On the impact of rigorous approaches on the quality of development

Software systems are expanding and becoming increasingly present in everyday activities. The constantly evolving society demands that they deliver more functionality, are easy to use and work as expected. All these challenges increase the size and complexity of a system. People may not be aware of a presence of a software system, until it malfunctions or even fails to perform. The concept of being able to depend on the software is particularly significant when it comes to the critical systems. At this point quality of a system is regarded as an essential issue, since any deficiencies may lead to considerable money loss or life endangerment. Traditional development methods may not ensure a sufficiently high level of quality. Formal methods, on the other hand, allow us to achieve a high level of rigour and can be applied to develop a complete system or only a critical part of it. Such techniques, applied during system development starting at early design stages, increase the likelihood of obtaining a system that works as required. However, formal methods are sometimes considered difficult to utilise in traditional developments. Therefore, it is important to make them more accessible and reduce the gap between the formal and traditional development methods. This thesis explores the usability of rigorous approaches by giving an insight into formal designs with the use of graphical notation. The understandability of formal modelling is increased due to a compact representation of the development and related design decisions. The central objective of the thesis is to investigate the impact that rigorous approaches have on quality of developments. This means that it is necessary to establish certain techniques for evaluation of rigorous developments. Since we are studying various development settings and methods, specific measurement plans and a set of metrics need to be created for each setting. Our goal is to provide methods for collecting data and record evidence of the applicability of rigorous approaches. This would support the organisations in making decisions about integration of formal methods into their development processes. It is important to control the software development, especially in its initial stages. Therefore, we focus on the specification and modelling phases, as well as related artefacts, e.g. models. These have significant influence on the quality of a final system. Since application of formal methods may increase the complexity of a system, it may impact its maintainability, and thus quality. Our goal is to leverage quality of a system via metrics and measurements, as well as generic refinement patterns, which are applied to a model and a specification. We argue that they can facilitate the process of creating software systems, by e.g. controlling complexity and providing the modelling guidelines. Moreover, we find them as additional mechanisms for quality control and improvement, also for rigorous approaches. The main contribution of this thesis is to provide the metrics and measurements that help in assessing the impact of rigorous approaches on developments. We establish the techniques for the evaluation of certain aspects of quality, which are based on structural, syntactical and process related characteristics of an early-stage development artefacts, i.e. specifications and models. The presented approaches are applied to various case studies. The results of the investigation are juxtaposed with the perception of domain experts. It is our aspiration to promote measurements as an indispensable part of quality control process and a strategy towards the quality improvement.

Health-related quality of life in school children: validation of instrument, child self assessment, parent-proxy assessment and school nursing documentation of health check-ups

The aims of this study were to validate an international Health-Related Quality of Life (HRQL) instrument, to describe child self and parent-proxy assessed HRQL at child age 10 to 12 and to compare child self assessments with parent-proxy assessments and school nursing documentation. The study is part of the Schools on the Move –research project. In phase one, a cross-cultural translation and validation process was performed to develop a Finnish version of Pediatric Quality of Life Inventory™ 4.0 (PedsQL™ 4.0). The process included a two-way translation, cognitive interviews (children n=7, parents n=5) and a survey (children n=1097, parents n=999). In phase two, baseline and follow-up surveys (children n=986, parents n=710) were conducted to describe and compare the child self and parent-proxy assessed HRQL in school children between the ages 10 and 12. Phase three included two separate data, school nurse documented patient records (children n=270) and a survey (children n=986). The relation between child self assessed HRQL and school nursing documentation was evaluated. Validity and reliability of the Finnish version of PedsQL™ 4.0 was good (Child Self Report α=0.91, Parent-Proxy Report α=0.88). Children reported lower HRQL scores at the emotional (mean 76/80) than the physical (mean 85/89) health domains and significantly lower scores at the age of 10 than 12 (dMean=4, p=<0.001). Agreement between child self and parent-proxy assessment was fragile (r=0,4, p=<0.001) but increased as the child grew from age 10 to 12 years. At health check-ups, school nurses documented frequently children’s physical health, such as growth (97%) and posture (98/99%) but seldom emotional issues, such as mood (2/7%). The PedsQLTM 4.0 is a valid instrument to assess HRQL in Finnish school children although future research is recommended. Children’s emotional wellbeing needs future attention. HRQL scores increase during ages between childhood and adolescence. Concordance between child self and parent-proxy assessed HRQL is low. School nursing documentation, related to child health check-ups, is not in line with child self assessed HRQL and emotional issues need more attention.

