Resumo: A humanização é vista como um conjunto complexo de atitudes e ações motivadas por pensamentos éticos, humanísticos, sociais e holísticos. Hoje, a proposta de humanização em UTI tem um horizonte mais amplo, englobando desde o ambiente físico até as relações entre as equipes de saúde. Dessa forma, valorizar a presença de acompanhantes na instituição hospitalar e apreender sua percepção é um processo fundamental para o alcance de uma prática assistencial realmente humanizada. Assim, esse estudo tem o objetivo de analisar a percepção do acompanhante de pacientes que estão em processo de hospitalização, na busca da assistência humanizada em Unidade de Terapia Intensiva. É uma pesquisa de abordagem qualitativa, sendo entrevistados os acompanhantes nas UTIs pediátrica e coronariana do HC da Faculdade de Medicina de Botucatu - UNESP. Os depoimentos foram analisados através da Técnica de Análise de Conteúdo proposta por Bardin (96). As categorias identificadas foram: acolhimento e ambiente da UTI: estrutura física e profissionais de saúde. As percepções dos familiares em ser acompanhante refletem uma não diferenciação em ser acompanhante e ser visitante, porém enfatizam que a presença da família, mesmo nos horários de visitas, auxilia na recuperação do paciente, como também os tranqüilizam. Os acompanhantes consideram as informações fornecidas pelos profissionais de saúde, adequadas e verdadeiras. O atendimento das unidades é percebido como satisfatório, porém revelam ser necessário um repensar sobre as normas e rotinas das unidades, principalmente em relação aos horários de visitas. A percepção sobre acomodação reflete a possibilidade de estar próximo ao paciente, porém revelam a dificuldade por não ter um local apropriado para se acomodar que se localize próximo a UTI. Percebem ainda... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Humanization is viewed as a set of complex attitudes and actions motivated by ethical, humanistic, social and holistic thoughts. Today, the proposal of humanization at ICUs has a broader horizon which includes the physical environment as well as relations between health care teams. Hence, valuing the presence of companions in hospitals and apprehending their perceptions is a fundamental process for accomplishing an actually humanized care provision practice. Therefore, this study aimed at analyzing the perceptions of companions of patients undergoing the hospitalization process in the search for humanized care at an Intensive Care Unit. It is a qualitative study in which companions of patients hospitalized at the pediatric and coronary ICUs of the Botucatu School of Medicine University Hospital - UNESP were interviewed. The reports were analyzed through the Content Analysis Technique proposed by Bardin (96). The identified categories were: patient reception and the ICU enviroment - physical structure and health care professionals. Family members' perceptions of being companions reflected a non-differentiation between being a companion and being a visitor; however, they emphasized that the presence of relatives, even if only at visiting hours, helped patients' recovery as well as made them calm. Companions considered the information provided by health care professionals to be adequate and truthful. The care given at the units was perceived as satisfactory although the respondents reported the need to reconsider the units' rules and routine, especially as concerns visiting hours. The perception concerning acommodation reflected the possibility of being close to the patient; however, they revealed the difficulty of not having an appropriate accomodation area near the ICU. They also perceived that the University Hospital... (Complete abstract click electronic access below) / Orientador: Maria de Lourdes da Silva Marques Ferreira / Coorientador: Ione Correa / Banca: Ilda de Godoy / Banca: Maria José Sanches Marin / Mestre

Advance care planning (ACP) is a process of discussing the patient’s wishes and preferences for future health care. ACP allows for the patient to retain their autonomy and involves informing the patient about their illness, prognosis, and their health care options. Despite the known advantages of completion of ACP forms, ACP discussions are minimal during primary care visits. The purpose of this DNP project was to identify primary care providers (PCP) beliefs and attitudes regarding barriers to addressing ACP with patients with a chronic illness in the primary care setting at one family practice clinic in Tucson, Arizona, and to determine if providing educational information will increase the PCPs intent to address ACP within clinical practice. A pre-survey, educational handout, and post-survey containing Likert-type scale questions and one ranking format question was created and sent via email to potential participants within the family practice clinic. The pre-survey requested demographic characteristics, and both the pre and post surveys assessed the PCPs beliefs and attitudes towards barriers to addressing ACP. 42 potential PCPs were asked to participate in the online surveys, eight (19%) completed the pre-survey, and four (9.5%) completed the post-survey. The data obtain from the surveys indicate lack of time, discomfort with the subject, and communication barriers as the most frequently reported perceived barriers to addressing ACP in the primary care setting. The results from this project can be used to understand PCPs beliefs and attitudes towards addressing ACP in the primary care setting and how this can affect future care of the patient when a serious illness occurs.

