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Understanding how patients and operators trust medical technology will provide insight into the role, implementation and use of technology in health systems. Models developed in aviation and manufacturing that predict operators' trust or distrust in technology (Biros, 2004; Jian, Bisantz, Drury, & Llinas, 1998; Lee & See, 2004; Muir & Moray, 1996; Parasuraman, 1997) may not be applicable to medical technology and health systems. The first objective of this research was to empirically define the construct trust in medical technology by differentiating it from trust in technology and providing a model of it's factors. The second objective of this research was to generate a theory of how patients and health care providers construct trust in medial technology in an applied context. The third objective of this research was to develop and validate an instrument to measure patients' trust in medical technology. The results of these combined studies identified 30 factors of trust in medical technology and provided evidence to support the hypothesis that trust in technology and trust in medical technology are different constructs. A grounded theory was developed that shows that patients' trust in medical technology is based on a combination of characteristics from the technology, providers and how the providers use the technology, while physicians' trust is constructed from the trustworthiness of the system and trust in their own abilities. An 80 item instrument for measuring trust in medical technology was developed and validated. Recommendations for the design of obstetric work systems are discussed. / Ph. D.

Individuals are considered the weakest link when it comes to securing a personal computer system. All the technological solutions can be in place, but if individuals do not make appropriate security protection decisions they introduce holes that technological solutions cannot protect. This study investigates what personal characteristics influence differences in individual security behaviors, defined as behaviors to protect against security threats, by adapting Protection Motivation Theory into an information security context. This study developed and validated an instrument to measure individual security behaviors. It then tested the differences in these behaviors using the security research model, which built from Protection Motivation Theory, and consisted of perceived security vulnerability, perceived security threat, security self-efficacy, response efficacy, and protection cost. Participants, representing a sample population of home computer users with ages ranging from 20 to 83, provided 279 valid responses to surveys. The behaviors studied include using anti-virus software, utilizing access controls, backing up data, changing passwords frequently, securing access to personal computers, running software updates, securing wireless networks, using care when storing credit card information, educating others in one's house about security behaviors, using caution when following links in emails, running spyware software, updating a computer's operating system, using firewalls, and using pop-up blocking software. Testing the security research model found different characteristics had different impacts depending on the behavior studied. Implications for information security researchers and practitioners are provided, along with ideas for future research. / Ph. D.

O sofrimento moral é descrito na literatura como o sentimento resultante do impedimento à uma ação considerada moralmente apropriada, devido, sobretudo, a obstáculos institucionais, como a falta de recursos e a carga de trabalho. As consequências envolvem sintomas físicos, como mal estar, choro e desordens do sono e sintomas psicológicos, como frustração, impotência e culpa, além de implicações organizacionais, principalmente relacionadas com afastamentos e abandono do emprego. Considerando que o contexto de trabalho pode influenciar na vivência de situações moralmente problemáticas, o objetivo do estudo foi analisar o fenômeno do sofrimento moral em enfermeiros no Brasil e em Portugal. Trata-se de uma pesquisa metodológica para desenvolvimento, busca de evidências de validade e refinamento de um instrumento de pesquisa. A investigação partiu da análise de 38 estudos da literatura para construção de uma escala para identificação de fatores de risco para sofrimento moral. A busca por evidências de validade incluiu uma análise de juízes, para validação de conteúdo, e uma análise fatorial exploratória, para validação de constructo, com uma amostra de 268 enfermeiros brasileiros e 278 enfermeiros portugueses. O resultado foi uma escala com evidência de validade para ambos os países, com Alpha de Cronbach de 0,913 e 0,790, teste de Kaiser-Meyer Olkin de 0,869 e 0,914 e índice de Bartlett significativo (p <0,001) para Brasil e Portugal, respectivamente. Cerca de 59,8% da variância é explicada por 30 itens, divididos em sete fatores, na versão brasileira, e cerca de 53,9% da variância é explicada por 20 itens, divididos em 4 fatores, na versão portuguesa. A vivência de fatores de risco para sofrimento moral foi considerada moderada no Brasil e baixa em Portugal. As variáveis que mostraram associação significativa com maiores médias totais de risco nos dois países foram o tipo de serviço, as horas de trabalho, estar em sofrimento moral e ter a intenção de deixar o emprego atual. Pesquisas no âmbito do sofrimento