Doctor of Philosophy in Nursing (PhD)
Developing a Taxonomy of Technology-Mediated Adverse Events
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I would like to express my special gratitude to Dr. Leanne Currie for her encouragement, patience, and support. As a supervisor, she is very motivating and helpful which inspired me to give my best efforts. She is my inspiration, motivation, and source of critique. I would like to express my gratitude and appreciation for her immense support, proper guidance, encouragement, and opportunities she had provided me during my first year of the PhD program.
@BCSUPPORTUnit Data Science Lead, Dr. Currie: always pushing but always has my back, three countries later! http://bcsupportunit.ca/wp-content/uploads/2017/03/Leanne_Currie_Methods... … #greatsupervisor
No abstract available.
Preliminary, mostly small observational studies, suggest that febrile intensive care unit (ICU) patients may be at higher risk of acetaminophen-associated hypotension and that acetaminophen may be a less effective antipyretic in this population than previously thought. A pilot double-blinded, randomized controlled trial was conducted to examine four questions: (a) what is the feasibility of conducting this study, (b) is there a difference in incidence of clinically significant hypotensive events, and/or blood pressure in the four hours post intervention between febrile, non-brain injured patients who received either a single dose acetaminophen or a placebo, (c) is there a difference in fever burden between participants who received the treatment versus placebo, and (d) what are the relationships between heart rate, blood pressure, core temperature, and fever burden? Over nine months, 83% of the 950 admitted ICU patients were screened, 100 patients were eligible but due to logistical challenges, only 27 were invited to participate, of which 17 refused. Only six of the 10 participants completed the study, and of those five were randomized to the acetaminophen group. The eligibility rate increased from 10.0% to 16.3% (p = 0.016) after small changes to the inclusion criteria were made. The sample size was too small to draw conclusions regarding the utility of outcome measures, participant safety, or the hemodynamic or antipyretic effects of acetaminophen; however, no participant had a safety event. Participants had variable heart rate, blood pressure, and fever patterns. There was little or no discernable antipyretic effect of acetaminophen in the five participants who received the drug. Additionally, strong linear relationships were detected between mean pre-post intervention differences in fever burden and mean arterial pressure (MAP) as well as core temperature and heart rate (p = 0.003 for both). Mean difference in MAP increased by 2.20 mmHg for every 1 °C-hour increase in net change in fever burden (R² = 0.906; 95% C I [1.214, 3.186]). Mean difference in heart rate increased by 4.840 beats/minute for every 1 °C increase in mean difference in core temperature (R² = 0.905; 95% CI [2.665, 7.014]).
Documentation is a professional responsibility in nursing because it facilitates communication, promotes good nursing care, and acts as a valuable method to demonstrate that legal and agency standards are followed. Nurses are increasingly using health information technologies, such as electronic health records, to document care. To be able to measure and compare the impact of nursing on patient outcomes, standardized clinical terminologies compliant with international standards are necessary. In British Columbia, Canada, nurses use a standardized wound care template to document their assessments and the care they provide to patients; however, the content of this assessment is currently not shared in a computable format between different electronic health records within the province. The purpose of this thesis was to map wound care data elements from the BC Standardized Nursing Wound Documentation standard to SNOMED-CT. To complete this “bottom-up” mapping activity, creation of a conceptual model of knowledge representation for nursing wound care was developed to inform three concurrent methods of mapping (manual, automated, and literature comparison) for 107 data elements. These methods produced candidate lists, which were reviewed by two expert wound care clinicians who created an expert consensus list. Results of this expert consensus list indicated that 40.2% of the terms had direct matches, 1.9% had one-to-many matches, and 57.9% had no matches. The outcome of this study was the creation of a conceptual model of nursing knowledge representation for wound care, a list of mapped wound care data elements to SNOMED-CT, identification of missing and duplicate concepts in SNOMED-CT, and application of concurrent mapping methods to inform the creation of an expert consensus list. The advancement of standardized clinical terminologies to support semantic interoperability between disparate electronic health records is an important measure to ensure patient information is shared throughout the continuum of care. This thesis work provides a method to incorporate local nursing standards into SNOMED-CT, with the intent to ensure that nursing care is represented.
Background: While obesity has been identified as a risk factor for post-operative surgical site infections in general, it is unclear if obesity is a risk factor for surgical site infections for low risk surgeries.Methods: A systematic review was conducted by searching PubMed, EMBASE, CINAHL and hand searching the references of included studies. Articles were included if the type of surgical procedure was low risk regardless of type of setting where the research was undertaken. All studies that used any obesity measurement were included if surgical site infections were the outcome of interest.Results: Three hundred and twenty-nine articles from three databases were identified. A full-text review of 58 articles that met inclusion criteria yielded 19 studies that were included in the analyses. Six studies had good study quality, 10 studies had fair study quality and three studies had poor study quality. Variations were noted among these studies in relation to definition of surgical site infection and cutoff levels used to define obesity. Due to heterogeneity of the definitions for surgical site infections, cutoff points for obesity and comparators, and variability of study quality, results from the studies could not answer the research question.Conclusion: The relationship between surgical site infections and obesity in the context of low risk surgeries is not yet determined. Future research should focus on patient safety reviews for low risk procedures, determine best methods to accurately measure obesity, and review obesity as a risk factor for patients undergoing low risk surgeries in all settings.