In this submission I use previously published works, my book Rethinking Residential Child Care and two articles ‘Reading Bauman for Social Work’ and ‘Care Ethics in Residential Child Care: A Different Voice’, to develop a critical account of changing rationalities of care in the context of residential child care. Much of my writing draws upon professional experience gained over 20 years of residential child care practice and I begin this account by justifying the use of this experience as the basis of professional and academic knowledge. I then go on to explicate some of the discursive influences that have fed into the way that residential child care is currently constituted. Specifically, I locate many current assumptions and practices within dominant neoliberal political systems and assumptions. This has led to the commodification, instrumentalisation and, within an increasingly regulated polity, the bureaucratisation of public care. Against this backdrop, public care is conceived of in narrow and abstract concerns around rights and protection. The concepts of care itself and of upbringing that ought to be at the heart of adult engagement with children are left, largely, unarticulated. I seek to address this gap by developing possible conceptualisations of care and upbringing. I conclude by arguing that residential child care and, indeed, much public care, is governed by the wrong rationalities, by economic and administrative priorities rather than caring and relational ones. Finally, I suggest some directions that future work might take.

Magister Public Health - MPH / Introduction: Nigeria operates a three tiered health care delivery system with a large percentage of health care delivery vested at the primary care level. There has been over the years a continued effort by the government to decentralize health care service thereby increasing the range of services provided at the primary care level. Despite all these efforts there is still low utilization of primary health care services. This study therefore seeks to explore the factors that may be responsible for poor utilization of primary health service in Nasarawa State, Nigeria using two primary health clinics in Lafia local government area as case studies. Methodology: The study was carried out using the qualitative research methodology primarily using two data collection methods, the focus group discussions and individual interviews. A total of sixty participants were sampled, these consisted of ten members of staff, twenty non facility users and thirty facility users. Thirty individual interviews were conducted and four focus group discussions held with staff and facility users at the two clinics. Facility users were randomly selected as they attended the clinic on the data collection days and were invited to participate in the study. Every second patient attending the clinic was selected for the focus group discussion and every third person for the interviews. The staff participants were randomly selected based on their availability while non-facility users were selected using snowballing. Data was analyzed using thematic analysis method. Findings: Two major themes emerged following data analysis; these were perception and experiences of facility users and barriers to utilization of health services. Users had a good perception of the services they received and are reasonably satisfied but certain deficiencies in the health care systems compromised the quality of service. Several factors were however hindering the utilization of these services and these include mainly institutional factors such as lack of infrastructure, equipment and staffing constraints; household factors such as cost of service and responsibility of decision making and other factors such as stigmatization and beliefs. Conclusion: Facility users of these clinics seem to have an overall good impression of services at the clinics; however there are certain fundamental deficiencies that need to be urgently addressed to improve the care provided at these clinics as these constitute barriers to utilization. These deficiencies such as the absence of electricity and water, lack of basic work equipment and inappropriate staff composition need to be addressed by the local government health department to ensure utilization and improved quality of service.

The aim of this study was to determine the knowledge of critical care nurses regarding forensic and liability issues in the critical care environment in order to design an education programme on the topic. A quantitative, descriptive, contextual research design was used and convenience sampling implemented. A survey, using a questionnaire as measuring instrument, was conducted among critical care nurses in selected private hospitals in South Africa. The response rate was 85%. Validity and reliability of the research was ensured. The total average percentage achieved by the group of 171 respondents was 38.46%, which was 21.54% below the set competency indicator of 60%. Only nine respondents achieved a percentage of or above 60%. Results proved that the respondents required intensive training on the topic. The outline of an education programme to address knowledge deficiencies regarding forensic and liability issues in the critical care environment was presented in PowerPoint presentation format. / Dissertation (MCur (Clinical))--University of Pretoria, 2007. / Nursing Science / MCur / unrestricted

