Thesis (Ph. D.)--University of Canterbury, 2008. / Typescript (photocopy). "11 April 2008." Includes bibliographical references (p. 245-260).

Thesis (M.T.S.)--Catholic Theological Union at Chicago, 1990. / Vita. Includes bibliographical references (leaves 108-114).

Thesis (Ph. D.)--University of Virginia, 1990. / Includes bibliographical references (leaves 197-206). Also available online through Digital Dissertations.

Thesis (M.S.)--University of Michigan, 1992.

Thesis (M.S.)--University of Michigan, 1992.

Thesis (M.S.)--University of Wisconsin--Madison, 1982. / Typescript. eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references (leaves 103-109).

Thesis (M.S.)--University of Wisconsin--Madison, 1982. / Typescript. eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references (leaves 79-82).

This thesis describes a qualitative study exploring the use of critical care diaries from the experiences and perspectives of patients, family members and nurses in a Scottish Intensive Care Unit (ICU). Diaries are currently used in some ICUs across Europe, the UK, Australia and other countries to help patients come to terms with the experience of critical illness. Started in the ICU, the diary is written at the bedside by nurses and family members providing an account of what happened when the patient was in ICU. Following discharge, the diary is handed over to the patient for them to read and refer to during their recovery. Therefore, the diary is used by different people, at different times and in different ways throughout the critical illness journey. However, until recently, research has mainly focused on the diary being read by the patient after ICU as an aid to recovery with little known about family members and nurses despite them being the main authors during the time in ICU. This doctoral research was designed to explore critical care diaries from multiple perspectives and experiences to gain a greater understanding of the different ways in which diaries can be used. Furthermore, it is the first known research study in this area to have been undertaken in NHS Scotland where the use of diaries remains a relatively new practice. The theoretical perspective of Symbolic Interactionism helped to inform the development and design of the research study. A focused ethnographic approach was taken to explore the use of critical care diaries from the different groups identified, during and after a stay in ICU. The setting was an Adult ICU in Scotland where diaries were being used as part of a follow up service for patients and family members after ICU. Data were collected from February 2013 to June 2014. Semi-structured interviews were the main method of data collection. A purposive sampling strategy was adopted to recruit participants in triads with a related patient, family member and nurse involved in their care during the time in ICU. This is a novel and unique approach to research in this area. Four complete triads and two incomplete triads were recruited giving a total of sixteen interviews with four patients, six family members and six nurses. Interviews were supplemented with a small number of formal observations of nurses carrying out diary related activities (n=9) and field notes from time spent at the site. Transcribed interview data were analysed using a thematic approach, uncovering five main themes: (1) Information; (2) Communication; (3) Emotion; (4) Person Centered and (5) Gender. The concept of ‘Stories as joint actions’ developed by the sociologist Ken Plummer in 1995 was used as a framework to discuss and explain the findings. Diaries were found to support information sharing and facilitate communication interactions between nurses, family members and patients in the ICU as well as promoting and demonstrating a person centered approach to care. Emotional support was experienced by family members from writing in and reading the diary during the time in ICU whereas patients experienced emotional support from reading diary entries after the time in ICU. However emotional effort was associated with reading and writing in the diary during and after the time in ICU for patients, family members and nurses. Male family members were found to be less likely to write in the diary compared to female family members. Factors such as gender and literacy appeared to influence diary use however this requires further investigation. A new conceptual model ‘Critical Care Diaries as Joint Actions’ was created to address the complex nature of experiences with critical care diaries. Exploring the use of diaries from multiple perspectives and experiences has provided valuable insight into the different ways in which diaries are used during and after the time in ICU demonstrating that although the diary is primarily written for the patient, family members, nurses and patients use the diary in different ways to support their needs and others needs throughout the experience of critical illness.

BACKGROUND: Infective endocarditis (IE) is an infectious disease, most often bacterial in etiology, which affects the endocardial tissue layer of the heart. Despite advances in diagnostic technology, surgical technique, and antimicrobial therapy, IE remains a high-mortality disease. OBJECTIVE: This is a proposed quality improvement initiative for the Boston Medical Center (BMC) inpatient medicine service. The initiative aims to identify predictors of mortality in patients with IE, and then use the predictors to create a mortality risk-assessment checklist. The checklist will serve as a clinical tool for medicine service providers to help determine if upgrade to ICU level of care is warranted. With early upgrade to an ICU setting, patients with a high risk of mortality will receive more individualized care and expedited medical intervention. The goal of this quality improvement initiative is to decrease mortality rate in patients with IE at BMC. METHODS: This quality improvement initiative will implement the PDSA (plan, do, study, act) model for quality improvement. The checklist will be integrated into the electronic health record system at BMC and will be implemented over a two-year time period. Each PDSA cycle will last one year, and between PDSA cycles the checklist will be modified according to medical provider feedback. The data will be gathered through chart reviews to determine pre and post-checklist differences in number of transfers to the ICU and overall mortality rates of IE patients at BMC. RESULTS: The literature review of this proposed quality improvement initiative has identified nine independent risk factors for mortality in patients with IE: Staphylococcus aureus as infective organism, New York Heart Association class IV heart failure, left ventricular ejection fraction < 40%, vegetation size ≥ 15 mm, age > 50 years, diabetes mellitus, peripheral dermatologic findings on physical examination, serum neutrophil-to-lymphocyte ratio > 5.45, and serum D-dimer level > 4.0 mg/L. CONCLUSION: If medical providers had access to a risk assessment tool to help identify IE patients with a high risk of mortality, they could more accurately determine appropriate level of care, expedite medical intervention, and possibly reduce rates of in-hospital death in patients with IE.

abstract: The physical environment influences the physiology, psychology, and the societal interactions of those who experience it. The environment can also influence human behavior. Critical care nurses are in constant interaction with the physical environment surrounding their patients. High acuity ICU patients are vulnerable and at risk for harm, infection, and poor outcomes while the physical and cognitive workload of nurses presents a demanding and continuous challenge. The goal of this qualitative study was to explore and understand the way critical care nurses navigate within the patient room and interact with its features. The study of critical care nurses interacting with the patient room environment was conducted in five critical care units at three tertiary care institutions in the Eastern United States, along with another unit in the pilot study at a community hospital in the Southwest United States. Nurses were observed in their typical work environment as they performed normal tasks and patient care activities for entire day and night shifts. The study involved ethnographic field observations, individual semi-structured participant interviews, and examination of photographs and floor plans. The exploratory study resulted in a comprehensive model for nurse navigation that includes both cognitive and action components, along with a conceptual framework for nurse behavioral activity. Repetitive patterns of nurse movement were identified and named. The findings produced recommendations for nurses’ effective use of space and architectural design of ICU patient rooms to improve patient outcomes. / Dissertation/Thesis / Doctoral Dissertation Nursing and Healthcare Innovation 2017