A substantive theory of the realization of stroke patients’ dignity in hospital care

Dignity is seen important in health care context but considered as a controversial and complex concept. In health care context, it is described as being influenced by for example autonomy, respect, communication, privacy and hospital environment. Patient dignity is related to satisfaction with care, reduced stress, better confidence in health services, enhanced patient outcomes and shorter stay in a hospital. Stroke patients may struggle for dignity as being dependent on other people has impact on the patients’ self-image. In all, stroke patients are very specific patient group and considered vulnerable from emotional aspect. Therefore study findings from other patient groups in the area of ethical problems cannot be transferred to the stroke patients. This master’s thesis consists of two parts. The first part is the literature review of patients’ dignity in hospital care. The literature defined dignity and described factors promoting and reducing it. The results were ambiguous and thus a clear understanding was not able to create. That was the basis for the second part of the master’s thesis, the empirical study. This part aimed to develop theoretical construction to explore the realization of stroke patients’ dignity in hospital care. The data of the second part was collected by interviewing 16 stroke patients and analyzed using the constant comparison of Grounded Theory. The result was ‘The Theory of Realization of Stroke Patients’ Dignity in Hospital Care’ which is described not only in this master’s thesis but also as a scientific article. The theory consists of the core category, four generic elements and five specific types on realization. The core category emerged as ‘dignity in a new situation’. After a stroke, dignity is defined in a new way which is influenced by the generic elements: life history, health history, individuality and a stroke. Stroke patient’s dignity is realized through five specific types on realization: person related dignity type, control related dignity type, independence related dignity type, social related dignity type and care related dignity type. The theory points out possible special characteristics of stroke patients’ dignity in control related dignity type and independence related dignity type. Before implementing the theory, the relation between the core category, generic elements and specific types on realization needs to be studied further.

Sensitive Troponin Assays: Diagnostic and Prognostic Use in Cardiology

Cardiac troponins (cTns) are the recommended biochemical markers in the diagnosis of myocardial infarction (MI). They are very sensitive and tissue-specific but are limited by their delayed appearance in the circulation. Biochemical markers with more rapid release kinetics, e.g. myoglobin and especially heart-type fatty acid-binding protein (H-FABP), have been used to enhance the early identification of MI. The implementation of cTns into clinical practice has shown that cardiomyocyte injury occurs in many other clinical conditions than MI. The aim of this study was to evaluate the impact of modern and highly sensitive cTnI assays on the early diagnosis of MI. In a patient cohort with suspected MI, such a sensitive cTnI assay enhanced the early diagnostic accuracy when compared to a less sensitive cTnI assay and to myoglobin. When compared to H-FABP during the early hours after symptom onset, the sensitive cTnI assay showed at least similar and, after 6 hours, superior diagnostic accuracy. A positive cTnI test result had superior prognostic value when compared to H-FABP, even among early presenters. The prognostic value of cTn in acute heart failure (AHF) was evaluated in 364 patients who participated in the FINN-AKVA study. The patients presented with AHF but no acute coronary syndrome (ACS). Up to half of the patients had elevated cTn levels which were associated with higher 6-month mortality. The magnitude of cTn elevation was directly proportional to mortality. Finally, the clinical spectrum of cTnI elevations was evaluated in 991 cTnI positive emergency department (ED) patients. 83% of the patients had MI and 17% had cTnI elevation due to other clinical conditions. The latter patient group was characterized by lower absolute cTnI levels and – importantly – higher in-hospital mortality when compared to the MI patients. In conclusion, the use of a highly sensitive cTnI assay enhances the early diagnostic accuracy and risk stratification in suspected MI patients. Cardiac troponin elevations are highly prevalent also in other acute clinical conditions and indicate an adverse outcome of these patients.

Nurse-led interpersonal counselling for depressive symptoms in patients with myocardial infarction

