Intégrer une conception infirmière dans la pratique : entre rapports au savoir, interprétations plurielles et mobilisation créative des acteurs

Le recours à une conception infirmière pour guider la pratique est un phénomène abondamment documenté dans les écrits disciplinaires. Toutefois, il bénéficie de très peu d’attention concrète dans les milieux cliniques. À cet égard, plusieurs auteurs questionnent les impacts véritables et durables de ce processus pour l’infirmière, sa pratique, ses relations professionnelles et les établissements soignants. Les «partisans» des théories soulignent quant à eux la résistance et l’ignorance des intervenants et des milieux en regard de ces «nouvelles pratiques». Nous avons donc procédé à une étude de cas portant sur la construction et l’évolution d’une pratique clinique guidée par une approche de soins, précisément celle de l’Humaindevenant de Parse (1998), en vue de déterminer si cet écart théorie-pratique tire ses racines du contenu enseigné, des moyens de diffusion ou de ses effets cliniques. Notre étude a été réalisée dans une maison de soins palliatifs, où des infirmières s’inspirent depuis 2008, de l’Humaindevenant pour réaliser leurs activités. Selon des procédures éthiques reconnues, les infirmières de même que divers membres de l’organisation ont participé à des entrevues individuelles. De l’observation et des analyses de documents ont également été réalisées. Un journal de terrain a été rédigé tout au long du déroulement de l’enquête. Les informations collectées ont été organisées et codifiées à l’aide du logiciel QDA Miner (version 4.0.4). Au terme de notre analyse, nous soutenons que l’enseignement et l’apprentissage d’une conception impliquent de nombreuses interprétations. Ils témoignent également de rapports identitaires au savoir et de représentations de la pratique parmi les acteurs. Par ailleurs, les effets constatés relèvent plus de la mobilisation créative des acteurs, que du «contenu intégré». Par conséquent, nous convenons que les conceptions infirmières ne contribuent pas nécessairement au développement des compétences des infirmières et pourraient même entrer en conflit avec certains mandats de la discipline. Ce regard, à la fois concret et indépendant du milieu et du projet d'implantation, nous permet de proposer quelques mises en garde à l'égard de l'enseignement de ce type d'approche en sciences infirmières et en soins palliatifs et d’offrir des sujets de réflexions pour le développement théorique et l’amélioration de la pratique.Theory-based practice is abundantly documented in the nursing discipline. However, it benefits from little attention in clinical environments. This situation is often called theory-practice gap. In this regard, several questions arise about the real and lasting impacts of this process for the nurse, her practice, her professional relationships and the healthcare environments. Some doubt the adequacy of the contents of theories, while their defenders criticize the resistance of the educational and clinical environments with respect to these "new practices". We conducted a case-study regarding the construction and evolution of a clinical practice inspired by a particular nursing approach, the Humanbecoming theory (Parse, 1998), in order to determine if the theory-practice gap has its origin in the content of these theories, the process of diffusion or its clinical effects. We carried out our study in a palliative care hospice where the Humanbecoming theory was implemented since 2008. In accordance with official ethical procedures, nurses and various members of this particular hospice participated in individual interviews. We also carried out observations and multiple document analyses (Gagnon, 2005). A field journal was maintained throughout the course of the investigation. The information collected was organized and codified with the help of QDA Miner software (version 4.0.4). At the end of our analysis, we suggest that the teaching and learning of a nursing theory implies a diversity of interpretations. This teaching and this learning also attest to the existence of different relations to knowledge and different practice representations among actors. Finally, we propose that the effects associated with the teaching of such theories result mostly from the creative mobilization of stakeholders around a common goal and not from the teaching itself. Hence, our analysis suggests that nursing theories and conceptual models do not contribute to professional emancipation and intellectual development of nurses, as it is claimed in theoretical discourse. In light of this portrayal, both accurate and independent, of the field and of a nursing theory implementation project we can offer some words of caution with regard to teaching theory-based practice in nursing and palliative care

Theory-based practice as plural interpretations: A case of the the integration of the Humanbecoming theory in a palliative care setting

