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Elderly Chinese residents in nursing homes in the United States experience cultural and language barriers, encounter Western health care practices, and have difficulty adjusting to a new environment. The purpose of this ethnographic study is to identify, describe, and analyze the factors: clinical, environmental, social, and cultural, that influence the care of elderly Chinese residents in nursing homes. Data were collected through participant observation and interviews on Chinese residents, their families, and nursing home staff at a 100-bed nursing home facility. The mission of this facility is to provide compassionate and quality care that recognizes the ethnic diversity of its residents. Kayser-Jones' Conceptual Model of Person-Environment Interaction was used to illustrate the effects that the interactions of multiple factors in the physical, organizational, personal-suprapersonal, and cultural and psychosocial environment have on elderly Chinese nursing home residents. It was found that the teamwork between the nursing home operator, Asian community, and the nursing home leadership team was important in helping this facility reach its goals in providing quality care. They have implemented and maintained an organizational structure with the goal of meeting the needs of the Chinese elders and the other residents in the facility (organizational environment). This affects the physical and cultural-psychosocial environment, as this team works together to provide a home-like environment sensitive to the needs of the Chinese residents (physical and cultural-psychosocial environment). Chinese elders seeking long-term care are thus drawn to this facility, one which supports an environment sensitive to the social, psychological, and cultural needs of this population (personal supra-personal environment). The outcome for the resident is that there is a good person-environment fit, resulting in high resident morale and self-esteem and thus, a high level of resident satisfaction. This research has shown that positive outcomes occur for Chinese elders in a nursing home providing culturally-specific care. These findings offer valuable information in helping to develop and implement interventions to improve the care of Chinese elders in nursing homes.

The purpose of this prospective, longitudinal repeated measures study was to explore the relationships between HIV-infected mothers' perceptions of uncertainty about infant HIV serostatus and maternal stress, distress, and social support during the infants' HIV viral testing. HIV-infected women were eligible to participate if they were at least 18 years old, English speaking, and were the primary caretaker for their infants. Six study visits were required: a visit during the third trimester of pregnancy and 5 postpartum visits clustered around infants' second and final HIV viral testing. Data collection included maternal and infant demographics, clinical variables, standardized questionnaires, and maternal responses to questions addressing their most worrisome concern. During the final study visit, maternal interviews about their infants' HIV testing were audiotaped and transcribed. Descriptive statistics, Pearson's r, and RMANOVA were used to analyze quantitative data; qualitative methods were used to analyze interviews. Twenty mothers enrolled: 40% African American, 40% white, 10% Hispanic, 10% Native American/Other; mean age = 32.25 years; mean education = 14.5 years. All infants in the study were determined to be HIV negative. Mothers were most concerned about infant health during the prenatal and early postpartum period. While infant concerns diminished after the second negative HIV test they rebounded prior to obtaining the final viral test. Family and psychosocial issues were the primary maternal concerns after infant viral testing was completed. Maternal health issues never surpassed infant or psychosocial issues as a primary concern. There was a significant decrease in maternal uncertainty about infant HIV serostatus over time (p

Evaluations of Physiologic and Behavioral Responses to Noxious Procedures in Sedated, Ventilated Critically Ill Adult PatientsDenise Tsai-Yun Liu Li, RN, MS, PhDAbstractAcute pain is caused by strong noxious stimulation and is associated with unpleasant sensory and emotional signs and symptoms. The significance of acute pain in critically ill patients in the Intensive Care Unit (ICU) is well documented, yet a standardized objective measure of nociception for use in nonverbal ICU patients remains elusive. The purpose of this dissertation was to evaluate clinically useful physiologic and behavioral indicators of nociception for use in deeply sedated, nonverbal ICU patients. The first study was a prospective description of mechanically ventilated ICU patients' perceptions of pain, dyspnea, thirst, nausea, hunger, tired/fatigue, anxiety, generalized discomfort, depressed feelings. Fifteen medical and surgical patients who were able to self-reported symptom intensity rated their symptoms by was assessed by using numeric rating scales (0=none, 10 worst possible intensity). The study found that over 33% of the patients experienced moderate to severe pain, thirst, tiredness, anxiety, hunger, and generalized discomfort. The study highlighted the need to develop an objective measure for pain and other symptoms since many ICU patients are not able to provide a self-report. The second study addressed this problem by examining physiologic and behavioral indicators of pain as proxy measures in patients unable to provide a self-report. We compared changes in heart rate (HR), blood pressure (BP), pupil size, and cortical arousal per the Bispectral (BIS) Index, and behaviors between a noxious procedure [endotracheal suctioning (ETS) or turning] and a non-noxious procedure (gentle touch) in 48 sedated, ventilated ICU patients. Repeated measures of the outcome variables were taken at baseline, during the procedure, and after the procedure. The study found that HR, systolic BP, pupil size, and the BIS Index increased significantly during the noxious condition but not during the non-noxious condition (p

Age Related Differences in Smoking Cessation OutcomesFor Women Hospitalized With Cardiovascular DiseaseDaniel M. Doolan RN, MSNABSTRACTBackground: Smoking is the number one preventable cause of death and disease. Smoking cessation has immediate health benefits, even among those who have smoked for many years. Despite the known risks of smoking and the benefits of cessation, the efficacy of smoking cessation interventions among older adults and women has received limited research attention. Objectives: To determine if there are age related clinical and demographic differences between older versus younger women with cardiovascular disease who smoke, and to determine if these two groups differ in their smoking cessation outcomes.Method: An existing data set from The Women's Initiative for Nonsmoking (WINS) is used for this study. The original WINS study was an RCT that tested the efficacy of a smoking cessation intervention for Bay Area women hospitalized with cardiovascular disease. The current study compares WINS participants who were 62 and older with those younger than 62. Results: The sample (n=277) contained 136 older smokers and 141 younger smokers. Older smokers were significantly more likely to be living alone, widowed, poorer, retired, have hypertension, and have multiple comorbidities. Older women were significantly less likely to be obese. Stanford Dependence Index scores showed older women had significantly lower levels of nicotine addiction. Older women were significantly less likely to have one or more housemates who smoke. At the 6 month follow-up, 52.1% of older smokers had quit smoking compared with 40.6% of younger smokers. At the 12 month follow-up, 52.0% of older smokers had quit smoking compared with 38.1% of younger smokers. The difference at 12 months was statistically significant. A Kaplan-Meier Survival Analysis found older women were significantly less likely to relapse over 12 months than younger women. Discussion: Older women with cardiovascular disease demonstrated extremely high rates of smoking cessation, higher even than younger women with cardiovascular disease. Further research is needed to determine how to optimize smoking cessation rates for older smokers. Clinicians should be sure to also include older smokers in smoking assessments and smoking cessation interventions.

This dissertation considers how certified nursing assistants (CNAs) construct the bodies of nursing home residents and how they assign meaning to work that is commonly viewed in one way or another as "dirty", tainted, or undesirable. CNAs invoked dignifying discourses to reinterpret meanings of their stigmatized work to mitigate the degrading implications of their labors. Together, body constructions and dignifying discourses shape the hands-on, intimate care aides provide to nursing home residents.Observations and interviews were conducted with 27 aides in three different types of nursing homes in California. Other data included a content review of texts such as job descriptions and observations of aide training classes. All participants were people of color and, except for three aides, were first generation immigrants. Most were women and reflected U.S. demographics of CNAs working in metropolitan areas. Nursing assistants constructed three distinct views of residents: resident as fictive kin, resident as commodity, and resident as autonomous person. Related dignifying discourses supported each construct and helped produce enactments of care giving. Caring practices were influenced by institutional forces such as commodifying the physical body while cultural understandings entered the rhetorics of duty and caring. The dominant discourses did not arise from training or other official sources but were generated by aides themselves in the course of their work. These findings extend the concept of "dirty work" to nursing assistants and contest some conventional views that aides accept stigmatized labels of their work.Implications for practice confirm other studies that recommend changes in the length and content of aide training. These findings also offer possible directions for nursing home policies to enhance worker retention and satisfaction. Areas for future research include taking up the central inquires across several contexts, such as in rural nursing homes and among licensed nurses and residents and their families. Additionally, the increasing globalization of healthcare workers would benefit from a closer look at the way immigrant workers experience and practice carework.

The Use of Transesophageal Echocardiography for the Assessment of Left Ventricular Volume and Function in Patients Undergoing Acute Normovolemic Hemodilution as a Human Hemorrhagic Model BACKGROUND: Since the development of the sphygmomanometer in 1896, the several methods to monitor volume resuscitation in hypovolemic trauma patients have been examined. Recently, transesophageal echocardiography (TEE) has been considered for this use. PURPOSE: This study examined the use of TEE for the assessment of left ventricular volume and function during graded blood removal in a human hemorrhagic model. DESIGN: Following IRB approval, 38 patients undergoing acute normovolemic hemodilution (ANH) intraoperatively were consented to have 15% of their total blood volume removed (according to ANH protocol) in 5% aliquots and stored in the operating room for re-infusion. After blood withdrawal, 5% aliquots of Hextend® was infused, equal the amount of blood removed. Left ventricular (LV) chamber dimensions and trans-mitral Doppler flow measurements were obtained with TEE at baseline and at each blood withdrawal and replacement of Hextend®. LV measurements analysis included: one-dimensional (1D) end-diastolic diameter (EDD), end-systolic diameter (ESD), and fractional shortening (FS); two-dimensional (2D) end-diastolic area (EDA), end-systolic area (ESA), and fractional area change (FAC); three-dimensional (3D) end-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF); trans-mitral Doppler flow measurements of E and A-wave morphology. RESULTS: Statistically significant differences were demonstrated for measurements of: 1D EDD (p < .0001) and ESD (p < .0001); 2D EDA (p < .0001) and ESA (p < .0001) during blood removal. No statistically significant differences were observed for FS (p = .371) or FAC (p = .369). Statistically significant differences were demonstrated for 3D measurements of EDV (p < .0001) and EF (p = .002) during both blood removal and replacement with Hextend®. No statistical significance was observed with ESV measurements (p = .427). Only the trans-mitral Doppler measurement of peak E-wave velocity demonstrated a statistically significant difference (p < .0001). CONCLUSION: Although all measurements of LV dimensions can detect 5% changes during blood removal, 3D measurements of EDV and EF can detect changes during both blood removal and replacement of Hextend®, possibly making it better at guiding volume replacement during blood loss. Trans-mitral Doppler flow may not be as effective as a guide for fluid management.

