Aggressive or explosive behaviors in children typically occur within the context of a variety of psychiatric diagnoses and pose additional challenges when children present with histories of abuse. These behaviors are often interpreted as deliberate or noncompliant and management of these extreme behaviors often results in locked seclusion in most inpatient psychiatric settings. Locked seclusion remains controversial at best and raises legal and ethical issues regarding its safe and therapeutic use. <br>This retrospective quantitative study evaluated the effectiveness of the Collaborative Problem-Solving (CPS) approach as a less restrictive behavioral intervention on an inpatient child psychiatric unit with children ages 5-12 years that introduced the CPS approach during a nine month performance improvement project from July 1, 2006 - March 31, 2007. This study sought to determine what variables, if any, impacted the use of locked seclusion before, during, and after CPS implementation and whether children with histories of abuse were placed in locked seclusion at a significantly different rate relative to admissions of children who did not have histories of abuse. Erik Erikson's Theory of Psychosocial Development served as the theoretical framework.<br>The closed medical record review involved 197 admissions and 167 children. All data were analyzed in two parts: the entire nine month period of 197 admissions and by time period, based on when the CPS intervention was introduced and implemented on the unit. <br>Length of stay was the only variable statistically significant during the nine month period (n=197) and third time period of January -March 2007 (n=65) when CPS was fully implemented and assessed. This finding suggests that a child's longer length of stay may have had a relationship with being placed in locked seclusion. When length of stay was controlled as an influence with history of abuse, the variable of interest for this study, children with histories of abuse for the nine month period were not significantly more likely of being placed in locked seclusion than children without histories of abuse; for the third time period, they were found to be almost eight times less likely of being placed in locked seclusion with an odds ratio of 7.81.<br>Although these findings suggest a favorable response to the CPS approach and that behaviors associated with traumatized children were normalized to that of their peer group, the results must be considered with caution. There were many limitations to the initial project and any inferred success with abused children and the CPS approach is based on statistical outcomes only. Other variables not measured or controlled must be considered as potential influences that may have impacted these outcomes. As such, future research evaluating CPS effectiveness with traumatized children is recommended. / School of Nursing; / Nursing / PhD; / Dissertation;

Bakgrund: Den psykiatriska slutenvården liksom sjuksköterskans roll har förändrats sedan seklets början. Institutionalisering har ersatts av vård och behandling av patienten, vilket har förändrat kravet på utbildad personal liksom synen på kompetens. Historien förefaller dock fortsatt påverka dagens psykiatriska vårdkultur, och möjligheterna för specialistsjuksköterskan inom psykiatrisk slutenvård att använda sin specialistkompetens förefaller vara beroende av mer än sjuksköterskans egen kunskap och förmåga. Syfte: Studiens syfte var att beskriva hur specialistsjuksköterskor och chefer inom psykiatrisk slutenvård ser på specialistsjuksköterskans kompetens och roll. Metod: Datamaterialet samlades in genom individuella semistrukturerade intervjuer med specialistsjuksköterskor och chefer verksamma inom psykiatrisk slutenvård. Materialet analyserades med kvalitativ innehållsanalys inspirerad av Elo och Kyngäs. Materialet sorterades därefter in i en analysram inspirerad av Kings konceptuella system: det personliga systemet, det interpersonella systemet samt det sociala systemet Resultat: Den kvalitativa analysen utmynnade i tre kategorier: Specialistsjuksköterskans fördjupade kompetens leder till inre trygghet (personliga systemet), specialistsjuksköterskans kompetens främjar patientens hälsoprocess (interpersonella systemet) och Specialistsjuksköterskans kompetens efterfrågas inte av organisationen (sociala systemet). Diskussion: Specialistkunskapen beskrevs som internaliserad i den enskilda sjuksköterskan och det beskrevs att specialistkunskapen gynnade patientens hälsoprocess. Specialistsjuksköterskorna uttryckte dock att de inte fick det mandat de behövde för att implementera sin fördjupade kunskap i slutenvården och att chefen behövde efterfråga specialistkunskapen och bekräfta dem i rollen. Brist på möjlighet att påverka kan vara en anledning till att specialistsjuksköterskor inte stannar i slutenvården. Detta behöver studeras ytterligare och även diskuteras i klinisk praxis. / Background: Psychiatric inpatient care as well as the nurse’s role has changed since the beginning of the century. Institutionalization has been replaced by the care and