Thèses sur le sujet « Car incident »

This thesis investigated how many critically ill patients in intensive care intensive care (ICU) in a single Australian metropolitan hospital developed incontinence-associated dermatitis (IAD). It also determined the severity of IAD using a newly developed IAD categorisation tool, the time to onset to IAD development, the association between IAD and faecal incontinence and diarrhoea, the association between patient characteristics and IAD development and severity and the association between disposable faecal containment devices and clean-up products with the development of IAD. It provides a benchmark for IAD exploration in the intensive care setting.

Bakgrund:En Central venös kateter (CVK) är en plastkateter som mynnar i ett centralt kärl nära hjärtat och används bland annat för administrering av läkemedel och blodprodukter. Användandet av CVK ökar inom sjukvården och kan förutom på intensivvårdsavdelningarna även ses i hemsjukvården och i den övriga slutenvården. Av alla patienter som får en CVK drabbas tre till sju procent av en infektion i blodbanan och varje infektionstillfälle innebär ett ökat lidande och en förlängd sjukhusvistelse. Dessa infektioner kan förhindras genom att hälso- och sjukvårdspersonal följer evidensbaserade riktlinjer och åtgärder. Syfte: Att beskriva hur sjuksköterskan kan arbeta preventivt för att förhindra uppkomsten av infektioner i blodbanan hos patienter med central venös kateter. Metod: Studien som genomfördes var en systematisk forskningsöversikt. För att finna relevanta artiklar skapades inklusionskriterier och söktermer. Databassökningarna gjordes i databaserna Cinahl och PubMed på Sophiahemmets Högskola under mars och april 2011. En söktabell med antal träffar och inkluderade artiklar skapades för att ge en överblick och en matris med kvalitetsbedömning gjordes. Både matrisen och bedömningsunderlaget bifogades studien. Totalt inkluderades 22 artiklar, varav en hittades genom manuell sökning. Resultat: Resultatet presenterades utifrån tre olika områden: kunskap och utbildning, sammansatta interventioner samt skötsel. Olika utbildningsinsatser visade sig vara en effektiv preventiv metod för att förhindra infektion. Detta område innefattade bland annat lektioner, affischer beteendeförändring och återkoppling. Området som handlade om sammansatta interventioner visade sig även vara effektivt, vilka bestod av ett antal evidensbaserade riktlinjer som användes tillsammans. Vissa delar av skötseln av CVK hade bra effekt och gav varierande resultat. Slutsats: Utbildning ger ökad kunskap och följsamhet vilket verkar vara en elementär och effektiv metod för att förhindra uppkomst av infektion. Hur sjuksköterskan sköter patientens CVK är av stor betydelse då till exempel olika förband och antiseptiska lösningar gav varierande resultat. Vidare forskning krävs inom området och gärna fler studier från Sverige.

