M.Med., Orthopaedic Surgery, Faculty of Health Sciences, University of the Witwatersrand, 2010

The purpose of this project was to identify the standards for the American Association of Critical Care Nurses (AACN). The employees of a 39-bed medical surgical unit within a 697-bed metropolitan medical center were selected through collaboration with the practicum site. Out of 68 allocated positions for this unit, only permanent employees were selected to participate. An employee presented the purpose of the project, the survey process, and inferred consent represented by online login to complete the survey. Following the online assessment, the employee explained the AACN healthy work environment standards in a subsequent presentation. The online healthy work environment assessment measured the AACN healthy work environment standards, which included skilled communication, collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership. A mean score was generated by the healthy work environment online assessment tool on a scale ranging from 1 (Needs Improvement) to 5 (Excellent). Data from the online assessment were analyzed by comparing mean pre- (3.03) and post- (2.17) project results, which revealed a need for greater understanding of AACN healthy work environment standards. Increased education of the AACN healthy work environment standards and implementation of a formal program would impact nursing turnover rates, improve employee engagement, and ultimately improve the care and outcome of patients, thereby promoting positive social change.

The purpose of this study was to examine the relationship among Healthy Work Environments (HWEs), nurse caring behaviors, and nursing-sensitive patient outcomes, specifically catheter-associated urinary tract infections (CAUTIs), patient falls with injury, and hospital-associated pressure injuries (HAPIs) Stage 2 and above in Magnet hospitals. A descriptive, cross-sectional, quantitative, study was conducted between January 1, 2018, and February 28, 2018, in seven Magnet-designated hospitals in a large faith-based system in the United States. A convenience, non-probability, purposive sample of permanently employed, direct-care RNs assigned to inpatient adult medical-surgical, telemetry, progressive care, stepdown, and critical care units were eligible to participate in the study. Three hundred and thirty-nine of 2632 eligible direct-care RNs participated in the study resulting in an overall response rate of 13.0% with a range of 5.5%–38.1% across hospitals. Nurse participants completed the AACN Healthy Work Environment Assessment Tool and the Nurse Caring Behaviors Inventory–24. Nursing-sensitive patient outcome data were obtained from patients cared for in the units during the study period. / Includes bibliography. / Dissertation (Ph.D.)--Florida Atlantic University, 2019. / FAU Electronic Theses and Dissertations Collection

AimsParticipant drop out is a major barrier to high-quality patient-reported outcome (PRO) data analysis in cancer research as patients with worsening health are more likely to dropout. To test the hypothesis that ovarian cancer patients with worse PROs would drop out earlier, we examined how patients differed by time of dropout on health-related quality of life (HRQOL), anxiety, depression, optimism and insomnia. MethodsThis analysis included 619 participants, stratified by time of dropout, from the Australian Ovarian Cancer Study - Quality of Life substudy, in which participants completed PRO questionnaires at three-monthly intervals for 21 months. Trends in PROs over time were examined. Pearson correlations examined the relationship between time of dropout and baseline PROs. Multiple linear regression models including age, disease stage and time since diagnosis examined relationships between baseline and final PRO scores, and final PRO scores and dropout group. ResultsParticipants who dropped out earlier had significantly worse baseline HRQOL (p<0.0001) and higher depression (p<0.0001). For all five PROs, final scores were significantly associated with baseline scores (p<0.0001). Time of dropout was significantly associated with final HRQOL (p=0.003), anxiety (p=0.05), depression (p=0.02) and optimism (p=0.02) scores. Depression, HRQOL and anxiety worsened at a faster rate overtime in dropouts than study completers. ConclusionsPoorer HRQOL and higher depression at baseline, and final HRQOL, anxiety, depression and optimism scores were predictive of time of dropout. These results highlight the importance of collecting auxiliary data to inform careful and considered handling of missing PRO data during analysis, interpretation and reporting.

The Georgia Department of Public Health has been engaged in a registry-based quality improvement initiative to monitor and improve the quality of stroke care. It is important to evaluate effectiveness of the quality improvement initiative in order to expand the effort to other sites or disease conditions. The studies, included in this dissertation, addressed whether acute ischemic stroke patients cared for by hospitals participating in the Georgia Coverdell Acute Stroke Registry (GCASR) had a better survival than those treated at other facilities, assessed whether quality of care as measured by nationally accepted ten performance measures is associated with improved patient outcome and evaluated the impact of intravenous alteplase treatment on 1-year mortality. Three data sources – GCASR, Georgia Discharge Data System and the death data – were used for analyses. These data sources were linked applying both a hierarchical deterministic and a probabilistic linkage methods. Survival after stroke incident was analyzed using the extended Cox proportional hazard model. Generalized estimating equation (glimmix procedure) and conditional logistic regression were applied, respectively, to assess the association of quality of care and intravenous alteplase use with 1-year mortality. Acute ischemic stroke patients treated at nonparticipating facilities had a hazard ratio for death of 1.14 (95% confidence interval, 1.03–1.26; p-value = .01) after the first week of admission compared with patients cared for by hospitals participating in the registry. Among patients treated in GCASR-participating hospitals, patients who received the lowest and intermediate quality care respectively had a 3.94 (95%CI: 3.27, 4.75; p-value <0.0001) and a 1.38 (95%CI: 1.12, 1.62; p-value=0.002) times higher odds of dying in one year compared to those who got the best quality stroke care. Patients who were eligible but did not receive IV alteplase had a 1.49 (95%CI: 1.09-2.04; p-value=0.01) times higher odds of dying within one year than those who were treated with the thrombolytic agent. The results strongly suggest that registry-based quality improvement effort has brought significant improvements in ischemic stroke patients’ outcomes. Therefore, it is critical that hospitals adopt a quality improvement strategy to change the process of care delivery for a better patient outcome.

