L’intimidation entre infirmières constitue une menace pour la santé et le bien-être de ces professionnelles de la santé et pour la qualité des soins. En dépit des efforts déployés jusqu’à présent pour lutter contre ce fléau, il existe peu d’actions efficaces pour le contrer. Or, pour que les acteurs concernés puissent s’engager à intervenir, il est essentiel d’appréhender les réalités entourant ce type d’intimidation et de renforcer l’assise théorique actuelle qui fait défaut dans les écrits, notamment en sciences infirmières. Cette étude vise à coconstruire une théorie des situations d’intimidation entre infirmières, selon le point de vue d’infirmières et d’infirmiers québécois les ayant vécues à titre de cibles ou de témoins dans le cadre de leur pratique. Cette étude s’inscrit dans le paradigme constructiviste social/constructionniste social inspiré de la pensée de Charmaz (2014) et est guidée par la perspective théorique interactionniste critique (Burbank et Martins, 2010; Martins et Burbank, 2011; Sandström et Fine, 2003). Elle prend appui sur une approche méthodologique interprétative/qualitative exploratoire qui résulte de la convergence entre la théorisation ancrée constructiviste (Charmaz, 2014), l’analyse situationnelle (Clarke et al., 2015) et l’analyse dimensionnelle (Schatzman, 1991; Schatzman et Strauss, 1973). Cinquante-deux infirmières et infirmiers répartis dans dix régions du Québec ont pris part à cette étude. Ils exerçaient différentes fonctions dans divers secteurs d’activité. Les données ont été recueillies à l’aide d’échanges informels, d’entretiens individuels et dyadiques de type conversationnel, de e-témoignages, de matériel invoqué et d’un questionnaire sociodémographique autoadministré. Le processus itératif de la collecte et l’analyse des données a permis de porter attention aux processus, aux actions, aux interactions sociales, aux structures sociopolitiques, aux contextes et aux discours sociaux dominants. Les résultats proposent une coconstruction théorique qui témoigne d’une conception multidimensionnelle des situations d’intimidation sous-jacentes à la pratique infirmière. Cette coconstruction théorique révèle la nature plurielle et évolutive de telles situations. Elle met en évidence quatre regroupements dimensionnels interdépendants : 1) des conditions situationnelles (antécédents) qui s’articulent autour des dimensions : contextes sociaux et conditions micro et macrosociologiques, 2) un processus de création des situations d’intimidation qui se déroule en cinq phases. Les trois premières phases a) la situation initiale : ç’a commencé comme ça ! b) l’ancrage : ça continue ! et c) l’impasse : être dedans ! s’inscrivent dans la tolérance et le statu quo, alors que les deux dernières phases d) la mobilisation de ressources de soutien et e) la rupture sont ancrées dans une perspective d’action vers le changement, 3) des conséquences sur l’état de santé et de bien-être personnel et professionnel de l’infirmière intimidée ou témoin et sur la qualité des soins et, 4) un continuum espace-temps inhérent aux situations d’intimidation. La coconstruction théorique dévoile le cycle de vie des situations d’intimidation sous-jacentes à la pratique infirmière permettant ainsi de mieux comprendre comment et pourquoi ce type de situations naissent, se produisent, se transforment et se terminent. Les résultats de cette étude révèlent, entre autres, des moments propices aux transitions professionnelles pouvant marquer le début de situations d’intimidation, la formation d’alliances informelles (en cliques), des divisions internes au sein de la profession, l’adaptation de la pratique de l’infirmière intimidée à son environnement de travail toxique et la dénonciation de son vécu d’intimidation prenant appui sur des principes semblables à l’advocacy et à la parrhèsia. Des conséquences sur la santé, le bien-être, la vie sociale, la dignité, l’identité professionnelle et le parcours de carrière de l’infirmière intimidée ou témoin sont constatées. Cette étude doctorale a permis d’appréhender de manière novatrice un sujet sensible et tacite comme des situations d’intimidation. Elle propose des recommandations pour les différents champs de la pratique infirmière et fournit des leviers de réflexion et d’action permettant de promouvoir des environnements de travail sains. Or, tout en contribuant au développement des connaissances en sciences infirmières, la présente étude offre un cadre de compréhension des situations d’intimidation sous-jacentes à la pratique infirmière. Les pistes de réflexions et