Introduction: In recent decades, there has been considerable international attention directed towards minimising healthcare-associated harm and improving the safety of hospital care. More recently, this attention has broadened to include primary medical care. In 2002, the World Health Assembly recognised the issue of inadequate levels of patient safety as a major threat to global public health. In the following years, many countries have developed national strategies for the measurement, monitoring and prevention of patient safety incidents (PSIs) and their outcomes. Experience accumulated from secondary care has shown that the initial steps for understanding patient safety include the systematic identification of the most frequent and most harmful threats. However, the safety profile of primary care dentistry remains poorly investigated. As a result, current evidence cannot provide reliable estimates of the types of PSIs in primary care dentistry, the causes of these incidents, or the associated disease burden caused by such incidents. In medicine, improvements in patient safety were achieved at a national level by developing a shared conceptual understanding, the standardisation of terminology and through preventive initiatives such as the introduction of a national incident reporting and learning system. In the United Kingdom (UK), the England and Wales’ National Reporting Learning System (NRLS) has been an important source of insight, from the perspectives of the reporter, into understanding why PSIs occur. This initiative has led to the implementation of patient safety oriented policies to monitor and reduce cases of healthcare-associated harm. Examples of such policy initiatives include national guidelines and national safety recommendations to encourage the reporting of serious reportable events called ‘never events’ (NEs). These are defined as serious, preventable PSIs that should not occur if the available preventive measures are implemented. At a national level, serious incidents and NEs must be reported to the NRLS and/or other reporting systems. However, little is known about NEs in dentistry as wrong-tooth extractions are the only currently defined NE that has a clear application in dentistry. Although surgical NEs, such as wrong-site surgery and wrong implants may be related to dental procedures, these overlap with procedures conducted in secondary care. As a result, there is no agreed list of NEs for primary care dentistry. The overall aim of my PhD was to explore patient safety, its concepts, including error and harm, and how these can help to create an understanding of the types of PSIs that occur in primary care dentistry, their contributory factors and their consequences. In addition, I also aimed to identify NEs with the greatest need and opportunity for future intervention strategies, in order to improve patient safety in primary care dentistry. Methodology and methods: My PhD was conducted in three phases. For the first phase, I conducted a systematic scoping review of the empirical evidence published over a 20-year period (1994-2014). To achieve this, I searched MEDLINE and EMBASE for articles reporting incidents that could have or did result in unnecessary harm from primary dental care. I also extracted and synthesised data on the types and frequencies of PSIs (including NEs) and adverse outcomes. Then, for the second phase, I undertook an exploratory sequential mixed-methods evaluation, which involved the qualitative exploration and analysis of a weighted-by-year randomised sample (n=2,000) of the most severe incident reports from primary care dentistry submitted to the England and Wales’ NRLS. This approach generated three coding frameworks, aligned to the International Classification for Patient Safety developed by the World Health Organization, for i) the classification of incidents, ii) contributor y factors and iii) incident outcomes. These coding frameworks informed the quantitative analysis, during which myself together with a trained second coder, applied codes to deconstruct the narrative of these patient safety incident reports whilst retaining the meaning of the report. To assess inter-rater reliability, Cohen’s Kappa statistic was calculated for the primary incident type which was defined as “the incident that resulted in the outcome experienced by the patient.” Finally, for the third phase, I undertook an electronic Delphi exercise to achieve international agreement on NEs for primary care dentistry. The results obtained from Phases 1 and 2 were used to identify candidate NEs. I then invited an international panel of 41 experts to complete two rounds of questionnaires; 32 (78%) agreed to participate and completed the first round, and 29 (91%) completed the second round. I provided anonymised controlled feedback between rounds and used a cut-off of 80% agreement to define consensus. The results from the first stage built the evidence base for the second and third phases. Likewise, the results from the second phase further informed the third and final stage of my PhD. Results: I undertook a systematic scoping review which demonstrated: a) there were considerable differences in definitions for terms used to describe patient safety, b) that a range of populations had been studied, and c) that major differences in sampling strategies exist between studies. The main five PSIs I identified were errors in i) diagnosis/examination, ii) treatment planning, iii) communication, iv) procedural errors and v) the accidental ingestion or inhalation of foreign objects. However, little attention has been paid to wider organisational factors such as problems within the physical environment, scheduling (e.g. errors in managing appointments) and patient access, management and lines of responsibility. Also there is very little evidence of interest in researching into the influence of policies for either quality or patient safety assurance. The retrieved evidence was used to build a conceptual literature-derived model of patient safety risks in primary care dentistry. This model helped to bring structure to the analysis of the 1,456 patient incident reports that were eligible for analysis out of a total of 2,000. These reports described incidents across the preoperative (40.3%; n=587), intra-operative (56.1%; n=817) and post-operative (3.6%; n=52) clinical stages of care delivery. Further analysis showed the more frequently reported incidents were related to a) delays in treatment (333/1,456; 22.9%), b) procedural errors (220/11,456; 15.1%), c) medication-related adverse incidents (160/1,456; 11.0%), d) equipment failure (90/1,456; 6.2%) and e) errors in obtaining or processing x-rays (87/1,1456; 6.0%). Only 5.3% (77/1,456) of the incidents resulted in harmful outcomes. Of the 77 incidents that resulted in a harmful outcomes (n=77; 5.3%), around half were due to wrong tooth extractions (37/77; 48.1%) and resulted in unnecessary procedures. Three out of the 1,456 incidents (0.2%) resulted in death. Data from the scoping review and the mixed-method analysis informed a list of 42 candidate NEs. I further sought and achieved international consensus for 23 of these NEs. These were related to routine assessment, and pre-operative, intra-operative and post-operative stages of dental procedures. Conclusions: The findings from my PhD have revealed that patient safety research in dentistry is mostly descriptive and poorly organised with various approaches to defining and measuring PSIs and their outcomes. This poor organisation of patient safety research also includes differing study designs and patient populations studied. The evidence-based conceptual framework from the systematic scoping review, and coding frameworks from analysis of PSI reports selected from a national database, can bring structure to future work by providing a robust approach to classifying PSIs, their contributory factors and outcomes.
My research findings also show that PSI reports are an important source of information that can generate important insights about patient safety in primary care dentistry. The mixed-method analysis of PSI reports showed that most incidents in primary dental care do not result in harm. PSIs that resulted in harmful outcomes more frequently occurred intra-operatively. My findings also reveal that unsafe care in dentistry is not limited to human error, but can also be ascribed to the presence of other administrative or organisational flaws that contribute to the reported incidents. Future initiatives to improve and research clinical practice should focus on improving administrative processes to reduce delays in treatment. Also, the reduction of procedural errors through the standardisation of x-rays, medication prescription and other clinical procedures is needed. Lastly, I have constructed the first comprehensive international list of NEs for primary care dentistry. I believe my findings, including the list of NEs, can provide an evidence-base which will encourage researchers to further expand the patient safety research and development agenda in dentistry, as well as encouraging decision-makers and professional bodies to translate my findings into quality improvement strategies.

