Patient Seclusion and Restraint Practices in Psychiatric Hospitals - Towards Evidence Based Clinical Nursing

The overall goal of this study was to support evidence based clinical nursing regarding patient seclusion and restraint practices. This was done by ensuring professional competence through innovative learning methods. The data were collected in three phases between March 2007 and May 2009 on acute psychiatric wards. Firstly, psychiatric inpatients’ experiences and suggestions for seclusion and restraint practices were explored (n=30). Secondly, nursing and medical personnel’s perceptions of seclusion and restraint practices were explored (n=27). Thirdly, the impacts of a continuing vocational eLearning course on nurses’ professional competence was evaluated (n=158). Patients’ perspectives received insufficient attention during the seclusion and restraint process. Improvements and alternatives to seclusion and restraint as suggested by the patients focused on essential parts of clinical nursing, but were not extensively adopted. Also nursing and medical personnel thought that patients’ subjective perspective received little attention. Personnel proposed a number of alternatives to seclusion and restraint, and they expressed a need for education and support to adopt these in clinical nursing. Evaluation of impacts of eLearning course on nurses’ professional competence showed no statistical differences between an eLearning group and an education-as-usual group. This dissertation provides evidence based knowledge about the realization of seclusion and restraint practices and the impacts of eLearning course on nurses’ professional competence in psychiatric hospitals. In order to improve clinical nursing the patient perspective must be accentuated. To ensure personnel’s professional competence, there is a need for written clinical guidelines, education and support. Continuing vocational education should bring together written clinical guidelines, ethical and legal issues and the support for personnel. To achieve the ambitious goal of such integration, achievable and affordable educational programmes are required. This, in turn, yields a call for innovative learning methods.

Information literacy as a social phenomenon in the nursing environment

Abstrakti

Economics of combined power plant and pyrolysis bio-oil production

There are reasons of necessity in bio-fuel use and bio-energy fast development. It includes the material about bio-energy technologies, applications and methods. There are basic thermodynamics and economic theories. The economic calculation presents the comparison between two combinations. There are boiler plant below 20 MW in combination with ablative pyrolysis plant for bio-oil production and CHP plant below 100 MW in combination with the RTP pyrolysis bio-oil production technology. It provides a material about wood chips and bio-oil characteristics and explains it nature, presents the situation around the bio-fuel market or bio-fuel trade. There is a description of pyrolysis technologies such as ablative and RTP. The liquid product of the pyrolysis processes is bio-oil. The bio-oil could be different even of the same production process, because of the raw material nature and characteristics. The calculation shows advantages and weaknesses of combinations and obtained a proof of suppositions. The next thing, proven by this work is the fact that to get more efficiency from energy project it is good possibility to built plants in combinations.

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.

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.

Adoption of information technology based patient education in psychiatric nursing

The overall goal of the study was to describe adoption of information technology (IT)-based patient education (PE) developed for patients and nurses use in psychiatric nursing. The data were collected in three phases during the period 2000-2006 in a variety of psychiatric settings in Finland. Firstly, the development process of IT-based PE for patients with schizophrenia spectrum psychosis was described. Secondly, nurses’ adoption of IT-based PE and the variables explaining adoption were demonstrated. Moreover, use of daily IT-based PE in clinical practice and factors associated with use were identified and described. And thirdly, nurses’ experiences of the IT-based PE after one year clinical use were evaluated. IT-based PE program was developed in several stages based on users’ needs and it included information and multimedia applications. Altogether, almost 500 IT-based PE sessions were carried out by the nurses on the study wards and revealed nurses’ activity in educating patients using IT to vary and depend on the hospital in which they worked. Almost 80% of all the possible IT-based PE sessions involved 93 patients and 83 nurses. Less than 2% of the IT-based PE sessions were interrupted and less than 10% suffered disturbances due to the patients or external causes. Moreover, the patients whose education took more days had poorer mental status than those whose education was carried out over a shorter period. After a year’s experience, advantages and disadvantages were described by the nurses for both patients and nurses of the IT-based PE. IT-based PE can be used even on closed acute psychiatric wards with patients with serious mental health disorders. However, technology adoption requires time, and therefore, it must fit in with clinical practice. Collaboration between users and developers is needed when developing user-centered methods in the area of mental health services. Moreover, it is important to understand factors that affect IT adoption in healthcare settings. IT-based PE is one option in interactive and co-operative health care practice between patients and nurses. Therefore the staff should begin to refer patients to established, credible and well-maintained Internet sites that provide information on common psychological problems. Even if every nurse should be trained and engaged to carry out IT-based PE, by targeting the training especially for the most active nurses aids them to support the less active ones. Adoption should also be understood from a perspective that includes aspects related to the context where it is implemented and examine how and in what circumstances it works.

