Rozprawy doktorskie na temat „Clinical practica”

This research explores how experienced nurses perceive their role as clinical teachers in an environment that is challenged not only with on-going changes in healthcare delivery, but also by the expectation that it will continue to provide positive clinical learning opportunities for undergraduate student nurses. Schools of nursing in Australia have undergone rapid and far-reaching change as a consequence of the legislated transfer of nursing eduction to the tertiary sector. Expectations that nurse academics will possess higher degrees and be actively involved in research mean that faculty members have less time to be directly involved in their students’ learning during clinical practice placements. The literature indicates that the responsibility for moment to moment teaching and learning thus appears to have been implicitly given to clinical staff who may not possess any formal qualifications for teaching, yet are largely responsible for students’ learning through clinical placements. Indeed some clinicians report a worrying lack of knowledge of clinical supervision models giving cause for further concern about the nature of the clinical learning environment. Schools of nursing expect that clinical practica will provide opportunities for students to learn how to be a nurse through guided questioning, analysis and critical thinking. It is evident that in some settings, this represents an ideal situation and not the reality. Critical reflection on these issues has informed the purpose of this research and helped to shape the following questions that focus the conduct of the study: Research Question One. How do experienced nurses create positive clinical learning environments for student nurses? Research Question Two. How do experienced nurses resolve the often-contradictory demands of nursing students and those of the practice setting? Research Question Three. How do changes in the healthcare environment impact on the experienced nurse's role as a clinical teacher? The theoretical framework for this study was underpinned by the interpretive philosophies of hermeneutic phenomenology and symbolic interactionism, because they acknowledge the personal experiences and meanings of the participants. A case study approach was utilised because it acknowledges the given context of the participants. Data were collected from six experienced nurses through a series of semi-structured interviews, informal interviews and periods of participant observation supported by field notes and the researcher’s diary. Participants identified that their perception of their role as clinical teachers was constructed of three intersecting roles: that of facilitator of learning, assessor and socialiser. This study concludes that several factors influence these nurses’ perception of their role as clinical teachers. In particular, the positivist work culture of the clinical setting and nurses’ own past experiences and world view of nursing combine to shape these nurses’ perception of their role as clinical teachers. The research concludes that the expectations that students will be supported in their endeavours to be critically thinking, problem solving and reflective practitioners may, in fact, be unrealistic in the current, economically constrained, clinical environment. It is evident that experienced nurses, despite being willing to be involved with clinical teaching, have to function in rapidly changing environments that do not always offer opportunities for nurses to reflect on their practice. However, the creation of positive clinical learning environments in these circumstances requires an increased understanding and appreciation by both schools of nursing and their students of the impact of change on these nurses and their clinical environment. This appreciation may result in more effective collaboration between nursing education and nursing service to assist student nurses to learn not merely through repetitive practice and busywork, but also through opportunities to observe, question and understand their nursing practice.

El dolor postoperatorio es un problema frecuente en los hospitales. Se han desarrollado Guías de Práctica Clínica para el control del Dolor Postoperatorio (GPCDP) con la finalidad de ayudar a los profesionales sanitarios y mejorar el tratamiento del dolor postoperatorio. Pocos estudios han evaluado el efecto de las GPCDP en la práctica clínica. OBJETIVOS El objetivo principal fue evaluar la prevalencia y la intensidad del dolor postoperatorio antes y después de la implementación de la GPCDP. Los objetivos secundarios fueron la evaluación de los registros del dolor, de las pautas analgésicas, y de la satisfacción de los pacientes con el tratamiento analgésico en ambos períodos. MATERIAL Y MÉTODO Estudio observacional de diseño antes-después, que incluyó dos estudios transversales realizados en un hospital de tercer nivel en dos períodos. El primer período fue en 2006, antes de la implementación de la GPCDP, y el segundo período en 2011, después de su elaboración y difusión. Se recogió información de variables demográficas y clínicas de los pacientes, y variables farmacológicas a partir de las historias clínicas. Además también se recogió información sobre la intensidad del dolor de los pacientes y del grado de satisfacción mediante una entrevista con los pacientes. Se realizó una comparación de los resultados en los dos períodos. RESULTADOS Se incluyeron 306 pacientes en el primer período y 317 en el segundo. No hubo diferencias significativas respecto a las variables demográficas y clínicas de los pacientes en los dos períodos del estudio. La prevalencia del dolor fue menor en el segundo período (77%) que en el primer período (92%) (p<0,05). El dolor más frecuente referido por los pacientes en las últimas 24 horas fue de intensidad moderada o intensa en el 53% de los pacientes del primer período y en el 33% de los pacientes en el segundo (p<0,05). En el segundo período la prescripción de los analgésicos se adecuaron a las recomendaciones de la GPCDP en el 50% de los pacientes. En el segundo período aumentó la prescripción de paracetamol, AINE y morfina, y de la pautas controladas por el paciente en comparación con el primer período, y disminuyeron las pautas a demanda. No se observó una mayor adherencia a las recomendaciones relacionadas con la dosificación de los analgésicos en el segundo período. En ambos períodos los pacientes manifestaron un grado de satisfacción elevado respecto al alivio del dolor con el tratamiento recibido. Se observó variabilidad de la prevalencia y la intensidad del dolor, y del grado de satisfacción de los pacientes en las diferentes áreas del hospital. CONCLUSIONES Tras la elaboración y difusión de la GPCDP se observó un descenso de la prevalencia del dolor y una disminución de la intensidad del dolor de los pacientes. Sin embargo, todavía existe margen de mejora en la adherencia a las recomendaciones de la GPCDP y la disminución de la intensidad del dolor postoperatorio. Son necesarias medidas continuadas de información, formación y evaluación del dolor para conseguir un tratamiento adecuado del dolor postoperatorio a lo largo del tiempo.
Introduction: Postoperative pain is a frequent problem in hospitals. Many Clinical Practice Guidelines for Postoperative Pain(CPGPP) control have been developed with the aim of helping health professionals, and improving the postoperative pain treatment. Few studies have evaluated the effect of this CPGPP in clinical practice. Objectives: The main objective is to evaluate the prevalence and the intensity of the postoperative pain, before and after the implementation of the CPGPP. The secondary objectives have been the evaluation of the pain registries, the analgesic schedule, and the grade of satisfaction of the patients after the analgesic treatment in both periods. Material and Methods: The observational study with before and after design, which included two transversal studies, was carried out in a third level hospital in two separate periods. The first period took place in 2006, before the implementation of the CPGPP, and the second period in 2011 after its elaboration and diffusion. Information of demographic and clinical variables from patients, and pharmacological variables were collected from the clinical histories. Furthermore, data over the pain intensity and the degree of satisfaction of patients was collected through a personal interview. A comparison between the two periods was stablished. Results: The study included 306 patients in the first period, and 317 in the second period. There were no significative statistical differences with respect to the demographical and clinical variables of patients in both periods. The prevalence of the pain was smaller in the second period (77%) than in the first period (92%)(p<0,05). The most frequent pain referred to by the patients in the last 24h was moderate or intense pain in 53% of patients in the first period, and was reduced to 33% of patients in the second(p<0,05). In the second period analgesics prescription were adjusted to the recommendations of the CPGPP in 50% of patients. In the second period an increase in the prescription of Paracetamol, AINE and morphine was observed, so were patient controlled analgesia in comparison with the first period, the schedules “as-need” decreased. No increase in the adjustment to the recommendations related to the analgesic dosage was observed in the second period. In both periods the patients expressed a high degree of satisfaction with the pain relief after the received treatment. A variability in the prevalence and intensity in the pain, and the degree of satisfaction of patients in different sections of the hospital were observed. Conclusions: After the elaboration and diffusion of the CPGPP, a decrease in the prevalence of pain and a reduction in patients pain intensity was observed. Nevertheless, there is still room for improvement in the following of the CPGPP recommendations, and the decrease of postoperative pain. There is need for constant information, formation and evaluation of pain analgesics in order to obtain the adequate postoperative pain treatment through time.

The present research involved the implementation / evaluation of several approaches to optimising antibiotic use and infection control. The first study reported within this thesis aimed at assessing the impact of an antibiotic policy on reducing high-risk antibiotic usage in hospital practice and the associated incidence rates of MRSA and C. difficile infection (CD!). There was a significant decrease in high-risk antibiotic use within the three studied hospitals as a result of the policy. MRSA and CD! incidence rates were monitored in one of the hospitals and both rates decreased significantly. The next study reported in the thesis focused on the influence of antibiotic prescribing in primary care on the incidence rates of ESBL-producing bacteria detected in patients who were hospitalised. It was clearly shown that previous exposure in primary care to fluoroquinolones and cephalosporins (second and third generation) were independently associated with ESBL detection in hospital. Moving to the wound infection area, an interrupted timeseries analysis was performed to examine the impact of infection control practices on rates of post-caesarean surgical site infection (SSI). In this work, there was a significant drop in the incidence rate of SSIs after the introduction of the main intervention in the study (use of ChloraPrep® skin disinfectant). In the final experimental chapter, the aim was to evaluate changes in the incidence of central venous catheter-related bloodstream infection (CRBSI when switching from mechanical-valve needleless connector use to the use of split-septum needle less connectors in an intensive care unit. A reduction in the CRBSI incidence rate was identified after this switch took place. Overall, the work presented in this thesis adds evidence which supports guidelines on controlling antibiotic use and healthcare acquired infections. The findings will help inform future new services and practices that will enhance healthcare quality and patient safety.

