The implementation of evidence-based clinical practice guidelines in primary health care can substantially improve health promotion, early disease detection and the reduction of the burden of chronic disease. However, the implementation of evidence into clinical practice is a highly complex endeavour that has been said to occur in a 'black box‘, defying easily reached explanations of how it happens in practice. The aim of this study is to explore the 'black box‘ of guideline implementation associated with primary health care nurses‘ use of a guideline that targets high health need populations in a region of New Zealand. The potential for improvement of cardiovascular health overall and the reduction of the marked disparities between Mäori (indigenous people of New Zealand) and non-Mäori drives the imperative to enact the recommendations of the Assessment and Management of Cardiovascular Risk guideline. Primary health care nurses are well positioned at the frontline of healthcare to implement the guideline and an investigation of the realities of their practice as they do so will help to illuminate the contents of this particular 'black box‘. The aim is achieved in two components by: 1. Exploring the complexities of primary health care nurses‘ use of the New Zealand Assessment and Management of Cardiovascular Risk guideline. 2. Employing the Promoting Action on Research Implementation in Health Services (PARiHS) framework to identify the enablers and barriers to guideline implementation in the primary health care setting. Method Both components of this study involve qualitative methods. The first component involves qualitative description utilising focus groups and interviews to explore the perceptions and experiences of a range of primary health care professionals involved in implementing the AMCVR guideline and thematic analysis of data. The second component utilises template analysis of the data, based on the Promoting Action of Research Implementation in Health Services (PARiHS) framework. There are three elements of the PARiHS framework: Evidence, Context and Facilitation. This second component of the study is a systematic analysis of the enablers and barriers encountered by nurses as they implement the AMCVR guideline. Results The first component of the study generated four themes, which together have provided a rich portrait of the realities for nurses as they implemented the guideline. The four themes are self-managing client, everyday nursing practice, developing new relationships in the health team, and impact on health care delivery. The template analysis revealed that there were several enablers and barriers to guideline implementation in relation to Evidence and Context and that Facilitation was not occurring in a planned way. Conclusion Successful guideline implementation demands multidisciplinary, transformational practice development to create an effective workplace culture. Practice development is a powerful approach well suited to supporting primary health care nurses to maximise their practice-based knowledge and skills, and for them to contribute to the development of systems that will meet the information and communication requirements of successful guideline implementation. The imperative to improve cardiovascular health overall and specifically to address Mäori health inequity mandates sustained effort and mobilisation of resources to ensure successful implementation of the AMCVR guideline.

The implementation of evidence-based clinical practice guidelines in primary health care can substantially improve health promotion, early disease detection and the reduction of the burden of chronic disease. However, the implementation of evidence into clinical practice is a highly complex endeavour that has been said to occur in a 'black box‘, defying easily reached explanations of how it happens in practice. The aim of this study is to explore the 'black box‘ of guideline implementation associated with primary health care nurses‘ use of a guideline that targets high health need populations in a region of New Zealand. The potential for improvement of cardiovascular health overall and the reduction of the marked disparities between Mäori (indigenous people of New Zealand) and non-Mäori drives the imperative to enact the recommendations of the Assessment and Management of Cardiovascular Risk guideline. Primary health care nurses are well positioned at the frontline of healthcare to implement the guideline and an investigation of the realities of their practice as they do so will help to illuminate the contents of this particular 'black box‘. The aim is achieved in two components by: 1. Exploring the complexities of primary health care nurses‘ use of the New Zealand Assessment and Management of Cardiovascular Risk guideline. 2. Employing the Promoting Action on Research Implementation in Health Services (PARiHS) framework to identify the enablers and barriers to guideline implementation in the primary health care setting. Method Both components of this study involve qualitative methods. The first component involves qualitative description utilising focus groups and interviews to explore the perceptions and experiences of a range of primary health care professionals involved in implementing the AMCVR guideline and thematic analysis of data. The second component utilises template analysis of the data, based on the Promoting Action of Research Implementation in Health Services (PARiHS) framework. There are three elements of the PARiHS framework: Evidence, Context and Facilitation. This second component of the study is a systematic analysis of the enablers and barriers encountered by nurses as they implement the AMCVR guideline. Results The first component of the study generated four themes, which together have provided a rich portrait of the realities for nurses as they implemented the guideline. The four themes are self-managing client, everyday nursing practice, developing new relationships in the health team, and impact on health care delivery. The template analysis revealed that there were several enablers and barriers to guideline implementation in relation to Evidence and Context and that Facilitation was not occurring in a planned way. Conclusion Successful guideline implementation demands multidisciplinary, transformational practice development to create an effective workplace culture. Practice development is a powerful approach well suited to supporting primary health care nurses to maximise their practice-based knowledge and skills, and for them to contribute to the development of systems that will meet the information and communication requirements of successful guideline implementation. The imperative to improve cardiovascular health overall and specifically to address Mäori health inequity mandates sustained effort and mobilisation of resources to ensure successful implementation of the AMCVR guideline.

