Ständige Weiterentwicklungen von Behandlungsmöglichkeiten, die Technisierung der Medizin und die Liberalisierung des Gesundheitssystems führen auf Seiten der Versorger zu vermehrten Anstrengungen, die eigenen Geschäftsprozesse in Klinischen Pfaden zu dokumentieren, um auf dieser Basis eine medizinische und betriebswirtschaftliche Optimierung durchzuführen. Für die Entwicklung Klinischer Pfade ist die Einbeziehung Medizinischer Leitlinien unablässig, da sie für definierte Symptomkomplexe den aktuellen Stand der Forschung aggregieren. Gleichwohl sind sie Schulungsunterlagen, direkte Entscheidungshilfen oder Aufklärungsdokumente für Patienten und damit keinesfalls ausschließlich auf die Entwicklung Klinischer Pfade ausgerichtet. Dadurch geht die Leitlinien-getriebene Entwicklung Klinischer Pfade mit einem hohen interpretativen Aufwand auf Seiten der Anwender einher. Aus der Motivation diesen Prozess methodisch zu unterstützen, leitet sich die zentrale Forschungsfrage der Arbeit ab: Wie kann eine Methode gestaltet sein, die eine zielgerichtete Ableitung von Klinischen Pfaden aus Medizinischen Leitlinien zulässt? Dieser Frage nimmt sich die vorliegende Arbeit an und präsentiert einen referenzmodellbasierten Ansatz, diese bestehende methodische Lücke zu schließen. Das Lösungsartefakt setzt dabei direkt auf Seiten der Medizinischen Leitlinie an. Die Methode, kurz MAC, besteht aus drei Methodenfragmenten: dem Rollenmodell, in welchem die Aufgabenträgertypen und ihre Verantwortlichkeiten beschrieben werden, dem Produktfragment, welches den Entwurf einer Modellierungssprache zur Kodierung von Medizinischen Leitlinien und deren Wiederverwendung in Klinischen Pfaden auf Basis einer Referenzmodelladaption vorsieht, und dem Vorgehensmodell, in dem Handlungsanweisungen für die zuvor beschriebenen Aufgabenträgertypen spezifiziert sind. Die Arbeit leistet damit einen Beitrag zum Methodenspektrum der Wirtschaftsinformatik. Forschungsmethodisch ordnet sich die Arbeit in die gestaltungsorientierte Artefaktforschung (Design Science) ein.

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Competition for seats in Canadian medical schools has driven many Canadians to seek medical education abroad. Systematic barriers make it necessary for internationally educated physicians (IEPs) hoping to practice in Canada to complete postgraduate residencies. To do so, they must transition into new medical education systems. The transitional experiences of internationally educated physicians are not well understood. This phenomenological qualitative study reveals the perspectives of twenty recent graduates from the University of Manitoba Family Medicine residency program. Canadians Studying Abroad constituted the majority of participants. Participant interviews revealed the presence of clinical practice gaps, created by curricular differences in the timing of graduated clinical responsibility between the Canadian and international medical education systems. Participants also shared their experiences of being singled out (visibility and invisibility), rejected and mistreated. They perceived that IEP residents were assigned low status in resident hierarchies. Their experiences are conceptualized as stigmatization.

