The purpose of this project is to develop a curriculum, which will examine the ethical methods or practices used by nurses in resolving ethical dilemmas in clinical practice utilizing the Moral Decision-Making Model for staff nurses at St.Bernardine Medical Center, Five Tower North.

Background The landscape of clinical decision support systems (CDSSs) is evolving to include increasingly sophisticated data-driven methods, such as machine learning, to provide clinicians with predictions about patients’ risk for negative outcomes or their likely responses to treatments (predictive CDSSs). However, trust in predictive CDSSs has shown to challenge clinician adoption of these tools, precluding the ability to positively impact patient outcomes. This is particularly salient in the hospital setting where clinician time is scarce, and predictive CDSSs have the potential to decrease preventable mortality. Many have advised that clinicians should be involved in the development, implementation, and evaluation of predictive CDSSs to increase translation from development to adoption. Yet, little is known about the prevalence of clinician involvement or the factors that influence clinicians’ trust in predictive CDSSs for the hospital setting. The specific aims of this dissertation were: (a) to survey the literature on predictive CDSSs for the hospital setting to describe the prevalence and methods of clinician involvement throughout stages of system design, (b) to identify and characterize factors that influence clinicians’ trust in predictive CDSSs for in-hospital deterioration, and (c) to explore the use of a trust conceptual framework for incorporating clinician expertise into machine learning model development for predicting rapid response activation among hospitalized non-ICU patients using electronic health record (EHR) data. Methods To address the first aim (presented in Chapter Two), a scoping review was conducted to summarize the state of the science of clinician (nurse, physician, physician assistant, nurse practitioner) involvement in predictive CDSS design, with a specific focus on systems using machine learning methods with EHR data for in-hospital decision-making. To address the second aim (presented in Chapter Three), semi-structured interviews with nurses and prescribing providers (i.e., physicians, physicians assistants, nurse practitioners) were conducted and analyzed inductively and deductively (using the Human-Computer Trust conceptual framework) to identify factors that influence trust in predictive CDSSs, using an implemented predictive CDSS for in-hospital deterioration as a grounding example. Finally, to address the third aim (presented in Chapter Four), clinician expertise was elicited in the form of model specifications (requirements, insights, preferences) for facilitating factors shown to influence trust in predictive CDSSs, as guided by the Human-Computer Trust conceptual framework. Specifications included: (a) importance ranking of input features, (b) preference for a more sensitive or specific model, (c) acceptable false positive and negative rates, and (d) prediction lead time. Specifications informed development and evaluation of machine learning models predicting rapid response activation using retrospective EHR data. Results The scoping review identified 80 studies. Seventy-six studies described developing a machine learning model for a predictive CDSS, 28% of which described involving clinicians during development. Clinician involvement during development was categorized as: (a) determining clinical relevance/correctness, (b) feature selection, (c) data preprocessing, and (d) serving as a gold standard. Only five studies described implemented predictive CDSSs and no studies described systems in routine use. The qualitative investigation with 17 clinicians (9 prescribing providers, 8 nurses) confirmed that the Human-Computer Trust concepts of perceived understandability and perceived technical competence are factors that influence hospital clinicians’ trust in predictive CDSSs and further characterized these factors (i.e., themes). This study also identified three additional themes influencing trust: (a) actionability, (b) evidence, and (c) equitability, and found that clinicians’ needs for explanations of machine learning models and the impact of discordant predictions may vary according to the extent to which clinicians rely on the predictive CDSS for decision-making. Only two of 28 categories/sub-categories and one theme emerged uniquely to nurses or prescribing providers. Finally, the third study elicited model specifications from fifteen total clinicians. Not all clinicians answered all questions. Vital sign frequency was ranked the most important feature category on average (n = 8 clinicians), the most frequently preferred prediction lead time was shift-change/8-12 hours (n = 9 clinicians), most preferred a more specific than sensitive model (71%; n = 7 clinicians), the average acceptable false positive rate was 42% (n = 9 clinicians), the average acceptable false negative rate was 29% (n = 6 clinicians). These specifications informed development and testing of four machine learning classification models (ridge regression, decision trees, random forest, and XGBoost). 249,676 patient admissions from 2015–2018 at a large northeastern hospital system were modeled to predict whether or not patients would have a rapid response within the 12-hour shift. The random forest classifier met clinician’s average acceptable false positive (27.7%) and negative rates (28.9%) and was marginally more specific (72.2%) than sensitive (71.1%) on a holdout test set. Conclusions Studies do not routinely report clinician involvement in model development of predictive CDSSs for the hospital setting and publications on implementation considerably lag those on development. Nurses and prescribing providers described largely shared experiences of trust in predictive CDSSs. Clinicians’ reliance on the predictive CDSS for decision-making within the target clinical workflow should be considered when aiming to facilitate trust. Incorporating clinician expertise into model development for the purpose of facilitating trust is feasible. Future research is needed on the impact of clinician involvement on trust, clinicians’ personal attributes that influence trust, and explanation design. Increased education for clinicians about predictive CDSSs is recommended.

