A mixed methods study of the work patterns of full-time nurse practitioners in nursing homes

Aims and objectives: The aim of this study was to explore the integration of the nurse practitioner role in Canadian nursing homes to enable its full potential to be realised for resident and family care. The objective was to determine nurse practitioners' patterns of work activities. 

Background: Nurse practitioners were introduced in Canadian nursing homes a decade ago on a pilot basis. In recent years, government and nursing home sector interest in the role has grown along with the need for data to inform planning efforts. 

Design: The study used a sequential mixed methods design using a national survey followed by case studies. 

Methods: A national survey of nurse practitioners included demographic items and the EverCare Nurse Practitioner Role and Activity Scale. Following the survey, case studies were conducted in four nursing homes. Data were collected using individual and focus group interviews, document reviews and field notes. 

Results: Twenty-three of a target population of 26 nurse practitioners responded to the survey, two-thirds of whom provided services in nursing homes with one site and the remainder in nursing homes with as many as four sites. On average, nurse practitioners performed activities in communicator, clinician, care manager/coordinator and coach/educator subscales at least three to four times per week and activities in the collaborator subscale once a week. Of the 43 activities, nurse practitioners performed daily, most were in the clinician and communicator subscales. Case study interviews involved 150 participants. Findings complemented those of the survey and identified additional leadership activities. 

Conclusion: Nurse practitioners undertake a range of primary health care and advanced practice activities which they adapt to meet the unique needs of nursing homes. Relevance to clinical practice: Knowledge of work patterns enables nursing homes to implement the full range of nurse practitioner roles and activities to enhance resident and family care.

Tool life and hole surface integrity studies for hole-making of Ti6Al4V Alloy

With a significant growth in the use of titanium alloys in the aviation manufacturing industry, the key challenge of making high-quality holes in the aircraft assembly process needs to be addressed. In this work, case studies deploying traditional drilling and helical milling technologies are carried out to investigate the tool life and hole surface integrity for hole-making of titanium alloy. Results show that the helical milling process leads to much longer tool life, generally lower hole surface roughness, and higher hole subsurface microhardness. In addition, no plastically deformed layer or white layer has been observed in holes produced by helical milling. In contrast, a slightly softened region was always present on the drilled surface. The residual stress distributions within the hole surface, including compressive and tensile residual stress, have also been investigated in detail.

Designing for dementia : an assessment of the impact of the physical environment on wayfinding success for residents in long term care settings

It is acknowledged that one of the consequences of the ageing process is cognitive decline, which leads to an increase in the incidence of illnesses such as dementia. This has become ever more relevant due to the projected increase in the ageing demographic. Dementia affects visuo-spatial perception, causing difficulty with wayfinding, even during the early stages of the disease. The literature widely recognises the physical environment’s role in alleviating symptoms of dementia and improving quality of life for residents. It also identifies the lack of available housing options for older people with dementia and consequently the current stock is ill-equipped to provide adequate support.
Recent statistics indicate that 80% of those residing in nursing or residential care homes have some form of dementia or severe memory problems. The shift towards institutional care settings, the need for specialist support and care, places a greater impetus on the need for a person-centred approach to tackle issues related to wayfinding and dementia.
This thesis therefore aims to improve design for dementia in nursing and residential care settings in the context of Northern Ireland. This will be undertaken in order to provide a better understanding of how people with dementia experience the physical environment and to highlight features of the design that assist with wayfinding. Currently there are limited guidelines on design for dementia, meaning that many of these are theoretical, anecdotal and not definitive. Hence a greater verification to address the less recognised design issues is required. This is intended to ultimately improve quality of life, wellbeing, independence and uphold the dignity of people with dementia living in nursing or residential care homes.
The research design uses a mixed methods approach. A thorough preparation and consideration of ethical issues informed the methodology. The various facets were also trialled and piloted to identify any ethical, technological, methodological, data collection and analysis issues. The protocol was then amended to improve or resolve any of the aforementioned issues. Initially a questionnaire based on leading design recommendations was conducted with home managers. Semi-structured interviews were developed from this and conducted with staff and resident’s next of kin. An evidence-based approach was used to design a study which used ethnographic methods, including a wayfinding task. This followed a repeated measures design which would be used to actively engage residents with dementia in the research. Complementary to the wayfinding task, conversational and semi-structured interviews were used to promote dialogue and direct responses with the person with dementia. In addition to this, Space Syntax methodologies were used to examine the physical properties of the architectural layout. This was then cross-examined with interview responses and data from the wayfinding tasks.
A number of plan typologies were identified and were determined as synonymous with decision point types which needed to be made during the walks. The empirical work enabled the synthesis of environmental features which support wayfinding.
Results indicate that particular environmental features are associated with improved performance on the wayfinding tasks. By enhancing design for dementia, through identifying the attributes, challenges with wayfinding may be overcome and the benefits of the physical environment can be seen to promote wellbeing.
The implications of this work mean that the environmental features which have been highlighted from the project can be used to inform guidelines, thus adding to existing knowledge. Future work would involve the dissemination of this information and the potential for it to be made into design standards or regulations which champion design for dementia. These would increase awareness for designers and stakeholders undertaking new projects, extensions or refurbishments.
A person-centred, evidence-based design was emphasised throughout the project which guaranteed an in-depth study. There were limitations due to the available resources, time and funding. Future research would involve testing the identified environmental features within a specific environment to enable measured observation of improvements.

