Objective: New Mexico nurse practitioners contribute to the prevention and management of pediatric obesity. This study aimed to assess nurse practitioners' knowledge, attitudes, and behaviors, which were unknown in New Mexico, to counseling frequency in the assessment and management of overweight and obese pediatric patients. This was done using clinical practice guidelines (CPG). The study also sought to learn nurse practitioners' insights on needed resources for clinical practice. Rural and urban nurse practitioners' responses were then compared to the study aims. Methods: This descriptive pilot study surveyed members of the New Mexico Nurse Practitioner Council (NMNPC) to evaluate their knowledge, attitudes, and behaviors, in addition to the counseling frequencies expected to result in patient change. The survey used the platform Qualtrics and measured answers using a four-point Likert scale. Rural and urban comparisons were evaluated for each variable (knowledge, attitudes, and behaviors) in order to investigate relationships. Despite the underpowered sample size, data were analyzed for feasibility of future studies using descriptive statistics, Spearman's Rho Correlation, and Mann-Whitney U testing. Results: Fifteen nurse practitioners were included in the statistical analysis. The data found the nurse practitioners' self-reported responses exhibited knowledge, positive attitudes, and confident behaviors using pediatric obesity CPGs. The increases in these parameters correlated reported needing a quick CPG tool that can be used in practice. In all, rural nurse practitioners reported a slightly higher usage of pediatric obesity CPGs than urban nurse practitioners. Conclusion: The feasibility of this study's assessment of nurse practitioners' knowledge, attitudes, and behaviors using CPGs will assist in developing interventions to impact patient outcomes. The study also found that resources needed by New Mexico nurse practitioners were similar to those desired by other providers throughout literature. Rural compared to urban nurse practitioners findings indicated the need for further research. Future studies should include all health care providers in New Mexico in order to further explore aims of this study and development of interventions on overweight and obese pediatric CPGs to positively impact practice.

The purpose of this thesis was to determine the feasibility of implementing an intervention tailored to overcome barriers to adherence to recommendations of critical care nutrition guidelines in the Intensive Care Unit (ICU). The thesis is comprised of four manuscripts. The first manuscript described the development of a 26 item questionnaire rating the importance of potential barriers as impediments to the provision of enteral nutrition (EN) in the ICU. Preliminary evaluation demonstrated acceptable face and content validity and internal reliability, but the test retest reliability and within group reliability were poor for some items. The second manuscript provided evidence to support the construct validity of the developed questionnaire by reporting the results of a multilevel multivariate regression analysis of cross-sectional data from 55 ICUs that demonstrated that a 10 point increase in the overall barrier score was associated with a statistically significant 3.5% (Standard Error (SE) 1.3) decrease in prescribed calories received from EN. The third manuscript provided data to inform whether the intervention should be tailored to site specific barriers by describing the barriers to enterally feeding critically ill patients identified by 138 nurses, and evaluating whether these barriers differed across the 5 participating sites. Statistically significant differences were found among ICUs for 4 out of the 22 potential barriers. The fourth manuscript described the results of a pretest posttest study involving 5 ICUs in North America and determined that all participating sites successfully developed the tailored intervention. A statistically significant 10% (Site range -4.3 to -26.0%) decrease in overall barriers score, and a non-significant 6% (Site range -1.5 to17.9%) change in prescribed calories received was observed following the intervention. However, there was variability in the degree of implementation achieved by each site. Taken together, the results of this thesis demonstrated that adopting a tailored approach to improving nutrition practice is feasible. However, the findings also resulted in revisions to the barriers questionnaire and modifications to the design of the tailored intervention. Thus, the next step is to formally test the hypothesis that a tailored intervention designed to address barriers to feeding critically ill patients will improve nutrition performance. / Thesis (Ph.D, Community Health & Epidemiology) -- Queen's University, 2013-04-28 21:37:54.695

