Thesis (Ph. D.)--Virginia Commonwealth University, 2006. / Prepared for: School of Allied Health Professions. Bibliography: leaves 189-212. Also available online.

Background Evidence-based medicine (EBM) involves the care of patients using the best available evidence from the results of good quality clinical research to guide clinical decision making 1 – 3. By incorporating the principles of Evidence-based Medicine (EBM), the family practitioner would be able to treat a patient according to the best clinical research available. This principle is implemented widely in the USA, Canada, the United Kingdom and Europe. In South Africa, however, EBM is not yet as widely incorporated into family practice. This is so despite the plethora of websites available to practitioners and the relative ease with which applicable research evidence can be found. Very few published studies are available regarding EBM or Evidence–based Practice (EBP) in the South African context. The findings of this study would thus highlight reasons and/ or barriers preventing family practitioners from implementing EBM in their respective practices. This could also lead to further research into possible methods of implementation of EBM into South African family practices. Aim: The aim of the study was to describe the perceptions, knowledge and attitudes of private practitioners regarding evidence based practice and to identify the barriers encountered in evidence based practice. Methods A questionnaire survey of general practitioners in Gauteng, South Africa, was conducted. Questionnaires were distributed to a random sample of practitioners in the Gauteng region. Two hundred and twenty one (221) practitioners participated in the survey and responded to questionnaires mailed to them. The questionnaire was mailed, faxed or e-mailed to the practitioners, which they then completed and returned for statistical analysis. Study design The study design is that of quantitative, statistical analysis (descriptive cross-sectional survey). Setting General practitioners were randomly selected from a list of practitioners in the Gauteng Province. Doing a nationwide survey would have been a mammoth undertaking. It was therefore decided to limit the research to one province and therefore it was only concentrated on practitioners practicing in the Gauteng area. Results It is interesting to note that of the two hundred and twenty one participants in this study; only 10% of the practitioners were against using EBM in their practices. This, however, stands in stark contrast to the 56% of practitioners who do not implement EBM in their practices or make use of the EBM principle at all. The major barriers preventing practitioners from implementing EBM is depicted in the following graph: Lack of time and the training in aspects of Evidence-based medicine were the main barriers preventing the full scale implementation of EBM in family practices in Gauteng. Conclusion Participating Gauteng doctors were in principle, very positive towards the implementation of EBM in their respective practices. Most of the participants agreed that EBM would benefit their patients’ care and treatment. Very few of the participants, however, make use of EBM in practice. A lack of training and time constraints were the main barriers with regards to the implementation of EBM. Proper training of medical students at undergraduate level at faculties of health sciences, would go a long way assisting prospective doctors in mastering the concept of EBM and increasing their overall awareness of EBM. Further definitive research would assist in establishing whether such awareness would be associated with improved implementation of evidence in the form of evidence based guidelines in practice.

Background: A serious problem in the work environment are threats and violence. This is a growing problem in health care. Workplaces providing mental health care is one of the workplaces that is at risk of exposure. Nurses may suffer from severe psychological and physical consequences afterwards. Aim: The aim of the study was to describe nurses' experiences of threats and violence in the field of mental health care. Method: The study was conducted at a hospital in southern Sweden. Ten nurses were interviewed for 30-60 minutes. The interviews were recorded in order to be written down later. The material was subjected to qualitative content analysis. Results: The processed material was subdivided into four categories: The view on threats and violence, approach to threats and violence over time, reactions on threats and violence and safety-creating factors. Everyone in the study had been exposed to threats and violence at work. Nurses described that with growing work experience, their approach to meet threats and violence changed. They were not as much affected as they were in the beginning of their work, and rather stood back instead of entering into confrontation with the patients. Experienced staff, education and secure premises are some of the factors to increase safety to staff. Conclusion: Working within psychiatric in-patient care department inevitably entails coming into contact with threats and / or violence at some point. Patients with a variety of psychiatric disorders may have difficulties expressing their needs in an appropriate manner. One last resort, when a patient is lacking a feeling of being understood, can be to communicate his needs through threats and violence. Linking a patient's behavior to his illness often helps nurses to gain a better understanding of why the patient is acting out.

