Orientador: Eliete Maria Silva / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-05T02:44:23Z (GMT). No. of bitstreams: 1 Takemoto_MairaLibertadSoligo_M.pdf: 51945196 bytes, checksum: c546828833b4f6a4e64af9e4cda93051 (MD5) Previous issue date: 2005 / Resumo: O objetivo geral dessa pesquisa é analisar, à luz do referencial teórico da Saúde Coletiva, o trabalho de enfermagem em Centros de Saúde do município de Campinas inserido em um momento de transformação do modelo de atenção à saúde impulsionada pelo Projeto Paidéia de Saúde da Família. Quanto aos objetivos específicos, buscou compreender as mudanças no processo de trabalho de enfermagem a partir da implementação do Projeto Paidéia. Para isso, utilizou-se a entrevista semi-estruturada com enfermeiras, auxiliares de enfermagem e coordenadoras de cinco Centros de Saúde do município, além de observação participante do trabalho de enfermagem nessas mesmas unidades. A análise dos dados obtidos revelou três categorias centrais de análise: Transformações no Trabalho de Enfermagem, Necessidades de Saúde e Acolhimento. Cada uma delas foi discutida e decomposta em estruturas relevantes no sentido de revelar os elementos constitutivos do processo de trabalho (objeto, finalidade, meios, instrumentos e trabalho em si). A análise mostrou que a implementação do Projeto Paidéia nas unidades pesquisadas resultou em transformações no trabalho de enfermagem. No entanto, o processo de trabalho continua tendo freqüentemente como objeto o corpo biológico individual e as manifestações do seu desgaste, recortado com os saberes e práticas advindos da Clínica médica, sem reconhecer de fato a complexidade das necessidades de saúde dos usuários, conseqüentemente logrando pouco sucesso em sua satisfação. A superação dessas questões é necessária para a reconstrução da intervenção de Enfermagem em Saúde Coletiva na produção de serviços de saúde que tenham como objeto os perfis epidemiológicos do coletivo e consigam alcançar a finalidade de transformar esses perfis / Abstract: Based on the Public Health theoretical framework, this research paper aims to analyze the nursing work carried out by Health Centers in the City of Campinas (São Paulo, Brazil) in a moment that the health care model is undergoing changes fostered by the Paidéia Family Health Project (PFHP). More specifically, an understanding of the changes in the nursing working process after PFHP's implementation was sought together with an identification of the nursing practice object, aims, means, tools and work in itself. Data were gathered by means of semi-structured interviews with nurses, nursing aides and coordinators in five Health Centers as well as by participant observation. Three major analytical categories emerged from data analysis: Changes in the Nursing Work, Health Needs and Receptivity, which were ali discussed and subdivided into relevant structures in order to get the constituting components of the nursing work (namely, the object, aims, means, tools and the work in itself). Although the PFHP's implementation in the Health Centers under study was shown to cause changes in nursing work, the nursing work process still focuses mainly on the individual biologic body and the wear and tear on it, being largely approached with knowledge and practice stemming from the Clinical view, thus failing to both truly recognize the complexity of the users' health needs and successfully meet his/her full needs. Such difficulties must be overcome if the Public Health Nursing intervention is to be reconstructed in order to provide health services focused on the collective epidemiological profile and designed to their successful improvement / Mestrado / Enfermagem e Trabalho / Mestre em Enfermagem

