Acknowledgements First and foremost, I am very grateful to my supervisor, Dr. Kerstin de Wit, for her mentorship and guidance throughout my time as a graduate student. It has been a pleasure to work with someone so innovative and passionate about clinical research. Her ability to bridge thrombosis and emergency medicine research to improve and change clinical practice is inspiring. I am grateful to my supervisory committee members, Dr. Teresa Chan, Dr. Lori-Ann Linkins, and Dr. Mathew Mercuri, for their continuous support throughout this process. Our scientific discussions were always insightful, and motivated me to push myself as a researcher. I am very thankful to the entire EMeRGE Research Group for creating such a helpful and friendly environment. Their diligence and commitment to conducting high-quality research motivated me to do the same, and greatly expanded my knowledge on clinical research. Working with this team made my experience as a graduate student very memorable. I would like to thank my family and friends for all of the support they gave me throughout this entire process. Their constant encouragement and emotional support helped me overcome challenges and persevere, for which I am infinitely grateful. / Background: There is an evidence-practice gap between guidelines for diagnosing pulmonary embolism (PE) and emergency physician practice. This is concerning because computed tomography (CT) scanning is being overused to exclude PE in the emergency department (ED). It is possible that the answer behind this lies within the physician-patient relationship. Past research on shared decision-making strategies have shown to decrease use of hospital resources, and improve patient outcomes. Objective: The aim of this three-part MSc thesis was to achieve a patient-centered approach to the testing of PE in the ED. Method: 1) A systematic review on existing shared decision-making models used for testing and/or treatment of medical decisions in the ED was conducted. 2) Qualitative interviews with ED patients being tested for PE identified patient-specific values and preferences which may present as barriers to patient-centered care in the ED. 3) Both the systematic review and patient interviews informed the development of a new shared information tool to be used in the ED. Results: The systematic review found that shared decision-making interventions in ED patients tested for acute coronary syndrome and clinically-important traumatic brain injuries can potentially reduce hospital admissions and increase discharge rates without negatively affecting health outcomes. The qualitative interviews highlighted four major themes: 1) patient satisfaction comes from addressing their primary concern; 2) preference for imaging over clinical examination; 3) patients expect 100% certainty when given a diagnosis; and 4) patients expect individualized care throughout their entire ED visit. This data led to the formation of a shared information sheet which ensures that testing decisions for low-risk PE patients align with patient-specific values. Conclusion: By placing the focus on patient-centered care, this study incorporates evidence-based medicine with patient priorities in order to improve patient outcomes in the ED. / Thesis / Master of Science (MSc) / Pulmonary embolism occurs when blood clots form in veins of the legs, and travel to the lungs, causing chest pain and shortness of breath. There are well-established, evidence-based guidelines on how to diagnose pulmonary embolism. Diagnostic tools such as the Wells score and D-dimer have been proven to be safe and effective in ruling out pulmonary embolism in low risk patients preventing the need for a CT scan. However, CT scans are still being overused to diagnose pulmonary embolism in low risk patients. Unnecessary testing in the emergency department (ED) exposes patients to the harms associated with CT scanning: such as increased risk of cancer, and diagnosing blood clots that are not actually there, resulting in unnecessary treatment. It is possible that the answer behind the over-testing of PE in the ED lies within the physician-patient relationship. This three-part study first reviewed all prior studies on shared decision-making strategies, which are techniques used to help physician align medical decisions with patient-specific values, in the ED. Second, we employed qualitative methods to identify patient-specific values and preferences on PE testing in the ED. Finally, both of these aims informed the development of a patient-centered shared information tool to overcome barriers to patient-centered care. Ultimately, the goal of this study is to achieve a patient-centered approach to the testing of pulmonary embolism in the ED.

