Background: Since 2012, nurse practitioners (NPs) in Ontario have the professional capacity to assume the role of the most responsible provider (MRP) in hospitals; however, few have implemented this model. Aim: To explore the barriers and facilitators to the integration of the NP as MRP model of care in a hospital setting. Methods: A qualitative descriptive design with secondary data collected from a larger study, was used with principles from integrated knowledge translation. Findings: Thirteen barriers and eleven facilitators were found, such as: (i) challenges with off hour coverage; (ii) funding and remuneration; (iii) discrepancies in the employment standards regulations; and (iv) lack of a critical mass. Facilitators included the plan for role implementation, establishment of trust and leadership from the team. Conclusion: Many barriers, predominantly at the healthcare system-level, make it difficult to integrate the NP as MRP model of care in hospitals.

No description available.

Introduction: Low back pain (LBP) is a common, globally occurring, and difficult to treat health issue. In Swedish primary health care, there is an issue with health care providers not using up-to-date practice when dealing with LBP. BetterBack😊 is an evidence-based model of care (MOC) providing guidelines for assessment and treatment of LBP to facilitate working with LBP for caregivers. Purpose: To investigate if patients treated by clinicians educated in the BetterBack😊 MOC in primary care leads to (a) patients having greater improvements in functional impairments and activity limitations according to physiotherapist assessment and (b) are receiving different treatment, compared to controls, compared to usual care. Method: Prospective cluster randomised trial with linear mixed model analysis was used to compare functional impairment and activity limitations based on the Clinical Reasoning and Process Evaluation tool. Chi2-test was used to analyse differences in choice of treatment between groups. Result: Analysis showed statistically significantly greater reduction in level of exercise tolerance and movement related functional impairments (0.25, 95%CI=0.04-0.46, p=0.02) and limitations of dynamic activities of daily living (0.35, 95%CI=0.17-0.69, p=0.04) in the intervention compared to control group. The intervention group was more frequently treated with behavioural medicine interventions and less with manual therapy interventions (18.4% vs. 30.1%, p<0.05) and physical modalities (4.9% vs 10.8%, p<0.05) compared to the control group. Conclusion: The use of the BetterBack😊 MOC can lead to better treatment outcomes, more use of behavioural medicine interventions and less use of manual therapy and physical modalities. / Introduktion: Ländryggssmärta (LBP) är ett vanligt förekommande globalt och svårbehandlat hälsoproblem. I svensk primärvård finns ett problem att vårdgivare inte följer senaste evidens vid hantering av LBP. BättreRygg😊 är ett evidensbaserat vårdprogram med riktlinjer för undersökning och behandling för att underlätta för vårdgivare att möta patienter med LBP. Syfte: Undersöka om patienter som behandlats av kliniker utbildade i BättreRygg😊 i primärvården leder till att (a) patienter, enligt utvärdering av fysioterapeut, har förbättrats mer gällande funktionsnedsättningar och aktivitetsbegränsningar samt (b) behandlas med andra interventioner, jämfört med ordinarie behandling vid tre månaders uppföljning. Metod: Prospektiv klusterrandomiserad studie med mixed model-analysjämförde funktionell och aktivitetsbaserad status genom Clinical Reasoning and Process Evaluation-verktyget. Chi2-test genomfördes för att analyseraskillnader av behandlingsval mellan grupperna. Resultat: Analysen visade att interventionsgruppen hade signifikant mer minskning av aktivitetstolerans och rörelserelaterade funktionsnedsättningar(0,25, 95%CI=0.04-0.46, p=0,02) och relaterade till dynamiska vardagsaktiviteter (0,35, 95%CI=0,17–0,69, p=0,04) jämfört med kontrollgrupp. Interventionsgruppen använde mindre sällan manuell terapi (18,4% vs. 30,1%, p <0,05) samt fysiska modaliteter (4,9% vs 10,8%, p <0.05). Konklusion: BättreRygg😊 kan bidra till bättre behandlingsresultat av LBP, ökat användande av beteendemedicinska åtgärder och minskat användande av manuell terapi och fysiska modaliteter.

