Thesis (Ph. D.)--University of Queensland, 2002. / Includes bibliographical references.

Thesis (M Nursing)--Montana State University--Bozeman, 2008. / Typescript. Chairperson, Graduate Committee: Susan Luparell. Includes bibliographical references (leaves 62-67).

Decision support systems (DSS) are traditionally designed to optimise the outcomes of a decision. This thesis explores how DSS design can also be driven by the optimisation of the decision process leading to the decision, and how it may enhance the human uptake and use of DSS. It identifies which tasks could be simplified by decision support, and how to build DSS that are likely to be readily adopted and so improve decision outcomes. It tests the hypotheses that: (a) The analysis of specific process attributes of a given clinical decision task, as well as the information needs of its users, improves the design of DSS and enhances systems?impact and acceptance. (b) The complexity of the decision task is the key process attribute that, in conjunction with the information seeking of users, shapes the outcome of the design process. The work is applied to the domain of antibiotic prescribing in critical care. To explore the first hypothesis, the key attributes of prescribing decisions associated with specific prescribing subtasks and different decision-makers and decision contexts are identified and then analysed. Based on our findings, an information-processing model of decision support for an antibiotic-prescribing task is proposed. The second hypothesis is addressed by applying and comparing metrics for decision complexity including minimum message length, cognitive effort assessment and clinical algorithm structure analysis to the prescribing task. A framework is developed to select clinical decision tasks that may benefit from automation, by characterizing decision support as a process of complexity reduction for users, and these ideas are tested in the context of antibiotic prescribing for ventilator-associated pneumonia. The hypotheses are then tested by applying the task complexity framework to the design of a DSS for antibiotic prescribing in critical care. A web-based experiment and a clinical trial of the DSS are described, both of which study the acceptability and effectiveness of the system and verify the usefulness of the design framework. Specifically, in a before-after controlled trial, with no difference in patient mortality or severity of presentation between the two periods, the use of the DSS was associated with statistically significant improvements in patient outcomes and a reduction in antibiotic usage. The length of stay and total consumption of antibiotics decreased respectively from 7.15 to 6.22 days (P=0.02) and from 1767 to 1458 defined daily doses/1000 patient days (P=0.04). The introduction of a hand-held computer-based DSS was associated with less administration of ???broad-spectrum?antibiotics. The relative impact of the uptake of the DSS on the prescribing quality was quantified. Clinicians chose to use guidelines for one third, and pathology data or the DSS for about two thirds of cases for which they were available to assist their prescribing decisions. When used, the DSS plus pathology data improved the agreement of decisions with those of an expert panel - from 65% to 97% (P=0.002). The impact of the DSS was more significant on prescribing decisions of higher complexity. The level of decision complexity appeared to affect the choice of decision support type. Prescribing guidelines were accessed more often for lower complexity decisions, whereas the infection risk DSS plus pathology data were preferred for decisions of higher complexity. The need for measurement of the effectiveness of a DSS in improving decisions, as well as their likely rate of adoption in the clinical environment, was demonstrated. The thesis concludes with a proposal to apply the framework described to the modelling of the DSS adoption and to include task complexity and user information seeking as determinants of the design and evaluation of clinical DSS.

