Abstract BackgroundWomen who are impacted by diverse forms of violence and structural disadvantage such as poverty, health inequities, and precarious housing experience significant barriers to health care. Outreach is a promising strategy to mitigate barriers to care. Until recently, outreach has focused on women’s behaviors, with less attention paid to the intersecting systemic inequities inclusive of stigma and discrimination, poverty, and compartmentalized health service delivery models that impact care engagement and access. ObjectiveThe research study aims to (1) describe the demographic characteristics, baseline health status, and care access among diverse women impacted by gender-based violence; (2) explore preliminary changes in trust in the outreach program over time; (3) explore trends in participants’ access to health and social care services and safety planning over time; and (4) explore the contextual factors impacting trends in trust, service access, and safety. MethodsAn exploratory outreach intervention will be conducted in 2 Canadian cities in partnership with community-based service organizations focused on housing security and victim support. Participants will be women eligible for these services who are experiencing barriers to timely and appropriate health and social services commensurate with their self-identified needs. The analysis will adopt a convergent mixed methods design in which quantitative and qualitative data will be collected concurrently and subsequently analyzed in parallel and then merged for data integration to fully contextualize study findings. Data will include surveys conducted at up to 4 time points to assess service access, trust and safety planning, and qualitative interviews with participants detailing sociostructural and individual factors impacting service access and trust and safety planning. Case notes will be recorded for all outreach engagement with participants. Descriptive statistics and data visualization analytic techniques will be used to document demographic characteristics and trends in trust, safety planning, and access to and engagement with care over time. Interview data will be thematically analyzed to note contextual factors associated with safety, engagement, and trust. Data integration will be carried out to examine how observed trends are influenced by contextual features and to identify nuance in variation over time. ResultsThe study was funded in April 2019. Intervention implementation began in the first of 2 study hubs in October 2023 and in the second hub in October 2024, and participant enrollment was open from November 2023 to June 2025. A total of 86 women were enrolled during that time; though enrollment has now closed, data collection is ongoing and is expected to continue through January 2026. Data analysis will commence in February 2026. Results are expected in late spring 2026. ConclusionsStudy results will be presented at community forums within study settings and at international conferences and will be submitted for publication in relevant journals. This study is expected to generate insight into interpersonal and structural factors shaping trends observed, extending beyond behavioral investigation with new insights into how intersecting inequities can impact trust, engagement in care, and women’s safety.

Widening social, economic, and health inequities intensify the need for equity strategies in health care if population health is to be improved. EQUIP Health Care, a program of research and knowledge mobilization aimed at supporting health care organizations to promote equity, has been developing and testing organizational-level interventions. This process evaluation of the implementation of EQUIP Emergency, a collaboration among staff and leaders at three diverse Emergency Departments, community and Indigenous leaders, and researchers, provides direction to organizations wishing to promote health and health care equity. This process evaluation, grounded in the Active Implementation Frameworks, is based on analysis of qualitative comments from a staff survey (n = 313 comments), qualitative interviews with staff, leaders, and researchers (n = 43), and observational data captured as fieldnotes (n = 784 entries). A thematic analysis identified four themes pertaining to the process and implications of engaging with EQUIP Emergency. Despite a rhetorical and practical commitment to equity at all levels, other priorities, including ensuring staffing adequate to provide care, orienting new staff, and responding to escalating crises such as the unregulated drug poisoning emergency, violence in Emergency Departments, and later in the study, COVID-19, overshadowed efforts toward equity. The material (e.g. staffing) and non-material (e.g. skills) resources available to support and aligned with equity goals shaped the capacity of staff, leaders, and the organizations to enact equity goals. Our analysis led to 10 suggestions for leaders at all levels of health care, including clinical, executive, and policy leaders, for systematically cultivating equity in health care service settings. To promote equity, health care organizations must approach equity as foundational, not as an “add-on,” link equity to key organizational issues, engage leaders from all relevant employment groups at the outset and throughout, engage and compensate staff at all levels and from all roles, and counter siloed bureaucracies (systemic structural misalignments) within their systems. Time for leaders to comprehensively plan should be augmented with analysis of local patient and staff data that can be shared with direct care providers to set the stage for implementing equity strategies and evaluating progress as an embedded way of doing business. Clinical Trials.gov #NCT03369678 (registration date November 18, 2017)

