Leadership is important to quality improvement initiatives in healthcare. However, few studies have evaluated leadership interventions to enhance nurses’ use of guideline recommendations in the field of knowledge translation. Purpose: To develop and evaluate an intervention designed to operationalize a leadership strategy composed of relations, change, and task-orientated leadership behaviours, and to examine its influence on nurses’ use of guideline recommendations in home-care nursing. Design: Sequential mixed methods pilot study with post-only cluster randomized controlled trial. Methods Phase I: Intervention Development 1. A participatory approach was used at a community healthcare organization with 23 units across the province of Ontario, Canada. The guideline selected was developed by the Registered Nurses’ Association of Ontario for the assessment and management of foot ulcers for people with diabetes. 2. Integrative literature review, qualitative interviews, and baseline chart audits were conducted. 3. Four units were randomized to control or experimental groups. 4. Clinical and management leadership teams participated in a 12-week intervention consisting of printed materials, interactive workshop, and teleconferences. Participants received summarized chart audit data, identified priority indicators for change, and created a team leadership action plan to address barriers and influence guideline use. Phase II: Evaluation 5. Chart audits compared differences in nursing process and patient outcomes. Primary outcome: eight-item nursing assessment score. 6. Qualitative interviews evaluated the intervention and leadership behaviours. Results: No significant difference was found in the primary outcome. A significant difference was observed in nurses’ documentation of five priority indicators chosen by the experimental groups (p=.02). Gaps in care included: 53%, 76%, and 94% of patients not assessed for ulcer depth, foot circulation, or neuropathy (respectively); 75% and 93% did not receive wound debridement or hydrogel dressings. Receiving data to identify priority indicators for change and developing a leadership action plan were reported as useful to guideline implementation. The experimental group described using more relations-oriented leadership behaviours conducting audit and feedback, and sending reminders. Conclusion: Findings from this pilot study suggest that leadership is a team process involving relations, change, and task-oriented behaviours enacted by managers and clinical leaders. A leadership model is proposed as a beginning taxonomy to inform future leadership intervention studies.

Self-regulation capacity allows individuals to manage their thoughts, feelings, and actions to attain personal goals (e.g., well-being and performance), as well as adjust to their changing social and physical environment (Zimmerman, 2000). Self-regulation as a positive adaptive skill and process has not been examined in relation to well-being in the context of medicine. The purpose of the current study was to examine self-regulation with 37 medical students and 25 supervising physicians to determine whether or not it may enhance well-being and performance, and reduce stress and burnout. A mixed-methods design was used to collect and analyze the data, and findings from the quantitative and qualitative phases were presented in two separate articles. Self-regulation capacity appears to be an important skill that may help both physicians and medical students to meet the demands of the medical profession and maintain an adequate level of well-being and performance in their work and daily life.

Sammanfattning En fallstudie gjordes bland medarbetare inom Hemtjänsten i Eskilstuna kommun. Syftet med studien är att erhålla förklaring och förståelse för medarbetares användning och attityder till de processkartor och dokument som ingår i det integrerade ledningssystemet (ILS) samt den förändring som införandet av dem innebär inom Hemtjänsten i Eskilstuna kommun. Syftet är även att erhålla förklaring och förståelse om medarbetarattityders påverkan på införandet av ILS genom att utgå ifrån teorier om attitydkonstruktioner.       Studien utfördes med en metodkombination av enkäter och intervjuer bland medarbetare inom HEK. Drygt 14% av alla medarbetare inom HEK deltog i studien varav 59st svarade på enkäter och tre intervjuades. Resultatet indikerade att många medarbetare visste när de skulle använda ILS även om inte alla hade börjat använda det ännu. Medarbetare var eniga om att ILS hade många fördelar och de hade allmänt positiva attityder till ILS. Deras attityder analyserades utifrån attitydkonstruktionerna beredskap för förändring (BFF), åtagande för förändring (ÅFF), öppenhet för förändring (ÖFF) och cynism mot organisationsförändring (CMO).   Slutsatserna var att attityder bland medarbetare inom HEK inte borde utgöra ett hinder för ett framgångsrikt införande av ILS. Införandet av ILS anses därför inte kräva drastiska attitydförändringar bland medarbetare för att möjliggöra dess framgång. / Summary in English A case study was carried out among home care employees in Eskilstuna municipality. The purpose of the study was to provide explanations and understanding regarding the employee’s usage of and attitudes towards an integrated management system (ILS), and it´s implementation, within the home care section of Eskilstuna municipality. The purpose was also to provide explanations and understanding about the impact of these attitudes based on theories on attitudinal constructs.   The study was conducted with a combination of methods. Approximately 14% of the home care employees participated in the study, 59 of them in a survey and three participated in interviews. The results indicated that many employees knew when to use ILS even though the usage did not seem to be extensive among them. The employees were in agreement that ILS had many benefits and their attitudes on ILS were mainly positive. The analysis of attitudes was based on the following attitudinal constructs theories: readiness for change, commitment to change, openness to change and cynicism about organizational change.    The conclusions were that the attitudes held by the home care employees should not be a barrier to a successful implementation of ILS. The implementation of ILS does therefore not seem to require drastic changes in attitudes among employees in order to enable it´s success.

