Telephone nursing (TpN) care is delivered in a wide range of settings and provides a variety of services to individuals and populations across the age span. Although a viable specialty practice, there is little evidence regarding how the process of care delivery contributes to successful outcomes. To study the effects of TpN care, and to develop appropriate clinical and education interventions, a solid understanding of the process is needed. This study utilized grounded theory method to identify and describe the core concepts of the TpN process, the relationships among these concepts, and the factors influencing the process. Study findings were validated through peer and participant review. Based on interviews with ten telephone nurses from four sites, the following components were identified and organized into a conceptual model of the TpN process. The process generally proceeds through three phases, gathering information to cognitive processing to output. Throughout these phases, the nurse engages in a goal oriented parallel process focusing on both explicit (e.g., verbal, physical) and implicit (non-verbal, contextual) dimensions. Inherent to this parallel process is a two-way interpreting process in which information from the caller is translated into health care language for processing and then health care information is translated back into the language of the caller to identify and meet their needs. Factors influencing the process include prioritization and the level of complexity of the call, resources of the nurse and the organization, and the nurse's desire for validation of the service and the appropriateness of the output. The model highlights the need for research further delineating how implicit information is gathered and processed and how it influences output. Research is also needed on the value of implicit output and on the effects of feedback regarding output on nurse performance and satisfaction. The model suggests that more nursing education should be focused on the sub-processes within the three phases, the interpreting process, and implicit aspects of the process. Finally, the model suggests that formal feedback regarding the quality of call output should be provided and the value of implicit nursing output should be recognized.

BACKGROUND: Over the past 10 years, molecular-based and targeted therapies in oral forms have emerged and continue to change the landscape of cancer care and care delivery. While cancer treatments traditionally have been administered at the hospital, oral anti-cancer medications (OAM) can be taken by patients at the comfort and convenience of their homes. However, this also creates implications for ensuring that patients take their oral chemotherapies correctly, timely, and safely, all of which can impact outcomes and tolerance. Studies have shown concerning gaps in patients’ knowledge of taking and handling their OAM, including lower rates of adherence. Interventions have largely consisted of a combination of nurse- and pharmacist-led approaches along with the use of various educational and reminder tools. However, few studies have examined the potential of an intervention led by a pharmacist and a medication (patient) navigator. OBJECTIVE: This ongoing pilot study aims to assess the feasibility of the intervention, the impact on patients’ understanding and adherence to their oral anti-cancer medications, and the patient perceptions of the helpfulness of the intervention. METHODS: Patients who were initiating oral chemotherapy were enrolled at Tufts Medical Center Cancer Center, which was the study site for this pilot intervention. Study participants met with the Specialty Pharmacist and Medication Navigator for their initial education session and teach-back using the Oral Agent Teaching Tool (MOATT). They were also given Information Sheets and individualized Calendars for their OAM. The Pharmacist and/or Navigator subsequently followed up with the participants for three more check-ins and educational boosters. Participants completed study measures including the self-reported Adherence Measure, MD Anderson Symptom Inventory, and study evaluation. RESULTS: A total of 37 patients have so far been enrolled in the study and completed their initial education session with the Pharmacist and 33 of those patients completed the Navigator-led booster check-in approximately one week later. These patients are receiving ongoing follow-up for their two remaining check-ins in the study. After the first teach-back with the Pharmacist, patients largely showed sufficient understanding of how to take and handle their medication. This level of understanding was sustained a week later at the Navigator booster. Despite high levels of self-reported adherence, patients showed insufficient understanding of refill logistics. Patients were highly satisfied with the intervention and had found both the check-ins and the educational tools provided useful. CONCLUSION: This Pharmacist- and Navigator-led intervention was found to be feasible to deliver, capable in enhancing patient understanding and adherence to their medications, and helpful to the patients throughout taking their OAM.

