This study conceptualises the workings of supervision within a South African community clinic setting, focusing specifically on trainees’ experiences of work and supervision in such contexts. Training and working in community contexts has become increasingly important in the field of clinical psychology in South Africa. Multiple and varied challenges face trainees learning and working in these contexts. The experience may evoke overwhelming emotional responses for trainees. Supervision can play an important role in offering support and providing a reflective space for trainees, thus helping to render their experiences manageable and meaningful. A qualitative research design was used in this study to explore the experiences of trainee psychologists learning and working at a community clinic in Johannesburg as a component of their clinical psychology Masters training. Six past clinical psychology trainees from the University of the Witwatersrand were interviewed in order to gain understanding of their experiences of work and supervision from their own perspectives. What emerged from analysis of the interview material was a rich description of the community clinic and the challenges trainees are faced with in working there. The impact of being a new therapist within the environment was an area commonly discussed in interviews. Most significantly, the importance of supervision within the context was highlighted, with interviewees focusing on the need for containment and a space to think. Bearing these ideas in mind, the study draws on psychodynamic theory, particularly that of Wilfred R. Bion, to help conceptualise the workings of supervision in such a context. The study illustrates that considerable and meaningful work and learning can be done in less than ideal circumstances.

Thesis (Ph. D.)--Drexel University, 2005. / Includes abstract and vita. Includes bibliographical references (leaves 94-109).

Student Number : 0317159E - MSc(Nursing) research report - School of Therapeutics - Faculty of Health Sciences / The learning environment and supervision in clinical placement play an important role in nursing education. The purpose of this study was to describe the opinions of student nurses with regard to the clinical learning environment and supervision at Malamulo Hospital, Malawi. A quantitative descriptive design was used. Data were collected from nursing students at Malamulo College of Health Science using the Clinical Learning Environment Scale (CLES) comprising structured questions. The questionnaire was administered to the total population of students (N=84) and the response rate was 87% (n=73). Descriptive statistics were used to analyze data. Relationships between variables were determined by using Fisher’s exact test and the t-test. The findings revealed that the majority of the participants were satisfied with their clinical learning environment and supervision in their latest clinical placement. Particularly, they were satisfied with the relationship that prevailed between students and members of nursing staff, feedback they received from their supervisors, the nursing care given to patients and the quality of learning opportunities. However, it was determined that nurse teachers did not regularly supervise students and also that some students were not clear about the nursing philosophy of their wards. Ward familiarization processes were not well planned as indicated by about a third of the participants. More than one third also indicated that the learning situations were not sufficient and not meaningful. While 73.98 % indicated that they received constructive feedback from their supervisors, about half of the participants indicated that the feedback was not given continuously.The majority (67.76%) of the participants experienced team supervision as opposed to individual supervision. Therefore it is recommended that nurse teachers increase the number of visits to the wards when students are in clinical placement to improve quality of clinical learning. The nursing college may need to have specific clinical instructors who are trained in clinical supervision and who will be available for students in the clinical placements regularly. The ward managers and the nursing staff need to clarify and display their ward nursing philosophy so that both nurses and students can have a common understanding and common goal in the provision of nursing care. It is also recommended that feedback be given to students continuously to enhance learning.

The high prevalence of back and neck pain results in enormous social, psychological, and economic burden. Most seeking help for back or neck pain consult general practitioners or chiropractors. Chiropractic is a regulated health profession (serving approximately 10 – 15% of the population) that has contributed to the health and well-being of North Americans for over a century. Despite available evidence for optimal management of back and neck pain, poor adherences to guidelines and wide variations in services have been noted. For instance, overuse and misuse of imaging services have been reported in the chiropractic literature. Inappropriate use of spine imaging has a number of potential adverse outcomes, including inefficient and potentially inappropriate invasive diagnosis and subsequent treatment, and unnecessary patient exposure to ionizing radiation. Although evidence-based diagnostic imaging guidelines for spinal disorders are available, chiropractors are divided on whether these guidelines apply to them. While guidelines can encourage practitioners to conform to best practices and lead to improvements in care, reviews have demonstrated that dissemination of guidelines alone is rarely sufficient to optimise care. Evidence regarding effective methods to promote the uptake of guidelines is still lacking. There is growing acceptance that problem analysis and development of interventions to change practice should be guided by relevant theories and tailored to the target audience. To date, very little knowledge translation research has addressed research-practice gaps in chiropractic. This thesis reports rigorous methods to: (1) assess practice and providers’ characteristics, (2) determine baseline rates and variations in spine x-ray ordering, (3) evaluate the impact of disseminating guidelines to optimise spine x-ray ordering, and (4) assess determinants of spine x-ray ordering and potential targets for change prior to the design of a tailored intervention. A mixed method using two disciplinary perspectives (epidemiology and psychology) was undertaken. A cross-sectional analysis of administrative claims data was carried out on a sample of chiropractors enlisted in a large American provider network. Despite available clinical practice guidelines, wide geographical variations in x-ray use persist. Higher x-ray ordering rates were associated with practice location (Midwest and South US census regions), setting (urban, suburban), chiropractic school attended, male provider, employment, and years in practice. The impact of web-based guideline dissemination was evaluated over a five year period using interrupted time series and demonstrated a stepwise relative reduction of 5.3% in the use of x-rays. Passive guidelines dissemination appeared to be a simple, cost effective strategy in this setting to improve but not optimise x-ray ordering rates. Focus groups using the theoretical domains framework were conducted among Canadian and US chiropractors to explore their beliefs about managing back pain without x-rays. Findings were used to develop a theory-based survey to identify theoretical constructs predicting spine x-ray ordering practice. Psychological theories and theoretical constructs explained a significant portion of the variance in both behavioural simulation and intention. Results from this thesis provide an empirically-supported, theoretical basis to design quality improvement strategies to increase guidelines adherence and promote behaviour change in chiropractic. Other researchers interested in improving uptake of evidenced-based information could use this method in their own setting to investigate determinants of behaviour among other professional groups. Future research may use knowledge gained to inform the development and evaluation of a theory-based tailored intervention to improve guideline adherence and reduce the use of spine x-rays among targeted providers.

