Carl-Ardy Dubois’s research while affiliated with Polytechnique Montréal and other places

Background Feedback on clinical performance aims to provide teams in health care settings with structured results about their performance in order to improve these results. Two systematic reviews that included 147 randomized studies showed unresolved variability in professional compliance with desired clinical practices. Conventional recommendations for improving feedback on clinical team performance generally appear decontextualized and, in this regard, idealized. Feedback involves a complex and varied arrangement of human and non‐human entities and interrelationships. To explore this complexity and improve feedback, we sought to explain how feedback on clinical team performance works, for whom, in what contexts, and for what changes. Our goal in this research was to present a realistic and contextualized explanation of feedback and its outcomes for clinical teams in health care settings. Methods This critical realist qualitative multiple case study included three heterogeneous cases and 98 professionals from a university‐affiliated tertiary care hospital. Five data collection methods were used: participant observation, doc‐ ument retrieval, focus groups, semi‐structured interviews, and questionnaires. Intra‐ and inter‐case analysis performed during data collection involved thematic analysis, analytical questioning, and systemic modeling. These approaches were supported by critical reflexive dialogue among the research team, collaborators, and an expert panel. Results Despite the use of a single implementation model throughout the institution, results differed on contextual decision‐making structures, responses to controversy, feedback loop practices, and use of varied technical or hybrid intermediaries. Structures and actions maintain or transform interrelationships and generate changes that are in line with expectations or the emergence of original solutions. Changes are related to the implementation of institutional and local projects or indicator results. However, they do not necessarily reflect a change in clinical practice or patient outcomes. Conclusions This critical realist qualitative multiple case study offers an in‐depth explanation of feedback on clinical team performance as a complex and open‐ended sociotechnical system in constant transformation. In doing so, it identifies reflexive questions that are levers for the improvement of team feedback. Keywords Nurses, Clinical audit, Feedback, Quality improvement, Performance measurement, Qualitative research, Theory, Learning health system, Comparative study

Background Care quality varies between organizations and even units within an organization. Inadequate care can have harmful financial and social consequences, e.g. nosocomial infection, lengthened hospital stays or death. Experts recommend the implementation of nursing performance improvement systems to assess team performance and monitor patient outcomes as well as service efficiency. In practice, these systems provide nursing or interprofessional teams with nursing-sensitive indicator feedback. Feedback is essential since it commits teams to improve their practice, although it appears somewhat haphazard and, at times, overlooked. Research findings suggest that contextual dynamics, initial system performance and feedback modes interact in unknown ways. This rapid review aims to produce a theorization to explain what works in which contexts, and how feedback to nursing or interprofessional teams shape nursing performance improvement systems. Methods Based on theory-driven realist methodology, with reference to an innovative combination of Actor-Network Theory and Critical Realist philosophy principles, this realist rapid review entailed an iterative procedure: 8766 documents in French and English, published between 2010 and 2018, were identified via 5 databases, and 23 were selected and analysed. Two expert panels (scientific and clinical) were consulted to improve the synthesis and systemic modelling of an original feedback theorization. Results We identified three hypotheses, subdivided into twelve generative configurations to explain how feedback mobilizes nursing or interprofessional teams. Empirically founded and actionable, these propositions are supported by expert panels. Each configuration specifies contextualized mechanisms that explain feedback and team outcomes. Socially mediated mechanisms are particularly generative of action and agency. Conclusions This rapid realist review provides an informative theoretical proposition to embrace the complexity of nursing-sensitive indicator feedback with nursing or interdisciplinary teams. Building on general explanations previously observed, this review provides insight into a deep explanation of feedback mechanisms. Systematic review registration Prospero CRD42018110128.

Introduction: The operationalization of nursing-sensitive performance measures has been highly variable. It results in measures that are sometimes suboptimal and difficult for managers and nurses to access. The objective is to propose a rigorous method for operationalizing nurse-sensitive performance measures based on routine data. Source of Information: The primary source of information for this article is an operationalization method adapted from a reporting guide and performance measure evaluation instrument. It includes 7 processes and 33 interrelated quality attributes. The application of this operationalization method was successfully tested in a university hospital. Discussion: Operationalization of nursing-sensitive performance measures is a complex process. This method is an original proposal that allows for the justification and argumentation of the choices made. We discuss how this method is a response to 3 methodological issues: (1) heterogeneous and poorly detailed operationalization methods; (2) critical attributes (e.g., relevance, scientific validity, feasibility) that lack consensus and (3) heterogeneous data architecture models. Implication and conclusion: This operationalization method provides a systematic and transparent approach to generating nursing-sensitive performance measures from routine data. It could improve their operationalization, facilitate their understanding and evaluation.