treatment of the patient, which has changed the requirement of trained staff as well as the perception of competence. History seems however continued to affect today’s psychiatric culture, and opportunities for specialist nurses in psychiatric inpatient care to use their specialist expertise seems to be dependent on more than the nurse’s own knowledge and skills. Aim: The aim of the study was to describe how specialist nurses and managers within psychiatric inpatient care views the specialist nurse competence and role. Method: The data were collected through individual semistructured interviews with specialist nurses and managers active in psychiatric inpatient care. Data were analyzed using qualitative content analysis inspired by Elo and Kyngäs. Data were also divided into an analysis framework inspired by Kings Conceptual system: the personal system, the interpersonal system and the social system. Results: The qualitative analysis resulted in three categories: The specialist nurse depth expertise leads to internal security (personal system), The specialist nurse competence promotes the health of the patient process (interpersonal system) and The specialist nurse competence is not requested by the organization (social system). Discussions: Specialist knowledge was described as internalized in the individual nurse and it was described how specialist knowledge favored the patient’s health process. Specialist nurses described, however, that they were not given the mandate they needed to implement their in-depth expertise of inpatient care. The nurses expressed that the manager had to ask for specialist knowledge and confirm them in their role. Lack of ability to influence may be one reason that specialist nurses do not stay in inpatient care. This needs to be studied further and discussed within clinical practice.

Incidence of suicide has been shown to increase dramatically during adolescence. Despite an established pattern of depression and hopelessness leading to suicide in adults, no such pattern emerges in the adolescent literature. Recent investigations suggest that impulsivity may play a key role in adolescent suicide attempts. This study examined the role of impulsivity in adolescent suicidal gestures, as well as the relationships among demographic variables, anger expression, impulsivity, and suicidal behavior. A total of 100 participants (ages 11-17; 71 females and 29 males) were recruited from 2 inpatient crisis centers for children. The Children's Depression Inventory, Hopelessness Scale for Children, Adolescent Behavior Checklist, Pediatric Anger Expression Scale, and Suicide Intent Scale were administered to inpatients, and demographic information was obtained (age, gender, ethnicity, income, and structure of family). It was hypothesized that patterns of depression, anger, hopelessness, and impulsivity would vary by age, gender, ethnicity, and suicidality (e.g., suicidal gesture vs. no gesture). The large majority of hypotheses were not supported. Results are explained in terms of alternative theories for the role of impulsivity in adolescent suicidal gestures.

Under åren 2008-2010 pågick ett familjeprojekt på barn- och ungdomspsykiatriska kliniken i Stockholm. Tjugofyra familjer skrevs in i projektet och sex behandlare medverkade. Projektets struktur byggde på att familjer, även syskon, till de inskrivna patienterna i högre grad än i vanlig slutenvård skulle närvara och delta i vården. Sessionerna var av en intensitet av tre timmar per dag, tre dagar i veckan, i tre veckor. Genom en kvalitativ studie med intervjuer med ett antal av de som var med, inventeras projektets genomförande och konsekvenser. De som svarat redogör för positiva förändringar, i synnerhet vad gäller relationerna i familjen. Föräldrarna uttrycker att de fått en annan förståelse för sitt barn och barnen att de känner sig mer förstådda. Samarbetet mellan familjerna och de professionella på kliniken verkar ha haft stor betydelse. Självskattningar på Client Satisfaction Questionnaire bekräftar de allmänt goda behandlingsresultaten. / During the years 2008-2010 a family treatment project was run at the child and adolescent psychiatric clinic in Stockholm. Twentyfour families were enrolled in the project and six therapists were involved. The project involved families, including siblings, related to the identified patients to a greater extent than in conventional inpatient care. The sessions had an intensity of three hours a day, three times a week, for three weeks. Through a qualitative study involving interviews with a sample of the participants the experiences and consequences of the project was explored. Respondents described positive changes, especially as regards the relations in the family. Parents expressed that they acquired a different understanding of their children while the children felt more understood than before. The collaboration between the families and the professionals at the clinic seems to have been of great significance to the participants. Ratings on the Client Satisfaction Questionnaire corroborate the positive results of the interviews.