Providing care services across several departments and care givers creates the complexity of the patient pathways, as it deals with different departments, policies, professionals, regulations and many more. One example of complex patient pathways (CPP) is one that exists in integrated care, which most literature relates to health and social care integration. The world population and demand for care services have increased. Therefore, necessary actions need to be taken in order to improve the services given to patients in maintaining their quality of life. As the complexity arises due to different needs of stakeholders, it creates many problems especially when it involves complex patient pathways (CPP). To reduce the problems, many researchers tried using several decision tools such as Discrete Event Simulation (DES), System Dynamic (SD), Markov Model and Tree Diagram. This also includes Direct Experimentation, one of techniques in Lean Thinking/Techniques, in their efforts to help simplify the system complexity and provide decision support tools. However, the CPP models were developed using a single tools which makes the models have some limitations and not capable in covering the entire needs and features of the CPP system. For example, lack of individual analysis, feedback loop as well as lack of experimentation prior to the real implementation. As a result, ineffective and inefficient decision making was made. The researcher also argues that by combining the DES and SD techniques, named the hybrid simulation, the CPP model would be enhanced and in turn will help to provide decision support tools and consequently, will reduce the problems in CPP to the minimum level. As there is no standard framework, a framework of a hybrid simulation for modelling the CPP system is proposed in this research. The researcher is much concerned with the framework development rather than the CPP model itself, as there is no standard model that can represent any type of CPP since it is different in term of its regulations, policies, governance and many more. The framework is developed based on several literatures, selected among developed framework/models that have used combinations of DES and SD techniques simultaneously, applied in a large system or in healthcare sectors. This is due to the condition of the CPP system which is a large healthcare system. The proposed framework is divided into three phases, which are Conceptual, Modelling and Models Communication Phase, and each phase is decomposed into several steps. To validate the suitability of the proposed framework that provides guidance in developing CPP models using hybrid simulation, the inductive research methodology will be used with the help of case studies as a research strategy. Two approaches are used to test the suitability of the framework – practical and theoretical. The practical approach involves developing a CPP model (within health and social care settings) assisted by the SD and DES simulation software which was based on several case studies in health and social care systems that used single modelling techniques. The theoretical approach involves applying several case studies within different care settings without developing the model. Four case studies with different areas and care settings have been selected and applied towards the framework. Based on suitability tests, the framework will be modified accordingly. As this framework provides guidance on how to develop CPP models using hybrid simulation, it is argued that it will be a benchmark to researchers and academicians, as well as decision and policy makers to develop a CPP model using hybrid simulation.

Philosophiae Doctor - PhD / Non-communicable diseases (NCD) continue to be a public health concern globally and contribute to the burden of disease. The formal health system in developing countries lacks the capacity to deal with these NCD as it is overburdened by communicable diseases. Thus, community health workers (CHWs) have been suggested as a solution for alleviating the burden for primary health facilities, by extending NCD care to the community. This thesis aims to develop an integrated model of care for CHWs working with patients with non-communicable diseases by describing and exploring current CHW roles, knowledge and practices in relation to community-based NCD care. The specific objectives for this study included 1) the exploration of the NCD roles of generalist CHWs in the context of a limited resource urban setting; 2) determining the NCD-related knowledge of CHWs, and factors influencing this in a limited resource urban setting and 3) a comparison of actual and envisaged roles in the management and prevention of NCD using the integrated chronic diseases management model (ICDM) as a benchmark, and propose key competencies and systems support for NCD functions of CHWs in South Africa Mixed methods were used to achieve the objectives of this study. First, a qualitative enquiry was conducted using observations to respond to the first objective. A quantitative cross-sectional design was then used to achieve the second objective, and a questionnaire was used to interview CHWs. A comparison of findings from both the quantitative and qualitative studies with policy guidelines was undertaken to address the third objective.