Reasoning Rights: Comparative judicial engagement

This edited book is about comparative reasoning in human rights cases, exploring the questions: How is it that notionally universal norms are reasoned by courts in such dramatically different ways? What is the shape of this reasoning? What techniques are common across the transnational jurisprudence? What techniques are diverse? With contributions by a team of world-leading human rights scholars, the book moves beyond simply addressing the institutional questions concerning courts and human rights, which too often dominate discussions of this kind. Instead, it seeks a deeper examination of the similarities and divergence in the content of reasons being developed by different courts when addressing comparable human rights questions. These differences, while partly influenced by institutional issues, cannot be attributable to them alone. The book explores the diverse and rich underlying spectrum of human rights reasoning, as a distinctive and particular form of legal reasoning, evident in the case studies across the selected jurisdictions. It is a fascinating study for all those interested in human rights law and legal reasoning.

A patient perspective of pharmacist prescribing: 'crossing the specialisms-crossing the illnesses'

Background: The drive for non-medical prescribing has progressed quickly since the late 1990s and involves a range of healthcare professionals including pharmacists. As part of a commissioned research project, this qualitative element of a larger case study focused on the views of patients of pharmacist prescribers. 

Objective: The aim of this study was to explore patients' perspectives of pharmacists as prescribers. 

Methods: Three pharmacists working as independent prescribers in the clinical areas of (i) hypertension, (ii) cardiovascular/diabetes management, (iii) anticoagulation were recruited to three case studies of pharmacist prescribing in Northern Ireland. One hundred and five patients were invited to participate in focus groups after they had been prescribed for by the pharmacist. Focus groups took place between November 2010 and March 2011 (ethical/governance approvals granted) were audio taped, transcribed verbatim, read independently by two authors and analysed using constant comparative analysis. 

Results: Thirty-four patients agreed to participate across seven focus groups. Analysis revealed the emergence of one overarching theme: team approach to patient care. A number of subthemes related to the role of the pharmacist, the role of the doctor and patient benefits. There was an overwhelming lack of awareness of pharmacist prescribing. Patients discussed the importance of a multidisciplinary approach to their care and recognized limitations of the current model of prescribing. 

Conclusion: Patients were positive about pharmacist prescribing and felt that a team approach to their care was the ideal model especially when treating those with more complex conditions. Despite positive attitudes, there was a general lack of awareness of this new mode of practice.

Public Private Partnerships: A Global Review

This book provides an international perspective on Public Private Partnerships. Through 21 case studies, it investigates the existing and fast developing body of principles and practices from a wide range of countries and is the first book to bring together leading international academics and practitioners under a common framework that enables convenient cross-country comparisons. The authors focus on the impact of the financial crisis has had on how governments have reviewed and overhauled their PPP policies as they have examined or tested new ways of partnering more effectively, efficiently and sustainably with the private sector.
Readers will be able to gauge the level of maturity of PPP development in the book’s case studies, understand similarities and differences in their practices, and gain useful insights into the regulatory framework and institutional infrastructure in place to support implementation of PPP. Finally, the book offers insights into the future challenges and opportunities that PPP offers stakeholders.

Standardizing the assessment of clinical competence: an overview of intensive care course design.

Rationale for the development of the Certificate in Health Studies: Intensive Care and High Dependency for Adults course developed at Queens University Belfast, Northern Ireland. Structure and content of clinical module reviewed. Clinical assessment strategy discussed. Focus on the utilization of a standardized portfolio, individualized learning contract and objective structured clinical examination (OSCE) to evaluate clinical competence. Evaluation of OSCE as an assessment tool and of the course provision.

Managing patient deterioration: evaluation of what works.