The broad interest of this intervention study is in two worldwide remarkable diseases, myocardial infarction and depression. The purpose of the 18-month follow-up study was to evaluate the outcomes of interpersonal counselling implemented by a psychiatric nurse, and to examine the recovery experienced by the patients after myocardial infarction. The interpersonal counseling consisted of a short-term (max 6 sessions) depression-focused intervention modified for myocardial infarction patients. The main principle of interpersonal counselling is that depressive symptoms relate to interpersonal relations. The measured outcomes of the intervention consisted of changes in depressive symptoms and distress, health-related quality of life and the use of health care services. The data consisted of 103 patients with acute myocardial infarction and with sufficient knowledge of Finnish language, and they were randomized into intervention group (n=51) and control group (n=52) with standard care. Depressive symptoms were measured using Beck Depression Inventory, and distress using Symptom Checklist-25. The instrument to measure health-related quality of life was EuroQol-5 Dimensions. All instruments were used at three measurements: in hospital, at 6 months and at 18 months after hospital discharge. The Use of Health Care Services questionnaire was used during the 6- and 18-month period after hospital discharge. In addition, satisfaction with the intervention and with information received from the health-care professional was evaluated during the follow-up. To examine recovery, the patients kept diaries during a 6-month period and they were interviewed at 18 months after myocardial infarction. The number of patients with depressive symptoms decreased significantly more in the intervention group compared with the control group during 18 months of follow-up. Distress decreased significantly more among patients under 60 years in the intervention group than in the control group, but the difference was not significant between the groups. No differences in the changes of health-related quality of life were found between the groups during follow-up. However, in the group of patients under 60 years, the improvement of health-related quality of life in the intervention was significantly better in the intervention group compared with the control group during the follow-up. During the follow-up period, there was even a decline in the use of somatic specialized health care services in the intervention group and among intervention patients who had no other long-term disease. Considering recovery experienced by the patients, main categories including many supporting and inhibiting factors and subcategories were identified: clinical and physical, psychological, social, functional and professional category. No differences between the groups were found in satisfaction with information received from the professionals. The brief and easy-to-learn intervention, with which the patients were satisfied, seems to decrease depressive symptoms after myocardial infarction. Interpersonal counselling seems to be beneficial especially with younger patients. These results justify adopting depression screening and interpersonal counselling as part of routine care after myocardial infarction. The first stage evaluation of the use of health care services is interesting, and calls for more studies. From the perspective of individual patients, recovery after myocardial infarction seems to consist of many supporting and inhibiting factors. This is something that is important to take into account in developing nursing practice. The results indicate a need for further studies in outcomes of interpersonal counselling and recovery experienced by the patients after myocardial infarction. In addition, the results encourage widening the research perspective to nursing administration and educational level.

Percutaneous Coronary Intervention in Patients with Atrial Fibrillation: A Study of Factors Affecting Outcome, with a Special Emphasis on Periprocedural Antithrombotic Treatment

Antithrombotic treatment of patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is a delicate balancing between the risk of thromboembolism and the risk of bleeding. The purpose of this dissertation was to analyze current antithrombotic treatment strategies at the periprocedural stage and report outcomes in-hospital and at 1-month follow-up, and to evaluate the effect of renal impairment and predictive values of various bleeding scores on 1-year outcome after PCI in patients with AF. The first article was based on retrospective data from 7 Finnish hospitals between 2002–2006 (n=377), while the others were based on a prospective 17-center European register (AFCAS) gathered between 2008–2010 (n=963). The main findings in patients with AF undergoing PCI were: The use of glycoprotein IIb/IIIa inhibitors during PCI was associated with a four- to five-fold increase in the risk of major bleeding (I). Uninterrupted warfarin treatment did not increase perioperative complications and seemed to decrease bleeding complications compared to heparin bridging (II). Already mild renal impairment (eGFR 60–90mL/min) was associated with a 2.3-fold risk of all-cause mortality during the 12 months following PCI (III). Major adverse cardiac events occurred in 4.5% and bleeding complications in 7.1% of patients in the AFCAS register by 1-month follow-up (IV). In a study of patients in AFCAS register, all currently used bleeding risk scores were poor predictors of bleeding complications by 1-year follow-up (V). The findings will help improve treatment strategies for this fragile patient population with a high risk of bleeding and thrombotic complications.

