Self-rating scales in the assessment of current and childhood symptoms of attention deficit hyperactivity disorder in adults

Objective: Attention deficit hyperactivity disorder (ADHD) is a life-long condition, but because of its historical status as a self-remitting disorder of childhood, empirically validated and reliable methods for the assessment of adults are scarce. In this study, the validity and reliability of the Wender Utah Rating Scale (WURS) and the Adult Problem Questionnaire (APQ), which survey childhood and current symptoms of ADHD, respectively, were studied in a Finnish sample. Methods: The self-rating scales were administered to adults with an ADHD diagnosis (n = 38), healthy control participants (n = 41), and adults diagnosed with dyslexia (n = 37). Items of the self-rating scales were subjected to factor analyses, after which the reliability and discriminatory power of the subscales, derived from the factors, were examined. The effects of group and gender on the subscales of both rating scales were studied. Additionally, the effect of age on the subscales of the WURS was investigated. Finally, the diagnostic accuracy of the total scores was studied. Results: On the basis of the factor analyses, a four-factor structure for the WURS and five-factor structure for the APQ had the best fit to the data. All of the subscales of the APQ and three of the WURS achieved sufficient reliability. The ADHD group had the highest scores on all of the subscales of the APQ, whereas two of the subscales of the WURS did not statistically differ between the ADHD and the Dyslexia group. None of the subscales of the WURS or the APQ was associated with the participant's gender. However, one subscale of the WURS describing dysthymia was positively correlated with the participant's age. With the WURS, the probability of a correct positive classification was .59 in the current sample and .21 when the relatively low prevalence of adult ADHD was taken into account. The probabilities of correct positive classifications with the APQ were .71 and .23, respectively. Conclusions: The WURS and the APQ can provide accurate and reliable information of childhood and adult ADHD symptoms, given some important constraints. Classifications made on the basis of the total scores are reliable predictors of ADHD diagnosis only in populations with a high proportion of ADHD and a low proportion of other similar disorders. The subscale scores can provide detailed information of an individual's symptoms if the characteristics and limitations of each domain are taken into account. Improvements are suggested for two subscales of the WURS.

Polymerization of Ethene and Branched α-olefins with Group IV Metal Complexes Bearing Nitrogen- and Oxygen-Based Ligands

The commodity plastics that are used in our everyday lives are based on polyolefin resins and they find wide variety of applications in several areas. Most of the production is carried out in catalyzed low pressure processes. As a consequence polymerization of ethene and α-olefins has been one of the focus areas for catalyst research both in industry and academia. Enormous amount of effort have been dedicated to fine tune the processes and to obtain better control of the polymerization and to produce tailored polymer structures The literature review of the thesis concentrates on the use of Group IV metal complexes as catalysts for polymerization of ethene and branched α-olefins. More precisely the review is focused on the use of complexes bearing [O,O] and [O,N] type ligands which have gained considerable interest. Effects of the ligand framework as well as mechanical and fluxional behaviour of the complexes are discussed. The experimental part consists mainly of development of new Group IV metal complexes bearing [O,O] and [O,N] ligands and their use as catalysts precursors in ethene polymerization. Part of the experimental work deals with usage of high-throughput techniques in tailoring properties of new polymer materials which are synthesized using Group IV complexes as catalysts. It is known that the by changing the steric and electronic properties of the ligand framework it is possible to fine tune the catalyst and to gain control over the polymerization reaction. This is why in this thesis the complex structures were designed so that the ligand frameworks could be fairly easily modified. All together 14 complexes were synthesised and used as catalysts in ethene polymerizations. It was found that the ligand framework did have an impact within the studied catalyst families. The activities of the catalysts were affected by the changes in complex structure and also effects on the produced polymers were observed: molecular weights and molecular weight distributions were depended on the used catalyst structure. Some catalysts also produced bi- or multi-modal polymers. During last decade high-throughput techniques developed in pharmaceutical industries have been adopted into polyolefin research in order to speed-up and optimize the catalyst candidates. These methods can now be regarded as established method suitable for both academia and industry alike. These high-throughput techniques were used in tailoring poly(4-methyl-1-pentene) polymers which were synthesized using Group IV metal complexes as catalysts. This work done in this thesis represents the first successful example where the high-throughput synthesis techniques are combined with high-throughput mechanical testing techniques to speed-up the discovery process for new polymer materials.

