Thèses sur le sujet « Nursing sensitive outcome »

Driven by the current need of achieving high-reliability and patient-focused organization, several efforts have been enacted with the purpose of identifying and qualifying nursing care’s contribution to patients’ outcomes in Intensive Care Unit (ICU). The main aim of this thesis was to advance knowledge in critical care nursing with regard to nursing outcomes in the ICU. Thirty-five Nursing Sensitive Outcomes (NSOs) have been identified from a scoping review. Pressure ulcers, ventilator-associated pneumonia, and physiological parameter changes have been the top three reported outcomes, while those related to the physical dimension (such as bowel status) and the experience of being in intensive care (such as family participation in care) have been rarely reported. In addition, as an expression of both the structural and process dimensions of care, a total of 21 nursing factors have been studied to date. Early mobility programmes, the use of algorithms, checklists and specific assessment tools, nurse staffing and compliance with care bundles have been largely studied as being able to affect NSOs in the ICU. Conversely, little research investigating family member’s contributions to care in ICU, including its outcomes on family itself and on patient care, has been rendered available. Thus, the aim of the Family ENgagement in Intensive Care Environments (FENICE) project was to assess the effects of a family engagement program on family members’ satisfaction and on patients’ well-being and quality of life post-discharge. When questioned, relatives of critically ill patients discharged from an ICU experienced a mix of negative and positive feelings in the early stages. Three main themes summarized the experience of relatives in the first three months after ICU discharge: ‘Being shaken following ICU discharge’; ‘Returning to our life that is no longer what it used to be’ and ‘Feeling powerless due to the COVID-19 pandemic’. Finally, from an educational perspective, ICUs were perceived as good learning environments where undergraduate nursing students reported learning a high degree of competences compared with other clinical rotations. Therefore, this context of care can promote positive attitudes regarding the NSOs, by moving nursing care from a task orientation to an outcomes focus since the undergraduate education.

The purpose of this study was to identify the characteristics of cancer patients and the most frequently chosen nursing diagnoses, outcomes and interventions chosen for care plans from a large Midwestern acute care hospital. In addition the patients' outcome change scores and length of stay from the four oncology specialty units are investigated. Donabedian's structure-process-outcome model is the framework for this study. This is a descriptive retrospective study. The sample included a total of 2,237 patients admitted on four oncology units from June 1 to December 31, 2010. Data were retrieved from medical records, the nursing documentation system, and the tumor registry center. Demographics showed that 63% of the inpatients were female, 89% were white, 53 % were married and 26% were retired. Most patients returned home (82%); and 2% died in the hospital. Descriptive analysis identified that the most common nursing diagnoses for oncology inpatients were Acute Pain (78%), Risk for Infection (31%), and Nausea (26%). Each cancer patient had approximately 3.1 nursing diagnoses (SD=2.5), 6.3 nursing interventions (SD=5.1), and 3.7 nursing outcomes (SD=2.9). Characteristics of the patients were not found to be related to LOS (M=3.7) or outcome change scores for Pain Level among the patients with Acute Pain. Specifically, 88% of patients retained or improved outcome change scores. The most common linkage of NANDA-I, NOC, and NIC (NNN), a set of standardized nursing terminologies used in the study that represents nursing diagnoses, nursing-sensitive patient outcomes and nursing interventions, prospectively, was Acute Pain--Pain Level--Pain Management. Pain was the dominant concept in the nursing care provided to oncology patients. Risk for Infection was the most frequent nursing diagnosis in the Adult Leukemia and Bone Transplant Unit. Patients with both Acute Pain and Risk for Infection may differ among units; while the traditional study strategies rarely demonstrate this finding. Identifying the pattern of core diagnoses, interventions, and outcomes for oncology nurses can direct nursing care in clinical practice and provide direction for future research tot targets areas of high impact and guide education and evaluation of nurse competencies.

The impact health care delivery changes have on nursing and subsequently on the health of individuals, families, and the community are unknown to the nursing profession as well as the public. Delineation of patient outcomes sensitive to nursing care and their benchmarks would enable the nursing profession to evaluate system changes being implemented. Establishing targets for patient outcomes will provide facilities with benchmarks to measure themselves against. The purposes of this study were first, to identify if the nurse sensitive patient outcomes identified by the AAN expert panel are appropriate and second, to establish benchmarks for these outcomes that are applicable across the continuum of care. The appropriateness and benchmarks were determined through a Delphi study with nurse experts identified from the health care continuum of primary health care providers, hospitals, home care, hospice, and long term care. The five patient outcomes are Appropriate Self Care Behaviors, Symptom Management, Health Promoting Behaviors, Perceptions of Being Well Cared For, and Health Related Quality of Life (HRQOL). All patient outcomes were deemed appropriate for all healthcare settings. Two indicators of Health Related Quality of Life were excluded by the panel from Acute Care. Consensus was reached for the majority of patient outcomes. There were only seven benchmarks out of 18 for each continuum of care (a total of 90) that did not achieve consensus. The acute care participants did not reach consensus on one indicator within Health Promoting Behaviors. The remaining six were from Hospice participants: one indicator of Appropriate Self Care, all indicators of Health Promoting Behaviors and two within Health Related Quality of Life. The majority of benchmarks were in the mid to high range. Long Term Care tended to have lower scores than the other settings. Patient self care behaviors were very low for hospice patients. The indicators that did not meet consensus criteria were stable indicating that scores were not changing between rounds. Sample size of participants prevent citation of results for Home Care, Hospice and Long Term Care. Benchmarks can be set and used to evaluate the effectiveness of nursing care and the impact of system changes.