moral podem, entre outros aspectos, auxiliar na identificação dos desafios e das dificuldades que mais preocupam os enfermeiros em seu contexto de trabalho. No intuito de contribuir no desenvolvimento de estratégias de enfrentamento e melhorar a retenção e a satisfação profissional, pesquisas acerca do sofrimento moral podem refletir positivamente na qualidade dos cuidados. / Moral distress is described as the feeling resulting from the impediment to an action considered morally appropriate, mainly due to institutional obstacles such as the lack of resources and the high workload. Main consequences are physical symptoms, such as malaise, crying and sleep disorders and psychological symptoms, such as frustration, impotence and guilt, as well as organizational implications, mainly related to withdrawal and abandonment of employment. Considering that the work context may influence the experience of morally problematic situations, the objective of these study was to analyze the phenomenon of moral distress among nurses in Brazil and in Portugal. It is a methodological research for development, searching for evidence of validity and refinement of a research instrument. The research started with the analysis of 38 studies for the construction of a scale to identify risk factors for moral distress. The search for evidence of validity included an analysis of judges, for content validation, and an exploratory factorial analysis, for construct validation, with a sample of 268 Brazilian nurses and 278 Portuguese nurses. The result was a scale with evidence of validity, Cronbachs Alpha of 0,913 and 0,790, Kaiser-Meyer Olkin test of 0,869 and 0,914 and a significant Bartlett (p <0,001). About 59,8% of the variance was explained by 30 items, divided into seven factors in the Brazilian version, and about 53,9% of the variance was explained by 20 items, divided into four factors in the Portuguese version. The experience of risk factors for moral distress was considered moderate in Brazil and low in Portugal. The variables that showed a significant association with the highest risk for moral distress in both countries were the type of work context, the hours of work, being in moral distress and having the intention to leave the current job. Research in the field of moral distress can, among other things, help in identifying the challenges and difficulties that most concern nurses in their work context. In order to contribute to the development of coping strategies and to improve professional retention and satisfaction, researches about moral distress may positively reflect on the quality of care.

Thesis advisor: Dorothy Jones / The importance of the nurse-patient relationship to the overall well- being of the person has been explored extensively by nurses. What is largely missing from this knowledge developed to date is the patient's perspective. The purpose of this study was to develop a reliable and valid measure of patients' perceptions of feeling known by their nurses during an acute, surgical, hospital admission. The development of the PPFKN Scale was guided by Newman's theoretical framework of Health as Expanding Consciousness (1994) and data from a qualitative descriptive study conducted in 2003 (Somerville). The current investigation focused on the development and psychometric testing of the PPFKN Scale. The four themes that emerged from the earlier qualitative study were used to guide the development of the 85-item scale. This scale was exposed to a panel of nurse experts to establish inter-rater agreement and content validity, item understandability and readability. The revised scale was piloted with five participants who had experienced an inpatient, surgical admission to determine content validity, item readability and understandability. The revised 77-item scale was then administered to 327 surgical inpatients across seven general care units at a large academic urban medical center. A sample size of 296 completed surveys was analyzed. A four-component solution was devised using Principal Components Analysis with Varimax rotation. This four-component solution accounted for 63.3% variance, with a total scale Cronbach's alpha coefficient of 0.99. A component loading cut-off was set at 0.3 and items not loading at this value on the expected component were dropped. This process resulted in a reliable and valid 48 item PPFKN Scale with four components and a total scale Cronbach's alpha coefficient of 0.98. / Thesis (PhD) — Boston College, 2009. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Introduction: Nursing presence occurs when nurses expend themselves on the behalf of a unique patient. This phenomenon requires further research to develop instruments. The Presence of Nursing Scale (PONS) measures the patient’s perspective (Kostovich, 2012). Psychometric testing of PONS-Revised using exploratory factor analysis is warranted to further develop a reliable and valid measure of nursing presence. Contextual workplace variables need exploration in inpatient settings for correlation with nursing presence. Method(s): A convenience sample of 122 adult inpatients from ten acute-care nursing units in a Southeastern Magnet hospital were surveyed to conduct the first psychometric testing of this revised instrument using exploratory factor analyses. Seven research questions evaluated potential correlations between the PONS-R, patient satisfaction using nurse-sensitive measures of HCAHPS, nursing unit-specific workforce factors and