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Purpose: To explore how people with end stage chronic obstructive pulmonary disease and their family members describe living in the face of impending death. Methods: A narrative inquiry was undertaken using a social constructionist perspective. Data were collected in 2017–18 in two in-depth interviews, lasting 90 to 120 minutes approximately 3–4 months apart, with a telephone follow-up 2–3 months later. Thematic analysis was conducted including analysis within and across participants. Results: Sixteen people with advanced chronic obstructive pulmonary disease and seven family members participated. For both people with the disease and family members, six key themes/storylines emerged including missing life, being vigilant, hope and realism, avoiding death talk, the scary dying process, and need to prepare. Conclusion: This study highlighted six key storylines about death and dying with advanced chronic obstructive pulmonary disease for people with the illness and their family members. The participants with the illness and their family members held similar perceptions about end of life. More supports are needed for people with advanced chronic obstructive pulmonary disease and their family members in living with their illness while ensuring that they experience a “good death.”

Background Most patients with advanced heart failure are ill-prepared and poorly supported during the end of life. To date, research has focused primarily on generalized patient accounts of the management or self-care phase of the syndrome. Little research has examined the end of life in depth or from the perspectives of family members. Aims The purpose of this study is to describe how people diagnosed with heart failure and their family members describe uncertainty related to impending death. Methods and results A narrative inquiry was undertaken using a social constructionist perspective. Twenty participants took part in over 60 interviews: 12 participants with heart failure (eight male and four female; mean = 67.3 years) and eight family members (mean = 61.6 years) engaged in two in-depth interviews, approximately 3–4 months apart, followed by a telephone follow-up 2–3 months later. Six key themes/storylines were identified. These included: prognosis messages received from physicians; whenever I die, I die; loss isn’t new to me but … ; carrying on amidst the fragility of life; ultimately living not knowing; and the need to prepare. Conclusion The six key storylines of death and dying with advanced heart failure were consistent for both patients and family members. There was a desire for better communication with physicians. Many participants were critical of how the prognosis of advanced heart failure was communicated to them, even if they anticipated the news. Participants wanted frank, open conversations with their healthcare providers that both acknowledged that they were at end of life but did not remove all hope.

The provision of MAiD will be in flux for a few years, as legislative challenges are underway. This article addresses what leaders need to know and do to support nurses today and in the future regarding care of patients choosing MAiD. Drawing on complexity leadership theory and research into nurses' experiences in caring for persons choosing MAiD, we share 10 simple yet foundational things a leader must know. Underpinning our key messages are current evidence and familiar nursing concepts such as end-of-life care, death trajectories, conscientious objection, scope of practice, ethics, sense-making and care cultures. These key messages are embedded in a framework of leadership practices where attention to inter-relationships, emergence and innovation are highlighted. They provide nurse leaders with concrete actions to inspire a team dynamic for creating inclusive cultures of quality care. Leadership is needed across healthcare settings where MAiD is being enacted.

Research into self-care practices suggests the need for conscientious and systematic support of nurses and other health care providers. The purpose of this study was to explore the impact of an innovative self-care initiative. The goals were to explore the experience of nurses and other health care providers participating in a reflective, creative nonfiction storytelling event called “Dinner and Stories” and the potential benefits and limitations of using an informal, storytelling model for self-care. A qualitative narrative design was used. Twenty-seven participants including nurses, social workers, and hospice volunteers wrote creative nonfiction stories about a lingering experience of providing care. At predefined dates, groups of up to six met for dinner in a home setting. Participants read aloud, listened deeply, and discussed their narrated stories. Four sources of data were collected: creative nonfiction stories, online forum discussions, in-depth interviews, and host facilitator field notes. Researchers identified four themes: (1) needing a self-care culture, (2) storytelling and writing as healing, (3) co-creating layers of connection, and (4) preferring face-to-face contact. Results add to knowledge about the therapeutic benefits of writing and storytelling for nurses and other health care providers including enriched meaning-making, emotional conveyance, and therapeutic connections between storytellers and listeners.

