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Abstracts, Oral (Listed Alphabetically by Authors Last Name) Academic research paper on "Health sciences"

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Academic research paper on topic "Abstracts, Oral (Listed Alphabetically by Authors Last Name)"

International Journal of Qualitative Methods 2016: 1-64

Abstracts, Oral (Listed Alphabetically by Author's Last Name) sDaOeipUbo.nr;706^7s625os;sr

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Engaging Women in Prison in Qualitative Research

Penelope Abbott, Western Sydney University Michelle DiGiacomo, University of Technology Sydney Parker Magin, University of Newcastle Joyce Davison, University of Western Sydney Kelly Watt, Western Sydney University Wendy Hu, Western Sydney University

Researchers face many challenges when seeking to recruit people who are in prison to actively participate in qualitative research, such as through interviews or focus groups. Informed by published literature, I will draw on my own research on the integration of health care services at the interface between prison and community for women in prison in New South Wales, Australia. I will reflect on my experiences as a clinician and researcher within the custodial environment and discuss the following questions. What practices are used to recruit prisoners to qualitative research interviews and focus groups, and what are the processes for undertaking the data collection? What contextual factors are taken into account? What ethical considerations are taken into account? I will discuss working within the structural limitations of access to prisoners, the impact of multisite institutional review board processes, obtaining informed consent, engaging with Aboriginal and Torres Strait Islander participants and participants from culturally and linguistically diverse backgrounds, maintaining confidentiality, reimbursement of participants' costs, managing secondary trauma, and the responsibilities of undertaking qualitative research in a prison setting.

Adolescent Girls in Distress: self-reported Sexual Abuse due to non-implementation of Reproductive Health Policy

Olufunke Adegoke, University ofIbadan Kayode Osungbade, University of Ibadan

Adolescents represent one of the main pillars of any society. In Nigeria, they form a large significant and growing population group. Adolescents have specific health and development needs, and many face challenges that threaten their well-being. A major contribution to poor adolescent health status is lack of accurate knowledge of sexual and reproductive health issues, lack of accurate information on existing policy, and limited access to adolescent-friendly health services. In consideration of the above-mentioned limitations, we conducted a project in Ekiti State, aimed at developing a strategic plan of action to improve reproductive health of youth in partnership with policy makers. This was a descriptive and explorative study that combined data collection methods of key informant interviews, in-depth interviews, focus group discussions, and observations. Data collected from important stakeholders (in school youth, teaching staff, key persons in the relevant State Ministries and Heads of youth related nongovernmental organizations) were triangulated. The transcription of the qualitative data was done verbatim. Data were thematically analyzed. Self-reported sexual coercion, exploitations, and victimization were common practices perpetuated by teachers. Main coping mechanisms were enduring punishment in class and self-assurance that their graduation year was near. This was made complex by lack of awareness and poor implementation of

Creative Commons CC-BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 3.0 License (http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page (https://us.sagepub.com/en-us/nam/open-access-at-sage).

existing national reproductive health policy on adolescents by decision makers. Thus, targeted sensitization and implementation of the national policy might help Nigerian adolescents to seek redress.

Advancing Health Research in Saudi Arabia: Is quantitative Research Always the Best Approach?

Aisha Namshan Aldawsari, Western University

Qualitative health research has been used on a global level, but it has yet to be effectively explored in nursing education in Saudi Arabia, where the majority of researchers tend to value statistics and numbers more than subjective data. The goal of this presentation is to discuss the main reasons for the lack of qualitative studies in Saudi Arabia. In so doing, I will refer to various published studies to support my claims. I will also highlight some of the benefits of adopting a qualitative research approach to advance knowledge in nursing education in Saudi Arabia, using real examples. As well, I will outline the value and challenges of doing qualitative research, reflecting on my own experiences.

Skype Interviews in Qualitative Research

Aisha Namshan Aldawsari, Western University

Qualitative research has traditionally used face-to-face, in-depth interview techniques to gain an understanding of a phenomenon. With the advancement of technology, a few programs allow people to communicate and conduct qualitative interviews without having to meet the person face-to-face. One of these programs is Skype. In this presentation, I will share my experience using Skype to interview participants located in different countries, showing that the benefits of such technology outweighs its disadvantages. Using Skype can save a researcher time and money by not having to travel to meet participants as long as the researchers and participants have a computer device and access to Internet. Additionally, using Skype allows researchers to interview participants anytime and anywhere. I will also discuss the challenges that I faced with Skype.

Reducing Communication Barriers Through Language Concordant Communication Among Patients and Nurses From Minority Ethnic Communities in UK

Parveen Ali, University of Sheffield

Nurses are responsible to provide care to their patients regardless of their culture, religion, and ethnic background. Effective communication remains an important aspect of quality care, as it helps in building an effective patientprovider relationship, assessing, and meeting the need of patients. Language barriers, however, are hurdles that affect

communication between nurses and patients. Eliminating language barriers is the first step to providing culturally competent and patient-centred care. The present study was conducted to explore current communication practices of bilingual/ multilingual nurses when dealing with patients from shared linguistic background and to identify barriers and facilitators to language-concordant communication among nurses and patients. Fifty-nine nurses, working in various hospitals, contributed to the study through 26 individual in-depth interviews and three focus group discussions. The data were analysed using thematic analysis. Preliminary analysis suggests three themes, which are "impact on patients,'' "impact on nurses,'' "impact on service,'' and "facilitators and barriers.'' The findings generated from the project will help develop a communication model and guidelines to shape language-concordant communication practices among bilingual/multilingual nurses and patients.

Exploring Health Perceptions of Deported Women From USA to Mexico

Zafiro Del Carmen Andrade Romo, National Institute of Public Health

Cesar Infante-Xibille, National Institute of Public Health

Blanca Estela Pelcastre-Villafuerte, National Institute of Public

Health

Women's migration is growing worldwide, and this is no exception at the Mexico-United States immigration corridor. Almost 25% of immigrants in the United States who come from southern countries are women, and almost 121 of them were deported daily to Mexico's northern frontiers in 2012. Deported immigrant women are vulnerable at this moment of the immigration process because they lack social support, and there are many barriers to access services, including those related to medical care. This study reports findings from a discourse analysis of 18 life stories that were used as a biographic register in order to reconstruct the experiences of deported women at different stages of their migratory process. We used this approach to identify their health needs, access to health care services, and social networks of support in different stages of the migratory process. It was also possible to identify how social organizations and governmental institutions respond to immigrant women's health needs. Findings suggest that deported women identify health needs through the different moments of their migratory process. Their needs are related to not only sexual and reproductive health issues but also acute, chronic, and mental health problems. The social response to women's needs identified was very different depending on their social networks and their perceived health risk. This methodological approach represents an opportunity to understand how health needs vary depending on the immigration process and how a social response is organized. These results are useful to inform policy makers about a proper response to deported women's health.

Developing a Game-Based Intervention to Prevent HIV Among Young Men Who Have Sex With Men in Mexico City

Zafiro Del Carmen Andrade Romo, National Institute of Public Health Laura Chavira-Razo, National Institute of Public Health Raluca Buzdugan, University of California-Berkeley Sergio Bautista-Arredondo, National Institute of Public Health

Gamification modifies attitudes towards activities that individuals are unmotivated to undertake by embedding them in gamelike environments, awarding points for targeted outcomes, and using "leaderboards" (relative rankings) and nonfinancial rewards to create an atmosphere of supportive competition or collaboration. "Serious" games can increase participants' knowledge and self-efficacy skills. The objective of the first stage of this project was to develop the most appropriate and effective elements for an online game and gamification platform to incentivize men who have sex with men (MSM) from Mexico City to learn about HIV/AIDS and get tested for HIV and syphilis. Thirty-nine MSM aged 18-40 years participated in a total of six focus group discussions (FGDs), and a discourse-based analysis was performed. After abridge transcribing and coding the first two FGDs, analytical categories were created for character profiles and game elements; in order to triangulate this information, we conducted four additional FGDs. We found that young MSM were highly interested in an online intervention exclusively for MSM and positively reacted to gamification elements and principles. Moreover, talking about HIV is still taboo among Mexican MSM and sources for trustworthy information are not well known, but including these topics in the intervention and addressing HIV/AIDS myths in a friendly environment was seen by men as a big opportunity to start talking about these issues. Key informants from Mexico's gay community have also reacted positively to the first version of the platform, which is already developed based on these findings and we will test it this year.

Unmasking the Self as a Fallible Health Professional: The Effect of Shame on Health Professionals When They Make a Mistake

Diane Aubin, University of Alberta

This grounded theory study investigated the effect of shame on health professionals who make mistakes. Interviews with nurses, physicians, pharmacists, and residents generated rich data about their experiences that expose a multifaceted process that is shrouded in shame and contaminated with myths such as ''all mistakes are avoidable,'' "health professionals are perfect,'' and ''mistakes are rare.'' The study also uncovered a system that is besieged by investigative processes that are more like inquisitions than analyses and organizations that are more apt to abandon than support health professionals, as they struggle with their self-identity as a result of the traumatic event of a mistake. The theory that was developed from this study challenges current ''systems thinking'' theories about how to

manage mistakes in health care. It highlights the danger of focusing too much on the system and ignoring the human-ness of mistakes, which can be detrimental not only to the investigation of what went wrong but to the health professional who is suffering emotionally and who is essentially isolated and ignored. The study also provides recommendations for organizations to better support their staff after a mistake and for educational institutions to better prepare health professionals for experience of making mistakes through targeted training and interprofessional education. The findings can also help health professionals better understand why they react the way they do and give them guidance for managing and coping with the shame they feel after a mistake.

A Prescription for Comfort? A Validation Study of Interviews With Caregivers of Persons With Dementia in Ontario and Alberta

Katie Aubrecht, Mount Saint Vincent University Janice Keefe, Mount Saint Vincent University Jenny Ploeg, McMaster University Kimberly Fraser, University of Alberta

This presentation shares the learnings from a cross-provincial validation study of findings from an iterative interpretive thematic analysis of interviews with family caregivers of older adults living with multiple chronic conditions (MCC) that included dementia, conducted in Ontario and Alberta. A phe-nomenological sociological theoretical framework structured the analysis. In the Ontario study, comfort emerged as a primary theme, and the pharmacist was depicted as a figure that care-givers used to make sense of the meaning of comfort within a context of uncertainty about how to manage MCC when dementia was present. Family caregivers described the pharmacist as a guide who helped them navigate the complexities of life lived with multiple chronic conditions in a pragmatic and nonjudg-mental way. These findings are compared with findings from the analysis of interviews conducted at the Alberta study site. The aim of this validation is to clarify caregivers' perceptions of MCC management, to identify whether learnings regarding comfort are transferrable across provinces, and to confirm the practical and symbolic significance of the role of the pharmacist in supporting family caregivers in making sense of how best to manage MCC when one of the conditions is dementia. Findings are situated within the contexts of health services and social policy in each province. The presentation closes with a reflection on the importance of qualitative validity in health research.

Navigating the Generic Ethical Research Pathways: A Heuristic Journey

Patricia Awty, CQ University

Anthony Welch, CQ University Noosa

Philip Warelow, Federation University Mt Hellen Ballarat

Disquieting disconnection: This research investigates finding both meaning and a sense of purpose in life when journeying with

a partner who has semantic early-onset dementia using a heuristic approach (Moustakas, 1994). In using a heuristic method, this research will illuminate and provide a greater understanding of the journey of the researcher, as she wrestles and contends with the impact, the disquiet, and the slow disconnections of her relationship with her partner. Navigating through the complexities of the generic ethics process that tends to be more comfortable with quantitative methodologies proved to be a challenging and frustrating experience that perhaps highlighted the lack of understanding of the heuristic method within the realms of the general research world and implied a lack of appreciation of this valuable qualitative research approach. The researcher found this stage of the journey a difficult road to navigate. In saying this, it proved to be an informative experience that provided additional insights into the value of the lived experience of an individual and adds to the rigor of demonstrating the value and contribution made to extant knowledge about the phenomenon of disquieting disconnection. This research is about my journey that will hopefully challenge those researchers, academics, and in particular those who mostly fear litigation on ethics committees to move slightly to the left and confront those structures, which tend to value the empirical and castigate the lived experience when in reality they should be juxtaposed and homogeneous.

Wellness Strategies for Youth With Bipolar Disorder: Building and Sharing Knowledge Through a Community-Based Research Partnership in British Columbia

Nusha Balram Elliott, University of British Columbia Eugenia Canas, University of Western Ontario

Bipolar disorder (BD) is a serious mental illness characterized by extremes of mood. BD research has expanded rapidly in the past decade, yet the field faces challenges in improving quality of life (QoL) and symptom outcomes, accessing marginalized communities, and disseminating research into practice. As onset of BD typically occurs in young adulthood, youth are a target group for early intervention and support. There is evidence that "self-management" or ''wellness'' strategies can positively impact health and QoL in adults with BD. Missing from a research perspective is knowledge about effective strategies for youth with BD. The Bipolar Youth Action Project (BYAP) brings together a qualitative BD research group (Collaborative RESearch Team to study Psychosocial Issues in Bipolar Disorder [CREST.BD]), a BD-specific community group, and youth coresearchers with BD to help fill this gap. In keeping with its community-based participatory research (CBPR) methodology, BYAP is designed to build knowledge about how youth live well with BD and identify ways for sharing knowledge with peers, families, and health care providers while empowering youth. BYAP is sponsored by the Vancouver Foundation, and primary investigator on the project is Dr. Erin Michalak of University of British Columbia (UBC). This presentation details the involvement of youth coresearch-ers with BD as collaborators in the generation of knowledge

about their condition. Presenters will share emergent findings on youth wellness strategies; concrete strategies for encouraging sustained, meaningful youth engagement with CBPR; and features of collaborative partnership between adult researchers and young adults. Stages of research described include formulation of CBPR goals with youth; establishing collaborative processes; data gathering and analysis; and knowledge translation design. Impact of the collaboration upon youth coresearchers will be discussed. The CREST.BD is a multidisciplinary network of researchers, health care providers, and people living with the condition. We are dedicated to research and knowledge exchange about psychological and social factors in BD. Our aim is to enhance the health and wellness of people living with the condition. Mindyourmind is a national youth engagement program specializing in the collaborative involvement of youth in knowledge generation and exchange and in the cocrea-tion of resources that fight the stigma of mental illness. Eugenia Canas coordinates mindyourmind's community of practice, a multidisciplinary group of professionals dedicated to youth mental health. Nusha Balram Elliott is CREST.BD's Research Coordinator at the UBC.

How Does Meditation Feel? Exploring Meditation With Novice Meditators Taking Part in a Short-Term Meditation Program

Denice Basnett, University of South Africa Beate von Krosigk, University of South Africa

The regular practice of meditation has been shown to reduce stress and increase well-being. However, there is limited information on how meditation feels or is experienced by the meditator. This phenomenological study explores the subjective experience of the phenomenon of meditation with novice meditators taking part in a 4-week mindfulness meditation program. Research participants met once a week for a 30-min group meditation session. Each session was immediately followed by a 30-min, audio-recorded focus group during which the research participants shared their experiences. Analysis of the transcribed data revealed 12 themes that formed two categories, mind and body. The 12 themes formed the key constituents of the experience of the phenomenon of meditation according to the participants in this study. The research participants spontaneously spoke of different stages of the meditation process, that is, beginning, middle, and end. Using this information, the 12 key constituents were placed along a timeline of a typical 30-min session. A diagrammatic representation was created to illustrate the general ''shape'' of a typical meditation session. The variable nature of the meditation experience was also revealed: No two meditation sessions were experienced in the same way by the same meditator, and no two meditators had the identical meditation experience. These findings provide a holistic view of the experience of meditation from which the essence of the phenomenon of meditation was extracted. This information may be useful in demystifying meditation and help encourage those considering taking part in this healthful practice.

Exploring the Experiences of Rural Women in the United States Living With HIV/AIDS: A Synthesis of Qualitative Research

Lisa Baumgartner, Texas A&M University

More rural women are living with HIV/AIDS in the United States (United States Health Resources and Services Administration, HIV/AIDS in Rural America, 2015). Most research has concerned testing, prevention, and risk behaviors (e.g., Brown, Smith, & Hill, 2007; Thompson, 2013). The purpose of this paper was to synthesize extant literature outside the aforementioned areas to obtain a fuller picture of the experiences of this population. The synthesis included 11 studies that met the following criteria: used a qualitative methodology; participants lived in rural areas only; were U.S. based; concerned women; the study's main focus was not testing, prevention, or risk behaviors; and articles were published in English in a peer-reviewed journal. Three areas of inquiry were uncovered: (1) health care studies (barriers and facilitators to health care and relationships with health care personnel); (2) exploring motherhood (being or becoming a mother); and (3) general experiences living with HIV/AIDS. Nine of the 11 studies primarily focused on the experiences of African American women who were less educated and from a lower socioeconomic class in the Southern United States. The term "rural" was not explicitly defined in 9 studies. Most studies were descriptive and used focus groups. There is a need to expand areas of inquiry, population demographics, data collection methods, and frame studies using critical theoretical frameworks. Study findings have implications for health professionals.

Bearing Witness: From Participant Observation to Knowledge Translation, The Researcher Role in Critical Ethnography in Residential Long-Term Care

Denise Beaton, Simon Fraser University Jennifer Baumbusch, University of British Columbia Marie-Eve LeBlanc, University of British Columbia Alison Phinney, University of British Columbia

The process of participant observation in residents with advanced dementia, family caregivers, and staff is not just one of recording but also of bearing witness. During participant observation sessions, the researcher is uniquely tasked with negotiating between being present and attentive to the experiences of the participants while acknowledging their own role in constructing the situation. Data have been generated through a critical ethnographic approach. To date, this has included in-depth interviews with 3 residents, 11 family members, and 12 staff members and 90 hr of participant observation. The process and experience of gathering data have been reflexively critiqued through the researcher's engagement in self-awareness and criticism. When engaged in participant observation with family caregivers, staff members, and residents with advanced

dementia, the researcher is required to attest to the authenticity of the participants' experience through their own experience of being in research—not as a neutral information gatherer but as an active coparticipant in the social construction of the research data. Possible guidelines to the production of an accurate and illuminating account of bearing witness and the impact of this lens throughout the different stages of critical ethnographic research are discussed.

Developing a Client Satisfaction Survey for Persons With Severe and Persistent Mental Illness Through a Participatry Action Research Model

Tracy Bellamy, Pinecrest-Queensway Community Health Centre ACT Team

Shannon Parsons, Carleton University

Consumers of mental health services have historically been oppressed and stigmatized by the institutions involved in their care, and there continues to be a general lack of research on effective ways persons with severe and persistent mental health issues can provide feedback to their care providers. Recognizing this, the Pinecrest-Queensway Community Health Centre's (PQCHC) Assertive Community Treatment Team (ACTT) and researchers from Carleton University departed from traditional methods and used a participatory action research approach to develop a tool that would encourage clients to provide the ACTT with feedback on their level of satisfaction with the services they are receiving. A research advisory committee (RAC) was developed to ensure ACTT clients were involved at each stage of the research process. Insight from the RAC resulted in the development of "The ACTT Client Feedback Form,'' a satisfaction survey formulated in a way that clients felt was nonthreatening and could be used as either a traditional paper survey or as a guide for an interview. The Feedback Form was piloted with 30% of PQCHC ACTT clients, and questions regarding satisfaction with ACTT services as well as with the method used to collect this information were posed. This method of collecting feedback resulted in a much higher response rate than previous methods used by the PQCHC and a similar or higher rate of response than methods used by other ACTT in Ontario. Results from the feedback form and the benefits of the process used to develop it will be discussed.

Strategies for Engaging the Duchenne Muscular Dystrophy (DMD) Community in Research

Roxanna Bendixen, University of Pittsburgh

Lauren Morgenroth, Hache Children's National Health System

Duchenne Muscular Dystrophy (DMD) is a pediatric-onset and rare degenerative neuromuscular disorder causing severe muscle loss and premature death. Research in DMD is critical to

provide advancements in treatment and care, to improve quality of life, and to ultimately find a cure for individuals with DMD. Yet our ability to achieve and measure progress in clinical research in DMD is constrained by recruitment challenges and low levels of participation. We seek to understand the barriers to engaging the DMD community in clinical trials as well as strategies that build healthy partnerships and inform and assist with our recruitment efforts. Our qualitative study included parent-centered and researcher-centered focus groups from five sites: Pittsburgh, PA; Washington, DC; Minneapolis, MN; Houston, TX; and Sacramento, CA. A total of 13 focus group sessions were completed with 33 researchers/clinicians participants and 28 parent participants of boys with DMD. Qualitative thematic analyses of focus group transcripts were conducted to identify themes from both parent and researcher/clinician focus groups. Major themes identified included incentives and barriers to research participation, the importance of open and honest communication and information to help families make informed decisions, and novel solutions for engaging families in research. Researchers/clinicians and parents shared similar ideas on research engagement, and disconnect between the two groups existed regarding perceived barriers and incentives to research participation. Identifying incentives and barriers to recruitment and research participation provided insight to develop recruitment plans that partner with and support families participating in research in DMD.

Concealable Stigmatized Identity Revelations: Familial Experiences of Telling, or Not Telling, Others About a Child's Epilepsy Diagnosis

Ailbhe Benson, Dublin City University

Stephanie O'Toole, Dublin City University

Veronica Lambert, Dublin City University

Pamela Gallagher, Dublin City University

Amre Shahwan, Temple Street Child's University Hospital

Joan Austin, Indiana University

Disclosure of a concealable stigmatized identity, such as epilepsy, to those external to the nuclear family presents a particularly salient challenge for children living with epilepsy (CWE) and their parents, as childhood/adolescence are critical periods for identity formation. Stigma experiences during this time can detrimentally affect psychosocial well-being. However, knowledge about the disclosure practices of such populations is limited. This study aimed to address this gap by examining the disclosure experiences of families living with epilepsy. Separate interviews were conducted with CWE (n = 33) and their parents (n = 40). A semistructured interview guide was employed to explore the interpersonal processes and context surrounding CWE's and parents' disclosure practices including barriers, facilitators, and consequences of familial disclosure. Thematic analysis revealed varying disclosure

management strategies ranging from total concealment to voluntary disclosure. Barriers to disclosure included perceived threats to the child's sense of normalcy, familial challenges in accepting the diagnosis, others' negative reactions to disclosure, and the invisibility of epilepsy. Facilitators to disclosure included the ability to verbally represent epilepsy and personality traits of the disclosure target. Concealment resulted in some CWE feeling burdened, while disclosure alleviated such feelings. Some parents viewed concealment as protecting the child, while others valued disclosure as a means to prepare others to react appropriately to seizures. This qualitative exploratory study is the first to primarily focus on disclosure amongst families living with epilepsy. It provides a nuanced understanding of the contextual factors that inform familial disclosure decisions, improving our understanding of the challenges CWE and parents face.

A Hidden Condition: The Stigma Experiences of Children Living Wth Epilepsy and Their Parents

Ailbhe Benson, Dublin City University

Stephanie O'Toole, Dublin City University

Veronica Lambert, Dublin City University

Pamela Gallagher, Dublin City University

Amre Shahwan, Temple Street Child's University Hospital

Joan Austin, Indiana University

On receiving a diagnosis of childhood epilepsy, families must not only contend with the medical aspects but also with the impact the condition has on psychosocial well-being and remnants of epilepsy-related stigma that still persists. Although epilepsy-related stigma is often reported as having more negative implications for children living with epilepsy (CWE) than seizures themselves, little research exists that examines the extent and ramifications of stigma experiences for CWE by capturing the voices of CWE and parents themselves. This study aims to address this gap in chronic illness literature. Data in this presentation emerged from qualitative interviews investigating disclosure practices and family communication surrounding epilepsy. Interviews were conducted with CWE aged 6-16 years (n = 33) and their parents (n = 40). Data were thematically analyzed. Findings from this study revealed that epilepsy-related stigma remains rife in modern day society. Experiences of both felt and enacted stigma emerged. Such experiences were highlighted not only by child and parent reports of exclusion, discrimination, and prejudice but also by the unwillingness of families living with epilepsy to be open and honest about it with others. This qualitative exploratory study presents a unique insight into the difficulties faced by families living with epilepsy, as a result of epilepsy-related stigma. In order to improve the psychosocial well-being of CWE and their parents, efforts must be made to eradicate such stigma and to create an environment in which families living with epilepsy feel comfortable disclosing and discussing epilepsy within a public forum.

Are Resources for 22/23 Week Neonates Ethically Justifiable?

Agnes Berger Kaufman, State University of New York Albany Medical

The extraordinary achievements in science, medicine, and technology in the past century have led to unimaginable advancements in health care applications. Many health care institutions are equipped with state-of-the-art sophisticated apparatus, which can be implemented, as needed, by highly skilled professional medical workers. With rising costs associated with costly medical equipment purchase and maintenance, there is an acknowledgement that these coveted instruments are in limited supply. The complement of scientific knowledge together with technological expertise has progressed to the point that of artificially maintaining the internal bodily functions of patients who are in fact deemed clinically dead. Since the publication of Dr. Henry Beecher's enlightening article in 1966, patient autonomy has steadily progressed. Should the bioethical principle of acceptance of and respect for patient autonomy not also include the right to request termination of life for those who are competent and have capacity? Furthermore, are those individuals who lack capacity but who are represented by a surrogate not entitled to the same freedoms and rights? This paper will address whether children, infants, and neonates have the same privileges and benefits as the adult population with respect to termination of life concerns. Irrespective of peoples' unease in discussing the merits of extending severely ill and terminal neonates' suffering this defenseless patient cohort deserves to be granted the same rights as adult patients who can speak for themselves or have a surrogate express their wishes. Nurses should be on the front line of decision making regarding neonatal euthanasia as primary providers at the bedside.

Inside, Outside, or In-Between: The Impact of Social Location(s) on Research With Adults and Children

Rachel Berman, Ryerson University Maggie MacNevin, Ryerson University, Natalie Royer, Ryerson University, Rubina Quadri, Ryerson University

When engaging in social research, being aware of and acknowledging one's social location in relation to research participants is necessary to avoid reproducing and reinforcing biases and stereotypes (Shope, 2006). Traditionally, ethnographers have described a researcher's location as being either ''inside'' or "outside'': An insider is defined as a researcher who can say "I hold prior knowledge and understandings of the group I wish to study, and am also a member of that group'' (Greene, 2014, p. 2). More recently, many social researchers have argued that our identities and social locations are not fixed, but rather fluid and shifting, and therefore resist easy categorization (Merriam et al., 2001). Such researchers

question the existence of clear boundaries between insiders and outsiders. In this presentation, we explore the issues related to researcher positionality, including some recommendations for maximising the benefits and minimising risks related to both insider and outsider research. Additionally, we will discuss how researchers working with children have conceptualized their social position in relation to their young participants and how they seek to mitigate the significant conceptual distance between adults and children. Finally, we will share our experiences as researchers and the various and multiple social locations we occupied while interviewing 30 children one-on-one about their racial identity.

Two Eyed Seeing as a Guiding Principle in Nursing Research With First Nations Youth: Enhancing Our Understandings of Health

Deanna Bickford, University of Saskatchewan

It is a complex web of factors that contribute to the health inequities experienced by the First Nations (FN) peoples in Canada. Research that includes the voices and experiences of FN peoples is needed in order to reduce inequities. How these voices and experiences are brought to light has historically focused on what is wrong with the peoples, how can it be fixed, and continued to colonize the peoples through the use of Western methodologies, showing no respect for FN ways of knowing or sharing their knowledge. In order to move forward, as researchers, we must recognize these ways of knowing and sharing, engaging and exploring with FN people to understand, incorporate, and strengthen knowledge and capacities. Two Eyed Seeing (TES) is an important part of research that is meaningful, respectful, and reflexive and that is conducive to learning and sharing. It has been defined as learning to see from one eye with the strengths of Indigenous knowledges and ways of knowing and from the other eye with the strengths of Western knowledges and ways of knowing ... and learning to use both these eyes together, for the benefit of all? (Bartlett, Marshall, Marshall, & Iwana, 2012, p. 11). TES not about merging or assimilating of the knowledges but is about listening, learning, suspending judgments and opinions, and enriching our understandings. This presentation will reflect on the use of TES in a CBPR project that utilized a traditional way of creating and sharing knowledge to enhance understandings of health.

A Voice-Centered Relational Approach to Analyzing the Life Stories of Older Adult Women Living in Hidden Homelessness in a Northern Context

Annie Boucher, Laurentian University Carol Kauppi, Laurentian University Lorraine Carter, McMaster University

Background/Problem Statement: Little is known about the life stories of older Canadian women living in hidden

homelessness in a northern urban center. Narrative studies to date were not located that selected the Voice Centered Relational approach to analysis in conjunction with thematic analysis. ''I poems'' derived from this method provide significant meanings and are a vital form of aesthetic knowing. Study purpose: The purpose of this study is to understand the life stories of older women who have experienced hidden homelessness within the past year in one population center in northern Ontario. Stories were focused on their experiences of home, life challenges, being homeless, and health. Findings were likely to unveil the intersections of age, gender, and place. Methods: A Post Colonial Feminist lens that integrates critical social theory and inter-sectionality was deemed most appropriate to address the research purpose. A narrative inquiry design and storytelling methodology were used. A purposive and network sample of nine English-speaking women in their 50s, who were experiencing or had experienced hidden homelessness in the past year were recruited from one northern urban center. Up to seven serial individual and digitally recorded interviews were conducted with each woman. Data were analyzed thematically and using the Voice Centered Relational Method to create ''I poems.'' Presentation: This presentation focuses on the Voice Centered Relational Method of data analysis, and the ''I poems'' developed to give voice to one participants experience. In addition, thematic analysis resulted in an extensive record of each life. Implications: Their stories reveal their personal truths and individual strengths that can inform interdisciplinary practice, future research, and possibly policy development.

Research With Vulnerable Persons: Considerations in a Narrative Study of Older Adult Women Living in Hidden Homelessness

Annie Boucher, Laurentian University Carol Kauppi, Laurentian University Lorraine Carter, McMaster University

Background/Problem Statement: Conducting research with vulnerable persons creates unique and difficult challenges that require the creation of ethically sound methodological strategies. Study purpose: The purpose of this study is to understand the life stories of older women who had lived in hidden home-lessness within the past year in a northern urban context. Of special interest were their experiences of home, life challenges, being homeless, and health. The intersections of age, gender, and place were likely to be illuminated through their stories. Methods: A Post-Colonial Feminist lens was chosen, which integrates critical social theory and intersectionality. A narrative inquiry using a storytelling methodology was used. A purposive and network sample of nine older English-speaking women in their 50s, who were experiencing or had experienced hidden homelessness in the past year were recruited from one northern urban center. Up to seven serial individual and digitally recorded interviews were conducted with each woman. In addition, participants provided pictures or other items to help

tell their stories. Data were analyzed using thematic and voice-centered relational approaches. Presentation: The methodological challenges of conducting sensitive research and evidence-based strategies (EBS) selected to improve the quality of the study will be discussed.

Navigating Silence: Understanding the Grief Experiences of Young Men Bereaved by Suicide

Chris Bowden, Victoria University of Wellington Elizabeth Banister, University of Victoria Kay de Vries, University of Brighton

Losing a close friend to suicide can significantly increase the risk of depression and suicide in young people. Previous studies of suicide bereavement experiences have focused on parents and parentally bereaved children, younger adolescents' experiences of peer suicide, and female college students. A paucity of qualitative research exists that examines young men's experiences of suicide bereavement. This lack of research has meant that their grief may go unnoticed, be minimized, or even misunderstood. In this descriptive phenomenological study, I explored the essence of losing a close male friend to suicide. In-depth interviews were used to explore the lived experience of eight young men (17-25 years of age). Interviews were audiotaped and transcribed for analysis. Data were analysed according to phenom-enological analytic gestures of epoche (i.e., bracketing), reduction, and writing and led to seven themes: being gutted, staying stoic, grieving in silence, being silenced by others, breaking the silence, being in silence, and transforming. The overarching essence of their experience and the phenomenon was silence. The men suffered, retreated, grieved, found comfort, and made meaning in silence. Their experience of loss and navigating silent grief fostered a new direction in life, values, identities, and ways of being in the world. Their experience suggests that health professionals, families, and friends need to learn to see, listen to, and interpret the silence of men in order to better understand their experience and needs for support.

A Few Good Men: Recruitment, Relationships, and "Handling the Truth'' in Research

Chris Bowden, Victoria University of Wellington Elizabeth Banister, University of Victoria Kay de Vries, University of Brighton

Men often adhere to a code of silence. Young men's voices and experiences of health, grief, and suicide bereavement are missing from the literature. This presentation discusses some key lessons learnt from encountering methodological challenges in a doctoral descriptive phenomenological study of young men's suicide bereavement experience. The most significant challenge in the research was how to break the silence of young men. Breaking the silence involved (i) finding invisible men, (ii) building a working alliance, (iii) taking a youth and male-friendly approach to interviewing, (iv) using silence, and (v)

understanding the life worlds of men. I will discuss tips for recruiting vulnerable and hard-to-reach populations and for capturing lived experience of phenomenon in qualitative research. My experience as a male suicide bereavement researcher suggests that researchers need to be present and invested in building connections and authentic relationships with health care providers and potential participants. Investing in ''just-in-case'' rather than ''just-in-time'' relationships within a community will help researchers access hard-to-reach populations; promote collaboration, credibility, and trustworthiness; and improve the quality and impact of qualitative research.

