People with severe mental illness experience medical comorbidities to a greater extent than the general population. When hospitalized in general hospital settings, they experience poorer outcomes and are experienced as difficult by nurses. An understanding of the experience of hospitalization from the patient's perspective is important to improving care and outcomes for this population. The purpose of this study was to explore the lived experience of nonpsychiatric hospitalization for persons with severe mental illness. Heideggarian phenomenology provided the philosophical underpinning and informed the methodology employed. Participants were recruited through mental health providers. Ten individuals with severe mental illness participated in minimally structured interviews and described their experience of hospitalization on a medical-surgical unit. Data, including transcribed interviews and field notes, were analyzed within the hermeneutic tradition as described by Cohen et al. (2000). The lived experience of nonpsychiatric hospitalization was expressed in four themes: taking care of me (subthemes: being cared for, not being cared for), it's my life, on my toes (subthemes: needing an advocate, managing my mental health), and being a good patient. Care providers' comportment, perception of the patient's illness, attentiveness, responsiveness, and personalized caring behaviors characterized the participant experience of being cared for or not being cared for. It's my life reflected participants' desire to be informed and involved so they could contribute to their recovery. Participants felt the need to be on my toes in order to look out for and advocate for themselves. The need to be on my toes extended to the management of a chronic illness while hospitalized for an unrelated acute condition. The final theme reflected the perceived patient role obligation to be a "good patient". Findings were consistent with the literature regarding experiences of hospitalization from the perspective of persons without mental illness. Identified themes emphasize the critical importance of the nurse-patient relationship to the patient experience. There are significant implications for how nurses come to know their patients in medical-surgical settings so that they can effectively personalize care. Reflective practices may empower nurses to solicit assistance and support to improve caring practices / text

A Mail Survey to Assess the Incidence and Impact of Drug Shortages within Texas Non – Government Acute Care Hospitals Tawfik Rajab Rajab, M.S.Phr. The University of Texas at Austin, 2013 Supervisor: Marvin D. Shepherd The objective of this study was to explore the incidence and impact of drug shortages within Texas Non-Government Acute Care Hospitals. A self-administered mail survey instrument was used to collect data. A convenience sample of 321 pharmacy directors of non-government acute care hospitals in the state of Texas was selected from the Texas Department of State Health Services (DSHS) Hospital List for 2012. A total of 125 completed surveys were received by mail and 8 surveys were returned as undelivered, resulting in a response rate of 39.84% (125/313). A total of 56 (45.5%) respondents reported 11 or more drug shortages for the month of April 2013. There was a significant association between the number of drug shortages experienced and hospital size (p = 0.003), inpatient medication budget (p = 0.001) and hospital location (p=0.015). Of the 124 respondents, 78 (62.9%) spent four to 12 hours a week on managing drug shortage situations. There was a significant association between the number of hours spent per week by hospital pharmacy personnel when managing drug shortages controlling for hospital size (p < 0.001), number of drug shortages experienced (p < 0.001), number of pharmacist FTEs (p < 0.001), and number of pharmacy technician FTEs (p < 0.001). A total of 107 (85.6%) reported that grey market vendors have contacted hospital pharmacy personnel in the month of April, 2013. A total of 96 (76.8%) ‘strongly agreed’ that grey market vendors are more likely to contact health care facility when drug shortage exists, 110 (88%) ‘strongly agreed’ that grey market vendors sell drugs in short supply at inflated prices and 70 (56%) ‘strongly agreed’ that the practice of buying drug products from grey market vendors should be eliminated. In summary, all surveyed hospitals experienced at least one drug shortage for the month of April 2013, pharmacy personnel devoted a significant amount of time managing drug shortages and the majority of the hospitals were contacted by grey market vendors with the aim of selling drugs in short supply. / text

Consolidation of Acute Care Surgical Services (ACSS) as a response to multiple challenges in providing timely and high-quality emergency services is a growing interest among healthcare policymakers. However, very little is known about patient experiences within this system. This study explores patient perceptions of their acute care surgical experiences within a consolidated ACSS program. A qualitative study guided by the tenets of Appreciative Inquiry was conducted. Data were collected by means of semi-structured interviews and personal stories. Thirteen participants were involved, seven females and six males of varying ages; all underwent emergency surgeries including appendectomy, cholecystectomy, and small bowel obstruction surgery. Findings suggest that clear and effective communication, excellent nursing care, timely access to surgical services, continuity of care, patient safety, transfer to an Acute Care Surgical (ACS) site, communication regarding transportation, and process of admission to an ACS site play important roles in patient experiences within a consolidated ACSS.