AN ABSTRACT OF THE DISSERTATION OF MICHAEL A. STROUD, for Doctor of Philosophy degree in HEALTH EDUCATION, presented on MARCH 20, 2014, at Southern Illinois University Carbondale. TITLE: PHYSICAL THERAPISTS' CLINICAL PRACTICES REAGARDING INTRINSIC AND EXTRINSIC FALL RISK FACTORS AND THEIR ATTITUDES TOWARD THE USE OF EVIDENCE-BASED PRACTICE MAJOR PROFESSOR: Dr. Stephen Brown The phenomenon of falls among community-dwelling adults--coupled with an aging baby boomer generation and an increasing life expectancy--presents a significant concern for an increased number of unintentional deaths and injuries and their associated costs. The risk factors associated with falling are often categorized as intrinsic and extrinsic. Physical therapists have a unique opportunity to positively impact issues involving physical dysfunction and to educate their community-dwelling adult patients about the environmental risk factors and interventions that lessen their risk of falling. Abundant evidence-based research exists regarding interventions for the treatment and prevention of falls; however, this research indicates that physical therapists fail to consistently utilize evidence-based practice (EBP) in their daily clinical practices. The diffusion of innovations theory examines how innovations are adopted (Rogers, 2012). However, the innovation of EBP is not always adopted by physical therapists. Lack of time to conduct literature searches was the most common barrier noted by physical therapists for not adopting EBP (Jette et al., 2003; Fruth et al., 2010; Salbach, Jagial, Korner-Bitensky, Rappolt, & Davis, 2007). This study, which utilized a cross-sectional descriptive research design, provided insight into physical therapists' clinical practices regarding intrinsic and extrinsic fall risks in the treatment of community-dwelling adults aged 65 years and older. It examined physical therapists' attitudes and beliefs toward the use of EBP and identified the barriers to their adoption of it. The demographic data provided a descriptive overview of the study respondents. There were 3,523 potential physical therapist respondents, and the study's return rate was 9% (316 respondents. The majority of the respondents held doctoral degrees (49.4%), more than half (55.4%) worked in an outpatient physical therapy clinical setting, and approximately half indicated that they were American Physical Therapy Association (APTA)-certified instructors. The results of the study indicated that physical therapists who had more experience displayed a higher level of attention to clinical practices than those with less experience. The physical therapists who were APTA-certified clinical instructors demonstrated a higher level of attention to the intrinsic and extrinsic risks of falling than those who were not APTA-certified instructors. The physical therapists whose highest level of education was a doctorate placed greater importance on the utilization of EBP than respondents with a baccalaureate or master's degree. Although most physical therapists believe that the utilization of EBP holds significant value, they do not always access or apply it. Insufficient time for using EBP was the major barrier noted by most physical therapists. The results of this study concurred with those of previous studies regarding common barriers to physical therapists' adoption of EBP. Rehabilitation organizations may want to examine methods to promote the use of the most current physical therapy practices based on the evidence revealed in the literature and to explore options for improving staff access to and utilization of EBP research.

Thesis (Ph.D.)--University of Florida, 2005.
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Aim The aim of this study is to develop an understanding of the factors which influence veterinary surgeons’ clinical decision making during routine consultations. Methods The research takes a qualitative approach using video-cued interviews, in which one of the veterinary surgeon’s own consultations is used as the basis of a semi-structured interview exploring decision making in real cases. The research focuses primarily on small animal consultations in first opinion practice, however small numbers of consultations from different types of practice are included to highlight contextual influences on decision making. Findings The study reveals differences between the way clinical decision making is taught and the way that it is carried out in practice. In comparison to human medicine, decision making in veterinary practice appears to be more a negotiated activity, relying on social context, which takes account of the animals’ and owners’ circumstances, as well as biomedical information. Conclusions Veterinary practice especially that provided for companion animals has similarities with medical practice, however there are also differences caused by the status of the animal; the contrast between predominately fee for service veterinary care and state funded medical provision; and the acceptability of euthanasia as a “treatment” option. Clinical decision making in veterinary practice is affected by a range of factors including the resources of the owner, the value placed on the individual animal and the circumstances in which the decision making takes place. Veterinary surgeons in practice need teaching and evidence based resources to take account of these factors in order to provide the best care to their animal patients. Further sociologically informed research is required to provide a greater understanding of the contextual factors which influence clinical decision making.

Pain is a common symptom of a number of conditions including cancer and one of the most frequent reasons for seeking healthcare. Acute and chronic pain result in considerable discomfort with a detrimental impact on the quality of life. Opioids are the mainstay of pain management for many patients with severe pain. Opioids are, unfortunately, also commonly abused drugs, and are well-represented in forensic toxicology investigations. Side effects related to the central nervous system are the major reasons fordiscontinuation of opioid treatment. In this thesis, we tested the hypothesis that local analgesic treatment by opioids, without the usual opioid-related side effects, could be a potential alternative to systemic opioid treatment. We examined the analgesic effect of topically applied morphine in a randomized, double blind, cross over study in patients with painful leg ulcers. Significant reduction of pain was obtained after application of both morphine and placebo gel. Morphine reduced pain more than placebo but the difference was not statistically significant. However, morphine could reduce pain considerably more than placebo in those cases where VAS (Visual analog scale) was higher initially. Another issue with opioid therapy is the substantial individual variability in response to opioids including morphine and tramadol. We investigated the significance of UGT2B7, CYP2D6, OPRM1 and ABCB1 polymorphisms for pharmacokinetic and pharmacodynamic properties of morphine and tramadol. We showed that genetic variants in CYP2D6 and UGT2B7 have an important role in the metabolism of tramadol and morphine respectively. While the role of SNPs in ABCB1 remained unclear, genetic variants in OPRM1 gene were correlated with the required dose of morphine. Taken together, these findings suggest that genotypes should be taken into consideration when interpreting clinical pharmacology and forensic toxicology results. Opioids, besides their analgesic properties, have other pharmacological effects including effects on immune system. We evaluated potential differences between commonly used opiates with regard to their effect on the immune system. We found an inhibition of cytokine release, in the order of potency as follows: tramadol > ketobemidone >morphine >fentanyl. All opioids with the exception of fentanyl were capable of inhibiting production of mRNAs for TNF-alpha and IL-8. Further studies are needed to understand the clinical implications of the observed immunosuppressive effects of opioids and to improve opioid treatment strategies in patients with cancer. Here, we have found that individual genotype matters and affects the individual response. Further research is warranted to tailor individualized treatment. Personalized medicine has increased in importance and will hopefully in the near future become standard procedure to improve and predict the outcome of treatment by opioids.

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Summary Background: Caring forms the core of nursing and midwifery. Despite caring being an important emotional aspect of midwifery and nursing, there are general public complaints about uncaring behaviour in midwifery. Therefore, there is a need to explore caring from midwives’ point of view with the hope of identifying solutions and recommendations for midwifery practice. Furthermore, the study aimed to stimulate debate and discussion about the caring behaviour of midwives. Objective: To explore caring during clinical practice as perceived and experienced by midwives. Method: The study was contextual, exploratory and qualitative. The participants were midwives working in state and private hospitals in Tshwane, South Africa where BTech II and III midwifery learners were allocated for work integrated learning (WIL). Data collection was carried out through self-report using a questionnaire and focus group. Questionnaires were distributed to 40 midwives at private and state hospitals in Tshwane. This was followed by two focus group sessions to ensure that data is enriched. The hermeneutic interpretive approach was used to analyse data, and analysis continued until saturation. Results: Themes of caring and uncaring related to patient care and midwives emerged. The findings illustrated that the midwives had excellent theoretical knowledge of caring, but some of them did not display caring behaviour during clinical practice. Conclusion: Some of the midwives did not display caring behaviour. Implication for practice was provided based on the research findings. Recommendations included measures of improving caring behaviours during midwifery practice.

