Organizational theory can assist in better understanding how changes made in clinical practice can be sustained in healthcare organizations. Organizational learning and knowledge transfer theories were used to develop and test a theoretical model, “Sustaining in Memory” (SIM) model, to explore how organizations disperse or distribute newly transferred knowledge in knowledge reservoirs situated in the organization. Three hypotheses were generated from the theoretical model and tested with data from a cross sectional postal survey of 148 patient/resident care units in one large Canadian province where a CPG on prevention of falls was widely disseminated. Findings confirmed that fall prevention practice knowledge was transferred and embedded in all six knowledge reservoirs; however, there were three specific knowledge reservoirs that were found to be significant predictors of perceived CPG adherence (activities consistent with the CPG recommendations). These were staff, policy and role expectation knowledge reservoirs. There was variation in the adherence to the eight CPG recommendations with greater adherence to recommendations that were mandatory. Additionally, findings showed that the relationship between staff knowledge reservoir and CPG adherence was the only relationship moderated by the practices that helped to prevent/address knowledge loss through various activities designed for reviewing and updating practice knowledge. Interestingly, although CPG adherence was reported significantly greater in LTC resident care units, its association with patient outcomes was much weaker than in hospital patient care units. Hospital units had significantly greater correlation between perceived CPG adherence and all four of the falls prevention outcomes reported by study participants. Lastly, quality management culture as managed by senior leaders in the organization was also found to be a significant predicator of adherence to the CPG. The research study validated key assumptions made in the theoretical model while helping to clarify the distinct influence of different knowledge reservoirs. The SIM model provided an alternate perspective within which to study knowledge transfer and sustainability of clinical practices and has potential to apply to other change initiatives. This study answered the call for greater theoretically driven studies of CPG implementation as well as attention on the organizational influences of CPG implementation and sustainability.

Attention is an acknowledged component of the therapeutic relationship that is the heart of clinical work and the base of competence. The centrality of the therapeutic relationship itself has been recognized throughout the history of clinical work. The clinician’s work is based, in part, in attending to the client by actively and openly listening to the client with attention and engagement. However, attention has been lacking within mental health disciplines to what occurs within the process of clinical attention. As a result, little knowledge exists about the structure of clinical attention itself. This dissertation studied the structure of clinical attention to understand what occurs when clinicians attend to their clients in sessions. The thesis focused on the internal processes occurring within the clinician, not on actions or interventions taken in sessions. The literature review grounded the study theoretically in mind science and contemplative science, the study of reality grounded in both objective and subjective experience. The literature review also conceptualized attention in its sub processes of mindfulness, meditation, reflective practice and affect regulation, examining literature relevant to those constructs as well as to the history, philosophy and psychology of attention. The literature revealed a lack of knowledge of the structure and process of clinical attention. Using the extant literature, a new theoretical framework of attention was constructed. Attention was conceptualized as composed of levels of pre-reflective and reflective attention as related to the attention sub processes. A phenomenological methodology was used to study the structure of clinical attention in relation to holistic competence. Fourteen clinicians, all of whom met the criteria for attaining expertise in the use of attention in their clinical work, participated in an explicitation interview. Data analysis followed a modified phenomenological methodology in a series of steps as the data were grouped in invariant constituents, reduced to emergent themes and analyzed for a textural structural description from which a structural description was constructed. From the structural description was distilled the essence of clinical attention. Clinical attention was seen to consist of a dynamic and iterative process of intention and intuition. Intention and intuition were seen to be based in different attentional levels, both of which were recursively and iteratively related to attention’s construction as a process grounded in inner awareness providing the potential abilities to reflect on experience and regulate affective experience. The study concluded with a discussion of the relationship of the skill of clinical attention to a holistic competence based in levels of procedural capability focused on concrete behavioural action and meta competence focused on clinical judgment, self-awareness and self-reflection on the actions taken. The implications of the study’s findings for training clinicians in attention were discussed.

