Patients with acute myocardial infarction (AMI) are at high risk for reinfarction and death, with the highest rate of death and reinfarction occurring within 30 days of AMI. Therapies that have been shown to reduce these risks (secondary prevention) continue to be underutilized. Nurse practitioners are well positioned to provide secondary prevention during and following hospitalization. The purpose of this pilot study was to examine the feasibility, acceptability, and preliminary effects of an NP delivered secondary prevention intervention. The specific objectives were: 1) to describe NP activities when delivering the secondary prevention intervention; 2) to evaluate the effect of the NP intervention on the rate of implementation of evidence-based secondary prevention treatment strategies and the patients’ achievement of secondary prevention target goals; and, 3) to examine the relationship between the NP activities delivering the intervention and secondary prevention goal achievement by patients. A prospective cohort design was used, in which patients’ achievement of target goals were compared between patients who received secondary prevention care from an NP and those who received usual care. The sample of convenience consisted of 65 patients with AMI. Data on practice activities and implementation of secondary prevention by the NP were collected before discharge from hospital and one week, two weeks, six weeks and 3 months after discharge. Data on patients’ achievement of goals were obtained before discharge from hospital and 3 months after discharge from both groups. This study’s results provide preliminary evidence that an NP delivered secondary prevention intervention, beginning prior to discharge and continuing for three months post myocardial infarction, significantly improves the implementation and uptake of guideline based secondary prevention treatments and risk factor reduction strategies. NP-led interventions such as this warrant replication. The unique contribution of the NP with this patient population is the training and skills needed to deliver all aspects of secondary prevention, including pharmacological and nonpharmacological therapies, without the immediate availability of a physician.

Canadian statistics on patient safety in acute care hospitals are alarming. Hospital safety concerns are not isolated to patient safety. Occupational safety is also important. With increasing shortages of nurses, stress in the work place is growing. Nurses report high levels of absenteeism of 14.5 days per year. The importance of a just and fair culture and the role of nurse leaders have been emphasized in safety literature. Although deemed important, studies of nurse leaders and patient outcomes are limited. The influence of interactional justice in the workplace on nurse and patient safety has not been studied. The purpose of this study was to test and refine a model developed from the literature which explains the impact of perceived interactional justice, relational leadership, and quality of nurse manager – clinical nurse relationships on the nursing work environment and ultimately patient and nurse safety outcomes. The model was tested on a random sample of 266 Ontario acute care registered nurses. Findings indicated the model reasonably fit the observed data, however could benefit from further refinement. The addition of 2 pathways (span of control to nurses’ intent to leave and number of medication errors to nurse emotional exhaustion) and trimming of the insignificant paths improved the overall model fit. The resulting model indicates that resonant leadership style and interactional justice improves the quality of nurse leader-nurse relationships which in turn improves quality of the nurses’ work environment and safety climate. A positive safety climate led to a decrease in the number medication errors and nurses’ intentions to leave their unit. A higher quality work environment predicted lower nurse emotional exhaustion. Additionally, higher numbers of medication errors led to an increase in nurse emotional exhaustion. This suggests that distress may be associated with making a medication error or fear of consequences. As well, larger manager spans were associated with less nurse intent to leave. As the span increased, the number of support personnel also increased. Contrary to other research findings, this result suggests that supportive personnel may mitigate the effect of large manager spans of control on nurses’ intent to leave their units.

Patients with acute myocardial infarction (AMI) are at high risk for reinfarction and death, with the highest rate of death and reinfarction occurring within 30 days of AMI. Therapies that have been shown to reduce these risks (secondary prevention) continue to be underutilized. Nurse practitioners are well positioned to provide secondary prevention during and following hospitalization. The purpose of this pilot study was to examine the feasibility, acceptability, and preliminary effects of an NP delivered secondary prevention intervention. The specific objectives were: 1) to describe NP activities when delivering the secondary prevention intervention; 2) to evaluate the effect of the NP intervention on the rate of implementation of evidence-based secondary prevention treatment strategies and the patients’ achievement of secondary prevention target goals; and, 3) to examine the relationship between the NP activities delivering the intervention and secondary prevention goal achievement by patients. A prospective cohort design was used, in which patients’ achievement of target goals were compared between patients who received secondary prevention care from an NP and those who received usual care. The sample of convenience consisted of 65 patients with AMI. Data on practice activities and implementation of secondary prevention by the NP were collected before discharge from hospital and one week, two weeks, six weeks and 3 months after discharge. Data on patients’ achievement of goals were obtained before discharge from hospital and 3 months after discharge from both groups. This study’s results provide preliminary evidence that an NP delivered secondary prevention intervention, beginning prior to discharge and continuing for three months post myocardial infarction, significantly improves the implementation and uptake of guideline based secondary prevention treatments and risk factor reduction strategies. NP-led interventions such as this warrant replication. The unique contribution of the NP with this patient population is the training and skills needed to deliver all aspects of secondary prevention, including pharmacological and nonpharmacological therapies, without the immediate availability of a physician.

