Darbo tikslas – Ištirti Viešosios Įstaigos Kauno Centro poliklinikos gydytojų, slaugytojų ir pacientų požiūrį į slaugytojos profesiją. Darbo uždaviniai: 1. Palyginti gydytojo, slaugytojo ir paciento požiūrį į slaugytojos profesiją. 2. Palyginti medicinos normose apibrėžtas slaugytojų funkcijas su gydytojų, slaugytojų ir pacientų požiūriu į slaugytojų atliekamas funkcijas. 3. Įvertinti slaugytojų pasitenkinimą darbu ir jo sąsajas su požiūriu į slaugytojos profesiją. Tyrimo metodika. Tyrimo metu buvo atlikta gydytojų, slaugytojų ir pacientų anoniminė anketinė apklausa. Gydytojų atsako dažnis 71 proc. ( N- 98), slaugytojų atsako dažnis 87 proc. (N-95) ir pacientų atsako dažnis 72proc. (N-420). Respondentų atsakymų įvertinimui buvo naudota 7 balų Likert skalė, kur: 1- visiškai nesutinku /niekada / visiškai nesvarbus / /labai blogai, o 7 – visiškai sutinku / visada /labai svarbus/ labai gerai. Duomenys buvo apdorojami naudojant statistinį duomenų analizės paketą SPSS 9.0. Duomenų analizei taikytos statistinės procedūros: chi kvadrato (χ2) kriterijus , Z – kriterijus ir 95proc. pasikliautinieji intervalai (PI), Kruskalio-Volison kriterijus ir 95proc. pasikliautinieji intervalai (PI), Spearmano koreliacijos koeficientas. Rezultatai ir išvados: 1. Nors slaugytojos vaidmuo teikiant pacientams paslaugas buvo įvertintas kaip svarbus, bet tiek gydytojų, tiek pacientų, tiek slaugytojų tarpe vyrauja požiūris į slaugytoją, kaip į gydytojo padėjėją. Gydytojai... [toliau žr. visą tekstą] / The aim of the Study – To investigate doctors’, nurses’ and patients’ attitude towards nursing specialists at Public Enterprise Kaunas Centre Outpatient Clinic. The tasks of the Study: 1. To compare doctors’, nurses’ and patients’ attitude towards nursing specialists. 2. To compare nursing functions specified in Medical Regulations with the doctors’, nurses’ and patients’ attitude towards nursing specialists. 3. To evaluate nurses’ satisfaction with their work and its link with nursing profession. Methods of the research. An anonymous inquiry of the doctors, nurses and patients using questionnaires has been applied during the research. Doctors’ response rate 71 % ( N- 98), nurses’ response rate 87 % (N-95) and patients’ response rate 72% (N-420). To evaluate the replies of the respondents, the 7-point Likert scale has been employed, where: 1- totally disagree /never/absolutely unimportant/very bad, and 7 – totally agree/always/extremely important/ very well. The data obtained have been processed using SPSS 9.0 statistical software package. The following statistical procedures have been applied to the data analysis: chi square (χ2) criterion, Z – criterion and 95% reliance intervals (RI), Kruskal-Wallis criterion and 95% reliance intervals (RI), Spearman’s coefficient of correlation. Results and conclusions: 1. Although the role of a nursing specialist during service provision to the patients has been assessed as an important one, the prevailing approach among... [to full text]

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Darbo tikslas – įvertinti šeimos gydytojo pasirinkimą ir keitimą lemiančius veiksnius priklausomai nuo įstaigos tipo. Uždaviniai :1. Nustatyti ir įvertinti PSP paslaugų teikėjo pasirinkimą lemiančius veiksnius priklausomai nuo įstaigos tipo. 2. Įvertinti ir palyginti šeimos gydytojo keitimą įtakojančius motyvus priklausomai nuo įstaigos tipo. 3. Įvertinti ir palyginti pacientų elgseną ir pasitenkinimą paslaugomis priklausomai nuo įstaigos tipo. Tyrimo metodika. Tyrimas atliktas 2013m. sausio- kovo mėn. Naudota anoniminė anketinė viešosiose: Prienų rajono PSPC ir Birštono PSPC bei privačiose PSP įstaigose besilankančių pacientų apklausa( n═247). Atsakas dažnumas 81,5 proc. Tyrimo rezultatų statistinė analizė atlikta naudojant SPSS 17.0 ( Statistical Package of Social Scienles ) for Windows statistinių duomenų paketą. Ryšiai tarp požymių vertinti pagal Chi kvadrato ( x2 ) kriterijų. Rodiklių skirtumas laikytas statistiškai reikšmingu, kai p< 0,05. Rezultatai. Pacientų tyrimo rezultatų analizė atskleidė, jog (48 proc.) privačių PSPC ir (46 proc.) viešųjų PSP įstaigų pacientų yra patenkinti šeimos gydytojo teikiamomis paslaugomis. Tyrimo metu nustatyta, kad statistiškai šeimos gydytojo paslaugų vertinimas neturi sąsajų su išsilavinimu, socialiniu statusu ir mokėjimu už paslaugas. Privačiose gydymo įstaigose (40 proc.) respondentų nepasirenka šeimos gydytojo dėl nepatenkinamų paslaugų kokybės, o (75 proc.) viešųjų PSP centrų respondentų - dėl netinkamo šeimos gydytojo... [toliau žr. visą tekstą] / The aim of the study is to assess factors that determine the choice and change of family doctor depending on the type of institution. Objectives: 1. To identify and assess factors that determine the choice of a primary healthcare service provider depending on the type of institution. 2. To assess and compare motives that influence the change of a family doctor depending on the type of institution. 