No description available.

No / The United Kingdom is considered to be the world leader in nurse prescribing, no other country having the same extended non-medical prescribing rights. Arguably, this growth has outpaced research to evaluate the benefits, particularly in areas of clinical practice where patients have complex co-morbid conditions such as palliative care. This is the first study of non-medical prescribing in palliative care in almost a decade. AIM: To explore the current position of nurse prescribing in palliative care and establish the impact on practice of the 2012 legislative changes. DESIGN: An online survey circulated during May and June 2013. PARTICIPANTS: Nurse members (n = 37) of a regional cancer network palliative care group (61% response rate). RESULTS: While this survey found non-medical prescribers have embraced the 2012 legislative changes and prescribe a wide range of drugs for cancer pain, we also identified scope to improve the transition from qualified to active non-medical prescriber by reducing the time interval between the two. CONCLUSION: To maximise the economic and clinical benefit of non-medical prescribing, the delay between qualifying as a prescriber and becoming an active prescriber needs to be reduced. Nurses who may be considering training to be a non-medical prescriber may be encouraged by the provision of adequate study leave and support to cover clinical work. Further research should explore the patients' perspective of non-medical prescribing.

Multiple chronic conditions (MCCs) are defined as two or more health conditions, each requiring treatment and limiting activities for a year or more. In the United States (US), MCCs are more common and costly than any individual chronic condition. The number of adults aged 65 years and older with MCCs is projected to nearly double between 2020 and 2050. Patients with MCCs often experience poor self-reported health and negative symptoms. In addition, they frequently visit emergency departments (EDs) and are hospitalized. Patients with MCCs need ongoing primary care services to manage their symptoms and prevent health deterioration. However, over 20% of the US population (many of whom have MCCs) resides in a primary care Health Professional Shortage Area (HPSA) and experiences poor access to primary care. The growing nurse practitioner (NP) workforce, which is projected to almost double in size between 2018 and 2030, can help meet the demand. Most NPs are trained to diagnose, treat, and manage chronic conditions and can provide a scope and quality of primary care comparable to physicians in many populations. Therefore, if distributed and supported strategically, the NP workforce can meet the complex care needs of patients with MCCs, especially in HPSAs. Maximizing the potential of the NP workforce to deliver MCC care will require enhanced care environments in the practices where NPs work, characterized by administrative support for NP care delivery and autonomous practice, collegial relationships between NPs and physicians, and NP professional visibility. On the other hand, poor NP care environments can negatively affect the quality of chronic disease care. Thus, improving the NP care environments within practices may increase the capacity of the NP workforce to care for MCC patients. Despite the potential of the NP workforce to meet the need for primary care among patients with MCCs, little is known about the impact of NP-delivered primary care models on outcomes in this population. Furthermore, the impact of HPSA status and NP care environments on NPs’ ability to care for patients with MCCs remains poorly understood. Thus, the overall purpose of this dissertation is to produce evidence on NP-delivered primary care models for patients with MCCs and examine the interplay between practice and community factors in shaping outcomes for these patients. In chapter 1, we introduce the unique healthcare needs of patients with MCCs, and the role of NPs in delivering and expanding access to care. In chapter 2, we synthesize the existing evidence on the effect of NP primary care models, compared to models without NP involvement, on cost, quality, and service utilization by patients with MCCs. Our synthesis suggests that NP-delivered primary care has similar or better impacts on outcomes among patients with MCCs compared to care delivered without NP involvement. In chapter 3, we perform secondary data analysis using multiple linked data sources including 1) patient data from the Medicare claims of 394,424 older adults with MCCs, 2) NP survey data on practice characteristics from 880 NPs at 779 primary care practices across five US states, and 3) data on HPSA status of the practice locations from the Health Resources and Services Administration. We examine differences in hospitalization and ED use among patients who receive care from NP practices in HPSAs compared to those in non-HPSAs. We find a higher likelihood of ED use among patients receiving care in NP practices located in HPSAs compared to practices in non-HPSAs, and no difference in the likelihood of being hospitalized. Our results suggest that relieving provider shortages may reduce ED use by MCC patients in HPSA practices that employ NPs, but may be insufficient to lower hospitalization rates unless combined with other interventions. Finally, in chapter 4, we analyze the same linked secondary data source as in chapter 3 to examine the effect of the NP care environment (measured by the NP survey) on the relationship between the HPSA status of the practice location and ED or hospital use among patients with MCCs. We find that the NP care environment moderates the association between primary care provider shortage areas and hospitalization but not ED use. Further analysis reveals that improved NP care environments have a more pronounced association with lowered odds of hospitalization among patients receiving care from practices located in areas with no shortage of primary care providers (i.e., non-HPSAs) compared to those receiving care in practices with provider shortages (i.e., HPSAs). Our findings suggest that improving the care environment may not have the effect of reducing MCC patients’ need for hospitalization unless sufficient providers are also available to care for patients. We suggest that cohesive solution sets addressing practice- and community-level interventions simultaneously may be needed to improve hospitalization outcomes for patients with MCCs. In the concluding chapter of this dissertation, chapter 5, we present a summary of findings, discuss the dissertation’s strengths, limitations, and its contributions to science. In this chapter, we also discuss implications for policy, practice, and directions for future research.

