Att göra bedömningar av risk för våld hos frihetsberövade personer på fängelser och i olika former av tvångsvård är en viktig del av arbetet med att reducera antalet våldsincidenter, vilket är till nytta både för frihetsberövade personer och för personalens arbetsmiljö. Syftet med denna studie är att göra en kunskapsöversikt över vad forskningen säger om att bedöma risk för våld hos frihetsberövade personer, beskriva aktuell forskning om riskbedömningar, hur strukturerade instrument för riskbedömningar definierar våld, vilka teoretiska utgångspunkter till uppkomst av våld som används och i vilken utsträckning riskbedömningsinstrument tar hänsyn till interaktion mellan personal och frihetsberövade personer. Studien genomförs igenom en litteraturstudie med en innehållsanalys av forskning på området utifrån frågeställningarna i syftet. Sökorden är ”inmate”, ”inpatient”, ”violence”, ”risk”, ”assessment”, ”juvenile” och ”youth”. Reslutatet av studien visar att det finns ett flertal instrument som som forskningen visar har god validitet och även inter-bedömarreliabilitet för att bedöma risk för våld, nämligen Brøset Violence Checklist (BVC), Historical-Clinical-Risk management-20(HCR-20), Dynamic Appraisal of Situational Agression (DASA) och Structured Assessment of Violencerisk in Youth(SAVRY). Utöver detta finns även några bedömningsinstrument som använder enbart statiska variabler för att bedöma risk för våld hos frihetsberövade, även kallade aktuariska modeller. Forskning visar generellt att föränderliga, dynamiska variabler som snabbare förändras har starkare prediktiv validitet för att bedöma risk för våld hos frihetsberövade på kort sikt, än historiska och statiska data. BVC och DASA tar större hänsyn till interaktionen mellan frihetsberövad och personal för att bedöma risk än HCR-20 och SAVRY, som inte är primärt konstruerade för att bedöma risk för våld i ett omedelbart kort perspektiv. Resultatet diskuteras utifrån studiens styrkor och svagheter och etiska problem med att bedöma risk för våld hos frihetsberövade. Syftet med olika typer av frihetsberövande och olika kategorier frihetsberövade personer som har olika behov, gör att resultaten inte utan reflektion kan överföras från en grupp till en annan. Etiska överväganden blir aktuella utifrån att informationen som framkommer vid en riskbedömning kan leda till repressiva interventioner, och att detta långt ifrån alltid är något önskvärt. / Assessing risk for violence among incarcerated people in prisons, in inpatient settings and otherwise, is an important part of the work aimed at reducing the number of violent encounters in these settings. Reducing violence is beneficial for both incarcerated persons and for the staffs work environment. The purpose of this thesis is to make a review of research of how to assess risk for violence among incarcerated people in different settings, describe research about the assessment methods, how these methods define ‘violence’ and what theoretical explanations to violence that are used. Furthermore, what level of consideration for the interaction between staff and incarcerated people is taken when assessing risk for violence. The thesis is performed by searching for, and analyzing written material with the questions asked in the purpose of the study. The following words are used for search in databases: “inmate”, “inpatient”, “violence”, “risk”, “assessment”, “juvenile” and “youth”. The findings in the study gives that there are models for assessing violence, with research-proven validity and mostly also interrater-reliability, namely: Brøset Violence Checklist (BVC), Historical-Clinical-Risk management-20(HCR-20), Dynamic Appraisal of Situational Aggression (DASA) and Structured Assessment of Violence Risk in Youth (SAVRY). Aside from these findings there are also some models using only static variables to assess risk for violence among incarcerated, also known as “actuarial” models. Generally, the research shows that more dynamic variables that are prone to change, has stronger validity in predicting violence among incarcerated than historical, static data. The BVC and the DASA takes greater consideration to interaction between staff and incarcerated than the HCR-20 and the SAVRY, that is not primarily constructed to assess risk for violence in forensic/caregiving settings in the immediate short term. The result is discussed on basis of the strengths and weaknesses of the thesis, as well as ethical problems with assessing risk for violence among people that have been deprived of their freedom. The purpose of different kinds of incarcerations and different categories of incarcerated people that have different needs, may cause need for the results to be carefully considered- What does apply in one setting may not be true in another. From an ethical point of view, it is to be taken into consideration how the information from violence risk assessments is used, since punitive and repressing interventions often is far from desired.