3. To assess and compare patientes behaviour and satisfaction depending on the type of institution. Methods of the research. The research was conducted in between January and March, 2013. An anonymous survey was performed on patients who visit public institutions of Prienai district primary health care and Birštonas primary health care and also private primary health care institutions (n=247). The response in public primary health care institutions was 81.5%. The statistical analysis of the research results was performed using SPSS 17.0 (Statistical Package for Social Sciences). The relationships between the features were assessed using x2 criterion. Results. The analysis of patient research results showed that 48% of patients of private primary healthcare and 46% of public healthcare institutions are satisfied with the services provided by family doctors. During the research it was found that statistically the assessment of family doctor service quality does not have connection with education, social status or payment for services, 40% of respondents do not choose family doctor... [to full text]

Recent decades have seen increasing recognition of the importance of patient involvement during patient-professional interactions and promotion of preventative and long term approaches to healthcare for those with long-term conditions. The concepts of 'shared decision making' and 'personalised care planning' have both been advocated by patient groups, policy-makers, professional bodies and academia as best practice. During shared decision making, patients and healthcare professionals work in equal partnership to decide the best course of action. Shared decision making is a central tenet of personalised care planning, as it aims to foster partnerships between patients and healthcare professionals when making decisions, but personalised care planning also describes an overall approach to healthcare that is forward-planning and preventative, rather than episodic and reactive. Despite the breadth of support for such approaches, in reality they are not routinely adopted. Multiple Sclerosis (MS) is a heterogeneous neurodegenerative long term condition, which is unpredictable with limited treatments available. Such uncertainty and complexity position MS as an interesting long term condition to explore decisional and information needs. This doctoral research comprises of three methods stages. Firstly, two systematic reviews assessing the effectiveness of personalised care planning for people with long-term conditions and people with MS were carried out. Secondly, 22 in-depth semi-structured qualitative interviews were carried out with people with MS across the UK to explore experiences of decision making and interactions with healthcare professionals. Purposive sampling was carried out and data saturation determined sample size. A modified grounded theory approach was used and thematic analysis of interview data was carried out. Lastly, a series of structured qualitative interviews were carried out with 6 consultant neurologists. This stage was iterative in that problematic areas identified during analysis of interview data from stage 2 were presented to neurologists in infographic form to further examine issues raised. Framework analysis was carried out on neurologist interview data to examine their interpretations and potential solutions. Although there appears to be some evidence demonstrating that personalised care planning is effective for people with long term conditions, such favourable effects were not demonstrated in the context of MS. Based on the findings from the systematic reviews it is unclear whether personalised care planning is effective for people with MS and there is a clear gap in the literature examining this. Findings from the interview stages suggest there are key areas which are lacking in terms of information and decisional support. Such areas included the type and amount of information around the time of diagnosis, support when choosing disease modifying drugs and discussions about approaches outside mainstream medicine. Findings from neurologist interview data corroborated those from MS interview data, but through examination of issues raised it also highlighted some of the complexities and challenges of involving patients and enacting shared decision making in reality. This research identified key areas that require improvement for people with MS in terms of provision of the information and decisional support. Although in theory personalised care planning and shared decision making are positioned as best practice, in reality it is unclear whether they are effective or appropriate for people with MS. The way in which such approaches are enacted are complex and require careful consideration. Potential barriers and pitfalls identified within this study suggest a lack of clarity in how to respond to challenges and further investigation into how patient involvement is enacted is needed.

