Bakgrund: Beslut om att avstå och avbryta livsuppehållande behandling har de senaste åren ökat i antal inom intensivvården i Europa. Intensivvårdspatienter har ofta nedsatt autonomi, och läkare och sjuksköterskor måste därför försöka avgöra vad som är rätt för patienten. Detta kan orsaka moralisk stress eftersom att det inte finns några enhetliga riktlinjer för när den livsuppehållande behandlingen övergår till att vara meningslös. Motiv: Beslut kring att avstå eller avbryta livsuppehållande behandling kan vara ett mångfacetterat etiskt beslut som försvåras av intensivvårdspatientens nedsatta autonomi. Den föreliggande studien syftar till att belysa de etiska utmaningar som uppstår när beslutet ska fattas. Syfte: Att belysa läkares och sjuksköterskors resonemang kring att avstå och avbryta livsuppehållande behandling på en intensivvårdsavdelning. Metod: En vinjettstudie genomfördes med individuella semistrukturerade intervjuer med intensivvårdsläkare (n=5) och intensivvårdssjuksköterskor (n=5). Insamlad data analyserades med kvalitativ innehållsanalys. Resultat: Deltagarnas resonemang kring att avstå och avbryta livsuppehållande behandling utmynnade i nio subteman som delades in i tre olika teman; Strävan efter att göra gott, Involvering av närstående och Behov av reflektion i teamet. Konklusion: Teamet ansågs betydelsefullt i beslut kring livsuppehållande behandling. Det fanns ibland olika uppfattningar inom teamet kring vilken behandling som gagnar patienten och vidare forskning behövs kring metoder, exempelvis etiska ronder, för att överbrygga dessa meningsskiljaktigheter. Om de etiska utmaningarna läkare och sjuksköterskor upplever kring beslut att avstå eller avbryta livsuppehållande behandling uppmärksammas och diskuteras, ökar chanserna för att alla involverade känner att rätt beslut fattas för patienten som individ. / Background: There is an increase of decisions to withhold or withdraw life sustaining treatment within intensive care units in Europe. Intensive care patients often have a limited autonomy and physicians and nurses therefore have to decide what is right for the patient. This can cause moral stress due to a lack of unitary guidelines for when life sustaining treatment becomes futile. Motive: Decisions to withhold or withdraw life sustaining treatment can be a multifaceted ethical dilemma that is complicated by the intensive care patients' limited autonomy. This study aims to illustrate the ethical challenges occurring when this decision is to be made. Aim: To illustrate the reasoning of physicians' and nurses' about withholding and withdrawing life sustaining treatment in an intensive care unit. Methods: A vignette study was conducted with individual semi structured interviews with intensive care physicians (n=5) and intensive care nurses (n=5). Collected data was analysed with qualitative content analysis. Result: The participants reasoning to withhold or withdraw life sustaining treatment resulted in nine subthemes that was further divided into three themes; Striving to do good, Involment of relatives and A need to reflect within the team. Conclusion: The team was considered important in decisions regarding life- sustaining treatment. Sometimes there were different views within the team about what treatment would benefit the patient and further research is needed of methods, such as ethical rounds to overcome disagreements regarding decisions to withhold and withdraw life-sustaining treatment within intensive care. If these ethical challenges experienced by physicians and nurses due to these decisions are acknowledged and discussed, chances increase that everyone involved feels that the right decision is made for the patient as an individual.

