The overall aim of this thesis was to cast light on the new phenomenon of Internet-based medical consultation. This was approached by studies of the use of an Ask the doctor service, by a web survey to the users who sent enquiries to the service, and by a questionnaire to the answering physicians of their respective expericence of the service. Written communication is becoming increasingly important, not only for communication between individuals outwith health care (e.g. by email, SMS and instant messaging), but also between doctors and patients. There is an ongoing shift in the way individuals look for medical information with an increasing number going first to the Internet berfore talking with their physicians. Also, there is an increasing interest from patients in accessing Internet-based services, including text-based consultations with doctors. These consultations can be part of the regular communication between a patient and his/her doctor or be carried out without any previous relationship. Our studies of the latter consultation type emanate from the free of charge Ask the doctor service at a Swedish public health web portal, Infomedica, financed by health authorities. At the Ask the doctor service, the communication has been merely text-based and the individual using the consultation service (here called the enquirer) might have been anonymous. We followed the development of the first four years use of the service (38 217 enquiries), finding that the typical enquirer was a woman aged 21-60 years. Three quarters of the enquirers were women, thus exceeding the gender difference seen in regular health care. The service was used all times of the day and night, seven days a week, and it was most used in densely populated areas as defined from postal codes. The enquiries submitted to the service included a broad variety of medical issues. Most enquirers asked on their own behalf. Almost half of the enquiries concerned a matter not previously evaluated by a medical professional. Only a few were frequent enquirers. The service was used e.g. for a primary evaluation of a medical problem, for getting more information on a medical issue under treatment, and for a second opinion. The most common reasons for turning to a doctor on the Internet were convenience, wish for anonymity and that doctors were experinced too busy. In free text a considerable number of participants expressed discontent and communication problems with a previous doctor as a reason to turn to the Ask the doctor service. Many participants expressed a view of the service as a complement to regular health care, and the majority were satisfied with the answer. Nearly half of the participants in the web survey stated that they received sufficient information in their answer and that they would not pursue their question further. The family physicians answering the enquiries at the Ask the doctor service were stimulated and challenged by the new task, in spite of the limitations caused by the lack of personal meetings and physical examinations. The opportunity to reflect on the answer before replying was appreciated, and the task was regarded as having a high educational value for themselves. The Internet not only allows easy access to medical information but also to medical consultation – to date mostly text-based. It is probable that in the near future an increasing number of doctors will adopt text-based communication via the Internet to be a natural part of their communication with patients. Therefore, training in text-based communication and carrying out Internet consultations should be integrated into the curricula of medical schools and of continuous professional development. Ethical guidelines should be established.

Författarna har studerat hur kvinnor utsatta för våld i en nära relation upplever bemötandet i vården, genom granskning av elva kvalitativa studier. Resultatet visar att känslan av skuld och skam är stor hos kvinnor som utsätts för våld i en nära relation. Kvinnorna vill berätta om sin situation, men endast om de upplever att sjuksköterskan vill lyssna, har tid och kan han-tera informationen. Flertalet kvinnor önskade att sjuksköterskan skulle fråga dem om våldet, de längtade efter att någon skulle ta kontroll över situationen. Oftast känner sig kvinnorna dömda, förlöjligade och respektlöst bemötta av hälso- och sjukvården efter de berättat om våldet som försiggår i relationen. Kvinnor som levt under hot och våld från sin man har ofta en bräcklig och skev självbild. Vilket ökar deras osäkerhet och förstärker eventuella negativa upplevelser i vården. I och med det kan ett dåligt bemötande från vårdpersonalen i värsta fall öka kvinnornas känsla av hjälplöshet och bekräfta skammen de bär på. Studien påvisar att hälso- och sjukvården är en mycket viktig instans