Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Background: According to Grawe’s psychological therapy approach, conflict reduction can be expected not only in psychodynamic, but also in cognitive-behavioral therapy (CBT). This was tested in an effectiveness study. Changes in cognitive conflicts, along with those of symptom severity and well-being were analyzed during alcohol inpatient treatment. Methods: Four times during treatment, groups of patients receiving psychodynamic therapy (n = 45 patients) or CBT (n = 49 patients) were measured and compared. Lauterbach’s Online Conflict Test was used to measure conflict. Symptom severity and well-being were measured using questionnaires. Results: Results showed significant conflict decrease in both groups with a tendency towards faster reduction under CBT. There was also significant change in symptom severity and well-being in both groups with no difference regarding reduction gradient. Moreover, patients in the psychodynamic treatment group exhibited lower symptom scores at treatment begin which may be a consequence of clinical group assignment. Conclusions: In general, the findings confirmed Grawe’s theoretical assumptions. Generalizability to other diagnostic groups and other clinical settings remains to be tested. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Abstract The theoretical part of this thesis focuses on health care issues related to the work of health care professionals in the context of a current legislation. In this part the work of health care professionals is linked to the ethical principles and pressures on the emotional, mental, physical and social levels. The work focuses on the possible symptoms of exhaustion and fatigue on these levels. The emphasis is put on a personal development and coping with emotions so the health care professional is able to provide his or her clients and patients with relevant support. Supervision also develops its potential as a system of control and improving the quality of the provided care. It also helps to achieve the necessary health care quality standards in all respects. This system of a complex support and care for an individual worker as well as team of professionals is rooted predominantly in the development of psychotherapy. In its empirical part this thesis deals with the reasons which prevent supervision to be fully accepted and generally adopted as a system of support for health care professionals. The research in the Regional Hospital in Příbram tries to find and identify possible barriers to the development of supervision and thus contribute to greater interest in its implementation. According to the research findings the main barriers involve inadequate experience and awareness of senior professionals about possibilities and purpose of supervision, their concerns about high financial expenses, the need to devote extra time to this method and last but not least the necessity to study and apply a large amount of professional methods and information to work. The last two mentioned criterions also reduce space which could health care professionals otherwise use for meeting their own needs and self -care. In terms of conditions supervision in health care institution would have to meet, the thesis comes to a conclusion that the possible supervisor should be well-informed about health care sector or experienced in own medical practice. In this respect he or she would be authentic and trustworthy for the supervised health care staff. This thesis also finds out that hospital management strongly supports supervision but so far has not recorded any interest in its implementation among the employees. However, findings of the survey aimed at health care professionals from the selected hospital departments show that more than 50% of respondents regard supervision in health care as needed. The specific need of support for health care professionals is found predominantly in inadequate recognition and appreciation of their work and in the feeling that their work does not bring them joy. In this respect the respondents to a large extent described somatic problems such as frequent headaches, difficulties in digestion and breathing and sleep disorders. According to the research there are good conditions for implementation supervision in a health care institution. However, first it is necessary to ensure that both hospital management and health care professionals are provided with good and sufficient information. The goal of this thesis is to support implementation of supervision among health care professionals in inpatient wards. It is intended for the health care professionals as well as for hospital management. Its aim is to promote the idea that only a person who is healthy, self confident and meets his/her own needs is able to cure well and help others.