The impact of the nursing work environment on patient safety has received national attention, and has led to efforts to reduce morbidity and mortality in the health care environment (American Hospital Association, 2004). According to the American Association of Critical-Care Nurses, (2005) there is mounting evidence that unhealthy work environments contribute to medical errors, ineffective care delivery, and stress among health care professionals. There are few studies that examine a healthy work environment and the effect on patient outcomes. The purpose of this integrative literature review was to analyze the research that has been completed on healthy work environments and the effect they have on nursing-sensitive patient outcomes. An extensive literature search was performed using the following databases: the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature On-Line (MEDLINE), The Agency for Health care Research and Quality Patient Safety Network (AHRQ PSN), and The Robert Wood Johnson Foundation publications on-line database. The studies were evaluated using the following strategies: overall quality, data reduction, and identification of patterns, themes, variations and relationships. They were then further analyzed and synthesized using; data display, data comparison, conclusion drawing and verification. Twelve studies met the inclusion criteria and were compiled, organized by theme and analyzed based on similarities and differences. The data was examined, discrepancies and gaps in literature were discussed and conclusions were drawn based on the patterns found in the literature. The majority (n= 9; 75%) of the articles that met inclusion criteria suggested that a healthy work environment effects nursing sensitive patient outcomes by showing a decrease in the number of negative outcomes. However researchers used multiple healthy work environment factors and different patient outcomes in each study making it difficult to compare results. The findings of this research suggests the need for better identification of a healthy work environment, the use of consistent nursing-sensitive patient outcomes by researchers, and suggests the importance of a healthy work environment on all aspects of patient care. Findings strengthen the principle that the work environment at the unit level mediates the effects of nursing interventions.

Cardiovascular diseases (CVD) and diabetes are the most significant chronic diseases globally due to their high prevalence and mortality. People with CVD or diabetes need to know how to self-manage their health conditions to promote, maintain, and restore their health status. The Nursing Outcomes Classification (NOC) has assisted nurses and other health care providers to evaluate and quantify the status of the patient and has reflected the current health care issues that are to prevent progression of chronic diseases. Based on the current health focus, additional knowledge and self-management NOC outcomes were developed and added to the latest edition of NOC published in 2013. Generally, validation of measurement tools is required to provide trustworthy evidence for use in practice. As measurement tools, NOC outcomes with their definitions, indicators, and measurement scales need to be validated for accuracy, meaningfulness, and usefulness before they are widely used in various health settings. To provide clinical evidence for effective nursing practice such as accurate assessments and evaluations, validation of NOC outcomes is required. The purpose of this study was to validate 12 NOC outcomes focused on knowledge and self-management for people with CVD and diabetes. A descriptive exploratory design was used to validate the selected NOC outcomes, and a two round survey using the Delphi technique was used to collect data from the invited experts via email. Two subject populations were invited. The first expert group was related to standardized nursing languages (SNL) and invited experts were members of NANDA International or a fellow of the Center for Nursing Classification and Clinical Effectiveness (CNC). The second expert group was related to self-management and invited experts were members of two research interest groups which are Health Promoting Behaviors Across the Lifespan and Self Care in the Midwest Nursing Research Society (MNRS). Descriptive statistics were used to determine the definition adequacy, clinical usefulness of measurement scales, and similarity between content of knowledge and self-management outcomes. The Outcome Content Validity (OCV) method was used for the content validity of outcomes and their indicators. A total of 46 and 27 nurse experts participated in the first and second round surveys, respectively. The mean age of participants was 51.87 years (SD=13.03) and the mean of experience in nursing was 27.67 (SD=14.75) years. Most participants had experience using SNL (82.6%). Each outcome reported acceptable psychometric properties. The range of definition adequacy of the 12 NOC outcomes was from 3.71 to 4.29 (perfect score is 5.0). The range of clinical usefulness for using measurement scales was from 3.77 to 4.29. The range of content similarity of the six pairs was from 3.88 to 4.35. Every evaluated NOC outcome identified as critical with over .80 OCV scores (perfect score 1.0). More than 80% of indicators were categorized in the critical level in the first round. Thus, psychometric properties of the 12 NOC outcomes were acceptable to use in the clinical settings. By using validated NOC outcomes, nurses caring of patients with CVD or diabetes can evaluate patient outcomes effectively, and determine the effect of nursing interventions accurately. Development of new NOC outcomes and validation of them will provide nurses with measurement tools to use with patients, clinical evidence for quality improvement and knowledge development in nursing.