Background: Medical assistance in dying opens up uncharted professional territory for Canadian physicians extending their practices to include assisting and hastening death for eligible patients. Objectives: To understand physicians’ experience of participating in assisted dying and the emotional and professional impact. Methods: An interpretive descriptive methodology and thematic analysis were used for this research. We interviewed eight physicians engaged in assessing and providing medical assistance in dying. Data were collected through audio taped, semi-structured interviews in person or by phone. Results: Three overarching themes included (1) rediscovering the art of medicine, (2) unexpected rewards, and (3) negotiating risks and challenges. Each theme has accompanying sub-themes. Conclusion: Medical assistance in dying is markedly different from other physicians’ practices in that it has an enriched capacity for caring. The process brings deep satisfaction characterized by intimate, personalized contact with patients and families. The professional rewards of providing medical assistance in dying outweigh the challenges, offering an alternative narrative to more publicly accepted views of assisting someone to die.

REVIEW QUESTION / OBJECTIVE The aim of this review is to identify the experiences of pre-licensure or pre-registration health professional students and their educators of intra-professional teams. The objectives of this review are: 1. To identify the experiences of pre-licensure or pre-registration health professional students about learning how to work in intra-professional teams. 2. To identify the experiences of health professional educators about teaching intra-professional collaboration across categorical and/or regulatory boundaries of professional groups. The specific question for this review is: What are the experiences of health professional students and educators learning to work in intra-professional teams? INCLUSION CRITERIA Types of participants This review will consider studies that investigate pre-licensure health professional students' and educators’ experiences of intra-professional teams. We will define pre-licensure health professional students as those students enrolled in a health-related diploma or degree program leading to the writing of a licensure or registration exam prior to engaging in practice (i.e. regulated health care provider programs). Health related programs that will be included are those that have multiple points of entry-to-practice under one disciplinary domain. This could include (but will not be limited to) disciplines such as dentistry, nursing, medicine, occupational therapy, pharmacy, physiotherapy or social work. Thus, we will consider studies that include experiences of students and educators working in various disciplinary domains (such as dentistry, medicine, nursing, occupational therapy pharmacy or physiotherapy) focusing on regulated health professions which have more than one point of entry into practice for their students (e.g. baccalaureate degree or diploma). TRUNCATED AT 250 WORDS

Work relationships between registered nurses (RNs) and practical nurses (LPNs) are changing as new models of nursing care delivery are introduced to create more flexibility for employers. In Canada, a team-based, hospital nursing care delivery model, known as Care Delivery Model Redesign (CDMR), redesigned a predominantly RN-based staffing model to a functional team consisting of fewer RNs and more LPNs. The scope of practice for LPNs was expanded, and unregulated health care assistants introduced. This study began from the standpoint of RNs and LPNs to understand their experiences working on redesigned teams by focusing on discourses activated in social settings. Guided by institutional ethnography, the conceptual and textual resources nurses are drawing on to understand these changing work relationships are explicated. We show how the institutional goals embedded in CDMR not only mediate how nurses work together, but how they subordinate holistic standards of nursing toward fragmented, task-oriented, divisions of care.

Background Advances in science and technology have resulted in longer lives for people with life-threatening illnesses. However, little research compares the stories of people with different life-threatening illnesses. Objectives The objectives of this study were to explore and contrast how people story and re-story life-threatening illness specifically cancer, chronic kidney disease (CKD) and HIV. Design Narrative inquiry within a social constructionist perspective was used. Methods A total of 113 in-depth interviews were conducted with 32 participants over a period of three years. Participants Study participants included 32 people: 10 with cancer, 14 with CKD and 8 with HIV/AIDS. Participants varied in age (37–83 years old, mean=61.2 years), gender (17 men and 14 women), location (urban and rural), time post-diagnosis (median=8 years), intensity or invasiveness of treatment, and prognosis (continuous treatment, remission, cure, palliative). Results Participants described living with a life-threatening illness as a delicate balance. They focused on living their lives yet were fully and acutely aware of their own mortality. There was an undercurrent of sustained uncertainty that permeated their lives. Stories of life-threatening illness differed across the three illness groups and shifted over time as disease trajectories changed. Each disease brought specific challenges. With cancer, turning points and uncertainty were prominent. With CKD, a stealthy beginning to life-extending treatment through dialysis or transplant was evident, and with HIV, a shift from a perceived death sentence to a focus on hope and living was notable. Conclusions Findings revealed that trajectories of illness for participants living with cancer, CKD and HIV are complex and differ markedly across the groups. Narratives shifted across all of the illness groups as participants navigated and re-storied the terrains of their life-threatening illness. Findings illuminated the need for health care providers to focus on person specific and contextualized aspects of the illness experience.

