Rozprawy doktorskie na temat „Healthcare Practice”

A central problem for the healthcare sector today is how to manage change and improvements. In recent decades the county councils in Sweden have started various improvement initiatives and programs in order to improve their healthcare services. The improvement program of the Kalmar county council, which constitutes the empirical context for this thesis, is one of those initiatives. The purpose of this thesis is to contribute to a broader understanding of large-scale improvement program in a healthcare setting. This is done by analyzing practitioner’s improvement ideas, describing participants in the improvement projects, revising and testing a survey to measure the development of improvement ideas and describing the improvement program from a theoretical perspective. The theoretical change model used looks at change from two opposing directions in six dimensions; Goals, Leadership, Focus, Process, Reward system and Use of consultants. The aims of the county council improvement program are to become a learning organization, disseminate improvement methodologies and implement continuous quality improvements in the organization. All healthcare administrations and departments in the county council were invited to apply for funds to accomplish improvement projects. Another initiative invited staff teams to work with improvement ideas in a program with support from facilitators, using the breakthrough methodology. Now almost all ongoing developments, improvements, patient safety projects, manager and leader development initiatives are put together under the county council improvement program umbrella. In the appended papers both qualitative and quantitative research approach were used. The first study (paper I) analyzed which types of improvement projects practitioners are engaged in using qualitative content analysis. Five main categories were identified: Organizational Process; Evidence and Quality; Competence Development; Process Technology; and Proactive Patient Work. Most common was a focus on organizational changes and process, while least frequent was proactive patient work. Besides these areas of focus, almost all aimed to increase patient safety and increase effectiveness and availability. Paper II described the participants in two of the initiatives, the categorized improvement projects in paper I and the team members in the methodology guided improvement programs. Strong professions like physicians and nurses were well represented, but other staff groups were not as active. Managers were responsible for a majority of the projects. The gender perspective reflected the overall mix of employees in the county council. Paper III described a revision and test of a Minnesota Innovation Survey (MIS) that will be used to follow and measure how quality improvement ideas develop and improve over time. Descriptive statistics were presented. The respondents were satisfied with their work and what they had accomplished. The most common comment was about time, not having enough time to work with the improvement idea and the difficulty of finding time because of regular tasks. This was the first test of the revised survey and the high use of the answer alternative “Do not know” showed that the survey did not fit the context very well in its present version. Trying to connect the county council improvement program and the initiatives studied in papers I and II with the change model gave rise to some considerations. The county council improvement program has an effort to combine organizational changes and a culture that encourages continuous improvements. Top-down and bottom-up management approaches are used, through setting out strategies from above and at the same time encouraging practitioners to improve their day-to-day work. Whether this will be a successful way to implement and achieve a continuous improvement culture in the whole organization is one of the main issues remaining to find out in further studies.

There are national and local concerns about a policy-practice gap in healthcare services which bring into question the effectiveness of traditional mechanisms for policy implementation. Using clinical governance as a focus, this report describes the rationale, development and evaluation of an alternative approach designed to integrate health policy with practice within a Mental Health and Learning Disability NHS Trust through a programme of social opportunities. A number of methodological compromises were made due to the pragmatic nature of the project and limited availability of resources to undertake the evaluation. Not all disciplines and services were involved in the approach so different methods may be needed to engage these groups. However, the potential impact of the process for local policy, practice and aspects of practice culture has been critically evaluated using a framework for policy analysis and mixed methods for implementation, data collection and analysis. The findings suggest that the intervention was successful in providing an opportunity for practitioners to meet, network and discuss policy and practice issues and virtually all attendees valued the opportunity to participate. Contextually, the key focus was on meeting the needs of different client groups, i.e. working age adults, older people, children and people with a learning disability. Generally, all practitioners value the principles of user-centred, safe and effective practice that underpin national policy although some are valued more than others and practice in all areas can be improved. Personal responsibility is accepted and satisfactory levels of support are available and accessed. However, culturally there is evidence of conflict created by perceived differences between practitioner and organisational values, increased workload without added value and a need for improved interdisciplinary working and better service integration. This is particularly evident in the adult community mental health services. A theoretical model and process to integrate policy and practice is presented that needs embedding within an organisational approach to learning that provides supportive structures, processes and cultures requiring time, leadership and management commitment. Recommendations are made for the dissemination of findings, further development and testing of the theoretical model and process.

Current literature regarding quality health services frequently identifies interprofessional collaboration (IPC) as essential to patient-centred care, sustainable health systems, and a productive workforce. The IPC literature tends to focus on interprofessionalism and collaboration and pays little attention to the concept of practice, which is thought to be a represented world of objects and processes that have pre-given characteristics practitioners can know cognitively and apply or manage correctly. Many strategies intended to support IPC simplify and codify the complex, contested, and unpredictable day-to-day interactions among interdependent agents that I argue constitute the practices of a community. These strategies are based in systems thinking, which understand the system as distinct from experience and subject to rational, linear logic. In this thinking, a leader can step outside of the system to develop an ideal plan, which is then implemented to unfold the predetermined ideal future. However, changes in health services and healthcare practices are often difficult to enact and sustain.This thesis problematises the concept of ‘practice’, and claims practices as thoroughly social and emergent phenomenon constituted by interdependent and iterative processes of representation (policies and practice guidelines), signification (sense making through negotiation and reflective and reflexive practices), and improvisation (acting into the circumstances that present at the point and in the moments of care). I argue that local and population-wide patterns are negotiated and iteratively co-expressed through relations of power, values, and identity. Moreover, practice (including the practice of leadership or consulting) is inherently concerned with ethics, which I also formulate as both normative and social/relational in nature. I argue that theory and practice are not separate but paradoxical phenomena that remain in generative tension, which in healthcare is often felt as tension between what we should do (best practice) and what we actually do (best possible practice in the contingent circumstances we find ourselves in). I articulate the implications this has for how knowledge and knowing are understood, how organisations change, and how the role of an internal practice consultant is understood. An important implication is that practice-based evidence and evidence-based practice are iterative and coexpressed(not sequential), and while practice is primordial, it is not privileged over theory.I propose that a practice consultant could usefully become a temporary participant in the practices of a particular community. Through a position of ‘involved detachment’, a consultant can more easily notice and articulate the practices of a community that for participants are most often implicit and taken for granted. Reflective and reflexive consideration of what is taken for granted may change conversations and thus be transformative.

This programme of research consists of eight studies which sought to determine how healthcare professionals' hand hygiene practice might be improved. The Theory of Planned Behaviour was used to isolate perceived cognitive and physical factors that may explain the variance in their hand hygiene behaviour. Practice was observed and healthcare professionals' understanding of the hand hygiene policy to which they were expected to adhere was assessed. Messages on hand hygiene posters were analysed. The effect of two educational interventions on students' attitudes was tested. Achieving change will be challenging for several reasons. Healthcare professionals hold false perceptions about their hand hygiene behaviour; they think it is better than it is but their practice is unrelated to their intentions and self-reports of behaviour. Adherence to the national guideline was poor and practice was neither rational nor informed by risk assessment, even when caring for patients colonised with methicillin-resistant Staphylococcus aureus. Student nurses' attitudes towards the importance of hand hygiene showed progressively downward trends between three cohorts in their first, second and third years of training. The difference was particularly pronounced between first and second years. Their attitudes also showed optimistic bias and false consensus beliefs. For all but one of the 11 clinical procedures measured, they said that they value hand hygiene practice significantly more than other nurses and doctors they work alongside. A microbiology laboratory practical and a demonstration using a fluorescent cream and an ultraviolet light hand inspection cabinet were equally effective at enhancing students' attitudes towards hand hygiene, but the improvement was quickly eroded by their first experience of clinical practice. Various factors in the clinical setting impact negatively on healthcare professionals' attitudes and practice and undermine the principles taught in the pre-clinical phase of training. These include poor role models, ambiguous hand hygiene policies and inappropriately framed messages on hand hygiene posters which lead to confusion in the minds of healthcare professionals about when hands should be washed. In order to improve healthcare professionals' hand hygiene behaviour, it is necessary to disambiguate their understanding about when hands should be washed. There needs to be more emphasis on infection prevention. An active process called the Dynamic Assessment Strategy for Hand Hygiene (DASHH) offers one way of changing poor practice. It does this by teaching healthcare professionals to consider hand hygiene before and after care as separate activities requiring separate risk assessment. Such a strategy provides them with a simple mind map to make the quick informed decisions that are required on a busy ward. The effectiveness of the strategy needs to be evaluated. Observation should form part of the assessment to ensure that there is a beneficial outcome and that good practice is becoming a habit.

