Thesis (M.S.)--Boston University / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / 2031-01-01

Thesis (M.S.)--Boston University / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / 2031-01-01

This thesis reports the outcomes of research into the use of restraint in the care of patients in an acute teaching hospital in Australia. The literature review undertaken for the study revealed much research into restraints showing evidence of the harm they cause, and their ineffectiveness as a safety measure. The literature indicates that the prevalence of restraint use is high - about a third of all hospital patients over the age of eighty-five years may be restrained at some time during the period of their admission.The main emphasis in my investigation was to uncover an understanding of how the use of restraints has remained possible, despite negative reports on their efficacy and questions about their possible abuse of human rights. Primarily, 1 set out to provide vide an understanding of restraint practice, and of how it is maintained and legitimised in a metropolitan teaching hospital.The study was guided by a Foucauldian approach to discourse analysis. The study reports on in depth studies of three patients. The case studies extend beyond observations of the patients to include interviews with members of the multidisciplinary team: nurses, doctors, occupational therapists and physiotherapists. Medical and nursing notes were another source of data.A discursive formation was identified by which restraint use is justified, and legitimised by the health professionals who use it. Five discourses were established, constituting: inability to 'self govern'; an appropriate environment; treatment; duty of care; and marginalisation.The study concludes that restraint use can be understood as a complex discursive practice. Through this discursive practice we can understand how staff maintain a monopoly over the truth and perpetuate claims about the inevitability of restraint use. Knowledge of these discursive practices enables an understanding of how the current ++ / educational approaches to restraint reduction are likely to have little immediate or sustained impact. With these understandings, we are hopefully better placed to change practice in a way that does not substitute one undesirable approach for another. If this is so, the value of this thesis will lie in its influence on practice as much as in its contribution to scholarship.

Thesis (PhD)--University of South Australia, 1998

The management of healthcare has changed dramatically over the past two decades. Such change has not just been in the way medicine is practiced, but also in the way the health dollar is spent. Hospitals have found themselves under constant and increasing pressure to not only reduce costs in relative terms, but also at the same time, provide new and expanded services. These pressures caused hospitals worldwide to closely examine the means by which they met the demands that were placed upon them (Royal Perth Hospital, 1994a; Asay and Maciariello, 1991). One common response was to embrace New Public Management strategies, such as devolved management. That is, to place the responsibility for managing diminishing health care resources, into the hands of those who use them the most - doctors (Chantler, 1993). To achieve this many hospitals adopted organisational structures known as clinical directorates (Chantler, 1993). Following international trends, the clinical directorate model was adopted by all of Western Australia’s public teaching hospitals in the mid 1990s. The belief was that by devolving hospital management to doctors, the clinical knowledge they possess will lead to improved clinical outcomes through the better allocation of resources. From the perceptions of Clinical Directors, Chief Executives, Nurse Managers, Business Managers and Department Heads, this research has developed a model, termed the Clinical Director Efficiency and Effectiveness (CD2E) model, that describes the dimensions of efficiency and effectiveness of Clinical Directors in the Western Australian public teaching hospital context. / The model proposes that there are three perceived dimensions of efficient and effective clinical directorship. They are: those that are brought to the role by doctors and governed by the health environment in which they develop (Domain Knowledge and Skills), those that are learned (Business Skills) and those that are innate (Personal Attributes). The three perceived dimensions consist of nine components. ‘Domain Knowledge and Skills’ comprise clinical expertise, peer influence, political expertise and environment knowledge. ‘Business Skills’ comprise financial management, strategic management and human resource management. ‘Personal Attributes’ comprise commitment and participation, and communication. The CD2E model not only describes the perceived dimensions of efficiency and effectiveness, it also outlines those dimensions that are brought to the role of a Clinical Director by the medical profession and those areas where there are perceived deficiencies. Whilst the final CD2E model can be used to assist in developing and selecting future Clinical Directors who are more appropriately equipped to improve healthcare delivery within Western Australia, the literature suggests that the model also has features which are common and applicable to other health environments.