Career Decision-Making Processes of Individuals With First Episode Psychosis

Christa Boychuk, Queens University

The first episode of psychosis often emerges at a time in life when individuals are achieving important educational and career milestones, which can become derailed, as a result of the development of significant impairments. Unfortunately, the career decision-making processes of individuals with first episode psychosis have not been previously investigated. This knowledge would provide a contextual understanding of the career decisions of individuals following their first episode of psychosis and enable vocational rehabilitation services to be more targeted and instrumental in empowering individuals. Thus, this study delineated the career decision-making processes of individuals following a first episode of psychosis and determined the aspects that influence it. Grounded theory was used to guide the study design, sampling, and analysis, using the method of Strauss and Corbin (1990, 1998). Three early intervention psychosis programs located in Ontario, Canada, were involved in this study. Participants included individuals treated for episode of psychosis by an early intervention team as well as family members of clients and program staff who had direct client contact. Data collection involved sociodemo-graphic questionnaires, one-on-one interviews, program documents, case-based memos, and a reflective journal. Analysis involved immersion in data and repeated sorting, coding, and constant comparison between passages of text and emerging categories within and between participants and programs. Analysis began with open coding, then proceeded to axial coding, and terminated with selective coding, which resulted in the development of a theoretical model.

Ending Up at the Emergency Department: Patient, Receptionist, and Doctors' Stories About the Role of Access to Primary Care

Emer Brangan, NIHR CLAHRC West Fiona MacKichan, University of Bristol Alyson Huntley, University of Bristol Lesley Wye, University of Bristol

Attendances at emergency departments are rising, and there is interest in what more, if anything, can be done at primary

care level to address this. This presentation draws on a mixed methods study in England which is bringing together findings from a systematic review of the literature, multi-variate analysis of routine data nationally, and six qualitative case studies in primary care practices. Three short stories about access to primary care, and what role this access plays in whether a patient ends up at the emergency department, are told in graphic form. These stories emerged from observation and interview data generated during the qualitative case studies. Each story places a different ''character'' centre stage: the patient, the primary care receptionist, and the primary care doctor.

Findings from the systematic review and the cross-sectional data analysis carried out within our study highlighted that the decision to attend the emergency department is the product of a complex interaction between individuals, their context, the organisation of health care, the behaviours and characteristics of health care practitioners, and the wider context of society. Our qualitative case studies, illustrated here by these stories, seek to unpack in more nuanced detail the operation of these factors and the complex interactions between them and to draw out implications for policy and practice

Critical Physical Therapy—Attitudes of Able Bodied Physical Therapists Towards Physical Therapists With Mobility Impairments: A Photo-Elicitation

James R. Brennan, The Sage Colleges Patricia Ryan, The Sage Colleges Ashley Crews, The Sage Colleges

Critical Physical Therapy (CPT) is physical therapy education and practice that is able to self-critique, which recognizes how the hegemonic nature of biomedicine disempowers and marginalizes persons with disabilities, is able to deconstruct authoritative physical therapy knowledge and control of the body and cocreates interdependence with persons with disabilities in order to facilitate a more liberating and democratic health care practice. The purpose this study was to examine the attitudes of able-bodied physical therapists toward physical therapist colleagues with mobility impairments using photo-elicitation. Thirty able-bodied physical therapists were shown two pictures of physical therapists in wheel chairs (one male and one female). They were asked a series of open-ended questions, beginning with ''what do you see?'' and ''what are your thoughts about having a colleague with a mobility impairment.'' From the data, the following themes were developed: tacit knowledge, insight, patient education, adaptation, and safety. Having colleagues with mobility impairments will practically insert the sociocultural model of disability into the biomedical reductionist paradigm transforming physical therapists and physical therapy practice, as persons with disabilities will be viewed as people and colleagues with complexity and context, possessing wisdom and insight and not just as subjects or patients needing to be fixed.

Bachelard's Poetics of Imagination: Toward a Hermeneutic-Poetic-Phenomenology in Health and Social Care

Helen Butlin, University of Western Ontario & London Health Sciences Centre

Elizabeth Anne Kinsella, University of Western Ontario

''Suddenly an image situates itself in the centre of our imagining being. It retains us; it engages us. It infuses us with being'' (Bachelard, 1969, p. 153). In this presentation, we draw on the philosophical work of Gaston Bachelard to propose hermeneutic-poetic-phenomenology as an enriching approach to research in health and social care contexts. Poetic inquiry is an emergent form of qualitative inquiry (Pre-ndergast, 2009; Todres & Galvin, 2006, 2008) and offers a conceptual space for investigating forms of ''embodied inquiry'' where text and embodied experiences meet (Pre-ndergast, Leggo, & Sameshima, 2009; Todres, 2007). Gaston Bachelard (1958, 1969) is an early 20th-century Continental philosopher of science who developed a unique form of phenomenology focusing on imagination, poetics, and embodied perception which he termed ''a poetics of the perceptible'' (Bachelard, 1969, p. 202). He states, ''A universe is born from a single image'' (Bachelard, 1969, p. 175) and illuminates the immediacy of the poetic image to elicit an embodied, transformative experience in the reader. Scheurich and McKenzie (2005) highlight Bachelard as an underutilized philosophical resource with the potential to contribute important epistemological insights into qualitative research. We propose that although his work has largely been overlooked in phenomenological research, Bachelard has much to offer contemporary qualitative studies. In this session, Bachelard's three approaches to phenomenology are discussed including (a) phenomenology of the material imagination, (b) phenomenology of reverie, and (c) phenomenology of the ''poetic image'' as mediating phenomenon from within lived experiences and intersubjective spaces. These dimensions are considered, as they inform a conception of hermeneutic-poetic-phenomenology that can be applied to research in health and social care contexts and in light of their relevance for poetic and embodied forms of qualitative inquiry.

Art-Based Methods in Youth-Centred Participatory Action Research: Praxis, Data Analysis, and Knowledge Translation in Investigations of Youth Health and Well-Being

Eugenia Canas, Western University Helene Berman, Western University Emanuela Bringi, York University

Art-based methods have been found to support qualitative and participatory approaches with vulnerable populations.

Yet, a question often posed is how art-based outputs of research constitute data and what methods of analysis are applicable and realistic within this research context. This presentation draws on work conducted under a national, 5-year Canadian Institutes of Health Research (CIHR)-supported grant titled Voices against Violence: Youth Stories Create Change. It describes a variety of art-based research groups that examine structural violence and its impact on the health and well-being of Canadian youth. In keeping with Y-PAR principles, the art-based methods in this project reflect a commitment to youth as experts in their own experiences and to creating supportive environments, so these experiences can be articulated in a language that is approachable and meaningful to youth. Presenters will provide concrete approaches to the iterative, collective, and collaborative analysis of art created by youth as well as the implications and opportunities available for knowledge translation that evocatively reflects youths' perspectives and reaches the ears of policy makers.

Ideology Trumps: Health Care Providers a Barrier to Abortion Services

Harneet Chahal, University of Alberta Zubia Mumtaz, University of Alberta

Abortions occupy a highly contentious space in Pakistan. Although at first glance the law and religion appear to denounce the procedure, poor clarity around these rules leaves providers with a negotiable space to conduct abortions. The dominant social narrative however remains heavily opposed to this procedure. Thus, it is possible that health care providers may experience an ethical or moral dilemma in making decisions around termination of pregnancy. To explore this further, this study examined provider views of induced abortion and how these views impact provider's provision of abortion services. A focused ethnography was conducted in Chakwal, Pakistan, from September to December 2013. Participants were recruited from a nongovernmental organization that provides abortion services. Twenty-three in-depth interviews were conducted with women seeking or who had an abortion and 14 with facility health care providers. One focus group discussion was conducted with health care providers. Providers viewed abortions to be wrong, felt they facilitated a deviation from God's will, and carried safety concerns for the mother's health. They also worried that abortions offered patients an ''easier'' fertility regulation option and would consequently incite a deviation from gendered norms. The extent these negative views impacted provider's provision of abortions depended on whether a social relationship existed with the patient. Most however did not have any relation to providers and were consequently subjected to a value-based assessment, aggressive counselling, and ultimately denied services. To support women's access to safe abortions, we recommend greater attention be given to hiring providers willing to conduct abortions.

"We Are the Ones in the Room the Most'': An Interpretative Phenomenological Analysis of the Experience of Hand Hygiene Among Critical Care Nurses

Sheryl L. Chatfield, Kent State University Jeffrey S. Hallam, Kent State University

Health care-associated infections (HAI) are responsible for substantial direct and indirect medical care costs, and improvement in hand hygiene among health care workers, including acute care nurses, has potential to reduce incidence of HAI. Despite this, hand hygiene compliance rates remain relatively low. We conducted qualitative interview research in the United States during 2014 using an interpretative phenomenological analysis (IPA) approach to explore how eight acute care nurses described their experiences with hygiene. Developed themes we will present include soap versus sanitizer, risky business, and hygiene on trial; the latter illustrates the parallels we drew between participants' described experiences and how often falsely accused defendants are depicted on television courtroom dramas. Our findings expand on findings from prior qualitative research studies, which have suggested that individual or subjective criteria might have more influence over health care workers' hand hygiene compliance than facility policies. Participants in this research distinguished between policy-mandated use of sanitizer and personal sense of cleanliness; the latter was more likely to be associated with purging or removal of contaminants, while the former was described as focusing on applications of coatings or other protection. While our participants supported facility hand hygiene policies, their behavior might be mediated by viewing some circumstances as exceptional situations as well as the belief that it is not currently possible to establish a casual link between HAI and a specific individual or occurrence.

Implementation Analysis of the Intercultural Health Policy in Mexico: A Case Study

Laura Guadalupe Chavira Razo, National Institute Of Public Health

Blanca Estela Pelcastre Villafuerte, National Institute of Public Health

Hortensia Reyes Morales, Children's Hospital of Mexico

Although many countries with indigenous populations acknowledge their multiculturalism, there are few who recognize it officially. Since the past decade, Mexico has had an explicit intercultural health policy, which is mainly focused on indigenous populations; however, there has been lack of evaluations of its process and results. Although there are official policy documents, there is no information about what happened at the implementation phase, to what extent this happened, its barriers, and enablers. The objective of this study was to reconstruct the implementation process of this policy in order to analyze its barriers, facilitators, and its possible determinants. A qualitative case study was carried

out in the forth Mexican state with the bigger amount of indigenous population. twenty-three semistructured interviews were conducted at different levels: federal (policy makers), state, and facility level. Findings suggest that the implementation process was closely linked to its context and the type of policy; in this case, this was a policy without resources assigned for its implementation and only based on recommendations and states' willingness to be implemented. Despite this context, the policy was found partially implemented. The major determinants to achieve this were the negotiation skills and the key strategies that the stakeholders took during the process once the implementation started. Since the policy does not end at the formulation phase, implementation studies are found to be very useful to inform policy makers about emerging barriers that might be happening and strategies to solve them.

How Brazil's Decentralized Health System Affects its HIV/AIDS Response: Preliminary Results From a Qualitative Study

Laura Guadalupe Chavira Razo, National Institute Of Public Health

Zafiro del Carmen Andrade Romo, National Institute of Public Health

Claire Chaumont, National Institute of Public Health Sergio Bautista Arredondo, National Institute of Public Health

Nearly one third of all people with HIV/AIDS in Latin America live in Brazil. The country is considered to have the boldest HIV/AIDS response on the continent. Brazil's response to HIV/AIDS has been a clear success in terms of access to anti-retroviral treatment and reduction in morbidity and mortality. This is why it is important to analyze the factors associated with this successful experience. The objective of this study was to investigate how specific characteristics of the Brazilian HIV/ AIDS response influence HIV/AIDS service delivery processes. Forty-five semistructured interviews were conducted with key informants at different levels of the Brazilian health system: national, state, municipal, and facility level. For the analysis, grounded theory steps were followed without reaching theory formulation. Preliminary findings suggest that the high level of decentralization found across government levels has a strong impact on HIV/AIDS service delivery processes. Decentralization was observed in the high level of autonomy and the horizontal relationships between government levels. These characteristics strongly influenced four aspects of health care delivery: human resources organization, health care delivery protocols, decision making, and monitoring and evaluation processes. Although the influence of decentralization was found positive in many aspects of health care delivery, there were others in which it represented a barrier. For example, the lack of systematization of clinical records information, patient reference systems, and assessment of facilities' processes. This type of study allows identifying potential areas for improvement even in successful policies.

Surfacing Regulatory Tensions in Ontario's Long-Term Residential Care Sector

Jacqueline A. Choiniere, York University

This paper explores the tensions and contradictions experienced by long-term care providers and residents as a result of Ontario's Long-Term Quality Inspection Process (LQIP). LQIP's system of prescriptive protocols and standardized guidelines, a response to serious quality concerns throughout the sector, is grounded in Ontario's 2007 Long-Term Care Homes Act. While there is evidence that some quality improvements have accompanied this regulatory change, there are significant concerns that its narrow, standardized, primarily clinical focus has meant less attention to residents' quality of life and providers' quality of work. Utilizing rapid ethnography methods, including observations and interviews, this paper reports on two pilot studies conducted in Ontario nursing homes. Observations and interviews with personal support workers (PSWs) registered practical nurses (RPNs), and registered nurses (RNs) were conducted over several days and during all three shifts. Staff members were both observed and reported being constrained from providing the quality of care they wanted to provide and that residents wanted. This devaluing of residents' individualized care needs and workers' care work conflicts with current resident-centered discourses and has significant gender implications. Residents and staff deserve better.

Maternity and Meaning-Making: A Qualitative Study Describing the Perinatal Educational Experiences of Pregnant and Parenting Youth Living in a Residential Program

Chantalle Clarkin, University of Ottawa Catherine Larocque, University of Ottawa

Pregnancy during adolescence presents a period of rapid biop-sychosocial change; pregnant and parenting youth (PPY) are simultaneously faced with the growth and developmental transitions associated with adolescence and the transformations accompanying motherhood. PPY are tasked with new roles and responsibilities including the management of pregnancy-related health needs, navigation of services, and development of maternal identities. While the challenges of adolescent motherhood are numerous and well documented, little is published about PPY who are homeless or at risk of becoming homeless. Moreover, little is known about their perinatal educational experiences or understandings of maternal health.

A constructivist paradigm provided the epistemological foundation for this multiple instrumental case study, and Bron-fenbrenner's bioecological systems theory formed the overarching conceptual framework. Grounded in the words and stories of PPY living in an urban residential program, this study examined how a group of women accessing community-based services constructed their perinatal health-related knowledge and views, encompassing both formal and informal learning

as well as the broader social and cultural contexts in which learning occurred. A series of in-depth, semi-structured interviews (n = 22) were conducted with 11 PPY (aged 17-20). Interviews were audio-recorded and transcribed verbatim. Data analysis consisted of within-case analysis followed by cross-case analysis. Each participant acted as an individual case and each participant's story contributed vital understanding of their experiences and contexts. Together, the cases as a collective present a collage that contributes insight into ways of actively engaging PPY to help them build links between perinatal health education and their day-to-day lives.

Developing HIV Primary Prevention Materials for Children in Haiti: A Qualitative Case Study of Cultural and Contextual Implications

Mary Clisbee, Nova Southeastern University Anna Shustack, Nova Southeastern University Jean-Claude Ulysse, Zanmi LaSante

Haiti has the highest AIDS rate in the western hemisphere, second only in the world to that found in sub-Saharan Africa (UNAIDS, 2011). Among other interventions, primary prevention educational programs delivered to children reduce the rate of spread of new infection (Aggleton et al., 2011) and are delivered both in schools and by community organizations (Aggleton et al., 2011). Since the rate of school attendance is low in rural Haiti, this delivery of primary prevention programs must include community-based organizations. Although there are many HIV prevention curricula specific to the more developed world, there is a general lack of appropriate educational materials related to HIV education for use in developing nations (Aggleton et al., 2011). These programs are often delivered outside the school setting where the members of these community organizations have little training about either HIV or how to teach children. Therefore, in addition to training needs (Mukherjee and Eustache, 2007), staff from the community organizations in Haiti who deliver these programs need a strong, well-developed, culturally relevant curriculum to follow. A strong curriculum design includes input from both subject experts and community members (Tyler, 1969). The purpose of this qualitative case study is to develop an understanding cultural and contextual implications to be considered in the development of an HIV primary prevention curriculum for children in Haiti. The international, interagency, interdisciplinary research team used a variety of qualitative data collection methods. In-depth interviews were the primary technique used to gather data. An interview protocol was used, with questions specifically designed to yield the data necessary to answer the research questions. Additionally, the research team kept observational field notes and gathered photographic data. Participants included both HIV subject matter experts and other individuals who work directly with children in Haiti. This study was quite unique. There were three co-pi's all from different countries of origin, representing two international

organizations and three disciplines. The team included a Haitian Obstetrics and Gynecology (Ob-Gyn) surgeon, an American university professor from the field of education, and a doctoral student of Canadian descent with a background in social work. All documents were translated into Haitian Creole, interviews conducted across languages, transcripts translated from Creole into English, and the final report was written in English. The U.S.-based researcher traveled to Haiti to gather data with the Haitian surgeon, and he later traveled to the states to engage in the data analysis phase of the study. Many lessons were learned by the researchers during this journey about conducting qualitative research in a developing country, and working across languages and across cultures, in a respectful manner.

Home Is Where My Dialysis Is: A Pilot Study

Laurie Clune, University of Regina Darlene Domshy, University of Regina

In this qualitative descriptive study, home dialysis, a popular technologic approach for the treatment of end-stage renal disease, is explored from the standpoint of the patient and family. The cost saving and convenience benefits of this type of treatment are well described in the literature. In this study, we explore how the home, a place with personal, geographic, and social meanings, is altered when medicalized treatment, like home dialysis, crosses the threshold. Interviews and photo-elicitation are used to collect data.The findings suggest that a total reorganization of the home is required in order to engage in home dialysis. In this pecha kucha-style presentation, images showing how the physical and social dimensions of the dialysis patient's home are reorganized will be presented.

Adaptation of a Structured Story-Dialogue Method for Research With Social Movement Activists

Roxanne Cohen, University of Toronto Blake Poland, University of Toronto Paul Antze, York University Cheryl Teelucksingh, Ryerson University

Dialogue and storytelling are essential elements of many qualitative methodologies, reflecting the constructivist paradigm in which Qualitative Research (QR) is grounded and the coconstruc-tion of knowledge that takes place between research participants (in group settings) and between participants and researchers. This paper reports on the adaptation of a structured story-dialogue method for research with social movement activists undertaken in the form of a series of regional weekend workshops animated by researchers and attended by Transition movement leaders and participants from multiple locales as part of the Transition Emerging Study (www.transitionemergingstudy.ca). We draw upon participant observation, animator reflections, research team meetings, participant feedback (written evaluations and group discussion), as well as workshop materials in relation to two different adaptations of Labonte and Feather's original formulation (1999)

and subsequent reflections (2011), setting this in the context of a broader literature on structured story-dialogue methods with groups. The potential of structured story-dialogue methods for the study of social movements is highlighted.

Cultural Influences on Coping and Adaptation of Filipino Immigrant Nurses

Jorgia Connor, Loyola University Chicago

Background: The purpose of this study was to explore coping strategies of Filipina nurses within the context of immigration and adaptation. Immigrant nurses face multiple challenges that may increase their vulnerability to negative physical and psychosocial outcomes. Members of different cultures not only respond differently to stress, they also differ in their preference of coping strategies. Therefore, it is important to understand the manner in which they cope in order to promote culturally appropriate interventions. Methods: A descriptive qualitative research design was used to gain a holistic understanding of the participants' experiences. Data collection included in-depth interviews using a semistructured questionnaire. Twenty women, 28-48 years old, working as registered nurses in midwest United States were interviewed. All received their bachelor's degree in nursing in the Philippines and lived in the United States for 2-17 years. Content analysis was conducted. Results: The findings revealed that the women faced resettlement demands because of unexpected social and environmental challenges. The data also revealed three phases within which occupational and adaptation process occurs, (1) surviving (2) achieving, and (3) self-determining, and that certain stressors and coping strategies predominate during each phase. Furthermore, culture undergirds their preferred coping strategies. Discussion: This study illustrates that stress and coping are dynamic, multidimensional, and highly influenced by culture. This study provides initial groundwork for a program of research to create culturally relevant interventions to assist immigrants to adapt and cope with stress. Findings also contribute to understanding of the working conditions within a diverse workforce.

The Role of Family Acceptance and Social Participation in the Mental Health and Wellbeing of Iranian LGBTQ+ Youth in Canada

Fay Mahdieh Dastjerdi, York University

Disclosure to the family is the hardest step for LGBTQ+ youth, and it can destroy their relationships with their families. Homophobia in ethnic communities and minority families is well documented. This situation is not better for transgendered youth. Reports show that even transgendered youth continue suffering from family rejection. In the Iranian collectivist culture family acceptance plays a significant role in the growth and maturity, social acceptance, and role development of youth. These have direct effects on youths' mental health and

wellbeing. The incidences of depression, anxiety, and suicide among LGBTQ+ individuals are higher than for their counterparts due to stigma, discrimination, and families' and friends' rejection. Immigrant LGBTQ+ youth might encounter double stigma by holding double marginalized identities, such as being immigrants and members of the LGBTQ+ population. The goal in this pilot study was to explore the role of family acceptance and social participation in the mental health and well-being of Iranian LGBTQ+ youth in Canada because researchers have paid limited attention to immigrant sexual minority youth. A narrative inquiry method was used to analyze data because it is an appropriate approach for studying this little known phenomenon. In narrative inquiry, researchers have the opportunity to listen to firsthand stories and experiences. This study involved a convenience sample of Iranian LGBTQ+ youth living in Toronto. Participants were recruited from community centres and by word of mouth. The participants were 10 individuals, 3 males and 3 females, ranging in age from 18 to 24 years. Five preliminary themes emerged from this study: Ongoing negativity from their families, feelings of being absurd, social isolation and limited social interaction, taking a distance from family and friends, and feelings of being discriminated. The results of this study show how youths' mental health and well-being will be at risk in the milieu of family, friend, and community rejections. Ultimately, it shows the journey of awareness of their sexual orientation and how they shape their identities in a new country. This study's findings revealed that the mental health and well-being of immigrant LGBTQ+ youth will be at risk if families, friends, and communities continue to reject these youths' identities. It is therefore essential to create a safe space for LGBTQ+ youth and their families and friends to talk about their needs and feelings. Through a safe dialogue, they can know and understand their needs and share their experiences. It is assumed that creating safe spaces will have positive effects on the mental health and well-being of Iranian LBGTQ+ youth in particular and immigrant LGBTQ+ youth in general.

Contributing Factors to Well-Being and Integration of Iranian and Afghan Older Adult Immigrant Women in Canada

Fay Mahdieh Dastjerdi, York University

Migration, either voluntary or involuntary, is a stressful event that affects the aging process and well-being. One reason for this is that through immigration, individuals lose control over their lives and their familiar connections. The effect of these losses and the additional stresses of immigration are magnified when the complexity of aging is factored in. These experiences have affected their mental health, social cohesion, and general well-being—all of which are key elements in continuing with the normal process of integration in Canada. Although Canada is one of the major immigrant and refugee-receiving countries, there is still a gap in immigrants' understanding of social needs upon immigration and the supports and resources that are

available. Little literature exists on the connection between mental health and the needs of elderly immigrants, especially in the case of elderly Iranian and Afghan women. The goal in this study was to explore the roles of gender and ethnicity in the well-being of Iranian and Afghan older adult immigrant women, and the impact of these factors on the women's integration into mainstream society. To understand the needs of elderly Iranian and Afghan women, narrative inquiry was used. Data were analyzed with respect to gender and intersectional perspective. Twenty-four in-depth semistructured individual interviews and one focus group were conducted with firstgeneration Iranians and Afghan older adult living in Toronto. Themes such as disconnectedness and separation, language barrier, isolation and loneliness, financial limitation, interge-nerational gap, and relying on the community's support were identified as significant factors contributing to the mental health and well-being of the elderly Iranian and Afghan women. This study revealed the richness of displaced narratives and their attempt in constructing and reconstructing of new meaning of self and life. Analysis of data showed a multilayer phenomenon overlapping each other. Social activity and involvement in one's ethnic community were considered as leading factors in one's well-being.

The Road Less Traveled: Lessons From Using an Emerging Research Method

Sandra Davidson, University of Alberta Kevin Clouthier, Tilburg University

Complexity Informed Narrative Inquiry is an emerging qualitative method. As with any novel method, there is an absence of detailed ''how-to's'' and well-traveled pathways to guide the work. Rather, methodological pioneers are creating the path as they walk so that others may follow. Much like being lost in the woods, using a complexity perspective to understand our day-to-day experiences in new ways can be disorienting and anxiety provoking. This golden nugget presentation will illuminate the tensions and tribulations of using Complexity Informed Narrative Inquiry in health care. We will share our collected wisdom about walking a less traveled methodological path. The three themes that we will address are: developing ambiguity endurance for the journey, using reflexivity as your compass, and learning to see the forest and the trees. Our aim is to encourage fellow travelers and to share strategies that have made our research journey rewarding and fruitful.

A Qualitative Research Study to Investigate Nurse's Experiences and Perceptions of Compassion Fatigue While Caring for Patients in a Rural Emergency Department

Patricia Dekeseredy, York University

Nurses who work in rural emergency departments (ED) are exposed to trauma, pain, and suffering on a daily basis. Many

of the patients they treat are friends and neighbors due to the small populations in rural communities. Thus, when tragedy occurs in the ED, nurses are not only affected professionally but often also personally. In addition, rural EDs often have limited resources available to effectively treat patients who require high-level urgent care, lack administrative support, and are often understaffed. These contextual factors do not only have a negative impact on provision of quality patient care but also create very stressful work environment putting these ED nurses at high risk for experiencing emotional trauma affecting their mental health. Compassion fatigue is a significant issue within the nursing profession and can have deleterious effects on the delivery of high-quality health care. This knowledge is needed in order to understand the complexity of compassion fatigue among rural ED nurses and to develop interventions to effectively prevent and treat compassion fatigue. A qualitative exploratory descriptive design was used for this study. A purposeful sample of 10 English-speaking registered ED nurses who work in a rural Emergency Room (ER) department and have at least 2 years ED experience were interviewed. The interviews have been transcribed and are being examined using qualitative content analysis. The results will be used to inform future research into early recognition and resiliency programs to mitigate the effects of compassion fatigue.

Public Health Nurses' Experiences During the 2009 HINI Response

Alana Devereaux, University of Ottawa

The purpose of this study was to describe public health nurses' (PHNs) experiences working during the H1N1 mass vaccination response. Semistructured qualitative interviews were conducted with a purposeful sample of 23 PHNs (16 frontline immunizers and 7 clinic supervisors) who worked in H1N1 clinics for a minimum of 2 weeks. Interviews were transcribed and analyzed using interpretive description. Most participants had full-time positions in public health programs that were unrelated to vaccination and voiced feeling stress when deployed as H1N1 immunizers. Those few individuals who felt equipped for H1N1 clinics were casual nurses who worked with regular influenza programs. Common challenges verbalized included inadequate training, problematic clinic locations, and the implementation of unfamiliar processes that impeded vaccinations. Despite these issues, participants expressed personal satisfaction from working with colleagues to provide the public with herd immunity. Due to the lack of timely communication regarding the implementation of the response and a subsequent unfamiliarity with mass immunization clinics, most PHNs felt they were inadequately prepared for their roles as immunizers and clinic supervisors. Public health agencies need to ensure that in future pandemics, nurses are well educated regarding the chosen immunization and overall clinic operations. Further, it is essential that immunizers have time to practice vaccine administration, as not all nurses are familiar with giving injections due to their current position

within the organization. This will allow nurses to become more comfortable and thus more efficient in immunization. This can contribute to increased population immunity and improved population health outcomes in future pandemics.

Youth Voices and Journeys in Mental Health: Arts-Based Methods for Invoking Unique Patient Perspectives

Tracy Deyell, University of Prince Edward Island Kate Tilleczek, University of Prince Edward Island Brandi Bell, University of Prince Edward Island

We know much about the alarming trends in youth mental health; however, we know far less about the journeys youth are taking toward better mental health. This presentation will provide a conceptual synthesis of the literature about the ways scholars are invoking the journeys and voices of youth in mental health research and present one such approach from our (Canadian Institutes for Health Research) CIHR-funded project, Atlantic Canada Children's Effective Service Strategies in Mental Health (ACCESS-MH). Youth voices and journeys are important for understanding youth mental health trends and system responses as they invoke unique narrative perspectives from within and across systems of illness and healing. It is now well recognized that people with firsthand knowledge and experience have the most insight into the ways in which supports, services, and treatments can be aligned to foster recovery. Our team of researchers across Atlantic Canada is working to deepen understanding of child/youth mental health in the region. This 5-year initiative employs the newest knowledge on youth journeys and arts-based methods and melds it with analysis of statistical data. We will describe our qualitative patient journeys approach to research with children/youth experiencing mental health challenges, parents, and service providers (sample of 240 individuals). Grounded in critical ethnography and Complex Cultural Nesting theory, we incorporate visual mapping and photovoice into in-depth interviews. We will present early learnings from this longitudinal study and discuss how journey and voiced approaches to youth mental health research can engage young people and families in a conversation to inform research, policy, and action.

Access and Ethics in Health Systems Research: Using a Gatekeeper Organization

Tracy Anne Deyell, University of Prince Edward Island

Multilevel qualitative research on health systems has become increasingly difficult to accomplish in part due to access barriers to multiple organizations and the lengthy process working through multiple beaucracies in order to gain access. Using the example of my dissertation that examined one city's mental health system, this presentation will discuss the use of gatekeeper organizations to gain access to an entire health system and the ethical questions it raises. Gatekeeper organizations can be hugely beneficial in order to gain access to other

organizations located within the same health system and to offer an opportunity to observe critical points of interorganiza-tional interactions. However, using gatekeeper organizations also presents an ethical conundrum when the researcher does not have formal organizational approval of all organizations involved. Additionally, this tactic creates a potential bias in analyzing interorganizational interactions and issues. In researching the correctional and medical components of one city's mental health system, I was effectively shut out of two of three critical organizations by upper administration: the jail and the hospital emergency room. By relying on the city's police department (which did grant me access with ten police officer ride-alongs) for observational data, I was able to gain access and observe the emergency room and county jail in the context of police involvement. I will present the benefits and drawbacks of using the police department as a gatekeeper organization to the quality of my data and the analytical process and the ethical questions I encountered.

Understanding Oral Health Using Qualitative Participatory Methods

Virginia Dickson-Swift, La Trobe University, Amanda Kenny, La Trobe Rural Health School Jane Farmer, La Trobe Rural Health School Sarah Larkins, James Cook University

Despite the fact that qualitative research improves our understanding about health and well-being, qualitative methodologies are not often employed in oral health research. Understanding the issues that communities face with regard to access to and understanding of oral health requires new and innovative approaches. The Rural ECOH study was designed as a community-based participatory study that used a range of methods to engage with local communities about oral health. As part of this approach, we partnered with a range of community members and other stakeholders to design plans for oral health improvements at the local level. Using a range of qualitative methods including focus groups, interviews, and structured workshops, we have connected with local people to highlight the many challenges with regard to oral health. Our findings have relevance for local communities, practitioners. and policy makers who are at the forefront of raising the awareness of oral health as a important determinant of overall health.

Understanding the Psychosocial Support Needs for Rural People With Cancer

Virginia Dickson-Swift, La Trobe University, Jan Pascal, Bishop Grosseteste University Nicole Johnson, La Trobe Rural Health School Amanda Kenny, La Trobe Rural Health School

In this presentation, we aim to describe the psychosocial support needs of rural people with a cancer diagnosis living in central Victoria, Australia. Heideggerian phenomenological

research methods were used to explore subjective experience and capture participants' voices. Nineteen rural and regional participants, with various stages and types of cancer and survival times, were interviewed about their experiences of psychosocial cancer care. Interviews were audio-recorded and thematically analyzed. Findings demonstrated that psychosocial support was essentially informal within the re-entry period after cancer diagnosis and treatment. Participants either cared for themselves or were supported by family, friends, and community members; however, many psychosocial needs remained unmet, and professional support was lacking. Despite current Australian clinical guidelines for the provision of formal psychosocial care for people with cancer, participants in this study largely cared for themselves or received informal support from their families, friends, and community members. This has implications for treatment protocols and discharge planning, the doctor-patient-family relationships, as well as the long-term well-being of people living with and beyond a cancer diagnosis.

What Really Improves Workplace Health? Qualitative Findings From Australian Workplaces

Virginia Dickson-Swift, La Trobe University Jon Willis, University of Queensland Christopher Fox, La Trobe Rural Health School Karen Marshall, La Trobe Rural Health School

Factors for successful workplace health promotion are well described in the literature but often sourced from evaluations of wellness programs. Less well understood are the features of an organisation that contribute to employee health which are not part of a health promotion program. The aim of this study was to inform policy on best practice principles and provide real-life examples of health promotion in regional Victorian workplaces. Individual case studies were conducted on three organisations, each with a health and well-being program in place. Forty-two employers and employees participated in a face-to-face interview. Interviews were transcribed verbatim, and the qualitative data were thematically coded. Employers and senior management had a greater focus on occupational health and safety than employees who felt that mental/emotional health and happiness were the areas most benefited by a health-promoting workplace. An organisational culture which supported the psychosocial needs of the employees emerged as a significant factor in employee's overall well-being. Respectful personal relationships, flexible work, supportive management, and good communication were some of the key factors identified as creating a health-promoting working environment. Currently, in Australia, the main focus of workplace health promotion programs is physical health. This study took a qualitative approach to an area dominated by quantitative biomedical program evaluations. It revealed new information about what employees really feel is impacting their health at work.