Nurses and students are generally encouraged to base their practice on nursing grand theories and models. However, the concrete benefits of these models in practice are often debated. Given that past studies were mostly dedicated to documenting the benefits of nursing theories in practice and were conducted by their supporters, their contribution to the debate is questionable. In 2012, we conducted a retrospective case study in a palliative care unit in Canada where caregivers have based their practice on the Humanbecoming theory since two years. We aimed to examine the process of integration and its effects. Data was obtained from individual interviews, direct observation and documents were analyzed using a network analysis method. Results suggest that integrating a grand theory in practice implies plural interpretations of what constitutes good practice, which brings about various effects, including some that are unexpected. The authors challenge the belief that theories and models necessarily have positive effects in practice. Résumé Les infirmières et les étudiantes sont généralement encouragées à fonder leur pratique sur les modèles et théories à large spectre en sciences infirmières. Cependant, les avantages concrets de ces modèles en pratique sont souvent débattus. Étant donné que les études antérieures étaient principalement dédiés à documenter les avantages des théories infirmières en pratique, et que ces études étaient menées par des partisans, leur contribution au débat en était affaiblie. En 2012, nous avons mené une étude de cas rétrospective dans une unité de soins palliatifs au Canada où les soignants basaient leur pratique sur la théorie de l’Humaindevenant depuis deux ans. Notre but était d’examiner le processus d’intégration et ses effets. Les données ont été obtenues à partir d’entrevues individuelles et d’observations directes. De plus, des documents ont été examinés par une méthode d’analyse de réseau. Les résultats suggèrent que le fait d’intégrer une théorie à large spectre en pratique implique de multiples interprétations de ce qui constitue une bonne pratique, ce qui entraine des effets divers, incluant certains effets inattendus. Les auteurs remettent en question la croyance selon laquelle les théories et modèles ont forcément des effets positifs dans la pratique

Accueillir et énoncer la mort aux soins intensifs : jeux d’acteurs, étapes et modalités

Cet article propose de réfléchir sur la place, l’énonciation et l’accueil de la mort au sein des unités de soins intensifs. Il décrit les jeux d’acteurs, les étapes et les modalités qui ont cours dans ces lieux, en égard au contrôle sur la vie et à une défiance de la mort qui, parfois, échoppe. Le recours à la métaphore théâtrale du sociologue Goffman sert donc à montrer le chemin emprunté dans les soins intensifs, les résistances, les lâcher-prises, les perturbations, les négociations, qui permettent de changer de cap et de laisser émerger l’idée d’une mort prochaine. Un scénario est déployé, constitué de séquences dans lesquelles on retrouve notamment un rituel d’intensification thérapeutique. Au-delà de cette analyse appuyée d’un cas concret emprunté dans la pratique des auteurs, ce texte questionne plus largement la possibilité de bénéficier suffisamment tôt de soins palliatifs, quand on est pris en charge dans une unité de soins intensifs

Qu’en est-il de la sédation palliative dans le débat au sujet de l’aide médicale à mourir? : analyse des mémoires déposés lors de l’étude du projet de loi 52 concernant les soins de fin de vie

Une des visées de la loi sur les soins de fin de vie consiste en la formalisation et l’encadrement de certaines pratiques cliniques dont celle de la sédation palliative. Néanmoins, la vaste majorité des discussions publiques liées à l’adoption de cette loi ont eu pour thème l’aide médicale à mourir (AMM), si bien que les travaux touchant la sédation palliative sont passés presqu’inaperçus. Pourtant, d’importantes différences sont palpables parmi les mémoires déposés lors de l’adoption du projet de loi 52, en ce qui concerne notamment le titre donné à cette pratique, sa portée de même que son rapport à l’AMM. Le but de cet article consiste à présenter les résultats d’une démarche d’analyse documentaire des 63 mémoires produits lors des consultations particulières du projet de loi 52 au sujet des soins de fin de vie. Ce projet, divisé en deux phases, visait d’abord à identifier les représentations de groupes variés au sujet de la sédation palliative et ensuite à dégager les relations existant entre les représentations de la sédation palliative, les positions au sujet de l’AMM et le statut des auteurs de ces mémoires. Les résultats de ces différentes phases suggèrent que les représentants des professionnels et des citoyens des mémoires analysés possédaient des visions différentes de la sédation palliative et de sa pratique actuelle au sein des milieux de soins du Québec et que celles-ci ont semblé avoir une influence sur leur position au sujet de l’AMM