The Centers for Disease Control (CDC) and the World Health Organization (WHO) estimate that there are approximately 1.4 million cases of hospital acquired infections (HAIs) at any given time worldwide. Recent reports indicate that 722,000 patients acquire HAIs, with 75,000 or more succumbing to the infections and dying. This quality improvement project focused on the value of re-educating practicing nurses on hand hygiene practices as an approach to reduce the incidence of HAIs. Pre-intervention rates of HAIs were compared with post-intervention rates of HAIs across 2 units (Unit A and Unit B) in an acute care setting to determine if re-educating nurses about hand hygiene was a plausible strategy in reducing HAIs in the acute care setting. The pre-intervention mean rate of Unit A was 0.146% and the post-mean rate was 0.00%. A Wilcoxon signed-rank test showed that the educational intervention did not elicit a statistically significant change in infection rates (z = -1.63, p > 0.05). Similarly, the pre-intervention mean rate of Unit B was 0.12% and the post-mean rate was 0.00%. A Wilcoxon signed-rank test showed that the educational intervention did not elicit a statistically significant change in infection rates (z = 1.732, p > 0.05). Despite the lack of statistical significance, there was a reduction in the mean rate to 0.00% following the educational intervention. The results of this quality improvement project suggest a value in re-educating nurses on the importance of hand hygiene as a strategy to reduce and prevent HAIs in health care organizations in order to promote positive patient outcomes.

The Centers for Disease Control (CDC) and the World Health Organization (WHO) estimate that there are approximately 1.4 million cases of hospital acquired infections (HAIs) at any given time worldwide. Recent reports indicate that 722,000 patients acquire HAIs, with 75,000 or more succumbing to the infections and dying. This quality improvement project focused on the value of re-educating practicing nurses on hand hygiene practices as an approach to reduce the incidence of HAIs. Pre-intervention rates of HAIs were compared with post-intervention rates of HAIs across 2 units (Unit A and Unit B) in an acute care setting to determine if re-educating nurses about hand hygiene was a plausible strategy in reducing HAIs in the acute care setting. The pre-intervention mean rate of Unit A was 0.146% and the post-mean rate was 0.00%. A Wilcoxon signed-rank test showed that the educational intervention did not elicit a statistically significant change in infection rates (z = -1.63, p > 0.05). Similarly, the pre-intervention mean rate of Unit B was 0.12% and the post-mean rate was 0.00%. A Wilcoxon signed-rank test showed that the educational intervention did not elicit a statistically significant change in infection rates (z = 1.732, p > 0.05). Despite the lack of statistical significance, there was a reduction in the mean rate to 0.00% following the educational intervention. The results of this quality improvement project suggest a value in re-educating nurses on the importance of hand hygiene as a strategy to reduce and prevent HAIs in health care organizations in order to promote positive patient outcomes.

This article introduces the feature article on policy implications of integrative nursing. It describes unitary ontology in nursing, highlighting the Rogerian view of holism. The importance of linking philosophy to practice policy is emphasized.

This study investigates experiences of accelerated pre-registration healthcare students of collaborative interprofessional working and examines their perceptions of the factors which influence this, including the interprofessional education they have undertaken. It is set in context of current NHS policy, where professional collaboration is advocated as a means of addressing issues of quality, efficacy and efficiency in patient care. Design: Mixed Methods Study Method: Three studies were undertaken. 1. Longitudinal panel survey examining students’ attitudes to interprofessional learning, (questionnaire administered at three points during the course) 2. Survey study using critical incident technique to explore examples of ’good’ and ’poor’ collaborative practice 3. Interview study examining beliefs and attitudes in depth. Subjects: Total sample of 207 students, from two cohorts of accelerated learning students (nursing, physiotherapy and dietetics) attending one university. Analysis: Descriptive statistical analysis was performed to describe the population characteristics, the context of their practice and reported practice incidents. Thematic content analysis, employing triangulation between data sources, was applied to the qualitative data. Results: This accelerated group was similar to standard pre-registration students, entering university with a strong professional identity and openness to interprofessional learning, which attitudes declined over time. ’On the job’ learning was identified as the predominant way students learned about working collaboratively. Five factors were identified as key in influencing interprofessional activity of which Communication and Teamwork were the most important.

Female health is a complex and dynamic component of the female lifecycle. It is not based on a single entity, rather it is holistic and comprised of several individual facets. Thus, female healthcare should be approached from a wellness perspective and treated in an integrative system. While an integrative approach to healthcare is optimal for all people, this research study explores female development holistically as it relates to wellness and integrated healthcare.

Current UK abortion law has been subjected to extensive feminist critique because of the relationships that it constructs between healthcare professionals (HCPs) and women with unwanted pregnancies. The law allows HCPs to opt out of abortion provision on the grounds of conscience, implying that it is not something which they have an automatic duty to provide to their patients. It also gives doctors the authority to decide whether an abortion can legally take place, thus suggesting that women’s reproductive decisions should be regulated by medical ‘experts’. However, little is known about how HCPs who are involved in twenty-first century UK abortion provision define their relationships with their patients in practice. My thesis makes an important empirical contribution by responding to this gap in the literature and exploring the subjectivities which these HCPs construct for themselves and their pregnant patients. I address this issue by analysing Scottish HCPs’ interview accounts of their involvement in (or conscientious objection to) abortion provision, using conceptual tools provided by Science and Technology Studies (STS) and feminist theory. I begin by utilising HCPs’ discussions of the practice of ‘conscientious objection’ as a means of exploring how they define the boundaries of their professional responsibilities for abortion provision. I then move on to address HCPs’ accounts of their interactions with women requesting abortion, and analyse how they define legitimate or ‘expert’ knowledge in this context. A key conclusion of the thesis is that HCPs do concede some authority to women with unwanted pregnancies; this is revealed by their reluctance to suggest that they have the right to prevent individual women from accessing abortion. At the same time, I argue that the legitimacy granted to pregnant women by HCPs is limited. My analysis reveals that, in constructing knowledge claims about the use of abortion, HCPs co-produce troubling definitions of femininity, socio-economic class, age and ethnicity. I develop a strong critique of this process, and highlight its potential implications for women’s experiences in the abortion clinic. However, I conclude that this situation cannot be addressed by simply attacking the practices of HCPs as individuals. Rather, it is necessary to understand and critique the limitations of the discursive context in which HCPs are working, because this context shapes the subjectivities available to pregnant women and HCPs.

Health and care services need to be optimised to meet the future demand that will be placed on them. This will require a closer coupling of service and research, whereby innovations in services can be rapidly tested and evaluated, and feed back into a continual process of service optimisation. The timely delivery of information from services into research is critical to this cycle. However, there are serious problems with the evidence on which healthcare and public health practice is based: it is expensive to produce; it takes a long time to produce; it takes a long time to influence professional practice; it is crude, relating to the average participant and simple treatment definitions under ideal conditions. In other words, it gives a low-resolution picture of how a patient might respond to treatment or a how a sub-group of the community might respond to a public health intervention. This work is an exploration of informatics solutions to these problems with an aim to re-engineer health care systems to make best use of the evidence available.

Training interprofessional healthcare teams continues to advance practice for patient-centered care. Empathy research is also advancing and has been explored in social work, psychology, and other healthcare areas. In the absence of understanding empathy in an interprofessional setting, educators are limited in preparing teams to develop empathy as part of core competencies This grounded theory study explored for a theory of how interprofessional healthcare teams conceptualize and operationalize empathy in their practice. Azjen's theory of planned behavior and Barrett-Lennard's cyclical model of empathy framed the study. Data were collected using 6 focus groups and 24 semistructured interviews of varied healthcare professionals working in an interprofessional setting in Ontario, Canada. Systematic data analysis utilizing Auerbach and Silverstein's (2003) approach revealed participants engaged in and valued empathy as a team. Empathy was identified as purposeful and intentional behaviors believed to be meaningful for positive patient outcomes. In addition, professionals identified the role of genuine intent in the practice of empathy. As a result of this study, a grounded theory of interprofessional intentional empathy centered care explains the conceptualization and operationalization of empathy in practice. Collective empathy in an interprofessional team model contributes to improved patient outcomes. The work of this study ascertains that empathy is not accidental; it should be cultivated in the form of intentional and genuine team experiences. This study advances social change by further identifying how the practice of empathy can be integrated into interprofessional healthcare education and praxis.

This research examines the relationship between quality management (QM) practices and performance in the healthcare industry via the conduct of three studies. The results of this research contribute both to advancing QM theory as well as in developing a unique text mining method that is illustrated by examining QM in the healthcare industry. Essay 1 explains the relationship between operational performance and QM practices in the healthcare industry. This study analyzed the findings from the literature using meta-analysis. We applied confirmatory semantic analysis (CSA) to examine the Baldrige winners' applications. Essay 2 examines the benefits associated with an effective QM program in the healthcare industry. This study addressed the research question about how effective QM practice results in improved hospital performance. This study compares the performance of Baldrige Award-winning hospitals with matching hospitals, state average, and national average. The results show that the Baldrige Award can lead to an increase in patient satisfaction in certain periods. Essay 3 discusses the contribution of an online clinic appointment system (OCAS) to QM practices. An enhanced trust model was built on understanding the mechanism of patients' trust formation in the OCAS. Understanding the determinants related to patients' trust and willingness to use OCAS can provide valuable guidance for medical institutions to establish health information technology-based services in the quality service improvement programs. This research has three significant contributions. First, this research analyzes the role of QM practices in the healthcare industry. Second, this research attempts to develop a unique text mining method. Third, this research provides a validated trust model and contributes to the body of research on the trust of healthcare information technology.