Background: Concerns about burnout, and its consequences, among German physicians are rising. However, data on burnout among German physicians are scarce. Also, a suspected association between burnout and German physicians’ wishes to leave remains to be studied. Therefore, the extent of burnout, and the association between burnout and wishes to leave clinical practice or to go abroad for clinical work was studied in a sample of young physicians in Saxony. Methods: In a cross-sectional survey, all physicians ≤40 years and registered with the State Chamber of Physicians of Saxony, Germany (n = 5956) received a paper-pencil questionnaire inquiring about socio-demographics, job satisfaction, and wishes to leave clinical practice or to go abroad for clinical work. Response rate was 40 % (n = 2357). Burnout was measured with the German version of the Maslach Burnout Inventory - Human Services Survey (MBI) consisting of the subscales emotional exhaustion (feeling emotionally drained), depersonalization (feelings of cynicsm) and personal accomplishment (feelings of personal achievement in job). Variables associated with burnout, and the association between burnout and wishes to leave were assessed in multivariate logistic regression analyses. Results: For emotional exhaustion participants reached a mean of 21.3 [standard deviation = 9.74], for depersonalization a mean of 9.9 [5.92], and for personal accomplishment a mean of 36.3 [6.77]. Men exhibited significantly higher depersonalization than women (11.3 [6.11] versus 9 [5.62], p < 0.001). Eleven percent of participants showed a high degree of burnout on all subscales, while 35 % did not show a high degree of burnout on any subscale. Confirming that one would become a physician again, and higher satisfaction with the components \"work environment\" and \"humaneness\", were associated with a lower chance for a high degree of burnout on all subscales. Higher emotional exhaustion and lower personal accomplishment were associated with an increased chance of wishing to leave clinical practice. Higher emotional exhaustion and higher depersonalization were associated with an increased chance of wishing to go abroad for clinical work. Conclusions: Preventing physician burnout may not only benefit the affected individual. It may also benefit the health care system by potentially preventing physicians from leaving clinical practice or from going abroad for clinical work.

Background: Physician migration is gaining attention worldwide. Despite increasing numbers of foreign physicians in Germany, their perceptions on working in Germany remain unexplored. Within a large survey on Saxon physicians, the aim of this study was to elucidate whether foreign-national physicians’ job satisfaction differed from German physicians'' job satisfaction. Methods: The study was designed as a comprehensive cross-sectional survey. All physicians ≤40 years and registered with the State Chamber of Physicians of Saxony (n = 5956) were mailed a paper-pencil questionnaire, of which 2357 were returned (response rate = 40 %). Questionnaires addressed socio demographics and assessed job satisfaction by asking participants to rate their satisfaction with the overall job situation and 20 different aspects on a 5-point Likert scale (1 = very dissatisfied to 5 = very satisfied). Results: Ten percent of participants were foreign-national physicians. The three main countries of origin were the Czech Republic, Slovakia, and Poland. Foreign-national physicians were more satisfied with aspects related to patient care, such as "possibility to treat patients as you deem optimal" and "relationship with patients". However, they were less satisfied with aspects related to human relations, such as "work atmosphere", relationship with co-workers, and "social status". Foreign-national physicians were also less satisfied with the aspect "work enjoyment". Conclusions: Further research on determinants promoting foreign-national physicians'' job satisfaction is needed as their professional well-being may influence quality of patient care. Measures teaching cross-cultural competence and awareness may be beneficial for both foreign-national and German physicians.

Patientenzufriedenheit spielt eine zunehmend wichtige Rolle im Qualitätsmanagement im Gesundheitswesen. Die ärztliche Empathie gilt dabei als ein wesentliches Element, um eine hohe Patientenzufriedenheit zu generieren. Vor dem Hintergrund abnehmender ärztlicher Empathie während der Aus- und Weiterbildung wird in der vorliegenden Arbeit untersucht, inwieweit Assistenzärzte im Vergleich zu Fachärzten die Patientenzufriedenheit in einer anästhesiologischen Prämedikationsambulanz beeinflussen. In einem prospektiv-beobachtendem Studiendesign wurden die Zufriedenheit der Patienten, deren demografische und medizinische Daten, deren vorhandene Vorinformationen sowie organisatorische und logistische Faktoren mithilfe eines selbst erstellten ZUF-8 adaptierten Fragebogens erhoben und anhand des Ausbildungsstandes des prämedizierenden Arztes der Assistenz- oder Facharztgruppe zugeteilt. Dabei zeigten sich Gesamtzufriedenheitswerte auf durchgehend hohem bis sehr hohem Niveau. Feine Unterschiede zugunsten der Assistenzärzte wurden in den Items Gesprächsqualität, Allgemeinzufriedenheit und Freundlichkeit gefunden. Im Bereich der organisatorischen und logistischen Faktoren ergaben sich u.a. länger empfundene Wartezeiten bei den Assistenzärzten. Abschließend macht diese Arbeit deutlich, dass Assistenzärzte im Vergleich zu Fachärzten trotz abnehmender ärztlicher Empathie eine gleichweg hohe Patientenzufriedenheit generieren können. Eine Verbesserung der organisatorischen Abläufe könnte eine weitere Optimierung der Patientenzufriedenheit versprechen.

