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Användningen av mindfulness i psykologisk behandling har vuxit kraftigt de senaste decennierna. Forskningen har dock nästan uteslutande fokuserat på dess positiva effekter. I denna studie genomfördes semistrukturerade intervjuer med tio yrkesverksamma psykologer om deras erfarenheter av svårigheter och problem på området. Intervjumaterialet analyserades med induktiv tematisk analys och visade att utmaningar, fallgropar och risker förekommer. Tre övergripande teman genererades; patientrelaterade egenskaper (bl.a. traumatiska erfarenheter, bristande affektreglering och felaktiga förväntningar på mindfulness), egenskaper hos behandlaren (bl.a. bristande förmåga att bedöma patienters behov och förutsättningar) och den övergripande synen på mindfulness (bl.a. bilden av en kostnadseffektiv ”dos” som kan distribueras i gruppformat istället för en individuell läroprocess liksom tendenser att systemproblem såsom arbetsmiljöfrågor läggs på individnivå). Deltagarna poängterar vikten av personlig erfarenhet, att arbeta individanpassat och ha respekt för metoden. / The use of mindfulness in clinical/therapeutical contexts has increased substantially during the past few decades. Most research in the field however has been solely focused on its positive effects. In this study ten clinical psychologists were interviewed regarding their experiences of difficulties and problems when using mindfulness with patients. The resulting material showed that challenges, pitfalls, and risks exist. Using inductive thematic analysis three major themes were generated: aspects relating to the patient (e.g. traumatic experiences, insufficient capacity in regulating affect and unrealistic expectations), aspects relating to the practitioner (e.g. insufficient capacity to assess the patient´s needs and capacities) and the overall view of mindfulness (e.g. as a cost efficient “dose” which can easily be distributed in a group setting instead of as an individual learning process as well as tendencies to individualize systemic problems such as working environment). The participants emphasize the importance of personal experience, to have respect for the method and to adapt and customize it to the patient.

PURPOSE Explore the competencies required by the child nurse practitioners in the child nursing practice in order to refine the current competencies in a programme for Child Nursing Science presented at a Nursing Education Institution in Gauteng. DESIGN AND METHOD A quantitative, non-experimental, descriptive, exploratory and applied research design was used. A structured self reported questionnaire was constructed based on the competencies derived from the current programme for Child Nursing Science used at the Nursing Education Institution, the Specialist Paediatric and Child Health Nurse by the Australian Confederation of Paediatric and Child Health Nurses and the World Health Organization Children’s Nursing Curriculum. The structured self reported questionnaire was distributed to 110 child nurse practitioners working in child nursing practices in Gauteng and a total of 82 responded. FINDINGS All competencies were regarded as important, except for competencies related to research, family-centred child care, complementary and traditional child care practices, evidence-based practice, mentoring and play activities. CONCLUSION Findings were used to refine the current competencies in a programme for Child Nursing Science / Health Studies / M.A. (Health Studies)

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Background: Maximum oxygen uptake is an established measurement of diagnosing chronic heart failure and underlies various central and peripheral factors. However, central and peripheral factors are little investigated, because they are usually measured invasively. The aim of this study was to compare non-invasively measured central and peripheral factors of oxygen uptake between patients with chronic heart failure and healthy controls. Methods: Ten male patients with heart failure with reduced ejection fraction (62 ± 4 years; body mass index: 27.7 ± 1.8 kg/m2; ejection fraction: 30 ± 4%) and ten male healthy controls (59 ± 3 years; body mass index: 27.7 ± 1.3 kg/m2) were tested for blood pressure, heart rate, stroke volume, cardiac output, and cardiac power output (central factors) as well as muscle oxygen saturation of the vastus lateralis and biceps brachii muscle (peripheral factors) during an incremental cycling test. Stroke volume and muscle oxygen saturation were non-invasively measured by a bioreactance analysis and near-infrared spectroscopy, respectively. Additionally, a maximum isometric strength test of the knee extensors was conducted. Magnitude-based inferences were computed for statistical analyses. Results: Patients had a likely to most likely lower oxygen uptake, mean arterial pressure, and heart rate at maximum load as well as very likely lower isometric peak torque. Contrary, patients had a possibly to likely higher stroke volume and muscle oxygen saturation of the vastus lateralis muscle at maximum load. Differences in cardiac output, cardiac power output, and muscle oxygen saturation of the biceps brachii muscle at maximum load were unclear. Conclusions: Non-invasively measured central and peripheral factors of oxygen uptake differ between patients with chronic heart failure and healthy controls. Therefore, it is promising to measure both types of factors in patients with chronic heart failure to optimize the diagnosis and therapy.

