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Understanding the conditions that influence the roles of midwives in Ontario, Canada's health system: an embedded single-case study.

ABSTRACT: BACKGROUND:Despite the significant variability in the role and integration of midwifery across provincial and territorial health systems, there has been limited scholarly inquiry into whether, how and under what conditions midwifery has been assigned roles and integrated into Canada's health systems. METHODS:We use Yin's (2014) embedded single-case study design, which allows for an in-depth exploration to qualitatively assess how, since the regulation of midwives in 1994, the Ontario health system has assigned roles to and integrated midwives as a service delivery option. Kingdon's agenda setting and 3i + E theoretical frameworks are used to analyze two recent key policy directions (decision to fund freestanding midwifery-led birth centres and the Patients First primary care reform) that presented opportunities for the integration of midwives into the health system. Data were collected from key informant interviews and documents. RESULTS:Nineteen key informant interviews were conducted, and 50 documents were reviewed in addition to field notes taken during the interviews. Our findings suggest that while midwifery was created as a self-regulated profession in 1994, health-system transformation initiatives have restricted the profession's integration into Ontario's health system. The policy legacies of how past decisions influence the decisions possible today have the most explanatory power to understand why midwives have had limited integration into interprofessional maternity care. The most important policy legacies to emerge from the analyses were related to payment mechanisms. In the medical model, payment mechanisms privilege physician-provided and hospital-based services, while payment mechanisms in the midwifery model have imposed unintended restrictions on the profession's ability to practice in interprofessional environments. CONCLUSIONS:This is the first study to explain why midwives have not been fully integrated into the Ontario health system, as well as the limitations placed on their roles and scope of practice. The study also builds a theoretical understanding of the integration process of healthcare professions within health systems and how policy legacies shape service delivery options.

SUBMITTER: Mattison CA

PROVIDER: S-EPMC7068956 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundOntario, Canada is home to eight native species of turtles; all eight are federally listed as Species At Risk, due to anthropogenic threats. However, until recently, reports of infectious disease have been lacking. Ranavirus is seen as an emerging threat for ectotherms globally, with mass die-offs most often reported in amphibians. Ranavirus has been detected in Ontario's amphibian populations, can be transmitted via water, and can be transmitted from amphibians to turtles. However, no studies on the prevalence of this virus in Ontario's turtles have previously been carried out. With recent reports of two confirmed positive case of ranavirus in turtles in Ontario, a knowledge of the ecology of ranavirus in Ontario's turtles has become even more important. This study estimates the prevalence of ranavirus in Ontario's turtles, and investigates the hypothesis that this is a newly emergent disease.MethodsSixty-three samples were tested for ranavirus via PCR. These included a variety of turtle species, across their home range in Southern Ontario. Fifty-two of the samples originated from the liver and kidney of turtles who had succumbed to traumatic injuries after being admitted to the Ontario Turtle Conservation Centre; ten of the samples were taken from cloacal swabs, lesion swabs, or tail clips collected from live turtles showing signs of clinical disease. One of the live turtles was later euthanized for humane reasons and PCR was also carried out on the liver/kidney.ResultsNone of the 63 samples were found to be positive for ranavirus via PCR. The zero prevalence found in this study translates into a population prevalence estimate of less than 5%, with no change in prevalence from 2014-2018.DiscussionThis is the first report on the prevalence of ranavirus in Ontario's turtles, and will help build an understanding of the ecology of this virus in Ontario. Ranavirus has historically been underreported in reptiles, but there has been an increase in global reports recently, most likely due to increased awareness. A carrier state is thought to exist in reptiles which makes surveillance in the population via random sampling a viable method of detection of prevalence. The first report of ranavirus in Ontario turtles occurred in 2018. This study suggests a continued low population prevalence for the years 2014-2018, however. Ongoing surveillance is necessary, as well as investigation of the eDNA presence in waterways as compared to the PCR of resident turtles, to further understand the sensitivity of these species to ranavirus infection. The utilization of qPCR would be helpful, to better quantify any positives encountered.

