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Background: The safety of critically ill patients during inter-hospital transfer is recognised as a globally important issue. However, little evidence exists pertaining to the care provided by transfer nurses throughout the processes of inter-hospital transfer in rural community hospitals where there is a high risk of adverse clinical events occurring during transportation. Aim: The overall aim of the study was to explore transfer nurses' understanding of the delivery of quality of care during the transfer of critically ill patients from rural community hospitals to a tertiary regional hospital in Thailand. Design and Methods: The theory of symbolic interactionism (Blumer, 1986) and focused ethnography methodology were used. Data were collected using multiple qualitative methods including sixteen semi-structured interviews with transfer nurses, fourteen observations of critically ill patients' transfers from three rural community hospitals to a tertiary centre and twenty-three subsequent handover events and the analysis of transfer documents from four hospital settings (e.g. one regional hospital and three rural community hospitals) in Thailand. Translation from Thai into English and back translation into vernacular language was required. Inductive, thematic analysis was conducted to identify major themes by using qualitative data analysis software, NVivo 10 to assist data management during the analysis. Results: Five major themes emerged including (i) protective factors influencing safe transfer care, (ii) barrier factors influencing safe transfer care, (iii) behavioural patterns in transfer care processes, (iv) maintaining the health condition of the patients, and (v) overcoming adverse events. These particular themes elaborate the meaning of the quality and patient safety of transfer care, the provision of care for safe transfer care, and significant contextual factors that influence the quality of inter-hospital transfer care for critically ill patients. In addition, Donabedian's model (Donabedian, 1966, 1988) incorporated within the concept of context and culture was utilised to assist in conceptualising the framework for the quality of inter-hospital transfer care of critically ill patients in Thailand. Conclusion: The Donabedian model is useful as it is simple, but it does not include detail of the organisational context and culture as determinants of care quality. A conceptual framework for the quality of inter-hospital transfer care of critically ill patients in Thailand was therefore proposed. This study has expanded on current theoretical knowledge of the quality of inter-hospital transfer care by elaborating the patterns of thought and the behaviour of transfer nurses during provision of care throughout the processes of the inter-hospital transfer. It also highlights the limitations of organisational structure and the environment in which transfer work takes place, including issues on handover processes in hospital transfer care. The results can be useful to transfer nurses in that they facilitate greater understanding of the provision of better quality of care. They also help to inform hospital policy makers how to ensure safety of critically ill patients being transferred from community hospital settings.

Purpose: The purpose of this ethnographic study was to describe the culture of care and nonpharmacological nursing interventions performed by NICU nurses for infants with NAS. Background: Infants with NAS are increasingly being cared for in the inpatient hospital setting by NICU nurses. Interventions used for the care of premature and sick infants in the NICU may or may not be the exact interventions that should be used for the care of the fragile infant with NAS. Research studies on the nonpharmacological nursing care of infants with NAS encompass 5 main areas of practice: environment, adequate rest and sleep, feeding, assessment and evaluation using Finnegan scoring by nurses, and nurses as caregivers. Method: Roper and Shapira’s (2000) framework for the analysis of ethnographic data was used for this research and included participant observation, individual interviews, and the examination to existing documents. Data analysis included: (a) coding for descriptive labels, (b) sorting to identify patterns, (c) identification of outliers or negative cases, (d) generalizing constructs and theories, and (e) memoing to note personal reflection and insights. Focused ethnography allows for the articulation of research questions before fieldwork while observing and describing a culture. Results: Five themes emerged from the data: learn the baby (routine care, comfort care, environment, adequate rest and sleep, feeding), core team relationships (support, interpersonal relationships), role satisfaction (nurturer or comforter, becoming an expert), grief, and making a difference (wonderful insanity, critical to them). Implications: The results of this were a description of the culture of care provided to infants with NAS by NICU nurses and provide general recommendations to the nurse caring for an infant with NAS in the areas of environment, adequate sleep and rest, feeding, and the role of the nurse. This study also has implications for future study of evidence-based research strategies to decrease withdrawal symptoms in infants with NAS. Research is needed in the areas of clinical practice guidelines to help the bedside nurse care for these infants using current research and evidence for practice. Nursing theory and nursing education both contribute to nursing research in how to better understand the culture of care provided by nurses.

