No / The perceived decline in care and benchmark standards is arguably a product of competing benchmarks and the decline of traditional mentoring approaches positioned with the patient experience at its core.

The quality of care of residents in nursing homes receive is an important issue facing our society, and reliable methods to assess and measure important indicators of quality of care are necessary to ensure that nursing homes are providing adequate services. Previous researchers have developed methodologies to evaluate indicators of quality of care, including environmental conditions, resident conditions, resident activities, and staff activities using momentary-time sampling procedures across a variety of settings and populations. The purpose of the present study was to replicate and extend the time-sampling methodology used in previous research in two units in a nursing home.

Yes / Workplace incivility is a pervasive complex problem within health care. Incivility manifests as subtle disrespectful behaviours, which seem inconsequential. However, evidence demonstrates that incivility can be harmful to targets and witnesses through negative emotions, poorer mental health, reduced job satisfaction, diminished performance and compromised patient care. It is unclear to what extent existing research critically explores how ethnicity, culture and racism influence how hospital staff experience incivility. This global scoping review systematically analysed existing research exploring the specific ways incivility manifests and impacts racially minoritised hospital workers. Of 2636 academic and 101 grey literature articles, 32 were included. Incivility experiences were categorised into four themes: (1) Cultural control, (2) Rejection of work contributions, (3) Disempowerment at work and (4) Managerial indifference. The included articles highlighted detrimental consequences, such as negative emotions, silencing, withdrawal and reduced support-seeking behaviours. Few studies presented evidence regarding the negative impacts of incivility on patient care. Racialisation and racial dynamics are a significant factor for hospital-based incivility. Currently we do not know the extent to which racialised incivility is associated directly or, perhaps either via burnout or disengagement, indirectly with poorer care. This knowledge can inform the creation of comprehensive, evidence-based interventions to address this important issue. / National Institute for Health Research Yorkshire and Humber Patient Safety Research Collaboration

Recent reforms in the South African health care and educational system were founded in the ideal that the country would produce independent, critical thinkers. Nurses need to cope with diversity in a more creative way, defining their role in a complex, uncertain, rapidly changing health care environment. Learning facilitators are held accountable for finding adequate learning experiences to prepare nursing students for such practice demands so that newly qualified nurses do meet expectations for entry level clinical judgement ability. Quality clinical judgement is therefore imperative as an identified characteristic of newly qualified professional nurses. There is a scarceness of information on the concept of clinical judgement especially within the South African nursing environment. Relevant information in this regard can assist in clarifying the meaning, which will facilitate a common understanding of the concept within the clinical nursing environment. This in turn can lead to the formulation of a teaching-learning strategy to facilitate clinical judgement in undergraduate nursing students, which would be of benefit in the nursing care environment. The objective of this study was addressed in three phases. The first phase of this research analysed the concept of clinical judgement through various data sources and a review of literature to clarify the meaning and facilitate a common understanding through identification of the characteristics and to develop a connotative (theoretical) definition of the concept. The second phase of the research investigated professional nurses‟ understanding of the meaning of clinical judgement, as well as the factors that influence the development of clinical judgement within the nursing environment. During the third phase a conceptual framework for an enabling teaching-learning environment was constructed from a modern day constructivist approach to facilitate clinical judgement. The section included a description and diagrammatic presentation of the framework. The conceptual framework formed the scientific basis from which a teaching-learning strategy for the creation of an enabling teaching-learning environment to facilitate clinical judgement in undergraduate nursing students within the South African nursing environment was synthesised. A qualitative design was used for the study. During the first phase (manuscript 1) an explorative, descriptive qualitative design was used to discover the complexity and meaning of the phenomenon. Multiple data sources and search engines were consulted for the time frame 1982-2013. An extensive concept analysis resulted in a theoretical definition of the concept „clinical judgement‟, a complex cognitive skill to evaluate patient treatment alternatives within the clinical nursing environment. The second phase (manuscript 2) is qualitative in nature and explored professional nurses‟ understanding of clinical judgement, as well as the factors influencing the development of clinical judgement in undergraduate nursing students. The findings emphasised clinical judgement as skill within the nursing environment. This assisted in the development of teaching-learning strategy for the creation of an enabling teaching-learning environment to facilitate clinical judgement in undergraduate nursing students within the South African Nursing environment as the third phase (manuscript 3). Such an environment should impact positively to promotion of autonomous and accountable nursing care. / PhD (Nursing), North-West University, Potchefstroom Campus, 2015