The novel contribution of this research is the development of a supervised algorithm that extracts relevant attributes from The Health Improvement Network database to detect prescription side effects. Prescription drug side effects are a common cause of morbidity throughout the world. Methods that aim to detect side effects have historically been limited due to the data available, but some of these limitations may be overcome by incorporating longitudinal observational databases into pharmacovigilance. Existing side effect detecting methods using longitudinal observational databases have shown promise at becoming a fundamental component of post marketing surveillance but unfortunately have high false positive rates. An extra step is required to further analyse and filter the potential side effects detected by existing methods due to their high false positive rates, and this reduces their efficiency. In this thesis a novel methodology, the supervised adverse drug reaction predictor (SAP) framework, is presented that learns from known side effects, and identifies patterns that can be utilised to detect unknown side effects. The Bradford-Hill causality considerations are used to derive suitable attributes as inputs into a learning algorithm. Both supervised and semi-supervised techniques are investigated due to the limited number of definitively known side effects. The results showed that the SAP framework implementing a random forest classifier outperformed the existing methods on The Health Improvement Network longitudinal observational database, with AUCs ranging between 0.812-0.937, an overall MAP of 0.667, precision values between 0.733-1 and a false positive rate ≤ 0.013. When applied to the standard reference the SAP framework implementing a support vector machine obtained a MAP score of 0.490, an average AUC of 0.703 and a false positive rate of 0.16. The false positive rate is lower than that obtained by existing methods on the standard reference.

Non-biomedical practices and practitioners serve as the primary source of healthcare for a majority of populations in low-income countries. The World Health Organization (WHO) has prioritised the integration of local non-biomedical healthcare practices and practitioners into formal state healthcare systems since the Declaration of Alma Ata in 1978. Heretofore, both WHO's representation of healthcare integration and its discourse of beneficence have been reified, yet largely unexamined. This research examines the processes of healthcare integration through qualitative research at multiple levels of analysis in the Philippines to better understand: what healthcare integration is; how stakeholders perceive healthcare integration; and how the practice of healthcare integration may differ from its discursive representation. This research was conducted in communities of four municipalities of the Philippines over a period of 22 months. The sample of 1,023 informants consisted of community members, community leaders, healthcare providers, and policy actors who participated in semi- structured interviews, focus groups, and pile sorts. Participant experience was also conducted over a year-long period in both the Traditional Medicine Unit of The Western Pacific Region Office of the WHO and the Philippine Institute of Traditional and Alternative Healthcare of the Department of Health of the Philippines. The integration of local birth attendants through prohibition of their practices serves as a case example. From this research, healthcare integration is understood as multiple independent and interdependent processes that occur simultaneously across global, state, and local levels of analysis, including the individual level. However, community level stakeholders were identified to resist healthcare integration practices, which they perceived as either inappropriate for their community and/or capable of compromising their access to healthcare. These findings are presented in terms of the development studies discourses concerning appropriate knowledge/technology transfer, community agency, complex adaptive systems, health reform and administrative decentralisation, and the relevance of subjectivity in development interventions.

This study explores how managers are coping within a changing public healthcare service context and how the role of service managers and the nature of Management Development are being transformed. With the public healthcare sector in the UK facing complex challenges including financial constraint and increasing service demand, it is inevitable that collaborative partnership working and service integration are viewed as a means of addressing such challenges. Using the views and experiences of service managers from Scottish Community Health Care Partnership cases, the study highlights the experiences of managers in relation to partnership working and service integration and explores the potential implications of this for managerial learning, training and development. The research evidence establishes the importance of changing roles, responsibilities and relationships for managers in a changing healthcare service environment and takes on board a Service-Dominant approach and propositions from New Public Governance theory to explain these and to address attendant issues. Specifically, the challenges surrounding the learning, training and development of managers in an increasingly integrated services environment are explored and reconceptualised through a Services-as-Systems approach. The outcomes of this study allow for a better understanding of the changing nature of work that managers do and attempts to reframe Management Development in such a context for the future.

Purpose: The purpose of this study was to explore the experiences of distracted practice across the healthcare team. Definition: Distracted practice is the diversion of a portion of available cognitive resources that may be needed to effectively perform/carry out the current activity. Background: Distracted practice is the result of individuals interacting with the healthcare team, the environment and technology in the performance of their jobs. The resultant behaviors can lead to error and affect patient safety. Methods: A qualitative descriptive (QD) approach was used that integrated observations with semi-structured interviews. The conceptual framework was based on the distracted driving model and a completed concept analysis. Results: There were 22 observation sessions and 32 interviews (12 RNs, 11 MDs, and 9 Pharmacists) completed between December, 2014 and July 2015. Results suggested that distracted practice is based on the main theme of cognitive resources which varies by the subthemes of individual differences; environmental disruptions; team awareness; and “rush mode”/time pressure. Conclusions and Implications: Distracted practice is an individual human experience that occurs when there are not enough cognitive resources available to effectively complete the task at hand. In that moment an individual shifts from thinking critically, being able to complete their current task without error, to not thinking critically and working in an automatic mode. This is when errors occur. Additional research is needed to evaluate intervention strategies to reduce and prevent distracted practice.

Lack of access to healthcare in rural communities has resulted in increased morbidity and mortality rates among diabetic patients. The problem identified in this project was the lack of access to healthcare among diabetic patients living in rural southeast Ohio. Tele-healthcare is a strategy that provides healthcare remotely and has been introduced into the rural setting and offers an appropriate healthcare delivery mode for the rural community. The purpose of the project was to develop a tele-healthcare clinical practice guideline, including smart phone applications, for the management of diabetic patients. An expert panel consisting of 2 advanced practice nurses in diabetic education and endocrinology as well as the director of nursing of the local health department scored the guideline using the Appraisal of Guidelines Research and Evaluation II model, which consisted of 23 items over 6 domains. Results were calculated by adding the maximum score expressed as a percentage and dividing by 6 domains. The result was 96.8%. The threshold for a high-quality guideline is 70%. Recommendations by the panel were implementation of the guideline incorporating smartphone applications into the process of providing care for diabetic patients as a way of increasing access and improving the quality of diabetic healthcare among rural populations. Using a tele-healthcare clinical practice guideline for diabetic management might achieve positive social change by expanding access to healthcare as well as improving the overall quality of healthcare services for diabetic patients living in rural southeast Ohio.

Adolescence is a unique period of rapid physical and psychosocial growth and development. Adolescents are most often physically healthy, but as a normal part of adolescent development the population commonly experiments with risky behaviors, which may lead to the development of unhealthy habits (National Research Council and Institute of Medicine [NRC/IOM], 2009). Additionally, risky behaviors are connected to the top three causes of potentially preventable adolescent death ? accidents/unintentional injury, homicide, and suicide (Goldenring & Rosen, 2004; NRC/IOM, 2009). Primary healthcare providers may have not received specialized training in providing healthcare to the adolescent population, or may feel uncomfortable engaging in communication about psychosocial risk factors with adolescents (NRC/IOM, 2009). One critical gap involves the fragmented healthcare services available to adolescents and the missed opportunities for health promotion and disease prevention when adolescents do seek healthcare. Incorporating comprehensive psychosocial adolescent histories into practice may help facilitate positive changes in adolescent healthcare delivery. In response to the need for improved adolescent friendly healthcare services, an online continuing education module was created in collaboration with the American Association of Nurse Practitioners Continuing Education Center. The psychosocial assessment focused on utilizing the HEEADSSS assessment, as psychosocial risk factors contribute to the leading causes of adolescent morbidity and mortality (Goldenring & Rosen, 2004; NRC/IOM, 2009). The module was evaluated through pretest, posttest, and evaluation questions. Data were collected for approximately two months, and there were 328 participants. Following completion of the module, over half (52.4%; n = 172) of the participants reported they will modify their practice, and nearly all of the participants (91.8%; n = 301) felt that the level of content was ?just right? for nurse practitioners. Five pretest and posttest questions related to the module?s content demonstrated increased knowledge as a result of the module. Additionally, a majority of the written qualitative responses were in support of or praising the quality of the module. Overall, data indicate a positive impact from the continuing education module about conducting comprehensive psychosocial interviews with adolescent patients.