Bakgrund Stress och liknande känslotillstånd hos nyutexaminerade sjuksköterskor är ett vanligt problem. Syfte Undersöka hur nyutexaminerade sjuksköterskor upplevde tiden före sin första anställning och under första året i yrkeslivet. Fokus lades på känslor av oförbereddhet och stress och huruvida det påverkade omvårdnaden, samt hur detta hade kunnat avhjälpas. Metodbeskrivning Sju semi-strukturerade kvalitativa intervjuer genomfördes. Insamlat material analyserades genom en modifierad version av kvalitativ innehållsanalys. Resultat Övergången från sjuksköterskestudent till yrkesverksam sjuksköterska kunde innebära psykiska och fysiska påfrestningar och leda till symptom på utmattningssyndrom. Faktorer för att undvika skadlig stress var att det sociala arbetet ansågs givande, god inskolning och handledning, samt stöd genom yrkesförlagd utbildning på arbetsplatsen. Positiv feedback under verksamhetsförlagd utbildning (VFU) ökade tron egenförmågan. Faktorer som påverkade övergången negativt var press från kollegor, brist på kunskap och rutin, höga förväntningar på sig själv och för lite undervisning i farmakologi, medicinsktekniska moment och medicinsk teori. Basal- och specialiserad omvårdnad, läkemedel- och medicintekniska moment blev lidande på grund av stress. Slutsats Första året inom sjuksköterskeyrket innebär ett stort ansvar med påföljande stress och liknande tillstånd. En trygg sjuksköterska riskerar mindre av dessa problem vilket leder till förbättrad omvårdnad och patientsäkerhet. För att få en trygg inskolning och kompensera för bristande erfarenhet i yrkesrollen krävs från arbetsgivarens sida en individanpassad handledning med mentor, god arbetsmiljö och handledning efter introduktionsperiodens slut och reflektionsgrupper. Utbildningen förser studenterna med trygghet genom VFU och omvårdnadsteori samtidigt som en större bredd inom medicin och farmakologi efterfrågas. En tuff inledande period kan delvis kompenseras av det sociala arbetet / Background Stress and similar feelings are common problems among newly graduated nursing students which can be caused by lack of skill while adjusting to work. Purpose The purpose of this study was to examine how newly graduated nurses experienced the time before their first employment as well the first year into the profession, focusing on whether feeling unprepared and/or stressed had any effect on patient-related care, and in that case unfold how this could have been prevented in any fashion. Method Seven semi-structured qualitative interviews with registered nurses were conducted. Data was analyzed through a modified version of qualitative content analysis. Results The transition phase from being a nursing student to becoming a certified nurse could cause both mental and physical stress, which in turn might lead to experiencing symptoms of fatigue. Factors that had a positive effect on coping were: a sense of fulfillment from social work, a positive acclimatization and tutoring, and receiving support throughout the entire trainee period. Positive feedback during this trainee period increased self-efficacy. Factors that had a negative effect on coping were; pressure from colleagues, a lack of competence and routine, high self-expectations and a lack of education regarding pharmacology, basic and specialized nursing, medicine and health technology. Conclusion The first year in the nursing profession includes great responsibility, stress and stress related conditions. The feeling of being confident in work related situations reduces the risk of developing stress related issues, and leads to improved care and patient safety. To compensate for the lack of experience in the professional role, the employers need to offer a good working environment with access to a mentor and participation in reflection groups during and after the introductory period. The nursing education provides a sufficient part of internship and nursing theory, but more training and theory in medicine and pharmacology is requested. Stress and related conditions during the first year in the nursing profession is partly compensated by feelings of joy perceived in the social work.