Organizational theory can assist in better understanding how changes made in clinical practice can be sustained in healthcare organizations. Organizational learning and knowledge transfer theories were used to develop and test a theoretical model, “Sustaining in Memory” (SIM) model, to explore how organizations disperse or distribute newly transferred knowledge in knowledge reservoirs situated in the organization. Three hypotheses were generated from the theoretical model and tested with data from a cross sectional postal survey of 148 patient/resident care units in one large Canadian province where a CPG on prevention of falls was widely disseminated. Findings confirmed that fall prevention practice knowledge was transferred and embedded in all six knowledge reservoirs; however, there were three specific knowledge reservoirs that were found to be significant predictors of perceived CPG adherence (activities consistent with the CPG recommendations). These were staff, policy and role expectation knowledge reservoirs. There was variation in the adherence to the eight CPG recommendations with greater adherence to recommendations that were mandatory. Additionally, findings showed that the relationship between staff knowledge reservoir and CPG adherence was the only relationship moderated by the practices that helped to prevent/address knowledge loss through various activities designed for reviewing and updating practice knowledge. Interestingly, although CPG adherence was reported significantly greater in LTC resident care units, its association with patient outcomes was much weaker than in hospital patient care units. Hospital units had significantly greater correlation between perceived CPG adherence and all four of the falls prevention outcomes reported by study participants. Lastly, quality management culture as managed by senior leaders in the organization was also found to be a significant predicator of adherence to the CPG. The research study validated key assumptions made in the theoretical model while helping to clarify the distinct influence of different knowledge reservoirs. The SIM model provided an alternate perspective within which to study knowledge transfer and sustainability of clinical practices and has potential to apply to other change initiatives. This study answered the call for greater theoretically driven studies of CPG implementation as well as attention on the organizational influences of CPG implementation and sustainability.

Attention is an acknowledged component of the therapeutic relationship that is the heart of clinical work and the base of competence. The centrality of the therapeutic relationship itself has been recognized throughout the history of clinical work. The clinician’s work is based, in part, in attending to the client by actively and openly listening to the client with attention and engagement. However, attention has been lacking within mental health disciplines to what occurs within the process of clinical attention. As a result, little knowledge exists about the structure of clinical attention itself. This dissertation studied the structure of clinical attention to understand what occurs when clinicians attend to their clients in sessions. The thesis focused on the internal processes occurring within the clinician, not on actions or interventions taken in sessions. The literature review grounded the study theoretically in mind science and contemplative science, the study of reality grounded in both objective and subjective experience. The literature review also conceptualized attention in its sub processes of mindfulness, meditation, reflective practice and affect regulation, examining literature relevant to those constructs as well as to the history, philosophy and psychology of attention. The literature revealed a lack of knowledge of the structure and process of clinical attention. Using the extant literature, a new theoretical framework of attention was constructed. Attention was conceptualized as composed of levels of pre-reflective and reflective attention as related to the attention sub processes. A phenomenological methodology was used to study the structure of clinical attention in relation to holistic competence. Fourteen clinicians, all of whom met the criteria for attaining expertise in the use of attention in their clinical work, participated in an explicitation interview. Data analysis followed a modified phenomenological methodology in a series of steps as the data were grouped in invariant constituents, reduced to emergent themes and analyzed for a textural structural description from which a structural description was constructed. From the structural description was distilled the essence of clinical attention. Clinical attention was seen to consist of a dynamic and iterative process of intention and intuition. Intention and intuition were seen to be based in different attentional levels, both of which were recursively and iteratively related to attention’s construction as a process grounded in inner awareness providing the potential abilities to reflect on experience and regulate affective experience. The study concluded with a discussion of the relationship of the skill of clinical attention to a holistic competence based in levels of procedural capability focused on concrete behavioural action and meta competence focused on clinical judgment, self-awareness and self-reflection on the actions taken. The implications of the study’s findings for training clinicians in attention were discussed.