This dissertation research examines Residential Care Facilities for the Elderly (RCFEs), often referred to as Assisted Living (AL), by considering policy and regulation, state licensing and monitoring systems and concerns regarding quality of care. The first study examines the intended and unintended consequences of federal and state policy and regulation affecting the Residential Care/Assisted Living industry. An economic framework forms the basis for the examination of two broad effects of policy: the availability of assisted living facilities, and residents' ability to afford those services. The conceptual framework is described and progresses through a description of illustrative policy domains and intended and unintended consequences are discussed.The second study proposes an adaptation of the Donabedian structure-process-outcome theory as a framework for designing and more effectively using the administrative data collected in the licensing and regulation of Residential Care/Assisted Living facilities. Structural components are represented by facility, staff and resident characteristics. Process components include the types of services available and safety and injury prevention. Possible outcome measures include deficiencies and complaints, changes of resident health status and quality indicators, and discharge and medical event data. Emphasis is on measures available in administrative records. The last study was designed to evaluate the applicability of adapting the State of California administrative data regarding Residential Care Facilities for the Elderly (RCFEs) into a statewide system to monitor the quality of care provided. A randomly selected sample of 340 facilities was identified from the 3349 facilities licensed in Northern and Central California. Stratification of the sample was by facility capacity and State district office. Data collection consisted of a five-year retrospective review of the public files maintained across offices. A conceptual framework was developed to identify components thought to be indicative of quality of care. Such information was abstracted from the public files for data analyses. Collected data were analyzed using various descriptive statistics. Findings suggest that substantial limitations in current State data sources exist, as do concerns regarding quality of care. Suggestions are made to inform future researchers to further evaluate and improve the current monitoring system and develop a comprehensive, accessible information system.

Assertive communication has been identified as key to maintaining safe operations in inpatient perinatal care. Perinatal nurses are positioned to detect and deflect evolving threats to patient safety, but evidence suggests nurses do not always take assertive action in response to clinical problems, and may be ignored when they do raise concerns. In contrast, evidence also suggests a direct effect for nursing on patient safety, but little is known specifically about how nurses keep patients safe. The purpose of this study was to articulate the direct contributions perinatal nurses make to maintaining safe care, and to identify processes affecting nurses' and other clinicians' agency for safety, or willingness to take a stand on issues of concern. This grounded theory study was conducted in two urban academic perinatal units with a purposive sample of 12 registered nurses, 5 physicians, and 2 certified nurse-midwives, using semi-structured interviews and participant observation. Data were collected and analyzed in an iterative fashion using the constant comparative method, dimensional, and situational analysis.Nurses maintained safety during labor and birth through skillful anticipation of the potential embedded in given clinical situations. They integrated medical and technical knowledge and skill with intimate knowledge of the woman and the operational context of care. Conditions and processes promoting skillful anticipation included being prepared, knowing, and envisioning the whole picture. Lack of available resources, fatigue, and environmental distractions challenged skillful anticipation and patient safety.Agency for safety fluctuated for all types of providers depending on the specifics of the situation. Agency was strongly influenced by interpersonal relationships. While physicians and CNMs believed they valued nurses' contributions to care, the units had deeply embedded hierarchies. Nurses were structurally excluded from important sources of information exchange and from contributing to the plan of care. Pervasive, mutually reinforcing segregation of activities by discipline impeded information flow, challenging safety. Nurses' confidence in their assessments was a key driver for asserting their concerns. Confidence was undermined in novel or ambiguous situations and by poor relationships, resulting in a process of redefining the situation as a problem of self and potential lack of persistence regarding their concerns.

Background: Recent studies suggest that standard dose chemotherapy (CTX) may cross the blood-brain barrier. However, the evidence for CTX-induced cognitive impairments in breast cancer patients is inconsistent.Purposes: 1) to describe the literature about CTX-induced cognitive impairments in women with breast cancer; 2) to review the domains of cognitive function and their corresponding neuroanatomic structures as well as present current evidence for neurotoxicity associated with specific CTX agents and potential mechanisms for CTX-induced cognitive impairments; 3) to estimate the effect sizes for the effect of CTX on each domain of cognitive function; 4) to determine the sensitivity of neuropsychological tests which have been used to evaluate CTX-induced impairment in various domains of cognitive function in breast cancer patients; and 5) to assess changes in cognitive function over time in breast cancer patients receiving CTX, and evaluate potential relationships between cognitive function and anxiety, depression, fatigue, hemoglobin levels, menopausal status, and perceived cognitive function. Methods: We performed meta-analyses to measure effect sizes to determine CTX effect on various domains of cognitive function and to determine neurological test sensitivity. In the longitudinal study, we recruited a multicultural sample of thirty women with breast cancer for neuropsychological testing prior to the initiation and a week after completion of treatment with doxorubicin and cyclophosphamide CTX. Paired t-tests were used to evaluate changes in cognitive scores over time and linear mixed modeling was used to determine whether significant changes remained after controlling for anxiety, depression, fatigue, hemoglobin level, menopausal status, and perceived cognitive function.Findings: Only two domains of cognitive function (i.e., language, visual memory) had small albeit significant negative effect sizes in the meta-analysis of CTX-induced cognitive impairments in breast cancer patients. We evaluated thirty tests used to measure cognitive changes in breast cancer patients who received CTX, but found only six tests to be sensitive in detecting changes in four of eight domains of cognitive function (i.e., language, motor function, visuospatial skill, and verbal memory). In the longitudinal study significant decreases in cognitive function were found after CTX in visuospatial skill (p < .001) and total cognitive (p = .001) scores over time.

Purpose: The purpose of this research was to describe registered nurses not working at all and those working in non-nursing compared to those working in nursing. Factors associated with registered nurses not working or working in non-nursing employment were examined in terms of sociodemographic characteristics, market factors, and political factors.Background & Significance: Empirical and anecdotal literature have demonstrated an exodus of registered nurses from the nursing profession. This study has policy implications for addressing these workplace losses.Conceptual Framework: This research was guided by economic labor market theory.Research Design & Methods: Secondary data from the 2004 National Sample Survey of Registered Nurses with a sample of 35,635 nurses was used for the analysis. A two-stage least squares model was estimated using a predicted market wage for all nurses in the sample and univariate probit equations were used. Key Findings: Nurses who worked in non-nursing and those who did not work at all were different from nurses who work in non-nursing. The main reason nurses gave for working in non-nursing was dissatisfaction with the nursing workplace. Salary was not a significant predictor controlling for other factors. Male nurses and nurses over the age of 45 were more likely to work in non-nursing than female nurses and younger nurses. Nurses with young children in the home, those with at least a baccalaureate degree in nursing, and those who lived in politically liberal counties were more likely to be employed in nursing than nurses without children, those in politically conservative states, and those with lesser education. Working in non-nursing was contingent upon not participating in the nursing market. Implications for Health Policy: New policy remedies are needed to recruit new nurses to nursing and to retain those who are leaving the profession. Continued salary enhancements in the absence of real changes in the nursing workplace will not contribute significant long-term solutions to the current nursing shortage.

Characteristics of Workers with Painful Acute and Chronic Low Back Pain in an Urban Occupational Medical Center Background: In the workplace, low back problems account for nearly a third of both occupational complaints and workers' compensation (WC) claims. Most low back pain (LBP) resolves within weeks or months. A small percentage becomes chronic or recurrent. This small group accounts for the largest percentage of costs in both personal and economic terms. Due to methodological variations in the literature, no firm conclusions regarding the natural history of work-related LBP can be reached. Objectives: To describe acute LBP in workers after recent injury (< 2 weeks) and determine the proportion that persist 3 months or greater. A second objective is to examine the relationship of predictor variables-gender, age, and history of previous LBP- and the outcome variable-development of chronic occupational low back disability. Design: The descriptive correlational study incorporates secondary data and a mailed questionnaire. Methodology: A database query identified 270 workers with LBP-related medical diagnosis codes (ICD-9) at an occupational medical clinic. A mailed questionnaire assessed post-injury symptoms, work status, and job satisfaction. Measures administered were the Oswestry Low Back Disability Index, Roland-Morris Disability Questionnaire, SF-12, and the Stanford Presenteeism Scale. Results: There were 38 workers with acute LBP in the sample; 65.8% attributed LBP to recent overexertion on the job. Twenty-three (60.5%) developed CLBP and fifteen (39.5%) had acute LBP that resolved within 3 months (binomial test, P = .10 (Z = 10.04, p < .0005). Predictors associated with CLBP were pain level, SF-12 Physical, Oswestry, Roland-Morris, previous LBP, radiating LBP, and perception of supervisor review of workers' rights. Conclusions: A high proportion of workers with acute LBP developed CLBP (60.5%). Fifteen (39.5%) had acute LBP that resolved within 3 months (median 38.0 days; QD 19.0). These finding suggest that acute OLBP, even when evaluated and treated early after report of injury, persists in many injured workers. This knowledge could support future prospective study of acute OLBP and early disability risk factors that predict CLBP disability.

