Bakgrund: Tanken med telefonrådgivningen var både att minska antalet besök hos läkarna men även öka tillgängligheten genom att slussa patienterna till rätt vårdnivå i början av sjukdomsprocessen. Sjuksköterskan i telefonrådgivningen ska göra adekvata och välgrundade omvårdnadsbedömningar utifrån den vårdsökandes individuella hälsoproblem. De ska även kunna bemöta och kommunicera på ett sätt som inger trygghet. Telefonrådgivning är en självständig och utmanande arbetsuppgift som kräver kompetens hos sjuksköterskan. Syfte: Att belysa sjuksköterskans upplevelser och erfarenheter av att arbeta med telefonrådgivning. Metod: Semi-strukturerade intervjuer genomfördes med åtta sjuksköterskor som arbetar med telefonrådgivning. Kvalitativ innehållsanalys användes för att granska och tolka materialet. Resultat: Genom bearbetning av analysen framkom fem kategorier vilka benämns; Att ge ett bra bemötande, Behov av återhämtning, Att möta utmaningar, Att vara professionell, Att utvecklas inom arbetet samt underkategorier. Slutsats: Denna studie har belyst komplexiteten i att arbeta med telefonrådgivning för människor med olika symtom i alla åldrar. Det är ett arbete som kräver gedigen erfarenhet, kompetens och självständighet. Studien har synliggjort en positiv upplevelse av arbetet och visar att det krävs tydliga strategier för att kunna utföra arbetet på ett patientsäkert sätt. / Background: The purpose of having telephone triage is to decrease the number of doctor appointments and to increase the availability by getting the patient to the right level of care from the start. The nurses working with telephone triage should make adequate and informed decisions based on the patient's health problem. They should also give the patient a sense of security. Telephone triage is an independent and challenging work task that requires the nurse to be competent.   Purpose: To illustrate how nurses experience working with telephone triage Method: Eight nurses working with telephone triage were interviewed using semi-structured questions. A qualitative analysis was performed to review and interpret the results.   Results: By performing the qualitative analysis five categories and some subcategories were found to be important. The five categories are; To give good service, The need of recovery, To be challenged, To be professional and To develop at work. Conclusion: This study has given light to the complexity of working with telephone triage to people with various symptoms in all ages. The job requires extensive experience, competence and the ability to work independently. The study has shown that the nurses have a positive experience of working with telephone triage and shows that it requires clear strategies for it to be performed without risking the patient safety.

Thèse numérisée par la Division de la gestion de documents et des archives de l'Université de Montréal.

Thesis advisor: Dorothy A. Jones / Thesis advisor: Pamela J. Grace / The purpose of the study was to explore the relationship between multiple variables within a model of critical thinking and moral reasoning that support and refine the elements that significantly correlate with accuracy and clinical decision-making. <bold>Background:</bold> Research to date has identified multiple factors that are integral to clinical decision-making. The interplay among suggested elements within the decision making process particular to the nurse, the patient, and the environment remain unknown. Determining the clinical usefulness and predictive capacity of an integrated ethically driven environmental model of decision making (IEDEM-CD) in emergency settings in facilitating accuracy in problem identification is critical to initial interventions and safe, cost effective, quality patient care outcomes. Extending the literature of accuracy and clinical decision making can inform utilization, determination of staffing ratios, and the development of evidence driven care models. <bold>Methodology:</bold> The study used a quantitative descriptive correlational design to examine the relationships between multiple variables within the IEDEM-CD model. A purposive sample of emergency nurses was recruited to participate in the study resulting in a sample size of 200, calculated to yield a power of 0.80, significance of .05, and a moderate effect size. The dependent variable, accuracy in clinical decision-making, was measured by scores on clinical vignettes. The independent variables of moral reasoning, perceived environment of care, age, gender, certification in emergency nursing, educational level, and years of experience in emergency nursing, were measures by the Defining Issues Test, version 2, the Revised Professional Practice Environment scale, and a demographic survey. These instruments were identified to test and refine the elements within the IEDEM-CD model. Data collection occurred via internet survey over a one month period. Rest's Defining Issues Test, version 2 (DIT-2), the Revised Professional Practice Environment tool (RPPE), clinical vignettes as well as a demographic survey were made available as an internet survey package using Qualtrics TM. Data from each participant was scored and entered into a PASW database. The analysis plan included bivariate correlation analysis using Pearson's product-moment correlation coefficients followed by chi square and multiple linear regression analysis. <bold>Findings: </bold>The elements as identified in the IEDEM-CD model supported moral reasoning and environment of care as factors significantly affecting accuracy in decision-making. Findings reported that in complex clinical situations, higher levels of moral reasoning significantly affected accuracy in problem identification. Attributes of the environment of care including teamwork, communication about patients, and control over practice also significantly affected nurses' critical cue recognition and selection of appropriate interventions. Study results supported the conceptualization of the IEDEM-CD model and its usefulness as a framework for predicting clinical decision making accuracy for emergency nurses in practice, with further implications in education, research and policy / Thesis (PhD) — Boston College, 2011. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Introdução: O Sistema Manchester de Classificação de Risco (SMCR) estabelece um tempo para o atendimento médico conforme o grau de urgência dos pacientes, a partir de um processo de tomada de decisão por registro eletrônico ou manual. Objetivo: Avaliar o grau de confiabilidade, a acurácia e o tempo despendido para a realização do SMCR em registros eletrônico e manual. Método: Estudo exploratório-descritivo de abordagem quantitativa, realizado com todos 43 (100%) enfermeiros do Hospital Universitário da Universidade de São Paulo (HU-USP) que foram aprovados no curso de classificador do SMCR pelo Grupo Brasileiro de Classificação de Risco (GBCR). A casuística do estudo correspondeu ao número total de casos clínicos simulados (37) validados e fornecidos pelo GBCR e ao número de casos aplicados para cada participante da pesquisa (4). A amostra foi estimada, para que se obtivesse um coeficiente kappa de Cohen maior ou igual a 0,5, confiança de 95% e poder de teste de 80%, considerando o número de pacientes classificados em cada nível de prioridade clínica no HU-USP em 2016. A amostra foi composta por 10 participantes. A coleta de dados foi realizada, em duas fases, utilizando 20 casos clínicos simulados, os quais passaram por processo de avaliação junto a especialistas do GBCR. Na fase 1, foram entregues 4 casos para uso no registro manual e na fase 2, após aproximadamente, 4 semanas, os mesmos casos foram entregues para realização do SMCR por meio do registro eletrônico. A confiabilidade inter-avaliadores foi calculada pelo coeficiente kappa de Cohen e, em relação ao padrão ouro (acurácia), pela porcentagem de concordância. O tempo despendido foi analisado com o teste Wilcoxon-Mann-Whitney, considerando intervalo de confiança de 95% e valor de p menor que 0,05. Resultados: O grau de confiabilidade foi igual para a escolha dos fluxogramas e dos discriminadores com o uso de ambos os registros e apresentou diferenças na determinação da prioridade e dos sinais vitais. A acurácia apresentou diferença estatisticamente significante, apenas, em relação aos sinais vitais. O tempo despendido para o registro do SMCR foi menor com o uso eletrônico. Conclusão: O uso do registro eletrônico apresenta vantagens referentes à confiabilidade, acurácia e tempo despendido para a realização da classificação de risco, indicando a importância da adoção de tecnologias no processo de trabalho gerencial e assistencial nos serviços de saúde. / Introduction: The Manchester Triage System (MTS) defines clinical priority by determining the maximum allowed waiting time for medical care for the different levels of urgency based on decision support process by electronic or manual registration. Objective: Evaluate the degree of reliability, accuracy and time spent of the use of MTS with an electronic or manual registration. Method: This is an exploratory-descriptive study applied for all (43) nurses of the University Hospital of the University of São Paulo (HU-USP) approved in the MTS classifier course by Brazilian Group of Risk Classification. The casuistry of the study corresponded to the total number of simulated clinical cases (37) and the number of cases applied to each participant (4). The sample were calculated to obtain a Cohen kappa coefficient equal to 0.5 or greater than it, 95% confidence and 80% test power, considering the number of patients classified in each clinical priority level at the HU-USP in 2016. The sample had 10 participants. Data were collected from the triage of 20 clinical cases. This clinical cases were evaluated by Brazilian Group experts. In phase 1, 4 cases were given for use in the manual registration. In phase 2, after approximately 4 weeks, the same cases were given for use in the electronic registration. The inter-rater reliability was calculated by the Cohen kappa coefficient. The accuracy (the comparison with the golden standard) was calculated by the concordance percentage. The efficiency was calculated by the Wilcoxon-Mann-Whitney test, with a 95% confidence interval and p-value less than 0.05. Results: The degree of reliability was the same for the choice of flowcharts and discriminators with the use of electronic and manual registration. There were differences in reliability for determination of priority and the recording of vital signs. The accuracy presented a statistically significant difference only in relation to vital signs. The time spent with use the MTS was shorter with electronic registration. Conclusion: The use of the electronic registration had advantages related to the reliability, accuracy and time spent to use the MTS, showing how important it is to adopt technologies in the manage and assistencial care working process of the health services.