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Magister Public Health - MPH / Introduction The Human Resource Strategic Plan of the Ethiopian Ministry of Health lists current health workforce problems as a high attrition rate among public service physicians, poor human resource management, non-conducive working conditions and high workloads. In Addis Ababa's public hospitals, the turnover of physicians is high and - as repeatedly and informally reported by hospital managers - the presence of the contributory factors listed above are also anecdotally thought to be present. These factors present a serious challenge to the delivery of high quality health care services and their presence indicates that the job satisfaction of physicians is likely to be low. However, factors responsible for job dissatisfaction among physicians and their implications for staff turnover have not been studied or documented in the context of Ethiopia's health system. It was this scenario that motivated the researcher to conduct this study in order to assist policy makers in taking appropriate actions, if and as required. Aim: The aim of the study was to assess the level of job satisfaction, the factors influencing job satisfaction and the consequences of job satisfaction among physicians in public hospitals in Addis Ababa, Ethiopia. Objectives: • To describe the job satisfaction levels of physicians in public hospitals in Addis Ababa, Ethiopia • To identify factors affecting the job satisfaction levels of physicians • To assess possible consequences linked to physicians' job satisfaction levels. A self-administered questionnaire was used to measure job satisfaction, composed of 65 individual variables grouped within 13 dimensions and adapted to the Ethiopian context from the Job Descriptive Index and the Minnesota Satisfaction Questionnaire. An additional questionnaire was used to assess socio-demographic variables and the possible consequences of low job satisfaction. Analysis: A composite job satisfaction score was obtained by summing the individual answers for each of the variables to assess overall job satisfaction. Bivariate analysis was undertaken, using 2X2 tables (with 95% confidence intervals) to calculate the prevalence ratio for each of the potential causes and consequences of low job satisfaction, using the composite score cut-off levels of job satisfaction. Multivariate analysis was undertaken to obtain the adjusted prevalence odds ratios for both the potential causes and consequences of low job satisfaction, using multiple logistic regression analysis.

Background: Compared to the general population, physicians are more likely to experience increased burnout and lowered work-life balance. In our article, we want to analyze whether the workplace of a physician is associated with these outcomes. Methods: In September 2019, physicians from various specialties answered a comprehensive questionnaire. We analyzed a subsample of 183 internists that were working full time, 51.4% were female. Results: Multivariate analysis showed that internists working in an outpatient setting exhibit significantly higher WLB and more favorable scores on all three burnout dimensions. In the regression analysis, hospital-based physicians exhibited higher exhaustion, cynicism and total burnout score as well as lower WLB. Conclusions: Physician working at hospitals exhibit less favorable outcomes compared to their colleagues in outpatient settings. This could be a consequence of workplace-specific factors that could be targeted by interventions to improve physician mental health and subsequent patient care.