Aims To describe the organization of nursing services (staffing, scope of practice, teamwork) and its association with medication errors and falls, in rehabilitation units. Background The healthcare system is greatly impacted by the ageing population and the complexity of care associated with chronic diseases. It is therefore necessary to have enough staff who are using their full scope of practice and who are operating in a favourable working environment. However, these conditions are not always met, which can lead to threats to patient safety. Design A correlational descriptive study. Methods Staffing data and reported safety incidents were collected by shift from 01 October 2019 until 15 January 2020 in five rehabilitation units. In addition, a total of 75 nursing staff members responded to a missed care and teamwork survey. Descriptive analysis and logistic regression analysis were performed. Results The mean staff hours per patient shift was 1.39 (SD = 0.60). The teams reported a lobal missed care score as ‘rarely missed’ at 1.14 (SD = 0.07) and a moderate teamwork score at 3.36 (SD = 0.58) on a five-point scale. The safety incidents decreased 10-fold with a predominance of bachelor compared with technician nurses and decreased by 67% when there was an increase of 1 h of care per patient shift. Conclusions This study showed that the organization of nursing services in the observed rehabilitation units is characterized by a moderate staffing intensity, a moderate perception of teamwork level and a relatively low level of missed care. It indicated the key role of the staffing in reducing the risk of occurrence of safety incidents. Future research specific to rehabilitation hospitals are greatly needed to improve patient outcomes in this setting. Impact Nurse Managers should consider all the aspects of the organization of nursing services (staffing, scope of practice and teamwork) in their efforts to improve patient safety in rehabilitation settings. A central finding of this study is that the staffing intensity, the proportion of bachelor prepared nurses and the proportion of agency staff were positively associated with a reduction of safety incidents.

Background: Nosocomial infections (NIs) are among the main preventable healthcare adverse events. Like all countries, Canada and its provinces are affected by NIs. In 2004, Ministry of Health and Social Services (MSSS) of Quebec instituted a mandatory surveillance NI program for the prevention and control (NIPC) in the hospitals of the province. One target of the MSSS 2015–2020 action plan is to assess the implementation, costs, effects, and return on investment of NIPC measures. This project goes in the same way and is one of the first major studies in Canada to evaluate the efficiency of the NIPC measures. Three objectives will be pursued: evaluate the cost of implementing clinical best practices (CBPs) for infection control; evaluate the economic burden attributable to NIs; and examine the cost-effectiveness of the NIPC by comparing the costs of CBPs against those of NIs. Methods: This project is based on an infection control intervention framework that includes four CBPs: hand hygiene; hygiene and sanitation; screening; and additional precautions. Four medical and surgical units in two hospitals (nonUniversity, University) in the province of Quebec will be studied. The project has four components. Component 1 will construct and content validate an observation grid for measuring the costs of CBPs. Component 2 will estimate CBP costs via 2-week prospective observations of health workers, conducted every 2 months over a 1-year period. Component 3 will evaluate, through a matched case-control study, the economic burden of the four most monitored NIs in Quebec (C-difficile, MRSA, VRE, and CPGNB). Archival patient data will be collected retrospectively. Component 4 will determine the optimal breakeven point for CBPs associated with NIPC. Discussion: This project will produce evidence of the economic analysis of NIPC and give health stakeholders an overview of NIPC cost-effectiveness. It will meet the objectives of the Canadian Patient Safety Institute and the MSSS action plan to analyze the efficiency of NIPC preventive measures. To our knowledge, this is the first such exercise in Quebec and Canada. It will provide governments with a decision support tool through a major empirical study that could be replicated nationally to capture the financial benefits of NIPC.