The intensification of Ontario’s communities through recent policies such as the Greater Golden Horseshoe Growth Plan (GGH) will reduce the amount of local natural spaces for residents. Presently many of Ontario’s youth experience the natural world primarily by visiting environmental education centres. This study used sequential exploratory mixed methods to discover the perceptions of environmental educators concerning the realities of their daily practice. The first phase of the study utilized a grounded theory approach to construct an understanding of environmental education in Ontario. The interrelated themes of increasing environmental consciousness, evaluation of programs and centres, influence of visiting adults on program effectiveness, and programming were revealed. The second phase utilized the themes derived to construct an online survey in order to measure the actual practice of environmental educators compared to their perceived best methods. The results indicate that the scarcity of effective program and institutional evaluation, ineffective communication between supervising adults, and the conflict over pedagogical aims lead to some centres potentially only achieving mediocre increases in the environmental consciousness of the participants. The need for explicit, accessible areas where youth can engage in repetitive unstructured activities in the natural world is highlighted as an area for community stakeholders to focus their efforts on if pro-environmental behaviour is a desired trait in residents.

The purpose of this research was to examine the implementation of Georgia's Medicaid family planning program, known as Planning for Healthy Babies or P4HB. This program is the first such program to provide both family planning services and inter-pregnancy care services through a Medicaid expansion to low-income, uninsured women. An evaluative case study design was employed using mixed methods. These methods incorporated process measures to study the implementation of P4HB and to assess whether P4HB was implemented as planned We incorporated theory from the policy implementation and health care access literatures to understand what served as facilitators or barriers to successful implementation. Findings suggest that despite precise goals and objectives, formal guidance about the program did not incorporate clear implementation planning. Many stakeholders, including advocates, providers, and representatives from implementing agencies felt left out of the implementation process and did not feel invested in the program. Considerable confusion existed among eligible clients and providers about the nature and scope of the P4HB program. This lack of awareness and understanding about P4HB likely contributed to the program's low enrollment and participation in the first year of its implementation. As many states prepare to expand their Medicaid programs under the Patient Protection and Affordable Care Act (ACA), this study provides important lessons for policy planning and implementation.

Bandura (1986) posited that self-efficacy beliefs help determine what individuals do with the knowledge and skills they have and are critical determinants of how well skill and knowledge are acquired. Research has correlated self-efficacy beliefs with academic success and subject interest (Pajares, Britner, & Valiante, 2000). Similar studies report a decreasing interest by students in school science beginning in middle school claiming that they don’t enjoy science because the classes are boring and irrelevant to their lives (Basu & Barton, 2007). The hypothesis put forth by researchers is that students need to observe models of how science is done, the nature of science (NOS), so that they connect with the human enterprise of science and thereby raise their self-efficacy (Britner, 2008). This study examined NOS understandings and science self-efficacy of students enrolled in a sixth grade earth science class taught with explicit NOS instruction. The research questions that guided this study were (a) how do students’ self-efficacy beliefs change as compared with changes in their nature of science understandings?; and (b) how do changes in students’ science self-efficacy beliefs vary with gender and ethnicity segregation? A mixed method design was employed following an embedded experimental model (Creswell & Plano Clark, 2007). As the treatment, five NOS aspects were first taught by the teachers using nonintegrated activities followed by integrated instructional approach (Khishfe, 2008). Students’ views of NOS using the Views on Nature of Science (VNOS) (Lederman, Abd-El-Khalick, & Schwartz, 2002) along with their self-efficacy beliefs using three Likert-type science self-efficacy scales (Britner, 2002) were gathered. Changes in NOS understandings were determined by categorizing student responses and then comparing pre- and post-instructional understandings. To determine changes in participants’ self-efficacy beliefs as measured by the three subscales, a multivariate analysis of covariance (MANCOVA) was conducted. Findings indicated that explicit NOS instruction was effective for all students except minority (Black, Hispanic, Asian, or multiracial) male students in improving NOS understandings. Furthermore, all students that received NOS instruction demonstrated decreased anxiety towards science. Future research should focus on long-term investigations of changes in anxiety and value of research constructs with regards to NOS instruction.