för kvinnor utsatta för våld av sin partner, trots detta finns sällan kunskap hos personalen. Författarna har funnit brister i bemötandet och omhändertagandet av kvinnorna och även i kontakten med andra viktiga instanser. Vårdpersonalen behöver kunskap, handlingsplaner och riktlinjer för att kunna lotsa kvinnorna vidare i deras väg mot ett liv utan hot och våld. När väl kvinnan samlat mod till sig för att erkänna sin situation i vården och inte blir tagen på allvar kan det i vissa fall få förödande konsekvenser. Medan en genuint intresserad sjuksköterska som har kunskap och är villig att lägga sin tid på kvinnan och relationen till henne, kan vara livsavgörande. Sjuksköterskan kan hjälpa henne en bit på vägen till ett liv utan smärta, rädsla och ensamhet. / Background: Violence against women is a major global public health issue, which has an impact on women’s lives and mental health. Aim: To explore healthcare experiences of women exposed to intimate partner violence. Method: Literature based study with eleven qualitative studies. Results: The women who sought help felt ashamed for the violence and most of them didn’t get the help they needed. They felt that the caregivers didn’t believe in their stories or their experiences. The health care professionals made them feel like objects and not human beings. Few women had a good experience of the care they were given, in those cases the caregivers had asked the women about the violence and gave them time to talk and made them feel safe and comfortable. Conclusion: Nearly all of the women had feelings of shame and guilt. They wanted the caregiver to ask them about the violence, because they found it hard to reveal it themselves. Caregivers need more knowledges about intimate partner violence and its impact on the women to offer right kind of help.They also need guidelines to know how to meet and help these women.

Background: Several nursing theorists emphasize the importance of establishing the so-called therapeutic relationship between the nurse and the patient in order to facilitate and provide better results of the treatment. Aim: The aim of this study was to investigate how nurses working in out-patient psychiatric care describe the concept of therapeutic relationship and its usage when working with patients. Method: Semi structured interviews were performed and the material was analyzed through qualitative content analyzis. Result: Four main categories that describe the different aspects of the therapeutic relationship emerged. These were: What the nurse does to establish the therapeutic relationship, The functions and definition of the therapeutic relationship, The qualifications of the therapeutic relationship and Challanges in establishing the therapeutic relationship. Conclusion: The therapeutic relationship was described as a tool in working with the patient, and individualized treatment, trust, sufficient time and the use of one's own personality was described as important factors in establishing this relationship.

O nascimento de um bebê malformado, especialmente, quando a aparência é defigurada, provoca um impacto nos profissionais que prestam atendimento ao recémnascido, imediatamente, após o nascimento, repercutindo na qualidade da assistência prestada. Este estudo foi motivado pela inquietação da pesquisadora procurar compreender as ações e reações dos enfermeiros quando assistem o nascimento de recém-nascidos com malformação desfigurante no contexto da sala de parto. O estudo teve como objetivo: compreender a experiência dos enfermeiros que assistem o nascimento de um recém-nascido com malformação desfigurante. Optou-se por realizar uma pesquisa com abordagem qualitativa, estudo de caso coletivo, e os dados foram analisados à luz do referencial teórico do Interacionismo Simbólico. A coleta de dados ocorreu por meio de entrevista semi-estruturada com enfermeiros que atuam no centro obstétrico de um Hospital Municipal, situado na zona sul da cidade de São Paulo. As entrevistas foram gravadas em fita cassete, posteriormente, transcritas em sua íntegra e analisadas. A análise dos dados permitiu identificar categorias conceituais que compuseram os dois temas: Compartilhando com a equipe médica a assistência ao recém-nascido e Assumindo a responsabilidade da assistência ao binômio mãe-recém-nascido. Os resultados do estudo salientaram a dificuldade enfrentada pelo enfermeiro na assistência do nascimento de um bebê malformado em decorrência do despreparo na formação profissional, relacionada ao processo de comunicação enfermeiro-paciente e dificuldade de lidar com as próprias emoções / The birth of a malformed child, specially when the malformation affects the baby appearance, provokes impact on caregivers who attend the baby immediately after childbirth and on quality of