d’actions proposées pourraient permettre des avancées dans la lutte contre cette forme de violence qui sévit dans certaines organisations de santé et, potentiellement, dans d’autres domaines du monde du travail. / Bullying among nurses poses a threat to the health and well-being of these health professionals and to the quality of care. Despite the efforts made to date to combat this scourge, there are few effective actions to counter it. However, so that the actors concerned can commit to intervening, it is essential to understand the realities surrounding the bullying situations underlying nursing practice and to strengthen the current theoretical basis, which is lacking in the literature, particularly in nursing sciences. This study aims to co-construct a theory of bullying situations between nurses, according to the point of view of Quebec nurses who have experienced them as targets or witnesses in the context of their practice. This study is part of the social constructivist/social constructionist paradigm inspired by the thought of Charmaz (2014) and is guided by the critical interactionist theoretical perspective (Burbank et Martins, 2010; Martins et Burbank, 2011; Sandström et Fine, 2003). It is based on an exploratory interpretive/qualitative methodological approach which results from the convergence between constructivist grounded theory (Charmaz, 2014), situational analysis (Clarke et al., 2015) and dimensional analysis (Schatzman, 1991; Schatzman et Strauss, 1973). Fifty-two nurses spread across ten regions of Quebec took part in this study. They performed different functions in various sectors of activity. Data were collected using informal exchanges, individual and dyadic conversational interviews, e-testimonies, invoked material and a self-administered sociodemographic questionnaire. The iterative process of data collection and analysis allowed attention to processes, actions, social interactions, socio-political structures, contexts, and dominant discourses. The results propose a theoretical co-construction which demonstrates a multidimensional conception of bullying situations underlying nursing practice. This theoretical co-construction reveals the plural and evolving nature of such situations. It highlights four interdependent dimensional groupings: 1) situational conditions (antecedents) which revolve around the dimensions: social contexts and micro and macrosociological conditions, 2) a process of creating bullying situations which takes place in five phases. The first three phases a) the initial situation: it started like that! b) anchoring: it continues! and c) the impasse: being in it! are part of tolerance and the status quo, while the last two phases d), the mobilization of resources and e) the rupture are anchored in a perspective of action towards change, 3) consequences on the state of health and personal and professional well-being of the bullied or witness nurse and on the quality of care and, 4) the space-time continuum inherent in bullying situations. The theoretical co-construction reveals the life cycle of bullying situations underlying nursing practice, thus allowing us to better understand how and why this type of situation arises, occurs, transforms, and ends. The results of this study reveal, among other things, moments conducive to professional transitions which can mark the beginning of situations of intimidation, the formation of informal alliances (cliques), internal divisions within the profession, the adaptation of the practice of the bullied nurse to her toxic work environment and the denunciation of her experience of bullying which is based on principles similar to advocacy and parrhesia in order to protect herself and ensure the safety of patients. Consequences on the health, well-being, social life, dignity, professional identity and career path of the bullied nurse or witness are noted. This doctoral study made it possible to approach a sensitive and tacit subject such as bullying situations in an innovative way. It offers recommendations for the different fields of nursing practice and provides levers for reflection and action to promote healthy work environments. However, while contributing to the development of knowledge in nursing sciences, the present study offers a framework for understanding the bullying situations underlying nursing practice. The proposed avenues of reflection and action could allow progress in the fight against this form of violence, which is rife in certain health organizations and, potentially, in other areas of the world of work.

