Rozprawy doktorskie na temat „Healthcare resilience”

This research examines the healthcare services ecosystem and the impact and role service interventions made by providers and patients have on this ecosystem. Each area has an important role in contributing to the value and sustainability of the ecosystem. Healthcare, as a community service, requires a minimum of two counterparts: the providers and the customers, in this case the patients. Healthcare is a unique ecosystem because often the customers are not conscious of the interplay of the ecosystem but are reliant upon the system for their health and wellbeing. The first section of this dissertation examines the effects that occur in the healthcare ecosystem when part of the system experiences a disaster and the impact and role of other areas of the system in response to the disaster, particularly regarding the resilience. Similar to a biological ecosystem that is undergoing a flood, in the healthcare services ecosystem if too many patients present to the Emergency Department (ED) at the same time disaster level overcrowding will occur. We aim to measure the resilience of the healthcare ecosystem to this disaster level overcrowding. The second section of this dissertation examines how the components of the healthcare ecosystem maintain sustainability and usability. Healthcare professionals are assessed regarding their ability to maintain the healthcare ecosystem, with a specific focus on what occurs after patients are in the hospital system. To examine the ability of the healthcare professionals to maintain the ecosystem we analyze the usability and adaptability of the electronic health record and the professional's workflows to determine how they use this tool to sustain the healthcare ecosystem. The third section of this dissertation examines patient self-management and the influence this has on the healthcare ecosystem. Much of the management of health in patients, particularly those with chronic illnesses, occurs outside of the hospital, thus examining this aspect of self-care provides insight on the overall system. This research examines patients with a chronic illness and their use of online health communities, with a particular focus on their reciprocal behaviors and the impact this support system has on their overall health state. By examining these aspects of the healthcare services ecosystem, we can better improve our understanding of these phenomena.
Ph. D.

In the U.S. medical sector, software failures in safety-critical systems in healthcare have led to serious adverse health problems, including patient deaths and recalls of medical systems. Despite the efforts in developing techniques to build resilient systems, there is a lack of consensus regarding the definition of resilience metrics and a limited number of quantitative analysis approaches. In addition, there is insufficient guidance on evaluating resilience design patterns and the value they can bring to safety-critical systems.

This research employed the interdependency analysis framework to evaluate the static resilience of safety-critical systems used in the healthcare field and identified software subsystems that are vulnerable to failures. Resilience design patterns were first implemented to these subsystems to improve their ability to withstand failures. This implementation was followed by an evaluation to determine the overall impacts on system’s static resilience.

The methodology used a common medical system structure that collects common attributes from various medical devices and reflects major functionalities offered by multiple medical systems. Fault tree analysis and Bayesian analysis were used to evaluate the static resilience aspects of medical safety-critical systems, and two design patterns were evaluated within the praxis context: Monitoring and N-modular redundancy resilience patterns.

The results ultimately showed that resilience design patterns improve the static resilience of safety-critical systems significantly. While this research suggests the importance of resilience design patterns, this study was limited to explore the impact of structural resilience patterns on static resilience. Thus, to evaluate the overall resilience of the system, more research is needed to evaluate dynamic resilience in addition to studying the impact of different types of resilience design patterns.

This medical anthropology dissertation is an intersectional study of the illness experiences of African-American women living with the chronic autoimmune syndrome systemic lupus erythematosus (SLE), commonly known as lupus. Research was conducted in Memphis, Tennessee from 2013 to 2015, with the aim of examining the healthcare resources available to working poor and working class women using public sector healthcare programs to meet their primary care needs. This project focuses on resources available through Tennessee’s privatized public sector healthcare system, TennCare, during the first phases of the Patient Protection and Affordable Care Act (ACA). A critical medical anthropological analysis is used to examine chronically ill women’s survival strategies regarding their daily health and well-being. The objectives of this research were to: 1) understand what factors contribute to poor women’s ability to access healthcare resources, 2) explore how shared illness experiences act as a form of community building, and 3) document how communities of color use illness narratives as a way to address institutionalized racism in the United States. The research areas included: the limits of biomedical objectivity; diagnostic timeline in relation to self-reported medical history; effects of the relationship between socio-economic circumstance and access to consistent healthcare resources, including primary and acute care, as well as access to pharmaceutical interventions; and the role of non-medical support networks, including personal support networks, illness specific support groups, and faith based organizations. Qualitative methods were used to collect data. Methods included: participant observation in support groups, personal homes, and faith based organizations, semi-structured group interviews, and open-ended individual interviews. Fifty-one women living with clinically diagnosed lupus or undiagnosed lupus-like symptoms participated in individual interviews. Additionally twenty-one healthcare workers, including social workers, Medicaid caseworkers, and clinic support staff were interviewed in order to contextualize current state and local health programs and proposed changes to federal and state healthcare policy.

