Dissertations / Theses on the topic 'Clinical Nursing: Primary (Preventative)'

The purpose of this scholarly project was to evaluate an evidence-based quality improvement program implemented in 2016 in a clinical practice setting to curtail overprescribing of opioids for noncancer pain management. In 2001, the National Pharmaceutical Council and The Joint Commission on Accreditation and Hospital Accreditation initiated a standard of practice for opioid use in noncancer pain management that resulted in opioid overprescribing and a 200% increase in opioid-related deaths and incalculable societal costs. Primary care providers including nurse practitioners issue the greatest number of opioid prescriptions; therefore, to address the problem of opioid overprescribing, the 2016 Centers for Disease Control and Prevention guidelines for opioid administration were implemented as a quality improvement program in a primary care setting with 10 providers. Lewin's change model was the vehicle for change and included an ongoing audit developed for tracking provider prescribing rates. The project sought to determine if adoption of the opioid administration guidelines reduced the prescribing rates in a clinical practice setting and thereby justify expanding the program to other primary clinic sites. A pre- post-single group comparison was conducted of prescribing rates from May 15, 2015 prior to implementing the guidelines and December 19, 2016 after the guidelines were in place. Analysis from t tests indicated a 41% (p < .01) reduction in prescribing rates. The project promotes positive social change through the decreased individual and societal cost of opioid- related deaths.

Thesis (MCur)--Stellenbosch University, 2011.
ENGLISH ABSTRACT: Simulation refers to a teaching method that is used to teach students clinical skills. The use of mannequins is the most common type of simulation. Given the pivotal role that simulation plays in teaching students clinical skills, it is important to understand the experience and perceptions students have utilizing simulation laboratories. The aim of the study was to explore the experience and perceptions of primary health care students utilizing simulation laboratories. The researcher posed the following research question as a guide for this study: “What are the experiences and perceptions of primary health care students utilizing simulation laboratories?” A qualitative approach with a phenomenological research design was applied. A purposive sample of n=10 and a focus group of 7 participants was drawn from a total population of 232 primary health care students. An interview guide was designed based on the objectives of the study and validated by experts in Nursing, Education and the Ethics Committee at the Faculty of Health Sciences, Stellenbosch University. Experts in the field of teaching and learning, nursing and research methodology were consulted to determine the feasibility and content of the study, to evaluate the research process and outcome. Two (2) trained fieldworkers were responsible for collecting the data. Data was collected by means of individual interviews and by interviewing a focus group. The transcription of the interviews was done by the researcher. The data that emerged from the data analysis was coded and categorised into themes and subthemes. The five themes that emerged were simulation as a teaching method; a mannequin offering effective learning; confidence in clinical practice; structure of the course; and a support system. The researcher compiled a written account of the interpretations that emerged from the data analysis and verified this with the fieldworkers. In addition, member checking was done on two (2) of the participants from the focus group as well as two (2) of the participants from the individual interviews, to validate the transcribed data. The Conceptual Theoretical Framework of Bloom supports the findings of this study. The findings suggest that the mannequins should be upgraded regularly and should be able to register a response. It is recommended that a mannequin should be designed which is computer programmed according to different conditions which will include the signs and symptoms of those diseases for example tuberculosis. The participants need to be placed in the clinical environment at a much earlier stage in their programme. Peer group teaching and assessment should be introduced in the programme. Further research is recommended since institutions and disciplinaries working with simulation were not included in the study.
AFRIKAANSE OPSOMMING: Simulasie verwys na ’n onderrigmetode wat gebruik word om studente kliniese vaardighede aan te leer. Die gebruik van mannekyne is die mees algemene vorm van simulasie. Gegee die deurslaggewende rol wat simulasie speel in die onderrig van kliniese vaardighede aan studente, is dit belangrik om die ervaring en persepsies van studente wat gebruik maak van simulasie-laboratoriums, te wete te kom. Die doel van hierdie studie was om die ervaring en persepsies van primêre gesondheidssorgstudente wat van simulasie-laboratoriums gebruik maak, te ondersoek. Die navorser het die volgende navorsingsvraag as ’n riglyn vir hierdie studie gestel: “Wat is die ervaringe en persepsies van primêre gesondheidssorgstudente wat simulasielaboratoriums gebruik?” ’n Kwalitatiewe benadering met ’n fenomenologiese navorsingsontwerp is toegepas. ’n Doelbewuste steekproef van n=10 en ’n fokusgroep van 7 deelnemers is geneem vanuit ’n totale bevolking van 232 primêre gesondheidsorgstudente. ’n Onderhoudgids is ontwerp, gebaseer op die doelwitte van die studie en gevalideer deur kundiges in Verpleging, Opvoedkunde en die Etiese Komitee van die Fakulteit van Gesondheidswetenskappe aan die Universiteit van Stellenbosch. Kundiges op die gebied van onderrig en leer, verpleging en navorsingsmetodologie is geraadpleeg om die haalbaarheid en inhoud van die studie te bepaal vir die evaluering van die navorsingsprosedure en uitkomste. Twee (2) opgeleide veldwerkers was verantwoordelik om die data te versamel. Die data was versamel deur middel van individuele onderhoude en ‘n onderhoud met ‘n fokus groep. Die onderhoude was getranskribeer deur die navorser. Die data wat uit die analise gekom het, is geënkodeer en gekategoriseer in temas en subtemas. Die vyf temas wat hieruit voortgespruit het, is simulasie as ’n onderrigmetode; ’n mannekyn wat effektiewe leer bied; vertroue in die kliniese praktyk; die struktuur van die kursus; en ’n ondersteuningssisteem. Die navorser het ’n geskrewe verslag saamgestel van die weergawe van die data-analise wat saamgestel en deur die veldwerker geverifieer is. Bykomend is die kontrole van lede van twee (2) van die deelnemers van die fokusgroep, asook twee (2) van die deelnemers vanuit die individuele onderhoude gedoen, om die getranskribeerde data se geldigheid te verklaar. Die Konseptuele Teoretiese Raamwerk van Bloom rugsteun die bevindinge van hierdie studie. Die bevindinge beveel aan dat die mannekyne gereeld opgegradeer behoort te word en dat hulle ’n respons moet kan registreer. Dit word aanbeveel dat ’n mannekyn ontwerp behoort te word wat rekenaar geprogrammeerd is volgens die verskillende toestande wat die tekens en simptome van siektes soos tuberkulose insluit. Die deelnemers behoort in ’n baie vroeë stadium van die program in die kliniese omgewing geplaas te word. Verdere navorsing word aanbeveel, aangesien inrigtings en dissiplines wat met simulasie gemoeid is, nie in hierdie studie ingesluit is nie.

Introduction and Rationale: Concussions account for the majority of traumatic brain injuries in children. Currently there more than 500,000 pediatric concussions per year and that number is likely low due to under-reporting (Rose, Weber, Collen,& Heyer, 2015). Most symptoms of concussion are easily recognized to the trained pediatric primary care provider. Yet, symptom management and recommendations for rest, exercise, specialty care referral, and return to normal activities can be challenging for many providers, due to the lack of evidence and lack of formal recommendations by any organization (Rose et al., 2015; Silverberg & Iverson, 2013). Purpose and Objective: The main purpose of this Doctor of Nursing Practice (DNP) project is to develop evidence-based clinical practice guidelines (CPG) for pediatric primary care providers. The objective is to provide a CPG that offers clinical guidance when managing pediatric concussion patients in the primary care setting. This CPG will also provide clarity for pediatric primary care providers (PCP) when determining what options are available in treatment for pediatric concussions. Methods: The working framework of this project was The Appraisal of Guidelines for Research & Evaluation II (AGREE II). The American Academy of Pediatrics (AAP) procedure for reporting clinical guidelines, in the form of key action statements, was used as the model for development of the CPG. Results: The CPG was appraised using the AGREE II instrument, which provides valid and reliable scores and data used in the evaluation of CPG's. Six domains were evaluated, and the CPG yielded scores above 80% for all categories. The overall standard deviation was 0, which indicts a very low level of discrepancy between users of the instrument. Conclusion: This DNP project addresses an evidence and primary care practice gap. With a large number of pediatric concussions, a consistent management approach will ensure a safe and therapeutic recovery. A CPG was developed and evaluated using the AGREE II instrument. The CPG was found to meet the standards for general recommended use in pediatric primary care.

