Thèses : « Clinical Practice Guidelines (CPG) »

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Mac, Donald Tanya. « Standardized functional capacity outcome measures in post-operative cardiac surgery : A survey of current clinical practice and development of a clinical practice guideline (CPG) ». Thesis, University of Ottawa (Canada), 2009. http://hdl.handle.net/10393/28369.

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The objectives of the thesis were to determine the prevalence of functional capacity outcome measure use among physiotherapists working with post-operative cardiac surgery clients and to develop evidence-based recommendations regarding their use in clinical practice. The thesis consisted of a systematic review of the literature; a survey of outcome measure use in clinical practice; and the development of a clinical practice guideline. Thirty-one functional capacity outcome measures were included in the review. Only 2.6% of survey respondents reported almost always using outcome measures in their clinical practice. The Six Minute Walk Test, the modified Borg Rating Scale of Perceived Exertion and vital signs were recommended for routine use in clinical practice. A variety of outcome measures are available for use in clinical practice however their use in clinical practice continues to be less than optimal. There is a need for continued training in outcome measure use in clinical practice.

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Shibu, Litty Mathew. « Examining the research-practice gap in Physical Therapy (PT) in the United States of America using knowledge translation interventions (KTIs) : a comparative study ». Thesis, Brunel University, 2018. http://bura.brunel.ac.uk/handle/2438/17553.

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This research was undertaken to study the impact of single and multicomponent knowledge translation interventions (KTIs) on barriers to the integration of Clinical Practice Guidelines (CPG) into Clinical Decision Making (CDM) in the context of physical therapists (PTs) and find out which of the two KTIs was more effective. A literature review showed that research knowledge (e.g. CPG) in the field of PT (Physical Therapy) is not being integrated in to clinical practice (e.g. CDM), thus leading to a research-practice (R-P) gap in other words CPG-CDM gap. It is suggested in the literature that the management and behavioural aspects of PTs might be acting as barriers hindering the integration of the research knowledge into clinical practice consequently affecting the delivery of optimum patientcare. Remedial measures, namely KTIs, are suggested to address those barriers and to bridge the R-P gap. However, the phenomenon of the R-P gap, the causes of it and the possible interventions are not well understood concepts in the literature, particularly in the context of PTs. CPG for Venous Thromboembolism (VTE) in PT was chosen as the example of research knowledge. It was argued that barriers have the potential to affect CDM which in turn can affect the CPG-CDM gap. Lack of knowledge about CPG-CDM gap is a major limitation in the literature that is affecting the integration of CPG into CDM. Other gaps found in the literature that have the potential to affect CPG-CDM gap include management and behavioural variables as probable causes of CPG-CDM gap (or barriers), use of KTIs to bridge the CPG-CDM gap and, KTIs. Furthermore, lack of knowledge about relationship between barriers and CPG-CDM gap, KTIs and barriers, KTIs and CPG-CDM gap and the impact of KTIs (effectiveness) in bridging CPG-CDM gap were the other gaps found in the literature that had potential implications to CPG-CDM gap. These gaps were addressed in this research to some extent. Relationships between the independent variables (lack of knowledge of PTs in CPG, lack of favourable attitude of PTs towards CPG and lack of self-efficacy and motivation of PTs to integrate CPG into CDM) and the dependent variables (CDM and CPG-CDM gap) were defined and models were proposed. Further, it was posited that KTIs could impact barriers based on theories and models found in the literature that provided some basis to create the linkage between KTIs and management and behavioural barriers. Education material (EM) and virtual communities of practice (VCoP) were chosen as of the KTIs in this study. The models of Cabana et al. (1999) and Fischer et al. (2016), primarily, were used to ground the conceptual models represented by figures and equations. Methodologically, a positivist approach with an objective ontological stance was employed and a deductive approach and quantitative research method were used to address the research gaps. The research design included a longitudinal element and survey questionnaire. The target population was licensed PTs in the USA. Random sampling was used. Two groups of PTs were identified namely EM-group and VCoP group. Data was collected from the groups before and after administering the KTIs. The results showed that single and multicomponent KTIs impacted barriers in different ways. EM impacted lack of favourable attitude of PTs towards CPG, and lack of self-efficacy and motivation of PTs to integrate CPG into CDM as barriers and narrow the CPG-CDM gap. VCoP was found to impact the combination of four barriers and narrow CPG-CDM gap. In addition, barriers in groups of two were also impacted by VCoP and narrowed the CPG-CDM gap. Furthermore, a CPG knowledge score card and a corresponding CDM score card developed by the researcher were used to test the change behaviour of PTs in integrating CPG into CDM. This experiment showed that barriers existed and caused CPG-CDM gap and KTIs could narrow the CPG-CDM gap. The findings indicate that this research has contributed to knowledge in many ways, including unearthing the relationship between CPG-CDM gap and barriers, better understanding of KTIs, their relationship with CPG-CDM gap and barriers, gaining knowledge about the impact of single and multicomponent KTIs on single and multiple barriers and identification of methods to bridge the CPG-CDM gap.

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Youssef, Sarah Jane. « Implant Maintenance Curriculum Among U.S. Dental Hygiene Programs ». The Ohio State University, 2020. http://rave.ohiolink.edu/etdc/view?acc_num=osu1586814568072554.

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Taylor, Michael Dennis. « Prostate cancer clinical practice guidelines clinical and economic outcomes / ». [Gainesville, Fla.] : University of Florida, 2005. http://purl.fcla.edu/fcla/etd/UFE0010098.

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Thesis (Ph.D.)--University of Florida, 2005.
Typescript. Title from title page of source document. Document formatted into pages; contains 99 pages. Includes Vita. Includes bibliographical references.

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Freemantle, Jane. « The impact of clinical practice guidelines for preterm labor on clinical care / ». Title page, table of contents and abstract only, 1997. http://web4.library.adelaide.edu.au/theses/09MPM/09mpmf855.pdf.

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Msosa, Yamiko Joseph. « Modelling evolving clinical practice guidelines : a case of Malawi ». Thesis, University of Cape Town, 2018. http://hdl.handle.net/11427/28388.

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Electronic medical record (EMR) systems are increasingly being adopted in low- and middle-income countries. This provides an opportunity to support task-shifted health workers with guideline-based clinical decision support to improve the quality of healthcare delivery. However, the formalization of clinical practice guidelines (CPGs) into computer-interpretable guidelines (CIGs) for clinical decision support in such a setting is a very challenging task due to the evolving nature of CPGs and limited healthcare budgets. This study proposed that a CIG modelling language that considers CPG change requirements in their representation models could enable semi-automated support of CPG change operations thereby reducing the burden of maintaining CIGs. Characteristics of CPG changes were investigated to elucidate CPG change requirements using CPG documents from Malawi where EMR systems are routinely used. Thereafter, a model-driven engineering approach was taken to design a CIG modelling framework that has a novel domain-speciﬁc modelling language called FCIG for the modelling of evolving CIGs. The CIG modelling framework was implemented using the Xtext framework. The national antiretroviral therapy EMR system for Malawi was extended into a prototype with FCIG support for experimentation. Further studies were conducted with CIG modellers. The evaluations were conducted to answer the following research questions: i) What are the CPG change requirements for modelling an evolving CIG? ii) Can a model-driven engineering approach adequately support the modelling of an evolving CIG? iii) What is the eﬀect of modelling an evolving CIG using FCIG in comparison with the Health Level Seven (HL7) standard for modelling CIGs? Data was collected using questionnaires, logs and observations. The results indicated that ﬁnegrained components of a CPG are aﬀected by CPG changes and that those components are not included explicitly in current executable CIG language models. The results also showed that by including explicit semantics for elements that are aﬀected by CPG changes in a language model, smart-editing features for supporting CPG change operations can be enabled in a language-aware code editor. The results further showed that both experienced and CIG modellers perceived FCIG as highly usable. Furthermore, the results suggested that FCIG performs signiﬁcantly better at CIG modelling tasks as compared to the HL7 standard, Arden Syntax. This study provides empirical evidence that a model-driven engineering approach to clinical guideline formalization supports the authoring and maintenance of evolving CIGs to provide up-to-date clinical decision support in low- and middle-income countries.

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Irving, Michelle. « Implementation of evidence in nephrology using clinical practice guidelines ». Thesis, The University of Sydney, 2010. http://hdl.handle.net/2123/13637.

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Chronic kidney disease (CKD) is becoming increasingly common in today’s society. It is estimated that 16% of the Australian population have some form of CKD. In 2007 over 16 000 were undergoing treatment for end stage chronic kidney disease (ESKD) this includes over 2000 new patients. Over 1600 died whilst undergoing treatment for ESKD in 2007. There has been a proliferation of evidence-based clinical practice guidelines for the treatment of chronic kidney disease patients, both locally and internationally. The Caring for Australasians with Renal Impairment (CARI) guidelines are guidelines produced for Australian and New Zealand practitioners. The CARI Guidelines have been written by doctors, nurses, allied health professionals and consumers on a voluntary basis. They are published on-line and in the journal Nephrology as biennial supplements. The use of these guidelines in practice is aimed at reducing mortality and morbidity for ch ronic kidney disease patients. Evidence shows that the attainment of evidence-based guideline recommendations is variable between practitioners, renal units, states and countries, often with a gap between guideline recommendations and practice. Research into the use of guidelines in practice is a new and emerging field of research. Current research into the strategies to bridge this gap has been unable to suggest one effective method to increase the rate of guideline implementation into practice. The research projects that form the basis of this thesis aimed to explore current implementation strategies used in chronic kidney disease and research best methods of implementation for evidence-based CKD guidelines within a framework of exploring barriers and enablers to this process. In chapter 2 of this thesis, to understand what is already known about the implementation of evidence-based guidelines in CKD, a systematic review of all published studies on implementation of evidence-based guidelines was ! undertak en. Twenty two studies including seven randomized controlled trials and 15 before-after studies were included. Four main interventions were evaluated in over 700 dialysis centres/hospitals or general practices: audit and feedback, computerized decision support system (CDSS), opinion leader/multidisciplinary team and passive dissemination of guidelines. Audit and feedback significantly increased 14 of the 25 study outcomes with a median improvement of 2.5% (range: -4.5-48.4%). CDSS significantly increased three of the four study outcomes with a median improvement of 12.8% (range: 1.1-42.1%). Opinion leader/multidisciplinary team significantly increased 24 of the 30 study outcomes with a median improvement of 8.2%(range: -4.0-79.8%). Dissemination of guidelines resulted in a median improvement in study outcomes of 2.7% (range 0.5-25.8). Well planned and executed interventions were able to improve CKD management to varying degrees. The achievement of quality indicators was assoc iated with improved patient outcomes. In Chapters 3 and 4, to gain a detailed understanding of the opinions of the end users of the CARI guidelines a survey was undertaken of all nephrologists and renal nurses in Australia and New Zealand. Chapter 3 outlines the results of the 211 nephrologists (70% of practising nephrologists) who responded. Over 90% agreed that the CARI guidelines were a useful summary of evidence, nearly 60% reported that the guidelines had significantly influenced their practice and 38% reported that the guidelines had improved health outcomes for patients. Only 8% indicated that the guidelines did not match the best available evidence. Older age and being male showed some association with a less favourable response for some domains. Chapter 4 discusses the results from the 173 renal nurses who responded. They were more positive in their responses, than nephrologists, in the range of 10-20% in many question domains. and improvemen ts in positive responses regarding the guidelines in the ran! ge of 10 -30% were seen in many domains between 2002 and 2006. Chapter 5 builds on the information obtained in the survey of nephrologists to further understand the role that guidelines have in clinical practice and clinical decision making. Face to face interviews with Australian nephrologists were undertaken. The results were analysed qualitatively and four major themes emerged. 1) There was a high degree of trust in the CARI process and output; 2) Guidelines had a range of functions in clinical practice, they provided a good summary of evidence, were a foundation to practice, an educational resource, could justify funding requests to policy makers, and promote patient adherence; 3) There was also non-guideline influences on clinical decision making, such as quality of life or patient needs, opinion leaders, previous experience, the clinical setting, the regulation and subsidy framework for drugs and devices, logistics, and other sources of evidence; 4) Nephrologists sug gested facilitators of guideline implementation such as audit and feedback and reminders. The process by which nephrologists engaged with and used the guidelines was noted and compared to Rogers’ diffusion of innovation theory. Some additional steps were added to this theory to make it applicable to the implementation of guidelines in CKD. Improvements in the evidence which underpins guidelines and improvements in the content and formatting of guidelines are likely to make them more influential on decision making. In chapter 6, to test strategies for implementation in CKD, we established an implementation project in six renal units in Australia. This centered on the implementation of the CARI iron guideline utilising audit and feedback, the use of an opinion leader and a purpose-designed computerised decision support system. Wide variation of iron indices was observed across the centres in the study. In the active implementation units, we saw improvements in iro n indices, especially in units that at baseline had iron sco! res well below the CARI guideline recommendations. We found that with a senior motivated opinion leader, the targeting of barriers and the use of a decision support system, implementation of a guideline can indeed be successful. Support from an external body such as CARI may be of assistance. The overarching purpose of these studies was to gain a better understanding of the place of guidelines in CKD practice and how we can ensure that evidence-based guidelines are used in practice and by doing so improve clinical outcomes for CKD patients. The findings show that guidelines hold a prominent place in clinical nephrology practice with both nephrologists and renal nurses, but there are many other competing influences on clinical decisions. Implementation of guidelines is possible and guideline groups should pursue this actively, utilising evidence-based implementation strategies. Strategies vary in their effectiveness and appropriate strategies should be used in differing si tuations. Renal nurses are an important resource in the implementation process. They should be involved in the guideline development process and their requirements for dissemination should be taken into account. Guidelines should be written using best methods that encourage implementation, such as the use of action statements, the provision of targets, be based on high levels of evidence, kept up to date and assistance given to encourage implementation into practice. Guideline groups should also foster close links with trials groups to facilitate a generation of evidence in required clinical areas. Finally, implementation requires hard work, by dedicated individuals at all levels, including the guideline producers and writers and those at the clinical level. A high level of detail regarding the implementation process is required, such as a thorough evaluation of barriers and strategies to overcome these. There is a need for guideline producers to understand their differing t arget audiences and tailor the guidelines depending on the n! eeds, us age and processes of these target groups.

