Nursing and Midwifery - Doctoral Theses

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    To what extent are Child and Adolescent Mental Health Services engaged in Trauma Informed Practice: an Irish study
    (University College Cork, 2023) Heffernan, Sinead; Leahy-Warren, Patricia; Drennan, Jonathan; Dalton O'Connor, Caroline
    Background: Children and adolescents attending the mental health services are likely to have experienced childhood or intergenerational trauma. International and national mental health policy recommends that services integrate TIP into mental healthcare provision. A lack of research studies exploring the integration of TIP, with this cohort were identified. Method: A descriptive correlational study design utilised a convenience approach to gain a sample from the target population: all CAMHS staff nationally. Data were collected using a psychometrically validated organisational assessment tool. Mostly descriptive, inferential, and some thematic analyses were deployed. Results: Respondents reported low levels of TIP, overall. The majority of respondents were female, community based, clinical staff. Levels of trauma informed therapeutic engagement with service users, and organisational supports for TIP were ascertained from a staff perspective. Results indicated a varied results with therapeutic engagement revealing higher scores than the organisational related areas in CAMHS. Areas that pertained to person centred approaches to consistent care delivery, safety and care planning, and de-escalation were to some extent developed. Gaps in care provision related to language, culturally sensitive care provision, and coproduction including eliciting feedback routinely, communication, flexibility, and staff supports to mitigate vicarious trauma were identified. Further gaps pertained to educating both service users and staff about trauma and its impact on mental health, as well as TIP delivery and evaluation. Overall organisational rather than individual staff factors represented require significant development to achieve TIP. The results of inferential analysis identified relationships between staffs’ levels of satisfaction in current role; which was found to be the strongest predictor of TIP (R2=14.7%, p<0.001), followed by location of role (R2=8.2%, p<0.001) and length of service (R2=3.3%, p<0.040). No relationships were found re: role in CAMH service (p=0.495) and attending TIP training (p=0.840). Thematic analysis found that training was not systematically provided or attended. Gaps in relation to TIP training content, frequency and duration were identified. Discussion: TIP has been described as a humanistic approach to care delivery that recommends approaches that can optimise therapeutic relationships and person-centred care characterised by flexibility, peer supports and collaboration and require further development. Organisational supports for training provision for all CAMHS staff, that is sustainable, evaluated, and accessible, is required. Staff supports that mitigate vicarious trauma for staff also requires further development. An organisational commitment underpinned by resources, strategies to deliver change, guided trauma-informed policy to support TIP, is recommended. Conclusion: CAMHS acute and even more so, community-based services are not currently engaged in TIP, as recommended by mental health policy. The multifaceted nature of TIP requires an organisational approach to guide implementation. The results from this study have identified gaps in relation to organisational support for TIP which can add to the growing knowledge base to support the integration TIP into CAMH Services.
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    The impact of a quality improvement complex intervention on the incidence of surgical site infection and the knowledge and attitudes of healthcare professionals
    (University College Cork, 2023) Horgan, Sinead; Hegarty, Josephine; Drennan, Jonathan; Saab, Mohamad
    Background Surgical site infection (SSI) is a serious post-operative complication that depletes hospital resources and has a detrimental impact on patient outcomes. There is published evidence to help healthcare professionals prevent SSIs, yet SSI prevention remains suboptimum and a complex problem to address. Implementing evidence-based prevention strategies to reduce SSIs in acute hospital settings is one example of this complexity. Therefore, it is critical that healthcare professionals have sufficient knowledge on SSI and an understanding of their role in SSI prevention, and are aware of and implement prevention strategies to reduce the incidence of SSIs. Aim The aim of this study was to develop and examine the effect of a quality improvement complex intervention on the incidence of SSI and the knowledge and attitudes of healthcare professionals regarding SSI prevention and surveillance in a university hospital setting. Methods Two systematic reviews of the literature were conducted. The first systematic review aimed to identify, describe, and review the evidence from the literature on the knowledge and attitudes of healthcare professionals towards SSI and SSI surveillance and to examine the effects of interventions that aimed to enhance healthcare professionals’ knowledge and attitudes. The second systematic review examined interventions conducted in acute health care on the incidence of SSIs as well as patient outcomes including length of stay, intensive care unit admission, and mortality rate. Two quantitative studies were conducted to evaluate the impact of a locally designed complex intervention named after the process - Initiation, Surveillance, Sharing, Improvements and Plan for future (ISSIP) using pre-post-test design. Normalisation Process Theory guided healthcare professionals in the design, development, understanding and implementation of the ISSIP intervention in a complex acute health care setting. A quasi-experimental study was conducted in a paired sample of 74 healthcare professionals to examine their knowledge and attitudes towards SSI prevention and surveillance using a questionnaire before and after the intervention. Records from a cohort of patients were retrospectively reviewed to ascertain the baseline SSI incidence rate in the first six months of 2018 (n=95). Consecutive patients (n=216) undergoing colorectal surgery were subsequently followed up postoperatively to measure the impact of the complex quality improvement intervention (ISSIP) on the incidence of SSI. Results Findings from the literature in the first systematic review showed that healthcare professionals’ overall knowledge of SSI and its prevention was poor, while their attitude towards SSI prevention was positive. In the second systematic review, literature revealed that interventions that were effective in reducing the incidence of SSIs had multiple components including bundles, stakeholder engagement, targeted surveillance, and education. Over the course of the current study, there was a statistically significant improvement in healthcare professionals’ understanding of SSI and its prevention after the ISSIP intervention. Pre-test and post-test, attitudes towards SSI prevention and surveillance were positive, with a noticeable positive shift in participants' attitudes in relation to the organisational role in implementing prevention strategies. The ISSIP intervention resulted in a 2.5-fold decrease in the incidence of SSIs and brought about improvements in practice, engagement of multidisciplinary healthcare professionals, and a collaborative approach to reducing SSIs. Other critical elements that supported the ISSIP intervention and were pivotal to its success were: leadership engagement, an implementation group, a dedicated facilitator, ongoing education, a surgeon champion, and the expertise of a surveillance scientist. Conclusion ISSIP is a theory-based multicomponent multidisciplinary complex intervention that was successful in reducing the incidence rates of SSIs in patients undergoing elective colorectal surgery. ISSIP also had a positive effect on healthcare professionals' knowledge and attitudes regarding SSI prevention and surveillance. The use of ISSIP provided a novel framework for the study which is transferable to other hospitals developing a programme for preventing SSIs. Numerous recommendations originate from this research including the recommendation that hospital leadership and staff engage in SSI surveillance supported through the utilisation of a quality improvement approach, underpinned by a national clinical guideline.
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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.