Congenital upper limb defects in Finland 1993-2005

Background: Interest in limb defects has grown after the thalidomide tragedy in the 1960s. As a result, congenital malformation registries, monitoring changes in birthprevalence and defect patterns, have been established in several countries. However, there are only a few true population based studies on birth prevalence of upper limb defects. The burden of hospital care among these children, specifically in terms of the number of admissions and total time spent in hospital, is also unknown. Aims and Methods: This study is based on information gathered from the Finnish Register of Congenital malformations (FRM) and the Finnish Hospital Discharge Register (FHDR). A total of 417 children born between 1993 and 2005 with an upper limb defect were gathered from the FRM. The upper limb defects were classified using the International Federation of Societies for Surgery of the Hand -classification that enables comparison with previous and future studies. Birth and live birth prevalence, sex and side distribution, frequency of associated anomalies as well as the proportion of perinatal and infant deaths according to the different subtypes were calculated. The number of hospital admissions, days spent in hospital, number and type of surgical operations were collected from the FHDR. Special features of two subgroups, radial ray defects (RRD) and constriction band syndrome (CBS), were explored. Results: Upper limb defects were observed in 417 of 753 342 consecutive births and in 392 of 750 461 live births. Birth prevalence was 5.5 per 10 000 births and 5.2 per 10 000 live births. Multiple anomalies or a known syndrome was found in 250 cases (60%). Perinatal mortality was 139 per 1000 births and infant mortality 135 per 1000 live births (overall Finnish perinatal mortality <5 per 1000 births and infant mortality 3.7 per 1000 live births). Altogether, 138 infants had RRD and 120 (87%) of these had either a known syndrome or multiple major anomalies. The proportion of perinatal deaths in RRD group was 29% (40/138) and infant deaths 35% (43/123). Fifty-one children had CBS in upper limbs. Fifteen of these (29%) had other major anomalies associated with constriction rings. The number of hospital admissions per year of children with congenital upper limb defects was 11-fold and the time spent in hospital 13-fold as compared with the general paediatric population. Conclusions: Birth prevalence of congenital upper limb defects was 5.5 per 10 000 births and 5.2 per 10 000 live births. RRD was especially associated with other major anomalies and high mortality. Nearly one third of the children with CBS also had other major anomalies suggesting different aetiologies inside the group. The annual burden of hospital care of children with congenital upper limb defects was at least 11-fold as compared with the general paediatric population.

The role of emotions in value creation for families in pediatric health care

The purpose of this study was to analyze emotions related to a child’s critical illness from the perspective of the family and discuss the link those emotions might form with value creation. High quality service is of paramount importance in hospital care, especially when a child is diagnosed with critical illness. Through the analysis of patient family emotions and their triggers, the study was aiming to deepen the understanding of value creation for customer. Therefore, the research sought to find answers to the following three sub-questions: 1. What are the emotions experienced? 2. What triggers them? 3. How are the emotions linked to amelioration or aggravation of value for patient and family? The theoretical background of this research is built on two core concepts: emotions and value creation. As both concepts are wide and multifaceted, the research concentrates on viewing emotions from the applicable cognitive angle, identifying and categorizing emotions in a general level. Value creation is studied from the service perspective, discussing the possible relations between emotions and value creation. Moreover, the suitability of views regarding customer value co-creation to health care encounters is analyzed. Qualitative approach was selected as the most appropriate methodology for conducting the empirical research. The empirical data was collected from public blogs, for which a total of 18 blogs were reviewed. Five blogs were selected for the analysis, which had the intent of identifying the emotions experienced by patient families and deepening the knowledge of their role in value creation during health care service encounters. The empirical study of this research discovered a wide range of positive and negative emotions, which denotes that a severe life situation does not prevent the feeling of positive emotions. Furthermore, by combining the empirical findings to the theoretical background, this study concludes that recognizing and treating the patient family as a partner and value creator is essential. The high quality technical aspect of care is vital, but it is not the sole attribute for service quality, as the interpersonal communication plays a large role in the customer’s overall assessment of the health care performance. The patients and their families largely evaluate the service encounter based on their perceptions, thus emotions play a significant role. Depending on the service experience, value maybe created or destructed. Hence, this study posits emotion at the core of the service encounter, indicating towards the importance of active assessment of customer perceptions and the recognition of the emotional states

Usability and Security in Medication Administration Applications

The traditional process of filling the medicine trays and dispensing the medicines to the patients in the hospitals is manually done by reading the printed paper medicine chart. This process can be very strenuous and error-prone, given the number of sub-tasks involved in the entire workflow and the dynamic nature of the work environment. Therefore, efforts are being made to digitalise the medication dispensation process by introducing a mobile application called Smart Dosing application. The introduction of the Smart Dosing application into hospital workflow raises security concerns and calls for security requirement analysis. This thesis is written as a part of the smart medication management project at Embedded Systems Laboratory, A° bo Akademi University. The project aims at digitising the medicine dispensation process by integrating information from various health systems, and making them available through the Smart Dosing application. This application is intended to be used on a tablet computer which will be incorporated on the medicine tray. The smart medication management system include the medicine tray, the tablet device, and the medicine cups with the cup holders. Introducing the Smart Dosing application should not interfere with the existing process carried out by the nurses, and it should result in minimum modifications to the tray design and the workflow. The re-designing of the tray would include integrating the device running the application into the tray in a manner that the users find it convenient and make less errors while using it. The main objective of this thesis is to enhance the security of the hospital medicine dispensation process by ensuring the security of the Smart Dosing application at various levels. The methods used for writing this thesis was to analyse how the tray design, and the application user interface design can help prevent errors and what secure technology choices have to be made before starting the development of the next prototype of the Smart Dosing application. The thesis first understands the context of the use of the application, the end-users and their needs, and the errors made in everyday medication dispensation workflow by continuous discussions with the nursing researchers. The thesis then gains insight to the vulnerabilities, threats and risks of using mobile application in hospital medication dispensation process. The resulting list of security requirements was made by analysing the previously built prototype of the Smart Dosing application, continuous interactive discussions with the nursing researchers, and an exhaustive stateof- the-art study on security risks of using mobile applications in hospital context. The thesis also uses Octave Allegro method to make the readers understand the likelihood and impact of threats, and what steps should be taken to prevent or fix them. The security requirements obtained, as a result, are a starting point for the developers of the next iteration of the prototype for the Smart Dosing application.

