O propósito deste estudo foi desenvolver um software-protótipo, que possibilite aos enfermeiros atender ao planejamento da assistência de enfermagem, prescrição de intervenções de enfermagem e toda sua documentação de forma informatizada.A equipe multiprofissional envolvida no desenvolvimento deste software-protótipo foi constituída pela pesquisadora, um analista de sistema e um programador. A metodologia utilizada fundamentou-se no ciclo de vida de desenvolvimento de sistema, baseando-se no conceito de prototipação. Sedimentou-se em duas fases: a fase de definição e a de desenvolvimento. A fase de definição iniciou-se com a etapa de planejamento, seguido pela definição e análise dos requisitos necessários para sua construção e culminou com a produção da especificação de requisitos do software. A fase de desenvolvimento traduziu o conjunto de requisitos em um modelo informatizado, estruturado em 10 módulos, referentes ao processo de sistematização da assistência de enfermagem. Os módulos denominados: Ficha de Identificação, Dados Clínicos, Internações, Informações adicionais e Entrevista armazenam dados relativos às necessidades humanas básicas e abrangem: o índice de massa corpórea, situação clínica, resumo de admissão, internações anteriores e os dados para identificação do paciente. O módulo para Coleta de Dados foi desenhado para cadastrar informações diferenciadas sobre os sinais e sintomas e gerar, automaticamente, o módulo Lista de Problemas. Este viabiliza a elaboração da prescrição de enfermagem específica para cada paciente por meio da utilização de uma base de dados previamente estabelecida pelo sistema. Para propiciar maior comodidade e agilidade nas atividades de documentação, o módulo sobre Sinais Vitais permite transformar, eletronicamente, os valores atribuídos à pressão arterial, pulso, respiração e temperatura em gráficos individualizados. O ambiente Balanço Hidroeletrolítico permite implementar, automaticamente, o balanço parcial e total oferecendo aos enfermeiros simplicidade na execução desta tarefa, bem como realizar seu acompanhamento posterior. A avaliação deste recurso inovador na performance da Sistematização da Assistência de Enfermagem nos diferentes estágios do seu processo será objeto de um estudo posterior. / The purpose of this study is to develop a software-prototype to help the nurses to plan the nursing care, to make nursing interventions and all documentation in a computerized way. The multi- professional team is involved in the development of this software-prototype and constituted by the researcher, a system analyst and a programmer. The methodology is based in the life cycle of system development, basing on the prototype concept. It is following up into two phases: the definition and the development one. The definition phase began with the planning stage, following for the definition and analysis of the requirements for the construction and it culminated with the specification of the software requirements.The development phase translated the group of requirements in a computerized model, structured in 10 modules, regarding the process of nursing care system. The Identification, Clinical Data, Interview and additional Information modules store data related to the basic human needs and they include: the index of corporal mass, clinical situation, admission summary, and the patient's identification. The Data Collection module was design to register information related to the signs and symptoms and to generate, automatically, the List of Problems module. This makes possible the elaboration of the nursing prescription of each patient using the data base established previously by the system. To make better the documentation activities, the Vital Signs module allows to transform, electronically, the values attributed to the blood pressure, pulse, breathing and temperature in individualized graphs.The fluid and electrolyte metabolism balance module allows to implement, automatically, the partial and total response helping the nurses in the execution of this task, as well as to accomplish the subsequent attendance. The evaluation of this innovative resource in the performance of Nursing Care System will be object of a subsequent study.