Background: There has been wide interest shown in the manner in which ethical dimensions in nursing practice are approached and addressed. As a result a number of ethical decision making models have been developed to tackle these problems. However, in this thesis it has been argued that the ethical dimensions of nursing practice are still not clearly understood and responded in Brunei. Design and method: This thesis describes a qualitative analysis into the Bruneian nurses’ perceptions of ethical dimensions in nursing practice. Drawing on constructivist grounded theory as a method of inquiry, twenty eight practicing and administrative nurses were individually interviewed. The nurses described how ethical dimensions were perceived in their practice, by means of the difficulties they are facing in the real world of nursing practice; how they have responded to these difficulties, and why they make such responses. Findings: The nurses described three ethical dimensions in their practice, namely ‘nurse at work’ which illustrates the ethical dimensions within the work environment; ‘nurse and doctor’ that elucidates the ethical dimensions in the nurse and doctor relationship and ‘nurse and patient’ which further examines ethical aspects in patient care. ‘Taking responsibility’ and ‘shifting responsibility to others’ were identified as approaches that the nurses took in responding to the ethical dimensions with the aim of avoiding the conflict and maintaining ward harmony. These responses provide new insights into how nurses’ response to ethical dimension in the ward settings where it puts strong emphasis on the nurses’ understanding of responsibility placed upon them as a professional nurse. ‘Negotiating ethical responsibility’ emerged as a core category within the data which illustrate that nurses’ responses to the ethical dimensions form a continuous process, involving constant consideration of the two types of responses. The core category described that ethical dimensions in the nurses’ practice were contextualised in the ‘ethical responsibility’ that is placed upon them within the nursing organisation. This thesis has expanded the current theoretical knowledge of ethical dimensions by elaborating on the concerns experienced in nursing practice and the responses individual nurses utilise to negotiate and discharge their ethical responsibilities at work. The study has also extended emphasis to the reasoning and responses that nurses are engaged in, whilst at the same time, negotiating ethical responsibility regarding the context in which they are placed during their working hours. This core category provides a number of possible implications for future research, nursing practice, education and policy, which would facilitate the exploration of ethical understanding for nurses in Brunei, and enable the provision of an ethical environment, so making ethical dimensions more transparent.

This is a Straussian grounded theory study about the impact of nurses’ values on pressure ulcer prevention. Semi-structured interviews were used to gather data from participants (n=16) who were recruited from the non-acute adult medical wards of 14 hospitals in one NHS Trust and a local university. The participants were asked to talk about their experiences of preventing and managing pressure ulcers and their values were elicited from their accounts. The data were analysed and interpreted with Straussian grounded theory. Nurses were found to work according to the value that they placed on pressure ulcer prevention, as this value influenced the manner in which they prioritised and delivered skin care to their patients. Similar links between nurses’ values and their delivery of care with regards to other aspects of nursing were also identified. The delivery of care to prevent pressure ulcers was found to be subject to clinical priorities and other factors. As a result, the majority of care to maintain skin integrity was delivered by nursing auxiliaries and students because nurses were busy doing other things. Despite this, nurses who place a high value on pressure ulcer prevention appear to be more proactive and determined to deliver care that protects the integrity of their patients’ skin than their peers. This is highlighted by the participants’ accounts of how their prioritisation and delivery of care to prevent pressure ulcers changed when the value that they placed on pressure ulcer prevention increased from low to high. This study also identified the manner in which the value that nurses place on pressure ulcer prevention is formed and evolves. The recommendations that arise from this study are: further testing of this grounded theory in other settings to increase its generalisability and a greater awareness of the impact that the value that nurses place on different aspects of patient care has on their delivery of care to patients, especially with regards to pressure ulcer prevention. Nurse education and training must also take into account some of the factors that help to form and change the value that nurses place on pressure ulcer prevention. Greater attention needs to be paid to the value that nurses place on different aspects of nursing in view of the relationship between nurses’ values and care delivery, if patients are to receive the best possible care.