Usability and Security in Medication. Administration Applications

The traditional process of filling the medicine trays and dispensing the medicines to the patients in the hospitals is manually done by reading the printed paper medicinechart. This process can be very strenuous and error-prone, given the number of sub-tasksinvolved in the entire workflow and the dynamic nature of the work environment.Therefore, efforts are being made to digitalise the medication dispensation process byintroducing a mobile application called Smart Dosing application. The introduction ofthe Smart Dosing application into hospital workflow raises security concerns and callsfor security requirement analysis. This thesis is written as a part of the smart medication management project at EmbeddedSystems Laboratory, A˚bo Akademi University. The project aims at digitising the medicine dispensation process by integrating information from various health systems, and making them available through the Smart Dosing application. This application is intended to be used on a tablet computer which will be incorporated on the medicine tray. The smart medication management system include the medicine tray, the tablet device, and the medicine cups with the cup holders. Introducing the Smart Dosing application should not interfere with the existing process carried out by the nurses, and it should result in minimum modifications to the tray design and the workflow. The re-designing of the tray would include integrating the device running the application into the tray in a manner that the users find it convenient and make less errors while using it. The main objective of this thesis is to enhance the security of the hospital medicine dispensation process by ensuring the security of the Smart Dosing application at various levels. The methods used for writing this thesis was to analyse how the tray design, and the application user interface design can help prevent errors and what secure technology choices have to be made before starting the development of the next prototype of the Smart Dosing application. The thesis first understands the context of the use of the application, the end-users and their needs, and the errors made in everyday medication dispensation workflow by continuous discussions with the nursing researchers. The thesis then gains insight to the vulnerabilities, threats and risks of using mobile application in hospital medication dispensation process. The resulting list of security requirements was made by analysing the previously built prototype of the Smart Dosing application, continuous interactive discussions with the nursing researchers, and an exhaustive state-of-the-art study on security risks of using mobile applications in hospital context. The thesis also uses Octave Allegro method to make the readers understand the likelihood and impact of threats, and what steps should be taken to prevent or fix them. The security requirements obtained, as a result, are a starting point for the developers of the next iteration of the prototype for the Smart Dosing application.

Clinical Learning Environment and Supervision. Development and Validation of the CLES Evaluation Scale

The purpose of the study is: (1) to describe how nursing students' experienced their clinical learning environment and the supervision given by staff nurses working in hospital settings; and (2) to develop and test an evaluation scale of Clinical Learning Environment and Supervision (CLES). The study has been carried out in different phases. The pilot study (n=163) explored the association between the characteristics of a ward and its evaluation as a learning environment by students. The second version of research instrument (which was developed by the results of this pilot study) were tested by an expert panel (n=9 nurse teachers) and test-retest group formed by student nurses (n=38). After this evaluative phase, the CLES was formed as the basic research instrument for this study and it was tested with the Finnish main sample (n=416). In this phase, a concurrent validity instrument (Dunn & Burnett 1995) was used to confirm the validation process of CLES. The international comparative study was made by comparing the Finnish main sample with a British sample (n=142). The international comparative study was necessary for two reasons. In the instrument developing process, there is a need to test the new instrument in some other nursing culture. Other reason for comparative international study is the reflecting the impact of open employment markets in the European Union (EU) on the need to evaluate and to integrate EU health care educational systems. The results showed that the individualised supervision system is the most used supervision model and the supervisory relationship with personal mentor is the most meaningful single element of supervision evaluated by nursing students. The ward atmosphere and the management style of ward manager are the most important environmental factors of the clinical ward. The study integrates two theoretical elements - learning environment and supervision - in developing a preliminary theoretical model. The comparative international study showed that, Finnish students were more satisfied and evaluated their clinical placements and supervision with higher scores than students in the United Kingdom (UK). The difference between groups was statistical highly significant (p= 0.000). In the UK, clinical placements were longer but students met their nurse teachers less frequently than students in Finland. Arrangements for supervision were similar. This research process has produced the evaluation scale (CLES), which can be used in research and quality assessments of clinical learning environment and supervision in Finland and in the UK. CLES consists of 27 items and it is sub-divided into five sub-dimensions. Cronbach's alpha coefficient varied from high 0.94 to marginal 0.73. CLES is a compact evaluation scale and user-friendliness makes it suitable for continuing evaluation.

