Thesis (Ph. D.)--University of Missouri-Columbia, 2008. / The entire dissertation/thesis text is included in the research.pdf file; the official abstract appears in the short.pdf file (which also appears in the research.pdf); a non-technical general description, or public abstract, appears in the public.pdf file. Vita. "August 2008" Includes bibliographical references.

Background: In nursing care, the steady increase of health related information implies aneed for useful Information and Communication Technology (ICT) tools that easilyprovide mobile access to accurate information. Updated information is usually available onthe Internet but personal computers are rarely available at the patients’ bedside. In Sweden,although handheld devices provide mobile access to information, they are rarely used innursing practice. Aim: This thesis aimed to explore the views of nurses and nursingstudents of using handheld devices in nursing practice. Method: Four intervention studieswere carried out during the years 2006 to 2008; a total of 30 nurses and 63 nursing studentsused handheld devices for 5-15 weeks in nursing practice, and answered questionnairesand/or participated in interviews. In 2012, a cross sectional study was undertaken with 111nurses and 287 nursing students answering a questionnaire about their views of usinghandheld devices. Quantitative data were analyzed using descriptive statistics andqualitative data were analyzed by content analysis. Results: The handheld device wasregarded to facilitate nursing practice and to be a useful tool with benefits for the patients,the nurses and for the nursing students. Independent of time and place, nurses and nursingstudents were able to access necessary information and also to make notes, plan their workand save time. The handheld device was regarded to improve patient safety and quality ofcare. The participants would not have to leave their patients to look up information,subsequently giving a more complete encounter. Additionally, the handheld device waspresumed to imply increased confidence, and support learning for nurses and nursingstudents. Conclusion: In order to continuously improve the safety and quality of healthcare,it is important to implement handheld devices in nursing practice. This issue is importantat all levels in the healthcare systems, from nurses to nursing management, policy makersand moreover for educators. Handheld devices adjusted for nursing, technical, statutory,cultural, and language country specific conditions, should be further developed,implemented, and evaluated in future research. / Omvårdnad är ett informationsintensivt område och sjuksköterskor hanterardagligen en omfattande mängd information. Kunskapsmassan växer stadigtoch behovet av tillgång till aktuell information ökar. Vanligen finns aktuellinformation tillgänglig via Internet men det är inte alltid som en dator finns tillhands vid patientens sängkant. Mobil informations- och kommunikationsteknik(IKT) såsom en handdator kan lätt ge tillgång till den information sombehövs. Trots att det finns flera fördelar med att använda mobil IKT som stödinom omvårdnad, framför allt avseende tillgång till information, såsombeslutsstöd och för lärandet, används det ännu i ringa omfattning i Sverige.Avhandlingens övergripande syfte var att undersöka sjuksköterskors ochsjuksköterskestudenters uppfattningar om att använda handdatorer inomomvårdnad.Fyra av avhandlingens fem studier genomfördes från 2006 till 2008. Sammanlagtanvände 30 sjuksköterskor och 63 sjuksköterskestudenter handdatorer5-15 veckor i arbete eller verksamhetsförlagd utbildning (VFU). Deltagarnabesvarade enkäter före och efter användningen, och intervjuades individuellteller i grupp. I den femte studien, som genomfördes 2012, besvarade 111sjuksköterskor och 287 sjuksköterskestudenter en enkät om sin uppfattning omhanddatorer. Kvantitativ data analyserades med beskrivande statistik ochkvalitativ data analyserades med innehållsanalys.Studierna visade att en handdator kan vara ett stöd i det dagliga arbetet och iVFU som informations-, antecknings- och planeringsverktyg, och kan enkeltge en översikt av patienters läkemedelsanvändning. Sjuksköterskorna