Psychiatric nurse practitioner (NP) turnover is a significant cost to healthcare employers. Psychiatric NP turnover due to private practice creation is not well understood. The purpose of this study was to better understand the transition of Psychiatric NPs as they moved from ambulatory/outpatient employment to private practice. Using a hybrid Grounded Theory approach, 17 Psychiatric NPs in private practice were interviewed from October - December 2023. Facilitating factors to private practice creation were: The COVID-19 pandemic, changes to telehealth regulation during the pandemic, increased demand for psychiatric services and decreased supply of providers, and progress within the NP full practice authority movement. While employed, NPs reported experiencing burnout, high patient load, poor schedule, poor compensation, increased administrative tasks not budgeted within the NP workday, and rampant disrespect of the NP role. NPs reported being managed by inappropriate supervisors from other disciplines, and reported little opportunity for growth. Most participants voiced an initial reluctance to enter private practice, and reported being “pushed” to entrepreneurship out of concern for their long term wellbeing. These factors combined contributed to poor NP job satisfaction and NP turnover. Strategies to improve the job satisfaction of employed psychiatric NPs were recommended.

Submitted in fulfillment for the requirements of M Technology : Nursing, Department of Nursing, Durban University of Technology, Durban, South Africa, 2015. / Background All nursing students need to undergo clinical training for them to be competent practitioners when they qualify. According to the South African Nursing Council (SANC) training facilities are accredited only if the clinical training component is effective. Therefore, it is important that students are accompanied in order for them to grow professionally and have values as future health care professionals. In nursing education, a student throughout the nursing training course receives instruction both theoretically and clinically in the subjects prescribed in the curriculum by the SANC. Clinical instruction is effected through clinical teaching and learning, which is a requirement by the nursing regulatory body, the SANC. For an undergraduate programme a student has to spend a minimum of 1000 hours per year in clinical placement to meet programme outcomes. It is the responsibility of all nursing schools, colleges and universities to ensure that each student meets these requirements. For this to be effective it has to be facilitated by lecturers and clinical instructors, through teaching and learning strategies to enable students to perform the clinical skill with knowledge and eventual competence. Therefore, clinical instructors are there to ensure that the students are competent in all skills, such as cognitive, affective as well as psychomotor skills. This will be beneficial to the programme in reduction of rates of failure and dropout and again by producing competent practitioners. A positive relationship and collaboration between the clinical training institutions and clinical placement facilities is vital for student achievement, especially because the clinical instructors assist students in correlating theory and practice. This study sought to assess the clinical training component of an undergraduate programme at this UoT in KwaZulu Natal. Findings may inform an improved clinical instruction programme as no such study had been undertaken. Methods A qualitative and quantitative design was used to explore feelings, perceptions as well as experiences of staff and student nurses with regard to clinical training component. Stratified random sampling was used to select student nurses according to levels of training and questionnaires were used to collect data. All permanently employed staff who had been working over six months were selected since they were directly or indirectly involved in the clinical facilitation. A focus group interview was conducted for the clinical instructors and questionnaires were used for the lecturers to collect data. Themes and sub-themes emerged and on analysis they were compared to the findings from the quantitative survey. Results and discussion The results revealed that collaboration of clinical placement facilities and training institutions is important for student’s support since all parties are able to communicate freely and students benefit. Students stated that they did not get enough support since the clinical facilitators were short staffed and they were also allocated to facilities that were far from the campus. The respondents cited problems during clinical accompaniments as there were very high expectations by staff members in the placement areas regarding student support. Lecturers were also expected to involve themselves in clinical accompaniment to bridge theory-practice gap. The employment of mentors will assist in student support as the mentors will be at placement areas and the staff and students easily contact them. Conclusion From the interviews the researcher managed to come up with important aspects that should be included in an accompaniment tool when developed, which should be user friendly to both lecturers and clinical facilitators. It will thus assist students with critical skills including critical thinking when performing any patient related nursing skill. It was recommended that the UoT management support staff by attending to their concerns including finding more clinical placement facilities close to the campus.