The U of A Health Research Data Repository and the Advanced Care Planning CRIO Program: A Case Study of How a Secure Virtual Research Environment Is Supporting Qualitative Research James Doiron, University of Alberta

Located within the Faculty of Nursing at the University of Alberta, Canada, the Health Research Data Repository (HRDR) is a secure virtual research environment developed to support the security, confidentiality, access, and management of health-related research data. The HRDR's operational phase commenced in January 2013, and at the time of the writing of this abstract thus far has provided support to over sixty multidisciplinary and collaborative health-related research projects, both quantitative and qualitative in nature, and with an excess of 150 users across local, national, and international institutions accessing these. This presentation will focus on one particular qualitative project within the larger Advanced Care Planning (ACP) CRIO Program (http://www.acpcrio.org/) that is being supported within the HRDR. The ACP CRIO program studies the implementation of a provincial policy on ACP and Goals of Care Designations in Alberta. A comprehensive overview of the essential supports that have been provided to support the research goals of this qualitative project, such as a secure virtual project space, users' 24/7 remote access, analytic software, quality assurance protocols, file naming, file version-ing, secure data collection and file transferring, and centralized transcribing services, will be discussed.

The Gap Between Care and Organizational Directives: Understanding the Voices of Public Health Nurses

Elizabeth Domm, University of Regina Ann-Marie Urban, University of Regina Kiyomi Gibney, University of Regina

Today's health care administrators are increasingly tasked with efficiency and cost-saving measures; because of this, decisions are made that influence the work of public health nurses (PHNs) and ultimately the care of their clients. Recently, the Saskatchewan government allocated millions of dollars to lean initiatives to improve efficiency and save money in health care settings across the province. While the influence of these initiatives is not entirely known, PHNs have experienced their impact. This qualitative study sought to understand how organizational directives affect work of PHNs and the care of their clients. Five focus groups with between 4 and 12 participants produced several themes. These included organizational and government priorities, for example, immunization protocols, lean quality improvement initiatives, and emergent public health needs; time constraints, for example, the need to meet changing population demographics; the reorganization of PHNs' work and role confusion; the perceived lack of value and contribution of PHNs'

work; and the emphasis on acute care hospitals. While public health nurses understand the need for improvements and cost-saving measures, more often than not they feel pressured to meet the organizational directives that they believe ignore the needs of their clients. In this presentation, we will share the stories of PHNs and the need to shift the focus back to the work of caring for clients balanced by the needs of the organization.

A Focused Ethnography of the Factors Influencing Child and Family Health Nurses' Ability to Work in Partnership With Parents

Eileen Dowse, The University of Newcastle Pamela van der Riet, The University of Newcastle Diana Keatinge, The University of Newcastle

Child and family health nursing services in Australia have evolved in this century from expert-led ways of working with families to a greater emphasis on therapeutic communication approaches underpinned by the Family Partnership Model. There are numerous challenges facing the current child and family health nursing workforce that required consideration in relation to the model being adopted into clinical nursing practice. Using a bioecological framework and critical ethnographic methodology, this study examined the views of one nurse manager, nine child and family health nurses, and nine parents who were individually linked to a participating nurse regarding the factors influencing, and the nature of the impact, on the child and family health nurse's ability to work in partnership with clients. Data were collected via interviews and participant observation. Participant observation included the use of video recordings of nurse-client consultations held at the nurses' centres. Data were analysed thematically. Findings indicate the presence of multiple constraining and supportive factors at the macro- to micro levels that influenced the nurses' work environment and culture and their ability to effectively manage their bodies to demonstrate partnership with parents. Despite constraints, the presence of a ''space'' for partnership practice with parents emerged for some that appeared consistent with nurses' capacity for mindfulness. Nurses were at varied points in their ability to remain present nonjudgementally with themselves, the mother, and baby during their consultations. Findings arising from the study that have been identified for nursing practice and further research are presented.

Ethical Tensions in Health care Practice: Challenges to Enacting an Ethics of Care in Occupational Therapy Practices

Evelyne Durocher, Western University Elizabeth Anne Kinsella, Western University Shanon Phelan, University of Alberta

Lisa McCorquodale, Parkwood Hospital St-Joseph's Healthcare

Ethical tensions arise daily in health care practice and have significant implications. They can cause delays in service, lead to

unhelpful actions, and result in burnout and attrition, all ofwhich can decrease the quality and effectiveness of services provided. Despite their potential implications, little work has been done to examine ethical tensions in occupational therapy practice. This paper presents findings of a pilot study exploring this topic. The data consisted of seven in-depth interviews with occupational therapists practicing in different settings. The methodological approach to the research combined constructivist grounded theory (Charmaz, 2014) with the feminist bioethics lens offered by Tron-to's (1993,2014) ethics of care framework. Tronto conceptualizes care as practice; in doing so, she brings into focus the interrelationship between thoughts and actions, which, in the practice of care, are directed toward the aim of responding to needs. The analysis revealed that therapists encountered ethical tensions related to their implicit aim to enact an ethics of care and barriers to actions directed toward this end. Ethical tensions arose when therapists were unable to enact crucial dimensions of care including ''atten-tiveness'' to patient needs, ''responsibility'' and ''competence'' to respond, and ''responsiveness'' to patient needs. The analysis offers new ways of interpreting the ethical tensions that health care providers encounter and opens the door to a deeper discussion directed at informing how practice settings can better facilitate an ethic of care directed at responding to patient needs.

Ethical Tensions Related to Systemic Constraints in Occupational Therapy Practice

Evelyne Durocher, Western University Elizabeth Anne Kinsella, Western University Lisa McCorquodale, Parkwood Hospital St-Joseph's Healthcare Shanon Phelan, University of Alberta

Ethical tensions arise daily in clinical practice and are frequently related to aspects of practice that are shaped by the structure of health care systems (e.g., funding, eligibility criteria, length of stay policies, resources, etc.). Despite evidence documenting ethical tensions related to systemic issues and resource constraints (Bushby et al., 2014), there is little research focused on these issues in occupational therapy practice. This work is part of an overarching project examining ethical tensions reported by occupational therapists. Following a comprehensive scoping review (Bushby et al., 2014), our team adopted constructivist grounded theory approach (Char-maz, 2014) to analyze seven in-depth interviews with occupational therapists in different settings. The predominant category of ethical tensions emerging in both the scoping review and the empirical research related to resource issues and systemic constraints. Participants reported ethical tensions related to resource issues and systemic constraints that precluded the provision of client-centred care. Participants also reported a need to balance client priorities with those of the health care service in which they practiced, in addition to those of the health care system and the insurance company or funder. Further, participants reported ethical tensions related to prescriptive length of stays, increasing caseloads, restricted

professional roles, limitations in available services, and inadequate funding to pay for treatment or adaptive equipment. This research provides empirical evidence of ethical tensions related to resource issues and systemic constraints in health care practice environments and sets the stage for important discussions exploring the cost of such tensions for health care systems, patients, and health care professionals.

Life Goes On: A Qualitative Exploration of the Post Treatment Experiences of Colorectal Cancer Survivors

Beth Edwards, University of Toronto

Doris Howell, Princess Margaret Cancer Centre

Jan Angus, University of Toronto

Jennifer Jones, Princess Margaret Cancer Centre

Approximately 1 in 14 Canadians will be diagnosed with color-ectal cancer (CRC) in their lifetime. Advances to early detection and treatment have improved the prognosis for CRC; however, posttreatment effects can be severe and persistent including physical, psychosocial, and practical issues. Moreover, CRC survivors may be encouraged to make significant lifestyle changes regarding nutrition and physical activity. Anticipation and management of posttreatment effects, along with adoption and maintenance of new health behaviours, can be very challenging. Recent conceptualizations of health and cancer survivorship highlight the public health significance of self-management for individuals surviving a cancer diagnosis. Further, survivors are considered high health care utilizers, placing a burden on current models of cancer care, with implications for individuals, the health care system, and public health. This study used a structural interactionist approach to explore how CRC survivors perceive, understand, and respond to their experiences. This approach facilitated exploration of the interplay between individual interactions and structural forces and subsequent impact on recovery. Individual interviews were conducted with 18 participants from diverse backgrounds 3-18 months posttreatment. Data were analyzed through interpretive interaction. Preliminary results indicate that most participants do not identify with the label cancer "survivor'' and, as such, do not access supports designed for this population. Findings serve to highlight the complexities inherent in recovering from CRC and contribute to the body of knowledge from which public health initiatives to improve the health and well-being of this population may be derived.

Tracking the Footsteps: A Constructivist Grounded Theory of the Clinical Reasoning Processes That Registered Nurses Use to Recognize Delirium

Mohamed El Hussein, Mount Royal University Sandi Hirst, University of Calgary

Delirium is often underrecognized in acute care settings, and this may stem from underdeveloped clinical reasoning

processes. Little is known about registered nurses' (RNs) clinical reasoning processes in complex situations such as delirium recognition. The aim of this research project is to construct a grounded theory that explains the clinical reasoning processes that RNs use to recognize delirium while caring for older adults in acute care settings. A grounded theory approach was used to analyze interview data about the clinical reasoning processes of RN in acute hospital settings. Seventeen RNs working in acute care settings were interviewed. Concurrent data collection and analysis, constant comparative analysis, and theoretical sampling were conducted in 2013-2014. The core category that emerged from data was ''Tracking the footsteps.'' This refers to the common clinical reasoning processes that RNs in this study used to recognize delirium in older adults in acute care settings. It depicted the process of continuously trying to catch the state of delirium in older adults. Understanding the clinical reasoning processes that contribute to delirium underrecognition provides a strategy by which this problem can be brought to the forefront of awareness and intervention by RNs. RNs could draw from the various processes identified in this research to develop their clinical reasoning practice to enhance their effective assessment strategies. Delirium recognition by RNs will contribute to quality care to older adults.

Institutionalizing Clinical Reasoning: A Constructivist Grounded Theory of the Clinical Reasoning Processes That Registered Nurses Use to Recognize Delirium

Mohamed El Hussein, Mount Royal University Sandi Hirst, University of Calgary

Delirium is a common disorder among hospitalized older adults leading to prolonged hospitalization and increased in cost, mortality, and morbidity. Delirium is often under-recognized by RNs due to their underdeveloped clinical reasoning processes. Little is known about registered nurses' (RNs) clinical reasoning processes in complex situations such as delirium recognition. The goal of this study was to to construct a grounded theory that explains the clinical reasoning processes that RNs use to recognize delirium while interacting with for older adults in acute care settings. A grounded theory approach was used to analyze interview data from 17 participants and 5 observations of acute hospital settings in 3 major hospitals in western Canada. Data collection and analysis occurred simultaneously lead by the logic of constant comparative and theoretical sampling. The core category that emerged from data was Institutionalizing Clinical Reasoning and represented the processes and its related properties that shaped and influenced the clinical reasoning of participants in acute care settings.

Addressing Ex-Offenders Inequity in Access to Healthcare Through the Provision of a Nurse Led Intervention

Cyril Eshareturi, University of Wolverhampton

The current context of offender health in England and Wales indicates that the health needs of ex-offenders are significantly greater than those of the general population with a lack of equity existing between need and supply. The study presented herein is aimed at mapping the ex-offender health pathway towards identifying ''touch points'' in the community for the delivery of nurse-led interventions. The study was underpinned by the ''Silences Framework'' which enabled the study to gain theoretically by situating power with ex-offenders. A total of 26 respondents were ranked on the basis of poor health with those scoring the lowest and confirming their ranking through a confirmation of a health condition selected as cases and interviewed over the course of 6 months. These interview narratives were validated by interviewing individuals in the professional networks of ex-offenders and were analysed using the inductive qualitative thematic approach. The study uncovered that ex-offenders were not prepared in prison for the continuity in access to health care in the community on release. Ex-offender's on-release preparation did not enquire as a matter of procedure on whether an offender was registered with a General Practitioner (GP) or had the agency to register self with a practice on release. Postrelease, the study uncovered a disparity between services, which address the physical health needs of ex-offenders and those which address their mental and substance misuse health needs. Finally, the study identified the site of postrelease supervision as the ''touch point,'' where a nurse-led intervention could be delivered.

Pushing Beyond Interpretation and Understanding in Qualitative Health Research: Potential Contributions of a Transformative Framework

Lisette Farias, Western University Debbie Laliberte Rudman, Western University Lilian Magalhes, Western University Denise Gastaldo, University of Toronto

The exclusion of particular collectives of people from full societal engagement, often driven by unequal access to resources, capabilities, and rights, has been acknowledged as a key determinant of enduring health inequities. Within qualitative inquiry, there is an increasing interest in how qualitative work can be employed to not only understand issues related to health inequities but also to take action with and for the communities with whom we engage. Although the interpretive mandate of qualitative research continues to be dominant, recent scholarship in ''critical'' qualitative inquiry calling for work towards equity and social change aims to delineate how qualitative health inquiry can support people's access to community resources and opportunities in the society. In this presentation, a transformative approach, informed by critical

and participatory epistemologies, is presented to advance efforts that seek to move away from research focused on ill-health and deficits to focus on how contextual factors shape societies, giving rise to privilege and disadvantage. Specifically, key scholarship advancing a transformative framework within qualitative inquiry is reviewed, and its application to addressing health inequities is discussed. We will consider epistemological issues that require the attention of scholars adopting the ideas and values underlying transformative research. We will also focus our attention on potential benefits and challenges that may arise when applying this type of qualitative inquiry. This approach has the potential to contribute to qualitative health research by revealing the current dominance of Western-based approaches within qualitative research as well as the absence of epistemological plurality.

Birthing on Country

Catrina Felton-Busch, James Cook University

Australian Aboriginal women's aspirations for birthing on country (having our babies born on our traditional land) are increasingly being reported in Australian scholarly and policy literature. The authors of these texts are primarily non-Aboriginal nurses or midwives, and there is a paucity of literature authored by Australian Aboriginal women. Although supportive in principle of the desire of Aboriginal people for birthing on country, much of the literature highlights a number of challenges in providing maternity care to Aboriginal and Torres Strait Islander women, including the impacts of colonization, socioeconomic disadvantage, and geographical remoteness. Birthing on country is not currently supported in Australia by maternity services policy or practice and remains an elusive ideal for Australian Aboriginal women. A critical discourse analysis of this literature exposed how these texts are ideologically shaped to give voice (and power) to the medical fraternity, maternity care services practitioners, and policy makers (whose knowledge is valued) while simultaneously silencing the voices of Aboriginal Australians who pose a challenge to that power. This poster will report on the approach taken to critically analyse this literature through an Indigenous lens. Research from an Indigenous standpoint with a decolonizing aim, reflecting an Indigenous epistemology and commitment to social justice, will also be discussed and findings summarised and presented.

Reasons Cross-Sector Partners Collaborated With Health Canada to Diffuse a Healthy Eating Campaign

Melissa Fernandez, Laval University Mylene Turcotte, Laval University Veronique Provencher, Laval University

The Eat Well Campaign (EWC) was a year-long healthy eating and education awareness initiative focusing on food skills (2013-2014) launched by Health Canada (HC) using cross-sector partnerships. Given that understanding why organizations engage in activities to promote public health initiatives would

help decision makers select the most appropriate partners to implement their initiatives and avoid conflicts of interest. The purpose of this study was to describe reasons why Canadian organizations engaged in cross-sector partnerships with HC to diffuse the EWC. Thematic content analysis, inspired by Roger's Diffusion of innovations decision process model, was conducted on hour-long semistructured telephone interviews with HC's partners (n = 18) who were purposefully selected. Dominant themes related to the reasons organizations engaged in the EWC collaboration were high compatibility with the organization's mission, values, and/or scope of business; social prestige; meeting needs of their customers/audiences; high capacity for adaptation and flexibility to integrate new programs into organizational activities; and low perceived complexity of activities. Several respondents indicated that social norms (i.e., knowing that other organizations in their network were involved in the collaboration) played a strong role in their decision to participate. In addition, the opportunity itself to participate in a cross-sector partnership was seen as a prominent relative advantage by many organizations. Findings suggest that reasons given by organizations to engage in a cross-sector health promotion partnership need to be considered by decision makers.

Maneuvering Academic Cultures: Action Research and Students

Lydia Forsythe, Walden University

In developing and revising curriculums, we need to consider the students perspective. Action research is a comprehensive way to bring students into the development and revision process to define relevant curriculums and course room content. However, trying to involve students as participants in research can be a complex and layered process when dealing with leadership and academic cultures. Two action research studies were started in 2014 in online academic nursing and public policy programs. There are several similarities whether one is functioning in a forprofit or not-for-profit academic community. The players may vary, however the hoops, red-tape, and issues prevail; thus, the principle investigator needs to stay calm, focused, clear, and positive as she or he maneuvers the obstacle course related to cultural norms and IRB functions. The PI needs to gain stakeholder support to be able to cross the finish line of research approval, outcome attainment, and ultimately the creation of new knowledge to improve collaborative learning!

Reconstructing the Good-Bad Mother Dichotomy: Understanding Maternal-Newborn Attachment in Pregnant women Who Use Substances Through a Critical Feminist and Social Justice Lens

Michelle Foulkes, University of Ottawa Wendy Peterson, University of Ottawa

There is no other collective of women who are more stigmatized than mothers who use substances during pregnancy.

This is because of the profound tension between the socially constructed image of the good mother and the behaviours that these women demonstrate with their substance use. Maternal-fetal attachment (MFA) is defined as the affec-tional bond between a mother and her fetus and is most often assessed by measuring the mother's desire to protect the fetus. Women who use substances during pregnancy are judged to be morally depraved for placing their fetuses in harms way. A qualitative study using a grounded theory approach was undertaken to gain a better understanding of how women who use substances during pregnancy experience the process of a developing relationship with their fetuses and to identify intersecting variables that may influence their health behaviours. Enablers and barriers to engaging in positive health behaviours were elucidated. All of the women in the study demonstrated increased MFA as pregnancy progressed and demonstrated efforts to reduce substance use, engage with the health care system, and improve dietary choices to limit negative consequences for their developing fetuses. The good mother-bad mother binary must be dismantled and rebuilt into a single category of mothers who are not judged but rather enveloped with support to improve health outcomes for women and their babies. Health care services must embrace a harm reduction and women-centred approach to meet the complex needs of this population.

Women's Healthcare Experiences Across the Young Adult Breast Cancer Continuum: Retrospective Perceptions of Medical and Social Support Networks

Cameron Froude, St Mary's Residency Program

Young adult women diagnosed with breast cancer face more severe, chronic, and pervasive biomedical and psychosocial effects than their older adult counterparts at the conclusion of the illness experience. A diagnoses of cancer during young adulthood brings a host of psychosocial concerns that medical communities should address during biomedical care. Despite consensus on the necessity for women with breast cancer to receive patient-centered care, the literature is conflicted about women's perceptions of the systems (i.e., social, medical, institutional, etc.) that are most influential for the provision of patient-centered care during young adulthood. Using a phe-nomenological, qualitative research design, I interviewed 29 women diagnosed with cancer regarding their illness experiences with breast cancer from the point of diagnosis through recurrence and/or survivorship. Findings from the study revealed (1) systemic influences on women's daily illness experience, (2) women's perceptions of systems' stability and their role within systems during illness, and (3) points during illness when women perceived themselves as personal agents of their health care. Finally, I will provide clinical recommendations for integrated, psychosocial health care practice based on these findings.

Amplifying the Voices of Women Diagnosed With Breast Cancer During Young Adulthood

Cameron Froude, St. Mary's Residency Program

Young adult women diagnosed with breast cancer face more severe, chronic, and pervasive biomedical and psychosocial effects than their older adult counterparts at the conclusion of the illness experience. A diagnoses of cancer during young adulthood brings a host of psychosocial concerns that medical communities should address during biomedical care. Despite consensus on the necessity for women with breast cancer to receive patient-centered care, the literature is conflicted about women's perceptions of the systems (i.e., social, medical, institutional, etc.) that are most influential for the provision of patient-centered care during young adulthood. Using a phenomenological, qualitative research design, I interviewed 29 women diagnosed with cancer regarding their illness experiences with breast cancer from the point of diagnosis through recurrence and/or survivorship. As a compliment to the oral presentation application I submitted, I would also like to complete a pecha-kutcha on women's moments of power in relationship with medical communities. During this presentation, I will illustrate poignant moments in women's illness experiences when they held power, agency, responsibility, and dependence within medical and social support systems in their lives.

An Exploration of Recovery From Post Traumatic Stress Disorder in Veterans of the Canadain Forces: A Phenomenological Approach

Amber Gilberto, Brandon Univeristy

Post-traumatic stress disorder (PTSD) within Canadian Forces Veterans has been described as complex, and currently there is limited empirical evidence to support or provide a solution to this issue (Pare, 2013). Given the rising numbers of veterans, the projected epidemiology in mental illness as a result of combat operations and current capacity of VAC to meet these increasing needs, it has been stated that the Government of Canada will experience significant challenges in addressing this increased service demand over the coming years. (Pare, 2013). Consequently, Veterans Affairs will not have the capacity to respond adequately to the needs of veterans, and the Canadian government will face significant challenges in addressing demands on mental health services (Pare, 2013). Although there is research that supports the efficacy of cognitive-behavioral therapeutic-based strategies such as prolonged exposure and cognitive processing therapy for the treatment of PTSD (Foa, Keane, Friedman, & Cohen, 2009), these therapies do not fully address the unique cultural of the military and specific characteristics of military trauma or the lived experience of combatants or the issues that tend to arise from

operational stress in the context of war (Gray et al., 2012). This qualitative study will help access the lived experience of clients who have completed the acute phase of treatment at the Winnipeg Operational Stress Injury Clinic. The aim of the research will be to capture the meaning of recovery by way of qualitative inquiry. Interpretive phenomenology will be the chosen methodology implemented to capture help the researcher interpret participant's interpretations of the healing journey in a way that quantitative measures have not been able to address. This research will help to fill the current gaps about recovery from combat-related PTSD and expand on our current knowledge of what may be needed in addition to acute treatment for PTSD. Findings will be used to provide a voice to the OSIC clients who will scientifically influence recovery-oriented services at the Winnipeg OSIC that fall outside the evidence-based trauma treatment protocols. Future implications of this research will be client-driven program development and a proposed multisite research project focusing on the lived experience of OSIC clients across the nation.

Observe, Coach, Assist, and Report: An Emerging Framework for Integrating Unregulated Healthcare Providers Into Interdisciplinary Stroke Home Care Teams

Justine Giosa, Saint Elizabeth Research Centre Paul Holyoke, Saint Elizabeth Research Centre Danielle Bender, Saint Elizabeth Research Centre Sandra Tudge, Saint Elizabeth Research Centre Wendy Gifford, University of Ottawa

Unregulated providers known as personal support workers (PSWs) provide the majority of home-care services in Ontario, Canada. However, there is little to guide their activities as members of interdisciplinary health care teams. This study explored and described the role of PSWs in interdisciplinary evidence-based stroke care. A concurrent triangulation mixed methods design was used. Data sources included surveys (n = 270); chart audits (n = 234); interviews with providers, stroke survivors, and family caregivers (n = 28); focus groups with providers (n = 7); textbook review, Advisory Committee meetings (n = 14); and Knowledge Fairs (n = 112). Descriptive statistics were used in the analysis of the quantitative data. Qualitative data were analyzed using successive, iterative emergent coding techniques. All data were compared and contrasted within an evaluative framework, and similar data from multiple sources emerged into themes. Interactive Knowledge Fairs were held in three cities to share and confirm the themes and supporting qualitative and quantitative data describing an enhanced role for PSWs with key stakeholders in community stroke care. We found that PSWs can participate in team-based stroke care by observing vital information about clients in their homes; coaching clients to follow care plans; assisting to implement recommendations made by other health care providers; and reporting client progress, challenges, needs, and preferences to the health care team. The observe, coach, assist, and

report themes from this work are now being used in new studies as a framework to guide improvements in intrateam communication, information sharing, and awareness of the PSW role and to support a better home care experience for clients and families.

Thinking on Things: A Phenomenology of the Bariatric Clinic Waiting Room Chair

Nicole M. Glenn, Universite de Montreal Marianne Clark, University of British Columbia

Weight loss surgery is an increasingly common treatment for clinically significant obesity. Imbalances in supply and demand have created long surgical queues in Canada. Outcomes of bariatric surgery are well understood; however, little research has focused on the presurgical period and the impact of these extended wait times on the people who wait. We undertook a phenomenological study to better understand how people experience the wait to have bariatric surgery, gathering accounts from seven individuals who were waiting to have the procedure. We employed phenomenological analytic practices (i.e., the epoch and reduction) in the writing and rewriting of this text. Emergent from this study was the importance of the ''things'' encounted in the clinic during the wait; particularly the enlarged waiting room chairs. In this presentation, we explore these chairs as they were experienced to understand what it can be like to wait in this context. We also reflect on the significance of seemingly inanimate objects, technologies, and things that populate clinical spaces. Our findings revealed that bariatric patients might be seeking to ''fit in'' but not in the way any chair could provide. Instead of providing rest and reprieve, the temporary comfort and accommodation afforded by the altered chairs in the bariatric clinic waiting room could act as a reminder of the shrunken world that exists outside the clinic walls, ultimately marking a journey far from complete. We discuss the possible clinical and pedagogical significance of these findings for bariatric care and clinical practice more broadly.

A New Way to Care? Exploring the Connections Between Nursing, Health, and Public Transit in Calgary

Suzanne Goopy, University of Calgary Andrew Estefan, University of Calgary Carla Ferreira, University of Calgary

The car has become an essential personal item. More than a means of getting from Point A to Point B, a car is a statement of identity and a marker of wealth and disposable income. The year 2014 saw the ''celebration'' of the registration of the one-millionth car in Calgary, a city of just over 1 million people. Yet, reliance on ''car culture'' is harmful to health and costly to society with its undeniable links to traffic accidents, air pollution, and physical inactivity. Despite these links, health is not typically central to transportation policy

and planning, even though transportation is one of the key economic and social factors that influences individual and community health. Transportation is also not traditionally a concern for nurses who tend to find themselves caring for the victims of transportation-related injuries and illnesses rather than advocating for an upstream approach to transportation and health. Nursing has a mandate to promote health beyond tending to the injured and the ill, which presupposes a commitment to caring for community by researching and advocating the factors that positively influence community health. This paper presents findings from a 2015 pilot project that examined community health through the lens of public transit. In this paper, we invite health care professionals to consider their relationship with nontraditional sectors as we present innovative ways of conceptualizing links between transportation and health. This paper shows how nursing research can bring nurses into conversation with policy makers and influence transportation policy in ways that promote health and healthy lives.

The Challenges of Using Ethnographic Methods in Acute Care Settings

Joanne Harmon, University of Newcastle Peter Summons, University of Newcastle Sian Maslin-Prothero, Keele University Isabel Higgins, University of Newcastle

This presentation will outline the experiences of the author in undertaking a study that used focused ethnography in hospital settings. The research was designed to explore the practices of registered nurses when assessing and managing pain in older people in an clinical setting on eight acute care (medical and surgical) wards in two tertiary referral hospitals in Australia. Focused ethnography is an innovative approach to research that is particularly useful for nursing research when exploring culturally mediated and patterned acts of care that occur within a small group in a specific context. The aim of this presentation is to discuss the methodological and practical challenges associated with undertaking fieldwork that included, amongst other forms of data collection, observations and interviews with nurses and older people in a hospital setting. Topics covered in the presentation will include the challenges associated with using a focused ethnographic approach, gaining access to the settings for the study, negotiating points for data collection and undertaking the fieldwork observations and interviews, and immersion as well as distancing oneself in multisite research. The dualistic roles of the researcher as a nurse when applying the ethical conduct of research and ensuring rigor as well as reflexivity will be addressed. Processes for dealing with gatekeepers and supporters are also outlined. The inclusion of older people in research within acute care settings requires a sensitive and respectful approach: an awareness of their situation and the vulnerabilities associated their illness state and hospitalisation. Recommendations are made for mitigating these challenges.

Thinking on Your Feet: Nursing Doctoral Student in Field Decisions

Joanne Harmon, University of Newcastle Jenny Day, The University of Newcastle Isabel Higgins, The University of Newcastle

It takes time to develop the ability to thoughtfully and independently undertake qualitative research. Early career researchers are ''beginners'' and, in their endeavours to learn their craft, are often challenged by unthought-of field situations. This presentation stems from our experiences as nursing doctoral students at an Australian University. In it, we share three unthought-of moments in our field experiences. These events are characterised by unanticipated changes in our research contexts which challenged our assumptions and beginner expectations. We identify our concerns ''in the moment'' and the decisions made, illustrating how our projects called on us to ''think on our feet.'' Far from being straight forward or easy, we were often challenged by the diverse and changing nature of our research contexts, including the research settings and individuality of our research participants, the very characteristics valued and assumed by qualitative research methodologies. The experiences we share reflect the complexity of qualitative research as a craft, the concerns and uncertainty experienced by early career or doctoral researchers, and the challenges faced when in the field collecting data with human research participants. Laying open these experiences provides real-life examples of early career researcher challenges and decisions, providing opportunities to reflect and learn, to consider how our research projects may unfold in the real world, and to prepare and to grasp some of the concerns beginning researchers have.

Provision of Pain Comfort Care for the Older Hospitalised Person: An Ethnographic Study of Nursing Clinical Pain Management Practices

Joanne Harmon, University of Newcastle Peter Summons, University of Newcastle Sian Maslin-Prothero, Keele University Isabel Higgins, University of Newcastle

The aim of this presentation is to present findings from research designed to explore the clinical practices of nine registered nurses (RN's) when managing pain in 42 older persons (those aged over 65 years). The study was located in an acute care setting on eight medical and surgical wards in two tertiary referral hospitals on the east coast of Australia. The study uses a qualitative-focused ethnographic approach. Focused ethnography is an innovative approach to research that is particularly useful for exploring culturally mediated and patterned acts of care expression that occur within a small group in a specific context. The point is to explore and gain insight from the older person and the RN's pain assessment and management-care practices. The methods used included participant observation, document review, and interviews with nurses and older

inpatients over a 6-month period of immersion in the field by the researcher. Thematic analysis identified that both the acute care system and the nurses who were providing care often excluded the older person from participating in the management of their pain. These differing views meant that communication and understanding regarding the assessment and management of pain was hampered. Findings suggest that pain relief and care require inclusion of the older person in the provision of care.

Nurse Managers' Views of Communication in Rural Settings: A Grounded Theory Study

Sheila Q. Hartung, Bloomsburg University

There is increasing awareness that poor communication is at the root of many chronic problems in health care. While poor communication and lack of teamwork of health care providers have been demonstrated to be harmful to patients and the health care team, nurse managers and administrators are challenged to respond appropriately to these threats to a healthy work environment. Challenges to the rural setting such as geographic diversity, features of the physical environment, and population density impact how professional staff and nurse managers interact. However, few studies have focused on nurse managers' view of their impact on communication and, thus, the creation and maintenance of the healthy work environment in rural settings. A qualitative study using Grounded Theory methods was conducted. The study population comprised nine nurse managers from rural, regional, and community settings in order to examine their perceptions of communication factors that promoted a healthy workplace and their role in setting the tone on the unit or program. Data collection of audiotaped semistruc-tured interviews was analyzed using the constant comparative method and assisted in the use of qualitative data software (ATLAS.ti). The inquiry revealed a substantive theory that included context, conditions, actions/strategies, and outcomes of successful communication. Findings indicated a more negative tone of communication in the workplace and various tools of communication that promoted or hindered effective and healthy communication. Nurse managers' described their role in setting the tone of communication and factors that helped or hindered the healthy work environment. The study provides insights for nurse managers in rural settings who are struggling with creation and maintenance of healthy work environments and strategies to promote effective communication. Accommodation of the rural limitations without sacrificing expanded use of technology is crucial for meeting the needs of health care staff, rural health care settings, and rural health care patients.

Parenthood After Preterm Birth—An Ethnographic Study of Lived Family-Life in Danish Families

Haslund Helle, Clinical Institute Aalborg University

Technological development of neonatology during the past 40 years has led to increased survival rates of extremely preterm

infants. Consequently moderate and late preterm infants born 3- to 8-weeks preterm have been marginalized both in clinical attention and in research. Late and moderate premature children have increased morbidity and count 80% of the total pre-term population. Most research regards the children even though it is well established that children's health is strongly associated with parental competences. This PhD study therefore examined how parenthood is affected after late or moderate premature birth during the first year. I conducted an ethnographic fieldwork within and around Danish families throughout the child's first year and for some main informants up to 2^ years. It predominantly consisted of participation/ observation of everyday life in the home and included semi-structured qualitative research interviews based on a thematic interview guide, focus group interviews in a version adapted for mother's groups, as well as informal interviews. My finding is that processes for parenthood construction are complicated and challenged by prematurity as a category and experience, in the interface between everyday life and disease/abnormality. I demonstrate that late and moderate premature birth increases the complexity in the construction of parenthood, as parents experience prematurity as flashing from behind. The implication is that preterm parents handle prematurity as a category embedded in development of a professionalized parenthood. Uncertainty and ambiguity is accentuated, as prematurity works as explanatory models, but also points at potentially uncertain future for the child.