À l'instar de la majorité des pays à revenu élevé, le Canada dispose, depuis 1996, de régimes pharmacologiques pour traiter les personnes vivant avec le VIH/SIDA. Parmi les réactions néfastes de la thérapie antirétrovirale, le syndrome de la lipodystrophie est une condition débilitante qui afflige les personnes vivant avec le VIH/sida et ce, tant sur le plan physique que psychosocial. Conscient de l'ampleur de cette problèmatique qui, à ce jour, ne semble pas avoir été étudiée en contexte québécois, cette recherche qualitative décrit le processus de transformations corporelles auquel font face les femmes atteintes de lipodystrophie et explore les répercussions psychosociales de cette condition qui se manifeste progressivement au cours du traitement. Un devis de recherche qualitatif, de type descriptif et exploratoire, convenait tout à fait aux objectifs de cette recherche. Compte tenu de la problématique de recherche et des objectifs de recherche, la théorisation ancrée a été privilégiée pour orienter ce projet au plan methodologique. La collecte des données s'est deroulée sur une période de 3 mois et a été réalisée par le biais d'entrevues semi-dirigées avec 19 femmes vivant avec le VIH/SIDA. En résumé, les résultats de recherche indiquent que le processus de transformations corporelles engendre une profonde détresse chez les femmes vivant avec le VIH/SIDA. Les résultats de l'étude montrent, d'une part, la détresse (physique et mentale) engendrée par le corps lipodystophie et attestent, d'autre part, des relations de pouvoir avec le complexe médico-pharmaceutique. Au terme de cette recherche les résultats montrent que: le corps est un objet de pouvoir au coeur de ce complexe; que les tensions relatives au traitement amplifient la détresse des femmes vivant avec le VIH/SIDA; que la visibilité du corps entraîne la stigmatisation des femmes vivant avec le VIH/SIDA; et que la lipodystrophie n'est pas la transformation banale de caractéristiques physiques, mais plutôt la reconfiguration définitive de la personne en entier.

Background. A paradox exists between preferred place of end-of-life cars (home/hospice) and actual place of care (hospital). Patients often need help with decision making yet practitioners generally lack skills in providing quality decision support. Purpose. To evaluate an intervention designed to address barriers to providing decision support for place of end-of-life care. Objectives were to: (1) describe nurses' perceptions of factors that affect their provision of decision support; and (2) design and evaluate the efficacy of an educational intervention for strengthening the quality of practitioners' decision support. Design and methods. (1) Systematic review: Synthesis of primary research studies investigating factors influencing place-of-care. (2) Needs assessment: Semi-structured interviews with 22 nurses. (3) Randomized trial: Comparison of intervention and control groups on the quality of decision support provided to simulated patients considering place of care before and after training. Setting of the Needs Assessment and Randomized Trial. Ontario palliative and oncology practice settings. Results (1) Systematic Review: Of 735 papers identified, 39 papers (33 studies) met inclusion criteria. Factors related to the illness, the individual and the care and social environment influence place of end-of-life care for cancer patients. Commonly identified factors were patient preference, social supports and health care resources. Stated preference, care-giver presence and contact patterns with health care services influence place of end-of-life cancer care. (2) Needs assessment: Nurses held favourable attitudes towards providing decision support for place-of-care at end-of-life. Nurses considered decision support an important part of patient-centred care yet identified a lack of skills, confidence and tools as barriers. (3) Randomized control trial: The before-after changes in the quality of decision support were greater (p

Neonatal weight measurements are used as a key indicator of breastfeeding adequacy. The purpose of this study was to explore non-feeding factors that might be related to newborn weight loss. The relationship between the intravenous (IV) fluids women receive during parturition (the act of giving birth including time in labour or prior to a cesarean section) and their newborn's weight loss during the first 72 hours postpartum was the primary interest. Three hypotheses guided the thesis. Specifically, the hypotheses stated that in the first 72 hours postpartum, there is a positive association between: (a) the amount of IV fluid given to a woman during parturition and the amount of weight her infant loses; (b) the amount of IV fluid given to a woman during parturition and the amount her infant eliminates; and (c) the amount an infant eliminates and the infant's weight loss. In an effort to clarify patterns of weight loss, a systematic review was completed to determine reference weight loss, and the results are reported in this thesis. Additionally, the issue of who should consent for neonates in lactation and breastfeeding research studies was raised during the ethics review, and the results of an examination of the underpinning principles for such consent are presented in this thesis. A prospective observational cohort study was conducted to explore associations between maternal fluids during parturition, neonatal output, and newborn weight loss. During labour or before a cesarean section, maternal IV and oral fluids were recorded. Participants weighed their newborns every 12 hours for 72 hours, then weight was measured daily from Day 4 to Day 14. Parents weighed all output (i.e. diapers) in the first 72 hours. Results of the systematic review show that the 7% maximum allowable weight loss recommended in four clinical practice guidelines appears to be based on mean weight loss and does not account for standard deviation. Although we determined patterns of weight loss, causes of weight loss and implications for morbidity and mortality were not established. Completing the systematic review clarified assumptions about how birth weight is used as the baseline for calculating weight loss and how clinical decisions are based on the percentage of loss from birth weight. The three hypotheses were supported. At 60 hours postpartum (point of maximum weight loss), mean loss was 237.2 grams (SD 98; n = 96, range 70-467 grams) and the percentage lost was 6.57 (SD 2.51; n = 96, range 1.83-13.06%). There was a positive relationship between maternal IV fluids from admission to birth and neonatal weight loss in grams (r(83) = .199, p = .035). Mean neonatal output for the first 24 hours was 83.04 grams (SD 47.81; n = 107, range 0-314 grams). There was a positive relationship between maternal IV fluids given in the final 2 hours before birth and neonatal output at 24 hours (r(17) = .426, p = .044) which explained 18% of the variability in weight loss. On Day 1, there was a positive relationship between output and weight loss (r(96) = .341, P < .0001) which explained 12% of the variability in weight loss. When groups, based on maternal fluids, were compared (≤1200 mls [n = 21] versus> 1200 [n =53]), newborns lost 5.51% versus 6.93% (p = 0.03). A hierarchical regression analysis indicated gestational age and birth weight were additional predictors of weight loss. It appears neonates experience diuresis in the first 24 hours with a related weight loss. Overall, the results indicate that maternal IV fluids before birth are related to weight loss in the early postpartum period. It appears neonate's experience varying degrees of diuresis, and consequent weight loss, in the first 24 hours is a correction. Clinicians (e.g. nurses, lactation consultants, and physicians working with breastfeeding women) should reconsider using birth weight as baseline when assessing newborn weight loss. These findings support using weight measured at 24 hours postpartum as the baseline for assessing newborn weight loss.

As the link between a healthy workforce and better patient outcomes is becoming more evident, creating healthy and safe workplaces for health care providers is now a concern for many employers. While a safe work environment includes being exempt from aggression, workplace aggression continues to be identified as a serious problem by health care professionals. Notwithstanding the importance and obligation of addressing all types of workplace aggression and all groups of perpetrators, dealing with instances of intra/inter professional aggression is essential since this type of aggression is often insidious and can be more disturbing to the victim than any other type of aggression. While nurse managers were identified as playing a central role in the management of workplace aggression, it is not clear how they deal with instances of intra/inter professional aggression given their current work environment and working conditions. The purpose of this study is to broaden the understanding of how nurse managers respond to intra/inter professional workplace aggression. Based on a theoretical framework developed from the work of Girard, Foucault and Weber, this study focuses on aspects of the social/cultural work environment influencing nurse managers' responses to intra/inter professional aggression as well as strategies deployed by nurse managers to deal with such aggression. Using principles from critical nursing ethnography, the research was conducted in both a university affiliated psychiatric hospital and a community hospital located in a large metropolitan city in Ontario. Data collection included 23 semi-structured interviews, collection of mute evidence and observations. The major study findings are that 1) aggression management is a non linear process involving managing perceptions, emotions and the actual aggressive act, which are all influenced by omnipresent and insidious power relations; 2) aggression management is not solely the responsibility of managers but must involve several actors including the aggressive individual, peers, human resources department and unions; and 3) each individual needs to play an active role in aggression management and be held responsible and accountable for his/her actions.