Consolidation of Acute Care Surgical Services (ACSS) as a response to multiple challenges in providing timely and high-quality emergency services is a growing interest among healthcare policymakers. However, very little is known about patient experiences within this system. This study explores patient perceptions of their acute care surgical experiences within a consolidated ACSS program. A qualitative study guided by the tenets of Appreciative Inquiry was conducted. Data were collected by means of semi-structured interviews and personal stories. Thirteen participants were involved, seven females and six males of varying ages; all underwent emergency surgeries including appendectomy, cholecystectomy, and small bowel obstruction surgery. Findings suggest that clear and effective communication, excellent nursing care, timely access to surgical services, continuity of care, patient safety, transfer to an Acute Care Surgical (ACS) site, communication regarding transportation, and process of admission to an ACS site play important roles in patient experiences within a consolidated ACSS.

BAKGRUND: Det är lätt att glömma bort närstående när en situation kräver akut omhändertagande, då det är patienten som drabbats som är i fokus. Att låta närstående vara delaktiga i omvårdnaden och att sjuksköterskan tar sig tid att skapa en delaktighet och involvera den närstående i vården. SYFTE: Syftet var att beskriva närståendes upplevelser av sjuksköterskans bemötande vid ett akut omhändertagande.  METOD: Studien utfördes som en allmän litteraturöversikt där tio vetenskapliga artiklar, med relevant innehåll valdes ut. De analyserades och skapade ett resultat. RESULTAT: Resultatet baseras på nio artiklar där fyra huvudkategorier presenteras och under varje huvudkategori finns upp till sex subkategorier. Studiens resultat visar att sjuksköterskans bemötande var viktigt inom området av akut omhändertagande. Behovet av att tillgodose de närstående, med att delta i omvårdnaden, få information och bli sedda var en övergripande och viktig punkt i relation till bemötandets helhet. SLUTSATS: Genom att vara öppen som sjuksköterska, kommunicera och se hela familjen med närstående som en enhet kan man utveckla sin profession. Närstående behöver lika mycket vård som patienten och sjuksköterskan får aldrig glömma bort närståendes betydelse i omvårdnadsarbetet. / BACKGROUND: It is easy to forget the relatives when a situation requiring emergency treatment, when it is the patient who suffered that is in focus. Allowing related parties be involved in the care and the nurse to take the time to create a participatory and involve the relatives in care. AIM: The objective was to describe the experiences related parties of the nurse's response in an acute care. METHOD: The study was conducted as a general literature review of ten scientific articles with relevant content was selected. They were analyzed and created a profit. FINDINGS: The results are based on nine articles where four main categories presented with six subcategories. Our results demonstrate that the nurse's attitude was important in the field of emergency care. The need to meet the relatives, to participate in the care, get information and be seen was a comprehensive and important point in relation to responding's entirety. CONCLUSION: By being open as a nurse, communicate and see all the family with related parties as a unit can develop their profession. Related needs as much care as the patient and the nurse must never forget related while nursing.