La loi du 04 mars 2002 relative aux droits des malades et à la qualité et à la qualité du système de santé et la loi HPST (Hôpital, Patients, Santé et Territoires) de 2009 qui accorde un cadre légal à l’éducation thérapeutique ont promu l’autonomie du patient en favorisant sa participation aux décisions médicales. L’autogestion de la maladie chronique voulue par les pouvoirs publics en fournissant ces outils juridiques pour améliorer la qualité de soins, a suscité notre intérêt pour programme d’éducation thérapeutique destiné à des patients insuffisants rénaux en pré-dialyse. L’un des objectifs est de favoriser la liberté des patients à choisir une méthode de dialyse. Dans notre travail de thèse, nous avons voulu montrer comment les déterminants sociaux des décisions médicales et ceux liés aux choix d’une méthode de dialyse sont construits. Si en France, les patients semblent davantage se tourner vers une prise en charge à l’hôpital, dans certains pays, c’est le pluralisme médical qui est de mise. L’exercice de l’auto-analyse a montré le poids de l’économique, de la culture, de la famille dans les choix de santé.Par ailleurs, la place de l’éducation thérapeutique dans le processus décisionnel n’est pas figée : l’éducation thérapeutique peut être complémentaire à la pratique médicale, être un outil d’aide à la décision pour certains patients insuffisants rénaux ou être utilisée par les médecins pour favoriser l’observance décisionnelle des patients. Nous avons montré que les patients et les médecins se basent sur plusieurs facteurs qui peuvent influencer la nature de la délibération.Cette étude a montré que le choix est réseauté et que les décisions sont construites car elles sont basées sur des interactions et des stratégies médicales. Ces déterminants permettent également de comprendre comment la confiance est construite dans le processus décisionnel. Tantôt distribuée, tantôt déplacée, la confiance est explicative du type d’information que le patient priorise. Le choix réseauté du patient amène finalement à la relativisation du modèle de décision médicale partagée qui semble de plus en plus avoir un caractère normatif dans la relation entre professionnels de santé et patients. / The law of March 04th, 2002 on the rights of patients and the quality of the health system and the law HPST (Hôpital, Patients, Santé et Territoires) of 2009 that grants legal framework for patients’ education, have promoted the patient’s autonomy by encouraging his participation in medical decisions. Self-management of chronic illness as favoured by public authorities in providing the legal tools to improve the quality of care has aroused our interest in patient education programs for patients with renal failure in pre-dialysis. One of the objectives of this program is to allow patients free choice when deciding on the method of dialysis.Our thesis aims to underline how the social determinants at work in medical decisions and those involved in the choice of a dialysis method are constructed.In France, patients seem to favor hospital patient care, but in some countries, medical pluralism is more frequent. The exercise of self-analysis has revealed the significant part played by economy, culture and family in health choices.Moreover, the part played by patient education in the decision-making process is neither fixed nor pre-determined: patient education can complement medical practice, can be a decision support tool for some kidney patients or be used by doctors to promote patient decision-making compliance.We have shown that patients and physicians rely on several factors that may influence the nature of the discussion.This study reveals that the choice is networked and that the decisions that are made are the outcome of several interactions and medical strategies. These determinants also help to understand how trust develops and leads to decision-making.Sometimes distributed, sometimes shifted, trust accounts for the type of information prioritized by the patient. The networked choice of the patient finally puts the shared decision-making model into perspective as it increasingly seems to have a normative character in the relationship between health professionals and patients.