Thesis: Ph. D. in Engineering Systems: Technology, Management, and Policy, Massachusetts Institute of Technology, School of Engineering, Institute for Data, Systems, and Society, February, 2020
Cataloged from student-submitted PDF version of thesis.
Includes bibliographical references (pages 135-145).
In the three decades since its introduction, Evidence-Based Practice (EBP) has become standard clinical practice and the subject of targeted interventions at all levels of the health system. Despite its prevalence, EBP is frequently challenged on philosophical, practical, empirical, and normative grounds. And EBP is often underused in practice relative to the considerable investment in training and sophisticated organizational interventions to implement EBP. In this dissertation, I identify what the concept of EBP means to health system stakeholders as a partial explanation for this persistent gap in EBP use and implementation outcomes. Through interviews with clinicians and healthcare administrators, I identify how providers and organizations use EBP in practice to clinical ends and in inter-professional relationships. First, I find that in contrast to the theoretical model, stakeholders vary in how they operationalize EBP for individual-level clinical use.
Stakeholders endorse a range of what I call implicit mental models of EBP that imply different approaches to clinical decision-making. Respondents' implicit mental models of EBP each emphasize an incomplete aspect of the full EBP model: Resource-Based EBP emphasizes specific evidence artifacts, Decision-Making EBP emphasizes the decision-making process, and EBT-Based EBP emphasizes specific Evidence-Based Treatments. These implicit models represent the decision inputs, process, and outputs, respectively. Second, I describe how and why healthcare organizations conduct EBP interventions, despite its initial design as an individual-level clinical decision-making model. I document a range of different organizational EBP activities and interventions, including disseminating resources, training providers, and implementing local standards. These organizational EBP activities both support individual EBP use and address broader organizational ends, which may conflict.
Finally, EBP takes on social and inter-professional meanings beyond its intended scope as a clinical decision-making model, which emerge in context and affect how providers understand and use EBP. Specifically, providers may renounce their standing to evaluate evidence, demonstratively use EBP, and administrators claim standing to evaluate evidence. This dissertation therefore demonstrates the varied uses of EBP that emerge in practice, contributing to our understanding of the challenges and contradictions that arise in applying general knowledge to individual cases and systematizing strategies for the same at the organization level.
by Henry Alan Fingerhut.
Ph. D. in Engineering Systems: Technology, Management, and Policy
Ph.D.inEngineeringSystems:Technology,Management,andPolicy Massachusetts Institute of Technology, School of Engineering, Institute for Data, Systems, and Society

Globally, higher healthcare demand strains existing systems, already overburdened by a lack of resources and funding while longer life expectancy and increased disease burden force higher patient loads. A majority of the South African population is medically uninsured and therefore depend on emergency care; consequently, the healthcare service demand easily exceeds available acute care to prevent life threat. When this happens, emergency centres suffer from overcrowding and long patient waiting times, which increases morbidity and mortality, associated patient risk. Moreover, critical resources such as staff and hospital beds are required for an even flow of patients through hospitals, but are distributed inefficiently. The South African healthcare system configuration therefore delays access to and compromises the delivery of equitable, unbiased life-saving healthcare in an environment moreover challenged by economic pressures. This calls for sustainable, cost-effective reform. Therefore, more efficient healthcare can save more lives by improving access to life-saving care. Research on current Healthcare Information Systems (HIS) shows an incoherent knowledge body with conceptual gaps in theories on healthcare, which disengages transformation potential. Comprehensive reform tactics thus require a priori concept discovery and diagnostics to make research practically useful. The systematic use of BPM theories allowed for the qualitative assessment of as-is process activity at patient touch-points at three hospitals – two public and one private – in the Western Cape of South Africa. Because a strategic Information Systems (IS) methodology, Business Process Management (BPM) poses business process activity improvement, this research draws from successful BPM activity as a means to improve patient flow processes in Emergency Centres (ECs). Success is evaluated by drawing from empirically supported enabler categories and prescriptive guidelines because BPM practice is not yet fully understood. The results show a clear correlation between the improvement areas at the three hospitals; improvements on aspects of actions and decisions taken during patient-flow process activity, therefore support a pragmatic approach to reform. The data confirms disparity between public and private healthcare. Healthcare appears to be a “doctor driven” service, which, based on qualitative decision-making, navigates patients along defined flows, enabled by supporting human capital and hospital assets. Optimal patient flow is a product of symbiotic working relationships and depends on efficient integration with wider hospital functions. Shorter waiting times and hospital stays reduce process burden. This leads to more efficient resource usage and regulated access to healthcare. However, integrated healthcare reform must consider the time demands and rigidity of clinical processes. The challenge lies in finding the space to invite parallel business agility to drive the reform of the stricken healthcare industry in South Africa.

Whereas there are various initiatives to standardize the storage, processing and use of electronic patient information in the South African health sector, the sector is fragmented through the adoption of various approaches on national, provincial and district levels. Divergent IT systems are used in the public and private health sectors (“Recommendations of the Committee on …” 2003). Furthermore, general practitioners in some parts of the country still use paper as a primary means of documentation and storage. Nonetheless, the use of computerized systems is increasing, even in the most remote rural areas. This leads to the exposure of patient information to various threats that are perpetuated through the use of information technology. Irrespective of the level of technology adoption by practitioners in private healthcare practice, the security and privacy of patient information remains of critical importance. The disclosure of patient information whether intentional or not, can have dire consequences for a patient. In general, the requirements pertaining to the privacy of patient information are controlled and enforced through the adoption of legislation by the governing body of a country. Compared with developed nations, South Africa has limited legislation to help enforce privacy in the health sector. Conversely, Australia, New Zealand and Canada have some of the most advanced legislative frameworks when it comes to the privacy of patient information. In this dissertation, the Australian, New Zealand, Canadian and South African health sectors and the legislation they have in place to ensure the privacy of health information, will be investigated. Additionally, codes of practice and guidelines on privacy of patient information for GPs, in the afore-mentioned countries, will be investigated to form an idea as to what is needed in creating and formulating a new code of practice for the South African GP, as well as a pragmatic tool (checklist) to check adherence to privacy requirements.

Healthcare in Sweden is in need of a transformation. The increase of chronic conditions poses a great challenge to the organisational structure of healthcare, which still largely remains based on acute, rather than chronic care. Development in the healthcare realm is commonly conducted in fragmented processes and from the professions', rather than the patients', perspective. A new type of design methodology has in recent years entered the field of healthcare development and innovation. It has progressively been used to enable the reorganisation of the healthcare system itself rather than solely developing artefacts, IT-systems or services within it. This thesis focuses on problems that can be described as open, complex, dynamic, networked, or wicked. The following research questions are investigated:    I.     How can designers' competence contribute to healthcare innovation?  II.     How can designers support the identification of complex problems in healthcare? Empirical data were collected during two healthcare innovation projects in which the author took an active role as both designer and researcher. The research work was based on qualitative data that were gathered using ethnographic methodology (i.e., interviews, participant observation and field notes). The data were analysed using open coding principles and activity theory. The results highlighted the valuable role of free-flowing design practice, supporting a thorough understanding of complex problems. The free-flowing design practice entails that the problem space and the solution space co-evolve. These spaces expand iteratively, continuously affecting each other while redefining problems in search of solutions that aim at radical innovation and not merely incremental ameliorations.
Hälso- och sjukvården är i behov av förändring. Ökningen av kroniska tillstånd utgör en stor utmaning för sjukvårdsorganisationens struktur som fortfarande till stor del baseras på akut, snarare än kronisk vård. Sjukvårdsutveckling sker ofta i fragmenterade processer, och utifrån professioners, snarare än patienters perspektiv. En ny typ av designmetodologi har på senare år börjat tillämpas för att utveckla och skapa innovationer inom hälso- och sjukvården. Den har allt mer börjat användas för att utveckla sjukvårdsorganisationen i sig, snarare än att bara utveckla dess produkter, IT-system eller tjänster. Avhandlingen fokuserar på problem som kan beskrivas som öppna, komplexa, föränderliga, sammanlänkade eller 'wicked' [onda]. Följande forskningsfrågor undersöks:    I.     Hur kan designers kompetens bidra till innovation inom hälso-och sjukvården?  II.     Hur kan designers bidra till att identifiera komplexa problem inom hälso- och sjukvården? Empirisk data har samlats in i samband med två innovationsprojekt inom sjukvården där författaren haft en aktiv roll som såväl designer som forskare. Forskningen baseras på kvalitativ data som har samlats in genom etnografisk metodologi (dvs. intervjuer, deltagande observationer och fältanteckningar). Datan har analyserats enligt 'open coding'-principer och aktivitetsteori. Resultaten lyfter fram värdet av en 'free-flowing design practice' [fritt föränderlig designpraktik] för att förstå komplexa problem. Den fritt föränderliga designpraktiken medför att problem-rymden och lösnings-rymden sam-utvecklas. Dessa rymder expanderar iterativt, medan de kontinuerligt påverkar varandra mot en omdefiniering av problem, i syfte att hitta lösningar som kan leda till radikal innovation, snarare än bara inkrementella förbättringar.

