Eettinen kasvu ja dialogisuus draaman näyttämöllä : valokiilassa päiväkodin draamaprosessi

This research is a phenomenological-hermeneutic case-study based on the methods of action research in which narrative methods are used to examine a process drama carried out in a day-care centre, focusing on its dialogicality and possibilities of offering children and adults ethical problems to examine and solve. A process drama built around a story was carried out in a Finnish day-care centre in 1999 with the aim of bringing ethical education to the level of conscious consideration and action. The research consists of two case-studies. The first focuses on Risto, one of the children who participated in the process, his actions in group situations, his commitment to the rules set by the leaders, his attitude towards the group and its members as well as the common agreements concerning the group, and his solutions to fictive dilemmas in relation to Lawrence Kohlberg’s and Carol Gilligan’s concepts of justice and care. On this basis conclusions are made on how drama can be applied to dealing with ethical dilemmas with children aged four to seven. The second case-study searches for ethical themes and signs of dialogicality in the story that was created together by the children and leaders, and in the action that took place in the drama sessions. The subjects of this study consist of two groups participating in the process drama, both consisting of seven children aged four to seven. Narratives were written on each child based on his/her participation in four drama sessions selected to be used in this study. The narratives include the writer’s interpretations of the dialogicality of the drama and the ethical themes observed and recognised in the videos and in the transcriptions of the video recordings. The description and interpretation of the dialogicality and the ethical themes observed in the drama sessions is based on the researcher’s dialogue with the writings of Georg Henrik von Wright, Martin Buber and Mihail Bahtin, as well as Nicholas C. Burbules’ definitions of the basic conditions for dialogical teaching. As a result of the study, drama activity proved to be a means by which dialogically abstract ethical questions and conflicts could be dealt with even with young children and which revealed the zone of proximal development of both children and adults. Drama became a stage for ethical growth and dialogicality, and the common play of children and adults could be seen as an indicator of deep dialogicality. On the basis of this study, it can be said that drama is a very suitable way of establishing a shape and form of ethical education in which it is possible to make planned, target-oriented progress and which can be consciously observed by following the development of both the child and the educator.

Treatment of Acute Otitis Media

Background: Acute otitis media (AOM) is the most common bacterial infection in young children, but the optimal management of AOM remains controversial. The aim of this study was to assess the efficacy of antimicrobial treatment, either immediate or delayed, for AOM and to compare parental experiences regarding the management of AOM in two countries with very different treatment guidelines. Methods: Altogether, 322 children participated in a randomized, double-blind, placebocontrolled trial. Children 6–35 months of age with AOM received amoxicillin-clavulanate or placebo for 7 days. The primary outcome was the time to treatment failure. In the second study, the delayed antimicrobial treatment group consisted of recipients of placebo who had received rescue treatment. The immediate antimicrobial treatment group consisted of children allocated to amoxicillin-clavulanate group. Parental expectations and opinions were evaluated by questionnaires sent via public day care in Turku, Finland, and Utrecht, the Netherlands. Results: Treatment failure occurred significantly more often in children receiving placebo as compared to antimicrobial treatment (45% vs. 19%, P<0.001). Delayed initiation of antimicrobial treatment did not worsen the recovery from AOM, but it was associated with worsening of the child’s condition, prolongation of symptoms, and absenteeism from day care and parental absenteeism from work. According to the comparative questionnaire, antimicrobial use was more common in Finland than in the Netherlands. Finnish parents believed more often than Dutch parents that antimicrobials are necessary in the treatment of AOM. Conclusions: Children with AOM benefit from antimicrobial treatment. Delayed initiation of antimicrobial does not worsen the overall recovery from AOM, but it might increase the symptom burden and create economic losses. Treatment practices and parental expectations seem to interact with each other. This needs to be considered when AOM treatment guidelines are updated.

Intuboidun hengityslaitehoitoa saavan aikuisen tehohoitopotilaan suunhoidon kirjaaminen