Ensimmäiset päivät sairaalassa : viiden iäkkään potilaan havainnointi vuodeosastolla

English summary: First 72 hours in hospital : observation of five older patients on a ward

Sairaalan tarkkailuosaston hyödyt ja kustannukset

Työn tavoitteena oli tutkia Etelä-Karjalan keskussairaalaan mahdollisesti perustettavan yhdistelmätarkkailuosaston kannattavuutta määrittämällä osaston kustannukset ja hyödyt. Määritettyjen kustannusten avulla vertailtiin päivystys-potilaiden eri hoitoketjuvaihtoehtoja. Lähdeaineistona työssä käytettiin sairaalan omia materiaaleja ja tilastoja, henkilöstön haastatteluja sekä muita kirjallisuuslähteitä. Kirjallisuuden mukaan sairaalan ylikuormitus johtuu sen huonosta potilasvirtojen kulusta, jota voidaan parantaa joko toimintaa tehostamalla tai investoimalla uusiin resursseihin. Eräs vaihtoehto ylikuormituksen purkuun on tarkkailuosaston perustaminen, joka ei ole vain lisätila vaan potilasvirtojen ohjauskeino. Tehtyjen laskemien mukaan Etelä-Karjalan keskussairaalan tarkkailuosasto vaikuttaisi kannattavalta. Tarkkailuosaston kustannukset vuodessa olisivat 1 099 745 €, tuotot 1 170 108 € ja voitto 70 363 €. Osaston perustamiskustannukset olisivat 950 324 €. Hoitoketjujen potilaskohtaisen kannattavuuden mukaan päivystyspotilaiden tarkkailu ja lyhytaikainen hoito kannattaisi tehdä joko vuodeosastoilla tai tarkkailuosastolla, mutta ei tappiota tuottavalla ensiapupoliklinikalla. Tarkkailuosastosta olisi taloudellisten tekijöiden lisäksi myös muita hyötyjä ja haittoja sairaalan sidosryhmille. Sairaalan valitsemasta ylikuormituksen vähentämiskeinosta riippumatta, on sen tärkeätä aloittaa jo lähivuosina valmistautuminen väestön ikääntymisen aiheuttamaan lisääntyvään kuormitukseen.