BACKGROUND: Streptococcus pneumoniae is the primary causative agent of pneumonia in older adults. Vaccination is the only tool to protect against pneumococcal infection; however, vaccination rates remain far below the Healthy People 2010 objective of 90% coverage. The number one reason for such low rates is attributed to controversy over the protective efficacy of the vaccine in preventing nonbacteremic pneumonia (eg, community-acquired pneumonia [CAP]). OBJECTIVES: The primary objectives of this study were to assess the incidence of pneumonia, pneumonia requiring hospitalization, and pneumonia hospitalization costs. METHODS: In this retrospective cohort study of Medicare beneficiaries aged 65 years in 2003, subjects were selected based on exposure status. Exposure was defined as receipt of the 23-valent pneumococcal polysaccharide vaccine (PPV23). Vaccinated persons were then matched 1:1 on gender and the presence of any comorbidity to unvaccinated persons. Subjects were followed up for 1 year (January 1, 2004 through December 31, 2004). The primary outcomes were pneumonia, pneumonia requiring hospitalization, and hospitalization costs. Mantel-Haenszel chi-square or logit was used to estimate the relative risk (RR) associated with vaccination and each outcome and Proc Ttest was used to test the difference between mean hospital costs of the vaccinated and non-vaccinated. RESULTS: During the follow-up period, 443 patients were diagnosed with pneumonia; 266 had previously been vaccinated and 177 had no documented receipt of prior vaccination. Results of the Chi-square analysis revealed a significant association between vaccination and the risk of pneumonia, as the vaccinated were 50% more likely to develop pneumonia than were the non-vaccinated (Adjusted RR: 1.50; 95% CI: 1.25, 1.81). Approximately 67% of patients diagnosed with pneumonia required hospitalization; of which, 183 were previously vaccinated and 115 had no documented receipt of prior vaccination. There was no association between vaccination and risk of pneumonia requiring hospitalization (P value 0.4001). However, the vaccine was associated with a significant reduction in hospital costs (P value 0.004). CONCLUSIONS: The results of this study suggest that use of the vaccine may be associated with cost savings due to a reduction in hospitalization.

Bakgrund: Anorexia nervosa är en sjukdom där självsvält leder till undervikt. Personer med sjukdomen har en störd kroppsuppfattning vilket påverkar självkänslan. Symtom är låg kroppsvikt, kraftig viktnedgång, psykisk ohälsa och utebliven mens. Behandling innefattar förebyggande arbete samt akuta psykiatriska och somatiska insatser. Anorexia nervosa kan behandlas inom öppenvård, dagvård eller slutenvård. Syfte: Syftet med denna studie var att beskriva individers erfarenheter av att vårdas för anorexia nervosa inom slutenvård. Metod: En litteraturstudie baserad på åtta kvalitativa artiklar. Sökningar är gjorda i CINAHL with Full Text och PubMED. Ytterligare sökningar gjordes i Medline, PsycINFO och AMED, dock utan relevanta träffar. Resultat: I resultatet återfanns tre teman och åtta subteman. Teman var “Kontrollförlust och önskan om delaktighet”, “Jämlika relationer och stöd” samt “Ansvar och lärande för livet”. Konklusion: Anorexia nervosa är en komplicerad sjukdom att vårdas för. Vårdpersonal behöver förstå patienters upplevelser av vården för att kunna ge bästa möjliga vård. Förståelsen kan bidra till en personcentrerad vård i mötet med dessa patienter. / Background: Anorexia nervosa is a disease where self-starvation leads to underweight. People with the disease have a disturbed body image which affects their self-esteem. Symptoms include low body weight, excessive weight loss, mental illness and absent periods. Treatment includes prevention along with acute psychiatric and somatic interventions. Anorexia nervosa can be treated in outpatient care, day care or inpatient care. Aim: The aim of this study was to describe individuals’ experiences of being treated for anorexia nervosa in inpatient care. Method: A literature review based on eight qualitative research articles. A literature search was conducted in CINAHL with Full Text and PubMed. Searches were also conducted in Medline, PsycINFO and AMED but no further hits were found. Results: The analyze identified three major themes and eight subthemes. The themes were “Loss of control and a desire for participation”, “Equal relationships and support” and “Responsibility and learning for life”. Conclusion: Anorexia nervosa is a complex disease to be treated for. Nursing staff must understand patients’ experiences of care to be able to give the best care possible. This understanding can contribute to a patient-centered care in the meeting with these patients.