Project description:BackgroundThe unprecedented amount of resources dedicated to humanitarian aid has led many stakeholders to demand the use of reliable evidence in humanitarian aid decisions to ensure that desired impacts are achieved at acceptable costs. However, little is known about the factors that influence the use of research evidence in the policy development in humanitarian crises. We examined how research evidence was used to inform two humanitarian policies made in response to the Syrian refugee crisis.MethodsWe identified two policies as rich potential case studies to examine the use of evidence in humanitarian aid policy decision-making: Lebanon's 2016 Health Response Strategy and Ontario's 2016 Phase 2: Health System Action Plan, Syrian Refugees. To study each, we used an embedded qualitative case study methodology and recruited senior decision-makers, policy advisors, and healthcare providers who were involved with the development of each policy. We reviewed publicly available documents and media articles that spoke to the factors that influence the process. We used the analytic technique of explanation building to understand the factors that influence the use of research evidence in the policy-development process in crisis zones.ResultsWe interviewed eight informants working in government and six in international agencies in Lebanon, and two informants working in healthcare provider organizations and two in non-governmental organizations in Ontario, for a total of 18 key informants. Based on our interviews and documentary analysis, we identified that there was limited use of research evidence and that four broad categories of factors helped to explain the policy-development process for Syrian refugees - development of health policies without significant chance for derailment from other government bodies (Lebanon) or opposition parties (Ontario) (i.e., facing no veto points), government's engagement with key societal actors to inform the policy-development process, the values underpinning the process, and external factors significantly influencing the policy-development process.ConclusionsThis study suggests that use of research evidence in the policy-development process for Syrian refugees was subordinate to key political factors, resulting in limited influence of research evidence in the development of both the Lebanese and Ontarian policy.

Project description:BackgroundNearly 30 years post legalisation and introduction, midwifery is still not optimally integrated within the health system of Canada's largest province, Ontario. Funding models have been identified as one of the main barriers.MethodsUsing a constructivist perspective, we conducted a qualitative descriptive study to examine how antepartum, intrapartum, and postpartum funding arrangements in Ontario impact midwifery integration. We conceptualized optimal 'integration' as circumstances in which midwives' knowledge, skills, and model of care are broadly respected and fully utilized, interprofessional collaboration and referral support the best possible care for patients, and midwives feel a sense of belonging within hospitals and the greater health system. We collected data through semi-structured telephone interviews with midwives, obstetricians, family physicians, and nurses. The data was examined using thematic analysis.ResultsWe interviewed 20 participants, including 5 obstetricians, 5 family physicians, 5 midwives, 4 nurses, and 1 policy expert. We found that while course-of-care-based midwifery funding is perceived to support high levels of midwifery client satisfaction and excellent clinical outcomes, it lacks flexibility. This limits opportunities for interprofessional collaboration and for midwives to use their knowledge and skills to respond to health system gaps. The physician fee-for-service funding model creates competition for births, has unintended consequences that limit midwives' scope and access to hospital privileges, and fails to appropriately compensate physician consultants, particularly as midwifery volumes grow. Siloing of midwifery funding from hospital funding further restricts innovative contributions from midwives to respond to community healthcare needs.ConclusionsSignificant policy changes, such as adequate remuneration for consultants, possibly including salary-based physician funding; flexibility to compensate midwives for care beyond the existing course of care model; and a clearly articulated health human resource plan for sexual and reproductive care are needed to improve midwifery integration.

Project description:BACKGROUND:To meet the complex needs of healthcare delivery, the Ministry of Health and Long Term Care (MOHLTC) introduced Physician Assistants (PAs) into the Ontario health care system in 2006 with the goal of helping to increase access to care, decrease wait times, improve continuity of care and provide a flexible addition to the healthcare workforce. The characterization of healthcare organizations as complex adaptive systems (CAS) may offer insight into the relationships and interactions that optimize and restrict successful PA integration. The aim of this study is to explore the integration of PAs across multiple case settings and to understand the role of PAs within complex adaptive systems. METHODS:An exploratory, multiple-case study was used to examine PA role integration in four settings: family medicine, emergency medicine, general surgery, and inpatient medicine. Interviews were conducted with 46 healthcare providers and administrators across 13 hospitals and 6 family medicine clinics in Ontario, Canada. Analysis was conducted in three phases including an inductive thematic analysis within each of the four cases, a cross-case thematic analysis, and a broader, deductive exploration of cross-case patterns pertaining to specific complexity theory principles of interest. RESULTS:Forty-six health care providers were interviewed across 19 different healthcare sites. Support for PA contributions across various health care settings, the importance of role awareness, supervisory relationship attributes, and role vulnerability are interconnected and dynamic. Findings represent the experiences of PAs and other healthcare providers, and demonstrate how the PAs willingness to work and ability to build relationships allows for the establishment of interprofessional, collaborative, and person-centered care. As a self-organizing agent in complex adaptive systems (i.e., health organizations), PA role exploration revealed patterns of team behavior, non-linear interconnections, open relationships, dynamic systems, and the legacy of role implementation as defined by complexity theory. CONCLUSIONS:By exploring the role of PAs across multiple sites, the complexity theory lens concurrently fosters an awareness of emerging patterns, relationships and non-linear interactions within the defined context of the Ontario healthcare system. By establishing collaborative, interprofessional care models in hospital and community settings, PAs are making a significant contribution to Ontario healthcare settings.

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Understanding the conditions that influence the roles of midwives in Ontario, Canada's health system: an embedded single-case study.

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