Context: The study of expertise in medical education has tended to follow the traditions of describing either the analytic processes or the non-analytic resources that experts acquire with experience. We argue that a critical function of expertise is the ability to transition from the automatic mode to the more effortful mode when required – a transition referred to as ‘slowing down when you should’. Objectives: To explore the phenomenon of ‘slowing down when you should’ in operative surgical practice and its role in intra-operative surgical judgment, and to develop conceptual models of the factors involved in the display of this transition in surgical operative practice. Design: In Phase 1A, 28 surgeons were interviewed about their views of surgical judgment in general and their perceptions of the role of this phenomenon in operative judgment. In Phase 1B, a subset of surgeons from Phase 1A was re-interviewed to explore their perceptions of automaticity in operative practice. In Phase 2, observational sessions (and brief interviews) were conducted of surgeons in the operating room to explore the nature of this phenomenon in its natural environment. Results: The surgeons in this study recognized the phenomenon of ‘slowing down’ in their operative practice and acknowledged its link to surgical judgment. Two main initiators were described and observed: proactively planned ‘slowing down’ moments occurring intra-operatively initiated by critical events anticipated pre-operatively and situationally responsive ‘slowing down’ moments initiated by emergent cues intra-operatively. Numerous influences of this transition were uncovered. A control dynamic emerged as surgeon’s negotiated ‘slowing down’ moments through trainees in their supervisory academic practice. Numerous manifestations of this phenomenon were observed in the operating room and considered using a cognitive psychology attention capacity model. Conclusions: This study offers a conceptual framework for understanding the role of ‘slowing down when you should’ in operative surgical practice, providing a vocabulary that will allow more explicit consideration of what contributes to surgical expertise. Consideration of this framework with its consequent ability to make surgical practices more explicit has implications for self-regulation in practice, surgical error, and surgical training.

New surgical approaches for total hip arthroplasty (THA) are being developed to reduce muscle damage sustained during surgery, in the hope to allow better muscle functioning afterwards. The goal of this study was to compare the muscle sparing anterior (ANT) approach to a traditional lateral (LAT) approach with three-dimensional motion analysis. Kinematics and kinetics were obtained with an infrared camera system and force plates. It was hypothesized that (1) the ANT group would have closer to normal range of motion, moments and powers, compared to the LAT group, and that (2) the ANT group would have higher peak hip abduction moment than the LAT group. Forty patients undergoing unilateral THA for osteoarthritis between the ages of 50 and 75 (20 ANT, 20 LAT) were asked to perform three trials of walking, stair ascent and stair descent. Patients were assessed between six to twelve months postoperatively. Twenty age- and weight-matched control participants (CON) provided normative data. Results indicated that both THA groups had gait anomalies compared to the CON group. Both THA groups had reduced hip abduction moment during walking (CON vs. ANT: p<0.001; CON vs. LAT: p=0.011), and the ANT group had a significantly lower hip abduction moment compared to the LAT group (p=0.008). Similar results were observed during stair descent, where the ANT group had reduced peak hip abduction moment compared to the CON group (p<0.001) and the LAT group (p=0.014). This indicates that the anterior approach did not allow better gait and stair climbing ability after THA. It is therefore thought that other variables, such as preoperative gait adaptations, trauma from the surgery, or postoperative protection mechanisms to avoid loading the prosthetic hip, are factors that might be more important than surgical approach in determining the mechanics of THA patients after surgery.

ABSTRACT The aim of this thesis is to illustrate how surgical operation theatre nurses perceive debriefing within emergency health care. The study has a qualitative design with semi structured interviews that have been performed with seven operating room nurses working in emergency health care. The strategic selection consists of professional operation theatre nurses working in emergency care at Uppsala University Hospital. The main goal of this thesis is to increase the understanding of debriefing and to highlight the need of debriefing after difficult or unexpected events in the emergency health care profession. The interviewed nurses perceive debriefing as an important way to develop the day to day work, but also as a way to unburden the staff at the time of bigger traumas. Even though the effect of debriefing is not univocally positive in the literature, the staff perceives that it reduces different kinds of stress. According to the interviewees, routines need to be written down in order for debriefing to be used in their work. The department should create a smaller work group with knowledge of debriefing. The work group should include two qualified leaders that can act as group leaders as well as instructor. One or two external resources (e.g. priest, behavioral) with appropriate qualifications should also be linked to debrief activities. The expected result is an improved working environment for surgical nurses. This is done as the stress level is reduced. Keywords: debriefing, mental health, defusing, surgical nurses