Tvång är en realitet i psykiatrisk slutenvård och påverkan på individens autonomi utgör en viktig kunskapskälla för omvårdnadspersonal. Under 1990-talet genomfördes betydande förändringar inom psykiatrins område med uppkomst av Psykiatrireformen, Lag om psykiatrisk tvångsvård och Lag om rättspsykiatrisk vård, i syfte att förbättra vård och behandling av individer med psykiatriska åkommor. Tvångsåtgärder som förekommer inom den psykiatriska vården utgörs av bältning, isolering, kvarhållande på en sluten psykiatrisk vårdenhet och dylika frihetsberövande åtgärder. Syftet var att beskriva upplevelser och erfarenheter hos individer som genomgått psykiatrisk tvångsvård inom slutenvården. Metoden var en litteraturstudie av kvalitativ design med induktiv ansats. Resultatets fyra bärande teman är: Individen och autonomi, Individen, tvångets skepnad och omgivningen, Individen och relationer samt Individen under tvång. Litteraturstudiens slutsatser består till en del utav informationens betydelse. Därutöver är en omvårdande relation utav yttersta vikt samt att innehållet i vad som upplevs som tvång differentierar. Tvång är alltid närvarande i omvårdnadssituationer där hot om detta föreligger. Implikationen för grundutbildningen till sjuksköterska är att öka sjuksköterskestudenternas förståelse för individens upplevelser och erfarenheter av tvångsvård samt tillhandahålla verktyg för bemötande. Framtida forskning bör koncentrera sig på individens upplevelser och erfarenheter av tvång inom psykiatrisk slutenvård, i syfte att höja kvalitéten på den omvårdnad som tillhandahålls. / Coercion is a reality in psychiatric inpatient care and how it affects the individual’s autonomy is an important source of knowledge for nursing staff. During the 1990´s, important changes were conducted within the area of psychiatry with creation of “Psykiatrireformen”, “Lag om psykiatrisk tvångsvård” and “Lag om rättspsykiatrisk vård”, aiming to improve care and treatment of individual´s with psychiatric diseases. Coercive measures that occurs within psychiatric care consists of mechanical restraint, seclusion, detention in a psychiatric unit and similar confinement measures. The aim was to describe the experiences of individuals who have undergone coercion within psychiatric inpatient care. The method was a literature study of qualitative design with an inductive approach.  The result’s four carrying themes are: The individual and autonomy, The Individual, the semblance of coercion and surroundings, The individual and relationships and The individual during coercion. Conclusions of this literature study consist to a part of the importance of information. In addition, a caring relationship is of the most importance and the content in the experience of coercion is differentiating.  Coercion is alwayspresent in nursing situations where the threat of this exists. Implication for thenurse basic education consists in providing greater understanding for the individual’sexperiences of psychiatric inpatient coercion and providing tools inencountering. Future research should concentrate at the individual’sexperiences of coercion in psychiatric inpatient care, aiming to increase thequality of the care that is provided.

