The nature of nursing judgment in clinical practice situations remains incompletely explored. It is known that nurses perform endotracheal suctioning as part of the nursing care of critically ill children. However, the ways in which nurses judge the need for suctioning and the method used to suction are not well understood. This research study was conducted to describe the cues that expert pediatric critical care nurses use in making the judgment to suction and to describe how those cues are used in determining the timing of endotracheal suctioning. A qualitative naturalistic study was conducted in a quaternary pediatric critical care unit in Central Canada. A purposive sample of seven expert pediatric critical care nurses participated in the study. Data were collected using three methods---participant observations (field notes), think aloud (concurrent verbalizations) and semi-structured interviews (retrospective verbalizations)---as participants cared for ventilated, critically ill children. (Abstract shortened by UMI.)

This study, conducted as a needs assessment, was guided by O'Connor's Decision Support Framework (DSF). The DSF describes a process of providing to both parents and practitioners decision support by identifying the sub-optimal determinants of the decision. The objectives of the study were to describe the decision making needs of parents making choices about neonatal male circumcision and the needs of prenatal instructors who inform parents about options. The study design was across-sectional survey of 88 mothers and 67 fathers and 10 prenatal instructors. Structured questionnaires were used, eliciting variables based on the DSF, such as: the perception of the decision; perception of others regarding the decision; resources to make the decision; and participant characteristics. Although all instructors stated that circumcision was discussed, the content of the discussion varied according to the instructor's experience and perception of the decision. Most instructors (9/10) believed parents lacked both information about options and chances of the benefits and risks. Few of the instructors (2/10) saw their role as instrumental in the decision. (Abstract shortened by UMI.)

The incidence of congestive heart failure (CHF) rises annually and, despite advances in medical treatments, the prognosis remains poor. Since CHF has no cure, the treatment is mostly supportive symptom management and prevention of exacerbation. Studies examining the impact of social support on CHF have found that social support helps to prevent hospitalization and helps patients with CHF adhere to the prescribed medication and lifestyle changes. The purpose of this study was to explore the meaning of social support to Arab Canadians with CHF. The Arab immigrant population is at risk of many health problems because of traumas associated with the immigration experience and limited knowledge of a complex health care system. The qualitative method of particularistic ethnography was used to gain a better understanding of the meaning of support in this cultural group. In depth, semi-structured, audio-taped interviews were conducted with a sample of 7 Lebanese Christian participants. The data analysis revealed 3 themes: "My family will take care of me"; "I rely on God"; and The illness is not important. Nursing implications and recommendations have been proposed to address the needs of this cultural group.

In order to plan for a new community leg ulcer service, local evidence was required on the regional population with venous leg ulcers and the current state of community practice. There is strong evidence in the literature supporting the assessment and management of venous leg ulcers, but little is known about the local population profile or whether they were receiving the internationally recommended care. This is a manuscript-based thesis that consists of three distinct papers intended for submission for publication. The first two papers detail the planning studies that were undertaken to generate local evidence in order to design a new nurse-led community leg ulcer service. The first paper provides a population profile of the venous leg ulcer population receiving home care in one Ontario region. The second paper provides a critical appraisal of the state of community venous leg ulcer care. In the final paper, an advanced practice nurse (APN) reflects on her role in the design and implementation of the new service. The new leg ulcer service was designed using the evidence from the population profile and to address the gaps and inconsistencies in the provision of "best practice" that were identified in the appraisal of care. In this third paper, a number of barriers to the new evidence-based service were identified on a number of different levels and the multiple strategies tailored to the barriers were described.

Objective. To describe a profile of school-aged children (5--14 years) living in shelters in Ottawa including risk and protective factors commonly associated with health related outcomes in children. Design. A descriptive research study using a pre-tested survey questionnaire designed by the researcher, based on the literature, and guided by a resilience framework. Setting. Three emergency family shelters in Ottawa. Participants. 34 parents with 61 children (aged 5 to 14 years) living at the shelters. Conclusions. Risk and protective factors at the individual, family, and community levels are presented. Protective factors of children living in shelters should be recognised, strengthened, and maintained. Efforts to minimise the risk factors should be undertaken. Implications for nursing practice and research are discussed. (Abstract shortened by UMI.)

