Achieving better in-hospital and after-hospital care of patients with acute cardiac disease

In patients hospitalised with acute coronary syndromes (ACS) and congestive heart failure (CHF), evidence suggests opportunities for improving in-hospital and after hospital care, patient self-care, and hospital-community integration. A multidisciplinary quality improvement program was designed and instigated in Brisbane in October 2000 involving 250 clinicians at three teaching hospitals, 1080 general practitioners (GPs) from five Divisions of General Practice, 1594 patients with ACS and 904 patients with CHF. Quality improvement interventions were implemented over 17 months after a 6-month baseline period and included: clinical decision support (clinical practice guidelines, reminders, checklists, clinical pathways); educational interventions (seminars, academic detailing); regular performance feedback; patient self-management strategies; and hospital-community integration (discharge referral summaries; community pharmacist liaison; patient prompts to attend GPs). Using a before-after study design to assess program impact, significantly more program patients compared with historical controls received: ACS: Angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering agents at discharge, aspirin and beta-blockers at 3 months after discharge, inpatient cardiac counselling, and referral to outpatient cardiac rehabilitation. CHF. Assessment for reversible precipitants, use of prophylaxis for deep-venous thrombosis, beta-blockers at discharge, ACE inhibitors at 6 months after discharge, imaging of left ventricular function, and optimal management of blood pressure levels. Risk-adjusted mortality rates at 6 and 12 months decreased, respectively, from 9.8% to 7.4% (P=0.06) and from 13.4% to 10.1% (P= 0.06) for patients with ACS and from 22.8% to 15.2% (P < 0.001) and from 32.8% to 22.4% (P= 0.005) for patients with CHF. Quality improvement programs that feature multifaceted interventions across the continuum of care can change clinical culture, optimise care and improve clinical outcomes.

Business strategy and the environment in a traditional manufacturing sector

This research is concerned with the relationship between business strategy and the environment within traditional sectors. It has sought to learn more about the strategic environmental attitudes of SMEs compared with large companies operating under the same market conditions. The sector studied is the ceramics industry (including tableware & ornamental-ware, sanitary ware & tiles, bricks, industrial & advanced ceramics and refractories) in the UK and France. Unlike the automotive, oil, chemical, steel or metal processing sectors, this industry is one of the few industrial sectors which has rarely been considered. The information on this sector was gathered by interviewing people responsible for environmental issues. The actual programme of valid interviews represents approximately a quarter of the UK and French ceramics industry which is large enough to enable a quantitative analysis and significant and non-biased conclusions. As a whole, all companies surveyed agreed that the ceramics activity impacts on the environment, and that they are increasingly affected both by environmental legislation, and by various non-legislative pressures. Approaches to the environmental agenda differ significantly among large and small companies. Smaller companies feel particularly pressed both by the financial costs and management time required to meet complex and changing legislation. The results of this survey also suggest that the ceramics industry sees environmental issues in terms of increased costs rather than new business opportunities. This is due principally to fears of import substitution from countries with lower environmental standards. Finally, replies indicate that generally there is a low level of awareness of the current legislative framework, suggesting a need to shift from a regulatory approach to a more self-regulated approach which encourages companies to be more proactive

Reducing medicines waste in the community

There is increasing concern at the amount and cost of prescribed medicines that are unused or wasted and then have to be disposed of. Previous studies have used health promotion and Dispose Unwanted Medicines Properly campaigns targeted at the patient to describe and quantify the annual cost of waste. The reasons patients return unused drugs to pharmacies have also been explored. The paper focuses on patient explanations for not needing medication; categorized as: over-collection in the past, self-management strategies, changes in medical condition, other changes in patient circumstances, or the repeat medicines policy at the surgery. The aim of the original study was to make a measurable change in prescribed medicines with a reduction in medicines wastage, whilst at the same time achieving improved standards of pharmaceutical care. Information on patient needs and behaviour came from consultation in the pharmacy monitoring forms and interview. The study was based on two medical practices in the West Midlands, UK, comparing an outer city and an inner city population. The participants were general practitioners, pharmacists and 350 repeat prescription patients. Prescriptions were issued for two three-month periods. The outcome was that 23.8% of the prescribed items were not dispensed, at a value of £13.1K, 58% of the medications that would be expected to be regularly supplied were collected. The study suggests that closer professional management at the point of dispensing and an understanding of patient experiences can help reduce the amount of unwanted medication collected by patients.