Background: The number of people suffering from myocardial infarction in Sweden is decreasing, despite this the prevalence is high. Being diagnosed with myocardial infarction results in medical interventions, lifestyle changes and eventual pharmacological treatment to prevent relapse. Aim: The aim of this study was to describe patients' experience of life after amyocardial infarction. Method: A literature-based study was used, based on ten qualitative articles. The articles were analyzed in a five step-model, which resulted in three main-themes and sixsub-themes. Results: The results present life after myocardial infarction as difficult to understandand manage. This could be related to their physical and mental changes, which resulted in fear and anxiety that affected their everyday lives through experienced limitations. Fatigue where also a contributing factor in the limitations of everyday life due to energyloss. This was hard to handle without support from both relatives and health care professionals. It was essential to be meet as a unique human and not reduced to a diagnosis. Life became more valuable through the survival and gave the individuals a second chance with different priorities. Some adjusted to the lifestyle changes, while others were reluctant. Returning to work where seen as an indicator for being healthy and a return to life as before. Conclusion: To establish well-being and security through nursing, a holistic approach that is the basis of person-centered care helps nurses to see the individual situation. / I Sverige minskar antalet personer som drabbas av hjärtinfarkt trots detta är förekomsten fortfarande hög och ca 5800 avlider varje år. Hjärtinfarkten medför både fysiska och psykiska förändringar hos den drabbade. Syftet med denna litteraturstudie är att belysa patienters upplevelse av livet efter en genomgången hjärtinfarkt. I studiens resultat framkom det att både män och kvinnor såg situationen och livet efter en hjärtinfarkt som svår att hantera, då både kroppen och hjärtat inte längre upplevdes pålitligt. Detta resulterade i rädsla och oro som begränsade det vardagliga livet. Personerna upplevde att det var svårt att tolka kroppsliga signaler, vilket gav en osäkerhet som resulterade i ångest och katastrof tankar om döden. Detta medförde även att de inte vågade anstränga sig fysiskt. Känslor som ilska, frustration och nedstämdhet upplevdes på grund av den mentala och fysiska utmattningen som var svår att förstå. Personerna kunde inte utföra vardagsaktiviteter i samma utsträckning som innan hjärtinfarkten, vilket resulterade i en känsla av passivitet. Det utrycktes även ett behovav stöd från anhöriga och vårdpersonal för att klara av sin situation och det vardagligalivet. Vårdpersonalens bemötande och agerande var avgörande för hur patienterna förstod informationen som gavs, deltog i rehabilitering och klarade att genomföra nödvändiga förändringar när det gäller ohälsosamma levnadsvanor. Vårdpersonalens förmåga att skapa en trygg atmosfär tillsammans med att se patienten som människa var viktigt för att uppnå välbefinnande. Anhöriga sågs som en resurs för personerna då de kunde avlasta vardagssysslorna samtidigt som de lyssnade, vilket gav trygghet och välbefinnande hemma. Patienter upplevde att familjen satt för höga krav och fick då stödet från vänner. Partnerrelationen kunde påverkas genom den minskade sexuella relationen som grundade sig i rädsla för de fysiska förändringarna och upplevdes svårt att prata om med partnern. Livet efter en hjärtinfarkt beskrevs som en ny chans till livet där nya värderingar uppstod. Personerna upplevde att arbetsgivarens attityd och förståelse för situationen var avgörande för fortsatt sjukskrivning. För att kunna möta patientens unika behov och skapa välbefinnande genom omvårdnad, är personcentrerat förhållningssätt lämpligt för att vidhålla en helhetssyn på patienten och inte bara det fysiologiska tillståndet.

Bakgrund: Idag finns cirka 150 000 individer i Sverige med demenssjukdom och gruppen växer i takt med att befolkningen blir äldre. Personcentrerad vård har sitt ursprung inom humanistisk psykologi och begreppet beskrevs redan på 1960-talet. Personcentrerad vård är en av sjuksköterskans sex kärnkompetenser och är en god grund för att tillgodose de varierande behov som finns hos den komplexa patientgruppen. Syfte: Syftet med litteraturstudien är att belysa vad sjuksköterskans erfarenheter är av att ge personcentrerad vård till patienter med demenssjukdom. Metod: En litteraturstudie vars resultat baseras på studier med kvalitativ ansats. Vid sökning användes databaserna; CINAHL, PsycINFO och PubMed. Resultatets femton artiklar analyserades enligt Forsberg och Wengströms (2016) femstegsmetod. Resultat: Resultatet presenterades med hjälp av fyra huvudteman; organisationen, patientrelationen, kommunikation, vårdmiljö samt sju underteman; stöd på arbetsplatsen, kompetensutveckling, tids- och personalbrist, livsberättelsen - patientens historia, personliga attribut, samverkan i team och dokumentationsrutiner. Konklusion: Hälso- och sjukvården är en komplex organisation och sjuksköterskan står inför många utmaningar. Otillräckligt stöd från både ledning och kollegor samt vårdmiljöns utformning var alla faktorer som påverkade sjuksköterskans möjlighet att tillgodose personcentrerad vård. Vidareutbildning i kommunikation och demenssjukdomar upplevde sjuksköterskorna gynnsamt för deras arbete. Även vikten av att ha en god relation till patienten och att lära sig deras livshistoria framhölls som viktiga komponenter i den personcentrerade vården. / Background: Today there is approximately 150 000 individuals with dementia in Sweden and the group is expanding at the same time the population is ageing. Person centred care has its roots in humanistic psychology and the concept was described already in the 1960’s. Person centred care is one of the nurses’ six core competencies and is a good foundation for the various needs amongst the complex patientgroup. Aim: The aim for the literature review is to illustrate nurses’ experiences of giving person centred care to patients with dementia. Method: A literature review with a result based on studies with a qualitative approach. Databases used was CINAHL, PsycINFO and PubMed. The fifteen articles of the result were analyzed according to Forsberg and Wengströms (2016) model of five steps. Results: The result was presented using four main themes; the organisation, patient-relations, communication, care environment and seven subthemes; workplace support, quality of competens, lack of time and personel, lifestory - a patient’s history, personal attributes, team cooperation and documentation routines. Conclusion: The health-care system is a complex organisation and the nurse faces many challenges. Insufficient support from both management and colleagues and the formation of the care environment was all factors that affected the nurses’ ability to provide person centred care. More education in communication and different types of dementia illnesses were seen by nurses as positive contribution in their work. Even the importance of having a good relationship with the patient and learn about their lifestory was brought to daylight as important components in person centred care.