FundaÃÃo de Amparo à Pesquisa do Estado do Cearà / O princÃpio da interprofissionalidade à critÃrio fundamental que orienta equipes multiprofissionais na EstratÃgia SaÃde da FamÃlia. A aÃÃo profissional, no entanto, parece ser marcada por uma lÃgica caracterizada pela delimitaÃÃo estreita de territÃrios de cada categoria, conformando um quadro de disputa entre as lÃgicas contraditÃrias da profissionalizaÃÃo e da interprofissionalidade. Esta à compreendida como a sÃntese de um processo de integraÃÃo de saberes e de colaboraÃÃo interprofissional, processos estes mediados pelos afetos. Considerando haver obstÃculos diversos para a efetivaÃÃo da interprofissionalidade, a pesquisa objetiva compreender a dinÃmica das relaÃÃes interprofissionais na produÃÃo do cuidado na EstratÃgia SaÃde da FamÃla, explorando a existÃncia de condiÃÃes de possibilidade para a construÃÃo da interprofissionalidade na AtenÃÃo PrimÃria à SaÃde no Brasil. Trata-se de estudo de caso, de natureza qualitativa, inspirado na HermenÃutica. O cenÃrio de estudo à um Centro de SaÃde da FamÃlia, numa capital brasileira. A recolha das informaÃÃes foi procedida no perÃodo de marÃo a agosto de 2011, com realizaÃÃo de entrevistas abertas, observaÃÃo das atividades desenvolvidas pelas equipes e realizaÃÃo de oficinas de produÃÃo de conhecimento, envolvendo 23 profissionais da ESF, NÃcleos de Apoio à SaÃde da Familia e residentes de Medicina e de SaÃde da FamÃlia e Comunidade. Foram identificadas condiÃÃes de possibilidades da interprofissionalidade na ESF, sintetizadas em trÃs dimensÃes: organizacional, coletiva e subjetiva. Incluem-se na dimensÃo organizacional dispositivos e arranjos institucionais, suportes para as atividades interprofissionais, quais sejam: a estruturaÃÃo de uma âRede de SaÃde â Escolaâ, transformando todas as unidades de saÃde de um municÃpio em espaÃos de ensino, pesquisa e assistÃncia; a âEducaÃÃo Permanente Interprofissionalâ que contribua para ultrapassar a lÃgica da profissionalizaÃÃo ainda hegemÃnica na formaÃÃo dos trabalhadores da saÃde; bem como a âAbordagem Centrada na FamÃliaâ, em contraposiÃÃo à tendÃncia de organizar os serviÃos de saÃde com base em interesses corporativos. A segunda dimensÃo enfoca aspectos relacionados à organizaÃÃo dos profissionais como grupo de trabalho, ou seja, a organizaÃÃo do coletivo em comunidade de prÃtica, caracterizada pela pactuaÃÃo de um projeto em comum, engajamento mÃtuo e repertÃrios compartilhados. Mesmo tendo sido os profissionais da saÃde formados hegemonicamente para a lÃgica da profissionalizaÃÃo, envolvendo luta por status e reserva de mercado de trabalho, a participaÃÃo numa equipe da ESF, constituida como comunidade de prÃtica, possibilita a aprendizagem de outros valores, favorecendo a integraÃÃo de saberes e a colaboraÃÃo interprofissional, embora nÃo livre de conflitos. A terceira dimensÃo privilegia aspectos subjetivos, como a identificaÃÃo dos profissionais com o modelo assistencial da ESF, saber lidar com frustraÃÃes e a afetividade. Consideramos ser possÃvel a interprofissionalidade, desde que sejam disponibilizadas condiÃÃes organizacionais e coletivas, mobilizadoras de aspectos subjetivos dos profissionais. A oferta das condiÃÃes de possibilidade, no plano organizacional, à indispensÃvel, mas nÃo suficiente para a integraÃÃo de saberes e a colaboraÃÃo interprofissional. Sem a mobilizaÃÃo dos afetos, dos desejos e dos micropoderes de cada sujeito, nÃo hà interprofissionalidade possÃvel. / The principle of interprofessional learning and practice is a fundamental criterion that guides multidisciplinary teams in the Family Health Strategy (FHS).The professional action however, seems to be marked by a logic characterized by the narrow boundaries of the territories of each category as a scene of contention between the contradictory logics of professionalization and interprofessional practice. This is understood as the synthesis of a process of integration of knowledge and interprofessional collaboration (COLET, 2002). These processes are mediated by affects. Considering that there are several obstacles to the realization of the interprofessional learning and practice, the research aims to understand the dynamics of inter-relationships in the production of care in the familyÂs health strategy, exploiting the existence of conditions of possibility for the construction of interprofessional learning and practice. This is a qualitative case study inspired by hermeneutics. The scenario is a study of the Family Health Center, in a Brazilian capital. The gathering of the information was provided from March to August 20122, with open interviews, observation of activities in the FHS and workshops for knowledge production, involving 23 professionals. Conditions were identified in the possibilities of interprofessional FHS, combined in the following groups: Organizational, collective, and subjective. Included in the organizational dimension are devices and institutional arrangements, cross-media activities for the structuring of a âHealth-Education systemsâ, transforming all health facilities of a municipality into areas of teaching, research, and assistance. The âinterprofessional continuing educationâ helps to overcome the hegemonic logic of professionalism, sill found in the training of healthcare workers and user-centered approach, in contrast to the trend of organizing health service base on corporate interests. The second dimension focuses on aspects related to the organization of professionals working as a group, or the organizations of the collective community practice, characterized by agreeing on a common project, mutual engagement and shared repertoire. Even though health professionals trained to the hegemonic logic of professionalization, involving a struggle to preserve status and labor market participation in the ESF team, the way they are formed as a community of practice, enables the learning of other values, knowledge and practice, favoring the integration of interprofessional collaboration and knowledge, though not free of conflict. The third dimension includes subjective aspects such as the identification of professionals of the ESF health care model, dealing with frustration and affection. We consider that the interprofessional learning and practice is possible, if subjected to the organizational and collective conditions, mobilizing subjective aspects of professionals. The offering conditions of possibility in the organizational level are essential but not sufficient for integration of knowledge and interprofessional collaboration. Without the mobilization of emotions, desires and micro powers of each subject, inter-professional learning and practice is not possible.

