Challenges to patient-centred care in a general internal medicine context: findings from an exploratory study

Introduction. If we are to promote more patient-centred approaches in care delivery, we have to better characterize the situations in which being patient-centred is difficult to achieve. Data from professionals in health and social care are important because they are the people charged with operationalizing patient-centred care (PCC) in their daily practice. However, empirical accounts from frontline care providers are still lacking, and it is important to gather experiences not only from doctors but also from the other care providers. Indeed, experiences from different professions can help inform our understanding of patient care, which is expected to be both patient-centred and collaborative. Methods. This study was based on the following research question: What factors make the provision of PCC difficult to achieve? Sample and setting. A purposeful sampling technique was used, allowing for a series of choices about the participants and their professional affiliation. Because patient-centredness is the focus, 3 professions appeared to be of special interest: general internists, nurses and social workers. The study was undertaken in the General Internal Medicine Division of a teaching hospital located in a North American context. Data Collection. To answer the research question, a methodological approach based on a theory called phenomenology was chosen. Accordingly, semi-structured interviews were used since they generate understanding of the meanings different individuals have of their lived world. Interviews with 8 physicians, 10 nurses and 10 social workers were eventually conducted. Data analysis. An inductive thematic analysis was employed to make sense of the interview data. Results. The thematic analysis allowed identifying various types of challenges to PCC. Although most of the challenges were perceived by all three groups of professionals, they were perceived to a different degree across the professions, which likely reflected the scope of practice of each profession. The challenges and their distribution across the professions are illustrated in Table 1. Examples of challenges are provided in Table 2. Discussion. There is a tension between what is supposed to be done - what stands in the philosophy of patient -centredness - and what is currently done - the real life with all the challenges to PCC. According to some participants' accounts, PCC clearly risks becoming a mere illusion for health care professionals on which too great pressures are imposed.

Simulated Patient as Co-facilitators: Benefits and Challenges of the Interprofessional Team OSCE (Submission #9350).

Hypothesis: The quality of care for chronic patients depends on the collaborative skills of the healthcare providers.1,2 The literature lacks reports of the use of simulation to teach collaborative skills in non-acute care settings. We posit that simulation offers benefits for supporting the development of collaborative practice in non-acute settings. We explored the benefits and challenges of using an Interprofessional Team - Objective Structured Clinical Examination (IT-OSCE) as a formative assessment tool. IT-OSCE is an intervention which involves an interprofessional team of trainees interacting with a simulated patient (SP) enabling them to practice collaborative skills in non-acute care settings.5 A simulated patient are people trained to portray patients in a simulated scenario for educational purposes.6,7 Since interprofessional education (IPE) ultimately aims to provide collaborative patient-centered care.8,9 We sought to promote patient-centeredness in the learning process. Methods: The IT-OSCE was conducted with four trios of students from different professions. The debriefing was co-facilitated by the SP with a faculty. The participants were final-year students in nursing, physiotherapy and medicine. Our research question focused on the introduction of co-facilitated (SP and faculty) debriefing after an IT-OSCE: 1) What are the benefits and challenges of involving the SP during the debriefing? and 2) To evaluate the IT-OSCE, an exploratory case study was used to provide fine grained data 10, 11. Three focus groups were conducted - two with students (n=6; n=5), one with SPs (n=3) and one with faculty (n=4). Audiotapes were transcribed for thematic analysis performed by three researchers, who found a consensus on the final set of themes. Results: The thematic analysis showed little differentiation between SPs, student and faculty perspectives. The analysis of transcripts revealed more particularly, that the SP's co-facilitation during the debriefing of an IT-OSCE proved to be feasible. It was appreciated by all the participants and appeared to value and to promote patient-centeredness in the learning process. The main challenge consisted in SPs feedback, more particularly in how they could report accurate observations to a students' group rather than individual students. Conclusion: In conclusion, SP methodology using an IT-OSCE seems to be a useful and promising way to train collaborative skills, aligning IPE, simulation-based team training in a non-acute care setting and patient-centeredness. We acknowledge the limitations of the study, especially the small sample and consider the exploration of SP-based IPE in non-acute care settings as strength. Future studies could consider the preparation of SPs and faculty as co-facilitators. References: 1. Borrill CS, Carletta J, Carter AJ, et al. The effectiveness of health care teams in the National Health Service. Aston centre for Health Service Organisational Research. 2001. 2. Reeves S, Lewin S, Espin S, Zwarenstein M. Interprofessional teamwork for health and social care. Oxford: Wiley-Blackwell; 2010. 3. Issenberg S, McGaghie WC, Petrusa ER, Gordon DL, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning - a BEME systematic review. Medical Teacher. 2005;27(1):10-28. 4. McGaghie W, Petrusa ER, Gordon DL, Scalese RJ. A critical review of simulation-based medical education research: 2003-2009. Medical Education. 2010;44(1):50-63. 5. Simmons B, Egan-Lee E, Wagner SJ, Esdaile M, Baker L, Reeves S. Assessment of interprofessional learning: the design of an interprofessional objective structured clinical examination (iOSCE) approach. Journal of Interprofessional Care. 2011;25(1):73-74. 6. Nestel D, Layat Burn C, Pritchard SA, Glastonbury R, Tabak D. The use of simulated patients in medical education: Guide Supplement 42.1 - Viewpoint. Medical teacher. 2011;33(12):1027-1029. Disclosures: None (C) 2014 by Lippincott Williams & Wilkins, Inc.

