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Introduction : La prévalence de l’obésité chez les adultes canadiens a atteint un niveau record en 2015 (28.1 %). Les professionnels de santé de première ligne (PPL) ont un rôle crucial dans le contrôle de cette épidémie. Bien que la littérature internationale suggère que la prise en charge de l’obésité en première ligne est sous optimale, aucune étude canadienne fondée sur l’analyse de dossiers médicaux ne s’est encore penchée sur la question. Ce manque d’information est problématique, car il est impossible de juger de l’étendue du problème au pays. De plus, puisque les aspects de la prise en charge qui représentent les plus grands défis pour les PPL canadiens restent à définir, il est difficile d’adapter les programmes de formation qui leur sont destinés. Objectifs du projet de maîtrise : Établir le premier portrait de la prise en charge de l’obésité au Québec et évaluer quels sont les déterminants de la prise en charge de l’obésité. Méthodologie : Une étude de cohorte rétrospective a été menée auprès de 439 adultes traités dans l’un des 10 groupes de médecine familiale (GMFs) participants. Des mesures anthropométriques ont été réalisées auprès des patients dans le cadre d’une visite initiale. Les notes des médecins et des infirmières présentes au dossier médical ont été révisées sur une période de 18 mois afin d’y déceler la présence d’interventions documentées liées à la prise en charge de l’obésité. Les interventions ont été extraites des lignes directrices canadiennes en matière de gestion de l’obésité. Des modèles de régression logistique mixtes généralisés ont été complétés afin d’identifier les déterminants de la prise en charge de l’obésité. Résultats : Le taux de dépistage de l’obésité était bas (31 %). Parmi les patients ayant un indice de masse corporelle (IMC) mesuré ≥30 (n=175), 52 % avaient un diagnostic d’obésité et 38 % avaient obtenu du counseling lié aux habitudes de vie au cours de la période de suivi. L’IMC et le nombre de comorbidités identifiées du patient étaient des déterminants indépendants associés à la présence d’un diagnostic au dossier médical. La présence du diagnostic de même que le nombre de visites avec une infirmière au cours des 18 mois de suivi étaient quant à eux des déterminants associés au counseling sur les habituds de vie. Quatre-vingts pour cent des dépistages et des diagnostics de l’obésité ont été réalisés par des médecins seulement. Les infirmières ont considérablement participé à la réalisation du counseling (65 % MDs/35 % infirmières). Conclusions : Les taux de dépistage, de diagnostic et de counseling liés à l’obésité dans les GMFs sont sous-optimaux. Des interventions devront être développées afin d’améliorer la qualité des soins. Ces dernières devraient explorer la promotion d’un meilleur accès à des infirmières spécialisées et l’adaptation des programmes de formation initiale et continue. / Abstract : Background : The prevalence of obesity among Canadian adults reached a record high in 2015 (28.1%). Primary care providers (PCPs) play a crucial role regarding the management of this epidemic. Although international literature suggests that the management of obesity in the primary care setting is suboptimal, no Canadian study based on medical record review has yet assessed this issue. The current lack of information is problematic because it makes it impossible to judge the extent of the problem in the country. Moreover, since the aspects of obesity management which represent the greatest challenges for Canadian PCPs remain unidentified, it is difficult to adapt PCPs’ education programs. Objectives of the project: Identify the rates of obesity screening, diagnosis and management in Quebec and evaluate the predictors of obesity management. Methodology: A retrospective cohort study was conducted among 439 adults treated in one of 10 participating family medicine groups (FMG). Anthropometric measurements were performed from each patient as part of an initial visit. The clinical encounter notes of physicians and nurses from every patient medical record were reviewed over an 18 months period in order to detect the presence of documented obesity management interventions. The looked-for interventions were extracted from the Canadian guidelines for the management of obesity. Mixed-effects regression models were used to identify the predictors of obesity management. Results: The rate of obesity screening was low (31%). Among patients with a measured body mass index (BMI) ≥30 (n = 175), 52% had an obesity diagnosis and 38% received physical activity or nutritional counseling during the follow-up period. Patient’s BMI and number of identified comorbidities were independant predictors of obesity diagnosis. The presence of an obesity diagnosis in the medical record and the number of clinical encounters with a nurse during the 18-months period were independent predictors of lifestyle counseling. Eighty percent of screening and diagnoses were performed by physicians. Nurses were considerably more involved in the provision of lifestyle counselling (65 % GPs/35 % nurses). Conclusions : The rates of obesity screening, diagnosis and counselling in Quebec FMGs are suboptimal. Interventions have to be deployed in order to increase the quality of care. Future researches should explore the impact of an enhanced access to specialized nurses and the adaptation of the current initial and continuous education programs on the rates of obesity management.