Background: Rapid Response Systems (RRS) have been implemented nationally and internationally to improve patient safety in hospital. However, to date the majority of the RRS research evidence has focused on measuring the effectiveness of the intervention on patient outcomes. To evaluate RRS it has been recommended that a multimodal approach is required to address the broad range of process and outcome measures required to determine the effectiveness of the RRS concept. Aim: The aim of this paper is to evaluate the official RRS programme theoretical assumptions regarding how the programme is meant to work against actual practice in order to determine what works. Methods: The research design was a multiple case study approach of four wards in two hospitals in Northern Ireland. It followed the principles of realist evaluation research which allowed empirical data to be gathered to test and refine RRS programme theory [1]. This approach used a variety of mixed methods to test the programme theories including individual and focus group interviews with a purposive sample of 75 nurses and doctors, observation of ward practices and documentary analysis. The findings from the case studies were analysed and compared within and across cases to identify what works for whom and in what circumstances. Results: The RRS programme theories were critically evaluated and compared with study findings to develop a mid-range theory to explain what works, for whom in what circumstances. The findings of what works suggests that clinical experience, established working relationships, flexible implementation of protocols, ongoing experiential learning, empowerment and pre-emptive management are key to the success of RRS implementation.  Conclusion:These findings highlight the combination of factors that can improve the implementation of RRS and in light of this evidence several recommendations are made to provide policymakers with guidance and direction for their success and sustainability.References: 1.Pawson R and Tilley N. (1997) Realistic Evaluation. Sage Publications; LondonType of submission: Concurrent session Source of funding: Sandra Ryan Fellowship funded by the School of Nursing & Midwifery, Queen’s University of Belfast

Sustainability indicators and local governance in Portugal

Esta tese tem como principal objectivo compreender o papel dos indicadores de sustentabilidade na governação local em Portugal, bem como perceber o seu potencial para transformar práticas institucionais correntes para o desenvolvimento sustentável. As duas últimas décadas têm testemunhado um crescente debate em torno dos indicadores de sustentabilidade e três abordagens específicas da literatura ganharam corpo: a ‘técnica’, a ‘participativa’ e a de ‘governação’. Esta tese pretende contribuir para a abordagem mais recente e menos explorada da ‘governação’, através do estudo da realidade local portuguesa. Considera crucial perceber como e em que circunstâncias e contextos o papel destes indicadores pode ser diminuído ou potenciado. Desta forma, pretende avaliar se e de que forma é que os indicadores de sustentabilidade têm contribuído para alterar e desafiar contextos de governação locais para o desenvolvimento sustentável no nosso país e se e de que forma estes indicadores têm sido usados. Foram seleccionados e analisados em detalhe sete casos-de-estudo na tentativa de compreender cada um e de construir uma grelha comparativa entre eles utilizando como suporte normativo um conjunto de critérios ‘ideais’ de boa governação. Assim, a tese identifica os principais obstáculos da construção destes indicadores em Portugal, bem como os seus principais contributos positivos e usos. Enquadra igualmente as suas conclusões no contexto de outras experiências locais Europeias e tenta formular algumas recomendações para reforçar o potencial contributo e a utilização destes indicadores. Através dos casos-de-estudo, foi possível verificar que a sua implementação não tem contribuído para fortalecer o diálogo entre os diferentes níveis de governo, para promover a participação de mais actores nas redes de governação, ou mesmo para melhorar mecanismos de participação e comunicação entre governos, cidadãos e actores locais. De qualquer forma, é importante acrescentar que as experiências mais bem sucedidas permitiram efectivamente mudar as capacidades dos governos locais na coordenação horizontal de políticas sectoriais, nomeadamente através de novas relações entre departamentos, novas rotinas de trabalho, novas culturas de recolha e tratamento de dados locais, novos estímulos de aprendizagem, entre muitas outras. O maior desafio coloca-se agora na transposição destes efeitos positivos para fora da esfera governamental. Esperamos que a tese possa contribuir para que decisores políticos, técnicos, académicos e comunidades locais encarem os indicadores de sustentabilidade como processos de aprendizagem que melhoram a capacidade das cidades enfrentarem os complexos desafios e as incertezas do desenvolvimento sustentável.

(Re)construir a prática pedagógica e criar oportunidades para pensar

Apresenta-se nesta tese um estudo de natureza qualitativa que inclui seis estudos de caso, a partir dos quais se desocultam as práticas pedagógicas de três salas de jardim de infância e de três salas do 1.º Ciclo do Ensino Básico. O quadro narrativo, interpretativo e de reflexão que elegemos, permitiu-nos identificar e discutir os processos de construção e gestão curricular e os estilos dos educadores e dos professores na promoção de oportunidades para a construção do pensamento crítico das crianças que frequentam a Educação Pré-escolar e o 1.º Ciclo do Ensino Básico.