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Over the last decade, long-term care facilities have transitioned from institutional care models that focus on person-centered care, in which the resident is the center of the care. The purpose of this study is to explore the nurse and certified nursing assistant perception of the person-centered care services they deliver. Jean Watson's theory of human caring is the theoretical framework that guided this study. The theory focusing on the human caring experiences and person-centered care is being characterized as a caring feeling. The carative factors of Watson's theory, the fundamental concept of caring, has been associated with improved outcomes for the resident and the caregiver. Using a phenomenology research design, 3 focus groups of 15 nurses and 10 certified nursing assistants (CNA), working in a long-term care facility, were asked questions to describe their perception of person-centered care. The responses from the 25 participants were stored and organized using Nvivo. The thematic analysis revealed that the nurses and CNAs perceived person-centered care to include the caring and compassionate approach taken when care is being delivered. The participants also shared that person-centered care included involving the resident in decision making through communicating openly and developing relationships. The discussions revealed that 8 carative factors influenced their understanding, with the main factor being the creative problem-solving method for decision making. The �ndings from this study have the potential to impact positive social change at the organizational level, influencing the delivery of care within long-term care settings.

Background: In Peru it is estimated that ten percent of the population suffers from a disability. Nursing in rehabilitation setting is when the nurse aims to maximize the quality of life for a patient suffering from disability or chronic disease. Aim: The aim is to describe nursing by care providers on a rehabilitation center in rural Peru. Method: The method in this thesis is observational study with ethnographic approach. The observations is performed on a rehabilitation center in rural Peru. Result: Two themes and four sub-themes were identified from the collected data. Nursing care with including sub-themes clinical investigation and family-centered care. Mobilization and independency with including sub themes improve the chance to mobilize and promote self-management. Conclusion: The Peruvian nursing care provided through a rehabilitation center in rural Peru shows that care providers are working with very basic equipment and limited instructions about how to maximize the patient outcome with very few recourses. Education methods are adjusted to their patient group to promote family centered care. Further research: Guidelines for rehabilitation nursing should be developed for settings without high technologized equipment as well as how to maximize the patient and family outcome through family centered care with limited resources. / Bakgrund: I Peru beräknas tio procent av befolkningen vara drabbad av ett funktionshinder. Rehabiliterings-omvårdnad syftar till att maximera livskvalitén för den patient som lider av ett handikapp eller en kronisk sjukdom. Syfte: Syftet är att beskriva vårdgivarens omvårdnad vid ett rehabiliteringscenter på Perus landsbygd. Metod: Metoden i denna studie är en observationsstudie med etnografisk ansats. Observationerna är utförda vid ett rehabiliteringscenter på Perus landsbygd. Resultat: Två teman och fyra sub-teman har identifierats utifrån insamlad data. Omvårdnad som inkluderar klinisk undersökning och familjecentrerad vård. Mobilisering och ökad självständighet som inkluderar ökad chans till mobilisering och främjande av egenvård. Slutsats: Den peruanska omvårdnaden som erbjuds vid ett rehabiliteringscenter på landsbygden i Peru visar att vårdgivare arbetar med väldigt basal utrustning samt begränsade instruktioner för att patienten ska kunna uppnå maximal funktion med få resurser. Undervisningsmetoder är anpassade till deras patientgrupp för att främja familje-centrerad omvårdnad. Vidare forskning: Riktlinjer för rehabiliteringsomvårdnad bör utvecklas avsett för en miljö utan högteknologisk utrustning samt beskriva hur patienter tillsammans med sin familj uppnår maximalt resultat med få resurser att tillgå.

