Nursing and Midwifery - Doctoral Theses

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    Primary care reform: international evidence and primary care doctors’ perspectives within the context of health system reform in Saudi Arabia
    (University College Cork, 2023) Alyousef, Mohammed; Naughton , Corina; Bradley, Colin; Savage, Eileen
    Background The Kingdom of Saudi Arabia (KSA) has launched and ambitious reform programme Vision 2030 including health system reform (Government of Saudi Arabia, 2016a). The health system challenges include the increasing burden of chronic diseases, inadequate access to healthcare, and health service fragmentation. The health strategy articulates a new model of care (MOC), targeting financial reform, provider reform, eHealth development, and public private partnerships. A strategic priority for the KSA health system is to strengthen primary healthcare (PHC) and to position primary care (PC) as the first point of access to healthcare. To date there is limited evaluation of the health reforms with a particular evidence gap on reform implementation in PC. The research aims: 1) to examine the international evidence on the implementation of PHC reform for chronic conditions in countries with high or very high human development index (Review 1); 2) to examine the qualitative evidence on PC doctors’ perspectives on PC reform within the context of health system reforms (Review 2); 3) to explore PC doctors’ perspectives on PC reform within the context of the health system reform in the KSA using a qualitative study design. Methods Review 1 was guided by the PRISMA statement including academic articles and grey literature from 1 March 2008 to 1 September 2020. Descriptive analysis and narrative synthesis were applied. Review 2 used a thematic synthesis of qualitative studies guided by Thomas and Harden (2008) three stage framework to identify descriptive and analytical themes. The qualitative study used interpretive description (ID) methodology. Semi-structured interviews were conducted with a purposive sample of 14 PC doctors (general practitioners (GPs) & family physicians (FPs)), recruited from primary health care centers (PHCC) in the Makkah region of KSA. Constant comparative analysis and Thorne (2016) six-steps was used to analyze the data. Results Review 1 included eight articles from four countries. It revealed a shift in chronic disease management from hospital to PC services involving new organizational and funding models (PC networks, commissioning of services, and shared governance structures). The need for leadership and engagement from PC doctors to support PC reform was identified. Review 2 included sixteen qualitative studies from eight countries. Three themes were identified: (1) Health system reform: lacking integrated and co-ordinated services; (2) Funding primary care: competition versus collaboration; and (3) GP/FP engagement in shaping primary care reform. The qualitative study on PC doctors’ perspectives on KSA PC reform identified five major themes: Changes in daily practice; Changes in the infrastructure of PC; Changes in Relationships, Gradation of awareness to understanding of the PC reform; and Barriers and enablers to engaging in PC reform. Participants observed changes in their daily practice with reference to chronic disease prevention and early intervention with a shift from hospital to PC management model. This corresponded to changes in infrastructure especially diagnostic services, access to medication, and information systems. Changes in relationships with patients were perceived as more patient/person-centred wile relationships between PHCCs were described as more collaborative which was attributed to the formation of health clusters as a collective of PHCC and acute hospitals serving a defined population. In contrast, participants’ viewed relationships with the hospital sector as largely hierarchical with no real collaboration. Participants’ understandings and engagement with the PC reforms as stakeholders varied. While there was some understanding of the MOC especially among FP participants, their understanding of financial reform and provider payments was limited. The GP/FP participants believed they had an important contribution to make to the reform agenda as frontline providers. Barriers and enablers to engagement related to trusted sources of information, education and leadership opportunities, and communication with policy decision making. Conclusion This thesis provides important insights from the literature reviews and the qualitative study into the crucial role that PC doctors as frontline health service providers can play in PC reform. PC doctors’ experiences need to be considered by policy makers to ensure successful implementation of PC reform that meets individual and population needs, and that are adequately resourced financially. There is a need for a deliberate process to engage with PC doctors to help them appreciate how observed changes link to policy and to support them as change agents rather than passive actors in the reorientation of the KSA PHC and wider health system.