Indiana University-Purdue University Indianapolis (IUPUI) / The PeerSpirit Circle is a non-hierarchical, intentional, and relationship-centered practice of collaboration. There is a lack of scientific knowledge about the phenomenon of the PeerSpirit Circle in nursing or its potential impact on nursing practice, education, research, and the evolution of the profession and health care. The health care milieu is often entrenched in ways of being that do not support sustained change. For vitality to prosper and creativity to abound, paradigmatic shifts and new models of practice that emphasize collaboration are being called for. The purpose and aims of this phenomenological research study are to explore and give voice to the experiences of nurses who have participated in the PeerSpirit Circle model of practice with other nurses. The study includes interviews from five registered nurses from Canada and the United States conducted from 2009–2010 and interpreted from a Gadamerian philosophical hermeneutic perspective. The research findings reveal three themes: (1) experiencing the Circle container” where participants begin to understand the value of intentional preparation of the interpersonal space for safe human interaction and stronger collaboration—there are experiences of gathering, protecting, appreciating ritual, and sharing stories; (2) Experiencing space where protected space seems to be the essential element to inspire the presencing of participants with self and other, which in turn engenders genuine dialogue, a sense of sacred space, and freedom to be authentic; and (3) Experiencing our humanity, an unfolding theme, where participants experience reconnection with and understanding of their deeper humanity, stronger congruence with their core values, deeper experiences of caring and courage, personal and professional growth, and a profound appreciation for belonging to a lineage of nurses. The findings inspire a deeper understanding of barriers to congruence between values and action in nursing and nurses’ need to acknowledge, honor, support, and protect each other’s vulnerability. The implications for nursing practice, education, and research show that the PeerSpirit Circle model is a beneficial for use in all settings.

The purpose of this study was to describe and compare the perceptions of the registered nurses and the nurse managers regarding the role of the registered nurse in integrated primary health care. Quantitative, descriptive research was conducted to determine if there were any discrepancies between role perceptions and role expectations. Data collection was done using structured questionnaires. Two groups of respondents participated in the study. The registered nurse group (n=40) provided direct clinical care in integrated primary health care settings. The second group was composed of nurse managers (n=20) managing integrated primary health care services. The findings revealed that there are some areas where there is lack of congruence between the perceptions of registered nurses and nurse managers regarding the functions that registered nurses perform. These differences may result in confusion and role conflict among registered nurses, which can ultimately impede the attainment of integrated primary health care goals. / Advanced Nursing Sciences / M.A.(Nursing Science)

Dans plusieurs milieux on s’attend à ce que les infirmières récemment diplômées fassent du préceptorat (Cubit et Ryan, 2011). Ainsi, les infirmières sont fréquemment affectées à ce rôle tôt après leur intégration sur le marché du travail et souvent sans préparation adéquate (Debra, 2014; Elmers, 2010). Le but de la présente étude était d’explorer l’expérience de devenir infirmières préceptrices auprès de Candidates à l’exercice de la profession infirmière [CEPI], dans un délai de 0 à 3 ans après avoir elles-mêmes été CEPI. La théorie de la transition d’Afaf Ibrahim Meleis (2010) a servi de cadre de référence en guidant la formulation du but de cette étude qualitative interprétative. La théorie de Meleis (2010) a également accompagné la discussion des résultats de notre recherche. Cinq infirmières nouvellement préceptrices âgées de 24 à 27 ans ont participé à des entretiens semi-structurés. L’analyse des données a été conduite selon les étapes d’analyse thématique proposée par Benner (1994) et Paillé et Muchielli (2006). D’abord, il résulte de notre étude que l’expérience de devenir préceptrice suscite chez les jeunes infirmières l’occasion d’un engagement réflexif sur leur propre expérience d’infirmière et de préceptrice. Puis, elles font l’expérience du sens des responsabilités pour «façonner» la CEPI. Finalement, une proximité avec l’expérience de la CEPI influence l’expérience de devenir préceptrice. Devenir préceptrice tôt dans la carrière d’infirmière semble être le moment opportun. Toutefois, il importe d’essayer d’uniformiser et de standardiser la préparation de l’infirmière soignante à devenir préceptrice. Également, jumeler une infirmière préceptrice plus aînée pour guider la nouvelle préceptrice dans cette expérience serait un atout. Finalement, l’approfondissement du besoin de soutien dans l’accompagnement de l’infirmière dans son expérience de devenir préceptrices est une des pistes pour la future recherche. / In today’s reality, nurses start to precept soon in their career (Cubit and Ryan, 2011), and often without any prior notice or preparation (Debra, 2014; Elmers, 2010). The purpose of the present study is to explore the experience of nurses becoming a preceptor for a Candidate to the Profession of Nursing Practice [CPNP], within 0 to 3 years of being CPNP themselves. Five young nurses who were newly preceptors participated in semi-structured interviews. Participants were between 24 et 27 years of age. Data was analysed using Benner`s (1994) and Paillé et Muchielli’s (2006) thematic analysis. The theoretical framework of Transition theory by Afaf Ibrahim Meleis (2010) directed the formulation of the purpose of this qualitative interpretive study. Meleis’s theory also accompanied the discussion of the results of the present study. The results of the present study suggest that the young nurses who are newly preceptors are living through the sense of responsibility of shaping the CPNP, they find themselves situated close to the CPNP experience and their experience of becoming a preceptor leads them to reflect on their personal experience as a nurse and a preceptor. Becoming a nurse preceptor early in their career seems to be an opportune moment. However, it would be recommended to standardise the preparation of the nurses for this new responsibility which could ease their experience of becoming a preceptor. Also pairing a more experienced nurse preceptor to guide the new nurse in the process of acquiring the new role of a preceptor would be an asset. Finally a further research could explore the need for support during the experience of becoming a preceptor.