A prevalência de Doença Mental Grave (do inglês Severe Mental Illness, SMI) atinge 5,4% em um ano segundo os estudos Baltimore Epidemiologic Catchment Area e National Comorbidity Survey. O conceito de SMI surgiu na década de 1970 para o planejamento dos serviços de saúde e apresentou importância crescente a partir do movimento de desinstitucionalização psiquiátrica. Uma das definições para SMI deriva do NIMH (National Institute of Mental Health) em 1987, e utiliza como critérios a presença de prejuízo funcional, decorrente de déficits em aspectos básicos do dia-a-dia, bem como a duração da doença. Casos agudos de SMI podem necessitar tratamento em Unidade de Internação Psiquiátrica em Hospital Geral (UIPHG). No entanto, há poucos estudos disponíveis no Brasil avaliando esta modalidade de tratamento e os desfechos destes pacientes. Evidências também apontam que os pacientes com transtornos psiquiátricos apresentam níveis reduzidos de Fator Neurotrófico Derivado do Cérebro (Brain-Derived Neurotrophic Factor, BDNF). O BDNF age no sistema nervoso central (SNC) promovendo crescimento e diferenciação de neurônios. Dentro deste contexto, a presente tese apresenta como objetivo principal a avaliação naturalística de desfechos clínicos e funcionais, associados à avaliação dos níveis séricos de BDNF, em pacientes com SMI. Os pacientes que foram encaminhados para tratamento na Unidade de Internação Psiquiátrica do Hospital de Clínicas de Porto Alegre foram incluídos se apresentassem os critérios de SMI: Avaliação Global de Funcionamento (Global Assessment of Functioning, GAF) menor ou igual a 50 e tempo de tratamento maior ou igual a dois anos. As avaliações ocorreram em dois momentos (admissão e alta). Compreenderam avaliação sociodemográfica, clínica e coleta de sangue (com dosagem de BDNF sérico). Foram realizadas avaliação diagnóstica pelo Mini-International Neuropsychiatric Interview (MINI) e aplicação das escalas Brief Psychiatric Rating Scale (BPRS), Clinical Global Impression scale (CGI-S), GAF e World Health Organization Quality of Life Instrument—Short Version (WHOQOL-Bref). Ainda, foram aplicadas escalas específicas nos diagnósticos principais (i.e., depressão maior, depressão bipolar, episódio maníaco, esquizofrenia): Hamilton Depression Rating Scale (HAM-D); Young Mania Rating Scale (YMRS). O primeiro artigo desta tese descreve os desfechos clínicos, funcionais e também de qualidade de vida durante a internação psiquiátrica. Observou-se melhora significativa nos parâmetros avaliados nos pacientes com SMI como um todo. Os pacientes com episódio maníaco apresentaram maior chance (em relação aos com episódio depressivo) de atingir remissão pela CGI (OR: 4.03; 95% CI: 1.14-14.30; p=0.03). A duração média da hospitalização (LOS) foi 28,95 (± 19,86) dias. No segundo artigo, observou-se redução dos níveis séricos de BDNF nos pacientes com SMI em relação aos controles saudáveis, independentemente do diagnóstico. Houve aumento significativo no BDNF entre a admissão e a alta. Os resultados apresentados replicam dados previamente publicados a partir de amostra única de pacientes com SMI, sua característica diferencial. Estes resultados reforçam que a internação em UIPHG, uma intervenção relativamente breve, demonstra desfechos positivos e é alternativa bem estabelecida no tratamento da SMI. Além disso, a redução inespecífica do BDNF sérico seguida de um pequeno aumento associado ao tratamento reforçam a possibilidade do BDNF como marcador transdiagnóstico de transtorno mental. / The estimated prevalence of Severe Mental Illness (SMI) according to Baltimore Epidemiologic Catchment Area and National Comorbidity Survey studies is 5.4% in one year. One suggested definition of Severe Mental Illness (SMI) derives from the 1987 National Institute of Mental Health (NIMH) definition and is based on two criteria: 1. duration, characterized as involving “prolonged illness”, and 2. disability, which includes dangerous or disturbing social behavior, and mild impairment in achieving basic needs. These acute psychiatric conditions may require psychiatric inpatient treatment located in acute wards in General Hospitals. However, little data is currently available evaluating the characteristics and the outcomes during an acute inpatient stay in Brazil. Evidence also suggests that Brain-derived neurotrophic factor (BDNF) levels are significantly decreased in neuropsychiatric disorders. BDNF is found throughout the brain and is involved in neurogenesis and neuroplasticity. So, the main objectives of this work are to evaluate SMI patients’ outcomes during treatment in a psychiatric unit in a general hospital by