Effective June 9, 2016, many terminally ill patients residing in the State of California will now have the legal option of terminating their life because of protections offered under The California End of Life Options Act. Social workers whose population of care includes terminally ill patients will likely be engaging in conversations about end of life options, including physician assisted death, with their patients. Little research exists addressing what factors may influence social workers perceived preparedness to discuss physician assisted death with patients, yet the expectation that social workers be prepared to discuss all available end of life options with patients is present. The purpose of this quantitative study is to explore the influence of demographic characteristics and experience with terminal illness on California social workers perceived preparedness to discuss physician assisted death as an end of life option with terminally ill patients. Convenience sampling was utilized which included sixty-two Master of Social Work level or higher social workers who are employed in medical social work positions and are providing direct care for chronically and terminally ill patients. Participants completed a voluntary paper survey that gathered demographic information, experience with terminal illness and perceived preparedness to discuss physician assisted death with patients through Likert Scale measures. The findings showed a positive relationship between California social workers who perceived themselves as prepared to discuss physician assisted death and the identification of their social work education as a source of their preparedness.

Road traffic deaths, which affect people in their productive years, are projected to be the third leading cause of death by the year 2030. While most studies have focused on road infrastructure and vehicle safety, this study examined something new: the impact of prehospital response to road traffic accidents on the rate of death. Some countries send physicians to the scene of an accident; some send paramedics or registered nurses. The question this research sought to answer was whether the use of physician responders resulted in a lower rate of death compared to the use of nonphysician responders. The literature makes it clear that rate of road traffic death is related to country income and governance indicators, so first those variables needed to be equalized. My conceptual framework for this cross-sectional correlation study was the Haddon matrix, which organizes injuries by temporal (pre-event, event, and postevent) and epidemiological (host, agent, and environment) factors. Using World Health Organization data on road traffic injury and country income, World Bank data on governance indicators, and a literature search of 67 countries' prehospital response profiles, significant negative correlations (p > 0.001) were found for road traffic deaths and income, r (65) = -0.68, and governance indicators, r (65) = -0.646. No significant difference in the rate of road traffic death was found between physician and nonphysician prehospital staffing. Because increasing countries' income and improving governance are long-term, ambitious goals for developing countries, training nonphysician prehospital responders appears to be the most effective social change to decrease the burden of road traffic deaths.

Information from anecdotal interviews at a practicum site indicated a lack of training for advanced practice providers (APPs) in core competencies critical for effective practice in a heart failure (HF) unit. The goal of this project was to assess the APPs' verbal reports and develop HF unit-specific training for APPs. The practice-focused question examined whether unit-specific training for HF APPs improved knowledge and skills in HF management. The Johns Hopkins nursing evidence-based practice model and Knowles's adult learning theory were used to create a survey, a focus group, and a pre/posttest assessment of knowledge and skills gap. Descriptive and inferential statistics could be used to analyze pre/post survey data, and thematic analysis could be used to analyze focus group data. Assessment data could be used to develop a targeted HF program based on identified skill deficiencies. The implications of this project related to social change are the potential to increase APPs' knowledge, job engagement, and retention. The program could affect length of stay and 30-day readmission of patients in the HF unit.

Physicians must participate in developing medical protocols to ensure that medical best practices are adopted for patients' social benefit. Healthcare leaders have struggled to gain sufficient physician participation in developing medical protocols. Using technology-based crowdsourcing to assimilate knowledge from physicians may help healthcare managers improve medical protocol development. Using self-determination theory, this quantitative causal-comparative design aimed to determine whether differences in intrinsic and extrinsic motivation existed among the 132 participating physicians who did or did not participate in developing medical protocols in a crowdsourcing environment. Participants were recruited by e-mail through an independent physician association. Motivation levels were measured by the Aspirations Index via an online survey. A total of 55.3% of respondents participated in developing medical protocols. Differences were anticipated in the levels of participation in developing medical protocols between intrinsically and extrinsically motivated physicians. Rank correlations were computed between the number of protocols completed and all of the motivation scores. Personal growth and community contribution were significantly correlated with the number of addressed protocols. Positive social change may occur through improving medical protocols and healthcare outcomes by informing healthcare leaders about physicians' motivation to participate in developing medical protocols. By understanding these motivators, leaders can highlight the benefits of protocol development to encourage physician participation. If participation is enhanced, protocol quality and healthcare effectiveness may be improved, benefitting patients and healthy individuals.