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Nupdal, Jason Bentley. « Implementing Clinical Practice Guidelines in Family Practice : Caring for Children with ADHD ». Diss., North Dakota State University, 2014. https://hdl.handle.net/10365/27368.

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The purpose of this Practice Improvement Project was to promote evidence-based practice in caring for children ages 4-18 with Attention Deficit Hyperactivity Disorder (ADHD) in the family practice setting. The American Academy of Pediatric Clinical Practice Guidelines (CPG) and the Diagnostic and Statistical Manual of Mental Health Conditions, 5th Ed. (DSM-V) diagnostic criteria for ADHD were embedded in the electronic health record (EHR) in the form of an evaluation tool/template to guide the Primary Care Providers (PCPs) in documenting evidence-based practice in the assessment, diagnosis and treatment of ADHD. Primary stakeholders are PCPs of Riverview Clinic who care for children with ADHD. Neuman?s System Theoretical framework was used assuring a comprehensive holistic approach to caring for children with ADHD. The logic model was applied to direct project process while providing a framework for project evaluation. A focused forum was held to educate PCPs on the American Academy of Pediatrics (AAP) CPG and the DSM-V ADHD diagnostic criteria. PCPs were introduced to the tool with instruction on use. Six weeks post launching, a retrospective chart audit was done to evaluate for the presence of evidence basedpractice documentation with the evaluation tool/template versus without. When utilized, the evaluation tool/template demonstrates a higher rate of documentation supportive of evidence-based practice. The tool enhances provider?s comfort level in caring for children with ADHD while promoting optimal quality outcome for the child. Project outcome suggests the tool be used by PCPs in documenting evidence-based practice. Key words: ADHD, children, management, EHR, template, co-morbid conditions, and clinical practice guidelines.

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Chan, Kit-ling Amy, et 陳潔玲. « Strengthening Hong Kong's primary care : role of clinical practice guidelines ». Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2010. http://hub.hku.hk/bib/B45170848.

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Santana, Sondra Michelle Phipps. « Practitioners' Use of Clinical Practice Guidelines : An Evidence-Based Approach ». UNF Digital Commons, 2013. http://digitalcommons.unf.edu/etd/462.

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Pre-diabetes is a serious health problem in the United States. Distinguished by plasma glucose levels that are above the normal threshold, patients with pre-diabetes are 10 times more likely to develop type 2 diabetes. Patients with pre-diabetes suffer the same complications as patients with diabetes including diabetic retinopathy, nephropathy, and microalbuminuria. There is considerable evidence to support the idea that early identification and aggressive treatment of pre-diabetes has the potential to delay disease progression. The American Diabetes Association’s clinical practice guideline recommends management of with lifestyle modification and metformin for patients who are at risk for developing type 2 diabetes. The purpose of this project was to evaluate the implementation of the 2012 ADA clinical practice guidelines regarding the management of patients with pre-diabetes by the health care providers at a volunteer-run clinic located in a large metropolitan area in the southeastern United States. This study, even with a small sample size (n=26) revealed that the providers at the clinic had not implemented the 2012 ADA clinical practice guidelines. Clinical practice guidelines promote health care interventions that have proven benefits and improve the consistency of care provided to patients. The greatest benefits of implementing clinical practice guidelines for patients with pre-diabetes are early diagnosis and aggressive disease management. This would improve patient outcomes and in the long run, decrease the cost of medical care.

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Taylor, Rosemary. « Clinical Practice Guidelines for Home Management of Intravenous Immunoglobulin Therapy ». ScholarWorks, 2019. https://scholarworks.waldenu.edu/dissertations/7342.

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The infusion of intravenous immunoglobulin therapy in the home setting requires a critical nursing assessment and interventions aimed at managing and preventing the escalation of adverse events. Some patients experience side effects that necessitate a rapid response by field nurses, requiring standing orders for nursing administration and the availability of essential medications to alleviate symptoms in the patient's home. The clinical practice issue was that the home health agency did not have a uniform clinical practice nursing guideline to assist field nurses in providing rapid responses for managing infusion-related reactions. The purpose of this project was to develop an evidence-based clinical practice guideline using standing orders for the comprehensive management of immunoglobulin side effects in the patient's home. The practice-focused question centered on whether the use of a nursing practice guideline based on interprofessional collaboration could manage the side effects of patients in the home by decreasing the use of emergent care and improved quality of care for those patients susceptible to significant side effects. An interdisciplinary expert panel experience in IVIG l used Newman's system theory and the reach, effectiveness, adoption, implementation, maintenance framework for interprofessional collaboration in developing a clinical nursing guideline with a standing order for rating side effects. Panelists used the appraisal of guidelines, research, and evaluation II tool to appraise the evidence for the guideline. The use of clinical guideline with standing orders to address the needs of patients in the home setting may lead to positive social change by enabling more rapid management of symptoms, more effective care in the home, and improved patient outcomes

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Gravas, Stavros. « TUMT treatment of BPH from evidence based guidelines to clinical practice / ». [S.l. : Amsterdam : s.n.] ; Universiteit van Amsterdam [Host], 2007. http://dare.uva.nl/document/45890.

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Fung, Yiu-ting Tina, et 馮耀婷. « Evidence-based clinical practice guidelines of smoking cessation programs for COPD patients ». Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2011. http://hub.hku.hk/bib/B46581856.

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Borok, Kathi Keaton. « Clinical practice guidelines for emerging ultrasound applications drafting for validity and usability ». Master's thesis, University of Central Florida, 2010. http://digital.library.ucf.edu/cdm/ref/collection/ETD/id/4540.

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Clinical practice guidelines (CPGs) are viewed by many people with interests in health care as valuable tools for reducing practice variations that undermine patient outcomes and increase medical costs. However, guidelines themselves vary in quality. Assessment tools generally base quality measures on strength of guidelines' evidence base, but particularly for newly emerging applications of ultrasound, standards for measuring guideline quality are controversial. The validity of a guideline is considered likely when strong research-based evidence supports its recommendations, but for newer medical procedures such as emerging ultrasound applications, available evidence is sparse. Existing assessment tools must be modified if they are effectively to measure the validity of these guidelines built on immature evidence. Focusing on ways document drafting affects CPG validity, this study rated six guidelines using the Appraisal of Guidelines Research and Evaluation (AGREE) tool which was customized according to categories of guideline purposes and their differing features of validity. Fine-tuning AGREE in this way may create a more consistent, informative method of evaluating guidelines for emerging applications, and standards established in such an instrument may be useful as a template during the guideline development process. Results from my analyses illuminate several common omissions that weakened documents. Most guidelines did not describe an updating procedure or identify areas for future research, but results also highlighted some highly effective techniques for building validity. Notable examples include providing full credentials for expert drafters, and embedding statement references directly in the text.; From the results of the analysis, I conclude that, although the adapted assessment tool I used needs additional adjustment, it may refine analysis of guidelines for emerging ultrasound guidelines and conversely serve as a useful tool during their development process.
ID: 029050071; System requirements: World Wide Web browser and PDF reader.; Mode of access: World Wide Web.; Thesis (M.A.)--University of Central Florida, 2010.; Includes bibliographical references (p. 102-105).
M.A.
Masters
Department of English
Arts and Humanities

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Cragin, Casey A. « Early Psychosis and Trauma-Related Disorders : Clinical Practice Guidelines and Future Directions ». Antioch University / OhioLINK, 2017. http://rave.ohiolink.edu/etdc/view?acc_num=antioch1490872798406533.

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Marcos, Cláudia. « Qual deverá ser a intervenção da fisioterapia no tratamento da lombalgia ? - uma revisão de orientações clínicas ». Bachelor's thesis, [s.n.], 2021. http://hdl.handle.net/10284/10605.

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Projeto de Graduação apresentado à Universidade Fernando Pessoa como parte dos requisitos para obtenção do grau de Licenciada em Fisioterapia
Objetivo: Avaliar criticamente as Normas de Orientação Clínica (NOC) mais recentes, com o intuito de resumir as recomendações e aferir a sua consistência no tratamento fisioterapêutico da lombalgia. Metodologia: Pesquisa nas bases de dados da PubMed, PEDro e Web of Science e o motor de busca Google Académico, recorrendo à expressão de pesquisa: (“Clinical Practice Guidelines” OR “Clinical Guidelines”) AND (“lumbar pain” OR “low back pain”). Também foram usados quatro repositórios de Guidelines online: Guidelines International Network (G-IN), National Health and Medical Research Council (NHMRC), National Guideline Clearinghouse of the Agency for Health Care Research and Quality (USA) e National Institute for Health and Care Excellence (NICE). Critérios de elegibilidade: NOC publicadas com um limite temporal de 5 anos (2016 e 2021), escritas em português,inglês ou espanhol, com foco na intervenção fisioterapêutica em indivíduos com diagnóstico de lombalgia. Resultados: Um total de 11 NOC atenderam aos critérios de elegibilidade e foram avaliadas. No geral, o domínio com maior classificação média foi Âmbito e Propósito (84%), seguido por Independência Editorial (83%), Clareza e Apresentação (81%), Rigor de Desenvolvimento (78%), Envolvimento das Partes Interessadas (75%) e Aplicabilidade (55%). Na avaliação geral das NOC, a média do item de Avaliação geral foi de 69% e a qualidade foi classificada na sua maioria como baixa. Foram identificadas 4 recomendações consistentes para o tratamento da lombalgia, nomeadamente, a favor da manipulação, aconselhamento e exercícios terapêuticos e contra a tração lombar. Conclusão: Foram encontradas limitações metodológicas que afetam a qualidade das NOC. Com base nas NOC revistas, o fisioterapeuta deverá intervir na lombalgia através de um programa multimodal que deve incluir a manipulação, o aconselhamento e os exercícios terapêuticos.
Objective: To critically evaluate the most recent Clinical Practice Guidelines (CPGs), in order to summarize the recommendations and assess their consistency in the physiotherapeutic treatment of low back pain. Methodology: Research in PubMed, PEDro and Web of Science databases and the search engine Google Academic, using the search expression: (“Clinical Practice Guidelines” OR “Clinical Guidelines”) AND (“lumbar pain” OR “low back pain”). Four online guidelines repositories were also used: Guidelines International Network (G-IN), National Health and Medical Research Council (NHMRC), National Guideline Clearinghouse of the Agency for Health Care Research and Quality (USA) e National Institute for Health and Care Excellence (NICE). Eligibility criteria: CPG’s published with a time limit of 5 years (2016 and 2021), written in portuguese, english or spanish, with a focus on physical therapy intervention in individuals diagnosed with low back pain. Results: Overall, the domain with the highest average rating was Scope and purpose (84%), followed by Editorial independence (83%), Clarity of presentation (81%), Rigour of development (78%), Stakeholder involvement (75%) and Applicability (55%). In the overall assessment of the guideline, the average for the Overall assessment item was 69% and the quality was mostly rated as low. Four consistent recommendations were identified for the treatment of low back pain, namely, in favor of manipulation, counseling and therapeutic exercises and against lumbar traction. Conclusion: Methodological limitations that affect CPGs quality have been found. Based on the revised CPG’s, the physiotherapist should intervene in low back pain through a multimodal program that should include manipulation, counseling and therapeutic exercises.
N/A

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Robin, Wilhelmus Maria Vernooij. « Updated clinical guidelines : improving their methods and reporting ». Doctoral thesis, Universitat Autònoma de Barcelona, 2018. http://hdl.handle.net/10803/462100.