Background Inter-professional initiatives are prevalent in the healthcare landscape, requiring professionals to collaborate effectively to provide quality patient care. Little attention has been given to intra-professional relationships, where professionals within one disciplinary domain (such as degree and diploma nursing students) collaborate to provide care. New care models are being introduced where baccalaureate and diploma students of a particular discipline (such as nursing, occupational therapy, dentistry or physiotherapy) work closely together in teams to deliver care. Questions thus arise as to how students and educators learn to work on intra-professional teams. Objectives To identify and synthesize evidence regarding experiences of pre-licensure health professional students and their educators on intra-professional teams and to draw recommendations to enhance policy and/or curriculum development. Inclusion criteria types of participants Pre-licensure students and educators, focusing on regulated health professions that have had more than one point of entry into practice. Phenomena of interest Experiences of intra-professional team learning or teaching within various entry-to-practice categories of a particular health-related discipline. Types of studies Eight qualitative studies were included in the review. Seven studies were descriptive in nature; one study was a critical analysis. Search strategy A comprehensive search of various databases was conducted between June 2, 2015 and August 16, 2015, and repeated in March 2016. The search considered all studies reported and published from January 1, 2001 to March 7, 2016. Only studies published in English were included in this review. Methodological quality Included papers were of low-to-moderate quality; however, it is important to consider that post-positivist assumptions underpinned much of the primary research, which could explain why researcher positionality and/or influence on the research would not be addressed. Data extraction Data were extracted using the standardized data extraction tool from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI). The data extracted included descriptive details about the phenomenon of interest, populations and study methods. Data synthesis Research findings were pooled using the JBI-QARI. Sixty-eight findings were organized into nine categories based on similarity in meaning. Results Four synthesized findings reveal how students value intra-professional learning experiences. These experiences build positive collaborative relationships (including trust and respect); however, educator and staff attitudes and conversations create hierarchies in academic and clinical contexts resulting in tension between student groups. Conclusion Despite its challenges, shared learning experiences assist students to understand each other's roles, develop communication and collaborative competencies, develop comprehensive care plans, provide more efficient care and help prepare them for their future roles as healthcare professionals. Various contextual elements could either hinder or facilitate shared learning experiences.

Purpose Increasingly, people are living their lives without strict attachment to one gender. In this paper, we discuss key discourses identified in a literature review of transgender and transsexual issues in nursing. Our aim is to highlight the power of dominant discourse and lack of adequate understanding of gender diversity on the part of nurses. We use stories of trans people to illustrate these discourses. An increased awareness may support respectful care of those who do not fit comfortably within culturally defined parameters of male and female. Conclusion The invisibility of gender diversity in health care remains a threat to ethical nursing care. The effects of invisibility of transgender people in health care result in a cycle of repetition where those who have been denied recognition in turn avoid disclosure. Key discourses addressing trans people in nursing literature include invisibility, advocacy, cultural competence, and emancipation. Practice Implications There is a need for further education about gender diversity in order to dispel and counter misunderstandings, stigma, and invisibility. This can be achieved through sustained efforts in nursing research and educational curricula to include gender diversity and trans people. Policies for the protection of those who change their sex or identify outside the dominant gender schema are urgently needed.

Widespread demands for high reliability healthcare teamwork have given rise to many educational initiatives aimed at building team competence. Most effort has focused on interprofessional team training however; Registered Nursing teams comprise the largest human resource delivering direct patient care in hospitals. Nurses also influence many other health team outcomes, yet little is known about the team training curricula they receive, and furthermore what specific factors help translate teamwork competency to nursing practice. The aim of this review is to critically analyse empirical published work reporting on teamwork education interventions in nursing, and identify key educational considerations enabling teamwork competency in this group. CINAHL, Web of Science, Academic Search Complete, and ERIC databases were searched and detailed inclusion-exclusion criteria applied. Studies (n = 19) were selected and evaluated using established qualitative-quantitative appraisal tools and a systematic constant comparative approach. Nursing teamwork knowledge is rooted in High Reliability Teams theory and Crew or Crisis Resource Management sources. Constructivist pedagogy is used to teach, practice, and refine teamwork competency. Nursing teamwork assessment is complex; involving integrated yet individualized determinations of knowledge, skills, and attitudes. Future initiatives need consider frontline leadership, supportive followership and skilled communication emphasis. Collective stakeholder support is required to translate teamwork competency into nursing practice.