This thesis is comprised of a systematic literature review, empirical paper and critical appraisal. Firstly, a systematic literature review of qualitative studies exploring staff experiences of violence and aggression in the emergency department was conducted. A meta-ethnographic approach was used to review 12 papers. The results showed that staff working in the emergency department appeared to resign themselves to the inevitable experience of violence and aggression. Staff made attributions about the cause of violence and aggression which affected their emotional responses. They also often felt isolated when managing violent incidents and the experience of violence and aggression had significant consequences on their psychological and physical well-being. A consistent organisational response to violence and aggression was recommended through both frontline and management staff training. Secondly, the empirical paper explores staff perceptions of well-being and resilience using a constructivist grounded theory framework. 11 staff were interviewed from a range of professional backgrounds across two forensic services. A model of staff perceptions of the factors which contribute to well-being and resilience when working in secure forensic services was developed. Staff resources were depleted through: working with clients who have complex difficulties, experiencing constant change and through the indirect impact of pressure from external organisations. This had a subsequent negative impact on their well-being. Factors including breaks and reflection in and out of work, support from colleagues and witnessing client progress allowed staff to feel ‘re-charged’ and motivated staff to continue working. Clinical implications included: organisations providing opportunities for time and reflection in work for staff, self-care training for new starters and advice for managers. The final section outlined a critical reflection of the journey conducting research with staff in the current climate of healthcare and considering the findings within the existing resilience literature base.

Nonlinear and chaotic environmental changes characterize health services organizations as complex adaptive systems in which leaders must exercise non-traditional leadership practices to succeed. Health services leaders who have learned and implemented traditional linear management approaches are ill prepared to lead in complex environments. This study tested complexity and adaptive leadership theories of agility and resilience in complex health systems. The purpose of this quantitative cross-sectional internet-based survey study was to quantify relationships between independent variables of agility and resilience and secondary dependent variables of financial, patient satisfaction, quality and human capital outcomes. The impact of turbulence was also examined. Included sample data were collected from 533 employed healthcare leaders using probability-based systematic proportional random sampling methods and were analyzed through correlation, regression, one-way analysis of variance, t tests, and Hayes PROCESS statistical analytics. Agility correlated with and predicted patient satisfaction outcomes. Resilience independently correlated with and predicted financial performance and patient satisfaction outcomes and augmented the correlation and predictability of agility. Agility and resilience cumulatively predicted financial performance outcomes. Turbulence was related to agility, resilience, financial performance, and patient care quality outcomes and mediated relationships with financial and patient care quality outcomes. Health services leaders may apply these findings to promote social change through the implementation of the agile and resilient leadership approaches necessary to achieve organizational performance outcomes that benefit vulnerable populations.