Background: Health-related quality of life (HRQL) outcomes have been increasingly used in phase III randomized controlled trials to characterize the benefits or risks of a cancer treatment. HRQL outcomes from clinical trials can also inform clinical practice in oncology settings. Previous qualitative research suggests that oncologists value HRQL outcomes but challenges to their clinical application exist. Little quantitative research has been conducted to examine these barriers. This study describes the opinions of oncologists toward HRQL outcomes, the ways in which HRQL outcomes can be presented, and the importance of suggested reporting standards for HRQL outcomes in clinical trials. It further examines the association between attitudinal and demographic factors associated with the self-reported current use and achievable use of HRQL outcomes in clinical practice. Methods: This study is a cross-sectional survey of oncologists. A web-based questionnaire was disseminated in Canada, United Kingdom, and Australia/New Zealand. The study included oncologist members of the NCIC Clinical Trials Group, the NCRI Clinical Studies Groups, and the Australasian Cancer Clinical Trials Groups. Respondents were asked to report their opinions toward HRQL outcomes and the factors associated with the use of these outcomes in clinical practice. Demographic characteristics were also collected. Chi-square tests were used to compare the proportion of responses between countries. Logistic regression was used to identify factors associated with the use of HRQL outcomes in clinical practice. Results: A total of 344 oncologists completed the survey. Most oncologists (65.9%) reported having a good knowledge of HRQL outcomes and 72% perceived HRQL outcomes to be useful. High current use of HRQL outcomes in clinical practice was associated with more medical practice experience; perceiving HRQL outcomes to be useful; perceiving HRQL measurements to be reliable; and reporting lack of understanding to rarely be a barrier to using HRQL outcomes. High achievable use of HRQL outcomes in clinical practice was associated with being a male oncologist, perceiving HRQL outcomes to be useful, and being an investigator in RCTs. Conclusions: Important factors associated with the use of HRQL outcomes in clinical practice were identified, highlighting the need for future research and education. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2013-09-30 12:56:09.362

The clinical learning environment (CLE) provides students with an opportunity to build confidence and competence in the provision of patient care (Benner, 2010). The aim of this qualitative descriptive research was to explore and describe student perceptions of developing confidence through their clinical learning experiences, discovering what features of the CLE support their learning and the development of confidence. Ten students were recruited through purposive sampling and participated in one-on-one semi-structured interviews. Self-efficacy theory (Bandura, 1997) was used as a theoretical framework to guide this research and for the interpretation of the content analysis. The analysis revealed five socio-structural themes that support student learning and development of confidence. These findings elaborate Bandura’s (1997) theory. The most influential, through verbal persuasion was the clinical nursing instructor (CNI) followed by self, the buddy nurse, peers, and the staff/unit environment. Students perceived their development of confidence through a bi-directional interaction between their cognitive/affective processes, behaviour and the CLE. Understanding student perceptions of their confidence development, signals the need for informed pedagogical strategies to support student learning and development of confidence. / October 2016

Clinical practice is a major component of nursing education wherein significant learning takes place. It is also a place where nursing students can experience stress which can have a negative impact on their learning. The purpose of this study was to explore nursing students’ perceptions of and experiences with their coping efforts as they face stress associated with clinical practice. Lazarus and Folkmans’ theory of stress and coping guided this study. Semi-structured interviews were conducted with 10 undergraduate nursing students. Qualitative thematic analysis was used to analyze the data. Four major themes emerged upon analysis: Learning about self, Social Support, Self-Care, and Clinical Instructors. Nursing students need clinical environments which let them face challenges and meet the responsibilities of nursing practice with support from clinical instructors (Emerson, 2007; Parker & Myrick, 2010). A non-punitive and respectful environment is essential for a student to learn and cope effectively with stressful situations. Clinical instructors play a significant role in the clinical practice of nursing students. Clinical instructors facilitate learning by helping students to overcome situational, knowledge-related or emotional stressors. Negative relationships with them can increase the amount of stress in students in their clinical practice. Whereas positive relationships with the instructors and the staff on the unit increase students’ comfort, decrease stress, and enhance learning. This study yielded qualitative data on nursing students’ views about and experiences with coping with the stress from their clinical practice. This study also provided valuable information regarding the clinical instructor’s role in the coping process. The findings have implications for improving the clinical instructor’s role in enhancing coping among nursing students with the stress that arises from clinical practice. / May 2016

