<p>Please insert 2 pages into the main thesis - page 39 and page 40</p> <p>- 2 separate PDF attachments will be included plus the main thesis.</p> / <p><strong>Background:</strong></p> <p><strong> </strong> Academic detailing (AD) provides evidence-based education to healthcare professionals in their practice setting and has been found to improve knowledge and prescribing in many situations. Personalized academic detailing (PAD) is a new initiative by the Hamilton Family Health Team (FHT) in which pharmacists integrated within the FHT provide an AD service to prescribers in their office.</p> <p><strong>Objective: </strong></p> <p>To describe and determine the feasibility of a smoking cessation (SC) PAD program.</p> <p><strong>Methods:</strong></p> <p>Design: Descriptive retrospective cohort pilot project</p> <p>Setting: Primary Care Setting</p> <p>Participants: FHT pharmacists, physicians, nurse practitioners (NPs) and their patients</p> <p>Intervention:</p> <p>Pharmacists receive basic AD training and education (upskilling) on SC; and provide education to clinicians</p> <p><strong>Feasibility Criteria for success:</strong> <ol> <li>PAD coordinator time to train pharmacists <40 >hours</li> <li>Average time for upskilling <20 >hours</li> <li>Average time for PAD session are <60 minutes and><30 minutes for initial and follow-up>visits, respectively</li> <li>Percentage of clinicians detailed within 3 and 6 months are >50% and >70%, respectively</li> <li>Number of new SC referrals to the pharmacist at 3 and 6 months are >5 patients/1.0 full-time equivalent (FTE) pharmacist and >10 patients/1.0 FTE pharmacist, respectively.</li> </ol></p> <p><strong>Results:</strong></p> <p>Eight pharmacists (5.8 FTE) received basic AD training and upskilling on SC PAD. Consent was obtained from 48/54 (88.9%) physicians and 9/10 (90.0%) NPs.</p> <p>The PAD coordinator training time was 29.1 hours. The median time for upskilling was 3.1 hours. The median time for PAD session was 15 and 5 minutes for an initial visit and follow-up visit, respectively. The number of clinicians detailed within 3 and 6 months were 50/64 (78.1%) and 57/64 (89.1%), respectively. The number of new SC referrals at 3 and 6 months was 66 and 200 patients, respectively.</p> <p><strong>Conclusion:</strong></p> <p>This pilot study showed that the main study is feasible with respect to the management, resources, process and scientific components.</p> / Master of Science (MSc)

Many communities across the United States, including those from low-income and racial and ethnic minority groups, have less access to quality, timely, and preventative primary healthcare services. One factor contributing to this disparity is the shortage of primary care providers to meet demands in underserved areas. Nurse practitioners (NPs), or advanced-practice registered nurses trained to diagnose, treat, and manage health conditions, are a solution to meeting the nation’s primary care needs. Over the past decade, the NP workforce has grown significantly, doubling its number between 2010 and 2017. NPs frequently care for individuals from medically underserved communities, including those receiving care in community health centers (CHCs). CHCs are a network of safety-net healthcare organizations delivering comprehensive primary care in many rural and inner-city areas. However, the NP workforce can be further optimized in CHCs. Despite the growing national NP supply, CHCs struggle with adequate NP staffing. Furthermore, providers working in CHCs and other safety-net settings report insufficient resources to care for patients, high workloads, and elevated staff turnover; these challenges may create poor practice environment and predispose CHC NPs to poor workforce outcomes, such as burnout and job dissatisfaction.Literature has demonstrated that poor clinician workforce outcomes, particularly burnout, negatively affect the safety and quality of care patients receive. Poor care and disease management may also result in disease exacerbation and, subsequently, preventable healthcare use by patients such as emergency department visits and hospital admissions. Preventable healthcare use increases the nation’s healthcare costs and may expose patients to harm. Despite the contributions of NPs to CHCs, little is known about how to optimize their staffing and workforce outcomes (e.g., reducing burnout, turnover intention, and improving job satisfaction) to assure positive patient outcomes. The overall purpose of this dissertation is to understand ways to optimize the NP workforce in CHCs to potentially improve outcomes for CHC patients. Specific aims include: 1) examining factors that influence the recruitment and retention of NPs in underserved areas; 2) assessing the practice environment and workforce outcomes of NPs in CHCs; and 3) understanding the consequences of NP burnout on CHC patient outcomes. Dissertation Chapters and Findings The first chapter of this dissertation summarizes the background on the NP workforce and CHCs and details the problem under investigation. The second chapter is a scoping review examining the factors influencing recruitment and retention of NPs in underserved areas. Factors influencing recruitment and retention of NPs in underserved areas exist at various levels, from individual (e.g., growing up in underserved areas) to policy factors (e.g., autonomous scope of practice). However, current literature lacks rigorous, up-to-date, and NP-focused studies. The third chapter is a cross-sectional analysis of survey data from 269 CHC NPs. This chapter assessed the practice environment, job satisfaction, burnout, and turnover intention of NPs working in CHCs to better understand the current workforce conditions of CHC NPs; this chapter also examined the relationship between CHC NPs’ practice environment and workforce outcomes. CHC NPs reported generally favorable practice environment and high job satisfaction. When CHC NPs report good relationships with their administration, they are more likely to report higher job satisfaction and lower intention to leave their jobs. The fourth chapter aimed to understand the implications of a negative workforce outcome (i.e., burnout) in the CHC setting. Through a cross-sectional analysis of merged NP survey and Medicare claims data, we examined the relationship between NP burnout and preventable hospitalization and emergency department use in patients. Patients receiving care in CHCs with higher NP burnout are more likely to use the emergency department for preventable reasons. The fifth and last chapter discusses the findings of this dissertation and its implications for policy, research, and practice.