Background: Type 2 diabetes mellitus (T2DM) is a complex health condition that impacts multiple organ systems and contributes to both acute and chronic health problems. In the United States (U.S.), T2DM is a growing health concern with increasing prevalence among both adult and pediatric populations (American Diabetes Association [ADA], 2015; Dea, 2011). Developing a comprehensive plan of care that incorporates a multifaceted treatment and prevention plan is necessary to address this growing health concern and reduce overall morbidity and mortality. Problem: The Edmund Primary Care (EPC) practice data for routine annual diabetic foot exams, annual eye exams, annual urine microalbumin, smoking cessation education and recommendations for pneumococcal polysaccharide do not meet the ADA (American Diabetes Association, 2015) recommendations for patients with T2DM.Design: Quality improvement (QI) project applying the Plan-Do-Study-Act (PDSA) cycle to develop a process change to improve diabetic preventative care measures for hemoglobin A1C, urine microalbumin, diabetic foot exams, and optometry referrals. Setting: A small, nurse practitioner owned, family practice clinic targeting patients 18 years and older with a diagnosis of T2DM.Intervention: A fishbone diagram to conduct a root cause analysis led to identification of key factors contributing to the problem. A comprehensive process change integrating a Diabetic Assessment Flow Sheet (DAFS) and diabetic foot exam sheet was developed to address the problem. Expected Outcome: Increase in rates of completion to at least 90% over eight weeks. Results: Analyzed with run charts demonstrating an increase in rates of completion to 100% for A1C, urine microalbumin, diabetic foot exams, and optometry referrals. A positive percent of change for each measure is as follows: A1C 7%; urine microalbumin 43%; diabetic foot exams 150%; and referrals to optometrist 43%. Significance: This QI project emphasizes the importance of implementing a system to evaluate the quality of care being delivered. It also highlights the usefulness of the PDSA cycle as a method to implementing quality improvement measures in health care. Lastly, this QI project demonstrated the effectiveness of flow sheets in improving the quality of care delivered to patients with T2DM.

When patients present with complaints of anxiety or depression, providers in the primary care setting often prescribe anxiolytics or antidepressants without conducting an early emotional trauma or adverse childhood experiences assessment. Several studies demonstrate the link between early emotional trauma (EET) or adverse childhood experiences (ACEs) and the increased risk of anxiety or depression as adults. This Clinical Scholarly Project (CSP) implemented the use of the Adverse Childhood Experience (ACE) Questionnaire with patients who had a diagnosis of anxiety or depression in the primary care setting to increase patient access to resources and align clinical practice with practice guidelines. Participants included eight primary care providers, 30 patients and 21 chart review patients. The CSP utilized a quasi-experimental design to determine if the use of the ACE Questionnaire by patients with anxiety or depression would result in patients receiving more community resources (to include counseling), strengthen the provider-patient relationship, increase provider comfort in discussing ACEs with their patients and result in patients receiving care that was evidence based. Patient sample participants received significantly more resources (M = 8.27, SD = 2.27) than the chart audit sample (M = 0.90, SD = 0.30). Patient sample members received an average of eight resources (M = 8.27) and utilized an average of five resources (M = 5.07). Use of the ACE Questionnaire resulted in more trust in provider-patient relationship by patients (80.0%) and the majority of the provider sample more comfortable discussing ACEs after the project (85.7%).

HIV infection is a leading cause of morbidity and mortality in our country today with nearly 1.2 million Americans living with HIV infection. Early recognition of infection is imperative for appropriate initiation of treatment to prevent comorbidities. Additionally, identification of infection can serve as a primary preventative measure to reduce spread of the disease. National organizations have supported the initiation of routine screening policies for HIV in health care settings. Primary care providers are uniquely positioned to be able to offer HIV screenings and identify infected persons very early in the course of the disease. Despite support for routine testing in the literature and by national evidence-based guidelines, testing is still not offered routinely in the primary care setting. The purpose of this project was to explore if a clinical reminder improves the frequency of HIV screening offered in a rural primary care clinic (PCC) located in Central Louisiana. Results of the project did show a statistically significant increase in the frequency of HIV screening offered following implementation of the clinical reminder system.

Thesis (DPhil (Psychology))—University of Stellenbosch, 2010.
ENGLISH ABSTRACT: This dissertation examines how nurses in primary health care in South Africa make use of guidelines. Primary level health care is reliant primarily on nurses, who are under-resourced and often overwhelmed by the complex needs of their clients in the context of the TB and HIV/AIDS epidemic. Despite various continuing education strategies to promote current and evidence-based practice, there are many barriers to providing optimal care. Clinical practice guidelines using best evidence are an important tool for updating health professionals in current practice, particularly at primary care level, where busy practitioners often do not have time or sufficient access to the best evidence. Despite this, we know little of the practitioners’ experiences of guideline use. This study describes experiences of nurses in implementing clinical practice guidelines in the delivery of health care in selected primary level contexts in the Free State Province. The primary research question for this study was “What are the experiences of nurses in using guidelines in primary health care facilities?” A qualitative research approach, drawing on a psychoanalytic framework, was adopted. Three linked studies were conducted, utilising secondary data analysis of transcripts collected during the PALSA (Practical approach to Lung Health in South Africa) RCT study (sub-study 1), document description and review of guidelines used in primary care settings (sub-study 2), observation of nurses in practice and during patient consultations, and focus group discussions with nurses in primary health care facilities (sub-study 3). After the introduction of new format guidelines with onsite training and access to good support and updates, nurses reported feeling more confident, as the guidelines were explicit and gave them clear direction as to when a patient would need referral to the medical practitioner. When the guidelines were followed, and the patient responded positively to an intervention, this gave nurses a sense of credibility and validated their role as primary level health care providers. Guidelines available in the primary care clinics covered a wide variety of clinical conditions, were inconsistent, often outdated and even contradictory. A detailed comparison of two selected guidelines, the South African TB control guidelines and the PALSA PLUS guidelines, both in everyday use in the Free State province, shows that the preferences expressed by the nurses in sub-study 1 are evident in the layout, colour, and user-friendliness of the PALSA PLUS guideline. Nurses in the Free State province do use guidelines, but not consistently. Nurses make clinical judgments and decisions based on experience, alternative knowledges and intuitive responses, in consultation with colleagues and through the use of guidelines. Very few guidelines were used regularly, and each nurse had her preferences for a limited number of guidelines which she found useful. There is a clear need for integrated approaches to the information needs and support of nurses and nurse practitioners at primary care level. Guidelines play a role in promoting learning, changing professional practice and strengthening health care delivery by nurse practitioners at primary level. They can also be thought of as a strategy the health care system uses to defend against the possibility of its health professionals not meeting its expectations of providing quality care. Guidelines may contain anxiety and improve the quality of care, or compromise practice through the imposition of controls. The use of guidelines in primary care settings facilitates decision making, may contain practitioner anxiety and improve the quality of care, yet guidelines pose challenges to creative discernment of the patient’s symptoms in relation to his/her personal circumstances and may impact on the personalised holistic care approach which characterises the essence of nursing. Today’s primary care nurse and nurse practitioner needs to be a competent clinician, compassionate carer, and confident co-ordinator – the overlapping roles of caring, diagnosing and treating and managing. The challenge for the nurse in primary care is to combine her traditional caring and co-ordination role into a role which encompasses curing, caring and co-ordination, a new, yet critically important identity for the 21st century nurse.
AFRIKAANSE OPSOMMING: Die proefskrif ondersoek hoe verpleegsters in primêre gesondheidsorg in Suid-Afrika van riglyne gebruik maak. Primêre vlak gesondheidsorg steun hoofsaaklik op verpleegsters, alhoewel hulle verswelg word deur die komplekse behoeftes van hul kliënte in die konteks van die TB en HIV/AIDS epidemie. Ten spyte van verskeie volgehoue onderrigstrategieë om die huidige en bewese basiese te bevorder, is daar verskeie struikelblokke om optimale versorging te voorsien. Kliniese praktyk riglyne voorsien die beste bewyse en is 'n belangrike hulpmiddel om praktiserende professionele gesondheidswerkers, veral op die vlak van primêre gesondheidsorg, op hoogte van sake te hou. Besige programme en onvoldoende toegang tot hierdie riglyne weerhou dikwels die gesondheidswerkers van bestaande inligting. Dit is egter onbekend wat gesondheidswerkers se ondervinding en gebruik van riglyne is. Die studie beskryf versorgers se ervaring van die implementering van kliniese praktyk riglyne vir gesondheidsorg in primêre vlak kontekste in die Vrystaatprovinsie. 'n Kwalitatiewe navorsingsbenadering wat steun op 'n psigoanalitiese raamwerk, is gebruik. Drie verbandhoudende studies is gedoen wat sekondêre data analise transkripsies gebruik het wat verkry is gedurende die PALSA (Practical Approach to Lung Health in South Africa): RCT (Willekeurig Gekontroleerde Toets) studie (sub-studie 1), beskrywing van dokumentasie en oorsig van riglyne wat in primêre vlak ontwikkeling gebruik is (sub-studie 2), en observasie van verpleegsters in die praktyk en gedurende konsultasies met pasiënte, en fokusgroep besprekings met verpleegsters in primêre vlak gesondheidsorg fasiliteite (sub-studie 3). Na die bekendstelling van 'n nuwe formaat riglyne vir indiensopleiding en toegang tot goeie ondersteuning, het die verpleegsters meer selfversekerd gevoel omdat die riglyne duideliker was en aan hulle 'n beter aanduiding gegee het wanneer 'n pasiënt verwysing na 'n mediese praktisyn benodig het. Wanneer die riglyne gevolg is en die pasiënt positief op behandeling gereageer het, het dit aan hulle 'n gevoel van agting en deug vir hulle rol in primêre vlak gesondheidsorg gegee het. Beskikbare riglyne in primêre sorg klinieke dek 'n wye verskeidenheid kliniese kondisies, is onsamehangend, dikwels verouderd en selfs soms weersprekend. 'n Gedetailleerde vergelyking is tussen twee geselekteerde riglyne gedoen: die Suid-Afrikaanse TB kontrole riglyne en die PALSA PLUS riglyne. Beide word daagliks in die Vrystaatprovinsie gebruik. Die verpleegsters in sub-studie 1 het a.g.v. die uitleg, kleur en gebruikersvriendelikheid die PALSA PLUS riglyne verkies. Verpleegsters in die Vrystaat gebruik wel riglyne maar nie op 'n gereelde grondslag nie. Hulle maak eerder kliniese keuses en besluite gebaseer op ondervinding, alternatiewe kennis en intuïtiewe gevoel, in konsultasie met kollegas en na bestudering van die riglyne. Baie min riglyne is gereeld gebruik, en elke verpleegster het haar voorkeure vir 'n beperkte aantal riglyne wat sy bruikbaar vind. Daar is 'n duidelike behoefte aan 'n geïntegreerde benadering tot die informasiebehoeftes en ondersteuning aan verpleegsters en praktisyns op primêre sorg vlak. Riglyne speel 'n belangrike rol in die bevordering van onderrig, verandering van professionele praktyke en die versterking van gesondheidsorg wat deur verpleegsters in primêre vlak gesondheidsorg gelewer kan word. Dit kan ook gesien word as 'n strategie wat die gesondheidsorgsisteem kan gebruik om te verseker dat gesondheidswerkers kwaliteit diens lewer. Riglyne kan moontlik angstigheid beperk en verhoogde versorgingskwaliteit bring, of dit kan gesondheidsorg benadeel deur die afdwing van kontrolemaatreëls. Die gebruik van riglyne in primêre sorg fasiliteer besluitneming, en mag dalk angstigheid by die praktisyn beperk, wat dan die kwaliteit van versorging kan verhoog. Riglyne bied uitdagings aan die kreatiewe oordeelsvermoë om die pasiënt se simptome te sien binne die konteks van sy/haar omstandighede en mag 'n impak hê op persoonlike holistiese versorging wat die aard en kern van verpleging is. Die huidige primêre sorg verplegingspraktisyn moet 'n bekwame klinikus, ontfermende versorger en betroubare koördineerder wees – met oorvleuelende rolle van versorging, diagnosering en behandeling, en bestuur. Die uitdaging vir die verpleegster in primêre sorg is om die tradisionele versorging en koördinering te kombineer tot 'n omvattende rol van genesing, versorging en koördinasie; 'n nuwe, maar krities-belangrike identiteit vir die 21ste-eeuse versorger.