ABSTRACT This thesis represents a two phase, qualitative study using both Expert Review Panel and Delphi Panel research methods. The two research questions guiding this study were: 1) Phase I: What does culturally safe nursing practice mean, and how do we know when it is being practiced; and 2) Phase II: Can proposed culturally safe nursing practices be coded through use of International Classification for Nursing Practice (ICNP®) and/or Nursing Intervention Classification (NIC)? Originating from the field of nursing in New Zealand, there is interest in adopting cultural safety in Canada to support culturally safe nursing care for Canada’s Indigenous people (Canadian Nurses Association, 2009). A synthesis of the literature was conducted in Phase I of this study revealing six hallmarks of culturally safe nursing care. Those are: 1) Creating trust; 2) Relinquishing power over relationships; 3) Approaching people with respect; 4) Seeking permission; 5) Listening with your heart and ears; and 6) Attending to those who’s beliefs and practices differ. Representing culturally safe care of an Indigenous elder, a case scenario, developed by the principle investigator (PI), was presented to cultural safety experts (n=3) participating on an Expert Review Panel (ERP). The results of ERP showed that all six culturally safe nursing practices were represented in the case scenario. Validating that culturally safe nursing practices could be succinctly defined contributes to new knowledge, and most importantly informs nurses how to practice in a culturally safe nursing way. The purpose of using a Delphi panel method in Phase II was to see if culturally safe nursing practices in the case scenario could be represented in the ICNP® and NIC nursing languages by experts in those particular languages. To explore this two groups of subject matter experts in ICNP® (n=3) and NIC (n = 3) were invited to participate in separate Delphi panels. Overall, the Phase II Delphi panel results reflected the divergent way ICNP® and NIC are structured, in that terms alone do not provide enough contextual meaning to support clinical practice. The results of the ICNP® Delphi Panel showed that one ICNP® nursing intervention could represent culturally safe nursing care: Establishing Trust. Otherwise, the abstract composition of ICNP® terms affected the study results. The NIC Delphi panel results reflect the content and structure of NIC, and as such the experts identified the following four NIC nursing interventions that reflect culturally safe nursing care, they are: 1) Culture Brokerage, 2) Complex Relationship Building, 3) Emotional Support, and 4) Active Listening. Succinctly defining what nurses do is important; therefore, nursing languages need to be unambiguous, contextual so they are accurately and consistently documented. Validating culturally safe nursing practices exist—and further ensuring they are represented in standardized nursing languages and terminology sets and thus coded for use in an electronic health record (EHR)—ensures that culturally safe nursing care data is captured in the EHR. / Graduate

State dependency and the lingering impacts of colonialism dancing with Aboriginal peoples are known realities across the Canadian health care landscape. However, delving into the discourses of how to reduce health disparities of a colonized population is a sophisticated issue with many factors to consider. Specifically, nurses can play a central role in the delivery of essential health services to the ‘Other’ within isolated Northern Aboriginal communities. As an extension of the state health care system, nurses have a duty to provide responsive and relevant health care services to Aboriginal peoples. The conducted qualitative research, influenced by a postcolonial epistemology, sought to explore the roles and challenges of nurses working within rural, remote, and Northern Canadian Aboriginal communities, as well as individual, organizational, and system level factors that supported or impeded nurses’ work in helping to meet Aboriginal peoples’ health needs with meaningful care. Theorists include the works of Fanon on colonization and racial construction; Kristeva on semiotics and abjection; and Foucault on power/knowledge, governmentality, and bio-power were used in providing a theoretical framework to help enlighten the research study presented within this dissertation. Critical Discourse Analysis of twenty-five semi-structured interviews with nurses, physicians, and regional health care administrators was deployed to gain a better understanding of the responsibilities and challenges of nurses working in Northern Canada. Specifically, the research study was conducted in one of the three health regions within Northern Saskatchewan. Major findings of this study include: (1) the Aboriginal person did not exist without being in a relation with their colonial agent, the nurse, (2) being ‘Aboriginal’ was constructed as a source of treating illnesses and managing diseases, and (3) as a collective force, nursing was utilized as means of governmentality and as provisions of care situated within colonial laws. Historically, nurses functioned as a weapon to ‘save’ and ‘civilize’ Aboriginal peoples for purposes of the state. Primarily, present day nursing roles focused on health care duties to promote a decency of the state, followed by missionary tasks. In turn, the findings of this research study indicate that nurses must have a better understanding of the impact of colonialism on Aboriginal peoples’ health before they engage with local communities. Knowledge development through postcolonial scholarship in nursing can help nurses and health service providers to strengthen their self-reflective practice, in working towards de-signifying poor discourses around Aboriginal peoples’ health and to help create new discourses.

Background: Mentoring is an intervention for implementing evidence into practice, but little is known about this intervention. The overall aim of this dissertation was to examine mentoring as a knowledge translation (KT) intervention to inform clinical practice. Methods: 1) A systematic review was used to determine the effectiveness of mentoring as a KT intervention. 2) An interpretive descriptive qualitative study was conducted to explore the use of mentoring in the Registered Nurses' Association of Ontario’s Best Practice Guidelines Implementation/ Knowledge Transfer Fellowship program. Findings: 1) Of 10,669 citations from 1988 to 2012, 10 studies were eligible. Findings showed that mentoring alone (n = 1 study) improved one behavioral outcome. When mentoring was used as part of a multi-faceted intervention (n = 9), there were various effects on knowledge, beliefs/attitudes, use of research evidence in clinical practice, and the impacts on healthcare professionals, patients and organizations. 2) Qualitative interviews with 6 fellows, 8 mentors and 4 program leaders revealed that mentoring involved building relationships, establishing a learning plan, and using teaching and learning activities. Mentors were described as accessible, dedicated, and having expertise; fellows were described as dedicated, self-directed, and having mixed levels of expertise. Mentoring was described as positively impacting upon mentoring relationships, fellows, mentors, and organizations. Participants reported no negative outcomes. Conclusion: Mentoring was used as a KT intervention to support the implementation of evidence into clinical practice. The systematic review and qualitative study findings informed the Mentoring for Guideline Implementation model. Mentoring involved mentees selecting more experienced mentors who provided individualized support based on mentees’ learning needs, which resulted in mutual benefits for mentees and mentors. Future research is required to validate this new mentoring model, develop an instrument to measure the mentor-mentee relationship, and evaluate the effectiveness of mentoring as a KT intervention for guideline implementation in nursing.