Background Nurse practitioners (NPs) have been added to primary healthcare teams to improve access to care. Team processes, including communication and decision-making, explicate how patients and families view team functioning. Yet, important gaps exist in our understanding of patient-reported experience and outcomes at the level of the healthcare team. We aimed to examine the influence of individual, team, and organizational characteristics, and role clarity on outcomes of care mediated by team processes in primary healthcare teams that include NPs. Methods A cross-sectional survey across six sites representing practices with NPs in Québec, Canada, was conducted between March 2018 and April 2019 as part of a multiple-case study. Patients and families (n = 485; response rate: 53%) completed a validated questionnaire, which included a patient-reported experience measure (PREM) and a patient-reported outcome measure (PROM) of team functioning (Cronbach alpha: 0.771 (PROM) to 0.877 (PREM)). We performed logistic regression and mediation analyses to examine relationships between the individual, team, and organizational characteristics, role clarity, and outcomes of care mediated by team processes. Results Patients and families expressed positive perceptions of team functioning (mean 4.97/6 [SD 0.68]) and outcomes of care (5.08/6 [0.74]). Also, high team processes (adjusted odds ratio [AOR] 14.92 [95% CI 8.11 to 27.44]) was a significant predictor of high outcomes of care. Role clarity (indirect effect coefficient ab = 6.48 [95% CI 3.79 to 9.56]), living in an urban area (-1.32 [-2.59 to -0.13]), patient as respondent (-1.43 [-2.80 to -0.14]), and income (1.73 [0.14 to 3.45]) were significant predictors of outcomes of care mediated by team processes. Conclusions This study provides key insights on how primary healthcare teams with NPs contribute to team functioning, using a validated instrument consistent with a conceptual framework. Results highlight that high role clarity, living in a non urban area, family as respondent, and adequate income were significant predictors of high outcomes of care mediated by high team processes. Additional research is needed to compare teams with and without NPs in different settings, to further explicate the relationships identified in our study.

Background Providing care to cancer patients is associated with a substantial psychological and emotional load on oncology workers. The purpose of this project is to co-construct, implement and assess multidimensional intervention continuums that contribute to developing the resilience of interdisciplinary cancer care teams and thereby reduce the burden associated with mental health problems. The project is based on resources theories and theories of empowerment. Methods The study will involve cancer care teams at four institutions and will use a mixed-model design. It will be organized into three components: (1) Intervention development. Rather than impose a single way of doing things, the project will take a participatory approach involving a variety of mechanisms (workshops, discussion forums, surveys, observations) to develop interventions that take into account the specific contexts of each of the four participating institutions. (2) Intervention implementation and assessment. The purpose of this component is to implement the four interventions developed in the preceding component, assess their effects and whether they are cost effective. A longitudinal quasi-experimental design will be used. Intervention monitoring will extend over 12 months. The effects will be assessed by means of generalized estimating equation regressions. A cost-benefit analysis will be performed to assess the cost-effectiveness of the interventions, taking an institutional perspective (costs and benefits associated with the intervention). (3) Analysis of co-construction and implementation process. The purpose of this component is to (1) describe and assess the approaches used to engage stakeholders in the co-construction and implementation process; (2) identify the factors that have fostered or impeded the co-construction, implementation and long-term sustainability of the interventions. The proposed design is a longitudinal multiple case study. Discussion In the four participating institutions, the project will provide an opportunity to develop new abilities that will strengthen team resilience and create more suitable work environments. Beyond these institutions, the project will generate a variety of resources (e.g.: work situation analysis tools; method of operationalizing the intervention co-development process; communications tools; assessment tools) that other oncology teams will be able to adapt and deploy elsewhere.

Introduction : Le rôle de l’infirmière praticienne spécialisée en soins de première ligne (IPSPL) est relativement récent au Québec. Il y a peu de données sur le déploiement de ce rôle. Objectif : Cette étude vise à décrire le temps passé dans les activités de soins selon les différentes dimensions cliniques et non-cliniques du rôle des IPSPL. Méthodes : Une étude de temps et mouvements (399 heures et 34 minutes (min)) a été réalisée dans 6 milieux de première ligne incluant les soins ambulatoires, l’hébergement et les soins de longue durée, et le soutien à domicile auprès de 12 IPSPL. Résultats : La dimension clinique occupe 72 % à 83 % du temps de travail. Le temps moyen de consultation est influencé par le milieu et varie de 13 min et 32 secondes (sec) à 26 min et 25 sec. En soutien à domicile, le temps (déplacement et coordination des soins) de consultation est plus long. La documentation, 9 % à 20 %, est l’activité qui prend le plus de temps. La durée des appels téléphoniques varie en moyenne entre 4 min à 8 min et 39 sec selon les milieux. Discussion et conclusion : La dimension clinique occupe la plus grande partie du temps de travail des IPSPL. Les consultations téléphoniques permettent de répondre aux interrogations des patients. Puisqu’elles sont fréquentes, ces dernières devraient être comptabilisées dans l’évaluation de la charge de travail des IPSPL. Une meilleure compréhension du rôle des IPSPL pourrait soutenir la planification de la main d’œuvre IPSPL pour mieux répondre aux besoins des patients.