Childhood bullying can lead to adverse physical and mental health outcomes for both the victim and the bully. Risk factors for bullying can be related to gender, race, sexual preference, and having any type of disability. A pediatric primary care clinic in a large, metropolitan area, the focus for this project, did not have an evidenced-based clinical practice guideline (CPG) for providers to facilitate the management of children who presented with reported bullying. The project, guided by the Tanner'€™s integrated model of clinical judgement, addressed the question whether a CPG would facilitate the early recognition and treatment of bullying in the pediatric clinical site. Using a literature search, a CPG was developed with evidence that included 6 recommendations ranging from clinical assessment and screening to advocacy. The CPG was then evaluated by 4 expert panelists using the AGREE II tool. Panelists included 2 pediatric medical doctors, 1 pediatric school nurse, and 1 mental health nurse practitioner. The panel evaluation results revealed a score of 81 out of a possible 100, where a score of 71 was the standard for acceptable results for the 6 recommendations. Results from the expert panel were used to modify the CPG, after which the guideline was presented to the panel for final approval. One final recommendation of the panel was to include a provision for referral and follow up for children identified with bullying. The finalized CPG was presented to the medical director of the pediatric clinic for implementation. The implications of the project for positive social change include decreased variations in clinical practice, early detection and intervention of bullying, improved effectiveness and quality of care, and decreased costly and preventable adverse events.

Objective: New Mexico nurse practitioners contribute to the prevention and management of pediatric obesity. This study aimed to assess nurse practitioners' knowledge, attitudes, and behaviors, which were unknown in New Mexico, to counseling frequency in the assessment and management of overweight and obese pediatric patients. This was done using clinical practice guidelines (CPG). The study also sought to learn nurse practitioners' insights on needed resources for clinical practice. Rural and urban nurse practitioners' responses were then compared to the study aims. Methods: This descriptive pilot study surveyed members of the New Mexico Nurse Practitioner Council (NMNPC) to evaluate their knowledge, attitudes, and behaviors, in addition to the counseling frequencies expected to result in patient change. The survey used the platform Qualtrics and measured answers using a four-point Likert scale. Rural and urban comparisons were evaluated for each variable (knowledge, attitudes, and behaviors) in order to investigate relationships. Despite the underpowered sample size, data were analyzed for feasibility of future studies using descriptive statistics, Spearman's Rho Correlation, and Mann-Whitney U testing. Results: Fifteen nurse practitioners were included in the statistical analysis. The data found the nurse practitioners' self-reported responses exhibited knowledge, positive attitudes, and confident behaviors using pediatric obesity CPGs. The increases in these parameters correlated reported needing a quick CPG tool that can be used in practice. In all, rural nurse practitioners reported a slightly higher usage of pediatric obesity CPGs than urban nurse practitioners. Conclusion: The feasibility of this study's assessment of nurse practitioners' knowledge, attitudes, and behaviors using CPGs will assist in developing interventions to impact patient outcomes. The study also found that resources needed by New Mexico nurse practitioners were similar to those desired by other providers throughout literature. Rural compared to urban nurse practitioners findings indicated the need for further research. Future studies should include all health care providers in New Mexico in order to further explore aims of this study and development of interventions on overweight and obese pediatric CPGs to positively impact practice.

ABSTRACT Introduction and Rationale: Atopic Dermatitis (AD) is a common skin condition, characterized by markedly pruritic eczematous lesions, that most often presents in childhood. The majority of children diagnosed with AD will have mild disease and will first present with symptoms to a primary care provider (PCP), however approximately 85% of pediatricians only provide limited initial care followed by a referral to dermatology (Eichenfield et al., 2015). While there are specialty care based treatment guidelines for childhood AD, there are no guidelines available that specifically address primary care management of childhood AD. Purpose and Objective: The primary purpose of this DNP project is to develop an evidence-based clinical practice guideline (CPG) for pediatric PCPs. The secondary purpose is to develop a corresponding atopic dermatitis action plan (ADAP) to be used by children and parents. The objective is to equip PCPs to better manage children with AD in the primary care setting and to guide patients and parents in the importance of daily control measures and in the individualized treatment plan prescribed by the PCP. Methods: The Appraisal of Guidelines for Research & Evaluation II (AGREE II) framework and Social Cognitive Theory (SCT) serve as the theoretical frameworks for CPG and ADAP development. The American Academy of Pediatrics (AAP) process for evidence based policy setting is used as a model for key action statement development. Results: Evaluation of the CPG was completed using the AGREE II tool, a reliable and validated tool for evaluating CPGs. Five of the six domains evaluated, yielded combined scores of at least 90%, with one domain a combined score of 63%. The overall standard deviation was 0.58, indicating an overall low level of user discrepancy Additions and revisions were made based on the results of the AGREE II evaluation scores with specific emphasis on the lowest scoring domain. Conclusion: This DNP Project identified the need for a CPG specific to pediatric primary care. A CPG with accompanying ADAP was developed and evaluated using the AGREE II tool. The CPG was found to meet the recommended standards and recommended for use in pediatric primary care.