Développement d'une échelle interdisciplinaire bilingue évaluant l'auto-efficacité à participer à l'aide médicale à mourir

Medical Assistance in Dying (MAiD) is a complex process involving the person seeking care and their relatives. MAiD involves physical, psychosocial and spiritual needs, and consequently the involvement of an interdisciplinary team is beneficial. Therefore, updating the knowledge and skills of healthcare and social services professionals is critical. An interdisciplinary team from Laval University (Quebec, Canada) has developed a continuous training program for all health care and social services professionals who could be involved in the care of persons who request MAiD and their loved ones. It is crucial to assess whether the objectives of the continuous training program are being met, especially since this new training addresses several complex issues (legal, ethical, and clinical). Bandura's self-efficacy theory has been widely used to develop scales for assessing the impact of training programs and identifying knowledge gaps. Bandura's theory states that feeling secure in one's self-efficacy leads to self-determined motivation. Although there are various scales intended to measure self-efficacy in palliative care, none include self-efficacy for participating in the process surrounding MAiD. As a result, we aim to create a bilingual (English-French) interdisciplinary scale to assess self-efficacy for participating in the process surrounding MAiD. The scale will allow decision-makers and researchers to identify current knowledge gaps. It will also be useful for assessing the impact of current and future training programs addressing this end-of-life practice. In this work in progress, we briefly introduce the training program and the future steps in the development and validation of the scale.L'aide médicale à mourir (AMM) est un processus complexe impliquant la personne qui demande le soin et ses proches. L'AMM implique des besoins physiques, psychosociaux et spirituels. Par conséquent, l'implication d'une équipe interdisciplinaire est bénéfique et la mise à niveau des connaissances et des compétences des professionnel.es est essentielle. Une équipe interdisciplinaire de l'Université Laval (Québec, Canada) a développé un programme de formation continue destiné aux professionnelles de la santé et des services sociaux susceptible d'être impliqué es dans ls soins et services des personnes qui demandent l’AMM et de leurs proches. Il est crucial d'évaluer si les objectifs du programme de formation continue sont atteints, d'autant plus que cette nouvelle formation aborde plusieurs questions complexes (juridiques, éthiques et cliniques). La théorie du sentiment d'auto efficacité de Bandura a été largement utilisée pour développer des échelles permettant d'évaluer l'impact des programmes de formation et d'identifier les lacunes en matière de connaissances. Cette théorie stipule que le fait de se sentir sûre de son efficacité personnelle conduit à une motivation intrinsèque à accomplir le comportement visé. Bien qu'il existe plusieurs échelles destinées à mesurer l'auto-efficacité dans le domaine des soins palliatifs, aucune n'inclut l'auto-efficacité pour la participation au processus entourant l’AMM. Par conséquent, nous développons une échelle interdisciplinaire bilingue (anglais-français) pour évaluer l'auto-efficacité à participer au processus entourant l’AMM. L'échelle permettra aux décideuses, décideurs et aux chercheuses et chercheurs d'identifier les lacunes actuelles en matière de connaissances. Elle sera également utile pour évaluer l'impact des programmes de formation actuels et futurs portant sur cette pratique de fin de vie. Dans cet article, nous présentons brièvement le programme de formation et les étapes futures du développement et de la validation de l'échelle

Comparing traditional and participatory dissemination of a shared decision making intervention (ADAPT-NC): a cluster randomized trial