The high prevalence of back and neck pain results in enormous social, psychological, and economic burden. Most seeking help for back or neck pain consult general practitioners or chiropractors. Chiropractic is a regulated health profession (serving approximately 10 – 15% of the population) that has contributed to the health and well-being of North Americans for over a century. Despite available evidence for optimal management of back and neck pain, poor adherences to guidelines and wide variations in services have been noted. For instance, overuse and misuse of imaging services have been reported in the chiropractic literature. Inappropriate use of spine imaging has a number of potential adverse outcomes, including inefficient and potentially inappropriate invasive diagnosis and subsequent treatment, and unnecessary patient exposure to ionizing radiation. Although evidence-based diagnostic imaging guidelines for spinal disorders are available, chiropractors are divided on whether these guidelines apply to them. While guidelines can encourage practitioners to conform to best practices and lead to improvements in care, reviews have demonstrated that dissemination of guidelines alone is rarely sufficient to optimise care. Evidence regarding effective methods to promote the uptake of guidelines is still lacking. There is growing acceptance that problem analysis and development of interventions to change practice should be guided by relevant theories and tailored to the target audience. To date, very little knowledge translation research has addressed research-practice gaps in chiropractic. This thesis reports rigorous methods to: (1) assess practice and providers’ characteristics, (2) determine baseline rates and variations in spine x-ray ordering, (3) evaluate the impact of disseminating guidelines to optimise spine x-ray ordering, and (4) assess determinants of spine x-ray ordering and potential targets for change prior to the design of a tailored intervention. A mixed method using two disciplinary perspectives (epidemiology and psychology) was undertaken. A cross-sectional analysis of administrative claims data was carried out on a sample of chiropractors enlisted in a large American provider network. Despite available clinical practice guidelines, wide geographical variations in x-ray use persist. Higher x-ray ordering rates were associated with practice location (Midwest and South US census regions), setting (urban, suburban), chiropractic school attended, male provider, employment, and years in practice. The impact of web-based guideline dissemination was evaluated over a five year period using interrupted time series and demonstrated a stepwise relative reduction of 5.3% in the use of x-rays. Passive guidelines dissemination appeared to be a simple, cost effective strategy in this setting to improve but not optimise x-ray ordering rates. Focus groups using the theoretical domains framework were conducted among Canadian and US chiropractors to explore their beliefs about managing back pain without x-rays. Findings were used to develop a theory-based survey to identify theoretical constructs predicting spine x-ray ordering practice. Psychological theories and theoretical constructs explained a significant portion of the variance in both behavioural simulation and intention. Results from this thesis provide an empirically-supported, theoretical basis to design quality improvement strategies to increase guidelines adherence and promote behaviour change in chiropractic. Other researchers interested in improving uptake of evidenced-based information could use this method in their own setting to investigate determinants of behaviour among other professional groups. Future research may use knowledge gained to inform the development and evaluation of a theory-based tailored intervention to improve guideline adherence and reduce the use of spine x-rays among targeted providers.