A organização do fluxo de atendimento de emergência é um dos grandes desafios para as instituições de saúde. Os sistemas de classificação de risco auxiliam os enfermeiros na priorização do atendimento dos pacientes com maior risco, que podem ter sua condição de saúde agravada durante a espera. Avaliar o desempenho de um sistema de classificação de risco institucional para pacientes com infarto agudo do miocárdio permite conhecer a sua capacidade para estabelecer adequadamente a prioridade de atendimento. Objetivos: Determinar a sensibilidade e especificidade de um sistema institucional de classificação de risco para infarto agudo do miocárdio em pacientes com dor torácica; verificar associações entre as variáveis sociodemográficas com o desempenho do sistema na priorização desses pacientes. Método: Estudo observacional em um hospital de cardiologia. A estimativa da sensibilidade foi avaliada pela capacidade do sistema em classificar nas categorias de maior prioridade (vermelha e amarela) os pacientes com diagnóstico de infarto agudo do miocárdio. A estimativa da especificidade foi avaliada pela capacidade do sistema em classificar com baixa prioridade (verde e azul) os pacientes sem infarto agudo do miocárdio. O padrão de referência foi o registro médico de infarto agudo do miocárdio. Resultados: A amostra foi constituída por 3.032 eventos de classificação de risco, sendo 1.534 (50,6%) do sexo masculino; idade média de 57,9 (DP 15,1) anos;146 (4,8%) eventos de infarto agudo do miocárdio. A sensibilidade do sistema foi de 73,3% (IC 65,2% - 80,1%) e a especificidade de 61,3% (IC 59,4% - 63,0%). O desempenho do sistema foi pior com o aumento da idade dos pacientes (p<0,001); melhor com prioridades mais elevadas (p<0,001) e na presença de supra desnivelamento de segmento ST (p<0,001). Conclusão: O sistema institucional de classificação de risco teve bom desempenho na avaliação de pacientes com queixa de dor torácica por otimizar o atendimento de pacientes com infarto agudo do miocárdio, embora haja espaço para melhoria de desempenho do sistema considerando o aumento do valor de sensibilidade e identificação dos falsos negativos. / The organization of the flow of emergency care is one of the great challenges for health institutions. Risk classification systems assist nurses in prioritizing the care of patients at higher risk, who may have their health condition aggravated during waiting. Evaluating the performance of an institutional risk classification system for patients with acute myocardial infarction allows to know their capacity to adequately establish the priority of care. Objectives: To determine the sensitivity and specificity of an institutional system of classification of risk for acute myocardial infarction in patients with chest pain; to verify associations between the sociodemographic variables with the performance of the system in the prioritization of these patients. Method: Observational study in a cardiology hospital. Sensitivity estimation was assessed based on the ability of the system to classify patients with a diagnosis of acute myocardial infarction into the highest priority categories (red and yellow). Estimating specificity was assessed based on the ability of the system to classify patients without acute myocardial infarction with low priority (green and blue). The gold standard was the medical record of acute myocardial infarction. Results: The sample consisted of 3,032 risk classification events, of which 1,534 (50.6%) were male; mean age of 57.9 (SD 15.1) years, 146 (4.8%) events of acute myocardial infarction. The sensitivity of the system was 73.3% (CI 65.2% - 80.1%) and the specificity was 61.3% (CI 59.4% - 63.0%). System performance was worse with increasing patient age (p <0.001); with higher priorities (p <0.001) and in the presence of ST-segment elevation (p <0.001). Conclusion: The institutional system of risk classification performed well in the evaluation of patients with chest pain for optimizing the care of patients with acute myocardial infarction, although there is space for improvement of the system performance considering the increase of sensitivity and identification of false negatives.