Teaching speaking:a holistic approach

Teaching Speaking A Holistic Approach brings together theoretical and pedagogical perspectives on teaching speaking within a coherent methodological framework. The framework combines understandings derived from several areas of speaking research and instruction including cognitive and affective processes, oracy for thinking and learning communicative competence, discourse theories, task-based language learning, and self-regulated learning. By explaining, interpreting, evaluating, and synthesizing these diverse perspectives from linguistics and language learning, the text offers a comprehensive and versatile approach for teaching speaking. Samples of authentic classroom data are used for illustrating important concepts to help readers see how theoretical perspectives can be applied in practice. It also includes a pedagogical model for sequencing learning activities with concrete guidelines on planning and conducting speaking lessons. Different types of learning tasks are explained and illustrated with examples, and each chapter includes short tasks and ends with a number of tasks that enable readers to extend their ideas.

From the outside in:consumer anti-choice and policy implications in the mobile gaming market

Significant growth in mobile media consumption has prompted a call to better understand the socio-cultural and policy dimensions of consumer choices. Contrary to industry and technology led analysis, this study argues that to guide consumer choice and innovation via regulatory policies requires an understanding of both ex-ante as well as in ex-post consumption conditions. This study examines mobile phone gaming to uncover how consumer anti-choice shapes decision-making as a framework for closely interrogating the ways in which policy concerns impact on consumers' behavior. Through eleven focus groups (n=62), the study empirically identifies voluntary, intentional, and positive consumer anti-choice behaviors all of which impact policy initiatives when consumers, both gamers and non-gamers, self-regulate their behaviors. Findings point to four types of policy implication: regulating the self-regulated, understanding anti-choice, boundary-setting and including the self-excluded. © 2012 Elsevier Ltd.

Naar verantwoorde zelfregulatie in opvoeding, onderwijs en diagnostiek.

De beoordeling van vorderingen en inzet van (extra) diagnostiek ('indicatiestelling') in het onderwijs kunnen de kans op het ontstaan van problemen bij een kind vergroten. Tijdige herkenning en preventieve ondervanging van de problemen vragen veranderingen in de inhoudelijke, evaluatieve, didactisch-organisatorische en diagnostische systematieken in en rond scholen. Daarom wordt gewerkt aan de opbouw van een inhoudelijk integrerende, pedagogisch-didactische kernstructuur (PDKS). Deze helpt de dialoog en samenwerking tussen opvoedeling(en) of leerling(en), opvoeder(s), leerkracht(en) en andere professionals eenduidig in te richten en te optimaliseren. Didactisch-organisatorische steun wordt verleend door passende software in de vorm van 'Diagnostische, Instructie en Management Systemen' (DIMS). De beoogde veranderingen worden samen met leerkrachten en schoolleidingen ontwikkeld en proefondervindelijk gerealiseerd in enkele scholen voor primair onderwijs. De schoolontwikkeling biedt de contextuele condities ter realisatie van 'verantwoorde zelfregulatie' van elk kind of elke leerling. Dit wordt toegelicht in verschillende praktijkvoorbeelden. Ook worden volgende ontwikkelingen geschetst.

Futures Shock: Are Greedy Brokers Ruining The Economy?

[Excerpt] In a recent public relations document, the New York Stock Exchange defines its mission statement as to: “Support the capital-raising and asset management process by providing the highest quality and most cost-effective, self-regulated marketplace for the trading of financial instruments.” The common thread that runs through this and similar statements made by organized financial markets from Frankfurt to Tokyo is that they hold as their primary goals to help companies raise capital and to provide a liquid and efficient aftermarket for those securities.