The Canadian Nursing Association promotes the use of evidence-based decision-making (EBDM) as a component of quality nursing care. A shift to a population health approach encourages public participation in health-related decision-making. Public health nurses (PHNs) participate in joint health-related decision-making with community partners. The purpose of this exploratory and descriptive study was to gain an in-depth understanding of EBDM from the perspective of the PHN. The meaning of EBDM, the perceived barriers and facilitators of using evidence, and the role of the PHN in bringing evidence to the joint decision-making process that they share with community partners was explored. A qualitative methodology known as ethnography was used and data were collected from two sources: observations at team meetings and semi-structured interviews with PHNs. Analysis of the data led to the identification of three sub-themes: holistically knowing the community, bridging 'evidence' to context, and actively managing information. All three sub-themes contribute to the main theme: the PHNs' role in fostering collaborative 'evidence-based' decision-making in the community. The PHNs' holistic view of evidence, which includes hard and soft data, contextual data and professional experience, is discussed. Basic steps in a shared EBDM process are described and dimensions of the context in which PHNs practice are explored. Implications for education, practice, research, and policy are discussed.

Traumatic injury occurs without warning leaving no time to prepare. The patient may be frightened about the unknown, their future, or the prognosis. The patient arrives in the Emergency Department (ED) where assessment and management of injuries begins. Little is known about the patient's experience of trauma resuscitation. Therefore, a qualitative study using interpretive phenomenology was undertaken to describe the lived experience of trauma resuscitation in the ED. A total of seven participants were interviewed after they experienced trauma resuscitation in the ED of a Lead Trauma Hospital. Tape-recorded interviews were conducted on the in-patient Trauma Unit between day 2 and day 7 post trauma resuscitation. Follow-up interviews were conducted with four participant's seven to twelve months after the initial interview. Data analysis utilized Colaizzi's eight-step analytical process. Four themes were revealed in the data analysis: I Remember, I Was Scared, I Felt Safe, and I Will Be OK. The findings also revealed that initial perceptions of vulnerability subsided as a sense of feeling safe became prominent. System factors were acknowledged to influence the overall conviction that it was a positive experience. Lastly, nursing interventions were important in contributing to the participants' feelings of being safe. This suggests that comfort care measures need to be at the forefront of trauma nursing care as well as measures aimed at attaining physiological stability.

Despite evidence that organizational outcomes are negatively affected when professionals have limited decision making and their practice is constrained, little is known about the relationship of decentralized decision making (DDM) structures to the professional practice environment (PPE). In this study, the relationship of DDM to clinical nurses' perceived aspects of a PPE was examined. DDM consisted of the hierarchy of authority for work decisions and participation in strategic and unit group decisions. The PPE aspects of interest to administrators in complex organizations who are charged with organizational effectiveness include: control over practice, professional development, innovation activity, and peer relationships. Using a correlational design, data were collected from a random sample of 320 clinical nurses employed in a university teaching hospital. Instruments used included the Index of Centralization and the Professional Practice Environment Scale. Multivariate procedures were used to test hypotheses and to construct models. Authority for work decisions was positively related to the four aspects of PPE. Participation in decision making was positively related to all aspects except control over practice. Several individual and situational characteristics were found to moderate the relationship between DDM and PPE. Work pressure was statistically controlled. Model building showed that unit decision making was the most important variable in the relationships with professional development and innovativeness. Results contribute to organizational and nursing administration theory and are a useful guide for administrators to enhance PPE as a way to help manage constant change.