In this dissertation the complex, dynamic, contextual and multi-dimensional practice of teachers’ use of digital technologies in their everyday work has been illustrated and presented. The research draws upon the experience of teachers and school leaders from two compulsory schools as well as representatives from the municipal Department of Education and IT-unit within a municipality in the south of Sweden. A focused ethnographic approach has been undertaken and applied observations and interviews. Systems Thinking, specifically Soft Systems Methodology in combination with Cognitive Mapping have been applied to analyze the empirical material. The theoretical foundation builds upon teachers’ worldview towards digital technologies, because it is noted that teachers more easily adopt and use innovations that are in accordance with their personal thoughts and beliefs about teaching and learning. Further, teachers’ attitude and perception towards use of digital technologies are addressed as well as the role of school leadership. Additionally, importance of context, teachers’ knowledge and pedagogics have been discussed referring to various frameworks. The dissertation aims to illuminate the complex nature of teachers’ everyday practice. To gain understanding of the situation as a whole, there is also need to shed light on various aspects and underlying perspectives. Thus, this research aims to illuminate and advance the understanding of the complexity of compulsory school teachers’ everyday work practices using digital technologies. The outcome of this dissertation illustrates the complexity of teachers’ everyday practices as well as additional issues adding to the complexity, and shows that these complex issues are worthy of further study. Among the issues emerged from this dissertation are differences in regard to how the complex situation is understood because different actors have multiple and sometimes conflicting worldviews. Ambiguities in core objectives and relevant concepts were found. Additionally, a pervasive lack of understanding about the realities of daily education and teaching practices, including variances in worldviews and mindsets was found adding to the complexity of teachers’ everyday practice using digital technologies.

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Plusieurs approches ont été proposées au fil du temps pour améliorer les taux d’adhésion à l’hygiène des mains des infirmières dans un contexte de prévention des infections associées aux soins de santé. Néanmoins, ces taux sont et demeurent faibles au Québec (Lacoursière, 2018) comme partout ailleurs (Stella et al., 2019). Depuis le milieu des années 1980, une approche de changement de comportement – la déviance positive - a fait son apparition dans les écrits en santé publique. Ladite approche propose de déterminer la présence de déviants positifs - personnes ou groupes plus performants que d’autres - puis d’explorer les facteurs qui expliquent cette meilleure performance afin de développer des moyens d’amener un changement à d’autres personnes ou d’autres groupes (Bradley et al., 2009). Même si des recherches utilisant l’approche de la déviance positive ont été publiées en sciences infirmières, il n’est pas clair si cette approche peut être utile et appliquée à la pratique infirmière au regard de l’hygiène des mains. Le but de cette étude était d’explorer, sous l’angle de l’approche de la déviance positive, les pratiques cliniques d’infirmières au regard de l’hygiène des mains et les facteurs qui les influencent en contexte hospitalier québécois ainsi que de discuter l’applicabilité de ladite approche à la pratique infirmière en lien avec l’hygiène des mains. Pour répondre à ce but, nous avons effectué deux ethnographies focalisées auprès de 21 infirmières sur deux unités de soins (unité de médecine-chirurgie et unité de soins palliatifs) d’un centre hospitalier universitaire de la région de Montréal. Ces deux unités ont été choisies sur la base des taux d’adhésion à l’hygiène des mains des infirmières plus élevés comparativement à ceux de leurs collègues des autres unités de soins du même centre hospitalier. La collecte des données s’est déroulée de janvier à octobre 2015, principalement lors de 18 entrevues individuelles et 14 périodes d’observation de type shadowing. Une grille d’observation a été utilisée afin d’y consigner les détails relatifs au contexte. Selon la méthode d’analyse décrite par Patton (2002, 2015), toutes les données colligées ont été codées et regroupées sous des catégories puis une analyse de fréquence des codes a été effectuée afin d’en permettre l’interprétation. Les résultats de cette étude montrent que les pratiques cliniques sont similaires sur les deux unités de soins; les participantes utilisent principalement les solutions hydro-alcooliques avant d’entrer et en sortant de la chambre des patients. Quant aux facteurs qui explicitent les taux plus élevés d’adhésion à l’hygiène des mains des infirmières, certains d’entre eux sont communs aux deux équipes de soins. Au niveau individuel, les participantes reconnaissent l’importance d’avoir les connaissances sur le rôle de l’hygiène des mains pour prévenir la transmission des infections, de se protéger soi-même et de protéger les patients; au niveau organisationnel, on constate une pratique collaborative à l’intérieur