The intellectual impulsiveness of man to understand the unknown and the continual need of the society to improve healthcare have encouraged extensive investigation on numerous and diverse cause-and-effect relationships. The nature of this endeavor, however, renders the inability of investigator at all levels to escape beyond the narrow conceptual boundary described by an early French philosopher as the vicious cycle. To enjoy the theoretically plausible benefits of refined labor division, data-driven healthcare management, and real-time evidence-based practices, it must first be acknowledged that co-occurrence is better than cause-and-effect in explaining how an observation takes place at a particular time. This paper details a co-occurrence framework, and discusses its implications for the global healthcare system.

A qualitative, grounded theory study was undertaken to explore and describe how nurses conceptualise spiritual nursing care, and how they integrate spiritual nursing care in practice. An in-depth literature review through concept analysis on the phenomenon was conducted to assist the researcher with theoretical sensitivity and theoretical saturation. In-depth Individual interviews and focus group interviews were conducted to generate data. Interviews were audio-taped and transcribed by the researcher verbatim. Symbolic Interactionism was the philosophical base for the study. Data analysis was done through the use of the NUD*Ist computer soft ware programme version 4.0. The direct quotes of participants were coded and arranged into meaning units for analysis. A constant comparison method of data analysis was applied by following a process of open, axial and selective coding. Tech’s (1990:142-145) eight steps of analysis to analyse textual qualitative data was used until themes, categories and subcategories were identified and developed. Data analysis revealed that nurses had difficulty to differentiate spiritual nursing care from emotional, psychological or religious care. Nurses still felt inadequately prepared educationally on how to integrate spiritual nursing care in nursing practice. A Humane Care Model and practice guidelines were developed to guide nurses in clinical practice on how to provide such care. Recommendations proposed that the matter be taken up by nurse managers, educators and nurse clinicians to guide nurses in this regard. / Health Studies / D. Litt. et Phil. (Health Studies)

Conselho Nacional de Desenvolvimento Científico e Tecnológico / A presente pesquisa sobre o gozo na clínica com mulheres devastadas teve como foco o lugar ocupado pelo gozo em seu aspecto mortífero, de excesso e falta de medida, que se manifesta no âmbito das parcerias amorosas. Partindo das experiências relatadas por algumas analisandas, que as descrevem como "sair do corpo", "ficar louca", "descontrolada" ou "fora de si", e das formulações psicanalíticas a respeito do gozo feminino, buscou-se discutir a questão a partir dos referenciais propostos por Freud e Lacan no que diz respeito à constituição da feminilidade e do feminino, tais como a catástrofe e a devastação na ligação com a mãe e com o parceiro, a forma erotomaníaca de amar, além das duas formas de gozo nas mulheres. Entre os temas abordados nesta dissertação destacam-se as operações da castração e do Complexo de Édipo, juntamente com o seu elemento central, o falo, que permitem trazer à discussão algumas consequências para as mulheres, sobretudo as posições implicadas, a saber: o falo e a mascarada. O conceito de gozo é examinado através de três ser mascarada articulações principais. Primeiramente, a tentativa de Freud, que parece a mais antiga na psicanálise, de circunscrever um gozo propriamente feminino, ligado à satisfação da pulsão pela via da zona vaginal; em segundo lugar, o pensamento de Lacan em Diretrizes para um congresso sobre a sexualidade feminina (1958), em que ele recupera a questão freudiana do congresso sobre a sexualidade feminina gozo feminino, e posteriormente no Seminário 7:a ética da psicanálise (1959-1960), desenvolvido durante o período de preparação para o referido congresso, no qual Lacan eleva o gozo ao estatuto de conceito. Como desdobramento, encontram-se algumas articulações clínicas acerca do gozo devastador nos relacionamentos amorosos, tomando como referência a personagem da Erwartung, op. 17 , de Arnold Schoenberg e as mulheres que encontramos no dia a dia da clínica. / This study on jouissance within the clinical work with devastated women focuses on female sexuality, emphasizing the place of jouissance in its deadly and unlimited aspect of excess as present in the realm of love partnerships. Based on the sayings of certain analysands, such as having "the sensation of leaving the body", "going crazy", "losing control" or "going out of mind", in addition to the formulations concerning feminine jouissance, this paper discusses the issue according to the Freudian and Lacanian fundamentals of the constitution of femininity and the feminine, such as catastrophe and devastation in the girl's relationship with her mother and with her love partner,the erotomaniacal form of feminine love, and the two jouissances women can experience. Among the subjects covered in this dissertation are the operation of castration and of the Oedipus complex along with its core element, the phallus, and the feminine positions known as being the phallus and the masquerade. The concept of jouissance is examined through a threefold discussion: first, Freud's attempt to circumscribe a feminine jouissance as the satisfaction of the drive by the means of the vaginal zone; second, Lacan's developments in Guiding remarks for a convention on feminine sexuality (1958) and, finally, his ideas introduced in Seminar 7: The ethics of psychoanalysis (1959-1960), where he develops the concept of jouissance. As far as the clinical discussion is concerned, this paper relies not only on the analysands' sayings but also on the text of the female character from Arnold Schoenberg's opera Erwartung, op. 17.