Chronic non-terminal pain (CNTP) is defined as pain lasting longer than three months, serves no functional role in healing, lasts beyond normal tissue recovery time and is unresolved despite appropriate treatment. CNTP triggers a complex set of central nervous system responses and a decline in social function. Opioids have been used to treat moderate to severe pain when non-opioid analgesics have not been sufficient. Multiple factors have led to increased use and higher prescribing dosages of opioids to manage CNTP in primary care. Higher dosages of opioids are associated with higher risk of adverse events, including death. Nationally, between 1999 and 2011, opioid related deaths rose over 300%. In Arizona, 41% of drug mortality is attributed to opioids and in 2011, the state ranked fifth in the nation for opioid prescribing rates. Statewide, a multi-professional, multi-agency strategy has been initiated to address this problem. The impact evaluation of the prescribing initiative led by the Arizona Criminal Justice Commission has been positive but little information exists regarding prescribers' practice patterns, prescribers' knowledge of evidence based recommendations synthesized in the guidelines, or the barriers to safe opioid prescribing in Arizona. The Statewide Interprofessional Practice-Based Research Network (IP PBRN) identified chronic pain management as a top research priority during their planning conference in 2012. The purpose of this project was to create and formalize a survey, eliciting responses that describe current practice patterns and identify implementation barriers to evidence-based recommendations for prescribing and monitoring opioids for patients with CNTP in Arizona primary care settings.

Background Patient safety is an undisputable part of healthcare. The use of clinical practice guidelines, usually based on evidence-based practice/best practice, promotes patient safety and high quality care, reduces unnecessary patient suffering, and healthcare costs. Analysing results from venous blood specimen collection is one of the most commonly used services within healthcare, and a substantial number of decisions on diagnosis, treatment, and treatment evaluation are based on the results. Hence, the accuracy of these tests are vitally important. Earlier research has demonstrated that healthcare staff report suboptimal adherence to venous blood specimen collection guidelines together with the need for improved practices. Blood sample collection is carried out by several professionals, among them registered nurses and, as a consequence, nursing students too. University nursing students learn and practice venous blood specimen collection in one of their first semesters. After initial skill training at clinical skill laboratories, they continue to perform the task during clinical placements in various clinical settings. Few or no studies have been performed on nursing students, hence it seemed important to assess guideline adherence to venous blood specimen collection among university students as well as to further explore adherence to guidelines among healthcare staff. Therefore, the overall aim for this thesis was to explore adherence to, and factors influencing venous blood specimen collection guidelines practice among university nursing students and healthcare staff. Methods The thesis includes four studies. Study I-III had a quantitative, cross-sectional design, study IV had a qualitative approach. Study I included 164 healthcare staff from 25 primary healthcare centres. Study II included 101 nursing students in their 5th and 6th semesters, and study III included 305 nursing students in their 2nd, 4th, and 6th semesters. To assess adherence to venous blood specimen collection guidelines, data were collected using the Venous Blood Specimen Questionnaire, completed with background variables (I, II, III) and additional scales (III). Descriptive statistics, multilevel and multiple logistic regression analyses were used to analyse the data. In study IV, data were collected through five focus group interviews among 6th semester nursing students (n=26). Data were analysed using qualitative content analysis. Results Workplace affiliation was found to explain variances in reported adherence between different primary healthcare centres. Associations between reported venous blood specimen collection practices and individual as well as workplace factors were revealed. Nursing students were found to increasingly deviate from guideline adherence during their education. Also among students, several associations between guideline adherence and other iv factors were revealed. Reported research use at clinical practice was associated with higher levels of adherence, as were higher capability beliefs regarding both evidence-based practice and academic ability. Analyses from focus group interviews summarised students’ reflections on deviations from VBSC guidelines in the overall theme ‘Striving to blend in and simultaneously follow guidelines’. Conclusion Both healthcare staff at primary healthcare centres and nursing students demonstrate decreasing levels of guideline adherence with time. Factors influencing adherence are both individual as well as contextual. This indicate that both students and staff are subjected to socialisation processes that influences levels of adherence. In order to enhance venous blood specimen collection practices and thereby patient safety, actions must be taken - both in healthcare clinical contexts and by educators. The use of models in practical skill training, and in the ambition to bridge the theory-practice gap may be the path to success. It is reasonable to assume that collaboration between, on the one hand, education representatives and on the other, supervising RNs in clinical settings, will be fruitful. Finally, by empowering students their self-efficacy may be strengthened, and hence their ability to maintain guideline adherence.

With the increase in the elderly, American's caregiver roles and responsibilities are also on the rise. Developing with this increase is the growing problem of caregiver burden. The Loma Linda V. A. Hospital has developed a service known as the Home-Based Primary Care program designed to combat caregiver burden. Studies were conducted among caregiver participants in this program in an effort to evaluate overall levels of burden and the program's efficiency at meeting caregiver needs. Overall this program provides a useful model for future programs aimed at reducing caregiver burden. Limitations that can be improved, however, include consistency in scheduling, reliable staffing, and continuity in care.

Background: In order to provide good diabetes care it is important for the health care professionals to share patients’ personal understanding of living with diabetes, which differs from a professional understanding of the illness. Patients’ beliefs about health, illness, control and cure are predictive of the outcome of lifestyle changes and pharmacological treatment. Narratives about illness could be used to elucidate what people believe to be central to their experience of an illness and its management. The overall aim of this thesis was to investigate experiences of diabetes and diabetes care among people with type 2 diabetes and district nurses responsible for diabetes care within primary health care. Methods: Forty-four patients diagnosed with diabetes during the previous 2 years were interviewed about their personal understanding of illness and experiences of care. They also participated in an intervention study consisting of group sessions during 9 months. The intervention focused on the patients’ understanding of living with diabetes and was directed at the patients and their nurses (n = 5). The outcome variables haemoglobin A1c (HbA1c), lipids, blood pressure (BP) and body mass index (BMI) as well as well-being, treatment satisfaction and diabetes symptoms of the intervention group were compared with those in a control group (n = 60). Another ten patients were interviewed about their views of their lives. Seventeen nurses in diabetes care were interviewed about their views of their work with patients. The narrative, thematic interviews and focus group interviews were analysed using qualitative content analysis. Findings: Patients’ personal understanding of illness included the categories “image of the disease”; “meaning of the diagnosis”; “integration of the illness”; “space for the illness”; “responsibility for care”; and “future prospects”. Patients’ narratives about their lives included views of knowledge, and capacity, motivation and courage, aspects important for effective self-management. Patients’ views on clinical encounters in diabetes care, interpreted as satisfying or not, included the themes “being in agreement v. in disagreement about the goals”; “being autonomous and equal v. being forced into adaptation and submission”; “feeling worthy as a person v. feeling worthless”; “being attended to and feeling welcome v. being ignored”; and “feeling safe and confident v. feeling unsafe and lacking confidence”. The results of the intervention study with group sessions showed improvements in metabolic balance and treatment satisfaction in the intervention group. At the 1-year follow-up the mean difference between groups in HbA1c was 0.94% (95% confidence interval (CI) 0.58–1.29). Nurses’ views of their work included the themes “Perspectives on illness and caring are not easily integrated into views of disease and its treatment”; “Nurses view their knowledge as more important than the patients’ knowledge”; Nurses’ conscience is challenged by some of their nursing decisions”; “The individuality of each patient is undermined when patients are regarded as a collective group”; and “Nurses are confirmed in their role of nurses by patients who assume a traditional patient role”. Conclusion: These results demonstrate that the understanding of illness and care differs between patients and nurses working in diabetes care; furthermore, that an intervention involving patients and their nurses based on patients’ personal understanding of illness is effective with regard to metabolic control and treatment satisfaction. The cost of the intervention is moderate. Also, we believe that it is possible to clinically implement this intervention within the existing resources for primary health care.