Transgression et initiation : tendances idéologiques et développement littéraire du récit de Genèse 2-3

Several questions about the story of Gen 2-3 remain unresolved in current scholarship. For instance, the implications and manifold consequences of the transgression act - the consumption of the forbidden fruit - are much debated. Interpreters generally agree that the story is connected to several "J" / "non-P" narratives of the primeval history. Besides the use of the tetragrammaton as the designation for God, a common characteristic of these stories is the strong opposition between Yhwh as a harsh deity on one hand and disobedient and transgressing humankind on the other. This paper reconsiders several open questions as well as the aforementioned consensus. The analysis of important motifs in Gen 2-3 leads to the conclusion that this story differs in theologically important ways from the postulated "J"-narrative in Genesis. This indicates that it was not composed as an integral part of that narrative. There are, in Gen 2-3, ideological features and linguistic elements typical of the "J" stratum, but they are all found in the sections that present Yhwh God's investigation and punishment of the couple (3,8-19.24). Since these verses are in tension with or even contradict their immediate context, it should be assigned to a redactional ("J") layer. According to this analysis, the transgression in Gen 2-3 should not be considered a sin. Rather, it is an important step in human evolution towards a self-conscious and autonomous being. The plot has a structure similar to some episodes in ancient Near Eastern myths. 'Initiation' functions as a central theme. Finally, the article discusses the literary milieu of the story. Because of several linguistic and thematic similarities with Gen 1, with P-texts in general, and with the book of Ezekiel, the relationship of Gen 2-3 to these literary entities needs to be reconsidered.

The learning about imaging diagnosis technology

Objective To investigate the learning about management of the technology (efficient use, acquisition and maintenance of imaging diagnosis equipment) in the radiology residency program of Escola Paulista de Medicina - Universidade Federal de São Paulo, with a view to improving the education of radiologists. Materials and Methods Exploratory research where residents, faculty staff and tutors of the program were quantitative and qualitatively approached with Likert scale questionnaires (46), and deepening with recorded interviews (18) and categorization based upon meaning units (thematic analysis). Results Among the participants, 66% agreed that they had the opportunity of learning about the use of radiological equipment; for 61% the program should include knowledge on the importance of acquiring equipment; and 72% emphasized the lack of learning about equipment management and maintenance. Conclusion As the major moment in the education of specialists, the medical residency program provides residents with a favorable environment to the learning of the skills required to the future of their professional practice, but with limited emphasis on the management of the technology: efficient use, acquisition and mainly maintenance of equipment, still poorly explored. Both the investigated program and the medical residency in radiology should incorporate, whenever possible, the commitment with the training in supplementary skills related to equipment management, developing the competence of the future radiologists.

