patients most commonly received mifepristone/misoprostol at community pharmacies (median 100.0%; interquartile range 50.0%-100.0%)., Conclusion: Our results suggest that there are many new first-trimester MA providers, an increase in the proportion of MAs since 2012 and a shift to primary care settings. Respondents widely adopted mifepristone., Implications Statement: Our results highlight that, following mifepristone introduction, many new primary care practitioners started providing first-trimester medication abortion throughout Canada, including the first non-physicians. This increased access to abortion particularly in rural and underserved communities. These results could inform future directions in policy, guidelines, and abortion access initiatives., (Copyright © 2022. Published by Elsevier Inc.)

Background: Polypharmacy is a major global problem. Evidence in primary care shows deprescribing can be beneficial. Behaviour change theories such as the Theoretical Domains Framework (TDF) and the Behaviour Change Wheel (BCW) can help develop successful implementation of deprescribing initiatives., Objectives: To link locally identified deprescribing influencers with components of successfully trialed deprescribing strategies, with the aim of informing the development of local deprescribing initiatives., Methods: Two background studies were completed. A qualitative study of interviews and focus groups identified influencers of deprescribing from local primary care physicians, nurse practitioners, and pharmacists. Transcripts were coded using the TDF and mapped to the Intervention Functions of the BCW. A scoping review identified studies that investigated primary care deprescribing strategies, which were mapped to the BCW Intervention Functions and the Behaviour Change Techniques (BCTs). For this analysis, six main TDF domains from the qualitative study were linked to the BCTs identified in the scoping review through the Intervention Functions of the BCW., Results: Within the BCW component Capability, one TDF domain identified in the qualitative study, Memory, Attention and Decision Process, was linked to strategies like academic detailing from the scoping review. For the Opportunity component, two TDF domains, Social Influences and Environmental Context and Resources, were linked to strategies such as pharmacist medication reviews, providing patient information leaflets, and evidence-based deprescribing tools. For the Motivation component, three TDF domains, Social/Professional Role and Identity, Intentions, and Beliefs about Consequences, were linked to strategies such as sending deprescribing information to prescribers, using tools to identify eligible patients, and having patients report adverse events of medications., Conclusions: This analysis identified deprescribing strategies that can be used to address influencers related to behaviour change from the perspective of primary care providers, and to assist with future deprescribing initiative development and implementation in the local context., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Polypharmacy and inappropriate medication use are an increasing concern. Deprescribing may improve medication use through planned and supervised dose reduction or stopping of medications. As most medication management occurs in primary health care, which is generally described as the first point of access for day-to-day care, deprescribing in primary health care is the focus on this review., Objective: This scoping review aimed to identify and characterize strategies for deprescribing in primary health care and map the strategies to the Behaviour Change Wheel (BCW)., Methods: A scoping review was conducted that involved searches of six databases (2002-2018) and reference lists of relevant systematic reviews and included studies. Studies that described and evaluated deprescribing strategies in primary health care were eligible. Two independent reviewers screened articles and completed data charting with charting verified by a third. Deprescribing strategies were mapped to the intervention functions of the BCW and linked to specific Behaviour Change Techniques (BCT)., Results: Searches yielded 6871 citations of which 43 were included. Nineteen studies were randomized, 24 were non-randomized. Studies evaluated deprescribing in terms of medication changes, feasibility, and prescriber/patient perspectives. Deprescribing strategies involved various professionals (physicians, pharmacists, nurses), as well as patients and were generally multifaceted. A wide range of intervention functions were identified, with 41 BCTs mapped to Environmental restructuring, 38 BCTs mapped to Enablement, and 34 BCTs mapped to Persuasion., Conclusions: Deprescribing strategies in primary health care have used a variety of BCTs to address individual professionals (e.g. education) as well as strategies that addressed the practice setting, including support from additional team members (e.g. pharmacists, nurses and patients). Further research is warranted to determine comparative effectiveness of different BCTs, which can help facilitate implementation of deprescribing strategies, thereby reducing polypharmacy, in primary health care., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Aims: The objective of this study was to compare the influence of breastfeeding and 24% oral sucrose on pain-related electrophysiologic activity, bio-behavioural pain scores, physiologic recovery, and adverse events during heel lance., Study Design: Single-blind randomized controlled trial., Subjects: 39 full-term infants were randomized to receive breastfeeding or 0.24 mL of 24% oral sucrose plus offered non-nutritive sucking 2 min prior to heel lance., Outcome Measures: The primary outcome of pain-related potential was