Denna avhandling inom arbetslivspedagogik syftar till att bidra med kunskap om villkor för gemensamma lärprocesser då ny kunskap utvecklas i en traditionstung kontext. Studien handlar om en grupp psykoanalytiker som utvecklar en ny behandlingsmetod, sk. spädbarnsanalys, för att arbeta med spädbarn och deras föräldrar. Studien handlar om professionella yrkesutövare i privat praktik, där verksamheten är av sådan art att de professionella aktörerna inte kan se varandra i handling, något som tidigare studier funnit vara av betydelse för kollektivt lärande. I avhandlingen studeras villkor för lärprocesser med en konstruktivistisk och handlingsteoretisk utgångspunkt, en utgångspunkt är också att den kontext lärandet sker inom är central för de lärprocesser som uppstår. Detta är en fallstudie och det empiriska materialet har samlats in mellan 2006 och 2012 och består främst av 17 transkriberade kvalitativa intervjuer med psykoanalytiker med spädbarnsinriktning, alla tillhörande samma grupp. Starka traditioner förs vidare inom den psykoanalytiska miljön genom en lång och formande utbildning. I arbetet med att utveckla en metod för att arbeta med spädbarn uppstår en spänning mellan det traditionstunga och det nydanande som får betydelse för gemensamma lärprocesser. Gruppen genomgår fyra olika faser, i vilka villkoren för lärande skiljer sig åt. De enskilda erfarenheterna av att arbeta kliniskt med metoden skaver mot vad man till en början tänkt sig att metoden ska innebära. I ett gemensamt sammanhang diskuteras och förändras successivt synen på olika aspekter av metoden: hur man ska fokusera i den kliniska verksamheten, vilken frekvens behandlingen ska ha och hur man förhåller sig till att vara rådgivande. Förstahandsarena respektive andrahandsarena föreslås som begrepp för att förstå relationen mellan den kliniska verksamheten (förstahandsarenan) och seminariearenan (andrahandsarenan). Då metoden får olika mening och innebörd på förstahands- och andrahandsarenan leder det till att dilemman uppstår som behöver hanteras och som triggar igång lärprocesser. Kollektiva lärprocesser bidrar till att metoden och sättet att arbeta utvecklas. / This thesis on working life education aims to contribute knowledge about the conditions for shared learning processes when new knowledge is developed in a tradition-laden context. The study is about a group of psychoanalysts who are developing a new treatment method, “infant psychoanalysis”, for working with infants and their parents. It deals with professionals in private practice, where the professionals involved are unable to see one another in action, an aspect which previous studies have found to be of significance for collective learning. The thesis examines the conditions for learning processes from a constructivist and action theory perspective. The context in which the learning takes place is seen as central to the learning processes that arise. This is a case study; the empirical material has been gathered over the period 2006 to 2012 consisting primarily of 17 transcribed qualitative interviews with psychoanalysts specializing in infant psychoanalysis. Strong traditions are passed down in the psychoanalytical environment. In developing a method of working with infants there is a tension between tradition and recreation which affects shared learning processes. The group undergoes four phases, each with different conditions for learning. The individual experiences of working clinically with the method are at times dissonant with initial preconceptions of the method. In the shared context, the views of different aspects of the method are successively discussed and changed: how to focus in clinical practice, what the frequency of the treatment should be and what approach to take. “Primary arena” and “secondary arena” are proposed as concepts to understand the relationship between the clinical practice (primary arena) and the seminar arena (secondary arena). The method has different meaning in the primary and secondary arenas, which causes dilemmas that triggers learning processes. Collective learning processes enable the development of the method.

