The objective of the thesis was to evaluate the quality of diabetes care in the Canadian Forces by determining the extent to which physicians adhere to recommendations outlined in the 2008 Canadian Diabetes Association (CDA) clinical practice guidelines. In addition, the effect of patient age, sex, rank and size of base on quality of care was assessed and the accuracy of a diagnosis of diabetes in an extract of the electronic medical record (EMR) was evaluated. Fourteen bases within the Canadian Forces were selected for investigation, representing roughly half of the Canadian Forces population. Cases of diabetes were ascertained based on laboratory criteria following a chart review. Twenty-one CDA guideline recommendations were considered. The Canadian Forces demonstrated greater than 75% adherence with each of 9 recommendations, 50-75% adherence with each of 7 recommendations and less than 50% adherence with each of 5 recommendations. The overall adherence with all applicable recommendations per patient was 60.3% (SE 0.66). Age, sex, rank and size of base were not important factors influencing guideline adherence. The sensitivity of a diabetes diagnosis in an extract of the EMR was 84.5%, the specificity was 99.8%, the positive predictive value was 85.1% and the negative predictive value was 99.8%. This is similar to the performance of provincial and national diabetes registries. The quality of diabetes care in the Canadian Forces compared favourably with that of the civilian population within Canada and internationally. The creation of a diabetes registry is expected to lead to further improvements in diabetes care.

Depression is common and disproportionately affects those with chronic medical comorbidity, such as diabetes mellitus (DM). Only a limited amount of information is available concerning the quality of guideline-concordant treatment of depression and its influence on glycemic control among those with DM. This is the first study to address these issues in a veteran population with DM. This is a retrospective cohort study (1997-2005) of veterans with and without DM from the Roudebush Veterans Affairs Medical Center in Indianapolis. Veterans with and without DM and a new episode of depression were identified. Administrative, clinical, and pharmacy data were linked to assess initiation of treatment, follow-up care, antidepressant dosage and duration, and change in antidepressant agent based on the Veterans Health Administration (VHA) clinical practice guidelines for depression. HbA1c levels were assessed following initiation of antidepressant therapy. Treatment of depression was not consistent with guideline recommendations. Only 60% of subjects received treatment within 30-days of the depression diagnosis. Veterans with DM were more likely to have received treatment within the first two weeks than veterans without DM. Few subjects received appropriate follow-up care for depression (<40%) or an adequate duration of antidepressant therapy (<9%), although most (88%) received a dosage consistent with guideline recommendations when treatment was provided. Most subjects (>75%) were treated with a serotonigenic agent and only 23% experienced a change in therapy during the treatment period, almost 84% of which received an adequate trial of therapy prior to the change or augmentation in agent. Presence of DM was associated with significantly increased odds for receipt of guideline-concordant care for depression in most multivariate analyses. Receipt of guideline-concordant care for depression was not a significant predictor of glycemic control but was associated with a clinically meaningful reduction of 0.5% in HbA1c levels. This research demonstrates that under-treatment of depression is common and may influence at least one medical outcome. Findings also support that the relationship between depression and DM is complex and that further research is necessary to help align current practice with evidence-based practices in the VHA.

Purpose To understand the factors that influence nursing students’ use of evidence-based pain management guidelines in their clinical placements. Methods/Design Guided by educational and knowledge translation theory, multiple approaches were used: 1. A scoping review of the literature to identify and describe educational strategies to promote evidence-based practice (EBP) by nursing students in the clinical setting, along with associated barriers and facilitators from the literature. 2. A process to develop indicators of the use of pain guidelines in clinical practice. 3. A descriptive case study to determine the gap between evidence-based guideline recommendations and actual practice and to understand the clinical and educational contextual factors that influence nursing students’ use of pain management practice guidelines. Findings The scoping review identified 37 papers in total, 14 descriptive and 23 evaluation studies. Commonly identified barriers were lack of EBP knowledge and skills and lack of support in the clinical setting. EBP projects were the most frequently evaluated educational interventions, alone, or in combination with workshops or journal clubs. During the indicator development process, eleven guidelines were reviewed for quality, resulting in three quality guidelines. From these three guidelines, 12 recommendations were extracted. Quality indicators were then identified by a consensus process, resulting in 24 discrete indicators for the chart audit. For the descriptive case study, fifty-four charts were audited, and interviews were conducted with nine students, seven nurses, one professor, and one clinical instructor. Multiple documents were reviewed, and a site visit was conducted. There are gaps between pain guideline recommendations and practice in the clinical setting. Examples of barriers include the perception that guidelines are not applicable for the clinical setting, lack of knowledge regarding guidelines and an emphasis on task completion in the clinical setting. Facilitators included access to resources, curriculum changes, and the integration of guidelines in policies and procedures. These findings can inform the development, implementation and evaluation of evidence based educational strategies that take into account the multiple actors that impact nursing students’ experience, namely, in-class professors, clinical instructors, and staff nurses. Future education and research approaches should be rooted in knowledge translation and education theory.

