MSc (Nursing), Faculty of Health Sciences, University of the Witwatersrand / Nurses working with critically ill patients in intensive care units (ICUs) have a unique role to play in health care. They spend 24 hours with patients and come into contact with all the disciplines which come to review these patients. Nurses therefore need to effectively collaborate with the multidisciplinary teams, especially physicians, in order to meet patients’ needs and maximise patient care outcomes. The purpose of this study was to identify and describe nurses’ perceptions towards nurse-physician collaboration in the intensive care units. A non experimental descriptive study design was utilised in this study. Data were collected using a questionnaire developed from the Jefferson Scale of Attitude toward Physician-Nurse Collaboration with additional two open-ended questions to cover the rest of the study objectives. Data were analysed using descriptive and inferential statistics as well as content analysis. Results showed that nurses working in Intensive Care units (ICUs) had positive attitude towards nurse-physician collaboration regardless of gender, years of working in the ICUs and whether registered intensive critical care nurse or not. The findings also showed that nurses perceive that the process of nurse-physician collaboration in Intensive Care Units provokes a number of challenges, such as superior-subordinate relationships which exist between nurses and physicians, workload and overlapping responsibilities hence, nurses feel inferior, undermined, mostly overwork and become frustrated. However, nurses suggested that promoting team-work; a focus on patient-centered care and staff motivation would assist in creating effective collaborative environment. collaborative environment

Thesis advisor: Christopher Maxwell / Though much research has been done on the subject of substituting nurse practitioners for physicians as health care providers, both analytic methods and results have been inconsistent. Various studies have shown nurse practitioners to provide equivalent or improved care especially in primary care settings. However, no consensus has been reached on whether or not and under what conditions this substitution is economically efficient. Because of variation in productivity and substitution rates, the economic viability of nurse practitioners must be assessed on a department specific basis, taking into account differences in nurse practitioners’ job descriptions.One specific area this economic efficiency could be assessed in is in the diagnosis of ear infections. A study conducted through the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey showed that 15% of pediatric visits included a diagnosis of middle ear infection (Freid, 1998). If employed properly, nurse practitioners could be used to achieve significant cost savings in this area.This thesis is intended to address the economic efficiency of nurse practitioners as compared to physicians in diagnosing ear infections. First nurse practitioner quality in this specific area will be assessed by comparing nurse practitioner diagnosis error rates to physician error rates based on surveys asking both types of providers to provide diagnoses based on tympanic membrane images collected through previous telemedicine visits. Next the economic practicality of employing nurse practitioners in this field will be assessed in terms of the relative costs of these errors, measured as the cost of unnecessary prescriptions in the case of overdiagnosis and the cost of an unnecessary follow-up visit in the case of underdiagnosis. / Thesis (BA) — Boston College, 2012. / Submitted to: Boston College. College of Arts and Sciences. / Discipline: College Honors Program. / Discipline: Economics Honors Program. / Discipline: Economics.

Background: Multiple factors influence end of life care and can lead to barriers in the experience of care for patients and the delivery of care for physicians. It is vital to determine the possible challenges physicians may face in providing end of life care in order to understand and decrease these challenges. Objective: The purpose of this study was to identify and understand the different challenges physicians face in the provision of quality end of life care. Methods: First, a scoping review was conducted on five databases to gather knowledge on the current literature on physician-perceived challenges in end of life care. Subsequently, a secondary data analysis was performed from the results of a pan-Canadian study with 1 060 respondents on medical end of life practices to: (1) measure the frequency of physician-perceived challenges based on the last patient who died under their care in the last 12 months, and (2) assess the relationship between the challenges and the physician’s or patient’s sociodemographic characteristics. Results: The results of the scoping review on 40 studies identified ten challenges: physician’s characteristics, family issues, team conflicts, team and family conflicts, institutional and organizational factors, training and educational factors, religious challenges, ethnicity and value-related challenges, human rights issues, and language challenges. Results from the secondary data analysis revealed that 26.9% of physicians reported at least one challenge, such as family conflicts, in the provision of end of life care with the last patient who died under their care in the last 12 months. Conclusion: These challenges restrict quality end of life care. As such, targeted strategies should be implemented to mitigate these barriers to end of life care and improve care.

BACKGROUND: The ability to disclose bad news to patients is a complex and essential skill for health care providers. Although certain specialties have a higher incidence of engaging in these conversations, this task is done regardless of a provider’s discipline. There are many components to breaking bad news, some of which include finding a private setting, eliciting how much the patient wants to know, providing clear information, and responding to the patients’ emotional needs and reactions. As this task is associated with a large amount of emotional stress, the outcome of this exchange can have lasting impact on both the provider and patient. Unfortunately, patients are dissatisfied with how they receive bad news, and providers admit to lack of comfort and knowledge with this task. LITERATURE REVIEW FINDINGS: Studies show that inadequate education is main area for improvement. Fortunately, the ability to break bad news is a teachable and retainable skill. Didactic sessions, role-play, and small groups are some of the available models used to educate learners. There is promising evidence for the incorporation of SPs into various curricula, because they provide an opportunity for students to learn without compromising patient safety and allow for feedback useful to enhancing skills. PAs are valued health care providers who practice across a variety of specialties. As their education is similar to that of a medical student, and they practice autonomously under the supervision of a physician, it is equally important that they are able to successfully break bad news. However, there are few studies that examine the PA student curriculum for breaking bad news education. Furthermore, there are no studies that examine PA student competency with this skill. PROPOSED PROJECT: The goal of this study is to use a literature review to create a novel curriculum that employs SPs to increase PA students’ competencies for breaking bad news. CONCLUSIONS: An optimal curriculum intervention will include opportunities for feedback, discussion, and practice. SPs can help aid with many of these components, as well as assess interpersonal and technical components of breaking bad news. SIGNIFICANCE: It is expected that the results of this study will parallel those identified for medical students, and PA students’ skills will improve to meet the standards set forth by the ARC-PA. It is the hope that the results of this study will serve as an initial platform for future studies aimed at PAs’ ability to disclose bad news to patients.

Liya Wang

Thesis (Ph.D.)--Ohio University, June, 2007. / Title from PDF t.p. Includes bibliographical references.

Adult literature has shown that quality of patient-physician relationships is associated with better patient adherence to treatment recommendations across chronic illnesses. However, few studies have examined this in youth with type 1 diabetes, particularly those of Hispanic origin. Evidence indicates that minority youth with type 1 diabetes are at higher risk for poorer metabolic control and experience less satisfaction in patient-provider relationships compared to their white, non-Hispanic counterparts. This study examined the association between satisfaction with the physician-patient relationship and regimen adherence and glycemic control in 120 Hispanic youth with type 1 diabetes. Most caregivers who participated were mothers (82.5%) and youths were primarily female (51.7%). Children ranged in age from 10 to 17 (M age = 13.63 ± 2.18 years). Mean duration of diabetes was 6.26 ± 3.72 years. Most caregivers were married (64.7%). Mothers? highest level of education included 35.3% who had a high school education or less, 34.5% who had some college, and 30.2% who completed college. Mean HbA1c level on recruitment date was 7.68 ± 3.56. Adolescents and their parents independently completed an adapted version of the Medical Interview Satisfaction Scale (MISS-21) (Meakin & Weinman, 2002), which assessed their personal satisfaction with their endocrinologist?s consultation, and the Diabetes Self Management Profile (DSMP) (Harris et al., 2000), which measures adherence over the past 3 months across multiple self-care domains. Spanish translations of both forms were used when appropriate in obtaining caregiver report. Also, physicians rated their patients? regimen adherence using an average of eight items concerning patient adherence. Youth and parents shared similar perceptions concerning youth regimen adherence, as measured by the DSMP (r=.68, p<.001). Youth and parent report of their relationship with their endocrinologist was modestly correlated (r=.27, p<.01). Due to high concordance between parent and child adherence scores, further analyses used a combined DSMP score, while separate scores were used for parent and child reports of satisfaction. Age, mother?s education, and single parent status were used as control variables and were correlated with parent and child satisfaction and a combined DSMP score. Including control variables, parent and child satisfaction did not significantly predict glycemic control (R2∆=.02, p<.10). Parent and child satisfaction also did not significantly predict adherence (R2∆=.02, p=.06). Due to these unexpected findings, further exploratory analyses were conducted. Parent and child satisfaction did not predict physician report of adherence. Interestingly, parent and child report of satisfaction with communication comfort with the physician predicted physician report of adherence (R2∆=.05, p<.01). More specifically, child report of communication comfort predicted physician report of adherence (ß=.26, p<.01), while parent report did not. No subscales of the satisfaction measure (MISS) or the adherence measure (DSMP) predicted glycemic control. Findings suggested that more positive patient-physician relationships are associated with better physician-reported regimen adherence, but not with family report of adherence. However, it is unclear whether better patient-physician relationships enhance adherence or whether more adherent patients are likely to be satisfied with their provider. Further studies are needed to prospectively examine the directionality of these relationships, as well as examine methods to improve the quality of physician-patient relationships in order to increase positive health outcomes.

In light of the competitions of different medical services and the National Health Insurance¡¦s patient-oriented goal, the quality of medical care in the emergency room has been a top priory for improvement in many major medical centers. The purpose of this research is to evaluate the differences of medical quality after adjustment of physician manpower in three emergency departments of three separate hospitals. We will attempt to suggest ways to improve medical quality and make good use of medical resources. This is a retrospective survey using data from three emergency departments of three separate hospitals. The date ranged from March to April of 2002 and March to April of 2003. A total of 66,025 cases were gathered, minus 311 cases with incomplete data, the total valid data were 65,714 cases. The three hospitals A, B, C have 24,010 cases, 17,690 cases, and 24,014 cases, respectively. The result of this study showed that hospital A had increased the number of medical staff when comparing 2003 to 2002 data, however, the quality of care did not improve. Hospital B had increased the number of physicians on duty, decreased the waiting time for the patients, and the number of patients taken care per doctor had been increased too. However, within the 72-hour clinic follow-up patient numbers have increased. Hospital C have decreased the number of physicians on duty, but the waiting time have also decreased. The number of patients being taken care of by physicians, and 72-hour clinic follow-up are all increased. When compare the month between March and April of 2002, the highest ratio of 72-hour clinic follow-up is hospital A, followed by hospital B and C, in descending order. When compare the two study period of March and April of 2002 and 2003, waiting time and the ratio of waiting time in emergency department more than 6 hours is hospital A more than hospital C more than hospital B; the ratio of waiting time less than 2 hours is hospital C more than hospital B more than hospital A. The ratio of waiting time more than 2 hour but less than or equal to 4 hours and waiting time more than 4 hours but less than or equal to 6 hours is hospital A more than hospital B more than hospital C. This study suggests that the hospitals must establish a complete quality indicators, and must conduct periodic evaluation. At the same time, we must incorporate these indicators into our hospital information system and monitoring the effectiveness, in order to promote the quality of care.

This study applied Andersen??s social cognitive paradigm for the experimental study of transference to the problem of understanding transference effects on the affective interactions and clinical inferences of student physicians with standardized patients. The investigator designed a 2X2 experimental study in which the independent variables were: source of information for statements about a standardized patient (participant??s own or matched participant??s) and valence of information in statements about the patient (positive or negative). Dependent variables were: affect expressed by a student physician in videotapes of a medical interview with a standardized patient, as measured by a modified version of the Specific Affect ?? 16 code system (SPAFF-16), and clinical inferences by the student physician as measured by the Physician Clinical Inferences Scale (PCIS) developed by the investigator. Covariates included gender, physician verbosity, and intergenerational family relationship variables as measured by the Personal Authority in the Family System Questionnaire ?? Version C (PAFS-QVC). A 2X2 MANCOVA was conducted, along with hierarchical regressions of gender and PAFSQVC variables as predictors of negative and positive affect and clinical inferences (likelihood of treatment success and patient as partner). One sample of undergraduate medical students (n= 71) provided data for the study. Results indicated no statistically significant differences between experimental groups regarding the effect of the experimental manipulation of patient information on student physicians?? affective interactions and clinical inferences with patients when gender, physician verbosity, and related PAFS-QVC variables were controlled. Hierarchical regression analyses of gender and related PAFS-QVC variables onto positive affect, negative affect, clinical inferences (patient as partner) and clinical inferences (likelihood of treatment success) revealed statistically significant effects of intergenerational family relationship and peer relationship variables on student physicians?? affective interactions and clinical inferences with patients.

Background: Informed consent is the autonomy of the patient who involves decision-making after being informed of and understanding the physician. Objectives: This study sought to investigate and compare patients¡¦ and physicians¡¦ perceptions of informed consent and the factors that influence their viewpoints on informed consent. Methods: The subjects were citizens without medical background and physicians working in four hospitals. Self-structured questionnaire was used to gather information. The physicians were recruited from two medical centers, a regional hospital and a district hospital in Kaohsiung. The data is analyzed by SPSS 14.0 and used descriptive statistics, item analysis, factor analysis, chi-square test, Fisher's exact probability test, t-test, and ANOVA. Results: The response rates were 97% in citizens (n=891) and 79 % in physicians (n=158). As for the concept of informed consent, 55.7% citizens thought that doctor should respect the opinion from the patient and family during the informed consent process. Furthermore, 91.2% the citizens prefer to know the information about their health condition from the physicians rather than from family (8.8%). Regarding the sequence of informing the physical condition, 29.9% citizens also prefer directly from the physician. As for the decision-making process, 55% respondents thought that patient¡¦s own decision is the most important. 52.5% physicians thought that doctor should respect the opinion from both the patient and family and the bad news should be informed by physicians (88.0%) rather than by family. As for the sequence of knowing the bad news, 46.2% physicians preferred to inform family first and inform patient after discussing with family. In decision-making process, 48.7% physicians thought that physician¡¦s opinion was still more important than opinion of patients and family. Further analysis revealed that patients¡¦ gender and the level of family visited hospital have significant difference on the perception of informed consent (p=0.027; p=0.000); gender, age, educational background and living locations also have significant difference on ¡§who to deliver the bad news.¡¨ (p=0.006; p=0.004; p=0.035; p=0.012); Citizens¡¦ age, educational background and career have significant influence on their opinion of informed consent of recently visiting doctor (p=0.014; p=0.006; p=0.001). The variables in the physicians¡¦ background have no relation with the means of informing and decision-making. The gender and position of the physician have significant effect on the opinion of practice of informed consent (p=0.015 and p=0.001). Conclusions: We concluded that the perceptions of informed consent, there was no difference between physicians and citizens; however the citizen chose the patient first, and the physician chose the family first during the process of informed consent. Physicians have better perceptions of informed consent than the common citizens.