symptomatology, functionality, quality of life and by the evaluation of BDNF serum levels. After the admission to a psychiatric unit in a general hospital in Brazil, patients were included and if they had two of the SMI criteria: Global Assessment of Functioning (GAF) ≤ 50 and duration of services contact ≥ 2 years. Patients were assessed in admission and upon discharge with Mini-International Neuropsychiatric Interview (MINI), Brief Psychiatric Rating Scale (BPRS), Clinical Global Impression Scale (CGI), GAF, World Health Organization’s QOL Instrument—Short Version (WHOQOL-Bref) and diagnostic specific scales (Hamilton Depression Rating Scale, HAM-D; Young Mania Rating Scale, YMRS; and Hamilton Anxiety Rating Scale, HAM-A). Blood samples were also obtained. The first manuscript showed that SMI patients had marked and significant improvements in symptomatic and functional measures during psychiatric hospitalization. Patients with manic episode had higher chance of CGI remission (OR: 4.03; 95% CI: 1.14-14.30; p=0.03) when compared with patients with depressive episode. Mean LOS was 28.95 (± 19.86) days. The second manuscript showed that BDNF serum levels were equally reduced among different SMI diagnoses. Also, the observed improvements in SMI patients were associated with a significant, but small increase in mean serum BDNF levels. Therefore, the results replicate evidence from previous findings in single samples, suggesting that SMI patients can have marked acute improvements during a a relatively short intervention (approximately 1 month) represented by the psychiatric hospitalization in a general tertiary hospital. Also, the similar reduction observed in BDNF levels among SMI patients with different diagnoses and the significant increase but non-restoration indicate that BDNF serum levels could be considered a marker for the presence of an unspecific psychiatric disorder and possibly a transdiagnostic and unspecific marker of disease activity.

abstract: ABSTRACT Leadership in Energy and Environmental Design (LEED) is a non-governmental organization of U.S. Green Building Council (USGBC) which promotes a sustainable built environment with its rating systems. One of the building segments which it considers is healthcare, where it is a challenge to identify the most cost-effective variety of complex equipments, to meet the demand for 24/7 health care and diagnosis, and implement various energy efficient strategies in inpatient hospitals. According to their “End Use Monitoring” study, Hospital Energy Alliances (HEA), an initiative of U.S. Department of Energy (DOE), reducing plug load reduces hospital energy consumption. The aim of this thesis is to investigate the extent to which realistic changes to the building envelope, together with HVAC and operation schedules would allow LEED credits to be earned in the DOE–hospital prototype. The scope of this research is to specifically investigate the inpatient block where patient stays longer. However, to obtain LEED credits the percentage cost saving should be considered along with the end use monitoring. Several steps have been taken to identify the optimal set of the end use results by adopting the Whole Building Energy Simulation option of the LEED Energy & Atmosphere (EA) pre– requisite 2: Minimum Energy Performance. The initial step includes evaluating certain LEED criteria consistent with ASHRAE Standard 90.1–2007 with the constraint that hospital prototype is to be upgraded from Standard 2004 to Standard 2007. The simulation method stipulates energy conservation measures as well as utility costing to enhance the LEED credits. A series of simulations with different values of Light Power Density, Sizing Factors, Chiller Coefficient of Performance, Boiler Efficiency, Plug Loads and utility cost were run for a variety of end uses with the extreme climatic condition of Phoenix. These assessments are then compared and used as a framework for a proposed interactive design decision approach. As a result, a total of 19.4% energy savings and 20% utility cost savings were achieved by the building simulation tool, which refer to 5 and 7 LEED credits respectively. The study develops a proper framework for future evaluations intended to achieve more LEED points. / Dissertation/Thesis / M.S. Built Environment 2012