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Bakgrund: Varje år examineras det cirka 4300 sjuksköterskor i Sverige. Under deras utbildning varvas teori och praktik för att studenterna efter examen ska kunna utföra omvårdnadsuppgifter med skicklighet och leda omvårdnadsarbetet. Den verksamhetsförlagda utbildningen är en viktig del av utbildningen som ska ge studenterna kompetens och bygga upp en trygghet inför deras kommande yrke. Handledningen är viktig för att stödja studenterna i att kunna utvecklas och bygga upp ett självförtroende.   Motiv: För att kunna arbeta med att förbättra kvaliteten på handledning under verksamhetsförlagd utbildning är det viktigt att veta hur studenterna faktiskt erfar handledning.    Syfte: Syftet med studien var att belysa sjuksköterskestudenters erfarenheter av handledning under verksamhetsförlagd utbildning.    Metod: För att besvara syftet användes en kvalitativ intervjustudie med öppna frågor, resultatet baserades på åtta intervjuer från studenter som gjort verksamhetsförlags utbildning på ett regionsjukhus i södra Sverige.    Resultat: Analysen resulterade i tre kategorier, ”omhändertagandet av studenterna”, ”handledarens sätt att handleda” och ”reflektionens betydelse” samt nio subkategorier. I resultatet framkom det att studenter har både bra och mindre bra erfarenheter av sin VFU. För studenterna var det viktigt med ett bra bemötande och att VFU platserna var förbereda och engagerade i studenternas lärande. VFU gav studenterna kunskap och kompetens och gjorde att dem blev mer redo inför sitt kommande yrke som sjuksköterska.   Konklusion: Genom att arbetsplatser och handledare visar engagemang och har förberett sig inför att studenterna ankomst skapas bättre förutsättningar för att kunna inhämta kunskap och kompetens under VFU. Det är även viktigt att studenterna får handledare med förmågan att kunna handleda studenter. Ett dåligt bemötande under VFU kan påverka sjuksköterskestudenters möjlighet till inlärning negativt. VFU:n är en viktig del av studenternas utbildning och förbereder dem inför sitt kommande yrke. / Background: Every year, approximately 4,300 nurses are examined in Sweden. During their education, theory and practice are alternated so that the students after graduation can perform nursing tasks with skill and lead the nursing work. The clinical practice is an important part of the education that will give the students competence and build a sense of security for their future profession. The supervision during VFU is important to support the students in being able to develop and build self-confidence.   Motive: In order to be able to work on improving the quality of supervision during clinical practice, it is important to know how the students actually experience the supervision.    Aim: The aim of the study was to illuminate nursing students' experiences of supervision during clinical practice.   Methods: To answer the purpose, a qualitative interview study with open-ended questions was used. The results are based on eight interviews from students who had done clinical practice on a hospital in the southern Sweden.   Result: The analysis resulted in three categories, "The care of the students", "the supervisor's way of supervising" and "the significance of the reflection" as well as nine subcategories. The results showed that students have both good and less good experiences of their clinical practice. It was important for the students to have a good attitude and that the clinical practice units were prepared and engaged in the students' learning. The clinical practice gave the students’ knowledge and skills and made them more ready for their future profession as a nurse.   Conclusion: When workplaces and supervisors show commitment and have prepared for the arrival of students, better conditions are created for being able to acquire knowledge and skills during clinical practice. It is also important that students get supervisors with the ability to supervise students. A bad attitude during clinical practice can affect nursing students' opportunities for learning negatively. The clinical practice is an important part of the students' education and prepares them for their future profession.