Problem: With an increasing aging Canadian population with chronic diseases such as arthritis, there is an urgent need for health professionals to promote evidence-based arthritis self-management support to their patients. Objective: The overall objective of this thesis was to determine the feasibility of using Facebook as a dissemination strategy for an online evidence-based arthritis self-management program, People Getting a Grip on Arthritis (PGrip), by arthritis health professionals with their patients. Methods: To identify the current evidence and knowledge gaps in regards to the use of innovative dissemination strategies for clinical practice guidelines (CPGs) and social media use for chronic disease self-management among health professionals, two systematic reviews of the literature were conducted. The first systematic review identified research on health professionals’ perceived usability and practice behaviour change of information and communication technologies (ICTs) for the dissemination of CPGs. The second identified research on the perceived usability of social media by health professionals to facilitate chronic disease self-management with their patients. To engage potential knowledge users in the research process, an advisory committee consisting of six arthritis health professional users (two registered nurses, two physiotherapists, and two occupational therapists) was convened to identify barriers and facilitators of using and accessing Facebook as a dissemination strategy for PGrip. The advisory committee was also convened to identify how the PGrip Facebook group page could be tailored to improve usability among arthritis health professionals. A feasibility study of 78 arthritis health professionals was then conducted to determine the feasibility of using Facebook as a dissemination strategy for PGrip among arthritis health professionals to their patients. To guide future research, a protocol for a pilot randomized controlled trial (RCT) was developed that will compare Facebook with an educational website and email to determine which strategy will demonstrate greater perceived usefulness among arthritis health professionals to disseminate the PGrip program with their patients. Results: The findings of the first systematic review revealed that health professionals’ perceived usability and practice behaviour change varies by type of ICT and the heterogeneity and paucity of properly conducted studies did not allow for a clear comparison between studies. The second systematic review revealed that health professionals perceived discussion forums and collaborative projects to be useful social media platforms to facilitate chronic disease self-management with patients. The feasibility study suggested that a Facebook group page can be used as a dissemination strategy for the PGrip program by arthritis health professionals. The Facebook group page was perceived to be usable with patients after two weeks and three months in regards its ease of use and high output quality. Conclusion: The overall research of this thesis provides advanced knowledge on how a Facebook group page as a dissemination strategy for an evidence-based self-management program for patients is perceived by arthritis health professionals. Facebook may provide arthritis health professionals with an additional option of how to best share evidence-based information to allow their patients to successfully self-manage their arthritis. A future pilot RCT is needed to determine whether Facebook is superior to other ICT intervention in regards its perceived usefulness among arthritis health professionals to disseminate the PGrip program with their patients.