Gender-based violence (GBV) remains a pervasive public health crisis with devastating impacts on women’s health and well-being. Women experiencing GBV face considerable barriers accessing appropriate and timely health and social services. This study explored women’s experiences with health and social services in three Canadian cities to understand critical challenges and strengths in service provision for women experiencing GBV. In-depth interviews were conducted with self-identifying women (n = 21) who had accessed health or social care services and with service providers (n = 25) in three Canadian cities between February 2021 and November 2022. Women’s interviews focused on experiences engaging with services including what worked well, the challenges they faced, and their recommendations to enhance service delivery to women experiencing violence. Staff interviews focused on their experiences of providing services within their organization, and the strengths and challenges in providing services to women within their community. Data were analyzed using reflexive thematic analysis with a gender-based violence critical feminist lens. We organized the findings into three interrelated themes. First our results show how the systems within which health and social services are organized, are not designed to meet women’s complex needs, with rigid structures, siloed services, and stigmatizing cultures creating significant barriers. Second, the data illustrate how service providers support and empower women through practices such as providing key information, assisting with administrative tasks, offering material resources, and addressing discrimination through advocacy and accompaniment. Third, our findings demonstrate how building an effective working relationship characterized by trust, non-judgment, and collaboration is crucial for service engagement and women’s overall well-being. Findings illuminate critical public health challenges as women navigate fragmented services across multiple and siloed systems not designed to meet their complex needs. There is an urgent need for systemic change to create more integrated, responsive support systems for women experiencing GBV. This includes addressing underlying structures perpetuating gender inequities and violence. Facilitating safe access to holistic services that consider women’s preferences is crucial. Effective working relationships built on trust, respect, and power-sharing are key to supporting women’s agency and addressing their interconnected needs.

Public health is tasked with addressing the urgent global priority of promoting the health and human rights of adults engaged in sex work and research is critical to support this endeavor. 'What' is studied, 'how' research is done, and 'who' is centered in this research is reflected in how research funding is allocated. In this article, we interrogate funding allocation for sex work-related health research in Canada. Drawing on critical perspectives aimed at illustrating how stigma operates in society, we examine operating grants (N = 64) awarded by the federal health research funding agency between 2003 and 2020. We find that sex workers' health is problematized disproportionately in a street marketplace context that centers on HIV and sexually transmitted infections. Limited work attends to the socio-structural context of sex work and instead perpetuates stigmatizing narratives about sex work. Public health intervention studies are rare, presenting a barrier for implementing and evaluating evidence-based health promotion strategies. Notably, the research projects were conducted by a small number of highly networked, geographically clustered researchers, illustrating gaps in research that considers the complexity of sex work. We propose that it is essential to consider funding as a process that may be limiting the range of health issues being addressed and privileging a small community of researchers, which can inadvertently serve to worsen health inequities among some sex work communities. Researchers and funding bodies may draw on this analysis to inform a research agenda that meaningfully supports the health, safety, and well-being of sex workers in Canada and globally.

The Russian developmental psychologist Lev Vygotsky provides important theoretical underpinnings for an alternative to business ethics pedagogy. Although Vygotsky's constructivist approach has been applied to other disciplines, such as cognitive development, moral development, and network analysis and learning, its application to business ethics education is virtually nonexistent. Vygotsky's focus on language and peer influence provides a novel approach to ethics education. Although many business ethics instructors already use group discussion in their classes, we provide evidence that will reinforce such techniques as a crucial pedagogical method. This study is an exploratory application of Vygotsky's developmental theory to business ethics education. Data were gathered in business ethics and management courses, with experimental and control groups, and analyzed using the Defining Issues Test and thematic-coded journal entries. Results indicated that discussions created a zone of proximal development improving the moral reasoning for most students giving them multiple perspectives and providing support to engage in deliberations and peer dialogue when discussing ethical frameworks, ethical scenarios, and ethical decision making.

Research incentivization with sex workers is common, yet limited guidance exists for ethical incentives practice. We undertook a critical qualitative inquiry into how researchers (n = 17), community services staff (n = 17), and sex workers participating in research (n = 53) perceive incentives in a Canadian context. We employed an interpretive thematic approach informed by critical perspectives of relational autonomy for analysis. Four themes illustrate how (un)ethical use of incentives is situated in transactional micro-economies among groups experiencing severe marginalization: i) transactional research economy, ii) incentive type: assumptions and effects, iii) incentive amount: too much too little?, and iv) resistance, trauma, and research-related harm. Paternalistic assumptions about capacities of sex workers to act in their own best interests conflicted with participants' rights and abilities for self-determination; with researchers maintaining ultimate decision-making authority. Power differentials create conditions of harm. Safe, equitable approaches concerning research incentive use must redress relations of power that perpetuate oppression.