From Embers to Flames: Identifying Strategies of Resilience Among Inner-City Aboriginal Youth

Andrew Hatala, University of Saskatchewan

The objective of this community-based research project is to identify sources of resilience and positive mental health strategies that can inform early intervention theory and policy to promote the mental and community health and wellness of aboriginal youth in Saskatoon and other Canadian urban contexts. In collaboration with our community partners, the operating principle behind this study is that the resources, knowledge, and capabilities required to address the mental illness and addiction inequalities of Aboriginal youth are already present within inner-city contexts and young people themselves. Qualitative stories along with a photovoice project will be generated from inner-city youth to determine their successful coping strategies. Thirty-two youth from inner-city Saskatoon contexts are participating in this project. The presentation will focus on the research methods and how indigenous paradigms, knowledge, and capacity building for youth has been integrated into the overall qualitative research approach and design. In addition, we will share how this project itself is being conceptualized as a transformation research project, that is, will potentially contribute to the resilience and well-being of the youth that are involved.

Doing Resilience With "Half a Brain'': Navigating Moral Sensibilities 35 Years After Hemispherectomy

Andrew Hatala, University of Saskatchewan

This paper investigates experiences of resilience in the context of individuals suffering from disability as a result of severe intractable seizure disorder and consequent hemispherectomy, a surgical procedure in which part or all of either the left or right cerebral hemisphere is removed. Two adults who underwent childhood hemispherectomies ''one left and one right'' are the focus of this study. Previous research has extensively detailed the clinical outcomes of this neurological procedure, yet the actual day-to-day experiences of individuals living post-hemispherectomy remain unexplored. Utilizing open-ended, qualitative, and narrative techniques from a phenomenology of performativity perspective, the authors question how each individual's experiences of daily living are invariably acts of resilience, involving several different strategies that are somewhat unique to each. Rather than working as an adjective or noun signifying certain environmental or individual attributes, this paper proposes that ''resilience'' is best conceptualized as the individualized intentional actions which disabled, distraught, or at-risk individuals perform in contextually relevant and idiosyncratic ways as they navigate health and well-being within their local social and moral worlds.

Observing Changes in Physician-Patient Interaction During Japanese Informed Consent Consultations

Taichi Hatta, Kyoto University Hospital Keiichi Naria, Kyoto University Hospital Masayuki Yokode, Kyoto University Hospital

Informed consent (IC) is essential in patient medical decision making. While the shared decision-making process requires patients to prepare themselves for IC consultation, Japanese patients rarely express their wishes. To investigate how reluctant patients disclose their interests during IC consultation, we observed 20 case conversations with a well-trained oncologist at an outpatient chemotherapy unit in a university hospital. As a participant observer, the researcher recorded the conversations and took field notes. The observation phase revealed the commonalities and characteristics between the cases. From our observation and preliminary analysis, we selected a breast cancer patient who seemed passive and less prepared as an analysis case. To depict the IC consultation process, we referred to sequential analysis and divided it into four stages. In the introduction stage, the patient quickly disclosed her anxiety at the beginning of the consultation. In the development stage, while the oncologist started to discuss chemotherapy's benefits, her attitude was somewhat vulnerable or passive. In the turn stage, the oncologist gently listened to her anxiety regarding chemotherapy and refrained from detailed explanations. In the conclusion stage, she finally disclosed her

true interest her need to participate in her son's wedding ceremony. The oncologist explained that the side effects could be controlled so she could participate, and the IC consultation was closed. Therefore, IC consultation could promote the shared decision-making process with a passive patient, which is beneficial from an ethical and legal perspective, and serve as a platform for constructing a physician-patient relationship in Japanese clinical practice.

In My Lifetime It's Been Pretty Bad ... I Try to Think Positive: Understanding Dimensions of Post Disaster Resilience in Rural Appalachia

A Qualitative Study of Health and Emergency Preparedness in an Appalachian Community

Meghan Hayes, University of Tennessee College of Nursing Lisa Davenport, University of Tennessee College of Nursing Cameron King, University of Tennessee College of Nursing Moriah McArthur, University of Tennessee College of Nursing

Background: Clay County, KY, situated in the foothills of the Cumberland Mountains, is located in the central Appalachia region. Once a thriving coal-mining area, Clay County, KY, is now reported as one of the hardest places to live. The remote, rocky mountainous area of Clay County, KY, is surrounded by rivers and valleys, which are prone to flooding. In spring, 2013, a major flooding event occurred in the southeast part of Clay County, KY, causing significant damage to homes and critical infrastructure. Purpose: To build the body of knowledge, an interprofessional team of nursing, architecture, and engineering students/faculty conducted a study to identify and document the long-term impact of flooding on families and their homes 12 months postdisaster as well as understand the multitude of factors that contribute to disaster vulnerability while developing strategies to strengthen preparedness among individuals, families, and communities. Methods: Knowledge development was achieved through a mixed-methods approach utilizing face-to-face interviews with residents about their disaster experience, photographs depicting structural conditions, and ethnography. A locally developed Health and Emergency Preparedness Assessment Survey Tool was utilized to collect demographic, health, housing, environment, and disaster readiness data. Community stakeholders facilitated purposeful sampling through coordination of scheduled home visits. Data sources were organized and securely managed using QSR's International NVivo 10 qualitative data analysis software. Through engagement and reflection of the text, a collaborative team conducted line-by-line readings to identify in vivo codes derived from the words or phrases of the participants. Results: The use of participants own words yielded rich descriptions of their disaster experience, highlighting resilience as an underlying theme throughout interpretation. Upon further reflection of a middle range theory of resilience, it was identified that the community had an innate capacity to utilize resources to manage and transcend adversity and to restore equilibrium.

Resilience was found to be an encompassing aspect of the community's antecedents, protective factors, risk factors, and interventions, which directly affects the community outcomes. Residents revealed coping strategies utilized to overcome adversity despite the hardships they face. Conclusion: Resilience can be utilized as the foundational aspect in the development of community focused interventions related to disaster preparedness. Disaster preparedness interventions should aim to enhance the community's resilience to more effectively overcome chronic poverty, isolation, historical neglect, and systemic vulnerability. Further research could yield a deeper understanding of the longitudinal effect of resilience within the disaster preparedness continuum.

Immigrant Women's Experience of Postpartum Depression in Canada: A Narrative Synthesis Systematic Review

Gina Higginbottom, University of Nottingham

Myfanwy Morgan, King's College

Joyce OMahonyJ., Thompson Rivers University

Background: Understanding the ethnocultural orientation of immigrant women in maternity is critical for their successful integration and for social cohesion. A key aspect is the need for timely identification and treatment of postpartum depression, which has high prevalence in this vulnerable population. Funded by Canadian Institute for Health Research and partnering with key stakeholders to ensure topic relevancy, we conducted a narrative synthesis systematic review of quantitative and qualitative primary research (Popay et al, 2006) to answer the research question: What are the ethnoculturally defined patterns of help-seeking behaviours and decision making and other predictive factors for therapeutic mental health care access and outcomes in respect of postpartum depression for immigrant women in Canada? Methods: Guidelines for systematic and grey literature review were followed to identify and select literature. Methodological quality was appraised using tools developed by the Centre for Evidence Based Management. The narrative synthesis methodology relied primarily on text to summarize and explain findings, using four elements: (a) developing a theory of why and for whom, (b) developing a preliminary synthesis, (c) exploring relationships in the data, and (d) assessing the robustness of the synthesis. ATLAS.ti software was used to synthesize findings. Results: Our review revealed precursors to differences in health care access and utilization by immigrant women with depressive symptomatology, and these differences are factors recognized to be critical determinants of effectiveness of services and patient/client outcomes. Analysis of 22 studies led to the development of four interrelated themes: (a) effects of immigration; (b) social support, isolation, and poverty; (c) ethnocultural determinants; and (d) gender roles and relationships. Conclusions: Findings will have direct relevance in guiding the provision of health care services, identifying themes for wider application for service delivery and public health initiatives in relation to providing

culturally acceptable and appropriate care for postpartum depression in immigrant women.

Reflecting Ambivalences: A Qualitative Study of the Experiences of Ecuadorian Children of Migrated Parents

Elena Monserrath Jerves Hermida, University of Cuenca Lucia De Haene, KU Leuven Paul Enzlin, KU Leuven Peter Rober, KU Leuven

Despite considerable attention given to the study of transnational migration and its impact on families and society, little is known about those family members who, without leaving their home country, are affected by transnational migration: children and adolescent who stay behind. The aim of this qualitative study was to explore adolescents experiences of close relationships in the context of transnational families. The study was conducted with male and female Ecuadorian adolescents who stayed at their home country while their parents migrated. The study was based on in-depth interviews that were conducted using a technique developed after it became apparent that discussing family relationships in the context of parental migration was too delicate and produced discomfort and deep sadness. The technique consisted in the use of wooden pieces to represent the family members to foster the discussion about this sensitive topic. The qualitative thematic analysis revealed that adolescents develop within trigenerational families in which their structure and dynamics allow providing a sense of stability for the younger members. In this context, adolescents build meaningful relationships that become important sources of support to face the difficult emotional situation that dynamics of transnational families entails. However, the study also showed that adolescents emotional struggle is accompanied by ambivalences that seem to mirror the tension at a societal level, where on one hand migration is a frequent phenomenon but on the other migrant parents and transnational families are stigmatized for not fitting in with societal models, which leaves left behind adolescents in a situation of helplessness and isolation and have an important impact on their psychological well-being.

Diverse Populations Experience With Health care Information Provision in Canada

Soodabeh Joolaee, University of British Columbia Anita Ho, University of British Columbia Yuan Zhou, University of British Columbia Kim Taylo, University of British Columbia

Understanding specific needs and expectations of diverse populations is a key component in providing respectful health care in a multicultural country such as Canada. This study is part of a larger qualitative study informed by grounded theory. We explored informational challenges patients and supportive decision makers (SDMs) from diverse populations encountered

during their health care decision-making process. We conducted semistructured interviews with 84 patients and 40 SDMs from Aboriginal, Chinese, Caucasian, Punjabi, and Persian background in a Western Canadian city. The interviews were audio recorded and transcribed verbatim. We used constant comparative approach for data analysis within and between groups. NVivo 10 was used for data management. Insufficient information provision and dismissal of patients and families' informational requests were two major themes that emerged from the data. Various subgroups, however, experienced these challenges differently. Participants across groups suggested that they might have made other and more appropriate decisions, if they had received sufficient information. Participants with English as their second language were most likely to report not receiving adequate information or have their informational request dismissed. Participants, particularly Aboriginal populations, perceived that negative stereotypes about their population group were influencing the process of information exchange. Providing proper information based on diverse populations' needs and expectations assessment as well as strong cultural understanding and training can better prepare health care providers to work with diverse populations and create a culturally safe health care environment.

Healthcare Supportive Decision Making as Perceived by Iranian Population in Western Canada: Reflection From a Qualitative Study

Soodabeh Joolaee, University of British Columbia Anita Ho, University of British Columbia Lovepreet Mutti, University of British Columbia

Since 1970s, many Iranians came to Canada as immigrants, constituting a population of 163,290 in 2011. As part of a larger qualitative study informed by grounded theory, we explored the challenges that Iranian patients and families faced during their health care decision-making process in Canada, and how they could be better supported in decisional processes. We conducted 11 semistructured interviews with four Iranian patients, four family members and three health care providers. The interviews were audio recorded and transcribed verbatim. We used constant comparative approach for data analysis. NVivo 10 was used for data management. Communication was the most important challenge to supportive decision making. Different expectations as well as language barrier played a significant role in miscommu-nication and hindered supportive decision making. Participants mentioned the Canadian referral system as being time consuming and complicated. Lack of access to timely specialist services and not receiving understandable and adequate information were perceived as other barriers for supportive decision making. Since part of Iranian participants' issues with the Canadian health system is related to their previous experience in Iran and different expectations from the health care system, having access to health care providers familiar with both health systems, and receiving adequate information regarding the available resources via effective communication, may help them to achieve a better

understanding of the system and enhancing supportive health care decision making.

Sketching Life: Young Homeless Mothers, Art, Research, and Social Change

Clara Juando-Prats, St. Michael's Hospital, University of Toronto

The understanding of the social mechanisms of health inequities in vulnerable groups requires an elaborated and articulated approach. Homeless young mothers in Toronto have worse health outcomes and experience marginalization while living in a complex situation; the perceived risk of losing the custody of their child and taking care of their child's health puts them in a fragile position that results in a more limited access to the health resources than their housed counterparts. This study addresses the understanding of the individual practices of homeless young mothers when using and accessing the health care resources in relation to the social values and to the structure of the health care system. This critical inquiry uses a combination of a discursive montage and a graphic-elicitation method to understand this complex phenomena and allowing for activism. The graphic elicitation used is based on the creation of a visual diary which combines writing, pictures, sketches, and drawings by the young mothers. The preliminary results of these two methods give a deep view of the mechanisms of reproduction of the health inequities. Using drawing and sketching in the research process not only creates a dialogue with the participants but also allow the young mothers to recreate the individual and social representations. Visual art in research may narrow the divide between theory and practice; it creates knowledge and finds a space for the transformative process of social change.

Enacting Mental Health Policy at the Local Level: Coproduction to Improve Service Access in Rural Communities

Amanda Kenny, La Trobe University Rural Health School Virginia Dickson-Swift, La Trobe University Rural Health School Carol McKinstry, La Trobe University Rural Health School

This Australian study used coproduction between mental health consumers, careers, health professionals, and service staff to improve service access for rural people with mental health issues. Coproduction has been defined as the development of services through equal and reciprocal partnerships between those who deliver services and those who use them. Global mental health policy identifies the need to involve consumers in all stages of health care design, delivery, and evaluation. At a service level, success in enacting this policy is often measured in terms of a tokenistic consumer on a service advisory group. Within the literature, there are few examples of health professionals, service staff, and consumers working together to coproduce health care. To enact coproduction at the health service level is challenging, and there are major gaps in the literature about processes, enablers, barriers, and outcomes. This study directly addresses this gap. In this participatory

action research study, service providers, consumers, and carers worked together to develop insights into mental health service access. Work of the group included an extensive scoping review designed to map the evidence base and to identify potentially innovative service access strategies. Interviews with 20 consumers and carers ensured local issues were con-textualised and helped inform strategies for their community.

PhD by Publication: A Panacea for Student/ Clinician Researchers?

Amanda Kenny, La Trobe University Rural Health School Virginia Dickson-Swift, La Trobe University Rural Health School Carol McKinstry, La Trobe University Rural Health School

Supporting clinicians through doctoral studies is an effective way to bring qualitative research into the mainstream of health service delivery. However, for many clinicians, becoming fulltime doctoral students is not an option. For these students, there is a heavy reliance on employer support to balance their employment and doctoral commitments. Employers want quick outcomes, and the protracted writing of traditional theses does not align well with demands for timely practice outcomes. Using cooperative inquiry, this study brought together experienced doctoral supervisors to share learnings on PhD by publication. We have promoted PhD by publication as a useful approach to support clinicians to complete their doctoral studies and as a mechanism to meet university demands for publication outputs. Our promotion at the health service level centres on the value that health services gain from doctoral students completing research written in manageable ''chunks,'' with immediate and visible outcomes to satisfy investments in time/financial support for clinician doctoral students. Health services, seeking ''published'' evidence, value the publications of their staff and they feature strongly in health service reports. Our success with PhD by publication has resulted in strong support for the process. Whilst we see many advantages in PhD by publication, there is a dearth of literature on the pros and cons of this approach. In this presentation, we draw on our extensive experience and highlight the value of PhD by publication but perhaps more importantly provide cautions for those who do view it as a panacea for the student clinician. Extensive qualitative date were collected and considered by the group, and this provided a powerful local citizen/service connection. Shared understandings of mental health service delivery and tailoring of initiatives have resulted in strong community ownership and dissemination of outcomes to policy makers, practitioners, and community members.

Carers' Experiences of Helpful Help in Mental Health Crisis

Trude Klevan, Akershus University Hospital

Mental health services have moved from an institution-based towards a community- and home-based care. Crisis Resolution Teams (CRT) is a community-based service targeting people

experiencing severe mental health crisis, offering home treatment as an alternative to hospitalization. The transition in mental health services has led to an altered role for carers. CRTs are intended to collaborate closely with carers. However, there is a limited amount of research exploring how carers experience mental health crisis and how the help offered by CRTs is in line with their needs. This qualitative study describes and explores carer's experiences of caring for someone in a mental health crisis, and what they experience as helpful or unhelpful help within the context of CRTs. Semistructured interviews have been conducted with 12 carers. A narrative approach has been used in the analysis, developing constructed stories through the process of emplotment. A competence group consisting of service users, carers, and CRT clinicians has contributed in analysis and interpretation of data. Preliminary results show that the experiences of carers are closely entwined with contextual factors. Experiences that appear as thematically similar show evident diversity when interpreted in the light of personal context. The study suggests that emphasizing the personal and contextual stories of carers can increase the possibility of collaboration around a crisis support that meets the specific needs of the unique family. Thus, it can be perceived as more helpful.

What Are We Missing With Impact Alone? Critical Insights From Arts-Based Initiatives

Pia Kontos, Symposium Chair

Symposium Description: The identification and use of ''best evidence'' through careful and rigorous clinical trials research and standardized application is increasingly emphasized by the governments of Canada, the United Kingdom, and others primarily due to concerns about cost containment, quality improvement, and accountability. Implementation frameworks rest on the assumption that the progression of research into practice occurs in a sequential, linear, and orderly way. This is reflected in evaluation strategies that have a program-based focus on what works with a reliance on quantitative methods alone to capture ''impact.'' This symposium explores impact from a critical qualitative perspective, acknowledging its inherent dynamic and complex character. Using examples from arts-based health research and dissemination studies, we argue for a conceptualization of impact that is concerned with process, context, and engagement rather than with whether interventions work in a way that is statistically generalizable. In doing so, we are broadening what it means when we ask, ''Does it work?''

Abstract #1: Impact Redefined: The Reciprocal Nature of Engagement Between Elder-Clowns and Persons With Dementia

Pia Kontos, Toronto Rehabilitation Institute—University Health Network

Julia Gray, Ontario Institute for Studies in Education, University of Toronto

A recent innovation in arts-based approaches to dementia care is specialized red-nosed clowns who engage residents in long-term

care settings (termed elder-clowns). Given the prevalence of medical and psychological perspectives in research on elder-clowning, it is not surprising that evaluation studies have focused on the psychosocial, behavioural, and cognitive impact of the presence of elder-clowns on persons with dementia. There has been little exploration of the aesthetic and relational components of elder-clown practice that account for its efficacy. With an interest in broadening the exploration of ''impact'' to include what the residents themselves may bring to the interaction, we examined elder-clown visits with 23 long-term care residents with moderate to severe dementia in central Canada. Each resident received two elder-clown visits per week for 12 weeks. Analysis was based on the videotaped clown-resident interactions, elder-clowns videotaped reflections, and postintervention interviews. Our analysis identified intrinsic capacities in persons with dementia even persons with severe dementia to initiate affective, creative, and playful engagement using verbal and nonverbal communication. Additionally, we identified the importance of elder-clowns' responsiveness to the deliberate playfulness and imaginativeness of those with dementia and their validation and support of residents' expressions of sadness. Conclusions focus on the importance of attending to these aesthetic and relational components for understanding the impact of this innovative arts-based approach to care.

Abstract #2: Generating Knowledge in Context: The Role of the (Imagined) Audience in Drawings Produced by Young People

Brenda Gladstone, Dalla Lana School of Public Health, University of Toronto

This paper revisits drawings generated during an ethnographic study of a psychoeducational intervention for children of parents with mental illnesses. One particular image is used as a case example to ask questions about how drawings generate knowledge that is complexly connected to the context(s) in which they are (re)produced; how power relations, social experiences, and interactions influence the image created; how it is produced; and who it is generated for and why. These are interrelated sites of meaning making that influence what we know in the immediate context but also as the image circulates and is taken up in other settings. By questioning who the audience is, or is imagined to be (a significant but problematic concept currently underdeveloped by visual sociologists), it is possible to consider more fully how and for whom the intervention worked and why. This is also the case when the image is shared with audiences in completely different contexts from that of the original setting. I describe a response from one such viewer to think about why this particular drawing impacted him. Impact and its various synonyms, for example, influence, impression, effect, and power, can be understood as part of the interactive meaning-making process, which unfolds over time, in different geographic locales and types of contexts, and between those occupying different social and even different generational positions.

Abstract #3: Deep Impact: (Re)imagining Research With Image, Story, and Sound

Janet Parsons, Applied Health Research Centre

Li Ka Shing, Knowledge Institute, St. Michael's Hospital

Arts-based health research is becoming increasingly popular as an approach to knowledge production and dissemination. Qualitative researchers have an array of genres and techniques from which to choose, including photography, film, and drawing, among others. But how should we understand the ''impact'' of such approaches and what added ''value'' do they bring to the field? How should we assess their influence? and What theories of change can we imagine?

Perceived Associations Between Teacher-Student Relationship, Students Mental Health, and Dropout From High School

Vibeke Krane, Buskerud and Vestfold University College

High school dropout is defined as a serious problem and a political concern in most Western countries. Resent research has found an association between students' mental health problems and dropout form high school. Schooling is central in young peoples' life and the relationship between teachers and students is a pivotal process in students' everyday lives. The purpose of this study is to explore strategies and dimensions in the daily interplay between teachers and students that are important to students' mental health and dropout. The study has a qualitative, descriptive, and explorative design. These data were collected in focus groups and individual interviews with 59 participants: students, teachers, parents, and helpers. Thematic analysis was used to obtain and systemize the participants' experiences and to explore strategies and dimensions in the relationship between teachers and students. The study has a participatory approach: A young woman with lived experiences of dropout from high school is working as a coresearcher in the study. A competence group of nine key stakeholders contributes throughout the research process. Preliminary findings from the analysis of the participants' experiences of the association between teacher-student relationship, students' mental health, and dropout will be presented at the conference. A deeper understanding of the dimensions of teacher-student relationships and its role as a possible protective or risk factor for students' mental health will be explored.

Dual Needs, Dual Strategies: Academic and Life Needs of University Students With Learning Disabilities

Consuelo M. Kreider, University of Florida Sharon Medina, University of Florida Mary de Laosa, University of Florida Carrie M. Comstock, University of Florida William C. Mann, University of Florida

Students with learning disabilities (LD) comprise approximately 60% of students reporting a disability in postsecondary

education. Academics and social encounters can be negatively impacted for students with LD. Students with LD need more than classroom accommodations to succeed, yet relatively few empirical studies inform as to needs beyond the classroom. Transcripts from focused discussions were analyzed for themes in order to assess the range of needs experienced by university students with LD. We conducted secondary data analysis from focused discussions (n = 15 discussions) with two cohorts of undergraduate students diagnosed LD (n = 30) who were enrolled in a larger study testing a multilevel model of support for students with LD. Between 5 and 13 students with LD contributed to each focused discussion. Discussions followed presentation of learning, introductory, and wrap-up modules whereby the discussion leader prompted the students to share their reactions to, and their experiences with, the topic at hand. Students described needs within two domains, which included academics and life. The life domain encompassed health, wellness, and social demands. While the students with LD described experiences with self-management and self-advocacy strategies for addressing both academic and life demands, they expressed more needs than the range of strategies shared. Dual academic and life needs point to the importance of self-management and self-advocacy interventions that extend beyond classroom situations to applications supporting daily life functioning, such as how to advocate with friends and roommates for support of routines needed for managing academics and life as a student with LD.

From Photovoice to Peer Task Groups—A Critical Exploration of Community Engagement in Community-Based Participatory Research

Ania Landy, SFU

Colleen Reid, Douglas College

Maggie Bosse, Douglas College

Community engagement strategies employed with people with lived experience of mental illness offer exceptional community and research benefits as well as unique challenges. Knowledge production and mobilization and capacity building rely on successful and meaningful community engagement. Although values of empowerment, social justice, reciprocity, and respect for diversity are crucial to the success of projects seeking to implement community engagement, incorporating these principles into the research process while maintaining research rigor can be challenging. Imagining Inclusion was a 2-year community-based participatory research collaboration that explored experiences of community inclusion, health, and well-being of people with lived experience of mental illness. Thirty-two participants took part in the Photovoice stage of the project. Considering participants strong interest in continuing with the project after the Photovoice stage, four Peer Task Groups were created: Photo Exhibit Group, Newsletter Group, Data Analysis and Photo Selection Group, and Speaker Series Group. Nineteen participants signed up for the Peer Task Groups which met throughout a year to plan, organize,

and complete various research tasks, such as data analysis and knowledge mobilization activities. This presentation will highlight strategies used to ensure meaningful and ongoing community engagement and the importance and complexity of community engagement as an approach to reducing health inequities among people with lived experience of mental illness.

The Experiences of Medical Interns Taking Part in Open Disclosure After Medication Error

Andrew Stuart Lane, University of Sydney Chris Roberts, University of Sydney

Open disclosure is a policy stating doctors should apologise for errors, discussing them with the harmed parties. Many junior doctors take part in open disclosure without any formal training or experience. By referencing the theoretical frameworks, apology by Slocum et al. and thinking fast and slow by Kahne-mans, a phenomenological study of medical interns who had been involved in open disclosure was conducted. Ten medical interns were purposively sampled, and these data were analysed using Interpretative Phenomenological Analysis, which identified three superordinate themes. One superordinate theme was labelled ''Rationalisation of medical error,'' which described how the interns rationalised error in three different ways. The theme Error is in the eye of the beholder described rationalisation of their observations. The interns demonstrated lack of knowledge and clinical reasoning when conceptualizing their clinical practice. The theme ''Apologetic justification'' described rationalisation of their thoughts. The interns justified and defended accepted errors using diffusion and distortion of responsibility. The theme '' Softening the blow'' described rationalisation of their language. The interns utilised euphemistic language and discourse markers. Their observations, thoughts, and actions demonstrated unconscious incompetence, however with facilitation they developed conscious incompetence and with further guidance progressed through conscious competence to unconscious competence. Rationalisation led to generalization of error and apology concepts, whilst critical reflection led to contextualization. Expert mentorship is required to instill the ability to achieve the desired trait of reflective competence, demonstrating the need to reflect with the right people, at the right time, in the right manner, thus avoiding ''Facebook reflection.''

Experience as Evidence for Healthcare Policy: Examples, Opportunities, and Challenges of Using the Results of Narrative Research on Personal Experiences of Illness to Influence Policy

Susan Law, McGill University Ilja Ormel, McGill University David Loutfi, McGill University

The world inhabited by policy makers and evidence-informed decision making is typically characterised as very distant from

that of researchers and knowledge generation. There are movements in opposite yet complementary directions to enhance the contribution of scientific evidence to policy and practice and to promote patient-centred health care systems. Strategies are required to bridge evidence about patient experience and policy-making processes to contribute to evidence-informed and patient-centered policies. In collecting narrative evidence about patient and family experience of illness, the results often yield information and evidence relevant to improving care in patient-centred ways, for example, through better information and support, service redesign, or policy reform. In this session, we will focus on the notion of experience as evidence for influencing policy in health care systems. We will present a basic overview of the processes relevant to policy development, implementation and evaluation, and consider key opportunities or points of potential influence, principles of knowledge transfer relevant to policy and qualitative research, and challenges inherent in such approaches. We will share sample policy-relevant data from studies involving maximum variation samples to collect personal narratives about Canadians' experiences of breast cancer and about family caregiving. We will also present examples of successful attempts to incorporate narrative research results from the literature and in policy documents elsewhere in Canada and in the United Kingdom. We will conclude by presenting the results of a workshop held in Germany in June 2015 with international participants to develop a framework for considering policy influence using narrative research.

Meta-Aggregation: Its Utility as a Method for Developing Evidence Syntheses to Support an Evidence-Based Approach to Healthcare, Using Stroke as a Clinical Example

Maggie Lawrence, Glasgow Caledonian University Susan M. Kerr, Glasgow Caledonian University Joanne Booth, Glasgow Caledonian University

Systematic reviews of effectiveness and meta-analyses, methods of evidence synthesis, represent the cornerstone of evidence-based health care. Such syntheses inform clinical guidelines and clinical practice across the globe. They also inform the development of Best Practice statements, Consensus statements, and other clinical documents formatted specifically to facilitate the transfer of research knowledge from repository to clinical practice. However, effectiveness of an intervention, for example, is not the only active element in knowledge transfer and evidence implementation. In addition to having an understanding of its effectiveness, clinicians and patients need to be satisfied that an intervention is also feasible, acceptable, and meaningful within specific contexts, including cultural and structural contexts. To address this need for a more nuanced understanding of how and why particular interventions ''work,'' innovative yet rigorous methods of qualitative synthesis are required and in particular methods that facilitate transfer of knowledge and implementation of evidence-based practice in a heterogeneous range of health care practice

settings. Qualitative synthesis is a contentious area of methodological development. One recent development is that of meta-aggregation, a method of qualitative synthesis developed by the Joanna Briggs Institute designed to facilitate knowledge transfer and clinical implementation. This paper provides an overview of the methodological context and, against that background, discusses a worked example of a meta-aggregation from the clinical specialty of stroke. The paper will then explore the utility of this approach within that practice context.

Communicating Lived Experiences in a Culture of Silence: Using Autoethnography to Inspire Dialogue in Mental Healthcare Contexts

Stephanie LeBlanc, Western University

A strong tendency among health care professionals to discourage the mention of lived experience with mental illness has been documented. Hinshaw (2008) and Price (2014) argue that this contributes to a culture of ''nondisclosure,'' wherein those working in health care are silenced by stigmatizing attitudes and fear of prejudice, discrimination, and rejection. This presentation explores the potential of critically reflexive autoeth-nographic inquiry as a source of empowerment, a form of resistance to the authority of canonical discourses, and as valuable tool for inspiring dialogue around important sociocultural issues (Ellis & Bochner, 2000). Autoethnographic writing offers a ''new vantage point'' as it provides insights into an author's motivations and emotions, in ways that other methodologies cannot afford (Laslett, 1999; Wall, 2008).In this presentation, I discuss my use of autoethnography as a means of reflexively interrogating my experience of mental illness as it has intersected with my roles as student in an occupational therapy educational program and as a ''patient'' within the mental health care system. This autoethnographic study involves the use of theoretical constructs and discourses from the field of Disability and ''Mad'' Studies as a frame for examining my situated experiences of living with mental illness. This work proposes that interrogation of lived experience has the potential to illuminate issues of social concern. Furthermore, I argue that the sharing of personal accounts of this kind has the potential to demystify the topic of mental illness, humanize experiences of mental distress, and allow health care professionals to disclose the truth of their experiences.

Brazilian Immigrant Womens Perspectives and Experiences of Health Care in the United States: A Qualitative Study

Ana Lindsay, University of Massachusetts Boston Mariana Goncalves de Oliveira, Federal University of Ceara Marcia Maria Tavares Machado, Federal University of Ceara

Brazilians began immigrating to the United States in large and ever-increasing numbers in the 1980s as a result of worsening

economic conditions in Brazil at that time. Many of the Brazilians who have immigrated to the United States since this decade have been undocumented, and more women have immigrated to the United States from Brazil than men. Accessing and utilizing health care in a new country is central to the quality of life of immigrants. Qualitative research methods are well suited to gain a deeper understanding of women's perspectives on health care services and to explore cultural differences, which may have an important influence on the utilization and satisfaction with health care services. This descriptive qualitative study used focus group discussions to explore Brazilian immigrant women's perspectives and experiences of health care in the United States. Thirty-five immigrant women participated in four focus groups. Emergent themes revealed women's perspectives and experiences of health care in the United States, and women compared and contrasted their experiences of health care in the United States with that of their home country. Several barriers and facilitators including language, immigration status, health insurance status, and differences in cultural perspectives emerged as important influences on women's perspectives and experiences with use and rating of health care services. Findings have important implications for the design and implementation of health care services for immigrant Brazilians.

Influencing Practice Development Within Organizations: Arts-Informed Narrative Inquiry

Gail M. Lindsay, UOIT

Jasna K. Schwind, Ryerson University

Exploring experience of practitioners and students, through Arts-Informed Narrative Inquiry, is our way to influence practice settings in health care and education. One way to change and transform organizations is to begin within the 3-D space of narrative inquiry (temporality, sociality, and place), wherein construction of professional identity, knowledge, and human-ness of care occur. We used creative reflective activities: stories, metaphor, drawing, collage, dialogue, and letter writing. Facilitating practitioners and students to explore experience in caregiving reveals how each contributes to relationships and practices that comprise organizational processes. Emerging from a qualitative research program, our inquiry process is a practice development that changes practitioners and students as well as uncovers the meaning and living of person-centred care in organizations. In this presentation, we engage the conference participants in a creative reflective activity as an exemplar from our inquiry that invites reflection on, and reconstruction of, relationships in practice. Conference participants are invited to articulate connections between their experience and professional practice with potential for impact within organizations. Following this activity, we critically reflect on how health and education structures support (or not) engagement of practitioners with person-centred care and how Arts-Informed Narrative Inquiry could be fruitful for colleagues and patients. Practitioners are empowered to articulate their values and to

critique organizational policies and practices. Qualitative health and education research matters and is influential for organizational renewal.

Waiting for Lung Transplant: The Support Persons Experience

Linda Liu, Ryerson University Jennifer Lapum, Ryerson Unviersity Heather Beanlands, Ryerson University Oona St. Amant, Ryerson University

In order to qualify for the lung transplant wait-list, patients must have a designated support person agree to provide constant care for them. The support person, usually a family member, must relocate with the patient to be within a 2.5 hr drive from the transplant site for the entire waiting period (ranging from 3 to 24 months). Despite this significant disruption to support persons' lives, little research exists about their waiting experiences. A narrative study framed by the concept of limin-ality was conducted to explore support persons' experiences of waiting for lung transplant. Support persons were recruited from a lung transplant program in Central Canada. All of the participants relocated distances ranging 550-1,750 km from their homes. Two semistructured interviews were conducted with each participant about 3-4 weeks apart and participants kept journals for 2 weeks between the interviews. Findings revealed that the waiting experience was isolating, whereby support persons became separated from their normal routines, relationships, and social life. Their lives revolved around the patient's health needs and the anticipation for a transplant call. The main narrative ideas were separation, prioritizing the patient's needs first, support, balancing hope and fear, and finding meaning in waiting. Findings from this study suggest the need for health care practitioners to assess the impact of waiting on support persons' own health and well-being. Additionally, practitioners need to consider the development of supportive interventions that are tailored and responsive to support persons' unique needs as they wait for lung transplant.

