MCur / Department of Advanced Nursing Science / See the attached abstract below

Patient decision support technology provides increasingly more opportunitiesto support disease self-management in the healthcare setting. However, it doescome with a disruptive impact on the health provision between health providerand patient. Recent work on the climate that they are introduced in in TheNetherlands, though, is lacking. Health professionals’ perceptions are informedby that adoption climate, but also shape it in turn. This study explores thethoughts, beliefs, perceptions, and attitudes of those Dutch healthprofessionals. It explores the perceptions on the adoption climate that isprojected or experienced for patient decision support technology in healthcare.The deployed qualitative approach is based on theory on the adoption space,complemented with an interaction model for e-health implementation. Ittargets both the health professionals’ beliefs on this technology, as theirprojections of the larger adoption climate. The health professionals consist ofgeneral practitioners, medical researchers, pharmacists, chronic pain therapists,nurses, and medical specialists. The analysis circles in on the value of healthprofessional interaction and the hindering force that is encountered inestablished mechanisms and health infrastructure. It furthermore proposes aset of guidelines for developments in patient decision support technology thatboth guides it as well as protects the current healthcare from downsides. Thestudy contributes in providing a first exploration of different healthprofessionals’ perceptions on the apparent adoption climate for patientdecision support technology in The Netherlands. The outcomes and guidelinescan furthermore serve future studies to expand on.

Philosophiae Doctor - PhD / The value of accountability as a key feature of strengthening health systems and reducing maternal, newborn and child mortality is increasingly emphasised globally, nationally and locally. Frontline health professionals and managers play a crucial role in promoting maternal, newborn and child health (MNCH) services in an equitable and accountable manner. They are at the interface between higher-level health system management and communities, facing demands from both sides and often expected to perform beyond their available means. Although accountability is a central topic in the governance of MNCH literature, it has mostly been approached at global and national levels, with little understanding of how accountability is integrated into the routine functioning of local health systems. This PhD explores the forms and functioning of accountability at the district level focusing on MNCH as a programmatic area with long-established institutional mechanisms (structures and processes) in South Africa (SA). The thesis is presented in the form of four empirical papers (published or submitted), exploring different dimensions of accountability, which are embedded in a series of narrative chapters. In this thesis, accountability is understood as a set of relations between an accountholder and ‘accountor’ (or duty bearer), in which the latter provides information or justification for actions or decisions taken, and faces the resulting consequences of his/her actions (reward or sanction). Accountability mechanisms are the means to regulate accountability relationships and include broad strategies, interventions or instruments. These mechanisms can take various forms including performance, financial and public accountability, and operate both vertically (accountability inside bureaucratic hierarchies, or towards external stakeholders and/or the community), or horizontally (between peers, ‘neighbour’ units, departments or ministries in a national health system). Drawing conceptually on the field of governance and considering the complexity of the accountability phenomenon, I adopted a case study approach to the PhD research, using a combination of policy document review, interviews (with managers, providers, community representatives and members of labour unions) and field observations, conducted iteratively over 16 months. The study was conducted in Gert Sibande District, one of the three South African health districts in Mpumalanga Province, with an in-depth focus on two of the seven sub-districts in the District. The research found that frontline health professionals have a clear understanding and conceptualisation of accountability in the SA health policy context, despite the reported inability to define accountability by health professionals described in the literature. Respondents referred to accountability as responsibility, answerability and virtue, and also argued for strengthening accountability mechanisms as critical to addressing maternal and child mortality. While deeming accountability as important, frontline professionals experienced the existing accountability mechanisms as ‘too much’ and indicated the desire for the streamlining of existing mechanisms. In this regard, the study documented numerous mechanisms at district level, almost all related to performance accountability in MNCH. These included a performance management system, quality assessment and accreditation processes, quarterly reviews, and death surveillance and response processes. The existence of multiple and overlapping accountability mechanisms engenders operational confusion and ‘accountability overload’ for frontline providers, encouraging empty bureaucratic compliance, while critical gaps – notably in community accountability – remain. In practice, at their best, some mechanisms operate following a reciprocal1 pathway of capacity building with resource provision (from management) and expectation for better performance (from providers). There were, however, contextual variations in the implementation and practice of the mechanisms between sub-district settings. The fieldwork observations and interviews were also able to document how formal institutionalised mechanisms are embedded within a complex system of informal accountability relationships and social norms (‘accountability ecosystem’) that enables or constrains the ability of frontline professionals to fulfil their tasks. In addition, using a Social Network Analysis approach, the research identified key actors and their involved network, which form the relational backdrop to the functioning of accountability mechanisms for MNCH. By revealing complex relationships and collaboration patterns among frontline health professionals, the study was able to show the multi-level action and multiple actors required to achieve MNCH goals.