Ce mémoire porte sur l’expérience de la maternité des Ouagalaises et son évolution. Il s’intéresse au déroulement de la première grossesse, de l’accouchement et de l’entrée en maternité de deux générations de femmes. Privilégiant une approche holistico-inductive en méthodologie qualitative, notre recherche s’est appuyée sur 31 entretiens semi-directifs avec des Ouagalaises, sur 15 d’heures d’observation participante à la maternité ainsi que sur 10 d’entretiens semi-directifs avec des sages-femmes. Les résultats de l’analyse montrent que le savoir de la maternité se transmet toujours de génération en génération, et qu’il demeure encore fortement encadré par les aînées. Toutefois, les transformations en cours dans le système de santé et dans la société burkinabè ne sont pas sans incidence dans la capitale. Les jeunes femmes étant plus renseignées en matière de santé reproductive, elles ont davantage reconnu les signes de la grossesse et le début des douleurs de l’accouchement. Les accompagnantes n’ayant plus accès à la salle d’accouchement et le pouvoir des sages-femmes s’agrandissant, l’expérience de l’accouchement se modifie. Bien que les vieilles femmes n’aient plus le même contrôle sur les parturientes durant l’accouchement, leur influence est toutefois toujours très importante pendant la période post-partum. Les femmes de la jeune génération n’étant généralement pas encore mariées ou installées dans leur propre maison au moment de la grossesse, la promiscuité avec leur belle-mère à l’issue de l’accouchement augmente et le pouvoir de cette dernière est plus important qu’il ne l’était à l’époque de la génération précédente. / This thesis explores the maternity experience of women from Ouagadougou and its evolution through time. It focuses on the unfolding of the first pregnancy, the delivery process and the entrance in maternity for two generations of women. Using a analytic induction approach in qualitative methodology, our research is based on 31 semi-directed discussions with woman, 15 hours of participative observation on maternity, and, on 10 semi-directed interviews with mid wives. The results of the analysis demonstrate that the accumulated knowledge surrounding maternity, has always been transmitted from generation to generation [among woman,] and that it’s still largely influenced by the elderly. However, the transformations happening in the burkinabé society and most importantly in their health care system, is having an impact on this ‘sharing of knowledge.’ Young woman are now receiving more information on their reproductive health, and are more inclined to recognize both, the signs of pregnancy, and the on-set of labour. Because the old women doesn’t have access to the delivery room, and because of the mid wives’ growing power, the birth process of the women is changing. Even though the elderly women don’t have the same influence over their parturients during the delivery process, their impact is still present during the post-partum period. Countless of these young urban women are now residing with their mother-in-law, translating into increased power of the mother-in-law in many facets of the pregnancy. This exertion of power is now more noticeable than ever before compared to any prior generation.

Various local and international neonatal nursing organisations have identified the dire need for a comprehensive administrative database reflecting the true status of neonatal intensive care practice in South Africa. This would enable neonatal interest groups to give input into policy-making; implement, monitor, and evaluate policies; identify particular needs to be addressed by quality improvement initiatives or projects; and to promote international benchmarking. The overall aim of this study was to determine the content of an administrative neonatal database instrument to enhance delivery of the highest quality nursing care to ill and highrisk neonates nationwide. The specific research objectives of this study were to describe and refine the content of such an instrument. This was achieved by using two consensus research methods, the Nominal Group Technique (NGT) and the Delphi method. For the NGT session representatives of organisations such as NNASA, SANITSA, SANC and The National Department of Health as well as trained neonatal nurses from both public and private sector hospitals were invited. Five participants attended the NGT session. An electronic format of the Delphi method, the e-Delphi, was used and included the participants from the NGT as well as additional unit managers, paediatricians and neonatologists. By the end of the third round of the e-Delphi method, six participants had fully participated. Through both phases data collection and analysis took place simultaneously. Based on the analysis, a draft instrument for data collection was compiled. This instrument will in the near future be piloted on a larger scale. / Dissertation (MCur)--University of Pretoria, 2014. / lk2014 / Nursing Science / MCur / Unrestricted