Since 1995, a thrombolytic therapy, rt-PA, has been approved for use with acute stroke that significantly reduces, and sometimes reverses, neurological damage. Treatment has to be given within a few hours of the start of symptoms and can only commence once a CT-scan has confirmed a particular type of stroke. In the evidence-based medicine and knowledge translation literature, variations in practice are constituted as a problem to be solved. It is assumed that a physician decides whether or not to use this therapy based on his/her evaluation of the scientific evidence. In this thesis, I demonstrate that what are less evident in many of these claims are issues related to the social production of knowledge. Little attention is paid to who conducts research, who promotes its findings, and who is expected to implement them. The positivist discourse of evidence-based medicine assumes that research produces knowledge that is neutral and can be translated into treatment that is in the patient’s best interest. Yet these assumptions remain empirically unexamined, despite social science critiques of these processes. Institutional Ethnography is an approach in sociology developed by Dorothy Smith. Based on Smith’s understanding of the social organization of knowledge, it allows for an examination of the complex social relations organizing people’s experiences of their everyday working lives. Beginning in the experiences of physicians who provide acute stroke services, this dissertation explores an example of how best practice medicine is developed, translated, and taken up in practice across various sites in the province of Ontario. For Smith, texts mediate and organize people’s experiences. In my study, the discourses of both evidence-based medicine and knowledge translation, designed to improve patient care, come into view as managerial tools designed to control the delivery of care. I render visible how in fact things work as they do in real life settings in a way that links back actual people to the texts, or discourse, organizing their experiences. In so doing, I am able to uncover some of the assumptions and hidden priorities underlying the current emphasis on translating scientific knowledge in medicine into practice.

Increasing numbers of older patients with cognitive impairment and disturbed behaviour are likely to present to acute care hospitals in the future. Nurses are not well disposed towards care due to safety and morale issues caused by knowledge deficits, job stress, oppressed group behaviours and ageist attitudes. Patient outcomes are often poor with multiple adverse events, long lengths of stay and levels of mortality. Disturbed behaviour may be caused by delirium, depression or other mental disorders and dementia or all. The research question addressed was “Can the instigation of a person-centred approach to care of patients with cognitive impairment and disturbed behaviour result in decreased nursing stress, improved patient care practices, outcomes and relatives’ satisfaction?” A conceptual framework incorporating the constructs of Person-Centred Care, the Integrated Structural Model of Human Behaviour and Practice Development informed the action research methods utilised. The processes of facilitation were used to undertake four action research cycles incorporating plans, actions, observations and reflections in one 25-bed acute aged care ward in a large tertiary referral hospital The first cycle involved setting up the study, recruitment of nurses and patients, gathering of baseline data and application of nonparticipant observational studies of the quality of nurse-patient interactions which served to inform the plan for interventions. The following three cycles demonstrated efforts to undertake those interventions through strategies to increase nursing empowerment and knowledge in the context of constant staff turnover and diversions that compromised support and participation. During the study there were few apparent adverse patient outcomes with significant improvements in patient analgesic administration, relatives’ satisfaction with care, nursing care practices involving the completion of a Communication and Care Cues form and nurses’ interactions with the patients. New care planning tools were developed that will enable ongoing activities for practice improvement. Conversely, there was a significant increase in the nurses’ stress levels when caring for hypoactive delirious patients, a trend towards more emotional exhaustion, high nursing turnover and increased sick leave rates. Nursing care practices were unchanged and the new care planning tools were not well utilised. Reflection on the implications and limitations of action research methods supported by practice development strategies in the dynamic, often chaotic environment experienced during the study, suggested that if there is an absence of hierarchical managerial sponsorship for such activities, then sustainable change is difficult. Therefore, it was shown that a person-centred approach to care of patients with cognitive impairment and disturbed behaviour using action research methods in this environment, can result in some enhanced nurse-patient interactions, patient care practices, outcomes and relatives’ satisfaction. However, progress is likely to be slow and time consuming. Further improvements require attention to the well-being status of the nurses through actions that generate feelings of empowerment through individual recognition, knowledge enhancement, adequate access to patient information and sufficient time to undertake their duties as equal members of the multidisciplinary team.