>Magister Scientiae - MSc / Many South African Deaf people use their mobile phones for communication with SMSs yet they would prefer to converse in South African Sign Language. Deaf people with a capital `D' are different from deaf or hard of hearing as they primarily use sign language to communicate. This study explores how to design and evaluate a prototype that will allow a Deaf person using SASL to tell a hearing doctor how s/he is feeling and provide a way for the doctor to respond. A computer{based prototype was designed and evaluated with the Deaf people in a previous study. Results from the user trial of the computer{based mock{up indicated that Deaf users would like to see the prototype on a cell phone. Those user trial results, combined with our own user survey results conducted with Deaf people, are used as requirements. We built a prototype for a mobile phone browser by embedding SASL videos inside XHTML pages using Adobe Flash. The prototype asks medical questions using SASL videos. These questions are arranged in an organized way that helps in identifying a medical problem. The answers to the questions are then displayed in English and shown to the doctor on the phone. A content authoring tool was also designed and implemented. The content authoring tool is used for populating the prototype in a context free manner allowing for plug and play scenarios such as a doctor's office, Department of Home A airs or police station. A focus group consisting of Deaf people was conducted to help in the design and pilot trial of the system. A final user trial was conducted with more than thirty Deaf people and the results are presented and analyzed. Data is collected with questionnaires, semi-structured interviews and video recordings. The results indicate that most of the Deaf people found the system easy to learn, easy to navigate through, did not get lost and understood the sign language in the videos on the mobile phone. The hand gestures and facial expressions on the sign language videos were clear. Most of them indicated they would like to use the system for free, and that the system did not ask too many questions. Most of them were happy with the quality of the sign language videos on the mobile phone and would consider using the system in real life. Finally they felt their private information was safe while using the system. Many South African Deaf people use their mobile phones for communication with SMSs yet they would prefer to converse in South African Sign Language. Deaf people with a capital `D' are different from deaf or hard of hearing as they primarily use sign language to communicate. This study explores how to design and evaluate a prototype that will allow a Deaf person using SASL to tell a hearing doctor how s/he is feeling and provide a way for the doctor to respond. A computer{based prototype was designed and evaluated with the Deaf people in a previous study. Results from the user trial of the computer{based mock{up indicated that Deaf users would like to see the prototype on a cell phone. Those user trial results, combined with our own user survey results conducted with Deaf people, are used as requirements. We built a prototype for a mobile phone browser by embedding SASL videos inside XHTML pages using Adobe Flash. The prototype asks medical questions using SASL videos. These questions are arranged in an organized way that helps in identifying a medical problem. The answers to the questions are then displayed in English and shown to the doctor on the phone. A content authoring tool was also designed and implemented. The content authoring tool is used for populating the prototype in a context free manner allowing for plug and play scenarios such as a doctor's office, Department of Home A airs or police station. A focus group consisting of Deaf people was conducted to help in the design and pilot trial of the system. A final user trial was conducted with more than thirty Deaf people and the results are presented and analyzed. Data is collected with questionnaires, semi-structured interviews and video recordings. The results indicate that most of the Deaf people found the system easy to learn, easy to navigate through, did not get lost and understood the sign language in the videos on the mobile phone. The hand gestures and facial expressions on the sign language videos were clear. Most of them indicated they would like to use the system for free, and that the system did not ask too many questions. Most of them were happy with the quality of the sign language videos on the mobile phone and would consider using the system in real life. Finally they felt their private information was safe while using the system. / South Africa