de chacune des équipes; au niveau environnemental, l’accessibilité et la disponibilité des distributeurs de solution hydro-alcoolique facilitent grandement la pratique de l’hygiène des mains; au niveau sociopolitique, les deux équipes sont confrontées aux compressions survenues suite à la réforme du réseau de la santé et à l’incertitude face à un déménagement vers un nouveau centre hospitalier; au niveau culturel, les membres des deux équipes travaillent ensemble vers un but commun, ce que nous avons nommé cohésion sociale telle que décrite par Kwok, Harris et McLaws (2017). Cependant, ce qui favorise cette cohésion diffère selon l’équipe de soins. Sur l’unité de médecine-chirurgie, l’équipe s’est mobilisée sous le leadership de son infirmier-chef afin d’améliorer les taux d’adhésion à l’hygiène des mains. Sur l’unité des soins palliatifs, l’équipe partage une pratique de soins empreinte d’humanisme afin de protéger des patients qui sont en fin de vie. Ce qui nous amène à postuler que la déviance positive s’applique à une équipe de soins - et non seulement à des individus - qui travaille ensemble afin de protéger les patients des infections associées aux soins de santé. Les connaissances découlant de cette étude permettent de comprendre qu’afin d’améliorer l’adhésion à l’hygiène des mains des infirmières, il serait préférable de cibler les équipes de soins qui performent le mieux, d’élaborer des interventions qui intègrent des facteurs à plusieurs niveaux, non seulement au niveau individuel, et d’ajouter des ressources humaines et financières. / Many approaches have been advocated over time to improve nurses’ hand hygiene adherence rates in order to prevent healthcare-associated infections – nosocomial infections. Nevertheless, these rates have been and continue to be low in Québec (Lacoursière, 2018), as they are everywhere else (Stella et al., 2019). In the mid-1980s, a behavioural change approach – positive deviance – appeared in public health literature. This approach proposes to identify the presence of positive deviants – individuals or groups who outperform others – and to explore the factors that explain the better performance, in order to develop ways to encourage change among other individuals or groups (Bradley et al., 2009). Although studies using the positive deviance approach have been published in the nursing literature, it is unclear whether this approach can be applied to nursing practice with regard to hand hygiene. The purpose of this study was to explore, from the perspective of the positive deviance approach, the clinical nursing practices related to hand hygiene and the factors that influence them in a Québec hospital setting, as well as to examine the applicability of this approach to hand hygiene in nursing practice. To this end, we conducted two focused ethnographies with 21 nurses on two care units (a medical surgery unit and a palliative care unit) at a university hospital centre in the Montréal region. These two units were chosen because the nurses’ hand hygiene adherence rates were higher than their colleagues’ rates on other care units at the same hospital centre. The data were collected from January to October 2015, mainly through 18 individual interviews and 14 shadowing periods. An observation grid was used to record the contextual details. According to the method described by Patton (2002, 2015), all the collected data were coded and grouped under categories and then a frequency analysis of the codes was carried out in order to allow interpretation. The results of this study show that the clinical practices are similar on both healthcare units; the participants use mainly hydro-alcoholic solutions before entering and leaving the patients’ rooms. Some of the factors that explain the higher hand hygiene adherence rates are shared by both care teams. On the individual level, the participants recognize the importance of having knowledge about the role of hand hygiene to prevent the transmission of infections, protect themselves and protect the patients; on the organizational level, there is a collaborative practice within each team; on the environmental level, the accessibility and availability of the hydro-alcoholic solution distributors greatly facilitate hand hygiene practices; on the sociopolitical level, both teams are facing cuts under the health reform and uncertainty related to a move to a new hospital; on the cultural level, the members of both teams work together toward a common goal, which we called “social cohesion” as described by Kwok et al. (2017). However, the factors that lead to this cohesion differ in each team. On the medical surgery unit, the leadership of the head nurse mobilizes the team to improve their hand hygiene adherence rates. On the palliative care unit, the team shares a humanist care practice to protect patients who are at the end of their lives. This led us to postulate that positive deviance applies to a care team – not just to individuals – who are working together to protect patients from healthcare-associated infections. The knowledge from this study suggests that to improve nurses’ hand hygiene adherence, it would be preferable to target the care teams that perform best, to develop interventions that include factors on several levels, not just the individual level, and to increase human and financial resources.