Introdução: A crescente prevalência das condições crônicas de saúde traz a demanda por Cuidados Paliativos (CP) para a agenda da Atenção Primária á Saúde (APS), gerando questionamentos acerca do impacto da incorporação dos CP sobre os problemas éticos da APS. A bioética não é só reativa, mas precisa reconhecer prospectivamente desafios éticos. Objetivos: Discutir desafios éticos (DE) para incorporação dos CP na APS, considerando o desempenho dos atributos deste âmbito do sistema de saúde na Região de Parelheiros, São Paulo; Cotejar os: problemas éticos dos cuidados paliativos na APS com o Instrumento PCATool-Brasil; problemas éticos dos CP na APS com a avaliação que os profissionais fazem do desempenho dos atributos deste nível do sistema de saúde na Região de Parelheiros, SP; o discurso dos gestores da saúde sobre a atenção às condições crônicas com os problemas éticos dos CP na APS. Método: Estudo de Caso, com múltiplas fontes de dados: entrevistas com profissionais da ESF para aplicação do PCATool-Brasil Versão Profissionais; discursos dos gestores locais sobre a rede de atenção às condições crônicas; resultados de uma scoping review sobre problemas éticos dos CP na APS. As perguntas e os resultados do PCATool foram correlacionadas com os desafios éticos sintetizados a partir dos problemas éticos da scoping review. O cenário de estudo fica na Região Sul da cidade de São Paulo, área com cobertura de ESF em quase 100%, com carência de serviços especializados e alta vulnerabilidade em saúde. Resultados: Os DE foram: o despreparo dos profissionais frente aos CP; a comunicação falha entre os profissionais na rede de atenção à saúde; infraestrutura inadequada para assegurar a continuidade da assistência paliativa por 24 horas; desgaste dos profissionais da APS devido á sobrecarga do trabalho; desconforto para falar sobre CP com o paciente; apoio familiar inapropriado; desconhecimento das Diretivas Antecipadas de Vontade. Considerando o desempenho dos atributos da APS como avaliado pelos profissionais da ESF na Região de Parelheiros, os três primeiros desafios éticos são as áreas de maior tensão ética para a incorporação dos CP na APS. Os discursos dos gestores reconhecem a demanda por CP existente no território, porém, mencionam que as demandas relativas às condições de violência e vulnerabilidades da Região acabam sendo prioritárias pelas urgências que representam. Todos os atributos do PCATool foram relacionados com os desafios éticos indicando que a avaliação do desempenho dos atributos permite reconhecer áreas de tensão ética na releitura feita do Instrumento. Conclusão: Identificando proativamente os DE dessa incorporação, com base na experiência de equipes que já ofertam este serviço e contextualizando-a à realidade local por meio do desempenho dos atributos da APS, torna-se possível confrontá-los com questões éticas correntes na APS, apontando caminhos para os profissionais e gestores com educação continuada, deixando-os mais preparados para o reconhecimento e manejo dos CP, com vistas a fomentar os valores necessários para o novo cenário dos serviços com a incorporação dessa atenção na APS.
Introduction: The increasing prevalence of chronic health conditions brings demand for Palliative Care (PC) to the agenda of Primary Health Care (PHC), raising questions about the impact of the merger of PC on the ethical problems of APS. The bioethics is not only reactive, but must prospectively recognize ethical challenges. Objectives: To discuss ethical challenges (EC) for incorporation of PC in the PHC, considering the performance of the attributes of this part of the health system in Parelheiros Region, São Paulo; Collating: ethical problems of palliative care in PHC with PCATool-Brazil Instrument; ethical problems of PC in the PHC with the assessment that the professionals do the performance attributes of this level of the health system in Parelheiros Region, SP; the discourse of health managers of care for chronic conditions with the ethical problems of PC in the PHC. Method: Case Study with multiple data sources: interviews with Family health strategy (FHS) professionals for the application of PCATool-Brazil Version professionals; speeches by local managers on the network of care for chronic conditions; results of a scopingreview on ethical problems of PC in the PHC. The questions and results of PCATool were correlated with the ethical challenges synthesized from the ethical problems of scopingreview. The study scenario is in the southern region of São Paulo, FHS coverage area with almost 100%, with lack of specialized services and high vulnerability to health. Results: the EC were: the unpreparedness of the professionals in the PC; communication failure among professionals in the health care network; inadequate infrastructure to ensure the continuity of palliative care for 24 hours; wear PHC practitioners due to work overload; discomfort to talk about PC with the patient, familiar support inappropriate; ignorance of the Advance Directives Will. Considering the performance of PHC attributes as evaluated by FHS professionals in Parelheiros Region, the first three ethical challenges are the areas of highest ethical tension to the incorporation of PC in the PHC. The speeches of the managers recognize the demand for PC existing on the territory, however, mention that the demands on the conditions of violence and Region vulnerabilities end up being priority by the urgencies they represent. All PCATool attributes were related to the ethical challenges indicating that the attributes of performance assessment allows us to recognize areas of ethical tension in rereading made the instrument. Conclusion: Identifying proactively the EC this merger, based on the experience of teams that have proffer this service and contextualizing it to local conditions through the performance attributes of the PHC, it is possible to compare them with current ethical issues in PHC, pointing paths for professionals and managers with continuing education, making them more prepared for the recognition and management of PC, designed to promote the values needed for the new scenario for services with the incorporation of this attention in the PHC.

Syfte: Syftet med studien var att beskriva distriktssköterskors erfarenheter av vad som underlättade och hindrade evidensbaserad vård av ben- och fotsår inom primärvården. Metod: En kvalitativ intervjustudie med semistrukturerade intervjuer genomfördes med åtta distriktssköterskor. Samtliga arbetade på hälsocentraler i södra Hälsingland. Intervjuerna transkriberades och analyserades med kvalitativ innehållsanalys. Som teoretisk referensram användes PARIHS modellen. Huvudresultat: I studien framkom olika faktorer som underlättar respektive hindrar distriktssköterskor inom primärvården att arbeta efter en rutin för ben- och fotsår. Det som underlättade var ett välfungerande teamarbete på arbetsplatsen, att rutinen var anpassad så att den var lätt att arbeta efter och att den fanns lättillgänglig i datasystemet, specifik kunskap om sårvård och ett engagemang för patienten och för ämnet sårvård samt att patienten behöver stöd och utbildning för att kunna medverka i vården. Det som hindrade var bristande förståelse och engagemang från chef och kollegor, svårigheter att motivera patienterna till att medverka till behandling samt att journalsystemet inte var anpassat efter ben- och fotsårsrutinen. Slutsats: I studien framkom olika faktorer som underlättade och hindrade distriktssköterskor att använda sig av evidensbaserad vård av ben- och fotsår i det dagliga arbetet. Det som påverkade distriktssköterskornas användning av rutinen var i störst utsträckning faktorer i omgivningen. För att underlätta för distriktssköterskor att kunna arbeta enligt evidensbaserad sårvård måste ansträngningar göras för att undanröja hinder. PARIHS modellen kan användas som stödjande verktyg före, under och efter implementeringsprocessen.
Purpose: The purpose of the study was to describe district nurses' experiences of the facilitating and preventative factors that influence the use of evidence-based wound care in primary healthcare. Method : A qualitative interview study with semi-structured interviews was conducted with eight district nurses. All worked at health centers in southern Hälsingland. The interviews were transcribed and analyzed by qualitative content analysis. As a theoretical reference frame, the PARIHS model was used. Main outcome : The study revealed different factors that facilitate or prevent district nurses in primary healthcare to work for a routine for leg and foot ulcers. What facilitated was a well-functioning team work at the workplace, that the routine was adapted so that it was easy to work after and was easily accessible in the computer system, specific knowledge about wound care and commitment to the patient and on the subject of wound care and that the patient needs support and education to be able to participate in healthcare. What was prevented was insufficient understanding and commitment from the boss and colleagues, difficulty in motivating patients to participate in treatment and that the journal system was not adapted to the leg and foot routine. Conclusion : The study identified various factors which facilitated and prevented district nurses from using evidence-based care of leg and foot ulcers in their daily work. What influenced the use of the routine by district nurses was to the greatest extent factors in the environment. In order to facilitate district nurses to work according to evidence-based wound care, efforts must be made to eliminate obstacles. The PARIHS model can be used as a supporting tool before, during and after the implementation process.