Disertaciniame darbe nagrinėjama depresija sergančių asmenų savijauta ir subjektyvus gyvenimo vertinimas stacionarinio gydymo laikotarpiu, šių reiškinių sąsaja bei pokyčiai gydymo metu. Siekiama atskleisti subjektyvaus asmens savo ligos ir sveikatos vertinimo svarbą prognozuojant sveikimo nuo depresijos rezultatus. Darbe siekiama detaliai išanalizuoti depresija sergančių asmenų savijautos struktūrą, taip pat patikrinti prielaidą, kad subjektyvus gyvenimo vertinimas gali būti laikomas psichikos sveikatos išteklių rodikliu. Teorinėms darbo prielaidoms patikrinti gydymo pradžioje ir pabaigoje buvo ištirti 195 depresija sergantys asmenys besigydantys psichiatrijos stacionare, naudojant klausimyną depresijos pokyčiams vertinti (Pranckevičienė, Goštautas, 2007), Pasaulinės sveikatos organizacijos gyvenimo kokybės klausimyną (PSOGK – Trumpas) ir kitas papildomas metodikas. Statistinė rezultatų analizė atskleidė, kad depresija sergančių asmenų savijauta yra daugiakomponentė ir psichologinių bei somatinių savijautos komponentų išskyrimas yra naudingas analizuojant depresija sergančių asmenų sveikimą stacionarinio gydymo laikotarpiu. Subjektyvus gyvenimo vertinimas neprognozuoja gydymo rezultatų, tačiau yra tinkamas subjektyvus visuminės sveikatos matas, nes gerai parodo funkcines ir kognityvines depresijos pasekmes, t.y. pasikeitusį suvokimą. Tyrimas iliustruoja psichologinės pagalbos svarbą stacionarinio depresijos gydymo laikotarpiu. / The study analyses patients’ subjective complaints and subjective evaluation of life, and seeks to evaluate changes and relationships of these phenomena during inpatient treatment of depression, stressing the importance of subjective experience in understanding the burden of the illness, resources for recovery and treatment outcomes. The study seeks to analyze the structure of depressed patients’ subjective complaints, as well as to evaluate the utility of the subjective evaluation of life for treatment outcome evaluation. 195 depressed inpatients were assessed at the beginning of the treatment and at the time of discharge, using measures of subjective depressive complaints (Pranckevičienė, Goštautas, 2007), subjective quality of life (WHOQOL-Bref) and other clinical and social-demographic data. The results of the study show that additional attention to psychological and somatic components of patients’ subjective complaints is useful and compliments the analysis of depressed inpatients’ recovery process. The subjective evaluation of life should be interpreted as a more generic measure of consequences of depression, but not as a measure of depressed inpatient’s recovery resources. The results validate the need of psychological interventions during inpatient treatment.

The study analyses patients’ subjective complaints and subjective evaluation of life, and seeks to evaluate changes and relationships of these phenomena during inpatient treatment of depression, stressing the importance of subjective experience in understanding the burden of the illness, resources for recovery and treatment outcomes. The study seeks to analyze the structure of depressed patients’ subjective complaints, as well as to evaluate the utility of the subjective evaluation of life for treatment outcome evaluation. 195 depressed inpatients were assessed at the beginning of the treatment and at the time of discharge, using measures of subjective depressive complaints (Pranckevičienė, Goštautas, 2007), subjective quality of life (WHOQOL-Bref) and other clinical and social-demographic data. The results of the study show that additional attention to psychological and somatic components of patients’ subjective complaints is useful and compliments the analysis of depressed inpatients’ recovery process. The subjective evaluation of life should be interpreted as a more generic measure of consequences of depression, but not as a measure of depressed inpatient’s recovery resources. The results validate the need of psychological interventions during inpatient treatment. / Disertaciniame darbe nagrinėjama depresija sergančių asmenų savijauta ir subjektyvus gyvenimo vertinimas stacionarinio gydymo laikotarpiu, šių reiškinių sąsaja bei pokyčiai gydymo metu. Siekiama atskleisti subjektyvaus asmens savo ligos ir sveikatos vertinimo svarbą prognozuojant sveikimo nuo depresijos rezultatus. Darbe siekiama detaliai išanalizuoti depresija sergančių asmenų savijautos struktūrą, taip pat patikrinti prielaidą, kad subjektyvus gyvenimo vertinimas gali būti laikomas psichikos sveikatos išteklių rodikliu. Teorinėms darbo prielaidoms patikrinti gydymo pradžioje ir pabaigoje buvo ištirti 195 depresija sergantys asmenys besigydantys psichiatrijos stacionare, naudojant klausimyną depresijos pokyčiams vertinti (Pranckevičienė, Goštautas, 2007), Pasaulinės sveikatos organizacijos gyvenimo kokybės klausimyną (PSOGK – Trumpas) ir kitas papildomas metodikas. Statistinė rezultatų analizė atskleidė, kad depresija sergančių asmenų savijauta yra daugiakomponentė ir psichologinių bei somatinių savijautos komponentų išskyrimas yra naudingas analizuojant depresija sergančių asmenų sveikimą stacionarinio gydymo laikotarpiu. Subjektyvus gyvenimo vertinimas neprognozuoja gydymo rezultatų, tačiau yra tinkamas subjektyvus visuminės sveikatos matas, nes gerai parodo funkcines ir kognityvines depresijos pasekmes, t.y. pasikeitusį suvokimą. Tyrimas iliustruoja psichologinės pagalbos svarbą stacionarinio depresijos gydymo laikotarpiu.