Mental capacity is the ability to understand, reason, and exercise choice by making informed decisions. Acute and/or critical illness may impact upon the decision making abilities of hospitalised adult patients. Assessment of patients for reduced, fluctuating or absent capacity gives the healthcare team the legal authority to assess best interests and to make treatment decisions without consent under this justification. Qualified nurses are the everpresent professional group in acute and critical care settings. They may initiate assessments of mental capacity which may be influential in the ways that the decision making of patients is facilitated or substituted. There are, however, few studies that focus on processes employed by them in this area in fast-moving clinical settings, although it is recognised that physical illness may have a significant impact upon capacity status.

There is growing evidence that the way patients and families relate to healthcare professionals influences their experience of illness and healthcare, and may affect their psychological and physical wellbeing. Relationships between professional groups may also have a significant impact on healthcare provision to children and families. Previous research has focused on dyadic relationships within paediatric healthcare (mother and child, nurse and parents, doctors and nurses), but little has been published concerning the complex inter-relationships and roles of family members, doctors and nurses. The aim of this research was to undertake a systemic analysis of the roles and relationships of nurses and doctors with children, adolescents and families. A qualitative methodology was used to explore how the three groups (nurses, doctors and families) understand their respective roles and relationships in the care of ill children within a tertiary paediatric hospital. While systemic and social constructionist theory informed the overall conception of the study, grounded theory was the method used for structuring data collection and analysis. Data collection involved semi-structured interviews with doctors, nurses and families. These were audio-taped and each set of transcripts analysed according to grounded theory principles. Theoretical coding then allowed comparisons to be made across each set of data. Two theoretical categories describing key processes involved in the care of ill children emerged from the analysis. These were: “Building emotional connections and focusing on medical goals: complementary or contradictory relationship discourses for families and staff?” and “Shifting relationships around expertise and power: the gains and losses associated with new positionings” The first category highlights that both professionals and families appear to draw on particular societal discourses to inform their roles and relationships. These discourses (about the therapeutic value of emotional connections between staff and families and the need for ‘medical professionalism’) can appear at odds with each other. creating tensions and dilemmas for each group. The second theoretical category highlights that power relationships between nurses, doctors and families are in a process of change. Fundamental change may be hard to achieve however, as each group may experience losses and well as gains in their emerging positions. It is further argued that changes in government policy relating to these core processes creates challenges for each participant group as they struggle to balance positive working relationships, the medical care of the child and status and power issues. Change in any one aspect of these professional and family roles and relationships may have both adverse and beneficial effects, which need to be recognised. These findings raise important questions about the feasibility and desirability of family centred care. The implications of this research for training, consultation and future research are explored. The research adds to a small but growing body of literature focusing on the interface between professionals, patients and families in healthcare settings.

Class of 2011 Abstract / OBJECTIVES: To examine the effects of pharmacist-provided direct patient care with consideration to the patients’ socioeconomic status as determined by the patients’ health insurance. METHODS: A meta-analysis was conducted to evaluate the effects of pharmacist-provided direct patient care on different socioeconomic populations as determined by the patients’ health insurance by including results from several independent randomized control trials. A standardized and tested data extraction form was used to collect primary data on outcome category (therapeutic, safety, and humanistic), disease category (diabetes, hypertension, cardiovascular, dyslipidemia, asthma, and other), insurance status (Medicaid, Medicare, Veterans Affairs/ Department of Defense, private and uninsured), and outcome measures. The potential for bias data were analyzed by calculating a total potential for bias score and by construction a forest plot ordered by bias score. RESULTS: Twenty-two studies were included in the meta-analysis. The insurances most often reported were Medicaid (13.6%), Medicare (18.2%), the Veterans Affairs/ Department of Defense (VA/DoD) (41%), and private insurance (27.2%). All insurance groups benefited from pharmacist intervention (p<0.01). The Medicare patients benefited the least from the pharmacist interventions [standard mean difference (SMD) = 0.21], and the benefit of intervention was significantly less than the benefit for subjects having Medicaid, Private Insurance or VA/DoD coverage (p<0.02). CONCLUSION: While patients in all insurance type benefited from pharmacist intervention, Medicare patients seemed to benefit the least; further studies are needed to verify the findings and to explore why the benefit is less than for other groups.