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Antecedentes: Las guías de práctica clínica (GPC) tienen como objetivo orientar en la toma de decisiones a profesionales de la salud, pacientes y responsables de elaborar políticas sanitarias, mediante recomendaciones para un problema de salud. Sin embargo, dado que regularmente se publica nueva evidencia, la actualización de las GPC es necesaria para garantizar la validez de las recomendaciones. A diferencia de lo que ocurre con la metodología para elaborar GPC de novo, existen pocas guías disponibles sobre el proceso de actualización de las GPC y los conocimientos sobre los métodos que utilizan las instituciones para mantener la validez de sus GPC son limitados. Objectivos: Los objetivos de esta tesis son 1) identificar y describir las guías de actualización incluidas en los manuales metodológicos de las GPC, 2) desarrollar una lista de verificación para informar sobre el proceso de actualización de las GPC actualizadas y 3) evaluar la exhaustividad de la información sobre el proceso de actualización en las GPC actualizadas mediante el uso de la lista de verificación. Métodos: En el primer estudio realizamos una revisión sistemática de los manuales metodológicos de las GPC mediante una búsqueda en MEDLINE, en la base de datos de Guidelines International Network (G-I-N) y en la base de datos de US National Guidelines Clearinghouse. Dos autores seleccionaron la evidencia y extrajeron los datos de forma independiente. Para analizar los datos, utilizamos variables estadísticas descriptivas y una síntesis narrativa. En el segundo estudio desarrollamos un instrumento para informar sobre el proceso de actualización de las GPC. Esta herramienta se elaboró siguiendo un proceso con múltiples etapas que incluyó una evaluación de GPC actualizadas, entrevistas semiestructuradas con expertos en GPC, un cuestionario de consenso Delphi, una encuesta con metodólogos y entrevistas semiestructuradas con usuarios de GPC. En el tercer estudio evaluamos sistemáticamente la información sobre el proceso de actualización en las GPC actualizadas publicadas en 2015. Las GPC incluidas debían haber sido elaboradas por una sociedad profesional, incluir una revisión sistemática de la evidencia y presentar al menos una recomendación. Tres revisores aplicaron, de forma independiente, la lista de verificación desarrollada en el segundo estudio a las GPC. Resultados: En el primer estudio incluimos 35 manuales. Se identificaron pocas guías para la actualización de las GPC. La mayoría de los manuales se centraban principalmente en proporcionar guías para elaborar GPC de novo. La mayoría de los manuales no proporcionaron guías para la búsqueda bibliográfica, la selección de la evidencia, la evaluación de la calidad, la síntesis de la evidencia ni la revisión externa durante el proceso de actualización. En el segundo estudio desarrollamos la lista de verificación para la publicación de GPC actualizadas (CheckUp), que incluye 16 ítems sobre 1) la presentación de una GPC actualizada, 2) la independencia editorial y 3) la metodología del proceso de actualización. Además, desarrollamos un documento adicional de explicación y elaboración para facilitar su utilización a los potenciales usuarios. En el último estudio incluimos 60 GPC actualizadas. La mediana de puntuación global con el CheckUp, en una escala de 10 puntos, fue de 6,3 (rango 3,1 a 10). La información fue limitada en relación con los ítems presentación y justificación a nivel de recomendación, métodos para la revisión externa e implementación de modificaciones. Conclusiones: Las guías disponibles para actualizar las GPC y la información de las GPC actualizadas son subóptimas. El CheckUp es el primer instrumento en el ámbito de las GPC que se centra en el proceso de actualización. El CheckUp puede utilizarse para evaluar la exhaustividad de la información sobre el proceso de actualización en GPC actualizadas y también para guiar a los grupos de trabajo de las GPC, ya que proporciona los estándares metodológicos y la información que deberían incorporar al proceso de actualización.
Introduction Clinical guidelines (CGs) aim to guide healthcare professionals, patients, and policymakers in decision-making by providing recommendations for a healthcare problem. However, since new evidence is published on a regular basis, CGs may require to be updated in order to guarantee the validity of recommendations. As opposed to the methodology for developing de novo CGs, there is scarce guidance available for the updating process of CGs and little is known about the methodology that CG institutions use to maintain the validity of their CGs. Objectives The objectives of this thesis are: 1) to identify and describe the updating guidance available in CG methodological handbooks, 2) to develop a checklist for the reporting of updated CGs, and 3) to assess the completeness of reporting of updated contemporary CGs. Methods For the first study, we conducted a systematic review of CG methodological handbooks searching in MEDLINE, the Guidelines International Network (G-I-N), and the US National Guidelines Clearinghouse. Two authors independently selected evidence and extracted data. We used descriptive statistics and a narrative synthesis to analyse the extracted data. For the second study, we developed a reporting instrument for the updating process of CGs. This tool was constructed through a multi-step development process that included an assessment of updated CGs, semi-structured interviews with key informants, a Delphi consensus survey, a single-round survey with CG methodologists, and semi-structured interviews with CG users. For the third study, we systematically assessed the reporting of the updating process in updated CGs published in 2015. To be eligible, CGs had to be developed by a professional society, report a systematic review of the evidence, and contain at least one recommendation. Three reviewers independently applied the reporting instrument developed in the second study to the included CGs. Results For the first study, we included 35 handbooks. Little guidance for updating CGs was identified. Most handbooks focused mainly on providing guidance for developing CGs de novo. The majority of the handbooks did not provide guidance for the literature search, evidence selection, quality assessment, evidence synthesis, or external review during the updating process. In the second study, we developed the Checklist for the Reporting of Updated Guidelines (CheckUp), which includes 16 items regarding: 1) the presentation of an updated guideline, 2) editorial independence, and 3) the methodology of the updating process. We also developed and explanation and elaboration document for CheckUp with the goal to facilitate the potential users. In the last study, we included 60 updated CGs. The median overall score with CheckUp on a 10-point scale was 6.3 (range 3.1 to 10). The presentation and justification items at recommendation level and the methods for external review and implementing changes in practice were poorly reported. Conclusions The guidance available for the updating of CGs and the reporting of updated CGs is suboptimal. CheckUp is the first reporting instrument in the CG enterprise with a focus on the updating process. CheckUp can be used to assess the completeness of reporting of the updating process in updated CGs, and also guide CG panels by providing methodological and reporting principles that should be incorporated into the updating process.

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Aziz, Ayesha. « A service oriented architecture to implement clinical guidelines for evidence-based medical practice ». Thesis, University of Sussex, 2015. http://sro.sussex.ac.uk/id/eprint/53223/.

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Health information technology (HIT) has been identified as the fundamental driver to streamline the healthcare delivery processes to improve care quality and reduce operational costs. Of the many facets of HIT is Clinical Decision Support (CDS) which provides the physician with patient-specific inferences, intelligently filtered and organized, at appropriate times. This research has been conducted to develop an agile solution to Clinical Decision Support at the point of care in a healthcare setting as a potential solution to the challenges of interoperability and the complexity of possible solutions. The capabilities of Business Process Management (BPM) and Workflow Management systems are leveraged to support a Service Oriented Architecture development approach for ensuring evidence based medical practice. The aim of this study is to present an architecture solution that is based on SOA principles and embeds clinical guidelines within a healthcare setting. Since the solution is designed to implement real life healthcare scenarios, it essentially supports evidence-based clinical guidelines that are liable to change over a period of time. The thesis is divided into four parts. The first part consists of an Introduction to the study and a background to existing approaches for development and integration of Clinical Decision Support Systems. The second part focuses on the development of a Clinical Decision Support Framework based on Service Oriented Architecture. The CDS Framework is composed of standards based open source technologies including JBoss SwitchYard (enterprise service bus), rule-based CDS enabled by JBoss Drools, process modelling using Business Process Modelling and Notation. To ensure interoperability among various components, healthcare standards by HL7 and OMG are implemented. The third part provides implementation of this CDS Framework in healthcare scenarios. Two scenarios are concerned with the medical practice for diagnosis and early intervention (Chronic Obstructive Pulmonary Disease and Lung Cancer), one case study for Genetic data enablement of CDS systems (New born screening for Cystic Fibrosis) and the last case study is about using BPM techniques for managing healthcare organizational perspectives including human interaction with automated clinical workflows. The last part concludes the research with contributions in design and architecture of CDS systems. This thesis has primarily adopted the Design Science Research Methodology for Information Systems. Additionally, Business Process Management Life Cycle, Agile Business Rules Development methodology and Pattern-Based Cycle for E-Workflow Design for individual case studies are used. Using evidence-based clinical guidelines published by UK's National Institute of Health and Care Excellence, the integration of latest research in clinical practice has been employed in the automated workflows. The case studies implemented using the CDS Framework are evaluated against implementation requirements, conformance to SOA principles and response time using load testing strategy. For a healthcare organization to achieve its strategic goals in administrative and clinical practice, this research has provided a standards based integration solution in the field of clinical decision support. A SOA based CDS can serve as a potential solution to complexities in IT interventions as the core data and business logic functions are loosely coupled from the presentation. Additionally, the results of this this research can serve as an exemplar for other industrial domains requiring rapid response to evolving business processes.

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Ismaile, Samantha. « Nursing studies : promoters and barriers for adherence to clinical practice guidelines among nurses ». Thesis, Durham University, 2014. http://etheses.dur.ac.uk/10893/.

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Clinical practice guidelines (CPGs) are designed to improve the care and safety of patients in hospitals. This thesis explores the promoters and barriers for CPG adherence among nurses. The research is based on a combination of a systematic literature review, qualitative research and a quantitative study. The systematic literature review included searching three data bases, namely, the British Nursing Index (BNI), Medline and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The qualitative research study included one-to-one interviews and focus groups. The quantitative study consisted of a questionnaire distributed to nurses to extend and check the findings of the qualitative studies. The systematic literature review revealed that the attitude of doctors to any CPG is influenced most by the level of their agreement with the guideline and by its applicability in practice. The adherence of nurses to CPGs is influenced most by the support and feedback they receive and by team interactions. A previous framework for CPG adherence by doctors has been produced by Cabana (1999) based on a literature review. This thesis extends that framework to nurses, and adapts it on the basis of my original research findings. Three principal themes emerged from the qualitative studies; namely, nurses’ attitudes to CPGs, their knowledge of CPG and external factors that influence CPG adherence. Within these, the most prominent promoters of CPG adherence were nurses’ sense of their accountability, professional values and self-efficacy, as well as managerial monitoring and belief that a CPG would achieve the expected desirable outcome. The last of these depended to a large extent on nurses’ trust in the credibility of the guideline authors. The main barriers to CPG adherence were lack of knowledge about the guidelines caused by insufficient time to read them, poor presentation and inadequate dissemination of CPGs and the low priority given to training within a nurse’s schedule. Other barriers included lack of staff resources to apply CPGs, the exigencies of individual patient problems and wishes, the frequent movement of nurses between specialisms and a general failure to involve nurses in drafting the guidelines. All these results were confirmed by the results of a questionnaire survey. The revised framework presented here could help health care organisations, medical educators, policy makers and managers to develop better models for CPG development and awareness, especially among nurses, and to have a greater insight into the factors that promote or inhibit CPG adherence. Based on the framework, recommendations are made to help these groups of people, and nurses themselves, improve nurses’ adherence to CPGs. These are presented below, and are found as Table 7.1 in the thesis.

