A program of nurse algorithm-guided care for adult patients with acute minor illnesses in primary care

Background: Attention to patients with acute minor-illnesses requesting same-day consultation represents a major burden in primary care. The workload is assumed by general practitioners in many countries. A number of reports suggest that care to these patients may be provided, at in least in part, by nurses. However, there is scarce information with respect to the applicability of a program of nurse management for adult patients with acute minor-illnesses in large areas. The aim of this study is to assess the effectiveness of a program of nurse algorithm-guided care for adult patients with acute minor illnesses requesting same-day consultation in primary care in a largely populated area. Methods: A cross-sectional study of all adult patients seeking same day consultation for 16 common acute minor illnesses in a large geographical area with 284 primary care practices. Patients were included in a program of nurse case management using management algorithms. The main outcome measure was case resolution, defined as completion of the algorithm by the nurse without need of referral of the patient to the general practitioner. The secondary outcome measure was return to consultation, defined as requirement of new consultation for the same reason as the first one, in primary care within a 7-day period. Results: During a two year period (April 2009-April 2011), a total of 1,209,669 consultations were performed in the program. Case resolution was achieved by nurses in 62.5% of consultations. The remaining cases were referred to a general practitioner. Resolution rates ranged from 94.2% in patients with burns to 42% in patients with upper respiratory symptoms. None of the 16 minor illnesses had a resolution rate below 40%. Return to consultation during a 7-day period was low, only 4.6%. Conclusions: A program of algorithms-guided care is effective for nurse case management of patients requesting same day consultation for minor illnesses in primary care.

Evaluation de la satisfaction des infirmiers(-ères): développement et validation d'un nouvel outil d'analyse [Evaluation of satisfaction of nurses: development and validation of a new analysis tool]

A new device for the analyses of nurses' satisfaction has been developed and validated on two types of general and intensive treatments at the University Hospital in Vaudois, Switzerland. A questionnaire has been elaborated for identifying the variables linked with characteristics of the nurse's work, as well as personal variables of the employer which could have an influence on the level of satisfaction. In identifying the sources of satisfaction and dissatisfaction, it has been possible to propose recommendations and corrective measures in order to improve the level of global satisfaction of the nursing team.

A program of nurse algorithm-guided care for adult patients with acute minor illnesses in primary care

Background: Attention to patients with acute minor-illnesses requesting same-day consultation represents a major burden in primary care. The workload is assumed by general practitioners in many countries. A number of reports suggest that care to these patients may be provided, at in least in part, by nurses. However, there is scarce information with respect to the applicability of a program of nurse management for adult patients with acute minor-illnesses in large areas. The aim of this study is to assess the effectiveness of a program of nurse algorithm-guided care for adult patients with acute minor illnesses requesting same-day consultation in primary care in a largely populated area. Methods: A cross-sectional study of all adult patients seeking same day consultation for 16 common acute minor illnesses in a large geographical area with 284 primary care practices. Patients were included in a program of nurse case management using management algorithms. The main outcome measure was case resolution, defined as completion of the algorithm by the nurse without need of referral of the patient to the general practitioner. The secondary outcome measure was return to consultation, defined as requirement of new consultation for the same reason as the first one, in primary care within a 7-day period. Results: During a two year period (April 2009-April 2011), a total of 1,209,669 consultations were performed in the program. Case resolution was achieved by nurses in 62.5% of consultations. The remaining cases were referred to a general practitioner. Resolution rates ranged from 94.2% in patients with burns to 42% in patients with upper respiratory symptoms. None of the 16 minor illnesses had a resolution rate below 40%. Return to consultation during a 7-day period was low, only 4.6%. Conclusions: A program of algorithms-guided care is effective for nurse case management of patients requesting same day consultation for minor illnesses in primary care.