Cette thèse tente d'apporter une réponse nouvelle à la question de savoir comment pourrait être soulagée la souffrance humaine associée à l'annonce de l'imminence de la mort . Elle pose d'abord la question des savoirs disponibles quant aux causes de la souffrance en question, puis la question des pouvoirs permis par ces savoirs, qui permettraient de l'atténuer ou de l'éliminer. À chacune des questions, elle répond en termes des acquis disponibles ainsi qu'en termes de prolongements inédits. Elle procède, dans un premier temps, à l'identification d'invariants conceptuels dans tout discours sur la question de l'acquisition des connaissances, qu'il s'intéresse à des savoirs ou à des pouvoirs. Cette présentation culmine dans la proposition & un design computationnel, le Design Cognitif Universel, ou DCU, établissant une matrice formelle présentée comme pouvant servir à la formalisation de quelque fonction cognitive que ce soit. Au chapitre des savoirs , la thèse prolonge à la fois une tradition de recherche sur la douleur et la souffrance, et une tradition de recherche sur le Soi. La souffrance s'y trouve définie en référence à une comptabilité inhérente aux processus de gestion des structures de contrôle caractérisant l'individu, ces structures étant définies comme des mises en rapport d' intentionnalités et d' attentionnalités spécifiques se cristallisant sous la forme de divers Sois. Le nouvel éventail de Sois proposé s'inscrit sur deux axes, un premier axe métaphysique/physique et un second axe individuel/collectif, définissant un plan identitaire . La séquence des Sois physiques définissant la portion physique de l'axe métaphysique/physique est établie dans la foulée de la perspective génétique piagétienne. La notion d' Identité , comme schème-synthèse de la variété des Sois disponibles à chaque niveau de développement vient coiffer cette proposition générale. La souffrance associée à l'annonce de l'imminence de la mort devient souffrance associée à l'imminence de la perte du corps, au substrat physique, et devient le fait d'une menace Jugée incontournable aux rapports d'intentionnalité/attentionnalité constituant l' Identité Substrative . L'Identité Substrative ne reposant que sur une synthèse des Sois substratifs, à l'exclusion des Sois métaphysiques, la possibilité de développer, par le biais du Soi Formel, une Identité Transsubstrative, i.e. incluant les Sois métaphysiques en plus des Sois physiques, est évoquée. Cette Identité Trans-substrative est présentée comme dominant la mort, dont la portée ne peut, formellement, être conçue comme portant au-delà du domaine substratif, et comme permettant de contenir la souffrance associée à son imminence. Au chapitre des pouvoirs , la thèse prolonge une tradition de recherche sur les environnements d'apprentissage, en proposant de mettre au service de ceux et celles qui souffrent de l'annonce de l'imminence de la mort, un micromonde pédagogique, appelé micromonde corps/esprit, susceptible de favoriser leur transition d'une Identité Substrative à une Identité Trans-substrative.

Au moyen d'une recherche qualitative de type exploratoire, la question de la prise en charge d'un proche parent âgé est abordée dans une problématique des rapports sociaux de sexe. Ce cadre analytique oriente nos réflexions nous permettant de faire ressortir l'importance des capacités intellectuelles d'organisation dans l'exécution du travail de soins effectué par les femmes et d'interroger la participation des conjoints. Les témoignages recueillis à partir d'entrevues réalisées auprès de femmes adultes s'occupant de leur mère ou belle-mère révèlent que le travail de soins nécessite l'élaboration d'une gestion temporelle par la prise en considération de temps institutionnels, dont les horaires des services spécialisés et des experts en santé ainsi que les temps personnels, dont le rythme de la personne âgée. Cet ensemble complexe et diversifié des tâches de soins et des autres activités de la vie quotidienne exige également une gestion de l'espace. L'accroissement du temps consacré aux soins de la personne âgée entraîne une réduction des déplacements. Les sorties à l'extérieur de la maison, en plus d'être réduites, sont davantage calculées et planifiées. Par ailleurs, l'analyse des données révèle l'importance du soutien affectif apporté par les conjoints à la retraite. Pour mettre en relief la gestion proprement dite des activités de soins et de la vie quotidienne et pour mettre en évidence la préoccupation constante exprimée par les filles se retrouvant dans des «échanges inégaux» avec leur mère nécessitant toujours plus de soins, nous suggérons d'utiliser la notion de «poids mental».