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De, Angelis Gino. « The Dissemination of Clinical Practice Guidelines to Arthritis Health Professionals Using Innovative Strategies ». Thesis, Université d'Ottawa / University of Ottawa, 2018. http://hdl.handle.net/10393/37802.

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Problem: With an increasing aging Canadian population with chronic diseases such as arthritis, there is an urgent need for health professionals to promote evidence-based arthritis self-management support to their patients. Objective: The overall objective of this thesis was to determine the feasibility of using Facebook as a dissemination strategy for an online evidence-based arthritis self-management program, People Getting a Grip on Arthritis (PGrip), by arthritis health professionals with their patients. Methods: To identify the current evidence and knowledge gaps in regards to the use of innovative dissemination strategies for clinical practice guidelines (CPGs) and social media use for chronic disease self-management among health professionals, two systematic reviews of the literature were conducted. The first systematic review identified research on health professionals’ perceived usability and practice behaviour change of information and communication technologies (ICTs) for the dissemination of CPGs. The second identified research on the perceived usability of social media by health professionals to facilitate chronic disease self-management with their patients. To engage potential knowledge users in the research process, an advisory committee consisting of six arthritis health professional users (two registered nurses, two physiotherapists, and two occupational therapists) was convened to identify barriers and facilitators of using and accessing Facebook as a dissemination strategy for PGrip. The advisory committee was also convened to identify how the PGrip Facebook group page could be tailored to improve usability among arthritis health professionals. A feasibility study of 78 arthritis health professionals was then conducted to determine the feasibility of using Facebook as a dissemination strategy for PGrip among arthritis health professionals to their patients. To guide future research, a protocol for a pilot randomized controlled trial (RCT) was developed that will compare Facebook with an educational website and email to determine which strategy will demonstrate greater perceived usefulness among arthritis health professionals to disseminate the PGrip program with their patients. Results: The findings of the first systematic review revealed that health professionals’ perceived usability and practice behaviour change varies by type of ICT and the heterogeneity and paucity of properly conducted studies did not allow for a clear comparison between studies. The second systematic review revealed that health professionals perceived discussion forums and collaborative projects to be useful social media platforms to facilitate chronic disease self-management with patients. The feasibility study suggested that a Facebook group page can be used as a dissemination strategy for the PGrip program by arthritis health professionals. The Facebook group page was perceived to be usable with patients after two weeks and three months in regards its ease of use and high output quality. Conclusion: The overall research of this thesis provides advanced knowledge on how a Facebook group page as a dissemination strategy for an evidence-based self-management program for patients is perceived by arthritis health professionals. Facebook may provide arthritis health professionals with an additional option of how to best share evidence-based information to allow their patients to successfully self-manage their arthritis. A future pilot RCT is needed to determine whether Facebook is superior to other ICT intervention in regards its perceived usefulness among arthritis health professionals to disseminate the PGrip program with their patients.

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Chua, Kao-Ping. « Quasi-Experimental Evaluations of Pediatric Health Care : Clinical Practice Guidelines and Insurance Coverage ». Thesis, Harvard University, 2015. http://nrs.harvard.edu/urn-3:HUL.InstRepos:17467284.

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The underlying theme of this dissertation is the effects of clinical and federal policy on health, utilization, and expenditures among children and young adults. In Chapter 1, I evaluate the clinical and economic benefits of clinical practice guidelines recommending universal cerebrospinal fluid testing in the emergency department for febrile infants aged 29-56 days. Using a difference-in-differences approach and administrative data from 31 U.S. children’s hospitals, I find that these guidelines are not associated with better clinical outcomes or lower health care spending, suggesting that many families of older infants could be spared the stress associated with cerebrospinal fluid testing without harm. The optimal management of older febrile infants in the emergency department has been debated for decades, and results from this study have the potential to change clinical practice at the hospital level. In Chapter 2, I assess the impact of the Affordable Care Act dependent coverage provision on health care utilization, health, and health care expenditures among young adults aged 19-25 years. Using a difference-in-differences analysis of nationally representative data, I find that implementation of the provision was associated with improved self-reported health and improved financial protection against the costs of health care among young adults. These findings highlight the importance of continued efforts to expand insurance coverage in this population. In Chapter 3, I investigate whether insurance coverage loss drives differences in access and health care utilization between older adolescents and young adults with asthma. I find that young adults with asthma are less likely to have a usual source of care, to use outpatient care, and to fill asthma medication prescriptions compared with older adolescents with asthma. Differences in insurance coverage account for large proportions of these differences. In a longitudinal analysis, I also find that older adolescents with asthma who lose insurance coverage as they transition to young adulthood are less likely to have a usual source of care. Taken as a whole, these results suggest that insurance coverage plays a crucial role in ensuring access to care and encouraging optimal health care utilization patterns for adolescents and young adults with asthma.
Health Policy

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Keller, Linda. « Assessment of Evidence-Based Practice Readiness and Plan for Implementation of Clinical Practice Guidelines in a Tertiary Hospital ». ScholarWorks, 2018. https://scholarworks.waldenu.edu/dissertations/5208.

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Using evidence-based practice (EBP) to deliver patient care in a hospital setting improves patients' care and their outcomes. The use of clinical practice guidelines (CPG) enables nurses and other healthcare professionals to translate current evidence into bedside care. However, there continue to be barriers for hospitals in adopting and implementing evidence-based care using CPGs, including a lack of understanding about EBP by nursing staff. The purpose of this project was to explore readiness of registered nurses in a tertiary hospital to use EBP and provide recommendations for a plan to implement CPGs successfully. Melnyk's research identified EBP as an approach to care, and the concept of using CPGs to shape patient care served as a foundation for the project. In addition, Kotter's theory of change was used to guide the recommendations to promote implementation. The Academic Center for Evidence-Based Practice-Readiness Inventory (ACE-ERI) created by Stevens was used to survey nurses' EBP readiness and knowledge at one Florida tertiary hospital. Data were analyzed using descriptive and inferential statistics. Survey results revealed the nurses' overall moderate level of confidence in using EBP, but limited EBP knowledge. Therefore, recommendations to develop education programs for EBP as well as guidance on follow-up assessments were proposed to nursing leadership. Educating the nurses will increase the likelihood of adoption of the CPGs, which will promote positive social change by improving the bedside care delivered by hospital nurses, which will result in better patient outcomes.

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Gaines, Jenna H., et Jenna H. Gaines. « Barriers to Implementing Clinical Practice Guideline Nutrition Recommendations in Mild Acute Pancreatitis Patients : Provider's Knowledge and Practice ». Diss., The University of Arizona, 2017. http://hdl.handle.net/10150/624502.

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The spectrum of acute pancreatitis (AP) affects between 4.9 and 73.4 patients out of 100,000 worldwide annually (Tenner, Baillie, DeWitt, & Vege, 2013). AP uses the Atlanta classification system to establish a diagnosis of mild, moderate, or severe. The American College of Gastroenterology (ACG) has established comprehensive clinical practice guidelines (CPG) for the management of AP, the most recent version published in 2013 (Tenner et al., 2013). There have been similar CPGs published internationally that integrate current evidence-based research into recommendations for practice. These guidelines along with the ACG's guidelines recommend initiating a diet for mild acute pancreatitis patients due to research findings of improved patient outcomes (i.e. reduced length of hospital stay, decreased rate of infections, and reduced mortality) (Horibe et al., 2015; Lariño-Noia et al., 2014). There is an international awareness of the need for increased CPG nutrition recommendation compliance in the practice setting as many studies have found providers prefer to keep patients nil per os (NPO) and do not adhere to CPGs (Andersson, Andrén-Sandberg, Nilsson, & Andersson, 2012; Greenberg et al., 2016; Sun et al., 2013). The purpose of this doctor of nursing practice (DNP) project is to assess providers' current nutrition therapy practice and knowledge of the ACG’s CPG nutrition recommendations for mild AP patients. The researcher conducted the assessment with a hospitalist practice at Banner University Medical Center in Phoenix, Arizona. The results of the project contribute to the current body of research on national adherence to CPGs for AP and act as a needs assessment for future projects where a nutrition protocol order set may be established. The investigation of nutrition therapy for AP patients seeks to improve and standardize the care this patient population receives while in the acute care setting.

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Prentice, Jennifer Lorna. « An evaluation of clinical practice guidelines for the prediction and prevention of pressure ulcers ». University of Western Australia. School of Surgery and Pathology, 2007. http://theses.library.uwa.edu.au/adt-WU2007.0170.

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[Truncated abstract] Pressure ulcers affect a substantial proportion of patients admitted to health care services worldwide imposing considerable physical, social and economic burdens on patients and communities. As largely preventable wounds their prevalence is likely to escalate as the life expectancy and incidence of people living longer with other chronic diseases increases. Clinical practice guidelines are promulgated as evidence-based tools to assist clinicians and patients to determine care strategies, reduce inequities in healthcare provision and lower the burden of illness through improved health outcomes. This prospective multi-centre study evaluated the effectiveness of the Australian Wound Management Association?s Clinical Practice Guidelines for the Prediction and Prevention of Pressure Ulcers within ten selected Australian tertiary hospitals. The data, collected in 2000, examined pressure ulcer prevalence in a subset of five of these hospitals and junior doctors’ and nurses’ knowledge of pressure ulcers in all ten hospitals at two time points, before and after guideline implementation. Pressure ulcer prevalence was ascertained by two surveyors who independently examined the skin of all consenting adult patients on a designated day. ... In addition, it is recommended that all Australian health care facilities providing in-patient, residential aged or domiciliary care services be required to demonstrate compliance with the Australian Council of Health Care Standards framework for pressure ulcers in order to be an accredited healthcare provider. The use, benefits and cost utility of pressure reducing / relieving devices in the prediction and prevention of pressure ulcers in Australian contexts of care, is required to substantiate current guideline recommendations and assist service providers and clinicians in choosing devices according to patient need. A recommendation will be forwarded to the Australian Wound Management Association suggesting the Association develop a toolkit to facilitate implementation and adoption of their guidelines. It is recommended that training of doctors, nurses and allied health personnel in the prediction, prevention and management of pressure ulcers should be of a higher priority within under-and-postgraduate education programs. From a community perspective and with a view to improving the health of the community, it is proposed that pressure ulcers be the subject of ongoing health promotion campaigns aimed at raising patients’, caregivers’ and community awareness of the potential for pressure ulcers due to the secondary effects of lifestyle related chronic diseases and ensuing reduced levels of immobility.

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Sin, Tak-nam, et 冼德藍. « Evidence-based clinical practice guidelines for care of skeletal pin sites in orthopaedic patients ». Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2010. http://hub.hku.hk/bib/B44626332.

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Lundy, Jo Lynne. « Using The Internet to Build Community and Provide Clinical Practice Guidelines for Camp Nurses ». NSUWorks, 2002. http://nsuworks.nova.edu/gscis_etd/690.