Education for professional practice is a complex process. In recent years, increasing attention has focused on the importance of reflection as a significant component of preparation for practice. However, empirical evidence shedding light on the process of learning to reflect on practice is comparatively sparse. Practice-based attempts to systematically describe essential aspects of the process as it occurs in nursing students during early experiences with clients have been Virtually nonexistent. This exploratory study was undertaken to investigate reflection on practice by first year nursing students during early patient care experiences. Reflection, for purposes of the study, was considered a multi-step process consisting of three phases: awareness, critical analysis, and synthesis (emergence of changed perspectives). Constructivism, a theoretical position which focuses attention on the creation or construction of knowledge by the learner, provided the theoretical framework for the research. Particular attention was directed to describing aspects of the situation on which student reflections focused, how the reflection process changed over time, and ways of facilitating related learning. Twenty-five students enrolled in the first year of a college-based nursing program, located in the downtown core of a large metropolitan area, volunteered to participate in this research. Data were collected during clinical conferences, focus groups, and individual interviews as participants reflected on practice in the course of a ten week block of early experiences with adult clients in acute care settings. Reflection was found to be a frequently occurring, fundamentally important activity among this group of participants. Principal foci of reflections were care-giving activities at the bedside, and the process of learning a professional role. Basic changes were noted in two major aspects of the reflecting process: participant input, and patterns of interaction during group sessions. Factors which were found to facilitate or impede reflection exerted their influence either directly by impacting reflecting activities while conferences, focus groups, and interviews were in progress, or indirectly by effecting the quality and quantity of practice-related information brought by participants to these sessions. Findings underlined the potential significance of a number of factors in enhancing participant reflecting skills: growing ability to attend to, attach meaning to, interpret, and verbally describe essential aspects of patient care situations; ongoing opportunities to reflect and receive pertinent feedback; increased understanding of clinical expectations; and concurrent attendance at classes presenting relevant theoretical material. Questions about whether these factors are, in fact responsible for the changes noted, the extent of their relative importance, and the possible presence of other significant influences in these situations suggest fertile territory for further research.

Les questions du discours permettent d'explorer de nouveaux horizons en matière de recherche en sciences infirmières. S'y rattachent notamment les questions liées aux représentations sociales, à l'identité et au pouvoir, des concepts dont on commence à reconnaître les contributions essentielles dans la discipline et la profession infirmières. Le discours prend plusieurs formes et est doté d'instruments lui permettant d'être maintenu et transmis, voire imposé. La pratique infirmière rend possible de nombreux espaces discursifs ou se rencontrent et parfois s'opposent, une multitude de discours différents. Dans un contexte hybride de psychiatrie correctionnelle, ces discours peuvent notamment définir les multiples manières dont la relation entre le personnel infirmier et les patients prend forme, se concrétise et produit des effets. De tels discours créent des conditions d'existence pour certaines catégories sociales (construites) et déterminent les pratiques congruentes avec ces catégories. Les espaces discursifs existants dans un milieu de pratique infirmière tel qu'une unité de psychiatrie pénitentiaire (UPP) sont multiples et offrent autant de possibilités d'investigation. Dans le cadre de cette recherche, nous avons choisi d'explorer la manière dont le personnel infirmier d'une UPP, par le biais de pratiques discursives, construit l'identité des patients qu'il soigne, de même que les effets de telles constructions sur le soin. Afin d'explorer la question de la construction identitaire, nous avons recouru à une déconstruction de discours couplée à une ethnographic de type critique. La déconstruction de discours a porté sur un espace que nous qualifions d'"infirmier", à savoir les notes évolutives. La portion ethnographique de notre recherche a inclus des entrevues semi-directives avec des membres du personnel infirmier de même qu'une période d'observation directe de 14 semaines. Nous avons cible spécifiquement l'unité d'admission d'une UPP canadienne. Les sources de données ciblées constituent des espaces discursifs dans lesquels le personnel infirmier s'exprime au sujet de la clientèle soignée et manifeste des élements de rôles s'inscrivant dans un contexte de "double enfermement" de la population soignée. Notre analyse indique que les notes évolutives et les entrevues individuelles constituent des espaces discursifs dans lesquels le personnel infirmier construit de façons différentes l'identité des patients qu'il soigne. Les notes évolutives constituent une surface mettant en évidence un discours écrit (et permanent) alors que les entrevues permettent une forme orale de discours qui est beaucoup plus fluide et contextuelle. Chacune de ces formes étant soumise à des contraintes particulières, la construction de l'identité des patients soignés est différente. Les identités de patient identifiées sont les suivantes: patient ambivalent, patient comme risque, patient déviant, patient perturbe et patient discipline. À travers les représentations qui découlent de ces constructions identitaires, le personnel infirmier situe le soin de manière précise de même que l'exercice de ses fonctions soignantes. Les constructions du soin que nous avons identifiées à travers les notes évolutives et les entrevues sont le soin (in)visible, le soin sécuritaire, le soin localise et le soin socialisé. Par ailleurs, en examinant les notes évolutives à la lumière des principes (théoriques, éthiques, légaux) modulant la pratique infirmière, nous avons noté que les soins décrits s'accordaient peu avec ces derniers. Les catégories de patient et de soin sont l'oeuvre de divers discours. Nous avons identifié cinq types de discours à travers nos sources de données: discours de soins, discours pénitentiaire, discours biomédical psychiatrique, discours de professionnalisme et discours de résistance. Malgré la multitude d'espaces discursifs qui investissent un milieu de pratique tel que l'unité d'admission d'un centre de soins psychiatriques pénitentiaire, seules les notes évolutives laissent une trace permanente de la pratique infirmière, bien qu'elles ne soient pas representatives des soins prodigués.

Research shows that across a variety of settings, nurses demonstrate a lack of attention to the impact of illness or disability on sexual health. Individuals with disabilities often exhibit lower sexual knowledge, and are at a higher risk of being sexually abused. Unlike their 'able-bodied' peers, the sexual health of youth with disabilities may be overlooked, in part due to preconceived ideas about this population. Nurses enter into a therapeutic relationship with patients and families, and are in an ideal position to promote sexual health with patients and families. This project focused on sexual health care, provided by nurses, to adolescents with physical and/or developmental disabilities, with attention to the institutional and social discourses that shape these interactions. A critical ethnography was employed, supported by a theoretical framework based on the works of Foucault, Goffman, and Shouldered. Interviews were conducted with nurses and social workers. The study involved the collection of mute evidence and an observation of the institutional setting. Results show that nurses were supported and encouraged to address sexual health with youth and families, however they did so within a clinical milieu imbued with opposition - from structural issues, to the presence of larger social misconceptions such as beliefs of the asexuality of people with disabilities. The major findings of this project are that: (1) nurses occupy, and strive to maintain the role of caring agent in their relationships with patients and families; (2) that despite institutional support for the integration of sexual health care, remnants of the total institution remain which undermine the larger agenda to promote sexual health, and finally (3) in order to both maintain therapeutic relationships with patients and address sexual health care, sexual health is often medicalized. These findings point to the importance of continuing to modify the clinical milieu to support nurses in their endeavours to address sexual health. In addition, it raises an important need for further research to be conducted on the impact of repeated experiences in health care on perceptions of sexuality held by youth with disabilities.

Purpose. To describe women's postpartum experiences with mother-baby togetherness in hospital, and the concordance of their experiences with the recommendations from Health Canada (2000a) on family-centred maternity and newborn care (FCMNC). Design. Descriptive study based on secondary analysis of a telephone survey conducted at one week and six weeks postnatally. Five elements reported by women were examined: the timing of first physical contact, physical proximity during the first few hours, transfer together to postnatal unit, rooming-in, and combined mother-baby care. Setting. Four maternity units in Ottawa (Ontario, Canada) including two level I units, one level II and one level III unit. A proportionate sample was drawn from each unit. The overall response rate to both interviews was 88.3%. Participants. Women (N = 552) who returned home with their babies within the first postnatal week, between October 2000 and March 2001. Findings. While in hospital, 95.8% of mothers and babies were separated. Combined care was reported by 84.7% of women and rooming-in by only 33.9% of women. Only 8.8% of women experienced all five FCMNC recommended practices. Practices varied between the units (p < .001). Women who had a caesarean birth were more likely to be separated from their infants than those who had a vaginal birth. Routine procedures performed in the nursery was the most frequently reported reason (55.8%) for the first separation of mothers and babies. Conclusion. Few women reported receiving care based on the FCMNC recommendations about mother-baby togetherness. Hospital practices varied considerably. It is recommended that healthy newborns receive care at their mothers' bedside. Further research is recommended to study the relationship between unit policy, actual practices, nurses' beliefs and women's preferences about the elements of mother-baby togetherness.