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Contexte. La pandémie de la COVID19 (maladie à coronavirus) a entrainé une réorganisation rapide des services de santé en mars 2020, au Québec et dans le monde. La télésanté, qui ouvre de larges perspectives pour faciliter l’accès aux services de santé, a gagné en popularité durant cette période. Les systèmes de soins de différents pays ont mis sur pied des solutions de télésanté ; plus particulièrement des programmes de téléconsultation afin de maîtriser l’afflux des patients dans les centres de soins de première ligne, de gérer le nombre de lits disponibles et de limiter les contacts pour éviter la propagation du virus. Plusieurs travaux actuels décrivent le potentiel d’utilisation de la téléconsultation dans le contexte de la COVID-19 dans les soins médicaux et infirmiers, mais très peu dans les autres types de soins dispensés par d’autres professionnels de la santé. Objectifs. Cette étude vise à apporter des connaissances sur l’utilisation et la perception des professionnels de la DSM, ayant utilisé la consultation à distance durant la pandémie de la COVID-19 au Québec. Notamment à travers les facteurs qui ont influencé son utilisation. Nous ferons ressortir aussi les avantages et contraintes perçus de cette modalité de prestation de soins. Méthodologie. Le devis mobilisé pour atteindre cet objectif est une étude de cas qualitative descriptive, exploratoire et rétrospective. Cette recherche est basée sur l’analyse de 16 entrevues individuelles semi-structurées réalisées auprès de personnes affiliées à la direction des services professionnels d’un centre hospitalier universitaire au Québec. Ces entrevues ont été réalisées avec les professionnels qui ont recouru à la téléconsultation durant la crise de la COVID-19. Elles ont fait l’objet d’une analyse de contenu à l’aide du logiciel QDA Miner 5 selon une approche thématique émergente. Résultats. Au terme de cette étude, l’analyse des résultats montre une évolution de la perception des professionnels de la téléconsultation pendant la pandémie de COVID-19 et une nette augmentation de son utilisation. Les répondants ont partagé divers avantages perçus et améliorations à apporter. Les principaux bénéfices perçus concernaient l’amélioration de la continuité des soins, une meilleure observance du traitement par les patients et la personnalisation des soins par l’accès au milieu de vie des personnes. Les obstacles les plus importants étaient le réseau internet et l’augmentation de la charge de travail. Un modèle hybride de prestation de soins est en train d’émerger. Conclusion. L’expérience des répondants par rapport à la téléconsultation s’avère particulièrement positive, et ce, malgré les contraintes mineures rencontrées en contexte de pandémie de COVID-19. Ces résultats permettront d’élaborer des stratégies pouvant les aider dans leur pratique au-delà du contexte de COVID-19. / Background. The COVID 19 (coronavirus disease) pandemic led to a rapid reorganization of health services in March 2020. Telehealth, which opens great prospects for facilitating access to health services, gained in popularity during this period. Healthcare systems in different countries have developed telehealth solutions; more specifically, teleconsultation programs to control the influx of patients into primary care centers, manage the number of available beds and limit contacts to prevent the spread of the virus. Several current studies describe the potential for the use of teleconsultation in the context of COVID-19 in medical and nursing care, but very little in other types of care. Objective. This study aims to provide knowledge on the use and perception of DSM professionals, having used remote consultation during the COVID-19 pandemic in Quebec. In particular through the factors that influenced its use as well as the perceived advantages and constraints. Methods. The design used to achieve this objective is a descriptive, exploratory, and retrospective qualitative case study. This research is based on the analysis of 16 semi-structured individual interviews conducted with people affiliated with the professional services department of a university hospital in Quebec. These interviews were conducted with professionals who used teleconsultation during the COVID-19 crisis. They were subjected to content analysis using QDA Miner 5 software using an emerging thematic approach. Result. The results show that the main perceived benefits focused on improving the continuity of care, better adherence to treatment by patients, and personalization of care by having access to people’s living environment. The biggest barriers were the Internet and the increased workload. Conclusion. The experience of respondents with teleconsultation is particularly positive, despite the minor opposites encountered in the context of the COVID-19 pandemic. These results will make it possible to develop strategies that can help them in their practice beyond the context of COVID-19.