Recent reforms in the South African health care and educational system were founded in the ideal that the country would produce independent, critical thinkers. Nurses need to cope with diversity in a more creative way, defining their role in a complex, uncertain, rapidly changing health care environment. Learning facilitators are held accountable for finding adequate learning experiences to prepare nursing students for such practice demands so that newly qualified nurses do meet expectations for entry level clinical judgement ability. Quality clinical judgement is therefore imperative as an identified characteristic of newly qualified professional nurses. There is a scarceness of information on the concept of clinical judgement especially within the South African nursing environment. Relevant information in this regard can assist in clarifying the meaning, which will facilitate a common understanding of the concept within the clinical nursing environment. This in turn can lead to the formulation of a teaching-learning strategy to facilitate clinical judgement in undergraduate nursing students, which would be of benefit in the nursing care environment. The objective of this study was addressed in three phases. The first phase of this research analysed the concept of clinical judgement through various data sources and a review of literature to clarify the meaning and facilitate a common understanding through identification of the characteristics and to develop a connotative (theoretical) definition of the concept. The second phase of the research investigated professional nurses‟ understanding of the meaning of clinical judgement, as well as the factors that influence the development of clinical judgement within the nursing environment. During the third phase a conceptual framework for an enabling teaching-learning environment was constructed from a modern day constructivist approach to facilitate clinical judgement. The section included a description and diagrammatic presentation of the framework. The conceptual framework formed the scientific basis from which a teaching-learning strategy for the creation of an enabling teaching-learning environment to facilitate clinical judgement in undergraduate nursing students within the South African nursing environment was synthesised. A qualitative design was used for the study. During the first phase (manuscript 1) an explorative, descriptive qualitative design was used to discover the complexity and meaning of the phenomenon. Multiple data sources and search engines were consulted for the time frame 1982-2013. An extensive concept analysis resulted in a theoretical definition of the concept „clinical judgement‟, a complex cognitive skill to evaluate patient treatment alternatives within the clinical nursing environment. The second phase (manuscript 2) is qualitative in nature and explored professional nurses‟ understanding of clinical judgement, as well as the factors influencing the development of clinical judgement in undergraduate nursing students. The findings emphasised clinical judgement as skill within the nursing environment. This assisted in the development of teaching-learning strategy for the creation of an enabling teaching-learning environment to facilitate clinical judgement in undergraduate nursing students within the South African Nursing environment as the third phase (manuscript 3). Such an environment should impact positively to promotion of autonomous and accountable nursing care. / PhD (Nursing), North-West University, Potchefstroom Campus, 2015