Public health education in Europe: old and new challenges

The purpose of this article is to discuss some of the current challenges faced by European schools of public health. Perhaps most remarkable on the continent is the diversity, the magnitude, and the rapidity of the developments in public health education since the Second World War. This article discusses its evolution, its main characteristics and the underlying rationale with several examples. Further, it addresses specific aspects of the future development, namely the collaboration of academic schools with practice-oriented institutions, as well as the interactions between the constituent disciplines of public health. The Bologna process on post-graduate education in Europe has had an important impact on the overall design of most schools. There is a willingness to develop public health in each country of the European region and there is a need to develop common strategies to reach high standards in teaching, training and researching in all disciplines related to public health.

Cross-cultural clinical competence and post-graduate teaching: any impact(s) on doctors?

Context: Cross-cultural clinical competence (CCC) requires a mixtureof "knowledge" (K), "attitude" (A) and "skills" (S), in order to develop theability to give quality care to patients of different cultures. Theseattributes allow, while providing medical care, consideration of thepatient's medical, social, cultural and language needs. The LausanneUniversity Medical Policlinic (PMU) provides approximately 30000consultations per year to migrant patients and over the past five yearshas implemented a training course on CCC that focuses on trialogue,stereotypes and administrative procedures for the healthcare ofmigrants.Method: A quantitative survey of 18 new residents, was carried outusing a validated questionnaire, the "Multicultural AssessmentQuestionnaire" (the MAQ, 16 questions on K, A and S) to evaluate theimpact of CCC training. The questionnaire was distributed before theCCC course (J-1), three days after (J+3) and three months later (J+90).A descriptive univariate analysis of the difference in MAQ scoresbetween the times J-1 - J+3 and J-1 - J+90 was made. Three FocusGroups were conducted, at three months, to explore residents' thoughtsabout the course.Results: A significant increase was observed in global performancedeclared by residents. Following the intervention, the score of the MAQincreased from 31.4 points to 38.0 points at three days (p = 0.004) andto 37.7 points at three months (p = 0.003). This increase was mostnoticeable in the field of acquiring K: total score J-1: 118, J+3: 189,J+90: 190 (difference J-1 - J+3 and J-1 - J+90: p <0.005). There was nosignificant difference in acquiring A (J-1: 222, J+3: 228, J+90: 229), andS increases in a significant way at first (J-1: 222, J+3: 265, J-1 - J+3:p = 0.035), then comes back to the start value (J+90: 217). The residentswere interested by the course which they felt provides useful informationfor clinical practice. They had a great number of expectations in varyingfields (medical anthropology, cultural differences, epidemiology, etc.),hoping a "ready-made" solution for the approach of migrant patients.Conclusions: A unique training of CCC at the post-graduate level,upgraded K, and to a lesser extent A and S, for these 18 residents. Theywere interest and they had many expectations. Subsequent coursesshould consolidate these acquisitions. Future study should demonstratethe impact on patients' clinical outcome.

Infirmier en psychiatrie de liaison : développement de la supervision en milieu somatique [Liaison psychiatry nurse: The development of supervision in somatic medicine].