Research has demonstrated that problem gambling is associated with substance and alcohol abuse (Petry, Stinson, & Grant, 2005), participation in criminal activities (McCorkle, 2002; Meyer & Stadler, 1999), and involvement in the criminal justice system (NORC, 1999). This study assessed problem gambling and its relation to crime and substance use within a population in which these risk factors are compounded: Adults mandated to participate in drug and DUI courts. Results indicate that the prevalence and severity of problem gambling may be higher within this population than any other. Furthermore, the results of qualitative and quantitative analyses converged to highlight that gambling, crime and substance use are interrelated behaviors, as each may lead to and/or reinforce the other. These findings suggest that problem gambling is a salient issue among substance-abusing offenders and that resources should be dedicated to screening those involved with the criminal justice system for problem gambling, establishing evidence based best practices in the prevention and treatment of problem gambling within this population, and that such practices may incorporate components addressing gambling, crime, and substance use.

Research has demonstrated that problem gambling is associated with substance and alcohol abuse (Petry, Stinson, & Grant, 2005), participation in criminal activities (McCorkle, 2002; Meyer & Stadler, 1999), and involvement in the criminal justice system (NORC, 1999). This study assessed problem gambling and its relation to crime and substance use within a population in which these risk factors are compounded: Adults mandated to participate in drug and DUI courts. Results indicate that the prevalence and severity of problem gambling may be higher within this population than any other. Furthermore, the results of qualitative and quantitative analyses converged to highlight that gambling, crime and substance use are interrelated behaviors, as each may lead to and/or reinforce the other. These findings suggest that problem gambling is a salient issue among substance-abusing offenders and that resources should be dedicated to screening those involved with the criminal justice system for problem gambling, establishing evidence based best practices in the prevention and treatment of problem gambling within this population, and that such practices may incorporate components addressing gambling, crime, and substance use.

