A confident midwife has an impact on a pregnant woman’s clinical outcome and birth experience. Knowledge acquisition, competence, and confidence develops over a lifetime and is of great importance in developing and forming personal skills and allowing the personal traits to grow and mature. Previous international studies have shown that midwifery students do not feel confident in many areas in which they are supposed to practice independently. The aim of this thesis was to investigate confidence levels in basic midwifery skills in Swedish midwifery students in their final semester just before entering the midwifery profession. An additional aim was to describe clinical midwives’ reflections about learning and what factors that developes professional competence, and confidence. Study I was a cross-sectional survey with Swedish midwifery students (n=238). They assessed their own confidence in all competencies that a midwife should have and could practice independently. The results of study I confirmed that Swedish midwifery students feel confident in dealing with the most common procedures during normal pregnancy, childbirth, and postpartum and newborn care. However, they do not feel fully confident in cases in which there are deviations from the normal procedures and obstetric emergencies. When comparing groups of midwifery students, the younger group of midwifery students felt more confident in general compared to the older group. Students at a university with a medical faculty were also more confident than the students at a university without a medical faculty. In study II, focus group discussions were held with 14 midwives emphasizing the way in which midwives reflect on learning and the development of competence and confidence. Content analysis was used to analyze the focus group discussions. Four categories were identified as a result of study II: 1.) feelings of professional safety evolve over time; 2.) personal qualities affect professional development; 3.) methods for knowledge and competence expansion; and 4.) competence as developing and demanding. The conclusion of this thesis is that more practical and clinical training during education is desirable. Midwifery students need to have access and the opportunity to practice obstetrical emergencies within a team of obstetricians and pediatricians. Learning takes time, and one improvement is to extend midwifery education to include and increase in clinical training. This would strengthen the students theoretical, scientific, and clinical confidence. Clinical midwives claim that it takes time to feel confident and that there is a need to develop professionalism. / En trygg barnmorska har en positiv inverkan för förlossningsutfall samt förlossningsupplevelse. Kunskap, kompetens och trygghet är ett livslångt lärande och har stor betydelse för att utveckla och forma personliga färdigheter, att låta de personliga egenskaperna växa och mogna. Tidigare internationella studier har påvisat att barnmorskestudenter känner sig otrygga inom områden där förväntas vara självständiga. Syftet med denna avhandling var att undersöka graden av trygghet hos svenska barnmorskstudenter strax innan de var färdigutbildade. Ett annat syfte var att utforska hur kliniskt verksamma barnmorskor reflekterar över lärande och vilka faktorer som bidrar till att utveckla yrkesmässig kompetens och trygghet. Studie I var en tvärsnittsundersökning med svenska barnmorskestudenter (n = 238). De bedömde egen trygghet inom alla kompetenser som en barnmorska förväntas kunna samt utföra självständigt. Resultaten av studie I bekräftade att svenska barnmorskestudenter känner sig trygga att hantera de vanligaste rutinerna vid normal graviditet, förlossning, eftervård samt nyföddhets vård. De känner sig emellertid inte fullt så trygga när något avviker från det normala samt vid obstetriska nödsituationer. Vid jämförelse mellan yngre och äldre barnmorskestudenter samt grad av trygghet, var det den yngre gruppen av barnmorskestudenter som kände sig tryggare i allmänhet jämfört med den äldre gruppen. Studenter vid ett universitet med en medicinsk fakultet var också mer trygga än studenterna vid ett universitet utan en medicinsk fakultet. I studie II hölls fokusgrupper med 14 barnmorskor, de diskuterade och reflekterade över hur barnmorskor utvecklar kompetens. Metod för att analysera var innehållsanalys, i resultatet framkom fyra kategorier 1.) känslor av professionell trygghet utvecklas över tid ; 2.) Personliga kvaliteter påverkar yrkesutveckling. 3.) metoder för kunskap och kompetensutveckling; och 4.) Kompetens som utveckling och krävande. Slutsatsen av denna avhandling är att mer klinisk träning under utbildning är önskvärt. Barnmorskestudenter behöver tillgång och möjlighet att öva obstetriska nödsituationer tillsammans i team bestående av förlossningspersonal och barnläkare. Det tar tid att lära samt att känna trygghet, en möjlighet att underlätta för studenter vore att utöka samt förlänga barnmorskeutbildningen, att inkludera mer klinisk träning. Detta skulle innebära att stärka studenters möjligheter till en utökad klinisk trygghet. Kliniska barnmorskor hävdar att det tar tid att känna sig trygg och att det ett finns behov av att utveckla professionalism.