“The point is that you should be able to know your speech”. A study of the teaching practice of prepared speech, in upper-secondary school Swedish. Cristina Jarl This licentiate study explores the discursive construction of the classroom practice of teachers and students preparing a formal speech, within the Swedish language teaching. The explicit focus is on the teaching situation prior to the students’ prepared speech, and the actions per-formed by the actors within the language teaching context. The overall aim of the thesis is to increase the knowledge of teaching prepared speech as a social practice, by specifically describ-ing, analyzing, and problematizing the students’ opportunities to develop knowledge, connected to prepared speech in the language teaching classroom. By focusing on the instructional pro-cesses that lead to the delivery of the prepared speech this thesis contributes to new insights about the desired knowledge in the students’ prepared speech in school. The research questions guiding the investigation deal with aspects such as social actions, circulating discourses and the students’ subject positions as speakers in the teaching of prepared speech. A focused ethnography method was used, defined by short and intense periods of fieldwork engaging in a specific group activity in a social environment. The data production took place in two teaching groups, in two different upper secondary schools in Sweden. The empirical data consist of observations, sound and video recordings, field notes and texts produced by both teachers and students. During data production, the teaching alternated between on-site and online teaching due to the Corona pandemic. The classroom practice is explored as a social practice and as a discursive arena, where different perceptions exist. Social actors use discourse to mediate action, in which discourse impacts their ways of doing and being. By applying me-diated discourse analysis it is possible to study the complex relations between social action and discourse. The main findings suggest that teachers and students tend to focus more on the form and the production of the speech, and less on the specific subject content of the speech. The results display prominent and sometimes contradictory dichotomies in the teaching of speech: aspects of the prepared speech involve on one hand the practical, the spoken and the corporeal, and on the other hand the theoretical, the written and the visual. Additionally, the study illustrates the fixed and mobile dimensions of Swedish as a school subject. The importance of a speaker’s credibility shows a dynamic tension between students’ strategic, institutional and social posi-tions as a speaker. A concluding remark in the present study is that it seems important for the students to speak and having something to say, in a certain form and packaging, rather than what they have to say and why. Therefore the key instructional questions of what, why and who in terms of teaching prepared speech open up for further discussion.

Les vies de millions de personnes sont dévastées par des désastres naturels à travers le monde. Les écrits scientifiques relatifs aux efforts humanitaires dans ces contextes ciblent les travailleurs humanitaires sans toutefois les différencier quant à leur appartenance disciplinaire ou à l’organisation qui les emploie. Les connaissances liées à la pratique des infirmières dans le contexte d’urgence humanitaire sont limitées, malgré qu’elles jouent un rôle vital auprès des populations touchées. Cette ethnographie focalisée, guidée par la théorie du caring bureaucratique de Ray (1989) répond à la question de recherche: Comment des infirmières ayant participé à une mission humanitaire d’urgence suite au séisme à Haïti en janvier 2010 au sein de l’organisation Médecins Sans Frontières décrivent-elles leur pratique dans les contextes légal, politique, économique, éducationnel, socioculturel, physique et technologique de cette expérience? Des entrevues semi-structurées en profondeur de 90 minutes ont été menées auprès de quatre participantes qui ont également échangé à propos de photographies prises durant leurs missions. Les participantes ont discuté de leur préparation, de leurs objectifs, des rôles qu’elles assumaient, ainsi que des défis rencontrés au retour de leurs missions. Des facteurs inhérents à l’infirmière et à l’organisation ont émergé comme importants pour l’articulation et la délimitation de leur pratique. Cette étude révèle également que des facteurs contextuels importants, soit l’équipe, le temps, l’environnement physique, la médiatisation, la sécurité, ainsi que les conditions de travail et les contextes sociopolitique et culturel avaient une influence sur la pratique. Les participantes, selon leur évaluation de ces contextes et des besoins immédiats, devaient constamment ajuster leur pratique. Cette recherche permet une meilleure compréhension de la pratique d’infirmières dans un contexte d’urgence humanitaire de laquelle découlent des implications pour la pratique, la formation et la recherche. / Globally, millions of people experience significant upheaval in their lives due to natural disasters. Literature related to humanitarian relief efforts has primarily focused on the work of medical personnel without any differentiation with regards to their profession or sending organization. Knowledge related to the vital role that nurses play during these devastating and tumultuous times is scarce. The purpose of this focused ethnography is, therefore, to determine how nurses describe their practice while working with Doctors Without Borders during relief efforts resulting from the aftermath of the Haitian earthquake in 2010 within the legal, political, economical, educational, sociocultural, physical and technological contexts of their experience. Four nurses participated in semi-structured, individual, in-depth 90-minute interviews. During the interviews the nurses also discussed photographs they had taken that best represented their practice during their mission. Ray’s theory of bureaucratic caring (1989) was used as a theoretical framework for this study. Participants provided rich examples of their mission’s training, objectives, and roles. They also addressed the challenges that needed to be overcome when they returned. Some of their inherent personal assets, and characteristics of MSF itself, that emerged as important factors which defined their practice, were also described by participants. Contextual factors such as the team, time, physical environment, media coverage, security, working conditions, and the sociocultural and political context, had to constantly be taken into account by the participants so they could adjust their practice accordingly. This study leads to a better understanding of nursing practice in the humanitarian context. It has several implications for practice, future research, and curriculum improvement in the area of disaster nursing preparedness.

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