A Critical Evaluation of the MARS Treatment in Finland

The Molecular Adsorbent Recirculating System (MARS) is an extracorporeal albumin dialysis device which is used in the treatment of liver failure patients. This treatment was first utilized in Finland in 2001, and since then, over 200 patients have been treated. The aim of this thesis was to evaluate the impact of the MARS treatment on patient outcome, the clinical and biochemical variables, as well as on the psychological and economic aspects of the treatment in Finland. This thesis encompasses 195 MARS-treated patients (including patients with acute liver failure (ALF), acute-on-chronic liver failure (AOCLF) and graft failure), and a historical control group of 46 ALF patients who did not undergo MARS. All patients received a similar standard medical therapy at the same intensive care unit. The baseline data (demographics, laboratory and clinical variables) and MARS treatment-related and health-related quality-of-life data were recorded before and after treatment. The direct medical costs were determined for a period of 3.5 years.Additionally, the outcome of patients (survival, native liver recovery and need for liver transplantation) and survival predicting factors were investigated. In the outcome analysis, for the MARS-treated ALF patients, their 6-month survival (75% vs. 61%, P=0.07) and their native liver recovery rate (49% vs. 17%, P<0.001) were higher, and their need for transplantations was lower (29% vs. 57%, P= 0.001) than for the historical controls. However, the etiological distribution of the ALF patients referred to our unit has changed considerably over the past decade and the percentage of patients with a more favorable prognosis has increased. The etiology of liver failure was the most important predictor of the outcome. Other survival predicting factors in ALF included hepatic encephalopathy, the coagulation factors and the liver enzyme levels prior to MARS treatment. In terms of prognosis, the MARS treatment of the cirrhotic AOCLF patient seems meaningful only when the patient is eligible for transplantation. The MARS treatment appears to halt the progression of encephalopathy and reduce the blood concentration of neuroactive amino acids, albumin-bound and water-soluble toxins. In general, the effects of the MARS treatment seem to stabilize the patients, thus allowing additional time either for the native liver to recover, or for the patients to endure the prolonged waiting for transplantation. Furthermore, for the ALF patients, the MARS treatment appeared to be less costly and more cost-efficient than the standard medical therapy alone. In conclusion, the MARS treatment appears to have a beneficial effect on the patient outcome in ALF and in those AOCLF patients who can be bridged to transplantation.

Group Beliefs : Studies on the Nature and Logic of Collective Doxastic Attitudes

This thesis studies the nature and logic of collective doxastic attitudes, or what is referred to in ordinary language as "group beliefs". Beliefs and other intentional attitudes are attributed to groups and collections of people, and such attributions are used to explain and predict the actions of groups. The thesis develops an understanding of group beliefs as voluntarily adopted views or acceptances rather than as ordinary beliefs. Such an understanding can provide new answers to questions concerning collective knowledge and justification of group beliefs, and it allows developing modal logics with collective doxastic and epistemic notions. The thesis consists of six articles. The first three articles are philosophical studies concerned with the nature of group beliefs. The last three articles are logical studies that aim at developing proof-theoretical calculi for reasoning about collective doxastic attitudes.

An Analysis of the Concept of Citizenship: Legal, Political and Social Dimensions