Medication competence of nursing students in Finland

Lääkehoidon turvallinen toteuttaminen edellyttää sairaanhoitajalta hyvää lääkehoidon osaamisperustaa. Sairaanhoitajakoulutuksen tehtävänä on mahdollistaa tämän osaamisen kehittyminen. Kansainvälisissä tutkimuksissa on kuitenkin osoitettu, että lääkehoidon opetuksen laajuudessa, sisällössä ja toteutuksessa on vaihtelevuutta. Aikaisemmissa tutkimuksissa on raportoitu myös puutteita lääkehoidon osaamisessa sekä sairaanhoitajilla että sairaanhoitajaopiskelijoilla. Koulutuksen ja lääkehoidon osaamisen kehittämiseksi lääkehoidon opetuksen ja sairaanhoitajaopiskelijoiden lääkehoidon osaamisen monipuolinen arviointi ja osaamista selittävien tekijöiden tarkastelu on tarpeen. Tämän tutkimuksen tarkoituksena oli i) arvioida lääkehoidon opetusta suomalaisessa sairaanhoitajakoulutuksessa, ii) arvioida sairaanhoitajaopiskelijoiden lääkehoidon osaamista sekä iii) tunnistaa sairaanhoitajaopiskelijan lääkehoidon osaamiseen yhteydessä olevat tekijät. Tutkimus toteutettiin kolmessa vaiheessa. Ensimmäisessä vaiheessa kahden integroidun kirjallisuuskatsauksen kautta määriteltiin tutkimuksen kohteena oleva sairaanhoitajan lääkehoidon osaaminen ja aiemmin tunnistetut sairaanhoitajaopiskelijan lääkehoidon osaamiseen yhteydessä olevat tekijät. Toisessa vaiheessa toteutettiin valtakunnallinen lääkehoidon opetukseen liittyvä kysely hoitotyön koulutusohjelmasta vastaaville koulutuspäälliköille (n=22) ja opettajille (n=136). Tutkimuksen kolmannessa vaiheessa opintojensa alku‐ (n=328) ja loppuvaiheessa olevien sairaanhoitajaopiskelijoiden (n=338) lääkehoidon osaaminen arvioitiin ja osaamiseen yhteydessä olevat tekijät tunnistettiin. Aineistojen analyysissä käytettiin pääosin tilastollisia menetelmiä. Tulosten perusteella lääkehoidon opetuksen laajuus vaihteli eri ammattikorkeakouluissa, mutta opetuksen sisältö oli kuitenkin monipuolista. Lisää huomiota tulisi kiinnittää lääkehoidon teoreettiseen perustaan ja itsehoitoon sekä lääkehoidon ohjaukseen liittyviin sisältöalueisiin. Opiskelijoiden lääkehoidon osaamista arvioitiin säännöllisesti kaikissa ammattikorkeakouluissa. Sairaanhoitajaopiskelijan lääkehoidon osaamista arvioitiin tutkimuksessa tietotestillä, lääkelaskentatehtävillä ja lyhyiden potilastapausten ratkaisemisen avulla. Lääkehoidon osaamiseen yhteydessä olevia tekijöitä tarkasteltiin kolmesta näkökulmasta: 1) yksilölliset tekijät, 2) kliiniseen oppimisympäristöön ja 3) ammattikorkeakouluun liittyvät tekijät. Lääkehoidon teoreettista osaamista arvioivassa tietotestissä opiskelijat vastasivat keskimäärin 72 prosenttiin kysymyksistä täysin oikein; lääkelaskuista täysin oikein oli 74 % ja potilastapauksissa 57 % valitsi parhaan mahdollisen toimintatavan. Tulosten perusteella sairaanhoitajaopiskelijan osaamista selittivät eniten yksilölliset tekijät. Lääkehoidon osaamiseen yhteydessä olevien tekijöiden välillä oli eroa opintojen alussa ja lopussa. Opintojen alkuvaiheessa opiskelijan aikaisempi opintomenestys oli yhteydessä lääkehoidon osaamiseen, kun taas opintojen loppuvaiheessa siihen olivat yhteydessä opiskelijan kyky itseohjautuvaan oppimiseen sekä opiskelumotivaatio. Johtopäätöksenä voidaan todeta tutkimuksen tulosten olevan samansuuntaisia kuin aikaisemmissa tutkimuksissa. Lääkehoidon opetuksen laajuus vaihtelee opetussuunnitelmatasolla, mutta täsmällinen arviointi on vaikeaa opetuksen sisältöjen integroimisen takia. Sairaanhoitajaopiskelijoiden lääkehoidon osaaminen oli hieman parempaa kuin aikaisemmissa tutkimuksissa, mutta osaamisessa on edelleen puutteita. Lääkehoidon opetuksen ja osaamisen kehittäminen edellyttää kansallista ja kansainvälistä tutkimus‐ ja kehittämisyhteistyötä. Tutkimuksen tulokset tukevat lääkehoidon opetuksen sekä osaamisen tutkimusta ja kehittämistä.