Financial elder abuse is gaining increasing attention from researchers and policy makers. Such abuse can include theft of money as well as misuse of assets such as property. This research applied judgement analysis methodology to explore professional decision making in the context of such abuse and to identify the nature of the cues used to detect and prevent abuse. Participants included social care, health and banking professionals, who were established as key decision makers. In Phase I, semi-structured interviews (n = 63) were conducted. The critical incident technique was used to identify cue use and decisions taken in the most recent case experienced. Key cues for both social care and health professionals included the nature of the 'financial problem suspected', the older persons 'mental capacity' and the 'identifier of the abuse', this being whether the abuse was directly observed or instead reported by a third party. A separate cue used by health professionals was the individual's 'physical capacity'. Banking professionals did not use physical or mental capacity as cues, but independently considered 'who was in charge of the money'. Decisions made by social care professionals included determining whether safeguarding procedures should be implemented. In Phase II, a factorial survey approach was applied whereby social care, health and banking professionals (n=223) were presented with case scenarios incorporating the cues from Phase I in addition to cues from literature review. Multiple regression analysis and incremental F-tests identified the cues that explained a significant amount of the variance in judgements of certainty of abuse and likelihood of taking action. For example, for social care and health professionals this included the older person's mental capacity, and the nature of the financial problem suspected. The findings could be used to develop a training tool to enable other professionals to improve their strategies for detection and prevention of financial elder abuse.

The purpose of this case study was to explore the perceptions and experiences of hospital emergency preparedness coordinators of preparing for and responding to incidents. Stakeholder and protection motivation theories provided the theoretical framework for the study. The nonprobability sampling technique of purposive sample was used to identify 10 hospital preparedness coordinators employed at acute care hospitals with emergency departments located in Connecticut and Massachusetts. A field-tested researcher developed 20-question interview questionnaire guided data collection. This qualitative case study answers the questions: What are hospital emergency preparedness coordinators perspectives of hospital preparedness? How do hospital emergency preparedness coordinators prepare for a hospital incident? How do hospital emergency preparedness coordinators respond to a hospital incident? What factors do hospital emergency preparedness coordinators believe best prepares a hospital for incidents? Ranked in order of replication, the researcher identified three themes using first and second cycle coding techniques with pattern coding: (a) planning, (b) training, and (c) communication. Control and motivation emerged as subthemes. Results of the study provide detail rich data for hospital emergency preparedness coordinators, and provide insight and information for stakeholders from all types of private and public organizations to improve hospital emergency preparedness programs.

Introduktion: Vårdrelaterade infektioner (VRI) har negativ inverkan på folkhälsan med påverkan på mortalitet, morbiditet och livskvalitet. Inom hälso- och sjukvården är VRI en stor utmaning. Den vanligaste VRI i Sverige är vårdrelaterade urinvägsinfektioner (VUVI). För att förebygga VRI är regelbundna mätningar och återkopplingar viktigt. Mätinstrument som idag används på lokal och nationell nivå för att mäta incidens av VRI är bl.a. Markörbaserad journalgranskning och Infektionsverktyget. Syfte: Validera Infektionsverktyget och jämföra incidens av VUVI från Infektionsverktyget mot manuell journalgranskning och Markörbaserad journalgranskning samt studera förekomsten av urinkateter i samband med VUVI. Metod: Under 2017 samlades data in från 143 slumpmässigt utvalda journaler i slutenvården på Södra Älvsborgs sjukhus. Diagnostiserad VUVI och samhällsförvärvad urinvägsinfektion (SUVI) i Infektionsverktyget validerades mot manuell journalgranskning. Incidensen av VUVI i Infektionsverktyget jämfördes även mot VUVI i markörbaserad journalgranskning. Resultat: Incidens av VUVI innan validering var 1.5 % medan den uppskattade incidensen efter manuell journalgranskning och validering var 3.6 %. Markörbaserad journalgranskning visade en incidens på 1.1 %. I 65.6 % av fallen med VUVI fanns en koppling till urinkateter. Den mest förekommande orsaken till inkorrekt registreringen av VUVI var att patienter med urinkateter bedömdes som SUVI. Slutsats: Den rapporterade incidensen av VUVI skiljer sig mellan de mätinstrument som används idag och incidensen är troligtvis högre än vad som idag rapporteras. För att få bra kvalitet på övervakningsdata krävs kunskap och granskning av hög kvalitet. Dock begränsas resultatet från denna studie av att studiepopulationen var relativt liten och därmed begränsar generaliserbarheten.
Introduction: Health care associated infections (HCAIs) have a negative impact on public health, with an impact on mortality, morbidity and quality of life. The most common HCAIs in Sweden are health care associated urinary tract infections (UTI). One important component in preventing HCAIs are regular measurements and feedback to these. Instruments that are currently used for measuring HCAIs at a local and national level in Sweden are marker-based journal review and the Anti-Infection Tool (AIT). Aim:  The aim of this study was to validate the AIT and compare the incidence of health care associated UTI measured with the AIT against both manual journal review and marker-based journal review. The aim was also to study the presence of urinary catheters in conjunction with a healthcare associated UTI. Methods: In 2017, data was collected from 143 records from a random sample of patients admitted to somatic wards at Södra Älvsborg's Hospital. From the AIT, diagnosed health care associated UTI and community-acquired UTI were studied and validated against manual journal review. Also, the incidence of health care associated UTI in the AIT was compared with that found in marker-based journal review. Results: Incidence of health care associated UTI before the validation was 1.5% while the estimated incidence after manual journal review and validation was 3.6%. Marker-based journal review showed an incidence of 1.1%. In 65.6 % of the cases with health care associated UTI, the patient was equipped with urinary catheter. The most common cause of incorrect registration of health care associated UTI was that patients with urinary catheters were assessed as community-acquired UTI.   Conclusion:  The reported incidence of health care associated UTI differs greatly between these instruments. The incidence is probably much higher than what is currently reported using these instruments. To obtain good quality of monitoring data, knowledge and journal reviews of high quality are required. However, the generalizability of the result of this study is limited, due to the relatively small study sample.