This thesis uses an ethnographic study to interrogate the policy discourse of capturing ‘child voice’ specifically in relation to a ‘looked after’ child. In recent years, attempts have been made to involve children who are ‘looked after’ in discussions and decisions about their care arrangements to ensure that their voice is heard. To ensure this happens, children ‘in care’ are asked about their care placement regularly as part of the care planning review process and their views are incorporated into decisions about their care plan. This study focuses on the lived experiences of a seven-year old female child, who I have referred to as ‘Keeva’, who is ‘in care’ under a Kinship Care arrangement. Over a period of a year, I was based in Keeva’s home one afternoon a week to gain insights about her lived experience as a ‘looked after’ child and how she represented herself. I also observed three care planning review meetings to see how her voice was captured by those charged with her care and how she was represented. I relate Keeva’s experience through seven narrative episodes to capture the rich complexity of the social world she inhabits. I explore aspects of her home and family, her interactions with others and her experience of exploring physical spaces both inside and outside the home. I suggest that these experiences underpin her sense of self and how she relates to others. Drawing on the ideas of Bourdieu, I suggest these experiences and her sense of place in the social order write themselves ‘onto her’ through her habitus and dispositions. Using a Foucauldian lens, I problematise the notion of voice as I contest that the child I observed engaged fully in the statutory processes that surround her. I suggest Keeva, a child who is ‘looked after’, will neither have nor feel she has the agentive properties to influence the care planning process. Instead, as her voice is irrevocably bound up in a bureaucratic process that is uncritically accepted as representative of her, she is obscured as a consequence. I also examine the multivocity in representations of Keeva highlighting the competing discourses of safeguarding, child protection and the ’rights-based’ agenda. I conclude that Keeva was not well represented in care planning reviews and had very little influence in decision-making about her care plan. Despite believing the opposite, those charged with her care failed to hear her or take note of what she said. Furthermore, there was an absence of criticality in representations of Keeva allowing Keeva to be constructed by those professionals involved with her care, in an unchallenged way. As a consequence she was silenced and less visible than the process itself.

The economic evaluation (EE) component of health technology assessments (HTA) often defines value in terms of health related quality of life, with many HTA agencies requiring the use of EQ-5D based Quality Adjusted Life Years (QALYs). These approaches do not capture value derived from patient experience factors and the process of care. This thesis widens the valuation space beyond this limited perspective, taking account of such factors, using monetary values generated from a discrete choice experiment (DCE), incorporating these into a discrete event simulation (DES) and conducting a cost-benefit analysis (CBA). The case study is monitoring individuals with ocular hypertension. Five strategies were compared using a DES: 'Treat All' at ocular hypertension diagnosis with minimal followup; Biennial monitoring (either in primary or secondary care) with treatment according to predicted glaucoma risk; and monitoring and treatment according to the UK National glaucoma guidance (either conservative or intensive). DCE based Willingness to pay (WTP) estimates for relevant health outcomes (e.g. risk of developing or progressing glaucoma and treatment side effects), patient experience factors (e.g. communication and understanding with the health care professional) and process of care (e.g. monitoring setting) were obtained. Conditional logit, mixed logit preference space and mixed logit WTP-space (rarely used within health economics) econometric specifications were used. These WTP valuations were aggregated in the DES, as fixed mean values or allowing variation between simulated individuals. While the standard cost-utility analysis (CUA) using EQ-5D implied 'Treat All' was most likely cost-effective, CBA with broadened valuation space identified, consistently across different econometric specifications, 'Biennial hospital' as the best choice. This thesis proposes an approach to broaden the valuation space that can be promptly used for EE-HTA. Researchers should be attentive of the valuation space considered in their EE and choose wisely the EE approach to be used (e.g. CUA and/or CBA).

