Thesis (Ed.D.)--Duquesne University, 2009. / Title from document title page. Abstract included in electronic submission form. Includes bibliographical references (p. 86-113) and index.

SAMMANFATTNING Syfte och frågeställningar: Syftet med studien var att komma närmare i begrepp, diagnos och behandling gällande fenomenen stressrelaterad ohälsa till utmattningssyndrom (UMS). Ielitidrotten finns stressrelaterad ohälsa som överträningssyndrom (OTS). OTS kan också leda till utmattning. Det finns olika stadier av stressrelaterad ohälsa/OTS innan ett UMS utvecklas. Intervjustudien tar upp frågeställningar som rör fenomenen för att få en uppfattning och förklaring bland experter, kliniker och behandlare i Sverige. Frågeställningarna belyser behandlingsvägen för patienter som söker hjälp för stressrelaterad ohälsa. Frågeställningarna vill vidare belysa forskningsläget i de behandlingsmetoder vi använder i de olika faserna av stressrelaterad ohälsa både inom idrottsvärlden och i primärvården i Sverige. Metod: Metoden som valdes var en kvalitativ semistrukturerad intervjustudie som berörde frågeställningarna och syftet. 6 stycken experter varav 3 diagnosförskrivare (1 diagnosförskrivare och 2 experter inom idrottsområdet) och 3 stycken väl valda behandlare varav 2 inom idrottsområdet valdes in. Teman identifierades och frågorna bearbetades. Intervjuerna spelades in och transkriberades ordagrant. Analysen bearbetades med systematisk textkondensering. Resultat:  6 koder hittades. 1. ”Förmågan att förstå processen” handlar om acceptans.2. ”Sortering i stressrelaterad ohälsa” handlar om att sortera inom fenomenet för att visa på hur stort området är. 3.”Förebyggande arbete är behandlingen ”visar på den viktiga aspekten på allt vi kan göra innan och att få en tidig start är det som är kostnadseffektivt i det långa loppet. 4.”Vägen till läkning” beskriver hur vägen ser ut idag för de som drabbas. Behandlingen är individuell återhämtning med inslag av aktiviteter. Specifika åtgärder med individuell plan i ohälsosamma beteenden kräver bearbetning. 5. ”Hur ska vi tackla framtidens utmaningar?” koden beskriver hur samhället bör förändring i att inte individen värderas enbart av sin prestation. Kunskap och lärande om kropp, stress och återhämtning måste startas i låg ålder. 6. ”Återhämtning” ordet behöver få större slagkraft i alla behandlingar som rör stressrelaterad ohälsa. Slutsats: Begreppen är stora, framför allt stressrelaterad ohälsa. Arbete krävs med den medicinska diagnosen UMS för att den ska bli vedertagen både i Sverige och internationellt. Förståelsen om varför och hur en utmattningsprocess kan starta hos individer och behovet av individuell återhämtning och bearbetning måste komma ut tidigare till alla i samhället. Vi bör alltid sträva att stoppa sjukdomsförloppet i stressrelaterad ohälsa i tid. OTS är ett vanligt negativt beteende hos individer som lider av psykisk ohälsa i den stressrelaterade ohälsan. Kopplingen med den mot utmattningsprocessen och UMS bör fortsätta utvecklas. Den kunskapen vi har hittills borde redan nu anammas av vårdpersonal. / ABSTRACT Aim: The aim of this study was to get a more precise definition, diagnosis and treatment of the phenomenon stress related illness and the process to exhaustion. Stress related illness covers the term overtraining syndrome (OTS) which is a common problem in elite sports. Experts, clinics and health workers in Sweden have been interviewed. By recognizing early signals, stress related illness may be dealt with an earlier treatment which leads to a better prognosis. Stress related illness and OTS can be a long-lasting process before exhaustion comes. Sports and work give the same stress to our bodies and minds. Different treatments of the clients were investigated in this study. Method: The method chosen was a quality study with semi structural interviews that investigate these phenomenon’s. Five experts (three in clinics who regularly sets diagnosis) and five health workers (two in clinics who regularly sets diagnosis) were interviewed. Terms were developed after the aim and the interviews were recorded. Systematic text condensation (STC) was used for the analysis. Results: Six codes were found after the analysis. 1.” The capacity of understanding the process”. The patient must admit his problem in order to be able to treat it. 2.” Defining stress related illnesses”. A finer grade of definitions will aid psychologists and doctors to set a certain diagnosis. 3.” The preemptive work is the treatment”. The best treatment is to find it at an early stage. 4.” The road to recovery” visualizes the entire course, from the first symptoms, to treatment and finally recovery. 5.” Challenges of the future”. The highest virtues in our society today are efficiency and performance. In itself those are great and should be revered, but as all things in extreme they can be dangerous. Education is vital if we want to avoid these problems in the future. 6.” Recovery”. When examining and diagnosing stress related illnesses, attention to recovery should always be your first and foremost concern. Conclusions: The definition of stress related illness is still too broad and covers a large field. Cases regarding these kind of illnesses differs and is highly individual. Exhaustion may occur quickly or not at all. The goal should be to coordinate with the rest of Europe to get a joint medical diagnosis. As it is now, definitions and treatments vary even inside of Sweden. If the knowledge regarding stress would be more widespread, exhaustion could be avoided. One should strive to identify the symptoms at an early stage to prevent them becoming severe. OTS should be picked up by health workers in their daily work and not only as a term in elite sports.