Disasters, emergencies, incidents, and major incidents - they all come back to the same thing regardless of what they are called. The common denominator is that there is loss of life, injury to people and animals and damage and destruction of property. The management of such events relies on four phases: 1. Prevention 2. Preparation 3. Response 4. Recovery Each of these phases is managed in a different way and often by different teams. Here, concentration has been given to phases 2 and 3, with particular emphasis on phase 3, Response. The words used to describe such events are often related to legislation. The terminology is detailed later. However, whatever the description, whenever prevention is not possible, or fails, then the need is to respond. Response is always better when the responders are prepared. Training is a major part of response preparation and this book is designed to assist those in the health industry who need to be ready when something happens. One of the training packages for responders is the Major Incident Medical Management and Support (MIMMS) Course and this work was designed to supplement the manual prepared by Hodgetts and Macway-Jones(87) in the UK. Included is what the health services responder, who may be sent to an event in which the main concern is trauma, should know. Concentration is on the initial response and does not deal in any detail with hospital reaction, the public health aspects, or the mental health support that provides psychological help to victims and responders, and which are also essential parts of disaster management. People, in times of disaster, have always been quick to offer assistance. It is now well recognised however, that the 'enthusiastic amateur', whilst being a well meaning volunteer, isn't always what is needed. All too often such people have made things worse and have sometimes ended up as victims themselves. There is a place now for volunteers and there probably always will be. The big difference is that these people must be well informed, well trained and well practiced if they are to be effective. Fortunately such people and organisations do exist. Without the work of the St John Ambulance, the State Emergency Service, the Rural Fire Service the Red Cross and the Volunteer Rescue Association, to mention only a few, our response to disasters would be far less effective. There is a strong history of individuals being available to help the community in times of crisis. Mostly these people were volunteers but there has also always been the need for a core of professional support. In the recent past, professional support mechanisms have been developed from lessons learned, particularly to situations that need a rapid and well organised response. As lessons are learned from an analysis of events, philosophy and methods have changed. Our present system is not perfect and perhaps never will be. The need for an 'all-hazards approach' makes detailed planning very difficult and so there will probably always be criticisms about the way an event was handled. Hindsight is a wonderful thing, provided we learn from it. That means that this text is certainly not the 'last word' and revisions as we learn from experience will be inevitable. Because the author works primarily in New South Wales, many of the explanations and examples are specific to that state. In Australia disaster response is a State, rather than a Commonwealth, responsibility and consequently, and inevitably, there are differences in management between the states and territories within Australia. With the influence of Emergency Management Australia, these differences are being reduced. This means that across state and territory boundaries, assistance is common and interstate teams can be deployed and assimilated into the response rapidly, safely, effectively and with minimum explanation. This text sets out to increase the understanding of what is required, what is in place and how the processes of response are managed. By way of introduction and background, examples are given of those situations that have occurred, or could happen. Man Made Disasters has been divided into two distinct sections. Those which are related to structures or transport and those related directly to people. The first section, Chapter 3, includes: • Transport accidents involving land, rail, sea or air vehicles. • Collapse of buildings for reasons other than earthquakes or storms. • Industrial accidents, including the release of hazardous substances and nuclear events. A second section dealing with the consequences of the direct actions of people is separated as Chapter 4, entitled 'People Disasters'. Included are: • Crowd incidents involving sports and entertainment venues. • Terrorism From Chapter 4 on, the emphasis is on the Response phase and deals with organisation and response techniques in detail. Finally there is a section on terminology and abbreviations. An appendix details a typical disaster pack content. War, the greatest of all man made disasters is not considered in this text.

Syftet med studien var att beskriva patienters erfarenheter av hur den personligaintegriteten respekteras i olika vårdsituationer. Varje människa har rätt att blirespekterad som en individ och inte utsättas för intrång i den personliga sfären. Då dettainte alltid respekteras i vårdsituationerna blir det intressant att skaffa kunskaper om hurpatienter upplever detta. I studien användes en kvalitativ ansats. Med hjälp av criticalincident metoden undersöktes patienters positiva och negativa erfarenheter av hur denpersonliga integriteten respekterades i olika vårdsituationer. Nio informanter deltog istudien, dessa bidrog med arton berättelser. Materialet analyserades kvalitativt. Treöverordnade teman med fem underteman framstod. Övergripande handlar fenomenetom att bli respekterad som människa. De tre överordnade temana är att bli lyssnad till,att bli sedd och att bli förstådd. Resultatet visar att om den personliga integriteten interespekterades blev patienter kränkta och ett onödigt lidande orsakades därmed avvården. Studien har betydelse för vården då respekt för integriteten är ett grundläggandebehov för patienters upplevelse av hälsa och lidande.

