As the health care sector in the United States undergoes transformation, job dissatisfaction has become a problem that is confounded by the challenge that nurse executives encounter in understanding the aspirations of an increasingly diverse workforce. A quantitative survey was conducted online using a representative sample of registered nurses (RNs) nationwide. Approximately 127,000 RNs from across the nation received an invitation, and 272 RNs participated. Factorial ANOVAs were performed to answer the research questions of whether aspects of job satisfaction differ across the demographic factors of a diverse RN workforce. No differences exist in personal satisfaction or satisfaction with workload as a function of generational cohort (Baby Boomers, Generation X, and Generation Y), gender (female and male), or origin of training (United States or international). With Herzberg's motivation-hygiene theory as the theoretical framework, multiple linear regression analyses were conducted to examine the relative importance of job factors. Satisfaction with workload was a stronger predictor of global job satisfaction than personal satisfaction; this contradicts the motivation-hygiene theory. Work environment is a crucial factor in understanding global job satisfaction. This research has implications for social change by raising the nurse executives' understanding of factors that affect the job satisfaction of nurses and by doing so, may support patient advocacy, promote human gratification, and endorse economic gain.

Access to primary medical care and prevention services in Nigeria is limited, especially in rural areas, despite national and international efforts to improve health service delivery. Using a conceptual framework developed by Penchansky and Thomas, this case study explored the perceptions of community residents and healthcare providers regarding residents' access to primary healthcare services in the rural area of Isu. Using a community-based research approach, semistructured interviews and focus groups were conducted with 27 participants, including government healthcare administrators, nurses and midwives, traditional healers, and residents. Data were analyzed using Colaizzi's 7-step method for qualitative data analysis. Key findings included that (a) healthcare is focused on children and pregnant women; (b) healthcare is largely ineffective because of insufficient funding, misguided leadership, poor system infrastructure, and facility neglect; (c) residents lack knowledge of and confidence in available primary healthcare services; (d) residents regularly use traditional healers even though these healers are not recognized by local government administrators; and (e) residents can be valuable participants in community-based research. The potential for positive social change includes improved communication between local government, residents, and traditional healers, and improved access to healthcare for residents.

American Heart Association officials and other expert cardiologists recommend omega-3 (n-3) dietary supplementation for the secondary prevention of cardiovascular disease, a prevalent health problem in the United States. Physicians' lack of understanding of possible n-3 preventive health benefits results in underprescribing n-3 dietary supplements and lower n-3 dietary supplement product sales. N-3 dietary supplement marketers do not understand physician n-3 prescribing decision criteria enough to optimize high-impact communication to physicians to increase n-3 dietary supplement product use. The purpose of this phenomenological research study was to improve n-3 marketers' understanding of how physicians reach decisions to prescribe or recommend products including n-3 dietary supplements. Argyris' ladder of inference theory provided the study framework to facilitate understanding physicians' decision criteria. Rich data collected and analyzed from 20 primary care physician interviews in Kentucky, Indiana, and Tennessee revealed physicians use similar decision criteria for drugs and n-3s. Three essential influencers of physician decisions included clinical evidence, personal experience, and cost. Other influencers were opinions of peers, pharmaceutical representatives, samples, direct-to-consumer advertising, and knowledge of dietary supplements. Study outcomes may inform pharmaceutical marketers regarding presentation of clinical evidence, cost emphasis, and pharmaceutical representative skills and may facilitate competitive advantage for n-3 marketers. The social benefit of this study is improved physician understanding of n-3s may result in more accurate and appropriate prescribing to augment positive health outcomes.

<p></p> <p><strong><em>Background </em></strong></p> <p>Oral pharmacotherapy has the potential to offer multiple sclerosis patients improved clinical outcomes compared to traditional therapies.</p> <p><strong><em>Objectives </em></strong></p> <p>This review assesses the effects of oral therapies compared to placebo and interferon beta-1a in adults with relapsing-remitting multiple sclerosis (RRMS).</p> <p><strong><em> </em></strong></p> <p><strong><em>Search methods </em></strong></p> <p>We searched the MEDLINE, EMBASE, Cochrane Library, Web of Science (January 1980 to April 2011) and clinincaltrials.gov (April 2011) databases and reference lists of articles. The FDA website was also searched.</p> <p><strong><em>Selection criteria </em></strong></p> <p>Double-blind, placebo-controlled, randomized trials of RRMS patients who were treated with fingolimod, cladribine, laquinimod or interferon beta-1a.</p> <p><strong><em>Data collection and analysis </em></strong></p> <p>Two reviewers independently assessed articles for inclusion. Data extraction and quality assessment was completed by one reviewer and verified for accuracy. Meta-analysis and indirect treatment comparison methods were used to estimate relative measures of efficacy.</p> <p><strong><em>Results </em></strong></p> <p>Although 11 trials involving 7,127 participants were included in this review, only 2,109 (30%) and 1,738 (24%) participants contributed to the direct and indirect estimates respectively, for the primary outcome, annualized relapse rate. Oral therapy and interferon beta-1a had a significantly different rate of relapse compared to placebo (Mean difference [MD] -0.21, 95% confidence interval [CI] -0.27 to -0.16 , p < 0.00001 and MD -0.33 95% CI -0.65 to -0.01). There was a significant risk reduction of 37% and 19% in the number of patients with at least one relapse for oral therapy and interferon beta-1a compared to placebo respectively. Safety analysis favoured placebo for both sets of trials (p=0.002 and p=0.04). Indirect estimates were not significant for all three outcomes however; comparability between direct evidence was noted.</p> <p><strong><em>Conclusions </em></strong></p> <p>Oral pharmacotherapy and interferon beta-1a are effective compared to placebo in controlling relapse rate in patients with RRMS. The indirect measures of effect provide initial estimates of comparative efficacy and incorporation of future evidence will be necessary.</p> / Master of Science (MSc)