Objective – Some of the most vulnerable children and youths in our country are those in out of home care, and these children demonstrate higher rates of psychopathology and fare more poorly in school and in social relationships than their peers. Typically, when studying at risk populations, negative outcomes are examined, thereby ignoring those who do well despite their vulnerability. These children, who demonstrate positive patterns of functioning and development despite their exposure to adversity, are considered resilient. The objective of this study was to identify factors associated with a resilient outcome among children and youths in out of home care. Method – The study sample was comprised of 417 children 10 to 15 years old in Ontario who had been removed from their homes of origin and placed in out of home care. Predictor variables were selected based on previous research findings in the area of resilient outcome. In the cross-sectional study, a series of sequential logistic regression analyses were conducted to identify factors associated with a resilient outcome among children in out of home care. These children were then followed one year later. In the longitudinal study, another series of sequential logistic regression analyses were used to identify variables that were related to future resilient outcomes among the same children in out of home care. Results – The findings showed that many of the independent variables predicted resilient outcome on the different dimensions. Furthermore, overall resilient outcome was best predicted by the foster parental report of high sociability. Conclusion – The findings in the present study confirmed that there exists a subset of resilient children among children in out of home care. The findings allowed for the identification of some factors related to resilient outcome among this population. The practical implications of these findings are discussed.

Background: Improving coordination of care is a major challenge for health systems internationally. Tools are required to evaluate alternative approaches to improve coordination from the patient perspective. This study aimed to develop and validate a new measure of coordination for use in a primary care setting. Methods: Four methods were used. Firstly, a concept analysis was undertaken to identify the essential attributes of coordination drawing upon literature from health and organisational studies and to establish its boundaries with related concepts such as continuity of care, integration and patient centred care. Secondly, existing measures of coordination were reviewed to assess the extent to which item content reflected the definition arising from the concept analysis and to appraise psychometric properties. Thirdly, a new instrument, the Care Coordination Questionnaire (CCQ), was developed utilising items from existing questionnaires and others developed following focus groups with 30 patients. Ten cognitive interviews were used to evaluate the items generated. Finally, the CCQ was administered in a cross sectional survey to 980 patients. Item and model analyses were performed. Test-retest reliability was evaluated through a second administration of the CCQ after two weeks. Concurrent validity was evaluated through correlation with the Client Perceptions of Coordination Questionnaire (CPCQ). Construct validity was evaluated through correlation with responses to a global coordination item and a satisfaction scale and the testing of two a prior hypotheses: i) coordination scores would decrease with increasing numbers of providers and ii) coordination scores would decrease with increasing numbers of long-term conditions. Results: The concept analysis suggested that coordination should be considered as a process for the organisation of patient care characterised by: purposeful activity, information exchange, knowledge of roles and responsibilities, and responsiveness to change. The systematic review identified 5 existing measures of coordination and a further 10 measures which incorporated a coordination subscale. Only one demonstrated conceptual coverage but had poor psychometric properties. A new instrument was therefore developed and tested as described above. 299 completed surveys were returned. Respondents were predominantly elderly and of white ethnicity; approximately half were female. Five items were deleted following item analyses. Model analysis suggested a four factor two-level model of coordination comprising of 18 items. This correlated well with the CPCQ, the global coordination item and satisfaction scale. The a priori hypotheses were upheld. Retest reliability was acceptable at the patient group level. Conclusions: The CCQ has demonstrated good psychometric characteristics in terms of item responses, reliability and construct validity. Further exploration of these properties is required in a larger, more diverse sample before it can be recommended for widespread use, but it shows potential utility in the evaluation of different approaches to coordinating care.

Primary nursing is a system of delivering nursing care when one nurse is responsible and accountable for the assessment of the patient's needs as well as the planning, implementing and evaluating of the nursing care throughout the patient's hospitalization. These activities are done in collaboration with the patient and other members of the health team. This system is a relatively recent development in the field of nursing. There has been little research done to either describe or evaluate primary nursing, particularly in the area of psychiatry. This study was an attempt to include both patients and nurses in such an evaluation. A validated and reliable questionnaire was developed by the author to obtain data related to patients' and nurses’ perceptions of the occurrence, importance and satisfaction of specific primary nursing behaviours. The questionnaire was administered to twenty-nine patients and their primary nurses during the last week of the patient's hospitalization. Nurses and patients reported that primary nursing behaviours related to discharge had a low occurrence rate. However, they attributed a high degree of importance to these same behaviours. Both groups reported a low occurrence and importance score for primary nursing behaviours related to family involvement with the primary nurse and the patient's treatment program. Both nurses and patients agreed on the occurrence and importance of most of the primary nursing behaviours. There was less agreement in the area of satisfaction. / Applied Science, Faculty of / Nursing, School of / Graduate