The thesis aims at analyzing concept of citizenship in political philosophy. The concept of citizenship is a complex one: it does not have a definitive explication, but it nevertheless is a very important category in contemporary world. Citizenship is a powerful ideal, and often the way a person is treated depends on whether he or she has the status of a citizen. Citizenship includes protection of a person’s rights both at home and abroad. It entails legal, political and social dimension: the legal status as a full member of society, the recognition of that status by fellow citizens and acting as a member of society. The thesis discusses these three dimensions. Its objective is to show how all of them, despite being insufficient in some aspects, reach something important about the concept. The main sources of the thesis are Civic Republicanism by Iseult Honohan (Routledge 2002), Republicanism by Philip Pettit (Clarendon Press 1997), and Taking Rights Seriously by Ronald Dworkin (1997). In addition, the historical part of the thesis relies mainly on the works of Aristotle, Immanuel Kant, Adam Smith, Quentin Skinner, James Pocock and James Tully. The writings of Will Kymlicka, John Rawls, Chantal Mouffe, and Shane Phelan are referred to in the presentation and critique of the liberal tradition of thought. Hannah Arendt and Seyla Benhabib’s analysis of Arendt’s philosophy both address the problematic relations between human rights and nation-states as the main guarantors of rights. The chapter on group rights relies on Peter Jones’ account of corporate and collective rights, after which I continue to Seumas Miller’s essay on the (liberal) account of group rights and their relation to the concept of citizenship. Republicanism and Political Theory (2002) edited by Cécile Laborde and John Maynor is also references. David Miller and Maurizio Viroli represent the more “rooted” version of republicanism. The thesis argues that the full concept of citizenship should be seen as containing legal, political and social dimensions. The concept can be viewed from all of these three angles. The first means that citizenship is connected with certain rights, like the right to vote or stand for election, the right to property and so on. In most societies, the law guarantees these rights to every citizen. Then there is also the social dimension, which can be said to be as important as the legal one: the recognition of equality and identities of others. Finally, there is the political dimension, meaning the importance of citizens’ participation in the society, which is discussed in connection with the contemporary account of republicanism. All these issues are discussed from the point of view of groups demanding for group-specific rights and equal recognition. The challenge with these three aspects of citizenship is, however, that they are difficult to discuss under one heading. Different theories or discourses of citizenship each approach the subject from different starting points, which make reconciling them sometimes hard. The fundamental questions theories try to answer may differ radically depending on the theory. Nevertheless, in order to get the whole image of what the citizenship discourses are about all the aspects deserve to be taken into account.

Ryhmäidentiteetin mittaaminen verkkoroolipelissä World of Warcraft

The objective of the study was to explore the dimensions of group identity in the guilds of World of Warcraft. Previous research shows that social interaction has an important role in playing games for many players. Social identities are an important aspect of self-concept and since group related cues are more salient than personal clues in computer-mediated communication, the social gaming experience was approached through group identity. In the study a new scale will be developed to measure the group identity in games. Secondary goal is to study how different guild attributes affect the group identity and third goal is to explore the connection between group identity and gaming experience and amount of play. Subjects were 1203 guild members and 106 players not in a guild. The data was gathered by an Internet survey which measured group identity with nine scales, gaming experience with three scales and guild attributes with four scales. Also various background data was gathered. The construct of group identity was analyzed with explorative factor analysis. The typical experiences of group identity was analyzed with cluster analysis and effects of guild attributes with multivariate analysis of covariance. As a result of the study a new scale was developed which measured group identity on six dimensions: self-stereotyping, public and private evaluation, importance, interconnection of self and others and awareness of content. Group identity was experienced strongest in elder middle-sized guilds that had formal rules and that emphasized social interaction. The players with strong group identity had more positive gaming experience and played World of Warcraft more per week than the players who were not in a guild or identified to guild weakly. This result encourages game developers to produce environments that enhance group identity as it seems to increase the enjoyment in games. As a whole this study proposes that group identity in guilds is constructed from the same elements as in traditional groups. If this is truly the case, guild membership may have similar positive effects on individual’s mental well-being as traditional positively evaluated group memberships have.