The Application of Critical Realist Theory to Move Beyond the Rhetoric of Promoting Patient-Centered Care to Assessing its Implementation

John Macdonald, Laurentian University Nancy Lightfoot, Laurentian University Nancy L. Young, Laurentian University Janet E. McElhaney, Health Sciences North

The Ontario Ministry of Health and Long-Term Care has promoted patient-centered care (PCC) for decades, however PCC has roots within Western medicine since at least the 1950s and centuries in other traditions. Despite decades of PCC rhetoric, there continues to exist a disconnect between the mandate to provide PCC and a health care environment that facilitates this

model of care. Using Critical Realist (CR) theory, this study will explore the disconnect by examining the mandated provision of PCC for long-term care home (LTCH) residents afflicted with dementia. CR theory allows the researcher to move beyond the epistemic fallacy committed by both positi-vists and interpretivists, in that neither paradigm can discuss the world, or reality (Ontology) apart from their knowledge of it (Epistemology). As such, singularly using health outcomes data or the lived experiences of frontline dementia care providers to understand how and why there continues to be a disconnect between PCC promotion and application would be problematic. Conceptually, this study will attempt to explore the interconnectedness between older adults afflicted with dementia residing in LTCHs, the frontline care providers, and the larger structures that overtly and covertly shape these interactions using CR's retroductive technique, triangulating data from an embedded mixed-methods design. Retroduction is an iterative, hermeneutical process that allows the researcher to move between social phenomena that are empirically experienced as sensed expressions of actual events, draw logical inferences about these events, and then in turn, identify generative mechanisms and potentially the structures that caused them.

Using an Embedded Mixed-Methods Design to Triangulate Three Sources of Data Exploring the Delivery of Patient-Centered Care for Older Adults With Dementia in Some Northeastern Ontario Long-Term Care Facilities

John Macdonald, Laurentian University Nancy Lightfoot, Laurentian University Nancy L. Young, Laurentian University Janet E. McElhaney, Health Sciences North

Traditional models of care used within many long-term care homes (LTCHs) can foster an environment that diminishes per-sonhood from those afflicted with dementia through the routini-zation of daily activities and biomedical objectification. In contrast, person/patient-centered care (PCC) models are based upon value-driven approaches to holistic reciprocal patient care that improve health outcomes. This study will use a qualitatively weighted embedded mixed-methods design to explore the experiences of frontline caregivers' ability to implement PCC strategies in both ''traditional'' LTCHs and facilities receiving ''enhanced'' support through Behavioral Supports Ontario, gathering three distinct yet interconnected sources of data. In-depth interviews will be conducted with frontline dementia caregivers (n = 26-40) from eight LTCHs, including two urban and two rural enhanced sites and two urban and two rural traditional sites. Secondly, an embedded quantitative study will concurrently examine secondary InterRAI data of patients with dementia from the selected LTCHs, specifically: (1) physically abusive behaviors, (2) verbally abusive behaviors, (3) persistent anger with self or others, (4) repetitive anxious complaints, (5) withdrawal

from activities of interest, and (6) expressions of sadness or depression. These data will be analyzed to examine if older adults with dementia residing in enhanced LTCHs experience fewer behavioral incidents compared to those residing in some traditional settings. Thirdly, textual analysis of pertinent legislation and policies combined with key informant interviews with content/context experts (n = determined emergently) will be conducted to contribute to the iterative critical analysis necessary to inform and create inferences between the experiences of frontline caregivers and their workplaces.

Generating Theory to Further Understanding of Cystic Fibrosis Self-Management

Marilyn Macdonald, Dalhousie University

Cystic Fibrosis (CF) is a chronic illness that requires adherence to a rigorous and often complex treatment regimen that can include mucolytics, bronchodilators, steroids, antibiotics, pancreatic enzymes, and vitamins. Nonadherence for adults with CF can manifest in many ways, such as altering the dose, duration, frequency of therapy, or stopping medications completely. When nonadherence occurs, patients are at increased risk for adverse events, which are costly to the health care system both directly and indirectly. In 2010, 1,173 people with CF spent 23,146 days in hospital. Indirectly, nonadherence can contribute to lost productivity of patients and family members. Evidence abounds regarding rates of adherence with little theory to explain it. The question we are interested in is How is adherence in the medication management process understood by adults with CF, their family members, and health care professionals' qualitative research methodology, in particular Grounded Theory, is essential to advance understanding of adherence. We are conducting semistructured interviews for adults with CF, their family members, and health care providers to generate a theory about how adults with CF manage treatments including medications. Data analysis is simultaneous with data collection, including constant comparison, coding, development of categories, and theoretical sampling. The theoretical concepts comprising the theory will form the basis for the development of strategies to support adults with CF to optimize self-management and contribute to a definition of adherence that extends beyond the responsibility of the person with CF. Preliminary categories developed from the data gathered to date will be presented and discussed.

Saving the Emergency Department Through Better Primary Care: Does Continuity Have a Role?

Fiona MacKichan, University of Bristol Emer Brangan, University of Bristol Katherine Checkland, University of Manchester Sarah Purdy, University of Bristol

Unplanned care such Emergency Department (ED) visits and unscheduled hospital admissions is accelerating in the

United Kingdom and, in the context of growing financial pressures, this has contributed to the view that the National Health Service is ''in crisis.'' A high proportion of unplanned hospital care is felt to be care that could have been delivered in the community, and so primary care has become a focus of efforts to reduce unplanned care. We conducted a multimethod study to identify what features of primary care influence unplanned hospital care (ED use and unscheduled hospital admissions) and to establish how these features interact. The final part of this work was an exploratory qualitative case study phase involving six primary care centres (family practices). Data collection comprised 69 hr of observation in reception areas, document analysis, interviews with 19 centre staff, and interviews with 29 patients who had recent experience of using unplanned hospital care. Case descriptions were developed to inductively identify primary care features that might influence use of unscheduled secondary care. Subsequently, we considered on how our data related to theoretical propositions emerging from other phases of the research. In this presentation, I will describe the complexities of the relationship between primary care continuity, which is often seen in terms of relational continuity (seeing the same physician over time) and use of unscheduled care. I will reflect on this in the context of current health care policy, highlighting opportunities for changing policy and practice.

Appealing to Policy Makers and Practitioners Through Email-Based Dissemination

Fiona MacKichan, University of Bristol Lesley Wye, University of Bristol Lorna Duncan, University of Bristol Sarah Purdy, University of Bristol

Much qualitative health research is funded by public bodies and impacts need to extend far beyond academia. The process of moving from research-generated knowledge to positive impact on health and health care is often unclear and particular challenges exist for qualitative studies, for example, distilling complex and nuanced insights into ''easily digestible'' pieces that can inform decision making in ever-changing health care contexts. In this presentation, I will reflect on our experiences of how different dissemination formats are received by policy makers, health care commissioners, and practitioners. Findings from a study involving six qualitative case studies (primary care practices) were developed by the research team into three different formats for dissemination: a one-page written piece, an animation telling composite participant stories, and a video presentation by one of the research team. Commissioners, policy makers, and practitioners from three geographical areas in England, the United Kingdom, were randomly assigned one of the formats, which was sent as an attachment to a standardised cover e-mail. Using altmetrics that track the performance of email communication, we were able to evaluate the response to our different dissemination formats.

Activities of Patient Groups and Approval of a New Drug for Autosomal Dominant Polycystic Kidney Disease in Japan

Hiroki Maeda, Tokai University

Yumi Nishimura, Tokyo Metropolitan University

The purpose of this research is to explicate how patients in Japan with autosomal dominant polycystic kidney disease (ADPKD) experience their illness. In Japan, with a new drug for patients with ADPKD approved and a law regarding medical care for patients of intractable diseases enacted in 2014, the experiences of patients and their families have begun to change. By analyzing data obtained from interviews with patients, we are now able to describe the methods being used for treating this disease. This ethnomethodological study, originating in sociology, includes analysis of membership categorization in illness narratives. Our research plan has been reviewed and approved by the Ethics Committee. Identifying the responsible gene in the mid-1990s led to the official classification of ADPKD as a genetic disorder. This encouraged patients to pass down knowledge to younger generations as well as participating in clinical trials. Patient groups in Japan played an important role in delivering the information of clinical trials and sharing their situation with doctors, pharmaceutical companies, and administrative organizations. This process could be regarded as a kind of project on ''genetic citizenship.'' The recent approval of the new drug was a direct result of a movement and provided a new condition concerning the possibilities for their activities. Here, we describe the shift in their activities and their ''membership categorization,'' and explicate their effects on the lives of patients and their families.

Critical Directions for Visual and Arts-Based Methodologies in Health Research

Katie Mah, University of Toronto Laura R. Hartman, University of Toronto Nick Reed, University of Toronto

Qualitative visual- and arts-based research methods are growing in popularity and diversity, seeking to explore participant perspectives, give new voice to complex ideas, and create messages of change. In this presentation, we will focus on the use of critical visual and arts-based research methods with child, youth, and young adult populations. While biomedically oriented inquiry into childhood health and disability issues explores the medically measurable using concrete parameters, we posit that the social, experiential, and critical aspects of health and disability must also be considered. We will first explore the concepts of visual and arts-based research as we will apply them. We will then present the various points at which critical exploration may enter (i.e., research conception, question formation, collection, analysis, writing, and dissemination). Through this presentation, we will provide an example of a critical arts-based research program designed to explore children's conceptualizations of mild traumatic brain injury

(mTBI) and stakeholder reactions to mTBI as understood and communicated by children through art. The process of creating and actively sharing child-produced representations allows us to transition the health and disability research community's understanding of childhood mTBI beyond the purely biomedical realm into a broader, more nuanced realm that considers the varied social, experiential, and emotional effects of childhood mTBI. This presentation will close with a discussion of why and how to craft a critical visual or arts-based research project in the health and disability sphere with the intent of effecting change.

The Social Organization of Mental Ill Health in the Workplace Setting: Local and Translocal Ruling Relations

Cindy Malachowski, University of Waterloo Peter Sawchuk, University of Toronto Katheryn Boydell, University of New South Wales Bonnie Kirsh, University of Toronto

This article makes visible the ways in which peoples' experiences of mental ill health are coordinated and produced in the workplace setting. Drawing from data collected in an institutional ethnography conducted within an industrial manufacturing plant in Ontario, Canada, we explicate how texts organize activities and align worker consciousness and actions with company expectations of what constitutes a ''bona fide'' illness. By taking up the standpoint of the worker living with mental ill health, we shed light on how local activities are coordinated through a mental illness is an illness like any other discourse. These findings show how workplace expectations of a bona fide illness are textually mediated by biomedical and physical work restrictions and create a significant disjuncture between an experiential and a ruling perspective of mental ill health. In order to evade institutional processes, workers engage in respite from work formally through use of vacation time but also often engage in informal respite from work by ''hiding.'' We argue for increased attention to workplace practices and processes that address periodic or episodic mental ill health as a starting point for organizational change.

Study Abroad Locations and the Impact on Students Cultural Awareness: Does Place Matter?

Hendrika Maltby, University of Vermont

Bias and stereotyping by culturally unaware health care providers may contribute to health disparities among ethnic groups. Often, there is a communication mismatch between nurses and clients from diverse backgrounds. One method to address this issue is to enhance cultural awareness through study abroad immersion experiences. These trips can increase recognition of personal beliefs, values, practices, and behaviors, but it is unknown whether the destination of the immersion experience

affects this awareness. The purpose of this study was to discover if there is a difference in students' cultural awareness when completing a study abroad trip to a low-income country versus a high-income country. That is, does "place" impact students' cultural awareness? Using narrative content analysis, reflective journals of American nursing students who traveled to either Bangladesh or the Netherlands for their public health nursing course were compared. Analysis showed that both groups of students learned similar concepts through interacting with cultures different from their own. They became more self-aware of their own culture and how they fit into the global perspective. The emphasis of their journals, however, was distinct: Those who traveled to Bangladesh concentrated on the high levels of poverty they observed, while those who traveled to the Netherlands focused on the difference in the health care systems. Findings from this study show that cultural awareness changes regardless of where students travel. As nurse educators, we can revise curriculum to create experiences for all students to enhance cultural awareness that can inform practice and improve client health outcomes.

Understanding How Nurses Experience Living Their Values Amidst Organizational Change: A Narrative Inquiry

Louela Manankil-Rankin, McMaster University

Janet Landeen, McMaster University

Colleen McKey, McMaster University

Gail Lindsay, University of Ontario Institute of Technology

Values are foundational guidelines that underpin nurses' actions. They serve as fundamental points of reference for nurses and, as such, determine their moral nursing practice. Understanding how nurses' experience of living their values amidst organizational change sheds light on how this social condition influences the narrative composition of nurses' lives and their practice. This Narrative Inquiry (Clandinin & Connelly, 2000) illuminates the temporal connections of life events; how social conditions mutually shape personal conditions; and how actions that occur within a place gives meaning to the experience. Six nurses from a large academic health centre in Southern Ontario were recruited and interviewed over 8 months. Letters were constructed for each coparticipant to reveal the experience of living values amidst organizational change. Subsequently, a composite narrative in the form of a letter was composed, revealing four plotlines: responsive relationship, moral distress, reflection and reconstruction, and knowledge and identity. These plotlines intersect to describe the extent to which nurses meet their moral obligations within relational practice. This study brings to the foreground four narrative terms, including stories to commit by that contribute to a new way of thinking about familiar issues. It illuminates the personal and the active movement of reflection that reside in a person and the choice(s) he or she makes to recraft life. Considerations for practice, education, policy, and research highlight the importance of a deeper level of reflective practice,

the connection between personal and ethical knowledge, and the need for becoming aware of one's moral horizon.

Moving From Field to Research Text in Narrative Inquiry: Lessons Learned

Louela Manankil-Rankin, McMaster University Gail Lindsay, University of Ontario Institute of Technology Janet Landeen, McMaster University Colleen McKey, McMaster University

Clandinin and Connelly's (2000)Narrative Inquiry is about understanding the situated lives of people through reflection and reconstruction of experience, using stories as the founda-tional basis for such an understanding. It aligns with philosophical assumptions of the subjective and multiple natures of reality within qualitative research. Moving from field text to research text is perhaps one of the biggest challenges for new beginners using this methodology. It is one that I struggled to understand. How does one move from transcripts to research text? How does one use the 3-D inquiry space as an analytic frame for generating the knowledge that this methodology enables? This golden nuggets presentation will focus on lessons learned in the process of moving from field to research text with a particular focus on the strategies employed in staying true to the methodology and the paradigm. Narrative Inquiry is not just a methodology that necessitates cognitive processing and analysis. It requires that I embody the methods, stay present to the stories, and be reflexive in the process of looking backward and forward, inward and outward to the lives of my coparticipants and that of mine. Without the latter, an inquirer is void of the spirit that fuels Narrative Inquiry. The process of awareness is both emotional and cognitive in nature. I needed both processes to exist in order to hear and experience the stories of my participants and to understand the narrative of their experience.

Qualitative Findings to Inform the Use of Telehealth Via Videoconferencing in Oncology

Carole Mayer, Supportive Care Program, Northeast Cancer Centre Nicole McDonald, Northeast Cancer Centre, Health Sciences North

David Want, Northeast Cancer Centre, Health Sciences North

Through the Ontario Telemedicine Network (OTN), oncology patients receive follow-up care from physicians and staff at a tertiary cancer centre in Northeast Ontario. Telehealth, via videoconferencing, has helped close the gap between urban and rural/remote communities to provide cancer patients' access to oncology specialists. Results from a patient satisfaction survey completed in 2006 confirmed that patients approved the use of telemedicine in an outpatient oncology setting. As the program reached over 400 visits per month, patterns of high and low use of the technology were observed amongst various disciplines. It became evident that

it was important to understand the health care providers' perspective on the use of telehealth if processes and pathways were to be further developed, implemented, and improved when using this technology. After receiving ethical approval to pursue the study, focus groups and interviews were held in 2009 with several disciplines, including radiation and medical oncologists, primary nurses, OTN nurse coordinators, and other health care professionals. Key informant interviews were held with administrators and support staff to identify opportunities for service enhancement. All interviews were transcribed and coded by two researchers using thematic analysis; when discrepancy was noted for themes, agreement was reached through consensus. Study results will be presented demonstrating benefits and barriers for using tele-health in oncology. We will also review how the use of OTN has continued to evolve in the cancer centre for the past 6 years. In conclusion, findings from qualitative inquiries are beneficial to understand and improve clinical pathways for patient care.

Older People in Disasters

Monir Mazaheri, Malardalen University

Ali Ardalan, Tehran University of Medical Sciences

Older people have long been recognised as among the most vulnerable people in disaster events. The study reports a qualitative study of the self-perceived needs of older people in the aftermath of the Bam earthquake in Iran in 2003. A total of 56 people aged from 65 to 88 years were recruited to the study using purposive sampling, including 29 men and 27 women. Six focus group discussions and 10 semistructured individual interviews were conducted. Each focus group involved 6-10 people from the cities of Bam and Baravat and their rural suburbs. Content analysis was used to analyse the transcribed data. The analysis identified four major themes among the informants' concerns: inappropriate service delivery, affronts to dignity, feeling insecure, and emotional distress. A disaster-prone country like Iran needs to be appropriately prepared with culturally sensitive plans to meet the needs of those who suffer from their effects, not least older people. Emergency relief managers should note that for many older people in a disaster zone, customary forms of relief are neither required nor appropriate, and that their distinctive immediate and long-term needs should be assessed and met. Relief agencies need to be trained to be age sensitive and should mainstream older people's rights in the planning and implementation of both the response and recovery phases of assistance.

Situating and Constructing Diversity in Semistructured Interviews

Michele J. Mcintosh

Janice M. Morse, University of Utah

While semistructured interviews (SSIs) are used extensively in research, scant attention is given to their diversity, underlying

assumptions, construction, and broad applications to qualitative and mixed-method research. In this three-part article, we discuss the following: (i) How the SSIs is situated historically including its evolution and recent meteoric rise and diversification to suit phenomenological, feminist, neopositivist, and critical research aims. We advance a typology of SSIs: descriptive/ confirmative, descriptive/interpretive, and descriptive/corrective; (ii) The principles of constructing SSIs; and (iii) How SSIs are utilized as a strategy within a mixed-method design and as a stand-alone research method.

Voiceless and Powerless: Pediatric Nurses Experiences Within the Processes of Rapid and Continuous Organizational Change. Preliminary Findings

Kim McMillan, University of Ottawa Amelie Perron, University of Ottawa

Change in health care has become rapid and continuous for many reasons, in large part because of fiscal influence and restraint but also because of swift advances in health care technology, managerial structures, and scopes of practice for both regulated and nonregulated health care workers. Current research on the subject of organizational change, the vast majority coming from management, business, and organizational studies, has supported differing and sometimes conflicting conclusions about efficient and sustainable ways of devising and implementing change in health care organizations. Very little research is available on the impact of change for those employed in rapidly changing workplaces. What little research completed to date highlights is that workers experiencing large amounts of change can experience what has been identified as change fatigue. The experience of change fatigue can cause workers to become withdrawn, burnt out, and exhausted. It greatly influences their decision to leave the workplace and even their profession, issues that already affect the nursing workforce in disproportionate ways. This presentation will highlight a key finding of a critical hermeneutic study that explored the nature of frontline nurses' experiences of living with rapid, ongoing organizational change in a tertiary-care health institution. A key finding was that nurses feel voiceless in health care decision making, specifically decision making relating to changes that directly impact how nurses carry out their frontline work. Thus, the implementation of much change in health care does not increase efficiencies but rather increases nursing workload whilst simultaneously dis-empowering nurses. The participants of this study exhibit high levels of burnout, disengagement, and feelings of powerless-ness, which are consistent with current literature on change fatigue. The findings suggest frontline nurses must be actively engaged in all levels of health care decision making to ensure both fiscal and human resources are used in ways that truly support efficiency and facilitate the delivery of exceptional patient care.

CBT-Based Grief Interventions for Dementia Caregivers: A Case Study

Franziska Meichsner, Friedrich Schiller University Gabriele Wilz, Friedrich Schiller University

Dementia caregivers are not only at risk for the development of physical and mental health problems but also experience grief and loss related to general burden, depression, and complicated grief. Pilot intervention studies addressing caregiver grief used group settings, but although an individualized approach based on cognitive-behavioral psychotherapy (CBT) is best suited for dementia caregivers, no such grief-focused intervention has been realized to date. We therefore developed a grief-specific intervention module included in the manual of an Randomized Control Trial with dementia caregivers in Germany. It was the focus of the present study to gain insight into how this module was applied by therapists and if it fits caregivers' needs. Using qualitative content analysis, we conducted a single case study of the 64-year-old caregiving wife Mrs. F. She received 12 therapy sessions within 6 months. One session each from the beginning, middle, and last phase of therapy was selected and transcribed. To analyze the therapeutic strategies and the losses Mrs. F reported, three category systems were developed using a mostly deductive approach: Grief-specific Intervention Strategies, Standard CBT-Techniques, and Dimensions of Loss. Intercoder reliabilities were satisfactory; transcripts were coded using ATLAS.ti software. During the analysis, we focused on Mrs. F's individual grief experience and linked it to the therapist's intervention strategies. Changes occurring over the 6-month period were also analyzed. The results contribute to our understanding of the unique experience of grief in dementia caregiving and how CBT-based interventions can be used to support caregivers and prevent further mental health problems.

The Lived Experience of Professional Identity in Master Nursing Academics

Brenda Merrill, Metropolitan State University

Minimal research exists regarding professional identity in nursing faculty. The literature from teaching, nursing, and medicine shows professional identity promotes resilience, collaboration, and positive patient outcomes. These factors are relevant to the retention of nursing faculty, due to the aging of the workforce, workplace stress, and job satisfaction. This hermeneutic phenomenological study used the philosophy and methods of van Manen (1997) to explore, interpret, and understand the phenomenon of professional identity in expert nursing academics. The study utilized a bricolage design, as each participant completed a written narrative describing a defining moment, drew and labeled an Illustrated Career Trajectory, and participated in a narrative interview. The essential themes were Professional Identity as Individualized Construct, Workplace as Formative Agent, Teacher as Lifelong Student, Relationships, Focus

on the Students, and Constant Reconstruction Over Time. A conceptual model was developed to illustrate the relationships between the essential themes. The conceptual model of professional identity illustrates factors that should be integrated into graduate education, transition to academia, and throughout professional practice. Providing formal education, and continuing infrastructure in academia, supports professional identity development that promotes growth, expertise, and satisfaction, resulting in retention and development of novice and expert faculty. Retained, satisfied, and expert faculty benefits the profession of nursing, as faculty contribute to the knowledge of the discipline and guide nursing students in professional identity development. This oral presentation will provide an overview of the literature on professional identity; describe the study design; and discuss the findings, strengths and weaknesses, and implications for practice.

Development of a Smartphone and Web App for Qualitative Data Collection: Key Considerations

Ashleigh Miatello, McMaster University Christina Hackett, McMaster University Alison Mulvale, OCAD University Gillian Mulvale

Smartphone and web applications (apps) are emerging as useful tools to support youth with mental health problems. These technologies also have the potential to be used for realtime qualitative data gathering; however, limited literature exists to inform their development. We present lessons learned from a case study of developing apps to capture experiences of youth mental health services. An interdisciplinary team developed the MyExp smartphone app to understand youth's experiences of receiving mental health services and similar web apps for service providers and family members. These data will be used to inform system improvement as part of a participatory action research study using an experience-based codesign approach. An iterative development process featured qualitative input from the three user groups. Findings suggest that tensions exist when using apps for qualitative data collection. Researchers need to balance open- and closed-ended questions given limited screen space and recognize the restricted capacity to probe through follow-up questions. Characteristics of each user group and technical and ethical considerations must also be recognized. While apps provide an opportunity to collect data in real time over a long period, this may come at the cost of depth and richness of data. The MyExp apps are promising tools for data collection given their familiarity in this hard-to-reach and vulnerable population. The decision to use apps as tools for qualitative data collection requires researchers to weigh the benefits and possible drawbacks of this strategy, so as to maximize richness and frequency of data collection with minimum participant burden.

Everyday Activity in a Risk Society: The Mundaneness of the Being a Mental Health Consumer

Benjamin Milbourn, Curtin University Beverley McNamara, Curtin University Angus Buchanan, Curtin University

The oral presentation reports on the research findings of a 12-month qualitative, longitudinal community study in Western Australia, involving 11 people with severe mental illness. The presentation provides a sociological consideration of the research findings through the lens ''risk society'' and ''liquid modernity.'' The presentation will also consider the uses of illness narrative and personal recovery philosophy in interpreting how mental health consumers construct and often find safety within a manufactured ''everyday.''

Using Participatory Methods to Identify Service Developments for Improving Maternal and Birth Outcomes

Ghazala Mir, University of Leeds, Symposium Chair

Symposium Description: This symposium explores the opportunities and challenges of using participatory and other coproduction methods to understand inequalities in maternal and birth outcomes and stimulate action to reduce these. Despite a stated concern to reduce levels of maternal and infant mortality in various national settings, policy directives and interventions often fail to reach women who experience the worst health outcomes. The causes of the inequalities they experience are complex and contested and such women are most often perceived as the recipients of necessary support rather than key actors for the development of services and health interventions. The symposium will present methodological approaches that help avoid naturalising and reproducing the inferior position given to women from marginalised groups and the unequal social relations that disadvantage them in the United Kingdom and in South Asia. Discussion of findings will consider how these studies might contribute to development of a complex intervention to improve birth outcomes of cross-national relevance.

Abstract #1: Involving Bereaved Women in Maternity Service Development—The HOPE Groups as a Model for Social Change

Ghazala Mir, University of Leeds Nasreen Rafiq Shazma Zaman HOPE Group

This study explored professional and community support for maternal and infant health in a range of ethnic and social groups. Social network analysis explored the extent and nature of women's supportive relationships, and participatory

research was used to develop strategies for addressing gaps in support. Participatory methods supported women who had experienced an infant death to engage with other relevant stakeholders and stimulate specific projects that addressed the gaps identified. A number of initiatives had a considerable impact on service development and linking with influential policy makers and practitioners to make change happen was a key motivating factor for women. Research funding supported their sustained contribution. The study raised important ethical issues about research with women who have experienced an infant death and key lessons about the type of training women needed to participate effectively were also learned. The study in effect provided a model for the change needed to positively impact on social determinants of health affecting minority ethnic and religious communities in the United Kingdom. The project supported women to make critical and effective use of research evidence, with a view to using these insights in the development of solutions to reduce inequalities in infant mortality. Supporting women to ''bridge'' with key actors in maternal health networks in order to enhance professional and community practices modelled the structural change needed to reduce inequalities in health and facilitated the coproduction of knowledge between researchers, health care professionals, and other actors in social networks for maternal and child health networks.

Abstract #2: Understanding and Addressing Healthcare Inequity: The Challenges of Coproduction

Adrienne Levay, University of British Columbia Zubia Mumtaz, University of Alberta Sarah Salway, University of Sheffield

A concern to understand and address health care inequity in maternal and neonatal birth outcomes is growing. It can, however, be challenging to balance different perspectives on the processes of inclusion, exclusion, and disadvantage that operate within health care organisations. This paper draws on a narrative synthesis of selected studies, combined with the authors' experiential learning, to consider the opportunities and challenges presented to this agenda by methods that aim to bring together maternity service users, including migrant/ minority women, health care practitioners, policy makers, and academics. Privileging the voice and perspectives of women from marginalised populations and managing power relations in such research contexts is a key concern. There is often resistance among decision makers to findings that locate the causes of inequity within their own health care organisations and programme design. Findings based on such research can also be challenging to translate into research products that are familiar and credible to health care audiences. There is a need to explore how the strengths of ethnography might be combined with coproduction approaches in order to engage the end users of evidence, so that improved understanding might be better translated into effective action on inequity.

Abstract #3: Enhancing Genetic Literacy Among British Pakistani Community: A Participatory Action Research Project

Parveen Ali, University of Sheffield

Sarah Salway, University of Sheffield

Saima Ahmed, Pakistani Community Advice Centre

In the United Kingdom, the infant mortality rate in British Pakistani populations is much higher than that of the U.K. population. Multiple reasons exist for this increased rate, including rare genetic disorders linked to the practice of cousin marriage. The valued social practice affecting this marginalised population combines with complicated patterns of risk and low professional awareness generating a complex and contentious issue. World Health Organization recommends community-level action to raise genetic literacy combined with enhanced genetics services. U.K. interventions comprise varied local initiatives and no national response, with some interventions generating significant backlash. This study in a northern English city aimed to develop a community-level sensitive and responsive genetic literacy intervention. Using a participatory approach with core-searchers, data were collected through group discussions, interviews, and participatory exercises involving over 200 people. A series of testing-and-refinement cycles were then undertaken to coproduce a set of communication materials, with materials being tested for acceptability, appeal, and comprehension. Information needs and preferred communication channels varied widely, confirming population heterogeneity and diverse relationships to the issue. Despite some resistance, there was strong demand for information and willingness to discuss the topic, but conveying accurate and consistent information was challenging. Narrative, audio, and video resources were recommended and developed, supported by factual information in leaflet and website form, containing links to religious resources plus genetics services. The project demonstrates that the development of appropriate community-level genetic literacy interventions can be achieved through participatory action research.

Shadows, Silence, and Secrets: A Narrative of an Isolated Communitys Response to Intimate Partner Violence

Pertice Moffitt, Aurora Research Institute/Aurora College Heather Fikowski, Aurora College

Intimate partner violence (IPV) is a grave issue across Canada, but IPV causes immense suffering for women in small fly-in communities in the Northwest Territories. A research team from the Northwest Territories consisting of academics, students, and community members is engaged in a 5-year study (2011-2016) along with the Prairie Provinces to investigate rural and northern community response to IPV. The aims of this study are to create an action plan that maps the sociospatial problem of IPV, generate narratives describing northern response, and explicate a theory of ways to create and sustain nonviolent communities. In the first 2 years, incidents of IPV

across the Northwest Territories were collected from the Royal Canadian Mounted Police (RCMP); an environmental scan of resources in the territory available to victims of IPV was completed; geographical information system maps were developed to portray the data; and individual interviews were conducted with 31 frontline workers (RCMP, nurses, shelter workers, and others). These data were analyzed using grounded theory and a preliminary model created. In the third year, two community profiles were completed using focus group and individual interviews adding further depth to the model. Findings from this study demonstrated a core phenomenon of binding intersections that offered an explanation of ''our hands are tied'' (core phenomenon Year 2) through the processes of putting up, shutting up, and getting on with life. This presentation will focus on the narrativization of findings from Year 3/4 data collection of the project demonstrating an intersec-tionality of challenges faced by frontline workers. The consequences of the binding intersections along with the stories of strength, perseverance, and hope will be shared.

Creating Practice Knowledge Through a Virtual Discussion Forum (VDF): An E-Research Strategy

Ramadimetja Mogale, University of Pretoria Nomathemba Ngcobo, University of Pretoria Steppies Rikhotso, University of Pretoria

A virtual discussion forum (VDF) was established in the Department of Nursing Science at the University of Pretoria as a way of promoting transdisciplinary research and learning. The overall aim of this VDF is to create a space and platform for transdisciplinary knowledge embedded within the practices of traditional health practitioners and traditional leaders. It was important to explore such knowledge because it is often not confined to a fixed formal discipline or area of knowledge system. Such knowledge is usually taken for granted, ignored, and marginalized (Ocholla, 2007). Qualitative, e-interactive, and virtual-based tools, which are used are online moderated collaborate chartrooms, conversations, debates, and dialogues. The engagements give the impression of generating three specific types of evidences: (1) systems, (2) target knowledge, and (3) transformation knowledge. E-research strategies are novel interventions that can create practice knowledge in the worlds of virtual reality within qualitative health research.

Coming to Know and Understand the Culture of Prosecution of Violence Against Women (VAW) Through Sensory Ethnography

Ramadimetja Mogale, University of Pretoria Kaysi Kushner, University of Alberta Solina Richter, University of Alberta

This presentation reports the insights of a sensory ethnographic study that explored the culture of prosecution of violence

against women (VAW) in South African courts. Through the reflexive and experiential processes that sensory ethnography permits, we were able to identify what underpin the practices employed in prosecution of VAW. The identified practices indicated transdisciplinary, interactive, and women-friendly processes that can be used to thwart VAW.

Towards an Emancipated Decision-Making and a Bosadi (Womanhood) Approach: A Theoretical Framework

Seepaneng Salaminah, Moloko University of Pretori

Fhumulani Mavis Mulaudzi, University of Pretoria

Tanya Heyns, Department of Nursing Science, University of Pretoria

This was an African-oriented hermeneutic phenomenological study that explored the meaning and interpretations of the proverb ''lebitla la mosadi ke bogadi'' which is deeply rooted in the African heritage. This proverb is commonly used in premarital counselling. Individual interviews and focus group interviews with married, widowed, and divorced African women who were attending social clubs in the city of Tshwane and Johannesburg, South Africa, were conducted. The narratives obtained from the data were linked to Witmann-Price (2004, p.441) theory of emancipated decision making and Masenya (2004, p. 123) ''bosadi'' womanhood approach to develop a theoretical framework. Patriarchal system is the first context where women experienced challenges, and the second context is the impact of this proverb on women's health. And the last context is the critical attributes that lead to emancipated decision making. The interrelation of these three contexts signifies an interplay of various identified elements/constructs in the lives of African women.