ochsjuksköterskestudenterna ansåg att handdatorn kan bidra till ökad patientsäkerhetoch vårdkvalitet på grund av den snabba tillgången till aktuellinformation, oberoende av tid och plats. Patientmötet kan bli mer helt dåpatienterna inte behöver lämnas och samtalet inte behöver avbrytas;vårdrelationer kan bli vårdande relationer. Deltagarna ansåg att handdatornkan vara ett stöd avseende trygghet, minskad stress och kontinuerligt lärande. Iframtiden bör sjuksköterskor och sjuksköterskestudenter ges tillgång till mobilIKT som stöd i sitt arbete och VFU, och införandet bör därför prioriteras påalla nivåer inom vård och utbildning. IKT-kompetensen måste ökas ochslutanvändarna måste vara delaktiga i utvecklingen och införandet. Fortsattforskning behövs avseende avancerade mobila IKT-stöd; anpassade försjuksköterskans arbete. / Nurse Companion

Governance of the healthcare systems is one of the most important challenges forWestern countries. Within this, an accurate assessment of the quality is key to policy makers and public managers, in order to guarantee equity, effectiveness and efficiency. In this thesis, we investigate aspects and methods related to healthcare evaluation by focussing on the healthcare system in Lombardy (Italy), where public and private providers compete with each other, patients are free to choose where to be hospitalized, and a pay-for-performance program was recently implemented. The general aim of this thesis is to highlight the role of statistics within a quality evaluation framework, in the form of advancing the statistical methods used to measure quality, of evaluating the effectiveness of implemented policies, and of testing the effect that mechanisms of competition and cooperation can have on the quality of a healthcare system. We firstly advance a new methodological approach for measuring hospital quality, providing a new tool for managers involved in performance evaluations. Multilevel models are typically used in healthcare, in order to account for the hierarchical structure of the data. These models however do not account for unobserved heterogeneity. We therefore propose an extension of the cluster-weighted models to the multilevel framework and focus in particular on the case of a binary dependent variable, which is common in healthcare. The resulting multilevel logistic cluster-weighted model is shown to perform well in a healthcare evaluation context. Secondly, we evaluate the effectiveness of a pay-for-performance program. Differently from the existent literature, in this thesis we evaluate this program on the basis of five health outcomes and across a wide range of medical conditions. Availability of data pre and post-policy in Lombardy allows us to use a difference-in-differences approach. The statistical model includes multiple dependent outcomes, that allow quantifying the joint effect of the program, and random effects, that account for the heterogeneity of the data at the ward and hospital level. The results show that the policy has overall a positive effect on the hospitals' performance. Thirdly, we study the effect of pro-competition reforms on the hospital quality. In Lombardy, competition between hospitals has been mostly driven by the adoption of a quasi-market system. Our results show that no association exists between hospital quality and competition. We speculate that this may be the result of asymmetric information, i.e. the lack of transparent information provided to citizens about the quality of hospitals. This is bound to reduce the impact of pro-competition reforms on quality and can in part explain the conflicting results found in the literature on this subject. Our results should motivate a public disclosure of quality evaluations. Regardless of the specifics of a system, hospitals are altruistic economic agents and they cooperate in order to improve their quality. In this work, we analyse the effect of cooperation on quality, taking the network of patients' transfers between hospitals as a proxy of their level of cooperation. Using the latest network models, we find that cooperation does lead to an increase in quality and should therefore be encouraged by policy makers.