Objectiu: Valorar la qualitat de vida relacionada amb la salut en pacients sotmesos a ventilació mecànica en una Unitat de Cures Intensives i la seva relació amb els resultats sensibles a intervencions infermeres. Mètodes: Estudi d’una cohort prospectiva en que es van incloure durant 14 mesos consecutius els pacients ingressats a l’UCI de l’Hospital Universitari Vall d’Hebron sotmesos a ventilació mecànica durant més de 48 hores. Es va valorar la qualitat de vida relacionada amb la salut a l’ingrés mitjançant els qüestionaris SF-36 i Qüestionari Respiratori de Saint Georges (QRSG) i a l’alta de l’UCI. Els mateixos qüestionaris es van repetir a l’any de l’alta. Els Resultats Sensibles a Intervenció d’Infermeria (RSII) i les variables clíniques relacionades amb la patologia i l’evolució es van recollir de la documentació clínica diàriament. Es va realitzar una anàlisi descriptiva i analítica de la relació entre les variables principals. Resultats: La cohort inicial va estar formada per 184 pacients, a l’any se’n van poder estudiar 151. En els components resum (físic i mental) de l’SF-36 i la puntuació total del QRSG existien diferències estadísticament significatives entre la valoració a l’ingrés i a l’any (p= 0,001; p=0,001 i p<0,001 respectivament).Cap dels RSII van presentar associació estadísticament significativa amb els components resum de l’SF-36 ni amb cap dimensió del QRSG. Conclusions: Els pacients que van requerir ventilació mecànica durant el seu ingrés a l’UCI van presentar millor qualitat de vida a l'any de la seva alta que la que presentaven a l’ingrés, però va continuar sent pitjor que la de la població de referència. No es va poder determinar que existís relació entre els resultats sensibles a intervencions infermeres i la qualitat de vida a l’any dels pacients.
Objetivo: Valorar la calidad de vida relacionada con la salud en pacientes sometidos a ventilación mecánica en una Unidad de Cuidados Intensivos y su relación con los resultados sensibles a intervenciones enfermeras. Métodos: Estudio de una cohorte prospectiva en que se incluyeron durante 14 meses consecutivos los pacientes ingresados en la UCI del Hospital Universitario Vall d'Hebron sometidos a ventilación mecánica durante más de 48 horas. Se valoró la calidad de vida relacionada con la salud en el ingreso mediante los cuestionarios SF-36 y Cuestionario Respiratorio de Saint Georges (QRSG) y al alta de la UCI. Los mismos cuestionarios se repitieron al año del alta. Los Resultados Sensibles a Intervención de Enfermería (RSIE) y las variables clínicas relacionadas con la patología y la evolución se recogieron de la documentación clínica diariamente. Se realizó un análisis descriptivo y analítico de la relación entre las variables principales. Resultados: La cohorte inicial estuvo formada por 184 pacientes, al año se pudieron estudiar 151. En los componentes resumen (físico y mental) de l’SF-36 y la puntuación total del QRSG existían diferencias estadísticamente significativas entre la valoración al ingreso y al año (p = 0,001; p = 0,001 y p <0,001 respectivamente). Los componentes resumen de l’SF-36 (Físico = 46, Mental = 47) y la puntuación total del QRSG (12 vs 8) tuvieron peores resultados al año que la población de referencia. Ninguno de los RSIE presentaron asociación estadísticamente significativa con los componentes resumen del SF-36 ni con el QRSG. Conclusiones: Los pacientes que requirieron ventilación mecánica durante su ingreso en la UCI presentaron mejor calidad de vida al año del alta que la que presentaban al ingreso, aunque continuó siendo peor que la de la población de referencia. No se pudo determinar relación entre los resultados sensibles a intervenciones enfermeras y la calidad de vida al año de los pacientes.
Objective: To assess the HRQL of mechanically ventilated patients admitted to ICU and its relation to nurse-sensitive outcomes (NSO). Methods: A prospective cohort of admitted to d'Hebron University Hospital ICU who underwent mechanical ventilation for more than 48 hours were included for 14 consecutive months. Health-related quality of life at admission and discharge from ICU was assessed using the SF-36 and Saint Georges Respiratory (QRSG) questionnaires. The same questionnaires were also utilised 1 year after ICU discharge. Nursing Sensitive Outcomes (NSO) and clinical variables related to patient’s diagnosis and clinical course were collected from patient records on a daily basis. A descriptive and analytical analysis of variables’ relationship performed. Results: The initial cohort consisted of 184 patients. Follow-up a year after discharge was done on 151 patients. In the summary components (physical and mental) of the SF-36 as well as the total score of the QRSG there were statistically significant differences between the assessment performed at ICU admission and the one performed a year after ICU discharge (p = 0.001, p = 0.001 and p <0.001, respectively). The summary components of the SF-36 (Physical = 46, Mental = 47) and the total QRSG score (12 vs 8) results obtained a1 year after ICU discharge were worse if compared with the ones obtained from the reference population. None of the NSO had a statistically significant association with the SF-36 summary components or any dimension of the QRSG. Conclusions: Patients who required mechanical ventilation during ICU admission had better quality of life 1 year after ICU discharge when compared with ICU admission, but was worse when compared with the reference population. It was not possible to determine if there is a relationship between NSO and quality of life a year after ICU discharge.