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Approximately 10,000 camps are currently in operation in the United States, and an estimated 9 million youth attend camps annually. Each accredited camp is required to have a healthcare provider on the property when campers are present, and this provider is most often a registered nurse. Most nurses are unfamiliar with the outdoor milieu and must learn to adapt clinical skills and patient care to the camp setting. Camp nurses cannot rely on traditional medical equipment and supplies; they must use their own skills, clinical knowledge, critical thinking and problem-solving abilities to make independent decisions and nursing interventions. The many changes in healthcare and nursing in recent years have caused nursing professionals to realize that continuing education is necessary to insure professional advancement, and to keep current with the latest nursing research findings. The need for flexibility in the delivery of nursing education has been identified by various initiatives, and there is considerable pressure from professional nursing organizations, schools of nursing, and individual nurses to establish educational courses that are accessible and relevant. Nursing education is increasingly challenged to convert traditional course offerings to distance delivery, and courses in specialty nursing areas are in great demand. This research study focused on the collection of data in order to design, implement, and evaluate a Web-based course for camp nurses. The goals of this study were to increase the camp nursing knowledge base, optimize the visibility of camp nursing research, establish a repository of research resources and information related to best camp nursing practices, stimulate camp nurses to create communication and support networks, create more opportunities for collaboration between camp nurses and camping organizations, promote an environment of continuous quality improvement in the camp health center, and deliver self-directed educational programs that prepare healthcare professionals to assume the camp nursing role. Since there are currently no educational programs available for camp nurses, a Web-based course for camp nurses would fill an educational void for this nursing population.

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Fiset, Valerie Jean. « Nursing Students' Use of Guidelines for Pain Management in Clinical Practice : Context and Influencing Factors ». Thesis, Université d'Ottawa / University of Ottawa, 2019. http://hdl.handle.net/10393/39856.

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Purpose To understand the factors that influence nursing students’ use of evidence-based pain management guidelines in their clinical placements. Methods/Design Guided by educational and knowledge translation theory, multiple approaches were used: 1. A scoping review of the literature to identify and describe educational strategies to promote evidence-based practice (EBP) by nursing students in the clinical setting, along with associated barriers and facilitators from the literature. 2. A process to develop indicators of the use of pain guidelines in clinical practice. 3. A descriptive case study to determine the gap between evidence-based guideline recommendations and actual practice and to understand the clinical and educational contextual factors that influence nursing students’ use of pain management practice guidelines. Findings The scoping review identified 37 papers in total, 14 descriptive and 23 evaluation studies. Commonly identified barriers were lack of EBP knowledge and skills and lack of support in the clinical setting. EBP projects were the most frequently evaluated educational interventions, alone, or in combination with workshops or journal clubs. During the indicator development process, eleven guidelines were reviewed for quality, resulting in three quality guidelines. From these three guidelines, 12 recommendations were extracted. Quality indicators were then identified by a consensus process, resulting in 24 discrete indicators for the chart audit. For the descriptive case study, fifty-four charts were audited, and interviews were conducted with nine students, seven nurses, one professor, and one clinical instructor. Multiple documents were reviewed, and a site visit was conducted. There are gaps between pain guideline recommendations and practice in the clinical setting. Examples of barriers include the perception that guidelines are not applicable for the clinical setting, lack of knowledge regarding guidelines and an emphasis on task completion in the clinical setting. Facilitators included access to resources, curriculum changes, and the integration of guidelines in policies and procedures. These findings can inform the development, implementation and evaluation of evidence based educational strategies that take into account the multiple actors that impact nursing students’ experience, namely, in-class professors, clinical instructors, and staff nurses. Future education and research approaches should be rooted in knowledge translation and education theory.

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Mpasa, Ferestas. « Strategies for the implementation of clinical practice guidelines in the intensive care : a systematic review ». Thesis, Nelson Mandela Metropolitan University, 2014. http://hdl.handle.net/10948/d1020046.

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Implementation strategies for the use of clinical practice guidelines are an integral component in bridging the gap between the best research evidence and clinical practice. However, despite some remarkable investments in health research regarding clinical practice guidelines implementation strategies, it is not yet known which of these are the most effective for intensive care units. The purpose of this research study was to systematically identify and /or search, appraise, extract and synthesize the best available evidence for clinical practice guidelines implementation strategies in intensive care units, in order to develop a draft guideline for clinical practice guidelines implementation strategies in the intensive care units. A systematic review design was used to systematically identify and /or search, appraise, extract and synthesize the best available evidence from the eligible included Level 2 studies (randomized controlled trials and quasi-experimental studies). Level 2 studies were applicable because they present robust evidence in the research results regarding effectiveness of clinical practice guideline implementation strategies. Furthermore, although other systematic reviews conducted in this area before, they included studies of In addition, no systematic review was identified that reviewed Level 2 studies and developed a guideline for clinical practice guideline implementation strategies in the intensive care units. Hence, including only Level 2 studies was distinctive to this research study. Databases searched included: CINAHL with full text, Google Scholar, Academic search complete, Cochrane Register for Randomized Controlled Trials Issue 8 of 12, August 2013, and MEDLINE via PUBMED. Hand search in bound journals was also done. The search strategy identified 315 potentially relevant studies. After the process of critical appraisal, thirteen Level 2 studies were identified as relevant for the review. Of the 13 relevant studies, 10 were randomized controlled trials and three were quasi experimental studies. After the critical appraisal ten RCTs were included in the systematic review. Three studies (quasi-experimental) were excluded on the basis of methodological quality after the critical appraisal and agreement by the two independent reviewers. The Joanna Briggs Institute Critical Appraisal MASTARI Instrument for Randomized Controlled trials/ Experimental studies, and The Joanna Briggs Institute data extraction tools were used to critically appraise, and extract data from the ten included randomized controlled trials. The two reviewers who performed the critical appraisal were qualified critical care professional nurses and experts in research methodology. These reviewers conducted the critical appraisal independently to ensure the objectivity of the process. Appropriate ethical considerations were maintained throughout the process of the research study. The results indicated that 80 percent of the included studies were conducted in adult intensive care units while 20 percent were conducted in the neonatal intensive care units. Furthermore, 60 percent of the studies were conducted in the United States of America, 10 percent in France, a further 10 percent in Taiwan, another 10 percent in England and yet another 10 percfent was conducted in Australia and Newzealand. The included studies utilized more than one (multifaceted) implementation strategies to implement clinical practice guidelines in the intensive care units. The first most utilized were: printed educational materials; Information/ educational sessions/meetings; audit and feedback and champion/local opinion leaders; seconded by educational outreach visits; and computer or internet usage. Third most used were active/passive reminders; systems support; academic detailing/ one-on-one sessions teleconferences/videoconferences and workshops/in services. Fourth most used were ollaboration/interdisciplinary teams; slide shows, teleconferences/videoconferences and discussions. Fifth most used were practical training; monitoring visits and grand rounds. However all the strategies were of equal importance. Conclusively, the included studies utilized multifaceted implementation strategies. However, no study indicated the use of a guideline for the implementation strategies in the process of clinical practice guidelines implementation. The systematic review developed a draft guideline for clinical practice guideline implementation strategies in the intensive care units. The guideline will enhance effective implementation of clinical practice guidelines in such a complex environment.

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Simon, Judit. « Developing a systematic framework for the integration of health economic evidence into clinical practice guidelines ». Thesis, University of Oxford, 2008. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.497096.

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Ledward, Alison. « The interface between evidence-based maternity care clinical practice guidelines and the pregnant woman's autonomy ». Thesis, University of Leicester, 2017. http://hdl.handle.net/2381/40446.

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The importance of the pregnant woman’s autonomy and the role of increased choice in decision-making relating to her maternity care have gained widespread recognition. This is borne out in the healthcare and bioethics literature, key initiatives in policy documents and clinical guidelines. Although guidelines are a central feature of maternity care, little is known about how their recommendations are experienced by women and the impact on their autonomy. This thesis addresses that gap in knowledge. The methods I used in this research comprised a literature review and an empirical study consisting of semi-structured interviews with 20 participants in an inner-city teaching hospital. Data collection, transcription and analysis were informed by adaptation of the Constructivist Grounded Theory approach (Charmaz: 2006). My analysis generated two main thematic categories. First, women lack the appropriate in-depth pregnancy and birth knowledge to make decisions independently. Second, interactions with trusted professional carers were highly valued. Analysis suggested new insights, namely that the meaning of autonomy to women is more complex than self- government, a range of options and relational responsibilities can account for. Women felt empowered by being a genuine participant in the decision-making process. They expressed their autonomy by being invited to share their previous experiences, current expectations and concerns and request information in a manner consistent and timely with their own agendas. Women’s responses were also shaped by considered reflection of the impact of their decisions on others. My analysis revealed that some level of interdependence may be a precondition for women to exercise their autonomy. It is a paradox that the recommendation professionals should follow guidelines and be non-directive may result in the unintended consequence of women exercising their autonomy by in part reinstating authority to professional carers. Interpretation of findings led to the development of my grounded theory, ’Choosing when to choose’.

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Brown, Bernadette. « Clinician-Led Improvement in Cancer Care (CLICC) : Complementing Evidence-Based Medicine with Evidence-Based Implementation ». Thesis, The University of Sydney, 2016. http://hdl.handle.net/2123/15660.

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This thesis explores whether a multifaceted intervention implemented through the NSW Agency for Clinical Innovation (ACI) Urology Clinical Network can improve the rates of referral of men with high-risk prostate cancer post-radical prostatectomy for consideration for adjuvant radiotherapy in line with clinical practice guideline recommended care. It comprises seven iterative studies that address urologists’ knowledge, attitudes and equipoise for the use of adjuvant radiotherapy for high-risk prostate cancer, the development of a clinical network embedded intervention and the evaluation of this intervention within a step-wedge cluster randomised trial ‘Clinician-Led Improvement in Cancer Care (CLICC)’ (NHMRC Partnership Grant 1011474; Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001251910). The thesis found some evidence that the CLICC intervention resulted in desired practice change. Results are presented within the context of the CLICC conceptual program logic framework and are interpreted in relation to knowledge, attitudes and beliefs in the wider urological community. The thesis concludes with consideration of how findings could be translated to the implementation of other clinical practice guideline recommendations.

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Enochs, Shannon. « Bridging the Gap between Emotional Trauma Practice Guidelines and Care Delivery in the Primary Care Setting ». Thesis, Brandman University, 2019. http://pqdtopen.proquest.com/#viewpdf?dispub=13428017.

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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%).

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Al-Ketbi, Latifa Mohammed Baynouna. « The use of clinical practice guidelines in General Practice : a study to examine the effect of implementing radiological guidelines in General Practice clinic in the Al-Ain district of the United Arab Emirates ». Thesis, University of Aberdeen, 2001. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.394556.

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This was the first study undertaken in the United Arab Emirates, to investigate clinical practice guidelines. There were three parts to the investigation, 1. A survey of the knowledge, attitude and beliefs about clinical practice guidelines among General Practitioners; 2. A research enquiry into the effects of the guidelines of the Royal College of Radiologists' of the United Kingdom, on the request behaviour of General Practitioners; 3. A further enquiry into the effect of introducing information regarding the cost of radiograph ordered, on the 'request' behaviour of General Practitioners. The study took place among General Practitioners employed within the Al-Ain Medical District, in the United Arab Emirates. Important recommendations derived from this research were - The high percentage of inappropriate radiological referrals in the Practices studied is an alarming indication of substandard care provision, to counteract which, clinical practice guidelines are still highly recommended; Educational programmes are required which should be directed towards improving the knowledge of General Practitioners of the concept of clinical practice guidelines; Implementation of clinical practice guidelines requires an inclusive approach in planning. The strategy should be directed towards doctors, patients, the setting, administration and appropriate guidelines; how they are developed, evaluated and presented. The planning should ensure continuous reinforcement of the guidelines and appropriate marketing and public persuasion. In addition, a continuous evaluation system is essential to assess performance which could then be improved; Strategies which are more likely to be effective are those which involve the end user; in this case, the General Practitioner and those operating directly upon the consultation between the doctor and the patient. Examples of such strategies include, feedback on practice, opinion leaders, patient specific reminders and educational outreach visits; the guidelines adopted by a respected 'organisation' ensure a greater acceptance.