Tutkimuksen tarkoituksena oli tutkia potilastietojärjestelmien suunhoitosivut kaikilla suomalaisilla teho-osastoilla, joissa oli käytössä Clinisoft® -potilastietojärjestelmä ja, joilla hoidettiin intuboituja, hengityslaitehoitoa saavia aikuisia tehohoitopotilaita. Lisäksi tutkimuksessa analysoitiin yhden yliopistosairaalan teho-osaston hoitajien suunhoidon kirjauksia potilastietojärjestelmän vuorohuomioraporteista. Tutkimusosion 1 aineisto koostui aikuispotilaita hoitavien teho-osastojen (N=15) Clinisoft® -potilastietojärjestelmien suunhoitosivuista. Tutkimusosion 2 aineisto koostui yhden yliopistosairaalan teho-osaston intuboitujen, hengityslaitehoitoa saaneiden aikuisen tehohoitopotilaiden suunhoidon kirjauksista (n=97). Vuonna 2008–2009 hoidetuista intuboiduista, hengityslaitehoitoa saaneista tehohoitopotilaista (N=1180) valittiin satunnaisotannalla 100 potilasta, joiden suunhoitoon liittyvät potilasasiakirjat otettiin mukaan analyysiin. Aineistot analysoitiin sisällön erittelyllä. Suunhoitosivujen aihesisällöistä muodostettiin 14 sisältöluokkaa. Vuorohuomiokirjaukset oli kirjattu yleensä hengitys tai happeutuminen otsakkeiden alle, josta löytyi yhteensä 589 alkuperäislausumaa. Hoitajat kirjasivat ensin potilaan hengityslaitehoidosta ja happeutumisesta. Alkuperäislausumista tehohoitopotilaan suunhoitoon liittyviä lausumia oli 61 % (n=357). Vuorohuomiokirjauksista muodostettiin 11 sisältöluokkaa. Potilastietojärjestelmän suunhoitosivujen rakenne ei ohjannut VAP:a ehkäisevään suunhoitoon ja tehohoitopotilaan suunhoitoa kirjattiin usealle sivulle. Kaikkien tehohoito-osastojen suunhoitosivupohjissa oli kohdat suun kunnon arvioinnille ja suunhoidolle, mutta sivuilta ei aina selvinnyt tehohoito-osaston suunhoitoon käytättämiä välineitä. Sivuissa oli nähtävissä yksittäisiä VAP:n ehkäisyyn liittyviä interventioita. Vuorohuomioraportteihin kirjaaminen oli päällekkäistä suunhoitosivuun kirjattavien tietojen kanssa. Hoitajat kirjasivat tehohoitopotilaan hengityslaitehoidosta ja potilaan happeutumisesta. Suunhoidosta hoitajat kirjasivat eniten eritteiden määrää ja laatua ja vähiten suunhoidossa käytetyistä välineistä sekä suunhoitoon liittyvästä arvioinnista. Tehohoitopotilaan suuta hoidettiin keskimäärin 2.93 kertaa vuorokaudessa, eniten aamuvuoroissa. Suun kuntoa arvioitiin 1.12 kertaa vuorokaudessa. Pro gradu -tutkielma tuo uutta tietoa intuboidun, hengityslaitehoidossa olevan aikuisen tehohoitopotilaan näyttöön perustuvasta suunhoidosta, potilastietojärjestelmien suunhoitosivujen rakenteesta ja tehohoitopotilaan suunhoidon kirjaamisesta Suomessa. Tutkimustulosten ja kansainvälisten suositusten avulla kehitettiin Clinisoft® -potilastietojärjestelmän mallisivu tehohoitopotilaan suunhoidon tarpeen määrittämisen, suunnittelun, toteutuksen ja arvioinnin tueksi.

Spontaneous Focusing on Numerosity in the Development of Early Mathematical Skills