BACKGROUND: Over the years, somatic care has become increasingly specialized. Furthermore, a rising number of patients requiring somatic care also present with a psychiatric comorbidity. As a consequence, the time and resources needed to care for these patients can interfere with the course of somatic treatment and influence the patient-caregiver relationship. In the light of these observations, the Liaison Psychiatry Unit at the University Hospital in Lausanne (CHUV) has educated its nursing staff in order to strengthen its action within the general care hospital. What has been developed is a reflexive approach through supervision of somatic staff, in order to improve the efficiency of liaison psychiatry interventions with the caregivers in charge of patients. The kind of supervision we have developed is the result of a real partnership with somatic staff. Besides, in order to better understand the complexity of interactions between the two systems involved, the patient's and the caregivers', we use several theoretical references in an integrative manner. PSYCHOANALYTICAL REFERENCE: The psychoanalytical model allows us to better understand the dynamics between the supervisor and the supervised group in order to contain and give meaning to the affects arising in the supervision space. "Containing function" and "transitional phenomena" refer to the experience in which emotions can find a space where they can be taken in and processed in a secure and supportive manner. These concepts, along with that of the "psychic envelope", were initially developed to explain the psychological development of the baby in its early interactions with its mother or its surrogate. In the field of supervision, they allow us to be aware of these complex phenomena and the diverse qualities to which a supervisor needs to resort, such as attention, support and incentive, in order to offer a secure environment. SYSTEMIC REFERENCE: A new perspective of the patient's complexity is revealed by the group's dynamics. The supervisor's attention is mainly focused on the work of affects. However, these are often buried under a defensive shell, serving as a temporary protection, which prevents the caregiver from recognizing his or her own emotions, thereby enhancing the difficulties in the relationship with the patient. Whenever the work of putting emotions into words fail, we use "sculpting", a technique derived from the systemic model. Through the use of this type of analogical language, affects can emerge without constraint or feelings of danger. Through "playing" in that "transitional space", new exchanges appear between group members and allow new behaviors to be conceived. In practice, we ask the supervisee who is presenting a complex situation, to design a spatial representation of his or her understanding of the situation, through the display of characters significant to the situation: the patient, somatic staff members, relatives of the patient, etc. In silence, the supervisee shapes the characters into postures and arranges them in the room. Each sculpted character is identified, named, and positioned, with his or her gaze being set in a specific direction. Finally the sculptor shapes him or herself in his or her own role. When the sculpture is complete and after a few moments of fixation, we ask participants to express themselves about their experience. By means of this physical representation, participants to the sculpture discover perceptions and feelings that were unknown up to then. Hence from this analogical representation a reflection and hypotheses of understanding can arise and be developed within the group. CONCLUSION: Through the use of the concepts of "containing function" and "transitional space" we position ourselves in the scope of the encounter and the dialog. Through the use of the systemic technique of "sculpting" we promote the process of understanding, rather than that of explaining, which would place us in the position of experts. The experience of these encounters has shown us that what we need to focus on is indeed what happens in this transitional space in terms of dynamics and process. The encounter and the sharing of competencies both allow a new understanding of the situation at hand, which has, of course, to be verified in the reality of the patient-caregiver relationship. It is often a source of adjustment for interpersonal skills to recover its containing function in order to enable caregiver to better respond to the patient's needs.

New technologies and nursing: use and perception of primary healthcare nurses about electronic health record in Catalonia, Spain

This study was aimed to analyze and assess the use and perception of electronic health records (EHRs) by nurses. The study sample included 113 nurses from different shifts of primary health facilities in Catalonia, Spain, devoted to adult as well as pediatric outpatients using EHRs throughout the year 2010. A majority of the sample (87.5%) were women and 12.5% were men. The average age was 44.27 years and the average time working in primary healthcare was 47.15 months. A majority (80.4%) received specific training on the use of the EHR and 19.6% did not. The use of the application required side technical support (mean: 3.42) and it is considered necessary to learn more about the performance of the application (mean: 3.50). The relationship between the average ratings that nurses have about the EHR and age shows that there is no statistically significant linear relationship (r = - 0.002, p-value = 0.984). As to how long they have used the EHRs, there are significant differences (r= -0.304, p-value = 0.00), so the more time the nurse takes using the EHR, the greater degree of satisfaction is shown. In addition, there are significant differences between nurses" perceptions regarding the EHR and gender (t = - 0.421, p-value = 0.675). Nurses assessed as positive the contribution of the EHRs in their nursing care day work (average score: 2.55/5). Considering that the usability of the EHR device is assessed as satisfactory, the results of the perception of nurses show that we must also take into account the training and emphasize the need for a side technical support in the implementation process of the EHR. Doing so, the positive perception that nurses have in regard to information and communication technology in general and with respect to the EHR in particular may be increased.