Introduction The Integrated Management of Childhood Illness (IMCI) is a multicomponent health system strengthening initiative widely adopted in Sub-Saharan Africa to improve poor child health outcomes. Implementation and subsequent evaluation have largely centered on the clinical management component. This study examines the clinical component in tandem with the facility improvement component, while capturing aspects of the community component over a ten year period. Methods The study utilizes a modified Donabedian quality measurement model where expected outcomes are a function of the process and structural components of healthcare quality which corresponds respectively to the clinical management and facility improvement components of the IMCI strategy. The data source is the Demographic Health Survey-Services Provision Assessment on Kenya for years 1999, 2004 and 2010 and it consists of a sample of 3,884 children and their caretakers seeking care at 1,523 health facilities. Bivariate analyses examine the change in health quality indicators and the quality indices (aggregated quality indicators) over time. Then negative binomial models assess the effect of the process and structural quality indices on the Caretaker Perceived Quality of Care (CPQoC) over time. Results Since IMCI implementation in Kenya, the clinical management and facility improvement indicators have not followed a pattern of consistent improvement while the quality indices increased consistently over time. The technical aspects of care have a higher effect on the CPQoC than the structural aspects and some of the interpersonal aspects of care were statistically significant. Privately managed facilities showed the highest impact while access to care had no impact on the CPQoC. Conclusion The findings underscore the importance of clinical management while recognizing the importance of the facility and community components of the IMCI. Revising the strategy to encourage implementation of all components with increased emphasis on the community components as well as ownership from national governments can improve child health outcomes in the region. / 1 / Felicia Aurora Osenkor Amoah

Quality improvement (QI) has become an important issue in healthcare settings. A central question for many healthcare systems is how to manage improvement initiatives adequately. All county councils and regions managing healthcare in Sweden have started to work with QI at an organizational system level, to varied extents. The Kalmar county council improvement initiative constitutes the empirical basis of this thesis. The aim of the thesis is to provide knowledge about different aspects of a county-wide improvement initiative, and a broader understanding of factors and strategies that affect participation, management and outcomes. The overall study design is based on a case study. The first two studies illuminate the practice-based (micro level), bottom-up perspective. Inductively five different areas (categories) were identified. Factors influencing participation in improvement initiatives provided the basis for the next study. The result showed that different staff categories were attracted by different initiatives. The next two studies illuminate the top-down (macro/meso) management perspective. Managers’ views of how patients can participate were investigated and a content analysis of the written answers was made. Four main areas (categories) were identified. A survey study investigated all of the county council managers’ experiences of the whole improvement initiative. Overall the managers thought that the improvement work was worth the effort. To evaluate the Breakthrough Collaborative program, a survey was developed and tested. This survey was used to investigate process and outcome of the BC program. The majority of the respondents were satisfied with their work, but wanted more time for teams to meet and work. To find out if an improvement program can affect outcome and contribute to sustainable changes, interviews were made with project applicants (n=202). Almost half (48%) of the projects were funded, and of those 51% were sustained. Of the rejected (not funded) projects, 28% were accomplished and sustained anyway. The results in this thesis cannot show that the “golden mean” exists, or that a single best way to manage changes and improvements in a healthcare organization has been found, but the way QI initiatives are organized does affect participation and outcomes. The intention, from the management topdown system level, encouraging staff and units and letting practice-based ideas develop at all system levels, can stimulate and facilitate improvement work. / Kvalitetsutveckling och förbättringsarbete har blivit en viktig del av hälso- och sjukvården. En viktig fråga för landsting och regioner är hur kvalitetsutveckling skall drivas och styras. Syftet med detta arbete är att bidra till ökad kunskap om kvalitetsarbete i en hälso- och sjukvårdsorganisation, hur förbättringsinitiativ kan bedrivas och ledas, samt vilka faktorer som bidrar till ett framgångsrikt förbättringsarbete. Arbetet utgår empiriskt från en satsning på kvalitet och förbättringsarbete i landstinget i Kalmar län och är genomförd som en fallstudie (case). Resultatet speglar vad ett landstings satsning på förbättringsarbete utifrån mikro-, macro- och mesonivå kan ge. De första två delstudierna speglar det praktikbaserade förbättringsarbetet utifrån ett praktikbaserat perspektiv. En innehållsanalys av projekten som ansökt om ekonomisk ersättning gjordes. Fem kategorier utformades, och projekten betonade områden som patientsäkerhet, förbättrad tillgänglighet och effektivitet. Studie II kartlade deltagande i förbättringsarbete utifrån två olika initiativ. Resultatet visade att de olika initiativen attraherade olika personalkategorier, men kunde samtidigt utesluta andra grupper. Chefernas åsikter om och erfarenheter av landstingets satsning undersöktes i studie III och IV. Cheferna var överlag positiva och nöjda med arbetet. Förbättringsprogrammen följdes med frågeformuläret Swedish Improvement Measurement Questionnaire (SIMQ) som testats och utvärderats. Resultatet visade att deltagarna är nöjda med arbetet med sin förbättringsidé, men att metodiken kan upplevas som svår. Dessutom efterlyste deltagarna mer tid för förbättringsarbete i vardagen. Till sist analyserades de projekt som sökt pengar för att driva förbättringsarbete. Nästan hälften av alla projekt (48%) hade fått ekonomisk ersättning, och av dessa hade fler än hälften (51%) uppnått sitt mål och infört en bestående förbättring. Den här avhandlingen påvisar vikten av att ledningen uppmärksammar, möjliggör och stimulerar förbättringsarbete. Genom att erbjuda flera olika sätt att bedriva förbättringsarbete ökar möjligheten för allas medverkan.