Cartas al editor

Aim: The overall aim is to create knowledge about how nursing students’ learning in pairs can be supported in order to create prerequisites for encounters that provide caring and learning support during clinical practice. Approach and method: A reflective lifeworld research (RLR) approach founded on the epistemology of phenomenology and hermeneutics was used. Based on interviews, diary entries and observations with patients, students and supervisors, descriptive and interpretive analysis in accordance with the RLR approach was performed. Main findings: Students’ learning in pairs is based on encountering and caring for the patients together. The responsibility of caring for the patients, which is given to the students by their supervisors, is based on supportive relationships that are characterized by movements between independence and cooperation. Supporting students learning in pairs is characterized by a reflective approach focusing on learning in togetherness, where the individual student is also reached and seen, providing opportunities for developing important abilities for learning and caring. Depending on the ability to show respect and to take responsibility a more or less supportive relationship between the patients, the students and the supervisors is created within the learning space. Conclusions: Supporting students’ learning in pairs is complex due to it taking place in a caring context, where respect must be given towards the patients, the students, the supervisors and other participants who are closely connected to the learning space. Since learning in pairs affects and interweaves learning and caring environments, a reduction to either one of them, learning or caring, is not possible but instead the learning space must be understood as a whole. Optimal conditions for learning in pairs are based on dynamic movements, which require a reflective supervising approach. If these conditions are missing, there is a risk of creating both fragmented caring and learning, where the patients ́ vulnerability and safety needs to be taken into account. Keywords: caring science; clinical practice; learning space; learning support; pairs of nursing students; reflective lifeworld approach

Hintergrund: Angststörungen sind häufig, oft chronifizierend, jedoch auch gut behandelbar. Leitlinienbehandlung ist die auf Exposition fokussierende Verhaltenstherapie. In der ambulanten Versorgungspraxis finden Expositionen jedoch selten statt. Die Angst-Tagesklinik am Universitätsklinikum Dresden realisiert die evidenzbasierte Behandlung von Angststörungen. In einer 5-wöchigen Kurzzeitbehandlung werden wöchentlich 4 begleitete und zeitoffene Expositionssitzungen durchgeführt. Untersucht wurden die Symptomverläufe und die Responder-Raten. Methoden: Zu Therapieaufnahme und -ende sowie zur Katamnese nach 3 Monaten und 1 Jahr wurde die Entwicklung der Symptombelastung bei n = 332 PatientInnen untersucht, die von 2009 bis 2015 behandelt wurden. Etwa zwei Drittel waren psychotherapeutisch vorbehandelt. Eingesetzt wurden spezifische etablierte Fragebögen. Berechnet wurden Mixed Models, Effektstärken und Responder-Raten. Ergebnisse: 90% der PatientInnen schlossen die Behandlung regulär ab. Es zeigten sich signifikante Linderungen bei Belastungen durch Angst- und depressive Symptome. Die höchsten Effektstärken um 0,9 ergaben sich bei verhaltensbezogenen Skalen und besonders bei den Agoraphobien und Panikstörungen, die die größte Störungsgruppe ausmachen. Die Responseraten lagen bei 60%. Zu den Katamnesezeitpunkten waren die Symptomverbesserungen stabil und bei den kognitiven Symptomen weiter steigend. Schlussfolgerungen: Die Behandlung in spezialisierten (teil)stationären Versorgungssettings mit Fokus auf hochfrequente Exposition, wie hier beispielhaft vorgestellt, zeigt eine gute Akzeptanz und gute bis sehr gute und längerfristig stabile Veränderungen der Symptombelastung. Diese Settings erfordern eine besondere strukturelle Ausstattung und Ressourcen. / Intensive Exposure-Based Treatment of Anxiety Disorders in a Specialized Patient-Centered Day Hospital Background: Anxiety disorders are highly prevalent, often chronic, but effectively treatable by cognitive-behavioral therapy, especially by exposure therapy. However, exposure treatments rarely occur in outpatient healthcare. The day hospital for anxiety disorders at the University Hospital Dresden implemented