Clinical learning experiences form an integral part of the student nurse's training, for it is in the clinical setting that students acquire the knowledge, skills and values necessary for professional practice. The purpose of this research was to explore student nurses experiences during clinical practice. A qualitative, exploratory, descriptive and contextual design was utilised, employing the phenomenological method. Unstructured interviews were conducted with student nurses in their final year of the four year nursing programme at a nursing college campus in the Limpopo Province. Tesch's method of data analysis was used. The findings indicate that there are aspects which impact negatively on student nurses' clinical learning experiences, such as lack of teaching and learning support, lack of opportunities for learning, poor theory-practice integration, and poor interpersonal relationships between the students, college tutors and ward staff. Recommendations to enhance the clinical learning experiences of student nurses were made. / Health Studies / M.A. (Health Studies)

[pt] Este trabalho tem por objetivo examinar os impactos da difusão da Internet sobre o campo da psicologia clínica e, em particular, sobre as práticas psicoterápicas da atualidade. Para tanto, é feita, inicialmente, uma discussão teórica sobre as transformações em curso no contexto de produção científica contemporâneo, à luz do recente desenvolvimento das tecnologias digitais e, em especial, da Internet. Em seguida, a discussão concentra-se especificamente no contexto da psicologia clínica, no recente interesse desta área pelo estudo dos impactos subjetivos da Internet e no exame da produção a este respeito. Dado que esta produção é composta quase que exclusivamente de pesquisas empíricas e não contempla os efeitos da Internet sobre as práticas clínicas, o trabalho de campo da presente tese visou investigar esta lacuna. Em outras palavras, foi realizada uma pesquisa qualitativa junto a 16 psicoterapeutas com o objetivo de conhecer o que estes têm a dizer sobre a chegada da Internet aos seus consultórios. Os principais resultados obtidos podem ser divididos em dois grupos. O primeiro diz respeito a indicadores clínicos que, da ótica dos terapeutas entrevistados, apontam para impactos subjetivos sofridos pelos pacientes-usuários da Rede. São eles: o prazer no uso da Internet, a sensação de onipotência que experimentam, as novas formas de se relacionarem com o corpo, as diferentes formas de excesso às quais se expõem e as novas formas de controle exercidas por meio dos registros que a Rede disponibiliza. Já o segundo grupo de resultados refere-se aos impactos da Internet sobre os próprios terapeutas, ou seja, às suas reações frente à chegada da Internet aos consultórios e à desorientação que experimentaram diante das novas questões clínicas colocadas em cena pelas aventuras on-line de seus pacientes. / [en] The present thesis aims at examining the impacts of Internet diffusion on the clinical psychology fields and, particularly on the psychotherapy practice in use presently. Firstly, a theoretical discussion is done. It is about the current changes in the contemporaneous context of scientific production, considering the recent development of digital technologies and, especially Internet. Secondly, the discussion focuses specifically on the clinical psychology context, on the recent interest of this area for the studies of the Internet subjective impacts and, on the exam of the corresponding production. Due to the fact that such production is almost exclusively composed of empirical research and does not consider the effects of Internet on the clinical practice, the practical focus of the present thesis aimed at investigating the gap above. In other words, a qualitative research with 16 psychotherapists has been done to know what they have to say about the Internet arrival into their offices. The main results obtained can be divided into two groups. The first one refers to clinical indicators according to the interviewed therapists perspective. They expose subjective impacts suffered by the patientsusers of the Net. Those are: the pleasure in using Internet, the sensation of omnipotence they experience, the new ways of relationship with their own bodies, the new ways of excess they are exposed to and, the new ways of control done by means of the registers set available by the Net. Nevertheless, the second group of results refers to the impacts of the Net on therapists themselves, that is, their reaction to the Internet presence in their offices and to the disturbance they felt facing the new clinical issues set in scene by their patients on-line adventures.