BackgroundAsthma is a common disease that affects people of all ages and has significant morbidity and mortality. Poor outcomes and health disparities related to asthma result in part from the difficulty of disseminating new evidence and care delivery methods such as shared decision making (SDM) into clinical practice.This 3-year study explores the ideal framework for rapid dissemination of an evidence-based SDM toolkit for asthma management. The study leverages a partnership between the North Carolina (NC) statewide Medicaid network and the NC Network Consortium of practice-based research networks (PBRNs).Methods/designThis non-blinded study will randomize 30 primary care clinics in NC stratified by four PBRNs. We will test dissemination across these practices using a facilitator-led participatory approach to dissemination (FLOW), a novel method of participatory dissemination involving key principles of community-based participatory research, and a more typical “lunch and learn” dissemination method. Specifically, we will use cluster randomization to assign each of the 30 practices to one of three arms: (1) control, no dissemination; (2) traditional dissemination, one didactic session a year and distribution of educational material; and (3) FLOW dissemination. We hypothesize that at the unit of randomization, the clinic, patients in the FLOW dissemination arm will be more likely to share in their treatment decisions compared to patients in the traditional dissemination or control arms. All outcomes will be measured at the level of the clinic. Adoption of the SDM approach will be evaluated by 1) asthma exacerbations, 2) level of patient involvement in the decision making process, and 3) qualitative assessments from patients and providers.The research question is: What dissemination strategy most effectively increases practice level adoption of a shared decision making approach to asthma management? This study will provide important data to support best practices in dissemination of an evidence-based toolkit and implementation of shared decision making into primary care practices.Trial registrationThe trial was registered on January 27, 2014 through the United States National Institutes of Health’s ClinicalTrials.gov NCT02047929 and funded by the Patient-Centered Outcomes Research Institute (PCORI)

Promising Best Practices Implemented in Long- Term Care Facilities During the COVID-19 Pandemic to Address Social Isolation and Loneliness: A Scoping Review

Context: Throughout the current COVID-19 pandemic, tremendous effort has been made to implement innovative practices to address social isolation and loneliness (SIL) in long-term care facilities (LTCFs), disproportionally affected by COVID-19. These interventions have not yet been synthesized. This review intended to gather the current promising best practices (PBPs) implemented in LTCFs to alleviate SIL in older persons during the COVID-19 pandemic as well as during the SARS and H1N1 pandemics, using an intersectional lens. Methods: An extensive search was done in nine electronic databases. Arksey and O’Malley’s framework was used to format the scoping review. Two independent reviewers screened citations for inclusion, blindly. The selection of articles was conducted blindly by two coauthors. Finally, 16 studies were analyzed out of 9,077 records. Results: Two main themes of findings arose from this review. They comprised proximal PBPs directly addressing SIL in LTCF residents such as pseudo-contact interventions (e.g., chat from balcony or behind transparent barriers/glasses), remote communication tools (e.g., phone or video chat, voice mail/text messaging), and humanoid robots. Distal PBPs included measures implemented to prevent or mitigate the development of COVID-19, including COVID-19 screening approaches, outbreak preparedness, quarantining approaches for both residents and staff. Conclusion: This scoping review found varied PBP implemented during the multiple waves of the COVID-19 pandemic as well as evidence supporting their effectiveness. The contribution of this study is significant as most of the PBP investigated should be prioritized by public policymakers or institutions to provide more satisfactory services to the elderly and their families

Development of a bilingual interdisciplinary scale assessing self-efficacy for participating in Medical Assistance in Dying

Medical Assistance in Dying (MAiD) is a complex process involving the person seeking care and their relatives. MAiD involves physical, psychosocial and spiritual needs, and consequently the involvement of an interdisciplinary team is beneficial. Therefore, updating the knowledge and skills of healthcare and social services professionals is critical. An interdisciplinary team from Laval University (Quebec, Canada) has developed a continuous training program for all health care and social services professionals who could be involved in the care of persons who request MAiD and their loved ones. It is crucial to assess whether the objectives of the continuous training program are being met, especially since this new training addresses several complex issues (legal, ethical, and clinical). Bandura's self-efficacy theory has been widely used to develop scales for assessing the impact of training programs and identifying knowledge gaps. Bandura's theory states that feeling secure in one's self-efficacy leads to self-determined motivation. Although there are various scales intended to measure self-efficacy in palliative care, none include self-efficacy for participating in the process surrounding MAiD. As a result, we aim to create a bilingual (English-French) interdisciplinary scale to assess self-efficacy for participating in the process surrounding MAiD. The scale will allow decision-makers and researchers to identify current knowledge gaps. It will also be useful for assessing the impact of current and future training programs addressing this end-of-life practice. In this work in progress, we briefly introduce the training program and the future steps in the development and validation of the scale