There are theoretical and methodological difficulties in measuring the concepts of quality of care and patient satisfaction, and the conditions associated with these concepts. A theoretical framework of patient satisfaction and a theoretical model of quality of care have been used as the theoretical basis in this thesis. Aim. The overall aim was to describe and explore relationships between person-related conditions, external objective care conditions, patients’ perceptions of quality of care, and patient satisfaction with care in hospital. Methods. Quantitative and qualitative methods were used. In the quantitative study (I-III), 528 patients (83.7%) from eight medical, three surgical and one mixed medical/surgical ward in five hospitals in Norway agreed to participate (10% of total discharges). Data collection was conducted using a questionnaire comprising four instruments: Quality from Patients’ Perspective (QPP); Sense of Coherence scale (SOC); Big Five personality traits – the Single-Item Measures of Personality (SIMP); and Emotional Stress Reaction Questionnaire (ESRQ). In addition, questions regarding socio-demographic data and health conditions were asked, and data from ward statistics were included. Multivariate statistical analysis was carried out (I-III). In the qualitative study 22 informants were interviewed (IV). The interviews were analysed by conventional content analysis. Main findings. Patients’ perceptions of quality of care and patient satisfaction ranged from lower to higher depending on whether all patients or groups of patients were studied. The combination of person-related and external objective care conditions explained 55% of patients’ perceptions of quality of care (I). 54.7% of the variance in patient satisfaction was explained, and the person-related conditions had the strongest impact, explaining 51.7% (II). Three clusters of patients were identified regarding their scores on patient satisfaction and patients’ perceptions of quality of care (III). One group consisted of patients who were most satisfied and had the best perceptions of quality of care, a second group of patients who were less satisfied and had better perceptions, and a third group of patients who were less satisfied and had the worst perceptions. The qualitative study revealed four categories of importance for patients’ satisfaction: desire to regain health, need to be met in a professional way as a unique person, perspective on life, and need to have balance between privacy and companionship (IV). Conclusions. Patients’ perceptions of quality of care and patient satisfaction are two different concepts. The person-related conditions seem to be the strongest predictors of patients’ perceptions of quality of care and patient satisfaction. Registered nurses need to be aware of this when planning and conducting nursing care. There is a need of guidelines for handling over‑occupancy, and of procedures for emergency admissions on the wards. The number of registered nurses on the wards needs to be considered. Healthcare personnel must do their utmost to provide the patients with person‑centred care.

<p>Vid ortopedavdelning 3A och 3B inom länsverksamhet ortopedi Landstinget i Värmland har ett projekt startats för att förändra organisation och arbetssätt utifrån så kallade patientnärmre vård. Detta är en arbetsmodell som bygger på att vården skall ske i nära anslutning till patienterna och en förutsättning är att selektera bort så mycket vårdadministration som möjligt från sjuksköterskornas praktiska arbete. Syftet med studien, som är en del i ett större projekt, var att beskriva nuläget vid ortopedavdelningarna 3A och 3B före införandet av arbetsmodellen patientnärmre vård. Enkäter delades ut till patienter och medarbetare där de viktigaste frågeområdena var vårdkvalitet, hälsoindex, arbetsklimat och delaktighet. Undersökningsgruppen bestod av 130 patienter (96% svarsfrekvens) och 64 medarbetare (94% svarsfrekvens). Resultatet visade på en högt skattad vårdkvalitet i patientgruppen och en något lägre skattad vårdkvalitet i medarbetargruppen. Patientgruppens lägsta skattningar handlade om ”delaktighet i beslut”, ”egna önskemål” och ”information om ansvarig sjuksköterska”. Patienterna skattade genomgående de olika kartlagda vårdaspekterna som mer betydelsefulla än vad medarbetarna gjorde. Patienterna upplevde sitt hälsotillstånd som relativt gott, det psykiska välbefinnandet skattades dock som bättre än den fysiska hälsan. Medarbetarna upplevde stor delaktighet i det egna teamet och närhet till patienterna. Lägre värden framkom dock på möjligheter att observera patienterna och att påverka arbetet. Arbetsklimatet upplevdes som stagnerat inom dimensionerna konflikt, utmaning och frihet. I dimensionerna idé-stöd och risktagande närmade sig organisationen ett innovativt klimat, vilket kan ha positiv betydelse vid ett förändringsarbete.</p> / <p>At the Clinic of Ortopedic Surgery, wards 3A and 3B, in the County Board of Health Care in Värmland, a project has been initiated with the purpose of changing the workprocess in accordance with so called Patient-Focused Care. This is a working model built on the principle that care should take place in a close relationship with the patient with the prerequisite of reducing as much care administration as possible from the nurses’ work. The aim of the study, which is a part of a larger project, was to describe the current status at the wards, before the implementation of the Patient - Focused Care work model. Questionnaires containing questions on quality of care, a health index, organizational climate, and opportunities for participation were distributed among patients and staff. The study group consisted of 130 patients (96 % response rate) and 64 staff members (94 % response rate). The results showed that the patients rated the quality of care as high, while the staff members give somewhat lower ratings. The least favourable ratings in the patient group were noted on questions designed to measure “participation in decision making”, “own preferences,” and “information on the responsible nurse.” Compared to the staff members, the patients ascribed higher subjective importance to all mapped aspects of care. The patients experienced their health status as relatively good, however, the subjective well-being was rated as more favourable than the physical health. The staff members experienced a high participation in their team and a sense of being close to the patients. Less favourable ratings were noted on the possibilities to observe the patients and to have an influence on their own work. The organizational climate was perceived as declined in the dimensions of conflict, challenge and freedom. In the dimensions of idea-support and risk taking the organization approached an innovative climate, which might have a positive impact in an organizational change process.</p>