Mestrado em Biomedicina Farmacêutica
This paper proposes to present the main activities of a Research Nurse, its role in clinical research, and in the development and introduction of new drugs on the market. The Master in Pharmaceutical Medicine brought together knowledge and development of new technical and personal skills extremely valuable in daily activity as research nurse. During my professional activity as a research nurse, were detected many gaps in academic and professional training of nurses, with regard to this specific area. I intend to present a personal view, describing the main activities developed and how the knowledge acquired in this Master influenced my work performance. The main objective of this work is to provide a reference or guide to other nurses who want to enter into the area of clinical research.
O presente trabalho propõe apresentar as principais atividades de um Enfermeiro de investigação, o seu papel em investigação clínica, no desenvolvimento e na introdução de novos medicamentos no mercado. O Mestrado em Biomedicina Farmacêutica permitiu reunir conhecimentos e desenvolver novas competências técnicas e pessoais de extremo valor na atividade diária, como enfermeira de investigação. No decorrer da minha atividade profissional como Enfermeira de investigação, foram detetadas muitas lacunas na formação académica e profissional dos enfermeiros, no que diz respeito a esta área específica. Pretendo apresentar uma visão pessoal, descrevendo as principais atividades desenvolvidas e como os conhecimentos adquiridos neste Mestrado influenciaram o meu desempenho profissional. O principal objetivo deste trabalho é constituir uma referência ou guia para outros enfermeiros que queiram enveredar pela área da investigação clínica.

This project has been designed to increase our understanding of the clinical audit process, as it applies to veterinary practice in the UK, and to facilitate its introduction in a manner that brings maximum benefit to all stakeholders. It examines the medical scenario to define the process and glean any relevant information. It then takes the form of an action research project that examines in depth the introduction of the audit process into a small animal practice in outer NW London, including its impact upon the standard of clinical care supplied to its patients, and the sociological effect upon the working environment. The provisional conclusions reached in this way have then been triangulated with the findings of a focus group of veterinarians that are actively involved in the subject, and a broader questionnaire of veterinary practitioners and support staff. The research was able to highlight the key obstacles to introducing clinical audit into a veterinary practice, the benefits that can be achieved when its introduction has been successfully achieved, and how those benefits may ameliorate the time and expense involved. In particular, clinical audit was found to be an effective tool for improving client concordance with the recommended treatment regime for the animals in their care, and thus able to improve both patient welfare and practice income. The sociological changes that are needed to put clinical audit into place successfully, encouraging the development of an integrated team of highly motivated reflective practitioners working within a no-blame practice culture, can bring many additional benefits. This work has taken place at a time when various pressures, such as the RCVS Practice Standards Scheme, and an increased public demand for professional accountability have focused interest in the subject. The author has been leading the way in increasing public awareness of the process, encouraging further research, and ensuring that clinical audit is incorporated into the new modular postgraduate CertAVP designed to develop the learning and skills of the practicing vets of the future.

This thesis contributes knowledge to the areas of Reflective Practice and Clinical Effectiveness, both professional issues in clinical psychology, which have a direct link to patient care in the National Health Service (NHS). The literature review presented in Chapter 1 focuses on reflective practice. The review aimed to identify all published empirical research, which investigated the application and usefulness of reflective practice for staff qualified in healthcare professions, and working in health services specifically, including the NHS. The findings have clinical and professional implications for health care staff, their managers, and the broader organisations in which they work. The use of reflective practice has been linked in the literature to increased clinical effectiveness, which is the second professional issue. The empirical paper presented in Chapter 2 explored the measurement and demonstration of clinical effectiveness as experienced by clinical psychologists working within NHS using a qualitative methodology. Demonstrating clinical effectiveness was found to be particularly relevant given the current, changing financial climate of the NHS and a context in which clinical psychologists are expected to prove their professional worth. The review and empirical paper highlight the importance of practice-based evidence. Chapter 3 presents a reflective paper, which explores the impact of the review and research findings on the author who is approaching the end of her clinical psychology training. This paper may be of interest to more experienced clinicians who wish to understand the issues from a newly qualified perspective, or to readers interested in the transition from training to professional practice.

Many forms of distance clinical supervision (DCS) have been used in the last decade, but a sparse amount of research addressing (DCS) in counselor education exists to date. The author used random and snowball sampling to survey American Counseling Association members, with a analytic sample total of 96 participants. In the sample, 54.2% of participants were licensed counseling professionals and 39.6% were student or post-masters level interns. The average participant age was 43, ranging from 23 to 74 years. Participants had a mean of 8.1 years of experience. A total of 37.5% of participants had used DCS at some point for supervision sessions. Overall, participants have a positive attitude toward DCS, agreeing most that DCS is a valid form of supervision and that they are interested in learning about DCS. Overall, participants are being minimally exposed to DCS (x¯ = 1.61). A moderate, negative relationship (r = -.39, p < .001) exists between individuals whom have used DCS and attitudes toward DCS (Cohen, Cohen, West, & Aiken, 2003, p. 52). Also, a weak, negative relationship (r = -.23, p < .05) was found between individuals who have used DCS and their level of exposure to DCS. There is a limited amount of literature related to DCS and counseling professionals are being minimally exposed to distance clinical supervision. Despite limited exposure and literature, professionals are still using DCS to conduct supervision sessions. Therefore, it would seem important to increase research focused on DCS and develop relevant practices in order for DCS to be an effective form of supervision.

This thesis considers the relationship between the design of a visual acuity test and various aspects of its performance. Using contemporary test design theory, novel tests are developed and evaluated in an attempt to better meet the requirements of a visual acuity test most pertinent to clinical practice, clinical research, and population based surveys. The acuity test of choice in clinical practice is the Snellen chart, a test whose usefulness is limited by several design flaws. Clinical researchers favour the ETDRS logMAR chart which employs robust design principles, but is time consuming to use. A chart featuring an abbreviated ETDRS design was developed and its performance compared with that of the ETDRS and Snellen charts. The prototype chart allows acuities to be measured in half the time of the ETDRS chart with greater precision than the Snellen chart. A tumbling-E version of this chart has been successfully employed in population based surveys in Thailand, Bangladesh and Mongolia. It was noted during the study that the precision of even ETDRS acuities was relatively poor. A computerised version of the ETDRS test was developed and used to investigate the repeating and averaging of acuities as a means to improve precision. Whilst prolonging test time, the computerised test allowed acuities to be measured with improved precision. Optical defocus was investigated as a potential source of reduced precision in visual acuity testing. It was shown that even small degrees of defocus may significantly reduce test precision. An approach which considers test performance in terms of sensitivity and specificity was developed. A mathematical model was used to show that current methods of using estimates of precision to identify clinically important change, are overly optimistic. Predictions derived using the model were shown to agree well with empirical findings.

