Tools for measuring competence in delivering Cognitive Behavioural Therapy (CBT) provide a means of assessing the training of new CBT therapists and ensuring the quality of treatment provision within routine practice, provide a framework for delivering formative feedback, promote ongoing self-reflection, and are essential to establishing treatment integrity in research trials. As such, identifying an optimal strategy for assessing the competence with which CBT is delivered is crucial to the continued progression of the field. However, research in this area has been somewhat limited to date. Thus, there are at present no evidence-based best practice guidelines outlining the way CBT competence should be assessed. Furthermore, many of the assessment measures currently available have been widely criticised, indicating a need for improved tools for assessing CBT competence. To begin addressing this issue, the first two chapters of this thesis focus on reviewing and evaluating current assessment methods. Chapter one provides a systematic review of current methods of assessing CBT competence and chapter two outlines a qualitative exploration of experts’ understandings and experiences of assessing CBT competence. Findings from these studies provide tentative recommendations for practitioners and researchers assessing CBT competence. These initial studies also highlight ways in which the assessment of CBT competence could be improved and therefore provide a platform for guiding subsequent thesis chapters which focus on further developing existing assessment measures. Specifically, chapters three to six focus on the development and evaluation of a novel CBT competence rating scale: the Assessment of Core CBT Skills (ACCS). The ACCS builds upon currently available scales (especially the Cognitive Therapy Scale- Revised: CTS-R) to provide an assessment framework for assessors to deliver formative and summative feedback regarding therapists’ performance within observed CBT treatment sessions and for therapists to rate and reflect on their own performance. Development of the ACCS involved three key stages: 1- theory-driven scale development (chapter three), 2- an ‘expert’ review of the content validity, face validity, and usability of the scale (chapter four), and 3- an evaluation of the scale involving a pilot study examining its psychometric properties (chapter five) and a focus group examining its usability and utility (chapter six). Results from these studies indicate that the ACCS is a useful learning tool, is easy to use, has good psychometric properties, and offers an acceptable alternative to the CTS-R. Finally, chapter seven examines whether assessors require training in how to use the ACCS, concluding that simply reading the ACCS manual may be sufficient to achieve acceptable levels of reliability and usability. The results from the thesis are then drawn together in the final concluding comments in chapter eight, which discusses the findings within the broader context of the assessment of CBT competence.

A central part of the nursing profession is the performance of practical skills. In order to provide adequate care, maintain patient-safety, and feel comfortable in the profession, registered nurses (RNs) need to be equipped with requisite skills. Overall aim: To explore and describe how learning and development of practical skills occurs during the preparatory phases and within the nursing profession. Method: Qualitative (I, III, IV) and quantitative methods (II) were used. Data were collected through individual interviews (I, IV), questionnaires (II) and participant observations, including informal talks (III, IV). Results: Both students and new RNs expressed a need to learn and develop practical skills (I, II, III, IV). Less than half of the new RNs had access to a clinical skill laboratory (CSL), where they could learn and practice practical skills (II). The students described that learning at a CSL had been meaning for their clinical practice. They also expressed a great need for continuing learning in real patient situations (I, III, IV). During clinical practice, preceptors and students took different approaches which affected student’s learning processesö (I, III, IV). There was a tension between learning at a CSL and learning in clinical practice sites because students perceived differences in the performance of skills. Students described that they understood that performance of skills could be done in different ways without injuring patients. However, the data also showed deviations in performances that could jeopardize patientsafety. In these situations, student’s behavior differed (I, IV). One third of new RNs deviated from evidence based guidelines when they performed practical skills which they were unfamiliar with (II). Both students and new RNs reported that reflection in connection with the performance of practical skills was not common (I, II III, IV). Conclusions: Cooperation between university CSLs and clinical settings must be intensified in order to enhance the understanding of learning processes regarding practical skills. A consensus regarding academic approaches should be reached. Universities need to support preceptors in educational issues where the importance of reflection is clarified and exemplified. Increasing patient-safety requires that new RNs receive opportunities for training in artificial environments, and that a culture that reinforces the use of guidelines and a reflective stance is cultivated.