Hemophilia is a congenital bleeding disorder that predominantly affects men. Prophylactic intravenous replacement of missing clotting factor, known as prophylaxis, is the most effective treatment method to prevent all internal bleeds caused by hemophilia. Despite availability of prophylaxis, it is not well understood why adult men with severe hemophilia still experience bleeding episodes resulting in irreversible joint damage and disability, particularly in adolescence and young adulthood. The purpose of this qualitative study was to explore men’s experiences of hemophilia across age groups and to explore the connections to masculinity in relation to men’s hemophilia management decisions. Adult men with severe and moderately severe hemophilia A (less than 2% factor levels) participated in three age stratified focus groups: 19 to 24 years old (n=3), 25 to 39 years old (n=4), and 40 years and older (n=4). Qualitative descriptive and constructivist grounded theory methods were used to analyze the data. Findings suggest that pain, and not earlier symptoms of a bleed, is the primary sign that prompts men to treat or seek medical help. Older men were most insightful about hemophilia and experienced the most physical and work limitations, particularly those who acquired viral infections through factor use. Many men reported experiencing a high number of injuries in adolescence, particularly in high school, a critical time period in the development of a man’s identity. Findings suggest that the process of learning to manage hemophilia extends into young adulthood and masculinities impact men’s experiences of severe hemophilia and hemophilia management decisions. Limitations imposed on men by hemophilia prompted them to rebel or protest against it by engaging in risky physical activities or delaying treatment regardless of perceptions of long-term health consequences. Men with hemophilia may benefit from education about early signs of bleeds and improved support in transitioning from adolescence into adulthood. Some masculine ideals can be mobilized to optimize hemophilia management practices that could enable men to surmount limitations and achieve personal goals across their lifespan.
Student Practice Education is an important topic to clinical education. There has been little to no research assessing whether or not clinical units are prepared to host student practice education, nor has there been much research focused on how to evaluate readiness to host student practice education.The purpose of this study was to assess the content and face validity of an original questionnaire which will measure readiness to host student practice. The questionnaire includes concepts related to student practice education, such as communication processes, job descriptions, leadership structures, organizational goals, data collection and analysis and support.Data were collected via five focus groups, in which the items of the questionnaire were discussed with individuals in various leadership roles relating to student practice education. The questions were rated by the participants on a relevancy scale, which were later analyzed by calculating median scores. A thematic analysis was done of the focus group transcripts to identify themes related to student practice education infrastructure and processes.Median scores were calculated for the relevancy ratings and revealed that the questions of the survey were considered very relevant or essential to assess readiness to host student practice education. Content analysis also revealed four themes specific to student practice education: infrastructure for communication, lack of familiarity with leadership structure amongst health care professionals, job descriptions and lack of familiarity with organizational goals amongst health care professionals.Student practice education and health care are interconnected. The health care organization and clinical units provide experiential educational opportunities for students, in which effective leadership, communication and educational structures would be beneficial. More research on communication, leadership, and organizational infrastructure, in relation to student practice education could be beneficial in critically examining the health care system and readiness for student practice education.
A strong link has been made between dietary content and cardiac disease risk. Diets high in fruits, vegetables, whole grains, fish and poultry and lower in red meat have been shown to lower cardiac disease risk in both women and men. National diet guidelines, such as the Canada’s Food Guide (CFG), provide information on basic healthful eating. The CFG, however, lacks the details that are recommended in several cardiac disease-specific diets. The Alternate Health Eating Index (AHEI) is a scoring index that accounts for specific dietary factors such as types of fat, forms of carbohydrates and specific protein sources. High levels of adherence to the AHEI are associated with significantly lower cardiovascular disease risk in both men and women. This study evaluated dietary pattern for cardiac participants over a 16 month period; AHEI score and CFG adherence were measured, AHEI trends over time were examined and differences in AHEI scores based on sex, education level and income were examined. There was moderate correlation between the AHEI and CFG scores (r= 0.73, p=0.001). There were no significant changes over time for either food score and no sex differences noted. Participants with an education level greater than high school had significantly higher AHEI scores at baseline. Intake of fruits and vegetables did not meet recommended amounts at any time, though fibre intake well exceeded the recommendations for both men and women. Future evaluation of patients who receive formal cardiac rehabilitation may improve understanding of how the AHEI can be used as a tool for dietary evaluation in cardiac patients.
Sedation and analgesia are integral to successful colonoscopy completion and controversy surrounds the optimal pharmacokinetic agent that will target and maintain a moderate sedation level, offer operational efficiency with reduced recovery time, and minimize risk for cardiopulmonary complications. Current practice is imprecise; manual administration of procedural sedation using a combination of benzodiazepine and opioids puts patients at risk for descending into deeper levels of sedation, which can lead to risk for cardiorespiratory depression, and an increase in recovery times for up to two hours.Studies have reported that propofol, a sedative agent with a short half life, can result in a shorter recovery, however there is limited research that has used consistent measurement to evaluate the procedural sedation recovery process or the influence of predictors such as age, sex, medication history, medical history, procedure time and body mass index (BMI), on recovery time and cardiopulmonary risk.Therefore, a non-experimental descriptive retrospective study was undertaken with two groups of 100 subjects who had either midazolam administered manually or propofol administered using the Sedasys® System for colonoscopy to explore the differences in procedure length and recovery time between these groups.Participants in the propofol group were somewhat younger and healthier than those in the midazolam group; average age 50.1 years versus 58.9 years, took fewer cardiac medications, had a lower BMI, and a lower incidence of cardiac or respiratory disease.Multiple regression analyses were conducted to assess the contribution of independent clinical predictors (age, sex, BMI, medical history and medication history) for duration of recovery from procedural sedation and analgesia and the incidence of sedation-relatediiadverse events. Propofol provided the largest contribution to the variance in recovery time after controlling for other significant predictors (R-squared = 0.22). Based on the MOAA/S score, participants who received propofol were discharged home sooner than those who received midazolam. There were no adverse events in either group.The results of this study suggest that propofol for procedural sedation during colonoscopy may improve efficiencies and throughput in the endoscopy suite and may provide a safe means that can assist in meeting the rising demand for colonoscopy.