Purpose The purpose of this study is to better understand social media (SM) factors that physician leaders need to consider, as they adapt their cross-boundary practices to engage with colleagues and patients. Firstly, this study explores why SM is being used by physicians to cross horizontal (physician to physician) and stakeholder (physician to patient) boundaries prior to COVID-19. Secondly, based on the studies reviewed, this study provides insights on the practical SM implications for physician leaders working in the COVID-19 environment to actively enhance their practices, reduce public confusion and improve patient care, thus informing health-care practices. Design/methodology/approach A systematic literature review was used to conduct a structured transparent overview of peer reviewed articles that describe physicians' use of cross-boundary SM across several disciplines (e.g. health, information science). As a baseline assessment prior to COVID-19, the review synthesized 47 articles, identified and selected from six databases and Novanet. This study used NVivo 12 to thematical code the articles, leading to the emergence of four broad factors that influence SM use. Findings A key reason noted in the literature for physicians use of SM to cross horizontal boundaries is to share knowledge. Regarding stakeholder boundaries, the most cited reasons are to improve patient's health and encourage behavioural changes. Insights garnered on the practical SM implications include the need for physicians to be stronger leaders in presenting trustworthy and consistent facts about health information to the public and fellow peers. As role models for the effective use of SM tools, physician leaders can mentor and coach their colleagues and counterparts. Research limitations/implications As this was a literature review, the authors did not collect primary data to further explore this rapidly changing and dynamic SM world. Next steps could include a survey to determine firstly, how physicians currently use SM in this COVID-19 environment, and secondly, how they could leverage it for their work. Findings from this survey will help us better understand the role of physician leaders as health-care influencers and how they could better create trust and inform the Canadian public in the health information that is being conveyed. Practical implications Physician leaders can play a key role in positively influencing institutional support for ethical and safe SM use and engagement practices. Physicians need to participate in developing regulations and guidelines that are fundamentally to physician leader's SM use. Central to this research would be the need to understand how physicians cross-boundary practices have changed during and potentially post COVID-19. Physician leaders also need to monitor information sources for credibility and ensure that these sources are protected. As role models for the effective use of SM tools, physician leaders can mentor and coach their colleagues and counterparts in this area. Originality/value Although there have been studies of how physicians use SM, fewer studies explore why physician leaders' cross boundaries (horizontal and stakeholder) using SM. Important insights are gained in physician leaders practical use of SM. Key themes that emerged included: organizational and individual, information, professional and regulations and guideline factors. These factors strengthen physician leaders understanding of areas of foci to enhance their cross-boundary interactions. There is an urgency to study the complexity of SM and the effectiveness of regulations and guidelines for physicians, who are being required, at an accelerated rate, to strengthen and increase their cross-boundary practices.

The authors declare no conflict of interest.

Objective The purpose of this study was to explore personal and organizational factors that contribute to burnout and moral distress in a Canadian academic intensive care unit (ICU) healthcare team. Both of these issues have a significant impact on healthcare providers, their families, and the quality of patient care. These themes will be used to design interventions to build team resilience. Methods This is a qualitative study using focus groups to elicit a better understanding of stakeholder perspectives on burnout and moral distress in the ICU team environment. Thematic analysis of transcripts from focus groups with registered intensive care nurses (RNs), respiratory therapists (RTs), and physicians (MDs) considered causes of burnout and moral distress, its impact, coping strategies, as well as suggestions to build resilience. Results Six focus groups, each with four to eight participants, were conducted. A total of 35 participants (six MDs, 21 RNs, and eight RTs) represented 43% of the MDs, 18.8% of the RNs, and 20.0% of the RTs. Themes were concordant between the professions and included: 1) organizational issues, 2) exposure to high-intensity situations, and 3) poor team experiences. Participants reported negative impacts on emotional and physical well-being, family dynamics, and patient care. Suggestions to build resilience were categorized into the three main themes: organizational issues, exposure to high intensity situations, and poor team experiences. Conclusions Intensive care unit team members described their experiences with moral distress and burnout, and suggested ways to build resilience in the workplace. Experiences and suggestions were similar between the interdisciplinary teams.