La multimorbiditat i complexitat terapèutica poden comprometre els resultats en salut en poblacions cròniques d'elevada complexitat. Baixes xifres d'adherència terapèutica podrien estar relacionades amb aquesta complexitat, i resulten ser una causa directa de pèrdua de l'empelt i mort després d'un trasplantament cardíac. Les creences negatives del pacient versus la seva pauta terapèutica poden estar al seu torn afectant l'experiència del pacient i a l'adherència a les recomanacions. Molt poc es sap sobre la magnitud real en el nostre entorn d'aquest problema, quins són els instruments per a mesurar-lo, així com quines són les estratègies més eficients per a reduir el seu impacte. Tenint en compte aquesta problemàtica, es van implementar 4 fases abreujades com l'estudi mHeart (The mHeart Study). Els objectius de cadascuna de les fases van donar lloc a aquesta tesi doctoral dividida en 4 sub-estudis consecutius. La primera de les fases va ser dirigida a mesurar quantitativament la complexitat terapèutica mitjançant un índex àmpliament validat en patologia crònica i descrit en la literatura, així com la mesura de la càrrega de morbiditat que suporten les persones trasplantades cardíaques en estadi crònic (>1.5 anys des del trasplantament). El nivell de complexitat mitjançant el total pMRCI-S va obtenir una mitjana de 42 (SD 11), molt superior al nivell publicat per a altres patologies cròniques. Els tractaments per a les comorbiditats van ser els principals causants de l’elevada complexitat terapèutica [OR=3.1 (2.8;3.4), P-valor<.001]. L'objectiu de la segona fase va ser implementar un innovador model amb l'objectiu de millorar la pràctica clínica dels pacients trasplantats cardíacs ambulatoris. Aquest nou model dibuixa una innovadora ruta assistencial, dissenyada amb un caràcter holístic i basada en teories per a promoure el canvi conductual. L'estudi descriu quins van ser els factors facilitadors per a implementar-lo i avalua les principals barreres, beneficis i predisposició dels usuaris de la tecnologia. La combinació de diferents habilitats dels farmacèutics clínics involucrats, van ser essencials. El programari mHeart es va desenvolupar com a suport a aquesta pràctica, consistint en una aplicació per al mòbil i una pàgina web. El 98% dels pacients entrevistats estaven disposats a usar mHeart. El tercer estudi va ser un estudi pilot per a validar l'estratègia mHeart (the mHeart strategy). Dissenyada com una intervenció clínica multinivell duta a terme per una farmacèutica clínica en el si d'un equip interdisciplinari amb el suport de la salut digital i mitjançant l'ús de tècniques del canvi conductual. L'estratègia mHeart va millorar significativament les xifres d'adherència terapèutica entre un 16% i 26% [P-valor<.05]. Els qüestionaris electrònics van ser igual d'efectius que la versió en paper identificant al pacient no-adherent [Phi>0.7, P-valor<.001], i van superar les principals limitacions del mètode tradicional presencial. Sobre la base dels resultats obtinguts en les fases anteriors, es va dur a terme un assaig clínic aleatoritzat que va incloure a 180 pacients. L'estratègia mHeart va obtenir un impacte positiu en els resultats de salut preestablerts. La xifra de pacients adherents al tractament immunosupressor va millorar un 65% en el grup intervenció segons el qüestionari SMAQ [OR=2.3 (0.3;19.7), P-valor=.000]. A més, es va obtenir una millora en l'experiència del pacient amb la seva pauta terapèutica [P-valor<.05] i una reducció de la necessitat de seguiment presencial [OR=3.4 (1.7;6.9), P-valor=.001]. El programa assistencial mHeart és una alternativa viable per a proporcionar un seguiment individualitzat i anticipat a llarg termini dels pacients trasplantats cardíacs. Les implicacions futures d'aquesta tesi són un prometedor punt de partida per a l'establiment d'innovadores rutes assistencials per a poblacions d'elevada complexitat en el nostre entorn amb el suport de la Salut Digital.
La multimorbilidad y complejidad terapéutica pueden comprometer los resultados en salud en poblaciones crónicas de elevada complejidad. Bajas cifras de adherencia terapéutica podrían estar relacionadas con dicha complejidad, y resultan ser una causa directa de pérdida del injerto y muerte tras un trasplante cardíaco. Las creencias negativas del paciente versus su pauta terapéutica pueden estar a su vez afectando a la experiencia del paciente y a la adherencia a las recomendaciones. Muy poco se sabe sobre la magnitud real en nuestro entorno de este problema, cuáles son los instrumentos para medirlo, así como cuáles son las estrategias más eficientes para reducir su impacto. En base a la problemática, se implementaron 4 fases abreviadas como el estudio mHeart (The mHeart Study). Los objetivos de cada una de las fases dieron lugar a esta tesis doctoral dividida en 4 sub-estudios consecutivos. La primera de las fases fue dirigida a medir cuantitativamente la complejidad terapéutica mediante un índice ampliamente validado en patología crónica y descrito en la literatura, así como la medida de la carga de morbilidad que soportan las personas trasplantadas cardíacas en estadio crónico (>1.5 años desde el trasplante). El nivel de complejidad mediante el total pMRCI-S obtuvo una media de 42 (SD 11), muy superior al nivel publicado para otras patologías crónicas. Los tratamientos para las comorbilidades se asociaron con una elevada complejidad terapéutica [OR=3.1 (2.8;3.4), P-valor<.001]. El objetivo de la segunda fase fue implementar un innovador modelo con el objetivo de mejorar la práctica clínica de los pacientes trasplantados cardíacos ambulatorios. Este nuevo modelo dibuja una innovadora ruta asistencial, diseñada con un carácter holístico y basada en teorías para promover el cambio conductual. El estudio describe cuáles fueron los factores facilitadores para implementarlo y evalúa las principales barreras, beneficios y predisposición de los usuarios de la tecnología. La combinación de diferentes habilidades de los farmacéuticos clínicos involucrados, fueron esenciales. El software mHeart se desarrolló como soporte a esta práctica, consistiendo en una aplicación para el móvil y una página web. El 98% de los pacientes entrevistados estaban dispuestos a usar mHeart. El tercer estudio fue un estudio piloto para validar la estrategia mHeart (the mHeart strategy). Diseñada como una intervención clínica multinivel llevada a cabo por una farmacéutica clínica en el seno de un equipo interdisciplinar con el soporte de la salud digital y mediante el empleo de técnicas del cambio conductual. La estrategia mHeart mejoró significativamente las cifras de adherencia terapéutica entre un 16% y 26% [P-valor<.05]. Los cuestionarios electrónicos fueron igual de efectivos que la versión en papel en identificar al paciente no-adherente [Phi>0.7, P-valor<.001], y sobrellevaron las principales limitaciones del método tradicional presencial. En base a los resultados obtenidos, se llevó a cabo un ensayo clínico aleatorizado que incluyó a 180 pacientes. La estrategia mHeart obtuvo un impacto positivo en los resultados de salud preestablecidos. La cifra de pacientes adherentes al tratamiento inmunosupresor mejoró un 65% en el grupo intervención según el cuestionario SMAQ [OR=2.3 (0.3;19.7), P-valor=.000]. Además, se obtuvo una mejora en la experiencia del paciente con su pauta terapéutica [P-valor<.05] y una reducción de la necesidad de seguimiento presencial [OR=3.4 (1.7;6.9), P-valor=.001]. El programa asistencial mHeart es una alternativa viable para proporcionar un seguimiento individualizado y anticipado a largo plazo de los pacientes trasplantados cardíacos desde su domicilio. Las implicaciones futuras de la presente tesis son un prometedor punto de partida para el establecimiento de una innovadora vía para proveer asistencia de calidad a poblaciones de elevada complejidad en nuestro entorno con el soporte de la salud digital.
Multimorbidity and therapeutic complexity are undermining health outcomes in chronic populations such as the outpatient heart transplant (HTx) recipients. Medication nonadherence may be a consequence of this complexity and is a direct cause of graft loss and death after HTx. Nevertheless, even these are recognized problems, little is known about how best to quantify this complexity or the strategies that could reduce its burden. Based on this background, four sequential phases were implemented and abbreviated as The mHeart Study. This thesis is the result of the specific goals of these phases, presented as consecutive studies. All of them were conducted in the outpatient setting of the Heart Transplant Unit of a tertiary university hospital. The first phase aimed to quantitatively measure therapeutic complexity by using a validated quantitative index in chronic-stage HTx recipients. Therapeutic complexity observed was the highest compared with those previously published in chronic diseases and was mainly influenced by a higher count of drugs to treat comorbidities. Based on the results obtained in the first study, strategies were urgently needed to reduce post-HTx complexity. Therefore, the second phase aimed to develop the mHeart software and to implement an eHealth behavioral-based intervention model to provide healthcare to complex populations in the outpatient setting. The study the model implemented, outlines the facilitators and barriers, and the willingness to use the model reported by potential users. The tool was seek to improve medication safety and efficacy, to enhance patient-providers interactions and to provide comprehensive clinical care. Clinical pharmacists’ skills on patient engagement, motivational interviewing and managerial experience were essential to lead the implementation. The patients confirmed that 98% of them were willing to use the mHeart system. The third study came to validate the main clinical aim of the mHeart tool, which is to improve medication nonadherence in HTx recipients. With this aim in mind, the mHeart strategy designed consisted of an intensive follow-up program based on multilevel individually-tailored digital interventions aiming to change behavior by a pharmacist using the mHeart technology in an interdisciplinary environment. The mHeart electronic patient-reported outcome measures (ePROMs) met the existing quality standards, and the exploratory clinical intervention established showed a promising improvement of 30% in medication adherence rates. These results supported the mHeart mobile application widespread use in larger research and usual clinical practice. Based on above-mentioned stages, this thesis work went further including a randomized clinical trial. An alarming 36% of the recipients were non-adherent to immunosuppressive treatment at baseline according to the SMAQ test, and 41% of patients were unaware of the consequences of forgetting to take their antirejection medicines. Therefore, the main objective of this long-term study was to improve recipients’ adherence to immunosuppressive medication, their experience of therapeutic regimens, and to optimize in-clinic healthcare delivery. The intervention consisted of a long-term mHeart strategy versus a traditional in-clinic follow-up by a multidisciplinary team. The mHeart strategy positively impacted on the health outcomes preestablished. At the end of the study, medication adherence rates were statistically significantly improved in the intervention group (85%) versus the control group (46%). Furthermore, the strategy had a positive impact on patients’ experience of therapeutic regimens and showed statistically significant reductions in the number of patients needing to travel to the clinic for follow-up appointments. The implications of the thesis will be a promising starting point for an emerging way of providing further assistance to the most complex populations based on eHealth.