an evidence-based treatment. Every week, 4 guided time-open exposure sessions, not timelimited, are conducted during the 5-week treatment period. Improvements in symptomatology and response rates were examined. Methods: The symptomatology of n = 332 patients, treated from 2009 till 2015, was assessed at pretreatment and posttreatment, and at the follow-ups after 3 months and 1 year. Two-thirds had previously had other psycho therapy treatments. Established questionnaires were used. Data was analyzed by calculating mixed models, effect sizes, and response rates. Results: 90% of the patients finished the treatment regularly. Significant improvements occurred in anxiety and depressive symptoms. The strongest effect sizes of about 0.9 were achieved for behavioral scales, especially for symptoms of agoraphobia and panic disorder, the most frequent disorders in the sample. The response rates were 60%. Improvements remained stable at the follow-ups and even increased further for cognitive symptoms. Conclusions: Specialized day hospital healthcare settings, like the one presented here, are associated with good to very good and stable improvements and also with good acceptance. These therapeutic settings require specific structural equipment and resources.

Evidence-based practice, whose roots emanate from the mid-1960s, aims to provide fair, high-quality, and soundly researched health care with patients' best interests as a priority. Clinical practice guidelines are evidence-based and designed to assist clinicians with sound decision making. Despite the importance of evidence-based practice and the efforts invested into its development and dissemination, its uptake and implementation are poor. The disconnect between evidence-based practice and its translation into clinical practice was previously reported in low-to-middle income countries. This study investigated South African audiologists' and otorhinolaryngologists' (ear, nose and throat specialists') self-reported orientation to evidence-based practice. Second, adherence to evidence-based clinical practice guidelines was assessed with reference to the diagnosis and management of benign paroxysmal positional vertigo, a common vestibular condition for which a firm evidence base supporting treatment exists. A two-part quantitative approach was adopted. Part one surveyed South African audiologists and otorhinolaryngologists with the Evidence-Based Practice Profile Questionnaire and an additional researcher-developed questionnaire pertaining to the diagnosis and management of benign paroxysmal positional vertigo. A total of 130 survey responses were included in this study. Independent sample t-tests, one-way ANOVAs and Fisher's Exact tests were used to analyse the survey data. Part two used a retrospective record review at a tertiary academic hospital in the Western Cape of South Africa. Medical folders of patients diagnosed with benign paroxysmal positional vertigo, between 2010 – 2018 (n = 80), were analysed. The diagnosis and management strategies were recorded and compared against a gold standard evidence based guideline for congruence. Descriptive statistics were used to analyse and understand the data. Survey scores showed a positive association between increased years of experience and healthcare professionals' knowledge (p = .008) and confidence (p = .003) in evidence-based practice. Otorhinolaryngologists might be more knowledgeable than audiologists in evidence-based practice due to their increased training and exposure to evidence-based practice in their specialising years. Findings from the retrospective record review suggested adherence to the clinical practice guidelines in the diagnosis and management of posterior semi circular canal benign paroxysmal positional vertigo. The study outcomes propose that evidence-based clinical practice guidelines developed in the Global North may not be appropriate for the different health contexts that exist in low-to-middle income South Africa (e.g., rural settings). However, the benign paroxysmal positional vertigo clinical practice guidelines were adhered to at a tertiary, academic hospital in Cape Town. The results also support the notion that increased exposure to evidence-based practice reinforces its approach. Outcomes from this study raise implications for the development and dissemination of context-appropriate, evidence-based clinical practice guidelines.