Submitted in fulfillment of the requirements for the Degree in Masters of Technology in Chiropractic, Durban University of Technology, Durban, South Africa, 2018. / Background: There have been an increased number of patients using complementary alternative medicine (CAM), including chiropractic care. All population age groups are utilising chiropractic treatment for various ailments. Research has shown that general practitioners have limited knowledge and perception about chiropractic in many countries. Their perception towards other health care professionals is important, particularly in their role as gatekeepers in the health care system. The current perception in Zimbabwe is thought to be no referral of patients between general practitioners and chiropractors and a low degree of knowledge amongst general practitioners about chiropractic. Aim: The aim of this study was to determine the knowledge, utilisation and perceptions of general practitioners in Harare, Zimbabwe. Objectives: • To establish the knowledge about chiropractic amongst general practitioners in Harare, Zimbabwe. • To determine perceived role and utilisation of chiropractic by general practitioners in Harare, Zimbabwe. • To determine the relationships, if any, between knowledge, perception, and utilisation of chiropractic by general practitioners in Harare, Zimbabwe. Methods: The study was a descriptive, quantitative, cross-sectional study using a structured questionnaire adapted from similar studies. The questionnaire was validated by means of a focus group discussion. The survey was conducted on a random sample of 72 general practitioners practising in the Avenues area of Harare, Zimbabwe. A single stage sampling techniques was used to select participants from a list of 88 registered general practitioners from the Medical and Dental Practitioners Council of Zimbabwe who met the inclusion criteria. Questionnaires were provided to general practitioners who were in private practice in the Avenues area of Harare, Zimbabwe at the time of the study by the researcher. The data collected was analysed using the Statistical Package for Social Science (SPSS)® 2.4 (IBM, Armonk, NY. USA) software at a statistical significance of p<0.05. Pearson’s correlation was used to assess the relationship between continuous variables, while the t test was used to copmare the mean scores between independent binary variables. Results: Many of the participants had some kind of knowledge regarding chiropractic modalities, areas of chiropractic specialisation but only a few had adequate knowledge and a good perception of it. General practitioners who were knowledgeable about chiropractic tended to have a positive perception and were more likely to refer patients to a chiropractor. A response rate of 54.5 percent was achieved. Most of the respondents tended to be in the age group of 35-54 and most were female (54.2 percent). Over 90 percent of the participants referred patients with musculoskeletal complaints to physiotherapists while only 16.67 percent referred to chiropractors. More than 65 percent of the participants responded that they knew something about chiropractic, and of these almost 50 percent obtained their information from the media. Over 80 percent of the participants who knew something about chiropractic thought that extremities, neuro-musculoskeletal system, rehabilitation and sports injuries were areas chiropractors can specialise in. Almost all the participants who knew something about chiropractic were aware of adjustments or manipluation of joints as modalities of chiropractic treatment. Majority (75.8 percent) of the participants who knew something about chiropractic thought that chiropractic could help selected conditions, while only 3 percent felt it was not effective and 21.2 percent felt they were not informed enough to comment. GP’s surveyed considered chronic back pain (91 percent), sports trauma (85 percent), shoulder/knee problems (79 percent), arthritis (76 percent), back and pelvic problems during pregnancy (70 percent), nerve root entrapment (70 percent) and carpal tunnel syndromme (70 percent) as some of the appropriate conditions for chiropractors to treat. Forty two percent of the GP’s referred patients to chiropractors mostly on both the patient’s request and their own judgment. The main reason for not referring patients to chiropractors cited by most (70 percent) of the GPs was limited knowledge about chiropractic care. There was a statistically significant and moderately high positive correlation between knowledge and perception scores (r=0.668). This study suggests that GP’s who have a higher degree of knowledge about chiropractic tend to have a positive perception of chiropractic. There was a non-significant difference in knowledge between those who refer patients and those who do not (p=0.425). In this study knowlegde about chiropractic did not significantly influence referral to chiropractors. There was however a statistically significant difference in perception between those who refer patients and those who do not (p=0.006). The perceptions were higher in those who refer patients compared to those who do not refer patients. Perceptions were found to determine utilisation rather than knowledge even though there was a correlation between the two. / M