The principles of Evidence-Based Medicine (EBM) have been well documented in the medical literature, with many examples of the successful application of these principles to the clinical environment. Despite this widespread acceptance of these principles throughout the medical profession, there has been resistance to adopt such an approach in the veterinary profession. To date, there are. few examples in the literature of the application of the principles of evidence-based medicine to either clinical or scientific research. The aim of this study was to design a series of investigations of equine diseases, and implement them at three private equine hospitals. A variety of study designs were used, providing different classes of evidence when using the classification system proposed by Yusuf et al. (1998). The main focus of this investigation was to ascertain whether it was possible to apply the ethos of EBM to the veterinary profession, and provide good quality research and evidence form private practice. It was found that 85.6% of horses (95% c.l. 81.3 to 89.3) treated for septic arthritis were successfully discharged from the hospital, with 65% of these horses (95% C.l. 57.9 to 71.6) able to return to their previous level of athletic function. When considering those horses treated for septic digital tenosynovitis, 87.8% survived to be discharged from the hospital. However, the prognosis for future soundness was poorer than that achieved following resolution of septic arthritis, with only 50% of horses treated for septic digital tenosynovitis able to return to their previous level of athletic function. Racing Thoroughbreds, both neonates and mature horses, were identified as an important subset of the population. It was found that the occurrence of septic arthritis in neonatal Thoroughbreds significantly reduced the likelihood of those foals going on to make at least one start on a racecourse, with those foals being 3.5 times less likely to start on a racecourse when compared to their siblings. In contrast, when considering mature Thoroughbred racehorses it was found that the occurrence of septic arthritis did not affect the likelihood that they would make at least one start on a racecourse when compared to their siblings, or be able to achieve an Official Rating awarded by the British Horseracing Board's handicappers equal to, or higher than, either the highest rating achieved prior to the onset of sepsis in cases in which horses had raced previously, or equal to the highest rating achieved by their siblings. In a controlled, randomised trial it was found that 31.6% (95% c.l. 17.5 to 48.7) of horses wearing a belly band following an exploratory laparotomy developed incisional complications, compared with 76.6% (95% c.I. 62.0 to 87.7) of horses where no belly band was used. If a belly band was used following an exploratory laparotomy, the risk of developing post-operative incisional complications was reduced by 45% compared to those cases where no belly band was used. Following a clinical audit of elective surgical procedures at three private equine hospitals, there was found to be a higher rate of post-operative complications, when compared to results reported in both the medical and small animal veterinary literature. It was concluded that it was possible to apply the ethos of EBM to the veterinary profession, and provide good quality research and evidence from research performed in private practice. However, in order to be able to achieve sufficient case numbers to provide answers that are directly relevant to practice-based clinical situations, multi-centre studies are likely to be the best way forward.

This portfolio thesis comprises of four parts: a systematic literature review paper, an empirical paper, a reflective statement and appendices.Part one is a systematic literature review which examines whether personal therapy is an effective method of professional development for therapists. Quantitative and qualitative literature is critically reviewed. A model of the reported benefits of personal therapy for therapists is proposed. Implications for clinical practice are discussed.Part two is an empirical paper examining the relationship between stage of development and behaviour in clinical supervision for trainee clinical psychologists. Forty trainee clinical psychologists, from three years of a training course, completed a questionnaire (the SLQ-R[A]) measuring their stage of development as supervisees. A subsample submitted DVD-recordings of their supervision sessions which were coded using the Teacher's PET to analyse the supervision behaviours. Comparisons were made between the supervision behaviour of first (n = 8) and third (n = 3) year trainee clinical psychologists and their supervisors. Correlations between questionnaire responses and supervision behaviours were examined. Results are discussed in the context of the Integrated Developmental Model of Supervision. Implications for clinical practice are highlighted.Part three is a reflective statement which considers the process of conducting the research and developing this portfolio thesis.Part four is the appendices.

In the clinical setting, the term 'unwarranted variation' refers to variations in patient outcomes that cannot be explained by the patient's illness or medical needs, or the dictates of evidence-based medicine. These variations persist even after adjusting for patient-related factors. Unwarranted variation depends on a mix of disparities, including inequalities in access to appropriate care in a wide variety of geographical and cultural settings, in the uptake and application of clinical knowledge, in the prioritisation and allocation of resources, and differences in organisational and professional culture. Nevertheless unwarranted variation has been inexorably linked with clinical practice. The Multidisciplinary team (MDT) is an important component of cancer care and is analysed as one of the two strands of clinical practice. Temporal trends in colorectal cancer care, resource utilisation and MDT workings are analysed using mix-method approaches. Colorectal cancer and Liver MDTs in Oxford and Gothenburg were observed and its members interviewed. The framework on unwarranted variation is reviewed with the view of assessing its utility in colorectal cancer care while the implication Cancer Drug Fund has on variation in clinical practice is also explored. Results indicate significant mortality amongst the elderly with colorectal cancer and a significant number of patients not receiving surgery within oneyear of diagnosis. However 90-day post surgical mortality has improved. No association between colorectal cancer spend and patient outcomes were found. Members of MDTs were observed to have diverse views on the roles and responsibilities of their MDT. Potential antecedents to unwarranted variation were identified through MDT workings. This study makes a distinction between professional uncertainty and clinical uncertainty to address the potential source of unwarranted variation. Recommendations on issues MDTs need to address such as defining its core purpose and developing reporting standards are made. A modification to the definition of unwarranted variation is also suggested. This study also proposes a conceptual risk scoring approach based on clinical pathways for addressing unwarranted variation. Several research areas have also been suggested.

Cancer diagnoses affect millions of people in the United States each year. Today, cancer patients face many challenges when trying to navigate the complex healthcare system. Patient navigation programs were developed to address and overcome barriers patients may face as they make their way through the healthcare system. The purpose of this project was to provide an analysis and discussion of the current published literature to provide evidence for improving care coordination and patient satisfaction in the oncology clinical setting with a patient navigator program. The practice-focused question for this project asked if a patient navigator program for adult cancer patients improved patient outcomes. The systematic review, guided by Watson's theory of caring, included 11 studies published between 2010 and 2017 identified through Cochrane Library, CINAHL, ProQuest, PubMed, and Joanna Briggs Institute. Initially a total of 679 articles were identified; however the number reduced by removing duplicates and after review of titles and abstracts. The remaining articles were then evaluated by the level of evidence based on the Manly and Fineout-Overholt's guide on hierarchy of evidence. The results identified in this systematic review showed patient navigation can improve care coordination and patient satisfaction. This review offers findings on the impact of cancer care coordination and patient satisfaction, which may be used by healthcare leaders when determining how to improve cancer care and as a result may provide positive social change. If the organization implements a patient navigator program, it is expected that this change would benefit patients, families, healthcare providers and the organization.

Workplace bullying is repeated, aggressive action towards a victim, which especially affects new graduate nurses and can inhibit growth and lead to nursing burnout and staff turnover. The purpose of this Doctor of Nursing Practice project was to develop a clinical resource educational module. The case scenarios were developed using literature on workplace bullying and lateral violence. Clegg's circuits of power theory was applied to frame the organizational authoritative nursing power struggles that exist as a circular flow between different nursing group members, and the American Nurses Association (ANA) Practice Standards and Code of Ethics guided the assertive communication. The case scenarios consisted of 3 vignettes, terms and definitions, a summary of the ANA practice and code of ethical standards, the Appraisal of Guidelines Research and Evaluation (AGREE) II instrument, Workplace Bullying Inventory, Organizational Predictors and Consequences of Bullying Scale, flip cards, and content readability evaluation forms. The AGREE II instrument is a 7-point Likert scale for evaluating clinical guidelines with a threshold standard of 70%. The results of advisory committee members' rigor scores (mean = 50.8, median = 31, SD = 3.03) were compared with the scores of nurse evaluators (mean = 50, median = 31, SD = 4). The AGREE II reliability score is 0.93, with similar results found for the advisory members (0.939) and the nurse evaluators (0.941). The overall findings suggest that the AGREE II is a viable instrument for evaluating case scenarios, which can be used to improve the workplace environment for nurses by addressing workplace bullying.

Reviews the book, Complementary medicine and clinical practice edited by David P. Rakel and Nancy Faass (2006). Complementary and alternative medicine, or CAM, as it is known, has been an important and controversial topic for allopathic medicine. Although the majority of the patients in this country will use one or more forms of complementary medicine, and spend more out-of-pocket money on CAM techniques and practitioners than on allopathic ones, there is still a great deal of uncertainty among practicing physicians about what exactly CAM consists of. This book goes a long way toward helping to clarify this diverse and changing topic. Overall, each of the topics in the book emphasizes a refreshing focus on health compared with the antidisease focus of many more traditional medical articles and books. Each of the chapters integrates the technique and philosophy of the topic explored into an overall health-oriented approach to patient care. Rakel and Faass's book creates a template for a new model of medicine. Given its broad scope, it is ideal for family physicians to consider as we envision the evolution of our practices.