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    Self-leadership strategies and psychosocial outcomes among advanced nurse practitioners in Ireland
    (University College Cork, 2022-05-25) Duignan, Martin; Drennan, Jonathan; Mc Carthy, Vera
    Aim: The aim of this study was to investigate the relationship between Advanced Nurse Practitioners’ Self-Leadership and Commitment to the Workplace, Work Engagement, Influence at Work, Job Satisfaction, and Intention to Leave Background: The concept of self-leadership is particularly suited to ANPs who are required to take responsibility for their own work roles. An optimum balance between the ANPs’ psychosocial work environment and self-leadership may positively impact work ability in this group and can be compromised by interactions between and among these variables. Design A cross-sectional correlational study was conducted from July 2020 to August 2020 on a sample of 153 ANPs across one national health service. Methods Between July and August 2020, the survey was distributed online by the Health Service Executive (HSE) and the Irish Association of Advanced Nurse and Midwife Practitioners (IAANMP). The revised self-leadership questionnaire was used to measures self-leadership; three scales from the Copenhagen Psychosocial Questionnaire was used to measure commitment to the workplace, work engagement and influence at work; single-item measures were used to measure job satisfaction and intention to leave. Multiple linear regression models were used to examine the associations of self-leadership and the psychosocial variables. Results ANPs with high levels of self-leadership also reported high levels of work engagement (B = 0.17, 95% CI [.011. 0.22], p <0.001). Significant relationships between levels of self-leadership and commitment to the workplace (r = .495, p <.01, n = 153) and intention to leave were also found. The relationships between self-leadership and influence at work and job satisfaction were, however, not statistically significant. Conclusion Improving self-leadership among ANPs by involving them in strategic leadership activities at an organisational level could be an effective strategy for optimising the role and facilitating ANPs to contribute at an organisational level beyond the clinical interface. However, organisational support and role flexibility are required to ensure ANPs practice to the full potential of their training and capability.
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    Advanced practitioners’ experience of interprofessional collaboration when implementing evidence-based practice into routine care: an Interpretative phenomenological analysis
    (University College Cork, 2021-09-30) Clarke, Vanessa; Lehane, Elaine A.; Mulcahy, Helen; Cotter, Patrick
    Background: Implementation of Evidence-based Practice (EBP) is essential in ensuring high quality healthcare at minimum cost. Nurse practitioners as clinical leaders are responsible for leading and collaborating with interprofessional teams to implement EBP across patient groups and embed practice change into routine care. Interprofessional collaboration has been identified as an essential element for the successful implementation of EBP into routine care. Limited evidence from previous literature findings indicated that collaborative practice issues impeded nurse practitioners in implementing EBP into routine care. However, findings were not adequate to inform specific practice and policy recommendations nationally and internationally. Further research was therefore required into this aspect of the nurse practitioner role. Aim: To understand Registered Advanced Nurse and Midwife practitioners’ experience of interprofessional collaboration in implementing EBP into routine care in the Republic of Ireland. Methods: Qualitative Interpretative Phenomenological Analysis (IPA) was used for this study. A purposeful sample of ten Registered Advanced Nurse and Advanced Midwife Practitioners from a range of practice settings participated in semi-structured interviews which were audio recorded and then transcribed verbatim. NVivo version 12 was used for data management purposes. Data were analysed using IPA. Findings: Six superordinate themes emerged from the interpretative analysis. Advanced practitioners perceived that at times “Understanding of Advanced Practice” was limited. Advanced practitioners described being “Treated as an equal and as a nurse”. Being treated as a “nurse” was associated with being treated as subordinate to other professionals. The extent to which advanced practitioners enjoyed “Nursing Management Support” varied. Some advanced practitioners described having opportunities to participate in their organisation’s executive and decision-making forums which afforded them the opportunity to have “A Voice to Implement Anything New.”. However, others were unable to avail of these opportunities. Levels of participant “Confidence” and “Emotional Intelligence” impacted relationships with members of the interprofessional team. The issues identified in the six superordinate themes influenced the extent to which advanced practitioners could collaborate effectively to implement EBP into routine care. Conclusion and Implications: There is scope to improve advanced practitioners’ ability to collaborate with the interprofessional team in implementing EBP into routine care. Ameliorative measures should focus on increasing understanding of the advanced practitioner role; facilitating advanced practitioner access to organisational decision-making forums; and developing skills and attributes necessary for interprofessional collaboration and the implementation of EBP into routine care.