The science and technology of medicine is evolving and changing at a fast pace. With these rapid advances, it is paramount that physicians maintain a level of medical knowledge that is current and relevant to their practice in order to address the challenges of patient care and safety. One way physicians can maintain a level of medical knowledge that is current and relevant to their practice is through self-directed, lifelong learning, however little is known about how to develop these traits during clinical training. Schön (1983, 1987) theorized that one way learners can become self-directed, lifelong learners is through reflective practice. This study utilized an experimental design and employed quantitative methods to investigate the effects of a reflective practice exercise, based on Gibbs' (1988) model of reflection, on readiness for self-directed learning as measured by Guglielmino's (1977) Self-Directed Learning Readiness Scale/Learning Preference Assessment (SDLRS/LPA). A total of 51 anesthesiology residents training in three residency programs in the United States participated in this study. A follow-up survey was administered to all study participants to determine if participation in the reflective exercises affected future engagement in or attitudes about reflective practice. While the data analysis showed that participation in reflective practice did not affect readiness for self-directed learning in these study participants, this study has implications for medical education. Responses to the follow-up survey indicated that participants plan to engage in reflective practice in the future and that participating in reflective practice would have an impact on patient care. Chapter 5 includes ways to integrate the findings of this study into medical education and outlines next steps for future research utilizing both evidence from the literature and the qualitative responses from this study.

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Bakgrund: Lungemboli är den allvarligaste diagnosen av venös tromboembolism. Poliklinisk behandling istället för traditionell slutenvård kan erbjudas för patienter med LE som inte löper risk för plötslig död och allvarliga komplikationer. Men poliklinisk behandlingsmodell kräver att korrekt medicinsk behandling i hemmet och korrekt medicinsk uppföljning kan säkerställas. Det saknas dock kunskap avseende sjuksköterskor och läkares erfarenheter av polikliniskt omhändertagande av patienter med lungemboli. Syfte: Syftet var att belysa sjuksköterskors och läkares erfarenheter av polikliniskt omhändertagande av patienter med lungemboli Metod: En kvalitativ studie med 12 semistrukturerade intervjuer som analyserades induktivt enligt innehållsanalys.  Resultat: Utifrån analysen av intervjuerna framkom att det strukturerade omhändertagandet ledde till en känsla av kompetens där man kände att man kunde erbjuda denna patientgrupp en god och säker vård. Dessutom var det angeläget att arbeta på ett personcentrerat sätt med hänsyn till de individuella egenskaper och förutsättningar patienter hade och ha förmåga att bemöta deras oro och funderingar med respekt och empati. En viktig del utgjorde även insatser för att främja hos patienter delaktighet i egenvård. Slutsats: Sjuksköterskors och läkares erfarenheter tyder på att en välfungerande poliklinisk struktur skapar förutsättningar för en god och säker vård.  Enligt sjuksköterskor och läkare ligger fokus i möten med polikliniska patienter inte enbart på den medicinska behandlingen utan även på fysiska och psykiska påfrestningar som LE har orsakat. / Background: Pulmonary embolism is the most serious diagnosis of venous thromboembolism. Outpatient treatment instead of traditional inpatient care can be offered for patients with LE who are not at risk of sudden death and serious complications. But the outpatient treatment model requires that proper medical treatment at home and proper medical follow-up can be ensured. However, knowledge regarding nurses’ and physicians’ experiences of outpatient care is lacking of outpatient care for patients with pulmonary embolism.Purpose:The purpose was to illuminate nurses’ and physicians’ experiences of outpatient care of patients with pulmonary embolism.  Method: A qualitative study with 12 semi-structured interviews analysed inductively according to content analysis.  Results: Based on the analyse of the interviews it emerged that the structured outpatient care led to a feeling of competence to be able to offer this patient group good and safe care. In addition, it was important to work in a person-centered way, taking into account the individual characteristics and conditions patients had and to be able to respond to their concerns and questions with respect and empathy. Efforts to promote patients' involvement in self-care also constituted an important part.Conclusion:  The experiences of nurses and physicians indicate that a well-functioning outpatient structure creates the conditions for good and safe care. According to nurses and physicians, the focus in meetings with outpatients is not only on the medical treatment but also on the physical and psychological strains that LE has caused.