Maintaining the proper physician-patient relationship in health care is vital to the well-being of patients, especially when considering end of life decisions such as euthanasia. Because this topic has been in the forefront of media in recent years, there appears to be a need to understand how the relationship between physician and patient works in these practical situations, as well as understand what the most appropriate model of patient care is in regards to maintaining patient autonomy. However, before this can be done this paper will begin with a brief look at the overall permissibility of euthanasia, using the arguments of Dan Brock and Leon Kass. Once the issue of permissibility is discussed, I continue by investigating three main models of patient care presented by Linda and Ezekiel Emanuel: informative, interpretive, and deliberative. Each of these models presents a different view of patient autonomy that changes how the physician and patient interact. By discussing the philosophical requirements of autonomy presented by philosophers such as Harry Frankfurt, Susan Wolf, and Andrea Westlund, I argue that the deliberative model of patient care provides the most sufficient view of autonomy while also protecting the physician-patient relationship and patient well-being.

No description available.

Excerpt: More than 25.8 million people in the United States have diabetes. This metabolic disorder is associated with many health complications that result from microvascular and macrovascular diseases.

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This phenomenological study describes the lived experience of ten registered nurses who provided a standard of nursing care that they perceived to be impeded because of their negative reactions to their patient's condition. Purposeful sampling was used to recruit participants via an advertisement in a local nursing organisation's newsletter. In-depth interviews generated data about the nurses' personal and professional experiences. Data analysis incorporated the qualitative methods of Huserrlian (descriptive) phenomenology and Colaizzi's method of data analysis. Findings revealed that during some stage of the nurses' careers they had reacted negatively to a patient's condition. These negative reactions included frustration, annoyance, nurses fearing for their own safety, revulsion, sadness and feelings of guilt that impeded care had been provided. These reactions translated into behaviours that were associated with providing nursing care to the patient that the nurses themselves perceived to be of impeded quality. Behaviours included not being there or spending less time with the patient, not communicating well and having less rapport with the patient, not meeting the patient's psychological and social needs and not meeting the patient's spiritual needs. The nurses found their awareness that this had occurred disturbing and they devised strategies to cope personally and also to ensure that a better quality of care was provided in subsequent situations. Strategies included discussions with colleagues, arranging for colleagues to provide care for the patient, mental preparation, and using individual coping strategies. / There was a pattern of contextual factors impeding the provision of good care. These factors included an existing poor rapport with the patient, a bad experience with a patient with similar characteristics, time pressures and a lack of autonomy, chronic work stress, low staffing levels, a lack of clinical experience, negative reactions to the patient's condition by other staff members, a lack of visits by the patient's significant others and disagreement with the patient's medical treatment.