“Telemedicine” denotes medicine at a distance using telecommunications and information technologies. The aim of the thesis is to reveal determinants and outcomes of telemedicine diffusion—that is, the spread of telemedicine in time and space. Telemedicine is examined both at the national level and in a regional case study. At the national level, quantitative methodology is utilized to analyze the emergence of health care facilities using telemedicine to receive medical assistance. The regional case study examines the diffusion and outcomes of telemedicine networks in Northern Sweden based on non-quantitative data sources. The first telemedicine applications in Sweden emerged between hospitals in southern Sweden in the 1970s. It was in the 1990s, however, that the practice of telemedicine took off on a larger scale. By the year 2000, the number of remote sites was quite evenly distributed across the country and between specialist and primary care facilities. In northern Sweden, telemedicine was first implemented in the mid-1980s, and is now carried out in all counties in the region. The telemedicine networks in northern Sweden primarily concern teleradiology, general telemedicine, and telepathology. Commonly, telemedicine is carried out within counties in hierarchical hub and spoke-type networks connecting specialist and primary care facilities. The study shows that existing telemedicine facilitates its further diffusion at the regional level, but shows a lack of the obvious neighborhood effect that could be expected in light of many previous diffusion studies and geographical diffusion theory. The health care system in Sweden is characterized by a high degree of regional autonomy. Contacts between medical staff, and thus dissemination of information and opinions concerning telemedicine, are therefore likely to be more prevalent within than between the regional health care organizations. The health care organizations are also decision-making bodies with different telemedicine policies. In addition, already implemented telemedicine programs tend to expand within the health care organization in which they originated. Although no traditional neighborhood effect to speak of can be noticed in Swedish telemedicine diffusion, distance matters in the diffusion process in a quite different respect. The study shows that health care facilities located far from more specialized care are especially likely to adopt telemedicine. Another local factor, facility size, is also positively correlated with telemedicine diffusion. This correlation between facility size and telemedicine adoption, as well as the circumstance that the diffusion process started with, and has progressed the furthest in, specialist care, suggest that the diffusion of telemedicine exhibits hierarchical characteristics. The development of telemedicine technology significantly influences the rate of telemedicine diffusion. In a simulation of the diffusion process, it is shown that—given that computers and information technology continue to develop according to the present trend—there will be a significant increase in the number of primary care facilities functioning as remote telemedicine sites during the first decade of the 21st century. / digitalisering@umu

The complexity and lack of coordination of the U.S. health care system is especially challenging for older adults, many of whom have multiple chronic conditions. The faith community is a potential partner to assist them, due to strong religiosity of older adults and specific characteristics of faith communities. This study explores the knowledge and practices of faith community nurses (FCNs) in meeting care coordination needs of older adults and identifies a model of gap-filling by FCN practice. An approach combining both quantitative and qualitative approaches was used. A survey was distributed to all known FCNs in Kentucky. From the 60 respondents, 15 FCNs were selected for personal interviews, and six care recipients were also interviewed. Survey data revealed a relatively older workforce, M=57 years, with 73% in nursing for more than 20 years. All served as FCNs in their own congregations, mostly as volunteers. FCNs relied on informal rather than formal assessments, with little consistency in type of health-related information obtained from congregants. The combined interview data revealed themes including, strong grounding in faith, sense of congregational family, reliance on general nursing assessment skills, intentional empowerment, bridging expanses, trust, and continuity. Findings suggest that FCNs in Kentucky identify and fill significant gaps in health care for older adults. Spirituality and religious rituals were important for FCNs and those they served. Congregants sought out FCNs to answer questions, interpret medical information, and assist with health care interactions. The stability of the FCNs in the lives of congregations was regarded as important; congregants counted on FCNs presence through transitions in health. A model to explain FCN intervention was developed based on integration of a social ecological perspective with the WHO International Classification of Functioning, Disability, and Health. This model reflects contextual factors that occur throughout nested environments that surround each individual, including immediate family, congregational family, health and social care systems, and societal policies. FCNs serve as a bridge between and among these nested environments, connecting them and facilitating change within each level.

Thesis (Ph. D.)--Cornell University, June, 1974. / Includes bibliographical references (leaves 223-236).

Thesis (Ph. D.)--Cornell University, June, 1974. / Includes bibliographical references (leaves 223-236).