Recovering from a cardiac surgery procedure and the transition to home can be an overwhelming experience for patients and caregivers. A tertiary care hospital's cardiothoracic surgery department suspended a nurse-practitioner-coordinated transitional care program in the 1st quarter of 2016. Following this decision, the readmission rate increased from its previous rate of 15.6% in quarter 1 to 20% in quarter 3. The purpose of this scholarly project was to develop a clinical practice guideline (CPG) that can bridge the gap in the transitional care process. The transitional care model informed the design of the project. A draft guideline was distributed to 5 stakeholders from the inpatient cardiac surgery care team for initial review. After initial review and revisions an edited version was then distributed to 5 additional stakeholders. Those stakeholders provided an assessment utilizing the AGREE II tool to assess the 6 domains of scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, application and editorial independence, and overall quality. Four domains indicated a high level of agreement (96%-100%) and 2 domains indicated a response of < 76% for domains related to rigor and organizational resources. The overall guideline assessment of the quality of the CPG received a score of 96%, with a recommendation to adopt the guideline. Advanced practice nurses will utilize this guideline to provide a systematic process in bridging gaps in care for the transition of the cardiac surgery patient population from hospital to home. Social change will be promoted through improved patient management by using evidence-based transitional care, decreased readmissions, and improved health outcomes for the cardiac surgical population.

Research Doctorate - Doctor of Philosophy (PhD) / Despite the emergence of smoking care guidelines and best practice recommendations over the past 13 years, it has been suggested that smoking care is not routinely provided in hospitals. Although there is a relatively large body of evidence regarding the prevalence of patient smoking cessation after hospitalisation and the effectiveness of interventions to increase cessation levels, much less is known regarding the prevalence of best practice smoking care routinely provided in hospitals or the effectiveness of interventions to increase such care provision. This thesis seeks to address these deficiencies in the evidence base. In particular this thesis aimed to: 1. Examine the prevalence of hospital smoking care in the international and Australian contexts. This is addressed via a literature review of studies that have reported the level of smoking care delivered routinely in hospitals and a survey of hospital managers in New South Wales, Australia. 2. Examine the effectiveness of interventions to increase the routine delivery of smoking care in hospitals. This is addressed via a literature review of studies that have reported the effect of an intervention on smoking care levels, and via the implementation of a quasi-experimental study that was designed to increase the hospital-wide delivery of a broad range of smoking care elements. 3. Propose recommendations for future practice and research regarding the routine provision of hospital smoking care. This thesis consists of six chapters that address the above aims. Each of the chapters has been written as a relatively distinct report in the style of a journal article. The approach has been adopted to facilitate the reading of the thesis, and results in some repetition in some chapters. At the time of submission, two papers based on the chapters of this thesis have been published in peer-reviewed journals. A further two papers are under editorial review.

Health-Related Quality of Life (HRQOL) is an important outcomes measure in cancer and there are specific issues depending on the site, stage, treatment and patient age. Although numerous instruments are available for cancer HRQOL, most are designed for adults, some for children, but none for adolescents and young adults (AYA) who have special age-specific concerns and poor improvement in survival compared with other age groups. An existing HRQOL instrument was modified to ensure its suitability for AYA, its validity, reliability and sensitivity were tested in Australians aged 16 to 25 years old diagnosed with cancer or a blood disorder. Varni’s PedsQLTM Measurement Model (13-18 year olds) was selected, modified then administered to families recruited from haematology/oncology clinics and wards at three Sydney Metropolitan Hospitals in person or by telephone. The Memorial Symptom Assessment Scale was used to categorise participants into groups reflecting sensitivity of symptom severity (slight, moderate and severe). The instruments demonstrated excellent internal consistency reliability, making them suitable for both group and individual comparisons. Clinical validity, construct validity, and discriminant validity were demonstrated by “known-groups” analysis, exploratory factor analysis and correlations, respectively. These new versions of the PedsQL Generic Core and Cancer Module are reliable, valid and sensitive measures of HRQOL in patients aged 16-25 years diagnosed with cancer or a blood disorder. The measures will soon be available for use as outcome measures in clinical trials and clinical practice with this age cohort in Australasia and internationally.

