Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Dans les services de première ligne des Centres de santé et de services sociaux (CSSS) au Québec, les infirmières sont des acteurs clés des programmes destinés à des populations vulnérables. Ces programmes créent des opportunités pour les infirmières de développer une pratique à l’interface du CSSS et des ressources de la communauté afin d’agir pour réduire la vulnérabilité sociale. Des infirmières commencent d’ailleurs à se mobiliser au-delà de leurs frontières disciplinaires, organisationnelles et sectorielles pour s’engager dans l’environnement de personnes vulnérables, ce que nous désignons ici comme pratique infirmière d’interface. Aucune étude n’a toutefois été repérée en regard de cette pratique infirmière en émergence. Fondée sur une perspective constructiviste et systémique, de même qu’une analyse des conceptions de théoriciennes infirmières sur la pratique, notre recherche doctorale avait pour but de modéliser la pratique infirmière d’interface en contexte de vulnérabilité sociale. Elle a également constitué un cas à partir duquel contribuer aux savoirs théoriques sur le concept de pratique en sciences infirmières. Une étude qualitative exploratoire a été entreprise dans trois CSSS d’une région urbaine. Des entretiens semi-dirigés ont été réalisés avec quinze infirmières. La pratique d’interface de deux infirmières a ensuite fait l’objet d’une année d’observation directe et participante, ce qui a permis de procéder à des entretiens informels avec des gestionnaires ainsi que des membres des équipes interprofessionnelles et communautaires. Une analyse de documents programmatiques et gouvernementaux a complété notre description du contexte de la pratique d’interface. Une analyse thématique amorcée en cours de collecte de données ainsi que la méthode de modélisation systémique de Le Moigne ont permis de soutenir la démarche interprétative et de rendre compte des résultats. Quatre thèmes inter-reliés qualifient la pratique infirmière d’interface. Le premier met en évidence une finalité d’autonomie qui se traduit comme exigence de conformité sociale à l’endroit des personnes vulnérables. Le second porte sur des processus d’engagement relationnels des infirmières pour créer des liens et mettre en relation la clientèle et les acteurs du milieu. Le troisième thème est celui de l’action stratégique de l’infirmière. Enfin, le quatrième fait état d’un espace contradictoire à l’intérieur duquel se déroule la pratique d’interface, lequel comporte un processus de (re)configuration identitaire pour les infirmières. Une réflexion approfondie sur nos résultats, appuyée sur des savoirs disciplinaires en sciences infirmières et en sciences sociales, souligne des dimensions essentielles à considérer pour poursuivre le développement du concept de pratique en sciences infirmières. Spécifiquement, notre thèse permet de réfléchir les concepts centraux de soin et d’environnement en sciences infirmières, en plus d’expliciter le caractère fondamental de deux autres composantes à intégrer dans nos conceptions disciplinaires de la pratique, soit les savoirs et les projets. Cette thèse démontre la pertinence de contribuer à la création d’un « réseau de savoirs » avec d’autres disciplines pour soutenir notre capacité de théoriser la pratique et de renforcer l’intervention en contexte de vulnérabilité sociale. / Primary care nurses are key actors in programmes that are dedicated to vulnerable populations within Health and Social Service Centers (HSSC) in Québec. Such programmes provide opportunities to develop a nursing practice at the interface of an HSSC and community resources in order to reduce social vulnerability. Some nurses are now crossing their disciplinary, organisational and sectoral boundaries to engage in what we refer to here as interface nursing practice. Yet, to our knowledge, no study has documented this unfolding practice. Through a constructivist perspective, and building upon an analysis of nursing theorists’ conceptions of practice, the objective of this doctoral study was to produce a systemic model of interface nursing practice in the context of social vulnerability. This research also provides a case to reflect on the theory of practice in nursing science. A qualitative exploratory study was undertaken in three urban HSSCs. Fifteen primary care nurses participated in semi-structured interviews, followed by one year of direct and participant observation of the interface practice of two nurses. During this time, informal interviews with administrators, interprofessional teams and community actors, as well as an analysis of programme and governmental documents, were conducted to further our understanding of the context of interface nursing practice. Thematic analysis was initiated during data collection, whereas Le Moigne’s systemic modelling methodology was instrumental throughout the interpretive process of qualitative analysis and for the representation of our study results and further theoretical elaboration. Four inter-related themes qualify interface nursing practice. First, this practice is guided by a goal that is articulated as a social obligation for vulnerable populations, that of becoming autonomous. Second, relational processes are central as nurses interconnect vulnerable individuals with various actors and resources in the community. The third theme depicts interface nursing practice as strategic action. Finally, the fourth theme highlights opposing or contradictory processes that are experienced by nurses engaged in interface practice and that appear to change their sense of professional identity. Further examination of our results, at the intersection of nursing knowledge and social science theories, underscores fundamental dimensions of the concept of practice that are essential to consider in nursing theory development: the central concepts of care and environment, in addition to those of knowledge and projects. This thesis demonstrates the relevancy of creating coherent linkages with knowledge from various disciplines to strengthen our capacity to theorize nursing practice as well as intervention in the context of social vulnerability.