In this thesis, I present a series of papers which will: outline current issues with research in interruptions science, use theories in safety science to advance research in interruptions science, and provide some empirical data which highlight differences in perception between nurses and many researchers regarding interruptions and interruptions definitions. The papers presented in this thesis are either published, accepted, or submitted pieces of work. Researchers studying interruptions in laboratory settings have reported an association between interruptions and errors, with interruptions leading to more errors. Similarly, some investigators studying the impact of interruptions in various healthcare settings have reported an association between interruptions and medication errors. The discovery of this association has led to the development of interventions meant to reduce/remove interruptions in healthcare. While the development and implementation of these interventions seem reasonable, these interventions may actually be detrimental to healthcare work. Interventions to reduce/remove interruptions may actually lead to unintended negative consequences. Therefore, I began this thesis with a systematic review of unintended negative consequences of contemporary interruptions interventions. In this review, I discovered that 15 out of 33 studies reported some form of unintended negative consequences. The high number of studies with unintended negative consequences is likely due to the complexity associated with working in a healthcare setting, as well as the complexity surrounding the phenomenon of interruptions. Therefore, I considered it necessary to study the phenomenon of interruptions from another perspective. In the second paper of this thesis, I reviewed various prominent safety models in contemporary safety science research, such as high reliability organisations, resilience engineering, and safety drift. This summarises various concepts proposed in these models, as well as the various issues associated with these concepts. For example, various researchers have carried out their own research on high reliability organisations, and as a result, developed their own concepts regarding contributing factors to an organisation's high reliability. Therefore, it can be difficult to determine what exactly is a high reliability organisation. The review also introduced new ways of thinking and managing risk, such as learning from both failures and success, an idea proposed by advocates of resilience engineering. The knowledge gained from this review was then applied to the third paper of this thesis. In the third paper of this thesis, I showed how contemporary interruptions interventions research are based on the barrier model. The model proposes that safety can be achieved if blockades are placed between sources of risks and objects-to-be-protected. I proceed to argue that using the barrier model requires researchers to inaccurately conceptualise interruptions as sources of risk, which empirical studies have shown is not true. I then applied the three safety models, high reliability organisations, resilience engineering, and safety drift to interruptions research. Each of these models conceptualise interruptions in different ways, leading to new research avenues that can provide more information on the complex role interruptions play in daily clinical work. In the next paper of this thesis, I reached out to nurses in an attempt to understand the complex role of interruptions in their work. During my research, I noticed several differences in perception between nurses and many researchers when it comes to interruptions, in areas such as defining an interruption, and thinking how an interruption should be managed. These differences also led me to wonder about nurses' perception regarding contemporary interruptions interventions. Therefore, in the fourth paper of this thesis, I conducted a survey to collect information on these differences and perceptions. The findings of this survey indicate some differences between nurses and many researchers when it comes to: (a) defining interruptions, (b) the role interruptions play in daily clinical work, and (c) the types of interventions that are effective in dealing with interruptions. Nurses' responses in the survey were also consistent with some of the ideas proposed in the third paper of this thesis.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Hum, Lang & Soc Sc
Arts, Education and Law
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This research focuses on spiritual well-being in the workplace and its relation to work performance. Extant empirical studies have mostly focused on demonstrating statistical links between these two concepts to the exclusion of qualitative studies that can better explain what spiritual well-being may be and how the experience is possibly related to work performance. Especially under-researched is the ground-level employees’ perspectives and the possible incompatibility of spiritual and organisational goals. This research thus examined the experiences of spiritual well-being among successful healthcare sales representatives in Malaysia, particularly on how their spiritual inclinations or their inclination for meaningfulness interfaced with the need to meet work targets. This qualitative research is exploratory and is framed within a constructionist epistemological stance. It used narrative inquiry as its methodology. Its primary data were stories successful healthcare sales representatives in Malaysia told about their work. These were collected and analysed using narrative interviews and narrative analysis respectively. What the research found was that the relation between spiritual well-being and work performance was depicted to be diverse, fragile and transitory. This was predicated on the ground-level employees’ experience of the interface between their spiritual inclinations and the need to meet work targets, which was diverse and changeable. What the research also found was that spiritual well-being resembled an experience that was constructed as employees engaged with their work. Spiritual well-being is thus neither merely found at work nor merely brought to work but constructed in the interplay between the employees’ spiritual inclinations and what they do at work. The research contributes to theoretical development in the area by advancing an expanded understanding of spirituality in the workplace. It demonstrates that spiritual well-being is contingent upon the work employees do, and the extent to which the work may be amenable for the construction of the experience. Thus, the relation between spiritual well-being and work performance ought to be understood from the way individual employees construct and individualise their experience of work. The research also foregrounds the importance of using models of organisation that accommodate the constructed, interactive and evolving nature of spiritual well-being in the workplace.

This research focuses on spiritual well-being in the workplace and its relation to work performance. Extant empirical studies have mostly focused on demonstrating statistical links between these two concepts to the exclusion of qualitative studies that can better explain what spiritual well-being may be and how the experience is possibly related to work performance. Especially under-researched is the ground-level employees’ perspectives and the possible incompatibility of spiritual and organisational goals. This research thus examined the experiences of spiritual well-being among successful healthcare sales representatives in Malaysia, particularly on how their spiritual inclinations or their inclination for meaningfulness interfaced with the need to meet work targets. This qualitative research is exploratory and is framed within a constructionist epistemological stance. It used narrative inquiry as its methodology. Its primary data were stories successful healthcare sales representatives in Malaysia told about their work. These were collected and analysed using narrative interviews and narrative analysis respectively. What the research found was that the relation between spiritual well-being and work performance was depicted to be diverse, fragile and transitory. This was predicated on the ground-level employees’ experience of the interface between their spiritual inclinations and the need to meet work targets, which was diverse and changeable. What the research also found was that spiritual well-being resembled an experience that was constructed as employees engaged with their work. Spiritual well-being is thus neither merely found at work nor merely brought to work but constructed in the interplay between the employees’ spiritual inclinations and what they do at work. The research contributes to theoretical development in the area by advancing an expanded understanding of spirituality in the workplace. It demonstrates that spiritual well-being is contingent upon the work employees do, and the extent to which the work may be amenable for the construction of the experience. Thus, the relation between spiritual well-being and work performance ought to be understood from the way individual employees construct and individualise their experience of work. The research also foregrounds the importance of using models of organisation that accommodate the constructed, interactive and evolving nature of spiritual well-being in the workplace.