Background: Staphylococcus aureus (SA) infections are common and important within the hospital environment. The case fatality rate of invasive Staphylococcus aureus (SA) infections is between 20-40%. Whether the infection is due to methicillin resistant SA (MRSA) or methicillin sensitive SA (MSSA) may determine outcomes. Literature to date is inconclusive regarding whether antimicrobial resistance in SA affects patient outcomes. Host factors, infection-host interactions, and treatment-related factors may also influence case fatality. Objectives: The purpose of this study was to determine if patients with MRSA invasive infections were more likely to die than those with MSSA invasive infections, and what factors were associated with death. Methods: A retrospective matched case control study was designed, comparing cases of MRSA with controls of MSSA invasive disease from hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP). Two analyses were run: the first, to identify the variables associated with MRSA vs. MSSA infections, and the second, to determine the variables associated with death in invasive Staphylococcal aureus (S. aureus) infections. Backward logistic regression analysis was used for the MRSA vs. MSSA analysis and a hierarchical logistic regression model for assessment of risk factors for death. Results: In the logistic regression MRSA model the variables: recent prior use of antibiotics, Charlson Comorbidity Index score > 2 and not having received appropriate empiric antibiotics were associated with MRSA vs. MSSA infections. The hierarchical model identified older age, higher CCI scores, immunosuppression, bloodstream infection, septic shock, neurological dysfunction and not receiving appropriate empiric antibiotic as associated with death. MRSA infection was not more likely to be associated with increased mortality than MSSA infection. Those with a resistant infection (MRSA) however, were less likely to receive appropriate empiric antibiotic treatment. Conclusions: Appropriate empiric antibiotics are the most important and only modifiable risk factor identified. Elderly patients who are on immunosuppressive drugs and have chronic comorbid conditions need to be monitored and screened more often since they are more at risk for death than others.

Objective: This thesis aims to explore the concept of geriatric nursing-sensitive indicators (NSIs), which are used to measure care for the older population. Introduction: By the year 2050, the global number of older people is predicted to double, creating fiscal and practice challenges for nursing. Nursing is the largest workforce in the health sector and is best placed to influence the quality of care received by the older person as system demand increases. Geriatric NSIs provide the opportunity to describe this influence, as they reflect the quality and effectiveness of geriatric nurses when caring for the older person. Methods: Due to the broad nature of the research topic, a scoping review was considered appropriate. The methods were based on those of the Joanna Briggs Institute, which were in turn informed by Arksey and O’Malley. In addition, a group of context experts were utilised to ensure the conduct of the review was meaningful for clinical staff and policy makers. This thesis outlines the results of a scoping review prepared as a manuscript for publication. The manuscript presented for publication is positioned in chapter four as a continuation of the thesis that outlines the methods and results of the scoping review. Results: The scoping review was completed, and a manuscript was prepared and submitted for publication. Many indicators were identified that described the nursing care of the older person. In line with the methodology, these were mapped in a variety of ways including Donabedian’s Domains and Fundamentals of Care that are existing taxonomies and Specificity which was a novel approach. It was apparent that there was a great deal of inconsistency in the description of the indicators but grouping of indicators through commonality and classification simplified indicator descriptions. Conclusions: The scoping review identified that concepts associated with geriatric nursing sensitive indicators are complex, and that extracted indicators did not comprehensively reflect contemporary geriatric nursing care. The complexities identified in the scoping review included issues such as lack of indicator definition and consistency, relationships between indicators, methodology for risk adjustment of patient outcomes and performance measurement of indicators. Contemporary nursing issues were not comprehensively reflected in the extracted indicators. Additional indicators are required to address issues such as the consumer perspective of geriatric nursing care, nursing hospital avoidance strategies and case management of inpatients. The achievements of this project extended beyond the mere conduct of a review and subsequent reporting of results. The project provided an opportunity for the lead reviewer to immerse themselves and learn the methodology of a scoping review. In addition, the decision to present the thesis in this form also provided the experience of submitting a manuscript for publication.