The aim of this study was to describe patient’s experiences of how privacy is respectedin health care. Every human being has the right to be respected as an individual and notbe subjected to interference in the personal sphere. Since this is not always respected inhealth care, it is interesting to gain knowledge about patient’s experiences. Aqualitative method was used in the study. By using the critical incident techniquepatient’s positive and negative experiences of personal integrity in health care wasreviewed. Nine informants participated and contributed eighteen stories. The materialwas analyzed qualitatively. Three superior themes with five subthemes found. Overall,this phenomenon is about to be respected as a human being. The superior themes are tobe heard, to be seen and to be understood. The result shows that if the personal privacywas not respected, the patient’s felt violated and an unnecessary suffering was therebycreated of health care. The study has implications for health care because the integrityis a fundamental need for patient’s experiences of health and suffering.

Electronic prescribing systems (EPS) may be considered to enhance safe prescribing compared to paper-based prescribing systems. This thesis examined EPS safety, including in non-medical prescribers, in three studies. Firstly, a systematic review and meta-analysis examined the impact of EPS on the incidence of prescribing errors in hospital settings. EPS was associated with a reduction in prescribing errors based on a random effects model odds ratio (OR=0.26, 95% CI, 0.14 to 0.42, p˂0.00001). Secondly, prescribing errors detected and reported in hospital pharmacist interventions were examined. Errors were identified in 1.1% (95% CI 1.1 to 1.2%) of prescribed items. Most errors were considered significant (68.5%). Over half (56%) of errors occurred at the admission stage. Finally, a qualitative examination of semi-structured interviews was conducted with 23 medical and non–medical prescribers in a hospital. Prescribers described multiple contributory factors to electronic prescribing errors, including human factors and human-computer interactions. Prescribers’ perceptions of the benefits of EPS were clear, although concerns about overreliance on EPS and system complexity remained. Prescribers had useful suggestions to increase prescribing safety. In combination, the three branches of this thesis show EPS is an effective tool, and provides insights that can potentially optimise safe prescribing, including tailoring to end-user requirements.

Sammanfattning Bakgrund: I Sverige har cirka 200 000 personer hjärtsvikt. Sjukdomen kan vara kronisk, komplex och innebär en livslång behandling. Det är en allvarlig sjukdom där cirka 50 % med svår hjärtsvikt dör inom ett år. Det finns inga klara riktlinjer när transition till palliativ vård för patienter med hjärtsvikt sker. Syfte: Syftet var att identifiera erfarenheter som sjuksköterskor ansåg vara av betydelse för att initiera palliativ vård för patienter med hjärtsvikt, samt vilka åtgärder som därefter vidtogs. Metod: En kvalitativ design med induktiv ansats valdes. Totalt genomfördes 15 ostrukturerade intervjuer, alla intervjuer analyserades utifrån Critical Incident Technique. Resultat: Det framkom att ett allmänt försämrat hälsotillstånd var erfarenheter som sjuksköterskan ansåg vara av betydelse för transition till palliativ vård. I resultatet framkom även att åtgärder som vidtogs ledde till att vården blev mer palliativt inriktad. Slutsats: Att identifiera patienter med hjärtsvikt som var i behov av palliativ vård var viktigt men svårt och krävde kunskap. Det finns behov av att utarbeta hjälpmedel och verktyg för att underlätta identifieringen till palliativ vård, eftersom det leder till att vården blir mer personcentrerad och behandlingsstrategin förändras.
Abstract Background: In Sweden, approximately 200,000 people have heart failure. Heart failure can be chronic, complex and involves lifelong treatment. It is a serious disease in which about 50% with severe heart failure die within a year. There are no clear guidelines when transition to palliative care for patients with heart failure occurs. Objective: The purpose was to identify experiences that nurses considered to be important for initiating palliative care for patients with heart failure, and what actions thereafter were taken. Methods: A qualitative design with inductive approach was chosen for this study. A total of 15 unstructured interviews were conducted and analyzed on the basis of the Critical Incident Technique. Results: The result was divided into two parts. It was found that a generally deteriorated health were experiences that the nurse considered to be of importance for transition to palliative care. In the results it emerged that measures that was taken led to more oriented palliative care for the patients. Conclusion: To identify patients with heart failure who were in need of palliative care was important but difficult and required knowledge. There is a need to develop aids and tools to facilitate identification for palliative care, as it causes care to be more person-centered and the treatment strategy changes.