Modelação da qualidade do ar e da saúde humana: da mesoescala à dose

O actual, e crescente, padrão de consumo tem repercussões no ambiente que, inevitavelmente, se reflectem na saúde humana. A poluição atmosférica assume-se, na Europa, como um problema ambiental premente, por ter um elevado impacte na saúde dos cidadãos. Entre estes, há grupos particularmente vulneráveis, como os idosos, os doentes crónicos e as crianças. Vários estudos colocam em evidência a sensibilidade dos doentes asmáticos, em particular das crianças, à poluição atmosférica. No entanto, permanece por esclarecer o facto de a poluição atmosférica poder causar o aumento da prevalência desta doença, assim como a identificação dos principais poluentes atmosféricos responsáveis e os níveis de exposição seguros. O objectivo desta tese consiste no estudo da relação entre a poluição atmosférica e a saúde, contribuindo para o conhecimento nesta temática através do desenvolvimento de uma ferramenta e da sua aplicação a um caso de estudo concreto. Neste caso de estudo analisou-se a relação entre vários poluentes atmosféricos e o agravamento da sintomatologia em crianças asmáticas. Neste âmbito, foi desenvolvido o modelo doseAr, que possibilita o cálculo da exposição e da dose inalada, ao nível individual, de poluentes atmosféricos. Os resultados da aplicação do doseAr permitem a identificação dos microambientes onde a contribuição para a exposição e dose inalada de poluentes é mais relevante. Os microambientes interiores, em particular aqueles onde é desenvolvida actividade física exigente, são identificados como especialmente importantes. A relação entre a exposição e a dose inalada é claramente associada ao agravamento da asma nestas crianças, apesar dos níveis de poluição identificados serem baixos, face aos padrões de qualidade do ar existentes.

Exposições museológicas: a moda por narrativas, experiências e conexões

Este estudo apresenta o universo patrimonial pela perspetiva da acessibilidade pública conferida por instituições museológicas. Consiste em exploração e análise das informações e experiências proporcionadas por museus no âmbito da cultura material indumentária e de moda. O foco desta abordagem são as exposições presenciais e os websites institucionais, com ênfase à acessibilidade aos catálogos de coleções. Pela perspectiva do designer como antropólogo neste estudo – com base em estudos de caso e outros dados coletados – são apresentadas ferramentas comparativas da realidade atual e propostas para a disseminação mais alargada, diversificada e especializada das informações cultura material e imaterial de moda. Duas hipóteses orientaram esta tese: - A noção de que as exposições de artefatos de traje podem ser inovadoras em relação às exposições de outros objetos, já que a roupa vincula-se a movimento, toque, corpo e usabilidade que induz experiências e conexões, sentimentos e identidades em uma relação de metamorfose. - A noção de que o potencial de ensino e difusão de uma cultura de design, com destaque aos contextos de Portugal e Brasil, é um campo relevante à visibilidade pública da indústria da moda nestes países e alavanca para um melhor posicionamento na competitividade global. Pelas propostas específicas e pelo contributo de fornecer informações inéditas a respeito do universo investigado, este estudo abre novas perspectivas para futuras investigações, principalmente nas áreas de museologia, museografia, história e teoria da moda e do design, design de exposição, design de produto, estudos da cultura material, comunicação e antropologia do design.

Childrens experiences of domestic violence and abuse: Siblings accounts of relational coping

This article explores how children see their relationships, particularly their sibling relationships, in families affected by domestic violence (DV) and how relationality emerges in their accounts as a resource to build an agentic sense of self. The ‘voice’ of children is largely absent from the DV literature, which typically portrays them as passive, damaged and relationally incompetent. Children’s own understandings of their relational worlds are often overlooked, and consequently, existing models of children’s social interactions give inadequate accounts of their meaning-making-in-context. Drawn from a larger study of children’s experiences of DV and abuse, this article uses two case studies of sibling relationships to explore young people’s use of relational resources, for coping with violence in the home. The article explores how relationality and coping intertwine in young people’s accounts and disrupts the taken-for-granted assumption that children’s ‘premature caring’ or ‘parentification’ is (only) pathological in children’s responses to DV. This has implications for understanding young people’s experiences in the present and supporting their capacity for relationship building in the future.

Adding value to performance measurement by using system dynamics and multicriteria analysis

Tese de dout., Filosofia, Department of Management Science, University of Strathclyde, 2004

Marketing social : estratégia de promoção da inclusão social e da educação intercultural

Relatório de estágio de mestrado, Ciências da Educação (Educação Intercultural), Universidade de Lisboa, Instituto de Educação, 2011