The quality of care in our nation’s long term care facilities or nursing homes has been a steadfast matter of public policy for the past few decades. In response to research and reports of poor care, the Nursing Home Reform Act (NHRA) was born in 1987. Since that time, additional legislation has been passed to address the same issue. Continued research in early 2000 has shown that although there have been strides toward increasing the quality of care in these facilities, serious care issues continue to exist. As part of NHRA, every long term care facility in this country that accepts payment from the federal government must complete a survey every nine to fifteen months. There are two types of long term care surveys: the traditional and quality indicator survey (QIS). Recent research has documented that both survey processes are flawed. To date, the federal government has no way to monitor whether QIS is meeting its objectives. The purpose of this quality improvement project is to evaluate the use of a tool to assess surveyor efficiency and effectiveness on each survey task in the long term care survey. A tool was developed to evaluate surveyor efficiency and effectiveness and a pre-pilot was completed in early March of 2014, to test the tool. The outcome of that testing was that data collection was complex; many of the survey tasks were conducted simultaneously making it impossible for one researcher to conduct the evaluation. At the same time, the participating healthcare organization decided that another project took precedence. Although the project never was completed, the evaluation of surveyor efficiency and effectiveness is recommended in further research, as thousands of residents in long term care facilities depend on the survey process to ensure high quality of care.

The purpose of this study was to describe and compare the perceptions of the registered nurses and the nurse managers regarding the role of the registered nurse in integrated primary health care. Quantitative, descriptive research was conducted to determine if there were any discrepancies between role perceptions and role expectations. Data collection was done using structured questionnaires. Two groups of respondents participated in the study. The registered nurse group (n=40) provided direct clinical care in integrated primary health care settings. The second group was composed of nurse managers (n=20) managing integrated primary health care services. The findings revealed that there are some areas where there is lack of congruence between the perceptions of registered nurses and nurse managers regarding the functions that registered nurses perform. These differences may result in confusion and role conflict among registered nurses, which can ultimately impede the attainment of integrated primary health care goals. / Advanced Nursing Sciences / M.A.(Nursing Science)

Atrial fibrillation (AF), the most common cardiac arrhythmia in persons over age 65, is associated with an increased stroke risk necessitating the need for long-term oral anticoagulation for risk reduction. With the introduction of direct thrombin and factor Xa inhibitors in the US since 2010, these novel oral anticoagulants (NOACs) are increasingly being prescribed, replacing the use of warfarin, a vitamin K antagonist. AF catheter ablation (CA), an elective procedure requiring femoral vascular access is a treatment for drug refractory and persistent AF. Bedrest, limb immobilization, and limited head of bed elevation are nursing measures utilized following femoral venous, and sometimes arterial, sheath removal and hemostasis. Limited research is available on the appropriate duration of bedrest to minimize bleeding complications associated with AF ablation in patients who use NOACs. The purpose of this quality improvement project was to compare and evaluate the effect of bedrest duration on post-procedure bleeding outcomes, urinary complaints, and back pain among patients taking NOACs while undergoing AFCA. Thirty patients undergoing elective AFCA on NOACs were orally consented to participate in the study and placed on shortened (8 hours) or prolonged (>8 hours) bedrest following vascular hemostasis. Outcome measurements included bleeding after ambulation, back pain, and urinary complaints. Fifteen patients (50%) were on shortened bedrest and 15 (50%) were on prolonged bedrest. No statistically significant difference in bleeding, urinary complaints, or back pain were found. Since there is no clear advantage to prolonged bedrest for patients on NOACS after an AFCA procedure, clinicians should consider this when deciding on bedrest duration for their patients.