Thesis (MPhil)--Stellenbosch University, 2011.
ENGLISH ABSTRACT: Removable Prosthetic Dentistry (PRO400) is a fourth year module of the undergraduate dentistry programme which consists of a large clinical component. After reviewing relevant literature and conducting module evaluations, clinical tests were introduced and implemented in 2008 as an additional clinical assessment method. The intention of introducing the clinical tests was an attempt to ensure that students were assessed fairly, that their theoretical knowledge and the ability to apply it clinically were properly assessed, and to provide feedback on their clinical performance. The purpose of this concurrent mixed methods study was to compare the relationship between the students‟ performance in the clinical tests and daily clinical grades with their theoretical performance in the PRO400 module. The second part of the study explored the academic staff s‟ perceptions of the clinical test as clinical assessment tool in the PRO400 module. The case study design enabled the researcher to explore the question at hand in considerable depth. The mixed methods approach was useful to capture the best of both the qualitative and quantitative approaches. For the quantitative data-collection, record reviews of the results of fourth-year dental students‟ who completed the PRO400 module at the end of 2007 were used, and included 110 students. For the qualitative component three full-time lecturers within the Prosthetic department were interviewed. The clinical test marks and clinical session marks of all the students (n=109) in PRO400 were compared to their theory mark of that year. The tests marks were entered into a spreadsheet in Microsoft Excel and the data analysis was done with the assistance of a statistician. The analytical abstraction method was used to assist with the qualitative data analysis; first the basic level of analysis was done in the narrative form, followed by second higher level of data analysis. The basic and higher levels of analysis were discussed under the following themes: clinical tests, student performances, alignment of theory and clinical assessment and personal influence on supervisors‟ assessment practices and attitude. Role-taking and the supervisors‟ perceptions and concerns regarding the students were explored as emergent themes. The quantitative findings were displayed using tables and graphs. Forty five students. clinical marks were 10% higher than their theory mark, while only 8 students. theory marks were 10% higher than their clinical test mark. There appeared to be hardly any relationship between the students. clinical daily grade assessment marks and their theory marks. The average theory mark was 47%, the average clinical test marks were 55% and the average daily clinical grade was 63%. Integration of the data obtained from the different data collection methods was done at the level of data interpretation. The clinical test as an assessment tool is well accepted by the supervisors and they agreed that it is more reliable and accurate than the clinical daily grade assessment method. The quantitative findings relate well to other reported studies that concluded that the daily grade was poorly correlated with the competency exams (a similar phenomenon in the clinical test of the PRO400 module). From the findings of this study it appeared that there is a better correlation of the clinical test mark and the theory mark, than clinical daily mark and the theory mark. This finding related well with the lecturers. views that the clinical tests were more reliable as a clinical assessment tool than the daily clinical mark.
AFRIKAANSE OPSOMMING: "Removable Prosthetic Dentistry (PRO400)" is 'n vierdejaar-module in die voorgraadse tandheelkundeprogram wat 'n groot kliniese komponent bevat. Na 'n oorsig gedoen is van die relevante literatuur, en nadat die module-evaluering afgehandel is, is kliniese toetse in 2008 ingevoer en geimplementeer as 'n bykomende metode van kliniese assessering. Die kliniese toetse is ingestel in 'n poging om te verseker dat studente se teoretiese kennis en hul vermoe om dit klinies toe te pas op . regverdige wyse geassesseer word en om terugvoer te kan gee oor die studente se kliniese prestasie. Die doel van hierdie studie, waarin gelyktydige gemengde metodes gebruik is, was om die verband tussen die studente se prestasie in die kliniese toetse, asook hul daaglikse kliniese punte en hul teoretiese prestasie in die PRO400-module vas te stel. Die tweede deel van die studie het ondersoek ingestel na die akademiese personeel se persepsies van die kliniese toets as 'n instrument vir kliniese assessering in die PRO400-module. 'n Dwarssnit-gevallestudie-ontwerp is gebruik en 'n gemengdemetode-benadering was nuttig om sowel kwalitatiewe as kwantitatiewe data in te samel. Vir die kwantitatiewe data-insamelingverslae is die uitslae van 109 vierdejaar-tandeheelkundestudente in die PRO400-module aan die einde van 2007 gebruik. Vir die kwalitatiewe data-insameling is onderhoude gevoer met drie voltydse dosente in die Prostetiese Tandheelkunde-departement. Die kliniese toetspunte en die kliniese sessiepunte van al die studente (n=109) in die PRO400-module is met hul teoriepunte van daardie jaar vergelyk. Die toetspunte is op 'n sigblad in Microsoft Excel ingevoer en die data-analise is met die hulp van 'n statistikus gedoen. Die analitiese abstraksiemetode is vir die analise van die kwalitatiewe data gebruik. Die basiese vlak van data-analise in die narratiewe vorm is eerste gedoen. Dit is gevolg deur 'n tweede, hoervlak-data-analise. Die basiese en hoer vlakke van analise is onder die volgende temas bespreek: kliniese toetse, studenteprestasie, ooreenstemming van teorie en kliniese assessering, en persoonlike invloed op studieleiers se assesseringspraktyke en houding. Rol-aanneming en die studieleiers se persepsies, asook kwessies rakende die studente is as ontluikende temas ondersoek. Die resultate van hierdie studie het aangetoon dat die kliniese punte van 45 studente 10% hoër was as hul teoriepunte, en dat slegs agt studente se teoriepunte 10% hoër as hul kliniese toetspunte was. Dit het geblyk dat daar feitlik geen verband was tussen die studente se kliniese daaglikse assesseringspunte en hul teoriepunte nie. Die gemiddelde teoriepunt was 47%, die gemiddelde kliniese toetspunt was 55% en die gemiddelde daaglikse kliniese punt was 63%. Al die studieleiers het die kliniese toets as assesseringsinstrument goed aanvaar en hulle het saamgestem dat dit meer betroubaar en akkuraat is as die daaglikse kliniese assesseringsmetode. Die kwantitatiewe bevindings hou goed verband met dié van soortgelyke studies waarin daar bevind is dat die daaglikse prestasie swak gekorreleer het met die bevoegdheidseksamen (ʼn soortgelyke beginsel as die kliniese toets van die Pro400). Dit het ook uit die bevindings van hierdie navorsing geblyk dat daar ʼn beter korrelasie is tussen die kliniese toetspunt en die teoriepunt as tussen die daaglikse kliniese punt en die teoriepunt. Hierdie bevinding het ʼn duidelike verband getoon met die dosente se siening dat die kliniese toetse as ʼn kliniese assesseringsinstrument meer betroubaar is as die daaglikse kliniese punt in die PRO400-module in die Tandheelkunde-program.

The aim of this PhD thesis was to produce research that could inform and benefit clinical practice by exploring the application of basic science and clinical research methodologies to disorders in obstetrics and gynaecology. Chapter 1’s investigation of endometriosis is the first to 1) report detailed genetic mapping of endometriosis-associated ovarian cancer, 2) report the existence of micro-LOH (loss of heterozygosity) in ovarian endometriosis through a SNP 100K DNA array. Chapter 2 explores the efficacy of interventions to treat menstrual abnormalities using clinical cohort studies. Furthermore, Chapter 2 highlights how negligence in female sterilization failure may be mathematically (Bayesian) modelled. Chapter 3 explores the value of systematic reviews for preventing preterm delivery and use of LNG-IUS (Mirena coil). The clinical guidelines published in Chapter 4 include: vaginal birth after previous caesarean, ectopic pregnancy, safe laparoscopic entry and minimising risk of sterilisation failure. The thesis concludes (Chapter 5) by suggesting strategies to augment the research methodological approaches evaluated in this thesis in order fulfill the aim of benefitting clinical practice. Work included in this PhD thesis has been orally presented at international conferences, published in peer-reviewed journals, and published as a national clinical guideline by the Royal College of Obstetricians and Gynaecologists, UK (RCOG).

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.