Q-evankeliumi ja psykohistoria : Uuden testamentin eksegetiikan väitöskirja

In the course of my research for my thesis The Q Gospel and Psychohistory, I moved on from the accounts of the Cynics ideals to psychohistorical explanations. Studying the texts dealing with the Cynics and the Q Gospel, I was amazed by the fact that these texts actually portrayed people living in greater poverty than they had to. I paid particular attention to the fact that the Q Gospel was born in traumatising, warlike circumstances. Psychiatric traumatology helped me understand the Q Gospel and other ancient documents using historical approaches in a way that would comply with modern behavioural science. Even though I found some answers to the questions I had posed in my research, the main result of my research work is the justification of the question: Is it important to ask whether there is a connection between the ethos expressed by means of the religious language of the Q Gospel and the predominantly war-related life experiences typical to Palestine at the time. As has been convincingly revealed by a number of studies, traumatic events contribute to the development of psychotic experiences. I approached the problematic nature, significance and complexity of the ideal of poverty and this warlike environment by clarifying the history of psychohistorical literary research and the interpretative contexts associated with Sigmund Freud, Jacques Lacan and Melanie Klein. It is justifiable to question abnormal mentality, but there is no reliable return from the abnormal mentality described in any particular text to the only affecting factor. The popular research tendency based on the Oedipus complex is just as controversial as the Oedipus complex itself. The sociological frameworks concerning moral panics and political paranoia of an outer and inner danger fit quite well with the construction of the Q Gospel. Jerrold M. Post, M.D., Professor of Psychiatry, Political Psychology and Interna-tional Affairs at George Washington University, and founder and director of the Center for the Analysis of Personality and Political Behavior for the Central Intelligence Agency, has focused on the role played by charisma in the attracting of followers and detailed the psychological styles of a "charismatic" leader. He wrote the books Political Paranoia and Leaders and Their Followers in a Dangerous World: the Psychology of Political Behavior among others. His psychoanalytic vocabulary was useful for my understanding of the minds and motivations involved in the Q Gospel s formation. The Q sect began to live in a predestined future, with the reality and safety of this world having collapsed in both their experience and their fantasies. The deep and clear-cut divisions into good and evil that are expressed in the Q Gospel reveal the powerful nature of destructive impulses, envy and overwhelming anxiety. Responsible people who influenced the Q Gospel's origination tried to mount an ascetic defense against anxiety, denying their own needs, focusing their efforts on another objective (God s Kingdom) and a regressive, submissive earlier phase of development (a child s carelessness). This spiritual process was primarily an ecclesiastic or group-dynamical tactic to give support to the power of group leaders.

The influence of school smoking policy and school prevention programs on the smoking behaviour of high school students in Prince Edward Island, Canada

The aim of the study was to examine the influence of school smoking policy and school smoking prevention programs on the smoking behaviour of students in high schools in Prince Edward Island using the School Health Action Planning Evaluation System (SHAPES). A total sample included 13,131 observations of students in grades 10-12 in ten high schools in Prince Edward Island over three waves of data collection (1999, 2000, and 2001). Changes in prevalence of smoking and factors influencing smoking behaviour were analyzed using descriptive statistics and Chi-Square tests. Multi-level logistic regression analyses were used to examine how both school and student characteristics were associated with smoking behaviour (I, II, III, IV). Since students were located within schools, a basic 2-level nested structure was used in which individual students (level 1) were nested within schools (level 2). For grade 12 students, the combination of both school policies and programs was not associated with the risk of smoking and the presence of the new policy was not associated with decreased risk of smoking, unless there were clear rules in place (I). For the grade 10 study, (II) schools with both policies and programs were not associated with decreased risk of smoking. However, the smoking behaviour of older students (grade 12) at a school was associated with younger students’ (grade 10) smoking behaviour. Students first enrolled in a high school in grade 9, rather than grade 10, were at increased risk of occasional smoking. For students who transitioned from grade 10 to 12 (III), close friends smoking had a substantial influence on smoking behaviour for both males and females (III). Having one or more close friends who smoke (Odds Ratio (OR) = 37.46; 95% CI = 19.39 to 72.36), one or more smokers in the home (OR = 2.35; 95% CI = 1.67 to 3.30) and seeing teachers and staff smoking on or near school property (OR=1.78; 95% CI = 1.13 to 2.80), were strongly associated with increased risk of smoking for grade 12 students. Smoking behaviour increased for both junior (Group 1) and senior (Group 2) students (IV). Group 1 students indicated a greater decrease in smoking behaviour and factors influencing smoking behaviour compared to those of Group 2. Students overestimating the percentage of youth their age who smoke was strongly associated with increased likelihood of smoking. Smoking rates showed a decreasing trend (1999, 2000, and 2001). However, policies and programs alone were not successful in influencing smoking behaviour of youth. Rather, factors within the students and schools contextual environment influenced smoking behaviour. Comprehensive approaches are required for school-based tobacco prevention interventions. Keywords: schools, policy, programs, smoking prevention, adolescents Subject Terms: school-based programming, public health, health promotion