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Cluzeau, FrancÌ§oise AndreÌe. « Development and application of an appraisal instrument for assessing the methodological quality of clinical practice guidelines ». Thesis, St George's, University of London, 2001. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.249676.

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Karanfil, Özge 1978. « Why clinical practice guidelines shift over time : a dynamic model with application to prostate cancer screening ». Thesis, Massachusetts Institute of Technology, 2016. http://hdl.handle.net/1721.1/107531.

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Thesis: Ph. D., Massachusetts Institute of Technology, Sloan School of Management, 2016.
Cataloged from PDF version of thesis.
Includes bibliographical references.
Essay 1: A Dynamic Model for Understanding Long-Term Trends in Prostate Cancer Screening Cancer remains the second leading cause of death in the U.S. after heart disease. After 35 years of routine cancer screening, we still have only a limited understanding of screening dynamics. There is evidence of over-screening and resulting overtreatment in certain cases, and significant provider variation and fluctuations over time in screening criteria. Here I present empirical data for fluctuations in official screening guidelines and in actual practice for the use of the prostate-specific antigen (PSA) test. I explore how these dynamics are affected by the main guideline-issuing organizations in the U.S. and by clinicians, patient groups, and the media. Essay 2: Our Walk to the End of Cancer? Understanding Long-Term Trends in Medical Screening In this study we develop the first integrated, broad boundary feedback theory and formal model to explain the dynamics of medical screening. The theory includes a decision-theoretic core around harms and benefits including the fundamental tradeoff between sensitivity and specificity; and feedbacks that condition guidelines and actual practice. To provide context we use the case of PSA screening for prostate cancer as a motivating example, but our model is generic and applicable to other contexts. We present a behaviorally realistic, boundedly-rational model of detection and selection for health screening that creates oscillations in policy recommendation thresholds of formal guidelines. This core model, entailing only the evidence generation and translation processes, demonstrates how oscillations are natural to this category of problems due to inherent delays in evidence-based screening. These fluctuations lead to long periods during which screening guidelines are suboptimal. Essay 3: A Dynamic Model for Understanding Long-Term Trends in Prostate Cancer Screening Whereas guidelines for routine screening should be based on medical evidence, evidence often has relatively little impact on practice. This situation has led to ongoing controversy and conflict over appropriate guidelines among scientists, clinicians, and patient advocacy groups. There are significant variations in clinical practice, including evidence of over-screening for some diseases, and under-screening for others. To explain the patterns of over-screening, fluctuations, low adherence to guidelines, and conflict, I develop the first explicit broad boundary feedback theory of the dynamics of medical screening, tested in a formal mathematical model. The model presents an extended case study specific to PSA screening for prostate cancer, including realistic presentations for the fundamental tradeoff between test sensitivity and specificity, the natural progression of the disease, and respective changes in population size and composition.
by Özge Karanfil.
A dynamic model for understanding long-term trends in prostate cancer screening -- Our walk to the end of cancer?: understanding long-term trends in medical screening -- A dynamic model for understanding long-term trends in prostate cancer screening.
S.M. in Management Research

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Hoomans, Ties. « Economic evaluation of change in clinical practice methods for informing decisions about guidelines and implementation strategies / ». Maastricht : Maastricht : Universitaire Pers ; University Library, Universiteit Maastricht [host], 2008. http://arno.unimaas.nl/show.cgi?fid=14837.

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Pettersson, Billie. « Lipid‐modifying and glucose-lowering therapies in clinical practice : The impact of guidelines and changing reimbursement schemes ». Doctoral thesis, Linköpings universitet, Utvärdering och hälsoekonomi, 2012. http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-75545.

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cardiovascular disease, which is still a major cause of death that creates large burdens to society in terms of costs and morbidity. Dyslipidemia and type 2 diabetes mellitus are the main risk factors for cardiovascular disease, and national and international guidelines recommend lipid-modifying and glucose-lowering treatments for prevention. In 2010, about 836,000 (9% of the population) and 372,000 patients respectively were treated with these therapies in Sweden. Various pharmaceutical policies aimed at improving the efficiency of drug use have been introduced over the years. Health technology assessment (HTA) was introduced in Sweden in 2002 as a foundation for informing pricing and reimbursement decisions by the Dental and Pharmaceutical Benefits Agency (TLV). Following HTA reviews, new reimbursement schemes for lipid-modifying and glucose-lowering therapies were introduced in 2009 and 2010 respectively. To assess the impact of the changing reimbursement schemes on the use and costs of these therapies, we analyzed data from the Swedish drug registry, using a quasi-experimental design and interrupted time series analyses. Our results showed that the new reimbursement scheme for lipid-modifying treatment had a major effect on use; following the implementation of this scheme, there was a substantial increase in both discontinuation and switching to higher doses. Conversely, the new reimbursement scheme for glucose-lowering therapies had overall only a minor effect on use. Larger savings in the lipid market were anticipated but not fully realized, while even the minor anticipated changes in costs in the glucose-lowering market were not realized due to increased costs for insulins. We found that changes in reimbursement schemes might lead to unintended effects, which should be considered before implementation. Softer demand-side policies, such as recommendations and guidelines, might be a better option under some circumstances. Clinical and national guidelines are other policies aimed at improving quality of care and drug use. We assessed the impact of guidelines on the quality of lipid-modifying therapies, defined as proportions of patients attaining goal/normal levels according to guidelines for lipid management. A longitudinal retrospective observational study was carried out, covering time periods before and after initiation of lipid-modifying treatment. The findings show that about 40% of the patients attained the recommended low-density lipoprotein cholesterol goals following treatment, but only 18% attained goals/normal levels in all lipid parameters. Improvement in triglycerides was moderate, and low levels of high-density lipoprotein cholesterol persisted, showing only modest improvement following therapy. Treatment patterns were found to have a better degree of adherence to guidelines regarding low-density lipoprotein cholesterol as compared to other lipid parameters. The overall objective of treatment of type 2 diabetes mellitus is to improve glycemic control without negatively affecting quality of life. Hypoglycemia is a common side effect of intensive blood glucose control, mostly seen in patients treated with insulins. Earlier studies have suggested that hypoglycemia has a negative impact on quality of life, even in patients treated with oral glucose-lowering therapies. We carried out a cross-sectional retrospective study to assess the impact of self-reported experience of hypoglycemia on quality of life in Swedish adult patients with type 2 diabetes mellitus treated with a combination of metformin and sulfonylureas. The results showed that about 40% of the patients achieved the goal of glycemic control. About 19% reported experience of moderate or more severe hypoglycemia, and these patients were found to have lower quality of life than those patients reporting no or mild hypoglycemia, as measured by EQ-5D, a generic quality of life instrument. This could be important to consider in clinical practice.

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Reddy, Cordelia Kruparakshnam. « Guidelines for clinical research nurses about their self-leadership role in nursing practice at nursing units in the southern suburbs of Cape Town, Western Cape ». University of the Western Cape, 2014. http://hdl.handle.net/11394/4692.

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Magister Curationis - MCur
Clinical research nurses are at the frontline of clinical research. They act as nurse leaders in the area of patient-orientated research. This leadership role requires that they work independently with limited support from other nurses. The nursing practice of clinical research nurses’ associates patient care with research protocols, administration duties, management responsibilities, and role specific authority. At hospitals in the Western Cape, clinical research nurses support principal investigators in the conducting of clinical research. It was unclear how clinical research nurses in nursing units in southern suburbs, Cape Town, Western Cape Province experienced their self-leadership role in nursing practice. The aim of the study was to explore and describe the experiences of clinical research nurses’ self- leadership role in nursing practice in nursing units in the southern suburbs of Cape Town, Western Cape. In this study; a phenomenological, exploratory, descriptive, and contextual design was followed. The population consisted of all the clinical research nurses (n = 22) at Western Cape hospitals and health care institutions in the southern suburbs. Purposive sampling was applied according to selection criteria. Unstructured individual interviews were conducted until data saturation occurred. These interviews took place at a private office in the southern suburbs of the Cape Town and lasted between 45 minutes and an hour. Observation and field notes were taken during the interviews. Data was analysed by using open coding and data triangulation. The researcher applied Lincoln and Guba’s (1985) model of trustworthiness. Four themes and twenty one categories emerged from the data analysis. The findings emphasised that the clinical research nurses’ experienced their self-leadership role in nursing as an evolutionary process. The evolutionary role required that they needed to develop strategies with the aim of surviving the initial tedious and daunting phase that facilitated the development of skills needed for collaborative partnerships with stakeholders. As her general confidence increased, the clinical research nurse would be able to recognise her professional attributes and use self-leadership behaviour to enhance her daily practice. Appropriate self-leadership behaviour would assist the clinical research nurse to successfully navigate the complex, dynamic clinical research environment. Guidelines were developed from the four themes that were the result of the data analysis; namely the initial tedious and daunting phase, working in pursuit of collaborative action, personal traits of the clinical research nurse, and self-leadership behaviour. The UWC Higher Degree Committee at the Faculty of Community and Health Sciences and the Senate Research Committee respectively approved this research project. No risks were anticipated for participants in the study.

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Kardakis, Therese. « Strengthening lifestyle interventions in primary health care : the challenge of change and implementation of guidelines in clinical practice ». Doctoral thesis, Umeå universitet, Epidemiologi och global hälsa, 2017. http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-141323.