Doctor of Philosophy (PhD)
Effective clinical reasoning and its communication are essential to health professional practice, especially in the current health care climate. Increasing litigation leading to legal requirements for comprehensive, relevant and appropriate information exchange between health professionals and patients (including their caregivers) and the drive for active consumer involvement are two key factors that underline the importance of clear communication and collaborative decision making. Health professionals are accountable for their decisions and service provision to various stakeholders, including patients, health sector managers, policy-makers and colleagues. An important aspect of this accountability is the ability to clearly articulate and justify management decisions. Considerable research across the health disciplines has investigated the nature of clinical reasoning and its relationship with knowledge and expertise. However, physiotherapy research literature to date has not specifically addressed the interaction between communication and clinical reasoning in practice, neither has it explored modes and patterns of learning that facilitate the acquisition of this complex skill. The purpose of this research was to contribute to the profession’s knowledge base a greater understanding of how experienced physiotherapists having learned to reason, then learn to communicate their clinical reasoning with patients and with novice physiotherapists. Informed by the interpretive paradigm, a hermeneutic phenomenological research study was conducted using multiple methods of data collection including observation, written reflective exercises and repeated semi-structured interviews. Data were analysed using phenomenological and hermeneutic strategies involving in-depth, iterative reading and interpretation to identify themes in the data. Twelve physiotherapists with clinical and supervisory experience were recruited from the areas of cardiopulmonary, musculoskeletal and neurological physiotherapy to participate in this study. Participants’ learning journeys were diverse, although certain factors and episodes of learning were common or similar. Participation with colleagues, peers and students, where the participants felt supported and guided in their learning, was a powerful way to learn to reason and to communicate reasoning. Experiential learning strategies, such as guidance, observation, discussion and feedback were found to be effective in enhancing learning of clinical reasoning and its communication. The cultural and environmental context created and supported by the practice community (which includes health professionals, patients and caregivers) was found to influence the participants’ learning of clinical reasoning and its communication. Participants reported various incidents that raised their awareness of their reasoning and communication abilities, such as teaching students on clinical placements, and informal discussions with peers about patients; these were linked with periods of steep learning of both abilities. Findings from this research present learning to reason and to communicate reasoning as journeys of professional socialisation that evolve through higher education and in the workplace. A key finding that supports this view is that clinical reasoning and its communication are embedded in the context of professional practice and therefore are best learned in this context of becoming, and developing as, a member of the profession. Communication of clinical reasoning was found to be both an inherent part of reasoning and an essential and complementary skill necessary for sound reasoning, that was embedded in the contextual demands of the task and situation. In this way clinical reasoning and its communication are intertwined and should be learned concurrently. The learning and teaching of clinical reasoning and its communication should be synergistic and integrated; contextual, meaningful and reflexive.

The role of the Clinical Psychologist has developed to incorporate that of the reflective practitioner. This thesis aims to consider how reflective practice is incorporated into personal and professional development by clinical psychologists and trainees, and what impact it may have upon clinical practice. The first chapter of the thesis reviews the relevant literature from the past 10 years relating to the use of personal therapy among therapists and the links to reflective practice. The findings suggest that a number of studies demonstrate some benefits of personal therapy for therapists. However, the literature lacks a unified theoretical explanation of the processes that occur during personal therapy and of their influence on the development of reflective practice. This chapter offers a critique of the literature and proposes a potential model for understanding the development of reflexivity through personal therapy. Chapter Two is an exploratory study of clinical psychologists’ experiences of personal development groups whilst in training. The study adopts an interpretive phenomenological approach to the analysis and results are presented through four super-ordinate themes. The results suggest that personal development groups are seen as an effective method of developing reflective practice by participants. The processes which encourage and hinder this are also explored. The research suggests that engaging in reflective practice may become a luxury after training in some cases and this may result in an increased strain on the therapist. The clinical and research implications of the study are discussed. Chapter Three provides a reflective account of the author’s experience of the research process including; choosing the research topic, developing the research question, relationship to the research and personal experiences of personal development groups. The paper comments on the presence of bias within the research, the impact of conducting the study on the researcher and reflections on themes arising from the empirical paper.

Background: Risk assessment of sexual violence involves evidence based evaluation of the risks posed by sexual offenders. It informs risk management; the provision of treatment that reduces the risk of future sexual violence. Previous research has focused on assessment of the predictive accuracy of different risk assessment tools, as well as the identification of risk factors that are associated with recidivism. In contrast, the clinical practice of risk assessment is a research area that has been neglected. The aim of this thesis was to explore the practice of risk assessment in a specialist sex offender liaison service (SOLS). Particular attention was paid to the structured professional judgement method of risk assessment. Method: A systematic review of the literature identified psychological factors associated with sexual recidivism in adult male offenders. Study 1 employed a cohort quantitative design and aimed to ascertain whether risk judgements made by the SOLS were predicted by factors that were identified by the systematic review (and previously existing meta-analyses) as being evidence based. Ordinal logistic regression and linear regression analyses (N = 96) were used to investigate the hypothesised predictive associations between variables. Study 2 utilised a qualitative framework analysis (N = 31) and aimed to explore the views of users of SOLS risk assessments with respect to their practical utility. Results: The systematic review suggested that psychopathy and sexual deviance were supported as risk factors for sexual recidivism. Inconsistent results were found with respect to denial. Study 1 found that psychopathy, denial, and sexual preoccupation were significantly associated with risk judgement scores made by the SOLS, while sexual deviance, and problems with intimate relationships, were not. The best explanatory model accounted for only 40 per cent of the variance in risk judgement score. Study 2 revealed five major themes: informing risk management; confirming what was known and giving weight; understanding personality; treatment; and the usefulness and limitations of risk assessment.

Evidence-based practice (EBP) is now the dominant model in health care; its aim is to increase the use of research evidence to inform clinical decision making. Clinical practice guidelines are the predominant method by which research is distilled into practice recommendations. Clinical psychology has its own model which promotes the integration of research evidence with clinical expertise, the scientist practitioner model (SPM). Recent developments within the United Kingdom health service, such as the Improving Access to Psychological Therapies programme have stimulated debate about the types of evidence that is often prioritised within the EBP model. This study aimed to explore these concepts with current third year clinical trainee psychologists, with a view to seeing how they construct these models. The findings suggest that the SPM may be more accurately termed the reflective-scientist-practitioner, or the critical-reflective-scientist-practitioner; in acknowledgment of the importance placed on these skills by participants who saw them as central to their role. The current study indicates participants were unaware of the APA (2006) definition of EBP; recommendations include that clinical training courses consider including teaching around both models, exploring the complexity of the underlying debates, in doing so trainees will be more informed about the models that shape their chosen profession.

Dried blood spots (DBS) are drops of capillary blood collected onto filter paper from a finger prick. They have many advantages compared with traditional phlebotomy and enable patients to take samples at home. A DBS collection device was developed and incorporated into a CE marked DBS collection kit. This was successfully used in an international direct access vitamin D DBS service. A random access DBS CRP method was established for use with the DBS collection device and a new microsampling device called the Mitra. The quality of DBS received and the impact of lancet type was assessed and the effect of blood spot characteristics on CRP and vitamin D concentration was examined. The vitamin D service uptake and the population using it was analysed. The vitamin D concentration and status of users was compared to serum samples received in the laboratory from the local GP population. Significant differences between the populations were seen, with DBS users showing higher levels of vitamin D. In addition, the response to vitamin D testing for both populations was analysed. A higher rate of high to toxic vitamin D levels was seen in the blood spot population and the reasons for this were explored.

Critical care nursing is a clinical specialist nursing practice discipline. The critical care nurse provides a constant presence in the care of a critically ill patient. She/he creates a thread of continuity in care through the myriad of other health care professionals and activities that form part of a patient’s stay in the critical care environment (World Federation of Critical Care Nurses [WFCCN], 2007). During conversations with people who have had intimate experience of the critical care environment, they have offered anecdotes that describe their interaction with critical care nurses who they perceive to be different from and better than other critical care nurses they encountered. Despite having met common professional requirements to be registered as a clinical specialist nurse, these distinctive, unique abilities that seem to be influential in meeting the complex needs and expectations of critically ill patients, their significant others as well as nursing and medical colleagues, are not displayed by all critical care nurses. While students of accredited postgraduate nursing programmes are required to advance their nursing knowledge and skill competence, many students do not seem to develop other, perhaps more tacit, qualities that utilisers characterise in their anecdotes of ‘different and better’ nursing practice. The overarching research question guiding this study was how can ‘different and better’ critical care nursing practice as recognised by a utiliser be explained? The purpose of this study was to develop an understanding of the qualities that those people who use critical care nursing practice recognise as ‘different and better’ to the norm of nursing practice they encounter in this discipline. The participant sample included patients’ significant others, nursing colleagues and medical colleagues of critical care nurses, collectively identified as utilisers. The stated aim of this work was to construct a grounded theory to elucidate an understanding of the qualities that a utiliser of critical care nursing recognises as ‘different and better’ critical care nursing practice in order to enhance the teaching and learning encounters between nurse educators and postgraduate students in learning programmes aiming to develop clinical specialist nurses. The method processes of grounded theory are designed to reveal and confirm concepts from within the data as well as the connections between these concepts, supporting the researcher in crafting a substantive theory that is definitively grounded in the participants’ views and stories (Streubert & Carpenter, 2011: 123, 128-129). Two data collection tools were employed in this study, namely in-depth unstructured individual interviews and naïve sketch. Constant comparative analysis, memo-writing, theoretical sampling, theoretical sensitivity and theoretical saturation as fundamental methods of data generation in grounded theory were applied. The study unfolded through three broad parts, namely: Forming & shaping this grounded theory through exploration and co-creation; Assimilating & situating this grounded theory through understanding and enfolding; Reflecting on this grounded theory through contemplating and reconnecting. The outcome of the first part of the study was my initial proposition of a grounded theory co-created in the interactions between the participants and myself. This was then challenged, developed and assimilated through a focussed literature review through the second part of the study. Through these two parts of this study, an inductively derived explanation was formed and shaped to produce an assimilated and situated substantive grounded theory named Being at Ease. This grounded theory articulates how ‘better and different’ nursing is recognised from the point of view of those who use the nursing ability of critical care nurses through the core concern ‘being at ease’ and its four categories ‘knowing self’, ‘skilled being’, connecting with intention’ and’ anchoring’. The final part of this study unfolded in my reflections on what this grounded theory had revealed about nurses and elements of nursing practice that are important to a utiliser in recognising ‘different and better’ critical care nursing. I suggest that as nurses we need to develop a language that enables us to reveal with clarity these intangible and tacit elements recognised within the being and doing of ‘different and better’ nursing. I reflected on the pivotal space of influence a teacher has with a student, and on how the elements essential in being and doing ‘different and better’ nursing need to be evident in her/his own ways of being a teacher of nursing. Teaching and learning encounters may be enhanced through drawing what this theory has shown as necessary elements that shape ‘different and better’ nurses through the moments of influence a teacher has in each encounter with a student.