The aim of the present set of longitudinal studies was to explore 3-7-year-old children.s Spontaneous FOcusing on Numerosity (SFON) and its relation to early mathematical development. The specific goals were to capture in method and theory the distinct process by which children focus on numerosity as a part of their activities involving exact number recognition, and individual differences in this process that may be informative in the development of more complex number skills. Over the course of conducting the five studies, fifteen novel tasks were progressively developed for the SFON assessments. In the tasks, confounding effects of insufficient number recognition, verbal comprehension, other procedural skills as well as working memory capacity were aimed to be controlled. Furthermore, how children.s individual differences in SFON are related to their development of number sequence, subitizing-based enumeration, object counting and basic arithmetic skills was explored. The effect of social interaction on SFON was tested. Study I captured the first phase of the 3-year longitudinal study with 39 children. It was investigated whether there were differences in 3-year-old children.s tendency to focus on numerosity, and whether these differences were related to the children.s development of cardinality recognition skills from the age of 3 to 4 years. It was found that the two groups of children formed on the basis of their amount of SFON tendency at the age of 3 years differed in their development of recognising and producing small numbers. The children whose SFON tendency was very predominant developed faster in cardinality related skills from the age of 3 to 4 years than the children whose SFON tendency was not as predominant. Thus, children.s development in cardinality recognition skills is related to their SFON tendency. Studies II and III were conducted to investigate, firstly, children.s individual differences in SFON, and, secondly, whether children.s SFON is related to their counting development. Altogether nine tasks were designed for the assessments of spontaneous and guided focusing on numerosity. The longitudinal data of 39 children in Study II from the age of 3.5 to 6 years showed individual differences in SFON at the ages of 4, 5 and 6 years, as well as stability in children.s SFON across tasks used at different ages. The counting skills were assessed at the ages of 3.5, 5 and 6 years. Path analyses indicated a reciprocal tendency in the relationship between SFON and counting development. In Study III, these results on the individual differences in SFON tendency, the stability of SFON across different tasks and the relationship of SFON and mathematical skills were confirmed by a larger-scale cross-sectional study of 183 on average 6.5-year-old children (range 6;0-7;0 years). The significant amount of unique variance that SFON accounted for number sequence elaboration, object counting and basic arithmetic skills stayed statistically significant (partial correlations varying from .27 to .37) when the effects of non-verbal IQ and verbal comprehension were controlled. In addition, to confirm that the SFON tasks assess SFON tendency independently from enumeration skills, guided focusing tasks were used for children who had failed in SFON tasks. It was explored whether these children were able to proceed in similar tasks to SFON tasks once they were guided to focus on number. The results showed that these children.s poor performance in the SFON tasks was not caused by their deficiency in executing the tasks but on lacking focusing on numerosity. The longitudinal Study IV of 39 children aimed at increasing the knowledge of associations between children.s long-term SFON tendency, subitizing-based enumeration and verbal counting skills. Children were tested twice at the age of 4-5 years on their SFON, and once at the age of 5 on their subitizing-based enumeration, number sequence production, as well as on their skills for counting of objects. Results showed considerable stability in SFON tendency measured at different ages, and that there is a positive direct association between SFON and number sequence production. The association between SFON and object counting skills was significantly mediated by subitizing-based enumeration. These results indicate that the associations between the child.s SFON and sub-skills of verbal counting may differ on the basis of how significant a role understanding the cardinal meanings of number words plays in learning these skills. The specific goal of Study V was to investigate whether it is possible to enhance 3-year old children.s SFON tendency, and thus start children.s deliberate practice in early mathematical skills. Participants were 3-year-old children in Finnish day care. The SFON scores and cardinality-related skills of the experimental group of 17 children were compared to the corresponding results of the 17 children in the control group. The results show an experimental effect on SFON tendency and subsequent development in cardinality-related skills during the 6-month period from pretest to delayed posttest in the children with some initial SFON tendency in the experimental group. Social interaction has an effect on children.s SFON tendency. The results of the five studies assert that within a child.s existing mathematical competence, it is possible to distinguish a separate process, which refers to the child.s tendency to spontaneously focus on numerosity. Moreover, there are significant individual differences in children.s SFON at the age of 3-7 years. Moderate stability was found in this tendency across different tasks assessed both at the same and at different ages. Furthermore, SFON tendency is related to the development of early mathematical skills. Educational implications of the findings emphasise, first, the importance of regarding focusing on numerosity as a separate, essential process in the assessments of young children.s mathematical skills. Second, the substantial individual differences in SFON tendency during the childhood years suggest that uncovering and modeling this kind of mathematically meaningful perceiving of the surroundings and tasks could be an efficient tool for promoting young children.s mathematical development, and thus prevent later failures in learning mathematical skills. It is proposed to consider focusing on numerosity as one potential sub-process of activities involving exact number recognition in future studies.

Johtajan jäljillä – Johtaminen varhaiskasvatuksen hajautetuissa organisaatioissa laadun ja pedagogisen tuen näkökulmasta