The present doctoral thesis focuses mainly on the experiences of 20 women and men of becoming and being parents of a prematurely born child and on their perceptions of their contacts with health and medical care services. An additional aim was to investigate the utilisation of health care during the first year of life and its relation to high-risk diagnoses in the neonatal period. Data were obtained by interviews of the 20 sets of parents to infants born at a gestational age of &lt;34 weeks with no serious congenital defects. These parents were interviewed 1-2 weeks after the infant’s birth and at 2, 6 and 18 months of age. The interview texts were subjected to phenomenological and content analysis. Data was also obtained from the records of 36 infants born at a gestational age of &lt;31 weeks and with a birth weight of &lt;1500 g and 36 full-term infants. The records included information regarding contact with health care services including the child health centres (CHCs) and the outpatient clinics of the paediatric and ophthalmic clinics. Finally data from the other two quantitative studies were obtained from three questionnaires: Quality of Care from The Patient’s Perspective, The Swedish Parenthood Stress Questionnaire and The Toddler Behaviour Questionnaire. The result of the studies showed that the utilisation of health care by the very low birth weight infants was higher than that by the fullterm infants in paediatric and ophthalmic outpatient clinics. High-risk diagnoses in the neonatal period did not correlate with utilisation of care except for visits to the paediatric outpatient clinic, especially planned visits. The internalisation of parenthood was described by the parents as a time-dependent process, with four syntheses of experiences – alienation, responsibility, confidence and familiarity. The development and construction of the mothers’ and fathers’ parental identity followed a pattern that could be summarised into three themes: Unexpected start of parenthood, integration of parenthood into the sense of identity and recognition of parental identity. Important turning points in experiences of parenthood often occurred when the infant could be removed from the incubator, when it was discharged from the ward, and when the infant appeared normal compared to full-term infants. The quality of care was judged, from the parents’ and nurses’ perspective. In general the subjective importance of the given care was rated higher than the care actual given in both neonatal care and care at the CHCs. Higher ratings were given to neonatal care compared with the care at CHSs for medico-technical competence. It was also of importance, of both parents, to receive an optimal identity-oriented approach and socio-cultural atmosphere in the neonatal care and the care at the CHSs. High-risk diagnoses in the newborn did not affect the answers. Parental stress of very preterm children, at 18 months of age, did not differ notably from those parents of children born somewhat less premature, but they assessed their children as being rather later in the development of social behaviours. Parents of children who had had a difficult neonatal period were not more stressed when the child was 18 months old than those who had no problems in the neonatal period. In sum, this research project showed that the parents’ expectations and experiences of becoming mothers and fathers in preterm birth was a process of integrating the unexpected start of parenthood into the parents’ sense of identity and their way of being. When the parents developed a relationship with the infant, actively participated in its care on the basis of their own preferences, and received recognition as parents, this process was strengthened. It is therefore important that the professional caring of the staff should meet and involve the natural caring of the parents.