1.1 The focus of this thesis will be the nexus of statistical methods and clinical practice, as it applies to Critical Care Medicine and is reflected in the literature ( for instance : Anaesthesia and Intensive Care ( Anaesthesia and Intensive Care 2005 ) and Critical Care & Resuscitation ( Critical Care and Resuscitation 2005 ) in Australia ; and internationally : Critical Care Medicine ( Critical Care Medicine 2005 ), Intensive Care Medicine ( Intensive Care Medicine 2005 ), Chest ( Chest 2005 ), American Journal of Respiratory and Critical Care Medicine ( American Journal of Respiratory and Critical Care Medicine 2005 ) and Journal of the American Medical Association ( JAMA 2005 ) ). 1.2 Altman has documented the career of statistics in medical journals over a 20 year period and has lamented the general state of affairs ( Altman 1982 ; Altman 1991b ; Altman 1994 ; Altman 2000 ). The transfer of statistical techniques into medical literature is characterised by a significant lag - time ( Altman et al. 1994b ) and statistical input into medical research and publication, although " widely recommended ... ( is ) ... inconsistently obtained " ( Altman et al. 2002 ), perhaps reflecting an undervaluation of statistical contributions to medicine, as articulated by one of the doyen ' s of biostatistics, Norman Breslow ( Breslow 2003 ). The latter observed that, as opposed to the awarding of a Nobel Prize ( in 2000 ) to econometricians Daniel McFadden and James Heckman for work on discrete choice models and selection bias, similar contributions to medicine by statisticians and epidemiologists have been, as yet, unrecognized. 1.3 Our comparators in statistical " critique " ( Berk 2004 ; BROSS 1960 ) are drawn from analytic approaches, more than thirty years apart. First, the lucid contributions of Jerome Cornfield ( Greenhouse 1982 ) ; in particular : the classic intervention ( in 1959 ) into the tobacco smoking / lung cancer debate " Smoking and lung cancer : recent evidence and a discussion of some questions " ( Cornfield et al. 1959 ) ; and " Further statistical analysis of the mortality findings " of the University Group Diabetes Program ( Cornfield 1971 ), which was an elegant response to the controversy which raged ( for some years ( Kolata 1979 ) ) over the discontinuance of tolbutamide and diet arm in that trial. The textual lucidity to which we refer was presumably a function of the literary background of Cornfield, as documented in the classic review by Salsburg of the rise of the modern statistical paradigm in the twentieth century ( Salsburg 2001 ). Second, the muscular re - examination, or rather, dissection, by Freedman et al ( Freedman et al. 2004 ) of the controversy surrounding breast cancer screening and its efficacy ; being a detailed reading of the meta - analysis by Gotszche and Olsen ( Gotzsche et al. 2000 ), who had questioned the role of mammography in breast cancer screening in terms of potential lives saved. Third, the subtle 1994 reappraisal by Petitti of the mortality treatment effect of patient " compliance " in randomized trials, as it related to both therapy and placebo groups in the Coronary Drug Project ( The Coronary Drug Project Research Group 1981 ) and the Beta - blocker Heart Attack Trial ( Byington 1984 ). The demonstration that the ( cardiovascular ) mortality reduction of compliance with placebo was of the same magnitude as that experienced by users of oestrogen replacement therapy, followed the publication of a quantitative assessment of the of the efficacy of oestrogen on coronary heart disease by Stampfer and Colditz, in which a relative risk of 0.56 ( 95 % CI 0.5 - 0.61 ) was postulated ( Stampfer et al. 1991 ). Petitti ' s review anticipated the null effects ( of replacement oestrogen ) demonstrated in the subsequent randomized trials of the Women ' s Health Initiative ( The Women ' s Health Initiative Study Group 1998 ). These null effects caused extensive debate and some degree of angst in the epidemiological literature and the consequent death of observational epidemiology was rhetorically announced ( Lawlor et al. 2004 ). 1.4 The thesis is divided into two parts: 1.4.1 First, a detailed expository analysis of various questions relating to the interpretation of the results of recent noteworthy trials in the medical and Critical Care literature. Initially we come to terms with the seemingly intractable P - value question which has regularly surfaced in the literature over the years. We also address the thorny but perennial parametric versus non - parametric test controversy. Next we look at the methodology of recent trials in Critical Care and find some problematic areas in terms of interim analyses and the reporting of results. These concerns are expanded into a detailed consideration of the issues surrounding group sequential and equivalence trials. The subsequent section analyses particular aspects of ( i ) effect size ( ii ) prognostic factors and responsiveness ( iii ) sample size, power and interpretation of trials and we conclude ( iv ) with a critique of various aspects of Critical Care practice, as it relates to certain key trials and overviews ( meta - analyses ) of these trials : the PROWESS trial of activated protein C in sepsis ; hypothermia as therapy in cerebral injury ; selective decontamination of the digestive tract ; and nutrition as therapy. 1.4.2 Second, concrete focused analyses are performed on particular datasets and particular statistical techniques are subject to scrutiny. The first encompasses multivariate analysis of phosphate metabolism in ICU patients ; in particular, issues relating to regression to the mean, appropriate estimators ( ordinary least squares or generalized linear models ), model and variable selection, and missing data. The second looks at the analysis of cost data and explores the use of generalized linear models as appropriate estimators. The third introduces time - to - event analysis in and reviews the use of the Cox model and random effects estimators in a data set of patients with malignancies. The fourth is a in depth analysis of three aspects of meta - analysis as it applies in the Critical Care field : heterogeneity, publication bias and metaregression. 1.5 In this endeavour, we are mindful of certain cautions regarding treatment effects : ( i ) it is reasonable to find odds ratio ( s ) below 0.6 " extremely surprising " ( Speigelhalter et al. 2004 ) ( ii ) " If a result appears too good to be true, it probably is " ( Yusuf 1997 ) and ( iii ) we may " require that data indicate an increased relative risk for a characteristic of at least 50 percent, on the assumption that an excess of this magnitude would not arise from extraneous factors alone " ( Mantel et al. 1959 ). The latter proposition was first articulated in 1959 by Mantel and Haenszel, but needed to be reiterated ( by Mantel ) some thirty four years later ( Mantel 1993 ). Finally, we endorse the admonition of Jerome Cornfield that " Any set of hospital or clinical data that is worth analysing at all is worth analysing properly " ( Cornfield 1951). 1.6 The importance of statistical principles in both the interpretation and conduct of analysis would seem to be obvious and we must " grapple " with statistics in the same manner as Appleby urged with respect to health economics ( Appleby 1987 ). To this extent, the evidence - based - medicine movement has mandated " critical appraisal ", which incorporates, to varying degree, statistical methods ( Morris 2002b ) and at least one prominent medical journal has recently welcomed papers " detailing important contributions in the design of studies or analysis of epidemiological data " ( Dominici et al. 2004 ). Thus statistics is increasingly engaged with " front - line science " ( Efron 2005 ) and these recent trends prefigure the overall thrust of the sections below. / Thesis (M.D.) -- University of Adelaide, School of Medicine, Discipline of Medicine,