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    The investigation of paternal stress, anxiety and depression during the perinatal period and the coexistence of paternal stress, anxiety and depression in the early postnatal period
    (University College Cork, 2021-10-08) Philpott, Lloyd F.; Leahy-Warren, Patricia; Savage, Eileen; Fitzgerald, Serena
    Background: While there is growing interest in paternal postnatal mental health among clinicians and researchers, the major of research has focused primarily on depression. More recently, stress and anxiety have also begun to emerge as paternal postnatal mental health concerns. However, to date, studies have either explored stress, anxiety, and depression individually or reported the findings separately when all three have been measured. To the best of the authors’ knowledge, this is the first study to research the coexistence of paternal stress, anxiety, and depression symptoms in the early postnatal period. Study aim: The aim of this study was to investigate the coexistence of and predictive factors for paternal stress, anxiety, and depression symptoms in the early postnatal period. Methods: A quantitative, cross-sectional, correlational design was used. Data were collected over a period of 3 months from June to August 2019 at one large regional maternity hospital in Ireland using a self-administered questionnaire comprising of demographic questions, the Perceived Stress Scale, the State-Trait Anxiety Inventory, and the Edinburgh Postnatal Depression Scale. Non-probability, convenience sampling was employed. Descriptive and inferential analyses of the data was conducted to address the aim, and objectives of the study. Findings: A total of 336 questionnaires with complete data for the variables of interest were included in the statistical analysis. The majority of fathers in the study were Irish (n=282, 83.9%), educated to third level (n=241, 71.7%), married (n=238, 70.8%) and in full-time employment (n=278, 82.7%). Just over half (n=170, 50.6%) were first-time fathers. The prevalence rates were 41.1% (n=138) for moderate/high stress symptoms, 20.8% (n=70) for state-anxiety symptoms, 25.9% (n=87) for trait-anxiety symptoms, and 13.4% (n=45) for major depression symptoms. Forty-three fathers (12.8%) met the criteria for the coexistence of stress, anxiety, and depression symptoms as they exceeded the cut- off score on all three measurement tools. Predictive factors for the coexistence of stress, anxiety, and depression symptoms were a self-reported history of anxiety (p<0.001), a negative experience of labour and birth (p<0.001) and being of a younger age (p=0.034). Conclusion: The findings suggest that focusing on depression does not accurately represent the substantive risk to paternal mental health in the early postnatal period. Researchers and clinicians need to encompass a broader understanding of adverse paternal mental health to include stress, and anxiety and the coexistence of symptoms.
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    A mixed methods study of the relationship between organisational readiness to change, service user engagement and innovation adoption in community-based opiate substitute treatment services in Ireland
    (University College Cork, 2021-06) Kelly, Peter; Hegarty, Josephine; O’Donovan, Aine
    Introduction: While we know that treatment for opiate dependence, such as opiate substitution therapy and psychosocial interventions delivered in community settings are effective, we do not know exactly why they are effective. We do not know exactly what makes some services better than others at delivering treatment, and little is known about the attributes of services which can make them effective at improving service user outcomes or adopting new innovations. Organisational Readiness to Change (ORC) is a key concept from the field of organisational development and where it has been operationalised, it has helped to identify that some attributes of services within substance misuse treatment are important. ORC measurements have identified attributes of services which make some services more effective than others at adopting new innovations and delivering certain aspects of treatment such as service user engagement. No studies using ORC measures have been conducted in the context of Irish community treatment prescribing services and there is a dearth of qualitative studies which examine organisational aspects of addiction treatment services. Aim: The overall aim of this study was to identify and describe aspects of community-based opiate substitute treatment services which were perceived to make them more effective at adapting to change, and delivering treatment for people who are dependent on opiates. This was done by describing and exploring the relationship between staff perceptions of ORC and its relationship with (i) staff perceptions of innovation adoption (ii) service user engagement with treatment and seeking to understand the mechanisms which underpin those relationships. Method: The evidence base for this study was identified by conducting one systematic review (n=14 included studies) on the relationship between ORC and innovation adoption and one systematic review (n=8 included studies) on ORC and client outcomes in substance misuse treatment services. A cross-sectional study using a mixed methods study design which accessed both staff and services users was then conducted. Two separate quantitative studies were conducted concurrently in community-based opiate treatment prescribing services (n=12) across 10 geographic locations in Ireland. The first study, involving a range of staff who had direct contact with service users (n=132) measured the relationship between staff demographics, ORC and training adoption, and