Thesis (MCUR)--University of Stellenbosch, 2004. / ENGLISH ABSTRACT: This study attempts to provide a historic background of the clinical nurse practitioner. Areas of potential conflict, malpractice, future research, service delivery, tuition and support are revealed. The current role and function and the work environment of the clinical nurse practitioner functioning on primary health care level in the Metropole Region of the Western Cape were examined as major themes. Triangulation is applied as methodology. Structured questionnaires were completed by 60 clinical nurse practitioners that completed their training during the period 1994 to 2002. Pre-compiled checklists were completed at 8 different primary health care institutions. Qualitative data were obtained by comments on the questionnaires, field notes, as well as structured and unstructured interviews conducted with clinical nurse practitioners. Needs identified include outcomes based theoretical and clinical methods of tuition, additional training in pharmacology and chronic care, transcultural nursing and the development of criteria for recognition of prior learning and experience. Disparities were identified on service level pertaining to the difference between service delivery and service needs, daily checking of emergency equipment and the establishing of partnerships on service level to improve service delivery. Utilisation, post-levels and remuneration need attention. The development of courses in pharmacology for the Western Cape is identified as a priority as well as in service training, the possibility of a year of internship and the expedite of the amalgamation of fragmented services. Clinical nurse practitioners in managerial positions need to become more involved in promotion, motivation, development, audit and marketing of the clinical nurse practitioner and the establishment of a forum for clinical nurse practitioners. / AFRIKAANSE OPSOMMING: Hierdie studie poog om ʼn historiese agtergrond te skets van die kliniese verpleegpraktisyn. Areas is blootgelê vir potensiële konflik en wanpraktyke, sowel as areas vir toekomstige navorsing, dienslewering, onderrig en ondersteuning. Twee hooftemas, naamlik die huidige rol en funksie, asook die werkomgewing van die kliniese verpleegpraktisyn in die Metropoolstreek van die Wes-Kaap, is ondersoek. Triangulasie is as navorsingsmetodiek aangewend. Gestruktureerde vraelyste is deur 60 kliniese verpleegpraktisyns wat hul kursus gedurende die tydperk 1994 tot 2002 voltooi het, ingevul. Voorafopgestelde kontrolelyste is by 8 verskillende primêre gesondheidsorginstansies aangewend. Kwalitatiewe data is verkry deur middel van kommentaar op die vraelyste, veldnotas, sowel as gestruktureerde en ongestruktureerde onderhoudsvoering met kliniese verpleegpraktisyns. Uitkomsgebaseerde teoretiese en kliniese wyses van onderrig, aanvullende farmakologie, chroniese sorg, transkulturele verpleging, taalvaardigheid, asook die ontwikkeling van kriteria vir akkreditasie vir voorafleer en ondervinding blyk onderrigbehoeftes te wees. Leemtes op diensvlak sluit die verskil tussen diensverskaffing en diensbehoeftes, daaglikse kontrolering van noodtoerusting en vennootskappe ter diensverbetering in. Aanwending, posbenamings en vergoeding benodig aandag. Die ontwikkeling van aanvullende farmakologiekursusse vir die Wes-Kaap is as prioriteit geïdentifiseer asook indiensopleiding, die moontlikheid van ʼn verpligte internskapjaar en die bespoediging van amalgamasie van gefragmenteerde dienste. Kliniese verpleegpraktisyns in bestuursposisies behoort meer betrokke te raak by die bevordering, motivering, ontwikkeling, oudit en bemarking van die kliniese verpleegpraktisyn asook by die daarstel van ʼn forum vir kliniese verpleegkundiges.