Introduction There is a need in palliative care for development of structured methods to assess quality and support improvement. This need is present both within and outside specialised palliative care. Honest information from physicians is regarded as an important part of palliative care. Information about the transition to end-of-life care (ITEOL), conveyed by physicians to patients, has also been described as a ‘breakpoint conversation’. Quality registers enable monitoring and improvement of quality of care, and clinical research. The Swedish Register of Palliative Care (SRPC) is a Swedish national quality register that collects data from hospitals, hospices, nursing homes and home care, with an end-of-life questionnaire (ELQ) about palliative care content focusing on the last week of life. Aims Study I – The aim was to examine the validity of the ELQ from the SRPC. Study II – The aim was to examine whether participation in the SRPC increases the quality of palliative care over a three-year period regarding eight items in the ELQ. Study III – The aim was to examine whether an educational intervention for physicians and nurses in nursing homes and hospitals increases the proportion of patients who receive ITEOL. Study IV – The aim was to describe how patients with cancer perceive the information they receive from physicians during palliative chemotherapy. Methods Study I – Data from 100 medical records and data from the paper versions of the ELQ filled in at a specialised palliative unit were compared with data reported to the SRPC. Study II – Data from eight items in the ELQ reported to the SRPC from all healthcare units that had reported patients continuously during a three-year period were compared year-by-year with logistic regression. Study III – Two municipalities (in charge of nursing homes) and two hospitals were randomised to receive an interactive half-day course about ITEOL for physicians and nurses. Four hospitals and four municipalities were assigned matched controls. The proportion of patients who received ITEOL before and after the intervention was measured with the ELQ. The effect of the intervention was analysed with a multivariable logistic regression model. Study IV – Fifteen semi-structured interviews with patients with incurable cancer were conducted, transcribed verbatim and analysed with qualitative content analysis. Results Study I – The questions in the ELQ showed a congruity of 22% to 100% when comparing data from medical records with data reported to the SRPC. Eight questions fell below 80%. The paper versions filled in at the unit and the data reported to the SRPC showed a congruity of between 91% and 100%. Study II – The prevalence of six symptoms decreased. The prescription of PRN (pro re nata – ‘as needed’) medications for pain, nausea, anxiety and death rattle increased. A higher proportion of patients died in their place of preference. The patient’s next of kin was more often offered a follow-up appointment after the patient’s death. There was no change in the proportion of patients or next of kin who received ITEOL. Study III – The proportion of patients in the intervention group who received ITEOL increased from 35.1% (during a six-month period before the intervention) to 42.0% (during a six-month period after the intervention). The proportion in the control group increased from 30.4% to 33.7%. The effect of the intervention was significant (p=0.005) in the multivariable model. Study IV – Three categories were disclosed during the analytical process: ‘living with a death sentence’, ‘depending on chemotherapy’, and ‘living with uncertainty’. Conclusions A national quality register has the potential of contributing to quality improvement in palliative care. Study I showed varied validity in the ELQ, implying a need to modify the questionnaire. Study II showed that participation in the SRPC was covariant with quality improvements in end-of-life care over time. Study III showed that more patients received ITEOL after an educative half-day intervention directed to physicians and nurses. Study IV showed that patients undergoing palliative chemotherapy perceived that their disease was incurable and deadly, and that conditions for future treatment and survival were uncertain.