Income inequality in the process of economic development : An empirical approach

This thesis studies the effect of income inequality on economic growth. This is done by analyzing panel data from several countries with both short and long time dimensions of the data. Two of the chapters study the direct effect of inequality on growth, and one chapter also looks at the possible indirect effect of inequality on growth by assessing the effect of inequality on savings. In Chapter two, the effect of inequality on growth is studied by using a panel of 70 countries and a new EHII2008 inequality measure. Chapter contributes on two problems that panel econometric studies on the economic effect of inequality have recently encountered: the comparability problem associated with the commonly used Deininger and Squire s Gini index, and the problem relating to the estimation of group-related elasticities in panel data. In this study, a simple way to 'bypass' vagueness related to the use of parametric methods to estimate group-related parameters is presented. The idea is to estimate the group-related elasticities implicitly using a set of group-related instrumental variables. The estimation results with new data and method indicate that the relationship between income inequality and growth is likely to be non-linear. Chapter three incorporates the EHII2.1 inequality measure and a panel with annual time series observations from 38 countries to test the existence of long-run equilibrium relation(s) between inequality and the level of GDP. Panel unit root tests indicate that both the logarithmic EHII2.1 inequality measure and the logarithmic GDP per capita series are I(1) nonstationary processes. They are also found to be cointegrated of order one, which implies that there is a long-run equilibrium relation between them. The long-run growth elasticity of inequality is found to be negative in the middle-income and rich economies, but the results for poor economies are inconclusive. In the fourth Chapter, macroeconomic data on nine developed economies spanning across four decades starting from the year 1960 is used to study the effect of the changes in the top income share to national and private savings. The income share of the top 1 % of population is used as proxy for the distribution of income. The effect of inequality on private savings is found to be positive in the Nordic and Central-European countries, but for the Anglo-Saxon countries the direction of the effect (positive vs. negative) remains somewhat ambiguous. Inequality is found to have an effect national savings only in the Nordic countries, where it is positive.

Jaksaako opettaja kehittyä? : Ammatillisen kehityksen ja täydennyskoulutuksen merkitys opettajien työssä jaksamisessa

The aim of this study was to investigate the connection between teachers' burn-out and professional development. In addition, the study aimed at clarifying teachers' conceptions of the significance of in-service training on work-related well-being. The theoretical starting points of the study were based on a model of burn-out (Kalimo & Toppinen1997) and a model of teachers' professional development (Niemi 1989). Present study can be seen as an independent follow-up study for a working ability project called "Uudistumisen eväät" that was followed through in Kuopio. The study was carried out in two phases. First, the connection between teachers' burn-out and professional development was charted with the help of a quantitative survey study. 131 teachers participated in the survey. Some of them were from schools that participated in the working ability project and the remainder were from other schools in Kuopio. The questionnaire consisted of self-constructed instruments of burn-out and professional development. According to the results, burn-out and professional development were strongly correlated with each other. Burn-out was summed up in three factors: emotional exhaustion, feelings of depersonalization and low feelings of personal accomplishment. Professional development was summed up in four factors: personality and pedagogical skills, learning-orientation, social skills and confronting change. Personality and pedagogical skills and skills of confronting change were correlated strongest with burn-out and its symptoms. A teacher, who has not found his/her own personal way of acting as a teacher and who considers change as something negative, is more likely to become exhausted than a teacher, who has developed his/her own pedagogical identity and who regards change more positively. In the second phase of this study, teachers' conceptions of the significance of in-service training on well-being was investigated with the help of group interviews (n=12). According to the results, the importance of in-service training was significant on the well-being of teachers. It appeared that in-service training promotes well-being by providing teachers with motivation, professional development and the possibility of taking a break from teaching and cooperating with other teachers. It has to be based on teachers' own needs. It has to be offered to teachers frequently and early enough. If teachers are already exhausted, they will neither have enough resources to participate in training, nor will they have the strength to make good use of it in practice. Both professional development and well-being are becoming more and more essential now that society is changing rapidly and the demands set on teachers are growing. Professional development can promote well-being, but are teachers too exhausted to develop themselves? Professional development demands resources and teachers may regard it as a threat and an additional strain. When the demands are so high that teachers cannot cope with them, they are likely to suffer stress and see reduction of commitment to their work and its development as a means to survive. If teachers stop caring about their work and their own development, how can we expect them to promote pupils' learning and development? It should be considered in the planning and implementation of in-service training and in arranging teachers' working conditions, that teachers have enough time and resources to develop themselves. Keywords: Teachers, burn-out, well-being, professional development, in-service training