The past decade has seen increased patient acuity and shortened lengths of stays in acute care hospitals (Australian Institute of Health and Welfare (AIHW), 2005), resulting in an intensification of the work undertaken by nursing staff in hospitals. Changes in nursing work have also been compounded by the proliferation of health care roles, a blurring of skill boundaries (AIHW, 2001; Buchan & Dal Poz, 2002; Hayman, Cioffi & Wilkes, 2006; Jones and Cheek, 2003) and an aging nursing workforce that is predominantly working part-time (Creegan, Duffield & Forrester, 2003). Moreover, with increasing demand for acute care beds (ABS, 2005), there is simply not enough licensed nursing staff to fill current vacancies (AIHW, 2005; Duffield & O’Brien-Pallas, 2002). Since 2003, the main response from the Australian government to the declining numbers of nursing workers has been to recruit more people to the nursing profession. However, it is becoming clear that recruitment alone is not enough, with shortages growing even as nursing school enrolments are increasing; therefore, it was timely to undertake a study to understand nurses’ perceptions of scope of practice to improve future efficiency in the nursing workforce by using the information derived to provide baseline data to guide workforce planning. The specific aim of this study was to understand how medical and surgical nurses, from two Queensland hospitals, conceive their scope of practice in response to the available grade mix and skill mix of nurses—licensed and unlicensed—and other health care professionals in the acute care setting. By exploring these meanings, this study aimed to build an understanding of how nursing work patterns were shifting in the face of changing patient acuity, patient profiles and nursing skill mix. To address this aim, a constructivist methodology was used that allowed for exploration of nursing role and scope of practice. While the notion of constructivism best describes the main approach to this study, it was also naturalistic to the extent that participants were reflecting on day-to-day experiences. The method used in this study is situated around the Critical Incident Technique (CIT) (Flanagan, 1954). CIT generates data representing experiences or perceptions of aspects of best and worst practice (Byrne, 2001). The researcher asked 20 registered nurse (RN) and enrolled nurse (EN) participants to discuss up to two particular significant events during which they were undertaking a patient care activity they perceived they should be undertaking, and up to two events during which they believed those activities should have either been delegated or undertaken by a higher level of care provider. Using the CIT in this way, allowed the researcher to gain an understanding of the nursing scope of practice and the interactions between nurses and other clinicians (Byrne, 2001) while also minimising pre-interpretation of the events by participants and focusing on a rich description of the chosen event (Flanagan, 1954). Purposive sampling was used to assist with the discovery of opposing points of view (Guba & Lincoln, 1989) with all RN and EN participants being employed on selected medical and surgical wards within two large hospitals based in South East Queensland. Inductive analysis, a process for searching for themes within the data, rather than imposing theories on the data (Guba & Lincoln, 1989), was used. Analysis revealed that the nursing work environment was changing. This was causing nursing staff to question what it meant to provide patient care given the increased numbers of health care workers (HCWs) in the acute care setting, rising patient acuity, and increased patient turnover. RNs were struggling with the notions that ‘hands-on’ care was sometimes not the best use of their time, and delegation did not equate with laziness. Five themes arose from the data: (1) good nurses work in proximity to patients providing total patient care; (2) safeguarding patients; (3) privileging patients without mental illness or cognitive impairment; (4) developing teamwork strategies; and (5) picking up the slack to ensure patient safety. Findings have shown that negotiation has become a fundamental aspect of nursing practice given the variety of nursing care providers currently employed in acute care settings. Previously, there wasn’t a need for nurses to negotiate care between licensed and unlicensed staff because HCWs were not employed in these settings. Negotiation has allowed nurses to redefine appropriate nurse–patient proximity, promote patient safety and find innovative ways of working in nursing teams. Practice negotiation will become a prominent topic over the coming years as hospital administrators struggle to employ licensed nurses.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Nursing and Midwifery
Griffith Health
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Bakgrund: Specialistsjuksköterskan i en prehospital miljö ställs inför utmaningar när en svår luftväg inte längre kan hanteras genom basal luftvägshantering. Denna situation kräver spetskompetens inom avancerad luftvägshantering och anestesi, samt särskilda hjälpmedel. Inom vissa regioner finns en prehospital förstärkningsenhet som har som uppgift att komplettera ordinarie verksamhet med spetskompetens när det finns behov av avancerad luftvägshantering. Syfte: Syftet med studien var att studera anestesisjuksköterskors strategier vid hantering av svår luftväg i en prehospital förstärkningsenhet. Metod: En kvalitativ studie med datainsamling via enkät tillämpades och analyserades med kritisk incident teknik (CIT). Sexton anestesisjuksköterskor i en prehospital förstärkningsenhet i Sverige besvarade enkäten. Resultat: Analysen ledde fram till fyra betydelsefulla strategier för att hantera en svår luftvägprehospitalt. Förberedelse i att ställas inför en svår luftväg, mental förberedelse på väg ut på larm, möjligheten att lägga upp en primär samt en sekundär plan tillsammans med kollegan och att våga agera direkt var strategier som identifierades för att hantera en svår luftvägprehospitalt. Detsamma gällde att ta beslut i tid, att flytta patienten så att omhändertagandet inte behövde anpassas i onödan av omständigheter som kanske gick att undvika, att skapa åtkomst och insyn till patientens luftväg och ha närhet till egen utrustning vid hantering av en svår luftväg. Kollegan, teamkänsla, kommunikation, igenkännande, förståelse för varandras uppdrag och kännedom om varandras arbetssätt och utrustning var framgångsfaktorer för att få ett bra och effektivt teamarbete runt den svårt sjuka patienten. Utrustning som normalt inte fanns i en akutambulans som videolaryngoskop, endotrakealtub förberedd med ledare, kapnograf och en bra sug var framgångsfaktorer för att hantera en svår luftväg prehospitalt. Slutsats: Resultatet kan komplettera specialistutbildningar och introduktionsutbildningar för att göra specialistsjuksköterskan bättre förberedd på luftvägshantering i en prehospital miljö. Kunskapen kan bidra till en större förståelse för hur den svåra luftvägen på olika sätt kan undvikas eller hanteras. Basal luftvägshantering skall ambulanssjuksköterskan behärska i sin akutambulans men för hantering av den svåra luftvägen behövs särskild spetskompetens, hjälpmedel och förmåga.