Conselho Nacional de Desenvolvimento Científico e Tecnológico / A presente pesquisa sobre o gozo na clínica com mulheres devastadas teve como foco o lugar ocupado pelo gozo em seu aspecto mortífero, de excesso e falta de medida, que se manifesta no âmbito das parcerias amorosas. Partindo das experiências relatadas por algumas analisandas, que as descrevem como "sair do corpo", "ficar louca", "descontrolada" ou "fora de si", e das formulações psicanalíticas a respeito do gozo feminino, buscou-se discutir a questão a partir dos referenciais propostos por Freud e Lacan no que diz respeito à constituição da feminilidade e do feminino, tais como a catástrofe e a devastação na ligação com a mãe e com o parceiro, a forma erotomaníaca de amar, além das duas formas de gozo nas mulheres. Entre os temas abordados nesta dissertação destacam-se as operações da castração e do Complexo de Édipo, juntamente com o seu elemento central, o falo, que permitem trazer à discussão algumas consequências para as mulheres, sobretudo as posições implicadas, a saber: o falo e a mascarada. O conceito de gozo é examinado através de três ser mascarada articulações principais. Primeiramente, a tentativa de Freud, que parece a mais antiga na psicanálise, de circunscrever um gozo propriamente feminino, ligado à satisfação da pulsão pela via da zona vaginal; em segundo lugar, o pensamento de Lacan em Diretrizes para um congresso sobre a sexualidade feminina (1958), em que ele recupera a questão freudiana do congresso sobre a sexualidade feminina gozo feminino, e posteriormente no Seminário 7:a ética da psicanálise (1959-1960), desenvolvido durante o período de preparação para o referido congresso, no qual Lacan eleva o gozo ao estatuto de conceito. Como desdobramento, encontram-se algumas articulações clínicas acerca do gozo devastador nos relacionamentos amorosos, tomando como referência a personagem da Erwartung, op. 17 , de Arnold Schoenberg e as mulheres que encontramos no dia a dia da clínica. / This study on jouissance within the clinical work with devastated women focuses on female sexuality, emphasizing the place of jouissance in its deadly and unlimited aspect of excess as present in the realm of love partnerships. Based on the sayings of certain analysands, such as having "the sensation of leaving the body", "going crazy", "losing control" or "going out of mind", in addition to the formulations concerning feminine jouissance, this paper discusses the issue according to the Freudian and Lacanian fundamentals of the constitution of femininity and the feminine, such as catastrophe and devastation in the girl's relationship with her mother and with her love partner,the erotomaniacal form of feminine love, and the two jouissances women can experience. Among the subjects covered in this dissertation are the operation of castration and of the Oedipus complex along with its core element, the phallus, and the feminine positions known as being the phallus and the masquerade. The concept of jouissance is examined through a threefold discussion: first, Freud's attempt to circumscribe a feminine jouissance as the satisfaction of the drive by the means of the vaginal zone; second, Lacan's developments in Guiding remarks for a convention on feminine sexuality (1958) and, finally, his ideas introduced in Seminar 7: The ethics of psychoanalysis (1959-1960), where he develops the concept of jouissance. As far as the clinical discussion is concerned, this paper relies not only on the analysands' sayings but also on the text of the female character from Arnold Schoenberg's opera Erwartung, op. 17.

Suicide is an issue that plagues adolescents in the United States. Suicide crosses socioeconomic, racial, and gender divides and is difficult to predict and prevent. Primary care providers (PCPs) are in a position to detect suicidality in adolescents; however, PCPs lack the knowledge and confidence necessary to accurately identify suicidal adolescents. The author conducted an extensive review of current literature (meta-analyses, systematic reviews, literature reviews, case reports, and existing clinical practice guidelines) on identification of adolescent suicidality in pediatric primary care settings. This paper provides a set of recommendations for primary care providers on how to properly identify adolescents with suicidal ideation and behavior.

The purpose of this study was to explore how physiotherapists working in stroke care understand their role(s) in the context of clinical practice and how this is mediated by their post-licensure educational experiences. Specifically the study focused on their experiences with the Bobath Concept, a well-developed post-licensure neurology physiotherapy program. This study was oriented within sociocultural theory as a way to understand how the experiences and interactions of physiotherapists mediate their professional practice and their sense of professional identity in a way not previously studied in physiotherapy literature. In order to honour the voices of the participants, this study drew on hermeneutic phenomenology and used a principled data analysis tool to present an understanding of the interrelationships involved in stroke care from their perspectives. Four physiotherapists participated in this study by responding in writing and orally to a clinical case and participating in an in-depth interview regarding their professional roles and experiences. The findings suggest that these physiotherapists understand the Bobath Concept as a professional stance which informs their practice and contributes to an ethos of caring, which is reflected in the ways they understand their roles in clinical practice.