Ryhmärajoja ja hierarkioita : etnografinen tutkimus peruskoulun yläasteen liikunnanopetuksesta

This study examines gender as a dimension of group divisions and differences in physical education (PE) lessons at school. The aim is to look at those structures and practices which direct the ways the girls and the boys move their bodies at secondary school in 2000’s while growing up to become women and men. Theoretically, the goal is to clarify how the social is inscribed to the bodies in the context of physical education lessons at school. This ethnographic study was conducted in the physical education lessons of 7th graders (13-14-year-olds) by observing the everyday life in five PE groups and by interviewing pupils (N=27) and their teachers (N=2). This method has given the researcher “a sense of the game”; an embodied experience of the feel for the game of the studied phenomenon. The access to the contextual “positions of expertise” does not seem to be socially and materially equally distributed in physical education. In PE the criteria of inclusion and exclusion were intertwined with physical skills and friendships, these hierarchies becoming visible in the situations of team choice in PE lessons. Not all families have possibilities to enable their children to participate in expensive leisure sports activities. Therefore the family’s societal position is in relation to the construction of leisure time activities. The access to certain possibilities demands time and money. In Finland the physical education is mainly carried out in differentiated groups for girls and boys. In physical education, the gender-differentiated groups, and partially the different practices of these groups activate, and on the other hand suppress, situations of gender related borderwork. In this research, both pupils and PE teachers repeatedly mentioned the naturality of the differences while speaking about gender. The differences were also restored to gender. I apply Erving Goffman’s dramaturgical view to the social situations, ethnographic fieldwork and interviews. My central statement is that in ethnography the audience has access to the backstage of the researcher since reporting does not follow the traditional division to the public and the private.

Yliopisto-opetuksen yhteistoiminnallinen kehittäminen

The main aim of this work is to study the possibility of applying the cooperative learning approach to develop academic learning and teaching culture. In this work cooperative learning refers to a pedagogical approach that applies social psychological knowledge of group dynamics and small group teaching. Furthermore, theories of collaborative learning and organization development have been applied. Based on these theories a model of developing learning and teaching culture was developed. The model was tested in the development project that was carried out in the Faculty of Agriculture and Forestry of Helsinki University. The research questions were: How were the theories of cooperative and collaborative learning and organization development applied in the project? What kind of effects did the development project have on the learning and teaching culture? Through which kind of mechanisms did the project influence this culture? How should the development model be revised after the empirical test? The project lasted five years and the major part of the project consisted of a one-year pedagogical training course. Altogether 145 people (teachers, researchers, library staff, and students) participated in the training, two to three departments at a time. In the pedagogical training cooperative learning methods were widely used. A questionnaire was used to study effects of the development project. The questionnaire was sent to 87 people and 65.5 % answered it. Both the answers to the questionnaire and a sample of learning diaries (n=61) were used to study the mechanism of the project. A sample of the learning diaries consisted of two pedagogical training group members diaries. The frequency distributions were calculated as extrapolations from the answers to the structured questions. Furthermore the answers were classified by the main background variables. The analysis of the open answers to the questionnaire and the learning diaries were data-based. According to the answers to the questionnaire, the effects of the pedagogical training were as follows: The participants consider learning more as an active process of constructing knowledge. Furthermore they considered the individual learning styles and strategies, cooperation and motivation as more important part of the learning process than before the pedagogical training. The role of the teacher was viewed more challenging than before. Additionally the cooperation between teachers, other staff members and students had projected to increase. After the project had ended the teaching methods in the whole faculty were viewed to become varied and the teaching was considered to be more valued than before. According to the answers to the questionnaire, the project influenced through the following ways: the project stimulated the change process, provided new methods for learning and teaching, had an effect on conceptions of learning and teaching and facilitated meaningful communication with others (staff and students). The analysis of the learning diaries supported these findings. In addition, the analysis of the learning diaries deepened the understanding of how the cooperative learning methods supported positive learning atmosphere and reduced the negative effect of the status differences between the members of the group. The critical comments in the learning diaries could be interpreted as collision between cooperative and traditional teaching culture. Cooperative learning gives theory-based methods to develop academic learning and teaching culture. The approach helps the developer to create positive collaborative learning environment and gives ways to support learning in small groups, which can promote cultural change. On the other hand, to understand the whole process of organization development and promote change the theories of organizations and more sosioconstructivist theory of learning are needed. Cooperative learning, collaborative learning, higher education, group dynamics, social constructionism, organisational culture, organisation development