Competence in intensive and critical care nursing - development of a basic assessment scale for graduating nursing students

Intensive and critical care nursing is a speciality in its own right and with its own nature within the nursing profession. This speciality poses its own demands for nursing competencies. Intensive and critical care nursing is focused on severely ill patients and their significant others. The patients are comprehensively cared for, constantly monitored and their vital functions are sustained artificially. The main goal is to win time to cure the cause of the patient’s situation or illness. The purpose of this empirical study was i) to describe and define competence and competence requirements in intensive and critical care nursing, ii) to develop a basic measurement scale for competence assessment in intensive and critical care nursing for graduating nursing students, and iii) to describe and evaluate graduating nursing students’ basic competence in intensive and critical care nursing by seeking the reference basis of self-evaluated basic competence in intensive and critical care nursing from ICU nurses. However, the main focus of this study was on the outcomes of nursing education in this nursing speciality. The study was carried out in different phases: basic exploration of competence (phase 1 and 2), instrumentation of competence (phase 3) and evaluation of competence (phase 4). Phase 1 (n=130) evaluated graduating nursing students’ basic biological and physiological knowledge and skills for working in intensive and critical care with Basic Knowledge Assessment Tool version 5 (BKAT-5, Toth 2012). Phase 2 focused on defining competence in intensive and critical care nursing with the help of literature review (n=45 empirical studies) as well as competence requirements in intensive and critical care nursing with the help of experts (n=45 experts) in a Delphi study. In phase 3 the scale Intensive and Critical Care Nursing Competence Scale (ICCN-CS) was developed and tested twice (pilot test 1: n=18 students and n=12 nurses; pilot test 2: n=56 students and n=54 nurses). Finally, in phase 4, graduating nursing students’ competence was evaluated with ICCN-CS and BKAT version 7 (Toth 2012). In order to develop a valid assessment scale of competence for graduating nursing students and to evaluate and establish the competence of graduating nursing students, empirical data were retrieved at the same time from both graduating nursing students (n=139) and ICU nurses (n=431). Competence can be divided into clinical and general professional competence. It can be defined as a specific knowledge base, skill base, attitude and value base and experience base of nursing and the personal base of an intensive and critical care nurse. Personal base was excluded in this self-evaluation based scale. The ICCN-CS-1 consists of 144 items (6 sum variables). Finally, it became evident that the experience base of competence is not a suitable sum variable in holistic intensive and critical care competence scale for graduating nursing students because of their minor experience in this special nursing area. ICCN-CS-1 is a reliable and tolerably valid scale for use among graduating nursing students and ICU nurses Among students, basic competence of intensive and critical care nursing was self-rated as good by 69%, as excellent by 25% and as moderate by 6%. However, graduating nursing students’ basic biological and physiological knowledge and skills for working in intensive and critical care were poor. The students rated their clinical and professional competence as good, and their knowledge base and skill base as moderate. They gave slightly higher ratings for their knowledge base than skill base. Differences in basic competence emerged between graduating nursing students and ICU nurses. The students’ self-ratings of both their basic competence and clinical and professional competence were significantly lower than the nurses’ ratings. The students’ self-ratings of their knowledge and skill base were also statistically significantly lower than nurses’ ratings. However, both groups reported the same attitude and value base, which was excellent. The strongest factor explaining students’ conception of their competence was their experience of autonomy in nursing. Conclusions: Competence in intensive and critical care nursing is a multidimensional concept. Basic competence in intensive and critical care nursing can be measured with self-evaluation based scale but alongside should be used an objective evaluation method. Graduating nursing students’ basic competence in intensive and critical care nursing is good but their knowledge and skill base are moderate. Especially the biological and physiological knowledge base is poor. Therefore in future in intensive and critical care nursing education should be focused on both strengthening students’ biological and physiological knowledge base and on strengthening their overall skill base. Practical implications are presented for nursing education, practice and administration. In future, research should focus on education methods and contents, mentoring of clinical practice and orientation programmes as well as further development of the scale.

