In 1978, Primary Health Care (PHC) was formally recognised, in the Declaration of Alma-Ata, as the key to achieving the World Health Organisation's goal of 'Health For All by the Year 2000' (HFA). PHC was seen as the solution to the inadequate illness management systems that had developed throughout the world. It was hoped that PHC would address some of the major inequalities in health observed both within and between countries by its balanced system of treatment and disease prevention. The WHO envisaged that PHC would take place as close as possible to where people live and work and be the first element of a continuing health care process. Additionally, health service collaboration and multi-professional partnerships were expected to replace professional boundaries and competition. Shortly after the Declaration of Alma-Ata, the World Health Organisation, supported by national and international nursing bodies, proposed that nurses would be the driving force behind the HFA movement as active partners in inter-professional teams, leaders in health care and resources to people rather than resources to other health professionals. In the ensuing years, although community health nurses were acknowledged by the government and the nursing profession as key players in PHC in Australia, practice nurses (nurses who are employed in general medical practices) were not identified within this group. Hence, it appeared as though these practice nurses were 'invisible', not considered important to PHC in Australia, or simply overlooked as a major influence on population health. The purpose of this study was to describe the current role of these nurses and to identify and analyse the factors that influenced their scope of practice and hence their contribution to PHC. The research was conducted as a case study of practice nurses in one Division of General Practice in southeast Queensland. The study was influenced by the constructivist paradigm of inquiry and utilised a complementary sequence of quantitative methods followed by qualitative investigation. The first stage of the study comprised a telephone followed by mail survey of general practitioners and practice nurses employed within the Division. This was followed by a second stage, which involved group and individual interviews of key informants and was supported by document review and observation. The study revealed that the practice nurse role is essentially one of assistant to the general practitioner wherein the nurse undertakes basic assessment procedures to aid the medical diagnosis, carries out delegated therapeutic procedures, and contributes to the administrative functioning of the practice. Autonomous nursing initiatives, which appear to be largely opportunistic and incidental to delegated activities, include physical and emotional support of patients, clarification and reinforcement of medical instructions, and the provision of health education. The practice nurse's role, and hence contribution to PHC, was found to be constrained by a number of factors. These factors include the current funding arrangements for general practice, the view that practice nurses are an option rather than a necessity, the general practitioners' control of the practice setting, the appropriation of nursing work to medical receptionists, the lack of professional development opportunities, and the practice nurses' passive acceptance of their circumstances. However, both general practitioners and practice nurses appreciate the value of nursing services in general practice and GPs would sanction the employment of more nurses, if given financial incentives, especially for the purpose of preventive care. The majority of practice nurses believe their role should be expanded to include autonomous functioning while most of the GPs were amenable to some extension of nursing practice but reticent or opposed to any independent interventions. There appears a need in Queensland for courses to prepare practice nurses for advanced practice if they want to expand their role in PHC beyond that of assistants to GPs. It would also seem to be in the nurses' interests to initiate a professional association of practice nurses as a vehicle to explore other issues relevant to their professional development. In addition, if PNs want to expand their role they will need to demonstrate improved patient outcomes and cost effectiveness.

The nursing practice of monitoring patients in the post-operative (PO) phase upon returning to the general ward setting has traditionally consisted of the systematic collection of vital signs and observation of other aspects of the patient's recovery. For the most part the primary focus of this monitoring has been the detection of post-operative complications. There is a need for more substantive evidence to support an appropriate frequency of post-operative observation. The aim of this research was to identify if the current practice of PO vital sign collection detects PO complications in the first 24 hours after the patient has returned to the general ward setting. Due to the complex world in which nurses practice the research was undertaken using a combination of methods within a triangulated approach to collect data. A survey of 75 hospitals providing a surgical service enabled a description of the current models of PO monitoring as found in policy documents to be made. The majority of hospitals (91%) described a variety of regulated regimens for the collection of PO observations, with the most common for vital sign collection (27%) as hourly for the first four hours and then four hourly. An observation of 282 patient hours in two surgical wards identified the current practice of PO monitoring involved nurses collecting vital signs hourly for the first four hours, three hourly for the next eight hours and then every four hours. This was despite the existence of different models being described in the policies. The records of 144 patients were audited to identify what, if any, nursing interventions detected changes in a patient's recovery and to determine whether a relationship existed between vital sign collection and the detection of complications. It was found that the complications that occurred were minor in nature, occurred infrequently, and did not have a relationship with changes in vital signs. This research found that there was no relationship between the frequency of the collection of vital signs and the occurrence or detection of complications. PO observations were collected by nurses based on traditional patterns, were collected routinely, were ritualised and were not determined by individual clinician expertise or the needs of the individual patient. Recommendations are made regarding the need for a systematic program of research and alternative models of patient observation that focus on patient need rather than organisational need and that provide more efficient and effective practice in monitoring PO patient progress. / Thesis (Ph.D.)--School of Medicine, 2003.