Wang, Yue. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2009. / Includes bibliographical references (leaves 108-120). / Abstract and some appendixes also in Chinese. / Chapter CHAPTER 1: --- INTRODUCTION --- p.1 / Chapter CHAPTER 2: --- LITERATURE REVIEW / Clinical decision making in nursing --- p.4 / Definition of clinical decision making --- p.4 / How nurses make clinical decisions --- p.6 / The analytical model --- p.7 / The intuitive model --- p.10 / Cognitive continumm theory --- p.13 / Factors influencing clincial decision making --- p.17 / Knowledge --- p.18 / Clinical experience --- p.19 / Internal factors --- p.21 / External factors --- p.23 / Autonomy in nurses' clinical decision making --- p.27 / Clinical decision making among Chinese nurses --- p.31 / Summary of literature review --- p.35 / Chapter CHAPTER 3: --- METHODOLOGY / Aims and objectives of the study --- p.37 / Research design --- p.37 / Setting and sample --- p.39 / The setting --- p.39 / The informants --- p.40 / Data collection procedures --- p.42 / Interview guide --- p.42 / Data collection method --- p.43 / Data analysis --- p.45 / Data preparation --- p.45 / Content analysis --- p.46 / Rigour of data --- p.47 / Validity --- p.48 / Reliability --- p.49 / Pilot study --- p.50 / Ethical consideration --- p.50 / Chapter CHAPTER 4: --- FINDING AND DISCUSSION / Introduction --- p.53 / Socio-demographic characteristics of informants --- p.53 / Categories identified from content analysis --- p.54 / Understanding of clinical decision making --- p.55 / Understanding about patien´tةs health condition --- p.56 / Making nursing judgment --- p.57 / Taking intervention --- p.58 / Problem solving --- p.59 / A participatory process --- p.60 / Involving the patient --- p.61 / Role of the family --- p.62 / Involvement of other staff --- p.63 / Autonomy in clinical decision making --- p.65 / Depending on doctoŕةs instruction --- p.66 / Making judgment about doctoŕةs order --- p.68 / Making decisions independently in emergency --- p.69 / Making decisions within scope of nursing practice --- p.70 / Attributes required in clinical decision making --- p.75 / Effective communication skill --- p.75 / Use of critical thinking --- p.76 / Role of knowledge in clinical decision making --- p.78 / Facilitating nurses to solve patien´tةs health problems --- p.78 / Facilitating nurses to make efficient and accurate judgment --- p.79 / Contributions of clinical experiences to clinical decision making --- p.80 / Using clinical experiences to identify patients' problems --- p.81 / Use of previous clinical experiences in clinical decision for intervention --- p.82 / Helping nurses solve patien´tةs problems effectively --- p.83 / Making judgment efficiently and effectively --- p.84 / Workplace environment --- p.86 / Workload --- p.86 / Workplace atmosphere --- p.87 / Similarities and differences of concept of clinical decision making between clinical nurses and nurse educators --- p.88 / Intuition --- p.89 / Making decisions based on evidence --- p.91 / Teamwork spirit --- p.93 / Nurséةs attitude to drug administration --- p.94 / Chinese tradition of respecting older people --- p.95 / Chapter CHAPTER 5: --- CONCLUSION / Study limitations --- p.100 / Sampling method --- p.100 / Use of interview --- p.101 / Issue of data saturation --- p.102 / Recommendation for further research --- p.103 / Implications for practice --- p.104 / Conclusion --- p.106 / REFERENCES --- p.108 / APPENDICES --- p.121

Project (B.S.)--James Madison University, 2009. / Includes bibliographical references.