Health Related Quality of Life after Childhood Cancer - A Finnish Nationwide survey

The purpose of this Finnish epidemiological nationwide cross-sectional study was to evaluate the Health Related Quality of Life (HRQL) of young people that have survived childhood cancer at least four years after cancer diagnosis. The study aims were (1) to increase knowledge and understanding about the relationship between childhood cancer and its treatment and HRQL of childhood cancer survivors and (2) to identify survivors who need and could benefit from ongoing long-term follow-up, as well as (3) to identify what kind of aftercare the childhood cancer survivors will possibly need. HRQL and fatigue of currently still young survivors of extracranial childhood malignancies were evaluated with self-reports and parent proxy reports. HRQL was measured with age-appropriate generic instruments: PedsQL™, SF-36, 15D, 16D and 17D. Fatigue for children and adolescents aged below 18 years was measured with the PedsQL™ Multidimensional Fatigue Scale Finnish version. PedsQL™ parent-proxy and the PedsQL™ Multidimensional Fatigue Scale Parentproxy instruments were used to assess the perception of the parents on HRQL and fatigue of their children and adolescents. Postal-survey questionnaires were mailed to 852 childhood cancer survivors aged 11-27 years and their randomly selected gender-, age and living-place matched controls, as well as under 18-year-old children´s parents. A total of 474 survivors, 595 controls, 209 survivor’s parent and 253 control’s parent replied. The mean age of survivors at the time of the study was 18.4 years. The mean length of survival was 12.3 years, and the mean age at diagnosis 5.5 years. The most of the Finnish childhood cancer survivors evaluated that their HRQL as good. Survivors rated their HRQL equal or higher than their controls. The only dimension where the survivors scored poorer than the controls was the 15D mobility dimension. Survivors of childhood cancer did not suffer from significant fatigue. There were subgroups of childhood cancer survivors who had poorer level of HRQL, and suffered from fatigue more than the reference group. The demographic factors that associated with poorer HRQL were female gender, greater weight, living alone, need of remedial education, an additional non-cancer diagnosis, survivors with siblings, and self-reported unhappiness. Disease-related factors that associated with poorer HRQL were higher age at the time of diagnosis, the diagnosis of Wilms tumor, neuroblastoma, or osteosarcoma, and treatment with stem cell transplantation. The factors associated with more fatigue in survivors were male gender, older age at evaluation, the need of remedial education at school, lower overall average grade in the latest school marks report, length of survival more than 10 years, lower HRQL-scores, and a sarcoma diagnosis. However, all the used demographic and disease related factors explained only about one third of the variation in the HRQL scores. In open questions, the survivors were most worried about their physical health, but were also worried about their mental health, cancer inheritance, late-effects, and fertility and relapse issues. It seems that there are subgroups of survivors who need and could benefit from ongoing long-term follow-up. In the future, the survivors of childhood cancer need more information about their physical and mental health, as well as on their cancer inheritance, possible late-effects including fertility issues, and on the risk of relapse.

Focusing on the quality of learning processes

S. 327-333

Understanding and improving quality of secondary school education : conceptions among teachers in Tanzania