The aim of the presented thesis is to map the influence of heart arrhythmia on patients´ lives and the possibility of using the conceptual model by Imogen King into the nursing care at the patient with arrhythmia. The set goals were accomplished on the basis of the empirical research which was processed by both quantitative and qualitative research methods. The first part of the research was performed by the quantitative method of collecting data from the survey. The aim of this survey was to map the quality of life of patients with the heart arrhythmia. The second part of the research was performed by the qualitative method of collecting data from the interview with the patient. Total of 127 of valid questionnaires were evaluated for the quantitative part of the research and 20 interviews with the patients with heart arrhythmia were performed for the qualitative part of the research. Based on the qualitative research was found out that the most significant symptom of arrhythmia is fast or irregular heartbeat, usually causing faintness, anxiety and uneasiness. The patients with arrhythmia are mostly limited during physical activities. There have not been found out any statistically significant differences between the persistence of arrhythmia and the health condition and the quality of life of the patient. That means that the persistence of arrhythmia in the researched group of patients does not influence the health condition and the life quality of the patients who took part in the survey ASTA. There was also monitored the relation between uneasiness (anxiety) and selected indicators (how the patients are able to work or study, concentrate or do physical activity). In this case were proven statistically significant differences. The qualitative research complemented the qualitative data. The quality of lives of the respondents was evaluated according to Imogen´s King conceptual framework and the responses of the respondents were ordered according to the framework system: personality system, interpersonal system and social system. As emerged from the responses of the respondents, the most negatively perceived symptom of arrhythmia is palpitation which causes anxiety, uneasiness and leads to sleeping disorders and lower physical activity. In contrast to the restrictions that have to be taken up in connection with the heart arrhythmia are only temporary and do not influence interpersonal and social relationships. The thesis brings a complex view of the problematics of the life quality of patients suffering from arrhythmia when this is not only a medical problem but it also influences patient´s mental and social well-being. The very important element which influences the successful cooperation of the arrhythmia patient and the doctor is the nurse who thanks to the emphatic attitude helps to build the faith in the good results of the medication - recovery and keeping the life quality. Using the conceptual framework in nursing, specifically during the treatment of arrhythmia patients helps to provide individualized nursing care and achieving improvement of the quality of the care provided and also the patient´s satisfaction.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Constitui um desafio para profissionais de enfermagem atender o ser humano nas suas diversas necessidades e contemplar em sua assistÃncia as complexas dimensÃes humanas. Dentre todas as dimensÃes humanas, a espiritual tem destaque para a Ãrea da saÃde: primeiro, porque à a que diferencia o homem dos demais seres, pois integra a capacidade de ser livre, de ser responsÃvel e de buscar, constantemente, um sentido para a vida; segundo, por ser uma dimensÃo negligenciada, devido à Ãnfase dada Ãs dimensÃes psicofÃsicas e ao distanciamento histÃrico da ciÃncia tradicional. Constatamos ser necessÃrio um modelo de cuidado espiritual que sirva de suporte a enfermeiros que cuidam de pacientes gravemente enfermos, visto que vivenciam a dor, o sofrimento e a iminÃncia de morte. Nosso