Purpose: To examine the effectiveness of a community-based intensive multifactorial clinical intervention for patients with Type 2 diabetes, to evaluate the feasibility of achieving clinical targets for glycemic control in a community setting, and to identify factors that are predictive of glycemic control in this cohort (age, gender, disease duration, continuity of care, pharmacologic treatment, diabetes self-care and smoking status). Methods: Participants with Type 2 diabetes referred to the Diabetes Clinic following dissemination of the 2003 Clinical Practice Guidelines of Canadian Diabetes Association and who attended a minimum of two physician visits within a twelve month period were deemed eligible for participation. 70 patients were included in this retrospective study. Baseline and twelve month values for the following biomedical outcomes were collected via chart audit: BMI, hemoglobin A1c, blood pressure (systolic, diastolic) and lipid profile (HDL, LDL, triglycerides, total cholesterol, TC:HDL ratio). Data for identification of predictive factors for glycemic control were also retrieved by chart audit. Results: The results of the paired t-test yielded a significant improvement in hemoglobin A1c (p<0.05), systolic blood pressure (p<0.01), HDL-cholesterol (p<0.05), LDL-cholesterol (p<0.01), total cholesterol (p<0.05) and total cholesterol:HDL ratio (p<0.05) over twelve months. No significant difference in BMI, diastolic blood pressure or triglycerides was reported over twelve months. Over half the sample (52.9%) achieved clinical targets for glycemic control (hemoglobin A1c <7.0%) at twelve months. Logistic regression analysis identified disease duration (O.R. = 0.90, 95% CI Exp(B) = 0.079 - 0.773, p = 0.01) and continuity of care (O.R. = 0.25, 95% CI Exp(B) = 0.831 - 0.969, p = 0.02) as significant predictors of glycemic control at twelve months. Conclusions: These findings demonstrate the effectiveness of this community-based intensive multifactorial clinical intervention for patients with Type 2 diabetes and show that the implementation of CPGs related to glycemic control is feasible in a community-based setting. Additionally, patients in this cohort with increased disease duration and increased continuity of care were less likely to achieve clinical targets for glycemic control following a twelve month intensive multifactorial clinical intervention for Type 2 diabetes. In summary, health professionals should strive to implement similar intensive multifactorial interventions in community practice in order to decrease the likelihood of diabetes-related complications and improve the patients quality of life.

Chronic non-cancer pain (CNCP) affects approximately 25% of Canadians. Opioids are medications frequently prescribed for management of patients with CNCP. Concern about addiction, misuse, and diversion for illicit use led the Canadian medical regulatory bodies to release a national guideline on the safe and effective use of opioids in CNCP. This thesis used an online survey to determine how closely the self-reported practices of Canadian family physicians matched the recommendations of the Canadian Guideline. We received 710 responses suitable for analysis. Thirteen percent of respondents did not prescribe strong opioids for CNCP. Practice gaps indentified were infrequently using a management agreement and monitoring pain with a scale; incorrect choice of second line opioid for mild to moderate pain; incorrect choice of first, second, and third line opioids for severe pain, and starting fentanyl incorrectly. Findings provide baseline information for future follow-up to compare physicians’ adherence to the guideline.

No description available.

Clinical practice is an essential and integral component of nursing education. The decision-making process involved in student selection of clinical placements is influenced by a range of factors which are internal or external to students. As there was little research that explored these factors and the influence they have on student decisions, I wanted to investigate this further. A mixed-method approach was used, using a questionnaire and focus group interview, to give breadth and depth to the research. This study found that students are particularly influenced by previous positive experiences, or an interest in a particular area of practice. Their personality will also influence their placement decisions. Nurse preceptors and clinical lecturers also provide a key support role to students in the clinical environment.