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Background: Lifestyle habits like tobacco use, hazardous use of alcohol, unhealthy eating habits and insufficient physical activity are risk factors for developing non-communicable diseases, which are the leading, global causes of death. Furthermore, ill health and chronic diseases are costly and put an increased burden on societies and health systems. In order to address this situation, governmental bodies and organizations’ have encouraged healthcare providers to reorient the focus of healthcare and undertake effective interventions that support patients to engage in healthy lifestyle habits. In Sweden, national clinical practice guidelines (CPGs) on lifestyle interventions were released in 2011. However, the challenges of changing clinical practice and introducing guidelines are well documented, and health interventions face particular difficulties. The overall purpose of this thesis is to contribute towards a better understanding of the complexities of shifting primary health care to become more health oriented, and to explore the implementation environment and its effect on lifestyle intervention CPGs. The specific aims are to investigate how implementation challenges were addressed during the guideline development process (Study I), to investigate several dimensions of readiness for implementing lifestyle intervention guidelines, including aspects of the intervention and the intervention context (Study II), to explore the extent to which health care professionals are working with lifestyle interventions in primary health care, and to describe and develop a baseline measure of professional knowledge, attitudes and perceived organizational support for lifestyle interventions (Study III), and to assess the progress of implementing lifestyle interventions in primary care settings, as well as investigate the uptake and usage of the CPGs in clinical practice (Study IV). Methods and results: Interviews were conducted with national guideline-developers (n=7). They were aware of numerous implementation challenges, and applied strategies and ways to address them during the guideline development process. The strategies adhered to four themes: (a) broad agreements and consensus about scope and purpose, (b) systematic and active involvement of stakeholders, (c) formalized and structured development procedures, and (d) openness and transparent development procedures. At the same time, the CPGs for lifestyle interventions challenged the development-model at the National Board of Health and Welfare (NBHW) because of their preventive and non-disease specific focus (I). A multiple case study was also conducted, using a mixed methods approach to gather data from key organizational individuals that were accountable for planning the implementation of CPGs (n=10), as well as health professionals and managers (n=340). Analysis of this data revealed that conditions for change were favorable in the two organizations that served as case studies, especially concerning change focus (health orientation) and the specific intervention (national guidelines on lifestyle interventions). Somewhat limited support was found for change and learning, and change format (national guidelines in general). Furthermore, factors in the outer context were found to influence the priority and timing of the intervention, as well as considerable inconsistencies across the professional groups (II). A cross-sectional study among physicians and nurses (n=315) in Swedish primary healthcare showed that healthcare professionals have a largely positive attitude and thorough overall knowledge of lifestyle intervention methods. However, both the level of knowledge and the involvement in patients’ lifestyle change, differed between professional groups. Organizational support like CPGs and the development of primary health care (PHC) collaborations with other stakeholders were identified as potential strategies for enhancing the implementation of lifestyle interventions in PHC (III). In addition to interviews and case studies, a longitudinal survey among health professionals (n=150; n=73) demonstrated that their use of methods to encourage patients to reduce or eliminate tobacco or alcohol use, had increased. The survey also indicated that nurses had increased the extent to which they addressed all four lifestyle habits. The progress of the implementation of CPGs on lifestyle interventions in PHC was somewhat limited, and important differences in physicians and nurses’ attitudes, as well as their use of the guidelines, were found (IV). Conclusions: Health orientation differs in many ways from more traditional fields in medicine. To strengthen the implementation of this very important (but not “urgent”) field in health care, it needs, first of all, to be prioritized at all levels! The results of the studies demonstrate relatively slow adoption of lifestyle intervention CPGs in clinical practice, and indicate room for improvement. The findings of this thesis can inform healthcare policy and research on further development of the health orientation perspective, as well as on the challenges of implementing CPGs on lifestyle interventions in primary care. In summary, this thesis presents important lessons learned regarding health orientation - from the development of CPGs in the field, via assessing healthcare organizations’ readiness to change and health professionals’ attitudes to methods to support patients with lifestyle changes.
Bakgrund: Levnadsvanor som tobaksbruk, riskbruk av alkohol, ohälsosamma matvanor och otillräcklig fysisk aktivitet är riskfaktorer för att utveckla kroniska sjukdomar, vilka orsakar de flesta dödsfallen i världen. Ohälsa och dess följdsjukdomar utmanar också samhällen och hälsosystem världen över p.g.a. de höga kostnader som de medför. För att förbättra situationen så försöker regeringar och organisationer förändra hälso- och sjukvårdens perspektiv till att fokusera mer på hälsa och att arbeta med effektiva interventioner för att förebygga och att förändra människors ohälsosamma vanor. År 2011 i Sverige, publicerades nationella kliniska riktlinjer för vårdens arbete med att förebygga sjukdom genom att stödja förändring av patienters ohälsosamma levnadsvanor. Det är dock välkänt hur svårt det är att förändra klinisk praxis och att introducera riktlinjer, och interventioner på området hälsa i sjukvården brottas med specifika utmaningar. Det övergripande syftet med den här avhandlingen har varit att bidra till en bättre förståelse av komplexiteten i att hälsoorientera primärvården, och att utforska förutsättningarna till att implementera kliniska riktlinjer för att stödja förändring av patienters levnadsvanor. De mer specifika syftena var: att (I) utforska hur implementeringsutmaningarna behandlades i utvecklingsprocessen av riktlinjerna ; att (II) undersöka dimensioner av beredskapen för förändring i primärvården för att implementera riktlinjerna om levnadsvanor inkluderande aspekter av interventionen själv samt kontexten ; att (III) utforska i vilken utsträckning hälsoprofessionerna arbetar med levnadsvanor i primärvården, och att beskriva deras kunskap, attityder och uppfattat organisatoriskt stöd för livsstilsinterventioner ; att (IV) i en två-årig uppföljning utvärdera utvecklingen av arbetet med levnadsvanor i primärvården, och användningen av de specifika nationella riktlinjerna för levnadsvanor. Metod och resultat: En intervjustudie med riktlinjeutvecklare på nationell nivå (n = 7) visade att många utmaningar för implementeringen av riktlinjerna identifierades och bemöttes under utvecklingsprocessen i fyra teman av strategier: breda överenskommelser och konsensus om inriktning och syfte, systematiskt och aktivt inkluderande av stakeholders, formaliserad och strukturerad utvecklingsprocess, öppenhet och insyn utvecklingsprocess. Samtidigt utmanade dock riktlinjerna om livsstilsinterventioner Socialstyrelsens utvecklingmodell p.g.a. deras förebyggande och icke sjukdomsspecifika fokus (I). En multipel fallstudie med nyckelpersoner ansvariga för implementeringen av riktlinjerna i sjukvårdsorganisationerna (n = 10) samt vårdpersonal och chefer (n = 340), visade på gynnsamma villkor för förändring i båda organisationerna rörande förändringsfokus (d.v.s. hälsoorientering) och den specifika interventionen (d.v.s. riktlinjer om metoder för att stödja förändring av ohälsosamma levnadsvanor). Stödet för förändring och lärande visade på något svagare resultat, likaså formen för förändringen d.v.s. nationella riktlinjer i allmänhet. Faktorer i den yttre kontexten visade sig kunna påverka prioritering av och optimalt val av tidpunkt för interventionen, likaså betydande skillnader i uppfattningar mellan yrkesgrupperna (II). En tvärsnittsstudie bland läkare och sjuksköterskor (n = 315) i primärvården visade att de har en positiv attityd och en god kunskapsnivå om metoder för livsstilsförändring. Både kunskapsnivå och i vilken utsträckning man arbetar med patienters livsstil skiljer sig mellan yrkesgrupper. Organisatoriskt stöd som nationella riktlinjer och utvecklandet av primärvårdens samarbete med intressenter i närområdet identifierades som viktigt för att förbättra arbetet med livsstil interventioner (III). En longitudinell undersökning bland vårdpersonal visade att användning av metoder för att förändra patientens vanor beträffande tobaksbruk och riskbruk av alkohol har ökat över tid, och att sjuksköterskorna arbetar i högre utsträckning med alla fyra levnadsvanorna än i tidigare. Implementeringen av de nationella riktlinjerna för levnadsvanor hade inte kommit så långt vid det andra mättillfället, och stora skillnader visade sig i hur läkare och sköterskor ser på riktlinjer och i vilken utsträckning de använder dem (IV). Slutsats: Hälsofrämjande och prevention skiljer sig på många sätt från mer traditionella fält inom medicinen. För att stärka implementeringen av det här viktiga (men ej akuta) fältet i hälso- och sjukvården, så måste det först av allt prioriteras på alla nivåer! Resultatet visar på ett svagt upptag av riktlinjerna för livsstilsinterventioner i klinisk praxis, och lämnar utrymme till förbättring. Aspekter av resultatet som presenteras i avhandlingen kan vägleda fortsatt utveckling och implementering av hälsoorientering och riktlinjer för livsstilsinterventioner inom primärvården, samt användas för att påverka policy, praxis och framtida forskning. Det gäller framför allt aspekter av utveckling av nationella riktlinjer på området; hälso- och sjukvårdsorganisationernas beredskap till förändring; hälsoprofessionernas attityder, kunskap och i vilken utsträckning de arbetar med livsstilsinterventioner och riktlinjer.

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Westby, Marie D. « First steps in developing clinical practice guidelines for post-acute rehabilitation after primary total hip and knee arthroplasty ». Thesis, University of British Columbia, 2010. http://hdl.handle.net/2429/23734.

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Total hip (THA) and total knee arthroplasty (TKA) are cost-effective interventions for advanced osteoarthritis (OA) of the knee and hip. With the rapidly growing number of these procedures performed annually in Canada and the United States, greater attention needs to be directed to identify rehabilitation practices that optimize outcomes and minimize cost. Currently, there is no consensus on rehabilitation best practice and no evidence-based clinical practice guidelines to inform clinical decision-making on post-acute rehabilitation following THA and TKA. A multi-phase, mixed-method project integrated stakeholder perspectives, research evidence and expert opinion to develop best practice recommendations for THA and TKA rehabilitation. Chapter 2 involved 11 focus groups and eight interviews to identify key themes related from North American patients and health care professionals on rehabilitation practices and outcomes. Chapters 3-4 are Cochrane systematic reviews examining the strength of the evidence for post-acute physiotherapy after THA and TKA. Chapter 5-6 involved two parallel Delphi surveys with consumers, clinicians and researchers to develop consensus on a range of rehabilitation topics to inform best practice for THA and TKA rehabilitation. Chapter 2: Six key themes emerged relating to communication, patient expectations, patient attitude, forms of support, barriers to recovery, and diversity of outcomes. Chapters 3-4: Systematic reviews of THA (n=8) and TKA (n=7) trials revealed limited, low to high quality evidence with mixed findings for various forms of post-acute physiotherapy on pain, function and health-related quality of life. Trial heterogeneity prevented meta-analysis. Chapters 5-6: Consensus (80% agreement) was reached on the need for post-acute rehabilitation, types of interventions, rehabilitation providers, treatment settings, outcomes and outcome measurement. Consensus was not reached regarding timing and dosage of rehabilitation. Sub-group analysis revealed few differences comparing responses by profession, primary role and country. This thesis has taken important first steps in identifying appropriate rehabilitation interventions and health care resources to optimize individuals’ activity, participation and health-related quality of life after THA and TKA. Further, it highlights the need for more high quality research to address the knowledge gaps and inform policy on this important and understudied aspect of arthroplasty surgery.
Medicine, Faculty of
Graduate

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Westby, Marie D. « First steps in developing clinical practice guidelines for post-acute rehabilitation afater primary total hip and knee arthroplasty ». Thesis, University of British Columbia, 2010. http://hdl.handle.net/2429/23734.

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Total hip (THA) and total knee arthroplasty (TKA) are cost-effective interventions for advanced osteoarthritis (OA) of the knee and hip. With the rapidly growing number of these procedures performed annually in Canada and the United States, greater attention needs to be directed to identify rehabilitation practices that optimize outcomes and minimize cost. Currently, there is no consensus on rehabilitation best practice and no evidence-based clinical practice guidelines to inform clinical decision-making on post-acute rehabilitation following THA and TKA. A multi-phase, mixed-method project integrated stakeholder perspectives, research evidence and expert opinion to develop best practice recommendations for THA and TKA rehabilitation. Chapter 2 involved 11 focus groups and eight interviews to identify key themes related from North American patients and health care professionals on rehabilitation practices and outcomes. Chapters 3-4 are Cochrane systematic reviews examining the strength of the evidence for post-acute physiotherapy after THA and TKA. Chapter 5-6 involved two parallel Delphi surveys with consumers, clinicians and researchers to develop consensus on a range of rehabilitation topics to inform best practice for THA and TKA rehabilitation. Chapter 2: Six key themes emerged relating to communication, patient expectations, patient attitude, forms of support, barriers to recovery, and diversity of outcomes. Chapters 3-4: Systematic reviews of THA (n=8) and TKA (n=7) trials revealed limited, low to high quality evidence with mixed findings for various forms of post-acute physiotherapy on pain, function and health-related quality of life. Trial heterogeneity prevented meta-analysis. Chapters 5-6: Consensus (80% agreement) was reached on the need for post-acute rehabilitation, types of interventions, rehabilitation providers, treatment settings, outcomes and outcome measurement. Consensus was not reached regarding timing and dosage of rehabilitation. Sub-group analysis revealed few differences comparing responses by profession, primary role and country. This thesis has taken important first steps in identifying appropriate rehabilitation interventions and health care resources to optimize individuals’ activity, participation and health-related quality of life after THA and TKA. Further, it highlights the need for more high quality research to address the knowledge gaps and inform policy on this important and understudied aspect of arthroplasty surgery.

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Brink, Filip. « Safe handling of antineoplastic drugs at a public hospital in Guangzhou, China : an observational study in clinical practice ». Thesis, Sophiahemmet Högskola, 2016. http://urn.kb.se/resolve?urn=urn:nbn:se:shh:diva-2471.

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Background Antineoplastic drugs constitute an important cornerstone in treating malignant cancer diseases. The nurses administering these drugs risk developing short- and long-term side effects from exposure if not properly protected by personal protective equipment. The National Institute for Occupational Safety & Health produces guidelines and recommendations for healthcare personnel handling antineoplastic drugs in order to minimise exposure. Aim The aim of this study was to observe and describe registered nurses’ compliance to National Institute for Occupational Safety & Health guidelines and recommendations concerning the use of personal protective equipment during drug administration at a public hospital in Guangzhou, China. Method Data was collected at three different departments using structured direct observations, totalling 211 administrations encompassing day and evening shifts. Results Total compliance to National Institute for Occupational Safety & Health guidelines and recommendations was 0 percent as a result of non-existent gown use. The overall compliance for the use of double gloves was 76,3 percent. The Department of Medical Oncology had the highest department-specific compliance rate for double gloves at 80,7 percent, whereas the evening shift at Chemotherapy Outpatient Department boasted the highest shift-specific compliance rate for the same item at 83,3 percent. Conclusion Interventions are needed concerning the use of personal protective equipment, in particular the use of gowns. Obtained hospital-specific guidelines did not include the procedure of drug administration, warranting the implementation of hospital-specific standard operating procedure guidelines encompassing this aspect.