Thesis (MClinSc) -- University of Adelaide, Adelaide Nursing School, 2020

Patient safety is a global concern and the risks to this safety are higher in low- and middle-income countries (LMICs). The high rates of both communicable and non-communicable diseases, low numbers in the workforce, poor distribution of qualified professionals, and constraints in medical supplies and resources make the provision of quality health care challenging. There is a shortage of empirical evidence on nurses’ contribution to the quality of care generally, and patient safety outcomes particularly, in Ethiopia: a low-income country. The main aim of this study was to identify the determinants of nursing-sensitive patient safety outcomes among admitted patients in acute medical/surgical settings in Ethiopia. Specific objectives of the study were determining the level of nurse staffing, missed nursing care and associated factors, and exploring the experience and perception of nurses working in acute care units of the study hospitals. The results of the study will generate evidence to help redesign healthcare systems to improve patient outcomes associated with nursing practice. A parallel explanatory mixed-methods study was conducted. First, a systematic review was conducted to determine the impact of nurse staffing on patient and nursing workforce outcomes in LMICs. Simultaneously, a prospective observational study was conducted comprising a survey of 517 nurses at two time points, and a medical record review to assess nursing-sensitive patient safety outcomes in two hospitals in Ethiopia. An exploratory descriptive qualitative study using in-depth semi-structured interviews was also conducted among nurses who were working in the medical and surgical acute care settings of the two study hospitals. The interviews were designed to explore the experience and perceptions of nurses about patient safety and quality of care in their respective units of the study hospitals. The systematic review found that low nurse-to-patient ratios and high nurses’ workload were associated with higher rates of in-hospital mortality, hospital-acquired infection, medication errors, falls and abandonment of treatment in LMICs. Extended work hours, lesser experience, and working night or weekend shifts all significantly increased medication errors. Higher nurses’ workload was linked to higher levels of nurses’ burnout, needlestick and sharps injuries, intent to leave, and absenteeism. The quantitative study demonstrated that nurses working in acute care settings of the study hospitals typically work more than 40 hours per week and care for many patients per shift, which has the potential to impact patient safety. The level of missed nursing care in the study units was very high. The mean number of patients a nurse provided care for per shift was significantly associated with in-hospital mortality. For every extra patient per nursing shift, the odds of a patient dying increased by 27 percent. The qualitative study showed that nurses were very concerned for the safety of patients, the quality of care provided, as well as their own health and wellbeing, while providing care. Providing care for a high number of patients per shift, longer shift hours during night and weekend shifts, being responsible for non-nursing tasks, unfavourable work environments, inadequate resources to provide care, unclear job descriptions, inadequate financial compensation, and scant opportunities for training and capacity development were concerns routinely raised by nurses. Despite the reality of working in a poorly resourced working environment, nurses in this study could achieve positive changes through improved staff management practices that better align patient acuity with individual nurses’ education and expertise. Further, they believed that it was important that management listened to and valued clinicians’ views about models of nursing care delivery. This had the potential to not only improve patient outcomes but also the environment in which these nurses worked.
Thesis (Ph.D.) -- University of Adelaide, Adelaide Nursing School, 2021

Introdução: A dependência de drogas é um problema multidimensional com repercussões que frequentemente são associadas a estados de menor bem-estar e sofrimento. É um foco de atenção para os profissionais de saúde e para os enfermeiros em particular. Os cuidados de enfermagem, em resposta às necessidades dos consumidores de drogas, devem ser monitorizados tendo em vista a adequação a essas necessidades. O conjunto de intervenções constitui o processo de cuidados, influenciado pelos fatores estruturais das pessoas alvo de cuidados, dos enfermeiros e das próprias unidades onde os cuidados são prestados. A inexistência de estudos em Portugal, sobre a efetividade das intervenções de enfermagem, com pessoas que consomem drogas, levou-nos à procura de uma metodologia que fornecesse uma matriz de análise que se revelasse adequada e tivesse sido usada no estudo da efetividade dos cuidados de enfermagem em outros contextos. Escolhemos o Modelo da Efetividade do Papel de Enfermagem, que através da análise da relação entre variáveis de estrutura, processo e resultado, possibilita: uma visão sobre a efetividade dos cuidados de enfermagem; verificar a sensibilidade dos resultados em saúde, aos cuidados de