Clinical practice, public health, and policy guidelines should be developed based on a systematic approach that uses the best available evidence. The advent of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework has facilitated this, resulting in a transparent approach to guideline development. GRADE suggests that guideline developers seldom make strong recommendations based on low or very low confidence in effect estimates (strong l/vl). The World Health Organization (WHO) produces recommendations that guide public health policy and, in 2003, WHO adopted the GRADE approach to guideline development. Initial anecdotal evidence suggested that WHO issues a large number of strong recommendations and particularly strong l/vl. Our research team evaluated the nature of WHO recommendations and conducted a qualitative study using interviews of guideline panel members. Key findings included: i) WHO makes a large proportion of recommendations as strong l/vl ii) many strong l/vl are inconsistent with GRADE guidance iii) reasons guideline panel members offered for strong l/vl included skepticism about the value of making conditional recommendations; political considerations; a high confidence in benefits despite formal ratings of low confidence; and long-standing practices, funding, and policy; iv) methodologist interviewees indicated panelists’ lack of commitment to conditional recommendations; a perceived tension between methodologists and panelists due to resistance to adhering to GRADE guidance; both financial and non-financial conflicts of interest among panel members as explanations of strong l/vl; and the need for greater clarity of, and support for, the role of methodologists as co-chairs of panels. The understanding of when and why strong l/vl are formulated at WHO is an important methodological issue that has implications not just for WHO, but for a wide range of guideline developers elsewhere. Our findings offer insights that may guide interventions to enhance trustworthiness of practice guidelines. / Thesis / Doctor of Philosophy (PhD)

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Despite substantial healthcare costs, patient outcomes are sub-optimal in the United States and Canada compared to other countries that spend proportionally less on healthcare. This has led to recognition of the need to improve healthcare value, utilization of tools including clinical practice guidelines and development of initiatives such as the Choosing Wisely Campaign to achieve this goal. In spite of the intuitive appeal of these interventions designed to increase physician awareness of evidence and empower patients to engage in shared decision-making, they have had limited success in changing practice and physician prescribing behaviours. Using a mixed-methods approach, this thesis represents a purposeful attempt to understand the failure of existing approaches through an examination of the factors that influence clinical decision making. Specifically, the thesis integrates quantitative and qualitative methodologies to develop a deeper understanding of clinical decision-making. Consisting of a clinical vignette based survey, the quantitative study explores decision-making in four specific commonly encountered case contexts. After choosing the preferred management option, participants rated the influence of different factors on their decisions. Follow-up questions explored knowledge, attitudes and practices regarding incorporating cost considerations into decision-making. The results of the study were explored further in the qualitative component of the mixed study. The results indicate that clinical decision-making is influenced by an interrelated set of socioecological factors with evidence and clinical practice guidelines playing a secondary role. Because lack of knowledge is not a major factor in guideline discordant care, strategies to improve knowledge will have minimal effect in improving care. The qualitative study included an inquiry into the need for teaching and learning on the topic of cost and cost-effectiveness and sought input from physicians working in diverse settings on methods and topics that need to be included in medical education. The contributions of this thesis include a deeper understanding of the factors that influence clinical decision-making and suggestions for enhancing medical education. / Thesis / Doctor of Philosophy (PhD) / Despite the highest health-care expenditure in the world, patient health outcomes are suboptimal in the United States (US). Additionally, out-of-pocket patient costs are increasingly a cause of financial distress to American patients. Although Canada spends comparatively less than the US on healthcare, it is one of the top ten countries for healthcare spending as a proportion of the gross domestic product. In spite of this level of spending, patient outcomes in the US and Canada are worse when compared to many other economically developed countries that spend relatively less on healthcare. A substantial portion of healthcare spending is for services that do not improve patient outcomes while services proven to improve patient outcomes are underused. Utilizing sequential quantitative and qualitative studies this thesis is a purposeful attempt to identify and examine the factors that influence clinical decision making by physicians. The knowledge gained in this study may help inform the development and evaluation of strategies targeted at increasing adoption of evidence-based practices leading to improved health-outcomes at affordable costs.

To examine to what extent current general education pre-service teachers within a teacher preparation program at a private institution of higher education know and understand the principles of Universal Design for Learning (UDL), expert focus groups were conducted. General education program syllabi were examined for UDL content and found to be lacking in such content. General education pre-service teachers videotaped lessons were reviewed for UDL content and were also found to be inadequate in demonstrating knowledge and understanding of Universal Design for Learning principles. Focus groups comprised of university fieldwork instructors and teacher education experts were asked to review and give feedback on a current clinical observation tool being utilized. Feedback indicated that the current tool was insufficient for measuring pre-service teachers’ knowledge and understanding of UDL. Further, the current tool was not anchored to the UDL framework or any other teaching framework. In service to contributing to the field of teacher preparation, a new clinical practice tool grounded in Universal Design for Learning was created.

No / Studies of diagnostic accuracy often report paired tests for sensitivity and specificity that can be pooled separately to produce summary estimates in a meta-analysis. This was done recently for a systematic review of radiographers' reporting accuracy of plain radiographs. The problem with pooling sensitivities and specificities separately is that it does not acknowledge any possible (negative) correlation between these two measures. A possible cause of this negative correlation is that different thresholds are used in studies to define abnormal and normal radiographs because of implicit variations in thresholds that occur when radiographers' report plain radiographs. A method that allows for the correlation that can exist between pairs of sensitivity and specificity within a study using a random effects approach is the bivariate model. When estimates of accuracy as a fixed-effects model were pooled separately, radiographers' reported plain radiographs in clinical practice at 93% (95% confidence interval (CI) 92-93%) sensitivity and 98% (95% CI 98-98%) specificity. The bivariate model produced the same summary estimates of sensitivity and specificity but with wider confidence intervals (93% (95% CI 91-95%) and 98% (95% CI 96-98%), respectively) that take into account the heterogeneity beyond chance between studies. This method also allowed us to calculate a 95% confidence ellipse around the mean values of sensitivity and specificity and a 95% prediction ellipse for individual values of sensitivity and specificity. The bivariate model is an improvement on pooling sensitivity and specificity separately when there is a threshold effect, and it is the preferred method of choice.