Thesis advisor: Barabara Hazard / This randomized controlled trial (RCT) examined a discharge nursing intervention (DNI) aimed at promoting self-regulation of care for early discharge interventional cardiology patients. The purpose of this study was to compare medication adherence, patient satisfaction, use of urgent care, and illness perception in patients with cardiovascular disease (CVD) undergoing interventional revascularization procedures who receive usual care and those who receive a DNI. The Common Sense Model (CSM) of illness representation provided the theoretical foundation for this study. The CSM is a cognitive parallel processing model that draws relationships between illness representation, coping methods, and illness outcomes to help explain the process by which people make sense of their illness. Intervention research aimed at life style changes to reduce secondary events after treatment for CVD is needed to guide evidence based care. Treatment for CVD has shifted from surgical repair with prolonged hospitalizations to interventional procedures requiring shorter hospital stays. This trend reduces nursing time to monitor complications and provide education about medication management and lifestyle changes. Patients recover in short stay areas and return home within hours or one to two days of the procedure. Cardiac disease is then managed as a chronic, but often stable condition. With this change in the delivery of care, several trends have emerged that have implications for quality nursing care and patient outcomes: a) the burden of care shifts from the hospital setting to home, b) patients are discharged without extensive education about complications and disease management, c) the occurrence of secondary events and disease progression remain a valid threat, and d) nurses with expert practice are in a unique position to assist patients and families with CVD management. This study addressed the following questions. 1. Do patients receiving the nursing intervention differ significantly from those receiving usual care on medication adherence? 2. Do patients receiving the nursing intervention differ significantly from those receiving usual care on patient satisfaction? 3. Is there a significant difference in the utilization of urgent care between those patients receiving the nursing intervention when compared to those patients receiving usual care? 4. Does a difference exist between the patients receiving the nursing intervention and those patients receiving usual care on illness perception, as measured by seven components of the IPQ-R: time line (acute and chronic), consequence, personal control, treatment (cure) control, illness coherence, timeline (cyclical), and emotional representations? Purposive sampling was used to select a sample of patients admitted for interventional procedures at an academic teaching hospital. One hundred and fifty four patients were and randomized into control and experimental groups. Final analyses included data from 129 patients. Sixty-four participants in the experimental group received the DNI which included: 1) additional written information about taking medications, 2) a medication pocket card, 3) a list of 3 cardiac internet sites,and 4) a phone call, 24 hours post procedure, from an expert cardiac nurse to review discharge instructions. Sixty-five participants in the control group received usual care. Analyses on four outcome measures, medication adherence, use of urgent care, patient satisfaction, and illness perception, revealed one statistically significant result. Participants in the experimental group, receiving the DNI, scored significantly higher than the control group on one measure, the timeline (acute/chronic) component of illness perception (p = .006) indicating a greater appreciation of the chronicity of their disease. Otherwise, there were no significant group differences found. This study provides support for nursing intervention research guided by self-regulation theory that examines the patient's perception of illness. Patients with cardiac disease who received the DNI were statistically more likely to acknowledge that their illness would last a long time. This awareness, may improve adherence to a prescribed regimen of medication and lifestyle modification. Nursing interventions guided by an understanding of patients' belief that their cardiovascular disease is chronic will add to the body of knowledge that informs providers about decisions patients make concerning medication adherence and lifestyle modifications. However, the results underscore the limitations of adding additional discharge care to this population of patients to improve medication adherence, use of urgent care, and patient satisfaction. Future research should include a longitudinal study to examine how patients who perceive their disease to be chronic in nature managed their medications and care decisions at home. / Thesis (PhD) — Boston College, 2009. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Sous l’effet d’une concurrence de plus en plus forte et d’un nouveau système de tarification, les cliniques privées de court séjour françaises sont confrontées à des contraintes économiques de plus en plus nombreuses auxquelles elles tentent de s’adapter. Cette recherche a pour objet d’identifier quels sont les déterminants organisationnels et stratégiques de la performance financière des cliniques privées. Une revue de littérature française et étrangère conduite sur la performance des établissements de santé a révélé la présence de nombreux déterminants de la performance financière. Pour identifier les facteurs influençant celle des cliniques privées, une étude statistique a été réalisée sur la totalité des cliniques privées françaises de court séjour dont les données sont exploitables, soit 463 établissements. Les résultats des statistiques montrent que la performance financière des cliniques privées, mesurée par un score financier et par les ratios financiers le composant, subit l’impact de variables que les directeurs d’établissements peuvent influencer à moyen et à long terme. Le volume et la productivité de la masse salariale employée par les établissements, le volume d’activité, la présence d’un projet stratégique bien défini et dont la mise en œuvre est effective, ainsi que la qualité des soins, celle-ci étant mesurée par les résultats des cliniques privées sur les différentes démarches d’amélioration de la qualité des soins, sont des facteurs qui présentent un fort impact sur la performance financière. / Private short-stay clinics are confronted with increasing economic constraints, to which they are trying to adapt, due to stronger competition and a new system of pricing. This research identifies which are the organizational determinents and financial performance strategies of private clinics. A review of French and foreign literature pertaining to the performance of these health establishments revealed the presence of numerous determinents of the financial performance. To identify the factors influencing the private clinics, a statistical study was performed on 463 French short-term clinics, where the relevent data was available. The results of these statistics indicated that the financial performance of these clinics, as measured by financial scores and ratios, underwent an influential impact in the short and long term. The productivity of the paid employees, the volume of activity, the presence of a well-defined and effective strategic project, so that the quality of the care given, as measured by the results of these clinics on different steps towards improvement on the quality of care, are the factors which presented a strong impact on the financial performance.