Tutkimus sijoittuu varhaiskasvatuksen hajautetun organisaation kontekstiin, mutta tulokset ovat siirrettävissä muihinkin suomalaisiin kasvatus- ja opetustoimen organisaatioihin. Hajautettujen organisaatioiden tutkimus on ollut varhaiskasvatuksen kentällä vielä vähäistä, vaikka organisaatiomallin vaikutukset johtajuuden toteuttamiselle ovat merkittävät. Hajautetulla organisaatiolla varhaiskasvatuksessa tarkoitetaan sitä, että yhden johtajan alaisuudessa on monta eri päiväkotia tai erilaisia päivähoitomuotoja. Tämä organisaatiomalli on yhä enenevässä määrin kasvava suomalaisessa varhaiskasvatuksessa. Varhaiskasvatuksen hajautettujen organisaatioiden tutkimuksessa on aiemmin tarkasteltu johtajan ja työntekijöiden ja työntekijöiden keskinäisiä ammatillisia suhteita. Tässä tutkimuksessa näkökulma painottuu johtamiseen ja työskentelyyn hajautetuissa organisaatiossa sinänsä sekä myös laadunarviointiin sekä pedagogiikkaan. Viitekehyksenä tutkimuksessa on LMX-teoria (leader-member-exchange, johtajuuden vaihtoteoria), jossa tarkastellaan esimies-alaissuhdetta ja siihen kiinteästi liittyvää luottamuksen käsitettä. Luottamuksen merkitys hajautetuissa organisaatioissa korostuu, koska esimies ei ole fyysisesti päivittäin läsnä työntekijöiden arjessa. Tutkimuksessa tarkastellaan hajautetuissa varhaiskasvatuksen organisaatioissa työskentelyä seuraavien tutkimuskysymysten avulla: 1) Mitkä ovat varhaiskasvatuksen hajautettujen organisaatioiden johtamisen erityispiirteet? 2) Miten eri työntekijäryhmät kokevat hajautetussa organisaatiossa työskentelyn? 3) Millaisia kokemuksia esimiehillä ja työntekijöillä on heidän yksiköissään toteutetusta laadunarvioinnista? 4) Millaiseksi työntekijät ja esimiehet kokevat esimieheltään saadun tuen? Tutkimuksessa oli kolme eri aineistoa. Ensimmäinen aineisto koostui 11 hajautetun organisaation johtajan haastattelusta. Toinen aineisto (n = 223) sisälsi haastateltujen esimiesten lomakevastausten lisäksi heidän alaisuudessaan toimivien työntekijöiden, 10 esimieskoulutukseen osallistuneen johtajan sekä kolmen erillisyksikön työntekijöiden vastaukset. Kolmas aineisto oli kerätty pääkaupunkiseudulta varhaiskasvatuksen johtajilta lomakekyselynä (n = 112). Aineistoa on analysoitu teorialähtöisen ja aineistolähtöisen sisällönanalyysin ja tilastollisten analyysien avulla Tulokset osoittavat, että johtajat kokivat hallinnollisten töiden vievän paljon aikaa. Esimiehen kanssa eri työpaikassa työskentelevät työntekijät hahmottivat koko organisaation selkeämmin kuin esimiehen kanssa fyysisesti samassa paikassa työskentelevät. Esimiesten käsitysten mukaan laadunarviointia suoritettiin enemmän kuin mitä työntekijöiden mukaan. Työntekijät kaipasivat esimiehiltään tukea yhteistyöhön ja vuorovaikutukseen, pedagogiseen ohjaukseen, kehittämiseen ja toiminnan resursseihin liittyen. Erillisyksikössä työskentelevät kokivat saavansa enemmän tukea kuin esimiehen kanssa fyysisesti samassa yksikössä työskentelevät työntekijät. Sekä esimieheltä saadun pedagogisen tuen että luottamuksen kokemukset kiinnittävät tämän tutkimuksen tulosten mukaan huomion rakenteiden merkitykseen hajautetuissa organisaatioissa. Arviointiin, pedagogiseen tukeen ja tiedonkulkuun liittyvien rakenteiden huomioiminen helpottaa hajautetussa organisaatiossa johtamista. Edellisten lisäksi johtajan selkeä visio omasta johtamistyöstään ja jaetun johtajuuden hyödyntäminen edesauttavat työn hallinnan kokemuksia.

Expectations of elderly people on the nurse-client relationship and interaction in home care : "When I see the nurse's smiling face it feels likes sunshine on a rainy and gloomy day"

The purpose of the thesis was to explore expectations of elderly people on the nurse-client relationship and interaction in home care. The aim is to improve the quality of care to better meet the needs of the clients. A qualitative approach was adopted. Semi-structured theme interviews were used for data collection. The interviews were conducted during spring 2006. Six elderly clients of a private home care company in Southern Finland acted as informants. Content analysis was used as the method of data analysis. The findings suggest that clients expect nurses to provide professional care with loving-kindness. Trust and mutual, active interaction were expected from the nurse-client relationship. Clients considered it important that the nurse recognizes each client's individual needs. The nurse was expected to perform duties efficiently, but in a calm and unrushed manner. A mechanic performance of tasks was considered negative. Humanity was viewed as a crucial element in the nurse-client relationship. Clients expressed their need to be seen as human beings. Seeing beyond the illness was considered important. A smiling nurse was described to be able to alleviate pain and anxiety. Clients hoped to have a close relationship with the nurse. The development of a close relationship was considered to be more likely if the nurse is familiar and genuine. Clients wish the nurses to have a more attending presence. Clients suggested that the work areas of the nurses could be limited so that they would have more time to transfer from one place to another. Clients felt that they would benefit from this as well. The nurses were expected to be more considerate. Clients wished for more information regarding changes that affect their care. They wished to be informed about changes in schedules and plans. Clients hoped for continuity from the nurse-client relationship. Considering the expectations of clients promotes client satisfaction. Home care providers have an opportunity to reflect their own care behaviour on the findings. To better meet the needs of the clients, nurses could apply the concept of loving-kindness in their work, and strive for a more attending presence.