Risk and vulnerability analysis (RVA) is a widely used method to assess an organization's threat situation. Certain actors are obliged by law to perform the analysis to contribute to a national threat assessment. Among these are actors in the healthcare system. This study aims to understand how a systematized workflow for RVA can increase crisis preparedness and resilience within Swedish healthcare. In this context, a systematized workflow is defined as a systematic and uniform method within a designated digital tool to facilitate the analysis.  To understand how a systematized workflow could increase crisis preparedness and resilience, four semi-structured interviews were held with knowledgeable people within the area from different levels of the national risk and vulnerability chain. Further recurring meetings with people directly involved in such improvemenet work from AFRY were held, along with a review of existing literature. The result shows several challenges regarding RVA-related work; it is time-consuming, complex, resource-intensive, and lacks proper guidance in how it should be done. It shows a need for a better process, both in how they are performed and how the results are analyzed. It is concluded that a systematized workflow for risk and vulnerability analysis could increase crisis preparedness and resilience within Swedish healthcare. Having a designated tool with a set process, clear instructions, definitions, and guidelines would make RVAs easier to conduct and generate better outcomes regarding several aspects. Identifying essential dependencies would be facilitated for actors within the healthcare sector, which forms the basis to sustain those dependencies if a crisis occurs. Further, uniformly structured results would facilitate the analysis of results to make a nationwide risk assessment. In turn, this would probably increase crisis preparedness and resilience within the healthcare sector and several others.
Risk och sårbarhetsanalyser (RSA) är en utbredd metod för att värdera en organisations hotbild. Vissa aktörer är skyldiga enligt lag att genomföra analysen för att bidra till en nationell sammanställning av landets risker, varav skjukhussystemet är en av dessa. Denna studie ämnar att förstå hur ett systematiskt arbetsflöde för RSA kan bidra till ökad krisberedskap och resiliens inom svensk sjukvård. Genom denna rapport definieras ett systematiskt arbetssätt som en systematiserad och enhetlig metod i ett dedikerat digitalt verktyg för att underlätta analysen. För att förstå hur ett systematiserat arbetssätt kan öka krisberedskap och resiliens har fyra semistrukturerade intervjuer hållits med sakkunniga personer inom området. Dessa har varit från olika nivåer inom den nationella risk- och sårbarbetsanalyskedjan. Vidare har återkommande möten genomförts med människor som varit direkt involverade i denna typ av förbättringsarbeten från AFRY, tillika en granskning av befintlig litteratur. Resultaten från studien visar på flera svårigheter rörande RSA-arbete - det är tidskrävande, komplext, resursintensivt, och saknar tydlig vägledning i hur arbetet ska utföras. Dessutom visar resultaten ett behov av bättre arbetsprocesser, både rörande hur analyserna ska genomföras samt hur resultaten ska analyseras. De slutsatser som har kunnat dras är att ett systematiserat arbetssätt för risk- och sårbarhetsanalyser skulle kunna bidra till en ökad krisberedskap och resiliens inom svensk sjukvård. Genom att ha ett dedikerat verktyg med en satt process, tydliga instruktioner, definitioner och riktlinjer hade genomförandet av en RSA underlättats samt gett bättre resultat inom ytterligare områden. Att identifiera kritiska beroenden hade förenklats för aktörer inom sjukvården, vilket formar grunden till att upprätthålla dem vid en kris. Vidare hade enhetligt strukturerade resultat underlättat analysen av resultaten för att göra ett nationell riskbedömning. Detta i sin tur hade trolien lett till ökad krisberedskap och resiliens inte endast inom sjukvården, utan även inom andra sektorer.

Background: Non-medical use of prescription drugs (NMUPD) refers to the use of prescription drugs which are traditionally utilized to manage pain or treat psychiatric problems but without a doctor’s prescription. In 2010, an investigation by the Substance Use and Mental Health Services Administration (SAMHSA) revealed that 5.3% of young adults (18 to 25-year-olds) in the United States reported past-month NMUPD. NMUPD has become a growing concern owing to associations with consequences such as college dropout, poor academic achievement, and health jeopardizing behaviors. College students' NMUPD has been well documented in the United States. Limited studies, however, have been conducted among college students in China. The purposes of this study are to examine the prevalence and motives of NMUPD among college students in China, and to assess its relationship with stress (i.e., perceived stress and traumatic events), mental health problems (depression, anxiety, and post-traumatic stress disorder (PTSD)), utilization of healthcare, cultural orientation, and protective factors (i.e., resilience and future orientation). Methods: In Jan-April 2017, online data were collected using SONA system from a total of 720 undergraduates at Beijing Normal University (BNU) and University of Macau (UM) with an average age of 19.65. All participants reported their nonmedical use of prescription drugs (i.e., opioids, sedatives, stimulants, and anxiolytics) in their lifetime and the past three months, stress, mental health, utilization of healthcare, cultural orientation, and protective factors. Spearman’s rank-order corrections and logistic regression were employed for statistical analyses. Results: Findings indicate that 41.2% of Chinese students reported taking prescription drugs without a doctor’s prescription. The most commonly misused prescription drugs were opioids (40.5% lifetime use, 31.8% past-three-months use), followed by sedatives (1.8% lifetime, 0.8% past 3 months), anxiolytics (0.9% lifetime,0 .3% past three months), and stimulants (0.2% lifetime, 0% past three months). Bivariate analyses suggest significantly positive correlations of lifetime NMUPD with mental health problems (anxiety and PTSD), cultural orientation (individualism and collectivism), and utilization of healthcare (frequency of healthcare use, time spent for healthcare, and money spent for healthcare). Similar results were found in terms of past-three-month NMUPD. The results of logistic regressions indicate the significant association of lifetime NMUPD with individualism of cultural orientation, and frequency of healthcare use. Specially, individualism, frequency of healthcare use, and time spent for healthcare were found to be associated with lifetime opioid misuse, and depression was significantly associated with sedative misuse. Resilience was negatively associated with lifetime sedative misuse. Frequency of healthcare use was also found to be positively associated with past-three-month opioid misuse. Conclusion: Utilization of healthcare, cultural orientation, and mental health problems appear to be the factors associated with NMUPD among college students at BNU and UM. More discussion is needed in Chinese society about regulation of prescription drug use. Future culturally-tailored prevention intervention programs may be beneficial to reduce the risk of NMUPD among Chinese college students.