Clinical practice is the core of nursing education during which the student is socialized into the nursing profession. During this period, there is transfer of knowledge and skill from qualified nurses and other members of the multidisciplinary team to student nurses. The purpose of this study is to describe and explore student nurse’s experiences of clinical accompaniment in a public hospital in Gauteng Province by means of a qualitative approach that included the exploratory, descriptive and contextual study. Three focus group interviews were conducted with students and one with clinical accompanists. Qualitative methods included categorizing and coding. The major findings of the research revealed that participants regarded relationships and communication as important for clinical accompaniment. Both student nurses and unit supervisors expected nurse facilitators to accompany students in clinical settings; but some hospital staff members did not perceive clinical accompaniment to be their task. / Health Studies / M.A. (Public Health)

The purpose of the study was to explore the perceptions of professional nurses on student mentorship. A qualitative, explorative, hermeneutic phenomenological research was conducted to determine the meaning of mentoring as perceived by professional nurses and to identify the successes and challenges encountered by professional nurses with regard to student mentorship during clinical practice. A face-to-face semi-structured interviews were done to collect data from operational managers (n=16) who were managing all unit activities, student mentoring included. Each interview lasted for ± 45 minutes. A hermeneutic data analysis (hermeneutic circle) was followed for data analysis. Four (4) themes and 15 sub-themes emerged from data collected from operational managers. The findings revealed that mentoring was perceived as a valuable phenomenon to apply in the preparation of student nurses for future professional role. In the process of mentoring, the caring attitude is revealed. Factors found to drive mentoring process successful was amongst other commitment, interest and partnership which guarantee the mutual efforts to the process. Though it is beneficial to mentor, mentee and the organisation as according to findings, challenges were also seen impacting on this process limiting its intentions / Health Studies / M.A. (Health Studies)

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / O protocolo do benefício antecipado é uma modalidade de tratamento ortocirúrgico que não envolve o preparo ortodôntico prévio. De acordo com os preceitos da Odontologia baseada em evidências, é essencial que se conheça o impacto dessa modalidade de tratamento na vida diária dos pacientes, uma vez que, para ser considerada viável, deve-se comprovar que ela oferece benefícios significativos para a qualidade de vida. Esse estudo objetivou conhecer os efeitos do tratamento ortocirúrgico com o protocolo do benefício antecipado na qualidade de vida e na autopercepção estética dos pacientes, durante dois anos de acompanhamento, e compará-los com os percebidos pelos pacientes tratados pela técnica tradicional. A amostra foi constituída por dezesseis pacientes, sendo oito no grupo tratado com o benefício antecipado (GBA) e oito no grupo tratado com a técnica ortocirúrgica tradicional. A qualidade de vida dos pacientes foi avaliada com três questionários: o OQLQ (Orthognathic Quality of Life Questionnaire), o OHIP-14 (Oral Health Impact Profile Short Version) e o SF-36 (Medical Outcomes Study 36 Item Short-Form Health Survey), em suas versões traduzidas e validadas para o português, e a autopercepção estética e a gravidade da má oclusão foram avaliadas com o Índice de Necessidade de Tratamento Ortodôntico (IOTN). Os exames foram repetidos em sete momentos de avaliação dos participantes: no exame inicial (T0), um mês depois do início do tratamento (T1), três meses depois do início do tratamento (T2), seis meses depois do início do tratamento (T3), um ano depois do início do tratamento e dois anos após o início do tratamento ou no término do tratamento ortocirúrgico (T5). Para ambos os grupos, houve um tempo pós-operatório (TPO) que foi realizado entre duas e três semanas após a cirurgia ortognática. A análise dos dados foi realizada com os testes de Mann-Whitney e de Friedman. Os pacientes do grupo GBA tiveram uma redução significativa no OQLQ (p<0,001) e no OHIP-14 (p<0,001) após dois anos de avaliação. Essa melhora foi progressiva e iniciada após a realização da cirurgia ortognática. O SF-36 apresentou melhoras significativas nas dimensões de capacidade funcional, limitação por aspectos físicos e aspectos sociais (p<0,001). A autopercepção estética comportou-se de maneira similar, com uma melhora progressiva e significativa (p<0,001), acompanhada de uma melhora significativa na gravidade da má oclusão (p<0,001). Porém os indivíduos que removeram o aparelho tiveram OHRQoL e autopercepção estética melhores em relação aos pacientes que não finalizaram o tratamento no período de dois anos no grupo GBA (N=4). No grupo GTT nenhum paciente foi operado após os dois anos de acompanhamento, e pioras significativas foram observadas no OQLQ (p<0,001) e no OHIP-14 (p<0,001) e na autopercepção estética (p<0,001). O CPO-D não teve alteração significativa para nenhum dos dois grupos. Concluiu-se que o tratamento ortocirúrgico com o protocolo do benefício antecipado gerou efeitos mais positivos na qualidade de vida, na autopercepção estética e na gravidade da má oclusão do que o tratamento ortocirúrgico tradicional após dois anos. / The surgery-first approach is a treatment modality that does not involve previous orthodontic treatment. Evidence-based dentistry states that it is essential to know the impact in patients' daily life of this treatment modality since, to be considered viable, it must offers significant benefits to patients quality of life. This study investigated surgery-first approach effects in patients quality of life and aesthetic perception during two years of follow up, and compared it with these effects in patients treated with orthosurgical traditional approach. Sample consisted of sixteen patients, eight in the group treated with surgery-first approach (GBA) and eight in the group treated with orthosurgical traditional approach. Patients quality of life was assessed with three questionnaires: the OQLQ (Orthognathic Quality of Life Questionnaire), the OHIP-14 (Oral Health Impact Profile - Short Version), and the SF-36 (Medical Outcomes Study 36 - Item Short-Form Health Survey), translated and validated to portuguese. Aesthetic self-perception and malocclusion severity was assessed with the Index of Orthodontic Treatment Need (IOTN). Tests were repeated in seven stages of patients evaluation: at baseline (T0), one month after braces bonding (T1), three months after braces bonding (T2), six months after braces bonding (T3 ), one year after braces bonding, and two years after braces bonding or after treatment conclusion (T5). For both groups there was an evaluation stage after surgery (TPS) that occurred between two and three weeks after orthognathic surgery. Data analysis was performed using Mann-Whitney and Friedman tests. GBA group had a significant reduction in OQLQ (p <0.001) and OHIP-14 scores (p <0.001) after two years. These changes started after the orthognathic surgery, and were progressive throughout the evaluation period. The SF-36 showed significant changes in physical functioning, role-physical, social functioning dimensions (p<0.001). The aesthetic perception behaved similarly, with a progressive significant improvement (p <0.001), accompanied by an improvement in malocclusion severity (p<0.001). However, individuals who have had finished treatment showed better OHRQoL and aesthetic self-perception than those patients who have not completed treatment within two years in the GBA (N = 4). In GTT group no patient underwent surgery after two years of monitoring, and significant deterioration in OQLQ were observed (p<0.001) as well as in the OHIP-14 (p<0.001) and in aesthetic self-perception (p<0.001). The DMFT no significant change for either group. It was concluded that treatment with surgery-first approach had more positive effects on quality of life, in the aesthetic self-perception and malocclusion severity than traditional orthosurgical treatment after two years.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / O protocolo do benefício antecipado é uma modalidade de tratamento ortocirúrgico que não envolve o preparo ortodôntico prévio. De acordo com os preceitos da Odontologia baseada em evidências, é essencial que se conheça o impacto dessa modalidade de tratamento na vida diária dos pacientes, uma vez que, para ser considerada viável, deve-se comprovar que ela oferece benefícios significativos para a qualidade de vida. Esse estudo objetivou conhecer os efeitos do tratamento ortocirúrgico com o protocolo do benefício antecipado na qualidade de vida e na autopercepção estética dos pacientes, durante dois anos de acompanhamento, e compará-los com os percebidos pelos pacientes tratados pela técnica tradicional. A amostra foi constituída por dezesseis pacientes, sendo oito no grupo tratado com o benefício antecipado (GBA) e oito no grupo tratado com a técnica ortocirúrgica tradicional. A qualidade de vida dos pacientes foi avaliada com três questionários: o OQLQ (Orthognathic Quality of Life Questionnaire), o OHIP-14 (Oral Health Impact Profile Short Version) e o SF-36 (Medical Outcomes Study 36 Item Short-Form Health Survey), em suas versões