Thesis (MVoeding)--University of Stellenbosch, 2006. / Bibliography.

Decision support systems (DSS) are traditionally designed to optimise the outcomes of a decision. This thesis explores how DSS design can also be driven by the optimisation of the decision process leading to the decision, and how it may enhance the human uptake and use of DSS. It identifies which tasks could be simplified by decision support, and how to build DSS that are likely to be readily adopted and so improve decision outcomes. It tests the hypotheses that: (a) The analysis of specific process attributes of a given clinical decision task, as well as the information needs of its users, improves the design of DSS and enhances systems?impact and acceptance. (b) The complexity of the decision task is the key process attribute that, in conjunction with the information seeking of users, shapes the outcome of the design process. The work is applied to the domain of antibiotic prescribing in critical care. To explore the first hypothesis, the key attributes of prescribing decisions associated with specific prescribing subtasks and different decision-makers and decision contexts are identified and then analysed. Based on our findings, an information-processing model of decision support for an antibiotic-prescribing task is proposed. The second hypothesis is addressed by applying and comparing metrics for decision complexity including minimum message length, cognitive effort assessment and clinical algorithm structure analysis to the prescribing task. A framework is developed to select clinical decision tasks that may benefit from automation, by characterizing decision support as a process of complexity reduction for users, and these ideas are tested in the context of antibiotic prescribing for ventilator-associated pneumonia. The hypotheses are then tested by applying the task complexity framework to the design of a DSS for antibiotic prescribing in critical care. A web-based experiment and a clinical trial of the DSS are described, both of which study the acceptability and effectiveness of the system and verify the usefulness of the design framework. Specifically, in a before-after controlled trial, with no difference in patient mortality or severity of presentation between the two periods, the use of the DSS was associated with statistically significant improvements in patient outcomes and a reduction in antibiotic usage. The length of stay and total consumption of antibiotics decreased respectively from 7.15 to 6.22 days (P=0.02) and from 1767 to 1458 defined daily doses/1000 patient days (P=0.04). The introduction of a hand-held computer-based DSS was associated with less administration of ???broad-spectrum?antibiotics. The relative impact of the uptake of the DSS on the prescribing quality was quantified. Clinicians chose to use guidelines for one third, and pathology data or the DSS for about two thirds of cases for which they were available to assist their prescribing decisions. When used, the DSS plus pathology data improved the agreement of decisions with those of an expert panel - from 65% to 97% (P=0.002). The impact of the DSS was more significant on prescribing decisions of higher complexity. The level of decision complexity appeared to affect the choice of decision support type. Prescribing guidelines were accessed more often for lower complexity decisions, whereas the infection risk DSS plus pathology data were preferred for decisions of higher complexity. The need for measurement of the effectiveness of a DSS in improving decisions, as well as their likely rate of adoption in the clinical environment, was demonstrated. The thesis concludes with a proposal to apply the framework described to the modelling of the DSS adoption and to include task complexity and user information seeking as determinants of the design and evaluation of clinical DSS.