Conflict exists in all health care settings across the world. In a profession such as nursing, where there is constant interaction among staff, conflict is a common and often unavoidable challenge. Conflict represents a state where two parties have differing views on issues considered important to each of them. There are various forms of conflict such as intrapersonal, interpersonal, inter-group and/or inter-organisational conflict. While not all conflict can be managed or requires the need to be managed, learning how to manage it, may reduce the chances of it recurring or producing negative consequences. The inappropriate management of conflict has been reported to contribute to decreased productivity, poor morale and financial loss in and for healthcare organisations. The goal of this study was to make recommendations regarding how to optimise conflict management by Nurse Unit Managers (NUMs). A qualitative, explorative, descriptive and contextual research study was conducted to explore and describe the ability of NUMs to manage conflict in the nursing units of the Nelson Mandela Bay public hospitals. NUMs working in the three (3) public hospitals of the Nelson Mandela Bay Municipality situated in the Eastern Cape Province of South Africa were interviewed using unstructured individual interviews to collect meaningful data on how the NUMs would manage conflict based on a conflict scenario presented to them. Data was directly collected from the participants. The researcher developed a conflict scenario and the model answer in consultation with experts in both nursing management and human resource management. This was done to relate the responses and themes from the data collected with what literature suggest as the appropriate management of conflict. Tesch’s method of thematic synthesis was utilised to analyse this data. Recommendations were developed for nursing practice, nursing education and nursing research. Data was collected from eleven NUMs with each of the participating hospitals represented in the interviews. Unstructured interviews were conducted. The unstructured interview consisted of one central question and probing questions. This was done for all the interviews until data saturation was reached. The data collected was then transcribed and coded yielding the themes and sub-themes for this study. The model answer was then used to gauge the responses of the participants in comparison to what literature suggests regarding effective conflict resolution and management. The three themes that emerged from the data were Nurse Unit Managers managed the conflict in an appropriate manner, Nurse Unit Managers avoided the conflict and Nurse Unit managers did not apply the accepted process to manage the conflict. Thereafter the ability of NUMs to manage conflict in a nursing unit was described based on the findings. The researcher ensured trustworthiness by using Guba and Lincoln’s criteria, namely credibility, dependability, conformability, transferability. The participants’ rights and dignity were protected and the integrity of the study safeguarded by complying with the following ethical principles: autonomy, beneficence and non-maleficence, justice, privacy and confidentiality as well as authenticity. The limitations of the study were that only NUMs from the general hospitals in the public sector participated in the study and therefore the ability of NUMs in other types of hospitals and the private sector are not known. Other levels of nursing management were not included in the study. The findings in this study could be integrated into the orientation, training and preparation of nurse managers by health care organisations and educational institutions as well as Human Resource Management practices.