Temat för studien handlar om gymnasielärares uppfattningar om kvalitet och om hur kvalitet kan utvecklas i gymnasieutbildningen in Tanzania. Studien är till sin karaktär kvalitativ och består av utprövade semistrukturerade intervjuer med sammanlagt trettio lärare som arbetar i fyra gymnasieskolor både i urbana och rurala miljöer. Lärarna har varierande arbetserfarenhet och undervisar i olika ämnen. Huvudfokus har gällt identifieringen av variationer i lärares uppfattningar om kvalitet. På basen av två forskningsfrågor avslöjar analysen uppfattningar av hur lärare förstår och önskar utveckla kvaliteten på gymnasieutbildningen. Resultaten visar att lärare förstår kvaliteten på utbildningen i sina skolor som försök att möta skolans och samhällets mål, som individuella prestationer och förmågor som att inneha kompetenser och som att möta utmaningar inom utbildning, Identifierade uppfattningar var baserade på lärarnas personliga kunskap, arbetsmiljön och varierande omständigheter som rådde i deras skolor. Uppfattningar om en förbättring av kvaliteten i gymnasieutbildningen innefattade utveckling av lärares motivation, skolmiljön, arbetet i klassrum, kvaliteten på lärares kunskaper och färdigheter och undervisningsmaterial. Ambitionen bakom studien ar att erbjuda en plattform för strategier för att förbättra kvaliteten på gymnasieutbildningen. Resultaten strävar till att ge en fördjupad insikt i uppfattningar hos en utvald grupp av lärare som arbetar under samma villkor inom gymnasieskolor I Tanzania. Av den här anledningen är den genererade kunskapen därför relevant för att belysa lärares uppfattningar även utanför den studerade gruppen av respondenter.

Coercion, Perceived Care and Quality of Life Among Patients in Psychiatric Hospitals

The goals of the study were to describe patients’ perceptions of care after experiencing seclusion/restraint and their quality of life. The goal was moreover to identify methodological challenges related to studies from the perspective of coerced patients. The study was conducted in three phases between September 2008 and April 2012. In the first phase, the instrument Secluded/ Restrained Patients’ Perception of their Treatment (SR-PPT) was developed and validated in Japan in cooperation with a Finnish research group (n = 56). Additional data were collected over one year from secluded/restrained patients using the instrument (n = 90). In the second phase, data were collected during the discharge process (n = 264). In the third phase, data were collected from electronic databases. Methodological and ethical issues were reviewed (n = 32) using systematic review method. Patients perceived that co-operation with the staff was poor; patients’ opinions were not taken into account, treatment targets collated and treatment methods were seen in different ways. Patients also felt that their concerns were not well enough understood. However, patients received getting nurses’ time. In particular, seclusion/restraint was considered unnecessary. The patients felt that they benefited from the isolation in treating their problems more than they needed it, even if the benefit was seen to be minor. Patients treated on forensic wards rated their treatment and care significantly lower than in general units. During hospitalization secluded/restrained patients evaluated their quality of life, however, better than did non-secluded/restrained patients. However, no conclusion is drawn to the effect that the better quality of life assessment is attributable to the seclusion/restraint because patients’ treatment period after the isolation was long and because of many other factors, as rehabilitation, medication, diagnostic differences, and adaptation. According to the systematic mixed studies review variation between study designs was found to be a methodological challenge. This makes comparison of the results more difficult. A research ethical weakness is conceded as regards descriptions of the ethical review process (44 %) and informed consent (32 %). It can be concluded that patients in psychiatric hospital care and having a voice as an equal expert require special attention to clinical nursing, decision-making and service planning. Patients and their family members will be consulted in plans of preventive and alternative methods for seclusion and restraint. The study supports the theory that in ethical decision-making situations account should be taken of medical indications, in addition to the patients’ preferences, the effect of treatment on quality of life, and this depends on other factors. The connection between treatment decisions and a patient’s quality of life should be evaluated more structurally in practice. Changing treatment culture towards patients’ involvement will support daily life in nursing and service planning taking into account improvements in patients’ quality of life.

Association between Information and Communication Technology Usage and the Quality of Sleep among School-Aged Children during a School Week