attendance. This study was motivated by the necessity of understanding the performance of nurses when they attend babies with visible congenital malformation. The aim of this study was to understand the nurse`s experience for attending babies with visible congenital disfigurement in the context of delivery room. The qualitative methodological approach used in this study was the Collective Case Study and to analyse data it was used the Symbolic Interactionism theoretical framework. The sample was composed by ten nurses that work at the birth center of a public hospital located in the south district of São Paulo city. Data was obtained by interview that was recorded, transcripted and analysed. From data analysis categories emerged that composed two themes: Sharing the newborn care with medical staff and Assuming the responsibility of the mother-infant care. The results point out the difficulties faced by the nurses when they need to take care of the babies who have visible congenital disfigurement due to their unprepared formation related to the nurse-patient relationship and the difficulties to deal with their emotions

O objetivo geral deste trabalho foi compreender as práticas discursivas de pessoas diagnosticadas com Anorexia Nervosa (AN) ou Bulimia Nervosa (BN) com relação a produção de sentidos sobre as relações profissional-paciente no âmbito do tratamento desses transtornos alimentares (TA), aqui considerados não como quadros diagnósticos, mas como construções sociais. Esse objetivo foi traçado no diálogo com a literatura científica na área que identifica poucos espaços de escuta dessas pessoas sobre o que elas consideram importante em suas relações com os profissionais de saúde, e no diálogo com as narrativas das participantes deste estudo que apontaram a boa qualidade do relacionamento profissionalpaciente como importante na construção de um atendimento considerado satisfatório. De maneira específica, buscou-se compreender como o uso de diferentes repertórios interpretativos e discursos sociais participam da produção de sentidos sobre as relações profissional-paciente, além de investigar as implicações dos diferentes posicionamentos assumidos por ambos na coconstrução de descrições de si, direitos, deveres e lugares ocupados pelos pacientes na relação com os profissionais. Para tanto, foram entrevistadas 12 mulheres diagnosticadas com AN e BN atendidas por um serviço de assistência em TA. 5 dessas mulheres responderam de forma mais pessoal sobre o que é um relacionamento significativo com um profissional, oferecendo histórias de seus relacionamentos anteriores e atuais com os profissionais, narradas com riqueza de detalhes. Considerando-se a vasta quantidade de material a ser analisado, um recorte do material foi necessário e essa riqueza narrativa foi o critério utilizado para a seleção dessas 5 entrevistas para análise. O corpus de análise foi composto pelo recorte dos momentos das entrevistas nos quais o tema do relacionamento profissional-paciente estava presente. Assumindo-se uma perspectiva construcionista social sobre produção do conhecimento, utilizou-se, para a análise desse corpus, a Teoria relacional do sentido, a Teoria do posicionamento e a proposta teóricometodológica das Práticas discursivas e produção de sentidos. A partir da análise desse material foi possível abordar: as implicações do uso do discurso biomédico, que entende a AN e BN como psicopatologias, para as construções de si das participantes deste estudo e para a construção de possibilidades e limites da sua participação nas decisões sobre o tratamento; o pedido das participantes para uma maior proximidade afetiva com o profissional; o lugar ocupado pelo psicólogo e pelos demais profissionais da equipe multidisciplinar frente a esse pedido; os efeitos dos repertórios interpretativos disponibilizados pela literatura da área sobre a dificuldade no relacionamento profissional-paciente para as práticas discursivas das participantes ao falarem de seus desentendimentos com os profissionais; e as implicações da eleição do tratamento hospitalar como locus privilegiado de cuidado dessas pessoas. Alguns aportes teóricos construcionistas sociais, como a responsabilidade relacional, o ser relacional, o diálogo transformador e a postura colaborativa foram ofertados para pensar cenários relacionais entre profissionais e pacientes que pudessem incluir: a noção de identidade como movimento e não como estabilidade; o entendimento dos sucessos e insucessos nesses relacionamentos como ações conjuntas; a defesa do paciente como agente coconstrutor de seu cuidado e a possibilidade de convivência de diferentes verdades em saúde. / The general aim of this work was to understand the discursive practices of people diagnosed with Anorexia Nervosa (AN) and Bulimia Nervosa (BN) in the meaning