PURPOSE Explore the competencies required by the child nurse practitioners in the child nursing practice in order to refine the current competencies in a programme for Child Nursing Science presented at a Nursing Education Institution in Gauteng. DESIGN AND METHOD A quantitative, non-experimental, descriptive, exploratory and applied research design was used. A structured self reported questionnaire was constructed based on the competencies derived from the current programme for Child Nursing Science used at the Nursing Education Institution, the Specialist Paediatric and Child Health Nurse by the Australian Confederation of Paediatric and Child Health Nurses and the World Health Organization Children’s Nursing Curriculum. The structured self reported questionnaire was distributed to 110 child nurse practitioners working in child nursing practices in Gauteng and a total of 82 responded. FINDINGS All competencies were regarded as important, except for competencies related to research, family-centred child care, complementary and traditional child care practices, evidence-based practice, mentoring and play activities. CONCLUSION Findings were used to refine the current competencies in a programme for Child Nursing Science / Health Studies / M.A. (Health Studies)

Submitted by JOSIANE SANTOS DE OLIVEIRA (josianeso) on 2017-08-23T13:50:30Z No. of bitstreams: 1 Ângela Maria da Silva Vieira_.pdf: 1113837 bytes, checksum: e7656f0dd6d73b874fb5eb92ed5c9feb (MD5) / Made available in DSpace on 2017-08-23T13:50:30Z (GMT). No. of bitstreams: 1 Ângela Maria da Silva Vieira_.pdf: 1113837 bytes, checksum: e7656f0dd6d73b874fb5eb92ed5c9feb (MD5) Previous issue date: 2017-06-27 / Nenhuma / Os trabalhadores de enfermagem em um hospital, todo o tempo, estão expostos a riscos variados que podem comprometer a sua saúde de um modo geral. Desta forma, esses trabalhadores correm o risco de desenvolver doenças ocupacionais, bem como estão sujeitos ao aparecimento ou aumento do absenteísmo e acidentes de trabalho ao realizarem suas atividades laborais. Objetivo: Avaliar a frequência e motivos de absenteísmo dos trabalhadores da Equipe de Enfermagem de um hospital filantrópico de médio porte, localizado no litoral norte do Rio Grande do Sul. Método: estudo transversal. Foram analisadas 149 fichas dos trabalhadores, considerando dados como idade, sexo, tempo de serviço, unidade de trabalho, atestados médicos e absenteísmo. Resultados: foram levantados e observados 395 atestados no registro de 145 trabalhadores de enfermagem, a maioria era mulheres (83,4%). A categoria dos técnicos de enfermagem representa 73,1%, demais eram enfermeiros (16,6%) e auxiliares de enfermagem (10,3%). Mais de 60% dos trabalhadores apresentou pelo menos um afastamento durante o período levantado (dois anos). Os auxiliares e técnicos de enfermagem se afastaram mais do que os enfermeiros no período estudado (89,8%; 90,4% e 77,8% respectivamente) p >0,05. A unidade de internação apresenta 37,1% e a emergência 32,9%. Cerca de metade dos atestados teve duração de um dia (47,5%) e em 8,8% a duração foi superior a duas semanas. Em 341 afastamentos, apenas 29,3% (n=100 afastamentos) tinham informação do motivo (CID 10). Conclusão: foi elaborado um programa educativo de saúde do trabalhador que irá ajudar a identificar riscos e sinais que possam agravar a saúde dos trabalhadores no seu ambiente de trabalho e melhorando a qualidade da assistência de enfermagem. / Nurses at a hospital at all times are exposed to a variety of risks that can, in turn, compromise their overall health. In this way, these workers are at risk of developing occupational diseases, occupational accidents and consequently absenteeism when carrying out their work activities. Objective: to elaborate a Health Education Program for Nursing Staff of a medium-sized philanthropic hospital located on the north coast of Rio Grande do Sul. Method: cross-sectional method. It was analyzed 149 fiches of nursing professionals, with data such as age, sex, length of service, unit of work, medical certificates, and absenteeism. Results: 395 certificates were registered and 145 nurses registered. The mean age of nursing professionals was 39 years with standard deviation of 10 years. The majority were women (83.4%), the category of nursing technicians represents 73.1%, the other were nurses 16.6% and auxiliaries 10.3%. More than 60% of the employees presented at least one leave during the period raised (two years). Nursing auxiliaries and technicians moved farther than nurses in the study period (89.8%, 90.4% and 77.8%, respectively), p> 0.05. The hospitalization unit presented 37.1% and the emergency room (32.9%). Approximately half of the certificates had a duration of one day (47.5%) and in 8.8% the duration was more than two weeks. In 341 departures, only 29.3% (n = 100 departures) had motif information (ICD 10). Conclusion: an Health Education Program for Nursing has been developed that will help identify risks and signs that may aggravate the health of professionals in their work environment.