This study involves an investigation of the relationship between dependency and work resumption of patients with myocardial infarction. In the process of studying this problem, information concerning the different levels of dependency during the convalescence through employment continuum v/as gathered. The purposes of the study are to add to the body of knowledge concerning the concept of dependency and to make nurses and other members of the health team aware of the implications of dependency behaviour in the process of resuming normal function of patients with myocardial infarction. Its long range purpose is to increase the sense of well-being and achieving of the patient with myocardial infarction by helping him resume his productive role, both through the help of members of the health team and members of his family. The study was planned to test the following hypotheses: 1. The employed patients with myocardial infarction will show lower dependency ratings than the unemployed patients in the Navran Dy Scale. 2. The employed patients with myocardial infarction will show progressive decrease in the D-I Scale dependency ratings along the convalescence to employment period continuum, while the unemployed patients with myocardial infarction will maintain a constant level of dependency ratings in the D-I Scale along the convalescence to employment period continuum. 3. Low trait dependents with myocardial infarction will show progressive decrease in the D-I Scale dependency ratings along the convalescence to employment period continuum, while high trait dependent patients with myocardial infarction will continue to show steady dependency ratings in the D-I Scale along the convalescence to employment period continuum. Two structured questionnaires were constructed following a review of the literature to obtain information regarding the research problem. The Navran Dy and the dependency portion of the D-I Scale were also administered. The study population consisted of 21 men. The study population was restricted to men who were confined in the hospital for their first myocardial infarction, who were 64 years of age or younger, who could read and write English, and who had been employed for the 6 months immediately prior to the confinement. Analysis of the data included Frequency tables, T test and the Two-Factor Analysis of Variance. The findings of the study showed that patients with myocardial infarction showed different degrees of dependency, both trait and state. The findings failed to support the three hypotheses even though during the data analysis of the individual hypothesis, the group means showed leaning towards the direction of the hypothesis. The study suggests that steps should be taken to make nurses and family more aware of the varying degrees of dependency in patients. / Applied Science, Faculty of / Nursing, School of / Graduate

Background: Cardiovascular disease (CVD) has emerged as a major cause of morbidity and mortality in HIV-infected adults. Research in noninfected populations suggests that knowledge of CVD risk factors significantly influences perception of risk. Understanding the level of risk factor knowledge and risk perception can inform the development of innovative interventions to reduce risk. The purpose of this study was to describe cardiovascular risk factor knowledge and risk perception in a cohort of HIV-infected adults. Specific aims included (a) describing the estimated risk of CVD, the perceived risk of CVD, and the level of CVD risk factor knowledge; (b) describing the relationship between estimated and perceived risk, and (c) examining the influence of risk factor knowledge on perceived risk of CVD. The Health Belief Model was the theoretical framework that guided the study. Methods: A prospective observational cohort; cross-sectional design. A convenience sample of 130 HIV-infected adults was recruited from two hospital-based HIV clinics. Each participant had one study visit in which all data were collected by direct interview. Results: Results: Mean age of enrollees was 48 years (SD 8.4); 62% were male; 41.5% White, 32% Black, 23% Hispanic; 56% current smokers; mean years since HIV diagnosis were 14.7; mean BMI 27 (SD 5.5); 48.5% had prehypertension. Higher scores on the Heart Disease Fact Questionnaire indicate a higher degree of knowledge. In this sample, the Mean was 19, (S.D. 3.5; range 6–25), indicating a fair degree of knowledge. Estimated and perceived risk were significantly, though weakly, correlated r (126) = .24, p = .01. Controlling for age, risk factor knowledge was not predictive of perceived risk (F[1,117] = 0.13, p > .05). Conclusions: HIV-infected adults are at increased risk for cardiovascular disease. Traditional CVD risk factors such as smoking, prehypertension, and being overweight are highly prevalent. Despite having a fair level of risk factor knowledge, knowledge did not influence perception of risk for CVD. Research to improve risk perception and to develop innovative interventions that reduce CVD risk is needed for this population.