Bakgrund: Hälsan hos barn med funktionsnedsättning är sämre än hos andra barn. Tillståndet påverkas av den familj som barnet lever i samt den omgivande miljön. Familjerna har många samarbetspartners i vård och omsorg och barnet kräver mer stöd och omvårdnad än barn i allmänhet behöver av sina föräldrar. Det är viktigt att hitta metoder som sänker påfrestningarna samt förebygger ohälsa i familjen. Syfte: Syftet med denna uppsats har varit att beskriva föräldrars, barns och vårdgivares upplevelse av familjecentrerad omvårdnad, FCC, som riktar sig till familjer som har barn med funktionsnedsättning. Metod: Litteraturöversikt valdes som metod och baseras på 13 vetenskapliga artiklar med både kvalitativ och kvantitativ ansats som analyserats. Resultat: FCC definieras i artiklarna i termer av kvalitét och tillgänglighet men även som att som förälder bli lyssnad på, få tillräckligt med tid, bli bemött med respekt, ha ett gemensamt beslutsfattande mellan föräldrar och professionella och att få information, vid behov anpassad. Genom flexibla arbetssätt som är anpassade efter barnet och familjens behov både inom sluten och öppen vård och inom habilitering, kan stress minska både i familj och hos vårdpersonal. Det finns dock grupper med funktionsnedsättning som uppfattar vården som lägre familjecentrerad än andra familjer. Slutsats: Hörnstenen i familjecentrerad omvårdnad är samarbete mellan vårdgivare och familj vilket främjas av att vårdgivare tar hänsyn till och respekterar familjens kultur och bakgrund. Artiklarna i studien visar på att familjecentrerad omvårdnad ger stöd för att vara en framgångsfaktor inom vården. FCC främjar barnets och familjens hälsa vilket gynnar samhällsekonomin på sikt. / Background: The health of children with disabilities is worse than other children. The state is influenced by the family that the child live in and the surrounding environment. The families have many partners in health care and the child needs more support and care than children in general need of their parents. It is important to find ways to reduce stress and prevent illness in the family. Purpose: The purpose of this study was to describe parents, children and healthcare experience of family-centered care, the FCC, which is aimed at families who have children with disabilities. Method: Literature review was elected as a method and is based on 16 scientific articles with both qualitative and quantitative approach analyzed. Results: The FCC defined in the Articles in terms of quality and availability, but also as a parent to be listened to, given enough time, be treated with respect, have a joint decision between parents and professionals and to get information, if necessary, adapted. Through flexible approaches that are tailored to the child and family's needs both in inpatient and outpatient care, and in rehabilitation, stress can reduce both the family and the health professionals. However, there are groups with disabilities who perceive health care as a less family-centered than other families. Conclusion: The cornerstone of family-centered care is the collaboration between caregivers and family, which is promoted by the health care provider will take into account and respect the family's culture and background. Articles in the study shows that family-centered care provides support to be a success factor in health care. FCC promotes child and family health, which benefits the economy in the long term.

Thesis advisor: Dorothy A. Jones / Purpose: The purpose of this study was to define, develop, and psychometrically evaluate a scale designed to measure Nurse’s Perception of the Relationship Based Care Environment. Background: Relationship is a complex multidimensional concept. It is a critical component of professional practice and core to the interaction between nurse and patient. While there are a number of scales available to measure different dimensions of relationships between nurses and other groups there is no one scale that captures multiple dimensions. Methods: Based on a review of the literature and an earlier qualitative study, a theoretical representation was developed. This representation became the framework for development of elements and items for the NPRBCE scale. The content validity of the NPRBCE scale was determined by an expert panel of Registered Nurses. Four hundred and seventy three Registered Nurse participants completed the survey. Analysis: Data were subjected to Principal Components Analysis and Cronbach’s alpha was computed to determine reliability of the scale as a whole and each of the components of the scale. Results: The final solution was a five component 56-item scale. The five components include: nurse/ other discipline; nurse/organization; nurse/ nurse; nurse/ patient- knowing the patient; and nurse/patient-respecting the patient. The scale as a whole and each of the resulting components were found to be reliable. The components were parsimonious and interpretable. Keywords: relationship based care, relationship centered care, nurse practice environment / Thesis (PhD) — Boston College, 2016. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Submitted by admin tede (tede@pucgoias.edu.br) on 2017-02-23T17:48:27Z No. of bitstreams: 1 VANESSA DOS SANTOS PICÃO.pdf: 1451406 bytes, checksum: b3d821582fccdf2cf2fd9e4d0c796781 (MD5) / Made available in DSpace on 2017-02-23T17:48:27Z (GMT). No. of bitstreams: 1 VANESSA DOS SANTOS PICÃO.pdf: 1451406 bytes, checksum: b3d821582fccdf2cf2fd9e4d0c796781 (MD5) Previous issue date: 2016-02-26 / In Brazil, policies concerning women’s health are relatively new in Brazil, and in many states a program called Rede Cegonha is only gradually being realized. The present dissertation focuses the experience of obstetric intake at a service in hinterland of the state of Bahia. Objective: to investigate the experience of women in an obstetric unit during the moments immediately before childbirth. Method: Grounded Theory (GT) was chosen as theoretical and methodological reference for this study. Eleven women who had recently given birth were interviewed about their perception, feelings and experiences about the intake in the unit. Results: The analysis suggests three axes: Starting point, the Person in her context and e the Physical environment. These were constructed based on nine categories. The “Starting point” unites experiences and difficulties of transport to the unit. Many reported troubles in getting to the unit. The “Person in her context” describes vulnerabilities of the intake process, feeling cared for or not, valued or neglected. The recent mothers were sensitive to the interpersonal relation with the team, and to the rejection of their request to have a partner accompany them. However, most of them valued the service and the help they received. The axis “Physical environment” contains important ambient elements that positively or negatively influence the experience of the intake. Conclusion: Policies of personcentered care in obstetrics still have not been able to meet women’s real needs. Failure to meet the needs of women giving birth in the obstetric context leads to maladjustment in the process of delivery and birth. The perspectives analyzed in this study show that women are sensible to aspects like the personal relationship with the health professionals, care centered on the person with her vulnerabilities and the adequacy of the physical environment. Such factors can impact positively or negatively, depending on the experience of the woman giving birth. The same factors, when linked to the nursing practice, can also, aid or hinder adequate patient care. / As políticas de atenção à saúde da mulher no Brasil são relativamente novas e em muitos estados a Rede Cegonha ainda se encontra em fase de implantação. Esta dissertação enfoca a vivência do acolhimento à parturiente num serviço de obstetrícia no interior do estado de Bahia. Objetivo: investigar a vivência da parturiente em uma unidade obstétrica até os momentos que antecedem o parto. Método: a Grounded Theory (GT) ou Teoria Fundamentada nos Dados (TFD) foi escolhida como referencial teórico e metodológico para a realização deste estudo. Onze puérperas foram entrevistadas e as entrevistas concerniram à sua percepção, sentimentos e vivências acerca do acolhimento na unidade. Resultados: da análise das entrevistas surgiram três eixos norteadores, a saber: Ponto de partida, A pessoa no seu contexto e Ambiente físico; estes foram construídos a partir de nove categorias. O “Ponto de partida” abarcou vivências e complicações do deslocamento. Grande parte das parturientes apresentou dificuldade no transporte. “A pessoa no seu contexto” descreveu as fragilidades do processo, de sentir-se ou não assistida, valorizada ou negligenciada. As parturientes mostraram-se sensíveis à relação interpessoal com a equipe e à não permissão de acompanhante; contudo, quase todas valorizaram o serviço e o atendimento prestado, mesmo quando o percebiam de forma incompleta. O eixo “Ambiente físico” abarcou elementos importantes da ambiência que influenciam a vivência do acolhimento, positiva ou negativamente. Conclusão: as políticas e os programas de humanização na área obstétrica ainda não atendem às necessidades das parturientes. Falha em atender às necessidades das parturientes no contexto parto culmina em desajustes no processo de parto e nascimento. As perspectivas analisadas neste estudo mostram que as mulheres são sensíveis a aspectos como relacionamento com os profissionais, cuidados centrados na pessoa com suas fragilidades e adequação do ambiente físico. Tais fatores podem implicar positiva e/ou negativamente, a depender da vivência da parturiente. Essas mesmas vertentes, quando relacionadas à prática do enfermeiro, podem também, facilitar ou dificultar a assistência de enfermagem.

Learning Objectives: Describe the concept of patient ‐centered care from the pharmacist’s perspective. Summarize the science of patient ‐centered communication in pain management. Describe pharmacogenetic tests that are available to guide the use of opioids in pain management. Discuss research opportunities related to patient ‐centered care and genetic testing in pain management. Describe strategies used by pharmacists to implement genetic testing in clinical pharmacy practice.