Hearing loss is considered a global health concern with 466 million people affected worldwide. Current hearing health care delivery models are based on several consecutive face-to-face consultations that occur in-person. Information and communications technology, and especially mobile technology, can be used to support or enhance health care delivery. This can be employed in addition, or as an alternative to, current patient treatment pathways. This project developed a hybrid hearing health care approach by combining online and face-to-face services. The services were offered using a five-step approach: (1) online hearing screening, (2) motivational engagement by voice/video calling, messaging, or emailing, (3) diagnostic hearing testing in a face-to-face appointment, (4) counseling, hearing aid trial and fitting using face-to-face and online methods, and (5) online aural rehabilitation, counseling and ongoing coaching using face-to-face and online methods. Three studies were conducted. Study I investigated the readiness, characteristics and behaviors of patients who sought hybrid hearing health care. Over three months (June–September 2017), 462 individuals completed the online hearing screening test: 59% (271/462) of those failed (age M = 60; SD = 12), indicating that further assessment and treatment might be required. These patients had been aware of their hearing loss for a period of between 5 to 16 years. A significant positive correlation was observed between age and speech reception threshold (r = 0.21; p < .001), where older participants presented with poorer scores. Five participants completed readiness measurement scales and attended a face-to-face diagnostic hearing evaluation during this time. Study II investigated patient uptake, experience and satisfaction with hybrid hearing health care using a process evaluation. The process evaluation study was conducted over a three-month period for patients who sought services from the clinic over a period of 19 months (June 2017–January 2019). A total of 46 patients seen at the clinic were invited to complete an online questionnaire regarding their experiences and satisfaction with the steps completed and services provided. Of those, 31 (67%) patients responded (age M = 66; SD = 16). Of the 61% of patients who had previously sought hearing services, 95% reported the hybrid clinic services as superior. Two main themes emerged from the patient’s comparison of their experience with the hybrid clinic versus previous experiences: clinician engagement (personal attention, patience, dedication, thorough explanations, professional behavior, exceeding expectations, friendliness and trust) and technology (latest technology, advanced equipment and hearing aid trial). Patients who completed all five steps, including acquiring hearing aids and taking part in an online aural rehabilitation program (continued with hearing health care), were significantly older and had significantly poorer speech reception thresholds compared to those who did not acquire hearing aids after the diagnostic hearing test and hearing aid trial (discontinued hearing health care). A significant positive correlation was found between age and the number of face-to-face appointments attended per patient (r = 0.37; p = .007). Study III investigated whether digital proficiency (proficiency with mobile devices and computers) was a predictor of the uptake of hybrid hearing health care. A total of 931 individuals failed the online hearing screening test and had submitted their details to the clinic for further care over a 24-month period (June 2017–June 2019). Of the 931 online test takers, 53 persons (age M = 64; SD = 15) who attended a face-to-face diagnostic hearing testing completed a mobile device and computer proficiency questionnaire. An exact regression model identified age as the factor associated with patients completing all five steps, including acquiring hearing aids and taking part in an online aural rehabilitation program (continued with hearing health care) from a hybrid model (β = .07; p = .018). Older patients were more likely to continue to seek hearing health care. Digital proficiency was not significantly associated with adults with hearing loss taking up services through a hybrid hearing health care model. The results from these three studies demonstrate that asynchronous internet-based services such as an online hearing screening test can be used to create awareness of hearing health care. It is possible to provide online support to patients during the initial stages of seeking hearing health care online prior to the first face-to-face visit. Patient uptake, satisfaction and experience of using hybrid hearing health care services are positive when compared to traditional methods of service delivery. Hearing health care models that combine face-to-face and online methods hold promise for audiologists willing to incorporate online modalities into current treatment pathways. This research project highlights the opportunity for audiologists to provide services and personalized support to patients using a combination of face-to-face and online modalities. / Thesis (PhD)--University of Pretoria, 2020. / This work was supported by the National Research Foundation (NRF) of South Africa under the grant number 107728. / Speech-Language Pathology and Audiology / PhD (Audiology) / Unrestricted

A thesis submitted in partial fulfilment of the requirements for the degree of Masters of Arts in Clinical Psychology at the University of Zululand, South Africa, 2011. / South Africa is at a critical point in the debate about the future of health-care in the occupation-specific dispensation (OSD). It also faces the exodus of valuable human resources that was perceived as greener pastures, as medical practitioners become increasingly dissatisfied with governmental policy, wage negotiations, work-place disillusionment, lack of service delivery, expressions of corruptions, and lack of resources. This research aimed to thematically analyse the experiences, opinions and feelings of medical practitioners in both the public and private health-care sectors as well as explored international trends with the intention of drawing comparisons, highlighting problem areas, and discussion of possible solutions. It was hoped that this research would contribute towards understanding the dynamics that marked the exodus of medical practitioners from South Africa, at a time when change in the health-care system was imminent. In order for the medical practitioners to remain in the current health-care system, a new dialogue would have been opened in which their concerns could be raised and evaluated.

Indiana University-Purdue University Indianapolis (IUPUI) / Introduction: The U.S. is faced with a primary care (PC) workforce shortage; an estimated 43 percent of the population has unmet health care needs and 18.2 percent of the adult population lacks a usual source of care (USC) provider. The workforce shortage limits even those with a USC from receiving the full scope of recommended clinical services. One promising solution is reforming scope-of-practice (SOP) policies for PC nurse practitioners (NPs). Objectives: The primary objective of this dissertation was to assess the impact of NP SOP policy implementation on NP practice patterns and patient access to PC by evaluating NP time spent delivering patient care, NP role as USC providers, patient travel times, and appointment availability. Methods: The studies discussed in this dissertation leveraged cross-sectional data from the National Sample Survey of Nurse Practitioners (NSSNP), time-series data from the Medical Expenditure Panel Survey (MEPS), and the Nurse Practitioner Professional Practice Index (NPPPI) to quantify variations in state policy environments. We used generalized mixed effects models to examine relationships in the cross-sectional data analyses and two-way fixed effect models to evaluate longitudinal data. Results: Our analyses revealed several key findings: NP SOP policies do impact the percentage of time NPs spend providing direct patient care; the NP workforce role as USC providers has increased as SOP policies have changed; states with supportive reimbursement policies have more NPs working as USC providers; and states with fewer NP supervision requirements have shorter patient travel times to USC providers. Conclusion: The U.S. health care system must continue to evolve to address the growing demand for PC services. While strategies to increase the supply of PC providers may be an effective long-term solution, our findings suggest that NP SOP reform may be a viable and complementary strategy to increasing the capacity of the PC workforce, providing more immediate relief. / 2 years

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