Bakgrund: Att vänta är en del av livet och även en oundviklig del av patienters upplevelse av slutenvård. Patienter väntar på provresultat och undersökningar, på läkarsamtal och omvårdnad. Att beskriva väntans innebörd för patienter i slutenvård ger sjuksköterskan ökad förståelse för patientens vårdupplevelse och insikt i hur omvårdnadshandlingar kan påverka patientens väntetid. Syfte: Syftet var att beskriva väntans innebörd för patienter i slutenvård. Metod: Studien utfördes som en allmän litteraturstudie med induktiv innehållsanalys och litteratursökning gjordes i vårdvetenskapliga databaser. Resultat: Elva vetenskapliga artiklar låg till grund för resultatet. Resultatet visade att väntan innebar en känsla av overksamhet, ett behov av trygghet, en känsla av maktlöshet, ett behov av sociala relationer och en förhoppning om bättring. Slutsats:Väntan innebär en särskild utsatthet för patienter i slutenvård och skapar ett behov av trygghet och sociala relationer. Särskilt viktigt är att patienten delges adekvat information och att patienten ges möjlighet till en meningsfull och hoppfull väntetid. Fortsatt forskning fordras på väntans innebörd för patienter inom psykiatrin samt väntans innebörd för patientens närstående. Inom sjuksköterskeutbildningen krävs en större fördjupning i informatik för att ge sjuksköterskestudenter bättre kommunikativa verktyg för att tillgodose patienters behov av information under väntan. / Background: Waiting is a part of life and also an inevitable part of every inpatient’s experience of hospital care. Patients wait for test results and examinations, on medical consultation and nursing. Describing the significance of waiting, from the inpatient’s perspective, gives the nurse a better understanding of the inpatient’s care experience and insight into how nursing can affect the inpatient’s waiting time. Aim: The purpose was to describe the meaning of waiting from the hospitalized patient ́s perspective. Method: The study was conducted as a general literature study with inductive content analysis. The search for scientific articles was done in health science databases. Result: Eleven scientific articles formed the basis for the result. The result showed that the wait meant a sense of inactivity, a need for security, a feeling of powerlessness, a need for social relations and a hope of improvement. Conclusion: The waiting involves a particular vulnerability for hospitalized patients and creates a need for security and social relations. It is of importance that the patient is given adequate information and that the patient is given the opportunity to experience a meaningful and hopeful waiting time. Further research is required on the patient’s experience of waiting when in psychiatric care and the experience of waiting from the perspective of the patient’s significant other. Nursing education should provide better training in informatics so that nursing students are better equipped with communicative tools and can meet the patient’s need for information during the waiting time.

A prevalência de Doença Mental Grave (do inglês Severe Mental Illness, SMI) atinge 5,4% em um ano segundo os estudos Baltimore Epidemiologic Catchment Area e National Comorbidity Survey. O conceito de SMI surgiu na década de 1970 para o planejamento dos serviços de saúde e apresentou importância crescente a partir do movimento de desinstitucionalização psiquiátrica. Uma das definições para SMI deriva do NIMH (National Institute of Mental Health) em 1987, e utiliza como critérios a presença de prejuízo funcional, decorrente de déficits em aspectos básicos do dia-a-dia, bem como a duração da doença. Casos agudos de SMI podem necessitar tratamento em Unidade de Internação Psiquiátrica em Hospital Geral (UIPHG). No entanto, há poucos estudos disponíveis no Brasil avaliando esta modalidade de tratamento e os desfechos destes pacientes. Evidências também apontam que os pacientes com transtornos psiquiátricos apresentam níveis reduzidos de Fator Neurotrófico Derivado do Cérebro (Brain-Derived Neurotrophic Factor, BDNF). O BDNF age no sistema nervoso central (SNC) promovendo crescimento e diferenciação de neurônios. Dentro deste contexto, a presente tese apresenta como objetivo principal a avaliação naturalística de desfechos clínicos e funcionais, associados à avaliação dos níveis séricos de BDNF, em pacientes com SMI. Os pacientes que foram encaminhados para tratamento na Unidade de Internação Psiquiátrica do Hospital de Clínicas de Porto Alegre foram incluídos se apresentassem os critérios de SMI: Avaliação Global de Funcionamento (Global Assessment of Functioning, GAF) menor ou igual a 50 e tempo de tratamento maior ou igual a dois anos. As avaliações ocorreram em dois momentos (admissão e alta). Compreenderam avaliação sociodemográfica, clínica e coleta de sangue (com dosagem de BDNF sérico). Foram realizadas avaliação diagnóstica pelo Mini-International Neuropsychiatric Interview (MINI) e aplicação das escalas Brief Psychiatric Rating Scale (BPRS), Clinical Global Impression scale (CGI-S), GAF e World Health Organization Quality of Life Instrument—Short Version (WHOQOL-Bref). Ainda, foram aplicadas escalas específicas nos diagnósticos principais (i.e., depressão maior, depressão bipolar, episódio maníaco, esquizofrenia): Hamilton Depression Rating Scale (HAM-D); Young Mania Rating Scale (YMRS). O primeiro artigo desta tese descreve os desfechos clínicos, funcionais e também de qualidade de vida durante a internação psiquiátrica. Observou-se melhora significativa nos parâmetros avaliados nos pacientes com SMI como um todo. Os pacientes com episódio maníaco apresentaram maior chance (em relação aos com episódio depressivo) de atingir remissão pela CGI (OR: 4.03; 95% CI: 1.14-14.30; p=0.03). A duração média da hospitalização (LOS) foi 28,95 (± 19,86) dias. No segundo artigo, observou-se redução dos níveis séricos de BDNF nos pacientes com SMI em relação aos controles saudáveis, independentemente do diagnóstico. Houve aumento significativo no BDNF entre a admissão e a alta. Os resultados apresentados replicam dados previamente publicados a partir de amostra única de pacientes com SMI, sua característica diferencial. Estes resultados reforçam que a internação em UIPHG, uma intervenção relativamente breve, demonstra desfechos positivos e é alternativa bem estabelecida no tratamento da SMI. Além disso, a redução inespecífica do BDNF sérico seguida de um pequeno aumento associado ao tratamento reforçam a possibilidade do BDNF como marcador transdiagnóstico de transtorno mental. / The estimated prevalence of Severe Mental Illness (SMI) according to Baltimore Epidemiologic Catchment Area and National Comorbidity Survey studies is 5.4% in one year. One suggested definition of Severe Mental Illness (SMI) derives from the 1987 National Institute of Mental Health (NIMH) definition and is based on two criteria: 1. duration, characterized as involving “prolonged illness”, and 2. disability, which includes dangerous or disturbing social behavior, and mild impairment in achieving basic needs. These acute psychiatric conditions may require psychiatric inpatient treatment located in acute wards in General Hospitals. However, little data is currently available evaluating the characteristics and the outcomes during an acute inpatient stay in Brazil. Evidence also suggests that Brain-derived neurotrophic factor (BDNF) levels are significantly decreased in neuropsychiatric disorders. BDNF is found throughout the brain and is involved in neurogenesis and neuroplasticity. So, the main objectives of this work are to evaluate SMI patients’ outcomes during treatment in a psychiatric unit in a general hospital by symptomatology, functionality, quality of life and by the evaluation of BDNF serum levels. After the admission to a psychiatric unit in a general hospital in Brazil, patients were included and if they had two of the SMI criteria: Global Assessment of Functioning (GAF) ≤ 50 and duration of services contact ≥ 2 years. Patients were assessed in admission and upon discharge with Mini-International Neuropsychiatric Interview (MINI), Brief Psychiatric Rating Scale (BPRS), Clinical Global Impression Scale (CGI), GAF, World Health Organization’s QOL Instrument—Short Version (WHOQOL-Bref) and diagnostic specific scales (Hamilton Depression Rating Scale, HAM-D; Young Mania Rating Scale, YMRS; and Hamilton Anxiety Rating Scale, HAM-A). Blood samples were also obtained. The first manuscript showed that SMI patients had marked and significant improvements in symptomatic and functional measures during psychiatric hospitalization. Patients with manic episode had higher chance of CGI remission (OR: 4.03; 95% CI: 1.14-14.30; p=0.03) when compared with patients with depressive episode. Mean LOS was 28.95 (± 19.86) days. The second manuscript showed that BDNF serum levels were equally reduced among different SMI diagnoses. Also, the observed improvements in SMI patients were associated with a significant, but small increase in mean serum BDNF levels. Therefore, the results replicate evidence from previous findings in single samples, suggesting that SMI patients can have marked acute improvements during a a relatively short intervention (approximately 1 month) represented by the psychiatric hospitalization in a general tertiary hospital. Also, the similar reduction observed in BDNF levels among SMI patients with different diagnoses and the significant increase but non-restoration indicate that BDNF serum levels could be considered a marker for the presence of an unspecific psychiatric disorder and possibly a transdiagnostic and unspecific marker of disease activity.