objetivo, portanto, à produzir um modelo de cuidado espiritual, com base no referencial teÃrico-metodolÃgico da âAnÃlise Existencialâ, de Viktor Emil Frankl e da âRelaÃÃo Pessoa a Pessoaâ, de Joyce Travelbee. Para isso, desenvolvemos uma pesquisa-cuidado, que mostrou ser uma resposta Ãtica e humanÃstica na forma de fazer ciÃncia, visto que teve a preocupaÃÃo de beneficiar os sujeitos pesquisados, pois foram cuidados enquanto participavam da pesquisa. Trata-se de uma pesquisa realizada com trÃs pacientes, com o diagnÃstico de cÃncer, hospitalizados em um hospital pÃblico, terciÃrio da cidade de Fortaleza-CearÃ. A pesquisa foi dividida em duas etapas: [1] a coleta de dados, realizada durante o processo de cuidar, por meio da relaÃÃo de ajuda enfermeiro/paciente; [2] a produÃÃo do modelo, com base nos dados analisados e confrontados com o referencial teÃrico. O processo de construÃÃo deste modelo foi realizado, utilizando, de forma integrada, as categorias criadas do conteÃdo dos diÃlogos e dos comentÃrios das interaÃÃes, conforme recomenda Bardin. A construÃÃo do modelo foi discutida e apresentada em trÃs elementos do cuidado espiritual: os componentes; o desenvolvendo; a culminÃncia. Esta tese foi submetida ao Comità de Ãtica em Pesquisa e observou irrestritamente os princÃpios norteadores da pesquisa envolvendo seres humanos, conforme a ResoluÃÃo 196/1996, do Conselho Nacional de SaÃde. O modelo de cuidado produzido fundamenta-se filosoficamente e se sustenta em uma metodologia que orienta as aÃÃes de cuidado e se estrutura em dezessete pressupostos teÃricos, relacionados com cinco conceitos bÃsicos: ser humano; processo saÃde/doenÃa; enfermagem; ambiente; cuidado espiritual. AlÃm disso, segue os passos de construÃÃo e estabelecimento do cuidado espiritual, de cuidado propriamente dito e de manutenÃÃo e anÃlise do cuidado espiritual, estruturados em trÃs etapas: Khronos â fase de construÃÃo; KairÃs â fase de busca; AiÃn â fase de integraÃÃo. Este modelo contempla o cuidado total, mas enfatiza o espiritual, porque, perscrutando as virtudes e valores humanos, tem como foco central a busca e o encontro do sentido da vida. O presente trabalho nÃo à a Ãnica possibilidade de cuidado espiritual, tampouco tem a pretensÃo de ser a Ãnica e a Ãltima verdade sobre o assunto. Antes, convidamos todos a conhecerem, aplicarem, validarem, criticarem, ampliarem, contestarem ou rejeitarem, esta tese, se assim julgarem procedente.

In response to the needs of patients, coupled with nursing workforce predictions and the pressure of cost containment, a shift to a new team nursing model of care has been seen in Canada and Australia. Today's patients require multiple resources, nurses with additional skillsets and vast amounts of experience during their hospital stays, and a team of nurses can meet these needs. This project explored the experiences and perspectives of nurses during the implementation of a team nursing model of care on a 32-bed, inpatient, cardiology floor in southern Ontario. The purposes of this project were to conduct a formative evaluation of the pilot unit implementation and make recommendations for future units who will implement this change in model. The project tracked all nurses on the pilot unit, from frontline nurses to those of influence and authority. Guided by an action research framework and a qualitative approach, nurses' experiences were explored through observations and analysis of organizational reports. These data were triangulated and further validated with evidence from the current literature. Major themes included the need for clear definitions of roles and responsibilities, a strong organizational support system, and the recognition that team nursing was more than a division of tasks but was a shift in culture to that of shared responsibility and accountability for all patients. These findings have implications for positive social change by informing the work of those in the health care setting, illuminating the benefits of team-based nursing.