The Perceptions of Women in Northern Ontario About Their Reproductive Health Care

Lisa Morgan, Laurentian University

There is a documented need in the literature for an increased understanding of the elements that contribute to satisfaction in health care for women. Also, under the current climate of fiscal restraint, there exists interest in examining alternatives for care while maintaining quality. This presentation will report on findings from primary research undertaken to examine the opinions of women in northern Ontario about their current reproductive health care. In examining this issue from the perspective of women living in rural and northern communities, this research seeks to inform the design and implementation of care delivery systems that strengthen the reliability and quality of care while reflecting the priorities of women. Nineteen women in Northern Ontario were interviewed about their experiences. The framework adopted for this research was the Hierarchical Model of Health Service Quality which represents a new conceptualization of health care service quality,

as measured from a consumer's perspective, in a way that predicts client satisfaction and behavioural intentions. The findings suggest that many women prefer female practitioners for this care. They felt that geography (rural, remote, and northern) affected their access. Women described how they had to advocate for themselves in order to receive the necessary care and sought alternatives when available. Women are concerned about confidentiality due to smaller populations and offered many insights on their caregivers, options, and preferences. It is hoped that this examination will lead to a consideration of options and changes in health policy to support womens needs.

A Decolonizing Method of Health Inquiry

Melody Morton Ninomiya, Li Ka Shing Knowledge Institute

I make visible how institutional ethnography (IE) was used as a decolonizing method of inquiry. At the heart of decolonizing research is the task of shifting whose knowledge is privileged, from those with power (often researchers) to those who are being researched (those subject to the effects of colonization). I argue that when IE is used to facilitate community-based research and knowledge translation (KT), decolonizing research is made possible. I used IE to examine how supports and services are coordinated for children and youth medically diagnosed with fetal alcohol spectrum disorder in a rural indigenous community in eastern Canada. This presentation also outlines how principles for conducting research with indigenous people in Canada, community-based research, and integrated KT were embedded into the study. Furthermore, I discuss how IE is well positioned to facilitate both decolonizing research and emancipatory KT, making IE a means to a decolonizing ''end.'' This study offers new and exciting advances to the field of decolonizing health research, IE, and KT.

Catching Hermeneutics in the Act: Hermeneutic Research in the Action of Healthcare

Nancy Moules, University of Calgary Graham McCaffrey, University of Calgary Catherine Laing, University of Calgary

In the ways we have embraced hermeneutics as a research approach, hermeneutics is not really concerned with itself but rather with making sense of philosophy in a way that is applied in living examples. We take up Gadamerian hermeneutics in its research application to topics that inhabit our lives and professions, the act of interpreting living features of the world. The subtle and always interpretability of the world is made visible and available in the application of hermeneutics' the act of philosophy and catching it in the act. In 2014, we received a book contract with Peter Lang Publishing to write Conducting Hermeneutic Research: From Philosophy to Practice (Moules, McCaffrey, Field, & Laing, 2015). We had the privilege of Dr. John D. Caputo writing the foreword to the book and he offered this idea that what the book does is:

catches hermeneutics in the act. It brings home in the most vivid way just

what hermeneutics really is in the concrete. Its authors are concretely

engaged and hermeneutically enlightened practitioners who are describing the

difficult and delicate conditions under which concrete her-meneutical work takes place. (p. ix)

In this presentation, I will speak to tenets of Gadamerian philosophy that ''guide'' our research in understanding the complexity of human experiences: Topics such as childhood cancer, grief, mental illness, education and schools, arts and humanities, and other topics that show up in practice professions of nursing, teaching, social work, and psychology. Examples of specific hermeneutic studies around childhood cancer will be offered.

Integrating Qualitative Research Into Health Technology Assessment in Canada: Experiences of the Canadian Agency for Drugs and Technology in Health (CADTH)

Kristen Moulton, CADTH Laura Weeks, CADTH Sarah Berglas, CADTH

Health technology assessment (HTA) involves the systematic evaluation of evidence related to clinical effectiveness, safety, and cost-effectiveness to inform health policy. HTA agencies worldwide are increasingly incorporating patient perspectives into the HTA process to enhance legitimacy in public decision making and to ensure decisions that impact patients appropriately consider their perspectives and priorities. Beginning in 2015, Canadian Agency for Drugs and Technology in Health ''Canada's pan-Canadian HTA agency'' has introduced a process to integrate patient perspectives into HTAs of medical devices and procedures through a systematic review of qualitative literature. Within these reviews, research questions explore perspectives and experiences of people who could be impacted by resultant health policy recommendations. To facilitate integration with corresponding clinical and economic reviews, best practices in systematic review methods are incorporated (e.g., peer-reviewed search strategy, double screening of citations, data verification, and quality appraisal). Results of included studies are analyzed through thematic synthesis' a form of meta-aggregation that proceeds through three stages: coding, developing descriptive themes, and developing analytic themes. Two reviews are underway regarding mismatch repair deficiency testing and outpatient cardiac monitoring. Search strategies are being developed and both results and lessons learned will be available for presentation in October 2015. The integration of a qualitative systematic review into the HTA process is novel in Canada and worldwide and is helping to generate more meaningful and patient-centred evidence. It signals the increasing acceptance of qualitative literature as legitimate evidence to inform health policy. An ongoing focus on evaluation will

facilitate a process that maximizes rigor, impact on decision making and resource efficiency.

Operationalizing the Analytical Process to "Getting a Picture'' in a Study Using Constructivist Grounded Theory

Daniel A. Nagel, University of Ottawa Josephine Etowa, University of Ottawa Dawn Stacey, University of Ottawa Wendy Gifford, University of Ottawa Kathryn Momtahan, Ottawa Hospital

Many theoretical and expert perspectives have been offered on procedures for data analysis in grounded theory. Although there is literature available to help understand operationaliza-tion of analytical processes articulated in other approaches to grounded theory, few describe techniques of analysis for Char-maz's (2014) constructivist grounded theory. Constructivist grounded theory draws heavily on the works of Glaser, and Strauss and Corbin, however researchers opting to use this newer methodological approach must navigate lack of agreement on analytical processes between grounded theory traditions; the contested nature of emergence in grounded theory; individuality of researchers; and difficulty in elucidating what is invariably a complex, iterative, and dynamic process. This presentation illuminates how analytical processes were approached in a constructivist grounded theory study exploring how nurses come to know the person in a virtual environment. After a brief description of the study, the presentation will (a) describe steps taken within initial, focused, and theoretical coding; (b) highlight transitions between each of the coding levels to highest level of conceptualization; and (c) use an illustrated example from the study on how it was applied such that Getting a Picture evolved as the core category overarching seven other main processes for knowing the person in a virtual environment. Key learnings from navigating a grounded theory using a constructivist approach include the flexibility, creativity, and unique variations that can be adopted in this method to qualitative research. Having exemplars and perspectives to draw upon will help researchers conceptualize analytical processes when considering use of constructivist grounded theory.

Getting a Picture: A Grounded Theory of Nurses Coming to Know the Person in a Virtual Environment

Daniel A. Nagel, University of Ottawa Dawn Stacey, University of Ottawa Josephine Etowa, University of Ottawa Wendy Gifford, University of Ottawa Kathryn Momtahan, Ottawa Hospital Shelley Doucet, University of New Brunswick

Delivery of health care by nurses in virtual environments is rapidly increasing with uptake of technology to provide care

to, and exchange information with, persons using digitally mediated technologies, such as remote patient monitoring. It is imperative to understand how nursing practice may be influenced by adoption of such technologies given the mandate of nurses to provide appropriate, safe, and effective care. Knowing the person is a phenomenon in nursing practice deemed requisite to establishing professional relationships and to inform clinical decision making and entails appreciating complexities of an individual's physiological and psychological well-being within the context of interrelated phenomena that influence healing and health. We present results of a study to develop a theoretical conceptualization of how the nurse comes to know the person in a virtual environment. Constructivist grounded theory was used to explore the practice of registered nurses in New Brunswick and Ontario who used remote patient monitoring in provision of care. Through 33 interviews and 5 observational experiences in various clinical settings, Getting a Picture evolved as the core category to knowing the person in a virtual environment. Getting a Picture reflected a dynamic flow and integration of seven main processes, such as connecting with the person and recording and reflecting, to describe how nurses strive to attain a visualization of the person, whether or not a face-to-face encounter occurs during care provision. While often having to navigate disparate and disconnected information and communication technologies, Getting a Picture was important to nurses for providing safe, holistic person-centered care.

When Novice Researchers Adopt Constructivist Grounded Theory: Navigating Less Travelled Paradigmatic and Methodological Paths in PhD Dissertation Work

Daniel A. Nagel, University of Ottawa Diane Aubin, University of Alberta Carla Tilley, University of Victoria Victoria F. Burns, McGill University

Graduate students considering constructivist grounded theory as a qualitative methodological approach may benefit from recognizing the many challenges they could face when embarking in dissertation work. These challenges include the great diversity in approaches to grounded theory, a lack of congruity in how grounded theory methodology is described and understood within the literature, and a dearth of expertise and/or support within academic committees and institutions for both grounded theory and constructivist approaches to qualitative research. Drawing on our collective experiences in navigating a constructivist approach to grounded theory, we share our journey of discovery in qualitative research. We begin by describing our rationales in having selected constructivist grounded theory (ConGT) for our PhD work and the common challenges we encountered, which we refer to as the ''ConGT Crossroads for PhD Students.'' This crossroads we saw as the intersection of the Terrain within GT, the Terrain within ConGT, the Terrain within Committees, and the Terrain within

Institutions. Using the analogy of preparing for a journey, we offer strategies for future graduate students that will help them locate their ontological and epistemological worldview, find grounded theory mentors, and facilitate a methodological fit with academic stakeholders. Our recommendations focus on how to navigate the challenging terrain of conducting a con-structivist qualitative research project within a predominantly postpositivist landscape.

Mothering a Preterm Infant Receiving NIDCAP Care in a Level III Newborn Intensive Care Unit

Antonia M. Nelson, Saint Anselm College Pamela J. Bedford, Elliot Health System

The goal of the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) is to improve the neuro-developmental outcomes of high-risk newborns through systematic evaluation, individualized care planning, and implementation. This program is unique because it encourages parents to become central to the care of their hospitalized infants. Although many studies have evaluated the effectiveness of NIDCAP on various outcomes, little is known of the maternal perspective. An existential-phenomenologic method was used to investigate the experience of seven mothers of a preterm infant 30 weeks or less at birth who were participating in NIDCAP. Analysis of interview transcripts revealed one overarching theme, parenting with permission, and three essential themes with nine underlying subthemes: Choosing to participate (subthemes: managing, settling in, and making friends), Dealing with people (subthemes: meeting needs, facing judgment, and recognizing not everyone is ''on board,'' and Coming to feel like a mother (subthemes: overcoming fear, gaining understanding, and feeling empowered). Findings suggest that great sensitivity and patience is required on the part of staff to assist mothers to overcome their fear, gain confidence, and participate in NIDCAP to the extent they are able, without feeling judged. In addition, private rooms were found to hold great significance for mothers and should be maintained for the entire hospitalization whenever possible. Finally, ongoing staff education/support and focus groups to address concerns should be offered in order to address the inconsistent application of NIDCAP care plan recommendations by some nurses, which is the greatest source of maternal conflict and frustration.

An Exploratory Examination of the Transition to Adulthood in Autism Spectrum Disorder

David Nicholas, University of Calgary

Margaret Clarke, University of Calgary

Lonnie Zwaigenbaum, Glenrose Rehabilitation Hospital

Autism spectrum disorder (ASD) is a chronic neurological condition that impairs social interaction and communication

and is indicative of specific behavioural patterns. ASD is often a hidden disability, manifesting at multiple junctures in daily living. Currently, significant gaps exist that constrain the transition from adolescence to adulthood for young people with ASD, leaving them at risk of marginalization, under-achievement, and suboptimal quality of life. There is risk that the investment of resources and supports provided earlier in life are misaligned if this transition falters. To address this gap, this study explores the transition from adolescence to adulthood for young people with ASD. Study objectives include the examination of the process of transition to adulthood in ASD and key transition points, elements that inhibit and foster effective transition, what constitutes effective transition, and recommendations for transition support. Utilizing a grounded theory design, qualitative interviews were conducted with a sample of youth with ASD, parents, and service providers. Outcomes include recommendations and guidelines for enhanced transition planning in ASD. Preliminary results indicate the need for explicit, incremental transition planning for youth and their families. Content includes specific elements of anticipated need, goal setting, and activity planning. Recalibrating how we consider independence versus interdependence emerges as integral in optimizing the fit of transition planning relative to the developmental trajectory of the young person with ASD within the context of their family and community. Clinical and research implications will be presented.

An Examination of the Perspectives and Experiences of Street-Involved Youth Accessing Emergency Health Services

David Nicholas, University of Calgary Avery Calhoun, University of Calgary Amanda Newton, University of Alberta

Street-involved (SI) youth in urban centres are an under-served population. Previous research indicates that their access to health care is fragmented 0061nd episodic as opposed to receiving resources that proactively foster health maintenance or promotion. Currently, hospital emergency departments (EDs) are accessed highly for SI youth's health care needs. However, little is known about the experience of ED care for SI youth and what factors influence their use of the ED. This study explored how SI youth experience and navigate ED services, what components of ED service both foster and limit accessibility for SI youth, and what might optimize SI youth's accessibility to, engagement in, and experience with ED services. Utilizing a grounded theory method that incorporated a community-based approach, interviews and focus groups were conducted in hospitals or community agencies serving youth. A total of 48 SI youth ranging from 15 to 26 years of age participated in this study. Results indicated that youth perceived the care they received as suboptimal, and along with lengthy wait times, service delivery practices dissuaded access to needed care. A variety

of service gaps were also identified by youth, negatively impacting their overall health outcomes. Implications for policy and practice will be discussed, including recommendations for enhancing service provision.

Older Male Musicians Reflect on the Health Implications of Long-Time Participation in Wind Ensembles

Jennifer J. Nicol, University of Saskatchewan Jennifer McAllister, University of Saskatchewan

The fastest growing age-group globally is people over 60 years of age (World Health Organizatiom [WHO] 2002). More than ever before, a healthier, older population is living beyond the age of 60, and a life course perspective suggests that earlier life experiences have a major influence on the way people age (Butler-Jones, 2010; WHO, 2002). In this study, we took up the challenge issued by the WHO and by Canada's Chief Public Health Officer to use a life course framework in research intended to benefit an ageing population. A qualitative inquiry was undertaken to explore adult male musicians' perceptions of playing in wind band as a health promoting activity. Although there is a growing multi-disciplinary body of literature on the health benefits of singing and in particular, benefits associated with music making in groups (Creech et al., 2013), there is limited research on the group music making that occurs in a wind band. To address this gap, five older men (aged 56-76 years) were interviewed using a semistructured format. Data were analyzed thematically, and findings represented evocatively using metaphor to anchor findings in the specific act of making music in a wind ensemble. The three main components of the metaphor were (1) Instrumentation: Defining Roles (Purpose); (2) Sound: Making Meaning (Physical and Emotional Well-Being), and (3) Performance: Extending Self (Challenge, Accomplishment, and Connection). The findings further knowledge and research in the area of music making and health, especially wind ensemble playing participation and healthy aging. Implications for both practice and future research are identified.

A Social Phenomenology Approach to Explore How Young People Perceive the Role of Nursing in Society

Kay Norman, The Open University

Nursing is currently experiencing a shift in how it is viewed by the public in terms of professionalism and credibility, with widespread reports of substandard care. This research draws on social phenomenology and social constructionism to explore young people's perceptions of nursing in the United Kingdom. In depth, individual, interviews were conducted within four high schools to gain insights into how perceptions were formed, what the predominant influences

might be in their construction of meaning from the contexts in which they were situated, and how they understood nursing as a ''role'' within society and a possible career option. Findings suggest that young people hold onto traditional stereotypes of nursing and medical roles, with some health professions holding a more ''valued'' role in society. The strongest influencers are family, although school advisors are seen to have a part to play in affecting young people's perceptions of roles in society, in that consideration of a career depends on academic ability and predicted grades. Nursing was not seen as a role to consider if high grades were expected. Although young people felt nursing has a ''moral worth,'' their own ideas and expectations of a future role included wealth, opportunities to progress, and good working conditions and benefits. Nursing was felt to be fundamentally needed in society but was a role that ''anyone'' could do and not something to aspire to.

Using Boundary Objects to Adapt to Change: Lessons for Qualitative Health Research From Hospital Restructuring

Peter Nugus, McGill University Samer Faraj, McGill University Carla Sayegh, McGill University

This paper examines the challenges and processes for conducting ethnographic fieldwork that emerge from the need to take account of strategies to adapt to change. Despite the interdependence of local actors with their contexts, ethnographic observations are often assumed to be better suited to illuminating local cultures than broader policies and structural influences on situated interaction. Assuming that change provokes macro and micro adjustments, we examined a large-scale restructure in which four tertiary referral hospitals merged into one ''super hospital.'' We paid particular attention in this study to the emergency department, directed towards outward processes (admission and discharge), given its location on the boundary of the hospital with other services. We conducted approximately 80 hours of observation and clarifying field interviews before and after the relocation. We found a prominent ''boundary object'' to be new policies facilitating the change. Emergency physicians designed a policy, which hospital management sanctioned, to compel inpatient doctors to be more responsive to emergency physicians' requests for consultations and admissions. The government also created a new policy compelling community hospitals to accept as admissions patients who had been lingering in the new hospital for lack of appropriate facility to discharge them to. Awareness of the policy imperative to streamline patient transitions came to govern choices of what phenomena to observe and to overlook. This study shows that ethnographers need to understand broader policy imperatives in order to guide their empirical focus to particular documents and moment-to-moment actions that both give rise to and enact those policies.

Familial Interactions About Epilepsy: The Perspectives of Children Living With Epilepsy and Their Parents

Stephanie O. Toole, Dublin City University

Ailbhe Benson, Dublin City University

Veronica Lambert, Dublin City University

Pamela Gallagher, Dublin City University

Amre Shahwan, Temple Street Childrens University Hospital

Joan Austin, Indiana University

Little information exists regarding the epilepsy related interactions between children living with epilepsy (CWE) and their parents. Epilepsy has a long established association with stigma. Felt stigma is attributable to families employing information concealment strategies surrounding epilepsy. While it may be assumed that openness might result in positive outcomes, limited evidence exists to support this. This study aimed to explore parent-child dialogue about epilepsy, from child and parent perspectives, and the consequences of the communication strategies employed by families living with epilepsy. Interviews were conducted with CWE (n = 33) and their parents (n = 40). Interviews were undertaken separately using a semistructured interview guide to explore the contextual factors and interpersonal processes surrounding familial dialogue about epilepsy, including challenges, enablers, and consequences of communicating about epilepsy within the home. Data were thematically analysed. Communication strategies employed across families differed, ranging from open discussion about epilepsy to closed communication strategies. Challenges to communication included seeking to normalise the condition, lack of epilepsy-related knowledge, fear of causing worry, and the avoidance of restrictions. Parents' ability to effectively explain the condition served to enable familial communication. Feelings of reassurance were uncovered as a positive consequence of parent-child dialogue about epilepsy. In contrast, for numerous children, communication served to remind them of epilepsy-related restrictions. This study contributes considerably to the under researched area of family communication about epilepsy. The findings of this qualitative exploratory study provide valuable information relating to the contextual factors informing CWE's and parents' decisions to communicate about epilepsy.

Child and Parent Perspectives of Navigating the Education System With a Diagnosis of Childhood Epilepsy

Stephanie O. Toole, Dublin City University

Ailbhe Benson, Dublin City University

Veronica Lambert, Dublin City University

Pamela Gallagher, Dublin City University

Amre Shahwan, Temple Street Childrens University Hospital

Joan Austin, Indiana University

Receiving a diagnosis of epilepsy during childhood can have significant implications for the child's educational experiences. Epilepsy and epilepsy medications/treatments are known to

negatively impact on memory, concentration, and attention and can cause fatigue and/or hyperactivity among other things. However, while there is an abundance of research examining how epilepsy affects the learning of children, little is known about how schools respond to an epilepsy diagnosis and the associated challenges to learning. As part of a larger body of research, this study aimed to qualitatively explore the educational experiences of children living with epilepsy (CWE) from child and parent perspectives. Qualitative interviews were conducted with 33 CWE (aged 6 to 16 years) and 40 parents. Data were thematically analysed. Findings revealed that school and staff reactions to disclosure of an epilepsy diagnosis varied significantly. Positive reactions comprised teachers proactively learning about epilepsy and educating others about the condition, whereas negative reactions consisted of teachers having no desire to educate themselves and/or others about the child's epilepsy. In addition, some schools imposed unnecessary restrictions on CWE, further exacerbating feelings of differentness and promoting social exclusion. According to the findings of this qualitative exploratory study, a number ofrecommendations for schools in facilitating a safe and welcoming environment for CWE can be made. In particular, emphasis needs to be placed on creating a school environment that is free of stigma, exclusion, and over restriction. Implementing such recommendations could significantly enhance the psychosocial well-being of CWE and their parents.

Patients and Health Care Professionals Perception of the Quality of Care of Patients With Heart Disease at the University College Hospital Ibadan, Nigeria

Nse Odunaiya

Susan Ogwu, University of Ibadan. Aderonke Akinpelu, University of Ibadan

Objective: The purpose of this study was to explore patients' and health care professionals' perception of the quality of care of patients with heart disease at the University College Hospital Ibadan (UCH). Method: Descriptive survey and qualitative research were used in this study. One hundred and twenty-six patients with heart diseases and 28 health care professionals involved in their care were recruited into this study through purposive sampling technique. Two questionnaires, one for patients and one for health care professionals adopted from previous studies, interviews, and focus group discussions were used to collect data from the health care professionals and the patients. The data were analyzed using descriptive statistics of percentages and graphs. The qualitative data were analyzed using thematic analysis. Results: Quality of care was assessed through structure, process, and outcome of care indices. The mean age ofthe patients was 55.31 to 15.64 years and that of the health care professionals was 38.46 to 8.988 years. Patients perceived aspects of structure and process of care such as team work, staff strength, health record keeping, information on treatment, and waiting time as poor and inadequate. Sixty percent to 95% of the health care professionals reported suboptimal use of treatment guidelines and

evidence-based practice, and 66.7% reported that there was no system for internal quality assurance. Conclusion: In conclusion, patients and health care professionals perceived the quality of care for cardiac management at the UCH as poor and indicated the need for the improvement of the structure and process of care given to patients with heart problems.

Fear of HIV/AIDS and Attitudes Towards HIV Prevention in the Era of Antiretroviral Therapy (ART) in Rwimi, Uganda

Nicole Ofosu, University of Alberta L. Duncan Saunders, University of Alberta Arif Alibhai, University ofAlberta Gian Jhangri, University of Alberta

The impact of the widespread availability of antiretroviral therapy (ART) on the behaviours and practices of the general population who are not on ART in African countries is understudied. This study explores the community's views on the fear of HIV/AIDS and attitudes towards HIV prevention in the era of ART. Between June and August 2013, a cross-sectional random cluster survey and focus group discussions were conducted in Rwimi, Uganda. We administered survey questions to 639 participants. Based on the survey results, we conducted focus group discussions with sexually active participants. Data were collected in the local language, Rutooro, audio-recorded, and thereafter transcribed and translated into English and analysed using content analyses. We found that the fear of HIV is reduced because of the availability of ART. However, concern about HIV remains due to factors such as stigma and concern about the challenges associated with being on ART. Participants generally expressed a positive attitude toward HIV/AIDS prevention practices, although these practices were highly influenced by factors such as policy, gender roles, and trust in relationships. There is still the need to scale-up sustainable programs that encourage adherence to prevention practices with a consideration for how sociocultural influences such as gender roles and trust expectations play into HIV prevention.

Banging Down Doors: A Photovoice Project of Parents' Experiences of Access to Autism-Related Services

Brieanne Olibris, McMaster University

Although the state of autism care services in Ontario is garnering an increasing amount of attention in the media and academic literature, little of this attention has been focused on the services for school-aged children and the services in rural-remote regions. This exploratory project pilots the concurrent use of Photovoice and ecomapping to capture the access experiences of three parents of school-aged children (ages 4-12) in Northwestern Ontario. Key themes in the parents' experiences include having their experience of a service being dependent on one particular individual, a lack of compassionate understanding

from others, insufficiently informed service providers, and exclusion. Ultimately, parents adopt the role of the Navigator-Advocate in order to facilitate access to services for their child in three identified systems of care in which their experiences are based: education, health and medical services, and community-based services. From a policy perspective, the findings suggest that parents' experiences of access could be ameliorated through the development of an integrated care model for autism that is responsive to navigational experiences and the geographical and health resource challenges of Northwestern Ontario.

Learning and Being Part of a Group: The Experience of Participating in a Healthy Lifestyle Group

Tanya Park, University of Alberta Kim Usher, University of New England Kim Foster, University of Canberra

People living with a mental illness experience poorer physical health outcomes when compared to the general population. The issue of weight gain is an increasing global problem that increases the risk of metabolic issues, cardiovascular disease, and diabetes. For people with a mental illness, the issue of weight gain is complex and linked to the side effects of common psychopharmacological treatments and physiological processes related to mental illness. This paper brings to light the experience of a group of people with schizophrenia who participated in a healthy lifestyle program—Passport 4 Life. The participants' were asked about their experience of attending the weekly healthy lifestyle group sessions. An exploratory qualitative study was undertaken with volunteers (n = 10) from a larger randomised control trial (RCT) conducted to determine the effect of a healthy lifestyle program on weight, for people with serious mental illness who were taking second-generation antipsychotics. Four common themes emerged that give an insight into the experience of participating in a healthy lifestyle program. The themes were learning how to make healthy choices, recognizing the importance of exercise to weight management, support from a health professional, and being part of a group. This study found like other studies that the benefits of participating in a healthy lifestyle program are much more than physical health improvements. The experience of feeling part of a group cannot be underestimated, as so often people with schizophrenia report feelings of isolation and disconnection.

Supporting Families Through Withdrawal Life Support in ICU: A Foundation for an Educational Intervention With ICU Nurses

Cynthia Peden-McAlpine, University of Minnesota

The findings of our narrative study with 19 intensive care unit (ICU) nurses who were very experienced in supporting families through withdrawal of life support demonstrated a cohesive temporal approach in how they supported families through this

difficult process. This process can be translated into an educational intervention to teach novice nurses and nurses who are not skilled in providing families with the support they need to withdraw life support and provide a dignified death experience for the patient and family. Withdrawal of life support is one of the most difficult problems encountered by providers and families in ICU. The content of the proposed educational intervention is as follows. Nurses continually construct a story of the patient situation and communicate this to help families understand what is happening to their significant other. This communication lays out a temporal illness trajectory that becomes the focal point related to interventions and withdrawal of treatment. There are five important communicative processes involved in constructing this story for families: (1) organizing and interpreting knowledge of different kinds from different sources, (2) learning who the patient is as a person and putting the medical diagnosis into the biographical life of the patient, (3) helping families see the deteriorating status of the patient, (4) imagining and acting on moral possibilities for end of life care, and (5) facilitating saying goodbye. This intervention focuses on the complex communication necessary to support families navigate the difficult path of transitioning from aggressive care to palliative care and death of their significant other.

Holding Firm: Power, Push-Back, and Opportunities in Navigating the Liminal Space of Critical Qualitative Health Research

Jennifer Poole, School of Social Work, Ryerson University Corinne Hart, Ryerson University Marcia Facey, University of Toronto Janet Parsons, St. Michael's Hospital

Qualitative health researchers typically occupy and navigate liminal academic spaces, with one foot planted in the arts and social sciences and the other in biomedical science. They are at once marginalised and empowered, and this liminality presents both challenges and opportunities vis-a-vis qualitative research and knowledge production. In this presentation, we draw on our experiences of being the lone critical qualitative scholar on thesis advisory committees, examinations, and/or review panels to illuminate how particular discursive strategies and power and knowledge relations create micro (and macro) aggressions that shape the nature of our roles and experiences. Then with a nod to the collectivity we enjoy as part of the Centre for Critical Qualitative Health Research at the University of Toronto, we share strategies for responding to the micro-aggressions visited on us when we stand our theoretical and methodological ground and consider possibilities for a different kind of relational knowledge creation. We discuss how holding firm and staying true to our critical roots provides possibilities for (re)invigorating knowledge production from an ''outsider/ insider'' stance and can lead to new insights and ''solutions spaces.'' In doing so, we also explore how we can better ensure that qualitative research is not further relegated to the margins and its integrity is sustained.

Reconceptualizing Work in the Cancer Context: A Feminist Political Economy Analysis

Cheryl Pritlove, York University

Within mainstream medical literature, policy documents, and clinical practice, ''work'' is typically characterized as being synonymous with paid employment, and the problem of work in the cancer context is situated within ''return to work'' discourse. This propels an oversimplified assumption of work as something that ends once diagnosed and is to be resumed following acute cancer treatment and recovery. The work that patients perform in managing their health and care, however, is largely overlooked and unsupported. Drawing on a feminist political economy conceptualization of work as consisting of activities (paid and unpaid) that involve intent, time, effort, and skill, this study pursued the theme of work as it unfolded in relation to 12 women's experiences with cancer and care. Informed by women's interviews and photographs, I identify and explore six distinct forms of work performed by participants (1) illness work, (2) body work, (3) identity work, (4) everyday work, (5) vocational work and/or the work of maintaining income, and (6) coordination work. By developing a detailed description of the tasks and activities that a diverse sample of women did to fill gaps in care and manage their health alongside everyday life, the findings of this study help to illuminate the nuanced and often invisible work and work struggles that women may encounter and the health consequences and inequities, therein. Conclusions drawn from this study signal the need for a higher level of cancer care and support than that which is currently provided within the Ontario provincial health system and offers feasible clinical and policy solutions.

Positionality, Pregnancy, and Motherhood: A first-Time Expectant Mothers Journey to Understand Parents Stories of Caregiving for Children With Complex Chronic Conditions

Katherine Rafferty, Iowa State University

Researcher positionality is of paramount importance to qualitative health research because of its direct influence on the analysis and conclusions. Positionality is not a static entity during the data collection and analysis processes, but rather an ongoing and reflexive process that may change depending on how different characteristics and experiences impact these findings. As qualitative health researchers, it is important to consider our positionality within the data collection and analysis processes. In this paper, I present an autoethnography about my own positionality as an expectant mother while conducting face-to-face interviews with 35 mothers and fathers of children diagnosed with complex chronic conditions. This research was part of my dissertation. When I began my dissertation proposal and initial data collection, I was an expectant

mother who was in the second trimester of carrying my first child. Midway through data collection, I delivered my child and continued with the concurrent processes of data collection and analysis. In analyzing field notes and memos, I discuss my role as an expectant and first-time mother, and how this identity was socially constructed between the parents I interviewed and myself. I elaborate on how qualitative research may be transformative to both researchers and participants.

My Home Is Nowhere: South Asian Older Adults' and Family Caregivers' Experiences in Residential Long-Term Care

Sherin Rahim-Jamal, University of Victoria Kelli I. Stajduhar, University of Victoria Sheryl Reimer-Kirkham, Trinity Western University Karen Kobayashi, University of Victoria

The Canadian senior population is becoming increasingly diverse with respect to its ethnocultural composition prompting important questions regarding whether the current organization of residential long-term care (LTC) and end-of-life (EoL) services are designed to meet the needs of increasingly diverse ethnocultural older adults. We use ethnographic methods informed by a critical theoretical perspective to explore the needs, preferences, challenges, and decision-making processes of South Asian older adults (SAOAs) and their families regarding residential and EoL care and the extent to which existing residential LTC services are prepared to provide culturally responsive and competent care. Preliminary findings from participant observation and in-depth qualitative interviews with SAOAs in LTC and their Family Care Givers (FCGs) draw attention to the significance of family for SAOAs and the sense of loss and displacement they feel being separate and apart from family in LTC; the sense of being different from those around them, being among strangers with no commonality; feeling that everyone is treated the same, that staff are too rushed and lack sufficient time to communicate with them. While SA FCGs understood the implications of moving their relatives to LTC, they felt they had no choice. Posttransition, FCGs seemed uncomfortable with the move of their relatives to LTC demonstrated by their need to be vigilant and provide a range of supports and assistance to their relatives and because FCGs felt that institutional policies and practices took precedence over their relatives' personal care needs and quality of life. These findings inform improvements in LTC services for SAOAs.

Beyond Transition: Workplace Integration of Internationally Educated Nurses—A Qualitative Study

Zubeida Ramji, University of Ottawa Josephine Etowa, University of Ottawa

Internationally educated nurses (IENs) are a stable health human resource pool who are making an important

contribution and for whom further investments are needed in order to ensure long-term retention. The concept of workplace integration for IENs over the long term is not defined. How the workplace organizational context influences integration is also not well understood.

