None / Clinicians in general value the use of the best evidence in decision-making and consider that can improve patient care. However, a successful evidence based practice is hard to achieve in real life. In recent years, with the consolidation of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, the development of improved standards to judge the trustworthiness of guideline recommendations and the adoption of more strict policies to limit the influence of conflict of interests, trustworthy guidelines have become an attractive alternative for an evidence-based clinical practice. In this thesis we offer an explicit and easy-to-use guidance to clinicians regarding how to use guideline recommendations in the context of a real life practice. We also provide an in-depth explanation of the judgments involved in determining the direction and strength of recommendations. Finally, we expand the knowledge about how to manage conflict of interests in guideline developers. Through two studies evaluating the conflict of interest policy implemented at the American College of Chest Physicians 9th edition of the Antithrombotic Guidelines, we show what aspects of the policy were successful and what aspects need to be reformulated. / Thesis / Doctor of Philosophy (PhD) / None

No / Midwives collect considerable amounts of data as part of their routine practice. They also have access to extensive information about patients and, more generally, about effective interventions. an investigation of data related to smoking in pregnancy was undertaken in one UK NHs Trust. The brief was to identify what data were collected, how these data were transmitted to appropriate staff and how these data were used to inform practice. in addition, evidence on smoking in pregnancy in the research literature was reviewed and examples of best practice in other Trusts sought. a wide range of issues inhibiting optimal use of data were identified and recommendations for changes made. as well as changes in approaches to data use and collection, this led to changes in clinical practice. specifically, this research supported moving from ascertaining maternal smoking behaviour via asking questions to undertaking carbon monoxide tests as routine antenatal practice.

No description available.

Introduction and Rationale: Concussions account for the majority of traumatic brain injuries in children. Currently there more than 500,000 pediatric concussions per year and that number is likely low due to under-reporting (Rose, Weber, Collen,& Heyer, 2015). Most symptoms of concussion are easily recognized to the trained pediatric primary care provider. Yet, symptom management and recommendations for rest, exercise, specialty care referral, and return to normal activities can be challenging for many providers, due to the lack of evidence and lack of formal recommendations by any organization (Rose et al., 2015; Silverberg & Iverson, 2013). Purpose and Objective: The main purpose of this Doctor of Nursing Practice (DNP) project is to develop evidence-based clinical practice guidelines (CPG) for pediatric primary care providers. The objective is to provide a CPG that offers clinical guidance when managing pediatric concussion patients in the primary care setting. This CPG will also provide clarity for pediatric primary care providers (PCP) when determining what options are available in treatment for pediatric concussions. Methods: The working framework of this project was The Appraisal of Guidelines for Research & Evaluation II (AGREE II). The American Academy of Pediatrics (AAP) procedure for reporting clinical guidelines, in the form of key action statements, was used as the model for development of the CPG. Results: The CPG was appraised using the AGREE II instrument, which provides valid and reliable scores and data used in the evaluation of CPG's. Six domains were evaluated, and the CPG yielded scores above 80% for all categories. The overall standard deviation was 0, which indicts a very low level of discrepancy between users of the instrument. Conclusion: This DNP project addresses an evidence and primary care practice gap. With a large number of pediatric concussions, a consistent management approach will ensure a safe and therapeutic recovery. A CPG was developed and evaluated using the AGREE II instrument. The CPG was found to meet the standards for general recommended use in pediatric primary care.

Quelle est la force juridique des RBP en matière sanitaire, en plein contentieux comme en recours pour excès de pouvoir? Quelles sont les différences d'approche entre la France et les Etats-Unis? / What's the legal strength of CPGs in healthcare, in France and in the United States?The Institute of Medicine has defined as soon as 1992 Clinical Practice Guidelines as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." As they derive from various public and private bodies, and from the consensus of experts, CPGs are considered as consensus statements representing the prevailing standard of care in the medical profession. Clinicians and judges use clinical practice guidelines in their everyday life to appreciate individual situations and reach the best solutions for patients and plaintiffs: CPGs help improve their decision-making. But the legal strength of these tools is not totally consensual. In France, CPGs are seen as evidence of the standard of care expected from physicians. In theUnited States, where CPGs appeared some years earlier, they have been subject to questions, denounced as symptoms of a “cookbook medicine” and object of experiments by various States and insurance companies – not to mention lobbies. Their legal weight seems all the same better established in the U.S. than in France, although rulings in 2011 and 2016 by the french Conseil d’Etat have given them a more central role and a more recognized legal position in France.

The purpose of this study is to examine the role of spirituality in the social work practice and social worker’s perspective on it. This project focuses on spirituality in social work and the role that it plays in a social workers practice. The data collected for this research project consists of qualitative data in which the researcher conducted one-on-one interviews of eight different clinical professionals in the social work field. The study employed a purposive sampling by recruiting LCSW’s, MSW’s, ASW’s, and other clinical professionals in the Northern California area. The average years of experience amongst the participants was 19.375 years. Each participant has a broad range of experience from individual clinical one-on-one counseling, working with groups, and supervision.