Les infirmières qui travaillent avec des personnes atteintes de problématiques sexuelles, et plus particulièrement d'une ITS, sont souvent affligées d'un sentiment de malaise, manifestent de la désapprobation morale ou tout simplement démontrent un manque de sensibilité envers la situation de leurs clients, ce qui décourage plusieurs de ces derniers dans leur quête d'aide ou d'information (Kinghorn, 2001). La gêne, la honte, la peur du discours moralisateur ou le manque de discrétion de la part du professionnel infirmier expliquent souvent l'hésitation des personnes atteintes d'une ITS à consulter les services de soins appropriés (Germain et Langis, 1990; Holmes et O'Byrne, 2006). Bref, les infirmières jouent un rôle important dans la santé sexuelle de la personne et doivent être en mesure de prodiguer des soins adéquats et exempts de jugements moralisateurs. L'objectif de cette recherche est d'étudier le processus interactionnel, soit la nature de l'interaction, entre l'infirmière et la cliente consultant des services de santé sexuelle pour des tests de dépistage (ITS), et ce, lors de la rencontre initiale, c'est-à-dire à l'étape de la collecte de données. Plus précisement, la présente recherche cherche à comprendre comment les infirmières, exerçant en clinique de santé sexuelle, construisent l'identité de jeunes filles adolescentes qui consultent pour des tests de dépistage d'infections transmises sexuellement. Compte tenu de l'état des connaissances actuelles et de la question de recherche, la théorisation ancrée a été privilégiée pour orienter notre recherche au plan méthodologique alors que les travaux de Goffman (1998) ont été consultés pour assurer la sensibilité théorique de la chercheure. Les résultats de la présente étude, obtenus par l'entremise d'entrevues semi-structurées, sont très intéressants. La plupart des informants croient que le questionnaire est inapproprié pour amasser des données sur la santé sexuelle des clients et, tout particulièrement des clientes adolescentes, car les questions posées sont personnelles, intimes, privées et invasives, pour d'autres informants le questionnaire est complètement inutile; le questionnaire entrave le dialogue entre le client et l'infirmière; le questionnaire entrave l'établissement et le développement d'une relation thérapeutique entre le client et l'infirmière; le questionnaire décourage les clients à consulter des services de santé sexuelle offerts. De même, les informants attestent que les questions posées lors de la collecte des données suscitent des sentiments négatifs chez le client, sauf que la plupart d'entre eux reconnaissent également l'infirmière comme étant un outil de stigmatisation.

Incisional, chest and sternal pain is prevalent in patients after cardiac surgery. If pain is not properly managed it may prevent patients from performing activities such as deep breathing and coughing (DB & C) which are important for preventing postoperative respiratory complications. There is a scarcity of research about the nonpharmacologic modalities for treating post cardiac incisional and sternal pain. Of these modalities, cold therapy is a strategy that has been used effectively over many decades in a number of areas including orthopedic surgery. The beneficial effects of cold therapy for pain management have been widely documented and the side effects are minimal, yet its use is limited in post-surgical cardiac patients. Nurses can have an active role in relieving patients' surgical pain with cold therapy. Presently, there are no studies in the literature that specifically address cold therapy for sternotomy pain management following coronary artery bypass graft (CABG) surgery. The objectives of this study were: (1) to evaluate the effects of cold therapy on pain associated with DB & C post cardiac surgery; (2) to identify sensations from the patients' perspective when cold in the form of a gel pack is applied to the median sternotomy chest incision before DB & C; (3) to identify patients' preferences for gel or no gel pack application. A crossover research design was utilized and each patient served as their own control. Participants underwent four sessions of DB & C every two hours on postoperative day two. Two sessions were preceded by cold application and two sessions were without cold application. At the end of the four sessions of DB & C, patients were asked about their preferences for gel or no gel pack application. Pain scores associated with DB & C were significantly decreased with the application of cold therapy (F=28.69, p

Bien que le mouvement en soins palliatifs pédiatriques ait pris de l'ampleur en Amérique du Nord, il demeure que l'expérience vécue par les infirmières suivant le décès d'un enfant semble très peu explorée. Une approche phénoménologique a été utilisée dans le but de décrire l'expérience de deuil telle que vécue par des infirmières suivant le décès d'un enfant. Les données ont été recueillies au cours d'entrevues semi-structurées effectuées auprès de six infirmières autorisées travaillant dans un établissement de soins palliatifs pédiatriques. Les enregistrements ont été transcrits verbatim et analysés suivant la méthode de Colaizzi (1978). Trois thèmes majeurs ont émergé soit le rôle de l'infirmière durant l'accompagnement, la réflexion envers son deuil et la reconnaissance de son deuil. Les résultats démontrent que les infirmières comprennent clairement leur rôle et accordent beaucoup d'importance et d'attention aux besoins de la famille et de l'enfant. Elles ont décrit leur deuil comme étant unique et personnel et qui doit être reconnu afin qu'elles puissent le surmonter. Elles soulignent aussi l'importance de s'occuper de soi-même et de s'offrir un soutien entre collègues afin de continuer leur travail en soins palliatifs. Les résultats de cette étude apportent une contribution majeure sur l'expérience de deuil telle que vécue par des infirmières en soins palliatifs pédiatriques et peuvent servir de guide dans la prestation des soins à cette population.

The intent of this thesis was to increase understanding of the nurse's presence in clinical nursing practice within the critical care setting. Nurse presence is employed to achieve an enhanced connection with patients and has been described as both being there for and being with the other. Highly technological intensive care environments have the potential to objectify patients and present unique challenges to nursing professionals attempting to integrate this aesthetic art into their care. Purpose. The purpose of this study was to examine how critical care nurses practice and develop nurse presence with their patients. Method. Grounded theory method was used. Data were obtained from semi-structured interviews with nine expert critical care nurse participants. Results. Presence as a practice emerged as a three phased process---commitment, presencing strategies and connection. The development of nurse presence as an evolutionary process was gradual, iterative and cumulative and was subject to two major influences---transitional influences and professional influences. Each patient experience with presence contributed to knowing the uniqueness of the individual as a whole person as well as to knowing a richer and deeper understanding of presence as a nursing practice. This integration of the practice and developmental components of this nursing phenomenon is described by the basic social process 'knowing the whole'. Conclusions. Presencing emerged as a powerful and humanizing, aesthetic element of nursing the critically ill. Unlike previous studies on this concept, the grounded theory method revealed three stages of practicing presence and demonstrated that it is learned.

Oncology nurses are present in varying degrees in the lives of cancer patients and their families as they journey through the cancer trajectory. When the patient dies, it is common practice for the therapeutic relationship between the nurse and the family to end, leaving the bereaved individual without this relationship during the difficult bereavement period. Although bereavement has been acknowledged as a period of increased morbidity and overuse of health care system resources, nurse-led bereavement support programs are not commonplace in tertiary care settings. Currently, very little is known of the experience of oncology nurses who provide bereavement support, and scant research exists regarding the needs of nurses who take on bereavement support in addition to their main nursing role. This lack of knowledge and understanding of the role and experience of oncology nurses who provide bereavement support can impact on services provided to bereaved individuals.

Purpose/problem. Telephone nursing care (TNC) has replaced some home visits to increase efficiency of The Ottawa Hospital Antenatal Home Care Program (AHCP). There is limited published research addressing TNC in similar settings to guide program development. Therefore, chose an evaluation strategy to explore the clients' the researchers and organization perceptions of TNC. Objectives. (1) Perform a systematic literature review of TNC in the high risk antenatal population. (2) Profile high risk antenatal population receiving telephone nursing care. (3) Describe clients' perceptions of telephone nursing care. (4) Explore the feasibility of this methodology for continuous program evaluation and informing development and improvement. Method. A mixed methods approach was used. Two surveys and a semi-structured interview were completed by 13 participants. Data were analyzed using descriptive statistics and constant comparative analysis. Results. Sample was similar to the population in diagnosis, maternal and fetal outcomes. Anxiety scores were high and women identified the highest needs related to high risk pregnancy, psychological and information domains. Four main themes emerged: the experience of being at home, perceptions of the telephone care, perceived benefits, and perceived health systems issues.

Context. Ovarian cancer is the 5th leading cause of cancer death among women in Canada (National Cancer Institute of Canada, 2005). It is estimated that 2,400 women were diagnosed in Canada in 2005. Unfortunately mortality for ovarian cancer is high; in 2005 approximately 1,550 Canadian women died of the disease (National Cancer Institute of Canada, 2005). Despite response rates to primary treatment of between 70 and 80%, 70% of cancers will recur within 24 months (McGuire, 2002). Due to an increasing number of chemotherapy options available for recurrent ovarian cancer, its management has shifted from a palliative approach to that of a chronic disease approach (Fitch & Turner, 2003b). Randomized controlled trials have failed to demonstrate clear evidence that any one treatment provides superior long-term survival, response rates, or better quality of life (Fung Kee Fung, Elit, Hirte, Rosen, & Members of the Gynecologic Oncology Disease Site Group, 2003). It has been suggested that, in the absence of such evidence, treatment decisions should be based on patient preference (O'Connor et al., 2004). Objectives. The purpose of this pilot study was to describe the decision making needs of women considering treatments for recurrent ovarian cancer. Design. A retrospective, cross-sectional needs assessment was conducted to describe the treatment decision making needs of women with recurrent ovarian cancer. Data were collected from women using face-to-face interviews. A semi-structured interview guide was developed based on the Ottawa Decision Support Framework and a standard template developed by Jacobsen and O'Connor (1998). The data were analyzed using Silverman's (2001) approach to content analysis. Setting. The Regional Gynecologic-Oncology Program of the participating center. Participants. Thirteen women with recurrent ovarian cancer who had made treatment decisions within the past 3 months were recruited from the outpatient day care unit. Outcome measures. Participants' views of their needs when considering treatment decisions for recurrent ovarian cancer. The interview guide elicited: perceptions of the decision including decisional conflict; perceptions of others involved in the decision; resources to make the decision; and individual characteristics. The Control Preference Scale was used to measure role preference (Degner & Sloan, 1992). Additional questions were asked about the extent to which hope influenced decisions. Results. Only five of 13 women perceived that they had options, only two of 13 had manifestations of decisional conflict. All women understood the poor prognosis associated with ovarian cancer. Seven of 13 women had played a passive role in the treatment decision. When considering future decisions, 9 of 13 women stated that they would prefer a shared or autonomous role. Moreover, 7 of 13 women wanted to be presented with options. Participants valued the role of nurses in providing information. In addition, the women identified hope as an important element in their lives. Conclusions. This pilot study provides preliminary information on women's decision making needs related to treatment for recurrent ovarian cancer. The findings need to be replicated in a study with a larger sample and in multiple centers before recommendations can be made. The findings also provide some direction for the design of a multidisciplinary decision making approach. Such an intervention would fit well in Cancer Care Ontario's strategy to improve the flow of care by developing care pathways.