Examensarbetet har genomförts i samarbete med innovationsföretaget ProboNova Medical Innovations AB. ProboNova jobbar främst med konceptframtagning av medicintekniska produkter. ProboNova tar sedan en Provisional Patent Application på konceptet och licenserar ut det till ett större företag. Genom att licensera ut koncepten slipper de kostnaderna för kliniska tester bland annat.  Examensarbetet grundades i att ProboNova ville ha hjälp med att ta fram ett koncept på en ny sårhake. Projektet har genomsyrats av designprocessen där förstudie och idégenerering har varit de två dominerande delarna. I slutet av projektet presenterades ett koncept som uppfyllde alla krav och detta koncept togs det senare en Provisional Patent Application på.  Tanken är att examensarbetet ska ge läsaren en bättre förståelse för hur man kan jobba med designprocessen och lära sig fördelarna med att välja en Provisional Patent Application istället för en Nonprovisional ansökan. / The thesis was carried out in cooperation with the company ProboNova Medical Innovation AB. ProboNova works mainly with the concept development of medical devices. Then they take a Provisional Patent Application on the concept and licensing it out to a larger company. By licensing out the concepts they don’t have to take the costs of clinical trials for example.   The thesis was founded in that ProboNova wanted help with developing a concept on a new surgical retractor. The project has been characterized by the design process in which the feasibility studies and brainstorming has been the main parts. At the end of the project a concept was presented. The final concept met all the requirements from ProboNova and from the functional analysis that was done in the feasibility studies. A Provisional Patent Application was taken later on the final concept.    The idea is that the thesis should give the reader a better understanding of how to work with the design process, and learn the benefits of choosing a Provisional Patent Application instead of a Nonprovisional application.

Based on dialogical theory and empirical exploration of surgical operations in a Swedish hospital, this text contributes to the study of critical work practice. In empirical detail, ethnographic investigation and video analysis show that ‘everyday interactivity’, i.e. technical development beyond the control of individual participants, is a ubiquitous phenomenon of surgical work. This research interest can be contrasted to models of human-machine interaction, which describe how a given technology affords or impedes an intended outcome. Conclusions are that there may be fundamentally different ways of describing the regular course of surgery. From so-called ‘designer-oriented‘ perspectives, creative or unexpected results would be seen as emergent signs of design failure. According to dialogical theory, unfolding and multifunctional technical outcomes are necessary in working life. The latter is everything but trivial for research and development. As concrete products of collective practice, workplace technology cannot support individual ‘user experiences’ or workflows. Instead, we may recognise already present, parallel, and ongoing design changes. Thus, the thesis problematise the meaning of teamwork and technology in everyday practice. / Utifrån dialogisk teori, interaktionsanalyser och etnografiska undersökningar av kirurgiska operationer inom olika kirurgiska specialiteter, problematiserar avhandlingen betydelsen av vardagliga och kritiska verksamheter. I empirisk detalj av några fallstudier, tagna ur ett omfattande material av inspelningar och etnografiska data om arbetsplatsen, visar avhandlingens videoanalys att “vardaglig interkreativitet”, det vill säga teknisk utveckling inom och mellan arbetslag, är ett ständigt närvarande fenomen i kirurgisk praktik. Detta ska ses i förhållande till gängse beskrivningar av kritiska verksamheter, vilka i huvudsak handlar om hur givna instruktioner och verktyg stödjer, eller inte stödjer, planerade delmål. Slutsatsen är att det är möjligt att ge helt olika empiriskt grundade beskrivningar av kirurgi. Utifrån så kallade “designerorienterade” ansatser förklaras varje oväntad teknisk användning som tecken på underliggande designproblem. Enligt dialogisk teori framstår istället teknisk pluralism och förändring som nödvändiga delar av verksamheten. Det senare är allt annat än självklart inom området verksamhetsutveckling. Med föränderliga tekniker och tekniska system som grund, blir det inte längre prioriterat att undersöka eller stödja situerade “användarupplevelser”. Istället bör redan befintliga interkreativa design processer och konkreta samkonstruktioner lyftas fram som tekniska förutsättningar för forskning och utveckling. Avhandlingen problematiserar således både hur teamarbete kan förstås och hur teknologi gestaltas i vardagen.