Background: Little is known about the relationship between women's birthing experiences and the development of trauma symptoms. This study aimed to determine the incidence of acute trauma symptoms and posttraumatic stress disorder (PTSD) in women as a result of their labor and delivery experiences, and identify factors that contributed to the women's psychological distress. Method: Using a prospective, longitudinal design, women in their last trimester of pregnancy were recruited from four public hospital antenatal clinics. Four to six weeks postpartum, telephone interviews were conducted with participants (n = 499) and explored the medical and midwifery management of the birth, perceptions of intrapartum care, and the presence of trauma symptoms. Results: One in three women (33%) identified a traumatic birthing event and reported the presence of at least three trauma symptoms. Twenty-eight women (5.6%) met DSM-IV criteria for acute posttraumatic stress disorder. Antenatal variables were not found to contribute to the development of acute or chronic trauma symptoms. The level of obstetric intervention experienced during childbirth (beta = .351, p <.0001) and the perception of inadequate intrapartum care (beta = .319, p <.0001) during labor were consistently associated with the development of acute trauma symptoms. Conclusions: Posttraumatic stress disorder following childbirth is an under-recognized phenomenon. Women who experienced both a high level of obstetric intervention and were dissatisfied with their intrapartum care were more likely to develop trauma symptoms than women who received a high level of obstetric intervention or women who perceived their care to be inadequate. Such findings should prompt a serious review of intrusive obstetric intervention during labor and delivery, and the psychological care provided to birthing women.

Background: Little is known about the relationship between women's birthing experiences and the development of trauma symptoms. This study aimed to determine the incidence of acute trauma symptoms and posttraumatic stress disorder (PTSD) in women as a result of their labor and delivery experiences, and identify factors that contributed to the women's psychological distress. Method: Using a prospective, longitudinal design, women in their last trimester of pregnancy were recruited from four public hospital antenatal clinics. Four to six weeks postpartum, telephone interviews were conducted with participants (n = 499) and explored the medical and midwifery management of the birth, perceptions of intrapartum care, and the presence of trauma symptoms. Results: One in three women (33%) identified a traumatic birthing event and reported the presence of at least three trauma symptoms. Twenty-eight women (5.6%) met DSM-IV criteria for acute posttraumatic stress disorder. Antenatal variables were not found to contribute to the development of acute or chronic trauma symptoms. The level of obstetric intervention experienced during childbirth (beta = .351, p <.0001) and the perception of inadequate intrapartum care (beta = .319, p <.0001) during labor were consistently associated with the development of acute trauma symptoms. Conclusions: Posttraumatic stress disorder following childbirth is an under-recognized phenomenon. Women who experienced both a high level of obstetric intervention and were dissatisfied with their intrapartum care were more likely to develop trauma symptoms than women who received a high level of obstetric intervention or women who perceived their care to be inadequate. Such findings should prompt a serious review of intrusive obstetric intervention during labor and delivery, and the psychological care provided to birthing women.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Applied Psychology (Health)
Griffith Health
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Bakgrund: Vetenskapliga artiklar visar att patienter som får stroke under sin sjukhusvistelse får sämre omhändertagande än strokepatienter som direktinläggs. Litteraturen visar även att det behövs mer kunskap om vilka förbättringar som kan behöva göras för att få en säker, kunskapsbaserad och effektiv stroke sjukvård. Syfte: Studiens syfte är att identifiera händelser som har varit kritiska i omhändertagandet av inneliggande patienter som insjuknar i stroke. Metod: CIT (Critical Incident Technique) har använts som datainsamlingsmetod, denna har använts inom flygvapnet men har på senare tid fått större användning i bl. a hälso- och sjukvården. Kvalitativ innehållsanalys enligt Burnard (1996) ligger till grund för bearbetning av materialet. Analysen utgick ifrån 10 intervjuer med sjuksköterskor som har erfarenhet av patienter som insjuknat i stroke på vårdavdelning. Intervjuer är genomförda på 5 (fem) olika typer av avdelningar inom Sahlgrenska sjukhuset under våren 2016. Resultat: Kritiska händelser förekommer i samband med omhändertagande inom alla delar av vården av patienter som insjuknar i stroke under sin sjukhusvistelse. Övergripande kategorier är: oförutsedd händelse, bristande resurser riskerar patientsäkerheten och specialistvårdens baksida/organisatoriska hinder. Kategorierna identifieras inom mikro-, meso- och makrosystem för sig samtidigt som de interagerar mellan de olika systemen. Slutsatser: Tillgång till aktuella mätningar är viktig för att få en överblick över det aktuella läget för inneliggande strokepatienter i form av antal och var de inträffar. Studien visar att det finns ett stort behov av en välfungerande strokekedja för inneliggande strokepatienter och att det finns genomförda projekt i USA som kan vara till hjälp för framtida förbättringar i stroke vården. Det är även viktigt att lägga fokus kommunikation och information till anhöriga.
Background: Scientific articles has shown that patients that have had a stroke during their hospitalization receive lesser degree of care, than patients that has been admitted with a stroke. Literature has shown we need more knowledge how to improve stroke care to get a secure, knowledge based and effective stroke care in hospitals. Aim: The study aims to identify the events that have been critical in the management of hospitalized patients who suffer a stroke. Method: CIT has been used as a data collection method to bring in information, it has been used in the airforce and more recently has been used more widely in national healthcare. Qualitative contents analysis, according to Burnard (1996), gives basis for analyzing the material. The analysis was based on 10 interviews with nurses who have experience of patients diagnosed with stroke during hospitalization. Interviews were conducted at 5 (five) different departments within the Sahlgrenska Hospital in spring 2016. Result: Critical events occur in connection with care in all parts of the care of in-hospital patients who suffer a stroke. Overall categories: unexpected event, the safety of patients affected by department resources and the backside of specialist care. The categories identified in the micro, meso and macro systems are interacting between the different systems. Conclusion: Access to current measurements is important to get an overview of the current state of in-hospital stroke patients in the form of numbers and where they occur. The study shows that there is a great need for a well-functioning stroke chain for in-hospital stroke patients and that there are implemented projects in the US that could be helpful for future improvements in stroke care. It is also important to focus on communication and information to relatives.