A mixed method study was conducted to gain an understanding of the role of the eating disorders (ED) nurse and to explore the nurse-patient therapeutic alliance in this context. Thirty-five nurses from six ED treatment centres in Canada and America participated. The qualitative component involved manifest and latent content analyses of semi-structured interviews. From this, nine nursing roles were identified in addition to the skills, challenges and rewards of ED nursing. Three themes emerged in relation to the therapeutic alliance: creating a therapeutic environment, establishing a connection, and empowering patients. The quantitative component consisted of an established measure of therapeutic alliance in questionnaire form. Results from the survey supported the qualitative findings in identifying differences between Canadian and American nurses.

Health science students are faced with a reduction in acute care clinical placement opportunities, which are considered essential for developing clinical competence. Education methods using high-fidelity human patient simulation (HPS) may provide a way to ensure students are meeting minimal levels of competence. Using a quasi-experimental design pilot study, clinical competence among 19, third year baccalaureate nursing students was investigated. The experimental group (n = 10) received four days of HPS as part of their clinical practicum, while the control group (n = 9) participated in their regular clinical practicum. Clinical competence was measured using final grades from a medical-surgical theory course and an Objective Structured Clinical Examination (OSCE). There was no significant difference in clinical competence between the groups, as was evidenced by their final theory grades; t (17) = 1.090, p = .291 and OSCE scores (M = 60 for both groups). The results from this pilot study can guide future research using HPS in health care education. A randomized controlled study with a larger sample needs to be completed to provide more insight into the outcomes of HPS in health care curricula.

Background. Several theoretical models now suggest the need to promote an organizational approach to practice change for nursing. Objectives. To examine organizational factors that influence revisions and modifications to policies and procedures in health care agencies that participated in a pilot implementation and evaluation of six clinical practice guidelines developed by the Registered Nurses Association of Ontario. To describe the nature and extent of changes to policies and procedures from the perspective of nursing administrators, clinical resource nurses and nursing staff. Conclusion. Organizational support in the form of perceived support by top management, sufficient time and training to learn how to use the clinical guideline, adequate number of qualified staff and sufficient equipment and supplies to implement the clinical guideline is important and can influence nurses' awareness of evidence-based modification of policies and procedures. Further research is needed to compare nurses' actual practice with current policies and procedures. In addition, research is needed to determine whether organizations that modified or internalized their policies and procedures sustained the implementation of the clinical guidelines recommendations better over time. (Abstract shortened by UMI.)

Cette étude a pour but de décrire les perceptions et la pratique avouée des infirmières en regard des éléments clés de la philosophie de soins centres sur Ia famille (SCF) ainsi que d'identifier certaines variables personnelles ou professionnelles qui ont une influence sur ceux-ci, dans une unité de sains intensifs néonataux (USIN) de niveau III. Il s'agit d'un devis de recherche de type descriptif ayant un échantillon de convenance de 50 infirmières travaillant dans l'USIN au Centre Hospitalier pour Enfants de l'Est de l'Ontario (CHEO). Le questionnaire FCCQ-R développe par Bruce en 1995 a été modifié et a servi à identifier les perceptions, Ia pratique avouée et les variables personnelles et professionnelles des infirmières. Les résultats démontrent des perceptions positives des infirmières envers les éléments clés des SCF mais également une différence significative entre leurs perceptions et leur pratique avouée. La situation familiale semble influencer les perceptions des infirmières des SCF mais non leur pratique avouée. (Abstract shortened by UMI.)

Canadian nurses volunteered for military service in overwhelming numbers during the Second World War (1939--1945), comprising a second generation of military nurses known by rank and title as Nursing Sisters. Prevailing discourses portray them as 'extraordinary women,' patriots, heroines, feminists, and technological change agents. A small, diffuse body of literature documents their enlistments and postings but we know relatively little regarding how multiple identities and variables intersected to shape their experiences. This research examines Canadian military nurses' work from a feminist perspective through the lens of medical technology and discourse analysis, analyzing how variables such as gender, class, race, ethnicity, nation, marital status, and age intersected to shape their experiences during the Second World War. Based on oral histories, military records, professional literature, and archival sources, I ask: Who enlisted as Nursing Sisters? How did the military transform them into military nurses? What influenced decisions concerning where and how they served? In what technological and military contexts did they practice? How did these contexts shape the nursing care of soldiers? What influenced the transfer of technology to nurses? How did these experiences shape wartime and postwar civilian nursing practice? How did shared experiences as military nurses and as soldiers influence postwar identity as Nursing Sisters? War enabled the transformation of at least 4381 civilian nurses into Canadian Nursing Sisters who served 'for the duration.' They were posted to England, Northwest Europe, the Mediterranean, Hong Kong, and military hospitals across Canada, in Newfoundland, the United States, and South Africa. They worked in military general and specialty hospitals, hospital ships and trains, prisoner of war and internment camps, casualty clearing stations, field dressing stations, and field surgical units. Medical technology legitimated their presence within a complex military-medical-technological system while gender shaped their presence there as professional nurses, professional soldiers, and quintessential women. I argue that medical technology, gender, and war situated the Nursing Sisters as an expandable and expendable feminine workforce for the military, legitimated their presence at the frontlines of both war and medical technology, and facilitated the formation of a symbolic community and a social memory as military nurses.

Heart failure (HF) affects 350,000 Canadians, and is the third most common primary diagnosis for a hospitalization in Canada. People with HF experience periods of stability interspersed with exacerbations requiring hospitalization. During the fiscal year 2000-01, 85,679 patients were admitted to hospitals in Canada accruing a cost of over $1 billion per year for inpatient hospital services alone. These statistics indicate that in addition to the considerable influence on the lives of many Canadians, the burden of the problem is significant on the current and future health care system. This thesis examines factors that influence HF self-management as well as the profile characteristics of community dwelling individuals. The results of a systematic review and findings of a study that combines a mixed method approach including a quantitative secondary analysis, and a set of qualitative telephone interviews are presented. The qualitative data focuses on one factor, perception of social support, and how it relates to HF self-management. Finally, an integration of the information is presented. (Abstract shortened by UMI.)

The aim of this study was to describe, and to further understand the lived experience of intensive care nurses, who care for patients for whom life sustaining treatment is being withdrawn. It is known that a large percentage of patient deaths that occur in the Intensive Care Unit (ICU) follow the withdrawal of life sustaining treatment. Nurses are the primary care givers of patients in the ICU and are directly involved in end-of-life care and the initiation of withdrawal of life sustaining treatment. Interpretive phenomenology served as the methodology by which the researcher explored and interpreted the lived experience of these ICU nurses. Unstructured face-to-face interviews were conducted with six intensive care nurses employed in the ICU of a large tertiary care hospital. The interviews were transcribed verbatim and analyzed using approaches outlined by Colaizzi (1978) and van Manen (1990). The essence of this experience was described by intensive care nurses as "trying to do the right thing". Three major themes emerged from the data: A Journey -- Creating Comfort Along the Way; Working in Professional Angst and Providing Memories. The findings have given a voice to intensive care nurses in their role of providing care to patients and families during this experience.

Within the profession of nursing, reflective journal writing is enthusiastically endorsed as an essential pedagogical strategy for producing reflective practitioners. Despite a lack of empirical evidence to substantiate the claims associated with reflective journaling, the prevailing belief in contemporary nursing education reflects an assumption that this practice is essential in the production of critically engaged nurses. This has resulted in a totalizing discourse that presents the adoption of reflective journaling within nursing curricula as unproblematic. This study combines the methodological principles of grounded theory, along with a poststructuralist approach, to explore the experience of reflective journaling from the perspective of university nursing students. Application of a Foucauldian analysis demonstrates how assumptions related to the utility of reflective journal writing are embedded within a variety of powerful discourses that shape how we think and speak about this practice. Of particular relevance is Foucault's exploration of the impact of surveillance, observation and disciplinary power. Reflective journaling is identified as a ritual of confession that produces self-regulating and compliant students. This study reveals that journal writing is largely viewed as a prescribed activity and assumptions are made by nurse educators regarding the ability of journals to facilitate critical reflection. The discourses that emerged from this analysis reflect different aspects of the socialization process that ultimately results in the construction of an "authentic" nurse. In closing, students and nurse educators are encouraged to develop alternative discourses that challenge the uncritical acceptance of reflective journal writing within contemporary nursing education.