Abstrakt     Inledning: Att vara ny på arbetet är utmanande och innebär ökad stress. Tidigare studier visar att många upplever sin kunskap som begränsad och att de önskade mer praktisk erfarenhet och hade behov av en god introduktion. Gott lagarbete med goda relationer och tillåtande miljö var viktigt för att arbetet på operationsavdelningen skulle fungera tillfredsställande. Syfte: Studiens syfte var att belysa nyutexaminerade operationssjuksköterskors upplevelser av sin första yrkesverksamma tid. Metod: Studien hade en kvalitativ ansats där datainsamling har genomförts genom semistrukturerade intervjuer. Den utskrivna texten analyserades med en latent innehållsanalys. Resultat: I analysen framkom tre teman; Upplevda faktorer som påverkar utvecklandet av kompetens, Förmågan att inse sitt egenvärde och omgivningens inverkan på upplevelsen av trygghet, samt Behov av kontroll och stöd vid brist på kontroll. Resultatet visar hur nyutexaminerade operationssjuksköterskor upplevde en känsla av att vara dåligt förberedda inför de nya arbetsuppgifterna. Deltagarna beskriver hur de önskade en planerad inskolning med möjlighet till individuell anpassning. Erfarna och hjälpsamma kollegor upplevdes ge ökad trygghet och stöd från en kollega som det fanns förtroende för ansågs vara viktigt. Det framställdes hur betydelsefull självinsikten var över den egna kunskapen samt att ansvaret för kunskapsinhämtning låg på dem själva. Deltagarna menade också att det var viktigt att acceptera rollen som novis och därmed bristen på erfarenhet. Slutsats: Att belysa nyutexaminerade operationssjuksköterskors upplevelser av sin situation gör det möjligt att sträva efter en öppen och tillåtande arbetsmiljö. Detta ökar förutsättningarna för god inskolning av nyutexaminerade operationssjuksköterskor, vilket kan bidra till en mer patientsäker vård.   Nyckelord: Handledning, Innehållsanalys, Inskolning, Nyutexaminerade operationssjuksköterskor, Upplevelser. / Abstract     Introduction: To be new at work is challenging and involves increased stress. Earlier studies show that many experienced that their knowledge was limited and wished for more practical experiences and where in need of a good introduction. Good teamwork with good relationships and a permissive environment was important for work at the surgical department to perform satisfactorily. Aim: The purpose of the study was to highlight newly graduated surgical nurses experiences of their first professional career. Method: The study had a qualitative approach where data collection was carried out through semi-structured interviews. The transcript was analyzed with a latent content analysis. Results: The analysis revealed three themes: Perceived factors influencing the development of skills, the ability to recognize their intrinsic value and ambient effects on the perception of the Översätt från: svenskaSkriv text, ange adressen till en webbplatöversätt ett dokument.AvbrytExempel på hur "" kan användas:automatiskt översatt av Googlesense of security, and need for control and support in the lack of control. The result shows how graduates surgical nurses experienced a feeling of being not enough prepared for their new jobs. Participants describe how they wanted a planned induction with the possibility of individual adaptation. Experienced and helpful colleagues felt to provide greater security and support from a colleague that there was confidence was considered important. It was made how important self-realization was over their knowledge and that the responsibility for the acquisition of knowledge lay on them. Participants also felt that it was important to accept the role of a novice and thus the lack of experience. Conclusion: To highlight newly graduated surgical nurses' perceptions of their situation makes it possible to pursue an open and tolerant environment. This increases the chances of a good induction of newly graduated surgical nurses, which can contribute to a more patient-safe care.   Keywords: Content Analysis, Experiences, Induction, Newly graduates surgical nurses, Tutorial.

Die hier vorliegende Studie stellt die Früh- und Langzeitergebnisse der chirurgischen Vorhofablation zur Behandlung des ischämischen Vorhofflimmerns (VHF) in Kombination mit einer aortokoronaren Bypass-Anlage vor. Dabei wurden die epikardiale Pulmonalvenenisolation mittels Radiofrequenzenergie (RF) und die endokardiale Kryoablation inklusive einer Box-Läsion und Mitralisthmuslinie miteinander verglichen. Im Zeitraum von 2002 bis 2009 wurden die prä- und postoperativen Daten von 262 Patienten mit paroxysmalem oder lang-persistierendem VHF prospektiv erhoben und anschließend eine Nachbeobachtung von durchschnittlich 2,30 Jahren durchgeführt. Die Kryoablation war im Vergleich zur RF-Ablation mit einer signifikant höheren perioperativen Invasivität und Morbidität verbunden. Die Operations- und Ischämiezeit sowie die postoperative intensivmedizinische Betreuung waren nach der Kryoablation signifikant länger. Die Rate an Schrittmacherimplantationen (4,8 % vs. 0,0 %), kardialen bzw. zerebralen Komplikationen (22,9 % vs. 12,3 %) und die Krankenhausmortalität (8,4 % vs. 2,2 %) lagen ebenfalls signifikant höher. Hingegen waren die Langzeitergebnisse ohne signifikante Unterschiede zwischen den Ablationsmethoden. Sowohl das Überleben (81,9 % vs. 86,0 %) als auch die Konversionsrate in den Sinusrhythmus (55,6 % vs. 61,5 %), die Lebensqualität der Patienten und die Komplikations- und Reinterventionsraten zeigten im Langzeitverlauf vergleichbare Ergebnisse. Auf der Basis der oben erhobenen Befunde kann die endokardiale Kryoablation nicht als Standardverfahren zur Therapie des paroxysmalen und lang-persistierenden ischämischen VHFs begleitend zu einer aortokoronaren Bypass-Anlage empfohlen werden. Die epikardiale RF-Ablation ist hier aufgrund der geringeren operativen Invasivität bei vergleichbaren Früh- und Langzeitergebnissen der endokardialen Ablation vorzuziehen.