Introdução: A classificação de risco tem importância comprovada na organização dos serviços de emergência, mas algumas questões acerca de sua utilização ainda são apontadas. É comum pacientes chegarem ao serviço de emergência em situações críticas de ameaça à vida e necessitarem de avaliação profissional rápida (neste estudo denominada triagem rápida) ainda na porta de emergência do hospital. Assim, pode-se detectar com rapidez a gravidade do caso, bem como realizar o encaminhamento imediato para o atendimento médico. Objetivo: Analisar aspectos da triagem rápida realizada pelos enfermeiros na identificação de pacientes graves na porta de emergência, provenientes de demanda espontânea. Método: Estudo transversal, prospectivo, desenvolvido no Hospital Universitário da Universidade de São Paulo, entre maio e novembro de 2017. Foi realizada observação direta da triagem rápida. O grau de prioridade estabelecido pelo enfermeiro triador foi categorizado como alta prioridade (pacientes graves direcionados imediatamente à sala de emergência) e baixa prioridade (pacientes não graves encaminhados ao fluxo habitual de classificação de risco). Simultaneamente, os pacientes foram avaliados pela pesquisadora com aplicação do Sistema Manchester de Classificação de Risco (SMCR), dicotomizado em alta prioridade (vermelhos e laranjas) e baixa prioridade (amarelos, verdes e azuis). Sensibilidade, especificidade, acurácia, valores preditivos positivo e negativo, e razão de verossimilhança positiva e negativa foram calculados para avaliar o desempenho dos índices na predição de diferentes variáveis. O teste Mann-Whitney e a regressão logística múltipla foram aplicados, com nível de significância de 5%. Resultados: No total, 173 pacientes (52,0% mulheres; idade média 60,4±21,2 anos) foram avaliados e triados por enfermeiras na emergência. Nove pacientes foram avaliados em duas ocasiões diferentes, caracterizando 182 atendimentos (avaliações). Destes, 56,0% permaneceram em observação no pronto-socorro, 11,0% foram internados em enfermaria, e 5,0% em unidade de terapia intensiva. A taxa de mortalidade foi de 13,2%. A triagem rápida foi mais inclusiva para alta prioridade (n=154; 84,6%) do que o SMCR (n=132; 72,5%). Os sinais e sintomas mais frequentes no grupo da alta prioridade pela triagem rápida foram alterações do nível de consciência (34,6%) e da pele relacionadas ao choque (25,3%). A triagem rápida apresentou melhor sensibilidade e pior especificidade do que o SMCR na análise de quase a totalidade das variáveis (exceto para internação em enfermaria). Ainda, a probabilidade de pacientes não graves serem admitidos na observação do pronto-socorro (variável considerada padrão-ouro no estudo) foi menor pela triagem rápida do que pelo SMCR. Houve diferença significativa (p<0,001) entre os grupos (alta e baixa prioridade atribuída pela triagem rápida) em relação ao número de procedimentos/recursos utilizados. Os fatores associados à classificação de pacientes de alta prioridade pela triagem rápida foram alterações na ventilação (OR de 6,09), disfunção neurológica (OR de 44,96) e presença de dor (OR de 5,80). Conclusão: A triagem rápida obteve melhor desempenho que o SMCR na predição de admissão dos pacientes na observação do pronto-socorro. Os enfermeiros devem valorizar as alterações neurológicas e de ventilação, além da dor dos pacientes durante a triagem rápida, uma vez que estes sinais e sintomas estão associados à gravidade e à alta prioridade de atendimento. / Introduction: Triage plays an important role in the organization of emergency services, but questions about its use are still raised. It is common for patients to get at emergency services in critical life-threatening situations, demanding a fast professional evaluation (in this study, we called fast triage). Thus, we can quickly detect the severity of the case and immediately refer the patient to the medical care. Objective: To analyze aspects of fast triage performed by nurses to identify severe patients from spontaneous demand at the emergency door. Methods: A prospective, cross-sectional study was carried out at the University Hospital of the University of São Paulo, from May 2017 to November 2017. We performed direct observation of the fast triage. The triage nurse established the degree of priority as high priority (severe patients immediately directed to the emergency room) and low priority (non-severe patients referred to the usual