Continuity of patient care in day surgery

Continuity is a part of high-quality patient care. The purpose of this study was to analyse what factors are important in the continuity of patients’ care, and how well continuity is achieved in different stages of the care of day surgical patients. Day surgery has become significantly more prevalent in the past few decades, and in order for it to be carried out successfully, continuity in care is particularly essential. The study was carried out in two stages. In the first stage (2001–2005) of the study, continuity was examined through a review of literature from the perspective of critical pathways, naming the continuity categories of time flow, coordination flow, caring relationship flow, and information flow. The first stage also entailed an analysis of matters important to the patient and problems concerning the achievement of care continuity, carried out by interviewing 25 day surgical patients. In the second stage (2006–2015), the degree to which the continuity of day surgical patient care was achieved was analysed from the perspective of patients (n=203, 58%) and nurses working in day surgery units (n=83, 69%), and suggestions for developing the continuity of day surgery patient care were made. In this study continuity of care was examined through a review of literature from the perspective of critical pathways, naming the continuity categories of time flow, coordination flow, caring relationship flow, and information flow. Within these categories, several important factors for the patient were found. According to both patients and nurses, continuity of care is generally achieved to a high degree. Continuity of care is improved by patients being acquainted with and meeting the staff attending to them (nurse and surgeon) before and after the operation. From patients’ perspective, there is room for improvement especially in terms of being admitted to care and in the carer-patient relationship. From nurses’ perspective, there is room for improvement in terms of the smoothness of care. Nurses evaluated the continuity of care to be the least successful before and after the operation. An extensive social and health care reform is planned in Finland in the coming years, aiming to enhance social and health care services and to create smoothly functioning service and care. As a topic of further study supporting the development of the service system, it is important to follow the patient’s progress throughout the entire chain of care, e.g. as a case study. On the other hand, there is also a need to study the views of nurses and other health care professionals in health care, e.g. in primary health care.

Community-acquired pneumonia in adult patients with special reference to rapid methods for etiological diagnosis