The high prevalence of back and neck pain results in enormous social, psychological, and economic burden. Most seeking help for back or neck pain consult general practitioners or chiropractors. Chiropractic is a regulated health profession (serving approximately 10 – 15% of the population) that has contributed to the health and well-being of North Americans for over a century. Despite available evidence for optimal management of back and neck pain, poor adherences to guidelines and wide variations in services have been noted. For instance, overuse and misuse of imaging services have been reported in the chiropractic literature. Inappropriate use of spine imaging has a number of potential adverse outcomes, including inefficient and potentially inappropriate invasive diagnosis and subsequent treatment, and unnecessary patient exposure to ionizing radiation. Although evidence-based diagnostic imaging guidelines for spinal disorders are available, chiropractors are divided on whether these guidelines apply to them. While guidelines can encourage practitioners to conform to best practices and lead to improvements in care, reviews have demonstrated that dissemination of guidelines alone is rarely sufficient to optimise care. Evidence regarding effective methods to promote the uptake of guidelines is still lacking. There is growing acceptance that problem analysis and development of interventions to change practice should be guided by relevant theories and tailored to the target audience. To date, very little knowledge translation research has addressed research-practice gaps in chiropractic. This thesis reports rigorous methods to: (1) assess practice and providers’ characteristics, (2) determine baseline rates and variations in spine x-ray ordering, (3) evaluate the impact of disseminating guidelines to optimise spine x-ray ordering, and (4) assess determinants of spine x-ray ordering and potential targets for change prior to the design of a tailored intervention. A mixed method using two disciplinary perspectives (epidemiology and psychology) was undertaken. A cross-sectional analysis of administrative claims data was carried out on a sample of chiropractors enlisted in a large American provider network. Despite available clinical practice guidelines, wide geographical variations in x-ray use persist. Higher x-ray ordering rates were associated with practice location (Midwest and South US census regions), setting (urban, suburban), chiropractic school attended, male provider, employment, and years in practice. The impact of web-based guideline dissemination was evaluated over a five year period using interrupted time series and demonstrated a stepwise relative reduction of 5.3% in the use of x-rays. Passive guidelines dissemination appeared to be a simple, cost effective strategy in this setting to improve but not optimise x-ray ordering rates. Focus groups using the theoretical domains framework were conducted among Canadian and US chiropractors to explore their beliefs about managing back pain without x-rays. Findings were used to develop a theory-based survey to identify theoretical constructs predicting spine x-ray ordering practice. Psychological theories and theoretical constructs explained a significant portion of the variance in both behavioural simulation and intention. Results from this thesis provide an empirically-supported, theoretical basis to design quality improvement strategies to increase guidelines adherence and promote behaviour change in chiropractic. Other researchers interested in improving uptake of evidenced-based information could use this method in their own setting to investigate determinants of behaviour among other professional groups. Future research may use knowledge gained to inform the development and evaluation of a theory-based tailored intervention to improve guideline adherence and reduce the use of spine x-rays among targeted providers.

Post-traumatic stress disorder (PTSD) is classified as an anxiety disorder in the Diagnostic and Statistical Manual IV of the American Psychiatric Association. It is characterised by three main symptom clusters: re-experiencing (of which flashbacks are the hallmark symptom); hyperarousal; and avoidance. Diagnosis requires not only the occurrence of a traumatic event but also an intense emotional (fear, horror, or helplessness) reaction to it. Epidemiological data suggest that 80% of people will experience at least one qualifying event in their lifetime. However, prevalence rates of PTSD are much lower. Additionally, individuals with PTSD tend to experience flashbacks of only two or three particular ‘hot-spots’ of the entire trauma. Therefore, the question arises: why do some moments of trauma flash back and not others? Clinical-cognitive theories of PTSD suggest that shifts in information processing at the time of the trauma (i.e. peri-traumatically) are the mechanism whereby flashbacks are created. However, for ethical and practical reasons peri-traumatic processes in real trauma are seldom studied. An analogue traumatic event has been developed to help study peri-traumatic processes – the trauma film paradigm. This paradigm is used through-out this thesis with the goal of investigating peri-traumatic cognitive mechanisms in flashback formation. Studies 1 and 2 extend previous work using dual tasks to manipulate intrusions in-line with clinical-cognitive theories. Studies 3 and 4 use neuroimaging techniques to investigate brain regions involved in real-time peri-traumatic encoding of analogue flashbacks. Chapter 9 presents heart rate data relating to peri-traumatic physiological response to flashback encoding. All of these studies support the notion that peri-traumatic shifts in processing are involved in flashback formation. In particular, Study 3 suggests that there may be a particular neural signature associated with the formation of flashbacks. Investigation of these brain areas may help solve the questions of why some individuals are more vulnerable to PTSD and why only a few specific moments of a trauma subsequently flashback. Furthermore, an improved understanding of the cognitive mechanisms involved in flashback formation may allow theory and evidence led improvements in PTSD treatments.