Merged nursing inpatient ward is in the last few years becoming a trend of smaller, but also medium-sized hospitals. Due to the restructuring of beds of acute inpatient care in the Czech Republic, separate inpatient wards are merged to one joint ward, in the context of surgical as well as internal medicine. Merged inpatient ward is a combination of various disciplines (specialisms) of inpatient care under one senior consultant, or there is a common nursing ward, where senior consultants of individual disciplines are retained, while nursing care is merged. The main reason for the establishment of a merged inpatient ward is the optimization of beds and the related effective use of bed capacity in connection with an effort to preserve access to health care. The aim of the thesis Merged Nursing Inpatient Ward from the Perspective of Nurses and Management was to evaluate the contribution of a merged nursing inpatient ward, to identify the reasons for the project and the complications that accompanied the project. This research should analyze the problems in nursing care in connection with the origination of the project, to assess the demands of nursing on the ward and map errors in the field of nursing care in the context of the realization of the project. The thesis should evaluate interdisciplinary collaboration and map the occurrence of conflicts in a multidisciplinary team. During the survey it was found that the main reasons for the project were the financial savings associated with the restructuring of acute care beds in the Czech Republic. The establishment of a merged nursing inpatient ward helped the hospital to keep some expertise and it unified nursing care of the separate wards. In connection with the establishment of a joint nursing care, some complications and disadvantages that accompanied the project initially were analyzed. The survey showed how sensitively employees responded to the major change in the organization and how the cooperation between superiors and subordinates functioned. The study analyzed in what form the selection of employees for a common bed fund was realized and whether managers themselves could choose subordinates for their departments. One part of the research was the evaluation of the quality of nursing care on the merged inpatient ward, which showed that the establishment of the project did not have a negative impact on the quality of nursing care. In contrast, nursing care was united and there was also unified organization of nursing on the ward. The research evaluated the feedback from the subordinates to the top managers which was implemented through meetings and sessions. The survey refers to the greater workload on nurses in the working process on the merged ward. The origin of the project had an impact on the creation of new multidisciplinary teams and interdisciplinary collaboration. The project of a joint nursing inpatient ward was realized that the hospital can continue to provide quality health services to all patients. Research has shown that although the project had certain disadvantages and complications, it was certainly beneficial for the organization. The conclusions of the thesis may be presented in seminars, conferences and may be offered to professional journals for publication. The results of the research can help organizations that are going to realize the project of merged nursing inpatient ward.

Submitted by Cláudia Bueno (claudiamoura18@gmail.com) on 2015-10-16T20:26:47Z No. of bitstreams: 2 Dissertação - Ciro Mendes VArgas - 2014.pdf: 4522341 bytes, checksum: 6f69856baba60e9b908a309d91ea0294 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2015-10-19T13:36:27Z (GMT) No. of bitstreams: 2 Dissertação - Ciro Mendes VArgas - 2014.pdf: 4522341 bytes, checksum: 6f69856baba60e9b908a309d91ea0294 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2015-10-19T13:36:27Z (GMT). No. of bitstreams: 2 Dissertação - Ciro Mendes VArgas - 2014.pdf: 4522341 bytes, checksum: 6f69856baba60e9b908a309d91ea0294 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2014-09-30 / Information about pediatric and adolescent patients admitted to specialized psychiatric hospitals are rare and there are few data on the epidemiological profile of these patients. Two studies were conducted in order to investigate this population. Aiming to review the literature concerning this issue, the first study found 17 relevant articles that indicated conduct disorder and affective disorders as most prevalent diagnostics among the studies. There was gender balance. There was no ethnic differences. In the second study, were analyzed medical charts of 1318 patients under 18 years old admitted from January 2001 to December 2011 at a referral hospital in child psychiatric hospitalization. The most frequent diagnosis was Bipolar Disorder (35.4%). There was a significant male majority in bipolar disorder, organic mental disorder and substance-related disorder, female majority in depressive disorder and dissociative disorder. Prevalence of bipolar and related substance in the range 15-18 years and prevalence of organic mental disorder and attention-deficit hyperactivity disorder in the range of 10 to 14 years. Psychiatric family history occurred in