Objectives. (1) Identify the decisional needs of cystic fibrosis patients considering referral for bilateral lung transplantation and develop a decision aid to meet these needs. (2) Evaluate decision aid in a prospective trial. Conceptual framework. Ottawa Decision Support Framework Setting. Canadian and Australian Cystic Fibrosis clinics Methods. Phase 1. Comprehensive literature review, Canadian transplant statistics review and a survey identified the decisional needs and a decision aid was developed. Phase 2. The decision aid was evaluated in a randomized trial involving 149 patients. Results. Phase 1. A wide variation in transplant referral patterns was uncovered; patients not residing in transplant centers were significantly less likely to undergo lung transplants (P< 0.0001). Phase 2. Patients randomized to the decision aid had greater knowledge (P

This thesis explores traditional Aboriginal healing practices as they relate to health issues by asking the research question "How do urban-based First Nations peoples use healing traditions to address their health issues?" The purpose of this thesis was to explore the healing traditions of urban-based First Nations peoples. The objectives were to describe the use of Aboriginal healing traditions, discuss how these traditions addressed health issues, and explore the link between such traditions and holism in nursing practice. Critical ethnography was the qualitative research method used for this thesis. Data collection consisted of eight individual interviews, participant observations over a period of four months, and field notes. The three major categories that emerged from the data analysis were (a) the following of a cultural path, (b) the gaining of balance, and (c) the circle of life. The theme of healing holistically emerged. Healing holistically includes following a cultural path by regaining culture through the use of healing traditions; gaining balance in the four realms of the spiritual, emotional, mental, and physical self, and sharing culture between Aboriginal peoples and non-Aboriginal health professionals, as part of the circle of life. Implications for practice include incorporating the concepts of balance, a holistic outlook, and healing and culture into the health care of diverse First Nations groups. Healing holistically is an ongoing process that continues throughout the lifespan. This process can contribute to empowerment for Aboriginal peoples through an enhanced state of health reached by using traditional healing and understood through a critical ethnography approach.

Objective: To examine relationships between three modifiable work factors (autonomy, control-over-practice, workload) and Canadian public health nurses' job satisfaction. Design: Secondary analysis of a cross-sectional survey. Setting: All Canadian provinces and territories. Participants: Canadian registered nurses working in public health (n =271). Methods: Analysis of select data from the 2 005 National Survey of the Work and Health of Nurses (NSWHN). Bivariate analyses were used to examine demographic data, multivariate logistic regression analyses to examine relationships between the selected variables, and Chi-square tests to determine regional variations in job satisfaction across Canada. The relevance of findings was discussed with practicing public health nurses (PHNs), policy makers, and researchers at an end-of-study Knowledge Translation (KT) 'Think-Tank'. Results: The interaction between autonomy and workload was a significant predictor of PHNs' job satisfaction, (OR: 0.97, 95% CI: 0.96,0.99, p < 0.01) as was the interaction between age and workload (OR: 1.01,95% CI: 1.00, 1.01, p < 0.01). No statistically significant differences were found in PHNs' job satisfaction between regions. Think-Tank participants were interested in learning about results, selected priority areas for application to public health practice and management, and identified future directions for research. Conclusions: With the significant workload findings and generational differences, development of workload measurement tools and public health human resource strategies tailored to a multi-generational workforce are recommended. National enumeration strategies to identify the number of practicing PHNs are also recommended to inform public health practice and policy as are future KT activities to facilitate research dissemination.

From the time of admission through rehabilitation, trauma nurses are faced with the challenges of caring for the survivors of traumatic injuries (Neff & Stinson-Kidd, 1993). Trauma unit nurses are responsible for detailed assessments, documentation of all events, management of crisis situations and providing continued emotional support of patients and family members. Research shows that care of the trauma patient places great cognitive, emotional and physical demands on the trauma nurse. However, the literature review indicated that limited work had been done which captured the perspectives of trauma nurses and no studies could be found which explored the meaning of being a trauma nurse. Therefore, a qualitative study using interpretive phenomenology was undertaken to describe the lived experience of being a trauma nurse. Four themes were revealed in the data analysis: "Being on guard all of the time," "Being caught up short," "Facing the challenge," and "Sharing the journey." The seven participants agreed that the essence of being a trauma nurse was captured in the metaphorical statement: "Seeing through cloudy situations." Despite the many challenges participants faced on a daily basis, they were able to see through the cloudy situations and find meaning and satisfaction in being trauma nurses. The negative aspects about being a trauma nurse were offset by the positive moments. (Abstract shortened by UMI.)

The purpose of this thesis was to explore the effects of chronic neuropathic pain (CNP) and the process of acceptance of pain as it relates to adjustment to CNP in spinal cord injured (SCI) persons. The participants in two qualitative studies were community-living SCI persons who have CNP. They were currently or had previously received treatment at the out-patient clinic of a regional rehabilitation center. The first study involved a constant comparative analysis of narrative data obtained during three focus groups with 24 SCI persons. The second study involved a grounded theory approach to develop a conceptual framework that describes the process of 'acceptance' of CNP in SCI persons. The data was obtained during in-depth interviews with seven SCI persons with CNP. In Study 1, four interrelated themes emerged that illustrate the multidimensional impact of CNP in SCI. These themes include 'nature of pain', 'coping', 'medication failure', and 'pain impact'. In Study 2, the basic social process to describe acceptance of pain was 'moving forward with pain'. (Abstract shortened by UMI.)

Canada's aging population and increasing incidence of cancer, in both older and younger adults (Canadian Cancer Society, 2007), has resulted in palliative care becoming a growing concern for Canadians. Family caregivers are expected to provide care to ill family members at home with limited training, support or community resources. While research has recognized numerous challenges of providing care at home along with the consequences on the caregiver, a thorough literature review showed little research has been published about the caregiver's transitional experience of admitting a family member from home to the palliative care unit (PCU). Thus, a Heideggerian phenomenology qualitative approach was used in this study to explore the question: What are the family caregivers' transitional experiences of admitting family members from home to the PCU? Ten participants completed in-depth interviews and Colaizzi's (1978) approach guided the study's analysis. The findings produced a framework entitled: Transitional Experiences of Family Caregivers: A Puzzle of Care Provision. It contained eight themes of "In the beginning - Searching for answers", "Managing at home - Juggling act", "Trying to get through it", "A shifting situation - Triggers leading to PCU admission", "The transition - Making the decision to go to PCU", "Getting near the end - PCU", "Looking back on care", and "Getting ready to move on". Follow up interviews verified that the themes and framework accurately described participants' experiences. This study is the first to thoroughly illustrate the family caregiver's transitional experience of caring for a family member from home to the PCU. It is hoped that this study raises greater awareness and understanding of the family caregivers' transitional experiences.

The purpose of this thesis is to describe the experiences of individuals who continue to smoke following a myocardial infarction. This manuscript-based thesis consists of three distinct papers to be submitted to nursing journals for publication. The first manuscript provides a critique of the research literature pertaining to predictors and perceptions of continued smoking for individuals with coronary artery disease. The second manuscript reports the findings of a qualitative study that was conducted to describe the meaning of smoking within the context of a myocardial infarction, and to determine factors that influence continued smoking. The third manuscript explores ethical implications that emerged from the first two manuscripts. This thesis illustrates how addictive behaviours often have underlying meanings, how continued smoking becomes more understandable when viewed in the context of people's lives, and how possibilities for change can be derived from the ways that clients view their heart disease and smoking.

Introduction. In the last two to three decades, research findings have gradually been permeating the culture of nursing. Increasingly, nurses are expected to integrate evidence-based practices into specific nursing policy/protocols and patient care decisions (Polit and Beck, 2004; Rogers, 2004). In truth, research utilization is dependent on nurses' actual direct or indirect use of evidence in the clinical setting (Estabrooks, 1999). To date, researchers have been able to conclude that the more positive a nurse's attitude the more likely the nurse will use research findings (Ehrenfeld & Eckering, 1991; Camiah, 1997; Estabrooks, 1999; Olade, 20203, 2004). The nursing literature reveals a dearth of studies examining nurses' "actual ongoing use" of research and the related factors/challenges affecting their continued use of research findings in clinical practice. Purpose. Why do some nurses continue to use research while others do not where organizational policy supports the ongoing use of evidence-based practice? The purposes of this study are to validate whether nurses' are continuing to use the RNAO's Falls Risk Prevention Best Practice Guidelines (BPG) policy/protocol in 2 units of a tertiary clinical care setting, to examine practicing nurse's attitudes, beliefs and perceptions related to their intention continue to use the policy/protocol; to examine the importance of each variable (beliefs, subjective norms, perceived behavioural controls) related to their intention to continue to use the policy/protocol; and to examine nurses' perceptions and experiences regarding the facilitators, barriers and organizational structures that impact their continued use of research in their practice setting. Methods. This survey correlation design study used Ajzen's Theory of Planned Behaviour (Godin & Kok, 1996) as a theoretical framework to examine practicing nurse's attitudes, beliefs, perceptions related to their intention to continue to use the Registered Nurse's of Ontario Association (RNAO)'s Falls Risk Prevention Best Practice Guideline (BPG) in their clinical practice. Findings. Sixty four percent of surveyed nurses (n=22/44) report using the Falls protocol (a direct type of research) always (18%) and/or often (46%) in their clinical practice. They also reported using the Falls Protocol on their previous shift an average of 2.6 patients per nurse. The main sources of falls research education where nurses first learnt about the RNAO's BPG were during their nursing practice (46%), a form of continuing education (27%), or in a conference/seminar setting (18%). Composite mean scores related to surveyed nurses attitudes, social norm and control beliefs ranged from 1.71 to 2.43 indicating strong positive attitudes, a strong sense of social pressure and greater level of control over their ongoing use of the Falls Protocol in their daily practice. Nurses' attitudes, social and control beliefs explained 46% of the variance in intention related to its ongoing use every 3 months and 73% of ongoing use after a patient fall incidence. Surveyed nurses identified 9 facilitators and 4 potential barriers related to the ongoing use of the Falls Protocol in their clinical practice. Conclusions. Findings reveal nurses in a tertiary care facility demonstrate 'strong generalized intentions' towards the ongoing use of the direct form of research, the Falls Risk Prevention BPG on admission, on a quarterly basis and after a patient fall incident. The 'ongoing utilization of research' in practice is definitely of interest and viewed positively by nurses in this setting despite their educational profile, limited research education and minimal exposure to in-house continuing education. This result indicates exposure to research is necessary in developing favourable attitudes towards RU. Furthermore, nurses' intention to 'continue to use' the Falls Protocol in this tertiary care facility is significantly influenced by the social expectations of referent persons and by their perceived behavioural control (PBC) beliefs. Surveyed nurses also report that three factors facilitate their 'ongoing use' of the Falls Protocol in their setting; these are congruent with those found in the literature relating to the initial adoption of research. These facilitators include: (1) providing research in a usable form; (2) attending conferences or seminars to remain current with new research related to their clinical setting; and (3) engagement in research activities such as the development, updating and implementation of the Falls BPG for use on their units.