Pressure ulcers (PUs) present intrinsic risk factors that are not consistently identified by clinical assessments. The objective of this project was to develop a clinical practice guideline (CPG) to provide nurses with guidance in identifying and differentiating how intrinsic and extrinsic risk factors are associated with populations at risk for developing avoidable and unavoidable PUs. CPG development followed a systematic method to search the literature, organize findings, and assess the strength of the resulting evidence and its applicability to the CPG. Quality of the CPG was assessed by a panel of 8 health care professionals using the Appraisal of Guidelines for Research & Evaluation II instrument. Findings of the assessment indicated a high overall quality of the CPG; its immediate use was recommended and systematic evaluation was suggested to promote usage in a wider array of health care contexts. The quality domains with the highest scores were scope, purpose, applicability, editorial independence (all 100%), rigor of development (99.7%), and clarity of presentation (99.3%). The stakeholder involvement domain demonstrated the lowest--yet still robust--score (94.4%). The CPG can be used to emphasize appropriate and specific nursing competencies for making informed decisions when identifying and describing patients at risk for developing PUs. Further research and evaluation of the use of this CPG will be useful to demonstrate how CPGs can help to decrease the incidence of avoidable PUs. The potential for positive social change relative to the prevention of PUs is high. Decreased incidence of preventable PUs will eliminate unnecessary health care costs and improve overall health outcomes of patients at all levels of socioeconomic status.

Den psykiska ohälsan bland barn och ungdomar i Sverige har ökat under 2000-talet. Socialstyrelsen rekommenderar psykologisk behandling för de flesta psykiatriska tillstånd hos barn och unga samtidigt som utskrivning av läkemedel ökar. Förändrade strukturer och synsätt inom vården riskerar att viktig kunskap och kompetens går förlorad och att behandlingsutbudet inom vården minskar. Forskning kring hjärnan och barns utveckling kan bidra med värdefulla aspekter att ta hänsyn till i beslut kring det psykoterapeutiska arbetet och utbudet inom BUP. Studiens syfte var därför att belysa och undersöka hur modern neurovetenskap och mer specifikt teorin kring interpersonell neurobiologi kan användas i psykoterapi med barn, unga och familjer. Genom en litteraturstudie har tre centrala aspekter lyfts fram som viktiga när man försöker integrera denna kunskap med den kliniska tillämpningen: Hjärnutvecklande interventioner, Psykoedukation och Relationsfokus. Även om studiens avgränsning medför vissa svagheter, bedöms dock resultaten kunna vara intressanta för både kliniskt verksamma och andra individer och grupper i samhället. / The mental ill health among children and adolescents has increased in Sweden during the last two decades. The National Board of Health and Welfare recommends psychological treatment as a primary intervention for most of the psychiatric conditions seen in children and adolescents, at the same time as medical prescriptions continue to increase. Changes in organizational structure and perspectives within mental health care applies risk of losing important knowledge, experience and narrowing the range of treatment methods. Modern neuroscience has an opportunity to provide valuable aspects in decisions regarding the content and variety of treatment methods provided in child and adolescent psychiatry. The aim of this study was to illustrate and investigate how modern neuroscience and specifically the theory of interpersonal neurobiology can be applied in the clinical practice of psychotherapy with children, adolescents, and families. A literature review was carried out where three central themes emerged as important aspects of integrating this perspective in the clinical practice: Interventions for positive brain development, Focus on relationships and Psychoeducation. The selection of literature is relatively narrow and a limitation of the study, but the results could nonetheless be useful for both clinicians and other individuals and groups in the larger community.