New technologies and nursing: use and perception of primary healthcare nurses about electronic health record in Catalonia, Spain

This study was aimed to analyze and assess the use and perception of electronic health records (EHRs) by nurses. The study sample included 113 nurses from different shifts of primary health facilities in Catalonia, Spain, devoted to adult as well as pediatric outpatients using EHRs throughout the year 2010. A majority of the sample (87.5%) were women and 12.5% were men. The average age was 44.27 years and the average time working in primary healthcare was 47.15 months. A majority (80.4%) received specific training on the use of the EHR and 19.6% did not. The use of the application required side technical support (mean: 3.42) and it is considered necessary to learn more about the performance of the application (mean: 3.50). The relationship between the average ratings that nurses have about the EHR and age shows that there is no statistically significant linear relationship (r = - 0.002, p-value = 0.984). As to how long they have used the EHRs, there are significant differences (r= -0.304, p-value = 0.00), so the more time the nurse takes using the EHR, the greater degree of satisfaction is shown. In addition, there are significant differences between nurses" perceptions regarding the EHR and gender (t = - 0.421, p-value = 0.675). Nurses assessed as positive the contribution of the EHRs in their nursing care day work (average score: 2.55/5). Considering that the usability of the EHR device is assessed as satisfactory, the results of the perception of nurses show that we must also take into account the training and emphasize the need for a side technical support in the implementation process of the EHR. Doing so, the positive perception that nurses have in regard to information and communication technology in general and with respect to the EHR in particular may be increased.

Training graduate students to be teachers

Pedagogic education of graduate students, when and where it exists, is restricted to theoretical courses or to the participation of the students as teachers' assistants. This model is essentially reproductive and offers few opportunities for any significant curriculum innovation. To open an opportunity for novelty we have introduced a new approach in "Biochemistry Teaching", a course included in the Biochemistry Graduate Program of the Biochemistry Department (Universidade Estadual de Campinas and Universidade de São Paulo). The content of the course consists of a) choosing the theme, b) selecting and organizing the topics, c) preparing written material, d) establishing the methodological strategies, e) planning the evaluation tools and, finally, f) as teachers, conducting the course as an optional summer course for undergraduate students. During the first semester the graduate students establish general and specific educational objectives, select and organize contents, decide on the instructional strategies and plan evaluation tools. The contents are explored using a wide range of strategies, which include computer-aided instruction, laboratory classes, small group teaching, a few lectures and round table discussions. The graduate students also organize printed class notes to be used by the undergraduate students. Finally, as a group, they teach the summer course. In the three versions already developed, the themes chosen were Biochemistry of Exercise (UNICAMP), Biochemistry of Nutrition (UNICAMP) and Molecular Biology of Plants (USP). In all cases the number of registrations greatly exceeded the number of places and a selection had to be made. The evaluation of the experience by both graduate and undergraduate students was very positive. Graduate students considered this experience to be unique and recommended it to their schoolmates; the undergraduate students benefited from a more flexible curriculum (more options) and gave very high scores to both the courses and the teachers.

Becoming a caring nurse : the heart of the matter in nurse education

This thesis in caring science didactics is based on a thinking, where the fundamental basis for the didactic is science-based, i.e. it does not emanate from the nursing profession but brings forward a didactic that grows out of caring science and its core substance and ethos. This view on didactics arises from the caritative theory developed by Eriksson. The overall aim of the study is to clarify the meaning and essence of understanding, as well as to explore and deepen the understanding of student nurses' processes of understanding and becoming with the intention of developing a theory model for caring didactics. The overarching research questions are: What is the essence of understanding (of caring science knowledge)? What are the possibilities and importance of understanding in the appropriation of caring science? What characterizes and impels the process of becoming? The thesis consists of four sub studies and a summary section. The overall methodological approach is hermeneutic involving quantitative as well as qualitative methods. The data for the study has been collected through a longitudinal research project that followed student nurses at three universities during their entire education. The empirical sub studies form the basis for the interpreted knowledge that is formulated in the new understanding. This new understanding have, through additional theory-charging with the theory fragments from Gadamer, generated the heuristic synthesis which is illustrated in the theory model. The findings shows that understanding can be described as something unlimited, as an endless movement, which can be illustrated as a lying eighth, a lemniscate. The lemiscate of understanding is characterized by seeing, knowing and becoming and consists of seven differently named phases; the acquired horizon of understanding, the encounter of horizons, the dialogue of horizons, the fusion of horizons, application, reflection and shaping a new horizon of understanding. Bildung (formation), is the ultimate imprint of the endless spiral movement of understanding. Ethos and arête constitute the hubs around which the lemniscate of understanding circles. These include the spirit and driving force that the student carries within. The caring culture encloses the lemniscate of understanding. The caring culture provides the life space of understanding and the prevailing basic values are evinced in the culture.