Nurse educators believe that their graduates are well-prepared for entry level positions in nursing. In the acute healthcare setting, new graduates are placed on virtually every type of nursing unit, including critical care. Employers have developed formal orientations to familiarize new graduate nurses new with the institution and its policies and procedures and to teach the things employers believe new RNs need to know but do not, either because they were never taught the material or they have not retained it. The purposes of this project were to (a) examine the evidence relative to a disconnect between nursing education and nursing practice, (b) design a formal residency program for new graduates based on the evidence, and (c) implement and evaluate the residency program. Based on the evidence, a 16-week new nurse residency was developed in which Residents were each assigned both a Preceptor and Mentor to assist their progress. Weekly educational offerings were targeted at specific competency deficits identified by Residents, Preceptors and Mentors at the beginning of the residency program. Seven out of the original 10 Residents completed the Residency. Pre-residency, the Residents were very confident of their clinical skills and abilities and this was unchanged post-residency. The Preceptors and Mentors were much less confident of the clinical skills and abilities of the Residents pre-residency. Post-residency, the confidence level of the Preceptors and Mentors was improved, but significantly so only for the Mentors. It is imperative that nursing administrators be aware of the discrepancy between the confidence new nurses have in their own skills and the perceptions of the nurses who work side by side with them on a daily basis. Residencies for new graduate nurses are costly. Nursing administrators must make the determination if the benefits outweigh the costs. They may find the results of not having a residency are far more costly.

Standards of practice for hospital electrocardiogram monitoring were recommended in 2004 by the American Heart Association; however they are not widely followed. Many nurses monitor in a single lead regardless of diagnosis and are unable to differentiate wide QRS complex tachycardias. The purpose of this project was to evaluate the effectiveness of an interactive web-based education program combined with unit-based collaborative learning activities on both telemetry staff nurses‘ knowledge of dysrhythmias and their monitoring practices for patients at risk for wide QRS complex tachycardias. This interventional, one group before-and-after cohort study design consisted of four components: interactive web-based educational program with a pretest and posttest, unit-based collaborative activities, competency skills validation, and patient audits of electrode placement and lead selection at baseline, six weeks, and 18 weeks. There were 34 nurses who consented to participate, 16 started the program, and nine finished all the components. The pretest scores ranged from 0 – 60% with median of 36.5%. The posttest scores ranged from 47 – 93% with median of 80%. The Wilcoxon Signed Ranks test showed a significant difference between the pretest and posttest scores (p = .008). The patient audit results did not indicate significant differences in proportions of correct electrode placement and correct lead selection between baseline, 6 weeks, and 18 weeks. The program was effective in increasing nurses‘ knowledge about dysrhythmias; however, it was not effective in changing monitoring behavior. More research is needed to see if this type of program is more effective if it involves all the staff on the unit who are responsible for monitoring, and if additional strategies are used, such as unit champions and group rewards.

Recent studies show that more than one-third of U.S. adults (over 72 million people) were obese in 2005–2006. This includes 33.3% of men and 35.3% of women. Obesity is a primary factor in the development of metabolic syndrome, a condition that places individuals at high absolute risk of mortality and morbidity. The use of a nutritionally balanced diet aimed at weight reduction has the potential to decrease the prevalence of obesity, therefore reducing the incidence of metabolic syndrome and its consequences. The purpose of this project was to investigate whether individual nutrition counseling would improve the outcomes of patients with metabolic syndrome. A transdisciplinary team of faculty and graduate students from nutrition and nursing served as consultants and educators at a clinic for the uninsured in a southeastern city in the United States. This study was a one-group before-and-after design, with baseline data obtained on patients prior to the practice change. The study ran for six months. The intervention was an evidence-based practice change incorporating intensive dietary program for 19 patients with metabolic syndrome and an evaluation of the effect of that change on lipoproteins, glucose, blood pressure, weight, and waist circumference. Although there were no positive changes in weight or waist circumference, the participants did enjoy a significant decrease in blood pressure, fasting glucose and plasma lipids. None of these changes were significantly associated with the dietary intervention. Based on the most current evidence, the most effective way to reduce risks associated with metabolic syndrome is weight reduction, adequate nutrition, and exercise.