triage flow). At the same time, a researcher evaluated the patients considering the Manchester Triage System (MTS), dichotomized in high priority (reds and oranges) and low priority (yellow, green and blue). Sensitivity, specificity, accuracy, positive and negative predictive values and positive and negative likelihood ratio were calculated to evaluate the performance of indices in the prediction of different variables. The Mann-Whitney test and the multiple logistic regression were applied, with a significance level of 5%. Results: A total of 173 patients (52.0% women; mean age 60.4±21.2 years) were evaluated and triaged by nurses in the emergency door. Nine patients were evaluated on two different occasions, characterizing 182 visits (evaluations). Among them, 56.0% were in observation in the emergency department, 11.0% were admitted to the ward, and 5.0% were in the intensive care unit. The mortality rate was 13.2%. The fast triage was more inclusive for high priority (n=154; 84.6%) than MTS (n=132; 72.5%). The most frequent signs and symptoms in the high priority group for fast triage were disorders in the level of consciousness (34.6%) and in the skin related to the shock (25.3%). Fast triage showed better sensitivity and worse specificity than MTS in the analysis of almost all variables (except for admission to the ward). In addition, the probability of non-severe patients being admitted to observation in the emergency department (variable considered standard gold in the study) was lower by fast triage than MTS. There was a significant difference (p<0.001) between the groups (high and low priority by fast triage) in relation to the number of procedures/ resources used. The factors associated with the classification of high priority patients by fast triage were alterations in ventilation (OR 6.09), neurological dysfunction (OR 44.96) and presence of pain (OR 5.80). Conclusion: The fast triage performed better than MTS in prediction of admission of patients in observation in the emergency department. Nurses should value neurological and ventilation disorders, as well as patients pain during fast triage, since these signs and symptoms are associated with the severity and high priority of care.

Tidigare studier har visat vad patienten anser vara tillfredställande i samband med triage. Där framkommer att i mötet med vårdpersonalen vill patienten känna sig värdig, sedd och bekräftad. Detta ställer krav på vårdpersonalen och den kompetens de besitter. En förutsättning för patienttillfredsställelse är information om väntetider, patienternas medicinska tillstånd och en god vårdrelation. I mötet med patienten krävs kunskap om vad dessa tycker är viktigt och betydelsefullt i samband med triage. Kunskapen om vad som är viktigt är fortfarande inte tillräckligt belyst, ur ett patientperspektiv. Syfte var att beskriva patientens upplevelse av vad som var betydelsefullt för denne i samband med triage. En kvalitativ forskningsansats med en påföljande innehållsanalys valdes. 11 stycken intervjuer genomfördes på en mindre akutmottagning i väst Sverige.Informanterna som valdes ut var patienter på denna akutmottagning. I resultatet framträdde två domäner, bemötande och information. Kategorierna som följde var omvårdnad, trygghet, delaktighet, kompetens, omhändertagande, integritet, tid och kommunikation. Informanterna ansåg det vara betydelsefullt att bli bemötta på ett individuellt plan, detta innefattade allt från basal omvårdnad till att informanterna litade på triageteamets goda kompetens. Sanningsenlig information kring väntetider och prioriteringssystemet visade sig ha betydelse. Tidigare studier har visat att vården upplevdes som god om vårdpersonalen hade ett öppet förhållningssätt, visade hänsynsfullhet och lugn. Detta bekräftas i vårt resultat. Triageteamet skulle kunna tillgodose detta genom att våga uppskatta väntetiden, men också genom att vara tydliga i att informationen kan komma att förändras. / Program: Magisterprogram i vårdvetenskap med inriktning mot akutsjukvård