Darbo tikslas - Ištirti pacientų nuomonę apie paslaugas vaikų ligų stacionare. Tyrimo metodika. 2006 m. gruodžio – 2007 m. kovo mėnesiais Kauno medicinos universiteto klinikose II vaikų ligų (terapiniame) bei chirurginiame skyriuose buvo atlikta 11 – 18 metų amžiaus vaikų anoniminė anketinė apklausa. Apklausoje dalyvavo 150 terapinio ir 150 chirurginio profilio pacientų. Anketiniai duomenys buvo apdoroti ir analizuojami statistiniais duomenų paketais STATISTIKA/w 5 ir SPSS/w 12. Kokybinių požymių dažnumų hipotezių lygybė tikrinta Chi kvadrato kriterijumi. Lyginant du santykinius dydžius apskaičiuotas Z koeficientas. Rodiklių skirtumas laikytas statistiškai reikšmingu, kai p<0,05. Rezultatai. Didžioji dalis (68,3 proc.) Kauno medicinos universiteto klinikų vaikų ligų stacionaro pacientų buvo bendrai patenkinti gaunamomis paslaugomis. Du trečdaliai pacientų buvo patenkinti slaugytojų bei gydytojų darbu, gaunamomis procedūromis, gerėjančia sveikata bei skyriaus aplinka. Tačiau maitinimą ir laisvalaikį stacionare respondentai vertino prasčiau. Terapinio ir chirurginio skyrių pacientai gautas stacionaro paslaugas bendrai vertino panašiai, tačiau pastebėta, kad statistiškai reikšmingai terapiniame skyriuje daugiau informacijos gaunama iš slaugytojų ir pacientai šiame skyriuje yra labiau patenkinti gaunamomis naujomis žiniomis apie ligą ir gydymą. Tuo tarpu chirurginiame skyriuje daugiau informacijos pacientai gauna iš gydytojų. Terapinio skyriaus pacientai labiau liūdėjo negalėdami... [toliau žr. visą tekstą] / Aim of the study. To investigate patients’ opinion about inpatient care services in pediatric department. Methods. An anonymous questionnaire survey was carried in Clinic of Kaunas University of Medicine at the second pediatric department (therapeutic) and department of pediatric surgery. The age of respondents ranged from 11 to 18 years old. From each department 150 patients participated in the survey (300 in total). Statistical analysis was performed using the statistical packages STATISTIKA/5 and SPSS/12.0 for Windows. The associations between the variables were tested by Chi squared test. The hypothesis about the equality of two proportions was checked by using Z criteria. The differences between variables were considered as statistically significant, when p<0.05. Results. The majority of patients (63%) in pediatric department of Clinic of Kaunas University of Medicine in general were satisfied with the services. Two thirds of patients were satisfied with work of nurses and doctors, received treatment, improved health, and environment of the department. However, the respondents were less satisfied with the nutrition and leisure time activities. Satisfaction with the services of the patients from therapeutic and surgical departments was similar. Patients of therapeutic department in comparison to patients of surgical department got more information about treatment, procedures and disease from nurses than from doctors. They also were more sad than surgical patients, because... [to full text]