enfermagem e, identificar um conjunto de indicadores de resultado sensíveis aos cuidados de enfermagem. Pretendíamos apurar se a qualidade de vida, a saúde mental e as consequências da dependência de substâncias, em dependentes de drogas, são sensíveis aos cuidados de enfermagem e perceber que fatores se relacionam com estes resultados funcionais. Assim, realizamos um estudo que teve como objetivo geral, identificar os fatores que contribuem para a obtenção de melhores resultados funcionais em pessoas consumidoras de drogas, integradas num programa de metadona. Metodologia: Realizamos um estudo quantitativo, exploratório correlacional-preditivo, com uma abordagem transversal. Recolhemos dados de duas amostras, 180 participantes-utentes selecionados de forma aleatória (60 em cada unidade) e 10 participantes-enfermeiros (total das 3 equipas). Os dados foram recolhidos por questionário de auto resposta, com questões de caraterização sociodemográfica e instrumentos que caracterizam variáveis estruturais, de processo e de resultado. Com os enfermeiros, para caracterização estrutural, utilizamos a versão portuguesa do Job Diagnostic Survey (JDS). Com os utentes e para avaliar os resultados funcionais, utilizamos a Escala de Avaliação da Qualidade de Vida nos Consumidores de Substâncias em Programa de Substituição com Metadona, a versão portuguesa do Mental Health Inventory (MHI5), o resultado NOC Consequências da Dependência de Substâncias e a Escala de Satisfação com os Cuidados de Enfermagem no Centro de Saúde (SUCECS26). O tratamento e análise dos dados foram realizados recorrendo à estatística descritiva e inferencial. Recorremos essencialmente a testes paramétricos e utilizamos o modelo de equações estruturais para analisar um conjunto de relações entre variáveis, com base no modelo teórico. Resultados: As hipóteses colocadas, que tinham como propósito, orientar a análise das relações entre as variáveis de estrutura, de processo e de resultado, confirmaram a existência de relações significativas. Na dimensão estrutural, a formação de especialização em enfermagem de saúde mental, surgiu como o indicador mais relacionado com a afirmação de realização de mais intervenções de enfermagem e, a perceção de menores condições do trabalho, como um indicador relevante para condicionar o desempenho dos enfermeiros. Na dimensão processo, verificamos que equipas com um padrão mais uniforme de intervenção, promovem mais satisfação com os cuidados de enfermagem. Os enfermeiros intervêm de forma mais efetiva quando os utentes apresentam mais consequências da dependência de substâncias. Na dimensão de resultados, constatamos relações significativas entre variáveis estruturais e os resultados funcionais. Variáveis como desemprego, comorbilidades, policonsumo, idade de início de consumos, maior número de reentradas, associam-se à perceção de menores resultados funcionais. Por outro lado, viver maritalmente, mais habilitações, emprego, profissão qualificada, ausência de comorbilidades, menor consumo, maior permanência nos programas, associam-se à perceção de melhores resultados funcionais. Verificamos valores positivos de qualidade de vida, de saúde mental e das consequências da dependência de substâncias. Através do modelo de equações estruturais confirmamos que o “papel de enfermagem” incluindo variáveis como a formação especializada, as condições de trabalho, o número de intervenções e a satisfação com os esses cuidados, justifica 29% da variação dos “resultados clínicos e funcionais” que incluí variáveis como a qualidade de vida, a saúde mental, as consequências da dependência, as comorbilidades e o número de substâncias consumidas. Discussão: A confirmação da existência de relações significativas, entre as dimensões, aponta para que a efetividade das intervenções seja uma realidade e, evidencia a sensibilidade dos resultados funcionais, aos cuidados de enfermagem. Os dados que emergiram da verificação das hipóteses foram refletidos com base nos conceitos pessoa, saúde, ambiente e cuidados de enfermagem, o que nos ajudou na identificação de indicadores de resultado, sensíveis aos cuidados de enfermagem e indicadores relacionados com o processo de cuidados. A formação foi o fator que mais se destacou na relação com as intervenções de enfermagem, contrariamente ao que se esperaria face à experiência profissional, que surgiu neste estudo condicionada pela perceção das condições de trabalho. Os utentes assinalaram maior satisfação com os cuidados, na equipa que centra a sua intervenção na promoção do autocuidado e na avaliação das necessidades através da relação terapêutica. Os resultados funcionais relacionaramse de forma significativa entre si e com a satisfação face aos cuidados de enfermagem. O resultado com menor valor foi a saúde mental. Conclusão: Os dados reforçam na matriz do Modelo da Efetividade do Papel de Enfermagem, a relação entre as variáveis estruturais dos utentes e os resultados. O papel de enfermagem e a sua influência na variação dos resultados clínicos e funcionais, testado no modelo de equações estruturais, reforça a possibilidade de afirmarmos que os resultados funcionais são sensíveis aos cuidados de enfermagem. Os indicadores de resultado identificados podem contribuir para melhor planeamento dos cuidados de enfermagem, perspetivando mais efetividade.