Practice and law around informed consent in healthcare have undergone a revolution for the better over recent decades. However the way we obtain informed consent remains problematic and is imbued with irreducible but not ineliminable uncertainty. The reasons for this uncertainty are varied. The uncertainty is partly due to the conceptual opacity of important core concepts. The complexity of communication in clinical encounters is another. The role of autonomy, and the changing nature of the clinician patient relationship, have also contributed to this uncertainty remaining. This thesis is not a panacea for these difficulties. However there have been two quite profound revolutions in healthcare over the last decade or so, namely, the introduction of evidence-based medicine into clinical decision making, and the institutionalization of clinical governance and the application of quality improvement philosophy. I have examined ways in which these two “movements” can help in reducing some of the uncertainty in the practice of informed consent.

yes
The Health Care and Professions Council (HCPC) regulates fifteen different professions; some of these are large groups like Physiotherapists and some are much smaller such as Speech and Language Therapists (SLT). Most of the people registered by the HCPC work within their own areas of clinical expertise and defined professional scope of practice. However, an increasing number of registrants are undertaking new or additional roles beyond the traditional scope of practice for the defined profession. These roles are often shared with other medical or health professionals and persons undertaking these roles are often, but not consistently, referred to as Advanced Practitioners. Advanced Practitioners are employed within the NHS across all four countries of the UK and are also employed by private healthcare providers. The roles they undertake vary from the highly specialised (e.g. an advanced podiatrist might specialise in biomechanics) to more general roles with greater professional autonomy and decision-making (e.g. a paramedic working in a GP Practice assessing patients with undifferentiated acute problems). As a result, there is currently no consistency in role title, scope of advanced practice, necessary underpinning education or professional accreditation across the HCPC registered professions. This study was undertaken to explore these issues and seek opinion on the need for additional regulatory measures for persons working at an advanced practice level. NB: For the purposes of this study, advanced practice was considered to encompass all roles, regardless of role title, where the level of practice undertaken was considered to be advanced. Method Three approaches to data collection were undertaken to ensure the differing opinions across all HCPC registered professions, different stakeholders and the four nations of the UK were collected. Data were collected through: 1. A UK wide survey of HCPC registered healthcare professionals; 2. A UK wide survey of organisations delivering AHP & scientific advanced practice education; 3. A series of focus groups and interviews across a range of stakeholder groups. Findings The concept of advanced level practice was not consistently understood or interpreted across the different stakeholder groups. Those participants identifying as working at an advanced practice level undertook a range of activities both within and out with the traditional scope of practice of the registered profession adding a further layer of complexity. Educational support and availability for advanced level practice varied across professional groups and inequity of accessibility and appropriateness of content were raised as concerns. There is no consensus across participant groups on the need for regulation of advanced level practice. Perceived advantages to additional regulation were the consistent and equal educational and employer governance expectations, particularly where multiple professional groups are undertaking the same role, all be it with a differing professional educational foundation and lens. However, while some voices across the participant groups felt regulation was essential to assure practice standards and reduce risk of role title misuse, there was equally a lack of appetite for regulation that inhibited agility to respond to, and reflect, the rapidly changing healthcare environment and evolving scope of advanced level practice. Importantly, no evidence was presented from any participant group that advanced level practice within HCPC regulated professions presents a risk to the public. Conclusion The study data presented in this report reflect the complexity of the concept of advanced practice within the HCPC regulated professions. Much of this is a consequence of the differing speeds of professional role development across healthcare organisations and professional groups, often related to service capacity gaps and locally developed education to support local initiatives. Despite this, there is no clear evidence, based on the findings of this research, that additional regulation of advanced level practice is needed, or desired, to protect the public. However, as the HCPC is one of the few organisations with a UK wide remit, it may have a central role in achieving unification across the 4 nations in relation to the future role expectations, educational standards, and governance of advanced level practice.

Objectives: To determine misuse of prescription stimulant medications among future health care providers at an Academic Health Sciences Center. Method: Data were collected via a 62-item anonymous online survey distributed to medical, pharmacy, and rehabilitative health (RT) students at a large Academic Health Sciences Center. The survey instrument collected demographic information related to the respondent’s healthcare discipline, year(s) in professional program, and if the participant had been diagnosed with a disorder requiring a prescription stimulant medication. Nonmedical prescription stimulant use, motivation for nonmedical use, deceptive practices, frequency of use, consequences of nonmedical use, and peer group nonmedical use were also collected. Results: In aggregate, 11.3% of responders reported misuse of prescription stimulants. The rate of misuse was similar for pharmacy (9.7%) and medicine (10.9%) students with a trend towards an increased rate of misuse in RT students (26.3%) (p 5 0.08) The response rates were 70.5% (225/319) for pharmacy, 47.6% (128/269) for medical, and 54.3% (19/33) for respiratory therapy students. The most common reasons for misusing prescription stimulants were to improve academic performance (25/44; 56.7%) and increase alertness/energy (29/44; 65.9%). The most commonly reported adverse reactions were lack of appetite (30/44; 68.2%) and difficulty sleeping (24/44; 54.5%). Implications: Given the stigma associated with prescription stimulant misuse, it is difficult to assess the breadth and depth of this problem. Physical and/or psychological dependence, altered clinical judgment, and violation of misconduct policies and laws are possible consequences of prescription stimulant misuse. This is the first survey to assess misuse by multiple disciplines on a single Academic Health Sciences campus.

In this thesis I develop a new, wider and richer understanding of wellbeing, through developing a process of reflective practice, with healthcare professionals within their challenging work culture. As a healthcare chaplain, having witnessed poor staff morale, I conducted a critical examination of NHS wellbeing reports and strategies, which revealed an understanding of staff wellbeing that ironically follows simply a health model. Challenging this, I argue for a broader interpretation of wellbeing that, in addition to focusing on health, is more holistic, relational and contextual. I develop reflective practice to nurture this, the use of which extends in healthcare beyond education and professional development. In my action research, knowledge was generated through ethnographic participation and observation, over a year, reflecting as chaplain with eight teams of healthcare professionals. This used my simple and memorable HELP Wellbeing Reflection Cycle (building on Kolb's (1984) model of experiential learning) that combines reflection on work and personal development. My project also responds to Rolfe's call (2014) for greater use in healthcare of Schön's (1980) "reflection-in-action". Building on these works, I develop reflection for healthcare professionals to nurture their wellbeing. My encouragement of the participants to self-facilitate their own reflective groups, when familiar with this method of reflection, is also a contribution to reflective practice, healthcare and the chaplain's role. Thematic data analysis emerged from the reflexive field notes of our shared experience as co-reflective practitioners. The themes include healthcare professionals making the human connection between themselves and with their patients. They also value the space to reflect together, realising their desire for team support and a shared goal, as well as job satisfaction in this demanding culture. These themes, I argue, are consistent with the broader definitions of wellbeing, giving them the opportunity to be both a healthcare professional and human. Further data analysis also reveals consistency with wider wellbeing interpretations (including personal wellbeing measurements and data from the Office for National Statistics (2014, 2015)). I develop the role of chaplain as the healthcare professionals' co-reflector, sharing their reflective space as a pastoral encounter and a source for learning. This combines the images of "empty handed" (Swift, 2009) "welcoming guest" and "mutual hospitality" (Walton, M., 2012). I offer to national healthcare the wider understanding of wellbeing, and the value of creating provision for reflective space to nurture it, in the care of healthcare professionals. This research offers the potential for exciting further developments in a wider constituency both in and beyond healthcare.

Despite the phenomenal innovations and huge investments in healthcare, it is evident that some digital transformation innovations in the healthcare context fail to meet their desired outcomes. Whilst some researchers argue that this is partly due to ineffective implementation, others argue otherwise. Essentially, there is an outspoken need to evaluate implementation processes, and one way to do so is through the use of an implementation framework, where one such framework showing great potential is the Consolidated Framework for Implementation Research (CFIR). By using a qualitative case study through the lenses of the CFIR, the study carries out a summative evaluation and examination of a previously conducted implementation process in a region in the north of Sweden, with the purpose of developing a greater understanding of implementation processes in order to improve patient care, as well as experiences and outcomes of digital transformation implementations. The study successfully identifies factors of both success and challenge in relation to implementation processes, where some of the success factors include the involvement of caregivers in the process and competition of private healthcare providers, whilst some of the challenges include deficient involvement of end-users as well as lack of structure. The study unearths some lessons which can be used as a guide for future implementations within the healthcare context, but also other contexts as well.

With increased pressures from governmental and insurance agencies, todayâ s physician devotes less time to patient care and more time to administration. To alleviate this problem, Biological & Popular Culture, Inc. (Biopop) proposed the building of partnerships with healthcare professionals to provide high-quality, cost-effective medical care in a physician network setting. To assist Biopop in evaluating potential operating procedures, a discrete-event simulation model has been constructed. The model is built in an object-oriented, visual manner utilizing the Visual Simulation Environment (VSE). The model examines both internal Biopop operations and external clinic operations. The research presented herein describes the design of the simulation model and details the analysis of the clinical environment.