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. 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. 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. Clinical Trials.gov # NCT03369678 (registration date November 18, 2017).

Introduction: Hospital access block, often called Emergency Department (ED) overcrowding when it manifests there, is an important public health issue and seemingly intractable problem in our evolving Health Care system. The multiple, dynamic, and inter-dependent factors influencing its cause (and potential solutions) may best fit a complex adaptive systems analysis and approach. One technique described in similar contexts is Front Line Ownership (FLO) based on the theoretical framework of positive deviance. The aim of this study is to discover where pragmatic bottom-up insights and adaptive work-arounds can be elicited, described, iterated, and potentially implemented at a broader scale to catalyze systems change, in service of improving patient flow. Methods: This is a qualitative study which identified, convened, and surveyed stakeholders representing three components of the system. Purposive sampling was used to gather a full range of perspectives from three groups: 1) patients and or families, 2) front-line providers, and 3) management/leaders. Interviews were recorded and transcribed by a third party, then each transcription was coded independently by two investigators (at least one of which was the PI). Informed consent was obtained from all participants and each was offered the opportunity to review the transcription to ensure accuracy. A framework analysis was used to synthesize, reflect upon, and interpret the data from multiple perspectives using a structured, iterative approach. Results: In part 1 of this study, three broad over-lapping themes emerged from the analysis as being areas of opportunity for reducing hospital access block. They are: 1. Boundary Conditions (the historical, organizational cultural, psychological, economic, and other contexts influencing system performance), 2. Systems Integration (how well the parts interface with each other relate to the whole), and 3. Operations management (the more technical aspects of patient flow). When these three broad themes are cross-analyzed with a more conventional input-throughput-output approach, previously under-emphasized avenues for improvement may become apparent. Conclusion: A front-line ownership analysis of ED overcrowding is feasible. There are adaptive behaviors by some front-line individuals at each “level” of perspective that have been identified and could be modified and implemented locally to improve patient flow in the ED (and the rest of the health system).

Purpose Emerging evidence correlates increased physician leadership effectiveness with improved patient and healthcare system outcomes. To maximize this benefit, it is critical to understand current physician leadership needs. The purpose of this study is to understand, through physicians' self-reporting, their own and others' most effective and weakest leadership skills in relation to the LEADS leadership capabilities framework. Design/methodology/approach The authors surveyed 209 Canadian physician leaders about their perceptions of their own and other physicians' leadership abilities. Thematic analysis was used, and the results were coded deductively into the five LEADS categories, and new categories emerging from inductive coding were added. Findings The authors found that leaders need more skills in the areas of Engage Others and Lead Self, and an emergent category of Business Skills, which includes financial competency, budgeting, facilitation, etc. Further, Achieve Results, Develop Coalitions and Systems Transformation are skills least reported as needed in both self and others. Originality/value The authors conclude that LEADS, in its current form, has a gap in the competencies prescribed, namely, "Business Skills". They recommend the development of a more comprehensive LEADS framework that includes such skills as financial literacy/competency, budgeting, facilitation, etc. The authors also found that certain dimensions of LEADS are being overlooked by physicians in terms of importance (Systems Transformation, Achieve Results, Develop Coalitions), and this warrants greater investigation into the reasons why these skills are not as important as the others (Engage Others and Lead Self).

This study seeks to understand instructors’ perceptions of social network analysis (SNA) and network visualizations as learning analytics (LA) tools for generating useful insights about student online interactions in their class. Qualitative and quantitative data were collected from three graduate courses taught at a Canadian university at the end of the academic term and came from two sources: (1) class-wide forum discussion messages, and (2) interviews with instructors regarding their perceptions of student networks and interactions. This study is unique as it focuses on instructors’ self-assessments of online student interactions and compares this with the SNA visualization. The difference between instructors’ perceptions of social network interactions and actual interactions underlines the potential that LA can provide for instructors. The results confirmed that SNA and network visualizations have the potential of making the “invisible” visible to instructors, thus enhancing their ability to engage students more effectively.Cette étude vise à comprendre les perceptions des instructeurs sur l’analyse des réseaux sociaux (ARS) et la visualisation de réseaux comme outils d’analyse de l’apprentissage (AA) produisant des perspectives utiles sur les interactions en ligne des étudiants de leur classe. Des données qualitatives et quantitatives ont été collectées dans trois cours des cycles supérieurs d’une université canadienne à la fin de la session scolaire. Ces données proviennent de deux sources : (1) les messages du forum de discussion de l’ensemble du groupe et (2) des entretiens avec les instructeurs au sujet de leurs perceptions sur les réseaux et interactions des étudiants. Cette étude est unique en ce qu’elle se concentre sur les auto-évaluations des instructeurs portant sur les interactions étudiantes en ligne, et les compare à la visualisation de l’ARS. La différence entre les perceptions qu’ont les instructeurs des interactions sur les réseaux sociaux et les interactions réelles souligne le potentiel que l’AA peut offrir aux instructeurs. Les résultats ont confirmé que l’ARS et les visualisations de réseaux ont le potentiel de rendre « l’invisible »visible pour les instructeurs, améliorant ainsi leur capacité à motiver les étudiants plus efficacement.