The objective of the thesis was to evaluate the quality of diabetes care in the Canadian Forces by determining the extent to which physicians adhere to recommendations outlined in the 2008 Canadian Diabetes Association (CDA) clinical practice guidelines. In addition, the effect of patient age, sex, rank and size of base on quality of care was assessed and the accuracy of a diagnosis of diabetes in an extract of the electronic medical record (EMR) was evaluated. Fourteen bases within the Canadian Forces were selected for investigation, representing roughly half of the Canadian Forces population. Cases of diabetes were ascertained based on laboratory criteria following a chart review. Twenty-one CDA guideline recommendations were considered. The Canadian Forces demonstrated greater than 75% adherence with each of 9 recommendations, 50-75% adherence with each of 7 recommendations and less than 50% adherence with each of 5 recommendations. The overall adherence with all applicable recommendations per patient was 60.3% (SE 0.66). Age, sex, rank and size of base were not important factors influencing guideline adherence. The sensitivity of a diabetes diagnosis in an extract of the EMR was 84.5%, the specificity was 99.8%, the positive predictive value was 85.1% and the negative predictive value was 99.8%. This is similar to the performance of provincial and national diabetes registries. The quality of diabetes care in the Canadian Forces compared favourably with that of the civilian population within Canada and internationally. The creation of a diabetes registry is expected to lead to further improvements in diabetes care.

Unsatisfactory working conditions and job stress may be indicative of working in a society where work-life balance is a desired, but often elusive, goal (Duxbury & Higgins, 2001; Smola & Sutton, 2002; Sturges & Guest, 2004). Working conditions in the healthcare sector are reported to be particularly problematic and stress inducing compared to other work sectors (Yassi, Ostry, Spiegel, Walsh, & de Boer, 2002). In fact, quality of work life (QOWL) among healthcare workers is believed to have deteriorated to the point where it is impeding the capacity of the system to recruit and retain staff needed to provide effective patient care (Koehoorn, Lowe, Rondeau, Schellenberg, & Wager, 2002). The purpose of the study was to examine the experiences of healthcare staff who participate in QOWL initiatives aimed to provide employees with creative, educational, and fun activities designed to address feelings of stress. This study included thirteen staff members from disciplines that comprise the Health Care Team at a facility specializing in aging and veteran's care. Data were collected through conversational interviews with staff from each of the following disciplines: nursing, recreation therapy, physiotherapy, creative arts, clinical nutrition, social work, audiology, occupational therapy, and pastoral care. The data were deconstructed into common themes through an open-ended process, which lead to the identification of common experiences across the data provided by the staff. Upon further comparison of the themes, it was identified that work demands were believed to detract from care provision and strained manager relations were believed to minimize quality of care. However, a strong professional identity was evident as staff described being able to rise above adversity and use their skills and competencies to provide quality care to residents. The data also suggested QOWL initiatives seem to be valuable because they provide opportunities for staff to interact socially. This interaction helps foster and strengthen connections amongst staff, which they feel transfers to the work place through improved working relationships. Participants described feelings of personal gratification that can be derived from team cohesiveness. They also acknowledged the carry over value that team work brings to residents by way of improved care provision. Furthermore, the relationships that staff members develop with one another were viewed as sources of strength, particularly in times of increased stress. In addition to the social element associated with the QOWL initiatives, these initiatives also seem to address a need for restoration, humour, and balance within the work day. Without planned opportunities for rejuvenation and humour appreciation, participants admitted that they would seldom take the time to incorporate these into their work day. Therefore, QOWL initiatives can provide staff with a reason to take a break and find their balance. The findings indicate the factors affecting QOWL are varied and complex. The findings also indicate that there can be a paradoxical nature to work within a health care setting. Paradoxes exist in relation to the provision of professional care and the provision of minimized care. Paradoxes also exist in relation to the expressed need for restoration, humour, and balance and the low priority staff will place on taking time to fulfill these needs.