Doctor of Philosophy / Department of Industrial & Manufacturing Systems Engineering / David H. Ben-Arieh / Chih-Hang Wu / Patients who suffer from sepsis or septic shock are of great concern in the healthcare system. Recent data indicate that more than 900,000 severe sepsis or septic shock cases developed in the United States with mortality rates between 20% and 80%. In the United States alone, almost $17 billion is spent each year for the treatment of patients with sepsis. Clinical trials of treatments for sepsis have been extensively studied in the last 30 years, but there is no general agreement of the effectiveness of the proposed treatments for sepsis. Therefore, it is necessary to find accurate and effective tools that can help physicians predict the progression of disease in a patient-specific way, and then provide physicians recommendation on the treatment of sepsis to lower risk for patients dying from sepsis. The goal of this research is to develop a risk assessment tool and a risk management tool for sepsis. In order to achieve this goal, two system dynamic mathematical models (SDMMs) are initially developed to predict dynamic patterns of sepsis progression in innate immunity and adaptive immunity. The two SDMMs are able to identify key indicators and key processes of inflammatory responses to an infection, and a sepsis progression. Second, an integrated-mathematical-multi-agent-based model (IMMABM) is developed to capture the stochastic nature embedded in the development of inflammatory responses to a sepsis. Unlike existing agent-based models, this agent-based model is enhanced by incorporating developed SDMMs and extensive experimental data. With the risk assessment tools, a Markov decision process (MDP) is proposed, as a risk management tool, to apply to clinical decision-makings on sepsis. With extensive computational studies, the major contributions of this research are to firstly develop risk assessment tools to identify the risk of sepsis development during the immune system responding to an infection, and secondly propose a decision-making framework to manage the risk of infected individuals dying from sepsis. The methodology and modeling framework used in this dissertation can be expanded to other disease situations and treatment applications, and have a broad impact to the research area related to computational modeling, biology, medical decision-making, and industrial engineering.

We first studied factors associated with the rate of colonoscopy by primary care physicians (PCPs) in Ontario between the years 1996 and 2005. Next, we conducted an Instrumental Variable Analysis (IVA) to estimate the effect of colonoscopy on colorectal cancer (CRC) incidence and mortality on average-risk subjects aged 50-74 years. Finally, we explored two study cohorts, one by including subjects who had the outcomes during the exposure period (unselected cohort) and the other cohort by excluding those subjects (restricted cohort). We estimated the absolute risk reduction associated with colonoscopy in preventing CRC incidence and mortality using traditional regression analysis, propensity score analysis and IVA. PCPs who were Canadian medical graduates and with more years of experience were more likely to use colonoscopy. PCPs were more likely to use colonoscopy if their patient populations were predominantly women, older, had more illnesses, and if their patients resided in less marginalized neighborhoods (lower unemployment, fewer immigrants, higher income, higher education, and higher English/French fluency). Using PCP rate of discretionary colonoscopy as an instrumental variable, receipt of colonoscopy was associated with a 0.60% absolute reduction in 7-year CRC incidence and a 0.17% absolute reduction in 5-year risk of death due to CRC. The unselected cohort showed an increase in CRC incidence and mortality associated with colonoscopy, whereas the restricted cohort showed a reduction in CRC incidence and mortality associated with colonoscopy. In the restricted cohort, using different statistical models, the absolute risk reduction varied from 0.52-0.60% for CRC incidence and 0.08-0.17% for CRC mortality. There were social disparities in the use of colonoscopy by PCPs and this disparity increased as the overall use of colonoscopy increased over time. Colonoscopy is effective in reducing incidence and mortality due to CRC. Different methods of subject selection and statistical analysis provided different estimates of colonoscopy effectiveness.

We first studied factors associated with the rate of colonoscopy by primary care physicians (PCPs) in Ontario between the years 1996 and 2005. Next, we conducted an Instrumental Variable Analysis (IVA) to estimate the effect of colonoscopy on colorectal cancer (CRC) incidence and mortality on average-risk subjects aged 50-74 years. Finally, we explored two study cohorts, one by including subjects who had the outcomes during the exposure period (unselected cohort) and the other cohort by excluding those subjects (restricted cohort). We estimated the absolute risk reduction associated with colonoscopy in preventing CRC incidence and mortality using traditional regression analysis, propensity score analysis and IVA. PCPs who were Canadian medical graduates and with more years of experience were more likely to use colonoscopy. PCPs were more likely to use colonoscopy if their patient populations were predominantly women, older, had more illnesses, and if their patients resided in less marginalized neighborhoods (lower unemployment, fewer immigrants, higher income, higher education, and higher English/French fluency). Using PCP rate of discretionary colonoscopy as an instrumental variable, receipt of colonoscopy was associated with a 0.60% absolute reduction in 7-year CRC incidence and a 0.17% absolute reduction in 5-year risk of death due to CRC. The unselected cohort showed an increase in CRC incidence and mortality associated with colonoscopy, whereas the restricted cohort showed a reduction in CRC incidence and mortality associated with colonoscopy. In the restricted cohort, using different statistical models, the absolute risk reduction varied from 0.52-0.60% for CRC incidence and 0.08-0.17% for CRC mortality. There were social disparities in the use of colonoscopy by PCPs and this disparity increased as the overall use of colonoscopy increased over time. Colonoscopy is effective in reducing incidence and mortality due to CRC. Different methods of subject selection and statistical analysis provided different estimates of colonoscopy effectiveness.