Changing roles of nurse educators employed in acute and chronic care settings : the impact of professional and statutory mandates in Ontario at four sites of one hospital corporation /

The role of the hospital-employed nurse educator is evolving. Factors influencing this change include the introduction of standards for nurse educators by the College of Nurses of Ontario (CNO), a change in the way nurses are educated, the emergence of nursing as a profession, and hospital restructuring as a result of budgetary constraints. Two of these influencing factors: the introduction of the updated Standards of Practice for Registered Nurses and Registered Practical Nurses (1996) and hospital restructuring occurred over the last 7 years at several hospitals in southern Ontario. Current literature as well as the Standards of Practice (1996) were utilized to examine the current roles and responsibilities of nurse educators and subsequently develop a questionnaire to study the impact of these influencing factors on the role of the nurse educator. This questionnaire was piloted and revised before its distribution at 4 hospitals in southern Ontario. Twenty-five of the 41 surveys (61%) distributed were returned for analysis. The data reflected that the Standards of Practice had a positive influence on the role of the nurse educator, while hospital restructuring had a negative impact. In addition, many of the roles and responsibilities identified in the literature were indeed part of the current role of nurse educators, as well as several responsibilities not captured in the literature. The predictions for the future of this role in its current state were not positive given the financial status of the health care system as well as the lack of clarity for the role and the current level ofjob satisfaction among practicing nurse educators. However, a list of recommendations were generated which, if implemented, could add clarity to the role and improve job satisfaction. This could enhance the retention of current nurse educators and the possibility of recruiting competent nurse educators to the role in the future.

Exploring the events that engage graduate students in transformative learning /

This research explored the events that engaged graduate students in transformative learning within a graduate program in education. This context was chosen because one objective of a graduate program is to facilitate critical thinking and transformative learning. The question ofhow adult learners perceive and experience learning steered the direction ofthis study. However, the purpose ofthis research was to study critical incidents that led to profound cognitive and affective changes as perceived by the graduate students. Specifically, the questions to be answered were what critical incidents happened to graduate students while in the Master ofEducation program, how were the incidents experienced, and what transformation resulted? The research design evolved over the course of a year and was highly influenced by previous empirical studies and criticisms oftransformative learning theory. The overall design was qualitative and phenomenological. A critical and interpretive approach was made to empirical data collected through a critical incident questionnaire and in-depth interviews. Inductive analysis allowed theory to be built from the data by making comparisons. New questions emerged and attention was given to social context, the passage oftime, and sequence ofevents in order to give meaning and translation ofthe participants' experiences and to build the interpretive narratives. Deductive analysis was also used on the data and a blending ofthe two forms of analysis; this resulted in the development ofa foundational model for transformative learning to be built.The data revealed critical incidents outside ofthe graduate school program that occurred in childhood or adult life prior to graduate school. Since context of individuals' lives had been an important critique of past transformative learning models and studies, this research expanded the original boundaries of this study beyond graduate school to incorporate incidents that occurred outside of graduate school. Critical incidents were categorized into time-related, people-related, and circumstancerelated themes. It was clear that participants were influenced and molded by the stage oftheir life, personal experiences, familial and cultural conditioning, and even historic events. The model developed in this document fiom an overview ofthe fmdings identifies a four-stage process of life difficulty, disintegration, reintegration, and completion that all participants' followed. The blended analysis was revealed from the description ofhow the incidents were experienced by the participants. The final categories were what were the feelings, what was happening, and what was the enviromnent? The resulting transformation was initially only going to consider cognitive and affective changes, however, it was apparent that contextual changes also occurred for all participants, so this category was also included. The model was described with the construction metaphor of a building "foimdation" to illustrate the variety of conditions that are necessary for transformative learning to occur. Since this was an exploratory study, no prior models or processes were used in data analysis, however, it appeared that the model developed from this study incorporated existing models and provided a more encompassing life picture oftransformative learning.