Thesis (M.A.(Applied))--Victoria University of Wellington, 2004. / Includes bibliographical references.

A thesis submitted to the Faculty of Commerce, Law and Management, University of the Witwatersrand, in fulfilment of the requirements for the degree of Doctor of Philosophy. September 2018 / Intensive care is a small but complex system; context-specific and continually confronted by dynamic changes and challenges in the environment. Initiatives following the traditional reductionist approach to improve the delivery of intensive care has had limited success. The aim of this research was to develop a systemic framework for the improvement of intensive care delivery. The factors affecting the delivery of intensive care – in South Africa and internationally – were elucidated by a comprehensive review and analysis of intensive care literature. A further understanding of intensive care delivery in South Africa was obtained by “making sense of the mess” using a systems approach. Systemic intervention served as the meta-methodology and methods and techniques from interactive planning, critical systems heuristics, soft systems methodology and the viable system model were employed. Making sense of the mess emphasised the complexity of intensive care delivery, on both a situational and a cognitive level. It became clear that a single methodology would not suffice, but that a pluralist methodology was required to guide improvement in intensive care delivery. Based on this understanding, nine principles were formulated to guide the development of a framework for the improvement of intensive care delivery. Systemic intervention was used as the meta-methodology. Interactive planning was identified as the key methodology, incorporating methods and techniques from critical systems heuristics, soft system methodology and the viable system model to build a systemic framework for the improvement of intensive care delivery. Embedded in the proposed framework are matters relating to systemicity, complexity, flexibility, empowerment, and transformation of intensive care delivery. The proposed framework allows for multiple-perspectives, including that of marginalised stakeholders, the mitigation of multi-vested interests and power relationships. It is both flexible and adaptable to promote learning about the complex problems of intensive care delivery and it accommodates the strengths of various relevant approaches to complex problem solving. The proposed framework aims to facilitate sustainable improvement of intensive care delivery and to ensure the “just-use” of resources to foster distributive justice. It acknowledges the trajectory of intensive care delivery – the patient comes from the community and returns to the community and intensive care delivery functions on a continuum that ranges from basic to highly sophisticated. / E.K. 2019