The Quality of Paediatric Nursing Care - Children’s Perspective

Hoitotyön laatu - lasten näkökulma Tämän kolmivaiheisen tutkimuksen tarkoituksena oli kuvailla lasten odotuksia ja arviointeja lasten hoitotyön laadusta sekä kehittää mittari kouluikäisille sairaalassa oleville lapsille laadun arviointiin. Perimmäisenä tavoitteena oli lasten hoitotyön laadun kehittäminen sairaalassa. Ensimmäisessä vaiheessa 20 alle kouluikäistä (4-6v) sekä 20 kouluikäistä (7-11v) lasta kuvailivat odotuksiaan lasten hoitotyön laadusta. Aineisto kerättiin haastattelulla ja lasten piirustusten avulla, sekä analysoitiin sisällön analyysilla. Lasten odotukset lasten hoitotyön laadusta kohdistuivat hoitajaan, hoitotyön toimintoihin ja ympäristöön, fyysinen ympäristö korostui piirustuksissa. Ensimmäisen vaiheen tulosten, aikaisemman kirjallisuuden sekä Leino-Kilven “HYVÄ HOITO” mittarin pohjalta kehitettiin “Lasten Hoidon Laatu Sairaalassa” (LHLS) mittari ja testattiin sen psykometrisiä ominaisuuksia tutkimuksen toisessa vaiheessa. Mittaria kehitettiin ja testattiin kolmen vaiheen kautta. Aluksi asiantuntijapaneeli (n=7) arvioi mittarin sisältöä. Seuraavaksi mittari esitestattiin kahdesti kouluikäisillä sairaalassa olevilla lapsilla (n=41 ja n=16), samassa vaiheessa myös viiden lastenosaston hoitajat (n=19) yhdessä arvioivat mittarin sisältöä sekä 8 lasta. Lopuksi mittaria testattiin kouluikäisillä lapsilla (n=388) sairaalassa sekä hoitajat (n=198) arvioivat mittarin sisällön validiteettia. Mittarin kehittämisen aikana päälaatuluokkien: hoitajan ominaisuudet, hoitotyön toiminnot ja hoitotyön ympäristö Cronbachin alfa kertoimet paranivat. Pääkomponentti analyysi tuki mittarin hoitotyön toimintojen ja ympäristön alaluokkien teoreettista rakennetta. Kolmannessa vaiheessa “Lasten Hoidon Laatu Sairaalassa” (LHLS III, versio neljä) mittarilla kerättiin aineisto Suomen yliopistosairaaloiden lastenosastoilta kouluikäisiltä 7-11 -vuotiailta lapsilta (n=388). Mittarin lopussa lapsia pyydettiin lisäksi kuvailemaan kivointa ja ikävintä kokemustaan sairaalahoidon aikana lauseen täydennystehtävänä. Aineisto analysoitiin tilastollisesti sekä sisällön analyysilla. Lapset arvioivat fyysisen hoitoympäristön, hoitajien inhimillisyyden ja luotettavuuden sekä huolenpidon ja vuorovaikutustoiminnot kiitettäviksi. Lapset arvioivat hoitajien viihdyttämistoiminnot kaikkein alhaisimmiksi. Lapsen ikä ja sairaalantulotapa olivat yhteydessä lasten saamaan tiedon määrään. Lasten kivoimmat kokemukset liittyivät ihmisiin ja heidän ominaisuuksiinsa, toimintoihin, ympäristöön sekä lopputuloksiin. Ikävimmät kokemukset liittyivät potilaana oloon, tuntemuksiin sairauden oireista sekä erossaoloon, hoitotyön fyysisiin toimintoihin sekä ympäristöön. Tutkimuksen tulokset osoittavat lasten olevan kykeneviä arvioimaan omaa hoitoaan ja heidän näkökulmansa tulisi nähdä osana koko laadun kehittämisprosessia parannettaessa laatua käytännössä todella lapsilähtöisemmällä lähestymistavalla. “Lasten Hoidon Laatu Sairaalassa” (LHLS) mittari on mahdollinen väline saada tietoa lasten arvioinneista lasten hoitotyön laadusta, mutta mittarin testaamista tulisi jatkaa tulevaisuudessa

Kaatumisvaaraa lisäävät lääkkeet; Porissa toteutettu iäkkäiden monitekijäinen kaatumisten ehkäisy

Kaatumiset ovat ikääntyvien yleisimpiä tapaturmia. Niiden seuraukset voivat olla vakavia. Yksilöllisesti toteutetut ehkäisyohjelmat ovat vähentäneet kaatumisvaarassa olevien iäkkäiden kaatumisia. Psyykenlääkkeiden on osoitettu lisäävän kaatumisia ja murtumia. Niiden lopettaminen on vähentänyt kaatumisvaaraa. Monitekijäiset ehkäisyohjelmat kuvaavat harvoin psyykenlääkkeiden vähentämisen menetelmiä ja tuloksia. Satunnaistettuun, kontrolloituun kaatumisten moneen vaaratekijään kohdistettuun ehkäisytutkimukseen osallistui 591 porilaista. Tässä tutkimuksessa selvitettiin kotona asuvien 65 vuotta täyttäneiden, tutkimusta edeltäneiden 12 kuukauden aikana ainakin kerran kaatuneiden henkilöiden psyykenlääkkeiden käyttö, niiden vähentämisen onnistuminen ja vaikutus sekä ehkäisyohjelman merkitys kaatumisten ilmaantumiseen. Lisäksi tutkittiin kaatumisvamman takia hoitoon hakeutuneiden kaatumisvaaratekijöiden tunnistamista ja uusien kaatumisten ja murtumien ehkäisemiseksi suunniteltuja toimenpiteitä perusterveydenhuollossa ja erikoissairaanhoidossa. Joka neljäs osallistuja käytti säännöllisesti psyykenlääkkeitä. Kertaneuvonta niiden vähentämisestä, johon sisältyi kirjalliset ohjeet lääkemuutoksista ja luento lääkkeiden vaikutuksista kaatumisvaaraan, vähensi säännöllisten psyykenlääkkeiden käyttäjien lukumäärää 22 % ja bentsodiatsepiineja tai niiden kaltaisia lääkkeitä käyttävien lukumäärää 35%. Kaatumisen vuoksi terveyskeskukseen ja keskussairaalaan hakeutuneiden iäkkäiden kaatumisvaaratekijöiden selvittelyyn ja uusien kaatumisten tai murtumien ehkäisyyn kiinnitettiin erittäin vähän huomiota. Toimenpiteet keskittyivät syntyneiden vammojen tutkimiseen ja hoitoon. Monitekijäinen ehkäisyinterventio vähensi masentuneiden ja monikaatuilijoiden kaatumisia, mutta ei kaikkien osallistujien kaatumisten määrää 12 kuukauden ehkäisyohjelman aikana. Erityisesti bentsodiatsepiiniryhmän lääkkeitä käyttävät verrokkiryhmän jäsenet joutuivat herkemmin kaatumisen vuoksi lääkärinhoitoon ehkäisyohjelman jälkeisen vuoden aikana kuin nämä lääkkeet lopettaneet koeryhmän jäsenet. Johtopäätöksenä voidaan todeta, että psyykenlääkkeiden tunnistaminen kaatumisten vaaratekijäksi oli puutteellista. Niiden käyttöön tulisi kiinnittää enemmän huomiota, ja niiden käyttö tulisi purkaa aina, kun se on lääketieteellisesti mahdollista. Kaatumisten ehkäisy pitäisi kuulua terveydenhoitoon. Kohdennettuja ehkäisyohjelmia erilaisille kaatumisvaarassa oleville iäkkäille tulee kehittää edelleen.