Background: The overall quality of care has been defined in terms of a set of seven core attributes taken from contemporary conceptual frameworks for assessing primary healthcare systems. Attributes are assessed using sub-attribute questions picked from previously developed and validated national level survey instruments. Data has been collected through structured questionnaire survey utilizing Likert items and scale to capture respondents’ perceptions of care. Both descriptive and nonparametric statistical methods have been used for data analysis. Information on demographic factors helped to understand the response patterns across different cohort groups. Key objectives: 1) To determine the perception of patients and physicians regarding the overall quality of care and its constituent elements delivered through the primary healthcare clinics in Winnipeg. 2) To compare the perceptions about different quality of care attributes as expressed by participating patients and physicians. Results: Both patients and physicians have positive views about the overall quality of care (median score >=4 on a 1-6 scale). Regarding individual attributes, “Interpersonal communication” and “Respectfulness” received the highest average score (5) and long-term health management received the lowest score (2). Patient and physician responses were found to be statistically different for access, comprehensiveness and long-term health management. The long wait time for seeing a doctor appeared to be a widely shared concern – only 43% of the patients urgently needing to see a doctor could get a same-day appointment; for non-urgent cases, less than 3% got a same-day appointment. Patients with higher educational levels appeared to be more critical about the quality of care; conversely, patients in good health rated the quality of care attributes more favourably. Conclusion: Patients and physicians are generally satisfied with the overall quality of care. However, patients have identified issues related to access, comprehensiveness of care and long-term health management. Patients concerns were found to be consistent with national level results. Long wait time was also flagged as a key concern. Primary healthcare clinics should proactively seek patient feedback to identify issues and improve their quality of service.

Bakgrund: Delaktighet innebär en aktiv medverkan. I vården är delaktighet ömsesidig och beroende av både vårdpersonal och patient med anhöriga. Sjuksköterskans kärnkompetenser består bland annat av personcentrerad vård, vilken utgår från patientens behov. För att skapa en säker personcentrerad vård av kvalitet bör sjuksköterskan bland annat ha kunskap om delaktighet.   Syfte: Att beskriva patientens upplevelse av delaktighet i vården. Metod: En litteraturöversikt genomfördes med kvalitativ och induktiv ansats. CINAHL och MedLine har använts som databaser, vilket genererade i tio kvalitativa artiklar. Resultat: Fyra kategorier och nio subkategorier analyserades fram och resulterade i att patienten upplever delaktighet vid kommunikation, delaktighet genom relation, möjlighet till delaktighet och via vårdpersonalens förhållningssätt till delaktighet. Slutsats: Förståelse för patientens upplevelser av delaktighet har betydelse för att klarlägga och främja delaktighet samt forma en personcentrerad vård av kvalitét. / Background: Participation means an active involvement. In health care, participation is mutual and dependent on both healthcare professionals and patients with relatives. Six competencies for nursing consists among others patient-centered care, based on patient needs. In order to create a safe patient-centered quality care, the nurse should, for example, have knowledge of participation. Aim: To describe patients experience of participation in healthcare. Methods: A literature review was carried out with qualitative and inductive approach. CINAHL and MedLine were used as databases, which summed up in ten qualitative articles. Results: Four categories and nine subcategories were analyzed and resulted in patient´s experience of participation. Patient experienced participation thorough communication, participation thorough relationship, possibility to participation and by healthcare professionals’ attitudes to participation. Conclusions: Understanding of patients´ experience of participation is important to clarifying and promoting participation and shaping a patient-centered care of quality.