The thesis named "Current practice and possible ways of implementing clinical supervision in nursing" is the first doctoral dissertation establishing the concept of supervision in the Czech nursing environment. Itscentralresearch questionis as follows: How do nurses and university educators in nursing construct, interpret and practically apply theconcept ofclinical supervision and the supervisor's role in the context of nursing education at specific institutions of tertiary education and clinical nursing practice in the Czech Republic? The author draws on international theoretical literature and local empiricalevidence.Her qualitative research took the form of 26 semi-structured interviews with academic nursingeducators from the entire Czech Republic. In justified cases those are supplemented with qualitative data obtained through the study of legislative, policy and strategic documents in nursing and health care, including publicly available information and sources on clinical supervision, in order torefine the resulting picture of her interpretation of current clinical supervision practice in Czech nursing. A shift to the constructivist paradigm enabled one to conceive the term "clinical supervision" mainly in relation to learning, training and professional development of supervisees, also in the context of transformation of education and supervision not only of nurses but also of supervisors themselves in the Czech Republic. The author also focuses on the philosophical and theoretical foundations of clinical supervision and application of the postmodern approach in egalitarian clinical supervision. The empirical part of this dissertation is based on the qualitative research conducted. The author gradually presents her results as individual categoriesand relations between them that ensued from the analysed data in the process of open coding. The author draws a link between the category of implementation of clinical supervision in the context of nurses' professional education andexternal conditions, the environment and a broader professional and social-cultural context. Clinical supervision in nursing is constructed mainly as a unidisciplinaryconcept and a part of the nursing profession. The university nursing educatoris typically constructed as a role professional, but there is also an ongoing process ofdiversification, stratification, profiling and professionalization of non-academic nursing educators. Based on a content analysis of documents and post-modern philosophical-theoretical foundations and strategies of legitimizingclinical supervision, the author views the concept of clinical supervision in nursing as socially constructedand discursively legitimated. The author also defines the limitations of her research that arise from the choice of a qualitative research design. In the conclusion she outlines some future trends of clinical supervision in particular educational institutions that can be interesting and inspiring not only for supervisors but also for teachers of supervision themselves. Based on the results of her empirical analysis the author emphasises the need to integrate the theory and practice of education, clinical supervision and nursing. A comprehensive structure and methodology of system-wide implementation of clinical supervision, based on the situation of clinical nursing practice and supervision needs in the Czech Republic,should in future formthe basis of innovation of existing university programmes in nursing and approaches to the education and training of supervisors, as well as the subject of new research in clinical supervision.

A qualitative, non-experimental, explorative and descriptive research design based on the phenomenological philosophical tradition by Heidegger to broaden hermeneutics was conducted. The study was conducted at Umkhanyakude District to investigate the perspectives of eligible nursing students relating to the provision of spiritual care to patients. A purposive sample of 9 participants was recruited and consent form obtained. An unstructured interview guide, with a grand tour question, was used to conduct face to face individual interviews. The Thematic analysis and interpretative phenomenological method of analysis were employed until three themes, six categories and eleven subcategories emerged from the data. Data analysis revealed that nurses had difficulty to differentiate spiritual care from religious care. Commonly cited methods of providing spiritual care were prayer, reading sacred text and singing spiritual songs. Nurses still felt inadequately prepared educationally on how to provide spiritual care in nursing practice. Most of the participants provided spiritual care out of their own interest and not as part of their professional responsibility. Recommendations proposed that the matter be taken up by nurse managers to conduct related in-service education and mentoring programs and nurse educators to guide curriculum planning which evidently include spiritual care. / Health Studies / M.A. (Health Studies)