What's the difference under the gown? : new professors' development as university teachers

This study explores how new university teachers develop a teaching identity. Despite the significance ofteaching, which usually comprises 40% of a Canadian academic's workload, few new professors have any formal preparation for that aspect of their role. Discipline-specific education for postsecondary professors is a well-defined path; graduates applying for faculty positions will have the terminal degree to attest to their knowledge and skill conducting research in the discipline. While teaching is usually given the same workload balance as research, it is not clear how professors create themselves as teaching professionals. Drawing on Kelly's (1955) personal construct theory and Kegan's (1982, 1994) model ofdevelopmental constructivism through differentiation and integration, this study used a phenomenographic framework~(Marton, 1986, 1994; Trigwell & Prosser, 1996) to investigate the question of how new faculty members construe their identity as university teachers. Further, my own role development as researcher was used as an additional lens through which to view the study results. The study focused particularly on the challenges and supports to teaching role development and outlines recommendations the participants made for supporting other newcomers. In addition, the variations and similarities in the results suggest a developmental model to conceptions ofteaching roles, one in which teaching, research, and service roles are viewed as more integrated over time. Developing a teacher identity was seen as a progression on a hierarchical model similar to Maslow's (1968) hierarchy of needs.

Reflective practice and the novice nurse /

The importance of reflective practice to the novice nurse was explored in this study. The novice nurse, for the purpose of this study, was defined as a Registered Nurse who graduated from an accredited nursing program within a 1 2-month period prior to the data collection date and who had no prior experience as a Registered Nurse before graduation. All of the nurses enrolled in this study were female. This study explored the perceived link between transformational learning and reflective practice, and whether there may be a need to standardize a conceptual framework and definition for reflective practice in nursing academia. The literature that was reviewed for this study indicated that there were inconsistencies in the application of reflective practice within academic curriculums. The literature did identify that the majority of academic scholars have agreed that reflection is paramount in the development of critical thinking skills, self-awareness, and selfdirection. And, while all of these skills drive professional practice and effect excellent patient care, institutional health care has been reticent to support the value of reflective practice because of a lack of empirical data sets. The 4 novice Registered Nurses who participated in this study were asked 4 openended questions that provided a foundation for comparing the novice nurses' experiences, interpretations, and perceptions of reflective practice. These nurses participated in individual audiotaped interviews with the researcher. The study was based upon Heath's (1998) model of "Theory hitegration via Reflective Practice." The results demonstrated that reflective practice was significant to the novice nurse and was used as a tool to identify further learning needs. Transformational learning through reflection was described by the study participants. The findings within this study are consistent with previous work done in the area of reflection and the novice nurse.

The impact of scheduling on the implementation of the new Ontario curriculum: teachers' perceptions /

This qualitative study explored secondary teachers' perceptions of scheduling in relation to pedagogy, curriculum, and observation of student learning. Its objective was to determine the best way to organize the scheduling for the delivery of Ontario's new 4-year curriculum. Six participants were chosen. Two were teaching in a semestered timetable, 1 in a traditional timetable, and 3 had experience in both schedules. Participants related a pressure cooker "lived experience" with weaker students in the semester system experiencing a particularly harsh environment. The inadequate amount of time for review in content-heavy courses, gap scheduling problems, catch-up difficulties for students missing classes, and the fast pace of semestering are identified as factors negatively impacting on these students. Government testing adds to the pressure by shifting teachers' time and attention in the classroom from deeper learning to a superficial coverage of material, from curriculum as lived to curriculum as text to be covered. Scheduling choice should be available in public education to accommodate the needs of all students. Curriculum guidelines need to be revamped to reflect the content that teachers believe is necessary for a successful course delivery. Applied level courses need to be developed for students who are not academically inferior but learn differently.