Abstract The purpose of this study was to investigate treatment adherence among adolescents receiving mental health care, with a special focus on psychiatric inpatient treatment. Key goals were to derive a general definition of adherence suitable for this purpose and to assess adolescents’ adherence to medication and non-pharmacological treatments. This study had two phases; phase one involved conducting systematic literature reviews, and phase two was based on empirical research in which data were collected by analyzing notes on hospital patients. The aim of the reviews were to review current research evidence into treatment adherence in adolescents and factors relating adherence among adolescents receiving mental health care (original publication n=15 and original publication n=17). Phase two was part of a clinical follow-up project called STUDY-70 conducted at the Department of Psychiatry at Oulu University Hospital in Finland. This phase yielded two further original publications – papers III and IV. Paper III examined adherence among adolescents receiving psychiatric inpatient care (n=72), focusing on both medication and non-pharmacological treatments. Paper IV examined factors affecting treatment adherence among these 72 inpatient adolescents, including family- and clinic-related variables. The systematic reviews demonstrated that many different definitions of adherence have been used in the literature. A concept synthesis was applied to these definitions to establish a basis for empirical research. The main factors that were found to correlate positively with treatment adherence among adolescents were the patients’ own will to be treated and positive sentiments, but family also played an important role. Factors that correlated negatively with adherence included negative feelings, a lack of cooperation with treatment, and adverse mental symptoms. Adolescent who has received special support at school was found to favor treatment adherence, whereas involuntary treatment, self-mutilative behavior and a close maternal relationship were all linked to non-adherence. Treatment adherence is an ongoing process, and achieving high levels of adherence should be an important goal in all treatment processes. It is important for clinical staff to be aware of factors influencing adherence in order to support the provision of effective and high-quality care for adolescents. / Tiivistelmä Tutkimuksen tarkoituksena oli selvittää mielenterveyspalveluita käyttävien nuorien hoitoon sitoutumista ja erityisesti psykiatrisessa osastohoidossa olevan nuoren sitoutumista hoitoon. Keskeisinä tavoitteina oli kuvata hoitoon sitoutumisen määrittelyä ja arvioida nuoren sitoutumista lääke- ja ei-lääkinnälliseen hoitoon. Tutkimus sisälsi kaksi vaihetta: vaihe yksi systemaattiset kirjallisuuskatsaukset sekä vaihe kaksi empiirisen tutkimuksen, jossa tieto kerättiin analysoimalla potilasasiakirjoja. Systemaattisen kirjallisuuskatsauksen tarkoituksena oli selvittää nuoren hoitoon sitoutumista ja siihen yhteydessä olevia tekijöitä (alkuperäisjulkaisu I n=15, alkuperäisjulkaisu II n=17). Vaihe kaksi oli osa Oulun yliopistollisen sairaalan psykiatrian klinikan projektia, STUDY-70, joka tuotti kaksi osajulkaisua. Alkuperäisjulkaisun III tarkoituksena oli tutkia osastohoidossa olevan nuoren sitoutumista lääke- sekä ei lääkinnälliseen hoitoon (n=72). Alkuperäisjulkaisussa IV selvitettiin näiden nuoren sitoutumista hoitoon ja erityinen mielenkiinto tässä tutkimuksessa oli perhe- ja kliinisillä tekijöillä sitoutuminen (n=72). Systemaattisen kirjallisuuskatsauksen perusteella sitoutumisen määrittelyt vaihtelivat. Tästä huolimatta käsitteen määrittelyjen synteesi oli mahdollinen ja se loi pohjan empiiriselle tutkimukselle. Tämän tutkimuksen perusteella nuoren oma tahto ja positiivinen asenne olivat positiivisesti yhteydessä hoitoon sitoutumiseen. Myös perheen toiminta vaikutti hoitoon sitoutumiseen. Nuoren negatiiviset tunteet, yhteistyökyvyttömyys ja mielenterveysoireet vaikuttivat negatiivisesti sitoutumiseen. Lisäksi nuoren saamat erityispalvelut koulussa tukivat osastohoidossa olevan nuoren hoitoon sitoutumista. Vastentahtoinen hoito, viiltely sekä läheinen ja kestävä äitisuhde olivat yhteydessä sitoutumattomuuteen. Hoitoon sitoutuminen on kokonaisvaltainen prosessi ja yksi hoidon tavoitteista, joka voidaan saavuttaa. Hoitoon sitoutumisen edistämiseksi henkilökunnan tulee tiedostaa ne tekijät, jotka vaikuttavat hoitoon sitoutumiseen. Näin voidaan suunnitella ja toteuttaa laadukasta ja vaikuttavaa hoitoa.