production about professional-patient relationships in the treatment of eating disorders. Eating disorders are understood here as social constructions. This objective was delineated in dialogue with the scientific literature in the field that identifies a lack of spaces to listen to these people as well as in dialogue with this study participants\' narratives that associated meaningful assistance with the possibility of good quality in professional-patient relationship. Specifically, we aimed at understanding how the use of different interpretive repertoire and social discourses participate in the meaning production about the professional-patient relationship. We also tried to comprehend the implications of different positions assumed by both of them in the coconstruction of self descriptions, rights, duties and places occupied by patients in their relations with professionals. In order to do that, 12 women diagnosed with AN and BN assisted by an eating disorder service were interviewed. 5 interviews were selected to be analysed considering its richness of narratives about professional-patient relationship. Interview excerpts in which the theme of professional-patient relationship was discussed were selected to compose the analysis corpus Assuming a social constructionist perspective about knowledge construction, the following theoretical and methodological resources were used: Relational Theory of Meaning, Positioning Theory and Discursive practices and production of meanings. The analysis highlighted: the implications of biomedical discourse use, in which AN and BN is understood as psychopathologies, to the self constructions of the participants of this study and to the construction of possibilities and limitations of their participation in the decisions about the treatment; the participants\' request for closer and emotional relationship with professionals; the role of the psychologist and the rest of the multidisciplinary team to address this request; the effects of the use of the literature in the field that constructs the professional-patient relationships in terms of its difficulties in the discursive practice of the participants when they talked about their conflicts with professionals; and the implication of electing treatment as the privileged scenario of health care. Some social constructionist resources such as Relational Responsibility, Relational Being, Transformative Dialogue and Collaborative Partnership, were implemented to think about relational scenarios between professionals and patients that could include: the idea of identity as movement instead of stability; the understanding of the success and failure in these relationships as conjoint actions; the defense of the patient\'s protagonism in the construction of health; and the possibility of the coexistence of diverse realities.

Bakgrund: Alla patienter är oroliga inför anestesi då de förlorar kontrollen över sin kropp. De önskar ha en bra kontakt med anestesisjuksköterskan för att kunna förmedla sina behov. Informationsbehovet är dock olika för alla patienter, vissa vill veta allt medan andra vill få sparsamt med information. Syfte: Syftet är att beskriva anestesisjuksköterskors erfarenheter av att möta patienter inför och under anestesi. Metod: Kvalitativ systematisk litteraturstudie av bearbetat material. Resultat: Anestesisjuksköterskorna ansåg att det var viktigt att se patientens behov för att kunna skapa trygghet, likväl som att ha en bra kommunikation. Tidsbrist var dock vanligt förekommande vilket skapade hinder i mötet med patienten. Slutsats: Anestesisjuksköterskorna vill utföra ett bra arbete, men då patienterna och verksamheten ofta ställer motstridiga krav krävs en ständig avvägning för att avgöra vad som är bäst här och nu. / Background: All the patients are apprehensive prior to anesthesia, due to the fact that they lose control of their bodies. The patients desire good contact with the nurse anesthetist, in order to convey their needs. The need for information vairy for all the patients. Some require detailed information, while others only sparingly need information. Aim: The aim of the study is to describe nurse anesthetists experience in meeting the patients prior and during anesthesia. Method: A systematic qualitative literature study of published materials was conducted. Results: The nurse anesthetists believe that it is important to see the patients needs, in order to be able to build a sense of security, in addition to good communication. The common obstacle is shortage of time, which affects contact with the patient. Conclusion: The nurse anesthetists feel a need to perform good work. But the patienten och the administration often make conflicting demands, which means that a constant consideration is needed to decide what’s best here and now.