greater frequency in the range 10-18 years. Comorbidities were present in 46.2% of the sample. The psychotic syndrome was the most frequent described. In an overview of the two studies, externalizing disorders were more common in younger children and males, and internalizing disorders in older children and females. / Informações sobre pacientes crianças e adolescentes internados em hospitais psiquiátricos especializados são raras e existem poucos dados sobre o perfil epidemiológico desses pacientes. Dois estudos foram realizados no intuito de investigar essa população. Com o objetivo de revisar a literatura concernente a este tema o primeiro estudo encontrou 17 artigos relevantes que indicaram os transtornos de conduta e transtornos afetivos como predominantes entre os diagnósticos dos estudos. Houve equilíbrio entre os gêneros. Não houve diferença étnica. No segundo estudo, foram analisados prontuários de um total de 1318 pacientes menores de 18 anos internados de janeiro de 2001 a dezembro de 2011 em um hospital referência em internação psiquiátrica infantil. O diagnóstico mais frequente foi o Transtorno Bipolar (35,4%). Houve significante maioria masculina no transtorno bipolar, transtorno relacionado à substância e transtorno mental orgânico, maioria feminina no transtorno depressivo e transtorno dissociativo. Predominância do transtorno bipolar e transtorno relacionado à substância na faixa de 15 a 18 anos e do transtorno mental orgânico e déficit atencional e hiperatividade na faixa de 10 a 14 anos. Antecedentes familiares psiquiátricos ocorreram em maior frequência na faixa de 10 a 18 anos. Comorbidades estiveram presentes em 46,2% da amostra. A síndrome psicótica foi a mais frequente descrita. Em uma visão geral dos dois estudos, os transtornos externalizantes foram mais comuns em crianças menores e do sexo masculino, e os transtornos internalizantes, em crianças maiores e do sexo feminino.

Bakgrund: Gungstolsterapi som omvårdnadsåtgärd är outforskat inom den psykiatriska heldygnsvården. Vetenskapliga studier av den typ av gungstol som här studerats har inte gått att hitta. Syfte: Syftet med studien var att utvärdera gungstolsterapi som omvårdnadsåtgärd vid en psykiatrisk heldygnsvårdsavdelning. Metod: En naturalistisk studie med både kvantitativa och kvalitativa inslag genomfördes. Under studieperioden fick patienter som vårdades på en psykiatrisk heldygnsvårdsavdelning lämna självskattningar på en VAS-skala avseende sitt mående före och efter genomförd gungstolsterapi. Patienterna kunde också lämna en skriftlig kommentar om gungningen. Resultat: Resultatet visar att deltagarna skattat en genomsnittlig förbättring motsvarande 16%-enheter i sitt generella mående efter genomförd gungning. Genomsnittliga gungtid var 33 min/gungtillfälle. Majoriteten av patienterna som deltog i studien har bipolär sjukdom. Många deltagare föredrog att gunga en viss del av dygnet. Innehållsanalysen av kommentarerna ledde till att fem kategorier bildades som sammanfattades i temat "En stol som berör". Den genomförda studien visar att patienterna generellt sett upplevde ett ökat välbefinnande efter gungstolsterapin. Studien visar också att inga allvarliga händelser inträffat vid användningen av gungstolen. Resultatet i de båda delarna av studien harmonierar väl med varandra. Slutsats: Studien ger underlag att rekommendera patienter gungstolsterapi för att förbättra sitt mående eller i symtomlindrande syfte. Genomgången visar att många patienter har individuella preferenser för sitt gungande. Gungstolsterapi bör ses som en hälsofrämjande egenvårdsåtgärd som patienten kan utföra dygnet runt och som kan läggas in i patientens vårdplan. / Background: Rocking chair therapy has been poorly researched. There are no scientific research studies where the current rocking chair was evaluated. Aim: The aim of the study was to evaluate rocking chair therapy as a nursing intervention in an inpatient psychiatric setting. Method: A mixed method design, combining quantitative and qualitative approaches, was used. The participants were asked to rate their well-being in a form by using a Visual Analogue Scale (VAS) before and after rocking chair therapy. Participants also had the possibility to leave free text comments in the form. Results: The participants rated a 16% increase in their well-being after using the rocking chair. The average rocking time was 33 minutes. The majority of the participants are diagnosed with bipolar disorder. Many participants preferred to use the rocking chair during a specific time frame every day. The content analysis resulted in five categories and the underlying meaning could be expressed by the theme "Moving emotions". No adverse effects were recorded during the study. Both the quantitative and qualitative analysis show positive results and there are no contradictions in the results. Conclusion: This study support the mental health nurse to recommend psychiatric patients to try rocking chair therapy as a way to increase well-being or reduce distress, it is also a method well suited for self-management. Each patient has his/her own preferences for using rocking chair therapy. The use of rocking chair therapy can easily be included in the patient’s personal care plan.