Introduction: Physician assisted suicide (PAS) is the process where the patient terminateshis/her life with the aid of a physician who provides a prescription for lethal medication thatthe patient self-administers in order to commit suicide. PAS is practiced in several countriesand is now gaining support in Sweden. The debate shows some confusion regarding thedefinition of concepts and raises several ethical concerns. Aim: To provide an empirical background and clarify concepts. To analyze the ethical arguments for and against PAS. To investigate relevant ethical differences between PAS, euthanasia and withdrawal oflife-sustaining treatment. Materials and methods: Qualitative literature study based on argumentative- and conceptualanalysis on hermeneutic ground. Materials were gathered through a literature search andconsist of scientific articles, debate articles and official materials. Results: The main ethical arguments supporting PAS are autonomy, beneficence and dignity.PAS is by supporters seen as an act of compassion, which fulfills the physician’s obligation ofnon-abandonment. Opponents emphasize that PAS goes against the duty of beneficence andnonmaleficence and fear that there may be a slippery slope where more and more people willdemand PAS. Conclusion: There is no consensus on whether PAS is considered ethically defendable or not.PAS appears to involve a conflict of interest between the principles of beneficence andautonomy. There seems to be some factual disagreements as well as different positions as tohow the ethical principles should be interpreted, and which ethical principle should be valuedthe highest.

In 2015, there were 257,524 women with cervical cancer (CC) in the United States (U.S.). CC is preventable; screening detects early-stage cancer when treatment is most successful. This study aimed to identify predictors for CC screening adherence among U.S. women, describe predictors for screening adherence by marital status, and examine physician recommendation for CC screening and adherence to those recommendations. Predictors were grouped as demographic, acculturation, access to care, chronic conditions, and health behaviors. Descriptive analyses were performed on a sample of 10,667 women from the 2015 National Health Interview Survey, and multiple logistic regression models determined predictors of CC screening adherence, physician recommendations, and adherence to physician recommendations. Overall, 81.7% (95%CI=80.7-82.7%) of U.S. women adhered to CC screening guidelines. Adherence declined with increasing age after 39 years old. Never married women (adjusted odds ratio[aOR]=0.67, CI=0.56-0.79) or current smokers (aOR=0.70, CI=0.59-0.84) had lower odds, while college-educated women had greater odds (aOR=1.38, CI=1.14-1.67) of CC screening adherence. Among unmarried women, 78.6% adhered to CC screening. Unmarried women who were unemployed (aOR=0.48, CI=0.38-0.62), had no physician visits (aOR=0.58, CI=0.40-0.85), no usual source of care (aOR=0.67, CI=0.50-0.89), never heard of HPV (aOR=0.59, CI=0.46-0.76), never received HPV vaccine (aOR=0.50, CI=0.34-0.75), no birth control use (aOR=0.33, CI=0.23-0.47), no flu shot (aOR=0.62, CI=0.48-0.80), and perceived low breast cancer risk (aOR=0.66, CI=0.47-0.92) had lower odds of adherence. Among women with a physician, 55.6% received screening recommendations. Race/ethnicity, access to care, HPV knowledge and vaccine receipt, age when first child was born, and flu shot were significant predictors of physician recommendation for CC screening. Significant predictors of adherence to physician recommendation included education, employment, English proficiency, outpatient clinic visits, usual source of care, age when first child was born, birth control, alcohol use, smoking status, flu shot, and health status. Based on our results, two levels of intervention should be explored. First, targeted interventions are needed for women who are unmarried, have low socio-economic status, and limited access to care to reduce cervical cancer risk. Second, interventions for physicians to increase screening recommendations to all eligible women are needed to improve national screening rates.