Bakgrund: Många personer med utvecklingsstörning har kommunikativa svårigheter och har därför behov av att utveckla olika sätt att kommunicera för att kunna förstå andra och göra sig förstådda. Svårigheter i kommunikationen påverkar interaktionen mellan personer med utvecklingsstörning och deras vårdare. Detta ställer höga krav på vårdare att kunna tolka och förstå den enskilda individens sätt att uttrycka önskningar och behov. På samma sätt riskerar vårdares budskap att missförstås. Om vårdaren misslyckas att förstå den boendes kommunikation och vice versa, kan det leda till situationer med utmanande beteende exempelvis i form av vägran, verbal eller fysisk aggressivitet. Syfte: Det övergripande syftet med avhandlingen är att studera interaktion mellan vuxna personer med utvecklingsstörning och vårdare i gruppbostäder, samt att studera effekter av en utbildningsintervention för vårdare som arbetar i gruppbostäder. Metod: Avhandlingens samtliga delstudier har genomförts i gruppbostäder för personer med utvecklingsstörning bland boende och vårdare i ett län i norra Sverige. I studie I insamlades data kring 556 personer med utvecklingsstörning. I studie II och III deltog 16 vårdare och 11 personer med utvecklingsstörning. I studie IV deltog 7 vårdare. Studie I bygger på personalens skattningar av funktionsnivåer och förekomst av begränsningsåtgärder. I Studie II och III utgörs data av videoobservationer och narrativa intervjuer. I studie IV användes flera datainsamlingsmetoder i en mixed method design med både vårdarnas skattningar, med hjälp av instrument och semi-strukturerade intervjuer. Analys av materialet i studie II, III och IV har gjorts med kvalitativ innehållsanalys och i studie I och IV har data analyserats statistiskt. Resultat: I studie I framkom att av 556 boende hade 99 (18%) varit föremål för fysiska begränsningsåtgärder under den senaste veckan. Av dessa 99 hade nästan alla varit föremål för mer än en typ av begränsningsåtgärd. Den vanligaste begränsningsåtgärden var bälte i stol (74%). Användningen av begränsningsåtgärder var relaterade både till fysiska funktionsnedsättningar och till beteende. I studie II reflekterade vårdare över videoinspelad interaktion där vårdarna medverkat, både framgångsrik och misslyckad interaktion. Exempel på framgångsrik interaktion var att förstå tecken, kunna möta behov och hantera situationer med utmanande beteenden. Vårdarna reflekterade över att framgångsrik interaktion ledde till säkerhet, trygghet och självförtroende hos de boende. Vårdarna reflekterade även över de konsekvenser misslyckad interaktion fick i form av irritation, aggression och våld från de boende. I studie III studerades videoinspelad interaktion mellan 11 personer med utvecklingsstörning och 16 av deras vårdare. Verbal och icke-verbal interaktion identifierades. Fyra inspelade situationer valdes ut för att belysa framgångsrikt samspel. Resultatet visade att framgångsrikt samspel mellan personer med utvecklingsstörning och deras vårdare bland annat bygger på möjligheten att bekräfta varandra, dela vardagshändelser, ge tid och utrymme och på att använda ett kongruent och tydligt språk. I studie IV utvärderades effekterna av en web-baserad utbildningsintervention, vars syfte var att förbättra interaktionen mellan personer med utvecklingsstörning och vårdare samt att därmed reducera förekomsten av situationer med utmanande beteende. Resultatet visade att vårdarna hade förbättrat sin förmåga att hantera situationer med utmanande beteende och att förekomsten av utmanande beteende minskat. Vårdarna beskrev att den web-baserade utbildningen upplevts givande och möjlig att ta del av parallellt med arbetet. Slutsats: Fysiska begränsningsåtgärder förekommer i gruppbostäder för personer med utvecklingsstörning. Användningen av begränsningsåtgärder kan vara relaterade både till fysiska funktionsnedsättningar och till beteenden i samspelet mellan brukare och vårdare. Vårdare upplever användningen av fysiska begränsningsåtgärder svår och tröttande. Brott i kommunikationen mellan personer med utvecklingsstörning och deras vårdare kan leda till försvårad interaktion med risk för situationer med utmanande beteenden. När vårdare är framgångsrika i interaktionen med personer med utvecklingsstörning ger det tillfredsställelse både för de boende och vårdarna. Vårdarna upplever dock ofta hjälplöshet och osäkerhet i relation till hantering av situationer med utmanande beteende och efterfrågar utbildning. Web-baserad utbildning om interaktion med personer med utvecklingsstörning och utmanande beteende har i vår studie visat sig ge lovande effekter och bör vara möjlig att utveckla för både introduktion av nyanställda vårdare och för kompetensutveckling bland mer erfaren personal. / Background: People with learning disabilities communicate in various ways depending on their abilities. Communication difficulties affect interactions between people with learning disabilities and their professional carers’ and this places a high demand on the carers to interpret and understand each individual’s wishes and needs. At the same time, there is a risk that the carers will be misunderstood. If carers fail to understand what the residents are trying to communicate, and vice versa, situations with challenging behaviour such as an unwillingness to interact or verbal and physical aggression may occur. Aim: The overall aim of this thesis was to explore the interactions between adults with learning disabilities and carers in special accommodations as well as to evaluate the effects of an intervention created for carers working with people with learning disabilities at special accommodations. Method: The setting for the study was at special accommodations in one county in northern Sweden. In study I, information regarding 556 adults with learning disabilities was collected. In both study II & III, 11 people with learning disabilities and 16 of their carers participated. In study IV, 7 carers and one person with learning disabilities participated. Data in study I consist of carers’ estimations of the residents disabilities and frequency of restraint use. Video-recorded observations and individual narrative interviews were used in study II and study III, and in study IV multiple methods of data collection were used in a mixed method design with both carers’ estimations using instruments and with semi-structured interviews. Methods for analyses in study II, III and IV were qualitative content analysis and in study I and IV statistical analyses were used. Results: Study I revealed that of the 556 residents studied, 99 (18%) had been subjected to physical restraint use over the previous week. Of these participants, almost all were subjected to more than one type of restraint. The most commonly used physical restraint was a belt in chair (74%). Use of physical restraint can be related to both physical disabilities and challenging behaviours in the interaction between people with learning disabilities and their carers’. In interviews for study II, the carers reflected on both successful and unsuccessful interactions after viewing video of situations where they have been participating. Examples of successful interactions included understanding cues, satisfying needs, and managing situations with challenging behaviours. The carers’ reflected on how successful interactions could influence their feeling of security, confidence, and satisfaction among the residents. The carers also reflected on the consequences of unsuccessful interactions, which included causing irritation, aggression and violence. In study III, interactions between 11 residents with learning disabilities and 16 of their caregivers were recorded on video. Verbal and non-verbal interaction skills used among the carers were identified. Four ‘caring situations’ were chosen as examples of skilled interactions. The results showed that skilled interactions between the carers and their clients were based on being confirming, sharing daily life experiences, giving time and space, and using congruent and distinct language. Study IV evaluated the effects of a web-based learning intervention, based on a theoretical model, and the results showed an increased ability among the carers to handle situations with challenging behaviour and a decreased frequency of challenging behaviour. Conclusion: Physical restraint is commonly used in special accommodations for people with learning disabilities. Use of physical restraint can be related to both physical disabilities and challenging behaviours in the interaction between people with learning disabilities and their carers. Carers find the use of physical restraint difficult and exhausting. A break in communication between people with learning disabilities and their carers could lead to impaired interaction that creates situations of challenging behaviour. When carers are able to interact successfully with people who have limited ability to communicate verbally, it seems to give satisfaction to both the residents and their carers in group homes. Carers often experience helplessness and uncertainty in situations with challenging behaviour and express a need for support. The carers considered the web-based training program to be useful. Further, a decrease of situations of challenging behaviour was observed after the web-based program was implemented. This indicates that the web-based training program may be useful in training for carers, both novices and more experienced carers in special accommodations for people with learning disabilities