bruce a. & boston p. (2011) Relieving existential suffering through palliative sedation: discussion of an uneasy practice. Journal of Advanced Nursing67(12), 2732–2740. Abstract Aim. This article presents a discussion of the use of palliative sedation in response to intractable (not responsive to treatment) existential suffering. Background. Patients suffering from a terminal illness are often faced with severe symptoms at the end of life. Although palliative sedation is sometimes used when no other options are effective in relieving unbearable pain or suffering, its use in response to intractable existential suffering in terminal illness remains controversial. Data sources. A literature search was conducted for published articles addressing the use of palliative sedation between 1996 and 2009 using established databases. Discussion. Palliative sedation remains an uneasy practice. The debates have centred on ethical issues surrounding decisions to use sedation and on separating the intent of palliative sedation (relief of intolerable symptoms) from the intent of euthanasia (hastening death). There is lack of consensus in defining existential suffering. Consequently, there is limited understanding of how decisions are being made when using palliative sedation to treat intractable existential suffering. Conclusions. Given the confusion and uncertainty about ethical and clinical justifications for palliative sedation in treating existential suffering, we argue that a better understanding of the controversies and decision-making process is needed. Greater understanding is required to prevent palliative sedation from becoming a substitute for intensive treatment of this kind of suffering.

The terms hospice and palliative care are often used interchangeably in Canada. However, these words have distinct histories, from which the authors explore their ideological roots. Questions are posed concerning the impetus to combine these terms-to unite compatible ideologies or perhaps to mask the potentially divisive differences between the two. The modern development of the hospice palliative care movement in Canada is reviewed in the context of a social movement. Here again, questions are posed: Is this a social movement that has reached its conclusion with the mainstreaming and medicalization of palliative care? Finally, the effects of mainstreaming and medicalization are explored in terms of their impact on the interprofessional team: Who benefits and who stands to lose disciplinary ground? An approach to forward vision and movement in the field is posed, which, rejecting a binary posture, invites a curiosity toward the question of what divides and unites us in the care of the dying.

Spiritual care is a component of end-of-life care that has become an expectation for healthcare professionals seeking to provide holistic care. However, until recently spirituality and spiritual care were not included in the educational training of most health professionals. Little is known about how best to support and teach spiritual dimensions of dying to health professionals. This article reports on an evaluation of an innovative educational program that brings together the spiritual tradition of Buddhism alongside best practices of hospice palliative care. Findings suggest that contemplative approaches to end-of-life care presented through an experiential and online format hold potential benefits for health professionals both professionally and personally and contribute to our understanding of contemplative practices in addressing spiritual dimensions of dying. Copyright © 2007 John Wiley & Sons, Ltd.

Through advances in interpretive inquiry, diverse ways of knowing and experiencing reality are increasingly made explicit in nursing literature. Nevertheless, the privileges of empiricism continue alongside a lack of language to consider other realms of reality. In this column, Aboriginal ways of constituting health and reality are explored. Morley’s four categorizations of health belief systems provide a useful tool for understanding diverse worldviews. In contrast, Atleo drew on Nuu-chah-nulth origin stories to address the complexities and ambiguities of Aboriginal health beliefs. Approaches for bridging cultural differences are explored with a view toward inclusive healthcare and nursing practice.

Fatigue in adults with cancer has received considerable attention as a trouble some symptom that requires nursing intervention. Fatigue in children with cancer, however, has received considerably less focus. The first phase of the present study used qualitative methods to generate a detailed description of fatigue in children with cancer. Thirteen children (ages 5 to 15) and 12 parents from the oncology service in two regional children's hospitals participated in the initial interviews; a validation sample comprised another 7 children and 6 parents from a third site. Transcribed interviews were subjected to grounded theory analysis. Energy, as an overriding phenomenon, was a core concept in the descriptions of fatigue. Findings suggest that children with cancer may experience three subjectively distinct types of fatigue that represent different levels of energy: typical tiredness, treatment fatigue, and shutdown fatigue. Children managed their dwindling energy and minimized further energy loss through strategies of replenishing, conserving, and preserving. Children's use of these strategies was influenced by temperament, lifestyle, environmental factors, and treatment modalities. Knowl edge of the specific types of fatigue in children can offer direction for optimal intervention and for further research.