CHDS State/Local
One basic expectation that citizens have of government is to restore order in the face of devastation. With each catastrophic incident, politicians and administrators step under the public microscope, as they attempt to bring order out of chaos. Failure to perform such a basic governmental function subjects officials and agencies to immense scrutiny with personal and organizational repercussions. In the quest for the answers to What can be done better next time and How do we prevent this from happening again elected officials and bureaucrats seek various policies. A recent example of this is the National Incident Management System (NIMS). NIMS is a fusion of Incident Command Systems (ICS) and broad governmental policy aimed at providing a systematic response to incidents. The fact that NIMS became policy was quite possibly a predictable event in an incremental series of events that began in the early 1970s. This thesis reveals how these predictable and incremental efforts have pushed our national frameworks into an increasing state of complexity with the potential of catastrophic failure. Further, this thesis recommends ways that will harvest success in the face of a catastrophic or disastrous incident without increasing complexity.

Background: Globally there is an increasing awareness of the need for end-of-life care and palliative care in hospitalized patients that are in their final year of life. However, limited data are available in low and middle income countries which hinders the design and implementation of effective policies and health services for this patient group. Aim: To determine the proportion of patients who die within one year from their date of admission to hospital in public hospitals in South Africa. Design: Retrospective incident cohort study using record linkage of admission and mortality data. Setting: 46 acute care public hospitals in the Western Cape Province of South Africa. Results: Of the 10 761 patients (median age 44 years; IQR: 31 - 60) admitted to 46 hospitals over a 2 week period in March 2012, 1570 (14.6%) died within one year, the majority of the deaths occurring within the first 3 months. Mortality rose steeply with age as expected. The median age of death was 57.5 years; IQR: 45 - 70. A greater proportion of patients admitted to medical beds died in one year (21.3%) as compared with surgical beds (7.7%). Conclusion: Despite a median age under 60 years at admission, a large percentage of patients admitted to public sector hospitals in South Africa, an upper-middle income country with a high HIV and non-communicable disease burden, are in the final year of their lives. This finding highlights the need for planning and implementation of end-of-life and palliative care strategies for hospitals and patients.

Thesis (Ph. D.)--Illinois State University, 2001.
Title from title page screen, viewed March 14, 2006. Dissertation Committee: James C. Palmer (chair), W. Paul Vogt, Edward Hines, Alvin E. House. Includes bibliographical references (leaves 94-96) and abstract. Also available in print.

Researchers have increasingly directed attention to the importance of emotions in decision making. Recent theories have focused on the interpersonal effects of emotions--the influence of the decision maker's expressed emotions on observers' decisions and judgments. In the current research, we examine people's expectations of how incidental, discrete emotions affect behavior. We also study how these expectations affect decisions in interactive settings, and contrast them with how emotions actually impact other people's behavior.These ideas were tested in four studies. In Study 1a, participants (N = 58) answered a questionnaire asking their perceptions of how different emotions affect behavior. In Study 1b, participants (N = 203) read a number of hypothetical scenarios in which different interactions between them and another person took place. Studies 2 (N = 98) and 3 (N = 132) were two economic games -- a Stag-Hunt game and a Trust Game -- involving decisions with non-trivial financial consequences.Across these four studies, I found that people do have strong beliefs about how incidental emotions affect behaviors. Because of these beliefs, when told about their counterparts' emotional state, people in interactive settings modify their behavior. The impact of people's beliefs on behavior, however, was more consistent for negative emotions such as anger and fear, than for positive emotions such as happiness and gratitude. These findings also indicate that people are sensitive to the different effects of different emotions: different negative emotions such as guilt and anger have different effects on their expectations. Finally, I found that people's expectations about how their counterparts' emotions affect behavior can be inaccurate in specific settings.