Learning on human resources management in the radiology residency program

Objective To investigate the process of learning on human resource management in the radiology residency program at Escola Paulista de Medicina – Universidade Federal de São Paulo, aiming at improving radiologists' education. Materials and Methods Exploratory study with a quantitative and qualitative approach developed with the faculty staff, preceptors and residents of the program, utilizing a Likert questionnaire (46), taped interviews (18), and categorization based on thematic analysis. Results According to 71% of the participants, residents have clarity about their role in the development of their activities, and 48% said that residents have no opportunity to learn how to manage their work in a multidisciplinary team. Conclusion Isolation at medical records room, little interactivity between sectors with diversified and fixed activities, absence of a previous culture and lack of a training program on human resources management may interfere in the development of skills for the residents' practice. There is a need to review objectives of the medical residency in the field of radiology, incorporating, whenever possible, the commitment to the training of skills related to human resources management thus widening the scope of abilities of the future radiologists.

A qualitative study of adolescents with medically unexplained symptoms and their parents

Il est fréquent en médecine de premier recours de rencontrer des adolescents exprimant des symptômes somatiques pour lesquels aucune des investigations entreprises n'a permis de rendre compte d'une pathologie organique. De tels symptômes sont retrouvés dans la littérature sous la terminologie de symptômes médicalement inexpliqués (MUS) ou des troubles fonctionnels. Bien que la prévalence des adolescents souffrant de MUS est fréquente, les médecins éprouvent encore beaucoup de difficultés à prendre en charge et communiquer avec ces patients, principalement en raison d'une incompréhension de leurs besoins et préoccupations tant dans leur vie quotidienne que lors d'une consultation au cabinet. Le but de notre étude est de comprendre les expériences et vécus des adolescents avec des MUS ainsi que de leurs parents afin d'aider le praticien dans la compréhension de son patient dans sa globalité et ainsi d'améliorer sa prise en charge. Dans le premier article présenté, nous nous sommes intéressés à la vie quotidienne de ces adolescents en étudiant leurs relations avec leur famille et leur entourage ainsi que les répercussions sur leurs parcours scolaire et leurs activités extrascolaires. Dans le second article nous nous sommes penchés sur les relations qu'entretiennent ces adolescents et leurs parents avec le système de santé. Nous avons collecté des données qualitatives en moyennant des groupes focus incluant 16 adolescents atteints de troubles fonctionnels et leurs parents. L'analyse a permis de faire émerger les difficultés que ces jeunes et leurs familles vivent au quotidien et comment ils sont confrontés à la solitude dû principalement à l'incompréhension sociale. Les résultats mettent aussi en évidence l'insatisfaction de ces jeunes et de leurs parents par rapport à la prise en charge médical, notamment en raison d'un manque de communication. -- Medically unexplained symptoms (MUS) are common among adolescents and are frequently encountered in primary care. Our aim was to explore how these adolescents and their parents experience the condition and its impact on their daily lives and to provide recommendations for health professionals. Using a qualitative approach, six focus groups and two individual interviews were conducted. These involved a total of ten adolescents with different types of MUS and sixteen parents. The respondents were recruited in a university hospital in Switzerland. A thematic analysis was conducted according to the Grounded Theory. The analysis of the data highlighted four core themes: disbelief, being different, concealing symptoms, and priority to adolescent's health. Transcending these themes was a core issue regarding the discrepancy between the strategies that adolescents and their parents use to cope with the symptoms. Health professionals should be made aware of the emotional needs of these patients and their families.

Syväjohtaminen kokonaisvaltaisen oppimisen tukena Peikko Finland Oy:ssä

Tämän tutkimuksen tarkoituksena on ymmärtää yritystä oppivana organisaationa ja selvittää onko Syväjohtamisen valmennusmalli ja työkalu Peik-ko Finland Oy:lle organisaation ja yksilön oppimista tukevaa. Tutkimus on laadullinen tutkimus, jossa tutkimusaineiston muodostavat Peikko Finland Oy:n johdon ja esimiestehtävissä olevien henkilöiden teemahaastattelut. Tutkimuksen perusteella voidaan todeta, että Syväjohtamisen valmen-nusmalli on yrityksen ja yksilön oppimisen kannalta toimiva työkalu, joka ulkoisen valmennuksen jälkeen tulisi ylläpitää sisäisellä toimintamallilla. Oleellista on ulkoisen valmennuksen jatkamisen yhteydessä lisätä etukäteisinfon osuutta ennen valmennuksen alkamista. Peikko Finland Oy:ssä organisaation ja yksilön oma oppiminen edellyttää yritykseltä oppimista tukevien työkalujen ja yrityksen sisäisen toimintamallin toteuttamista, jonka avulla mahdollisestaan koko organisaation oppiminen ja yhteisten tavoitteiden ymmärtäminen.