The aim of the study was to explore the perceptions of nurses regarding communication with nurse managers in the workplace. The design of the study was a generic qualitative. The methodology of choice was qualitative, explorative method. The sample was non-probability and the approach or technique used was purposive sampling method. It comprised of thirty nurses, ten of each category. The category was a component of professional nurses, enrolled nurses and enrolled nursing auxiliary nurses. The data collection method used in the study was in-depth interviews using a self-designed interview guide. Face to face interviews was conducted in a quiet room within the hospital ward as a natural setting. Data was collected using a voice recorder for the sake of protecting the missing of information which may be important. The data analysis was with the help of employing transcribing and coding of voice recorded data and observation noted during the collection of data. The data collection method used in the study was in-depth interviews using a self-designed interview guide. Face to face interviews was conducted in a quiet room within the hospital ward as a natural setting. Data was collected using a voice recorder for the sake of protecting the missing of information which may be important. The data analysis was with the help of employing transcribing and coding of voice recorded data and observation noted during the collection of data. The findings showed that there were dynamics in communication from all nurse categories and that also indicated that there was a need to conduct a research so that the root cause may be identified and suggestions to be put in place to curb the challenges. In conclusion it showed that communication is the key problem of all and it is a worldwide problem. / Health Studies / M.A. (Health Studies)

Text in English / The purpose of the study was to explore the registered nurse’s perceptions with regard to the use of authority by nurse managers in the workplace. A qualitative approach using phenomenological descriptive design was used. Data was collected by means of audio-taped individual interviews and field notes. The sample included registered nurses aged 25-45 years with more than two years’ experience. Ethical issues were adhered to. The data was analysed using content analysis as proposed by Creswell (2013). Five themes and seventeen subthemes emerged from the data. The findings revealed that the registered nurses were unhappy with the way authority is being used, their non-involvement in decision-making; lack of two way communication between nurses and managers; poor relationship between nurses and health service managers which hindered nurses’ opportunity for growth. Autonomy is a major determinant of nurse job satisfaction, and failure to apply it may lead to high turnover and absenteeism. / Health Studies / M.A. (Health Studies)

Bien qu'il existe une abondante littérature scientifique sur les infirmières praticiennes spécialisées de première ligne (IPSPL), le soutien et les modalités d’encadrement de cette pratique restent très peu explorés. Au Québec, ces questions semblent d’autant plus importantes à étudier car la diversité des milieux de pratique, l’éloignement physique entre les acteurs-clés, le partage de l’encadrement et le cadre légal complexifient l’opérationnalisation de ce soutien. Par le biais d’une étude de cas multiples, ce mémoire propose une analyse des différentes structures d’encadrement et des mécanismes déployés pour soutenir le développement de la pratique IPSPL au Québec. Issu d’un projet de recherche plus large et multicentrique, ce mémoire de maîtrise a étudié trois milieux distincts par le biais de 18 entrevues auprès de professionnels de la santé et de gestionnaires. Grâce à un modèle en trois niveaux, les besoins en termes de soutien des IPSPL et des équipes ont été identifiés. Les principaux résultats de cette recherche démontrent la pertinence d’un encadrement par les acteurs de la Direction des soins infirmiers. De plus, le soutien aux professionnels des équipes qui incluent des IPSPL semble bonifié lorsque certaines structures organisationnelles sont présentes. Finalement, les comités décisionnels autour de l’implantation des IPSPL s’avèrent davantage bénéfiques lorsqu’ils tiennent compte de l’environnement et de l’expérience acquise par les milieux. / Although there is an abundant literature on primary health care nurse practitioners (PHCNP), the optimal structures and practices to support PHCNPs remain largely unexplored. In Quebec, this issue needs particular attention because of practice settings diversity and physical distance between major key players. Furthermore, the supervision role that seems to be shared by multiple professionals and the legal framework add to the complexity of the implementation of support structures and practices. Through a multiple case study, this paper aimed to explore the managerial structures in place and to analyze the mechanisms deployed to support the development of PHCNP practice. Issuing from a larger scale multicenter research, this study analyzed three separate cases, totaling 18 interviews with health professionals and managers. Based on a three levels model built on the central concept of support, the needs of PHCNP and their teams have been identified. The main results of this research demonstrate the relevance of supervision by the key players of the Department of Nursing. In addition, the coordination between professionals seems enhanced when some organizational structures are implemented. Finally, decision-making committees linked to the implementation of PHCNP appear to be more useful when the environment and experience of the organizations are taken into consideration.