Bakgrund: Forskningen idag visar att psykisk ohälsa ökar globalt. I samhället kan vi se en stigmatiserande och diskriminerande attityd gentemot personer med psykisk ohälsa. Det framgår att denna patientgrupp har ett större behov av vård men att de känner sig orättvist bemötta och behandlade inom hälso- och sjukvården. Syfte: Litteraturöversikten ämnar beskriva attityder hos sjuksköterskor inom somatisk vård gentemot personer med psykisk ohälsa. Metod: Litteraturöversikten har en integrativ metod vilket innebär att både kvalitativa (9) och kvantitativa artiklar (2) har använts för resultatet. Artiklarna är tagna från databaserna MEDLINE, CINAHL och PsycINFO. Alla artiklar har genomsökts för att svara på litteraturstudiens syfte och har kvalitetsgranskats enligt riktlinjer för Hälsohögskolan i Jönköping. Resultat: Efter analys framkom tre teman: Att ha en dömande attityd mot patienten, Undvikande attityder och Empatiska attityder. Slutsats: Diskriminerande och positiva attityder kan hittas hos sjuksköterskor. Däremellan fanns sjuksköterskor som bortprioriterar att vårda patienter med psykisk ohälsa relaterat till yttre och inre omständigheter såsom ansvarsuppfattning, vårdkultur, brist på tillgångar, maktlöshet, hopplöshet. Utbildning och erfarenhet kan enligt litteraturöversiktens resultat ge positiva attityder hos sjuksköterskan under rätt förutsättningar men samhällets syn på personer med psykisk ohälsa verkar vara en stark faktor som påverkar sjuksköterskors attityd. Sjuksköterskans attityd mot personer med psykisk ohälsa korrelerade med samhället hen levde i. / Background: Today's research shows that mental illness is increasing globally. In society, we can see a stigmatizing and discriminatory attitude towards people with mental illness. It appears that this patient group has a greater need for care, but that they feel unfairly treated and cared for in the health and medical care. Aim: The literature review aims to describe attitudes of nurses in somatic care towards people with mental illness. Method: This literature review has an integrative method which means that the result is based on both qualitative (9) and quantitative articles (2) from databases MEDLINE, CINAHL and PsycINFO. All articles have been read thoroughly to correlate to the studys’ aim and their quality has been assessed with guidelines from the School of Health and Welfare in Jönköping. Result: Three main themes emerged: Having a judgmental attitude towards the patient, avoiding attitudes and empathetic attitudes. Conclusion: Discriminatory and positive attitudes can be found in nurses. In between, there are nurses who prioritize caring for patients with mental illness related to external and internal circumstances such as perception of responsibility, care culture, lack of assets, powerlessness and hopelessness. Education and experience can, according to the results of the literature review, give positive attitudes to the nurse under the right conditions, but society's view of persons with mental illness seems to be a strong factor that influences nurses' attitude. The nurse's attitude towards people with mental illness correlated with society lived in.