Purpose The purpose of this study is to discern the physicians' perception of leadership effectiveness in their clinical and non-clinical roles (leadership) by identifying their political skill levels. Design/methodology/approach A sample of 209 Canadian physicians was surveyed using the Political Skills Inventory (PSI) during the period 2012-2014. The PSI was chosen because it assesses leadership effectiveness on four dimensions: social astuteness, interpersonal influence, networking ability and apparent authenticity. Findings Physicians in clinical roles' PSI scores were significantly lower in all four PSI dimensions when compared to all other physicians in non-clinical roles, with the principal difference being in their networking abilities. Practical implications More emphasis is needed on educating and training physicians, specifically in the areas of political skills, in current clinical roles if they are to assume leadership roles and be effective. Originality/value Although this study is located in Canada, the study design and associated findings may have implications to other areas and countries wanting to increase physician leadership effectiveness. Further, replication of this study in other settings may provide insight into the future design of physician leadership training curriculum.

We present the findings from a mixed methods study that provides preliminary support to a Vygotskian, social constructivist, and peer dialogue approach to teaching and learning business ethics. This study has provided an early indication of the possible positive effects of group discussions on students’ ability to comprehend complex ethical scenarios in business, the students’ ability to discuss and arrive at a consensus regarding these scenarios, and make ethical decisions themselves. The implications for teaching business ethics, we believe, are important. First, case studies are an effective tool for teaching ethics, stimulating group discussion, and encouraging independent thought. Second, group discussion, with the aid of structured questions, can improve student understanding of ethical concepts. Third, journaling, both group and individual, can improve student recognition of moral issues, and increase their ability to reflect and think about potential solutions. Four, group discussion is a good way to improve argumentative skills. And, finally, group discussion can improve the moral reasoning of students. We conclude by recommending that instructors create classroom environments where student can freely, and respectfully, express their opinions, free from the domination of others. Most importantly, student beliefs and values must be openly challenged as way of encouraging reflective thinking about business ethics. Our results provide greater insight into the use of group-peer learning as a critical component of teaching and learning business ethics, and indicate that a Vygotskian approach to ethics offers an important alternative to business ethics education.

Environmental threats associated with demographic and technological trends have resulted in calls for transition to a global economy that operates within the carrying capacity of the natural environment.Because of their centrality to economic activity, this transition must include small and medium-sized enterprises (SMEs).At the same time, because of their role as knowledge holders on both sustainability and business, higher education institutions (HEIs) can play a more active role in supporting SMEs to address this transition through the provision of timely and appropriate information.Dalhousie University's Eco-Efficiency Centre (EEC) works with SMEs to support them to identify opportunities to pursue sustainability through improved resource (material and energy) efficiency.To date, much of the support for improved resource efficiency within business has focused large corporations; it has not addressed the particular characteristics of SMEs.Supporting that transition needs a different approach, one that understands SMEs' learning dynamics; i.e. their drivers and motivators to apply new knowledge as part of their internal strategies.This paper will discuss one approach taken that focused specifically on developing the absorptive capacity of SMEs to incorporate innovationwhere in this case 'innovation' reflects the strategies for improved resource efficiency.By investigating the relationships and impacts of the EECs involvement with 70 SME manufacturers through their Eco-Efficiency Program for Manufacturers this paper looks at the development of a localized 'knowledge creation and transfer system'.By acting as an interlocutor within this system, they successfully promoted the transfer and integration of resource efficiency knowledge within the sector.