<p><strong>Introduction: </strong>eHealth Ontario and the Ministry of Health and Long Term Care (MOHLTC), with funding from Canada Health Infoway, are considering introducing a Drug Information System (DIS). This system will introduce and integrate ePrescribing, eDispensing and electronic data interchange (two-way electronic order communication between physicians via electronic medical records (EMR) systems and pharmacists via pharmacy management systems (PMS) regarding medications).</p> <p><strong>Objectives: </strong>To gather perceptions of family physicians, community pharmacists and patients on the DIS being implemented in Ontario. Before such an expensive large-scale system is implemented, areas of concerns should be identified to maximize utilization of the system.</p> <p><strong>Study Design: </strong>Three different group-specific electronic and paper questionnaires</p> <p><strong>Setting: </strong>Family physicians, community pharmacists and patients. The aim was to receive <strong>35</strong> questionnaire responses from each group from Waterloo, Hamilton, Guelph and the Greater Toronto Area in Ontario. <strong></strong></p> <p><strong>Methods: </strong>A<strong> </strong>Literature search was conducted to study the current two-way electronic order communication systems and perceptions of prescribers, dispensers and patients on ePrescribing or eDispensing within primary care. Group-specific questionnaires, used with consent from a Scottish study, were altered and tailored for Ontarians, and distributed to all 3 groups via convenience and snowball sampling. Study findings were compared to the same Scottish study.</p> <p><strong>Results: </strong>The ‘adjusted’ response rates were 82% (patients), 72% (community pharmacists) and 60% (family physicians). All three groups were in favour of DIS being implemented in Ontario. Generally only the pharmacist group had any knowledge of DIS before this survey. Most respondents agreed that patient care would improve with the implementation of DIS.</p> <p><strong>Conclusion: </strong>Implementation of the DIS in Ontario is perceived as a good idea amongst all pharmacists, family physicians and patients. However, eHealth Ontario and MOHLTC need to increase awareness amongst all three, but mostly consumer and prescriber groups of the potential benefits of the DIS in order for them to accept and adapt to this new system. <strong> </strong></p> / Master of Science (MSc)

<p>This research examined the barriers and facilitators involved in the development and sustainability of palliative care teams using a shared care model. Shared care is established when interdisciplinary specialist palliative care teams (usually comprised of a palliative care physician, an advanced practice nurse, a psychosocial spiritual advisor, a bereavement counselor, a case manager and an administrator) form partnerships with primary care providers (usually frontline family physicians and home care nurses) to support the complex needs of terminally-ill patients and their family members in the home setting. Palliative care teams overcome gaps in the current health care system, such as: lack of palliative care specialists; poor coordination and integration of care, and; a health care workforce with insufficient training in palliative care. This type of service delivery model is common in medical specialties such as mental health and obstetrics, and various forms of palliative shared care have been implemented in other countries such as the US, Australia, UK, Italy and Spain, where it has been shown to be cost-effective. There are few palliative care teams working in a shared care model in Canada; this provided the impetus to investigate the process of how this integrated approach is developed and sustained within the context of specific populations and geographies. A longitudinal case study in a Local Health Integration Network (LHIN) area in Southern Ontario, comprised of urban and rural communities, was conducted in order to evaluate barriers and facilitators in using a shared care model from the perspective of team members, key-informants and stakeholders. The evaluation of barriers and facilitators informed recommendations to guide the sustainability of palliative care teams working in a shared care model.</p> / Doctor of Philosophy (PhD)

There is a low representation of Black American women (BAW) in health care senior leadership. With the high level of health problems found among the Black community, diversifying the executive leadership with BAW may be instrumental in increasing provider trust and reducing discriminatory action. Using critical race theory as the conceptual framework, this study examined the experiences, perceptions, and influential or deterrent factors inhibiting advancement of BAW in the health care field. Inquiry centered on factors related to lack of advancement, experiences at different stages of career progression, and strategies impacting career advancement. A qualitative research design using a transcendental phenomenological approach was the chosen method. Seven BAW who met the criteria for inclusion were selected by purposive sampling. Data were collected from semi-structured, audio-recorded, interviews using a newly created protocol. Data analysis included open coding; line-by-line data review; and the use of NVivo to search for frequencies of themes, coding, and text queries. Emergent themes were identified that provided comprehensive descriptions of the participants' experiences. According to study findings, perceived and experienced racial issues were apparent in hiring and work relations. Disparate practices were evident through a lack of inclusion in succession planning, being overlooked despite qualifications, and stereotyping. These findings may stimulate social change by helping those BAW aspiring for senior healthcare leadership to be more successful and by improving health outcomes for BAW through enhanced trust.

