Findings from this study provide new understandings of supported decision making for people with severe or profound intellectual disability and have particular relevance for supporting decision making at the end of life.

BackgroundIn Canada, as in other parts of the world, there is geographic maldistribution of the nursing workforce, and insufficient attention is paid to the strengths and needs of those providing care in rural and remote settings. In order to inform workforce planning, a national study, Nursing Practice in Rural and Remote Canada II, was conducted with the rural and remote regulated nursing workforce (registered nurses, nurse practitioners, licensed or registered practical nurses, and registered psychiatric nurses) with the intent of informing policy and planning about improving nursing services and access to care. In this article, the study methods are described along with an examination of the characteristics of the rural and remote nursing workforce with a focus on important variations among nurse types and regions.MethodsA cross-sectional survey used a mailed questionnaire with persistent follow-up to achieve a stratified systematic sample of 3822 regulated nurses from all provinces and territories, living outside of the commuting zones of large urban centers and in the north of Canada.ResultsRural workforce characteristics reported here suggest the persistence of key characteristics noted in a previous Canada-wide survey of rural registered nurses (2001-2002), namely the aging of the rural nursing workforce, the growth in baccalaureate education for registered nurses, and increasing casualization. Two thirds of the nurses grew up in a community of under 10 000 people. While nurses’ levels of satisfaction with their nursing practice and community are generally high, significant variations were noted by nurse type. Nurses reported coming to rural communities to work for reasons of location, interest in the practice setting, and income, and staying for similar reasons. Important variations were noted by nurse type and region.ConclusionsThe proportion of the rural nursing workforce in Canada is continuing to decline in relation to the proportion of the Canadian population in rural and remote settings. Survey results about the characteristics and practice of the various types of nurses can support workforce planning to improve nursing services and access to care.Electronic supplementary materialThe online version of this article (doi:10.1186/s12960-017-0209-0) contains supplementary material, which is available to authorized users.

Background Social inequities are widening globally, contributing to growing health and health care inequities. Health inequities are unjust differences in health and well-being between and within groups of people caused by socially structured, and thus avoidable, marginalizing conditions such as poverty and systemic racism. In Canada, such conditions disproportionately affect Indigenous persons, racialized newcomers, those with mental health and substance use issues, and those experiencing interpersonal violence. Despite calls to enhance equity in health care to contribute to improving population health, few studies examine how to achieve equity at the point of care, and the impacts of doing so. Many people facing marginalizing conditions experience inadequate and inequitable treatment in emergency departments (EDs), which makes people less likely to access care, paradoxically resulting in reliance on EDs through delays to care and repeat visits, interfering with effective care delivery and increasing human and financial costs. EDs are key settings with potential for mitigating the impacts of structural conditions and barriers to care linked to health inequities. Methods EQUIP is an organizational intervention to promote equity. Building on promising research in primary health care, we are adapting EQUIP to emergency departments, and testing its impact at three geographically and demographically diverse EDs in one Canadian province. A mixed methods multisite design will examine changes in key outcomes including: a) a longitudinal analysis of change over time based on structured assessments of patients and staff, b) an interrupted time series design of administrative data (i.e., staff sick leave, patients who leave without care being completed), c) a process evaluation to assess how the intervention was implemented and the contextual features of the environment and process that are influential for successful implementation, and d) a cost-benefit analysis. Discussion This project will generate both process- and outcome-based evidence to improve the provision of equity-oriented health care in emergency departments, particularly targeting groups known to be at greatest risk for experiencing the negative impacts of health and health care inequities. The main deliverable is a health equity-enhancing framework, including implementable, measurable interventions, tested, refined and relevant to diverse EDs. Trial registration Clinical Trials.gov #NCT03369678 (registration date November 18, 2017).

People who experience the greatest social inequities often have poor experiences in emergency departments (EDs) so that they are deterred from seeking care, leave without care complete, receive inadequate care, and/or return repeatedly for unresolved problems. However, efforts to measure and monitor experiences of care rarely capture the experiences of people facing the greatest inequities, experiences of discrimination, or relationships among these variables. This analysis examined how patients’ experiences, including self-reported ratings of care, experiences of discrimination, and repeat visits vary with social and economic circumstances. Every consecutive person presenting to three diverse EDs was invited if/when they were able to consent; 2424 provided demographic and contact information; and 1692 (70%) completed the survey. Latent class analysis (LCA) using sociodemographic variables: age, gender, financial strain, employment, housing stability, English as first language, born in Canada, and Indigenous identity, indicated a six-class solution. Classes differed significantly on having regular access to primary care, reasons for the visit, and acuity. Classes also differed on self-reported discrimination every day and during their ED visit, ratings of ED care, and number of ED visits within the past six months. ED care can be improved through attention to how intersecting forms of structural disadvantage and inequities affect patient experiences.

This paper presents the findings from an Australian study in which forty-one people, who self-identified as having a psychosocial disability as a result of mental health problems, spoke about their priorities for treatment, care and support within a personalised funding context. The research enabled an improved understanding of the choices about support that people with psychosocial disabilities would make if offered individualised funding packages. Participant's prioritised specific supports to improve their health, financial situation, social connection, housing and personal relationships. A relationship with a support worker with a range of skills was identified as a key facilitator of these life goals, but people with psychosocial disabilities also valued opportunities to have discretionary funds to directly address the major problems they face including stigma, discrimination and poverty. The paper argues that social workers can potentially fill a range of roles and are well placed to work in partnership with people with psychosocial disabilities, having skills in co-production of services, negotiation and advocacy that are required if individual funding is to be maximised for user control, social justice and personal recovery outcomes.