Thesis (M.S.)--Boston University

Thesis (M.S.)--Boston University

Thesis (M.S.)--Boston University

Thesis (M.S.)--Boston University

<p>Abstract The aim of this quality improvement (QI) project was to explore whether the implementation of an enhanced telephone reminder system improved the rate of attendance at initial follow-up appointment and medication adherence. A total of 86 patients, discharged from inpatient psychiatric units with a follow-up within 7 days of discharge, were eligible to receive the enhanced telephone contact reminder and follow-up text. A preliminary retrospective chart review was conducted to collect historical data on medication and attendance adherence. A prospective interventional design was used to implement the QI project. Patients received telephone contact within 24-72 hours of discharge and text message reminder strategies. A medication adherence assessment was completed at telephone contact and at initial follow-up appointment. An analysis of the data examined the impact of the TCM strategy on patient?s rate of adherence to medication and initial follow-up appointments. Descriptive analysis assessed the frequency of medication adherence in retrospective and implementation data. Inferential statistics analyzed factors of association such as prior clinic services and rate of attendance at follow-up appointment. In the retrospective chart review (n=57), data revealed a 28% attendance rate and an 81% medication adherence at the follow-up appointment, with no statistical difference in a 145 history of prior series on attendance. Implementation data on medication adherence at telephone contact and at first follow-up appointment revealed a 61.5% medication adherence rate at telephone contact and 80% adherence rate at first follow-up appointment. The predictor value of a prior history of service on attendance at first follow-up appointment revealed no statistically significant difference. The project, however, resulted in clinically significant benefits that promoted individual patients? medication-taking behaviors and decisions to attend follow-up appointments, and improved clinical practices at the BHC.

<p> This quantitative study was an evaluation of the effectiveness of the online Training Home software program, designed for use with a national nonprofit business model. This study was undertaken because nonprofits have a difficult time resourcing training. If the Training Home program can deliver a comprehensive training program for minimal cost, then a nonprofit will be better able to deliver on the nonprofit&rsquo;s stated mission. For this study, six research questions centered on measuring the helpfulness of the program, the difference in job function training, improved knowledge of a national nonprofit, and perception of the Training Home program between those that had and or had not used the program. Additionally, cost per unit of training, the number of training vignettes delivered, time spent in training, ease of use by supervisors, and staff ratings of the effectiveness of the training home program. The population studied was the 450 staff at one affiliate of the national nonprofit. This staff group consisted of a mix of genders, ages, and education levels. This study used archival data gathered over the 2013, 2014, and 2015 calendar years and was analyzed using multivariate regression and descriptive analyses. The cost and number of training vignettes delivered in a 24-month period were compared to determine whether the Training Home program was a more cost-effective delivery model than the prior system for the year before the study. Analyses indicate that the Training Home program delivered more training to staff at a lower cost per unit of training when compared to the units of training delivered in the prior model. Supervisors and staff reported the program to be effective in knowledge management and tracking and the training of all staff. The study had positive results for the sample studied. It would be beneficial for any future studies to expand the sample size into other geographic regions.</p><p>

<p> <b>Rationale/Background:</b> Fall prevention is a paramount and lifesaving healthcare initiative. The investigation of interventions for the prevention of falls may lead to a decrease in injuries and promotion of superlative care for patients hospitalized in an acute healthcare environment. </p><p> <b>Purpose: </b>The purpose of this quantitative correlational direct practice improvement (DPI) project is to determine the relationship between the implementation of a fall prevention training program and changes in fall rates over a period over three months. </p><p> <b>Theoretical Framework:</b> The Neuman system model served as the theoretical foundation for this project. The model presents a holistic approach to patient at-risk for falling and guides bedside nursing care, assess stressors, safety needs, and environmental factors suggest potential indicators linked to fall-risk patients. </p><p> <b>Project Method and Design:</b> A quantitative method and correlational design was used to investigate the impact of the intervention. The intervention involved training for a total 28 nurses (N = 28) on two wards. The final data collection included fall rates for 56-patients (N = 56). </p><p> <b>Data Results:</b> The control ward had a fall rate of nearly twice as high than the ward who received the intervention. There is a statistically significant reduction in fall rates on the intervention ward (p = 0.04). </p><p> <b>Implications:</b> Based on the findings of this project, a fall education training program supported safety through a reduction of falls. The training program was adopted as a part of standard education for the site. </p><p>