[pt] A relação médico-paciente consiste numa díade que é hierarquicamente assimétrica. Uma parte cuida e a outra recebe cuidado, análogo ao que ocorre nas relações de apego. O médico teria o papel de figura de apego, possibilitando ativar o seu sistema de cuidado. O objetivo deste estudo é analisar como o sistema de cuidado está inserido na relação médico-paciente, analisando o estilo de apego do médico, além de relacioná-lo à capacidade de cuidado que o médico tem com seu paciente. Foram entrevistados onze hematologistas do Rio de Janeiro e São Paulo com experiência no SUS utilizando um roteiro de entrevista semiestruturado e foi aplicado o instrumento de autorrelato EVA (Escala de Vinculação do Adulto). Após análise de conteúdo das entrevistas e análise por clusters do EVA, os médicos entrevistados apresentaram apego seguro, com aspectos defensivos evitativos e amedrontados. Quatro categorias também foram estabelecidas: experiências pessoais com medicina e/ou hematologia; especificidade da hematologia; como lidar com as questões sobre perdas; e cuidado com o outro. Conclui-se que o presente trabalho prioriza o lado do médico nesta relação, e a importância do atendimento às suas necessidades psicológicas e relacionais. Com isso, intervenções podem ser propostas à equipe de saúde, de forma a cuidar de maneira consistente destes profissionais e aprimorar sua relação com o paciente e seus familiares. / [en] The doctor-patient relationship consists of a hierarchically asymmetrical dyad. One side cares and the other receives care, analogous to the attachment relationship. The doctor would have the attachment figure s role, being able to activate his or her caregiving system. The purpose of this study is to analyze how the care system is inserted in the doctor-patient relationship, analyzing the attachment style of the physician in addition to relating it to the care ability that the doctor has with his/her patient. Eleven hematologists from Rio de Janeiro and São Paulo with experience in SUS were interviewed using a semi-structured interview script and the self-report instrument AAS-R (Adult Attachment Scale-Revised) was applied. After content analysis of the interview and a cluster analysis of the AAS-R, all the doctors presented secure attachment, with avoidant-dismissing and avoidant-fearful defensive aspects. Four categories were also analyzed: personal experiences with medicine and/or hematology; hematology s specificity; how to deal with loss; and caring towards other. We concluded that the present it is important to prioritize the doctor s stance in the relationship, and to attend their psychological and relational needs. In that manner, interventions in the healthcare team can be proposed, providing the proper care to the healthcare professional, and, hence, improve their relationship with patients and their family members.

Comment un médecin peut-il devenir médecin-gestionnaire ? Un médecin peut-il même simplement devenir médecin-gestionnaire ? Cette thèse a pour vocation de mieux comprendre le phénomène de transition vers un rôle de médecin-gestionnaire, phénomène jugé difficile autant en pratique qu'en théorie. Celui-ci tend à se développer avec l'introduction de la gestion de la performance dans les organisations publiques européennes. Cette recherche prend comme illustration le rôle de responsable de pôle, nouveau rôle mêlant responsabilités médicales et gestionnaires, instauré au sein des hôpitaux publics français. Cette thèse s'articule autour de trois études menées de manière progressive. Une première étude envisage la transition de manière globale, en s'attachant à l'analyse des ajustements entre le médecin et son nouveau rôle. Elle est menée à partir d'une étude de cas et d'entretiens auprès de deux établissements de santé (un Centre Hospitalier Universitaire et un Centre Hospitalier) et de leurs 22 responsables de pôle. Elle met en avant l'importance de la dimension individuelle dans la transition analysée. Une deuxième étude se focalise sur l'influence de l'identification au rôle de médecin-gestionnaire sur la transition. Elle est menée à partir d'une étude de cas et d'entretiens auprès de 4 responsables de pôle d'un CHU et de leurs principaux collègues. Elle soulève l'effet de customisation de la posture d'identification au rôle sur la tenue de ce dernier. Une troisième étude s'oriente finalement sur le travail identitaire des médecins dans la tenue de leur rôle de médecin-gestionnaire. Elle est également menée à partir d'une étude de cas auprès des 4 mêmes responsables de pôle, mais au travers d'observations directes de leur comportement en réunion. Elle fait émerger l'importance de l'utilisation de l'identité en action pour tenir un rôle de médecin-gestionnaire. La thèse que nous défendons est que la transition vers un rôle de médecin-gestionnaire peut s'effectuer à partir d'ajustements et avec des postures d'identification variées, du moment que l'identité du médecin est retravaillée dans l'action. Nous conseillons aux établissements de santé de privilégier des dispositifs d'accompagnement personnalisés sur le terrain afin d'aider les médecins à comprendre la logique de leur rôle. / How can a doctor become a doctor-manager? Can a doctor even become a doctor-manager? This dissertation aims at better understanding the phenomenon of transition from a regular doctor