Current Care Guidelines for Cardiopulmonary Resuscitation : Implementation, skills and attitudes

Background: The national resuscitation guidelines were published in Finland in 2002 and are based on international guidelines published in 2000. The main goal of the national guidelines, available on the Internet free of charge, is early defibrillation by nurses in an institutional setting. Aim: To study possible changes in cardiopulmonary resuscitation (CPR) practices, especially concerning early defibrillation, nurses and students attitudes of guideline implementation and nurses and students ability to implement the guideline recommendations in clinical practices after publication of the Current Care (CC) guidelines for CPR 2002. Material and methods: CPR practices in Finnish health centres; especially concerning rapid defibrillation programmes, as well as the implementation of CC guidelines for CPR was studied in a mail survey to chief physicians of every health centre in Finland (Study I). The CPR skills using an automated external defibrillator (AED) were compared in a study including Objective stuctured clinical examination (OSCE) of resuscitation skills of nurses and nursing students in Finnish and Swedish hospital and institution (Studies II, III). Attitudes towards CPR-D and CPR guidelines among medical and nursing students and secondary hospital nurses were studied in surveys (Studies IV, V). The nurses receiving different CPR training were compared in a randomized trial including OSCE of CPR skills of nurses in Finnish Hospital (Study VI). Results: Two years after the publication, 40.7% of Finnish health centres used national resuscitation guidelines. The proportion of health centres having at least one AED (66%) and principle of nurse-performed defibrillation without the presence of a physician (42%) had increased. The CPR-D training was estimated to be insufficient regarding basic life support and advanced life support in the majority of health centres (Study I). CPR-D skills of nurses and nursing students in two specific Swedish and Finnish hospitals and institutions (Study II and III) were generally inadequate. The nurses performed better than the students and the Swedish nurses surpassed the Finnish ones. Geriatric nurses receiving traditional CPR-D training performed better than those receiving an Internet-based course but both groups failed to defibrillate within 60 s. Thus, the performance was not satisfactory even two weeks after traditional training (Study VI). Unlike the medical students, the nursing students did not feel competent to perform procedures recommended in the cardiopulmonary resuscitation guidelines including the defibrillation. However, the majority of nursing students felt confident about their ability to perform basic life support. The perceived ability to defibrillate correlated significantly with a positive attitude towards nurse-performed defibrillation and negatively with fear of damaging the patient s heart by defibrillation (Study IV). After the educational intervention, the nurses found their level of CPR-D capability more sufficient than before and felt more confident about their ability to perform defibrillation themselves. A negative attitude toward defibrillation correlated with perceived negative organisational attitudes toward cardiopulmonary resuscitation guidelines. After CPR-D education in the hospital, the majority (64%) of nurses hesitated to perform defibrillation because of anxiety and 27 % hesitated because of fear of injuring the patient. Also a negative personal attitude towards guidelines increased markedly after education (Study V). Conclusions: Although a significant change had occurred in resuscitation practices in primary health care after publication of national cardiopulmonary resuscitation guidelines the participants CPR-D skills were not adequate according to the CPR guidelines. The current way of teaching is unlikely to result in participants being able to perform adequate and rapid CPR-D. More information and more frequent training are needed to diminish anxiety concerning defibrillation. Negative beliefs and attitudes toward defibrillation affect the nursing students and nurses attitudes toward cardiopulmonary resuscitation guidelines. CPR-D education increased the participants self-confidence concerning CPR-D skills but it did not reduce their anxiety. AEDs have replaced the manual defibrillators in most institutions, but in spite of the modern devices the anxiety still exists. Basic education does not provide nursing students with adequate CPR-D skills. Thus, frequent training in the workplace has vital importance. This multi-professional program supported by the administration might provide better CPR-D skills. Distance learning alone cannot substitute for traditional small-group learning, tutored hands-on training is needed to learn practical CPR-D skills. Standardized testing would probably help controlling the quality of learning. Training of group-working skills might improve CPR performance.