Ohjaus ja oppilaiden urapohdinta. Turkulaisten peruskoulun päättöluokkalaisten ohjauskokemukset urapohdinnan selittäjinä

Tutkimuksessa selvitetään turkulaisten peruskoulun päättöluokkalaisten urapohdintaeroja ja sitä, miten oppilaiden arviot opettajien ja oppilaanohjaajien toteuttamasta ohjauksesta ovat yhteydessä heidän urapohdintaansa. Tutkimuksen kohdejoukkona ovat ensi sijassa yleisopetusta antavien suomenkielisten peruskoulujen yhdeksäsluokkalaiset. Tutkimus on poikkileikkaustutkimus, jossa tarkastellaan oppilaiden kokemuksia ohjauksen saatavuudesta ja hyödyllisyydestä sekä urapohdinnasta peruskoulun päättyessä. Tutkimusaineisto koottiin yhteishaun jälkeen huhti–toukokuussa 2014. Vuoden 2004 perusopetuksen opetussuunnitelman perusteista johdettujen väittämien avulla selitetään urapohdinta-mittarin sisältämien muuttujien vaihtelua. Taustamuuttujina käytetään oppilaiden koti- ja koulutaustaa. Urapohdinta-mittari on johdettu CIP-teoriasta (Cognitive Information Processing) ja muokattu CTI-mittarista (Career Thoughts Inventory). Tutkimusaineisto (N = 887) on koottu Webropol-kyselyn avulla. Oppilaiden urapohdintaa mitattiin neljän summamuuttujien avulla. Mittariston 48 väittämästä muodostettiin urapohdinta-summamuuttuja. Tämän lisäksi urapohdinnan osa-alueita arvioitiin sitoutuminen-, epävarmuus- ja konflikti-summamuuttujan avulla. Sitoutuminen-summamuuttuja mittasi sitä, miten vaikeaksi oppilas koki yhteen ura- ja jatkokoulutusvalintaan sitoutumisen. Epävarmuus-summamuuttuja mittasi päätöksenteon epävarmuutta ja konflikti-summamuuttuja vaikeutta tasapainoilla omien ajatusten ja toisaalta merkittäviksi koettujen läheisten ajatusten välillä. Kaikkien opettajien ohjaustyön näkökulmasta parhaiten hyvää urapohdintatulosta, jatkokoulutukseen sitoutumista ja päätöksentekovarmuutta ennustivat oppilaan hyvät kokemukset yhteistoiminnasta, hänen myönteinen suhtautumisensa koulunkäyntiin ja opintosuoritukset. Myös itseohjautuvuus oli tilastollisesti merkitsevässä yhteydessä urapohdintaan. Itseohjautuvuus-summamuuttuja mittasi sitä, oliko oppilas kokenut, että ohjaukselle asetetut tavoitteet saavutettiin. Opettajien tulisi kiinnittää ohjauksessaan huomiota hiljaisiin ja vähän huomiota vaativiin oppilaisiin ja tukea kaikkien oppilaiden toimintakykyä. Opinto-ohjaajan taas tulisi panostaa oppilaan itsetuntemuksen kehittämiseen ja valmiuteen toimia suunnitelmallisesti. Toisen asteen nivelvaiheohjauksen painopiste tulisi siirtää päättöluokkaa varhaisemmaksi. Tutkimustulos ei tue ajatusta, että tehostettu oppilaanohjaus kohdennettaisiin opintomenestyksen mukaan, koska heikkoja urapohtijoita oli kaikissa keskiarvosanaluokissa. Opinto-ohjaajien tulisi panostaa tieto- ja viestintätekniikan hyödyntämiseen ja tehostaa koko koulun työelämäyhteistyötä.