Background: Uncompensated vestibular hypofunction results in postural instability, visual blurring with head movement, and subjective complaints of dizziness and/or imbalance. We sought to answer the question, “Is vestibular exercise effective at enhancing recovery of function in people with peripheral (unilateral or bilateral) vestibular hypofunction?” Methods: A systematic review of the literature was performed in 5 databases published after 1985 and 5 additional sources for relevant publications were searched. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case control series, and case series for human subjects, published in English. One hundred thirty-five articles were identified as relevant to this clinical practice guideline. Results/Discussion: Based on strong evidence and a preponderance of benefit over harm, clinicians should offer vestibular rehabilitation to persons with unilateral and bilateral vestibular hypofunction with impairments and functional limitations related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) as specific exercises for gaze stability. Based on moderate evidence, clinicians may offer specific exercise techniques to target identified impairments or functional limitations. Based on moderate evidence and in consideration of patient preference, clinicians may provide supervised vestibular rehabilitation. Based on expert opinion extrapolated from the evidence, clinicians may prescribe a minimum of 3 times per day for the performance of gaze stability exercises as 1 component of a home exercise program. Based on expert opinion extrapolated from the evidence (range of supervised visits: 2-38 weeks, mean = 10 weeks), clinicians may consider providing adequate supervised vestibular rehabilitation sessions for the patient to understand the goals of the program and how to manage and progress themselves independently. As a general guide, persons without significant comorbidities that affect mobility and with acute or subacute unilateral vestibular hypofunction may need once a week supervised sessions for 2 to 3 weeks; persons with chronic unilateral vestibular hypofunction may need once a week sessions for 4 to 6 weeks; and persons with bilateral vestibular hypofunction may need once a week sessions for 8 to 12 weeks. In addition to supervised sessions, patients are provided a daily home exercise program. Disclaimer: These recommendations are intended as a guide for physical therapists and clinicians to optimize rehabilitation outcomes for persons with peripheral vestibular hypofunction undergoing vestibular rehabilitation.

Medical-surgical nurses at the project site demonstrated a knowledge deficit regarding the care of adult patients with a tracheostomy. Such knowledge deficits could expose patients to higher risks for infection, bedsores, prolonged hospital stays, increased costs, increased caregiver burden, and death. The purpose of this project was to develop an educational program to improve nurses'€™ knowledge and confidence in the provision of evidence-based tracheostomy care to answer the question if the content of an evidence-based educational program developed to improve nurses'€™ knowledge and confidence in managing adult patients with tracheostomy on a medical-surgical floor would meet the expectations of a panel of content experts. Bandura'€™s self-efficacy and social learning theories provided theoretical guidance for the project. Five local nurse practitioners served as content experts and made recommendations about how the program could be improved, as well as suggestions relating to the wording of and the time allowed for the simulation aspect of the program. Content experts used a 5-point Likert-scale survey to evaluate the education at the completion of the program. Results showed that all reviewers strongly agreed that the content of the program was relevant, was based on the best available evidence, and was well organized and easy to follow. This project may promote positive change on the medical-surgical floor by improving providers'€™ knowledge, skills, and confidence in the provision of care based on the best available evidence, which may lead to improvements in the quality of care provided to tracheostomized patients.

Teacher education researchers and policy makers recognize field experience, particularly student teaching, as a critical component of pre-service teacher learning and development. The co-teaching model of student teaching, in which cooperating teachers and student teachers jointly plan and deliver instruction, has been adopted by university-based teacher education programs across the United States. The purpose of this study was to examine the relationship between elements of the co-teaching model of student teaching and teacher efficacy outcomes for student teachers. Research suggests that teacher efficacy, a teacher’s beliefs in his or her capacity to affect student performance, is positively associated with teachers’ behaviors and commitment to teaching as well as student achievement and motivation. This quantitative study utilized multiple regression statistical analyses to examine the relationship between co-teaching overall and the relationship, communication, classroom applications, and knowledge base elements and teacher efficacy overall and the domains of efficacy in student engagement, efficacy in instructional strategies and efficacy in classroom management. Descriptive statistics indicated that the relationship and communication elements of student teaching were more prevalent than the classroom applications and knowledge base elements. Student teachers in the sample reported higher levels of efficacy in instructional strategies than efficacy in classroom management and efficacy in student engagement. A positive and statistically significant relationship between teacher efficacy overall, efficacy in student engagement, efficacy in instructional strategies, and efficacy in classroom management and the co-teaching model of student teaching, after controlling for gender and credential program, was found. The findings of this study substantiate teacher education policy makers’ support for the co-teaching model of student teaching.

京都大学 / 0048 / 新制・論文博士 / 博士(社会健康医学) / 乙第13121号 / 論社医博第10号 / 社新制||医||9(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 川村 孝, 教授 妹尾 浩, 教授 福原 俊一 / 学位規則第4条第2項該当 / Doctor of Public Health / Kyoto University / DFAM

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