Abstract Background: Access to adequate palliative care has been identified as a challenge globally, in Canada, and in the province of Ontario. While pockets of excellence exist, there is a national call for allocation of resources and implementation of best practices to improve the care for individuals with life limiting illnesses. Furthermore, the location of care along with a desire for dying at home has shifted responsibility onto family members often without the equivalent shift in community resources to meet patient and family needs. To respond to issues of access and quality, nurse practitioners (NPs) have been increasingly added to diverse practice settings across the globe and research showing how they are contributing to diverse care settings. As a strategy to improve community palliative care locally, NPs have been added to community settings in Ontario. However, because NPs are new to palliative care settings little is known about how NPs enact their role within this unique context. NP role enactment is defined as the actual activities that NPs engage in that constitute their daily work. Aim: The purpose of this study is to better understand how NPs enact their role as consultants in a specific community palliative care setting in Ontario. Methodology and Methods: A focused ethnography was conducted in one specific geographic health administration region of Ontario between July of 2018 and October of 2020. A convenience sample was used recruiting NPs from one community palliative care consultation team. Data collection methods included observation (487.5 hrs over 89 discrete observation sessions, distributed across 7 study participants), fieldnotes and semi-structured interviews with participants (n = 7 NPs). Results: The NPs enacted their role with patients by formulating relationships, that for them, facilitated a deeper understanding of the patient and family situation, strengths, challenges and desires. Using conversations and conversational skills to have difficult and important conversations, NPs facilitated future planning for patients. Conversations also included addressing questions about MAiD, which were nuanced and often about more than MAiD, also addressing fears of suffering and uncertainty. The NPs used advanced clinical judgment and skill to diagnose and treat complex and difficult to manage symptoms and supported families to understand complicated medication regimes. Valuing their role as educators, the NPs supported their peers by offering teaching and providing clinical support in complex care scenarios. Pull together disparate and loosely connected care providers, NPs created a shared understanding of patient needs. Deficiencies in community care resourcing and organization made it difficult at times for NPs to facilitate continuity in care or to build capacity. The NPs often navigated an environment where nursing staffing was transient, inconsistent and overextended and where physicians were inconsistently available to support rapidly evolving situations. Conclusion: Findings suggest that NPs have an important role to play in supporting patients and families as well as supporting their nursing and physician colleagues. Furthermore, the broader system would benefit from embedding palliative care NPs more systematically. However, broader structural enhancements like shared communication and documentation mechanisms and adequate staffing across care settings need to be addressed to maximize the potential contributions NPs are able to offer.

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Background: In the United States, currently about half (49%) of the 6.7 million pregnancies are reported as mistimed or unplanned, and this rate of unintended pregnancy is significantly higher than the rate in most other developed countries. Abortion services are critical to the prevention and management of unintended pregnancies. Abortion in the United States has been legal since the 1973; however this right has little meaning without access to safe abortion care and access is declining. Medication abortion, the use of medications to induce abortion and terminate an early pregnancy, has been legal in the United States since 2000, is ideal for the outpatient setting, and allows for increased provision of and access to abortion services. The literature assessing the provision of medication abortion has largely been conducted in populations of physicians, and combined groups of advanced practice clinicians including physician assistants (PAs), certified nurse midwives (CNMs), and nurse practitioners (NPs). No studies exist assessing provision of and barriers to medication abortion by NPs and CNMs (Advance Practice Registered Nurses or APRNs) in the state of Vermont. Purpose: This study sought to fill this gap in the literature. Data was collected in order to determine whether APRNs are providing care to women at risk for unintended pregnancy and are providing medication abortion, the characteristics of these providers, and perceived barriers or supports to practice. Methods: The design was a cross-sectional survey, using purposive sampling methods. Between July 2014 and September 2014, 21 eligible participants completed an anonymous, self-administered online survey, recruited via notifications sent out through professional listserv. The survey assessed their personal characteristics, beliefs and clinical practice related to reproductive health care and unintended pregnancy prevention and management. All participants had current APRN certification with prescriptive authority in the state of Vermont. Results: Ninety percent of respondents reported care for women of reproductive age as at least one-third of their clinical work and 85% of respondents reported seeing women with unintended pregnancies as part of their practice. Eighty-five percent agreed or strongly agreed that medication abortions fall within the scope of practice of an APRN and of a primary care provider, and 85% would like to be trained to provide medication abortions to manage unintended pregnancy. Lack of training opportunities, clinical facility constraints, and legal uncertainties were the most frequently reported barriers to provision of medication abortion. Conclusions: Many APRNs in Vermont may be interested in receiving medication abortion training. APRNs are experienced and highly trained health care professionals that have the competence and skills to provide comprehensive reproductive health care, including medication abortion. The perceived barriers of training, clinical facility constraints, and legal uncertainties are amenable to change, and can be decreased through inclusion of these topics into APRN education. The political and social climate of Vermont, combined with the findings of this preliminary study, suggest that the state of Vermont is ready, willing, and able to serve as a model for the primary provision of and improved population access to, comprehensive reproductive health care including abortion services.