Significant personal, social, emotional, and financial costs are incurred by IENs during the process of migration and obtaining nursing registration to practice here. Investments are also made by governments and employers in programs to support IENs. Most of the research on IENs is focused on the early phases of navigating through the regulatory process, getting oriented to Canadian nursing, and transitioning into the workplace. However, there is a lack of research on IENs' long-term progress. Findings and analysis from a qualitative case study informed by critical social theory will be presented. Within the context of a tertiary care teaching hospital in Toronto, IENs, their peers/mentors, managers/directors, and senior leaders conceptualize workplace integration of IENs as when IENs have transitioned effectively to become ''Canadian'' nurses; that they are progressing on their leadership journey in nursing and they have pride in their IEN identity. Organizations can effectively facilitate workplace integration of IENs when there is workforce diversity, policies, and practices related to equity, diversity, and inclusion are in place, leadership commitment to equity is evident and there is active engagement with the broader community on IEN-related initiatives. This research makes important contributions to nursing knowledge: a definition of workplace integration is developed based on the perspectives of IENs and other stakeholders in the workplace; there is a shift in focus to IENs who are in a later, posttransition phase and the workplace context provides insights about the employer's role and experience in facilitating integration of IENs.

Qualitative Examinations of Youth Work and Suicide Intervention: Unique Challenges Contributing to a Research Life at the Margins

Patti Ranahan, Concordia University

Traditionally suicide is investigated using quantitative research with an emphasis on delineating causes and explanations for suicidal behaviour. Suicidology journals have coconstructed this lens by largely publishing quantitative studies leaving little space for qualitative researchers. This approach stems from a medicalized view of suicide that has little to do with context, stories, locality, relationships, culture, or historical conditions. Despite the potential for qualitative examinations to illuminate the complexities of suicidality and variability of this subject, I experience continual challenges in finding a place for my qualitative work within suicidology circles. Additionally, the population of interest—youth workers—poses unique trials that contribute to this fringe position. Youth workers are likely to encounter adolescents who are suicidal, yet this population is often positioned on the periphery as gatekeepers with the sole

task of referring the youth to mental health services. This ''referral agent'' role reinforces a lack of confidence in their skills. Youth workers may not view themselves as having anything to contribute, and organizations have identified that suicide is not a priority concern making recruitment difficult. With the limited body of research specifically on youth work practice, education is informed by research within allied disciplines leading workers to believe research occurs with others and devaluing their contributions. Recruitment, data collection, and dissemination challenges have led this researcher to identify with a small ''misfit'' group of qualitative suicidology scholars positioned at the margins.

Qualitative Research on an Insurer-Sponsored Patient-Centered Medical Home Program: Research Findings and Lessons Learned

Cynthia S. Robins, Symposium Chair

Symposium Description: In 2013, Westat was one of the three organizations contracted by a private insurer to conduct a 5-year evaluation on how primary care practices are adopting the insurer's patient-centered medical home (PCMH) program. The qualitative component of Westat's evaluation consists of case studies with 12 ''panels'' (practices or groups of practices), involving in-depth interviews with primary care providers, practice staff, insurer staff, and patients who are enrolled in the program. These presentations will highlight preliminary findings and observations from the first 2 years of data collection, including critical factors that appear to encourage program adoption, lessons learned about how to successfully recruit busy medical practices into a research study, and observations about how this kind of program promotes an important interface between primary care and patients' mental health needs. The symposium aims to encourage discussion with audience members about the value and challenges of qualitative approaches in PCMH research.

Abstract #1: Assessing How Private Medical Practices Implement Outside Changes: Findings From a Program Evaluation on the Integration of New Work Flows into Existing Systems

Katy Trundle, Westat Karen Stewart, Westat

Westat has been tasked with conducting a longitudinal evaluation of the processes by which private medical practices implement an U.S. insurance company's patient-centered medical home (PCMH) program. The program aims to provide patients with the same or better quality care at a reduced cost through several means, including (1) encouraging primary care providers (PCPs) to adopt cost-conscious strategies while ensuring high-quality care (e.g., encouraging patients to use urgent care centers rather than emergency rooms); (2) getting PCPs to refer high-

cost, high-need patients to an insurer-sponsored nurse, who provides tailored, weekly support to those patients; and (3) sharing a portion of the cost savings with practices through monetary incentives. Integration of PCMH into practices was measured by, among other things, (1) practice staff's level of commitment to the program, (2) utilization of practice resources to implement the program, (3) presence of a program 'champion' within the practice, and (4) willingness of PCPs and practice staff to work with the insurer-sponsored nurses. Attendees to this session will learn how the researchers assessed these indicators, what aspects of the program appeared to foster program implementation, as well as some of the specific steps practices took between Years 1 and 2 of the evaluation to better integrate the program into their existing workflows.

Abstract #2: Know Your Audience: How Ethnographic Strategies Can Improve Recruitment and Cooperation

Cheryl Reidy, Westat

Recruiting study participants can be a time- and cost-intensive endeavor, thus researchers are always looking for new approaches to improve the effectiveness of recruitment efforts. An array of strategies have been explored, including how much and what kind of incentives are most enticing (e.g., Medway and Tourageau, 2015; Scherpenzeel and Toepoel, 2012) or what social media outlets (e.g., Craigslist, Facebook, print media) will best reach the target audience. But what if time matters more than money to the potential participants? Or the recruitment pool consists of organizations and not individuals? In this presentation, we describe several recruitment strategies that were successful in gaining the participation of 12 medical practices into a longitudinal study on the implementation of an insurer-sponsored patient-centered medical home (PCMH) program. Although the proposed incentives were helpful, other aspects of the recruitment effort—including the background and experience of the recruiter and the team's knowledge of various organizational characteristics—has resulted in a extraordinarily high rate of study participation for the first 2 years of data collection. Indeed, so successful were these approaches that one medical practice that refused to participate in Year 1 due to time constraints was reapproached and agreed to participate in Year 2. The presenter argues that a sound understanding of these organizations' structures and constraints goes a long way towards fostering goodwill.

Abstract #3: How the Structure of a Patient-Centered Medical Home Program Can Support the Integration of Mental Health Services into Primary Care

Jocelyn Marrow, Westat

Recent recommendations from the Centers for Disease Control and the Agency for Healthcare Research and Quality

emphasize the necessity of integrating mental/behavioral health care into the Patient-Centered Medical Home model. Yet a number of obstacles impede integration, including separate reimbursement systems for physical and mental health interventions and a lack of mental health training among primary care providers (PCPs). In one insurer-sponsored program, however, the structure of the program can potentially facilitate the treatment of psychosocial issues underlying some patients' physical disorders. The linchpins of this program are insurer-contracted nurse care managers, who are integrated into local primary care practices and provide vital additional clinical support for the PCPs. PCPs refer patients to the program who have multiple chronic conditions (e.g., diabetes, obesity, and COPD) that may be uncontrolled because of the patients' difficulty adhering to a treatment regimen. Nurses maintain at least weekly contact with enrolled patients to monitor their physical conditions and identify any reasons they are unable to follow their PCPs' recommendations. PCPs and patients described the value of the nurse's behavioral interventions, including encouraging dietary changes, adoption of exercise regimens, implementing strategies for stress reduction, active monitoring of health problems, and the appropriate use of medical services (e.g., urgent care centers instead of ERs). Moreover, some patients reported developing a therapeutic alliance with the nurse, which facilitated follow-through with the nurse's referral for counseling services. Program evaluation findings have important implications for improving the integration of mental health care into primary care practices.

Homer Simpsons and Mr. Mums: A Critical Perspective of Fathering Discourses

Brett Scholz, Synergy Nursing and Midwifery Research Centre, The University of Canberra, Australia

Abigail Locke, School of Human and Health Sciences, The University of Huddersfield

Sue Fick, Centre for Applied Psychology, The University of Canberra

Research suggests children's health and well-being are positively influenced by stronger father engagement. Numerous social and policy contexts impact upon fathers' engagement. We critique popular discourses around fathering, including predominant models of fathers' engagement that focus on direct and indirect care. Using data from two discrete research studies—the first conducted with fathers predominantly resident in the United Kingdom who have taken on a primary caregiving role for their children, and the second with fathers of young children living in Australia—we explore how particular discourses of fathering influence ways of engaging with children. We suggest that some dominant discourses of fathering position men as incompetent or as objects of fear and reproduce gendered expectations that parenting is women's work. Given the changing policy landscape on fathering engagement and the suggested impact on family health and well-being, a more critical reading of key discourses is needed.

No Mud, No Lily: Living Narratively on the Margins of the Dominant Paradigm

Jasna K. Schwind, Ryerson University

Gail Lindsay, University of Ontario Institute of Technology

We live in an academic world where qualitative researchers struggle to achieve professional recognition and promotion. Qualitative health research that explores the experience of those who care for vulnerable others (students and patients) matters to the world, as it is a fundamental value to involve people in creating the knowledge that is used to create effective and meaningful education and practice systems. Our Narrative Inquiry research focuses on person-centred care that includes the personhood of the practitioner, on faculty development and on education of students in health sciences. Our work is transferable to all health professions and students in diverse settings across the globe. Unlike some of the traditional methods that require large external grants, our inquiry requires human capital, involving extensive time in the field and intensive researcher involvement. Each time we complete a study, we are challenged to find hospitable publishers and conferences. We often negotiate contradictory peer reviews within editorial boards, which to us is a manifestation of marginalization and misunderstanding of the qualitative worldview. However, living within these tensions, we remain committed to the struggle in this muddy field. We use this "mud" to fertilize and to grow the metaphoric lily: qualitative health research. Join us as we continue to ponder: How do we navigate through a world that is in great need of qualitative understanding of life, yet resistant to the ways to achieve it?

Navigating the Turbulent Waters of Chronic Health: Self-Care Experiences and Strategies for Managing Health by Community-Dwelling Individuals

Craig R. Sellers, Symposium Chair

Symposium Description: We will explore the contexts, experiences, and strategies individuals who live in community settings navigate in caring for themselves, using an overarching construct of self-care. Using different qualitative lenses, we are studying two ends of the life span: teens, living with chronic asthma, and older adults, adjusting to a diagnosis of dysphagia or recovering from an acute on chronic health problem. Managing these conditions requires self-care. How these individuals perceive their health, and how they manage and make the complex decisions about how, when, and even if, to modify their therapeutic regimens is our focus. In our final paper, we apply our conceptual model to three cases of community-dwelling older adults as they navigate their health. Across these studies, we highlight tensions emerging from shifting health care needs and explore how participants are balancing care and health in everyday lives. The generative potential of these tensions leads to situated and meaningful ways of navigating chronic health through turbulent waters.

Abstract #1: It's Just My Normal Symptoms:' Understanding Teen Asthma Self-Management

Jennifer Mammen, University of Rochester School of Nursing Hyekyun Rhee, University of Rochester School of Nursing Sally A. Norton, University of Rochester School of Nursing

Community-based self-management of asthma is central to preventing morbidity and mortality. Many teens have inadequate asthma self-management resulting in suboptimal asthma control and outcomes. Yet, little is known about how teens experience and perceive their asthma self-management. Using a qualitative descriptive design, we collected in-depth interviews, 2-week voice-diaries, and used symptom-response card sorting techniques to explore teen's perceptions and experiences of asthma self-management. We selected 15 minority and nonminority teen-parent dyads (N = 30) with well-controlled or not well-controlled asthma using a criterion-based sampling approach, in order to identify differences and similarities in self-management between groups. We found teens' self-management depended largely on their perception of whether symptoms were "normal" or "unusual." Perceptions of normalcy were based on prior experiences and regular symptoms of asthma. Teens with uncontrolled asthma accepted a much higher level of asthma symptoms within their perception of normal compared to teens with well-controlled asthma. Decisions to manage asthma symptoms using medication involved minimizing perceived consequences (fear of overuse, dependence, side effects, and activity disruption), referencing prior experiences (likelihood of symptoms becoming better or worse if untreated), and evaluating inhaler accessibility (distance to, privacy, and social support/barriers). These processes interactively informed teens' decisions of when and how to manage and report acute symptoms and determined their treatment thresholds (i.e., the point at which rescue medication is taken for active symptoms). Treatment thresholds, and subsequent reporting of asthma symptoms, are relative to perceptions of normal, dynamic, and do not necessarily reflect severity or frequency of asthma symptoms as clinicians often presume.

Abstract #2: My Choice Was Breathe or Eat': Understanding the Choices Made by Community-Dwelling Older Adults With Dysphagia

Sandhya Seshadri, University of Rochester School of Nursing Craig R. Sellers, University of Rochester School of Nursing Margaret H. Kearney, University of Rochester School of Nursing

Several disease processes (e.g., strokes, other neurologic disorders, respiratory diseases, head and neck cancers, and others) that are common among older adults can result in dysphagia or difficulty with swallowing. Older adults with dysphagia often experience anxiety and decreased participation in activities that

entail eating with others. Clinical practices in the management of dysphagia include texture-modified diets that may exacerbate the feelings of anxiety and social isolation among community-dwelling older adults. Using interpretive description, we sought to understand community-dwelling older adults' experiences of dysphagia and their recommended restrictive texture-modified diet of pureed foods and/or thickened liquids, and how these experiences affect their perceptions of daily life, physical health, and social and psychological well-being. We visited the study participants in their homes twice over the course of 2 to 4 weeks and collected data in two in-depth interviews and participant observation during one meal. Four themes were identified: the choice of eating or breathing in the face of morbidity and/or aging is frightening, hiding perceived symptoms from the public eye are an important part of preserving self-identity, appraising sacrifices and making compromises are part of daily life, and adherence is not an "all or none'' phenomenon. These themes characterized the daily experiences of balancing health concerns and social and personal priorities with the symptoms of dysphagia and the restrictions of the prescribed diet. We discuss the choices made in balancing these tensions and the clinical implications for this population of older adults.

Abstract #3: It's Three Steps Forward, Two Steps Back: A Case-Comparison of Community-Dwelling Older Adults Balancing Tensions of Health and Ageing in Everyday Life

Sandhya Seshadri, University of Rochester School of Nursing Joyce M. Duckies, University of Rochester School of Nursing Craig R. Sellers, University of Rochester School of Nursing

In a longitudinal study of community-dwelling older adults with diverse health concerns and comorbidities, we conducted interviews in the ED and then over several weeks in homes of participants. We identified tensions associated with balancing health and ageing within the contexts of their everyday lives. Our analysis led to a conceptual model highlighting dialectical process within the tensions, relational strategies adopted to navigate health, and the influence of dominant discourses of ageing. Dialectical processes included staying healthy with multiple morbidities, staying busy with physical and psychosocial constraints, and staying independent while asking for help. Social discourses related to independence, health, and activity contributed to the tensions and resulted in relational strategies such as making trade-offs, negotiating relationships, and staying flexible. In this paper, we use a cross-case analysis method, consistent with Stakes' case-quintain dialectic method (2006), a naturalistic approach toward case studies. The "case-quintain dialogue'' entails using each case to engage the emerging themes of the quintain. In this case-comparison, the quintain was our model of navigating health in everyday contexts. We present three diverse cases to reflect the phenomenon studied and their application to our conceptual model, further informing our understanding of the unique needs of a diverse

population of community-dwelling older adults. We propose adopting a relational approach to both practice and research to better inform supports for community-dwelling older adults by bringing attention to the dynamic, situated, and interdependent ways they navigate health and manage care.

Intersectional Exposures: Exploring the Health Effect of Employment with KAAJAL Immigrant/Refugee Women in Grand Erie Through Photovoice

Bharati Sethi, McMaster University

The purpose of this community-based participatory research was to understand the employment-health association for immigrant/refugee women from Korea, Asia, Africa, Japan, Arab world, and Latin America (KAAJAL) in Grand Erie, a mid-sized urban/rural region in Ontario, Canada. The study utilized photovoice, a visual qualitative research methodology in which participants were given cameras to record their experiences. Intersectionality, analysis of 525 participant-generated photographs, diaries, and in-depth interviews of 20 women revealed that various markers of difference such as nationality (i.e., native or foreign born), immigrant status (i.e., family class sponsorship), geography (i.e., rural or urban residence), socioeconomic status, sexuality, age, ability, and race intersected to influence women's health and employment experiences. The results have several policy and practice implications including highlighting individual, organizational, and family factors that lead to health-related absenteeism, stress, and health problems such as backaches, muscular problems, and depression. The study builds on scant literature on work stress and women's health for this population in Canada's rural and mid-sized cities.

Punjabi Immigrant Mothers' Experiences of Postpartum Depression: A Narrative Inquiry

Poonam K. Sharma, Ryerson University Jasna K. Schwind, Ryerson University Sepali Guruge, Ryerson University

Depression is a fairly common complication following childbirth that can adversely affect not only a woman's health but also the health and development of her infant and her family relationships. The purpose of this qualitative study was to give voice to immigrant mothers by telling their stories of their postpartum experiences. Connelly and Clandinin's Narrative Inquiry approach was used to explore the experiences of two Punjabi immigrant mothers with symptoms of postpartum depression. Participants engaged in storytelling and in an adaptation of Schwind's Narrative Reflective Process, a creative data collection tool, which includes metaphor selection, drawing, and reflective dialogue. This process allowed the participants to access and express feelings they could not express in words alone, thus guiding them to a deeper level of self-

reflection. Using the Narrative Inquiry three levels of justification (personal, practical, and social), women's stories were analyzed, revealing three key narrative patterns: motherhood, relationships, and loneliness each informed by the narrative thread of immigration. The outcomes of this inquiry suggest that as health care professionals and policy makers, we need to broaden and deepen our understanding of postpartum depression from the immigrant mothers' perspective, so that we can provide them with a more effective support during this significant time in their lives. Such sensitive and thoughtful care has the ability to improve their well-being and the health of their infant as well as that of the whole family.

Adolescents' Strategies for Managing Life With a Parent in Hospice

Denice Sheehan, Kent State University M. Murray Mayo, Ursuline College Grace H. Christ, Columbia University Claire Burke Draucker, Indiana University

The final stage of a parent's illness is exceptionally stressful for adolescents as they struggle to gain independence from their families while losing parental support and guidance. We used grounded theory methods to generate an explanatory model of the coping strategies that adolescents use to manage the stressors they experience in the final months of their ill parents' life and shortly after their death. We conducted semistructured interviews with 30 adolescents, 17 well parents/guardians, and 14 ill parents before the parent's death and, additionally, with six of these families after the death. Constant comparison analysis was used to develop the model. The adolescents described two worlds: the well world of normal adolescence and the ill world of having a parent near the end of life. The model includes a core category labeled ''managing two worlds.'' The five stages in which adolescents manage their worlds are keeping the ill world and the well world separate, having the ill world intrude into the well world; moving between the ill world and the well world, being immersed in the ill world, and returning to the well world having been changed by the ill world. Unique strategies associated with each stage will be presented. The model can be used by health care providers who seek to help adolescents navigate the critical time when a parent is dying or has recently died. These results can also be used to inform the development of interventions that support families with strategies tailored to the adolescent's specific needs.

Advancing Population and Public Health Through Robust Policy-Practice-Research Partnerships

Debbie Sheehan, Simon Fraser University Susan Jack, McMaster University Donna Jepsen, BC Ministry of Health

''Knowledge translation'' has become a mantra for policy makers and researchers who are motivated to move evidence into

practice. This term is often used superficially, downplaying the considerable challenges and resulting in missed opportunities for advancing population and public health goals. We will discuss a novel approach to creating and sustaining robust policy-practice-research partnerships to address this issue. The British Columbia (BC) Healthy Connections Project (BCHCP), a province-wide evaluation of the Nurse-Family Partnership (NFP) program, serves as a case study. NFP is a primary prevention program with the potential to improve children's health and development—by addressing social determinants of health for both mothers and children, starting in early pregnancy and continuing until children reach 2 years of age. The BCHCP involves a randomized controlled trial evaluating NFP's effectiveness in comparison with BC's existing health and social services. To conduct the scientific evaluation and ensure that the BCHCP enhances BC's existing public health system, a unique and vigorous provincial policy-practice-research partnership was established. This session will focus on exploring how this partnership model helped us navigate through some specific study design issues: participant recruitment, low-income eligibility screening, ensuring delivery of intervention with fidelity to the NFP model, promoting the study with health care providers, working with First Nations communities, and seeking ethics approval. We will also explore how we embedded a process evaluation in the trial to describe how NFP is being delivered and implemented in all 5 regional health authorities as a way to address recruitment challenges in rural and remote communities.

Early Days of Collaboration: Patient Engagement Research to Inform Healthcare Culture Change

Symposium Chair: Nancy Marlett Symposium Description

This symposium presents the potential for influencing health care culture through developing collaborations between academic researchers, health care leaders, and trained patient researchers, working together in teams. This model was pioneered at the Patient and Community Engagement Research (PaCER) Program at the University of Calgary, Cumming School of Medicine, supported by Alberta Health Services. A year-long PaCER internship trains patients to design and conduct research, using adapted methods of qualitative inquiry: field observation, questionnaires, focus groups, and narrative interviewing. The method is designed to engage patients in health research, while working in collaboration with academics and decision makers, aiming at empowering all parties to own research findings—a strategy to impact change. Three PaCER teams will be represented by professional partners and a PaCER lead, sharing their experiences, challenges, and lessons learned. Within this joint venture, team members experimented with their evolving new roles in research to promote health care change.

Abstract #1: Building New Relationships in Research: A Model of Patient Engagement Research

Nancy Marlett, University of Calgary Svetlana Shklarov, University of Calgary

Tracy Wasylak, Strategic Clinical Networks & Clinical Care Pathways at Alberta Health Services

Almost every developed country is facing a crisis of health care sustainability and most have embraced the idea that systems that are patient centered, use patient values and quality indicators are more effective, relevant, and sustainable. A grant from the Canadian Foundation for Healthcare Improvement allowed for the creation of new roles for patients conducting research with other patients, families, and communities. This paper addresses a new role for patients who are trained to conduct patient experience research. We also review the specifics of qualitative methodology that evolved in various patient-led research settings. We introduced and tested innovative teaching methods through a 1-year internship. Outcomes of the new approach, called Patient Engagement Research, were analyzed using the grounded theory method with 21 patient participants and 15 key stakeholders through participant observation, semi-structured interviews before and after the intervention, focus groups, and document review, also using an Outcome Mapping process. Final personal accounts of the participants were analyzed to track the merging of the patient and researcher role. Patients, clinicians, policy makers, and researchers experienced new reciprocal relationships in collaborative decision making within Alberta Health Care Strategic Clinical Networks and quality improvement projects. The impact of qualitative research engaging patients is demonstrated using the example of five initial internship projects. The impact of the research has led to a social enterprise business in the intersection of qualitative health research, quality improvement, and health policy as they impact health care reform.

Abstract #2: Partnership in the Development of a Patient Centred Care Planning e-Tool

Marlyn Gill, Patient and Community Engagement Research (PaCER), University of Calgary

Maria Santana, W2IC Research and Innovation Centre, University of Calgary

Julie Stromer, W2IC Research and Innovation Centre, University of Calgary

Patients with multiple chronic diseases often experience difficulty ensuring that health care providers across specialties are updated and aware of all developments across their spectrum of diseases. We describe the partnership between patient researchers (Patient and Community Engagement Research [PaCER]) and academic researchers in the development of a patient-centred e-tool. The team developed a solid supportive partnership to gain insight into the experiences, beliefs, fears, and aspirations of chronically ill patients. PaCERs ran 4 focus

groups and 6 interviews with 18 participants, aged between late 30s and 70s, with one or more chronic diseases requiring interaction with multiple specialists. The combined team of patient researchers and traditional researchers explored two analytical perspectives: phenomenological reduction and grounded theory, with the emerging relevance of the theory of salutogenesis. The emerging message to health care providers concentrated on patients' wellness rather than disease, and the need for support as they manage their own lives (consistent with Antonovsky's salutogenesis theory). The recommendations called for health care culture change toward partnership, with more patient input in their wellness plans, and effective communication between professionals. Patients saw electronic records as way to relieve the burden of keeping multiple providers updated and coordinated with their care plans. Patient engagement research as undertaken by PaCER is a new, emerging discipline within the qualitative research community. Working together as a united team, we have been able to more comprehensively understand the needs of patients managing multiple health concerns that will guide the development of a user friendly care planning e-tool to support patients managing their complex health needs.

Abstract #3: Uncovering the Experiences to Close Care Gaps: Patients and Caregivers as Couples

Sara Shearkhani, Patient and Community Engagement Research

(PaCER), University of Calgary

Paul Holyoke, Saint Elizabeth Health Care

Caregiving studies had been traditionally focused on the care-giver as an individual, as well as the patient, disease, and demands of caregiving duties as sources of stress. It is only recently that the focus of these studies shifted to patient and caregiver together, as a unit of analysis. This peer-to-peer Patient and Community Engagement Research (PaCER) study is designed to add insights to this topic by understanding the experiences and concerns of spouses. Saint Elizabeth Health Care (Toronto) purposefully entered a supportive collaboration with the PaCER team to draw from this engagement study and inform the organization's efforts to consider the perspective of patient-caregiver couples in developing supports and services. This qualitative study is conducted by PaCER interns who have relevant patient/caregiver experiences, using a new PaCER methodology in which researchers and participants are peers. The method includes data collection through 3 focus groups (10 participants in each) and 5 narrative interviews. Participant sample includes both patients and spousal caregivers with diverse experiences (a variety of diseases or injuries, acute or chronic). Data collection and analysis follow the grounded theory method. This study is in progress, so findings are preliminary. Some major emerging findings include the impacts of the illness and treatment on couples' relationship, their coping, and the ways they use health care and community supports. Ongoing collaboration allows for sharing and owning the emerging results within the partnering team at Saint Elizabeth

Health Care, with the expectation to inform closing service gaps while considering couples' choices.

It Was Then That I Thought Woah This Is'nt My Dad: What the "Still the Same Person' Narrative Can Mean for Children and Young People Who Have a Parent With Dementia

Pat Sikes, University of Sheffield Mel Hall, University of Sheffield

It is often said of people living with dementia that they are ''still'' the same person they were before diagnosis. Indeed, this notion that, at the end of the day, Alice, for example, is Still Alice, appears to have achieved hegemonic status and become something of a master narrative, hard to question without causing eyebrows to be raised, or even occasioning vociferous negative criticism and denial. Some of the participants in our (United Kingdom) Alzheimer's Society funded project, The Problems and Effects of Children and Young People Who Have a Parent With Dementia find this narrative extremely problematic. Their lived experience is quite other and expectations that they will behave and feel towards their parent as they previously had is a cause of further stress in what is already often an almost unbearable situation. In this paper, we will share stories about the ''Still'' narrative told by youngsters and consider what they mean for informing and supporting members of this group.

Every Time I See Him He's Worst He's Been and the Best He'll Be? Interpretations of Time and the Trajectory of Dementia

Pat Sikes, University of Sheffield Mel Hall, University of Sheffield

This paper draws on stories told by children and young people who have a parent with dementia around time and the trajectory of their mum or dad's condition. In most cases the period, usually some years, leading up to a diagnosis of a dementia was characterised by confusion, uncertainty, trauma, and distress as the young people and, where they had them, siblings, the other parent, family members, friends, colleagues, and others struggled to make sense of significant and often extreme, behavioural and attitudinal changes. Following diagnosis, the struggle shifts to coming to terms with loss of abilities. We will be considering the biographical and interpretational work undertaken by the youngsters in light of George Herbert Mead's (1932, 1934, 1938) nonlinear, interactionist theory of time.

Attributed Meanings in Acute Pain Events

Flo J. Slomp, University of Alberta Maria J. Mayan, University of Alberta Gerri C. Lasiuk, University of Alberta B. D. Dick, Univeristy of Alberta

Meaning is an essential component of the human experience and it is intricately linked to individuals' core beliefs, values, and

feelings. Meaning is often challenged or altered by the experience of trauma. The meaning of pain has been implicated as a factor which can modify the perception of pain, yet little research to date has explored the meaning individuals associate with acute, traumatic, and painful events. The primary aim of this exploratory inquiry was to identify and investigate the meaning participants attribute to their acute pain event using Park's meaning making model as a framework for analysis. Semistructured interviews were conducted with 13 participants, who were asked about their experience about their acute pain event. The analysis yielded the following themes: significance of the accidental event, management of pain, consequences of injuries, the importance of being stoic, and anxiety of delayed treatment. These themes are contextual and pertain to various interactions at the personal, interpersonal, and organizational levels. The findings of this inquiry will benefit health care providers who are involved in pain assessment and treatment. Recognizing and addressing the contextual aspects of how each individual attribute meaning regarding situations during their acute pain event will help to assure best possible care for individuals who have sustained an acute injury. Identified meaning contributes to the understanding of the complex process of assessing pain.

Mental Health Legislation: The Need for a Better Connection with Practice

Nicole Snow, Memorial University of Newfoundland

The purpose of mental health legislation is to ''protect, promote, and improve the lives and mental wellbeing of citizens'' (World Health Organization [WHO], 2005, p. 1). In meeting this goal, legislation helps guide the development and operation of mental health services and how people access them. Legislation can also protect the rights of consumers of mental health services and address issues such as mental health promotion and community integration (WHO). The process of creating and revising legislation is a lengthy one that involves considerable stakeholder consultations and research. However, it is not without flaws as well-intentioned legislative work might not be implemented in the intended manner. Mandatory community treatment for individuals with severe mental illness is a component of many provincial mental health acts in Canada. However, there is considerable debate regarding the effectiveness and ethics of their use. This presentation will provide relevant findings of an institutional ethnographic study that explored the implementation of community treatment orders. The use of institutional ethnography (Smith, 2005) was instrumental in uncovering the disconnect in mental health legislation, policy, and practice. Through analysis of documents and informant interviews, it became visible how the intended purpose in the implementation and influence of legislation was not fully actualized. It was filtered from its textual form through policies and by its operationalization by health care professionals in everyday practice. The gaps between legislative and therapeutic intents must be identified in order to authentically expose and address the needs of individuals living with severe mental illness in the community.

A Life-Course Perspective on Vocational Experiences of Canadian Men With Hemophilia

Neale Smith, University of British Columbia Claude Bartholomew, Providence Health Care Shannon Jackson, Providence Health Care and UBC

Historically, people with hemophilia have had poor employment prospects relative to the Canadian average; however, new developments in treatment and prophylaxis may serve to decrease many of the barriers which exist. We investigated the following research question: How is quality of life impacted by vocational experiences and opportunities among males (age 19+) with moderate and severe hemophilia throughout the life-cycle? We conducted three focus groups in Vancouver, British Columbia. These groups were stratified by age (''early career,'' ''mid-career,'' late-career''). Transcripts were analyzed to identify key themes, with particular attention to age and stage differences among groups. Our findings are best described as exploratory; they are precursor to the development of a quantitative data collection instrument, which will be followed by further qualitative investigation for interpretation and validation. A number of themes emerge from the life-course perspective: Do early career planning choices successfully account for the emerging impacts of hemophilia as one ages? How prepared have participants of different generations been to disclose their illness to employers and co-workers? What role do social networks among people with hemophilia play in job and career advancement? How do participants deal with loss of career options at early and at later stages in life? The findings allow us to better understand how changes in medicine, the economy, and social norms affect the ability of men with hemophilia to fulfill career aspirations and engage in the workforce.

The Impact of Nursing Regulation on Professional Advancement and Innovation

Sarah Stahlke Wall, University of Alberta Diane Kunyk, University of Alberta

Over the last several decades, there have been calls for system reform, based on expanded scopes of practice and innovative roles for health care professionals, including nurses. Despite such a vision for change, there has been very little movement away from the traditional structure and functioning of the health care system. Regulatory associations play a significant role in defining the parameters of professional nursing practice. Although most Canadian regulatory bodies also perform professional advocacy functions, they do not tend to focus on this, seeing it as being at odds with their primary responsibility for public safety. Thus, professional regulatory processes and decisions tend to be quite conservative. The purpose of this research was to explore the impact of nursing professional regulation, specifically the licensing function, on nurses' abilities to expand their scopes of practice, develop innovative and advanced roles for nurses, facilitate interdisciplinarity, create

educational curricula that respond to emerging health and system needs, and ensure that nursing is able to attract and retain an effective, diverse, and forward-thinking workforce. Interviews were conducted with nurses in a range of unique practice situations, including those in nontraditional roles and/or settings, those with cross-jurisdictional career histories, those working in interdisciplinary practices, and those working in educational settings, in order to explore their experiences with their regulatory body. Participants reported considerable difficulty in their interactions with the nursing regulator because their unique circumstances did not fit well with standard regulatory perspectives. This exploratory study raises questions about the consequences of conservative regulatory practices on nurses' abilities to contribute to innovation in health care delivery.

The Development of Institutional Ethnography as a Method of Inquiry in Health Care: A Scoping Review

Elaine Stasiulis, University of Toronto Cindy Malachowski, University of Waterloo Christina Skorobohacz, Brock University

Institutional ethnography (IE) is a comparatively new approach to social inquiry that over the past two decades has spawned a rapidly growing network of scholars, particularly in the health care sector. Developed by feminist sociologist Dorothy Smith, IE explores and attempts to understand the social relations that organize individuals' daily/nightly lives. Its focus on the system-level coordination of people's everyday life has made it an increasing methodological/theoretical choice for health researchers. We are conducting a scoping review to examine the range and nature of IE's uptake as a method of inquiry. From a literature search encompassing databases between the years of 2003 and 2013, we have currently identified 171 original peer-reviewed articles (across all sectors and disciplines) that meet our criteria for utilizing IE. Approximately a third of these are situated in the field of health care. We expect to identify further articles as we continue the review. Drawing from the full review, this presentation will focus specifically on IE research conducted within the health sector. Findings will include an examination of how and by whom IE is being used. Understanding the implications, challenges, and limitations of IE's use will be beneficial to health researchers and practitioners considering this innovative alternative approach.