Aikuispotilaan kotisyntyisen keuhkokuumeen etiologinen diagnostiikka mikrobiologisilla pikamenetelmillä Tausta. Keuhkokuume on vakava sairaus, johon sairastuu Suomessa vuosittain n. 60 000 aikuista. Huolimatta siitä, että taudin hoito on kehittynyt, siihen liittyy yhä merkittävä, 6-15%:n kuolleisuus. Alahengitystieinfektion aiheuttajamikrobien tunnistaminen on myös edelleen haasteellista. Tavoitteet. Tämän työn tavoitteena oli tutkia Turun yliopistollisessa keskussairaalassa hoidettujen aikuispotilaiden keuhkokuumeen etiologiaa sekä selvittää uusien mikrobiologisten pikamenetelmi¬en hyödyllisyyttä taudinaiheuttajan toteamisessa. Aineisto. Osatöiden I ja III aineisto koostui 384 Turun yliopistollisen keskussairaalaan infektio-osastolla hoidetusta keuhkokuumepotilaasta. Osatyössä I tutkittiin keuhkokuumeen aiheuttaja¬mikrobeja käyttämällä perinteisten menetelmien lisäksi antigeeniosoitukseen ja PCR-tekniikkaan perustuvia pikamenetelmiä. Osatyö II käsitti 231 potilaasta koostuvan alaryhmän, jossa tutkittiin potilaiden nielun limanäytteestä rinovirusten ja enterovirusten esiintyvyyttä. Osatyössä III potilailta tutkittiin plasman C-reaktiivisen proteiinin (CRP) pitoisuus ensimmäisten viiden sairaalahoitopäi¬vän aikana. Laajoja tilastotieteellisiä analyysejä käyttämällä selvitettiin CRP:n käyttökelpoisuutta sairauden vaikeusasteen arvioinnissa ja komplikaatioiden kehittymisen ennustamisessa. Osatyössä IV 68 keuhkokuumepotilaan sairaalaan tulovaiheessa otetuista näytteistä määritettiin neutrofiilien pintareseptorien ekspressio. Osatyössä V analysoitiin sisätautien vuodeosastoilla vuosina 1996-2000 keuhkokuumepotilaille tehtyjen keuhkohuuhtelunäytteiden laboratoriotutkimustulokset. Tulokset. Keuhkokuumeen aiheuttaja löytyi 209 potilaalta, aiheuttajamikrobeja löydettiin kaikkiaan 230. Näistä aiheuttajista 135 (58.7%) löydettiin antigeenin osoituksella tai PCR-menetelmillä. Suu¬rin osa, 95 (70.4%), todettiin pelkästään kyseisillä pikamenetelmillä. Respiratorinen virus todettiin antigeeniosoituksella 11.1% keuhkokuumepotilaalla. Eniten respiratorisia viruksia löytyi vakavaa keuhkokuumetta sairastavilta potilailta (20.3%). 231 keuhkokuumepotilaan alaryhmässä todettiin PCR-menetelmällä picornavirus 19 (8.2%) potilaalla. Respiratorinen virus löytyi tässä potilasryh¬mässä kaiken kaikkiaan 47 (20%) potilaalta. Näistä 17:llä (36%) löytyi samanaikaisesti bakteerin aiheuttama infektio. CRP-tasot olivat sairaalaan tulovaiheessa merkitsevästi korkeammat vakavaa keuhkokuumetta (PSI-luokat III-V) sairastavilla potilailla kuin lievää keuhkokuumetta (PSI-luokat I-II) sairastavilla potilailla (p <0.001). Yli 100 mg/l oleva CRP-taso neljän päivän kuluttua sairaa¬laan tulosta ennusti keuhkokuumeen komplikaatiota tai huonoa hoitovastetta. Neutrofiilien komple¬menttireseptorin ekspressio oli pneumokokin aiheuttamaa keuhkokuumetta sairastavilla merkitse¬västi korkeampi kuin influenssan aiheuttamaa keuhkokuumetta sairastavilla. BAL-näytteistä vain yhdessä 71:stä (1.3%) todettiin diagnostinen bakteerikasvu kvantitatiivisessa viljelyssä. Uusilla menetelmilläkin keuhkokuumeen aiheuttaja löytyi vain 9.8% BAL-näytteistä. Päätelmät. Uusilla antigeeniosoitus- ja PCR-menetelmillä keuhkokuumeen etiologia voidaan saada selvitettyä nopeasti. Lisäksi näitä menetelmiä käyttämällä taudin aiheuttajamikrobi löytyi huomattavasti suuremmalta osalta potilaista kuin pelkästään tavanomaisia menetelmiä käyttämällä. Pikamenetelmien hyödyllisyys vaihteli taudin vaikeusasteen mukaan. Respiratorinen virus löytyi huomattavan usein keuhkokuumetta sairastavilta potilailta, ja näiden potilaiden taudinkuva oli usein vaikea. Tulovaiheen korkeaa CRP-tasoa voidaan käyttää lisäkeinona arvioitaessa keuhkokuumeen vaikeutta. CRP on erityisen hyödyllinen arvioitaessa hoitovastetta ja riskiä komplikaatioiden ke¬hittymiseen. Neutrofiilien komplementtireseptorin ekspression tutkiminen näyttää lupaavalta pi¬kamenetelmältä erottamaan bakteerien ja virusten aiheuttamat taudit toisistaan. Antimikrobihoitoa saavilla potilailla BAL-tutkimuksen löydökset olivat vähäiset ja vaikuttivat hoitoon vain harvoin.

Quality of Abdominal Surgical Nursing Care

The study evaluates the quality of abdominal surgical nursing care. The data were collected from patients (n=1208) having undergone abdominal surgical operations on their last day of hospitalization and nurses (n=218) working in the same wards. Three instruments originally created in Finland and adapted to the Lithuanian context were used: (1) Good Nursing Care Scale for patients and nurses (GNCS-P, GNCS-N), (2) Nurse Competence Scale (NCS), and (3) Nurse Empowerment Scale (NES). Patient and nurses’ perceptions of the quality of nursing care were evaluated. In addition, nurses’ perceptions of their competence and empowerment were evaluated. The patient and nurses' perceptions of the quality of abdominal surgical nursing care were positive, with more criticism in the nurses’ perceptions. Both patients and nurses gave the lowest evaluation to the quality in the progress of nursing care and the co-operation with significant others. The nurses gave the highest evaluation to the self-assessed level of their competence and the frequency of using competences in practice, with the highest assessment given to situation management and their role at work and the lowest to teaching-coaching and ensuring quality. The nurse perceptions of their empowerment were positive in the qualities and performance of an empowered nurse and empowerment promoting factors, with the highest evaluation in moral principles and sociability and the lowest evaluation in the future-orientedness and expertise. The empowerment-impeding factors were evaluated as negative. The perceptions of the quality of nursing care of both patients and nurses had significant correlations with patient and nurse satisfaction and nurse job independence. The nurse perceptions of their competence and empowerment correlated with their education, the type of the nurse license, completed courses of development of their knowledge and skills, nurse job independence, and nurse satisfaction. The nurse perceptions of the quality of nursing care had a positive correlation with their perceptions of competence and empowerment. Generally, the quality of nursing care was evaluated as high and had correlations with the patients' demographic and satisfaction factors and with the nurse demographic, work-related, and satisfaction factors. The study produced the knowledge that the quality in co-operation with significant others and the progress of nursing process, surgical nurse competence in teaching-coaching, and future-orientedness of surgical nurse empowerment need to be improved in order to develop the quality of abdominal surgical nursing care. The knowledge may be used to offer better services for abdominal surgical patients and increase their satisfaction with nursing care, as well as to increase nurses' satisfaction with work and independence at work. The study suggests implications for clinical practice and management, nursing education, and nursing research.