Thèse en administration des services-infirmiers subventionnée par "Formation et expertise en recherche administration des services infirmiers" (FERASI) / Cette étude a pour but de comprendre les processus de transformation de la pratique clinique chez les infirmières à la faveur des initiatives d’intégration des soins et services et d’examiner l’impact de ces processus sur le bien-être au travail des infirmières. De façon spécifique, l’étude vise: 1) à décrire les pratiques infirmières dans le contexte d’intégration des soins et services au Québec 2) à analyser la relation entre les processus de changement sous-jacents aux efforts d’intégration et le bien-être au travail des infirmières selon leurs perceptions et 3) à identifier les principaux leviers, sur les plans de la gestion et de la clinique, que peuvent mobiliser les organisations afin de soutenir la pratique infirmière dans un contexte d’intégration des soins. L’étude a été organisée en trois volets correspondant respectivement aux trois objectifs précédemment mentionnés. Le cadre de référence développé et utilisé pour cette étude est le « Modèle infirmier du développement de l’intégration des soins » (MIDIS). Il s’appuie sur les prémisses du modèle de Cazale, Touati et Fleury (2007), qui couvrent les interrelations entre les variables contextuelles (organisationnelles et structurelles), l’adoption et l’institutionnalisation des pratiques intégratives, et les effets qui y sont associés pour les infirmières en termes de bien-être au travail. Pour atteindre les objectifs de l’étude, un devis mixte a été utilisé, incluant : un devis quantitatif descriptif (volet 1), un devis quantitatif corrélationnel (volet 2) et un devis qualitatif d’étude de cas unique avec niveaux d’analyse imbriqués (volet 3). La collecte des données a été menée dans le cadre de quatre trajectoires de soins (TdeS) : Soutien à l’autonomie (SoAu), Palliatifs/oncologiques (PaOn), Santé mentale (SaMe) et Maladie pulmonaire obstructive chronique (Mpoc). L’étude a été effectuée auprès d’infirmières, de professionnels autres, et de gestionnaires. Pour les volets un et deux, 107 questionnaires ont été complétés et 37 entrevues semi-dirigées ont été effectuées pour le volet 3. Les résultats du premier volet ont démontré non seulement d’importantes variations dans le développement de l’intégration entre les TdeS mais également un décalage entre l’évolution de la pratique infirmière et l’introduction des changements visant une plus grande intégration des soins. Deux dimensions seulement de la pratique intégrative sur neuf (Qualité des soins et Équipe interprofessionnelle) prévalent dans l’ensemble des TdeS et seule la TdeS PaOn a atteint une étape plus avancée du processus d’intégration. Les résultats du deuxième volet démontrent que plus l’intégration se situe à un niveau avancé de développement, moins elle est associée à une perception de menace chez les infirmières et plus elle est associée à des réactions positives et un bien-être au travail. Le troisième volet a mis en lumière trois types de leviers qui doivent être mobilisés de manière complémentaire dans le but de favoriser l’intégration : les processus organisationnels, les processus cliniques, les investissements dans des ressources clés et dans le renouvellement de certaines structures organisationnelles. Ces résultats apportent des éclairages quant aux défis posés par les processus d’intégration des soins et montrent l’importance d’une pluralité d’interventions qui doivent être conduites à tous les paliers organisationnels afin de faciliter l’institutionnalisation des pratiques intégratives et obtenir les effets escomptés. / The aim of this study is to understand processes of transformation of clinical practice among nurses in the context of care and service integration initiatives, and to examine the impact of these processes on nurses’ well-being at work. Specifically, the study’s objectives are to: 1) describe nursing practices that underpin efforts to integrate care and services in Quebec; 2) analyze the relationship between the change processes underpinning integration efforts and nurses’ self-perceived well-being at work; and 3) identify the main levers that organizations can use at management and clinical levels to support nursing practices in an care integration context. The study was set up in three parts, corresponding respectively to the three objectives mentioned above. The reference framework developed for this study, is the Modèle infirmier du développement de l’intégration des soins (MIDIS – Development model for integrated care in nursing). It is based on the premises of the model of Cazale, Touati et Fleury, (2007) that cover the interrelationships between contextual variables (organizational and institutional), the adoption and institutionalization