Childhood obesity is a national problem in the United States and has known implications as a potential cause of chronic illnesses as the child transitions into adulthood. A primary care clinic in the southwestern United States had a high percentage of obese Hispanic children within its population; therefore, the nurses and the pediatrician needed an evidence-based clinical practice guideline (CPG) to manage Hispanic children with a body mass index greater than the 95th percentile for their age. The purpose of the project was to develop a culturally competent CPG to manage childhood obesity in this primary care practice. The social cognitive theory provided the framework to develop the CPG. The final project resulted in an evidence-based CPG that was validated by an expert physician panel. The implication of this project is that nurses and providers can provide culturally competent education to the parent and child to reduce obesity among the pediatric Hispanic population. This project may create positive social change by modifying unhealthy cultural practices and behaviors, preventing chronic diseases, and reducing health care costs for the children within the selected practice.

This workplace study examined the every day ethical dilemmas of a multidisciplinary team in one acute psychiatric setting and the social factors affecting their moral domain of practice. The research design was a case study involving both qualitative and quantitative data. The context that shaped the team's process of ethical dilemma identification was conceptualised for the purpose of this research within a systems theory framework of interrelated factors at a societal, organisational and clinical level with ethics theory pervading the entire scene. The findings indicated that dilemmas arose in situations concerning patient care, team strain, and limited resources with the most common dilemma across disciplines arising from lack of community resources. Further findings suggested that clinicians were aware of various forces shaping practice but these ideas were not well connected conceptually. Staff felt wary of identifying ethical dilemmas because they were unsure of the process and sensed a reticence in the unit's social processes around negotiation and problem solving. Important social factors that were perceived to affect their abilities around ethical dilemma identification included rational economics, professional socialisation, medical-legal monopoly with a concomitant use of the ethic of justice, and managerial strategies. The concept of transference and countertransference issues within the staffing group was explored. These results are useful for the team to understand the nature of their own particular dilemmas and what factors constrain and enhance their abilities to identify dilemmas. Other health care settings may find that replication of the research results in a similar way may raise awareness of their moral situation. Generalisability at a theoretical level contributes to the current research agenda in applied ethics about the effect of context in the ethical domain of clinical practice.

Healthcare professions are known to be inherently moral. They confront on a daily basis essential ethical problems. However, my experience as a nurse shows a different reality. In practice healthcare professionals often have difficulty to even identify the ethical problem before attempting to resolve the situation. In a plethora of literature moral case deliberation (MCD) is discussed as method to address these limitations of healthcare professionals. In general MCD can be defined as a discussion with the different parties involved about the ethical issues of a real case in clinical practice. In order to achieve a more comprehensive understanding of MCD I identified MCD's main features and reviewed two methods (Clinical pragmatism and the Hermeneutic method) as examples. This review  unfolded certain assumed normative ideas more or less common in many models of MCD. However it is unclear how to understand these normative ideas and as to whether they should indeed guide MCD. Throughout the thesis I concentrate on some of these assumptions. I focused on the three, which I considered the most relevant for the implementation of MCD into clinical practice: 1) the involvement of everyone concerned the case, 2) consensus as an ideal within MCD and 3) MCD improves decision making. The aim of the thesis was to reflect on how these assumptions could be reasonably understood and to outline remaining ambiguities and points for critique in their application within MCD. Hence I am not arguing whether MCD should be part of clinical practice or not, I am critically reviewing the process of MCD within clinical practice. Finally, in the thesis it is illustrated that for each assumption various plausible explanations are possible, which all might have a role in practice. The usefulness of MCD might depend on what relevance these explanations are given in practice.

This thesis is an enquiry into the nature of process in nursing. The study was initiated by the experience of the researcher as a nurse attempting to utilise the Nursing Process in clinical practice. From the outset however, the focus of the study shifted from the utility of the Nursing Process to the nature of process in nursing. The data were collected by in depth, unstructured interviews with twenty staff nurses from general medical and surgical wards in five district general hospitals in the South of England. The interviews were transcribed, and analysed following grounded theory methods. The analysis produced a number of categories related to nursing practice and the context in which it occurs. The major finding of the study is represented as the core category and is labelled Nursing carea s clinicalh ermeneuticIsn. identifying this category the researcher considers nursing to be essentially a process of interpretation of clinical situations, that is to say that process in nursing is essentially hermeneutic in nature. Other categories were identified relating to the strategies used by nurses and the context of nursing practice. These were labelled as; latching over,T hinking about,B eingt here,D oing to,f orand with, Letting go, Climate of Constantc hangeL, andscapeo f predictabilitya nd Landscapeo f perfect expectation. These categories were linked to each other and to the core category forming an illumination of the core category. The categories of SufferingC' omfortinga nd Healing were identified as providing the impetus for nursing care. The categories have been linked together in a statement of substantive theory which describes nursing care as clinical hermeneutics in the following way: A process, which is the resultant of a complex, dynamic interplay between knowing, thinking, feeling, doing and context, in which the nurse seeks to prevent and relieve suffering, to promote comfort and facilitate healing. This interpretative process is achieved by helping the patient to understand the illness process, by reducing the alienating effects of illness and by facilitating a return to a taken-for-granted state of wholeness of mind and body. It is achieved through the nursing strategies of watching over, thinking about, being there, doing to, for and with and lettinggo and shaped by the context in which it occurs. In using grounded theory to achieve this theoretical stance, the thesis makes and seeks to justify four important claims about nursing. These are firstly, that nursing is more than simply a collection of tasks, but rather is a process of interpretation involving certain kinds of tasks. Secondly that apparently simple (or indeed complex) tasks involved in nursing are themselves an integral part of the process of interpretation. Thirdly that as a hermeneutic process, nursing may claim to have a philosophical basis. And finally that as a hermeneutic process, nursing is supported by and requires many forms of knowing, none of which are privileged but all of which are legitimate.