patient demographic factors. Results: PONS-R demonstrated high internal consistency reliability (r = .974), test-retest reliability (statistically significant at the .01 level) and divergent validity (p=.002). PONS-R compared to nurse HCAHPS measures was statistically significant at the .01 level, (r = .736). EFA revealed one factor (eigenvalues over 1), with a weak secondary factor centered on intimacy factors suggesting addition of items and repeated study with a larger sample size to further psychometrically develop the instrument. Unexpected negative correlations were found with unit-workforce factors including average RN experience level (r= -.185, significant at the .05 level), and average RN age (r = - .218). An unexpected positive correlation was found - percentage of Associate degree nurses (r = .269, statistically significant at the .05 level. The Triangle region was correlated with a higher PONS-R score (p = .038; n=4), otherwise no statistically significant correlations were found for PONS-R and patient demographics nor patient-specific variables such as estimated number of RN providing care, nor length of stay on the unit. Discussion & Conclusions: Further psychometric testing is indicated with larger samples and perhaps with the inclusion of intimacy factor items. Additional correlational studies focused on other patient quality outcomes measures with expansion of nurse demographics is indicated to explore for confounding variables.

The overall aim of this thesis was to describe quality of care from different perspectives in the psychiatric setting, to develop an instrument for measuring quality of care from the in-patient perspective and to use this instrument empirically. A qualitative descriptive design involving a phenomenographic analysis was used in Studies I, III and IV, and a descriptive and comparative design with statistical analysis in Study II. In Study I, 20 patients were interviewed. The results showed that quality of care was perceived as a positive, normative concept namely as good quality of care. Five descriptive categories emerged: the patient’s Dignity is respected; the patient’s sense of Security with regard to care; the patient’s Participation in care; the patient’s Recovery; and the patient’s care Environment. In addition, two conceptions that had not explicitly emerged in previous studies on quality of care were identified: Being helped to reduce the shame and Being looked upon as like anyone else. In Study II a definition of quality of care from a patient perspective was formulated on the basis of the results in Study I. A two-part instrument the Quality in Psychiatric Care (QPC) was developed for measuring the patients’ expectations regarding quality of care (QPC-1) and their subsequent experience of it (QPC-2). One hundred and sixteen patients answered both parts of the instrument. Overall, the quality of care was rated high in both parts. However, experienced quality of care was significantly lower than the patient’s expectations in all the dimensions of the instrument: Total dimension, Dignity, Security, Participation, Recovery and Environment. Patients who perceived that the time of discharge was consistent with the stage of their illness experienced significantly higher Recovery; patients with good psychiatric health also experienced this, but had in addition significantly higher levels of Participation. This new instrument exhibited too high Cronbach’s alpha values (QPC-1 0.87–0.98, QPC-2 0.85–0.98), which means the instrument needs to be further tested in order to improve its psychometric properties. Twelve next of kin were interviewed in Study III. The next of kin described quality of care mainly from their own perspective, but also to a large extent from the patient’s perspective as well. They described it in both positive and negative terms. Five descriptive categories resulted: Dignity, Security, Participation, Recovery and Health-promoting surroundings. Good relations and communication between staff, patients and next of kin emerged as the central factors regarding the quality of care. The next of kin asked for information about mental illnesses and wanted to co-operate and participate in the patient’s care. They avoided telling others about their family member’s psychiatric illness because of a feeling of shame and guilt. In Study IV, 20 care staff and care associates were interviewed. They described quality of care both from the patient’s perspective and from a professional perspective. They perceived the concept as a positive one and as being of great importance for the patient’s health and life situation. Four descriptive categories resulted: the patient’s Dignity is respected; the patient’s Participation in the care; the patient’s Recovery; and the patient’s care Environment plays an important role. The main contribution of this thesis with regard to the concept of quality of care in the psychiatric setting is its emphasis on the significance of the different perspectives described above, as such knowledge is vital when planning and implementing and evaluating quality of psychiatric care. In addition, the descriptive categories that emerged in this thesis clearly highlight the importance of interpersonal relationships in the care situation. The new instrument (QPC) needs psychometric testing before it routinely can be used as a self-rating instrument for the purpose of improving psychiatric inpatient care and help guide the proper allocation of care resources.