of integrative practices, and the associated effects on professionals with respect to well-being in the workplace. To achieve the study’s objectives, a mixed-method design was used, which included: a descriptive quantitative component (Part 1), a correlational quantitative component (Part 2), and a single case qualitative study with nested levels of analysis (Part 3). Data were collected within four care pathways (CPs): autonomy support for the elderly (ASE); palliative oncology services (POS); mental health services (MHS); and chronic obstructive pulmonary disease (CPOD). Data were collected from nurses, health professionals, and managers. For Parts 1 and 2, 107 questionnaires completed and 37 semi-structured interviews conducted for Part 3. The results of the first part of the study showed not only significant variations across CPs in the development of integration, but also a gap between the evolution of nursing practice and the introduction of changes aimed at greater integration of care. Only two out of nine dimensions of integrative practice (‘quality of care’ and ‘interprofessional teamwork’) were prevalent across all CPs and only one CP (POS) had reached a more advanced stage in the integration process. The results of the second part of the study showed that, as integration became more highly developed, it was associated less with a perception of threat by nurses and more with positive reactions and well-being at work. The third part of the study identified three types of levers that should be used in a complementary way to speed up the progress of integration: organizational processes; clinical-administrative processes; investment in key resources and in renovation of certain organizational structures. These results shed additional light on the challenges posed by the process of integration of care, and show the importance of leading multiple interventions at all organizational levels to facilitate institutionalization of integrative practices and achieve the intended effects.

Pre-diabetes is a serious health problem in the United States. Distinguished by plasma glucose levels that are above the normal threshold, patients with pre-diabetes are 10 times more likely to develop type 2 diabetes. Patients with pre-diabetes suffer the same complications as patients with diabetes including diabetic retinopathy, nephropathy, and microalbuminuria. There is considerable evidence to support the idea that early identification and aggressive treatment of pre-diabetes has the potential to delay disease progression. The American Diabetes Association’s clinical practice guideline recommends management of with lifestyle modification and metformin for patients who are at risk for developing type 2 diabetes. The purpose of this project was to evaluate the implementation of the 2012 ADA clinical practice guidelines regarding the management of patients with pre-diabetes by the health care providers at a volunteer-run clinic located in a large metropolitan area in the southeastern United States. This study, even with a small sample size (n=26) revealed that the providers at the clinic had not implemented the 2012 ADA clinical practice guidelines. Clinical practice guidelines promote health care interventions that have proven benefits and improve the consistency of care provided to patients. The greatest benefits of implementing clinical practice guidelines for patients with pre-diabetes are early diagnosis and aggressive disease management. This would improve patient outcomes and in the long run, decrease the cost of medical care.

Performance of hand hygiene is among the most effective means of preventing healthcare associated infections (HAI) among patients. Deaths resulting from HAIs are one of the top ten leading causes of death in the United States. Any improvement in the frequency of hand hygiene among healthcare professionals may have a direct impact on patient mortality and associated costs. While anesthesia professionals have been found to have low rates of hand hygiene adherence, few targeted studies seeking to improve hand hygiene adherence among this group exist. Studies conducted to improve hand hygiene among health care professionals have reported limited improvement, with overall inconclusive recommendations for improving prolonged hand hygiene adherence rates. The purpose of this project was to improve anesthesia professionals’ hand hygiene through encouragement of performance and education on the current state of research in the area of anesthesia associated HAIs. Hand hygiene rates were evaluated through measuring the amount of hand sanitizer used at eleven anesthesia workstations in the main operating room of a hospital. Measurements were taken at baseline and continued for three months after the educational program was implemented.