This thesis aims to: investigate the motivations of why many individuals with developmental dyslexia are successful despite experiencing traumatic schooling. It details seven studies that investigate the emotional coping amongst individuals with developmental dyslexia, investigating successful post-school careers as ‘post-traumatic growth’, an outcome from school-based trauma. The first two studies with school-aged dyslexics were quantitative and whilst helpful in understanding different coping strategies utilised, it was perceived to lack depth in understanding the emotional side of the dyslexia experience, and any long-term emotional ramifications from school-based trauma. A third study sought to understand the discrimination, stigma, and the dangers of self-disclosure of dyslexia, experienced by adult dyslexics. Two investigations of self-harm and possible post-traumatic stress disorder followed to better understand how adults with dyslexia emotional cope with learned helplessness experienced at school. Lastly, two studies investigating post-school workplace success, firstly to understand concepts of ‘success’ amongst adults with dyslexia, and secondly to understand how school-based trauma could be used positively. This thesis offers original contributions to literature through the use of standardised measures to measure emotional coping in school-aged dyslexic samples (especially depression); comparing the sources and manifestations of stress between school-aged dyslexics and their siblings; the types of self-harm used by dyslexic adults and where the source of their helplessness/depression begun; and how the concept of ‘post-traumatic stress disorder’ could be correlated to the reactions that many dyslexic adults experience now as parents returning to school. Original contributions were also made regarding adult dyslexics in regard to self-perceptions of success and understanding the role that school plays in motivating them to post-school success in the workplace, argued to be a form of ‘post-traumatic growth’. Lastly, the author proposes the use of ‘bi-abilities’ to better understand the experience of dyslexia, rejecting both the medical and social models of disability, as dyslexics reject a disability identity.

Alcohol use in later life has received little attention. Among older people psychosocial factors including bereavement, retirement, boredom, loneliness, and depression are associated with higher rates of alcohol use. The loss of a home has been compared to bereavement; therefore, where older people live has an impact on the quality of their lives (Tinker, 1997). This thesis focuses on alcohol use of older people who live in sheltered accommodation in Newcastle upon Tyne. No published work has been conducted on this population to date and therefore it is not known whether or why they drink at different levels to the general population of older people because of their loss of their home. The population for this research was people living in sheltered accommodation in one city in the North East of England. Sheltered accommodation is housing designed to help older people live independently, where there is support available onsite. Alcohol use in residents of sheltered accommodation was assessed in two studies. The aim of Study 1 was to investigate the levels at which the sheltered housing population are consuming alcohol. The study comprised of a postal survey using the alcohol disorders identification test survey tool (AUDIT) (Babour, Higgins-Biddle, Sanders et al, 2001). The AUDIT score is a method of measuring a person’s risk from alcohol related harm which goes beyond purely measuring consumption as it also measures the frequency of use and the effect of alcohol use. Data were analysed using SPSS. Findings showed that 3 men in the research population scored higher than the women and that the younger age group (< 70) had higher scores than the other two age groups (71-80 and >80). The aim of Study 2 was to investigate the factors determining decisions to drink in later life. Study 2 comprised 16 in-depth interviews using a life course approach. Data were analysed using a framework approach with a biographic narrative overlay. Findings showed that there were a number of factors influencing the decision to drink to harmful and or hazardous levels including mental health, domestic violence, social contact, family and work. Case studies were developed and presented based on these findings. This research found that older people’s lives do not simplify as they age and therefore the reasons for using alcohol are complicated and individualised. They are influenced by early life experiences, traumatic or life changing events as well as the strength of the person’s locus of control. Further work is needed to establish support needs for drinkers in later life, both to reduce drinking levels and to reduce harms from current levels of drinking. Older people are the group who are most likely to lack knowledge of what these units and limits are (McInnes & Powell, 1994). An older person specific unit guide should be developed and implemented. There needs to be improved multidisciplinary staff training to facilitate an increase in the identification of those older people who consume over the advised alcohol limits. Policy should consider the move away from a one size fits all model of alcohol management to a more individualised approach to support the adjustment of later life events.