Thesis (MCur (Nursing Science))--University of Stellenbosch, 2010. / Thesis presented in partial fulfilment of the requirements for the degree of Master of Nursing at Stellenbosch University / ENGLISH ABSTRACT: The trend towards specialisation in nursing has resulted in the development of the role of the Clinical Nurse Specialist (CNS) since the 1960s and 1970s in North America and the United Kingdom respectively. A Clinical Nurse Specialist should demonstrate excellent skills in leadership, communication, critical thinking, clinical and collaborative ethical decision-making, as well as mentoring. Research done internationally has shown that advanced practice nursing leads to higher patient satisfaction and compliance, fewer hospitalisations and shorter length of stays. The development of the CNS role in SA is slow in implementation. The South African Qualifications Authority has only recently published qualification rules for a master’s certificate and master’s degree in Nursing for advanced specialist nurses in SA. This situation led to the following research question: What is the expected role of the Critical Care Clinical Nurse Specialist in private hospitals in the northern and southern suburbs of the Cape Peninsula, South Africa? A non-experimental, explorative, descriptive study with a quantitative orientation was conducted in eight private hospitals in the Cape Peninsula. Through non-probability sampling 73 critical care health professionals (critical care professional nurses, clinical nurse specialists, nursing managers, unit managers, nurse educators, clinical facilitators, clinical coordinators and doctors) out of a population of 170 critical care health professionals participated in the study. A survey tool was designed and validated to collect the data. Quantitative data was analysed through Statistica® and qualitative data was analysed thematically. It was found that 81% of the participants agreed that Clinical Nurse Specialists should be appointed in the South African critical care environment as soon as possible to improve patient outcomes, to contribute to safer nursing care, to relieve work stress of shift leaders and bedside nurses and to improve the professional status of nursing. It is recommended that greater awareness regarding the Clinical Nurse Specialist should be developed. The relevant educational requirements should be finalised and a clear job description should be compiled. Nursing managers should appoint Clinical Nurse Specialists in each critical care unit as soon as possible. / AFRIKAANSE OPSOMMING: Die rol van die Kliniese Verpleegspesialis het as uitvloeisel van spesialisering in verpleging sedert 1960 en 1970 in Noord-Amerika en Groot-Brittanje onderskeidelik ontwikkel. `n Kliniese Verpleegspesialis behoort die volgende eienskappe te openbaar: uitmuntende vaardighede met betrekking tot leierskap, kommunikasie, kritiese denke, kliniese en etiese besluitneming en mentorskap. Internasionale navorsing het aangetoon dat gevorderde verpleegkunde tot `n hoër vlak van pasiënttevredenheid en nakoming van behandelingsvoorskrifte, minder hospitalisasie en korter hospitaalverblyf aanleiding gee. Die ontwikkeling van die rol van die Kliniese Verpleegspesialis in Suid- Afrika geskied langsaam. Die Suid-Afrikaanse Kwalifikasie-Outoriteit (SAKO) het eers onlangs die reëls vir `n meestersertifikaat en meestersgraad in Verpleegkunde vir gevorderde spesialisverpleegkundiges gepubliseer. Hierdie situasie het tot die onderstaande navorsingsvraag aanleiding gegee: Wat is die verwagte rol van die Kritiekesorg- Kliniese Verpleegspesialis in privaathospitale in die noordelike en suidelike voorstede van die Kaapse Skiereiland, Suid-Afrika? `n Nie-eksperimentele, beskrywende studie met `n kwantitatiewe benadering is in agt hospitale in die Kaapse Skiereiland onderneem. Deur nie-waarskynlikheids-, toevallige steekproefneming is 73 professionele betrokkenes by kritiekesorggesondheid (professionele kritiekesorgverpleegkundiges, kliniese verpleegspesialiste, verpleegbestuurders, eenheidsbestuurders, opvoeders in verpleegkunde, kliniese fasiliteerders, kliniese koördineerders en dokters) uit `n populasie van 170 professionele betrokkenes by kritiekesorggesondheid in die studie ingesluit. `n Vraelys is ontwerp en gevalideer vir die insameling van data. Kwantitatiewe data is deur middel van Statistica® ontleed terwyl die kwalitatiewe data tematies ontleed is. Daar is gevind dat die meerderheid van die deelnemers saamgestem het dat Kliniese Verpleegspesialiste so gou moontlik in die kritiekesorgomgewing in Suid-Afrika aangestel behoort te word. Die Kliniese Verpleegspesialis dra by om pasiëntuitkomste te verbeter, om tot veiliger verpleegsorg by te dra, om werkspanning van skofleiers en verpleegsters te help verlig en om die professionele status van verpleging te verbeter. Daar word aanbeveel dat daar groter bewusmaking aangaande die Kliniese Verpleegspesialis moet wees. Vereistes vir opleiding behoort gefinaliseer te word en `n duidelike werksbeskrywing moet opgestel word. Verpleegbestuurders behoort Kliniese Verpleegspesialiste so gou moontlik in die kritiekesorgomgewing aan te stel.

The purpose of this study was to explore and describe nurse-patient communication during critical illness events. The theoretical structure of the study was drawn from communication, sociolinguistic, and nursing theory. Data were collected in a 374-bed private hospital in the Southwest. The sample consisted of six registered nurses and nine patients experiencing cardiac surgery. Nine observed and audiotaped nurse-patient interactions, and fourteen audiotaped partcipant interviews provided the data base for analysis. Content analysis was used to organize the data. Findings were presented in terms of language, paralanguage, and nonverbal expression, and in terms of content, process, and product of nurse-patient communication. Participants used biomedical-technical language and casual-everyday language during the interactions. Nurses talked about what patients would experience while patients talked about themselves as a way of establishing their credibility within the biomedical setting. Nurses viewed nurse-patient communication as variable depending on the patients' needs and responses. Patients viewed nurse-patient communication as straightforward, not requiring adjustment for the needs of the participants. Products of communication for patients involved increased knowledge, reassurance, and increased confidence. Products of communication for nurses involved relieving the patients' anxieties, considering the patients' remembering, and increasing the nursing staff's knowledge about the patient while helping the patient to know the goals of the nursing staff. The introduction and closure segments of the six nurse-patient interactions for preoperative preparation of the patient were analyzed. Nurses began the introductions by assuming that the patients needed relief from anxiety but the patients demonstrated politeness more than anxiety. Nurses used strategies of questioning, starting the physical assessment, topic persistence, and self-monitoring to control the closure segments. Patients used narratives and humor as control strategies. The study findings suggest conceptual areas relevant to nurse-patient communication which may ground theoretical model development for nurse-patient communication. Nurses in clinical settings can compare their patient communication experiences with the findings of the study in order to increase their understanding of expression, form, and function of nurse-patient communication.