ilm OKM 2013

Quality of radiotherapy care by development of e-feedback knowledge

The aim of this three phase study was to develop quality of radiotherapy care by the e-Feedback knowledge of radiotherapy -intervention (e-Re-Know). In Phase I, the purpose was to describe the quality of radiotherapy care and its deficits experienced by cancer patients. Based on the deficits in patient education in Phase II, the purpose was to describe cancer patients’ e-knowledge expectations in radiotherapy. In Phase III, the purpose was to develop and evaluate the outcomes of the e-Re-Know among breast cancer patients. The ultimate aim was to develop radiotherapy care to support patients’ empowerment with patient e-education. In Phase I (2004-2005), the descriptive design was used, and 134 radiotherapy patients evaluated their experiences by Good Nursing Care Scale for Patients (GNCS-P) in the middle of RT period. In Phase II (2006-2008), the descriptive longitudinal design was used and 100 radiotherapy patients’ e-knowledge expectations of RT were evaluated using open-ended questionnaire developed for this study before commencing first RT, in the middle of the treatment, and concluding RT period. In Phase III, firstly (2009-2010), the e-Re-Know intervention, i.e. knowledge test and feedback, was developed in terms of empowering knowledge and implemented with e-feedback approach based on literature and expert reviews. Secondly (2011-2014), the randomized controlled study was used to evaluate the e-Re-Know. Breast cancer patients randomized to either the intervention group (n=65) receiving the e-Re-Know by e-mail before commencing first RT and standard education or the control group (n=63) receiving standard education. The data were collected before commencing first RT, concluding last RT and 3 months after last RT using RT Knowledge Test, Spielberger’s State Trait Inventory (STAI) and Functional Assessment of Cancer Therapy - Breast (FACT-B) –instruments. Data were analyzed using statistical methods and content analysis. The study showed radiotherapy patients experienced quality of care high. However, there were deficits in patient education. Furthermore, radiotherapy patients’ multidimensional e-knowledge expectations through Internet covered mainly bio-physiological and functional knowledge. Thus, the e-Re-Know was developed and evaluated. The study showed when breast cancer patients’ carried out the e-Re-Know their knowledge of side effects self-care was significantly increased and quality of life (QOL) significantly improved in line with decrease in anxiety from time before radiotherapy period to three months after. In addition, the e-Re-Know has potential to have positive effects on anxiety and QOL, regardless of patient characteristics or knowledge level. The results support the theory of empowering patient education suggesting that empowerment can be supported by confirming patients’ understanding of own knowledge level. In summary, the e-Feedback knowledge of radiotherapy (e-Re-Know) intervention can be recommended in development of quality of radiotherapy care experienced by breast cancer patients. Further research is needed to assess and develop patient-centred quality of care by patient education among cancer patients.

Geochemistry and water quality of Lake Qarun, Egypt

Water geochemistry is a very important tool for studying the water quality in a given area. Geology and climate are the major natural factors controlling the chemistry of most natural waters. Anthropogenic impacts are the secondary sources of contamination in natural waters. This study presents the first integrative approach to the geochemistry and water quality of surface waters and Lake Qarun in the Fayoum catchment, Egypt. Moreover, geochemical modeling of Lake Qarun was firstly presented. The Nile River is the main source of water to the Fayoum watershed. To investigate the quality and geochemistry of this water, water samples from irrigation canals, drains and Lake Qarun were collected during the period 2010‒2013 from the whole Fayoum drainage basin to address the major processes and factors governing the evolution of water chemistry in the investigation area. About 34 physicochemical quality parameters, including major ions, oxygen isotopes, trace elements, nutrients and microbiological parameters were investigated in the water samples. Multivariable statistical analysis was used to interpret the interrelationship between the different studied parameters. Geochemical modeling of Lake Qarun was carried out using Hardie and Eugster’s evolutionary model and a model simulated by PHREEQC software. The crystallization sequence during evaporation of Lake Qarun brine was also studied using a Jänecke phase diagram involving the system Na‒K‒Mg‒ Cl‒SO4‒H2O. The results show that the chemistry of surface water in the Fayoum catchment evolves from Ca- Mg-HCO3 at the head waters to Ca‒Mg‒Cl‒SO4 and eventually to Na‒Cl downstream and at Lake Qarun. The main processes behind the high levels of Na, SO4 and Cl in downstream waters and in Lake Qarun are dissolution of evaporites from Fayoum soils followed by evapoconcentration. This was confirmed by binary plots between the different ions, Piper plot, Gibb’s plot and δ18O results. The modeled data proved that Lake Qarun brine evolves from drainage waters via an evaporation‒crystallization process. Through the precipitation of calcite and gypsum, the solution should reach the final composition "Na–Mg–SO4–Cl". As simulated by PHREEQC, further evaporation of lake brine can drive halite to precipitate in the final stages of evaporation. Significantly, the crystallization sequence during evaporation of the lake brine at the concentration ponds of the Egyptian Salts and Minerals Company (EMISAL) reflected the findings from both Hardie and Eugster’s evolutionary model and the PHREEQC simulated model. After crystallization of halite at the EMISAL ponds, the crystallization sequence during evaporation of the residual brine (bittern) was investigated using a Jänecke phase diagram at 35 °C. This diagram was more useful than PHREEQC for predicting the evaporation path especially in the case of this highly concentrated brine (bittern). The predicted crystallization path using a Jänecke phase diagram at 35 °C showed that halite, hexahydrite, kainite and kieserite should appear during bittern evaporation. Yet the actual crystallized mineral salts were only halite and hexahydrite. The absence of kainite was due to its metastability while the absence of kieserite was due to opposed relative humidity. The presence of a specific MgSO4.nH2O phase in ancient evaporite deposits can be used as a paleoclimatic indicator. Evaluation of surface water quality for agricultural purposes shows that some irrigation waters and all drainage waters have high salinities and therefore cannot be used for irrigation. Waters from irrigation canals used as a drinking water supply show higher concentrations of Al and suffer from high levels of total coliform (TC), fecal coliform (FC) and fecal streptococcus (FS). These waters cannot be used for drinking or agricultural purposes without treatment, because of their high health risk. Therefore it is crucial that environmental protection agencies and the media increase public awareness of this issue, especially in rural areas.