Background: Psychiatric inpatient staff members work with arguably the most challenging service users. However, reference to these challenges often does not go beyond ‘challenging behaviour’, offering no insight into the actual presentation, thus preventing formulation of the perceived challenges, or subsequent interventions. Moreover, studies have shown that staff responses to challenging presentations can impact on both the staff member and the service user. In particular, staff causal attributions have been shown to impact on their therapeutic response (Apel & Bar-Tal, 1996), as well as being associated with staff emotions (Colson et al., 1987). In turn, the emotional response has been found to be associated with coping, both of which have also been found to effect staff behavioural response, as well as staff members’ psychological well-being (Wykes & Whittington, 1998). However, there have been limited studies assessing these relationships with psychiatric inpatient staff. This may be due to the lack of assessment tools developed for this staff group to measure these particular domains. A specifically designed tool would enable consistent assessment to take place to build on our theoretical knowledge of psychiatric inpatient staff members’ perceived challenges, and their responses to them, as well as highlight specific areas within these domains where further staff training and support is required. Aims: The first aim of the study was to explore psychiatric staff’s views on the challenges they faced when working with service users in inpatient settings, their emotional responses, attributions, and coping strategies about those challenges and then to develop a measure which would accurately capture these (the SEACCS). The second aim was to assess the reliability of the new scale as well as explore relationships within the SEACCS. Finally, the third aim was to assess content and face validity, as well as conduct preliminary psychometric investigations of the construct validity of the newly developed measure. Method: The study was conducted using various methods across three phases. In order to generate items for the SEACCS, a systematic review of the relevant literature and semi-structured interviews took place during the first phase. Secondly, the results of Phase I were combined in order to develop and construct the SEACCS. The third phase involved a postal survey of the SEACCS (including re-test), followed by psychometric investigations to scrutinise the items, explore the reliability, and construct validity of the SEACCS.Results: Twenty three studies were included in the systematic review. The results highlighted inconsistent measurement and findings of the domains concerned. Seven multi-disciplinary staff interviews took place. Thematic analysis was used to conduct four separate analyses focusing on each of the research questions. Several themes and sub-themes were found. Themes such as: ‘Engagement’, ‘Attributions of controllability’, and ‘Behavioural responses’. Findings from the review, thematic analyses, and consultation groups (content and face validity) were combined in order to develop the 64 item SEACCS. A total of 76 multi-disciplinary psychiatric inpatient staff members completed the SEACCS, 15 of which completed re-tests. No items were removed following item scrutiny assessments. Preliminary psychometric investigations indicated good reliability, significant relationships across domains within the SEACCS, and partial construct validity with the GHQ-28.Conclusion: The results of the current study provide the first step in the development and construction of a clinically relevant tool that can be used to assess these domains. The methodological limitations and clinical implications are considered, and future directions for research in this area are suggested.