Research Doctorate - Doctor of Philosophy (PhD) / In recent decades, complementary and alternative medicine (CAM) has gradually assumed a growing popularity and economic importance in the health care systems of Western nations including Australia. Personal expenditure on CAM now represents a significant investment by the Australian general population. During this period, various CAM professions have steadily emerged as popular, if unofficial, healthcare providers. Despite the growing popularity of CAM, little is known outside of special interest groups about most CAM practices or about the professionals who provide them. In Australia one of the most well known and popular forms of CAM is herbal medicine. The focus of this thesis is on the professional practice of herbal medicine in Australia, specifically Western Herbal Medicine (WHM). It is estimated that practitioners of WHM conduct almost two million consultations a year representing an investment of $AUS 85 million (excluding the cost of medicines)in the Australian health economy. Typically described as a complete system of medicine, WHM boasts a comprehensive philosophy and claims to offer a unique approach to treatment, diagnosis and prescription. WHM practitioners reputedly operate within a broad range of autonomy, including some acting as primary health care professionals. Nevertheless, little is known about the Australian WHM profession: their approach to clinical practice; their use of herbal medicines; the patients and problems seen in WHM practice; or the nature of the WHM profession’s relationship with the mainstream healthcare sector. This thesis presents a pragmatic health services inquiry that aims to provide empirical data for the purpose of stimulating reflective practice within the WHM profession and seeks to inform discussion about the role of WHM in the Australian healthcare system. The analysis employs the concept of 'mainstreaming' (the increasing popularity, acceptance and legitimacy of CAM within the dominant healthcare structures) to explore the response of WHM to the changing role of CAM within mainstream healthcare. Mainstreaming is interpreted as an active social process in which the boundaries between CAM and mainstream healthcare are shifting, and is a concept that implies the dominance of the mainstream medical paradigm. The investigation triangulates quantitative and qualitative methods to provide an in-depth account of WHM practice from the perspective of the WHM practitioner. The study population is the membership of the National Herbalists’ Association of Australia (NHAA), and the unit of analysis is the individual WHM practitioner. The research describes the clinical practice of WHM and explores the WHM profession’s developing relationship with the mainstream – including the Australian public and the mainstream healthcare professions, particularly medical practice. A social theoretical framework is employed to examine WHM practice within its social context. The conceptual framework directs the examination of the evolving relationship between WHM and mainstreaming towards three core areas of intersection: (1) the inter-professional; (2) the intra-professional; and (3) the professional/non-professional. The inquiry consists of a mixed methods design in which an initial survey study is followed by a qualitative in-depth interview study. The rationale of adopting a mixed methods approach was threefold: firstly, to increase the scope of inquiry by selecting methods most appropriate for each inquiry component; secondly, to better understand the research problem by converging both types of data; and finally, to increase the validity of constructs and inquiry results by triangulation of data sources. The survey study consisted of a postal questionnaire that was distributed to the membership of the NHAA. The survey was specifically designed for this study in consultation with the NHAA. A preliminary pilot study of the draft questionnaire was conducted consisting of both a formal and informal stage of testing. The questionnaire was distributed with the association’s quarterly professional journal (The Australian Journal of Medical Herbalism) in December 2003 and again in March 2004. Achieving a response rate of 58% (n=378), the survey data described key aspects of the WHM profession; its approach to clinical practice, herbal prescribing and aspects of its professional relationships. The survey results demonstrated an increased influence of medical science on WHM principles and practices including the incorporation of medical concepts,clinical procedures, technologies and language into clinical practice. Although the survey provided strong evidence of a trend towards the rationalisation of WHM clinical practice, the results showed how the prescription of herbal medicines remains a predominantly traditional practice. In terms of the WHM profession, the survey results indicate that WHM practitioners are not assuming a primary healthcare role in Australia but are predominantly providing treatments for chronic conditions. The data indicated high levels of concurrent patient care, including concurrent use of pharmaceutical and herbal medicines;thus, suggesting that WHM clientele consider WHM a complementary rather than an alternative form of medicine. The survey also showed that WHM practitioners would welcome improved inter-professional and intra-professional relationships. The second phase of the mixed methods study consisted of a series of qualitative in-depth interviews with a sub-sample of survey respondents (n=18)resident in NSW, Australia. The objectives of the in-depth interview study were twofold: firstly, to add depth and meaning to survey data; and secondly, to understand the practice of WHM from the perspective of the WHM practitioner.To ensure flexibility and to uncover novel data from the participants the in-depth interviews were carried out on a semi-structured basis. Building upon the survey findings, the qualitative study explored the WHM practitioners���� conceptualisations, explanations and rationalisations of their approach to WHM practice. The interview participants represented a broad range of WHM practitioners who commonly shared a holistic worldview, but who also offered a range of interpretations of the philosophical and theoretical basis of WHM. The investigation described how mainstream conceptualisations of healthcare have impacted upon the traditional model of WHM practice. The analysis identifies a number of competing sub-groups within WHM who each advocate particular approaches to WHM practice. In particular, the analysis highlights a significant degree of internal tension operating within WHM about the salience of medical science within WHM. The analysis also revealed how the perceived subordination to, and thus distinction from, mainstream medicine is a dominant issue within the WHM practitioner’s discourse. The explanation for this emerged from the perception amongst the in-depth interview participants of the widespread appropriation of herbal medicine by the mainstream, as well as systematic discrimination towards the WHM profession. Furthermore, there was evidence of not only poor intra-professional cohesion but significant intra-professional differences regarding the apposite location of WHM in relation to mainstream healthcare. This research provides new understandings about the clinical practice of WHM practice, but also about the role of the WHM practitioner in Australian healthcare. The thesis reveals a story of irony. Despite the increasing popularity of herbal medicines and significant concessions within WHM to the medicalparadigm, the WHM profession is struggling to achieve legitimate participation within the mainstream and continues to operate on the fringe of Australian healthcare. The thesis concludes that the process of mainstreaming is challenging the authenticity of WHM herbal tradition and challenging the future viability of the WHM profession, the implications of which suggest that the WHM practitioner will continue to experience financial insecurity unless the WHM profession can collectively move to demarcate its scope of practice and legitimate its professional role.