recorded on electroencephalogram. Secondary outcomes included Premature Infant Pain Profile - Revised (PIPP-R) score, physiologic recovery, and adverse events. Data were analyzed per protocol (ClinicalTrials.gov: NCT03272594)., Results: Between November 2017 and January 2019, 20 infants were randomized to breastfeeding and 19 infants to receive oral sucrose. Infants who were breastfeeding had an appreciably smaller, yet not statistically different (F[1,15.9] = 0.58, p = 0.64, SE = 11.79), amplitude pain-related potential (peak amplitude 0.29 μV) following heel lance compared to infants who received oral sucrose (peak amplitude 8.97 μV). Mean PIPP-R scores were not statistically significantly different between groups following heel lance, however, they were indicative of low pain across groups. Mean time in seconds to physiologic recovery was faster in breastfeeding infants (M = 17.5, SD = 31.1) compared to oral sucrose (M = 70.8, SD = 144.3). There were no safety concerns., Discussion: Breastfeeding and oral sucrose both reduce bio-behavioural responses to pain, however, may differentially modulate pain response in the infant brain. Further research to understand the neurophysiologic effects of these interventions during acute painful procedures is needed., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Optimal mouth care is integral to the health and quality of life of dependent older adults.Yet, a persistent lack of adequate oral care in long-term care (LTC) facilities exacerbates the burden of disease experienced by residents. The reasons for this are complex and create enormous challenges for care providers, clinicians, and administrators dedicated to comprehensive high quality care., Objective: The aim of this study was to develop, implement, and evaluate a comprehensive program for daily mouth care for LTC., Design: A case study design using a participatory and qualitative approach examined how individual, organizational (workplace practices and culture), and system factors (standards and policy) influenced the development and implementation of a comprehensive program to improve the delivery of daily oral care in LTC., Setting and Participants: The research was undertaken in 3 LTC residences administered under the same health authority and included personal care providers, nurse managers, and directors of care., Intervention: A comprehensive program for care providers including, education, resources, and organizational guidelines, to improve the delivery of daily mouth care to LTC residents was created, rolled out, and refined over a 12-month period., Measurements: Data was collected through diary studies, targeted interviews, field notes, oral care activities records, site team meetings, and direct feedback from members of the care team., Results: The oral care intervention resulted in a heightened awareness, support and greater efficiency amongst care team. The presence of a "champion" was a key feature for sustaining processes. Management had a clear role to play to ensure support and accountability for the intervention., Conclusions: Optimizing oral care in long-term care can be achieved through an integrated approach that includes education, provision of resources, an oral care champion, support from managers and administrators, and appropriate organizational policy., (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate the effectiveness of (1) dissemination strategies to improve clinical practice behaviors (eg, frequency and documentation of pain assessments, use of pain medication) among health care team members, and (2) the implementation of the pain protocol in reducing pain in long term care (LTC) residents., Design: A controlled before-after design was used to evaluate the effectiveness of the pain protocol, whereas qualitative interviews and focus groups were used to obtain additional context-driven data., Setting: Four LTC facilities in southern Ontario, Canada; 2 for the intervention group and 2 for the control group., Participants: Data were collected from 200 LTC residents; 99 for the intervention and 101 for the control group., Intervention: Implementation of a pain protocol using a multifaceted approach, including a site working group or Pain Team, pain education and skills training, and other quality improvement activities., Measurements: Resident pain was measured using 3 assessment tools: the Pain Assessment Checklist for Seniors with Limited Ability to Communicate, the Pain Assessment in the Communicatively Impaired Elderly, and the Present Pain Intensity Scale. Clinical practice behaviors were measured using a number of process indicators; for example, use of pain assessment tools, documentation about pain management, and use of pain medications. A semistructured interview guide was used to collect qualitative data via focus groups and interviews., Results: Pain increased significantly more for the control group than the intervention group over the 1-year intervention period. There were significantly more positive changes over the intervention period in the intervention group compared with the control group for the following indicators: the use of a standardized pain assessment tool and completed admission/initial pain assessment. Qualitative findings highlight the importance of reminding staff to think about pain as a priority in caring for residents and to be mindful of it during daily activities. Using onsite champions, in this case advanced practice nurses and a Pain Team, were key to successfully implementing the pain protocol., Conclusions: These study findings indicate that the implementation of a pain protocol intervention improved the way pain was managed and provided pain relief for LTC residents., (Copyright © 2012 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.)