As healthcare and health systems become increasingly complex, expectations of what constitutes high quality care continue to evolve. Stakeholders now require contemporary and meaningful measures of system performance. As such, valid healthcare quality metrics are rapidly becoming essential for those providing and receiving healthcare to assess performance and motivate change. This thesis investigates the utility of quality indicators in trauma care. Multiple in-hospital indicators have been promulgated by various bodies for assessing quality of trauma care. The properties of ideal indicators have been widely documented however few published data have reported these properties for many trauma measures. The emphasis on trauma process measures (eg. time to interventions) highlights the need for indicators with known links to patient outcomes. This process-outcome link may be viewed as a measure of an indicator’s construct validity. As this property is unknown for many trauma indicators, this thesis focuses on the construct validity of a number of routinely utilised trauma indicators. In this thesis, the available in-hospital indicators proposed by The American College of Surgeons Committee on Trauma and additional indicators used in the Victorian State Trauma System were investigated for their relationships with patient outcomes. A small number of indicators were found to have statistically significant relationships with patient outcomes, however many indicators demonstrated counter-intuitive relationships, whereby high quality care was linked with poorer patient outcomes. These results suggested that links between indicators and outcomes may not be best measured using individual indicators for individual patients. Rather, a strategy for measuring patient outcomes at the hospital level may be needed. To combine multiple indicators into a single measure of hospital level performance, a number of composite methods were explored using two trauma registries. Three composite weighting schemes were employed. As composite measures are often used for provider ranking or benchmarking, the stability of hospital ranks between providers and over time was investigated. The composites were found to have moderate to strong correlations (0.76-0.99) however variability in composite hospital rankings existed, particularly for middle ranking facilities. The construct validity of each available indicator and composite score was investigated through the relationship with hospital level risk-adjusted mortality using Poisson regression models, risk adjusting for expected deaths using the TRISS formulation. Each composite measure demonstrated a significant association with mortality, with the mortality decrease across the middle 50% of each composite score ranging from 12.06% – 16.13%. These findings suggest that complex measures such as trauma composite indices may be better able to measure the interactions between processes within complex systems that influence quality of care. This thesis adds valuable insight into the use of indicators for assessing quality of care in trauma systems. The combination of individual indicators into composite forms appears to strengthen the construct validity of these measures. By demonstrating the process-outcome link for trauma composite indices, this thesis has identified a means of utilising process measures to assess hospital level performance that may become important for future public reporting and hospital funding schemes.

Research Doctorate - Doctor of Philosophy (PhD) / Despite the emergence of smoking care guidelines and best practice recommendations over the past 13 years, it has been suggested that smoking care is not routinely provided in hospitals. Although there is a relatively large body of evidence regarding the prevalence of patient smoking cessation after hospitalisation and the effectiveness of interventions to increase cessation levels, much less is known regarding the prevalence of best practice smoking care routinely provided in hospitals or the effectiveness of interventions to increase such care provision. This thesis seeks to address these deficiencies in the evidence base. In particular this thesis aimed to: 1. Examine the prevalence of hospital smoking care in the international and Australian contexts. This is addressed via a literature review of studies that have reported the level of smoking care delivered routinely in hospitals and a survey of hospital managers in New South Wales, Australia. 2. Examine the effectiveness of interventions to increase the routine delivery of smoking care in hospitals. This is addressed via a literature review of studies that have reported the effect of an intervention on smoking care levels, and via the implementation of a quasi-experimental study that was designed to increase the hospital-wide delivery of a broad range of smoking care elements. 3. Propose recommendations for future practice and research regarding the routine provision of hospital smoking care. This thesis consists of six chapters that address the above aims. Each of the chapters has been written as a relatively distinct report in the style of a journal article. The approach has been adopted to facilitate the reading of the thesis, and results in some repetition in some chapters. At the time of submission, two papers based on the chapters of this thesis have been published in peer-reviewed journals. A further two papers are under editorial review.

The study evaluated the cost-effectiveness of community based Nurse Case Management (NCM) utilizing existing hospital information systems data. Program outcomes of intensive NCM were compared with those of existing hospital programs for a group at high risk for readmission. Thirty-one elderly patients were assigned to one of three groups. A retrospective pretest-posttest design was used and multivariate analyses were performed. Outcomes were measured at six month intervals before and after NCM. The intensive NCM group had a higher length of stay and inpatient costs than the other two groups. Direct costs of NCM were estimated at $1.55 per active case per day. The study found that cost-effectiveness of NCM cannot be determined accurately unless health risk assessments are quantified, NCM is clearly translated into categories of intervention, and direct costs of NCM are measured consistently. These factors must be integrated into routine hospital information system reports.