Submitted by Raquel Vergara Gondran (raquelvergara38@yahoo.com.br) on 2016-03-09T22:14:56Z No. of bitstreams: 1 dlenice.pdf: 1516345 bytes, checksum: 930c729b0216458e24773e1f6778bc27 (MD5) / Approved for entry into archive by Lilian M. Silva (lilianmadeirasilva@hotmail.com) on 2016-03-13T15:54:53Z (GMT) No. of bitstreams: 1 dlenice.pdf: 1516345 bytes, checksum: 930c729b0216458e24773e1f6778bc27 (MD5) / Made available in DSpace on 2016-03-13T15:54:53Z (GMT). No. of bitstreams: 1 dlenice.pdf: 1516345 bytes, checksum: 930c729b0216458e24773e1f6778bc27 (MD5) Previous issue date: 2013 / Este estudo teve por objetivo analisar o trabalho do enfermeiro sob a ótica da produção de cuidados em saúde e do exercício da clínica. Para sua realização, optou-se pela utilização do referencial filosófico de Deleuze e Guattari devido às suas convicções acerca de um modo de pensar interconectado. Para tanto, foi realizada uma pesquisa qualitativa e exploratória, na forma de Estudo de Caso, em uma unidade de internação cirúrgica de um hospital universitário, tendo como unidade de análise um grupo de seis enfermeiros dessa mesma unidade de internação. Utilizou-se a observação não participante, a pesquisa documental e a entrevista em profundidade como métodos de coleta de dados. Os dados foram analisados, de acordo com a análise textual discursiva. O projeto dessa pesquisa, elaborado consoante às diretrizes da Resolução196/96 do Conselho Nacional de Saúde, foi aprovado sob parecer n° 87/2012. Obteve-se como um dos principais resultados que o resgate da clínica como saber pode ser um mecanismo de fortalecimento da Enfermagem capaz de propiciar um cuidar que, concomitantemente, legitima a autonomia e a visibilidade das ações de enfermagem. Verificou-se que o modelo clínico/biomédico de assistência traz em suas raízes conhecimentos advindos da clínica como ciência arborífica que, quando incorporados ao trabalho do enfermeiro, possibilitam cuidados resolutivos e coerentes às necessidades de saúde da clientela assistida e ao contexto de trabalho. Os cuidados de enfermagem são instituídos pelo enfermeiro de maneiras distintas e dependentes de conhecimento clínico: seja a partir de conexões diretas com o paciente, assim como, com a criação de linhas de fuga com outros membros da equipe de saúde multiprofissional. Atua como base para a conexão de outros saberes e práticas que expandem o fazer do enfermeiro, por meio de interligações com o ambiente. Deste modo, existe a formação de rizomas, por meio de linhas de fuga que partem da própria estrutura arborífica. Os rizomas são fundamentados e transformados, com base nas necessidades que emergem da prática clínica do enfermeiro e demonstram a capacidade desse profissional de superar o modelo clínico/biomédico hegemônico de assistência, confirmando a tese de que: o trabalho da enfermagem é organizado segundo duas perspectivas interconectadas e interdependentes: a perspectiva do modelo clínico, que compõe a estrutura-mestre da sua prática e equipara-se à estrutura arborescente do referencial de Deleuze e Guattari, que é representada pelos saberes biológico, fisiológico, patológico e farmacológico; e a perspectiva caracterizada por uma estrutura rizomática, composta por elementos múltiplos e heterogêneos, que pode ser representada por aspectos que interferem no ambiente em que o paciente está inserido, seja no âmbito social, familiar, de trabalho, entre outros. Deste modo, o modelo clínico de assistência organiza-se como uma estrutura centrada que possibilita a resolutividade das necessidades biológicas e atua como base para a conexão de outros saberes e práticas que expandem o fazer do enfermeiro, por meio de interligações com o ambiente, resultando em uma prática clínica mais próxima do que se considera/denomina integralidade. / This study aimed at analyzing the nurse's work in the perspective of health care production and clinical practice. For carrying out this study, Deleuze and Guattari's philosophical reference was chosen for their convictions about an interconnected way of thinking. Therefore, a qualitative and exploratory case study was performed in a surgery unit of a university hospital, and a group of six nurses from this unit were taken as unit of analysis. Data were collected through non-participant observation, documentary research and depth interview. They were analyzed according to the discursive textual analysis. The project of this research was set up in accordance with Resolution n. 196/96 of the National Health Council and approved by the opinion n. 87/2012. One of the main results indicated that the revival of clinical practice as knowledge might be a strengthening mechanism in Nursing which would provide a sort of health care which concurrently legitimates autonomy and visibility of nursing actions. It was determined that the clinical/biomedical model of health care has in its roots knowledges based on clinical practice as an arborescent science. When such knowledges are incorporated in the nurse's work, they enable resolutive health care which is coherent to