This research project investigated the impact of an action research intervention implemented to reducing surgical wound infection in one of the acute care hospitals in India. The study aimed to develop and implement a clinical practice improvement program in reducing surgical wound infection by improving the hand washing and wound dressing practices of nurses. The study also aimed to identify the important contributing factors to a model that predicts surgical wound infection. Pre-post evaluation measures were taken to compare the results of surgical wound infection rate before and after the implementation of the intervention. Surgical wounds of two thousand patients (one thousand before the intervention and another one thousand after) were assessed to determine the wound infection rate and severity of wound infection. The hand washing and wound dressing practices of forty nurses were observed. These same nurses were involved in the intervention using a participatory action research process. The results of the study suggest that there was a marked, significant reduction in the rate and severity of wound infection following the implementation of the intervention. By increasing the hand washing facilities in the ward, educating nurses on the importance of better hygiene, pre-operative shaving and post-operative wound care, the hand washing and wound dressing practices of nurses improved considerably. These improvements resulted in a reduction in the number and severity of patients' surgical wound infections. The study also examined the contribution of different factors to surgical wound infection in a Indian hospital. Significant predictive factors were the patients' age, longer pre-operative hospital stay, extended pre-operative shaving time before surgery, wound class, and co-morbidity of the patient. The identification of risk factors that contributed to increased surgical wound infection for example pre-operative skin preparation, pre-operative hospital stay of the patient would help in taking appropriate measures at the ward level and organisation as a whole. Nosocomial infections extends to an unnecessary lengthy hospital stay, additional treatment increased mortality and morbidity, and increased cost to the patients and the nation as a whole. This project proved that educational mentoring, data surveillance processes and involving the nurses in an action research process were effective in enabling participants to improve their clinical practice and thereby reduce the incidence of patients' surgical wound infections. Establishing infection control teams, ongoing surveillance and feedback to staff of nosocomial infection rates is an urgent need in all Indian hospitals. Organisational management, as a priority, need to provide funding and staff dedicated to undertaking this essential work. Health care professionals can no longer plead ignorance of a situation for which all have a moral and professional responsibility.