Les professionnels de l'analyse de la pratique et de l'organisation des soins interviennent dans un système complexe où interagissent des facteurs biologiques, culturels et sociaux. Ce travail de recherche porte sur les vécus du patient cardiovasculaire entrant dans un programme d'éducation thérapeutique, suite à un évènement aigu (infarctus du myocarde ou accident vasculaire cérébral). Il se justifie par la nécessité de comprendre le phénomène des récidives, rechutes et retours à l'hospitalisation malgré une prise en charge informative et éducative des facteurs de risques cardiovasculaires (tabagisme, sédentarité, mauvaise alimentation) durant l'hospitalisation initiale. Notre principal objectif est donc de comprendre ces récidives, rechutes et retours à l'hospitalisation des patients cardiovasculaires autrement que le résultat d'une non-observance. Cette recherche de type qualitatif est menée au Centre Hospitalo-Universitaire de Clermont-Ferrand (service de cardiologie court séjour) et à la clinique cardiopneumoloique de Durtol (centre de soins de suite et de réadaptation). La recherche est basée sur 22 situations d'observations de pratiques professionnelles, 9 entretiens centrés avec les professionnels dans ces 2 sites ci-dessus et 31 entretiens semi-directifs avec les patients. Ces enquêtes sont complétées par une analyse de la littérature française et anglo-saxonne, dans le domaine de l'éducation thérapeutique, de l'observance et du changement des comportements. En termes de résultats, la recherche présente les récidives, rechutes et retours à l'hospitalisation court séjour des patients comme le résultat d'une prise en charge inadaptée à leurs besoins. Des discordances de temps, de vécus et de ressentis entre professionnels de santé et patients durant l'hospitalisation initiale, l'inadaptation structurelle du court séjour, la discontinuité de la prise en charge et les ruptures de cohérence en fonction des différents niveaux de complexité (court séjour, centre de soins de suite et de réadaptation et chez les médecins traitants), mais surtout la confusion entre éducation du patient et information du patient, rendent les prescriptions médicales et soignantes en matière de changement des comportements à risques difficilement observables par les patients. Le format actuel de la relation et des interactions patients/professionnels de santé durant les soins, ne favorise pas l'implication et la participation active des patients dans leur prise en charge. En conclusion, nous retenons que les éléments qui influencent les comportements des patients vis-à-vis de leurs traitements ne relèvent pas seulement d'un apprentissage, mais de leur vécu et ressentis et également de leurs interactions avec les professionnels de santé. La prise en charge informative et éducative des facteurs de risques occulte parfois l'aspect relationnel de cette thérapeutique et les capacités cognitives et émotives des patients. Elle devrait suivre une double évolution : celle du patient (ses émotions, ses attentes, ses projets de vie…) et celle de la pathologie. Ce travail cherche également à répondre à la question suivante : en quoi et comment une approche socio-anthropologique permet-elle de comprendre les comportements des patients d'une part et des professionnels de santé d'autre part dans un contexte d'ETP en court séjour ? Il milite pour une reconnexion entre sciences sociales et sciences médicales et soignantes dans le système de soin et de santé français et montre l'apport considérable mais encore trop peu exploité des sciences sociales dans ce domaine. / The professionals of the practice analysis and care organization take part in a complex system where biological, cultural and social factors interact. This research task focuses on the experiences of the cardiovascular patient entering a therapeutic education program, after an acute event (myocardial infarction or stroke). It is justified by the need to understand the phenomenon of recurrence, relapse and hospitalization returns despite an informative and educational treatment in cardiovascular risk factors (smoking, physical inactivity, poor nutrition) during the initial hospitalization. Our main goal is therefore to understand these recurrences, relapses and hospitalization returns of cardiovascular patients other than the result of non-compliance. This qualitative research is carried out at the University Hospital Center of Clermont-Ferrand (Cardiology Department short stay) and at the cardio-pneumologic clinic of Durtol (follow-up and rehabilitation care center). The research is based on 22 observation situations of professional practices, nine focused interviews with professionals in these two sites above and 31 semi-structured interviews with the patients. These surveys are supplemented by an analysis of the French and Anglo-Saxon literature in the field of therapeutic education, compliance and behaviours change. In terms of results, the research presents the recurrences, relapses and returns to patients' short stay hospitalization as the result of an inappropriate care to their needs. Time discrepancies, experiences and felt between health professionals and patients during the initial hospitalization, inadequate structural short stay, the discontinuity of care and the inconsistencies in accordance with different levels of complexity (short stay, follow-up and rehabilitation care center and at the attending physicians', but mostly the confusion between the patient's education and the patient's information, makes medical and nursing requirements in terms of the change of risky behaviours hardly observable by patients. The current format of the relationship and the interactions patient/health professionals during the care doesn't promote the involvement and the active participation of patients in their care. In conclusion we retain that the elements which influence the patients' behaviours with respect to their treatments do not only depend on training, but on their experiences and felts and also on their interactions with health professionals. The informative and educational care of the risk factors sometimes conceals the relational aspect of this therapeutic and the cognitive and emotive capacities of the patients. It should follow a double evolution: that of the patient (his emotions, his expectations, his life plans) and that of the pathology. This work also seeks to answer to the following question: why and how a socio- anthropological approach allows us to understand the patients' behaviours on one hand and the health professionals on the other hand in a context of PTE (patient's therapeutic education) in short stay? It argues for a reconnection between social sciences and medical and nursing in the French health care system and shows the significant contribution but still too little used by social sciences in this area.

No description available.