The hepatitis C virus (HCV) was characterised in 1989. HCV was transmitted through transfusion of blood/blood products, but injection drug use is now the most common route of transmission. The infection is usually asymptomatic but becomes chronic in about 75%, and in 20 years 15-25% develops liver cirrhosis, with a risk for liver failure and liver cancer. HCV has also been associated with lymphoproliferative disorders. The aim of this thesis was to study morbidity and mortality in a national, population-based cohort of HCV-infected individuals. The study population consisted of all persons with a diagnosed HCV-infection recorded in the national surveillance database. This file was linked to other national registers to obtain information of emigration, deaths, cancers, and inpatient care. All personal identifiers were removed before analysis. In Paper I the standardized incidence ratios (SIR) for Hodgkin’s and non-Hodgkin’s lymphoma (NHL), multiple myeloma, acute and chronic lymphatic leukaemia, and thyroid cancer were studied. In the HCV-cohort (n: 27,150) there was a doubled risk for NHL and multiple myeloma in patients infected for more than 15 years, compared with the general population (age-, sex- and calendar-year specific incidence rates). The results strengthened these earlier controversial associations. The SIR and also the absolute risk for primary liver cancer were estimated in Paper II. In the HCV-cohort (n: 36,126) the individuals infected for more than 25 years had a more than 40 times increased risk for liver cancer compared with the general population. The absolute risk of primary liver cancer was 7% within 40 years of HCV-infection. Mortality and cause of death were studied in Paper III. The standardized mortality ratio (SMR) demonstrated a 5.8 times excess mortality in the HCV-cohort (n: 34,235) compared with the general population, and a 35.5 times excess mortality from liver disease. Deaths from illicit drugs and external reasons were common in young adults. Paper IV presents a study of inpatient care. The HCV-cohort (n: 43,000) was compared with a matched reference population (n: 215,000). Cox regression was used to estimate the likelihood, a hazard ratio, for admission to hospital, and frequencies and rates to estimate the total burden. In the HCV-cohort inpatient care was high and about 50% was psychiatric, often drug-related care. The likelihood for liver-related admissions was very high, and serious liver complications increased in the 2000s, indicating that HCV-associated liver disease will increase the next decade. In the 2000s, about 1000 individuals per year were treated with HCV-combination therapy. To conclude, the risk for NHL and multiple myeloma was doubled, and liver- and drug-related morbidity and mortality was very high in the HCV-cohort. Serious liver complications increased in the 2000s and will probably increase the coming decade.

Abstract Attention deficit hyperactivity disorder (ADHD) and disruptive behavior disorder (DBD) are two very common and co-occurring psychiatric disorders among children and adolescents. They are among the leading reasons for clinical referrals to child and adolescent mental health facilities worldwide and have many unfavorable consequences with a high cost to society. In this thesis, the potential early risk factors associated with ADHD and/or DBD were examined, the current well-being of the adolescent with ADHD and/or DBD was evaluated and the later education and the psychiatric morbidity of the adolescent were researched. The study population in this thesis is based on a subsample of the Northern Finland Birth Cohort 1986 (NFBC 1986) containing 457 study subjects, of which 91 (19.9%) were diagnosed with ADHD, 44 (9.6%) with DBD, 72 (15.6%) with comorbid ADHD and DBD and 250 (54.7%) with neither of these disorders. Confirmatory factor analysis, Kaplan-Meier survival analysis, Kruskal-Wallis one-way analysis of variance and several regression analyses were carried out in the study. This thesis contains four original publications. The results in the first publication indicated that there are different