Integrated micro fuel cells with on-board hydride reactors and autonomous control schemes

Miniaturization of power generators to the MEMS scale, based on the hydrogen-air fuel cell, is the object of this research. The micro fuel cell approach has been adopted for advantages of both high power and energy densities. On-board hydrogen production/storage and an efficient control scheme that facilitates integration with a fuel cell membrane electrode assembly (MEA) are key elements for micro energy conversion. Millimeter-scale reactors (ca. 10 µL) have been developed, for hydrogen production through hydrolysis of CaH2 and LiAlH4, to yield volumetric energy densities of the order of 200 Whr/L. Passive microfluidic control schemes have been implemented in order to facilitate delivery, self-regulation, and at the same time eliminate bulky auxiliaries that run on parasitic power. One technique uses surface tension to pump water in a microchannel for hydrolysis and is self-regulated, based on load, by back pressure from accumulated hydrogen acting on a gas-liquid microvalve. This control scheme improves uniformity of power delivery during long periods of lower power demand, with fast switching to mass transport regime on the order of seconds, thus providing peak power density of up to 391.85 W/L. Another method takes advantage of water recovery by backward transport through the MEA, of water vapor that is generated at the cathode half-cell reaction. This regulation-free scheme increases available reactor volume to yield energy density of 313 Whr/L, and provides peak power density of 104 W/L. Prototype devices have been tested for a range of duty periods from 2-24 hours, with multiple switching of power demand in order to establish operation across multiple regimes. Issues identified as critical to the realization of the integrated power MEMS include effects of water transport and byproduct hydrate swelling on hydrogen production in the micro reactor, and ambient relative humidity on fuel cell performance.

Men's experiences of receiving objective feedback on physical activity and other indicators of health risk, within the context of a gender-sensitised weight loss intervention

Receiving personalised feedback on body mass index and other health risk indicators may prompt behaviour change. Few studies have investigated men’s reactions to receiving objective feedback on such measures and detailed information on physical activity and sedentary time. The aim of my research was to understand the meanings different forms of objective feedback have for overweight/obese men, and to explore whether these varied between groups. Participants took part in Football Fans in Training, a gender-sensitised, weight loss programme delivered via Scottish Professional Football Clubs. Semi-structured interviews were conducted with 28 men, purposively sampled from four clubs to investigate the experiences of men who achieved and did not achieve their 5% weight loss target. Data were analysed using the principles of thematic analysis and interpreted through Self-Determination Theory and sociological understandings of masculinity. Several factors were vital in supporting a ‘motivational climate’ in which men could feel ‘at ease’ and adopt self-regulation strategies: the ‘place’ was described as motivating, whereas the ‘people’ (other men ‘like them’; fieldwork staff; community coaches) provided supportive and facilitative roles. Men who achieved greater weight loss were more likely to describe being motivated as a consequence of receiving information on their objective health risk indicators. They continued using self-monitoring technologies after the programme as it was enjoyable; or they had redefined themselves by integrating new-found activities into their lives and no longer relied on external technologies/feedback. They were more likely to see post-programme feedback as confirmation of success, so long as they could fully interpret the information. Men who did not achieve their 5% weight loss reported no longer being motivated to continue their activity levels or self-monitor them with a pedometer. Social support within the programme appeared more important. These men were also less positive about objective post-programme feedback which confirmed their lack of success and had less utility as a motivational tool. Providing different forms of objective feedback to men within an environment that has intrinsic value (e.g. football club setting) and congruent with common cultural constructions of masculinity, appears more conducive to health behaviour change.