Thesis submitted in fulfilment of the requirements for the degree Master of Technology: Design in the Faculty of Informatics and Design at the Cape Peninsula University of Technology 2014 / If a patient arrives at a general practice whether with a scheduled appointment or at random during office hours, the general practitioner should be able to assist the patient’s with direct access to the patient folder which is stored at the office. What this research study focuses on is the accessing of patient information when the general practitioner is not at the office (usually after working hours). The research study takes place within the Durbanville suburb of Cape Town, South Africa. Interaction design is used as a framework to develop a solution by using smartphone technology.

Litteraturöversiktens teoretiska referensram utgår från Patricia Benners teori om kompentensstadium. Detta ramverk nyttjas för att beskriva vikten av klinisk erfarenhet under sjuksköterskors professionsutveckling. Klinisk erfarenhet anses vara grundläggande för sjuksköterskors utveckling i yrkesrollen (Benner, 1993). Bakgrund: Att åldras är en naturlig del av livet. Många människor vårdas palliativt vilket resulterar i att sjuksköterskor kräver kunskap och kompetens inom området. Sjuksköterskor som arbetar inom den palliativa vården uttrycker ofta att de vill göra gott för patienten samt anhöriga. Syfte: Syftet med denna litteraturöversikt var att belysa sjuksköterskors erfarenhet av att arbeta inom den palliativa vården. Metod: Studien är en litteraturöversikt med kvalitativ forskning i form av vetenskapliga artiklar. Datasökningarna utfördes i databaserna Cinahl, MEDLINE, PsycINFO och PubMed. Artiklarna granskades med hjälp av Statens beredning för medicinsk och social utvärdering (SBU) granskningsmall. Resultat: Visade för- och nackdelar med att arbeta inom den palliativa vården. Viktiga faktorer hos sjuksköterskor var ansvar, samarbete, känslor och tid samt resurser. En god palliativ vård grundades i sjuksköterskors tillgänglighet och närhet. Slutsats: Resultatet har visat att ett utbildningsbehov framträdde vilket pekar på att grundläggande utbildning inte är tillräcklig inom den palliativa vården. God kommunikationsförmåga, utbildning samt kunskap inom området kan vara alternativ som underlättar för sjuksköterskor.

This research study explores in general the nature of a private general medical practice [PGMP] and whether analysis of the PGMP as a social system can lead the Group Dynamics Practitioner towards developing interventions that will enhance group effectiveness in the PGMP support staff group. The main assumption is that, through the application of a framework of analysis based on that of G. C. Homans and the AGIL functional prerequisites developed by T. Parsons, a structured analysis of the external and internal variables that impact on the PGMP as a social system can be undertaken. The findings of the analysis would lead to the formulation of interventions that would improve the performance effectiveness of the PGMP as a social system. Following a two-questionnaire survey of 17 practices that provided demographic information as well as soft skills training needs, a single PGMP was identified for the case study. Data pertaining to the group as a social system were collected, and by using direct observation, content analysis and a sociometric test, the practice support staff sub-system, being the main focus of this research, could be analysed. By linking the findings to the elements of the framework of analysis, areas of ineffective group functioning could be identified and interventions suggested. This research indicates that the choice of soft skills is associated with the nature and size of the practice, as well as the dynamics of the sociometric patterns characteristic of the relations within the practice support staff subsystem; that while some practice support staff have preferences for sociometric task and socio-emotional relations outside their work clusters, these seem to serve as a buffer against clique forming, thus enhancing the function of integration within the social system as a whole; and that the physical practice layout, and the interaction dynamics that it creates, tend to hinder integration between the members of the practice support staff group, as a social subsystem.