Assessing offenders' risk of future violent behavior continues to be an important yet controversial role of forensic psychologists. A key debate is the relative effectiveness of assessment methods. Specifically, actuarial methods (see Quinsey et al., 1998 for a review) have been compared and contrasted to clinical and structured clinical methods (see e.g. Hart, 1998; Webster et al., 1997). Proponents of each approach argue for its superiority, yet validity studies have made few formal comparisons. In advancing the available research, the present study examines systematically the type of forensic case (i.e., sexual violence versus nonsexual violence) and type of assessment method (i.e., actuarial, structured clinical, and unstructured clinical). As observed by Borum, Otto, and Golding (1993), forensic decision making can also be influenced by the presence of certain extraneous clinical data. To address these issues, psychologists and doctoral students attending the American Psychology Law Society conference were asked to make several ratings regarding the likelihood of future sexual and nonsexual violence based on data derived from actual defendants with known outcomes. Using a mixed factorial design, each of these assessment methods were investigated for its influence on decision-makers regarding likelihood of future violence and sexually violent predator commitments. Finally, the potentially biasing effects of victim impact statements on resultant decisions were also explored.

The purpose of this research study was to examine the current use of clinical practice by full-time occupational therapy faculty members. Clinical practice, including faculty clinical practice and moonlighting were addressed. The seven research questions addressed were: (a) the perceived benefits of clinical practice as identified by occupational therapy faculty members; (b) the perceived barriers to clinical practice as identified by occupational therapy faculty; (c) if perceived benefits and barriers of clinical practice as identified by occupational therapy faculty differ as a function of their academic institution's Carnegie Classification (The Carnegie Foundation, 2000); (d) if perceived benefits and barriers of clinical practice differ among respondents according to tenure at the institution, tenure status, doctoral degree, rank, administrative duties, and gender; (e) the incidence of clinical practice in occupational therapy faculty members; (f) the relationship between participation in clinical practice and the Carnegie classification of the occupational therapy member's academic institution; (g) the characteristics (tenure status, doctoral degree, rank, administrative duties, and gender) of faculty members that participate in clinical practice either within or outside the faculty role; and (h) the characteristics of clinical practice as described by faculty members and how these differed if the clinical practice is conducted as part of the faculty role or outside the faculty role. Data were collected using an on-line survey that contained 43 questions designed to elicit information that addressed the research questions. The surveys were electronically mailed to the population of full-time occupational therapy faculty members obtained from a search of each academic program's website. A total of 224 responses were obtained. Descriptive statistics, ANOVAs, and Chi Square Test of Associations were used to analyze the data for the independent variables. The results showed that 60 respondents indicated that they participated in some type of faculty clinical practice as part of their faculty role. Most of this work was in a facility that was associated with the academic institution. Most of these respondents were not tenured, did not have a doctoral degree, and did not participate in administrative tasks. Most of these respondents worked in Doctoral-Extensive universities and held the Assistant Professor rank. Most worked two to four hours per week and did not receive release time or financial benefits. There were 99 respondents that indicated that they participated in moonlighting in a wide variety of settings. Most worked in their area of clinical expertise. Most of these respondents were not tenured and did not participate in administrative tasks. Only 37% had a doctoral degree. Over half had the rank of Assistant Professor. Almost 42% worked in Masters I academic institutions. Most worked less than 2 hours per week outside the faculty role and they received full financial benefits. The top three benefits for participating in clinical practice were to maintain clinical skills, enhance teaching, and improve credibility with students. The top three barriers for participating in clinical practice were teaching responsibilities, not a component in tenure decisions, and the additional responsibilities of practice. There were no statistically significant differences between the benefits or barriers to clinical practice and the Carnegie Classification of the respondent's academic institution. One ANOVA was significant between the barriers to clinical practice and if the respondent had a doctoral degree. There were no statistically significant differences between the benefits or barriers and tenure at the institution, the respondent's tenure status, the respondent's degree status, faculty rank, administrative duties, and gender except the respondents that had a doctoral degree had significantly higher barrier scores than those that did not have a doctoral degree. In general, less than five percent of the variance was explained by any of the independent variables. None of the Chi Square analyses revealed any significant differences between the academic institution's Carnegie Classification and if clinical practice was required, if a faculty participated in faculty clinical practice, or if a faculty member participated in moonlighting. In conclusion, although many faculty members recognize the benefits to participation in clinical practice, the barriers to clinical practice may be too great to outweigh the benefits for some faculty members. Most reported that clinical practice carried little weight in promotion or tenure decisions. In order for the scholarship of practice to flourish, active support from all academic institution administration is critical.
Ed.D.
Department of Educational Research, Technology and Leadership
Education
Educational Leadership

The study answers the question: 'How can nurses' properly considered decisions relating to patient care be demonstrated?' Nurses in the United Kingdom have a professional requirement to demonstrate': the properly considered clinical decisions relating to patient care' (UKCC, 1994; NMC, 2002). However, their decisionmaking has been reported as complex and poorly understood, and apart from nursing records, little evidence exists to demonstrate their decisions. The development of the nurses' role as a decision-maker is traced from an origin in Nightingale's text (1860) through to the present day. This role is shaped by organisational, nursing and medical profession influences. Having established that nurses have a role as decision-makers, a conceptual framework is used to examine different explanations about the decision process, outcome, context and how decisions are made. Before undertaking fieldwork, a survey of nurses' decision-making in general medical and surgical wards was conducted. The findings were compared with the conceptual framework to generate questions and avenues for enquiry. An ethnographic study was undertaken in 1999 - 2000 in four general medical wards in two English provincial NHS Trusts with registered nurses (general). A model of decision-making was developed as a mid range theoretical explanation of how they made decisions. This involved a narrative based approach in which nurses generated an account (narrative) of knowing a patient and used this to identify needs. The patient was known in a narrative through three categories of information: nursing, management and medical. These categories were constructed through nurses' information seeking and processing using a tripartite conceptual lens. These facets correspond to different aspects of the nurse's role as a carer, care manager and medical assistant. The patient is known in three ways in a narrative, as a person to care for, an object to be managed, and as a medical case. An oral tradition surrounded its use, and nursing records were not central to decision-making. The narrative was used to make decisions and influence medical decisions. Once it was established how nurses made decisions, a method was developed to show how they could demonstrate their properly considered clinical decisions relating to patient care. This involved using the narrative based decision-making model as an analytical framework applied to nurse decision narratives. Narrative based decisionmaking offers a development of existing descriptive theoretical accounts and new explanations of some features of the decision process. This particularly includes the use of personal note sheets, the role of judgements and the cycle of communicating the narrative to nurses and its subsequent development as a process of developing an explanation of how the patient is known. Having addressed how nurses can demonstrate their properly considered clinical decisions relating to patient care, conclusions are drawn and implications explored in relation to practice, professional regulation, education and method. Recommendations include a challenge to the assumption about decision-making underpinning existing NMC guidance on recordkeeping, and the need to recognise diversity of decision-making practice across different nursing sub-groups. The narrative revealed nurses' ways of constructing knowing patients and rendering this visible. Nurses' not only have a duty, but also a need, to demonstrate decisions so that they can render visible what it is they are and do.