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Parents do not always receive accurate, timely and comprehensive information regarding a positive newborn screening from their infants’ primary care providers. The dissertation outlines the investigation of this problem. The methodology of the study is discussed including the survey of parents and primary care providers using the past system, the development of a web portal with a focus on plain language and action focused handouts. Without a simple to understand parent handout the newborn screening process is more stressful to families. Review of the literature is detailed including newborn screening, patient education, health literacy, Internet usage, online health education, design of patient education websites and the evaluative process of learning tools. Surveys informed the content of the web-based patient portal for both parents and PCP. Abbreviated parental stress scores did not identify elevated stress in parents during the initial PCP visit when the NBS results and plan of care were discussed. Evaluation of the planned web portal was permanently delayed related to change in statewide policies; thus, a standalone website was developed using Agency for Health Care Research and Quality’s patient education material tool for understandability and actionability of both patient handouts and web portals. Physician actionable NBS handouts were also developed. Formative evaluation using experts’ input, one-to-one trials and small group trials of the handouts for the site were completed with minor revisions made to the portal. The formative evaluation using the simple survey tool would have provided any additional portal changes required. Strengths of the study to include survey response rates, rigor of the comments by both parents and PCPs as well as constructive feedback from NBS experts are highlighted. The weakness is the lack of having a final participant group identified or available related to local NBS policies. Recommendations for future research are highlighted as well as discussion of changes in federal policy that will now allow further NBS research without the limitations once imposed.

This study examines the influence of an educational program on the nursing assessment and management of post-operative pain. A problem-based retrospective audit was implemented to initially determine the nursing assessment and management of post-operative pain. Based on the results of the audit, educational strategies were implemented and a re-audit was carried out to evaluate the changes in nursing practice. There was evidence in the study to support the notion that nurses do not assess or manage post-operative pain effectively. The study suggested that an educational program based on the results of the problem-based audit may improve the frequency and accuracy of documentation of the assessment of pain and the documentation of the utilization of a variety of alternate approaches to relieve post-operative pain. However, the results also indicated that an educational program may not increase the frequency and dosage of analgesic administration and that nurses' perception of their nursing practice may be inconsistent with their actual practice. The study also indicated that nurses will attend educational programs if given the opportunity to participate in the development of these programs. Further studies should be carried out to examine the relationship between written documentation of assessment and management of pain and the actual assessment and management of pain by nurses, between nurses' perceptions of their clinical practice and their actual practice, and among variables environment which may affect nurses' clinical performance. Further studies should also be undertaken to determine if practice-based education programs can influence nurses' clinical practice. / Thesis / Master of Science (Teaching)

Corporate sustainability comes in a variety of shapes and the boundaries defining what can be called sustainability are disputed. This thesis explores the making of sustainability at a medium-sized company in Sweden, in this study called HygieneTech, that actively works with sustainability. Inspired by theories from science and technology studies (STS), the author discusses how different versions of sustainability are created in practices. The study is based on a theoretical approach, actor network theory (ANT), which understands reality as performed rather than observed, and since reality and its objects are enacted differently in diverse situations, reality and objects are considered multiple. Moreover, inspired by Maria Puig de la Bellacasa, “thinking with care” enables the study to tell new stories about how companies work with sustainability. This view of the actors as doing sustainability through care practice in a corporate setting paves the way for a caring analysis, exploring the different versions of sustainability as different matters of care. The enactment of sustainability is studied through participant observation, interviews and document studies. The most frequently enacted versions of sustainability are sustainability as saving resources, sustainability through standards/labels, sustainability as caring for people, and sustainability as a conscious choice. The study shows how some versions of sustainability in one setting can clash, such as when the employees at HygieneTech have to decide between caring for saving resources or caring for labelled products. Even so, in other settings versions of sustainability can be added together and thus enable the employees to care for sustainability both as a marketing device and as a conscious choice. Furthermore, the thesis shows that sustainability is sometimes made absent in relation to other matters of care, such as cleanliness and economy, while in other settings economy and sustainability can be added together. Finally, the thesis shows how sustainability, while enacted in several versions, still can cohere though professional tinkering. / Hur företag arbetar med hållbarhetsfrågor kan se väldigt olika ut och många gånger uppstår stridigheter kring vad som får kallas hållbart. Denna avhandling studerar hur hållbarhet iscensätts i ett medelstort företag i Sverige som arbetar aktivt med hållbarhetsfrågor. Företaget är i denna studie anonymiserat och kallas HygieneTech. Genom att använda teorier från studier av teknik och vetenskap (STS) studeras hur olika versioner av hållbarhet skapas i olika praktiker. Studien utgår från ett teoretiskt angreppssätt, aktör-nätverksteori (ANT), som genom en symmetrisk analys studerar såväl materiella som mänskliga aktörer. ANT anser att verkligheten och dess objekt görs snarare än upplevs och eftersom verkligheten iscensätts på olika sätt i olika situationer, är verkligheten och objekten multipla. Genom att studera hållbarhet som omsorgspraktiker, inspirerad av Maria Puig de la Bellacasa, skriv nya typer av historier kring hållarbetsarbete på företag. Att tänka med omsorg (”thinking with care”) ger forskaren möjlighet att istället för att återberätta den traditionellt återkommande historien om företaget som en vinstmaximerande rationell agent, lägga fokus inte bara på rationalitet, utan även affektion. Hur hållbarhet görs i praktiken studeras genom deltagande observationer, intervjuer samt dokumentstudier. Denna avhandling visar på att det finns ett flertal olika versioner av hållbarhet som iscensätts vilka ofta är sammanknutna i varandra. Några av de viktigaste versionerna av hållbarhet i HygieneTech handlar om hållbarhet genom att spara resurser, hållbarhet genom märkningar/standarder, hållbarhet genom omsorg om människor och hållbarhet som ett medvetet val. Vissa av dessa versioner kan adderas samman, men i andra situationer ställs de mot varandra. Studien diskuterar även exempel på när hållbarhet görs osynligt på grund av att andra värden såsom renlighet och ekonomi istället sätts i fokus, samt hur hållbarhet trots sina olika versioner hålls samman.