Few bodies consistently portray natural or unaltered forms. Instead, humans inhabit bodies imbued with sociocultural meanings about what is attractive, appropriate, functional, and presentable. As such, embodiment is always gendered. The social, extra-corporeal body is a central locus for expressing gender. Surgical body modifications represent inherently gendered technologies of the body. But psychomedical institutions subject people who seek gender-crossing surgeries to increased surveillance, managing and regulating cross-gender embodiment as disorderly. Using mixed research methods, this research systematically compared transgender and cisgender (non-transgender) people’s experiences before, during, and after surgical body modification. I conducted a content analysis of 445 threads on a message board for an online cisgender surgery community, an analysis of 15 international protocols for transgender-specific surgeries, and 40 in-depth interviews with cisgender and transgender people who had surgery. The content analysis of the online community revealed similar themes among cisgender and transgender surgery users. However, detailed protocols existed only for transgender consumers of surgery. Interview findings showed that transgender and cisgender people reported similar presurgical feelings toward their bodies, similar cosmetic and psychological motivations for surgery, and similar benefits of surgery. For both cisgender and transgender people, surgery enhanced the inner self through improving the outer gendered body. Despite these similar embodied experiences, having a cisgender gender status determined respondents’ abilities to pursue surgery autonomously and with institutional support. Ultimately, this research highlights inequalities that result from gender status and manifest in psychomedical institutions by identifying the psychosocial impacts of provider/consumer or doctor/patient interactions, relating gendered embodiment to regulatory systems of authority, and illuminating policy implications for clinical practice and legal classifications of sex and gender.

Introduction: Balance between the essential nutritive substances is important for a person to maintain health. The surgical patient can be stricken with conditions, which have a negative impact on this balance and can lead to malnutrition. Working as a nurse it is important to identify patients that are malnourished or is in the risk zone of malnourishment since 30 % of all patients in hospitals are malnourished. Aim: The aim of this study was to examine the compliance to the guidelines for nutritional assessment and parenteral nutrition on a surgical ward. Also whether the nutritional treatment/-support was reported to the next caregivers if the patient was malnourished or was in the risk zone of malnourishment at the time of discharge. Method: 80 patients enrolled on the ward in the beginning of year 2011 were included. Audit of patient records was made according to the hospital guidelines for nutrition and parenteral nutrition and followed a study specific protocol. Results: The examination of the case records showed that the guidelines for nutrition were partly complied with. Nutritional treatment/-support was reported to the next caregivers when needed. Compliance to the guidelines for parenteral nutrition was deficient. Conclusion: The guidelines for nutritional assessment and parenteral nutrition are not used adequately. / Introduktion: En stadig balans mellan de livsviktiga näringsämnena krävs för att en person ska kunna hålla sig frisk och för att kroppen ska fungera. Den kirurgiska patienten kan drabbas av tillstånd som har en negativ inverkan på denna balans och kan riskera att drabbas av malnutrition. Det är viktigt att som sjuksköterska identifiera de patienter som är malnutrierade eller är i riskzonen för att drabbas av malnutrition då 30 % av alla patienter som vårdas på sjukhus är malnutrierade. Syfte: Syftet med denna studie var att undersöka om de riktlinjer som finns för nutritionsbedömning och parenteral nutrition följs på en kirurgisk vårdavdelning samt om nutritionsbehandlingen/-stödet rapporteras vidare till nästa vårdform då en malnutrierad patient/riskpatient för malnutrition skrivs ut. Metod: 70 patienter som var inskrivna på den aktuella avdelningen i början av år 2011 inkluderades i studien. En journalgranskning gjordes utifrån ett journalgranskningsprotokoll, där innehållet utgick från de nutritionsriktlinjer som finns för verksamhetsområdet för kirurgi samt riktlinjerna för parenteral nutrition. Resultat: Journalgranskningen visade att de riktlinjer som finns för nutrition följs till viss del. Vad gäller rapportering av nutritionsbehandling/-stöd till nästa vårdgivarform görs detta då det är aktuellt. Följsamheten till riktlinjerna för parenteral nutrition var det som var mest bristfälligt. Slutsats: Riktlinjerna för nutritionsbedömning och parenteral nutrition följs inte i den utsträckning som det borde.

名古屋大学博士学位論文 学位の種類 : 博士(医学)(論文) 学位授与年月日:平成3年9月14日 安田公氏の博士論文として提出された