”Kyllähän nyt pitäs olla jo semmonen aika, että pääsis niin kö keskustelemhan näistä asioista.” Tutkimus lappilaisten sotavankien, partisaanien uhrien ja huutolaisten elämänkulusta, voimavaroista, terveydestä ja sairauksista

Research into the course of life, mental stamina and health status of wartime prisoners, victims of Soviet partisan attacks, and paupers in Finnish Lapland The basis of this research comprised the issues raised during the interviews conducted in my work as a general practitioner in Lapland, regarding factors that have possibly affected the life stories and health conditions of Lappish people who had lived through the war as war prisoners, victims of partisan attacks, or paupers. The purpose of the study was to describe how the different life phases and experiences emerged from the interviewees’ stories and to identify their mental stamina. Another goal was to make observations on their health status, in which the main emphasis became to address mental symptoms. The cohort consisted of elderly Finns who lived in Lapland during the war and experienced war imprisonment, pauperism, or became victims of partisan attacks. All three groups consisted of 12 interviewees. The interview transcripts were read several times and then investigated using the content analysis methods applicable to the material. The research methodology was based on building awareness and understanding. Thematic tagging and data coding were used as structured analysis tools. In all three groups most of the interviewees clearly identified their mental stamina, the most fundamental of which were home, family and work. The war prisoners’ injuries and nervous sensibility symptoms had been shown in earlier studies on war prisoners, and on this basis they had been granted disability pensions. However, many of them had suppressed their traumatic experiences and mental difficulties, and they could not talk about these issues until at the time of these interviews held at old age. Four of them still suffered from a post-traumatic stress disorder. The victims of Soviet partisans had had to carry their mental load alone for decades before the cruel ravages on civilians in remote areas of Lapland became publicly known. Most of them still had disturbing nervous sensibility symptoms. Four interviewees had a post-traumatic stress disorder, and in addition to these, the mental symptoms of one had developed into a post-traumatic stress disorder during old age. Many of the interviewees who had been left paupers remembered their childhood as filled with grief and feelings of inferiority, and had nightmares relating to their wartime experiences. Yet none of them suffered from post-traumatic stress disorder. The results showed that the exceptional suffering caused by the war, the wartime imprisonment and the devastating attacks by Soviet partisans had led especially to mental difficulties. These were left almost completely unnoticed in the post-war conditions, and the war victims were unable to seek help on their own. Based on the results, our health care for the elderly should focus on familiarization with the individual experiences and life stories of each elderly person. This can facilitate geriatric diagnostics and individual therapy planning. Empathic familiarization with the life experiences of the elderly may strengthen their mental stamina and improve the quality of successful aging.