Years ago it was typical for a physician to serve as a hospital's Chief Executive Officer (CEO). However, with the development of Master of Health Administration, Master of Public Health, and Master of Business Administration programs, hospitals began to move away from this model. Today however, as hospitals search for innovative ideas to reduce healthcare costs and improve the quality of care, the idea of the physician hospital CEO has returned. Little empirical research is available in the health services literature on the physician hospital CEO. The study aims to examine the relationship between organizational and environmental factors and physician CEOs, and whether or not physician CEOs are associated with improved hospital performance.The conceptual framework is adapted from Donabedian's structure, process, and outcome perspective, which when applied to the organizational level becomes context design-performance. The theoretical perspective applied to the conceptual framework to guide the development of hypotheses is contingency theory, which suggests that organizations are most successful when they can adapt their structures to fit their environment.Data for this study were obtained from multiple sources: American Hospital Association Annual Survey, the Centers for Medicare and Medicaid Services Hospital Cost Reports, SK&A, Area Resource File, and the Centers for Medicare and Medicaid Services Hospital Quality Alliance.Besides descriptive analyses, logistic regression was used in this study to evaluate the relationship between the organizational and environmental hospital characteristics. Ordinary least squares regression was used to explore the relationship between physician CEOs and hospital performance.Results indicate that hospitals in markets with greater physician competition are more likely to have physician CEOs. Hospitals that are affiliated with a system are also more likely to have physician CEOs. The study found that while teaching hospitals and specialty hospitals were associated with placement of physician CEOs, it was in the opposite direction of what was hypothesized. This may be a result of the small sample size of both teaching and specialty hospitals in the study sample. The study concludedthat having a physician CEOs is associated with hospital financial outcomes but not associated with its quality of care outcomes.

This dissertation proposal seeks to understand if the increasingnumbers (density) of recognized PCMH practices incommunities affect avoidable hospitalizations related toambulatory care sensitive conditions (ACSC), as measured bythe AHRQ Composite Prevention Quality Indicators (PQI). Theresearch has two purposes: 1. Establish constructs and hypotheses to measurethe effect of the increasing numbers of NCQA-Recognized PCMH practices in communities(counties). 2. Using an outcomes-based measurement approach,investigate the relationship between growingdensities of NCQA-Recognized PCMH practicedoctors among all primary care doctors (PCD) ina community and the associated impact on theutilization of inpatient care, specifically related toACSCs, as measured by the AHRQ CompositePQIs. The research is quasi-experimental in design and is based on aretrospective (2008–2011) analysis of existing data from theNCQA PCMH program, the AHRQ Composite PQI and theCenters for Medicare & Medicaid Services (CMS) NationalProvider Identification (NPI) databases. Analysis will linkNCQA-Recognized PCMH practices (independent variable),AHRQ Risk Adjusted Composite PQIs (dependent variable),and the CMS NPI (total PCDs) on Federal InformationProcessing Standard (FIPS) identifiers across 114 state andcounty-level geographical areas in Vermont and North Carolina.

Nationally, it has been estimated that 10 to 21% of children with psychosocial concerns are seen in primary care settings (Jellinek et al., 1999; McInerny, Szilagyi, Childs, Wasserman & Kelleher, 2000; Palermo et al., 2002). Often, however, children go undiagnosed with/treated for psychosocial concerns in pediatric primary care due to lack of physician time and poor referral rates to mental health providers. Evaluations of integrated care models, in which a behavioral health consultant is present in primary care practices, has shown to increase the availability of mental health services (Stancin, Perrin, & Ramirez, 2009). Using extant data from patient records extracted by a trained nurse, this study aims to assess practice scheduling habits and seasonal variation in behavioral health consultant (BHC) usage on days when a BHC is present versus non-BHC days in one rural pediatric office over the course of four years. This study aims to evaluate economic efficiency based on the number of patients scheduled per day. It is hypothesized that the presence of an onsite BHC will increase patient volume and, thus, economic efficiency. Information gathered from the clinic’s electronic scheduling system included: 1) the number of patients scheduled on a BHC day and 2) the number of patients scheduled on a non-BHC day for each week of the BHC’s employment. These data—both overall and by year and season—were analyzed using one-way ANOVA and post hoc Tukey testing. There were no significant differences in scheduled patient volume found between the day types overall. However, yearly analysis revealed significant differences between 2010 and 2012, 2013, and 2014 on BHC days and between 2010 and 2014 on non-BHC days. When examined by season, significant differences were found between Fall/Winter and Spring/Summer on both day types in post hoc Tukey testing. These findings have important implications for the trajectory of benefits provided by a BHC in a rural integrated care model.