Care home admission following acute hospitalisation is a lived reality across Scotland, experienced by over 8,000 people annually. The aim of this thesis was to develop an understanding of new care home admission following acute hospitalisation. Methods and findings from the mixed-methods approach are presented in three parts. Part One: Identifying relevant research - includes a review of quality assessment tools for systematic reviewing; a systematic review and meta-analysis of quantitative data from observational studies of predictors of care home admission from hospital; and a methodological chapter on developing a search filter to improve accessibility of existing research findings supported by the findings of an international survey of care home researchers. The systematic review identified 53 relevant studies from 16 countries comprising a total population of 1,457,881 participants. Quantitative synthesis of the results from 11 of the studies found that increased age (OR 1.02 per year increase; 95%CI 1.00-1.04), female sex (OR 1.41; 95%CI 1.03-1.92), dementia & cognitive impairment (OR 2.14; 95%CI 1.24-3.70) and functional dependency (OR 2.06; 95%CI 1.58-2.69) were all associated with an increased risk of care home admission after hospitalisation. Despite international variation in service provision, only two studies described the model of care provided in the care home setting. The survey identified that there is a lack of shared terminology in the published literature to describe settings for adults who are unable to live independently in their own homes and require care in a long-term institutional setting. A search filter to identify relevant research could help to overcome differences in terminology and improve synthesis of existing research evidence. Part Two: Exploring current clinical practice - reports the findings of a retrospective cohort study of new care home admissions from hospital using case-note review methodology accompanied by findings from inductive thematic analysis of a single dataset from a qualitative case study design exploring the experiences of a patient, their family, and practitioners (n=5). The cohort study (n=100) found a heterogeneous picture with long hospital admissions (range 14-231 days), frequent transfers of care (31% experienced three or more transfers), varied levels of documented assessment and a lack of documented patient involvement in the decision-making processes. The qualitative interviews allowed the patient voice to emerge, alongside the professional and family narrative which dominated case-note documentation. Inductive thematic analysis identified nine major themes exploring how decisions are made to discharge individuals directly into a care home from the acute hospital setting: biography & personality; professional role; family role; limitations in local model of care; ownership of decision; risk; realising preferences; uncertainty of care home admission process; and psychological impact of in-hospital care. Part Three: Harnessing routinely-collected data - includes the challenges of identifying care home residency at admission and discharge from hospital, presenting analysis of the accuracy of Scottish Morbidity Record 1 (SMR01) coding in NHS Fife and the Community Health Index (CHI) Institution Flag in NHS Fife and NHS Tayside. This is followed by a descriptive analysis of the Scottish Care Home Census (2013-16) as a novel social care data source to explore care home admissions from hospital and the methodology for a data linkage study using these data. Identifying care home residents in routine data sources is challenging. In 18,720 admissions to NHS Fife, SMR01 coding had a sensitivity of 86.0% and positive predictive value of 85.8% in identifying care home residents on admission. At discharge the sensitivity was 87.0% and positive predictive value was 84.5%. From a sample of 10,000 records, the CHI Institution Flag had a sensitivity of 58.6% in NHS Fife and 89.3% in NHS Tayside, with positive predictive values of 99.7% and 97.7% respectively. From 2013-16, of 21,368 admissions to care homes in Scotland, 56.7% were admitted from hospital. There was significant regional variation in rates of care home admission from hospital (35.9-64.7%) and proportion of Local Authority funded places provided to admissions from hospital (34.4-73.9%). Those admitted from hospital appeared to be more dependent and sicker than those admitted from home. This thesis has established a series of challenges in how care homes and their residents are identified. It has questioned the adequacy of the evidence to guide practitioners and sought to raise the profile of this vulnerable and complex population and how best to support them in making decisions regarding admission from the acute hospital. It has progressed our understanding of this under-explored area and proposes a programme of future mixed-methods research involving patients, families, practitioners and policy-makers.