Background: Among patients with multiple chronic conditions, care coordination and integration remains one of the major challenges facing the U.S. health care system. A home-based, patient-centered primary care program has been offered through the Veterans Health Administration (VHA) since the 1970s for frail veterans who have difficulty accessing VHA clinics. The VHA Home Based Primary Care (VHA HBPC) aims to integrate primary care, rehabilitation, disease management, palliative care, and coordination of care for frail individuals with complex, chronic diseases within their homes. Early research suggested that VHA HBPC was associated with positive outcomes (e.g., reduced resource use and patient satisfaction). However, evidence regarding the effect of the VHA HBPC program on health services use (especially hospital and nursing home use), expenditures, and other patient outcomes remains limited. The present study is designed to fill this gap as the rise in the number of veterans with complex health care needs will likely increase in the coming decades. Objectives: The current study aimed to examine the impact of VHA HBPC on health services use, expenditures, and mortality among a cohort of new VHA HBPC enrollees identified in the national VHA data system. The specific aims of this study were: 1) to examine the effect of VHA HBPC on major health service use (hospital, nursing home, and outpatient care) paid for by the Veterans Administration; 2) to examine the effect of VHA HBPC on total health services expenditures; and 3) to examine whether VHA HBPC enrollees experienced similar mortality and survival as compared to a matched concurrent cohort. Methods: This study used a retrospective cohort design. A new VHA HBPC enrollee cohort (the treatment group) and a propensity matched comparison cohort (the comparison group) were identified from VHA claims in fiscal years (FY) 2009 and 2010 and were followed through FY 2012. Data on health service use, expenditures, and mortality/survival data were obtained via the VHA administrative datasets (i.e., Decision Support System, Purchased Care, and Vital Status Files). Propensity scores of being enrolled in the VHA HBPC were generated by a logistic regression model controlling for potential confounders. After 41,244 matched pairs were determined adequate through several diagnostic methods, means tests, relative risk analyses, and generalized linear models were used to estimate the effect of VHA HBPC on outcomes. Additionally, a Cox proportional hazards regression model was used to estimate the effect of VHA HBPC on survival. Subgroup analyses were conducted stratifying by age (85 and older), comorbidities (2 or more), and the receipt of palliative care. Based on the results of the original analyses, a series of sensitivity analyses were conducted that modified the described sample selection criteria and matching algorithm. Results: Analyses of the original cohort revealed that VHA HBPC patients had significantly higher risks of being admitted into a hospital (RR 1.53, 95% CI 1.51-1.56) or nursing home (RR 1.65, CI 1.50 - 1.81). The average total expenditures during the study period were significantly higher for the VHA HBPC group as compared to the control group ($85,808 vs. $44,833, respectively; p < .001). In terms of mortality and survival, VHA HBPC enrollees had higher mortality (RR 1.45, CI 1.43 - 1.47), and shorter survival (HR 1.89, CI 1.86 - 1.93) as compared to those in the comparison group. Subgroup analyses found that these relationships generally remained when stratified by age 85 or older or having two or more comorbidities. However, for those who received palliative care, VHA HBPC participants had significantly lower risk of VHA hospitalization overall (RR 0.84, CI 0.81 - 0.87) and immediately prior to death. Finally, exploratory post-hoc analysis suggested that VHA HBPC recipients were at higher risk of VHA hospitalization at 30 (RR 1.11, CI 1.06 - 1.16), 60 (RR 1.16, CI 1.11 - 1.20), and 90 days (RR 1.16, 1.12 - 1.21) prior to death relative to the comparison group. After selecting only those that had a baseline hospitalization and refining the matching algorithm to account for time to death and additional comorbidities, VHA HBPC participants who had been enrolled in the program for at least six months had lower risks for hospital (RR 0.89, CI 0.88 - 0.90) and nursing home admissions (RR 0.74, CI 0.67 - 0.81). However, total expenditures remained significantly higher among those in VHA HBPC relative to the comparison group ($89,761 vs. $85,371, respectively; p < .001). Discussion: This study found that without accounting for important covariates such as initial hospitalization, time to death, and a range of comorbidities, VHA HBPC was associated with higher health service use, higher expenditures, higher mortality, and shorter survival as compared to a similar group of patients not receiving VHA HBPC. After accounting for these factors, VHA HBPC was associated with a lower risk of nursing home use, and after six months, VHA HBPC was associated with lower risk of both nursing home and hospital use. These findings suggest that while VHA HBPC may improve quality of life and patient satisfaction through patient-centered integrated primary care, it may not generate cost savings for the healthcare system. Future research is needed to understand variation in program implementation and how this affects the impact of VHA HBPC on service use and cost.

Despite advances in medical technologies, interpersonal communication remains the primary tool physicians use to exchange information, make diagnoses, and treat patients (Cameron & Williams, 1997; Groopman, 2007; Ong, de Haes, Hoos, & Lammes, 1995). In the medical encounter effective communication between physician and patient is essential so that beneficial health and wellbeing outcomes are achieved for patients. Taking a discourse analytic approach, this study examined interactions occurring between international medical graduate (IMG) residents, attending physicians, and patients during the treatment advice phase of the supervised medical encounter. The aim of the study was to examine the co-constructed nature of the delivery and receipt of treatment advice and the ways in which physicians and patients managed interpersonal relations through the negotiated activity. The theoretical framework of pragmatic competence was utilized to underpin the study. Physician-patient interactions served as the primary data source. Medical encounter interactions between five different IMG residents and 31 patients were observed and audio-recorded. Observations and a post-medical encounter survey completed by patients served as secondary data sources. The analysis of the data revealed that this medical speech activity embedded within the medical encounter was realized through the use of a variety of discourse strategies and contributions from multiple participants as they attended to the interpersonal and transactional goals associated with the delivery and receipt of treatment advice. Findings provided insights into how multi-party discourse worked to jointly construct and negotiate treatment recommendations. Findings indicated that IMG residents utilized indirect advice giving strategies. Additionally, both IMG residents and patients utilized interrogatives in various ways to engage actively in the treatment decision-making process. Finally, the data revealed how the participants attended to each other's face needs as they worked to enhance, maintain, or challenge face through the dynamic process of negotiating relationships.

This thesis explores, through critical dialogue and personal experience, various aspects of rehabilitation in the context of Myalgic Encephalomyelitis or Chronic Fatigue Syndrome. The journey visits broad, in principle, government policy reports. It touches on insurance and political aspects of health care; the separation between medical, convalescent and tertiary divisions of the rehabilitation professions; and, most importantly, it is concerned with the personal struggle to find some ‘meaning’ in the experience of a chronic illness for which there is, at this stage, no cure. From this arises the complexity of the inter-relationships between professionals and clients and the vexed question of ethics. The writing or methodology is first-person narrative, with deep roots in natural philosophy, and the dissertation can be read on several levels. It can also be read as a meta-thesis, that is, as an illustration of the process of researching/writing in an experiential methodology / Master of Science (Hons) Social Ecology

People with hepatitis C (HCV) face stigma and discrimination because of the association of this disease with injecting drug use (IDU). Research has found that many instances of HCV-related discrimination occur in the health care sector. Health care workers' beliefs about their HCV positive clients are likely to influence how they relate to clients and their treatment delivery. This research assessed the implicit and explicit attitudes of both health care workers and their HCV positive injecting drug using (HCV+) clients toward each other and then established whether these affect the treatment experiences of health care workers and clients. The sample consisted of 60 health care workers (doctors and nurses), 120 HCV+ and 120 HCV- clients, recruited from the same treatment facility. Participants were given a series of attitude and treatment experiences measures to complete. Data illustrate that while health care workers' and HCV+ clients' explicit attitudes towards each other were positive, clients with HCV still rated their health care workers less highly and reported less satisfaction with their treatment than HCV- clients. Analyses also indicated that more conservative health care workers displayed greater prejudice toward their HCV+ clients because they believe that injecting drug use is controllable. This prejudice toward IDUs on the part of health care workers was associated with worry about the behaviour of IDU clients and this worry in turn predicted differences in treatment experiences reported by HCV+ and HCV- clients. These data support the contention that health care worker concerns, particularly those related to injecting drug use, underlie discriminatory treatment of people with HCV. Finally the research also addressed the impact of health care worker contact with HCV+ clients on their attitudes towards this group. Analysis revealed that while health care workers who have had more contact with people with HCV show more positive explicit attitudes, they also show less favourable implicit attitudes toward IDUs. This may reflect the difficulties and stresses associated in caring for IDUs and may provide insight into the hidden costs involved for health care workers working with a population that may be challenging and at times difficult to manage.