This study is designed to assess the effectiveness of closed-circuit television (CCTV) as a post-partum teaching tool using an interactive problem-solving approach, compared with conventional group classes, in fostering the acquisition of skills and knowledge around baby care. A second primary objective is to determine the level of satisfaction of respondents with both approaches to post-partum education. An extensive discussion of the theoretical basis for the proposal is presented, drawing upon and synthesising concepts from the literature of Sociology, Education and Health Sciences. The conceptual model (Sword 1990) represents a synthesis of Mezirow’s (1978) theory of the transformation of meaning perspective with D’Zurilla’s (1986) cognitive-appraisal approach to the acquisition of new knowledge. In addition, adult learning principles are applied to the selected teaching strategies to identify optimal conditions of learning (Zemke and Zemke 1988). A two-group cohort design was used for randomisation, and the data collected was subjected to both quantitative and qualitative analysis. Two measures of learning were not significantly different for the videotape and live class groups. Statistically significant differences were identified between the groups in the attitude measures of convenience and ease of understanding. There was also a measurable difference in levels of satisfaction with the different approaches used. However, the results of this study suggest that combining an interactive, problem-solving approach to post-partum education with CCTV, is no more effective than live group classes in achieving knowledge acquisition for new mothers. CCTV can be used to address the basic and repetitive aspects of patient education and it appears to be effective for short-term knowledge gain. Several issues for further study are proposed in relation to the planning and implementation of alternative approaches to conventional post-partum teaching, as well as the design of future televised patient education programmes. / Thesis / Master of Science (MSc)

Hospital admissions for patients close to the end of life are considered ‘inappropriate’ in contemporary English health policy. Hospitals are supposedly unable to offer a ‘good’ death for patients, and dying there is thought to contradict patient choice, since patients are assumed to want to die at home. However, almost half of all deaths in England in 2015 occurred in hospital, and of these, nearly a third died within three days of admission. This thesis seeks to explore why these admissions are considered to be a problem and how they occur. Through a systematic review of UK literature I found that it cannot be stated that most patients want to die at home, because of the extent of missing data (preferences not asked, expressed, reported or absent). This finding challenges the justification that admissions are inappropriate because they contravene patient choice. Similarly inconclusive evidence about the undesirability, cost, and lack of need for patients to be in hospital were also found in a review of policy. Together with analysis of historical trends in hospital and hospice provision, it is apparent that attitudes towards end-of-life admissions reflect existing tensions about the role of hospital as an acute provider, and as a place of death. An analysis of interviews conducted with healthcare staff and next-of-kin involved in the admission of patients (case-patients) who died shortly after being admitted to Meadowbridge, a large English hospital explored these tensions further. I found that whilst hospital was not recognised as a place where ‘good’ deaths typically occurred, it was acknowledged as an emergency place of care. In this context, patients without obvious need for hospital care were nevertheless admitted to the hospital and the environment was subsequently recognised to offer distinct benefits. The need for emergency care reflected the difficulties of providing end-of-life care in the community. For dying to occur appropriately, home had to be adapted and care organised by healthcare staff. Both tasks were complicated by the unpredictability of dying, and family carers helped to absorb much of the uncertainty and support patients to die at home. Ambulance staff became involved when patients had care needs that exceeded care quickly and easily available in the community. When called to the case-patients, ambulance staff instituted familiar practices in transferring them to hospital. Hospital was recognised as a default place of care because ambulance staff struggled to facilitate alternative care and lacked sufficient professional authority to keep patients at home. The admissions of the case-patients represent the best attempts of staff to navigate the tangled practices of end-of-life care. These practices are the result of the actions of the staff, which in turn both constrained and enabled their action in providing care to patients. The term ‘inappropriate’ to describe admissions does not encompass these attempts, and moreover, devalued the significant care provided by healthcare staff in the community and hospital.