A methodology for determining appropriate staffing and physical resources in a clinical environment is presented. This methodology takes advantage of several simulation-based statistical techniques, including batch means; fractional factorial design; and simultaneous ranking, selection, and multiple comparisons.

An explanation of the experimental design is provided and results of the experimentation are presented. Based upon the experimental results, conclusions are drawn and recommendations are made for an appropriate staffing and facility size for a two-physician family practice healthcare clinic.
Master of Science

Asylum seekers are a socially excluded migrant population, presenting specific healthcare needs, which are often not acknowledged, nor properly addressed by national and European laws. Hailing from areas with poor sanitary attention, exposed to violence during the journey, they arrive to Italy with a high health vulnerability. The aim of this thesis is to find the discrepancies between the legislation providing healthcare access to the asylum seekers, in compliance with the fundamental human rights, and the practical healthcare responses in the Italian context of the North African Emergency (2011-2013), relying on a systematic literature review. The emergency-driven responses to the asylum inflow resulted in a heterogeneous reception and healthcare assistance, as the Italian asylum legislation focuses more on asylum procedures than healthcare, which remains regionally fragmented too. Asylum seekers faced discrimination and barriers in accessing healthcare, mainly due to information, linguistic and bureaucratic difficulties. Therefore, NGOs and associations intervened locally to fill the gap left by the institutional response, with a better focus on the social determinants of health and the importance of social integration as well. After 2013, better reception conditions were formulated and the legislation revised. However, the difference between legislation and practice on the asylum seekers healthcare access constitutes a human rights violation still present nowadays. Clearer approaches should be developed to address the issue uniformly.

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

Introducció. La millora de l’adequació de la pràctica clínica fa referència a l’elecció de proves diagnòstiques, tractaments i altres prestacions que, segons l’evidència científica, tenen més beneficis que riscos, un balanç cost-benefici raonable i s’ajusten a les preferències de les persones i de la societat. Aquest procés inclou identificar i eliminar pràctiques de poc valor i promoure aquelles de valor. Objectius 1. Documentar les iniciatives destinades a millorar l’adequació de la pràctica clínica en l’àmbit mundial; 2. Desenvolupar recursos metodològics que permetin avaluar i millorar l’adequació en l’entorn hospitalari i 3. Analitzar la percepció dels professionals sobre les pràctiques de poc valor i sobre les recomanacions per a eliminar aquestes pràctiques. Mètodes. Vam dur a terme cinc estudis. Per a documentar les iniciatives vam fer una revisió de la literatura. Com a nous recursos metodològics vam crear una pàgina web que permet consultar iniciatives per millorar l’adequació de la pràctica clínica i información d’interés. A més, vam desenvolupar una sèrie d’indicadors basats en revisions sistemàtiques per a avaluar l’adequació en dues àrees de l’entorn hospitalari. Finalment, per a aconseguir el tercer objectiu vam realitzar dues enquestes i dos grups focals amb professionals de medicina i infermeria. Resultats. Amb la cerca vam identificar 22 iniciatives de 10 països, incloent-hi Espanya. Fins a juliol de 2015, aquestes iniciatives havien generat 2.940 recomanacions i anàlisis d’adequació procedents principalment de guies de pràctica clínica i majoritàriament de societats científiques. Vam trobar una gran variabilitat en el rigor metodològic per a desenvolupar aquests recursos i garantir que estiguessin basats en la millor evidència científica disponible. A partir d’aquests resultats vam crear el lloc web Dianasalud.com, que inclou una base de dades amb aquestes iniciatives i les seves recomanacions i anàlisis d’adequació. Vam obtenir 18 indicadors aplicables en l’atenció del part a partir de 303 revisions sistemàtiques (6%) i sis indicadors procedents de 149 revisions (4%) en l’atenció de la malaltia arterial perifèrica. En les enquestes vam trobar un alt grau d’acord amb les recomanacions per a reduir pràctiques de poc valor entre professionals de medicina i infermeria (83% i 96%, respectivament). Aquests creuen que hi ha una bona adherència a aquestes recomanacions a l’hospital (90% i 80%) i les consideren útils (70% i 90%). En els grups focals vam identificar com a principals barreres per a reduir pràctiques de poc valor: medicina defensiva, mala gestió de la incertesa i evidència científica contradictòria. Com a facilitadors destaquen el lideratge positiu i el treball en equip. Conclusions. Les iniciatives més conegudes són aquelles que han produït recomanacions per a eliminar pràctiques de poc valor, provinents de societats científiques. Malgrat les seves importants contribucions, la falta d’una metodologia rigorosa i estandarditzada desperta inquietuds i limita la seva implementació. Respecte als dos recursos metodològics desenvolupats, el lloc web contínua actiu i és consultat sovint. Quant als indicadors, la quantitat que se’n podrien formular està limitada per la falta d’evidència sòlida sobre pràctiques de poc valor i que la seva implementació depèn del grau de detall i la qualitat de la informació clínica. A més de l’evidència científica, la millora de l’adequació implica altres aspectes relacionats amb les creences i actituds dels professionals sanitaris, l’entorn hospitalari i la dinàmica del sistema sanitari i de la societat en general. Aquests aspectes s’han de treballar simultàniament i amb la mateixa intensitat amb la qual es busca assegurar que les iniciatives es basen en la millor evidència disponible.
Introducción. La mejora de la adecuación de la práctica clínica hace referencia a la elección de pruebas diagnósticas, tratamientos y demás prestaciones que, según la evidencia científica, tienen más beneficios que riesgos, un balance coste-beneficio razonable y se ajustan a las preferencias de las personas y la sociedad. Este proceso incluye identificar y eliminar prácticas de poco valor y promover aquellas de valor. Objetivos. 1. Documentar las iniciativas destinadas a mejorar la adecuación de la práctica clínica a nivel mundial; 2. Desarrollar recursos metodológicos que permitan evaluar y mejorar la adecuación a nivel hospitalario y 3. Analizar la percepción de los profesionales sobre las prácticas de poco valor y sobre recomendaciones para eliminar aquellas prácticas. Métodos. Llevamos a cabo cinco estudios. Para documentar las iniciativas hicimos una revisión de la literatura. Como nuevos recursos metodológicos creamos una página web que permite consultar iniciativas para la mejora de la adecuación de la práctica clínica e información de interés. Además, desarrollamos una serie de indicadores basados en revisiones sistemáticas para evaluar la adecuación en dos áreas del entorno hospitalario. Finalmente, para el tercer objetivo realizamos dos encuestas y dos grupos focales con profesionales de medicina y enfermería. Resultados. Con la búsqueda identificamos 22 iniciativas originarias de 10 países, incluyendo España. Hasta julio de 2015, dichas iniciativas habían generado 2940 recomendaciones y análisis de adecuación procedentes principalmente de guías de práctica clínica y mayoritariamente de sociedades científicas. Encontramos una gran variabilidad en el rigor metodológico para desarrollar estos recursos y garantizar sus bases en la mejor evidencia científica disponible. A partir de éstos resultados creamos la página DianaSalud.com que incluye una base de datos con dichas iniciativas y sus recomendaciones y análisis de adecuación. Obtuvimos 18 indicadores aplicables en la atención del parto a partir de 303 revisiones sistemáticas (6%) y seis indicadores a partir de 149 revisiones (4%) en la atención de la enfermedad arterial periférica. En las encuestas encontramos un alto grado de acuerdo con las recomendaciones para reducir prácticas de poco valor entre profesionales de medicina y enfermería (83% y 96% respectivamente), quienes creen que hay una buena adherencia a dichas recomendaciones en el hospital (90% y 80%) y las consideran útiles (70% y 90%). En los grupos focales identificamos como principales barreras para reducir prácticas de poco valor: medicina defensiva, mala gestión de la incertidumbre y evidencia científica contradictoria. Como facilitadores destacan el liderazgo positivo y el trabajo en equipo. Conclusiones. Las iniciativas más conocidas son aquellas que han producido recomendaciones para eliminar prácticas de poco valor, provenientes de sociedades científicas. Pese a sus importantes contribuciones, la falta de una metodología rigurosa y estandarizada para identificar prácticas de poco valor o generar recomendaciones despierta inquietudes y limita su implementación. Con respecto a los dos recursos metodológicos desarrollados, la página web continua activa y es frecuentemente consultada. En cuanto a los indicadores, observamos que la cantidad que podrían formularse está limitada por la falta de evidencia sólida sobre prácticas de poco valor y que su implementación depende del grado de detalle y la calidad de la información clínica. Además de la evidencia científica, la mejora de la adecuación implica otros aspectos relacionados con las creencias y actitudes de los profesionales sanitarios, el entorno hospitalario y la dinámica del sistema sanitario y de la sociedad en general. Estos aspectos deben trabajarse simultáneamente y con la misma intensidad con la que se busca asegurar que las iniciativas se basan en la mejor evidencia científica disponible.
Introduction. Improving the appropriateness of clinical practice refers to the choice of tests, treatments and other interventions that, according to scientific evidence, possess more benefits than risks, a reasonable cost-benefit ratio, and are compatible with the preferences of people and the society. This process includes identifying and eliminating low-value practices and promoting those that are more appropriate. Objectives. 1. to describe the initiatives aimed at improving the appropriateness of clinical practice worldwide; 2. to develop methodological resources that assess and improve appropriateness in the hospital setting; and 3. to analyse the perceptions of health professionals about inappropriate or low-value practices and recommendations to reduce them. Methods. We carried out five studies. To document initiatives of interest, we conducted a literature review. As methodological resources, we developed an open online database for consulting initiatives to improve the appropriateness of clinical practice and other information of interest. We also developed a set of indicators based on systematic reviews to assess appropriateness in two areas of the hospital setting. Finally, to achieve our third objective, we carried out two surveys and two focus groups with doctors and nurses. Results. With the literature review we identified 22 initiatives from 10 countries, including Spain. As of July 2015, these initiatives produced 2,940 outputs in the form of recommendations and appropriateness analyses mainly from clinical practice guidelines and most commonly from scientific societies. We found great variability in the methodological rigor employed to develop these resources and to guarantee that they draw on the best evidence. Based on our search results we created the website DianaHealth.com, which includes a database of the initiatives and their associated recommendations and appropriateness analyses. We obtained 18 indicators applicable on delivery care from 303 systematic reviews (6%) and six indicators on peripheral arterial disease care from 149 reviews (4%). In the surveys, we found a high agreement among doctors and nurses (83% and 96% respectively) with the recommendations for reducing low-value practices. In both groups, professionals believe that there is good adherence to these guidelines in the hospital (90% and 80%) and consider them useful (70% and 90%). In the focus groups we identified defensive medicine, bad management of uncertainty and contradictory scientific evidence as the main barriers to reducing low-value practices. As facilitators, positive leadership and teamwork stand out. Conclusions. The best-known initiatives for improving the appropriateness are those producing recommendations to reduce low-value practices, developed by scientific societies. Despite their important contributions, the lack of a rigorous and standardised methodology for identifying low-value practices or producing recommendations arouses concerns and jeopardises the implementation of their contributions. Regarding the two methodological resources developed in this tehsis work, DianaHealth.com is still active and it is frequently consulted. As for the indicators based on systematic reviews, we found that the number of indicators that could be produced is limited by the lack of solid evidence on low-value practices and their implementation depends on the degree of detail, as well as the quality of clinical information. In addition to employing scientific evidence, improving the appropriateness of clinical practice involves other aspects related to the beliefs and attitudes of healthcare professionals, the hospital environment and the dynamics of the healthcare system and society in general. These aspects should be worked on simultaneously and with the same intensity that should be devoted to ensuring that the initiatives are supported by the best scientific evidence available.