O sofrimento moral é descrito na literatura como o sentimento resultante do impedimento à uma ação considerada moralmente apropriada, devido, sobretudo, a obstáculos institucionais, como a falta de recursos e a carga de trabalho. As consequências envolvem sintomas físicos, como mal estar, choro e desordens do sono e sintomas psicológicos, como frustração, impotência e culpa, além de implicações organizacionais, principalmente relacionadas com afastamentos e abandono do emprego. Considerando que o contexto de trabalho pode influenciar na vivência de situações moralmente problemáticas, o objetivo do estudo foi analisar o fenômeno do sofrimento moral em enfermeiros no Brasil e em Portugal. Trata-se de uma pesquisa metodológica para desenvolvimento, busca de evidências de validade e refinamento de um instrumento de pesquisa. A investigação partiu da análise de 38 estudos da literatura para construção de uma escala para identificação de fatores de risco para sofrimento moral. A busca por evidências de validade incluiu uma análise de juízes, para validação de conteúdo, e uma análise fatorial exploratória, para validação de constructo, com uma amostra de 268 enfermeiros brasileiros e 278 enfermeiros portugueses. O resultado foi uma escala com evidência de validade para ambos os países, com Alpha de Cronbach de 0,913 e 0,790, teste de Kaiser-Meyer Olkin de 0,869 e 0,914 e índice de Bartlett significativo (p <0,001) para Brasil e Portugal, respectivamente. Cerca de 59,8% da variância é explicada por 30 itens, divididos em sete fatores, na versão brasileira, e cerca de 53,9% da variância é explicada por 20 itens, divididos em 4 fatores, na versão portuguesa. A vivência de fatores de risco para sofrimento moral foi considerada moderada no Brasil e baixa em Portugal. As variáveis que mostraram associação significativa com maiores médias totais de risco nos dois países foram o tipo de serviço, as horas de trabalho, estar em sofrimento moral e ter a intenção de deixar o emprego atual. Pesquisas no âmbito do sofrimento moral podem, entre outros aspectos, auxiliar na identificação dos desafios e das dificuldades que mais preocupam os enfermeiros em seu contexto de trabalho. No intuito de contribuir no desenvolvimento de estratégias de enfrentamento e melhorar a retenção e a satisfação profissional, pesquisas acerca do sofrimento moral podem refletir positivamente na qualidade dos cuidados. / Moral distress is described as the feeling resulting from the impediment to an action considered morally appropriate, mainly due to institutional obstacles such as the lack of resources and the high workload. Main consequences are physical symptoms, such as malaise, crying and sleep disorders and psychological symptoms, such as frustration, impotence and guilt, as well as organizational implications, mainly related to withdrawal and abandonment of employment. Considering that the work context may influence the experience of morally problematic situations, the objective of these study was to analyze the phenomenon of moral distress among nurses in Brazil and in Portugal. It is a methodological research for development, searching for evidence of validity and refinement of a research instrument. The research started with the analysis of 38 studies for the construction of a scale to identify risk factors for moral distress. The search for evidence of validity included an analysis of judges, for content validation, and an exploratory factorial analysis, for construct validation, with a sample of 268 Brazilian nurses and 278 Portuguese nurses. The result was a scale with evidence of validity, Cronbachs Alpha of 0,913 and 0,790, Kaiser-Meyer Olkin test of 0,869 and 0,914 and a significant Bartlett (p <0,001). About 59,8% of the variance was explained by 30 items, divided into seven factors in the Brazilian version, and about 53,9% of the variance was explained by 20 items, divided into four factors in the Portuguese version. The experience of risk factors for moral distress was considered moderate in Brazil and low in Portugal. The variables that showed a significant association with the highest risk for moral distress in both countries were the type of work context, the hours of work, being in moral distress and having the intention to leave the current job. Research in the field of moral distress can, among other things, help in identifying the challenges and difficulties that most concern nurses in their work context. In order to contribute to the development of coping strategies and to improve professional retention and satisfaction, researches about moral distress may positively reflect on the quality of care.

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