Bakgrund: Riksrevisionens statistik visar på en allt högre belastning på ambulanssjukvården i landet, detta har medfört att flera regioner infört rutiner för ambulanssjuksköterskan att bedöma det aktuella vårdbehovet hos patienterna för att hänvisa till rätt vårdnivå om det inte föreligger transportbehov med ambulans. Syfte: Syftet med studien var att undersöka ambulanssjuksköterskors upplevelser av att hänvisa patienter till annan vårdnivå när inget behov av ambulanstransport föreligger. Metod: Två kvalitativa fokusgruppsintervjuer genomfördes på två ambulansstationer inom Region Norrbotten. Ett ändamålsenligt urval användes för att rekrytera ambulanssjuksköterskor. Deltagarna var mellan 33 och 48 år och yrkeserfarenheten sträckte sig mellan 8 och 20 år. Data analyserades med en kvalitativ innehållsanalys. Resultat: Analysen resulterade i fyra huvudkategorier: Erfarenheter, magkänsla och bemötande gav förutsättningar för bedömning, Att välja vårdnivå var tidskrävande men värt arbetsinsatsen, Patienter som transporteras utan vårdbehov skapar frustration, En förändring kräver information, utbildning och stöd i beslut. Resultatet visade att ambulanssjuksköterskorna använde sig av intuition tillsammans med de befintliga rutinerna och kände sig då trygga med att bedöma och hänvisa patienterna till en annan vårdnivå. De saknade möjligheten till stöd av ambulansläkare för att underlätta vid bedömning och beslut. Ambulanssjuksköterskorna upplevde det som en begränsning att inte privata vårdgivare var anslutna till rutinen för att hänvisa patienter. Frustration uppstod när de var tvungna att transportera patienter utan vårdbehov.  Slutsats: För att kunna optimera akutsjukvårdens resurser så behöver rutiner ses över så att samtliga hälsocentraler i regionen ingår i “vårdstigen”. En ambulansläkare bör omgående rekryteras som ett stöd i ambulanssjuksköterskornas dagliga arbete och vid hänvisning av patienter till annan vårdnivå.

Problemos aktualumas: Jaunesniame mokykliniame amžiuje (I-IV kl.) formuojasi nauji, svarbūs vaiko psichikos bruožai, kurių pagrindu ugdosi labai svarbios savybės ¬­ savistaba, s¬ugebėjimas analizuoti savo poelgius ir kt. sudaro sąlygas formuotis valingam dėmesiui. Tačiau pastaruoju metu aktualia problema tampa auganti karta, kurioje yra nemažai vaikų, turinčių emocinių ir elgesio sutrikimų, kurie turi neigiamą reikšmę vaiko tolesnei psichikos raidai. Apžvelgiant kokybinių mokslinių tyrimų publikacijas Lietuvoje pasigendama mokslinių darbų, kuriuose emocijų ir elgesio problemos būtų tirtos taikant objektyvias standartizuotas metodikas. Dažniausiai duomenys renkami taikant anketavimo metodą, kurio autoriai būna patys tyrėjai. Šiuo metu užsienio šalyse emocijų ir elgesio sutrikimams vertinti plačiai naudojama BASC-2 metodika (Behavior Assessment System for Children, Reynolds ir Kamphaus, 2004, 2005), kuria galima nustatyti vaikų asmenų emocijų, jausmų ir elgesio modelių (pozityvaus ir klinikinio) ypatumus. Tyrimo objektas – 4 kl. mokinių elgsenos ir emocijų problemos. Tyrimo tikslas: Ištirti 4 kl. mokinių savo elgsenos ir emocijų problemų vertinimą ir palyginti jį su auklėtojos įvertinimu. Uždaviniai: 1. Ištirti ir palyginti 4 kl. mokinių internalių ir eksternalių problemų vertinimą mokinių ir mokytojo požiūriu. 2. Išanalizuoti ir palyginti mokinių problemų mokykloje patiriamus sunkumus jų pačių ir mokytojo vertinimu. 3. Ištirti ir palyginti mokinių asmeninio prisitaikymo... [toliau žr. visą tekstą]
Topicality of the problem: At the primary – school age (I – IV forms) new important formatives of a childs mentality start farming. They are basic for developing such important qualities as self – observation, ability to analyze ones actions and others that help to maintain volitional attention. However a new generation has recently become an urgent problem because there are a lot of children with behavioral and emotional disorders and that has negative influence on the further development of mentality. After surveying the publications of scientific studies in Lithuania it can be stated that there are no studies in which emotional and behavioral problems would be analyzed using objective standardized methods. The data is usually collected using questionnaire method the investigators themselves. At present BASC – 2 methodic (Behavior Assessment System for Children, Reynolds and Kamhaus, 2004, 2005), which makes it possible to establish peculiarities of models (positive and clinical) of childrens emotions, feelings and behavior is being widely used in foreign countries for estimation emotional and behavioral disorders. The object of the study – emotional and behavioral problems in 4 th formers. The aim of the study: To examine the 4 th formers estimation of their behavior and emotions and to compare it with the class – teachers estimation. The tasks: 1. To examine and compare the estimation of the 4 th formers internal and external problems both, in their own and their teacher... [to full text]

M.Cur.
Primary clinical nurses (PCNs), traditionally known as primary health care nurses (PHCNs) in South Africa, are expected to function as ‘frontline providers’ of clinical primary health care (PHC) services within the public PHC facilities (Department of Health (DoH), 1996: 8; DoH, 2001a: 23). This extended role of the registered nurse (as set out in section 38A of the Nursing Act, No. 50 of 1978) demands high quality clinical competencies. The purpose of the study is to describe guidelines to improve clinical competencies of learners within the context of a learning programme PHC: Clinical Nursing, Diagnosis, Treatment and Care (the programme) provided at a specific university in Gauteng where the study was conducted. The research objectives are to: o Explore and describe the perceptions of both clinical instructors and learners with regard to reasons for poor clinical competencies of learners of the programme. o Explore and describe the demographic profile of learners registered at the university in the 2003 academic year for the programme with regard to reasons for poor clinical competencies. o Explore and describe the correlation between scoring/rating of learners by different clinical evaluators during summative clinical evaluations of learners registered for the programme in the 2003 academic year at the university, in order to ensure inter-rater reliability with regard to reasons for poor clinical competencies. o Describe guidelines to improve clinical competencies of learners of the programme provided at a university in Gauteng, as informed by the research study findings. To achieve the purpose and objectives of the study, a mixed methodological design, qualitative and quantitative in nature, was used (Creswell, 1994: 184), utilising the sequential exploratory strategy (Creswell, 2003: 215). Other research strategies used are descriptive and contextual (Creswell, 1994: 145 & 175). Qualitative data were collected from purposively selected participants in separate focus group interviews of clinical instructors and learners. Analysis was done following Tesch’s method (1990). Trustworthiness was ensured using Lincoln and Guba’s method (1985). Ethical considerations were maintained throughout the study and consent was obtained from the participants. Quantitative data were collected using a summative clinical evaluation instrument (checklist) administered by clinical evaluators and a self-administered questionnaire for collecting a learner profile from a purposively selected sample of learners and clinical instructors, respectively. Statistics were analysed using a reliable computer program SPSS. Validity and reliability were ensured throughout the study. Data of correlated marks/scores revealed that there was no ecologically significant difference between the marking/scoring of learners by clinical evaluators during summative clinical evaluations of learners. Qualitative data yielded two main themes from the focus group interviews as challenges that participants perceived as reasons for poor clinical competencies of learners of the programme, viz: o Challenges within the PHC clinical practice field; o Challenges within the learning programme (university). Major categories and subcategories also emerged from the two themes. Interpretation of both quantitative and qualitative results was integrated and reported as similar findings from which the guidelines to improve clinical competencies of learners of the programme PHC: Clinical Nursing, Diagnosis, Treatment and Care were formulated. The guidelines focused on both the learning programme and the PHC clinical practice field.

thesis report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the Degree of Masters in Nursing Science Johannesburg, 2014
Shortage of human resources is a major problem which has become an international emergency that in recent years has caused substantial international attention and concern. Mid-level medical workers were introduced internationally, in Africa and recently in South Africa as a strategy to overcome health workforce challenges and improve access to essential health services, as well as achieve the health related targets of the Millennium Development Goals. Mid-level workers in South Africa are called Clinical Associates. The aim of the study was to explore and describe the PHC nurses’ perception of the Clinical Associate role. A qualitative, contextual, exploratory and descriptive design was used to explore and describe the PHC nurses’ opinions and thoughts concerning the role the clinical associates would play in the health care system; and to obtain an understanding of how the PHCNs see the feasibility of working with these newly introduced health workers. A purposive convenient sampling was used to select participants who were most likely to offer information required in the study. The study findings show that PHC nurses had insufficient knowledge regarding who Clinical Associates are and what their role is. Although to some extend the PHC nurses acknowledged the important role the Clinical Associates would play, the PHC nurses expressed more concern related to their professional status. The concerns included matters like: who would be senior between the Clinical Associate and the PHC nurses taking into consideration the level of education and training of Clinical Associates versus that of nurses; who would take orders from whom between Clinical Associates and PHC nurses. Another worry was the possibility of clinical associates taking over the PHC nurses roles.