Primary care physician (PCP) shortages have been a barrier to accessing care for millions of Americans, particularly those living in areas facing the worst shortages - primary care health professional shortage areas (HPSAs). Increased use of nurse practitioners (NPs) has been proposed as a solution to the shortages as NPs can effectively substitute for PCPs. However, this proposal has been hampered by regulatory restrictions on NP scope-of-practice (SOP) that exist in many states. While some states permit NPs to practice and prescribe medications independent of physicians (NP independence), others require extensive physician supervision that limit NPs ability to provide care and substitute for PCPs. Despite the limitations that restrictive regulations pose to improving access to primary care, research evidence of their effect on access in primary care HPSAs is limited. This dissertation fills this gap in the literature. Using individual-level data from the Medical Expenditure Panel Surveys (1996-2015) and a difference-in-differences approach, I exploit variation in NP independence across states and over time to evaluate the impact of NP independence on access to primary care in HPSAs Further, I examined for heterogeneity in the effect of NP independence between HPSAs and non-HPSAs as well as effect heterogeneity in HPSAs based on individual (age, insurance status, and insurance type) and health system characteristics (availability of primary care facilities and NP Medicaid reimbursement rate) I find that NP independence led to a 5% increase in the number of individuals with a primary care provider and a 2% increase in the use of non-physicians (relative to physicians) as the primary care provider in HPSAs. However, non-HPSAs experienced no significant changes in access to care. Further, I find evidence of heterogeneity in the effect of NP independence in HPSAs for all three individual characteristics but find no significant effect heterogeneity for any of the health system characteristics. Non-elderly individuals experienced greater improvements in access following NP independence compared to their elderly counterparts, and while both insured and uninsured individuals experienced improvements in access to care, uninsured individuals benefitted more from NP independence. Further, I find evidence of greater improvements in access to care among Medicaid beneficiaries relative to their privately insured and Medicare counterparts. These findings imply that removing regulatory restrictions on NP SOP could be an effective policy strategy for mitigating the effects of PCP shortages and improving access to care in HPSAs. Further, they demonstrate that NP independence could be a viable tool for addressing access to care issues in two traditionally underserved populations – the uninsured and Medicaid beneficiaries. Beyond addressing access issues, NP independence could also mitigate rising health care costs. The finding of increased use of lower-cost non-physicians rather than their more costly physician counterparts after NP independence indicates that this policy change could also bring about cost savings for society.

Department structure and leadership functions can influence work climate. In one healthcare system, advanced practice providers (APPs) worked in a decentralized structure with multiple leaders. This project explored the impact of the change to centralized leadership for APPs working in an academic healthcare system in which employee turnover was high and satisfaction was low. An ad hoc committee led by the chief medical officer created a centralized department with a designated leader. Surveys and interviews were used to identify the benefits of the strategies implemented and understand whether the change in organizational structure resulted in an improved work climate for APPs in the large multicampus academic healthcare system,. Data were collected from departmental reports, 12 APP interviews, and 2 online surveys with a total of 73 responses. Results showed that centralization improved leadership support and communication with APPs within the system by 11.4%. Feedback from APPs indicated the physicians maximized APPs' expertise and licensure, thus creating a supportive work climate and environment, professional growth, and job satisfaction. With the implementation of the centralized department in 2014, the turnover rate dropped from 20.47% in 2013 to 6.1% in 2016 resulting in positive social change for APPs, providers, and patients.

Thesis (M.S.)--University of Michigan, 1987.