Opportunistisen sopimusrikkomuksen ongelmasta, erityisesti Suomen vahingonkorvaus- ja rikoslainsäädännön näkökulmasta tarkasteltuna. Law and Economics -näkökulma.

Tämä pro gradu -tutkielma käsittelee opportunistisen sopimusrikkomuksen ongelmaa erityisesti Suomen vahingonkorvaus- ja rikoslainsäädännön näkökulmasta tarkasteltuna. Tutkielman lähestymistapa on oikeustaloustieteellinen (engl. Law and Economics). Opportunistisella sopimusrikkomuksella tarkoitetaan toimintaa, jossa sopimusosapuoli rikkoo sopimuksen tarkoituksellisesti, pyrkimyksenään tällä toiminnalla saavuttaa enemmän hyötyä kuin sopimuksessa pysymällä. Opportunistinen sopimusrikkomus on mahdollista toteuttaa tilanteessa, jossa sopimusasetelma itsessään antaa mahdollisuuden enemmän hyödyn saavuttamiseen rikkomus toteuttamalla kuin sopimus asianmukaisesti täyttämällä. Suomalaisessa vahingonkorvausjärjestelmässä sovelletaan sopimusrikkomusten osalla positiivisen sopimusedun mukaista vahingonkorvausta, joka hyvittää rikotulle osapuolelle sopimussuhteeseen ryhtymisestä syntyneet kustannukset sekä sopimusrikkomuksen johdosta saamatta jääneen tuoton. Positiivisen sopimusedun soveltaminen ei kuitenkaan ole opportunistisen sopimusrikkomuksen ehkäisemiseksi riittävää, sillä opportunistisesti toimiva sopimusosapuoli voi jäädä rikkomuksensa johdosta voitolle vielä sen jälkeenkin, kun kärsineelle osapuolelle on jo positiivista sopimusetua noudattaen korvattu sopimussuhteessa syntyneet kustannukset sekä rikkomuksen johdosta saamatta jäänyt tuotto. Keskeinen ongelma koskien opportunististen sopimusrikkomustilanteiden syntyä onkin juuri vallitsevan sääntelyn liiallinen keskittyminen rikotun osapuolen kärsimän vahingon kompensoimiseen, ei rikkomustilanteiden synnyn ennaltaehkäisemiseen. Suomen vahingonkorvausjärjestelmää tulisi kehittää suuntaan, jossa järjestelmä paremmin ennaltaehkäisisi opportunististen sopimusrikkomustilanteiden syntyä. Common law -oikeusjärjestelmässä käytössä olevan disgorgement principle -suuntaisen ajattelun, jossa korvauksen perustana toimisi rikkomuksella saatu hyöty kärsityn vahingon sijaan, omaksuminen olisi yksi mahdollinen kehityskulku. Olennaista olisi kuitenkin se, että järjestelmää kehitettäisiin suuntaan, jossa rikkomus ei enää voisi tulla rikkojalle kannattavaksi. Opportunistisen toiminnan kannustimet tulisi lainsäädäntöä tarkistamalla poistaa. Tällä olisi sekä sopimusinstituutiota turvaavaa että vaihdantaa edistävää vaikutusta.

Effects of mineral sorting on concentrator design and economics

Ore sorting after crushing is an effective way to enhance the feed quality of a concentrator. Sorting by hand is the oldest way of concentrating minerals but it has become outdated because of low capacities. Older methods of sorting have also been difficult to use in large scale productions due to low capacities of sorters. Data transfer and processing and the speed of rejection mechanisms have been the bottlenecks for effective use of sorters. A fictive chalcopyrite ore body was created for this thesis. The properties of the ore were typical of chalcopyrite ores and economical limit was set for design. Concentrator capacity was determined by the size of ore body and the planned mine life. Two concentrator scenarios were compared, one with the sorting facility and the other without sorting. Comparison was made for quality and amount of feed, size of equipment and economics. Concentrator with sorting had lower investment and operational cost but also lower incomes due to the ore loss in sorting. Net cash flow, net present value and internal rate of interest were calculated for comparison of the two scenarios.