Challenges, Strengths and Opportunities Related to Implementing Comprehensive Evidence-Based Guidelines on Breast Cancer Survivorship Care by Primary Care Physicians and Nurse Practitioners in Southeastern Ontario

Background Many breast cancer survivors continue to have a broad range of physical and psychosocial problems after breast cancer treatment. As cancer centres move forward with earlier discharge of stable breast cancer survivors to primary care follow-up it is important that comprehensive evidence-based breast cancer survivorship care is implemented to effectively address these needs. Research suggests primary care providers are willing to provide breast cancer survivorship care but many lack the knowledge and confidence to provide evidence-based care. Purpose The overall purpose of this thesis was to determine the challenges, strengths and opportunities related to implementing comprehensive evidence-based breast cancer survivorship guidelines by primary care physicians and nurse practitioners in southeastern Ontario. Methods This mixed-methods research was conducted in three phases: (1) synthesis and appraisal of clinical practice guidelines relevant to provision of breast cancer survivorship care within the primary care practice setting; (2) a brief quantitative survey of primary care providers to determine actual practices related to provision of evidence-based breast cancer survivorship care; and (3) individual interviews with primary care providers about the challenges, strengths and opportunities related to provision of comprehensive evidence-based breast cancer survivorship care. Results and Conclusions In the first phase, a comprehensive clinical practice framework was created to guide provision of breast cancer survivorship care and consisted of a one-page checklist outlining breast cancer survivorship issues relevant to primary care, a three-page summary of key recommendations, and a one-page list of guideline sources. The second phase identified several knowledge and practice gaps, and it was determined that guideline implementation rates were higher for recommendations related to prevention and surveillance aspects of survivorship care and lowest related to screening for and management of long-term effects. The third phase identified three major challenges to providing breast cancer survivorship care: inconsistent educational preparation, provider anxieties, and primary care burden; and three major strengths or opportunities to facilitate implementation of survivorship care guidelines: tools and technology, empowering survivors, and optimizing nursing roles. A better understanding of these challenges, strengths and opportunities will inform development of targeted knowledge translation interventions to provide support and education to primary care providers.

Disruptive Threads and Renegade Yarns: Domestic Textile Making in Selected Women's Writing 1811-1925

Images of domestic textiles (items made at home for consumption within the household) and textile making form an important subtext to women’s writing, both during and after industrialization. Through a close reading of five novels from the period 1811-1925, this thesis will assert that a detailed understanding of textile work and its place in women’s daily lives is critical to a deeper understanding of social, sexual and political issues from a woman’s perspective. The first chapter will explore the history of the relationship between women and domestic textile making, and the changes wrought to the latter by the Industrial Revolution. The second chapter will examine the role of embroidery in the construction of “appropriate” feminine gentility in Jane Austen’s Mansfield Park (1814). The third chapter, on Elizabeth Gaskell’s Cranford (1853), will explore how the older female body became a repository for anxieties about class mobility and female power at the beginning of the Victorian era. The fourth chapter will compare Sara Jeannette Duncan’s A Social Departure (1890) and Kate Chopin’s The Awakening (1899) to consider how later Victorian women both internalized and refuted public narratives of domestic textile making in a quest for “self-ownership.” The last chapter, on Martha Ostenso’s Wild Geese (1925), examines the corrosive, yet ultimately redemptive, relationships of a family of women trapped by abuse and degradation. For all five authors, images of textiles and textile making allow them to speak to issues that were usually only discussed within a community of women: sexuality, desire, aging, marriage, and motherhood. In all five works, textile making “talks back” to the power structures that marginalize women, and lends insight into the material and emotional circumstances of women’s lives.