La structuration territoriale des soins primaires peut être définie comme un processus de transformation évolutif et stratégique visant à réorganiser et renforcer l'organisation des soins et services de santé de première ligne. Ce processus consiste à passer d'un modèle traditionnel d'activité isolée à un modèle d'organisation territoriale plus intégré et coopératif entre professionnels, conduisant le secteur des soins primaires à se saisir d'enjeux de santé publique territoriaux. La gestion des situations sanitaires exceptionnelles constitue l'un de ces enjeux. Ce travail de thèse a pour objectif d'étudier le lien entre la structuration territoriale des soins primaires et la capacité de ce secteur à répondre aux situations sanitaires exceptionnelles, en s'appuyant sur l'exemple de l'épidémie de COVID-19.Le premier volet de la thèse présente une étude mixte visant à mieux comprendre le concept de structuration territoriale des soins primaires et à en proposer une typologie en France métropolitaine sur les territoires de vie-santé. La partie qualitative, réalisée au sein de 7 territoires, a permis d'identifier des facteurs clefs de cette structuration. A partir de ces facteurs, la partie quantitative a conduit, au moyen d'une classification hiérarchique sur composantes principales, à définir 4 types de territoires de vie-santé : des territoires peu ou pas structurés, des territoires à potentiel de structuration, des territoires en voie de structuration et des territoires déjà structurés abritant une communauté professionnelle territoriale de santé (CPTS).Le deuxième travail de la thèse a consisté à utiliser cette typologie dans une étude épidémiologique transversale portant sur l'évolution de l'activité des médecins généralistes lors de la première vague du COVID-19 en 2020. Cette étude a montré que les territoires bien structurés ont permis aux médecins de mieux s'adapter à la pandémie par un recours accru à la téléconsultation. Les résultats ont ainsi mis en évidence un lien significatif entre le niveau de structuration territoriale des soins primaires et la capacité d'adaptation des médecins généralistes.Le troisième volet s'est intéressé aux établissements d'hébergement pour personnes âgées dépendantes (EHPAD) et à leur adaptation à la crise en fonction de la structuration territoriale des soins primaires. En évaluant plusieurs catégories d'EHPAD, l'étude a montré que ceux situés dans des zones où les soins primaires étaient bien structurés présentaient une meilleure capacité de réponse face à la crise, avec moins de recours à l'hospitalisation et une mortalité plus faible. Cela souligne l'importance de la coopération entre les soins primaires et le secteur médico-social pour renforcer la résilience territoriale.La structuration territoriale des soins primaires apparaît comme un levier important pour améliorer la réponse aux crises sanitaires. Ce travail a montré que les territoires dotés d'une organisation des soins primaires structurée étaient mieux à même de maintenir la continuité des soins et de collaborer avec les autres secteurs de santé. Les perspectives pour l'avenir incluent le renforcement de cette structuration, catalyseur de la responsabilité populationnelle des acteurs, afin de mieux préparer le système de santé français aux futures crises
The territorial structuring of primary care can be defined as an evolving and strategic transformation process aimed at reorganising and strengthening the organisation of first-line healthcare services. This process involves moving from a traditional model of isolated practice to a more integrated and cooperative territorial organisation among professionals, leading the primary care sector to address territorial public health challenges. The management of exceptional health situations is one of these challenges. The main objective of this thesis is to study the relationship between the territorial structuring of primary care and the sector's capacity to respond to exceptional health situations, using the COVID-19 epidemic as an example.The first part of the thesis presents a mixed-methods study designed to better understand the concept of territorial structuring of primary care and to propose a typology for mainland France at the level of life-health territories. The qualitative component, conducted in seven territories, helped identify key factors of this structuring. Based on these factors, the quantitative component used a hierarchical clustering on principal components approach to define four types of life-health territories: territories that are poorly or not structured, territories with potential for structuring, territories in the process of structuring, and fully structured territories hosting a health territorial and professional community (HTPC).The second part of the thesis used this typology in a cross-sectional epidemiological study focused on changes in the activity of general practitioners during the first wave of COVID-19 in 2020. This study showed that well-structured territories allowed physicians to better adapt to the pandemic, notably through increased use of teleconsultation. The results highlighted a significant link between the level of territorial structuring of primary care and the adaptability of general practitioners.The third part focused on nursing homes and their adaptation to the crisis based on the territorial structuring of primary care. By evaluating several categories of nursing homes, the study demonstrated that those located in areas with well-structured primary care exhibited a better capacity to respond to the crisis, with fewer hospital admissions and lower mortality. This underscores the importance of cooperation between primary care and the medico-social sector to enhance territorial resilience.The territorial structuring of primary care appears to be an important lever for improving responses to health crises. This work has shown that territories with structured primary care organisations were better able to maintain continuity of care and collaborate with other health sectors. Future perspectives include strengthening this structuring, which serves as a catalyst for population-level responsibility among stakeholders, to better prepare the French healthcare system for future crises