Elämänlaatu ja iäkkäiden kaatumisten ehkäisy

Quality of life and fall prevention among the aged Improvement of quality of life is considered to be one of the most important goals of prevention, treatment and rehabilitation among the aged. The study aimed to describe and assess fall prevention interventions as a quality of life indicator, and to describe the social dimension of health-related quality of life among the aged. In addition, it aimed to assess the effects of fall prevention intervention on quality of life among the aged. The study was implemented by using a methodological triangulation. The data in the systematic review was retrieved from the databasis of medical and nursing sciences. Home-dwelling aged (n=19) participated in the qualitative study of a social dimension of quality of life. The data was gathered by the thematic interview method. The quantitative multifactorial fall prevention study comprised 591 participants, either the aged living at home or in sheltered housing, showing an increased risk of falling. Participants were randomized into an intervention or a control group. Follow-up measurements were carried out after a 12 month intervention. The data was collected by the 15D quality of life instrument and a structured questionnaire. Based on the systematic review, only in a few studies fall prevention produced positive effects on dimensions of quality of life (physical function, social function, vitality, mental health, environmental domain). Based on the thematic interview the social dimension of quality of life consisted of three themes: personal values, personal milieu and personal daily life. Based on the fall prevention program, depressive symptoms and distress decreased, managing in usual activities improved, sexual activity and phone contacts increased among men. In women, managing in usual activities improved, socializing increased and discomfort and symptoms decreased. Within the groups, self-perceived health improved among women in the intervention group and among men in the control groups. In addition, fear of falling and feelings of insecurity reduced among women in the intervention group. Personal daily life with its activities opened up new perspectives into the social dimension of good quality of life, which was emphasized especially in the interviews of the oldest participants. Multifactorial fall prevention can affect positively some physical and psychosocial dimensions of quality of life among the community-dwelling aged. Additional studies with larger sample sizes, longer follow-up periods and multiple outcome measures are needed. Fall prevention intervention may affect quality of life by different mechanisms, and the quantitative and qualitative assessment of its effects should also be included in the interventions of randomized controlled trials.

Core communication components along the cancer care process: the perspective of breast cancer patients

This study sought to assess the impact of health care professional (HCP) communication on breast cancer patients across the acute care process as perceived by patients. Methodological approach was based on eight focus groups conducted with a sample of patients (n ¼ 37) drawn from 15 Spanish Regions; thematic analysis was undertaken using the National Cancer Institute (NCI) framework of HCP communication as the theoretical basis. Relevant results of this study were the identification of four main communication components: (1) reassurance in coping with uncertainty after symptom detection and prompt access until confirmed diagnosis; (2) fostering involvement before delivering treatments, by anticipating information on practical and emotional illness-related issues; (3) guidance on the different therapeutic options, through use of clinical scenarios; and, (4) eliciting the feeling of emotional exhaustion after ending treatments and addressing the management of potential treatment-related effects. These communication-related components highlighted the need for a comprehensive approach in this area of cancer care

Ba in Virtual Communities

Virtual communities – interactive networks in cyberspace seasoned with feelings – are a highly topical research theme. Besides academics, more and more companies ponder upon the nature and implications of the sense of virtual communities. This thesis takes a novel viewpoint on this research and examines virtual communities from virtual ba perspective. Ba is the space – in this case a virtual and a mental one, where knowledge based interaction occurs. The aim of this thesis is to clarify the concept of virtual ba, and the development and appearance of ba in virtual communities. The scientific contribution of this qualitative case study is conceptual clarification and validation of the concept of virtual ba. The empirical part of the thesis examines blogs: Internet-based communication media, using data triangulation (observation, narratives and a thematic interview). The thesis provides insights into the development of virtual ba that has also managerial relevance.

Lääkintähuollon ja materiaalihallinnon yhtenäisen RFID-seurannan perusteita

Tässä diplomityössä tarkastellaan radiotaajuisen tunnistamisteknologian (RFID) seurannan yhtenäisiä perusteita puolustusvoimien lääkintähuollolle ja materiaalihallinnolle. Nykytilaa selvitettiin pääpainona lääkintähuollon ja materiaalihallinnon osa-alueet ja samalla tarkasteltiin koko puolustusvoimien RFIDtekniikan käyttöä. Puolustusvoimissa RFID-teknologiaa käytetään myös vaatehuollon ja kulunvalvonnan toiminnoissa. Tämän työn teoriaosuudessa tarkastellaan RFID-tekniikkaa ja sen komponentteja sekä niiden hyödyntämistä eri sektoreilla ja logistiikassa. Työn empiirisessä osuudessa selvitetään, mitkä ovat puolustusvoimien tarpeet RFID:n käytöllä ja vaatimuksia ensihoidon kiireellisyysluokittelulle (TRIAGE) sekä materiaalihallinnon ja niiden kautta saatavalle tilannekuvalle. Työn tuloksena saadaan perusteita puolustusvoimien RFID-ratkaisujen suunnittelun pohjaksi.