Introduction: Drug addiction is a multidimensional problem with repercussions that are often associated with lower welfare states and suffering. It is a focus for health professionals and nurses in particular. Nursing care in response to drug addicts needs, should be monitored in order to fit those needs. The set of interventions is the process of care, which is influenced by patients structural factors, nurses factors and from the own units where care is provided. The lack of studies in Portugal, on the nursing interventions effectiveness in the context of drug addicts nursing care, led us to search for a methodology that provides a relevant suitable matrix for analysis and that it had been used in study of the nursing care effectiveness in other contexts. We chose the Nursing Role Effectiveness Model that by analyzing the structure, process and outcome variables relationship lets us to determine the nursing care effectiveness, check the nursing sensitivity health outcomes and identify a set of nursing sensitive outcomes indicators. We wanted to study if quality of life, mental health and substance dependence consequences, in a drug addicts outpatient community, and understand the factors that are relate to these functional results. Thus, we conducted a study which main goal was to identify the factors that contribute to achieving better functional outcomes in drug addicts, integrated in a methadone maintenance program. Methods: We performed a cross-sectional, exploratory, quantitative, correlational-predictive study. We collected data from two samples, 180 randomly selected participants- users (60 in each unit) and 10 participants-nurses (total of 3 teams). Data were collected by self response questionnaire with socio-demographic issues characterization and instruments that characterize structural, process and outcome variables. With nurses, to structural characterization, we use the Portuguese version of the Job Diagnostic Survey (JDS). With users and to evaluate the functional outcomes, we used the Drug addicts in a methadone substitution program quality of life Scale, the Portuguese version of the Mental Health Inventory (MHI5), the result NOC Substance dependence Consequences and Nursing care at the primary health centre satisfaction Scale (SUCECS26). Data were processed and analyzed using descriptive and inferential statistics. We use parametric tests mostly and used the structural equation model to analyze a set of relationships between variables, based on the theoretical model.Results: The hypothesis made to guide structure, process and outcome variables relationships analysis, confirmed the existence of significant relationships. In the structural dimension, the educational expertise in mental health nursing, seems to be the main indicator associated with more interventions, and the minor working conditions perception, seems to be an important indicator to decrease nurse’s performance. In the process dimension, we found that teams with a more uniform pattern of interventions, promote more nursing care satisfaction. Nurses intervene more effectively when users have more substance dependence consequences. In the results dimension, we found significant relationships between structural variables and functional outcomes. Variables such as unemployment, comorbidities, multiple drug use, age of onset of consumption, the higher number of re-entries, are associated with lower functional outcomes perception. On the other hand, living maritally, more qualifications, employment, skilled profession, comorbidities absence, lower consumption, longer stay in the programs, are associated with better functional outcomes perception. Positive values of quality of life, mental health and substance dependence consequences were observed. Through structural equation model we confirmed that the “nursing role" including variables such as specialized training, working conditions, number of interventions and nursing care satisfaction, it justifies 29% of "clinical and functional outcomes" variation which includes quality of life, mental health, addiction consequences, comorbidities and the number of consumed substances variables. Discussion: The confirmation of significant relationships between dimensions, points that interventions effectiveness is a reality, and demonstrates the functional outcomes nursing care sensitivity. The data that emerged from hypotheses were reflected based on person, health, environment and nursing care concepts, which helped us to identify nursing care sensitive outcome indicators and indicators related to the care process. The expertise specialization was the factor that most stood out in relation to nursing interventions, contrary to what one would expect given the professional experience that emerged in this study influenced by the working conditions perception. Users indicated greater care satisfaction with the team that focuses its intervention in promoting self-care and needs assessment through the therapeutic relationship. The functional outcomes were related significantly with each other and with nursing care satisfaction. Menthal health was the lowest outcome value.Conclusion: Data reinforce in the Nursing Role Effectiveness Model, the relationship between patients structural variables and outcomes. The nursing role and its influence on the clinical and functional outcomes variation, tested in structural equation model, enhance the possibility of affirming that the functional outcomes are nursing care sensitive. Outcome indicators identified can contribute to better nursing care planning, looking for more effectiveness.

Tese de Doutoramento do Programa de Doutoramento em Ciências da Saúde, ramo de Enfermagem, apresentada à Faculdade de Medicina da Universidade de Coimbra
A Diabetes Mellitus é uma doença crónica com uma elevada prevalência a nível mundial e onerosa para as pessoas afetadas, famílias e sistemas de saúde. O autocuidado é um componente fundamental para fazer face às atuais exigências em saúde e essencial para reduzir os custos associados à doença, obter resultados positivos para a saúde, melhorar a qualidade de vida e o bem-estar das pessoas. As pessoas com diabetes mellitus tipo 2 necessitam de desenvolver capacidades de autocuidado terapêutico. Mas, a sua gestão é complexa, dada a influência de fatores cognitivos, psicossociais, físicos e sociodemográficos. O apoio profissional dos enfermeiros é determinante para a gestão de autocuidado terapêutico bem-sucedida. As intervenções de enfermagem centram-se em capacitar as pessoas com diabetes mellitus tipo 2 e as suas famílias para o autocuidado terapêutico e criar as oportunidades para que se envolvam ativamente na tomada de decisão. O autocuidado terapêutico é um importante resultado sensível aos cuidados de enfermagem. A sua medição em pessoas com diabetes mellitus tipo 2 é fundamental nos cuidados de saúde primários, uma vez que as pessoas desempenham as atividades de autocuidado terapêutico no contexto natural. Por outro lado, permite criar evidência sobre a eficácia dos cuidados de enfermagem e intervenções individualizadas dirigidas às necessidades reais das pessoas. Em Portugal, existe ainda uma lacuna de instrumentos válidos e fiáveis para a avaliação do autocuidado terapêutico e de conhecimento específico sobre os preditores deste fenómeno.