Bakgrund: Sjuktalen har ökat till följd av psykisk ohälsa världen över. En av de främsta orsakerna till detta har varit den ökade förekomsten av stressrelaterad ohälsa och utmattningssyndrom. En grupp som har varit extra utsatt är personer i inom yrken i hälso- och sjukvården. Idag fokuseras det huvudsakligen på behandling och rehabilitering av utmattningssyndrom i forskning och praxis och det finns begränsad kunskap och initiativ kring primär- och sekundärprevention för utmattningssyndrom. Det är dock viktigt ur både ett individ- och samhällsperspektiv att förebygga utmattningssyndrom då utmattningssyndrom är ett allvarligt tillstånd som kan leda till stort lidande för individen och lång sjukfrånvaro från arbetslivet, vilket även är kostsamt för samhällsekonomin. Syfte: Syftet med detta examensarbete var att undersöka skyddsfaktorer mot utmattningssyndrom hos personer inom yrken i hälso- och sjukvården. Metod: En litteraturöversikt genomfördes och 12 vetenskapliga artiklar uppfyllde inklusion- och exklusionskriterierna och matchade forskningsfrågorna. Dessa lästes igenom. En tematisk analys av studiernas resultat genomfördes och resulterade i ett övergripande tema och fem underteman. Resultat: Resultatet beskriver faktorer som skyddar mot utmattningssyndrom för personer inom yrken i hälso- och sjukvården. Exempel på dessa faktorer var vikten av autentisk och god arbetsmiljö, känsla av egenmakt och kontroll, deltagande i meningsfulla aktiviteter, återhämtning och praktiska tekniker som exempelvis mindfulness, yoga och bildterapi. Att få socialt stöd från närstående, kollegor och exempelvis kuratorer och präster var även en viktig faktor för att skydda mot utmattningssyndrom. Slutsats: Skyddande faktorer för utmattningssyndrom finns på både individ-, organisations- och samhällsnivå och bör beaktas i utvecklingen av förebyggande insatser för utmattningssyndrom.

This thesis takes as its focus the Maggie’s Cancer Centres exploring for the first time the impact of their designed gardens. This research is situated within the immediate context of Maggie’s ambitions as an organisation and looks closely at their design process. It is also set within the wider debates about the effects of green space on health and the historical context of the restorative garden. By exploring both historical and contemporary examples, it argues that a healthcare garden may be a space for transformation. Using four different Maggie’s gardens as case studies, the research seeks to investigate the role of these outdoor spaces and their impact on users. Through ethnographic and sensory methods, each garden is considered and mapped. It looks at the design brief and the intentions of the designers’, but the core work is an exploration of the experiences of staff and visitors. The focus is on the everyday use of these gardens as well as the design historiography. The experiences of gardens within healthcare are examined in order to expose the ways in which gardens, people, health and care are entwined. Through the qualitative research process this thesis develops a new hypothesis as to how healthcare gardens may operate – offering a new definition for them as “resilient places”. Careful analysis of the data reveals the specific networks and affordances presented by these gardens. The thesis argues, based on the evidence of users, that healthcare gardens can uniquely embrace certain “essences” where essence is defined as conveying a quality or attribute. These garden essences are identified as thresholds, sensory richness, the density of time and homeliness. The thesis also argues that a healthcare garden can provide specific and unique opportunities for care and this, in turn, can enhance the healing ethos of an organisation such as Maggie’s.