Det ökade inflödet på landets akutmottagningar ställer stora krav på sjukvårdspersonal att de ger patienterna ett snabbt och säkert omhändertagande. Sjuksköterskan har som uppgift att bedöma, prioritera alla vårdsökande samt dokumentera all viktig information. Bedömningen sker utifrån riktlinjer som är baserade på sökorsak. Dokumentationen av olika åtgärder har betydelse för det fortsatta vård- och behandlingsarbetet och kan vara helt avgörande för patientsäkerheten. Syftet med studien var att beskriva hur väl dokumentationen genomfördes i patientens journal vid besök på akutmottagning. För att synliggöra dokumentationen valde författarna i denna studie att granska samtliga akutjournaler på patienter som var över 18 år och som sökt vård inom specialiteterna medicin och kirurgi, under ett dygn, på en akutmottagning i Väst Sverige. Exkluderade journaler var trauma journaler under det aktuella dygnet. Resultatet av studien visade på en generellt bristande dokumentation i akutjournalen. Av de granskade journalerna var det mer än hälften som saknade en dokumenterad anamnes/status, det var drygt en tiondel som inte hade någon dokumenterad prioritet. Det var fler män än kvinnor som sökte vård under det aktuella dygnet och flertalet av patienterna var födda före 1945. / Program: Magisterprogram i vårdvetenskap med inriktning mot akutsjukvård

Patienter utsätts för onödiga transporter och efterföljande väntetid på akutmottagningen, vilket i sin tur leder till ett onödigt vårdlidande. Det är inte längre en självklar åtgärd för ambulanssjukvården att transportera alla patienter till akutmottagningen för fortsatt vård. Detta innebär att kravet har ökat på ambulanssjukvården och den prehospitala bedömningen. Mot bakgrund av dessa förutsättningar som idag gäller för ambulanssjukvård, är frågan om forskningen kan vägleda till hur den prehospitala bedömningen ska kunna underlättas.Syftet med studien är att beskriva prehospital bedömning i ambulanssjukvård och genom en forskningsöversikt har kvalitativ och kvantitativ forskning analyserats.I resultatet framkommer det att prehospital bedömning består av två huvudinnehåll, dels en vårdvetenskaplig där den prehospitala bedömningen ses som en kontinuerlig process och dels en medicinsk där den prehospitala bedömningen inriktas på att utifrån fastställda kriterier ringa in patientens vårdbehov. I den vårdvetenskapliga forskningen framkommer att vårdrelationen är en central del i den prehospitala bedömningen liksom att vinna patientens förtroende. I den medicinska forskningen framkommer att prehospital bedömning och triagering med hjälp av protokoll kan vara ett sätt att minska patientens vårdlidande. Protokoll kan ge en vägledning till alternativa vårdnivåer men måste kombineras med ett vårdvetenskapligt patientperspektiv och ett öppet förhållningssätt för att möta patienters individuella nyanser. Genom att möjliggöra patientstyrning till alternativa vårdnivåer, kan akutmottagningar avlastas och leda till att fler patienter kan vårdas hemma, dock i ringa omfattning. / <p>Program: Fristående kurs</p><p>Uppsatsnivå: C</p>

Akutmottagningarna i Sverige har på 74 akutintag besök av 2,5 miljoner människor. Problemet med långa väntetider blir allt större. Forskningen påvisar att de medicinska riskerna ökar när väntetiderna förlängs. När politikerna kräver att patienterna skall träffa läkare inom 60 minuter ställer det stora krav på akutmottagningarna. Akutmottagningarna svarar med att optimera flödesprocesserna, utnyttjar tiden maximalt samt omorganiserar sin personal. Vårdpersonalen upplever att mötet är kort och under stress därför bör det undersökas om patienterna upplever det samma. Syftet med uppsatsen är att beskriva patienternas upplevelse av det första mötet med sjuksköterska och läkare i samband med den första bedömningen i vårdrummet. Det är en empirisk studie med öppna intervjufrågor. En kvalitativ innehållsanalys med en induktiv ansats gjordes för att få svar på patienternas upplevelser. Upplevelserna kommer att ligga till grund för att öka vårdpersonalens förståelse och förhållningssätt till patienterna i triagemötet. Resultatet visade att patienternas upplevelse är att de blir snabbt omhändertagna. Patienterna är nöjda med effektiviseringen samtidigt upplever de att mötet är något stressat. Mötet i triagen är symtominriktat, men de får förmedla den information de tycker är viktig. Vårdrummet noteras men har ingen större betydelse. Det viktigaste är ett snabbt förlopp med vårdpersonal som uppmärksammar patienterna. I diskussionen framkommer att informanterna inte förväntar sig att vara delaktiga i mötet, men om vårdpersonalen möter dem med förståelse, uppmärksamhet och helhetssyn så känner de sig bekräftade och därmed delaktiga. Sker mötet i avskilt vårdrum och en behaglig miljö skapas bättre förutsättningar för mötet. / Program: Fristående kurs