The purpose of this master's thesis is to explore intersections within Aboriginal womens' descriptions of their experiences of accessing care in an urban context, and to explicate how service provider's perceptions of women's identity featured in their care encounters. This thesis is divided into three chapters. The first chapter provides a background on access to care for Aboriginal women living in urban contexts, outlines the methodology of the primary study, and explores the intersectionality paradigm used to complete the secondary analysis done for this study. The second chapter describes the results of the study. It begins by providing a general overview of the major themes and subthemes, followed by two manuscripts that have been written for submission for publication in scholarly journals. The third chapter discusses how this study has contributed to new knowledge for nursing, as well as the implications for nursing education, research and policy.

Studies show nurses experience many barriers to research use in practice. Nursing education needs to prepare nurses to evaluate and apply research as a basis for practice. Clinical teachers have the opportunity to close the gap between research and practice by preparing students to use research in their practice. However, little is known about how clinical teachers use health care research in nursing clinical teaching practice. The purpose of this qualitative research study is to explore the use of health care research in nursing clinical teaching practice. Study objectives are: (a) to explore the use of health care research by clinical teachers (current practices); (b) to examine clinical teachers' concerns about using health care research in their practice; (c) to explore factors that impede or facilitate clinical teachers' use of health care research in their teaching; and (d) to explore strategies used by clinical teachers to promote use of heath care research by students. A grounded theory approach was used. A convenience sample of 15 clinical teachers in a baccalaureate nursing collaborative program were interviewed using a semi-structured questionnaire. Analysis of the data led to the identification of the main theme making the connections. Also identified were the sub categories of valuing the connections, conditions affecting the connections, connections strategies, students seeing the connections and strengthening the connections. The findings were presented to 9 of the original 15 participants and feedback indicated they agreed with the results of analysis and the model developed. Implications for nurses teaching clinical practice, nurses in full-time faculty or administrative roles and research are discussed.

The purposes of the study were to investigate homeless men's experiences of taking medications while living in a homeless shelter and the factors that affect medication adherence; and to describe medication adherence, as it pertains to homeless men residing in a shelter, from the perspective of the shelter staff. This is a manuscript-based thesis. The first manuscript provides a description of a proposed ecological model, based on clinical experience of the author and from the literature. The second paper is a summary of the findings of the qualitative research on medication adherence and homeless men's shelters. The third manuscript, directed at pharmacists, offers recommendations and strategies based on results of the qualitative study, to improve medication adherence. This thesis suggests that when health professionals view adherence to medications as an individual, cognitive choice, it does not take into account the challenges imposed by a homeless individual's environmental context.

Cancer is predominantly a disease affecting older persons. 43% of new cancer cases in Canada occur among those who are at least 70 years old, while 25% occur in those aged 60--69 years. Cancer fatigue is the most common symptom associated with cancer and its treatment, and is often the most distressing symptom reported by cancer patients. Cancer fatigue adversely affects physical activity levels, physical function, and quality of life. Physical function is essential to older adults in maintaining independence and associated quality of life which is often more important to older adults than cancer survival. Recent research studies suggest that physical activity may reduce fatigue, and maintain or improve physical function levels and quality of life in cancer patients during and following treatment. This thesis examines cancer fatigue and its relationship to physical activity, physical function, and quality of life in older adults with cancer. The results of a systematic review and the findings of a secondary analysis research study are presented. The systematic review provided evidence that physical activity may reduce fatigue in older cancer patients during and after cancer treatment and may help to maintain or improve physical function and quality of life in this population. Results of the secondary analysis indicated that cancer fatigue is prevalent and was the most frequently reported symptom at baseline, three months and six months post consultation for cancer treatment. Cancer fatigue was associated with lower levels of physical function and quality of life. Physical activity, a modifiable factor, was found to be significantly related to cancer fatigue at three months and six months, regardless of age, and was significantly related to physical function at six months.

Dans le cadre d'un traitement des dépendances, les infirmières jouent un rôle important (Rassool & Villar-Luis, 2004). Chaque jour, elles composent avec une clientèle non seulement en situation de sevrage mais aussi gravement malade sur les plans physique et psychologique (Naegle & Erickson D'Avanzo, 2001). La recension des écrits rapporte peu de recherches sur les rôles exercés par les infirmières em milieux de désintoxication. En effet, les infirmières doivent articuler des fonctions visant à maintenir l'ordre allant même jusqu'à la mise en oeuvre d'un traitement forcé ou fortement suggéré par des instances juridiques (Thomas 2005). Or certains articles sur le sujet mentionnent le besoin d'offrir au client "un encadrement" afin de lui permettre de suivre son traitement ou de cesser sa consommation. Bien que la nécessité d'un encadrement strict ait été évoquée, aucune recherche sur cet aspect de la pratique infirmière dans ce type de milieu n'est documentée dans les écrits consultés. Étant donné que l'unité de désintoxication est fortement investie par une régulation comportementale, il est nécessaire de s'attarder non seulement à l'angle caritatif de l'exercice infirmier mais aussi aux aspects politiques du soin. Les rapports de pouvoir entre le personnel infirmier et les personnes admises en désintoxication constituent donc la pierre angulaire de cette recherche. Dans la mesure ou les aspects politiques du soin sont au coeur de cette recherche, notre choix de cadre théorique s'est arrêté sur les travaux de Michel Foucault. Plus spécifiquement, notre analyse foucaldienne s'appuiera sur le concept de pouvoir disciplinaire afin de supporter notre recherche au plan théorique. Au plan méthodologique, un devis qualitatif a été privilégié. Les résultats de cette recherche montrent que le soin infirmier dans une unité de désintoxication est assorti de composantes caritatives et disciplinaires qui se juxtaposent continuellement. Les infirmières qui ont participé à cette étude ont clairement exprimé qu'il leur serait impossible de soigner la clientèle sans la structure, les mécanismes de contrôle et les mesures disciplinaires dont elles disposent. L'examen des données de l'observation du milieu et des documents écrits a corroboré l'existence de telles pratiques, qui sont entérinées, du moins en partie, par la direction sous formes de politiques et procédures.

Buts: En utilisant l'ethnographie ciblée, cette recherche qualitative cherche à comprendre l'expérience de la transition à la pratique des infirmières praticiennes (IP) francophones diplômées, de leur propre perspective et de celle d'un coparticipant (CP) choisi par l'infirmière praticienne. Cette recherche cherche aussi à explorer les besoins de soutien de ces IP au cours de leur première année de pratique en soins de santé primaires et à identifier les besoins particuliers des IP francophones pour dispenser des services de santé en français dans un contexte minoritaire. Méthodes: Des entrevues en profondeur, de type ouvert, par téléphone, ont été effectuées a trois intervalles de temps (trois mois, six mois et douze mois) auprès d'un groupe de six infirmières praticiennes et de leurs six coparticipants désignés. Cette recherche vise les IP francophones, diplômées en 2006, du programme francophone du Consortium ontarien de formation des infirmières et infirmiers praticiens en soins de sante primaires et qui, au moment de l'enquête, travaillaient à titre d'infirmière praticienne dans un milieu de soins de sante primaires en Ontario ou au Manitoba. La revue de la documentation fournie par l'IP, notamment l'organigramme, la description de tâches et les documents de politique ont servi à comprendre le contexte organisationnel. Résultats: Les participants ont décrit une transition comparable à celle décrite par Brown & Olshansky (1997). Les infirmières praticiennes francophones ont évolué à partir d'un sentiment d'inconfort à titre de débutantes dans leur nouveau rôle, vers un sentiment de confiance envers leurs habiletés, tout en cherchant à élargir leur perspective professionnelle vers la fin de leur première année de pratique. Dans l'ensemble, la familiarité avec le milieu de travail et le soutien important fourni par les employeurs ont contribué à produire une expérience positive de la transition. La contribution essentielle de cette étude est résumée dans une liste de quinze recommandations qui servent de stratégie de base pour une transition réussie. Cette recherche contribue à la compréhension des expériences et des besoins de soutien des infirmières praticiennes francophones diplômées et de leurs employeurs en soins de santé primaires. Elle fournit de l'information pour appuyer la mise en oeuvre d'outils et de ressources qui permettront aux IP francophones de travailler au meilleur de leur capacité; pour appuyer la mise en place d'interventions appropriées qui pourraient appuyer les nouvelles IP dans leur quête a perfectionner leurs connaissances et leurs compétences qui leur permettront de fournir des soins d'excellente qualité.