Dental schools are faced with the challenge of incorporating varied instructional methodologies into their curriculum. Various dental schools distinguish different modules in their program under preclinical and clinical disciplines with minimal connections between the two. This study investigated students' perceptions of their curriculum and, more specifically, compare and contrast dental students' perceptions of learning during the first or freshman years, the second or junior years, and the third years as seniors in 2005, 2006, and 2007. It contrasts the results from students' perceptions and students' actual learning to establish correlations between these two phenomena. Various standard assessments were used. Students' understanding of the use of dental materials including base, liner, and cement were measured as predicting factors to substantiate the accuracy of the students' perceptions. A questionnaire was used to elicit a total of 853 responses over the three consecutive years. Pearson correlations were applied to analyze the data. The main finding was a positive correlation between the accuracy of students perceptions of learning and their participation in clinical practice; whereas no correlation was confirmed with regard to the accuracy of students' perceptions of learning when students had only or primarily participated in preclinical courses. The results suggest that advanced students' perceptions and knowledge can be considered by faculty when making decisions regarding reform of their dental curriculum

Sjuksköterskehandledare bedömer och handleder studenter på den verksamhetsförlagda utbildningen, något som ingår i deras arbetsuppgifter. Syftet med studien var att få en djupare förståelse om vad handledare anser att en student ska ha för kunskaper, förmågor och attityder. Fokus låg på att undersöka fenomenet ur handledarens perspektiv, eftersom jag upplevde att det saknades forskning ur den synvinkeln. Studiens teoretiska referensram utgick från yrkeshabitus, ett begrepp som har utvecklats från Pierre Bourdieus begrepp habitus. Empirin inhämtades med hjälp av tio kvalitativa intervjuer, som genomfördes digitalt med sjuksköterskor som hade erfarenhet av att handleda studenter. Empirin analyserades med hjälp av en kvalitativ innehållsanalys och fem kategorier och 15 underkategorier skapades. Resultatet visade att handledarna ansåg det vara viktigare att studenterna uppvisade sociala och emotionella förmågor, framför praktiska och teoretiska kunskaper. De kunskaper och förmågor som framkom, överensstämde i stort med examensmålen för sjuksköterskor. Informanterna hade alla en relativt homogen bild över vad studenter bör inneha och sträva efter för dispositioner som finns i sjuksköterskans yrkeshabitus. Resultatet påvisade även oskrivna och dolda kriterier och förmågor som en student bör uppfylla, där det ansågs att för att bli rätt person för yrket behövde de socialisera sig med dessa yrkesidentiteter som finns i sjuksköterskan yrkeshabitus. Åsikter om vad en student ska kunna grundar sig inte enbart på vad de gör utan även på hur de är. / Nursing supervisors assess and supervise students on the clinical training, which is part of their work. The purpose of the study was to get a deeper understanding of what supervisors believe a student should have in terms of knowledge, abilities and attitudes. The focus was on investigating the phenomenon from the supervisor's perspective, as I felt that there was a lack of research from that point of view. The study's theoretical frame of reference was based on professional habitus, a concept that has been developed from Pierre Bourdieu's concept of habitus. The data was collected using ten qualitative interviews that were conducted digitally, with nurses who had experience of supervising students. The data was analyzed using a qualitative content analysis and five categories and 15 subcategories were created. The result showed that the supervisors considered that the most important abilities for the students were social and emotional abilities, rather than the practical and theoretical knowledge. The knowledge and abilities that emerged corresponded well to the graduation goals for nurses. The informants all had a relatively homogenous view of the dispositions that students should have and strive for and that are found in the nurse's professional habitus. The result also demonstrated unwritten and hidden criteria and abilities that a student should meet, where it was believed that to become the right person for the profession, they needed to socialize with these professional identities found in the nursing professional habitus. Opinions about what a student should know are not only based on what they do but also on how they are.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23756号 / 医博第4802号 / 新制||医||1056(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 中山 健夫, 教授 村井 俊哉, 教授 小杉 眞司 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM