Made available in DSpace on 2016-08-19T18:32:12Z (GMT). No. of bitstreams: 1 Dissertacao VANIA CRISTINA REIS CAVALCANTE.pdf: 1474768 bytes, checksum: ed5024e7d2cc31b84e5bede60a33c6a5 (MD5) Previous issue date: 2014-03-30 / FUNDAÇÃO DE AMPARO À PESQUISA E AO DESENVOLVIMENTO CIENTIFICO E TECNOLÓGICO DO MARANHÃO / Introduction: a review of the structure of health services is an important tool in the management practice. Objective: To analyze the structure of the Basic Health Units (BHU) of Maranhão (MA), according to adherence (PMAQ-AB) Program for Improving Access and Quality of Primary Care in the NHS. Methods: We developed a cross-sectional ecological study. Data were collected in 2012. We evaluated all of the 217 municipalities of UBS MA, subdivided into two groups: those who joined the PMAQ - AB (G1) and those who did not adhere (G2). Differences between groups were tested by chi- square test (alpha = 5 %). Organizational resources, infrastructure / ambience and strategic elements, subdivided into categories, subcategories and indicators: four components of the structure were evaluated. Results: 1,879 UBS were evaluated. Organizational: most teams was the Family Health Strategy (FHS) with oral health team (ESB), reported working five days a week, two shifts, but few listened to alternative schedules. Reported availability of automotive vehicles. The average FHS with ESB (p < 0.001) and parameterized teams (p< 0.001) was higher in G1 than in G2. Resources: There was a shortfall in basic professional teams and expanded in both groups. There was still a deficit of general and dental equipment, dental supplies, printed materials and for rapid testing. All the routine immunization schedule was always available in only 92 (4.9%) UBS. But there was good availability of consumer medicines in general and in most UBS materials. The availability of resources was significantly better in G1 (p < 0.001). Infrastructure / ambience: there was inadequate physical plant, ambiance, and accessibility signage in most UBS. The physical plant conditions and ambience were better in G1, since the electrical and hydraulic conditions in G2 (p < 0.001). Strategic elements: telehealth, complementary and integrative praticas herbal practically were not offered in MA. Conclusion: the structure of UBS in MA is inadequate, except in the organizational component. The UBS joined the PMAQ-AB have better structure than the others. This demonstrates the possibility of interference in the work processes and the quality of primary care. / Introdução: a avaliação da estrutura dos serviços de saúde constitui instrumento importante na prática gerencial. Objetivo: analisar a estrutura das Unidades Básicas de Saúde (UBS) do Maranhão (MA), de acordo com a adesão ao Programa de Melhoria do Acesso e Qualidade da Atenção Básica do SUS(PMAQ-AB). Métodos: desenvolveu-se estudo ecológico transversal. Os dados foram coletados no ano de 2012. Avaliaram-se todas as UBS dos 217 municípios do MA, subdivididas em dois grupos: as que aderiram ao PMAQ-AB (G1) e as que não aderiram (G2). Diferenças entre os grupos foram testadas pelo qui-quadrado (alpha=5%). Foram avaliados quatro componentes da estrutura: organizacional, recursos, infraestrutura/ambiência e elementos estratégicos, subdivididos em categorias, subcategorias e indicadores. Resultados: avaliaram-se 1.879 UBS. Organizacional: a maioria das equipes era da estratégia saúde da família (ESF) com equipe de saúde bucal (ESB), referiram funcionar em cinco dias da semana, dois turnos, mas poucas atendiam em horários alternativos. Referiram disponibilidade de veículos automotivos. A média de ESF com ESB (p<0,001) e de equipes parametrizadas (p<0,001) foi maior no G1 que no G2. Recursos: houve déficit de profissionais nas equipes básica e ampliada, em ambos os grupos. Verificou-se ainda déficit de equipamentos gerais e odontológicos, insumos odontológicos, impressos e materiais para testes rápidos. Todo o calendário vacinal de rotina estava sempre disponível em apenas 92 (4,9%) UBS. Porém, havia boa disponibilidade de materiais de consumo em geral e medicamentos na maioria das UBS. A disponibilidade de recursos foi significativamente melhor no G1 (p<0,001). Infraestrutura/ambiência: verificou-se inadequação da planta física, ambiência, sinalização e acessibilidade na maioria das UBS. A planta física e condições de ambiência foram melhores no G1, já as condições elétricas e hidráulicas, no G2 (p<0,001). Elementos estratégicos: telessaúde, práticas integrativas complementares e fitoterápicos praticamente não eram ofertados no MA. Conclusão: a estrutura das UBS no MA está inadequada, exceto no componente organizacional. As UBS que aderiram ao PMAQ-AB têm melhor estrutura que as demais. Isso demonstra a possibilidade de interferência nos processos de trabalho e na qualidade da atenção básica.

Bakgrund: Föräldrar som drabbats av en cancerdiagnos befinner sig i en sårbar situation där oro över framtiden och rädslan över hur deras barn skulle klara sig utan dem som förälder är stor. Dessa föräldrar ansåg att föräldrarollen är den viktigaste rollen att bibehålla, patientrollen kommer i andra hand. Syfte: Syftet med studien var att belysa hur cancerdrabbade föräldrars upplevelser inverkar på föräldrarollen. Metod: En kvalitativ litteraturstudie baserat på fem litterära gestaltningar i form av självbiografier utifrån en induktiv ansats. Insamlad empiri analyserades utifrån manifest innehållsanalys. Resultat: I resultatet framkom det att cancerdrabbade föräldrar inte ville uttrycka sina känslor framför sina barn, detta ansågs vara en strategi för att skydda sina barn mot effekten av sjukdomen. Att bibehålla en så normal vardag som möjligt framkom också som mycket vanligt i samband med sjukdomen. Resultatet presenterades med tre kategorier och tillhörande underkategorier. Kategorierna är följande: Behålla normalitet, Föräldrars existentiella situation, Utmanande föräldraroll och Behovsanpassad kommunikation. Slutsats: Studien visar på att föräldrar är i behov av stöttning, speciellt när det kommer till hur de ska samtala om existentiella frågor med sina barn. Alla föräldrar upplevde detta som svårt och ångestfyllt. Det är därför av betydelse att sjukvården stötta denna patientgrupp och se helheten av patienten där barnen är av största betydelse genom denna svåra sjukdoms situation.

Submitted by Rosina Valeria Lanzellotti Mattiussi Teixeira (rosina.teixeira@unisantos.br) on 2017-03-20T18:51:19Z No. of bitstreams: 1 Bruna F.R. Carnevali.pdf: 863864 bytes, checksum: 8d5c9aaa30a2116000f7a42632834319 (MD5) / Made available in DSpace on 2017-03-20T18:51:19Z (GMT). No. of bitstreams: 1 Bruna F.R. Carnevali.pdf: 863864 bytes, checksum: 8d5c9aaa30a2116000f7a42632834319 (MD5) Previous issue date: 2016-12-13 / Introduction: The use of health services is a central element for the analysis of health systems and services. Women make up the majority of the Brazilian population, which in 2013 was equivalent to 51.4% of the population. They are also the main users of the Unified Health System (SUS) for their own care or monitoring of children and / or other relatives. Thus, they constitute a fundamental social segment for health policies. Objective: The objective of this study is to characterize the profile of women between 19 and 59 years of age who used health services. Method: population survey, in 2012, in the city of Praia Grande, State of São Paulo, which has a high coverage of the Family Health Strategy, in women aged 19 to 102 years. The independent variables included the sociodemographic characteristics, beneficiaries of the income transfer program, health plan users, service scheduling, medical exchange, health service exchange, health problems in daily activities, pap smear in the last 12 months, use of family doctor in the last 12 months, use of a gynecologist in the last 12 months, mammography in the last 12 months, clinical examination of the breasts in the consultations and contraceptive use. The dependent variables were: they attended health service and then performed papsmear, both in the last 12 months. For differences between proportions Pearson's Chi Square or Fisher's Exact, with significance level of 5% was used. Results: A total of 493 women were interviewed, with a average age of 39,63 years; The predominant socioeconomic class was C; Most did not have health insurance. Of the 65,31% (322) who attended the health service in the last 12 months, 64,70% scheduled their services easily and more than half would not change doctors or services; 64,77% of them considered their health good and more than 90% of them reported that the health condition does not interfere with their daily activities. Only 9% of the women were beneficiaries of income programs, with Bolsa Familia being the most used. The Pap smear exam was performed by 35,09% of the women interviewed in the last 12 months; More than 60% of them did not use the Family Health doctor in the last 12 months nor did they go through a Gynecologist. Mammography was performed in 24,23% and the breasts were examined in the consultations in 57,20%. Most did not use contraception. Conclusion: The profile found on the one hand expresses the conditionality of the use of health services foreseen in income transfer policies, and on the other, indicates that even in an area with high FHS coverage, affiliation to health plans still present sit self as an Important factor for access. / Introdução: A utilização dos serviços de saúde é um elemento central para a análise dos sistemas e serviços de saúde. As mulheres constituem a maioria da população brasileira, e também elas são as principais usuárias do Sistema Único de Saúde (SUS) para seu próprio atendimento ou acompanhamento de crianças e/ou outros familiares. Conformam, portanto, um segmento social fundamental para as políticas de saúde Objetivo: Analisar os fatores associados à utilização de serviços de saúde nas mulheres entre 19 e 59 anos que utilizaram os serviços de saúde no município de Praia Grande, São Paulo. Método: inquérito populacional, realizado no município de Praia Grande, em 2012, com mulheres de 19 a 102 anos. Processo de amostragem complexo realizado no setor censitário e domicílio. As variáveis independentes incluíram classificação socioeconômica, beneficiárias do programa de transferência de renda, usuárias de plano de saúde, agendamento de serviço, trocaria de médico, trocaria de serviço de saúde, condição de saúde, saúde atrapalha nas atividades diárias, utilização de médico da família nos últimos 12 meses, utilização de ginecologista nos últimos 12 meses, exame clínico das mamas nas consultas e uso de anticoncepcional. As variáveis dependentes foram: frequentaram serviço de saúde, realização de papanicolaou e realização de mamografia, ambos nos últimos 12 meses. Para diferenças entre proporções foi utilizado o Qui Quadrado de Pearson ou Exato de Fisher, com nível de significância de 5%. Resultados: Foram entrevistadas 493 mulheres, com média de idade de 39,63 anos; a classe socioeconômica predominante foi a C; a maioria não possuía plano de saúde. Entre as 65,31% (322) que frequentaram o serviço de saúde nos últimos 12 meses, 64,70% agendaram seus serviços com facilidade e mais da metade não trocariam de médico e nem de serviço utilizado; 64,77% consideraram a sua saúde boa e mais de 90% delas referiram que a condição de saúde não atrapalha suas atividades diárias. Mulheres que tinham plano de saúde, que realizaram Papanicolaou e que fizeram mamografia no último ano utilizaram mais o serviço de saúde nos 12 meses prévios à entrevista. Observou-se associação positiva para a utilização de serviços de saúde nos últimos 12 meses entre as variáveis usuárias de plano de saúde, realização de papanicolaou, utilização de ginecologista e utilização de anticoncepcional com orientação médica. A realização de Papanicolaou nos últimos 12 meses foi maior entre as que frequentaram médico de família e ginecologista no mesmo período analisado; mais realização do Papanicolaou entre as usuárias de plano de saúde, entre as mulheres que passaram pelo ginecologista, que fizeram o exame clínico das mamas e que usaram anticoncepcional com orientação médica. A realização de Mamografia nos últimos 12 meses foi maior entre as que frequentaram ginecologista nos últimos 12 meses; entre as que NÃO realizaram o ECM nas consultas e aquelas que não tinham plano de saúde. Conclusão: O perfil encontrado por um lado expressa a condicionalidade do uso de serviços de saúde previsto nas políticas de transferência de renda, e por outro indica, que mesmo em área com alta cobertura da ESF, a afiliação a planos de saúde ainda se apresenta como fator importante no acesso.

Bakgrund: Aggressivitet, hot och våld inom hälso- och sjukvården är ett problem som ökar i Sverige och världen över. Sjuksköterskor som arbetar patientnära står i riskzonen för att bli utsatta, särskilt inom akutsjukvården eftersom det är en av de mest utsatta verksamheterna inom vården. Att utsättas för aggressivitet, hot och våld är förenat med ett flertal konsekvenser för sjuksköterskan och för patientsäkerheten. Syfte: Att belysa sjuksköterskors upplevelser av aggressivitet, hot och våld på akutvårdsmottagningar. Metod: En litteraturstudie med kvalitativ metod där elva vetenskapliga artiklar granskas. Resultat: Ur resultatet framkommer det att sjuksköterskor upplever en rädsla och otrygghet i arbetet som följd av tidigare upplevd aggressivitet, hot och våld. En känsla av ensamhet i mötandet av problemet upplevs även då arbetsledningen inte finns där som stöd. Sjuksköterskorna anser sig själva vara orsaken till att dessa beteenden uppstår och det medför en känsla av frustration och maktlöshet. Dessa upplevelser resulterar för en majoritet av sjuksköterskorna i en normalisering av problemet. Slutsats: Studien visar att sjuksköterskors upplevelser av aggressivitet, hot och våld påverkar deras arbetsutövning och resulterar i ett påverkat vårdande. Därmed bör det uppmärksammas i högre grad för att undkomma dess konsekvenser, både på individnivå men även på organisationsnivå. / Background: Aggressiveness, threats and violence in health care is a problem that is increasing in Sweden and all over the world. Nurses who works close to patients have a higher risk of becoming vulnerable, especially in emergency care, because it is one of the most vulnerable activities in healthcare. Being exposed to threats and violence creates insecurity in the nurse's work life and can have consequences for patient safety. Purpose: To illuminate nurses' experiences of aggressiveness, threats and violence in emergency care clinics. Method: A literature study with qualitative method in which eleven scientific articles were examined. Result: The result shows that nurses experience fear and insecurity in their work as a result of previously experienced aggression, threats and violence. A sense of loneliness in the encounter with the problem is also experienced because the work management is not there as support. The nurses consider themselves to be the cause of these behaviors and it causes a feeling of frustration and powerlessness. These experiences result in a majority of the nurses in a normalization of the problem. Conclusion: The study shows that nurses' experiences of aggression, threats and violence affect their workpractices and result in an influenced caring. Thus it should be paid more attention to avoiding its consequences, both at the individual level and at the organizational level.

Undersköterskans välbefinnande och hälsa kan påverkas av arbetsmiljön där inflytande och påverkan på arbetsinnehåll har betydelse. Tid för återhämtning kan vara svårt att få till stånd då undersköterskan arbetar oregelbundna arbetstider. Arbetsuppgifter som kan leda till en god hälsa och arbetsmiljö kan vara känslan av delaktighet och inflytande. Syftet med detta examensarbete var att beskriva undersköterskans erfarenheter av delaktighet och dess inverkan på hälsan. Examensarbetet genomfördes med en kvalitativ ansats och som metod för datainsamling användes semistrukturerade intervjuer. Individuella intervjuer genomfördes med sex undersköterskor som arbetar inom äldreomsorgen. Innehållsanalys användes som metod för att bearbeta data. Resultatet visar att tid för återhämtning och att kunna medverka och ta ansvar har betydelse sett ur individens perspektiv. Arbetsgruppen har betydelse för hälsa och delaktighet genom samspel, öppenhet och förmågan att lyssna på varandra. Ur ett organisatoriskt perspektiv är samspel med andra professioner och upplevelsen av en hälsosam arbetsmiljö viktigt. Chef för verksamhet bör tillsammans med undersköterskor skapa en miljö där välbefinnande råder genom delaktighet i en hälsosam och hållbar organisation. Genom detta förhållningssätt kan arbetsrelaterade problem förhindras vilket i sin tur kan bidra till en förbättrad hälsa hos den enskilde och att minska sjukfrånvaron.

Bakgrund. Att få en allvarlig bristning i samband med förlossning kan ge kvinnor smärta, lidande, och låg livskvalitet under lång tid. Syfte. Syftet med förbättringsarbetet har varit att förbättra eftervården genom att införa strukturerad uppföljning, öka kvalitén i bedömning och diagnostik, förbättra informationen till patienten och utveckla former för patientdelaktighet i förbättringsarbetet. Syftet med studien har varit att ur ett verksamhetsperspektiv beskriva erfarenheterna av patientdelaktigheten i förbättringsarbetet. Metod. Förbättringsarbetet har designats med hjälp av Förbättringstrappan och utgått från ett patientprocessorienterat perspektiv. Metod för studien var kvalitativ i form av en fallstudie. Resultat. Genom förbättringsarbetet följs kvinnorna upp via bristningsregistret, uppföljningsbesök med 3D- ultraljud görs på en specialinrättad mottagning. Vidare får kvinnorna individuell fysioterapeutinformation innan hemgång, en vårdkedja har införts och former för patientdelaktighet har utformats och använts. Dessa är frågeformulär, intervjuer, workshops och patientföreträdare i förbättringsnätverket. Resultatet från studien visar att formerna för patientdelaktighet ger skilda förutsättningar för delaktigheten. Resultatet visar på betydelsen av organisatoriska förutsättningar, värdet av patientdelaktighet, utmaningar vid införande och vilket reellt inflytande som patientdelaktigheten haft under processen och för resultaten av förbättringsarbetet. Slutsatser. Patientdelaktighet skapar värde i flera dimensioner. Patientdelaktighet behöver designas, anpassas till kontexten och förbättringsarbetets mål och dess syfte behöver vara tydligt uttryckt. / Background. Perineal tears during childbirth can lead to after-delivery complications that leads to great suffering and low quality of life for a long time. Purpose. The purpose has been to improve after-delivery care by systematic follow-up, increasing the quality of diagnostics and management of these women, improving the information for the patient and developing new ways of improving including patients in the improvement work. The purpose of the study has been to study the effect of patient participation in the improvement work. Method. "The improvement ramp" and patient process-oriented perspective has been used to design the improvement work. The method of the study was qualitative in the form of a case study. Results. Follow-up using 3D-ultrasound is introduced. A care chain has been introduced and ways of patient participation have been designed and used. These are questionnaires, interviews, workshops and patient representatives in the improvement network. The results of the study show that the ways of patient participation provide different conditions for participation. The result shows the importance of organizational conditions, the value of patient participation, challenges in the introduction and the real influence that patient participation has had during the process and on the results of the improvement work. Conclusions. Patient-participation in QI creates values in several dimensions. Patient-participation needs to be carefully designed in compliance with context, goals and purpose.

With an increasing migrant population there is a growing need to organize interpreting practices in healthcare in order to deliver equitable high-quality care. This thesis focuses on healthcare institutions’ organization of interpreting services. The aim of the study was to explore interpreting practices in a healthcare context by comparing two different healthcare areas – elderly and emergency healthcare. The study aimed to highlight the impact of the organizational and institutional context. This study was designed as an explorative and descriptive qualitative study including 79 healthcare professionals with experience of interpreting practices recruited via purposeful sampling in elderly and emergency healthcare. Data were collected through individual and focus-group interviews and analysed with inductive qualitative content analysis. The main findings show that the processes and structures around interpreting practices were complex and mainly linked to individual and interpersonal levels and, to a limited extent, to the institutional level. On the institutional level the Public Procurement Act was the only formal policy to follow. On individual and interpersonal level interpreting practices were structured by self-established informal workplace routines developed by the professional groups. The norms and routines used was determined by access to interpreters, time aspects, characteristics of the care given, health conditions and the person’s problem, expectations and requests from the person and also from healthcare professionals. There were wishes for improvement, with better flexibility in access to professional interpreters, training for users and interpreters, and also better technical solutions and equipment. In conclusion, the use of interpreters was rooted in the organizational environment of interpreting practice, including the availability of laws, policy and guidelines, and closely related to individuals’ language skills, cultural values and social factors. The use of professional interpreters was based on the nature of care in context and access to interpreters and determined by health professionals’ estimation of the person’s current health status in order to deliver fast and individualized care based on humanistic values. Thus, it is important to consider organizational framework and cultural awareness when formulating interpreting practices adapted to the context, and formal guidelines in order to achieve the aim of personcentered and equal health care.

The purpose of this thesis is to explore the institutionally shaped response to the introduction of the national guidelines on the Swedish regional health policy arena. The thesis consists of two case studies. Adapting a qualitative approach, the data is based on individual interviews and these were analysed thematically. The first paper explores the response by four Swedish regional health authorities to the introduction of the National Guidelines for Cardiac Care, while the second paper aims to broaden the understanding of how the national guidelines are used for strategic purposes among politicians. As illustrated in this thesis, organizations will respond, adjust and react to external pressure according to conditions shaped by the institutional context. Key findings here are that the national guidelines are a complex policy instrument that, beyond being able to be used in an instrumental fashion by the medical managment, can also serve a legitimizing function for political decision-makers. The goals of the national guidelines, i.e. equal and efficient care, and the uncertainty about who, among multiple stakeholders, is responsible for the guidelines in the regional health authority, is a source of ambiguity and potential conflict. Those who are potentially responsible represent different rationales – a political rationale and a scientific rationale. The dominating scientific rationale of the national guidelines can create instability, when pushing towards the use of explicit priority-setting. Priority-setting in the institutional setting of a regional health authority has strong elements of becoming “wicked problems” since the dilemma of prioritization remains regardless of ambitions to apply a “technocratic fix”. A wicked problem is characterized by high complexity and being persistently hard to solve (Williams et al. 2012). A recurring dilemma is that priority-setting still contains many wicked problems, as social values and political considerations remain important parts of the policy process. One weakness of the national guidelines, identified in this thesis, is that the guidelines discuss each service area separately, and thereby reinforce a silo mentality in the Swedish health policy arena. To sum up, the national guidelines create a multifaceted and complex response in the Swedish health policy arena where different rationalities collide, and where conflicts appear and are dealt with within the regional health authorities.

Sjuksköterskors praktiska kunskaper är avgörande för säker vård. Inom sjuksköterskeutbildningen kontrolleras färdigheter genom färdighetsexaminationer. Utifrån kartlagda brister i rättssäkerhet och arbetsmiljö vid färdighetsexaminationer initierades ett förbättringsarbete. Syftet med förbättringsarbetet var att förbättra processen för klinisk träning inom sjuksköterskeprogrammet genom att utveckla färdighetsexaminationer. En studie av förbättringsarbetet genomfördes i syfte att: Undersöka samsyn mellan lärare kring färdighetsexamination som pedagogisk aktivitet. Analysera och utveckla initial programteori utifrån intervjudata. Förbättringsarbete har utformats efter förbättringsmodellen, förbättringsrampen och programteoretisk ansats. Studie genomfördes med kvalitativa intervjuer och innehållsanalys utifrån en interaktiv och abduktiv ansats. Förbättringsarbetet resulterade i minskad variation mellan lärare i bedömningen av färdighetsexaminationer. Nya arbetssätt har lett till ökad samsyn mellan lärare och bättre arbetsmiljö. Programteorin reviderades utifrån intervjudata. Minskad variation visar på en ökad rättssäkerhet. Reviderad programteori har ökat möjligheten att dra lärdom av förbättringsarbetet såväl lokalt som generellt. Arbetet har bidragit till en utveckling av sjuksköterskeutbildningen och dess bidrag till en god och säker hälso- och sjukvård. / Nurses' practical knowledge is crucial for safe care. Within the nursing program skills are checked through clinical examinations. Based on identified deficiencies in terms of legal validity and working environment related to clinical examinations improvement work was initiated. The purpose of the improvement work was to improve the process of clinical training within the nursing program by developing the clinical examination. A study of the improvement work was conducted with the purpose of: Exploring teachers shared interpretations with clinical examinations as an educational activity. Analysing and developing initial program theory based on interview data. Improvement work was designed according to the model for improvement, improvement ramp, and a program theory approach. The study includes qualitative interviews with content analysis based on an interactive and abductive approach. The improvement work led to improved consensus between teachers and a better work environment. A reduction in variation between teachers’ assessments of clinical examinations was reached. The program theory was revised based on interview data. Reduced variation shows increased legal validity. Revised program theory has increased the possibility of learning from the improvement work both locally and in general. The work has developed the nursing education and its contribution to good and safe healthcare.

Immersed in a context of constrained health resources, nurse managers are at great risk of the experience and negative consequences of values clashes and ethical conflict, such as burnout and attrition. Replicating a qualitative descriptive study previously conducted in Canada (Gaudine & Beaton, 2002) this research is aimed at increasing knowledge of the experience of nurse managers’ ethical conflict with their health care organizations in New Zealand. Semi-structured interviews were used to gather data from eight nurse managers in New Zealand, which was analyzed using a general inductive approach to qualitative research. The experience of advocating for values that may be shared by both nursing and the health care organization, such as safety, teamwork and quality patient care, were revealed in the conceptual category of Nursing Management Advocacy. As with their Canadian study counterparts, Isolation was revealed as a key factor that made the experience of ethical conflict worse and involves the social experiences of silencing, employment barriers and invisibility. Support describes the factors that mitigated the experience of ethical conflict and involves personal, professional and organizational support, and are likewise similar to the experiences of Canadian nurse managers. The Bottom Line describes a focal point of the experience of ethical conflict where the health care organizations predominantly fiscal bottom line was confronted and challenged by nurse managers, and where the nurse manager might reach their own bottom line and choose to leave the organization. Being and Becoming Nursing Leaders describes the outcomes of ethical conflict for nurse managers who were not only transformed into nursing leaders, through learning, reflection, and growth but also counted the costs of nursing leadership. This study concludes that supportive colleagues, organizational structures and culture are essential to mitigating the experience of ethical conflict and isolation which nurse managers encounter. The study also concludes that reducing isolation and supporting nurse managers will ensure that nursing values are appropriately represented and articulated in the health care organization’s decision making systems and processes.