data was analysed at the individual level. The second study involved the same staff sample and additional sample of service users (n=262) from the same services. This study measured the relationship between staff and service user characteristics, ORC and client engagement, and data was analysed at the centre level. A concurrent qualitative study with staff, (n=12) was also conducted which explored the narratives of staff about the factors which influence the relationships between ORC and innovation adoption. Results: The systematic literature reviews showed that although the same tool was used to measure ORC across all of the included papers there was significant heterogeneity in study designs and outcomes measured. ORC is predictive of how effectively services can deliver treatment and adopt new innovations into practice. Better ORC ratings (resources, staff attributes, change drivers and in particular organisational climate), related to more effective innovation adoption and better client engagement. Having good organisational climate was of particular importance. The majority of studies were cross-sectional and there was a dearth of qualitative, interventional or quasi-experimental studies which involved the use of ORC measures. Little was known about how to address ORC deficits once they are identified, and generalisability of findings outside the US was not clear. In the first cross-sectional survey undertaken in Irish community opiate substitution treatment services, ORC and staff characteristics were shown to be predictive of training adoption. Staff who were longer in post and with higher levels of education were more likely to engage in a process of training adoption. In services where staff perceived there to be better resources, lower organisational needs, fewer pressures for change, less stress, and better influence with peers they reported higher engagement in a process of training adoption. Disciplines, such as counsellors, reported higher levels of training adoption than other professional groups. In the second cross-sectional survey, involving staff and service users, staff perceptions of ORC were also predictive of better service user engagement. In particular, in services where staff reported greater levels of autonomy, service users reported higher levels of treatment participation, better therapeutic relationships, and higher satisfaction with treatment. Service users who were the longest in treatment reported significantly poorer rapport with staff and were less likely to seek support from peers, while those in stable accommodation reported greater participation in treatment. Levels of peer support were not related to ORC measures, but those with lower levels of education and those in early treatment were more likely to seek support from peers. Findings from both these quantitative studies expanded results using ORC from the US to the Irish context. Concurrent qualitative inquiry with staff showed that change itself was described both in respect of how a service responded to immediate service user needs or supported planned change. Little distinction was made in respect of service attributes which facilitated a response in either context. Overwhelmingly, staff contextualised current service effectiveness, historical change, and desired change in how effectively their services met service user needs, which was also viewed as a significant motivation for change. Differences in operational standards across services in terms of practices, policy implementation, job roles, divisions between professional groups, and recruitment and retention of staff inhibited change adoption. Factors which were identified in terms of inhibiting or facilitating planned change were consistent with the wider literature on change implementation but provided unique insights in the context of substance misuse services. Consideration of the qualitative findings provided possible explanations for relationships identified in the quantitative inquiry in this mixed methods study. Qualitative data also identified aspects of organisations which were important to staff and relevant to ORC but were not identified as being important in quantitative inquiry. Analysis of quantitative and qualitative data within the context of the wider literature provided more understanding of the mechanisms which underpinned relationships between ORC, service user engagement, innovation adoption and helped to understand how some of these relationships might work in practice. Qualitative inquiry also identified organisational factors which were identified as being important to staff but were not captured by ORC measurements. This also helped to understand both currently and retrospectively how cultural factors, social factors and policy can influence staff and service user evaluations of services. These related to areas such as drivers of change, resources, staff recruitment and retention, governance and standardisation of practices and the organisation and planning of services. Conclusion: A wide range of complex but interdependent factors which influence how the ‘eco-system’ of services operate were identified. ORC measures provide valuable insights into the dynamics and process of treatment and these can be used to identify what aspects of services make a service more likely to adopt new innovations or more effectively engage service users. Qualitative inquiry provides rich information which can be used to understand how and why relationships might exist or not in quantitative inquiry. Evidence presented in this thesis, including primary research confirms the importance of assessing staff, organisational and service user attributes as part of an overall systemic approach to bolster policy and improve the quality of substance misuse treatment.