The process of patient care relies on clinical data spread across specialized hospital departments. Powerful software is being designed to assimilate this disconnected patient data before treatment can be decided. However, these data are often presented to clinicians on interfaces that do not fit clinical workflows, leading to poor operational efficiency and increased patient safety risks. This project relies on ethnographic design methods to create evidence of clinician preferences pertaining to the presentation and collection of information on user interfaces in patient rooms. Using data gathered in clinical observation, a prototype interface was designed to enable doctors to conduct clinical tasks through a usable patient room interface. The prototype evaluation with doctors identified clinical tasks that are relevant in the patient room and provided insight into the perceived usability of such an interface. The evaluation sessions also elucidated on issues of patient-centeredness in technology design, effortless authentication and interface customizability.

Chronic disease is rising globally, but LMICs may require novel approaches to management suited to a low-resource setting. Private health care providers in LMICs have experimented and developed new models for organizing, financing, and delivering care. This thesis examines some of the innovations that have emerged in LMICs to manage chronic disease. Using a common performance measurement framework and drawing from a database of over 1200 innovative health programs, I identify and evaluate 46 programs addressing chronic disease in LMICs. I then go on to identify, innovative practices used by the subset of 19 diabetes focussed programs and catalogue them according to the Chronic Care Model (CCM). Delivery system design is the most commonly used domain of the CCM, which even earlier has shown to have great potential to impact health outcomes. Few of the identified innovations may also have the potential for ‘Reverse innovation’ in high income countries.

The concept of home care nursing workload has not been widely studied and no evidence was found that an analysis of the concept had been undertaken. Consequently, there was a knowledge gap regarding the definition and attributes for the concept of home care nursing workload as it is currently experienced. To address that gap, a descriptive, three-phase, mixed methods (quantitative and qualitative) study was conducted. In Phase One, Rodgers’ (2000) evolutionary method was used to analyze the concept of home care nursing workload based on the empirical literature. Phase Two was situated within the naturalistic inquiry paradigm and involved observation of ten home care registered nurses during their visits to 61 patients. In Phase three a questionnaire was administered to validate the draft definition and attributes for the concept of home care nursing workload. It was completed by 88 home care nursing experts from clinical practice, education, management and research. Qualitative findings were analyzed using inductive content analysis. Quantitative data were analyzed descriptively using SPSS. Data triangulation was used extensively within and between the study phases. Of 14 attributes in the phase three draft concept definition, respondents assigned the highest level of relevance to the attribute of cognitive effort and the lowest to physical effort. The final definition contained 20 attributes and includes the following excerpt: “Home care nursing workload is the totality of the cognitive, emotional and physical effort home care nurses expend to meet the expectations of all stakeholders in providing holistic, outcome directed and patient/family focused care within the context of a short or long-term therapeutic relationship.” Respondents reported high levels of agreement with the accuracy and completeness of the definition and the majority indicated the definition would be useful or very useful in their day-to-day work. The comprehensive concept exemplar that emerged from the study includes each of the identified attributes. The study findings provided evidence of the complexity and challenge inherent in quantitatively measuring home care nursing workload. Accordingly, implications of the findings are shared for the management and monitoring of workload and associated outcomes, as well as for nursing practice, education and research.

The concept of home care nursing workload has not been widely studied and no evidence was found that an analysis of the concept had been undertaken. Consequently, there was a knowledge gap regarding the definition and attributes for the concept of home care nursing workload as it is currently experienced. To address that gap, a descriptive, three-phase, mixed methods (quantitative and qualitative) study was conducted. In Phase One, Rodgers’ (2000) evolutionary method was used to analyze the concept of home care nursing workload based on the empirical literature. Phase Two was situated within the naturalistic inquiry paradigm and involved observation of ten home care registered nurses during their visits to 61 patients. In Phase three a questionnaire was administered to validate the draft definition and attributes for the concept of home care nursing workload. It was completed by 88 home care nursing experts from clinical practice, education, management and research. Qualitative findings were analyzed using inductive content analysis. Quantitative data were analyzed descriptively using SPSS. Data triangulation was used extensively within and between the study phases. Of 14 attributes in the phase three draft concept definition, respondents assigned the highest level of relevance to the attribute of cognitive effort and the lowest to physical effort. The final definition contained 20 attributes and includes the following excerpt: “Home care nursing workload is the totality of the cognitive, emotional and physical effort home care nurses expend to meet the expectations of all stakeholders in providing holistic, outcome directed and patient/family focused care within the context of a short or long-term therapeutic relationship.” Respondents reported high levels of agreement with the accuracy and completeness of the definition and the majority indicated the definition would be useful or very useful in their day-to-day work. The comprehensive concept exemplar that emerged from the study includes each of the identified attributes. The study findings provided evidence of the complexity and challenge inherent in quantitatively measuring home care nursing workload. Accordingly, implications of the findings are shared for the management and monitoring of workload and associated outcomes, as well as for nursing practice, education and research.