Purpose: Transitional care is an emerging model of health care designed to decrease preventable adverse events and associated utilization of healthcare through temporary follow-up after hospital discharge. This study describes the approach and outcomes of two transitional care programs: one is provided by masters-prepared clinical nurse specialists (CNS) with a chronic disease self-management focus, another by physicians specializing in palliative care (PPC). Existing research has shown that transitional care programs with intensive follow up reduce hospitalizations, emergency room visits, and costs. Few studies, however, have included side-by-side comparisons of the efficacy of transitional care programs varying by health care providers or program focus. Design: This is a retrospective cohort study comparing the number of Emergency Department (ED) visits and hospitalizations in the 120 days before and after the intervention for patients enrolled in each transitional care program. Each program included post-hospitalization home visits, but included difference in program focus (chronic disease vs. palliative), assessment and interventions, and population (rural vs. urban). Data from participants in the CNS program 9/2014 ' 12/2014 were analyzed (n=98). The average age of participants was 69 and they were 65% female. Data was collected from patients from the PC program from 9/2014 to 4/2015 (n=71). Thirty participants died within 120 days after the intervention and were excluded, the remaining 41 were included in the analysis. Participants had an average age of 81 and were 63% female. Methods: For the CNS program, a secondary analysis of existing data was performed. For the PC program, a review of patient charts was done to collect encounters data. A Wilcoxon Matched-Pair Signed-Rank test was performed to test for significance. Findings: Patients in the CNS intervention had significantly fewer ED visits (p Conclusions: Both transitional programs have value in decreasing health care utilization. The CNS intervention had a more significant effect on ED visits for their target population than the PC program. Further study with randomized control trails is needed to allow for a better understanding of the healthcare workforce best fitted to enhance transitional care outcomes. Future study to examine the cost savings of each of the interventions is also needed.

Tobacco use is one of the most preventable sources of death and disease, and yet remains a worldwide problem. With the rising costs of healthcare, the focus of efforts to control them has honed in on lifestyle behaviors that contribute to the escalating costs. Within the scope of this scrutiny, the prevention or cessation of smoking and tobacco usage has become a global priority and a major focal point of worldwide anti-tobacco initiatives. The World Health Organization (WHO) has identified cessation interventions by health care professionals as a crucial factor in successful patient smoking cessation, and studies have shown that personal smoking behaviors by health care professionals are a barrier to effective smoking cessation interventions by those professionals (Lally et al., 2008; Radsma & Bottorff, 2009). This knowledge fueled the creation and distribution of global surveys by the WHO, the Centers for Disease Control and Prevention (CDC), and the Canadian Public Health Association (CPHA) to investigate the prevalence of smoking behaviors in health care professionals and in health care students (“Global Health Professions,” 2014; “WHO/CDC Global,” 2014). This study utilized the Global Health Professions Student Survey. The current study investigated the prevalence of smoking in nursing students of all educational levels at East Tennessee State University, with the expectation that the percentage of students who currently smoke would be substantially lower than that of students who do not smoke. The survey also investigated attitudes towards the role of health professionals in patient smoking cessation and towards personal smoking behaviors.