Viestintä ravitsemusosaamisen kehittämisessä Case:Sairaalan ateriaprosessi

Tutkielman tarkoituksena oli tutkia viestinnän merkitystä osaamisen kehittämisessä. Tavoitteena oli tutkia, miten viestintä edistää ravitsemusosaamisen kehittämistä sairaalan ateriaprosessissa. Tutkimuksessa etsittiin vastausta kysymyksiin, mitkä ovat ravitsemusosaamisen kehittämisen ja viestinnän tavoitteet, millä työyhteisöviestinnän foorumeilla uuden ravitsemushoitosuosituksen ja ravitsemushoidon strategian edellyttämiä muutoksia käsitellään ja millaisia työssä oppimisen prosesseja näillä foorumeilla on tunnistettavissa. Empirian näkökulmasta tutkimusta voidaan kuvata tapaustutkimukseksi. Tapauksena on sairaalan ateriaprosessi. Tutkimuksen valmistelevana aineistona käytettiin uutta ravitsemushoitosuositusta (Nuutinen ym. 2010), jota täydennettiin haastatteluaineistolla. Tutkimuksessa ovat edustettuina hoitotyön, ruokapalvelun ja ravitsemushoidon asiantuntemuksen näkökulmat sairaalasta sekä ammatti- ja aikuisopistosta. Tutkimusmenetelmänä käytettiin teemahaastatteluja. Haastattelut nauhoitettiin ja litteroitiin tekstimuotoon. Aineisto analysoitiin teemakortiston ja teemoittelun avulla. Tutkimuksen tulokset osoittavat, että ravitsemusosaamisen kehittämisen tavoitteena on uuden ravitsemushoitosuosituksen ja ravitsemushoidon strategian edellyttämien muutosten toteuttaminen sairaalan ravitsemushoidon prosesseissa ja tuotteissa. Ravitsemusosaamisen kehittämisen tavoitteena on tässä yhteydessä ateriaprosessin ja ruokapalvelun tuotteiden eli ruokavalioiden kehittäminen. Ravitsemushoidon kehittämisen tarkoituksena on asiakkaiden toipumisen, elämänlaadun ja hyvinvoinnin edistäminen sekä terveydenhuollon kustannusten säästäminen. Viestinnällä on tärkeä merkitys ravitsemusosaamisen kehittämisessä. Viestinnän avulla edistetään yksilöllistä ja yhteistä eli tiimioppimista vuorovaikutuksen kautta. Ruokapalvelu- ja hoitohenkilöstön sekä ravitsemushoidon asiantuntijoiden välinen vuoropuhelu nähdään tärkeänä ravitsemusosaamisen kehittämisessä. Vuoropuhelun avulla vahvistetaan ravitsemushoitoon liittyvää tietopohjaa ja yhteistä käsitteistöä. Tavoitteena on yhteisen kielen ja toimintamallin luominen ravitsemushoidon kehittämiseen. Ravitsemushoitosuosituksen ja ravitsemushoidon strategian edellyttämiä muutoksia käsitellään ulkoisissa ja sisäisissä verkostoissa esimerkiksi ravitsemus-yhdyshenkilöverkoston tapaamisissa, moniammatillisissa työryhmissä, henkilöstö- ja oppisopimuskoulutuksissa sekä työfoorumilla eli fyysisessä työtilassa ja hyödyntäen viestintäteknologiaa. Hoitotyön, ruokapalvelun ja ravitsemushoidon asiantuntijoilla/opettajilla on tärkeä rooli ravitsemusosaamisen kehittämiseen liittyvässä työssä oppimisen ohjaamisessa. Ravitsemusosaamisen kehittämisessä on tunnistettavissa sosiaalisia, reflektiivisiä, kognitiivisia ja operationaalisia työssä oppimisen prosesseja. Sosiaalisia prosesseja ovat työkokemusten vaihdanta ja reflektiivisiä niiden arviointi. Kognitiivisten prosessien tarkoitus on tiedonhankinta ja prosessointi, jolloin yhdistetään kokemustietoa sekä uutta ravitsemustieteellistä tietoa. Tavoitteena on yhteisen kielen ja toimintamallin luominen, jota kokeillaan käytännössä. Operationaalisia prosesseja ovat fyysisessä työtilassa tapahtuva kokeilemalla, tekemällä ja soveltamalla oppiminen, jolloin uutta toimintamallia esimerkiksi vajaaravitsemuksen seulontaa, ateriatilausta tai reseptiikkaa kokeillaan käytännössä. Johtopäätöksenä voidaan todeta, että sairaalassa on omaksuttu oppivan organisaation periaatteita ravitsemusosaamisen kehittämisessä. Ravitsemusosaamisen kehittäminen on yhteydessä muutokseen, strategiaan, prosessien ja tuotteiden kehittämiseen. Viestinnän avulla edistetään ravitsemushoitosuosituksen ja ravitsemushoidon strategian edellyttämien muutosten toteuttamista sairaalan ateriaprosessissa ja ruokavalioissa. Hoito- ja ruokapalveluhenkilöstön sekä ravitsemushoidon asiantuntijoiden välisen vuoropuhelun tavoitteena on yhteisen kielen ja toimintamallin luominen ravitsemushoidon kehittämiseen. Tutkimus palvelee ravitsemusosaamisen kehittämistä sairaalan ateriaprosessissa. Tutkimuksen tuloksia on mahdollista käyttää vertailuoppimismateriaalina terveydenhuollon organisaatioissa ja verkostoissa.