Diabetes Mellitus is a chronic disease with a high prevalence worldwide and costly for the affected people, their families and the health systems. Self-care is a key component to meet people’s health requirements. It is essential for reducing the costs of the disease, to achieve positive health outcomes and to improve quality of life and well-being. People with type 2 diabetes mellitus must develop therapeutic self-care abilities. But, their management is complex, given the influence of cognitive, psychosocial, physical and sociodemographic factors. Nurses’ professional support is determinant for a successful therapeutic self-care management. Nursing interventions focus on empowering people with type 2 diabetes mellitus and their families for therapeutic self-care and creating opportunities for them to become actively involved in decision-making. Therapeutic self-care is an important outcome sensitive to nursing care. Its measurement in people with type 2 diabetes mellitus is fundamental in primary health care, since people perform therapeutic self-care activities in their natural context. On the other hand, it provides evidence on the effectiveness of nursing care and individualized interventions targeting people’ real needs. In Portugal, there is still a gap of valid and reliable instruments for the evaluation of therapeutic selfcare and of specific knowledge on the associated predictors.

Problématique : Les organisations de santé font face à des pressions diverses pour offrir des soins et des services qui répondent aux plus hauts critères de performance et rendre compte de cette performance. Ces pressions proviennent de différents acteurs tels que les usagers du système de santé et les décideurs politiques. En raison de la place importante que prennent les infirmières dans l’offre de services de santé, il existe un intérêt croissant pour la mise en place d’interventions visant à mesurer et à améliorer la performance des services infirmiers. Cependant, dans le cadre de ces processus, les organisations sont souvent confrontées à des visions différentes et conflictuelles de la performance et à diverses approches pour la mesurer. Objectifs : Cette étude qualitative exploratoire a pour but d’explorer les conceptions de la performance des membres de l’équipe d’encadrement impliqués dans la prestation des services infirmiers et des infirmières soignantes et d’examiner dans quelle mesure les conceptions de la performance des deux groupes d’acteurs correspondent ou entrent en conflit. Méthodologie : Des entrevues semi-dirigées ont été conduites auprès de cinq membres de l’équipe d’encadrement et de trois infirmières. Une analyse de contenu a été effectuée à la fois pour faire ressortir l’éventail des conceptions et celles qui sont les plus prépondérantes dans les discours. Le cadre de référence ayant guidé cette analyse est une adaptation du modèle conceptuel de Donabedian comprenant trois dimensions soit la structure, le processus et les résultats (Unruh & Wan, 2004). Résultats : L’analyse des données recueillies auprès des membres de l’équipe d’encadrement fait ressortir dix conceptions distinctes, mais interreliées de la performance qui mettent l’accent sur les éléments de processus de soins infirmiers et de résultats chez la clientèle. Concernant les infirmières, neuf conceptions ont été répertoriées et l’accent a été porté surtout sur les éléments concernant l’adéquation des ressources humaines infirmières et de processus de soins infirmiers. Certaines similitudes et différences ont été repérées entre les conceptions de ces deux groupes d’acteurs. Conclusion : Cette étude permet de mieux comprendre les conceptions de la performance des acteurs impliqués dans l’offre de services infirmiers. Le modèle intégrateur qui résulte de la combinaison de ces différentes conceptions offre un cadre utile pour guider la construction d’outils de mesure de performance directement en lien avec les soins infirmiers et répondre à la demande d’imputabilité par rapport à ces services.
Background : Healthcare organizations face pressure to supply care and services that meet the highest level of performance and to show accountability in regards to this performance. These pressures come from different individuals ranging from the users of the healthcare system to political leaders. Since the nursing staffs occupy an important part in the supply of the healthcare services, there is a growing interest to put in place actions that would increase the performance of the nursing services as well as measure it. However, as part of this process, healthcare organizations often face conflictual notions of what performance is and how to properly measure it. Objectives : This qualitative exploratory study aims to explore the different notions of what performance is as seen by management teams involved in the nursing services delivery and by the field nurses to determine how much these notions are similar to each other or rather in opposition. Methodology: Semi-directed interviews have been held with five management teams’ members and also with three nurses. A content analysis has been made to illustrate the various notions of what performance is and those that show up the most. The framework used in this study is an adaptation of Donabedian’s model which includes three components: structure, process and results (Unruh & Wan, 2004). Findings: Ten distinct but related performance notions that focus on nursing’s process and impact on the users have been identified from data collected from management team members. On the nurses’ side, nine notions have been identified and put the focus mainly on the adequacy of nursing human resources with the nursing process. Some differences and similarities have also been identified between the performance notions of the two groups. Conclusion : This study gives a better understanding of the different performance notions that come from the various individuals involved in the nursing supply. The integrator model that result from the mix of these different notions will be useful in the creation of performance measurement tools directly linked with the nursing services, which will help respond to the accountability demand towards these services.