Immediate Decision-Making and Information Needs in Intensive Care Coordination

The aim of this study was to develop a theoretical model for information integration to support the deci¬sion making of intensive care charge nurses, and physicians in charge – that is, ICU shift leaders. The study focused on the ad hoc decision-making and immediate information needs of shift leaders during the management of an intensive care unit’s (ICU) daily activities. The term ‘ad hoc decision-making’ was defined as critical judgements that are needed for a specific purpose at a precise moment with the goal of ensuring instant and adequate patient care and a fluent flow of ICU activities. Data collection and research analysis methods were tested in the identification of ICU shift leaders’ ad hoc decision-making. Decision-making of ICU charge nurses (n = 12) and physicians in charge (n = 8) was observed using a think-aloud technique in two university-affiliated Finnish ICUs for adults. The ad hoc decisions of ICU shift leaders were identified using an application of protocol analysis. In the next phase, a structured online question¬naire was developed to evaluate the immediate information needs of ICU shift leaders. A national survey was conducted in all Finnish, university-affiliated hospital ICUs for adults (n = 17). The questionnaire was sent to all charge nurses (n = 515) and physicians in charge (n = 223). Altogether, 257 charge nurses (50%) and 96 physicians in charge (43%) responded to the survey. The survey was also tested internationally in 16 Greek ICUs. From Greece, 50 charge nurses out of 240 (21%) responded to the survey. A think-aloud technique and protocol analysis were found to be applicable for the identification of the ad hoc decision-making of ICU shift leaders. During one day shift leaders made over 200 ad hoc decisions. Ad hoc decisions were made horizontally, related to the whole intensive care process, and vertically, concerning single intensive care incidents. Most of the ICU shift leaders’ ad hoc decisions were related to human resources and know-how, patient information and vital signs, and special treatments. Commonly, this ad hoc decision-making involved several multiprofessional decisions that constituted a bundle of immediate decisions and various information needs. Some of these immediate information needs were shared between the charge nurses and the physicians in charge. The majority of which concerned patient admission, the organisation and management of work, and staff allocation. In general, the information needs of charge nurses were more varied than those of physicians. It was found that many ad hoc deci-sions made by the physicians in charge produced several information needs for ICU charge nurses. This meant that before the task at hand was completed, various kinds of information was sought by the charge nurses to support the decision-making process. Most of the immediate information needs of charge nurses were related to the organisation and management of work and human resources, whereas the information needs of the physicians in charge mainly concerned direct patient care. Thus, information needs differ between professionals even if the goal of decision-making is the same. The results of the international survey confirmed these study results for charge nurses. Both in Finland and in Greece the information needs of charge nurses focused on the organisation and management of work and human resources. Many of the most crucial information needs of Finnish and Greek ICU charge nurses were common. In conclusion, it was found that ICU shift leaders make hundreds of ad hoc decisions during the course of a day related to the allocation of resources and organisation of patient care. The ad hoc decision-making of ICU shift leaders is a complex multi-professional process, which requires a lot of immediate information. Real-time support for information related to patient admission, the organisation and man¬agement of work, and allocation of staff resources is especially needed. The preliminary information integration model can be applied when real-time enterprise resource planning systems are developed for intensive care daily management