role to a doctor-manager role, a transition that is experienced as difficult in practice and theory. This phenomenon tends to be developed with the spread of performance management within European public organizations. This research draws upon the example of the clinical director role, a new role in French public hospitals that is mixing both medical and managerial responsibilities. This dissertation is based on three progressive studies. A first study examines this transition with a global view by analyzing the adjustments between a doctor and his/her new role. It is carried out through a case study within two health care organizations (a teaching hospital and a hospital) and through interviews with their 22 clinical directors. This study shows the importance of the individual dimension for the transition to succeed. A second study focuses on the influence of role identification on the way a doctor-manager role is enacted. A case study and interviews with 4 clinical directors and their main colleagues within a teaching hospital are used to reach this goal. This study reveals the customization effect of identification on a doctor-manager role. A third and last study deeply focuses on the identity work of doctors in their enactment of a doctor-manager role. We address this issue by using a case study with the same 4 clinical directors, but through direct observations of their behavior during meetings. This study shows the importance of activating of identity into the context to enact a doctor-manager role. Finally, our main argument in this dissertation is that a transition to a doctor-manager role can be lead through various adjustments and identification situations, as long as identity is reworked during role enactment. We suggest to hospital directors to give priority to the use of field management tools oriented on personalization, in order to help doctors understand the logic of their roles.

Contexte. Objectifs principaux : explorer l’expérience vécue vécu des neurologues et des patients des annonces de mauvaises nouvelles dans la sclérose en plaques, le vécu de la pathologie ainsi que de la qualité de leur relation dans le contexte du suivi d’un projet thérapeutique, et d’envisager la création d’un outil clinique réflexif pour les neurologues destiné à contribuer au maintien d’une relation de qualité durant l’ensemble du parcours de soins. Méthodologie. Étude qualitative multicentrique ; analyse des verbatims : 63 entretiens cliniques de recherche - 35 patients et 20 entretiens - 20 neurologues ; 3 entretiens - relecture d’items ; triangulation méthodologique ; triangulation des observateurs/résultats ; analyse IPA et analyse clinique d’orientation psychodynamique. Résultats. Les annonces de mauvaises nouvelles dans la SEP sont vécues comme des expérience anxiogènes pour la majorité des neurologues de la recherche, des situations source de frustration et parfois d’impuissance. Les impacts psychiques engendrés par les annonces de mauvaises nouvelles, la perception dans certains cas d’une relation au médecin dénuée d’empathie, le sentiment d’impuissance lié au caractère imprévisible de l’évolution de cette maladie progressivement handicapante ainsi qu’une défiance quant à l’efficacité des traitements proposés expliquent en partie la fragilité de l’alliance thérapeutique avec le neurologue et les réactions psychologiques parfois extrêmes des patients qui en découlent. Conclusion et ouverture. Résultats obtenus : engager une réflexion éthique sur les informations à transmettre au patient, et proposer une formation aux neurologues basée sur l’outil élaboré / Context. This research aims to explore the neurologist’s and patient’s lived experiences of breaking bad news in multiple sclerosis and the lived experience of this disease, to understand the basic conditions of their relationship, and to create reflective clinical tools aimed at helping neurologists to maintain the quality of their relationship with the patients. Methodology. Multicentre qualitative study presents the results obtained from the analysis of 83 clinical research interviews with 35 patients and 20 neurologists, using IPA and a clinical psychodynamic. Results. Breaking bad news (BBN) in multiple sclerosis are lived as stressful experience for the majority of the neurologists of the research, a situations lived with frustration and sometimes powerlessness. Psychic impacts engendered by the BBN, the perception in certain cases of a relation to the doctor divested of empathy, the feeling of powerlessness linked to the unpredictable character of the evolution of this gradually crippling disease as well as a mistrust as for the efficiency of the proposed treatments explain partially the fragility of the therapeutic alliance with the neurologist and sometimes the extreme psychological reactions of the patients. Conclusion and opening. Results obtained : engage an ethical reflection on the information to transmit to the patient, and to suggest training to neurologists based on the tool created in tis research