Introduction: Cancer poses a substantial burden on the health of Canadians. Although advancements in screening and treatment have reduced, cancer-related morbidity and quality of life remain important concerns throughout cancer treatment and survivorship. <p>Purpose: This study examined the impact of Iyengar yoga on quality of life and other cancer-related symptoms among people with cancer. <p>Methods: All individuals registered for the Fall 2006 and Winter 2007, 10-week Iyengar yoga programs, offered by CancerCare Manitoba through private donations, were invited to participate in the study. Participants were asked to complete standard self-report questionnaires and participant diaries at baseline, week-5, week-10, and 6 weeks following the last class. The interventions impact on study outcomes were determined using repeated measures ANOVAs and paired samples t-tests. Six participant interviews and a review of participant diaries were conducted and analyzed using categorical aggregation and direct interpretation to identify other relevant issues as raised by participants and to document any negative effects of the program.<p>Results: Nineteen female participants completed the yoga intervention. The mean age of the sample was 50 years and the majority self-identified as Caucasian. Approximately one third had breast cancer and 63% were undergoing treatment for cancer at baseline. Results from the questionnaires showed statistically significant improvements in quality of life, mood disturbance, spiritual well-being, anxiety, nausea, pain, participants most bothersome symptom at baseline, and trait anxiety. Results from the interviews and participant diaries showed that participants experienced increases in social support, relaxation, mental concentration, and in flexibility, strength, and mobility in problem areas. Participants also expressed that their Iyengar yoga practice was empowering and supported their need to take an active role in their health and take a holistic approach to care. It was suggested that Iyengar yoga might contribute to the benefits reported through an ability to facilitate the development of coping skills or mindfulness.<p>Conclusions: The Iyengar yoga program for people living with cancer offered by CancerCare Manitoba can be considered a complex, multi-level, multi-modal intervention. Although, due to design limitations, neither causality nor a dose-response relationship between the Iyengar yoga intervention and the improvements in cancer-related outcomes could be inferred, the present study lends support to the assertion that Iyengar yoga is beneficial to the well-being of those living with cancer.