O Sistema Único de Saúde apresenta a descentralização da gestão das ações de saúde como uma das principais estratégias para a reorganização do setor. O poder municipal se apresenta como o principal responsável pela prestação da assistência da atenção à saúde, garantindo os princípios da universalidade e da integralidade do atendimento em todos os níveis da atenção. As Normas Operacionais Básicas e as Normas de Assistência à Saúde estabeleceram os mecanismos que impulsionaram o processo de descentralização das ações de saúde. O Estado do Ceará iniciou o processo de descentralização das ações de saúde para os municípios ao aderir ao Programa de Sistemas Unificados e Descentralizados de Saúde (SUDS). O estudo descreve este processo de descentralização, com ênfase na microrregião de Baturité, a partir da descentralização político-administrativa, da organização da regionalização e hierarquização como a identificação de mudanças no processo de atenção à saúde, a partir das ações de atenção à saúde da mulher, à saúde da criança, de controle de tuberculose e de controle de hipertensão O referencial do estudo foi a base normativa da Norma Operacional de Assistência à Saúde - 2001 (NOAS/ 2001). As condições oferecidas aos municípios para efetivar a descentralização das ações de saúde contribuíram para uma melhor estruturação dos serviços de saúde, resultado numa maior cobertura em ações básicas a partir da estratégia da Saúde da Família, e melhor organização da atenção em termos de hierarquização e regionalização como maior percentual de aplicação de recursos financeiros próprio. / The Brazilian Unified Health System presents the decentralization of management of health actions as one of the main strategies for reorganization of the sector. City Hall proves to be the main agent accountable for provision of health care support, guaranteeing the principles of universality and completeness of services at all levels of care. The Basic Operational Norms and Health Care Norms established the mechanisms which drove the process of decentralization of health actions. The state of Ceará began the process of decentralization of health actions to municipal administrations upon adhering to the Unified Health System (SUDS). This study describes this process of decentralization, with emphasis on the Baturité District, in terms of its political-administrative decentralization, organization of regionalization and ranking as identification of changes in the process of health care, based on health care services for women, children, tuberculosis control and control of high blood pressure. The benchmark for the study was the normative framework of the Health Care Operational Norms - NOAS/2001. The conditions offered to municipal administrations to perform decentralization of healthcare contributed to improvement in the Family Health structure, resulting in greater coverage in basic care from the standpoint of Family Health and better organization of care in terms of hierarchy and regionalization such as best percentage of investment of own financial resources.

O Sistema Único de Saúde apresenta a descentralização da gestão das ações de saúde como uma das principais estratégias para a reorganização do setor. O poder municipal se apresenta como o principal responsável pela prestação da assistência da atenção à saúde, garantindo os princípios da universalidade e da integralidade do atendimento em todos os níveis da atenção. As Normas Operacionais Básicas e as Normas de Assistência à Saúde estabeleceram os mecanismos que impulsionaram o processo de descentralização das ações de saúde. O Estado do Ceará iniciou o processo de descentralização das ações de saúde para os municípios ao aderir ao Programa de Sistemas Unificados e Descentralizados de Saúde (SUDS). O estudo descreve este processo de descentralização, com ênfase na microrregião de Baturité, a partir da descentralização político-administrativa, da organização da regionalização e hierarquização como a identificação de mudanças no processo de atenção à saúde, a partir das ações de atenção à saúde da mulher, à saúde da criança, de controle de tuberculose e de controle de hipertensão O referencial do estudo foi a base normativa da Norma Operacional de Assistência à Saúde - 2001 (NOAS/ 2001). As condições oferecidas aos municípios para efetivar a descentralização das ações de saúde contribuíram para uma melhor estruturação dos serviços de saúde, resultado numa maior cobertura em ações básicas a partir da estratégia da Saúde da Família, e melhor organização da atenção em termos de hierarquização e regionalização como maior percentual de aplicação de recursos financeiros próprio. / The Brazilian Unified Health System presents the decentralization of management of health actions as one of the main strategies for reorganization of the sector. City Hall proves to be the main agent accountable for provision of health care support, guaranteeing the principles of universality and completeness of services at all levels of care. The Basic Operational Norms and Health Care Norms established the mechanisms which drove the process of decentralization of health actions. The state of Ceará began the process of decentralization of health actions to municipal administrations upon adhering to the Unified Health System (SUDS). This study describes this process of decentralization, with emphasis on the Baturité District, in terms of its political-administrative decentralization, organization of regionalization and ranking as identification of changes in the process of health care, based on health care services for women, children, tuberculosis control and control of high blood pressure. The benchmark for the study was the normative framework of the Health Care Operational Norms - NOAS/2001. The conditions offered to municipal administrations to perform decentralization of healthcare contributed to improvement in the Family Health structure, resulting in greater coverage in basic care from the standpoint of Family Health and better organization of care in terms of hierarchy and regionalization such as best percentage of investment of own financial resources.