Bakgrund: Patienter med psykiatrisk problematik drabbas oftare än befolkningen i övrigt av somatisk sjukdom och lever i genomsnitt kortare. Akut somatisk sjukdom uppstår även inom den psykiatriska heldygnsvården och för att patienten skall få bästa möjliga vård är det av stor vikt att sjuksköterskan är väl insatt i principerna för akut somatiskt omhändertagande. Till sin hjälp att agera vid akuta tillstånd har sjuksköterskan akutväskan samt hjärtstartaren. Sjuksköterskans kunskaper om akut somatiskt omhändertagande med hjälp av akutväskan är i mycket liten utsträckning beforskade. Syfte: Att undersöka sjuksköterskors uppfattningar om akutväskan som redskap för akut somatiskt omhändertagande inom den psykiatriska heldygnsvården. Metod: Material samlades genom semistrukturerade intervjuer av totalt sex informanter. Informanternas utsagor analyserades sedan med hjälp av en kvalitativ innehållsanalys. Resultat: Sjuksköterskornas uppfattningar akutväskan redovisas genom fyra kategorier samt tillhörande nio subkategorier. Slutsats: Sjuksköterskorna ansåg att akutväskan inte var ändamålsenlig med vilka behov de hade. Sjuksköterskans kunskap var inte på samma nivå som akutväskans avancerade innehåll. För att i framtiden kunna säkra ett patientsäkert omhändertagande med hjälp av akutväskan vid akut somatisk sjukdom bör sjuksköterskorna få hjälp att uppdatera sina kunskaper samt träna med hjälp av akutväskan. / Background: Patients with psychiatric diseases are more likely than the rest of the population to suffer physical illness. Acute somatic illness occurs within the psychiatric inpatient ward and it is of great importance that the psychiatric nurse is proficient in the principles of acute somatic care. In case of a medical emergency, the nurse has resources as the Emergency bag and the AED to help. There is very little research made regarding the knowledge of the nurse and her skills handling the Emergency bag. Aim: To examine what perceptions nurses have about the Emergency bag within the psychiatric inpatient care. Method: The data material was gathered through semi structured interviews from a total of six informants. Their stories were analysed by a qualitative content analysis. Results: The thoughts of the nurses regarding the Emergency bag are presented through four categories with nine attached sub categories. Conclusion: The nurses did not consider the Emergency bag purposive for the requirement they had at the psychiatric inpatient ward. The knowledge of the nurses was not congruent with the advanced content of the Emergency bag. To be able to maintain patient safety using the Emergency bag in a medical emergency the nurses need to update their knowledge as well as to practise using the Emergency bag.

Bakgrund: Enligt Hälso- och sjukvårdslagen ställs kravet att vården ska bygga på respekt   för patientens integritet och självbestämmande. Trots detta visar studier att kravet inte uppnås, då patienter inte känner sig delaktiga i vården i den utsträckning de önskar. Studier visar på att det inom psykiatrin kan ta tid att införliva patientdelaktighet, då ett gammalt paternalistiskt synsätt på patienter lever kvar på sina håll. Inom ätstörningsvården beskrivs patientdelaktighet som en ledstjärna i behandlingen, men många människor med ätstörningar är svåra att engagera i behandling då de kan vara ambivalenta eller förnekar och inte ser allvaret i sjukdomen. I vårdsituationer uppstår ibland en konflikt mellan patientens rätt till delaktighet i sin egen vård och vad vårdpersonal tänker är det rätta och bästa för personen. Sjuksköterskan är den som står patienten närmast i omvårdnaden och har ett professionellt ansvar att göra patienten delaktig i sin behandling.  Syfte: Syftet med föreliggande studie är att undersöka hur sjuksköterskor beskriver  patientdelaktighet vid ätstörningsbehandling i psykiatrisk heldygnsvård. Metod: Studien är en kvalitativ studie med induktiv ansats där semistrukturerade intervjuer genomfördes med sex sjuksköterskor verksamma inom ätstörningsvården, från två olika heldygnsavdelningar i Stockholm. Intervjuerna spelades in och transkriberades för att sedan analyseras enligt kvalitativ innehållsanalys. Resultat: Studien resulterade; i sex huvudkategorier; Påverkan, Bemötande, Relation,  Organisation och vårdmiljö, Sjuksköterskans situation och Patientens situation med vardera tre underkategorier. Diskussion: Resultatet diskuterade utifrån Kari Martinsens omvårdnadsteori samt annan relevant forskning. / Background: The Swedish Health Care Act states that all care in Sweden should be based in the respect for patient integrity and self-determination. Despite     this, studies show that this requirement is not achieved, as patients do not feel involved in the care to the extent that they would wish. Studies have shown that in psychiatric care, it may take time to incorporate patient- participation, as healthcare professionals' view of patients in many places still tends to be characterized by paternalism. Patient participation is described to be a guiding principle in the treatment within eating disorder care, but as patients can often be either ambivalent to their illness, deny it or not take it seriously, their involvement in the treatment can be difficult to achieve. In situations of care giving, a conflict sometimes occurs between the patient’s right to participate in his or her own care, and the healthcare professional´s ideas of what is right and best for the person. The nurse is the one working the closest to the patient in nursing care and hence has a professional responsibility to make the patient involved in the treatment. Aim: The aim of the study is to investigate nurses’ descriptions of patient participation in eating disorders treatment in psychiatric inpatient care. Method: The study is a qualitative inductive study. Semi-structured interviews were conducted with six nurses from two different inpatient care wards specialized in treatment of eating disorders. The interviews were recorded and transcribed and then analyzed through qualitative content analysis. Results: The study resulted in six main categories; Influence, response,  Relationship, Organization and care environment, The nurse´s situation and The patient´s situation with each three respective subcategories.  Discussion: The results were discussed based on Kari Martinsens theory about nursing       and other relevant research.