The purpose of this study was to identify the characteristics of cancer patients and the most frequently chosen nursing diagnoses, outcomes and interventions chosen for care plans from a large Midwestern acute care hospital. In addition the patients' outcome change scores and length of stay from the four oncology specialty units are investigated. Donabedian's structure-process-outcome model is the framework for this study. This is a descriptive retrospective study. The sample included a total of 2,237 patients admitted on four oncology units from June 1 to December 31, 2010. Data were retrieved from medical records, the nursing documentation system, and the tumor registry center. Demographics showed that 63% of the inpatients were female, 89% were white, 53 % were married and 26% were retired. Most patients returned home (82%); and 2% died in the hospital. Descriptive analysis identified that the most common nursing diagnoses for oncology inpatients were Acute Pain (78%), Risk for Infection (31%), and Nausea (26%). Each cancer patient had approximately 3.1 nursing diagnoses (SD=2.5), 6.3 nursing interventions (SD=5.1), and 3.7 nursing outcomes (SD=2.9). Characteristics of the patients were not found to be related to LOS (M=3.7) or outcome change scores for Pain Level among the patients with Acute Pain. Specifically, 88% of patients retained or improved outcome change scores. The most common linkage of NANDA-I, NOC, and NIC (NNN), a set of standardized nursing terminologies used in the study that represents nursing diagnoses, nursing-sensitive patient outcomes and nursing interventions, prospectively, was Acute Pain--Pain Level--Pain Management. Pain was the dominant concept in the nursing care provided to oncology patients. Risk for Infection was the most frequent nursing diagnosis in the Adult Leukemia and Bone Transplant Unit. Patients with both Acute Pain and Risk for Infection may differ among units; while the traditional study strategies rarely demonstrate this finding. Identifying the pattern of core diagnoses, interventions, and outcomes for oncology nurses can direct nursing care in clinical practice and provide direction for future research tot targets areas of high impact and guide education and evaluation of nurse competencies.

Background: The International Outcome Inventory for Hearing Aids (IOI-HA) was develo developed as a global hearing aid outcome measure targeting seven outcome domains. The published norms were based on a private-pay sample who were fitted with analog hearing aids. Purpose: The purpose of this study was to evaluate the psychometric properties of th the IOI-HA and to establish normative data in a veteran sample. Research Design: Survey. Study Sample: The participants were 131 male veterans (mean age of 74.3 years, SD = 7.4) who were issued hearing aids with digital signal processing (DSP). Intervention: Hearing aids with DSP that were fitted bilaterally between 2005 and 2007. Data Collection and Analysis: Veterans were mailed two copies of the IOI-HA. The participants were instructed to complete the first copy of the questionnaire immediately and the second copy in two weeks. The completed questionnaires were mailed to the laboratory. The psychometric properties of the questionnaire were evaluated. As suggested by Cox and colleagues, the participants were divided into two categories based on their unaided subjective hearing difficulty. The two categories were (1) those with less hearing difficulty (none-to-moderate category) and (2) those who report more hearing difficulty (moderately severe severe+ category). The norms from the current veteran sample then were compared to the original, published sample. For each hearing difficulty category, the critical difference values were calculated for each item and for the total score. Results: A factor analysis showed that the IOI-HA in the veteran sample had the ident identical subscale structure as reported in the original sample. For the total scale, the internal consistency was good (Chronbach's α = 0.83), and the test-retest reliability was high ( λ = 0.94). Group and individual norms were developed for both hearing difficulty categories in the veteran sample. For each IOI-HA item, the critical difference scores were <1.0. This finding suggests that for any item on the IOI-HA, there is a 95 percent chance that an observed change of one response unit between two test sessions reflects a true change in outcome for a given domain. Conclusions: The results of this study confirmed that the psychometric properties of th the IOI-HA questionnaire are strong and are essentially the same for the veteran sample and the original private-pay sample. The veteran norms, however, produced higher outcomes than those established originally, possibly because of differences in the population samples and/or hearing on aid technology. Clinical and research applications of the current findings are presented. Based on the results from the current study, the norms established here should replace the original norms for use in veterans with current hearing aid technology.

Aim: Research on close relationships demonstrates that dyadic convergence, or two people becoming more concordant in their experiences and/or beliefs over time, is commonplace and adaptive. As psychotherapy involves a close relationship, patient–therapist convergence processes may influence treatment-specific outcomes. Although prior research supports that patients and therapists tend to converge on their alliance perspectives over time, which associates with subsequent patient improvement, no research has similarly examined belief convergence during therapy. Accordingly, this study focused on patient–therapist convergence in their outcome expectation (OE), a belief variable associated with patient improvement when measured from individual participant perspectives. I predicted both that significant OE convergence would occur and relate to better posttreatment outcome. Method: Data derived from a trial of naturalistic psychotherapy. Patients and therapists repeatedly rated their respective OE through treatment, and patients rated their symptom/functional outcomes at posttreatment. For dyads (N = 154) with the requisite OE data, I tested my questions using multilevel structural equation modeling. Results: There was no discernable OE convergence pattern over treatment (g100 = 0.02, SE = 0.04, p = .275) and OE convergence was unrelated to outcome at the between-dyad (b02k = 1.86, SD = 10.08, p = .406) and between-therapist (g002 = -0.06, SD = 3.54, p = .473) levels. However, higher early patient OE was significantly associated with better outcome at the between-dyad level (b05k = -0.04, SD = 0.01, p < .001). Discussion: Results suggest that OE may be more of a facilitative patient versus relational process factor.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24970号 / 医博第5024号 / 新制||医||1069(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 中山 健夫, 教授 川上 浩司, 教授 大鶴 繁 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

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