Limnological research in the Iberian Peninsula: a ten-year survey of published literature.

Research on limnology in southern Europe had achieved a notable presence in the international arena before the onset of the current dramatic cuts in public investment in science. We assessed the limnological research published in peer-reviewed journals by Spanish and Portuguese (i.e., Iberian) researchers during the decade prior to the economic recession (2000 to 2009). The Thompson Reuters Web of Knowledge database was used to retrieve all publications on limnology authored by researchers affiliated with Spanish or Portuguese institutions independently of the geographical setting of the study. The publishing pattern was characterised in terms of authors, journals, and citation statistics. In addition, a thematic characterisation of the research was performed by a manual assignation of several categorical descriptors combined with a blind word count analysis. Iberian researchers produced an annual mean of 278 papers on limnology. Papers were published in journals that had impact factors ranging from 0.1 to 31.4, with a mean of 2.0. Based on citations, the impact of the Iberian limnological research was not due to a few highly cited papers but rather to a wide number of publications; each paper received a mean of 8 citations. The Iberian limnological research involved up to 5460 researchers, with a mean of 4.3 authors per paper. The research largely focused on fluvial systems, with 47 % of total publications (2778) devoted to these ecosystems. There was a dominant focus on local, within-system aspects of study sites and the research was mostly restricted to the Iberian Peninsula; larger spatial scales of analysis (i.e., landscape, regional, or global) tended to be overlooked. Iberian research addressed fundamental (75 %) rather than applied (17 %) or methodological (5 %) questions and was vastly dominated by observational approaches (75 %). Interestingly, Iberian limnological research increased its scientific productivity during the analysed decade at a higher rate than its international counterpart (increase of 119 %). Overall, Iberian research on limnology appeared to be in good health during the analysed decade. Certain areas have been more studied than others, which opens opportunities to develop new research.

Development of corporate social responsibility in Finnish forest industry

The main objective of this thesis was to map the development of corporate social responsibility (CSR) in Finnish forest industry. The aim was to describe the development and find factors that explain the development. Another objective was to understand the influence of different stakeholders on the development as well as examine the development of CSR reporting. This qualitative case study used thematic interviews as the research method. The research data were collected by conducting 11 interviews among the case company representatives and stakeholders. Based on the research results, no single factor in the background of the phenomenon could be showed. Instead, CSR has developed in stages through its different dimensions. The main drivers of CSR turned out to be environmental organizations, customers and local communities. It can be concluded that the forest industry has taken CSR seriously for a long time, which has benefited the forest companies in many ways.

Experiència dels cuidadors i les cuidadores principals informals que tenen cura d'un familiar vell amb demència des de fa més de quatre anys

El treball que es presenta vol respondre la pregunta de quina és l’experiència dels cuidadors i les cuidadores principals informals que tenen cura d’un familiar vell amb demència des de fa més de 4 anys. Després de plantejar les hipòtesis de partida, es defineixen els objectius generals i específics i s’expliquen l’interès, la justificació, la rellevància i l’aportació d’aquest estudi. En l’apartat corresponent a l’estat de la qüestió i la fonamentació conceptual, després de fer una revisió bibliogràfica, es descriuen els elements que formen part d’aquesta temàtica: perfils dels receptors de cures i de les cuidadores, significat de tenir cura, vida quotidiana i qualitat de vida i descripció del model conceptual de Virginia Henderson. En el capítol següent s’exposen la metodologia, el paradigma i el mètode d’investigació utilitzats en aquest treball, així com les matrius d’anàlisi del contingut i del discurs. A partir d’aquí s’exposen els resultats en funció dels objectius plantejats. En la discussió, s’analitzen i s’interpreten les dades obtingudes i es contraposen amb altres estudis, a més de fer-se una reflexió personal sobre els aprenentatges adquirits i una proposta de línies de treball futures. A continuació s’exposen unes conclusions per resumir la informació obtinguda. En la secció de referències bibliogràfiques es detallen les fonts consultades, i en els annexos hi consten els models d’entrevista i de matriu per a l’anàlisi de dades, el full de consentiment informat, així com el buidatge i l’anàlisi de les entrevistes.