This thesis explores the provision of services for people with multimorbidity in general practice. It considers 3 broad research questions: how services are organised; why they are configured in this way; and the impact this organisation has on service delivery. At present, there is no formalised system for managing multimorbidity in general practice. Current arrangements reflect the wider organisation of care for chronic conditions which typically involves managing individual chronic conditions. The needs of people with multimorbidity are often complex and require a number of services from several providers. Coordinating these services is challenging, not least because of the fragmented system within which professionals and providers are situated. Different clinical, managerial and funding arrangements complicate this situation, creating as it does a number of parallel work streams. Effective healthcare for people with multimorbidity requires different providers to work collaboratively to promote linkage across professional and service boundaries. Information flows and administration play an important role in promoting continuity and coordination within and across work streams that span primary, secondary and tertiary care. In some instances, inefficiencies in services can be linked to the lack of integrative working between the clinical and administrative aspects of care. At present, fragmented systems are perpetuated by the lack of a whole systems approach that would align clinical, managerial and financial aspects of service provision across organisations. This thesis demonstrates that, services in general practice are increasingly determined by factors external to it. Most notably the division of care across multiple providers and the financial and contractual arrangements which require an organisation of services that promotes a division of labour and a routinsation, aimed at optimising the daily through put of patients. If the present and future needs of people with multimorbidity are to be effectively met, changes to the way services are provided in general practice must be considered as part of a whole system of healthcare, whereby collaborations between different professionals and services are intentionally organised and actively managed. Although the evidence base for managing multimorbidity is limited, there is a growing recognition that in terms of improving outcomes for people with multimorbidity, improving clinical care alone is not as effective as simultaneously improving the organisation or design of services across the whole system of provision.

General practice emerged as a distinct medical discipline in the nineteenth century. As independent contractors, General Practitioners (GPs) have however largely been 'untouched' by centrally derived policy. As a result, the profession has possessed wide discretion in relation to the way they dealt with their patients. However, due to increasing concerns over the cost and quality of care within the NHS, general practice increasingly became a focal point for the attentions of central policy makers who sought to control aspects of frontline practitioner behaviour. In order to do attempt to align the frontline behaviour of GPs with such policy aims, policy makers turned to their main tool, the contract. In this thesis I am concerned with the most recent contractual changes (and its later variants) introduced in 2004. In particular, the study is concerned with the impact of the large element of Pay-for-performance (P4P) known as the Quality and Outcomes Framework (QOF) contained within the new contract. QOF rewards practices on the basis of meeting a number of targets in relation to clinical, organizational, and patient experience indicators. As a result of the scale and prescriptive nature of the targets, QOF had the potential to change the nature of GP work at the micro-level should GPs choose to follow this voluntary policy. Previous evidence in relation to GP responses to other prescriptive policies such as National Service Frameworks (NSFs) and clinical guidelines suggests that GPs responded as workers, specifically as street-level bureaucrats (SLBs) by selectively by choosing aspects of policies based upon the on the criteria of whether or not they made the practicalities of processing their daily workload easier. However, the evidence suggests that there were also instances of GP principal (those that (part-) own their practices) behaviour that did not conform to expected SLB behaviour but instead resembled behaviour that would be expected of those managers who are 'results oriented.' Based upon this evidence and the analytical possibilities the SLB framework provided, the theoretical view of GPs as frontline public sector workers or street-level bureaucrats (SLBs) was employed to understand the continuing perceived impact and responses of GPs to the new contract and in particular QOF. Unlike previous analyses of GPs as SLBs however, this study distinguished between GP principals and salaried GPs employed by the GP principal counterparts. Ultimately, the aim of the thesis was to address the question of whether or not the conceptualization and responses of GPs as SLBs was still relevant and useful post-contractual change. Data was collected (between Feb 2008 and Sept 2009) via semi-structured interviews. In total 62 first round interviews and 24 second round interviews were conducted and analysed thematically. The findings indicate that the financial incentives within the QOF appear to strongly influence the responses of GP principals and reflect their priorities as owners of, rather than workers in their organisations. In addition, it appears that the Evidence Based Practice (EBP) movement means that salaried GPs priorities are also aligned to those of their organisations as they believe most of the QOF to be evidence-based. As a result, the application of Lipsky's SLB framework to explaining GP behaviour in relation to QOF is less useful than previous applications.