„Lernen nicht, aber ...“ - Bildungsprozesse im Breaking

With over 30 years of tradition, breaking in Germany provides fascinating insights into the learning of dance in Hip Hop culture, reaching from informal street learning to the introduction of courses in educational institutions. This article draws information from a qualitative empirical study based on the Grounded Theory Methodology. The study asked subjects ranging from first-generation German B-Boys and B-Girls to teenage students about how they have learned and currently learn to break. The interview material reveals a rich and self-regulated learning culture with strong impact on protagonists. A synergy of social, aesthetic, and ethical principles seems to be characteristic, creating a gravitational field of learning with a unique and complex form of imitation at its core. (DIPF/Orig.)

La influencia del discurso sobre cambio social en la agenda de los medios. El caso de la Plataforma de Afectados por la Hipoteca

Los movimientos sociales son uno de los motores del cambio social. Organizaciones como la Plataforma de Afectados por la Hipoteca (PAH) denuncian injusticias y cuestionan la construcción de significados sociales a través del discurso. Impulsan estrategias de automediación para, especialmente a través de las redes sociales, influir en la agenda mediática y el debate público. Mediante un análisis crítico del discurso cualitativo, nuestro objetivo es conocer si la PAH introduce sus temas y encuadres en la agenda mediática. Los resultados demuestran que este movimiento activista logra condicionar de qué se habla y también cómo se habla, obteniendo una cobertura favorable.

Déterminants qui favorisent ou non l’autogestion du diabète de type 2 chez les personnes souffrant de cette maladie en Haïti

Cette étude exploratoire menée à Mirebalais (Haïti) vise à mieux comprendre les stratégies d’autogestion utilisées par les personnes diabétiques vivant dans cette commune. Nous nous sommes basés sur le modèle de la triade desease / illness / sickness décrit par Kleinman et al. (1978) et Young (1982) pour appréhender l’adaptation des personnes diabétiques dans leur environnement social et familial. Treize entrevues individuelles semi-structurées de diabétiques ont été réalisées. Les personnes qui arrivent à mieux vivre avec le diabète sont celles qui ont combiné les recommandations médicales, le savoir populaire et leur contexte de vie. Les résultats de cette étude peuvent être utilisés comme piste d’intervention dans des programmes entourant la prévention des complications de la maladie et l’amélioration des conditions de vie des diabétiques.

Contributos das percepções de auto-eficácia e de instrumentalidade para a promoção da aprendizagem auto-regulada no ensino profissional

Assumindo a teoria sociocognitiva de Bandura como marco teórico, o presente estudo aborda as percepções de auto-eficácia e de instrumentalidade enquanto preditoras da auto-regulação da aprendizagem e as influências que as variáveis sexo, idade, habilitações escolares e profissão do pai e da mãe, ano de escolaridade, curso profissional, quantidade de módulos em atraso e quantidade de horas de estudo semanais poderão ter. A amostra é constituída por 521 formandos de ambos os sexos de uma escola profissional privada. Os instrumentos utilizados foram a Ficha de Dados Pessoais e Escolares, o Questionário de Auto-Eficácia da Auto-Regulação da Aprendizagem e o Questionário de lnstrumentalidade da Auto-Regulação da Aprendizagem. Os resultados corroboram a literatura ao verificar-se que as raparigas são mais auto-reguladas na sua aprendizagem, estudam mais tempo e têm menos módulos em atraso do que os rapazes. Verificou-se também a influência do curso profissional sobre as percepções de auto-eficácia e instrumentalidade percebidas. /ABSTRACT: Assuming Bandura’s social-cognitive theory as our framework, the present study refers to the perspectives of self-efficacy and instrumentality as predictors of self­regulated learning and the influence that the variables sex, age, parents school degree and profession, grade and vocational course, the number of modules in which the students weren't successful at and the amount of study hours per week might have on them. The sample is formed by 521 students of both genders from a private vocational school. The instruments used were the FDPE (Sociodemographic data file), QSEsrl (Questionnaire of Self-Efficacy of Self-Regulated Learning) and and Qlsrl (Questionnaire of lnstrumentality of Self-Regulated Learning). The results corroborate previous studies and reveal that female students have higher perceptions of self-efficacy and instrumentality, possess fewer non-successful modules and study more time than the male students. There are significant differences throughout the vocational courses for the perceived self-efficacy and instrumentality.