Internet-based breast cancer patient’s pathway as an empowering patient educational tool

This three-phase study was conducted to examine the effect of the Breast Cancer Patient’s Pathway program (BCPP) on breast cancer patients’ empowering process from the viewpoint of the difference between knowledge expectations and perceptions of received knowledge, knowledge level, quality of life, anxiety and treatment-related side effects during the breast cancer treatment process. The BCPP is an Internet-based patient education tool describing a flow chart of the patient pathway during the breast treatment process, from breast cancer diagnostic tests to the follow-up after treatments. The ultimate goal of this study was to evaluate the effect of the BCPP to the breast cancer patient’s empowerment by using the patient pathway as a patient education tool. In phase I, a systematic literature review was carried out to chart the solutions and outcomes of Internet-based educational programs for breast cancer patients. In phase II, a Delphi study was conducted to evaluate the usability of web pages and adequacy of their content. In phase III, the BCPP program was piloted with 10 patients and patients were randomised to an intervention group (n=50) and control group (n=48). According to the results of this study, the Internet is an effective patient education tool for increasing knowledge, and BCPP can be used as a patient education method supporting other education methods. However, breast cancer patients’ perceptions of received knowledge were not fulfilled; their knowledge expectations exceed the perceived amount of received knowledge. Although control group patients’ knowledge expectations were met better with the knowledge they received in hospital compared to the patients in the intervention group, no statistical differences were found between the groups in terms of quality of life, anxiety and treatment-related side effects. However, anxiety decreased faster in the intervention group when looking at internal differences between the groups at different measurement times. In the intervention group the relationship between the difference between knowledge expectations and perceptions of received knowledge correlated significantly with quality of life and anxiety. Their knowledge level was also significant higher than in the control group. These results support the theory that the empowering process requires patient’s awareness of knowledge expectations and perceptions of received knowledge. There is a need to develop patient education to meet patients’ perceptions of received knowledge, including oral and written education and BCPP, to fulfil patient’s knowledge expectations and facilitate the empowering process. Further research is needed on the process of cognitive empowerment with breast cancer patients. There is a need for new patient education methods to increase breast cancer patients’ awareness of knowing.