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.

Expanding our Constitutional Horizons: A Comprehensive Study of Quasi-Constitutionality in Canada

A number of laws in Canada which uphold rights are referred to as quasi-constitutional by the courts in recognition of their special importance. Quasi-constitutional statutes are enacted through the regular legislative process, although they are being interpreted and applied in a fashion which has become remarkably similar to constitutional law, and are therefore having an important affect over other legislation. Quasi-constitutionality has surprisingly received limited scholarly attention, and very few serious attempts at explaining its significance have been made. This dissertation undertakes a comprehensive study of quasi-constitutionality which considers its theoretical basis, its interpretation and legal significance, as well as its similarities to comparable forms of law in other Commonwealth jurisdictions. Part I examines the theoretical basis of quasi-constitutionality and its relationship to the Constitution. As a statutory and common law form of fundamental law, quasi-constitutionality is shown to signify an association with the Canadian Constitution and the foundational principles that underpin it. Part II proceeds to consider the special rules of interpretation applied to quasi-constitutional legislation, the basis of this interpretative approach, and the connection between the interpretation of similar provisions in quasi-constitutional legislation and the Constitution. As a statutory form of fundamental law, quasi-constitutional legislation is given a broad, liberal and purposive interpretation which significantly expands the rights which they protect. The theoretical basis of this approach is found in both the fundamental nature of the rights upheld by quasi-constitutional legislation as well as legislative intent. Part III explores how quasi-constitutional statutes affect the interpretation of regular legislation and how they are used for the purposes of judicial review. Quasi-constitutional legislation has a significant influence over regular statutes in the interpretative exercise, which in some instances results in conflicting statutes being declared inoperable. The basis of this form of judicial review is demonstrated to be rooted in statutory interpretation, and as such it provides an interesting model of rights protection and judicial review that is not conflated to constitutional and judicial supremacy.