How does the organizational micro culture in emergency departments (EDs) impact the care of older adults presenting with a complaint or condition perceived as non-acute? This scoping study reviews the literature and maps three levels of ED culture (artifacts, values and beliefs, and assumptions). Findings on the artifact level indicate that EDs are poorly designed for the needs of older adults. Findings on the ED value and belief level indicate that EDs are for urgent cases (not geriatric care), that older adults do not receive the care and respect they should be given, that older adults require too much time, and that the basic nursing needs of older adults are not a priority for ED nurses. Finally, finding on the assumptions level underpinning ED behaviors suggest that older adults do not belong in the ED, most older adults in the ED are not critically ill and therefore can wait, and staff need to be available for acute cases at all times. A systematic review on the effect of ED micro culture on the quality of geriatric care is warranted.

AIM To present a case example of using an arts-based approach and the development of an art exhibit to disseminate research findings from a narrative research study. BACKGROUND Once a study has been completed, the final step of dissemination of findings is crucial. In this paper, we explore the benefits of bringing nursing research into public spaces using an arts-based approach. DATA SOURCES Findings from a qualitative narrative study exploring experiences of living with life-threatening illnesses. REVIEW METHODS Semi-structured in-depth interviews were conducted with 32 participants living with cancer, chronic renal disease, or HIV/AIDS. Participants were invited to share a symbol representing their experience of living with life-threatening illness and the meaning it held for them. DISCUSSION The exhibit conveyed experiences of how people story and re-story their lives when living with chronic kidney disease, cancer or HIV. Photographic images of symbolic representations of study participants' experiences and poetic narratives from their stories were exhibited in a public art gallery. The theoretical underpinning of arts-based approaches and the lessons learned in creating an art exhibit from research findings are explored. CONCLUSION Creative art forms for research and disseminating knowledge offer new ways of understanding and knowing that are under-used in nursing. IMPLICATIONS FOR PRACTICE/RESEARCH Arts-based approaches make visible patients' experiences that are often left unarticulated or hidden. Creative dissemination approaches such as art exhibits can promote insight and new ways of knowing that communicate nursing research to both public and professional audiences.

Background: Existential and spiritual concerns are fundamental issues in palliative care and patients frequently articulate these concerns. The purpose of this study was to understand the process of engaging with existential suffering at the end of life. Methods: A grounded theory approach was used to explore processes in the context of situated interaction and to explore the process of existential suffering. We began with in vivo codes of participants' words, and clustered these codes at increasingly higher levels of abstractions until we were able to theorize. Results: Findings suggest the process of existential suffering begins with an experience of groundlessness that results in an overarching process of Longing for Ground in a Ground(less) World, a wish to minimize the uncomfortable or anxiety-provoking instability of groundlessness. Longing for ground is enacted in three overlapping ways: by turning toward one's discomfort and learning to let go (engaging groundlessness), turning away from the discomfort, attempting to keep it out of consciousness by clinging to familiar thoughts and ideas (taking refuge in the habitual), and learning to live within the flux of instability and unknowing (living in-between). Conclusions: Existential concerns are inherent in being human. This has implications for clinicians when considering how patients and colleagues may experience existential concerns in varying degrees, in their own fashion, either consciously or unconsciously. Findings emphasize a fluid and dynamic understanding of existential suffering and compel health providers to acknowledge the complexity of fear and anxiety while allowing space for the uniquely fluid nature of these processes for each person. Findings also have implications for health providers who may gravitate towards the transformational possibilities of encounters with mortality without inviting space for less optimistic possibilities of resistance, anger, and despondency that may concurrently arise.

Objectives Although patients with Chronic Obstructive Pulmonary Disease (COPD) who adhere to a pulmonary rehabilitation program are better able to manage their illness and experience a better health-related quality of life, pulmonary rehabilitation remains underused. This study aims to describe the experiences of patients who are in a pulmonary rehabilitation program, and explore the perceptions of both patients and health professionals about what improves effective pulmonary rehabilitation. Methods A qualitative research design, including focus groups and individual interviews with 25 patients and 7 program health professionals, was used to obtain combined perspectives about the factors underpinning the COPD patient's reasons for participation in a rehabilitation program. Results Three themes were derived from the descriptive content analysis: (1) building confidence, (2) a perception of immediate tangible results, and (3) being ready and having access to the program. Conclusions and Practical Implications Qualitative findings from this study suggest that a patient's adherence to a COPD rehabilitation program can be improved by quickly building up the participant's confidence, promoting tangible results, and by timely recognizing and responding to the issues of readiness and access. Based on these findings, health care providers could develop strategies to better serve COPD patients who face multiple barriers to access and successfully complete a pulmonary rehabilitation program.