risk factors in childhood associating with different behavioral problems in adolescence. The differences between behavioral problems were also visible in the results of the second publication, where those adolescents who were diagnosed with both ADHD and DBD had more severe conduct disorder symptoms and had increased risks for many psychiatric disorders. The results from the third publication suggested that those adolescents who were diagnosed with both ADHD and DBD fared worse in school at the end of ninth grade and were later less likely to achieve higher than basic education. Finally, the fourth publication showed that the adolescents diagnosed with DBD (both with and without ADHD) seemed to have an increased risk for admittance to the psychiatric inpatient hospital. This thesis underlines the differences between children and adolescents diagnosed with ADHD and/or DBD and emphasizes the role of comorbidity between these disorders as an indicator of poorer outcomes later in life. / Tiivistelmä Tarkkaavaisuus- ja ylivilkkaushäiriö (attention deficit hyperactivity disorder, ADHD) sekä käytös- ja uhmakkuushäiriöt (disruptive behavior disorder, DBD) ovat hyvin yleisiä – ja usein yhtä aikaa ilmeneviä – lasten ja nuorten psyykkisiä häiriöitä. Nämä häiriöt ovat hyvin usein syynä lasten ja nuorten psykiatristen terveyspalveluiden käyttöön. Niillä on myös todettu olevan useita epätoivottuja seurauksia, joiden hoitaminen puolestaan nostaa yhteiskunnan kuluja. Tämä väitöskirjatyö tutkii mahdollisia varhaisia riskitekijöitä, jotka assosioituivat ADHD- ja/tai DBD-häiriöiden kanssa, arvioi näillä häiriöillä diagnosoitujen nuorten sen hetkistä hyvinvointia ja tutkii näiden nuorten kouluttautumista sekä muuta psykiatrista sairastavuutta. Tutkimusaineisto koostuu Pohjois-Suomen syntymäkohortti 1986 (Northern Finland Birth Cohort 1986, NFBC 1986) -aineiston osaotoksesta, johon kuuluu 457 henkilöä. Osaotoksesta 91:llä (19,9 %) oli diagnosoitu ADHD, 44:llä (9,6 %) DBD ja 72:lla (15,6 %) komorbidi ADHD ja DBD. 250 henkilöllä (54,7 %) osaotoksesta ei ollut diagnosoitu kumpaakaan diagnoosia. Aineiston analysoinnissa käytettiin konfirmatorista faktorianalyysiä, Kaplan-Meierin elossaolomenetelmää, Kruskal-Wallisin yksisuuntaista varianssianalyysiä ja useita regressioanalyysejä. Tämä väitöskirja koostuu neljästä osajulkaisusta. Ensimmäisen osajulkaisun tulokset osoittivat, että eri riskitekijät lapsuudessa assosioituivat eri käytösongelmiin nuoruudessa. Eri käytösongelmien eroavaisuudet olivat myös nähtävillä toisessa osajulkaisussa: niillä nuorilla, joilla oli diagnosoitu komorbidi ADHD ja DBD, todettiin olevan vakavampia käytöshäiriöiden oireita sekä kohonnut riski useisiin muihin psykiatrisiin sairauksiin. Kolmannen osajulkaisun tulokset viittasivat näiden nuorien, jotka oli diagnosoitu komorbidillä ADHD:lla ja DBD:llä, pärjäävän huonommin koulussa ja valmistuvan muita todennäköisemmin vain peruskoulusta. Lopuksi neljännessä osajulkaisussa todettiin, että DBD diagnoosin nuorena saaneilla (riippumatta ADHD diagnoosista) näytti olevan kohonnut riski psykiatriseen osastohoitoon joutumiselle. Tämä väitöskirjatyö alleviivaa tarkkaavaisuus- ja ylivilkkaushäiriöllä sekä käytös- ja uhmakkuushäiriöillä diagnosoitujen lasten ja nuorten eroavaisuuksia ja korostaa kyseisten häiriöiden komorbidin ilmenemisen roolia huonon lopputuloksen ennustetekijänä myöhemmin nuoren elämässä.

Magister Public Health - MPH / The Outpatient Therapeutic Programme (OTP) is an integrated public health innovation for treating severe acute malnutrition without medical complications in children 6 to 59 months of age as outpatients within their communities using Ready to Use Therapeutic Food with the aim of reducing case fatality rates. The OTP approach is implemented in the three districts in Eastern Province of Zambia namely; Chipata, Katete and Petauke. Since inception of the OTP in the province, an evaluation of the OTP has not been conducted. The study is aimed at assessing the effectiveness of the implementation of the OTP for management of severe acute malnutrition in the three districts of Eastern Province of Zambia.