Text in English / Little is known about the current practice of the nurse practising as an independent private practitioner in South Africa. There is also limited information available about his/her needs for establishing and maintaining a private practice. In this exploratory, descriptive study the AFFIRM model was applied and specific data regarding the practice and needs of the nurse in private practice was collected through a questionnaire. Based on the analysed data, it would appear that the majority of private nurse practitioners are married females and fall into the age group below 44 years. Although a variety of nursing services are offered, quality control appears to be minimal. It was found that private nurse practitioners have specific learning needs particularly regarding business management skills, quality control and current nursing practices. Recommendations were made for the maintenance of standards in private practices and the introduction of short courses for nurses in private practice. / Health Studies / M.A. (Nursing Science)

One of the key factors influencing the quality of nursing care practice is the research applied within nursing processes. Therefore it is vital for theory to be closely linked with practice. To perform research and apply its results in practice is one of the conditions which lead to the development of evidence-based practice. Research applied in nursing care is a key strategy resulting into the unification of the human educational and scientific aspects of nursing care. This thesis focuses on the nursing care research and its application in practice together with the role of senior nurses within this process. The aim was to investigate whether and how the nurses are actually involved in nursing care research plus to examine whether ordinary nurses are willing to accept any changes associated with the introduction of the results of nursing care research into nursing practice. Besides this, also to determine whether nurses are encouraged to implement the results of nursing research into nursing practice, to observe nursing care deputies and leading nurses experience in respect to the implementation of the nursing care research results into practice in different types of hospitals plus to determine whether and how nurses introduce the results of nursing care research into practice. The final objective of this thesis was to determine whether the head nurses manage to introduce the results of the nursing care research into their nursing practice. In quantitative survey performed, the research sample consisted of nurses who work in inpatient departments at clinics and regional hospitals - public limited companies of the Central, South, West Bohemia, and Prague. 350 questionnaires were distributed. The research involved 186 questionnaires. Qualitative research data collection involved 12 respondents, out of which there were 3 head sisters employed at clinics and 3 nursing care deputies plus 3 head nurses from regional hospitals - public limited companies. All interviews were entirely anonymous. According to the survey findings, most of the nurses replied that they are not actively involved in the nursing care research. Nurses generally follow published results of nursing care research, but on the other hand, it is obvious, that they follow nursing care research outcomes randomly and without particular focus. Nurses not only that they refuse any changes, but they do not see any benefits of the implementation of research findings into the nursing care practice. The qualitative survey performed met objectives and all questions were answered. Any of the responses can serve for further quantitative research, especially when the results of the implementation of the nursing care research into practice at clinics and regional hospitals are compared.

Submitted in fulfilment of the requirements for the Master of Health Sciences in Nursing, Durban University of Technology, 2017. / Tuberculosis (TB) is South Africa’s greatest community health problem. Nurses have a critical role in supporting patients in the TB treatment process. An estimated 480 000 new cases of Multidrug-Resistant Tuberculosis (MDR-TB) and 190 000 people died in 2014. An estimated 43 million lives were saved between 2000 and 2014 with effective diagnosis and treatment of TB. Despite these measures TB remains one of the world’s biggest threats. In an attempt to improve the practice of nurses in the prevention of MDR-TB, the knowledge of nurses with regards to the prevention of MDR-TB is essential. Aim of the Study The aim of the study was to describe the practice of the nurses in the prevention of MDR-TB and to determine whether the practice was effective in the prevention of MDR-TB. Methodology Quantitative, descriptive survey was used to conduct the study. Purposive sampling method was employed to select six primary health care clinics at uThungulu District. The target population consisted of professional nurses and enrolled nurses working in these clinics. The sample size was 122. The questionnaire was used to collect data. Descriptive statistics was used to describe the data graphically. In order to test for significant trends in the data, inferential statistics were applied. Results The findings of the study revealed that nurses were implementing measures of preventing MDR-TB like tracing of patients who interrupted TB treatment although there were inconsistencies with implementation of other measures. There were gaps related to attendance of TB courses by TB staff. Nurses were working in an overcrowded environment where it was difficult to implement measures for preventing MDR-TB. There was an increase in the workload due to the high number of patients having TB. Conclusion In this study, the majority of nurses working in primary health care clinics scored well in infection control measures with regard to practicing cough hygiene, placing patients in a well-ventilated area, collection of sputum from patients suspected of having TB and giving of health education to patients with TB and relatives but there areas that need improvement. The findings indicate knowledge gap with regard to TB. There is a need for attendance of short courses in TB, increase of staff attending to TB patients so as to cope with the workload and efficient allocation of resources. / M