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Nilsson, Karin. « Adherence to Venous Blood Specimen Collection Practice Guidelines Among Nursing Students and Healthcare Staff ». Doctoral thesis, Umeå universitet, Institutionen för omvårdnad, 2016. http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-120082.

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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.

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Hayawi, Lamia. « Assessment of an Evidence Practice Gap at the Population Level : Screening for Osteoporosis in Ontario ». Thesis, Université d'Ottawa / University of Ottawa, 2018. http://hdl.handle.net/10393/37926.

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Osteoporosis is a common health problem and it is increasing in prevalence due to the increase in the aging population. The interest to treat osteoporosis has increased in recent years, due to availability of screening modalities, advances in medications that may prevent osteoporotic fractures. Many studies have showed the high medical and economic burden of the disease on the patients, their caregivers and on the health system. Clinical practice guidelines for management of osteoporosis varied nationally and internationally, and the adherence of physicians to guidelines were always reported as suboptimal, though most studies were for after fragility fracture care gap and vert few looked at the primary screening to identify patients at risk before the occurrence of fractures. This thesis is composed of two manuscripts research project assessing the development and impact of screening for osteoporosis guidelines. The first chapter is an overview of osteoporosis, definition, risk factors, diagnosis and treatment. A follow up discussion of the literature on adherence of physicians to the osteoporosis guidelines, which ends up with the rational for this thesis. The first paper is a systematic review to identify guidelines for screening for osteoporosis from 2002-2016 (Chapter 2). We assessed the quality of these guidelines using the AGREE II and IOM standards, compared between the two tools, and assessed if the quality has changed over time. We extracted recommendations in key areas with summary of the systems that were used to assign the level of evidence and strength of recommendations. We found that the quality of guidelines has varied greatly between different countries with no significant change over time. The recommendations and systems for level of evidence were variable and all this may create confusion to clinicians. In the second paper, we used an interrupted time series design to assess the effect of three clinical practice guidelines for screening for osteoporosis in Ontario on the baseline bone mineral density (BMD) testing for older adults 65 years of age and above using administrative data by ICES from 1998-2006. All three guidelines recommend baseline BMD testing for this age population. In addition, we analyzed the pattern of repeated testing in accordance with the latest guideline. We have found low rates of baseline BMD testing with a decreasing pattern of testing. The last guideline in 2010 had gradually increased the trend of BMD testing, though it was a very small change. Stratified analyses by sex showed that the decrease in the total BMD testing is due to decrease in the testing for female population while there is an increasing trend of BMD testing in male population. CPG by Osteoporosis Canada in 2010 caused an immediate reduction in the BMD testing for female, yet, over a period of time, the guideline increased the BMD testing. For male population; the 2002 CPG had immediately increased the BMD testing, while over time this trend has decreased. Despite the low baseline BMD testing by physicians, there is an over use of repeated BMD testing in the low risk population, especially the annual and the 2 yearly BMD repeats. In conclusion: This research project found a varied quality of guideline development and reporting of guidelines for osteoporosis screening, and no improvement in the quality over time (2002-2016). Several systems were used to assign the level of evidence and strength of recommendations with conflicting recommendations between different health organizations in the same country such as in Canada. Many tools are available to appraise the quality of guidelines, however, comparing between two tools (AGREE II & IOM standards) showed that they may give conflicting results for guidelines quality. There is no effect of guidelines for screening for osteoporosis on the ordering of BMD testing to screen adults 65 years and above living in Ontario between 1998- 2016. A small increase the rate of baseline BMD testing followed the release of the 2010 guideline. For male population the 2002 guideline showed an evident immediate and gradual effect over time on the rate of baseline BMD testing ordering for male population. Despite the low baseline BMD testing rates for adults 65 years and above, there is an unnecessary repeated BMD testing for low risk population in Ontario between 2011-2016 which is not in compliance to the latest guideline for screening for osteoporosis.

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Quam, Jennifer M. « Knowledge of Assessment and Management of Childhood Obesity Among Rural Primary Care Nurse Practitioners ». Diss., The University of Arizona, 2016. http://hdl.handle.net/10150/612863.

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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.

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Paulus, Deborah Marie. « Performance of a Process Evaluation System in Outpatient Hospital-Based Cardiac Rehabilitation ». Thesis, Virginia Tech, 1997. http://hdl.handle.net/10919/10169.

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This study retrospectively evaluated patient records from two cardiac rehabilitation (CR) service centers located in large urban hospitals using a Process Evaluation System (PES) recently developed through a collaborative project of the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), Madison, WI, and the Center for Clinical Quality Evaluation (CCQE), Washington, DC. The major aims were to: 1) evaluate the utility of the PES as an audit instrument for assessment of adherence to the 24 quality process criteria that comprised the PES; and 2) determine whether adherence to the PES criteria resulted in different patient outcomes for those cases where intervention need was documented at patient admission. Using the data abstraction manual and audit procedures developed by AACVPR/CCQE, a trained medical technician audited 150 CR records for consecutively treated outpatients who typically received 36 sessions of treatment in either Moses H. Cone Memorial Hospital, N.C. Heart Institute, Greensboro, NC, or CarolinaÃ Âs Medical Center, Charlotte, NC, covering a calendar period between 1995-97. The data were pooled from both sites for analyses and included patients with one or more of the following diagnoses: MI (37%), angina (14%), coronary revascularization (76%), and other (18%). The cost of utilizing the PES was assessed by evaluating the technician time required to abstract a patient record and this was observed to improve over the course of the review period, i.e., mean abstraction time for initial versus final 20 records = 13.2 min. and 4.6 min., respectively. Experience with the PES suggested areas where instrument revision should be considered, e.g., the operational guidelines for extracting acceptable markers were not always clear enough or sufficiently flexible to allow determination of adherence of a record to the 24 quality process criteria. Adherence to the PES was determined, case by case, for each of the 24 criteria. In 129 cases (86% of the sample), complete adherence was found, i.e. 100% adherence to all 24 criteria that included indicators of key clinical steps for patient intake, treatment planning, and follow-up. The remaining 21 records (14%) showed adherence to at least 21 of the 24 criteria (87.5%). Given the uniformly high levels of adherence to the PES documented by these two program sites, the data could not resolve the question of whether patient outcome effects were different between cases of high versus low adherence to PES. Nonetheless, outcome data were examined to evaluate achievement levels in four different areas widely considered by clinicians as important to treatment success: blood cholesterol, smoking status, exercise tolerance, and body mass index (BMI). Of the study patients diagnosed with dyslipidemia 12 of 27 (44%) had levels < 200 mg/dl by exit. Seven of 14 documented smokers (50%) reported quitting at exit from treatment. Forty-nine patients of 117 (42%) who initially could only maintain treadmill walking for 10 min. at levels below 4 METs, were able to exceed this level by treatment end. Six of 104 (6%) with BMI values > 24.9 kg/m2 had a documented decrease in this indicator of overweight by treatment end. The threshold levels for outcome criteria used here to describe achievement levels in this data set are somewhat arbitrary. However, the criteria are reflective of the standards typically suggested as meaningful for effective secondary risk reduction in CR programs (Franklin et al., 1996). The PES system was developed to audit the quality of CR process in treatment centers, as standardized by a consensus panel to reflect the content of the evidenced-based CR guideline recently published by the US Agency for Health Care Policy and Research (Cardiac Rehabilitation as Secondary Prevention: #17, 1995). The findings of this study suggest that the content markers of quality process in the PES are relevant and the instrument is efficient to administer. When field tested against two urban centers in North Carolina where state statutes require program certification for CR treatment centers, these centers demonstrated uniformly high adherence to the PES and a pattern of good achievement for several patient outcome measures accepted as relevant to evaluation of treatment success for individual patients.
Master of Science

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Fung, Ching-shan, et 馮清珊. « Evidence-based clinical practice guidelines on the frequency of central venous catheter (CVC) dressing change for hematologicalmalignancy adult patients ». Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2011. http://hub.hku.hk/bib/B46581686.

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Abdullah, Ghadah Mubarak. « Mentoring as a Knowledge Translation Intervention to Inform Clinical Practice : A Multi-Methods Study ». Thesis, Université d'Ottawa / University of Ottawa, 2015. http://hdl.handle.net/10393/32497.

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Background: Mentoring is an intervention for implementing evidence into practice, but little is known about this intervention. The overall aim of this dissertation was to examine mentoring as a knowledge translation (KT) intervention to inform clinical practice. Methods: 1) A systematic review was used to determine the effectiveness of mentoring as a KT intervention. 2) An interpretive descriptive qualitative study was conducted to explore the use of mentoring in the Registered Nurses' Association of Ontario’s Best Practice Guidelines Implementation/ Knowledge Transfer Fellowship program. Findings: 1) Of 10,669 citations from 1988 to 2012, 10 studies were eligible. Findings showed that mentoring alone (n = 1 study) improved one behavioral outcome. When mentoring was used as part of a multi-faceted intervention (n = 9), there were various effects on knowledge, beliefs/attitudes, use of research evidence in clinical practice, and the impacts on healthcare professionals, patients and organizations. 2) Qualitative interviews with 6 fellows, 8 mentors and 4 program leaders revealed that mentoring involved building relationships, establishing a learning plan, and using teaching and learning activities. Mentors were described as accessible, dedicated, and having expertise; fellows were described as dedicated, self-directed, and having mixed levels of expertise. Mentoring was described as positively impacting upon mentoring relationships, fellows, mentors, and organizations. Participants reported no negative outcomes. Conclusion: Mentoring was used as a KT intervention to support the implementation of evidence into clinical practice. The systematic review and qualitative study findings informed the Mentoring for Guideline Implementation model. Mentoring involved mentees selecting more experienced mentors who provided individualized support based on mentees’ learning needs, which resulted in mutual benefits for mentees and mentors. Future research is required to validate this new mentoring model, develop an instrument to measure the mentor-mentee relationship, and evaluate the effectiveness of mentoring as a KT intervention for guideline implementation in nursing.

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Mayers, Patricia Margaret. « Nurses’ experiences of guideline implementation in primary health care settings ». Thesis, Stellenbosch : University of Stellenbosch, 2010. http://hdl.handle.net/10019.1/1437.

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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.

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Zolezzi, Cédric. « La force juridique des recommandations de bonne pratique : regards croisés France - Etats Unis ». Thesis, Rennes 1, 2016. http://www.theses.fr/2016REN1G008.

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Quelle est la force juridique des RBP en matière sanitaire, en plein contentieux comme en recours pour excès de pouvoir? Quelles sont les différences d'approche entre la France et les Etats-Unis?
What's the legal strength of CPGs in healthcare, in France and in the United States?The Institute of Medicine has defined as soon as 1992 Clinical Practice Guidelines as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." As they derive from various public and private bodies, and from the consensus of experts, CPGs are considered as consensus statements representing the prevailing standard of care in the medical profession. Clinicians and judges use clinical practice guidelines in their everyday life to appreciate individual situations and reach the best solutions for patients and plaintiffs: CPGs help improve their decision-making. But the legal strength of these tools is not totally consensual. In France, CPGs are seen as evidence of the standard of care expected from physicians. In theUnited States, where CPGs appeared some years earlier, they have been subject to questions, denounced as symptoms of a “cookbook medicine” and object of experiments by various States and insurance companies – not to mention lobbies. Their legal weight seems all the same better established in the U.S. than in France, although rulings in 2011 and 2016 by the french Conseil d’Etat have given them a more central role and a more recognized legal position in France

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