The practice of midwifery by those other than physicians is illegal in Canada and despite recommendations of nursing, medical and consumer groups, no trials evaluating the effectiveness of the nurse-midwife as a member of the modern obstetrical team have occurred here. To demonstrate a nurse-midwifery model, four nurse-midwives provided primary care to forty-seven childbearing women and their families over a twenty-two month period in a maternity teaching hospital. This clinic presented a unique opportunity for comparing the prenatal care provided by nurse-midwives with that of general practitioners who attended deliveries in the same setting. Utilizing a retrospective chart audit, case control study design, the nurse-midwife cases (NM cases) were each matched to two general practitioner controls (GP controls) through the use of the hospital's prenatal data base. The matching characteristics included low risk status, date of delivery, age, parity, gravidity, previous pregnancy losses and census tract income. Prenatal criteria that had been developed and tested in "The Burlington Randomized Clinical Trial of the Nurse Practitioner" for assessing the quality of care were reviewed and updated for this study. With these criteria two blinded abstractors audited the prenatal record forms of all the subjects and scored them as either "superior", "adequate" or "inadequate". Seventy-seven percent of the records of the NM cases received a "superior" score, where as 60% of the GP controls' records received an "inadequate" score [mathematical formula omitted] Overall, the general practitioners' records indicated more erratic care than those of the nurse-midwives. Although the physicians met most of the initial assessment criteria, they failed to meet the criteria that evaluated the ongoing routine assessment process by recording an inadequate number of prenatal visits (36%), or by omitting urine test results (38$) and blood pressure readings (21%). No differences were found in variables relating to labour and delivery with the exception of the incidence of episiotomies. The results indicate that nurse-midwives as part of an obstetrical team are able to provide safe prenatal care to a low risk population in a Canadian urban context, and that their records are thorough and more consistent than those of general practitioners. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

Yes / This study aimed to explore the challenges and barriers faced by staff involved in the delivery of the National Health Service (NHS) Health Check, a systematic cardiovascular disease (CVD) risk assessment and management program in primary care. Data have been derived from three qualitative evaluations that were conducted in 25 General Practices and involved in depth interviews with 58 staff involved all levels of the delivery of the Health Checks. Analysis of the data was undertaken using the framework approach and findings are reported within the context of research and practice considerations. Findings indicated that there is no ‘one size fits all’ blueprint for maximising uptake although success factors were identified: evolution of the programme over time in response to local needs to suit the particular characteristics of the patient population; individual staff characteristics such as being proactive, enthusiastic and having specific responsibility; a supportive team. Training was clearly identified as an area that needed addressing and practitioners would benefit from CVD specific baseline training and refresher courses to keep them up to date with recent developments in the area. However there were other external factors that impinged on an individual’s ability to provide an effective service, some of these were outside the control of individuals and included cutbacks in referral services, insufficient space to run clinics or general awareness of the Health Checks amongst patients. The everyday experiences of practitioners who participated in this study suggest that overall, Health Check is perceived as a worthwhile exercise. But, organisational and structural barriers need to be addressed. We also recommend that clear referral pathways be in place so staff can refer patients to appropriate services (healthy eating sessions, smoking cessation, and exercise referrals). Local authorities need to support initiatives that enable data sharing and linkage so that GP Practices are informed when patients take up services such as smoking cessation or alcohol harm reduction programmes run by social services.