Background and Objectives: To describe patterns of healthcare utilization among patients with generalized anxiety disorder (GAD) in general practitioner (GP) settings in Germany. Methods: Using a large computerized database with information from GP practices across Germany, we identified all patients, aged > 18 years, with diagnoses of, or prescriptions for, GAD (ICD-10 diagnosis code F41.1) between October 1, 2003 and September 30, 2004 ("GAD patients"). We also constituted an age- and sex-matched comparison group, consisting of randomly selected patients without any GP encounters or prescriptions for anxiety or depression (a common comorbidity in GAD) during the same period. GAD patients were then compared to those in the matched comparison group over the one-year study period. Results: The study sample consisted of 3340 GAD patients and an equal number of matched comparators. Mean age was 53.2 years; 66.3% were women. Over the 12-month study period, GAD patients were more likely than matched comparators to have encounters for various comorbidities, including sleep disorders (odds ratio [OR] = 6.75 [95% CI = 5.31, 8.57]), substance abuse disorders (3.91 [2.89, 5.28]), and digestive system disorders (2.62 [2.36, 2.91]) (all p < 0.01). GAD patients averaged 5.6 more GP encounters (10.5 [SD = 8.8] vs 4.9 [5.7] for comparison group) and 1.4 more specialist referrals (2.3 [2.9] vs 0.9 [1.7]) (both p < 0.01). Only 58.3% of GAD patients received some type of psychotropic medication (i.e., benzodiazepines, antidepressants, and/or sedatives/hypnotics). Conclusions: Patients with GAD in GP practices in Germany have more clinically recognized comorbidities and higher levels of healthcare utilization than patients without anxiety or depression.

Coronary heart disease (CHD) is associated with a high morbidity and a high mortality, especially premature death, in low and middle-income countries, in developing countries such as Iran and in developed countries such as the United Kingdom. CHD affects individuals in their peak mid-life years, altering the future of family dependents and damaging the development of a population by its impact on productivity. Treatment of CHD consumes a significant proportion of health system capacity. Among decision makers, treatment costs can be just as important as the beneficial effects of treatment on health and maintaining quality of life. To control increasing demand, resources need to be allocated most effectively. Cost benefit analysis and assessment of willingness to pay (WTP) are health economics techniques that might be utilised for assigning priority of resource use and to better match costs of and demands for health care. In spite of vast experiences of applying health economics in the west, developing countries like Iran are only at the beginning of this process. A few WTP studies in health in Iran have been carried out but there is no reported use of WTP in CHD. This thesis consists of one study in each of two different communities, which together provide key information on one aspect of the economic evaluation of coronary heart disease in Iran and UK, which potentially can be used in policy-making relevant to a developing nation such as Iran, faced with an impending epidemic of CHD in the next ten years. Different approaches to health economics analysis are described. This 'willingness to pay' study compares patients' preferences with healthy volunteers in both the UK, where healthcare is predominantly publicly funded and in Iran, where a mixture of public and private healthcare is in place. To compare the main health care concerns in the UK and Iran on management of cardiovascular disease using epidemiological factors and a health economics tool; cost benefit analysis. This study is to address the scale of potential risk, losses and benefits of decisions made in the management of coronary heart disease in a developing country like Iran compared with a developed country such as the UK. Objectives ~ To establish what communities may be willing to sacrifice to prevent a heart attack or, in the event of a heart attack, to receive the best treatment and avert death risk ~ To find out whether individuals might be prepared to pay for prevention or new treatment of heart disease before it becomes widely available ~ To establish community preferences if they were required to prioritise the health services Design 1 - Perspective The perspective of WTP study is societal. 2 -Methods Using different elicitation methods in WTP, survey data were obtained from four sources in the UK and six centres in Iran. The WTP values in different scenarios amongst patients, family member of patients and healthy volunteers in each country have been compared. Several predictors influencing on individuals' WTP such as: household income, education, employment, quality of life age, gender and socioeconomic class have been investigated. Individuals' attitudes toward health priorities have been approached. 3 -Setting This WTP study is a comparative survey study, comparing AMI patients, healthy volunteers and members of the family of patients in Iran with the UK. The Nottingham population comprised patients under the care of cardiologists at Nottingham University Hospitals, and healthy volunteers selected from general practices. Iranian patients and volunteers were similarly recruited from Qazvin teaching hospital, Shahid Beheshti hospital and several health centres. 4 - Participants The study populations described in this thesis were selected from adults in British and Iranian communities. Within each community, subjects either were patients with a history of heart attack or were a healthy, volunteer group, comprising family members of patients, not known to have CHD. Data collection Data has been collected from 518 participants in Iran and 309 participants in the UK for WTP. Outcome measures Willingness to pay or willingness to accept for different health gains Data analysis SPSS (version 11.00, 15.00) and Excel software (office 2003) were used. Univariate and multivariate analysis like regression analysis and descriptive statistics were applied as appropriate. Results - Willingness to pay Most participants in both countries were willing to pay for either treatment, prevention of CHD, reduction of mortality and saving life. Education, income, having insurance, quality of life, social class and some other confounders influenced WTP but there were significant differences between the two communities. - Prioritisation The public, whether patients or not, were willing to prioritise and were motivated to rank the CHD as a top priority in healthcare for extra allocation or re-allocation of resources. Conclusion Patients, not usually involved in the prioritisation of health care services, can have an impact on decision-making through willingness to pay and willingness to accept techniques. This study has presented a high community profile for treatment, prevention of CHD in both countries, which will be instructive to decision makers.