La parentalité des mères psychotiques est devenue une réalité sociale plus fréquente depuis l'avènement des neuroleptiques et du développement des soins extrahospitaliers, mais elle demeure peu étudiée. La plupart des recherches portent sur les facteurs de risque et les incapacités des mères présentant un trouble psychotique. Afin de mieux comprendre l'expérience de la parentalité des mères psychotiques, nous avons conduit une recherche, alliant des méthodes qualitatives et quantitatives, auprès de 18 mères présentant un diagnostic de trouble psychotique et suivies en service de psychiatrie adultes. Nous avons également interrogé 16 professionnels de santé exerçant en psychiatrie pour connaitre leur point de vue et leurs représentations sur ces parentalités et leur suivi. Nous avons adopté une perspective nouvelle, centrée sur les facteurs de protection et le processus résilient des mères psychotiques. Nous avons souhaité mettre en lumière les facteurs de l'environnement qui peuvent aider ces mères dans leur rôle parental et explorer leurs besoins spécifiques. Les mères psychotiques et les professionnels de santé ont répondu à un entretien semi-directif. Six échelles ont également été soumises aux mères pour apporter des résultats complémentaires à leur témoignage (échelle de conscience du trouble SUMD, de stress parental PSI, de soutien social SSQ6, d'attachement RQ, de conduites parentales PACOTIS et de résilience RSA). Les résultats montrent que malgré des difficultés dans la gestion des symptômes et le quotidien de leurs enfants, ces mères se disent satisfaites de leur rôle parental. Toutefois, le niveau de stress parental rapporté est élevé chez l'ensemble de ces mères. La majorité de ces mères se sentent seules et coincées dans leur rôle, alors même qu'elles bénéficient toutes d'un étayage perçu comme satisfaisant (familial ou professionnel). Au-delà de ces difficultés, la parentalité semble constituer un facteur de protection en soi. En effet, elle favorise la recherche de soutien social, le suivi du traitement médical et le sentiment d'avoir un sens à leur vie. Les résultats montrent, par ailleurs, une corrélation positive forte entre le score de résilience et l'impression d'être un bon parent. D'autre part, le rôle de l'environnement est prépondérant dans ces situations. Pourtant de nombreux jugements négatifs sont ressentis, notamment lors de l'annonce de la grossesse et ils peuvent freiner la demande d'aide. Le témoignage des professionnels montre qu'ils perçoivent tous les difficultés de ces mères, alors que les capacités parentales sont difficiles à identifier. De manière générale, la parentalité de ces mères est peu évoquée par les professionnels de psychiatrie pour adultes, par manque d'intérêts ou de connaissances. Toutefois, comme pour les mères interrogées, les professionnels confirment l'importance que cette problématique soit traitée par les services de psychiatrie. Des accompagnements spécifiques autour de la parentalité ou des dispositifs de formation ont été envisagés. La confrontation des expériences montre aussi des limites liées à l'organisation des services, à des questions éthiques et à des représentations qui rendent complexes la prise en charge de cette problématique. Cette étude suggère l'importance d'une approche écosystémique de ces situations parentales afin de favoriser un processus de résilience chez ces mères et leurs familles. Elle met enfin en lumière la nécessité d'interroger de nouvelles approches centrées sur la personne, plutôt que sur le symptôme, comme l'empowerment ou des programmes de rétablissement, pour que les mères puissent développer tout leur potentiel intérieur
The parenting of psychotic mothers has become a social reality more frequent since the advent of neuroleptics and the development of extra-hospital care, but it remains little studied. Most research focuses on the risk factors and disabilities of mothers with psychotic disorders. To better understand the experience of parenting psychotic mothers, we conducted a research, combining qualitative and quantitative methods, with 18 mothers diagnosed with psychotic disorder and followed in adult psychiatry. We also interviewed 16 health professionals practicing in psychiatry to know their point of view and their representations on these parenting and their follow-up. We took a new perspective, focusing on the protective factors and the resilient process of psychotic mothers. We wanted to highlight the environmental factors that can help these mothers in their parenting role and explore their specific needs. Psychotic mothers and health professionals responded to a semi-directive interview. 6 scales were also submitted to the mothers to provide additional results to their testimony (SUMD disorder awareness scale, PSI parental stress scale, SSQ6 social support scale, RQ relationship attachment scale, PACOTIS parenting competence scale and RSA resilience scale). The results show that despite difficulties in managing the symptoms and the daily lives of their children, these mothers say they are satisfied with their parenting role. Nevertheless, the score on the parental stress scale is high among all of these mothers interviewed and the majority of mothers feel lonely and stuck in their role, while they all benefit from a particular support (family or professional). Although these aspects may be a negative aspect of their parenthood, it seems to be a protective factor in itself. Indeed, it promotes the search for social support, the monitoring of medical treatment and the feeling of having meaning in their lives. The results also show a strong positive correlation between the resilience score and the impression of being a good parent. The role of the environment is paramount in these situations. Yet many judgments are felt, especially during the announcement of pregnancy and can slow down the demand for help. The testimony of the professionals shows the representations existing around this question. While all professionals perceive the difficulties of these mothers, parenting skills are difficult to identify. This question seems little mentioned by adult psychiatry professionals for lack of interest or knowledge. However, as for the interviewed mothers, the professionals confirm the importance that this problem be treated by the psychiatric services. Specific accompaniments around parenting or training schemes were considered. The confrontation of the experiments also shows the limits related to the organization of the services and representations which make the handling of this problematic complex. These results therefore suggest the importance of an ecosystem approach to these parenting situations in order to foster a process of resilience for these mothers and families. Finally, they highlight the need to question new approaches that focus on the individual rather than the symptom such as empowerment or recovery programs so that mothers can develop their full inner potential