Asleep or not asleep? Evaluation of the Quality of Patients’ Sleep in Critical Care Nursing

Sleep is important for the recovery of a critically ill patient, as lack of sleep is known to influence negatively a person’s cardiovascular system, mood, orientation, and metabolic and immune function and thus, it may prolong patients’ intensive care unit (ICU) and hospital stay. Intubated and mechanically ventilated patients suffer from fragmented and light sleep. However, it is not known well how non-intubated patients sleep. The evaluation of the patients’ sleep may be compromised by their fatigue and still position with no indication if they are asleep or not. The purpose of this study was to evaluate ICU patients’ sleep evaluation methods, the quality of non-intubated patients’ sleep, and the sleep evaluations performed by ICU nurses. The aims were to develop recommendations of patients’ sleep evaluation for ICU nurses and to provide a description of the quality of non-intubated patients’ sleep. The literature review of ICU patients’ sleep evaluation methods was extended to the end of 2014. The evaluation of the quality of patients’ sleep was conducted with four data: A) the nurses’ narrative documentations of the quality of patients’ sleep (n=114), B) the nurses’ sleep evaluations (n=21) with a structured observation instrument C) the patients’ self-evaluations (n=114) with the Richards-Campbell Sleep Questionnaire, and D) polysomnographic evaluations of the quality of patients’ sleep (n=21). The correspondence of data A with data C (collected 4–8/2011), and data B with data D (collected 5–8/2009) were analysed. Content analysis was used for the nurses’ documentations and statistical analyses for all the other data. The quality of non-intubated patients’ sleep varied between individuals. In many patients, sleep was light, awakenings were frequent, and the amount of sleep was insufficient as compared to sleep in healthy people. However, some patients were able to sleep well. The patients evaluated the quality of their sleep on average neither high nor low. Sleep depth was evaluated to be the worst and the speed of falling asleep the best aspect of sleep, on a scale 0 (poor sleep) to 100 (good sleep). Nursing care was mostly performed while the patients were awake, and thus the disturbing effect was low. The instruments available for nurses to evaluate the quality of patients’ sleep were limited and measured mainly the quantity of sleep. Nurses’ structured observatory evaluations of the quality of patients’ sleep were correct for approximately two thirds of the cases, and only regarding total sleep time. Nurses’ narrative documentations of the patients’ sleep corresponded with patients’ self-evaluations in just over half of the cases. However, nurses documented several dimensions of sleep that are not included in the present sleep evaluation instruments. They could be classified according to the components of the nursing process: needs assessment, sleep assessment, intervention, and effect of intervention. Valid, more comprehensive sleep evaluation methods for nurses are needed to evaluate, document, improve and study patients’ quality of sleep.