The acute care setting is designed to provide short-term care for people who require treatment for a severe episode of acute illness and exacerbations of chronic conditions. Yet, more than half of Canadians die in acute hospitals every year. Evidence shows that nurses in acute care units feel limited in their ability to provide quality end-of-life care due to a variety of factors. As a result, the needs of patients that are dying are often overlooked, which can cause them to experience a loss of identity and control, as well as suffering at the end-of-life; a unique time in one’s life trajectory marked by significant changes in personhood. Personhood is the philosophical underpinning of the frequently used concept ‘person-centered care’ – one of the fundamental ideologies of nursing and a central concept in palliative care. An interpretive description design was used to explore the following research question: What do nurses’ stories reveal about the ways in which they engage, or fail to engage, with personhood in end-of-life care in acute care units? To appreciate the culture in which participant stories were situated, a literature review of acute care culture, end-of-life care in acute care units, and the concept of personhood was conducted. Eight nurses from an acute medical-surgical ward of a tertiary care hospital in Eastern Ontario were interviewed for this study. Thematic analysis was used to analyze the data, which elucidated tensions between participants’ ability to enact ethical end-of- life care reflective of their values and the contextual constraints of working in a culture of biomedicine. Exploring these tensions provided insight on the nuances and complexities of navigating ethical end-of-life care in an acute care setting as well as implications for nursing practice, education, and research with particular attention to promoting moral communities in acute care that value personhood and biomedicine equally.

Purpose: to describe the knowledge, beliefs, and attitudes of physicians and hospital administrators regarding the role and scope of practice of acute care nurse practitioners in rural Montana. Background: Nurse practitioners have been increasingly called upon to provide high quality and cost-effective healthcare in variety of settings and have consistently shown to provide a high-level of patient care in both the primary and acute care settings. The acute care nurse practitioner specialty is relatively new, and with very few licensed acute care nurse practitioners in the state of Montana, the role and scope of practice is not well understood by physicians and hospital administrators who are often tasked with hiring and recruiting providers in the hospital setting. The Consensus Model, which served as the conceptual framework for this project, advocates that nurses provide care for the population that is specific to their licensure, accreditation, certification, and education. Method: Some 28 physicians and hospital administrators completed a survey that included 21 Likert scale statements that were divided into the subscales of Knowledge, Belief, and Attitude. Results included: 1) An existing gap in knowledge regarding the role and scope of practice of acute care nurse practitioners, 2) acute care nurse practitioners should always have some form of physician oversite, and 3) there is disparity in patient outcomes when patient care is provided by nurse practitioners. Conclusion: Attitudes of survey respondents were overwhelmingly positive for the future of acute care nurse practitioners filling various provider roles in the hospital setting. These results can provide a foundation for future inquiry and can assist in the development of education and collaborative efforts to further advance the utilization of acute care nurse practitioners in Montana.

Doctor of Philosophy / School of Family Studies and Human Services / Jared R. Anderson / Addiction to mood-altering substances i.e., drugs and alcohol is a public health concern impacting society in many contexts (e.g., employment, financial costs, family welfare, healthcare, and criminal activity). As a result of the substantial personal and societal costs associated with substance abuse, significant federal dollars have been spent on addiction recovery services in an attempt to ameliorate the negative impacts of these disorders. Like many chronic diseases, relapse (40-60%; National Institute on Drug Abuse, 2012) and dropout (23-50%) rates for clients in drug and alcohol outpatient treatment tend to be high (McHugh et al., 2013; Santonja-Gomez et al., 2010; Evans, Li, and Hser 2009; Stark, 1992). Over time, it has become clear that a single course of treatment is simply not enough to meet the needs of a person in recovery from alcohol and/or other drug abuse. The field of addiction treatment and recovery has been dominated by an acute-care model of treatment. A new model, recovery-oriented systems of care (ROSC), defined as “networks of organizations, agencies, and community members that coordinate a wide spectrum of services to prevent, intervene in, and treat substance use problems and disorders” (Sheedy & Whitter, 2013, p. 227), has been endorsed by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Substance Abuse Treatment (CSAT). As communities begin to implement ROSC it is imperative to understand the barriers to transitioning out of the traditional, acute-care model. Findings from in-depth qualitative interviews revealed that both treatment and probation professionals described more alignment with the ROSC model than the acute-care model. For treatment professionals, this alignment was stronger at an individual level and for probation professionals it was stronger at the system level. For both professional groups, the system-level barriers to moving toward a ROSC model were much greater than any individual-level barriers. Facilitators were found evenly split for the most part between individual and system level codes. For communities making movement toward the ROSC model, the systems of treatment and probation have great potential at the individual level for ROSC alignment and have available facilitators for overcoming system-level barriers in place. Although the acute-care model served a purpose at one time, it is now time for the ROSC model to be implemented as a comprehensive response to addiction and needs in recovery.