Development of a bilingual interdisciplinary scale assessing self-efficacy for participating in Medical Assistance in Dying

Medical Assistance in Dying (MAiD) is a complex process involving the person seeking care and their relatives. MAiD involves physical, psychosocial and spiritual needs, and consequently the involvement of an interdisciplinary team is beneficial. Therefore, updating the knowledge and skills of healthcare and social services professionals is critical. An interdisciplinary team from Laval University (Quebec, Canada) has developed a continuous training program for all health care and social services professionals who could be involved in the care of persons who request MAiD and their loved ones. It is crucial to assess whether the objectives of the continuous training program are being met, especially since this new training addresses several complex issues (legal, ethical, and clinical). Bandura's self-efficacy theory has been widely used to develop scales for assessing the impact of training programs and identifying knowledge gaps. Bandura's theory states that feeling secure in one's self-efficacy leads to self-determined motivation. Although there are various scales intended to measure self-efficacy in palliative care, none include self-efficacy for participating in the process surrounding MAiD. As a result, we aim to create a bilingual (English-French) interdisciplinary scale to assess self-efficacy for participating in the process surrounding MAiD. The scale will allow decision-makers and researchers to identify current knowledge gaps. It will also be useful for assessing the impact of current and future training programs addressing this end-of-life practice. In this work in progress, we briefly introduce the training program and the future steps in the development and validation of the scale

Omega-3 polyunsaturated fatty acids favourably modulate cardiometabolic biomarkers in type 2 diabetes: a meta-analysis and meta-regression of randomized controlled trials

BACKGROUND: Randomized controlled trials (RCTs) suggest that supplementation with omega-3 polyunsaturated fatty acids (n-3PUFAs) may favourably modify cardiometabolic biomarkers in type 2 diabetes (T2DM). Previous meta-analyses are limited by insufficient sample sizes and omission of meta-regression techniques, and a large number of RCTs have subsequently been published since the last comprehensive meta-analysis. Updated information regarding the impact of dosage, duration or an interaction between these two factors is therefore warranted. The objective was to comprehensively assess the effect of n-3PUFAs supplementation on cardiometabolic biomarkers including lipid profiles, inflammatory parameters, blood pressure, and indices of glycaemic control, in people with T2DM, and identify whether treatment dosage, duration or an interaction thereof modify these effects. METHODS: Databases including PubMed and MEDLINE were searched until 13th July 2017 for RCTs investigating the effect of n-3PUFAs supplementation on lipid profiles, inflammatory parameters, blood pressure, and indices of glycaemic control. Data were pooled using random-effects meta-analysis and presented as standardised mean difference (Hedges g) with 95% confidence intervals (95% CI). Meta-regression analysis was performed to investigate the effects of duration of supplementation and total dosage of n-3PUFAs as moderator variables where appropriate. RESULTS: A total of 45 RCTs were identified, involving 2674 people with T2DM. n-3PUFAs supplementation was associated with significant reductions in LDL [ES: - 0.10, (95% CI - 0.17, - 0.03); p = 0.007], VLDL (ES: - 0.26 (- 0.51, - 0.01); p = 0.044], triglycerides (ES: - 0.39 (- 0.55, - 0.24; p ≤ 0.001] and HbA1c (ES: - 0.27 (- 0.48, - 0.06); p = 0.010]. Moreover, n-3PUFAs supplementation was associated with reduction in plasma levels of TNF-α [ES: - 0.59 (- 1.17, - 0.01); p = 0.045] and IL-6 (ES: - 1.67 (- 3.14, - 0.20); p = 0.026]. All other lipid markers, indices of glycaemic control, inflammatory parameters, and blood pressure remained unchanged (p > 0.05). CONCLUSIONS: n-3PUFAs supplementation produces favourable hypolipidemic effects, a reduction in pro-inflammatory cytokine levels and improvement in glycaemia. Neither duration nor dosage appear to explain the observed heterogeneity in response to n-3PUFAs. Trial registration This trial was registered at http://www.crd.york.ac.uk as CRD42016050802