Psychological well-being of the parents and child development, behavior, and quality of life in very low birth weight infants

The parents of premature infants, especially the mothers, are at increased risk for distress. Infants born prematurely are at risk for developmental problems. The aim of this study was to investigate whether the psychological well-being of both parents is associated with child development in very low birth weight (VLBW, ≤1500g) children. The burden of prematurity-related morbidity to the children and to the family was also assessed. A cohort of 201 VLBW infants born during 2001–2006 in the Turku University Hospital, Finland, and their parents were studied (I–IV). One study included a control group (n=166) of full-term infants (IV). The psychological well-being of the parents was evaluated by assessments of depressive symptoms, parenting stress, the sense of coherence and general family functioning. Cognitive, behavioral, and socio-emotional development, and the health-related quality of life (HRQoL) of the children were determined when the children were 2 to 8 years old. The psychological well-being of the parents was associated with the cognitive, behavioral and social development of the VLBW children. The VLBW infants with prematurity-related morbidities had a poorer HRQoL and the general functioning of the family was inferior compared to the control children and their families. 64.5% of the VLBW children survived without morbidities. Most of the VLBW children did not have significant behavior problems (93%), had normal social skills (63%), had no emotional problems (64%), and had no problems in executive functioning (62%). Only 3% of the surviving VLBW infants had significant cognitive delay. In conclusion, the depressive symptoms and stress of the parents can be risk factors for disadvantageous child development, while a strong sense of coherence can be protective. Parents of the premature children with developmental delays might also experience more depressive symptoms and stress than other parents. Prematurity-related morbidities were a burden to the VLBW child as well as to the family.

Quality of outsourced IT services in different degrees of offshoring

The Finnish IT service market can be described to be at a turning point. The clients are ever more interested on services delivered from offshore but certain issues keep them cautious. There is a lack of knowledge on what implications different degrees of offshoring have on service quality. Although there has been significant amount of research related to both service quality and offshoring, several questions are unanswered, terminology remains ambivalent and research findings are inconsistent. The study focuses on the interception of these two fields. The purpose of the study is to learn more about service quality in different degrees of offshoring. At the same time it aims to contribute in narrowing the research gaps. The degree of offshoring can be divided to three delivery modes: onshore, collaboration and offshore. The study takes a mixed method approach where the quantitative and qualitative phases are executed sequentially. First data was gathered from incident management system. Resolution time in different degrees of offshoring was analyzed with Kruskal-Wallis and Jonckheere-Terpstra tests. In addition, the compliance to Service Level Agreement (SLA) in different degrees of offshoring was examined with cross tabulation. The findings from the quantitative analysis suggested that the services with offshore delivery mode perform the best in terms of promptness and SLA compliance. However, several issues were found related to the data and for that reason, the findings should be considered with prudence. After the quantitative analysis, the study moved on to qualitative data collection and analysis. Four semi-structured interviews were held. The interviewees represented different organizational roles and had experiences from different delivery modes. Several themes were covered in the interviews, including: the concept of quality, the subjectivity or objectivity of service quality, expectations and prejudices towards offshore deliveries, quality produced in India, proactiveness of offshore resources, quality indicators and the scarcity of collaborative deliveries. Several conclusions can be made from the empirical research. Firstly, the quality in different delivery modes was found to be controversial topic. Secondly, in the collaborative delivery covered in the study, the way tasks and resources are allocated seem to cause issues. On the other hand inexperienced offshore resources are assigned to the delivery and on the other hand only routine tasks are assigned to the resources. This creates a self-enforcing loop that results in low motivation, low ownership and high employee turnover in offshore. Nevertheless, this issue is not characteristic only to collaborative deliveries but rather allocation of tasks and resources. Moreover, prejudices were identified to affect the perceived service quality in non-predictable way. The research also demonstrated that there is a need in focal company for further data gathering and analysis.