Postoperative pain is of serious concern to patients and anesthesia providers alike. Management of a patients’ pain is a central component of anesthesia care. Ketamine as an anesthetic agent has been available for 50 years. It has been utilized as a general anesthetic and selectively as an anesthetic agent for high-risk patients. Due to dysphoric side effects associated with the dosage required to render general anesthesia, anesthesia providers may be reluctant to utilize this medication to its full potential. Recently there has been a resurgence of interest in ketamine as an analgesic agent. The researcher for this project performed a thorough literature review focusing on intravenous ketamine as an adjunct to standard opioid-based analgesia for postoperative pain. Four systematic reviews published in the last 10 years support the safety and efficacy of ketamine when administered intravenously in sub-anesthetic doses. The purpose of this project was to provide evidence-based education to anesthesia providers regarding the benefits of ketamine and follow-up to evaluate for evidence of changes in practice after the educational At a large community hospital data concerning ketamine utilization by anesthesia providers as a component of multimodal analgesia was collected for a six-month period, including three months pre- and three months post-educational intervention. Despite various methods utilized to present evidence regarding the safety and efficacy of ketamine, the results of this study demonstrated no significant change in practice. Based upon the extensive published literature the evidence is compelling that the addition of a sub-anesthetic (0.5 mg/kg) dose of ketamine to the surgical patient’s operative pain management plan would improve comfort and decrease opioid-related side effects with minimal negative impact.

Cette recherche porte sur la co-construction d'une stratégie pour implanter dans la pratique infirmière une échelle d'évaluation du risque de constipation du patient hospitalisé (ERCoPH). Elle s'appuie sur le Modèle humaniste des soins infirmiers (Girard et Cara, 2011) et sur le modèle d'apprentissage socio-constructivisme (Vygotsky, 1997). Le design s'inscrit dans une approche collaborative (Desgagné, 1997). Les objectifs sont de co-construire une stratégie pour implanter cette nouvelle échelle et d'évaluer l'impact de cette approche sur le développement professionnel continu (PDC) des infirmières ayant participé à cette étude et sur le raisonnement clinique de leurs pairs. Cette approche a permis à un groupe d'infirmières lors de séances d'analyse en groupe (Van Campenhoudt &al. 2005) de modéliser des perspectives pour implanter l'échelle ERCoPH. L'impact sur le DPC des équipes non participantes s'est appuyé sur une enquête avant-après. A partir de l'observation d'entretiens d'accueil de patients hospitalisés et d'une enquête sur la capacité à catégoriser les patients à risque de constipation. L'approche collaborative a entrainé chez les infirmières du groupe collaboratif un développement professionnel, notamment dans leurs capacités réflexives. La co-construction de cette stratégie d'implantation de l'échelle ERCoPH peut être associé à un modèle de transfert de connaissances tel que défini par Fixsen et al. (2005) et Graham et al. (2006) dont le but est de permettre l'intégration dans la pratique de nouvelles connaissances et ainsi réduire les écarts avec la pratique. / This study focuses on the co-construction of a strategy aiming to implement, in nursing practice, a rating scale to assess the risk of constipation in hospitalised patients (ARCoPH). It is based on humanistic model of nursing (Girard et Cara, 2011) and on the social constructivist approach to learning (Vygotsky, 1997). The research design uses a collaborative approach (Desgagné, 1997). The objectives are to co-construct a strategy to implement this new scale and the impact of this approach on the continuing professional development (CPD) of nurses who participated in the study and on the clinical reasoning of their peers. Using a collaborative approach, a group of five nurses developed, during group analysis sessions (Van Campenhoudt et al., 2005), practical insights to implement the ARCoHP scale. The impact on their CPD was determined through a group interview and a questionnaire. The effect of this approach on the clinical reasoning of the teams was established using a before and after survey based on the observation of patient intake interviews, and to assess the nurses' ability to identify patients at risk of constipation. This collaborative approach led to the professional development of participating nurses, specifically to the improvement of their reflective skills.The co-construction of this implementation strategy for the ARCoHP scale can be associated with the transfer of learning model as defined by Fixsen et al. (2005) and Graham et al. (2006), and thus help close the gaps between theory and practice.