Reinforcing Reoffending? Exploring Mental Health Care Needs of Offenders in a Nigeria Prison

Oluyemi Stephens, University of South Africa TK Bello, University of Pretoria

The presentation centers around a research study which is in progress on the mental health of offenders in a Nigeria prison. The focus of the study is on offenders who have committed

serious crimes. In Nigeria, there is a lack of policy and a serious dearth of mental health care professionals to meet the mental health needs of those that require mental health care. Especially in the case of offenders, mental health care services leave much to be desired. Some offenders have mental health care challenges even before their incarceration. Privation of imprisonment and the associated stress increase the risk of developing mental health illnesses or may even contribute to the relapse of existing chronic mental health illnesses. This paper's objective is primarily to stimulate discourse among stakeholders such as mental health care practitioners, administrators in the penal system, and policy makers on the mental health care needs of offenders who committed serious crimes. The research study will follow the qualitative research paradigm. Data collecting instruments will include individual interviews with offenders, prison authorities, and participant observation. Purposive sampling based on certain criteria would be adopted to select the prison and offenders. Based on the findings of the study, the researcher intends to develop a framework that could inform Nigerian mental health policy for offenders who committed serious crime.

Development of a Conceptual Framework for End-of-Life Spirituality

Pam Stephenson, Kent State University Denice Sheehan, Kent State University, Ghada Shahrour, Kent State University

One major barrier to spirituality research is that spirituality has not been universally conceptualized because of its abstract and subjective nature. A prior literature review of spirituality research found that researchers most often used five attributes to define or describe end-of-life (EOL) spirituality. These attributes provide a framework for conceptualizing spirituality at the EOL. Attributes include meaning, beliefs, connections, value, and self-transcendence. These findings report on analyzed data from the prior study Strategies to Help Adolescents with a Parent in Hospice. Semistruc-tured interviews were conducted with 61 participants from 26 families in which one parent was enrolled in hospice. Participants included 11 terminally ill parents, 20 well-parents, and 30 adolescents. In addition, follow-up interviews were conducted with surviving adolescents (n = 9) and parents (n = 6) from six of the original families after the parent's death to test the feasibility of future longitudinal research and collect pilot data about how adolescents were managing after their parent's death. A total of 76 interviews were analyzed for this study. These data were particularly useful because participants were not asked about spirituality directly so their stories about spirituality happened spontaneously. This enabled researchers to examine spirituality within the context of their day-to-day lives. Findings support the five spiritual attributes as contributing to the overall essence of EOL spirituality and provide an early conceptual understanding of how the attributes related to each other.

The Silencing of Gender Relations in Hospice Palliative Home Care

Nisha Sutherland, Lakehead University, Catherine Ward-Griffin, Western University

As the population ages and sociopolitical trends towards home care continue, there will be greater demands for quality hospice palliative home care. While evidence indicates gender differences and potential inequities in the type of care provided and received in hospice palliative home care, few have critically examined gendered processes in this context. As part of a larger study, we employed a critical feminist lens to examine gendered processes in the sociopolitical context of hospice palliative home care. We collected ethnographic data of in-depth interviews with clients, their family caregivers and primary nurses (n = 25), observations of home visits (n = 9), and documents from professional associations and home-care agencies (n = 12). A gender-based analysis revealed that gender enactments, the Regulating of Gender Relations, were silenced and made invisible through the ideological processes of Normalizing Gender Relations and Equalizing Gender Relations. Participants in this study normalized gender relations by essen-tializing men's and women's roles, while they simultaneously used the egalitarian notion of treating people the same, suggesting a just environment and permitting clients, caregivers and nurses to leave unexamined the consequences of gendered practices. (Re)produced through institutional discourses of individualism and egalitarianism, these gendered processes both advantaged and disadvantaged men and women, shaping opportunities and constraints to quality hospice palliative home care. Findings suggest that health care providers, educators, and policy makers alike must attend to gender as a pervasive social determinant of health and health care experiences. Implications for policy, practice, education, and research are discussed.

Conducting Gender Research During Vulnerable Times: Challenges and Insights

Nisha Sutherland, Lakehead University,

Receiving hospice palliative home care can be a vulnerable time when clients and family caregivers are actively engaged in finding meaning in living and dying. Participants often are unable or unwilling to recognize or confront inequities shaped by social relations such gender. In this context, it is crucial to ensure that policies and practices promote gender equity in health and health care. The purpose of this presentation is to share the challenges faced and the insights gained in conducting gender research during vulnerable times. Using a critical feminist lens with a critical ethnographic methodology, I examined the dynamics of gender relations in the sociopolitical context of hospice palliative home care. I collected data consisting of interviews with six home care triads, which included the client with terminal cancer, the family caregiver, and the primary nurse; observations of nine agency

home visits; and review of documents. During the data collection and analysis stages of this study, I faced three major challenges of (a) participants resisting discussions of unfair practices for which they did not want to be reminded; (b) participants reluctant to discussing issues that deflected from the individual dying; and (c) participants regarding gender relations as irrelevant in the context of end of life. Despite being ever-present, gender relations were rendered invisible by participants, presenting epistemological and ethical challenges to conducting gender research. To enlighten investigators conducting similar research during vulnerable times, I share the methodological insights gained and strategies used to collect and analyze data.

Eating Cognitions and Behaviors in Japanese Students Before, During, and After International Study: Implication for Cross-Cultural Eating Education From the Perspective of the Longitudinal Health Education for Sojourners

Tomoko Tanaka, Okayama University Moe OZAKI, Okayama University Yohsimi HYODO, Okayama University Mitsuhiko TOJO, Okayama University

Purpose: Changes in eating cognitions and behaviors of eating before, during, and after studying abroad were assessed in Japanese students. Implications for longitudinal cross-cultural eating health education for people who stayed in foreign countries were investigated. Method: Nineteen Japanese university students (6 male and 13 female; M age = 21.4, SD = 0.67) who had studied internationally (1) completed a questionnaire about eating before, during, and after international study; (2) were interviewed for precise information; (3) described their observations concerning their eating; and (4) evaluated their nutrition using a software program. Duration of international stays were M = 7.3 (SD = 3.93) months. International locations were North America (12), Europe (4), Asia (3), and Oceania (1). The KJ method and content analysis were used. Result and Discussion: Although the students initially enjoyed novel food, they reconsidered their eating after satiation and worsening of health. They used ethnic and host food for communication in oversea countries. After returning to Japan, some showed increasing awareness of healthy eating. However, some lost eating moderation because they believed Japanese food was sufficiently healthy, and others just maintained unhealthy eating habits. And they rediscovered fascination of Japanese food and missed their host countries' foods. Software for nutrition evaluation helped obtain an objective view of eating. Cross-cultural eating health education concerning information, techniques, and awareness of healthy eating for travelers should be conducted in this global era, since relocation includes an application of eating self-management.

Nursing Home Health Care Aide Perspectives of Decision Making Processes in Transfers From the Nursing Home to the Emergency Department

Kaitlyn Tate, University of Alberta Jude Spiers, University of Alberta Greta Cummings, University of Alberta Rowan El-Bialy, University of Alberta

Transfers of nursing home residents via ambulance to the emergency room (ED) are usually necessary. However, transfers may lead to deleterious effects for the resident such as stress, increased confusion, and dehydration. Some transfers are perceived by acute care staff as unnecessary, yet decision making around transfers is complex and poorly understood. As part of a larger focused ethnographic study using experiential data from regulated nurses and managers, we examined 20 health care aides (HCAs) perceptions of decision processes and factors influencing decisions via 6 focus groups and 6 individual semi-structured interviews. Iterative data collection and analysis accommodated verification of evolving analysis. Analytic codes were collapsed into categories, and emerging themes were identified. The HCA role provides close, sustained contact and familiarity with residents, making them a crucial catalyst in initiating decision-making processes. Role and hierarchical restraints limit their ability to effectively communicate clinical concerns that lead to decisions to transfer. Decisions occur within the context of team-based care. As such, perceptions of nurse clinical competence, professional respect, and responsiveness were important influences on communication processes that facilitate detection, assessment, and interventions to prevent ED transfers. This research illuminated the extent to which HCA responsibilities constitute more than task allocation and accountability in reporting resident conditions significantly impacts appropriate interventions. While scope of practice is expanding for regulated nursing staff, there is urgent need to improve conceptualization of HCA role, communication, and recognition of interdependence of clinical expertise in care of nursing home residents.

Older Chinese Canadian Immigrant's Individual Stories of Depression in an Arts-Informed Narrative Inquiry

Elizabeth Suen, University of Ontario Institute of Technology

Chinese Canadians are one of the fastest growing immigrant populations in the Greater Toronto Area, yet they tend to underutilize mental health services, even if they are at a moderate to high risk of depression. Past research has indicated that Chinese Canadian immigrants may be reluctant to disclose mental health issues due to social, cultural, and linguistic factors. Yet, as the majority of Canada's population continues to age, there is an increased need to recognize the heterogeneity of experiences of immigrant older adults with mental illness. To explore this issue, I conducted an arts-informed narrative

inquiry to learn how older Chinese immigrants experience depression. The use of an arts-informed research approach was purposeful to this study, as the arts can enable participants to share historically silenced stories and feelings that would be otherwise difficult to articulate with words. I reflect upon how personal, practical, and social implications concerning the mental health of older immigrants can be extrapolated from individual experiences with depression. I will also share about how the personal interactions, thoughts, and feelings of my study's participants spoke of the benefits of intersectoral collaboration in increasing the accessibility of mental health services to older adults who may concurrently experiencing occupational stress and mental illness.

The Silencing of Gender Relations in Hospice Palliative Home Care

Nisha Sutherland, Lakehead University Catherine Ward-Griffin, Western University

As the population ages and sociopolitical trends towards home care continue, there will be greater demands for quality hospice palliative home care. While evidence indicates gender differences and potential inequities in the type of care provided and received in hospice palliative home care, few have critically examined gendered processes in this context. As part of a larger study, we employed a critical feminist lens to examine gendered processes in the sociopolitical context of hospice palliative home care. We collected ethnographic data of in-depth interviews with clients, their family caregivers and primary nurses (n = 25), observations of home visits (n = 9), and documents from professional associations and home care agencies (n = 12). A gender-based analysis revealed that gender enactments, the Regulating of Gender Relations, were silenced and made invisible through the ideological processes of Normalizing Gender Relations and Equalizing Gender Relations. Participants in this study normalized gender relations by essentializing men's and women's roles, while they simultaneously used the egalitarian notion of treating people the same, suggesting a just environment and permitting clients, caregivers, and nurses to leave unexa-mined the consequences of gendered practices. (Re)produced through institutional discourses of individualism and egalitarian-ism, these gendered processes both advantaged and disadvan-taged men and women, shaping opportunities and constraints to quality hospice palliative home care. Findings suggest that health care providers, educators, and policy makers alike must attend to gender as a pervasive social determinant of health and health care experiences. Implications for policy, practice, education, and research are discussed.

Conducting Gender Research During Vulnerable Times: Challenges and Insights

Nisha Sutherland, Lakehead University

Receiving hospice palliative home care can be a vulnerable time when clients and family caregivers are actively engaged

in finding meaning in living and dying. Participants often are unable or unwilling to recognize or confront inequities shaped by social relations such gender. In this context, it is crucial to ensure that policies and practices promote gender equity in health and health care. The purpose of this presentation is to share the challenges faced and the insights gained in conducting gender research during vulnerable times. Using a critical feminist lens with a critical ethnographic methodology, I examined the dynamics of gender relations in the sociopolitical context of hospice palliative home care. I collected data consisting of interviews with six home care triads, which included the client with terminal cancer, the family caregiver, and the primary nurse; observations of nine agency home visits; and review of documents. During the data collection and analysis stages of this study, I faced three major challenges of (a) participants resisting discussions of unfair practices for which they did not want to be reminded, (b) participants reluctant to discussing issues that deflected from the individual dying, and (c) participants regarding gender relations as irrelevant in the context of end-of-life. Despite being ever-present, gender relations were rendered invisible by participants, presenting epistemological and ethical challenges to conducting gender research. To enlighten investigators conducting similar research during vulnerable times, I share the methodological insights gained and strategies used to collect and analyze data.

Through the Lens of the Youth: Exploring Culturally Relevant Physical Activity With a Northern Aboriginal Community Through Participatory Action Research

Keren Tang, Community Wellness Program Cindy Jardine, School of Public Health

Guided by an overarching participatory action research framework, this research explored physical activity within the sociocultural context of northern aboriginal communities. I worked in partnership with the Yellowknives Dene First Nation Community Wellness Program in the Northwest Territories, Canada, to develop, implement, and evaluate the research. Together, we aimed to (1) document the community's perspective of and experience with physical activity through the eyes of the youth, (2) investigate how physical activity is embedded in local and traditional culture, (3) raise consciousness about physical activity in the community, and (4) develop a strategic plan for sustaining new and existing physical activity initiatives. Ultimately, this research highlighted the critical role of culture and traditions in the Dene peoples physical activity experience and more broadly, their health and well-being. Moreover, it demonstrated that a participatory action research project is entirely feasible within the capacity of a master's thesis, given the appropriate circumstances, partnership, and researcher attitude. This study contributes to the current understanding of physical activity from an indigenous

perspective and provides recommendations for future research, policy, and practice to develop meaningful and effective interventions for chronic disease preventions.

Theoretical Sampling: A Few Words to an Emergent Theme

Karyn Taplay, McMaster University

While exploring how organizational cultures of undergraduate programs of nursing shape the adoption and incorporation of simulation as a teaching and learning strategy, data were gathered from 43 interviews and 67 documents representing 13 different Ontario nursing programs. A challenge arose when a key organizational role was identified and discussed as part of the uptake among every institution that participated in the study. A further challenge that arose was the discovery that there was no consistent job title nor job description yet this role continued to emerge as part of the process of adoption and incorporation of simulation into the curriculum among all institutions. The objective of this presentation will be to share examples of how theoretical sampling was used to drive data collection and to facilitate data analysis of this role. The purpose of theoretical sampling is to focus data collection so that the properties of the data can emerge and to understand and clarify the relationships between that data. This presentation will discuss six constructs that are allied with grounded theory research that were used to facilitate theoretical sampling and move a few words about this role into an emergent theme. These constructs include, the fluid nature of the interview guide, the constant comparison method of analysis, documents, memoing, member checking, considering the emergent fit, and diagraming.

Insight into Cross-Cultural Research: Safety of Involving Interpreters in Research Processes Using Cross-Cultural Research Interpretation Management Framework

Lily Tsai, Central Queensland University Jennieffer A. Barr, Central Queensland University

The management of bicultural-bilingual workers (BBW) involved in research has not been explored in-depth. BBW may be involved in numerous stages of the research. Obligations in managing the involvement of BBW include ensuring research rigor and the safety of participants, researchers, and BBWs. A management tool was developed to guide cross-cultural researchers for their decision-making process of when and how BBW should be involved in their research; how to manage involvement of a BBW; and evaluation of involving BBW. This presentation will present the Cross-Cultural Research Interpretation Management Framework and provide an exemplar of implementing this framework during a qualitative health research project.

Where is Home in Nurse Home Visiting?

Natasha VanBorek, McMaster University

Susan Jack, McMaster University

Colleen Varcoe, University of British Columbia

Historically, public health nurses (PHNs) have conducted home visits to provide support to new mothers and to improve child health by promoting competent caregiving. The goal of this presentation is to transform perceptions about what defines a ''home'' visit and how this influences the nurse-client relationship in the Nurse-Family Partnership (NFP), a home visitation program for vulnerable first-time mothers. NFP effectiveness is currently being evaluated in a randomized controlled trial as part of the British Columbia Healthy Connections Project (BCHCP). BCHCP also includes an embedded mixed methods process evaluation to describe how NFP is implemented and delivered across BC's five health authorities, including fidelity to all NFP model elements. Qualitative interviews are conducted every 6 months with all NFP PHNs (n = 60) and supervisors (n = 11) over a 5-year period. Data are synthesized using conventional content analysis. Nurse and supervisor narratives confirm that visiting a client in her home is highly valued as it allows a PHN to directly assess environmental conditions and maternal-infant attachment. However, many home visits occur in other locations, this presentation will focus on explaining where and why visits are conducted in alternate locations to ensure the delivery of client-centered and safe health promotion services. To retain clients in NFP, nurses are flexible in occasionally changing the setting for the visit should a client determine that an alternative location better suits her needs. This further promotes the development of trust in the nurse-client relationship.

At Least I Would Be Able to Feed Myself Properly: Subsidized Housing, Health, and Waiting for Both

Biljana Vasilevska, McMaster University

Across Canada, a number of factors have led to there being a housing affordability crisis, particularly in larger cities. The increased cost of housing, the stagnation of wages for the majority of workers and for social assistance recipients, and the lack of construction of affordable and rental housing have resulted in increased demand for subsidized housing, while also increasing the waiting periods. In Toronto, for example, the waiting period for a subsidized housing unit can be as long as a decade. While they are waiting for subsidized housing to become available, applicant may be ''discounting'' important features of a healthy physical life, such as quality food and medication, while also being unable to engage in a healthy social life. The stress due to financial hardship is compounded by the uncertainty of when an offer of housing will be made. This presentation presents key findings from the qualitative portion of The Greater Toronto Area (GTA) West Housing and Health Study, longitudinal study of applicants to Rent-Geared

to Income housing. Participants in this study recounted the various ways that waiting for housing has had a negative impact on their health (including physical, social, and emotional) and the ways they hope or expect their health to improve, if they were to move in to subsidized housing. The act of waiting is itself a stressor and one that qualitative methods are well-equipped to document.

Ethical Challenges in Addressing Sensitive Issues: The Case of Sexual Violence and Quality of Response in India

Bilkis Vissandjee, Universite de Montreal

Sexual violence in any countries is anchored in a complex socio-cultural context which becomes significant at the interface of access of health and social services especially when it comes to quality and rapidity of response. It is documented and understood as a form of gender-based violence which usually results in unjustifiable consequences among girls and women, such practices are culturally engrained traditions with complex meanings calling for ethically and culturally sensitive health and social service provision. Sexual violence is rampant worldwide and particularly pervasive in India, where it has reached and all time high rate during the last decade. Although the country pledged to abolish all forms of marginalization and discrimination against women, the social construction of gender in India remains associated with sustained systematic discrimination against women. While present in a number of spheres of everyday life, it is increasingly an issue when seeking care, through the institutio-nalization of the triangular system of gender, caste, and class. This is a dynamic that contributes to gender-based violence while dictating biased access to health care and justice. One of the consequences is that women victims of sexual violence end up confronting inadequate response from health care services and medicolegal systems, demonstrating issues in regards to quality of response. It is widely accepted that the quality of health care response offered by health care providers creates a safe environment for survivors and allows gathering of medical and legal evidence needed for a valid case for medicolegal response and justice. Sexual violence will be discussed as a global public health issue with complex legal and ethical dimensions which impacts ability to access services, let alone gender sensitive. To tackle this growing issue of sexual violence in India and to better understand the origins of disparities in the medico-legal response, it is important to take a closer look at a series of crucial points: (1) the psychosocial support provided to victims, the practices and services surrounding health care provision in the context of rape and sexual violence; (2) the process of collection of forensic evidence and practice associated with the clinical exam postevent; the reliability of applying protocols and guidelines when and if available; and (3) the sensitivity by health care providers to social determinants of health and contextual experiences affecting the ''victims.'' These factors highlight the current situation in India where forensic evidence collection is the main focus to the detriment of care and psychosocial support

of victims of sexual violence. An overview of a narrative review of international policies in regards to rapid and quality response will be provided. The ethics of terminology will be addressed, building on the sustained controversial debate in regards to the delicate issue of conceptualization. Sociocultural and ethical challenges will be discussed in light of selected findings from a community-based research project. Actions and reforms are required to take into consideration the victims' voices in the forensic evidence collection process and establish empathetic medical and legal services for better provision of care and justice. This implies sensitization of health and legal professionals and appropriate policy changes inspired from western models. While guidelines and standard protocols for interventions post rape do exist, and standard protocols for the collection of forensic evidence are being improved over the years, what is lacking is a better understanding of the premises, which would allow for an increased quality response. A culturally competent, gender, and ethically sensitive approach is argued for to ensure the provision of quality ethical care for girls and women exposed to sexual violence. Working partnerships between the public health sector and active engagement of community-based organisations will allow for more sensitive and congruent clinical guidelines. In order to honour the fundamental principles and values of medical ethics, such as compassion, beneficence, nonmalfea-sance, respect, and justice and accountability, socio-cultural interactions at the interface of health and health system response will continue to require attention at a global level. It entails a commitment to recognise the intrinsic value and dignity of girls' and women's context.

Nurses' Experience of Creating an Artistic Instrument for Their Nursing Practice and Professional Development: An Arts-Informed Narrative Inquiry

Neelam Walji, Ryerson University Jasna K. Schwind, Ryerson University

Passion for the arts as a medium motivated me to create an art piece related to my nursing practice, which enriched my professional development. This experience lead me to inquire: How do nurses experience creating their own art pieces and what meaning these hold for their nursing practice and professional development? Extant literature revealed that nurses seldom use visual arts to reflect on, and make meaning of, such a process. Arts-Informed Narrative Inquiry was used to give voice to two nurses to coconstruct knowledge and give meaning to their practice through visual art. Stories were collected using narrative interviews and Schwind's Narrative Reflective Process, an artistic approach where participants used metaphors, drawing, journal writing, and reflective dialogue. Nurses' stories were transcribed verbatim, co-constructed with participants, and then analyzed using Connelly and Clandinin's Narrative Inquiry three-dimensional space, and Carper's ways of knowing, to reveal narrative patterns: empathy, quality of life, communication, power imbalance, and personal-

professional development. Outcomes of this inquiry expose the value of person-centered care and creative reflective practice, and the need for further research into the use of arts in health care practice and education. Future research may focus on engaging interprofessional health care providers in creating art and reflective dialogue in relation to self-care practices, communication, relationship building, and importantly, patient care. Furthermore, health care professionals engaging in the use of arts can expand their comfort and confidence in using art, with the potential to offer such opportunities to their patients, which can lead to practice changes across diverse settings.

Wellness, Not Weight! A Case Study of the Paradigm Shift and Transformative Pedagogy Within the Janeway Lifestyle Program in Newfoundland and Labrador Canada

Pamela Ward, Centre for Nursing Studies

Erin McGowan, Memorial University of Newfoundland

Erin Cameron

Over the last decade, concerns about a global obesity "epidemic'' have become widespread resulting in health messages that may reinforce fat-phobic practices. These messages are particularly evident with regards to children who, because of obesity, have been labelled ''the first generation that will not outlive their parents.'' Calls for action have resulted in an environment where obesity prevention and treatment programs have become commonplace. Yet, despite years of weight-centred interventions, childhood obesity rates remain relatively unchanged and concerns have arisen regarding the harm inherent in weight-centred health paradigms including body dissatisfaction and weight stigma. Despite a growing body of research suggesting that traditional approaches do not work, alternative approaches that shift the focus from weight to wellness are rare. More recently, there has been a call for research into exemplary programs that challenge conventional weight-centered health paradigms and disrupt the dominant obesity discourse. To date, few studies have explored how childhood obesity programs could serve as sites for challenging dominant messages and addressing weight bias. This presentation will provide an overview of an intrinsic case study (informed by poststructural, feminist and critical pedagogical theories) of the Janeway Lifestyle Program (JLP) which, in 2009, transformed from an obesity orientated program to a chronic disease prevention program whose vision is ''Good Health for EveryBody!'' Using narratives from interdisciplinary JLP team members, we will highlight their lived experiences as they worked through this paradigm shift as well as the impact of this shift on the care they provide for children and families.

Falls in an Acute Care Hospital

Barbara Watson, Western University

The increasing number of falls in hospitals precipitates the need to gather information about the fall from various sources.

Staff documentation gives a crucial glimpse into the clinical setting and contributing factors. The purpose of this study was to identify problems associated with reporting falls in an acute care hospital over the 5 years from the implementation of the Adverse Event Management System (AEMS). Falls data recorded in the AEMS system from February 2009 to February 2014 were analyzed to observe trends in various hospital units. A qualitative approach of this study was used to gather staff's perspectives on the challenges of reporting and documenting patient falls. A total of 7,721 falls were recorded during the study period. There were 2,275 falls which resulted in an injury. A qualitative analysis revealed multiple reasons that contributed to challenges associated with reporting into the AEMS. Themes identified included units being too busy at certain times of the day, insufficient resources and lack of knowledge around the purpose of AEMS. A qualitative research approach should be used in hospitals to gather the perspectives and opinions of participants directly linked to patient safety and falls. A qualitative analysis provides context to the situation surrounding the falls.

How Best to Pay Interdisciplinary Primary Care teams?

Dominika Wranik, Dalhousie University

Maryna Korchagina, Alberta Health

Jeanette Edwards, Winnipeg Regional Health Authority

Ian Bower, Nova Scotia Department of Health and Wellness

Adrian Levy, Dalhousie University

Alan Katz, University of Manitoba

Across Canada, interdisciplinary teams are an increasingly more common model for delivering primary care. Given our fragmented system, provinces have developed a variety of approaches to the funding of teams and remuneration of providers. Decision makers want to know which approaches work best in which contexts. The literature on this topic discusses the need for an alignment of incentives, but there is no clear description of potential approaches, nor any concrete examples or evidence of success and/or failure. Relying primarily on qualitative interviews (n = 24) and a roundtable discussion (n = 14) with key decision makers, we collect data from three provinces (Alberta, Manitoba, and Nova Scotia) to develop a functional framework of funding and remuneration approaches in interdisciplinary primary care teams settings. We use qualitative content analysis. The resultant generalized functional framework captures all potential options of funding flows and lines of accountability between funders, teams, and providers. The framework supports a common understanding of funding and remuneration models, a prerequisite to the evaluation of options. We provide a qualitative assessment of strengths and weaknesses of the funding/remuneration models used in the three provinces in terms of their ability to support team-based care, care continuity, and comprehensiveness. We find that models, where physicians activities lie at the core of the funding formula and/or patients are attached to physicians, are

less preferred. Models in which patients are attached to clinics, and funding is calculated on the basis of estimated service requirements are preferred. The multiplicity of funding sources can be a disadvantage to care continuity.

Culturally Appropriate Data Collection Methods for Use by the Nurse Researcher in Research Involving Aboriginal People in Canada

Amy Wright, McMaster University Olive Wahoush, McMaster University Marilyn Ballantyne, McMaster University Chelsea Gabel, McMaster University Susan Jack, McMaster University

Research involving aboriginal peoples has been fraught with problems, including cases of unethical consent procedures, researchers failing to utilize culturally appropriate methods, and not addressing aboriginal research priorities. Due to this history, some aboriginal populations may be reluctant to participate in research projects. In response to these concerns, the Government of Canada has developed the Tri-Council Policy Statement, Chapter 9 (TCPS). These guidelines stipulate requirements for research collaborations with the aboriginal community, including the use of culturally appropriate data collection methods. Qualitative methodology is increasingly used by nurse researchers to give voice to vulnerable populations. It is important for nurse researchers wishing to conduct qualitative research with aboriginal populations to use data collection methods that are respectful of aboriginal cultures and beliefs. Interviews and focus groups have traditionally been used to collect data in qualitative research but have been criticized for the potential for researchers to exert power over participants. While there are studies that attempt to use culturally appropriate data collection methods with aboriginal populations, no papers were located that synthesize these methods, while also providing a critique of rigor and cultural appropriateness. The purpose of this paper is to describe, critique, and synthesize the literature on alternative oral-data collection methods, excluding interviews and focus groups, for use with aboriginal people in Canada. The literature has been assessed for quality using the Critical Appraisal Skills Program framework and for cultural appropriateness using the standards outlined in the TCPS. The results of this paper suggest that photovoice, symbol-based reflection, circles and storytelling are both rigorous and culturally appropriately methods of oral data collection in research with aboriginal people in Canada. Nurse researchers conducting this work must first have a strong knowledge base on the history and culture of aboriginal people in Canada and the TCPS prior to embarking on research with this population. They must collaborate with the aboriginal communities and elders, with whom research is being conducted, to ensure the methods are tailored to the specific traditions and cultures of the community. The aboriginal community should be involved throughout the research project

to build research capacity and ensure that results are interpreted and disseminated appropriately. Finally, future research on the application of these oral data collection methods is necessary to promote respectful and collaborative research partnerships with aboriginal people in Canada.

Emerging Medical Technologies and Policy Process: Public Health Decision-Making Regarding HPV Vaccine Programming in Ontario

Michelle Wyndham-West, York University Peter Tsasis, York University Mary Wiktorowicz, York University

This study examines public health policy decision making for the HPV vaccine in Ontario. While emerging technologies like the vaccine can bring about change, they present ethical and political challenges. To address these challenges policy makers engage in ''sensemaking'' (Weick et al., 2005, p. 410). Sensemaking is an understanding of when individuals who are experiencing uncertainty pull together the threads of a ''story'' to make sense of shifting informational terrain (Weick et al., 2005, p. 410). As such, policy makers undergo a process whereby meanings are questioned, reformulated, and woven into a continually developing narrative. In order to trace sensemaking, 17 policy makers and medical stakeholders were interviewed in our study. Interviews covered policy development, evidence-based practices, and linkages between the pharmaceutical industry and policy making. Narratives were reviewed through ''categorical-content'' (Lieblich et al, 1998, p. 13) analysis, which examines overarching narratives before identifying common themes. Findings indicate that policy decision making is tied to public health narratives surrounding infectious disease, protecting the ''public good'' and success stories. However, policy makers explain they are ''victims of their own success'' for the public no longer necessarily sees the need for vaccines, as diseases like polio are not a mainstay in Canada. Nimble approaches, such as introducing catch-up clinics, have led to increased HPV vaccine uptake, although rates are still below targets. Medical societies, who function as ''policy entrepreneurs'' (Kingdon 1984), and the manufacturer also advocated for these changes, and this presents potential conflict of interest for policy makers. As a result, policy making is a fluid and contested ''field'' (Metcalf, 2001, p. 168), which is embedded in policy makers' experiences of enacting meanings within relations of power and systems of governance.

Understanding and Using Patients' Experiences to Improve Health Care

Sue Ziebland, University of Oxford

The Health Experiences Research Group in Oxford, United Kingdom, has developed an approach to qualitative narrative

interviewing which involves gathering national collections of interviews and applying this understanding for (we hope) patient benefit. To date, our team has studies nearly 100 different health conditions, with around 4,000 participants. We analyse our studies for publication in social science and health journals and, more unusually for academic qualitative researchers, we also work closely with the DIPEx charity which publishes video and audio extracts from our studies on the award-winning www.healthtalk.org. The approach has been emulated by colleagues in 12 countries, including Canada, who have together established the DIPEx International collaboration. Our studies have been used to inform policy, training, and participatory service improvement. In this talk, I will draw on our experiences of applying these qualitative interview studies to improve health and care. I will discuss some of the issues that arise when using this sort of material for secondary analysis and present some examples to demonstrate that patients' narratives can be used successfully to improve understanding of what matters to patients and to support improvements in health and care.

Promoting Health and Health Care Access in the African Refugee and Immigrant Community: A Focused Ethnography

Rick Zoucha, FAAN Duquesne University School of Nursing Yinka Aganga-Williams

The purpose of this focused ethnography was to understand health and health care access in African immigrant and refugee communities. The specific aims were (1) explore the health promoting needs of African immigrants and refugees, (2) describe the health care access needs of African immigrants and refugees, and (3) understand the culturally congruent process of developing strategies within the specific immigrant and refugee community to address the health promoting and health access needs of the community. Thirty-two informants were interviewed (18 men and 14 women) from 5 cultural groups (7 Somali, 8 Burundi, 4 Sudanese, 4 Liberian, and 7 Zambian). Data were analyzed using Leininger's four phase of qualitative data analysis. The themes were: (1) The Somali, Burundi, Sudanese, Liberian, and Zambian refugee communities share a common journey with various stops and lengths of stays from their country of origin to the United States; (2) poverty, inability to pay for health care serves as a major barrier to health care access for African refugees and immigrants; (3) language, social isolation, and mistrust of health care professionals and institutions restrict the use of health care services for African refugees and immigrants; (4) community and family violence is a major health care issue due to lack of community and elder support and misunderstandings of the host culture. The findings suggest that African immigrant and refugees must be given a voice in how, when, and where care is provided based on cultural needs and values in cooperation with available health care institutions and providers.

Preparing for Adulthood: An Exploration of the Social, Educational, and Vocational Needs of Children Survivors of Traumatic Brain Injury According to Caregivers

Rosslynn Zulla, University of Calgary Janki Shankar, University of Calgary

Education, social support, and having a job remain instrumental to the health and well-being of an individual. Accordingly, fostering the educational, social, and vocational development of survivors of pediatric traumatic injury (TBI) is critical to their well-being as an adult. In this study, we use a phenomen-ological approach to explore caregivers' perceptions of their child's educational and social experiences following their

child's traumatic brain injury and into adulthood. As well, this study uses concept mapping to illustrate caregivers' priorities in fostering their child's educational, social, and vocational development as they move into adulthood. Study findings illustrate (i) the impact of a lack of awareness, limited experience of personnel, and limited resources in fostering the educational, social, and vocational development of survivors of pediatric TBI in community-based settings (e.g., schools and support groups) and (ii) the required information and continual emotional support that is needed to meet their child's educational, vocational, and social goals. Implications of the study will be discussed in terms of developing approaches and strategies to support collaborative transition planning that extends beyond the hospital and into community settings.