traduzidas e validadas para o português, e a autopercepção estética e a gravidade da má oclusão foram avaliadas com o Índice de Necessidade de Tratamento Ortodôntico (IOTN). Os exames foram repetidos em sete momentos de avaliação dos participantes: no exame inicial (T0), um mês depois do início do tratamento (T1), três meses depois do início do tratamento (T2), seis meses depois do início do tratamento (T3), um ano depois do início do tratamento e dois anos após o início do tratamento ou no término do tratamento ortocirúrgico (T5). Para ambos os grupos, houve um tempo pós-operatório (TPO) que foi realizado entre duas e três semanas após a cirurgia ortognática. A análise dos dados foi realizada com os testes de Mann-Whitney e de Friedman. Os pacientes do grupo GBA tiveram uma redução significativa no OQLQ (p<0,001) e no OHIP-14 (p<0,001) após dois anos de avaliação. Essa melhora foi progressiva e iniciada após a realização da cirurgia ortognática. O SF-36 apresentou melhoras significativas nas dimensões de capacidade funcional, limitação por aspectos físicos e aspectos sociais (p<0,001). A autopercepção estética comportou-se de maneira similar, com uma melhora progressiva e significativa (p<0,001), acompanhada de uma melhora significativa na gravidade da má oclusão (p<0,001). Porém os indivíduos que removeram o aparelho tiveram OHRQoL e autopercepção estética melhores em relação aos pacientes que não finalizaram o tratamento no período de dois anos no grupo GBA (N=4). No grupo GTT nenhum paciente foi operado após os dois anos de acompanhamento, e pioras significativas foram observadas no OQLQ (p<0,001) e no OHIP-14 (p<0,001) e na autopercepção estética (p<0,001). O CPO-D não teve alteração significativa para nenhum dos dois grupos. Concluiu-se que o tratamento ortocirúrgico com o protocolo do benefício antecipado gerou efeitos mais positivos na qualidade de vida, na autopercepção estética e na gravidade da má oclusão do que o tratamento ortocirúrgico tradicional após dois anos. / The surgery-first approach is a treatment modality that does not involve previous orthodontic treatment. Evidence-based dentistry states that it is essential to know the impact in patients' daily life of this treatment modality since, to be considered viable, it must offers significant benefits to patients quality of life. This study investigated surgery-first approach effects in patients quality of life and aesthetic perception during two years of follow up, and compared it with these effects in patients treated with orthosurgical traditional approach. Sample consisted of sixteen patients, eight in the group treated with surgery-first approach (GBA) and eight in the group treated with orthosurgical traditional approach. Patients quality of life was assessed with three questionnaires: the OQLQ (Orthognathic Quality of Life Questionnaire), the OHIP-14 (Oral Health Impact Profile - Short Version), and the SF-36 (Medical Outcomes Study 36 - Item Short-Form Health Survey), translated and validated to portuguese. Aesthetic self-perception and malocclusion severity was assessed with the Index of Orthodontic Treatment Need (IOTN). Tests were repeated in seven stages of patients evaluation: at baseline (T0), one month after braces bonding (T1), three months after braces bonding (T2), six months after braces bonding (T3 ), one year after braces bonding, and two years after braces bonding or after treatment conclusion (T5). For both groups there was an evaluation stage after surgery (TPS) that occurred between two and three weeks after orthognathic surgery. Data analysis was performed using Mann-Whitney and Friedman tests. GBA group had a significant reduction in OQLQ (p <0.001) and OHIP-14 scores (p <0.001) after two years. These changes started after the orthognathic surgery, and were progressive throughout the evaluation period. The SF-36 showed significant changes in physical functioning, role-physical, social functioning dimensions (p<0.001). The aesthetic perception behaved similarly, with a progressive significant improvement (p <0.001), accompanied by an improvement in malocclusion severity (p<0.001). However, individuals who have had finished treatment showed better OHRQoL and aesthetic self-perception than those patients who have not completed treatment within two years in the GBA (N = 4). In GTT group no patient underwent surgery after two years of monitoring, and significant deterioration in OQLQ were observed (p<0.001) as well as in the OHIP-14 (p<0.001) and in aesthetic self-perception (p<0.001). The DMFT no significant change for either group. It was concluded that treatment with surgery-first approach had more positive effects on quality of life, in the aesthetic self-perception and malocclusion severity than traditional orthosurgical treatment after two years.