This research project investigated the impact of an action research intervention implemented to reducing surgical wound infection in one of the acute care hospitals in India. The study aimed to develop and implement a clinical practice improvement program in reducing surgical wound infection by improving the hand washing and wound dressing practices of nurses. The study also aimed to identify the important contributing factors to a model that predicts surgical wound infection. Pre-post evaluation measures were taken to compare the results of surgical wound infection rate before and after the implementation of the intervention. Surgical wounds of two thousand patients (one thousand before the intervention and another one thousand after) were assessed to determine the wound infection rate and severity of wound infection. The hand washing and wound dressing practices of forty nurses were observed. These same nurses were involved in the intervention using a participatory action research process. The results of the study suggest that there was a marked, significant reduction in the rate and severity of wound infection following the implementation of the intervention. By increasing the hand washing facilities in the ward, educating nurses on the importance of better hygiene, pre-operative shaving and post-operative wound care, the hand washing and wound dressing practices of nurses improved considerably. These improvements resulted in a reduction in the number and severity of patients' surgical wound infections. The study also examined the contribution of different factors to surgical wound infection in a Indian hospital. Significant predictive factors were the patients' age, longer pre-operative hospital stay, extended pre-operative shaving time before surgery, wound class, and co-morbidity of the patient. The identification of risk factors that contributed to increased surgical wound infection for example pre-operative skin preparation, pre-operative hospital stay of the patient would help in taking appropriate measures at the ward level and organisation as a whole. Nosocomial infections extends to an unnecessary lengthy hospital stay, additional treatment increased mortality and morbidity, and increased cost to the patients and the nation as a whole. This project proved that educational mentoring, data surveillance processes and involving the nurses in an action research process were effective in enabling participants to improve their clinical practice and thereby reduce the incidence of patients' surgical wound infections. Establishing infection control teams, ongoing surveillance and feedback to staff of nosocomial infection rates is an urgent need in all Indian hospitals. Organisational management, as a priority, need to provide funding and staff dedicated to undertaking this essential work. Health care professionals can no longer plead ignorance of a situation for which all have a moral and professional responsibility.

Purpose: To examine the effectiveness of a community-based intensive multifactorial clinical intervention for patients with Type 2 diabetes, to evaluate the feasibility of achieving clinical targets for glycemic control in a community setting, and to identify factors that are predictive of glycemic control in this cohort (age, gender, disease duration, continuity of care, pharmacologic treatment, diabetes self-care and smoking status). Methods: Participants with Type 2 diabetes referred to the Diabetes Clinic following dissemination of the 2003 Clinical Practice Guidelines of Canadian Diabetes Association and who attended a minimum of two physician visits within a twelve month period were deemed eligible for participation. 70 patients were included in this retrospective study. Baseline and twelve month values for the following biomedical outcomes were collected via chart audit: BMI, hemoglobin A1c, blood pressure (systolic, diastolic) and lipid profile (HDL, LDL, triglycerides, total cholesterol, TC:HDL ratio). Data for identification of predictive factors for glycemic control were also retrieved by chart audit. Results: The results of the paired t-test yielded a significant improvement in hemoglobin A1c (p<0.05), systolic blood pressure (p<0.01), HDL-cholesterol (p<0.05), LDL-cholesterol (p<0.01), total cholesterol (p<0.05) and total cholesterol:HDL ratio (p<0.05) over twelve months. No significant difference in BMI, diastolic blood pressure or triglycerides was reported over twelve months. Over half the sample (52.9%) achieved clinical targets for glycemic control (hemoglobin A1c <7.0%) at twelve months. Logistic regression analysis identified disease duration (O.R. = 0.90, 95% CI Exp(B) = 0.079 - 0.773, p = 0.01) and continuity of care (O.R. = 0.25, 95% CI Exp(B) = 0.831 - 0.969, p = 0.02) as significant predictors of glycemic control at twelve months. Conclusions: These findings demonstrate the effectiveness of this community-based intensive multifactorial clinical intervention for patients with Type 2 diabetes and show that the implementation of CPGs related to glycemic control is feasible in a community-based setting. Additionally, patients in this cohort with increased disease duration and increased continuity of care were less likely to achieve clinical targets for glycemic control following a twelve month intensive multifactorial clinical intervention for Type 2 diabetes. In summary, health professionals should strive to implement similar intensive multifactorial interventions in community practice in order to decrease the likelihood of diabetes-related complications and improve the patients quality of life.