The 2008 World Health Report emphasises that we need “primary health care (PHC) now more than ever”. Competent primary health care providers who “put people first” are required in the front line in order to make a difference. The need for widely accessible, competent and caring professional nurses thus places expectations on training programmes and health services. In South Africa, a number of studies have been conducted on primary health care and methods of teaching clinical competence to nursing students (Truscott 2010; Magobe et al. 2010; Naledi et al. 2010) but not on the experiences of nursing students during PHC practice. The researcher observed that the emphasis on the positive, supportive and helpful experiences of nursing students in coping with challenges during their clinical practice was distinctly lacking. The objective of the study was to explore and describe the experiences of nursing students during the clinical practice in PHC settings. It was expected that this information will enable the researcher to formulate recommendations to support nursing students to cope with challenges during clinical practice in a PHC setting. A qualitative descriptive inquiry, with an appreciative approach was used. Five semi-structured focus group interviews were conducted to obtain data. The population comprised of 4th year nursing students who were selected using purposive sampling with the assistance of a mediator, namely the Head of the Department for PHC at a Nursing College. The sample size was determined by data saturation. Data analysis was carried out simultaneously with the collection of data. Fifteen main themes were identified during a consensus discussion between the researcher and the co-coder. The main findings related to the meaning students attached to being placed in a PHC clinic; positive, supportive and helpful experiences; how they can be supported and what help them cope irrespective of challenges they experienced. Conclusions were drawn which pertained to: placement in a PHC setting for clinical practice; positive, supportive and helpful experiences; support when placed at a PHC setting for clinical practice and coping measures when placed at a PHC setting for clinical practice; and recommendations were formulated for nursing education, nursing research and nursing practice that focused on supporting and empowering nursing students to cope with challenges experienced at a PHC setting.
MCur, North-West University, Potchefstroom Campus, 2015

Submitted in fulfilment of the requirements for the Degree in Master of Technology: Nursing, Durban University of Technology, 2012.
Background : Work Integrated Learning is an educational approach that aligns academic and workplace practices for the mutual benefit of students and workplaces. Work Integrated Learning like in any other nursing course is essential in primary health care as required by the South African Nursing Council. In the clinical setting, students develop clinical and diagnostic reasoning; they also learn how to make the appropriate clinical decisions which they need as qualified primary health care practitioners. This is achieved through instruction and guidance by lecturers, mentors and clinical staff. However it has been noted that the clinical learning environment confronts students with challenges that are absent from the classroom situation. So this study seeks to explore and describe the experiences of post basic nursing students in primary health care clinics so as to address the challenges that are faced within the clinical settings. Aim of the study The aim of the study was to explore and describe primary health care post basic nursing students’ experiences during clinical placements. Methodology : A descriptive exploratory qualitative approach was used to guide the study. In-depth interviews were conducted with ten primary health care post basic nursing students who were allocated for Work Integrated Learning at the clinics in District A and District B in 2011. The main research question for this study was asked: ‘What are the experiences of primary health care post basic nursing students regarding Work Integrated Learning?’ Results : The findings of this study revealed that Work Integrated Learning is vital for the development of clinical skills amongst primary health care post basic nursing students. However, shortage of staff, inadequate material/ non-human resources, lack of supervision in the clinical facilities, distant clinical facilities and insufficient practice in the clinical skills laboratory were identified as challenges that students experience during Work Integrated Learning placement.

The reduction of the maternal mortality rate is part of the priority agenda of governments in Africa, including South Africa. Research shows that a large portion of maternal deaths are preventable because they are largely due to lack of inappropriately prepared staff. In South Africa, outcome studies on the quality of comprehensive prepared nursing graduates reflect some concerns regarding their levels of competence. These studies, however, are general; they did not directly target the competence of these graduates in their midwifery practice, therefore, the purpose of this study was to explore and describe the perceived level of competence of newly qualified-midwives functioning in midwifery units. Based on the positivist paradigm, an exploratory descriptive design, using a quantitative approach, was adopted in this study. Two structured questionnaires were used to collect data: one for the newly-qualified midwives and one for the supervisors. A total of 48 newly-qualified midwives and 26 supervisors from five hospitals at eThekwini District participated in this study. Ethics principles and other considerations were observed throughout the study. Data were analyzed statistically using a computer Software Package (SPSS, version 15.0) and a variety of statistical tests were carried out. . From the findings there was a positive congruence between graduates and their supervisors' ratings of the newly-qualified midwives clinical competencies. There were, however, significant differences in a few skills with graduates tending to rate themselves higher than did their supervisors. On the whole though one can conclude that although VI the findings in this study are not conclusive, compared to the previous studies in this area, there is an improvement in the level of competence of newly-qualified midwives. The improvement was noted in their level of competence in midwifery clinical practice, clinical teaching, management and research. The findine;s, however, revealed some areas that need special attention in the theory and clinical preparation of midwives. Recommendations included reviewing the curriculum and strengthening the research component. In midwifery clinical practice there needs to be more attention paid to neonatal care skills, problem solving and record keeping. Further research is also recommended.
Thesis (M.N.)-University of KwaZulu-Natal, Durban, 2011.

Aim of the study is to explore the role caring practices within the nurse-patient relationship, in facilitating effective chronic pain management in the primary health care context. Objectives are to analyse the current caring practices within the nurse-patient relationship during the management of patients with chronic pain within primary health care services; explore the challenges experienced by nurses in primary health care services when managing patients with chronic pain; observe the caring practices within the nurse patient interaction for the patients suffering from chronic pain within the Primary health care setting and explain the nurses‟ caring practices when managing their chronic pain in the primary health care setting. Method The research design for this study is sequential, explanatory and mixed method, which is more appropriate due to the complexity of the phenomenon under study. Findings: Although the survey measured the caring practices subjectively which other studies had done consistently, generally nurses associated caring as their core function within the health profession. Nurses do not actively involve the patients in the development of a treatment plan and as a result the caring behaviours that are intended to benefit the patients are not realised and, thus patients report nurses as not being caring. The results indicated that lack of an inclusive treatment plan, which can only be discovered through the development of the therapeutic NPR, is not given priority in the management of patients with chronic pain Conclusions: Caring should not be seen as concrete execution of the set of activities towards the patient but rather as a joint venture between the nurse and the patient. The strength of the model developed in this study is the identification of the nurses‟ internal readiness to create a caring environment by experiencing the love, faith and hope before engaging with the patient.
Health Studies