Potilaan tiedollinen yksityisyys heräämössä

Tutkielman tarkoituksena oli kuvata potilaan kokemuksia tiedollisesta yksityisyydestään sekä tiedollista yksityisyyttä edistäviä ja estäviä tekijöitä heräämössä. Tämän tiedon pohjalta on mahdollista kehittää heräämön hoitotyötä potilaiden tiedollisen yksityisyyden osalta. Tutkimus toteutettiin kuvailevana haastattelututkimuksena. Aineisto kerättiin puolistrukturoidun teemahaastattelun avulla. Tutkimuksessa haastateltiin yhden suomalaisen yliopistosairaalan korva-, nenä- ja kurkkutautien (KNK) klinikan heräämössä hoidettuja aikuispotilaita 1-2 tunnin kuluessa heräämöhoidon päättymisestä. Haastatteluaineisto koostui 17:stä päiväkirurgisen – tai vuodeosastopotilaan haastattelusta. Tallennetut haastattelut litteroitiin ja aineisto analysoitiin induktiivisella sisällönanalyysillä. Potilaat kuvasivat tiedollista yksityisyyttä potilaan tietojen hallintana: potilaan tietojen luottamuksellisena käsittelynä ja oikeutena omiin tietoihin. Tiedollista yksityisyyttä pidettiin tärkeänä, mutta potilaat eivät olleet erityisen huolissaan tämän toteutumisesta heräämössä. Tiedollinen yksityisyys toteutui potilaiden mielestä melko hyvin heräämössä lukuun ottamatta tilanteita, joissa henkilökunta vaihtoi suullisesti tietoja potilaasta keskenään. Suurin osa potilaista totesi KNK-vaivojen olevan niin neutraaleja, ettei niiden joutuminen ulkopuolisten tietoon ollut heistä merkityksellistä. Tieto leikkauksesta kiinnosti potilaita ja he olivat tyytyväisiä saatuaan siitä tietoa heräämössä. Tiedollisen yksityisyyden toteutumista edistivät potilaan uppoutuminen omaan maailmaansa, mahdollisuus kontrolloida ja saada tietoa asioistaan, kahdenkeskinen vuorovaikutus, tieto tiedollisesta yksityisyydestä, heräämön tilajärjestelyt ja tiedollista yksityisyyttä koskevien sääntöjen noudattaminen. Muiden potilaiden uteliaisuus, potilaan kyvyttömyys suojata omia tietojaan ja ulkopuolisuus omissa asioissaan, kahdenkeskeisen vuorovaikutuksen mahdottomuus, yksityisen tilan puute ja tiedollista yksityisyyttä koskevan sääntelyn noudattamattomuus koettiin tietojen luottamuksellisen käsittelyn esteiksi heräämössä. Potilaiden tietojen luottamuksellista käsittelyä voitaisiin parantaa kiinnittämällä huomiota raportointimenetelmiin ja -paikkaan heräämössä. Käytettävissä olevia keinoja, kuten sermejä ja potilaiden sijoittelu heräämössä, kannattaa käyttää hyödyksi potilaan tiedollisen yksityisyyden suojaamiseksi. Tiedollisen yksityisyyden määritelmää tulisi jatkossa täsmentää käsiteanalyysin avulla. Lisäksi tiedollista yksityisyyttä olisi hyvä tutkia hoitotyön ympäristöissä, joissa potilaiden hoitoon liittyy mahdollisesti arkaluonteisempia tietoja kuin KNK- potilailla.

Anaesthesia and Pain Management for Use in Orthopaedic Day Surgery

Day surgery has gained a large popularity during the last decades. In Finland, 57% of the elective procedures, and 50% at Turku University Hospital, were already conducted on day basis during 2012. The steady growth of day surgery is mostly due to an increased safety in perioperative care and cost-effectiveness. The development of surgical techniques and anaesthetic methods has advanced the modern day surgery and extended the repertory of the procedures for use in day surgery operations. Day surgery also offers certain benefits like reduced risk for hospital-related infections, stress and confusion. Patient satisfaction, regarding several issues, is high. Most concerns and complaints are related to postoperative pain, nausea and vomiting pain and nausea. Pain can hamper recovery and pain management is a crucial factor for hospital discharge. Appropriate pain treatment is effective, safe, easy and economical. A procedure-specific approach and an individually planned, multimodal analgesia should be the basis of modern pain management. The main aim of this thesis was to evaluate the effectiveness and safety of anaesthetic technique and methods in pain treatment of orthopaedic day case surgery, and following conclusions were made. Unilateral spinal block was achieved using hyperbaric bupivacaine with a small dose of clonidine but clonidine prolonged the block. Continuous subacromial bupivacaine was found to be safe but conferring only moderate efficacy in pain care after shoulder arthroscopy. Transdermal fentanyl, 12 g/h, as part of multimodal analgesia, offered a safe and easy option to pain management in this patient group. However, after forefoot surgery, it did not reduce pain any further. In general, pain scores in all patient groups were low and the need for rescue opioid moderate.