The purpose of this study was to predict the psychological outcomes (compassion fatigue, job satisfaction, compassion satisfaction, resilience) of Australian healthcare professionals using a salutogenic approach. Between-group differences in health professional’s psychological wellbeing were examined, as were possible moderation effects between the significant work environment predictors and pathogenic outcomes. A total of 380 participants accessed an online survey which measured ways of coping, resilience, job satisfaction, professional quality of life, and psychological distress. Work environment factors (nature of work, process, pay, benefits), adaptive (problem solving, acceptance, social support) and maladaptive (escape avoidance, confrontative coping, responsibility, self-control) coping strategies, and psychological distress were among the variables contributing to health professional’s psychological outcomes. Between-group differences were limited to a select few categories (sex, relationship status, mental health status). All salutogenic outcomes (compassion satisfaction, job satisfaction, resilience) moderated the relationship between at least one predictor and pathogenic outcome. Future research is needed to confirm the results of the present study and to evaluate the effectiveness of proposed interventions.

History demonstrates the impacts a disaster can have on a healthcare system. Nurses are the largest group of healthcare workers and are pivotal to an effective societal response to a range of critical events, including disasters. They are the most likely to be involved during and affected by any type of disaster that impacts an inpatient healthcare facility. This presents nurses with significant and complex challenges that require them to function effectively under highly challenging and stressful circumstances, often for prolonged periods. This research used an ecological and systems framework to examine how hazard event characteristics and demands interact with personal, team, and organisational factors to create interdependent and complementary contributions to sustained resilience and adaptive capacity in nurses. Nurse participants completed a survey comprised of demographic and disaster event characteristics before participating in a semi-structured interview. The survey results reported on disasters triggered by natural hazards, namely earthquakes, weather events, and bushfires. The impacts of these events caused a range of structural and functional damages to facilities and were described as moderate to catastrophic. Stage One of the sequential mixed method study used a pluralistic approach to explore the scope of issues facing nurses working within inpatient healthcare facilities in New Zealand and Australia during and after a natural hazard disaster. Findings from the inductive analysis of qualitative data, derived from fifteen in-depth interviews, identified that the nurse participants maintained a strong sense of professional duty, personal commitment, and responsibility to their family, patients, and the team members within their facility. Thematic analysis identified a chronology of event characteristics and demands that influenced the ability of nurses to adapt, cope, and respond, whilst experiencing diverse personal, structural, functional, and organisational barriers. These findings identified the need to consider changes in the relationship between demands and adaptive capacities over time. Stage One findings contributed to the systematic and integrated process of analysis of theoretical concepts and qualitative data in Stage Two. This approach was used to critically explore and develop an operational definition of nursing empowerment in a disaster context. This, in turn, informed the adaptation and reconceptualization of an existing ecological model of adaptive capacity, developed by Paton, Violanti, Norris, and Johnson (2011), into a nurse focused ecological model of adaptive capacity. This study identified factors that helped and hindered a nursing workforce to anticipate, adequately prepare for, cope with, adapt to, respond, and learn from the consequences of critical incident events, such as natural hazard disasters. The findings from this study have significant implications for how nursing leadership and healthcare organisations empower their nursing workforce to function confidently and competently during, and to recover from, complex and ad hoc conditions. Predicted exponential growth in the number of disasters means that knowledge of disaster preparedness and its implementation to facilitate the development of resilient and adaptive nurses and healthcare organizations is an important adjunct to nurse education, policy development, and research considerations.

Stroke is the third most common cause of death in Australia. To date, there has been extensive research conducted on the reactive consequences following the diagnosis of stroke. In contrast, there has been limited research effort directed at understanding how some stroke survivors manage to adjust to their adversity and altered circumstances. This study took a phenomenological approach and explored the experiences and strategies stroke survivors employed in their renegotiation of living.