Inom intensivvården vårdas patienter med sviktande vitala funktioner där respiratorbehandling ofta kan vara en del av behandlingen. Invasiv respiratorbehandling leder till att patientens förmåga till verbal kommunikation upphör. Patienten befinner sig ofta i en utsatt situation där förlust av förmågan till verbal kommunikation kan leda till känslor av rädsla, oro och frustration. Patientens nedsatta kommunikationsförmåga ställer höga krav på vårdpersonalens förmåga att förmedla och tolka information.Syftet med studien är att beskriva vårdpersonalens upplevelser av att kommunicera med den vakna intuberade intensivvårdspatienten. Studien genomfördes som en kvalitativ intervjustudie med induktiv ansats. Specialistsjuksköterskor och undersköterskor på fyra olika intensivvårdsavdelningar intervjuades i fokusgrupper. Intervjumaterialet analyserades med kvalitativ innehållsanalys som resulterade i tre huvudkategorier samt åtta underkategorier. Intervjupersonernas upplevelser återges som svårigheter och frustration, där upplevelse av att inte nå fram samt hinder för kommunikation beskrivs. Strategier för att underlätta kommunikation behandlar de förhållningssätt och tekniker som vårdpersonalen använder i sin vardag och att använda sig av kommunikation som omvårdnadshandling handlar om att skapa trygghet och förståelse. I modern intensivvård tillåts ofta patienten vara så vaken som sjukdomstillståndet tillåter. Denna förändring har resulterat i ökad arbetsbelastning för vårdpersonalen. Strukturella brister observerades relaterat till det undersökta fenomenet, men även lösningar som i framtiden skulle kunna förbättra kommunikationen med vakna intuberade patienter. Studien skulle kunna bidra till ökad medvetenhet och förståelse kopplat till de utmaningar som vårdpersonalen dagligen ställs inför relaterat till kommunikation med vakna intuberade patienter. / Program: Specialistsjuksköterskeutbildning med inriktning mot intensivvård

Background: In the post-operative phase, the patient's ability to communicate is impaired. The postoperative patient is therefore in great need of that the information given is being individually adapted. Objectives: The aim of this study was to investigate communicative barriers and facilitating factors between the nurse and the patient in postoperative care and to describe areas of improvement. Methods: Literature study consisting of 12 qualitative scientific original articles focusing on communication between the nurse and the patient in postoperative care and the patient's communicative needs and the nurse's approach to this. Findings: The literature study showed that barriers like stressful working conditions led to short or no communication between the nurse and the patient, and that the postoperative care time thereby was prolonged. Different language, dialects, gender, cultural beliefs and socio-economic backgrounds meant that the information from the nurses was not perceived - or interpreted correctly - and that the time spent developing the message increased the workload. Patients who took an interest in their treatment and asked questions, acted as a positive facilitator. In by doing this, the patients increased the likelihood of being helped and communicated with by the nurses. Conclusion: The result of the literature study shows that an established clear communicative interaction between the nurse and the patient, with individualized care, could be perceived by the patient as just as important and desirable as a quick recovery from illness. / Bakgrund: I det postoperativa skedet är patientens förmåga att kommunicera nedsatt. Den postoperativa patienten är därför i stort behov av att informationen som ges är individanpassad. Syfte: Syftet var att undersöka kommunikativa barriärer och underlättande faktorer mellan sjuksköterskan och patienten i postoperativ vård samt beskriva förbättringsområden. Metod: Litteraturstudie bestående av 12 stycken kvalitativa vetenskapliga originalartiklar med fokus på kommunikation mellan sjuksköterskan och patienten i postoperativ vård samt patientens kommunikativa behov och sjuksköterskans förhållningssätt till detta. Resultat: Litteraturstudien visade på att barriärer likt stressiga arbetsförhållanden ledde till kort eller ingen kommunikation mellan sjuksköterskan och patienten samt att den postoperativa vårdtiden därigenom blev förlängd. Olika modersmål, dialekt, kön, kulturell övertygelse och socioekonomisk bakgrund gjorde att informationen från sjuksköterskorna ej uppfattades- eller tolkades korrekt samt att tiden lagd på att få fram budskapet ökade arbetsbördan. Vad som agerade underlättande var patienter som själva var framåt och frågade om sin behandling. Detta resulterade i att dessa patienter fick hjälp samt ökade sannolikheten för kommunikation med sjuksköterskorna. Slutsats: Resultatet av litteraturstudien visade att ett etablerat tydligt kommunikativt samspel mellan sjuksköterskan och patienten, med individanpassad vård, kunde av patienten upplevas som lika viktigt och önskvärt som ett snabbt tillfrisknande från sjukdom.

Chang Anne Marie. / "April 1999." / Thesis (Ph.D.)--Chinese University of Hong Kong, 1999. / Includes bibliographical references (p. 245-280). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Mode of access: World Wide Web. / Abstracts in English and Chinese.