8 ABSTRACT This thesis discusses the theme: "The principles of the safe administration of medication and it's impact on the quality of care". This work is divided into two sections - theoretical and practical. The main purpose of the theroretical part is to focus on recapping the theories of quality in healthcare, especially in terms of safety for patients during medication administration. The drugs are the most frequently used therapeutic means of the modern medicine and therefore the topic of safe administration is so often the matter of discussion. Theoretical part of my thesis defines quality in healthcare and also includes chapters about methods for improving the quality and standardization of health care. This work presents an effective tools for dealing with misconducts and describes possible reasons and causes of patient's harm during the administration processes. The practical part of the thesis is dedicated to the content analysis of the selected nursing standards from hospitals within the Czech Republic. The main objective of this thesis is to compare the formal and practical aspects of nursing standards (injection administration) in three different health care facilities with regards to the structural, procedural and results criteria. The results of the content analysis are compared with respect...

Bakgrund: Globaliseringen medfört ökad förekomst av språkbarriärer, inte minst i Sverige. För att undkomma problemet finns det professionella tolkar, som översätter samtal mellan parter med olika modersmål. Ett sammanhang där tolk spelar en avgörande roll är inom hälso- och sjukvården, där samtal kan innebära enorma konsekvenser för människors liv och hälsa. Individers behov av tolk har stora implikationer för sjuksköterskans yrkesutövande liksom patientens liv.   Syfte: Att undersöka hur patienter med annat modersmål beskriver sina upplevelser av tolksamtal i ett vårdmöte. Metod: En litteraturöversikt där 10 vetenskapliga originalartiklar med studier av kvalitativ ansats granskades. Artiklar som motsvarade studiens syfte söktes i databaserna PubMed och CINAHL.  Resultat: Negativa upplevelser av tolkade samtal var misstanke om feltolkning, bekymmer om sekretess, skamkänslor kopplade till tolkens närvaro och upplevd utlämnande av emotionella budskap. Många nämnde även vikten av att tolk och patient delar samma dialekt av samma språk, vilket vårdpersonal ofta inte tog hänsyn till. Positiva upplevelser av tolkade samtal beskrevs som ökad delaktighet och autonomi, möjlighet till kulturkongruent vård och ökad förståelse för vården. Olika faktorer påverkade också deltagarnas uppfattningar av tolkens kompetens, som exempelvis tolkens ålder, kön, religion, etnisk tillhörighet, klädsel, och personkemi, vilket i sin tur påverkade patientens tillit till tolken och upplevelsen av vårdmötet.  Slutsats: Patienter med annat modersmål hade såväl positiva och som negativa upplevelser av tolkade samtal. Många faktorer påverkade tolkade möten, såsom patientens upplevelse av tolkens kompetens samt huruvida tolken och patienten talade samma dialekt. / Background: Globalization has led to increased prevalence of language barriers, not least in Sweden. Professional interpreters combat this, by translating conversations between parties with different native languages. An area where interpreters play a crucial role is healthcare, where discussions can have enormous consequences for peoples’ lives and health. Individuals’ need for interpreters carry great implications for the nurse’s professional practice as well as patients’ lives. Aim: To explore how patients with a different native language describe their experiences of interpreted communication in a healthcare setting.  Method: Literature review whereby 10 original research articles with studies of a qualitative approach were reviewed. Articles corresponding to the study’s aim were retrieved from the databases PubMed and CINAHL. Results: Negative experiences of interpreted healthcare encounters were suspected misinterpretation, worries about confidentiality, feelings of shame related to the interpreter’s presence and perceived omission of emotional messages. Additionally, many mentioned the importance of dialect, which healthcare providers often didn’t consider. Positive experiences of interpreted meetings were increased participation and autonomy, culture-congruent care and increased understanding of healthcare. Different factors affected the participants’ impressions of the interpreter’s competence, for instance the interpreter’s age, sex, religion, ethnicity, clothes and personal chemistry, which in turn affected the patient’s trust for the interpreter.  Conclusion: Patients with a differing native language had both positive and negative experiences of interpreted health encounters. Many factors had influence, such as the patient’s perception of the interpreter’s competence and whether the interpreter and patient speak the same dialect.