Cette recherche qualitative avait pour but d’explorer le raisonnement clinique d’infirmières de première ligne en CSSS/CLSC lorsqu’elles priorisent leurs interventions auprès de familles vivant en contexte de vulnérabilité dans le cadre du programme des Services intégrés en périnatalité et pour la petite enfance (SIPPE). Il s’agit d’une étude de cas qui comporte un échantillon intentionnel de sept épisodes de soins impliquant deux infirmières auprès de sept familles en période postnatale lorsqu’elles priorisent leurs interventions. La collecte de données a procédé par méthode think aloud, suivie d’entretiens semi-dirigés auprès des infirmières. Une analyse qualitative des données a été effectuée selon des méthodes interprétatives et par comptage de catégories. Ces dernières ont été formulées et mises en relation en s’inspirant de la modélisation du processus de raisonnement clinique de Tanner (2006) ainsi que des stratégies de raisonnement clinique proposés par Fonteyn (1998). Au terme de cette étude, le processus de raisonnement clinique ne semble pas être différent selon le type de priorité d’intervention auprès de familles en contexte de vulnérabilité, particulièrement lorsque nous distinguons la priorité selon un degré d’urgence (prioritaire ou secondaire). Aussi, nous constatons qu’il existe peu de diversité dans les processus de raisonnement clinique mobilisés à travers les sept épisodes de soins; et qu’un processus narratif de raisonnement est fréquent. Si une famille exprime un besoin urgent, l’infirmière y répond prioritairement. Par ailleurs, lorsque des conditions suggèrent un potentiel accru de vulnérabilité des familles, un mode de raisonnement clinique plus systématique, qui comporte une collecte et une mise en relation d’informations afin de formuler une proposition pour soutenir le passage à l’action, semble être mobilisé pour prioriser l’intervention. Il en est ainsi s’il s’agit d’un premier bébé, que la famille n’utilise pas d’autres ressources formelles de soutien. Autrement, s’il s’agit d’un deuxième bébé et que les familles utilisent d’autres ressources, les infirmières tendent plutôt à appliquer une routine d’intervention SIPPE. Aussi, cette recherche témoigne de l’engagement soutenu des infirmières auprès de familles vivant d’importants défis. Il importe toutefois de soutenir le développement d’un répertoire plus varié de processus de raisonnement clinique afin de renforcer leur capacité de prioriser leur intervention qui se déroule dans un contexte de multiples contraintes organisationnelles et interpersonnelles.
The goal of this qualitative study was to explore the clinical reasoning of primary care nurses in CLSC/CSSS when they set priorities for their interventions with vulnerable families as part of the Integrated Perinatal and Early Childhood Services (SIPPE) program. This case study comprises a purposeful sample of seven postnatal care episodes involving two nurses and seven families. Data were collected using the think-aloud method, followed by semi-structured interviews with nurses. Qualitative data analysis was performed using interpretive methods and category counting. The resulting categories and patterns were developed based on Tanner's (2006) model of clinical judgement in nursing and Fonteyn's (1998) clinical reasoning patterns. Study results suggest that clinical reasoning processes do not differ according to the type of priority, whether the situation is more or less urgent. Moreover, there is diversity in the types of clinical reasoning employed within the seven care episodes; and it appears that a narrative reasoning process is favoured. If a family's needs are urgent, nurses prioritize these needs. When conditions indicate that there is greater potential for vulnerability, a more systematic form of clinical reasoning, identified here as «collecting data to form relationships and to present a proposal for action», is used to prioritize interventions. This pattern is more likely when a first child is involved and when the family is less likely to turn to other support resources. Otherwise, if this is a second child and the family uses other resources, the nurse tends to apply routine SIPPE interventions. Finally, our results suggest that a systemic view of a family's living circumstances, rather than keeping the focus on the infant's well-being, could make it more difficult to set intervention priorities. This study highlights nurses' ongoing commitment to families facing significant challenges. However, it is important to support the development of a broader inventory of clinical reasoning processes to bolster nurses' capacity to prioritize interventions that take place in contexts of multiple organizational constraints.

Une meilleure utilisation des ressources infirmières représente une avenue prometteuse dans l’amélioration de la performance des services de première ligne. La mesure de la performance des services infirmiers constitue une composante centrale à l’amélioration de leur organisation et à la qualité des soins dispensés dans ce secteur d’activités. Le but de cette recherche était de mesurer et de valider des indicateurs de performance des services infirmiers en première ligne à partir d’un cas traceur en soins de plaies ainsi que d’évaluer la fiabilité des données clinico-administratives utilisées pour mesurer les indicateurs à partir des dossiers cliniques. Cette étude a adopté un devis longitudinal corrélationnel. Les données ont été collectées sur une période d’une année dans un service de soins courants d’un Centre local de services communautaires (CLSC) à partir de données clinico-administratives contenues dans le système informatique I-CLSC. L’épisode de soins constituait l’unité d’analyse. Huit indicateurs ont été mesurés, dont cinq indicateurs de processus : 1) le suivi infirmier; 2) la continuité relationnelle; 3) l’enseignement; 4) l’évaluation initiale; et 5) la rencontre avec une infirmière spécialisée en soins de plaies, et trois indicateurs de résultats : 1) la fréquence; 2) la durée; et 3) l’intensité du suivi. Les objectifs de mesure et de validation ont été réalisés à partir d’un échantillon de 482 épisodes de soins de plaies d’une durée supérieure à sept jours. L’étude de fiabilité a été réalisée à partir d’un sous-échantillon de 107 épisodes. Des analyses descriptives et corrélationnelles ont été réalisées. Les résultats de validation ont démontré des associations fortes statistiquement significatives entre les indicateurs de suivi infirmier et de continuité et les trois indicateurs de résultats. Les résultats de fiabilité ont démontré un haut taux de concordance entre les données contenues dans les dossiers cliniques et les données clinico-administratives pour six des huit indicateurs à l’étude. En conclusion, des indicateurs de processus valides et pertinents dans la pratique infirmière de première ligne peuvent être mesurés de façon régulière par les gestionnaires à partir de données clinico-administratives fiables et facilement accessibles.
Better use of nursing resources is a promising avenue for improving the performance of primary care services. Measuring the performance of nursing services is a central component in improving their organization and the quality of care delivered in this sector. The aim of this study was to measure and validate primary care nursing performance indicators from a tracer case in wound care and to assess the reliability of clinical-administrative data used to measure indicators from clinical records. This study adopted a correlational longitudinal design. Data were collected over a one-year period in a Local community services centre (CLSC) using clinical-administrative data contained in the I-CLSC electronic database. The episode of care was the unit of analysis. Eight indicators were measured, including five process indicators: 1) nursing follow-up; 2) relational continuity; 3) teaching; 4) initial assessment; and 5) consultation with a specialized nurse, and three outcome indicators: 1) frequency; 2) duration; and 3) intensity. Measurement and validation objectives were performed using a sample of 482 episodes of wound care lasting more than seven days. The reliability study was based on a sub-sample of 107 episodes. Descriptive and correlational analyzes were performed. Validation results demonstrated very strong associations between nursing follow-up and continuity indicators and the three outcome indicators. Reliability results demonstrated a high concordance between clinical records and clinical-administrative data for six of the eight indicators. In conclusion, valid and relevant process indicators in primary care nursing can be measured on a regular basis by managers using reliable and easily accessible clinical-administrative data.

The diploma thesis deals with problems of depression in older people. Mainly the work is focused on identifying and analyzing the role of nurses in screening for depression in older people in primary care, acute care, long-term care and home care. This thesis was focused on theoretical direction and was used the method of design and demonstration. In this thesis was set one main goals with five research questions. The main goal was to identify and analyze the role of nurses in screening for depression in the elderly. RQ 1: What is the role of the nurse in screening for depression in the elderly? RQ 2: What is the role of the nurse in the primary care in screening for depression in the elderly? RQ 3: What is the role of the nurse in screening for depression in hospitalized patients in acute care? RQ 4: What is the role of the nurse in screening for depression in seniors in long-term and home care? RQ 5: What rating scales and methods are used in screening for depression in the elderly? The thesis introduce the concept of depression. The following are specified the causes of and the important factors that affect depression in the elderly. It also deals the differences in the clinical symptomatology of depression in old age. It explains possibilities and various barriers in the diagnosis of depression. Another chapter introduces complete geriatric examination, diagnostic classification systems, possible screening methods and scales for detection of depression in the elderly population. It also deals methods of pharmacological and non-pharmacological treatment and its possible complications associated with older age. By reason of increased suicide rate caused by depressive disorder the issue of suicidal behavior in the elderly is introduced. The next chapter deals with the nursing process, which is used by nurses in practice. It consists of the evaluation of the patient's health condition, making nursing diagnosis, creating nursing plan and subsequent implementation and evaluation. The nursing process is also needy for providing quality care. The nursing process in the stage of nursing diagnosis, introduces possible nursing diagnosis for a patient suffering from depression, which are based on the latest classification. Finally is described the role of nurses in screening for depression in the elderly in different health facilities and their contribution to the timely evaluation of depression in the elderly. This chapter introduces the role of nurses, nursing screening and collaboration with a physician. The role of nurses in screening for depression in different medical facilities is based on the first phase of the nursing process of assessment. On the basis of objective and subjective information, the nurse will assess the overall health and mental condition of the patient. Primarily, it was investigated what is the role of the nurse in screening for depression. On the basis of content analysis and synthesis it was necessary to used and processed domestic and foreign literature. A number of relevant sources are the results of various studies and Meta-analyzes, mostly from abroad, but also from the Czech Republic. The thesis can serve as a basis for nurses. The result of this thesis is to create e-learning material available for students in the Faculty of Health and Social Sciences of South Bohemia in Ceske Budejovice in the tutorial called Moodle.