Metsän erirakenteisuutta edistävien hakkuiden kannattavuustarkastelu metsäaluetasolla

Tutkimuksessa vertailtiin metsän erirakenteisuutta edistävien poimintahakkuiden ja pienaukkohakkuiden kannattavuutta metsänhoitosuositusten mukaiseen metsänkasvatukseen Keski-Suomessa. Poimintahakkuut ja pienaukkohakkuut ovat menetelmiä, joilla voidaan lisätä luonnonmetsän häiriödynamiikan mukaista pienipiirteistä elinympäristöjen vaihtelua ja siksi ne sopivat etenkin erityiskohteisiin monimuotoisuuden, maiseman tai metsien monikäytön vuoksi. Ne johtavat yleensä vähitellen eri-ikäisrakenteiseen metsään, jossa puuston läpimittaluokkajakauma muistuttaa käänteistä J-kirjainta. Eri-ikäisrakenteisen metsänkäsittelyn taloudellista kannattavuutta puoltavat uudistumiskustannusten poisjäänti ja tukkipuihin painottuvat säännöllisin väliajoin toteutuvat hakkuut. Menetelmän soveltumista Suomen olosuhteisiin pidetään kuitenkin epävarmana. Tässä tutkimuksessa tarkasteltiin tasaikäisrakenteisen metsän muuttamista eri-ikäisrakenteiseksi 40 vuoden siirtymäaikana Metsähallituksen hallinnoimassa Isojäven ympäristöarvometsässä Kuhmoisissa. Tutkimusaineisto koostui 405 kuusivaltaisesta tasaikäisestä kuviosta, joiden pinta-alasta metsämaata on 636 hehtaaria. Metsän kehitystä simuloitiin puutason kasvumalleja käyttäen ja käsittelytoimenpiteet simuloitiin viisivuotiskausittain SIMO-metsäsuunnitteluohjelmistolla. Simulointien avulla selvitettiin jokaisen käsittelyskenaarion hakkuumäärät puutavaralajeittain, diskontatut kassavirrat ja puustopääoman muutos tarkasteluajanjakson aikana. Puunkorjuun yksikkökustannusten laskennan apuna käytettiin automatisoitua seurantajärjestelmää, jossa metsäkoneisiin asennettuilla matkapuhelimilla kerättiin MobiDoc2-sovelluksella metsäkoneiden käytöstä kiihtyvyystiedot, GPS-paikkatiedot ja syötetiedot. Lopulta jokaiselle käsittelyskenaariolle laskettiin metsän puuntuotannollista arvoa kuvaavalla tuottoarvon yhtälöllä nettonykyarvot, josta vähennettiin diskontatut puunkorjuun kustannukset. Tutkimuksen tulosten mukaan poimintahakkuun NPV oli 3 prosentin korkokannalla noin 91 % (7420 €/ha) ja pienaukkohakkuiden noin 99 % (8076 €/ha) metsänhoitosuositusten mukaisesta käsittelystä (8176 €/ha). Komparatiivinen statiikka osoitti, että korkokannan kasvattaminen 5 prosenttiin ei olennaisesti lisännyt nettonykyarvojen eroja. Poimintahakkuiden puunkorjuun yksikkökustannukset olivat 0,8 €/m3 harvennushakkuita pienemmät ja 7,2 €/m3 uudistushakkuita suuremmat. Pienaukkohakkuiden yksikkökustannukset olivat 0,7 €/m3 uudistushakkuita suuremmat.Tulosten perusteella on väistämätöntä että siirtymävaihe tasaikäisrakenteisesta eri-ikäisrakenteiseksi metsäksi aiheuttaa taloudellisia tappioita siitäkin huolimatta, että hakkuut ovat voimakkaita ja tehdään varttuneeseen kasvatusmetsään. Tappion määrä on metsän peitteisyyden ylläpidosta aiheutuva vaihtoehtoiskustannus.