clientele's health needs and to the work context. Nursing cares are distinctively instituted by the nurse and depend on clinical knowledge from direct connections with patients as well as by creating lines of flight with other members of the multi professional health team. The clinical model of health care acts as a basis for the connection of other knowledges and practices which expand the nurse's practices through interconnections with the working environment. This way, the creation of rhizomes occurs through lines of flight which comes from the very arborescent structure. The rhizomes are founded and transformed according to the needs which arise from the nurse's clinical practice and show the professional's capacity to overcome the hegemonic clinical/biomedical model of health care. This confirms the thesis that the nursing work is organized according to two interconnected and interdependent perspectives. First, the perspective of clinical model, which forms the main structure of the nursing practice and is on the level with the arborescent structure of Deleuze and Guattari's referential, which on its turn is represented by biological, physiological, pathological and pharmacological knowledges. Second, the perspective characterized by a rhizomatic structure, formed by multiple and heterogeneous elements, which can be represented by the aspects that interfere in patient's environment - be it social, family, work or other. This way, the clinical model of health care is organized as a centralized structure that enables resolutivity of biological needs and acts as a basis for connecting other knowledges and practices that expand the nurse's practice through interconnections with the work environment. As a result, clinical practice gets closer to what is considered as or called integrality. / Este estudio tuvo como objetivo analizar el trabajo de enfermeros bajo la óptica de la producción de asistencias en la salud y del ejercicio de la clínica. Para su realización se optó por el uso del referencial filosófico de Deleuze y Guattari debido a sus convicciones acerca de un modo de pensar interconectado. Para eso fue realizada una investigación cualitativa y exploratoria con la forma de estudio de caso en una unidad de internación quirúrgica de un hospital universitario, teniendo como unidad de análisis un grupo de seis enfermeros de esa unidad de internación. Se usó observación no participativa, investigación documental y entrevista en profundidad como métodos de recopilación de datos. Los mismos fueron analizados de acuerdo con el análisis textual discursivo. El proyecto de esta investigación, elaborado de acuerdo con las directrices de la Resolución 196/96 del Consejo Nacional de Salud, fue aprobado por el Dictamen N° 87/2012. Uno de los principales resultados obtenidos fue que el rescate de la clínica como un saber puede ser un mecanismo de fortalecimiento de la enfermería, capaz de proporcionar una asistencia que, concomitantemente, legitima la autonomía y la visibilidad de las acciones de enfermería. Se verificó que el modelo clínico/biomédico de asistencia posee en sus raíces conocimientos provenientes de la clínica como ciencia arborífica que al ser incorporados al trabajo de los enfermeros hacen posibles asistencias resolutivas y coherentes con las necesidades de salud de la clientela asistida y con el contexto de trabajo. Las asistencias de enfermería son proporcionadas por los enfermeros de modos distintos y dependientes del conocimiento clínico: sea a partir de conexiones directas con los pacientes como con la creación de líneas de fuga con otros miembros del equipo de salud multiprofesional. Por lo tanto, existe la formación de rizomas por medio de líneas de fuga que parten de la propia estructura arborífica. Los rizomas son fundamentados y transformados con base en las necesidades que surgen de la práctica clínica de los enfermeros y demuestran la capacidad de esos profesionales para superar el modelo clínico/biomédico hegemónico de asistencia, confirmando la tesis de que el trabajo de la enfermería se organiza de acuerdo con dos perspectivas interconectadas e interdependientes: la perspectiva del modelo clínico, que compone la estructura maestra de su práctica y se equipara a la estructura arborescente del referencial de Deleuze y Guattari que es representada por los saberes biológico, fisiológico, patológico y farmacológico; y la perspectiva caracterizada por una estructura rizomática, compuesta por elementos múltiples y heterogéneos, que puede ser representada por aspectos que interfieren en el ambiente en que el paciente está inserido, sea en el ámbito social, familiar o de trabajo, entre otros. De ese modo, el modelo clínico de asistencia se organiza como una estructura centrada que hace posible la resolutividad de las necesidades biológicas y actúa como base para la conexión de otros saberes y prácticas que expanden el hacer de los enfermeros por medio de interligaciones con el ambiente, resultando en una práctica clínica más próxima de lo que se considera/denomina integralidad.