Masters of Art / High rates of substance use and its associated problems afflict Cape Town, underscoring the need for easily accessible substance abuse treatment. Despite the substantial benefits for both individuals and society at large that substance abuse treatment confers, substance abusers often first have to negotiate considerable challenges in order to access treatment and accumulate these gains. That is, experiencing barriers to accessing treatment, together with the presence of socio-demographic features, rather than “need for treatment”, decides who accesses treatment. Referrals are the gateway to inpatient substance abuse treatment in the Western Cape. While several barriers to accessing treatment have been identified by prior studies, none examine these phenomena from the point of view of the agents responsible for referring substance users for treatment. Moreover, access barriers to inpatient substance abuse services are a neglected area in extant literature. To address this gap, this study explored the perceptions of referring agents‟ of the barriers to accessing state-funded inpatient substance abuse treatment centres in the Western Cape. This enabled the researcher to compare existing access barriers to treatment as identified by prior research, to those elucidated in the study. Bronfenbrenner‟s Process-Person-Context-Time model was employed as the basis for understanding identified barriers. In accordance with the exploratory qualitative methodological framework of the study, six semi-structured individual in-depth interviews were conducted with referring agents‟ of differing professional titles who were purposefully selected and expressed a willingness to participate in the study. Interviews were audio-recorded, and transcripts were analysed and interpreted by means of Thematic Analysis. Two broad thematic categories of access barriers were identified: Person-related barriers (denial, motivation for treatment, gender considerations, disability, active TB disease, homelessness, psychiatric co-morbidity) and Context-related barriers to treatment (cultural and linguistic barriers, stigma, community beliefs about addiction and treatment, awareness of substance abuse treatment, affordability/ financial barriers, geographic locations of treatment facilities, waiting time, lack of collaboration within the treatment system, beliefs of service providers‟, lack of facilities/ resources within the treatment system, practices at inpatient facilities, referral protocol and uninformed staff). Results suggest that by targeting the aforementioned barriers, access to inpatient and outpatient treatment services can be improved, and recommendations for interventions are offered in this regard. Ethical principles such as obtaining informed consent and ensuring confidentiality were abided by throughout the study and thereafter.

Abstrakt   Att vårda frivilligt inlagda patienter på en låst heldygnsvårdsavdelning är ett vanligt förekommande fenomen i Sverige idag. Inom psykiatrin på olika platser i Sverige har diskussioner förekommit tidigare huruvida dörrarna ska vara låsta eller öppna. Information om att dörren är låst och varför bör ges till patienten samt att de som vårdar vet varför avdelningen är låst. Gott bemötande vid psykisk ohälsa är väsentligt. Tydlig information ger möjlighet till att patienten känner sig delaktig i sin vård. Syfte: Att belysa sjuksköterskors erfarenheter av vård och vårdrelation av frivilligt vårdade patienter i en låst avdelningsmiljö Metod: Studien utformades utifrån en kvalitativ metod. I studien användes semistrukturerade intervjuer. Fem allmänsjuksköterskor och sju specialistsjuksköterskor inom psykiatrisk heldygnsvård intervjuades. En kvalitativ innehållsanalys användes för att analysera insamlade data. Resultat: Det framkom fyra kategorier i studiens resultat: Vårdrelationen bakom den låsta dörren, Makten bakom den låsta dörren, Konsekvenser av den låsta dörren och Sjuksköterskors erfarenheter kring lagar och regler på en låst avdelning. Slutsats: Studiens resultat pekar på att personalen har mer makt än patienten. Men denna maktobalans kan ändå leda till en god vårdrelation när sjuksköterskor försöker ha patientens värdighet och integritet i fokus. Sjuksköterskor som arbetar på en låst psykiatrisk avdelning behöver reflektera över skälen till den låsta dörren. Den låsta dörren medförde till svåra etiska dilemma hos sjuksköterskorna. En känsla av frustration framkom hos sjuksköterskor när de behövde begränsa och hindra frivilligt inlagda patienter på grund av lagar och riktlinjer. Sjuksköterskor bör ges möjligheter till att förbättra sina kunskaper kring lagar och regler för att kunna ge en god och säker vård.