Proper handwashing is one of the simplest, most affordable and effective means of stopping the spread of infection. Due to the close proximity of children in schools and child care settings, there is a high risk for the spread of infectious disease. The purpose of this project was to improve handwashing behaviors of three to six year old children in a community school setting by implementing an evidence based multi-activity handwashing education program. The objective was to increase understanding of the relationship between germs and handwashing, as well as increase the frequency and correct technique procedure of handwashing behavior in children in the community. The evidence based handwashing education program was implemented over several weeks and included multiple activities that were found in the literature to be effective. These activities included a lecture and presentation, a return demonstration, a Glo Germ™ training device, and a video and story on handwashing. The results of the statistical analysis found that the program was effective in increasing both the frequency and correct technique procedure of the children. Most parents (80%) reported that they noticed an increase in how often their child washes his/her hands. A majority of parents (83%) noticed an increase in the duration of how long their child washes his/her hands; a larger majority (90%) noticed a decrease in how often they needed to prompt their child to wash his/her hands. Nurses working collaboratively with other disciplines in the community can implement evidence based practice handwashing education programs in a variety of public child care settings. The effects of the handwashing programs may significantly decrease child healthcare costs associated with prescriptions, visits to the provider, hospital admissions and emergency room visits and influence positive health promotion behaviors in children. Implementing affordable and effective handwashing education programs can lead to a reduction in infectious diseases, absenteeism, antibiotic resistance and health care costs. By fostering positive health promotion practices, such as proper handwashing behaviors in children, habits may be instilled that carry into adulthood. These habits can increase the health of a child and the community.

Proper collection of blood cultures is needed to identify pathogens causing serious infections and direct appropriate antibiotic therapy. Blood culture contamination can lead to longer hospital stays, incorrect antibiotic treatment, additional testing, and overall increased costs for the patient and hospital. Blood culture collection technique is the most important factor affecting contamination rates. The purpose of this project was to determine the effect of simulation reinforcement of blood culture collection processes on the rate of contamination of blood cultures drawn by nurses in a community medical center emergency department. This one-group before-and-after cohort study utilized a convenience sample of 50 nurses who collect blood cultures on adult clients. Each participant completed a pretest, attended a simulation in-service class, and completed a posttest immediately after the simulation and again one-month later. There was significant knowledge gained from pretest to immediate posttest, with no significant decrease in knowledge at I-month post-intervention. The 3-month blood culture contamination rate was 3.26% prior to the intervention, 4% during the intervention period, 3.7% after the intervention, and 2% in months 4 aI1d 5 postintervention. The use of simulation in the professional development of practicing nurses has the potential to improve clinical practice performance and patient outcomes.

Metabolic syndrome is a serious health problem in the United States. The presence of metabolic syndrome significantly increases the risk of developing type II diabetes and cardiovascular disease by producing a prothrombic state. The prothrombic state that results from the clustering of several independent cardiovascular risk factors within one individual increases the risk of micro and macro vascular changes and eventually to end organ damage. There is considerable evidence to support the serious nature of this medical condition. Medications used to treat the hypertension, diabetic, and dyslipidemia components of metabolic syndrome can be a significant drain on the monthly budget of individuals and families, especially if they do not have health insurance. Diet and exercise programs have been shown to be effective in reducing adiposity and decreasing insulin resistance. These changes in lifestyle may be adjuncts or a low cost alternative to expensive medications for some individuals. The purpose of this project was to identify the effect of an intensive dietary and exercise program on patients with metabolic syndrome. This study even with a small sample size (n = 5) showed that waist size, systolic blood pressure, diastolic blood pressure, and high density lipoprotein levels were trending towards levels that would remove the patient from the diagnosis of metabolic syndrome. The greatest benefit for the general population would result from intervention prior to a diagnosis of hypertension and diabetes and with medication naïve individuals. Early intervention would decrease the cost of medical treatment and hospitalizations.