This thesis examines how cultural understandings are generated and transmitted in a Canadian multicultural teaching hospital. It explores how issues of 'culture' are addressed formally and informally in the experiences of patients and practitioners. Using the approach of an institutional ethnography, emphasis is placed upon informal strategies of cultural care as a taken-for-granted practice in clinical life. It illuminates how pressure to learn culturally sensitive care seeps into the fabric of daily clinical life, and how cultural practices are constructed within a complex set of organized social practices. / The study concludes that advocacy of multicultural policies, must consider the dominance of existing western health care paradigms. It advocates culturally responsive care as a parallel force that can collaborate with the regimes of formal health practices. It argues that providing effective health care to all segments of Canadian society requires structural changes in health education which need to address existing disjunctures between 'effective ideals' and ideological knowledge, in order that all are ensured optimum health care.

Thesis (M.H.S.A.)--University of Michigan, 1976.

Thesis (M.H.S.A.)--University of Michigan, 1976.

Orientador: Edison Iglesias de Oliveira Vidal / Coorientador: Fernanda Bono Fukushima / Banca: Edison Iglesias de Oliveira Vidal / Banca: Regina Célia Popim / Banca: Ivana Regina Gonçalves / Resumo: Introdução: A comunicação de más notícias envolve situações como a comunicação sobre diagnósticos que ameaçam a vida, a deterioração clínica ou mesmo a morte de um paciente. A forma como esse tipo de informação é transmitido pode ter um impacto profundo na compreensão dos pacientes e de seus familiares sobre a doença, sobre sua capacidade de lidar com a nova situação e pode amplificar ou diminuir o seu sofrimento. Várias pesquisas relativas à comunicação de más notícias nos cuidados de saúde enfatizam a importância de um ambiente físico apropriado para a condução desse processo. Todavia não foram encontrados estudos que tenham avaliado os espaços físicos onde essa comunicação se dá. Portanto, propôs-se o presente projeto de pesquisa com o objetivo de avaliar a presença e as características de ambientes apropriados para a comunicação de más notícias em hospitais escola do estado de São Paulo. Métodos: Todos os hospitais de ensino elegíveis foram convidados a participar do projeto. Uma vez que os hospitais aceitassem participar, era agendada uma visita guiada aos seguintes setores de cada hospital: Unidades de Terapia Intensiva (UTI), antessalas do centro cirúrgico, enfermarias de clínica médica, cirurgia, oncologia, neurologia, geriatria, pediatria e cuidados paliativos. Resultados: Foram convidados 30 hospitais para o estudo, dos quais 15 concordaram em participar. De 156 setores hospitalares visitados havia apenas 15 (9,6%) com salas para comunicação privada entre profission... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: The breaking of bad news involves situations such as the communication about life-threatening diagnoses, the clinical deterioration or even the demise of a patient. The way in which those types of information are conveyed may have profound impact in the under-standing of patients and families about the illness, in their ability to cope with the new situa-tion, and may amplify or lessen their suffering. Several guidelines concerning the communi-cation of bad news in healthcare emphasize the importance of an appropriate physical envi-ronment for the conduction of that process. However there are no studies about the physical environments where such communication processes take place. Therefore we proposed the present research to assess the presence and the characteristics of appropriate places for the communication of bad news within teaching hospitals in the state of Sao Paulo. Methods: All eligible teaching hospitals of state of São Paulo were invited to participate in the project. Once one of those hospitals accepted to participate, we scheduled a guided visit to the following sectors of each hospital: Intensive Care Units (ICU), access points to operating suites, Internal Medicine, General Surgery, Oncology, Neurology, Geriatrics, Pediatrics, and Palliative Care wards. Results: Thirty teaching hospitals were invited for the study and 15 agreed to participate. Out of 156 hospital sectors visited there were only 15 (9.6%) rooms for private communications between ... (Complete abstract click electronic access below) / Mestre

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