My research focuses on the experience of policy development and implementation. It draws on my involvement in a government policy taskforce, the development of an organisation’s strategy to the taskforce’s recommendations and the commissioning of frontline services. The research material is my personal experience contained in a number of narrative accounts of important happenings. These are then used as a basis to engage with literature and conversation with practitioners, academics and fellow researchers. It is from this iterative process that the argument develops. The approach is therefore qualitative and reflexive in nature. I have argued against the traditional separation between the content of research and methodology. This is on the basis that human experience does not distinguish between the two as we make sense of new emerging situations. The research has been heavily influenced by analogies drawn from complexity sciences as a way of increasing our understanding of ongoing human interaction, namely complex responsive processes of relating (Stacey et al, 2000). By paying careful attention to the experience of policy development and implementation over an extended period of time I am illuminating that the development of policy can often be seen in literature and in the techniques people use as an activity that is isolated from the work of frontline staff. For example, a policy group is formed, policy or a strategy is drafted and the work is then seen to be done. This can be demonstrated by paying attention to the modus operandi of how policy and strategy groups work and how performance criteria are established. When it comes to frontline practice, policy is often silent to the multitude of unfolding interconnected possibilities that present themselves to practitioners as they seek to go about their activities. The way that policy is often presented implies that there is linearity from policy to implementation. Drawing on Elias’s notion of Involvement and Detachment (1987) I am highlighting a paradoxical relationship between policy and implementation. In introducing the notion of paradox, there is a “vitality” that is required to prevent a collapse to one of the two ends of a continuum; for example a conscious or unconscious rejection of policy in favour of embracing frontline practice, or an over reliance on policy to blindly drive through organisational change. In spending three years looking at the policy and implementation I argue that it is more helpful to consider policy and implementation as a “flow”, rather than a series of discrete activities that are seen to be completed before moving to the next policy area. In looking at policy as something that occurs over a span of time (as opposed to an isolated bounded activity) there is an opportunity to prevent the collapse of the paradox outlined above. By accepting the concept of paradox and considering policy from a temporal perspective, rather than one that is a spatially bound system, the issue of policymaking practice can be considered. There are books and management experts that recommend that managers should “walk the walk”, and get closer to frontline activity. My research has sought to add clarity here, arguing for an experiential and temporal form of reflexivity of practice (as opposed to reflective practice). In this context working and being present with frontline practitioners, paying very careful attention to the experience of the unfolding contingent nature of activity influences the practice of policy making. This is a different experience from simply being present, and being seen to be present. It would be ironic for my research to be converted into a policy document with key elements extracted and condensed into bullet points to be applied like a rule. Instead my research is best kept alive in evoking stories and reminiscences between people as they make sense of their experience of policymaking and implementation together.

Evidence-based practice is an integral part of multi-disciplinary healthcare, but its routine clinical implementation remains a challenge internationally. Written asthma action plans are an example of sub-optimal evidence-based practice because, despite being recommended, these plans are under-issued by health professionals and under-used by patients/carers. This thesis is a critical analysis of the generation and implementation of evidence in this area and provides fresh insight into this specific theory/practice gap. This submission brings together, in five published papers, a body of work conducted by the candidate. Findings report that known barriers to action plan use (such as a lack of practitioner time) are symptomatic of deeper and more complex underlying factors. In particular, over-reliance on knowledge derived from randomised controlled trials and their systematic review, as the primary and sole source of evidence for healthcare practice, hindered the implementation of these plans. A lack of evidence reflecting the personal experience of using these plans in the real world, rather than in trial settings, contributed to a mismatch between what patients/carers want from asthma action plans and what they are currently being provided with by professionals. This submission illustrates the benefits of utilising a broader range of knowledge as a basis for clinical practice. The presented papers report how new and innovative research methodologies (including meta-ethnography and cross-study synthesis) can be used to synthesise individual studies reporting the personal experiences of patients and professionals and how such findings can then be used to better understand why interventions can be implemented in trial settings rather than everyday practice. Whilst these emerging approaches have great potential to contribute to evidence-based practice by, for example, strengthening the ‘weight’ of experiential knowledge, there are methodological challenges which, whilst acknowledged, have yet to be fully addressed.

Background and Objectives: To describe patterns of healthcare utilization among patients with generalized anxiety disorder (GAD) in general practitioner (GP) settings in Germany. Methods: Using a large computerized database with information from GP practices across Germany, we identified all patients, aged > 18 years, with diagnoses of, or prescriptions for, GAD (ICD-10 diagnosis code F41.1) between October 1, 2003 and September 30, 2004 ("GAD patients"). We also constituted an age- and sex-matched comparison group, consisting of randomly selected patients without any GP encounters or prescriptions for anxiety or depression (a common comorbidity in GAD) during the same period. GAD patients were then compared to those in the matched comparison group over the one-year study period. Results: The study sample consisted of 3340 GAD patients and an equal number of matched comparators. Mean age was 53.2 years; 66.3% were women. Over the 12-month study period, GAD patients were more likely than matched comparators to have encounters for various comorbidities, including sleep disorders (odds ratio [OR] = 6.75 [95% CI = 5.31, 8.57]), substance abuse disorders (3.91 [2.89, 5.28]), and digestive system disorders (2.62 [2.36, 2.91]) (all p < 0.01). GAD patients averaged 5.6 more GP encounters (10.5 [SD = 8.8] vs 4.9 [5.7] for comparison group) and 1.4 more specialist referrals (2.3 [2.9] vs 0.9 [1.7]) (both p < 0.01). Only 58.3% of GAD patients received some type of psychotropic medication (i.e., benzodiazepines, antidepressants, and/or sedatives/hypnotics). Conclusions: Patients with GAD in GP practices in Germany have more clinically recognized comorbidities and higher levels of healthcare utilization than patients without anxiety or depression.

Many instruments have been developed to determine whether someone claims to be religious, but they do not address the degree to which someone is satisfied with their religious commitment. Therefore, an instrument was revised to measure both a person’s level of religious commitment and satisfaction with that level of religious commitment. The instrument was named the Religious Surrender and Attendance Satisfaction Scale (RSASS). This study was conducted to determine initial validity for the satisfaction portion of the RSASS. Construct validity measures provided initial confirmation of the utility of RSASS as a measure of satisfaction with religious commitment that can be used by nurses in practice and research.

To offer an insight into the themes which will be explored at the Masterclass, in this short video Dr. McKenzie Calhoun and colleagues at the ETSU Family Physicians in Kingsport, Tennessee discuss how a model of interprofessional collaboration is typically applied and put into practice in the care of patients at the center. They highlight the importance and value of a team-based approach in enhancing the provision of primary healthcare.

The history of psychiatry is littered with serious failures of governance, to the detriment of mentally disordered people, especially those resident in psychiatric hospitals. Current mental health providers, increasingly focussed on community care, have also struggled to develop effective internal governance systems. Nine peer-reviewed research papers, published by the author (mostly with others) and the wider literature, reveal deficits in mental health governance at a jurisdictional, professional, and corporate level. In this thesis new governance solutions are developed against this background, built on contemporary principles in mental health and healthcare management. A new model of mental health governance is presented, based on the key demands of the strategic and regulatory environment, articulated as rights, risks and recovery. This integrated healthcare governance approach, covering provider policy, staff training and service audit, can monitor and ensure the protection of patients’ rights, as well as those of others; it also promotes the management of clinical risks, and of patients’ recovery outcomes. Rights-based risk-reduction training is the core interventional element of the model, whilst the monitoring element can be formalised as part of a Balanced Scorecard reporting system. This thesis makes a contribution to research methodology, theory and practice in mental health, human rights, healthcare management and governance. The model generates specific propositions for testing in mental health governance, with the potential for application in wider settings of service provision.

Healthcare around the world is facing strenuous times, whereby there is a need for reduced costs, improved efficiency, and effectiveness. Digitalization is a transformational phenomenon argued to solve the many problems of healthcare. As of such, this thesis studies digitalization in a healthcare setting - considering how digitalization is achieved in practice, and what elements hamper and enable sociotechnical changes required for digitalization. To study these aspects, a qualitative case study was carried out on the recently implemented mandatory electronic dental card among the dental care professionals from a Baltic country. The study allowed contributions to digitalization research by looking at the phenomenon from industry-level analysis, also revealed the elements that hamper and enable digitalization, outlined the different digitalization patterns, and argued that digitalization relies on the extent by which the new system provides value to the users without interfering with professional expertise and ethics.

Studies have reported that the most trusted health care relationship is that of the prenatal healthcare professionals (PHPs) and the prenatal patient. Yet many of the patient’s environmental health questions go unanswered for a variety of reasons. To better understand the situation, this research examines environmental health education practices of PHPs – obstetricians, prenatal nurses, family physicians, midwives and doulas - offered during the preconception and prenatal period. Specifically, this thesis discusses some of the PHP self-reported opportunities and barriers surrounding the provision of environmental health education (EHE). In person (n=17) and telephone (n=4) interviews were conducted with PHPs in the Ottawa Region. Additionally, a key informant within the Society of Obstetricians and Gynaecologists of Canada (SOGC) was asked specific questions about the association’s role in the development of standardized educational care guidelines. The results show that most PHPs have a limited knowledge of EHE and are reluctant to discuss it without access to more professional research. PHPs feel that there is little professional association support and that guidelines for adding EHE to their current prenatal care plans are non-existent. This study is one of the first studies that uniquely examined EHE in the prenatal period from perspective of prenatal healthcare professionals.