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[pt] O presente estudo tem por objetivo geral analisar a relação dos profissionais em formação nas residências multiprofissionais em saúde no que tange ao atendimento de pessoas trans em um hospital universitário do município Rio de Janeiro. Evidenciar o tema da transexualidade a partir do olhar das profissionais de saúde é fundamental para a construção de uma formação profissional e de uma educação permanente em saúde de qualidade que contribua para a criação de espaços de diálogos entre as profissionais de saúde e a população atendida. Para isto, este trabalho teve como objetivos específicos: 1) Identificar a percepção das profissionais de saúde em formação acerca das demandas das pessoas transexuais que comparecem aos serviços de saúde, 2) Analisar a interação entre profissionais de saúde e as pessoas trans no atendimento de suas demandas e 3) Analisar a incorporação e reificação da dimensão de gênero na formação da residência em saúde pública a partir do olhar das profissionais. Os episódios de atitudes discriminatórias contra as sexualidades consideradas desviantes da norma são recorrentes nos ambientes de saúde. Foram realizadas oito entrevistas individuais com profissionais de saúde residentes do segundo ano de formação dos programas de residência multiprofissionais. Na análise dos dados coletados, utilizamos a análise de conteúdo das narrativas das profissionais de saúde entrevistadas, a partir de três categorias: Noções sobre transexualidade e demandas em saúde, atendimento às pessoas trans e interação com as profissionais de saúde e gênero e formação profissional. Observamos que as dificuldades de lidar com as questões relativas ao gênero e à sexualidade, especialmente à sexualidade feminina, faz com que as profissionais de saúde reduzam o impacto de suas ações. Os resultados apontam que a maneira como esses profissionais entendem e constroem as noções de gênero e sexualidade, torna-se uma das principais barreiras de acesso das pessoas trans aos serviços. / [en] This study aims to evaluate healthcare professionals (HCP) during their multiprofessional postgraduate training - residency - and their perceptions of the care dispensed to transgender people in a university hospital in Rio de Janeiro city. It is highly important to value the transexuality subject from the HCP perspective in order to build proper professional education and permanent health education that allows experience exchange spaces between those professionals and the population. This work has as specific goals: 1) To identify the in-training HCP perception about the demands of transgender people who attend to the health facility, 2) To evaluate the intercommunication between HCPs and trans people regarding the resolution of their needs and 3) To evaluate the internalization and reification of gender dimension in the public health education during residency from the professionals perception. Gender discrimination episodes against people whose sexuality is considered deviating is recurrent in health care institutions.. For this work, we conducted 8 interviews with 2nd-year health care students during their multiprofessional residency. To perform data analysis the content analysis method was used to evaluate the narratives of the interviewees, using three categories: basic knowledge on transexuality and health needs, health care to trans people and interactions with HCP and gender and professional training. We observed that the difficulties in dealing with gender and sexuality topics, specially those regarding female sexuality, reduce the impact of the action of those health professionals. Our results evidentiate that the manner the HCPs deal with gender and sexuality and how they understand those subjects are barriers to transgender people on their access to health care services.

Computer technology is developing so rapidly that the extent to which it is being utilized by counselors and counselor educators in their work is virtually unknown. The purpose of this study was to assess how much and in what ways counselor experts believe computer-related technology (CRT) is being utilized by professional counselors today. An additional purpose of this study was to determine projected use of CRT by the year 2008.Data were collected by means of a modified futures Delphi method in which a panel of 21 counselor experts comprised of one group of counselor educators, three groups of counselor practitioners, and one group of computer technologists completed three rounds of questions. The study, which was conducted entirely on the World Wide Web, requested Likert-type ratings of 53 generic work-related tasks in eight task categories for frequency of CRT use to accomplish the tasks and reasons for the selections. In addition, panelists rated ten specific CRT tools for frequency of use, and supplied written examples of current and future CRT use by counseling professionals.The findings of the study indicate counselors and counselor educators are using a large variety of CRT tools, including word processors, spread sheets, a variety of software programs, e-mail, chatrooms, listservs, databases, and other web-related tools to assist them in over half of job-related tasks today. Experts forecast CRT use by counselors will significantly increase by the year 2008, when professional counselors are expected to utilize CRT for at least 90% of their work-related tasks.It is suggested that findings of this study may provide an important foundation for much needed research investigating potential differences between therapeutic work accomplished with the help of CRT and traditional therapy, i.e., face-to-face therapy, in which computer technology is not utilized. Finally, results establish the need to implement and promote computer skills training and competency assessments in counselor education programs. / Ph. D.

Yes / Objectives: Making a medical error can have serious implications for clinician wellbeing, affecting the quality and safety of patient care. Despite an advancing literature base, cross-country exploration of this experience is limited and a paucity of studies has examined the coping strategies used by clinicians. A greater understanding of clinicians¿ responses to making an error, the factors that may influence these, and the various coping strategies used are all essential for providing effective clinician support and ensuring optimal outcomes. The objectives were therefore to investigate a) the professional or personal disruption experienced after making an error, b) the emotional response and coping strategies used, c) the relationship between emotions and coping strategy selection, d) influential factors in clinicians¿ responses, and e) perceptions of organisational support. Methods: A cross-sectional, cross-country survey of 265 physicians and nurses was undertaken in two large teaching hospitals in the UK and USA. Results: Professional and personal disruption was reported as a result of making an error. Negative emotions were common, but positive feelings of determination, attentiveness and alertness were also identified. Emotional response and coping strategy selection did not differ due to location or perceived harm, but responses did appear to differ by professional group; nurses in both locations reported stronger negative feelings after an error. Respondents favoured problem-focused coping strategies and associations were identified between coping strategy selection and the presence of particular emotions. Organisational support services, particularly including peers, were recognised as helpful, but fears over confidentiality may prohibit some staff from accessing these. Conclusions: Clinicians in the UK and US experience professional and personal disruption after an error. A number of factors may influence clinician recovery; these factors should be considered in the provision of comprehensive support programmes so as to improve clinician recovery and ensure higher quality, safer patient care. / This research was funded by the Bradford Institute for Health Research as part of a PhD studentship and supported by a travel grant through the Postgraduate Study Visits scheme by the British Psychological Society.