No momento em que a creche integrou o sistema educativo brasileiro, o Estado depara-se com o desafio de estabelecer parâmetros de qualidade e critérios de avaliação do atendimento oferecido às crianças de 0-6 anos. Desta maneira, uma avaliação instrumentalizada da qualidade de ambientes de creches poderia auxiliar nesta tarefa. Dada a inexistência de instrumentos brasileiros, esta pesquisa objetivou verificar a adequabilidade para o nosso contexto da versão traduzida da escala norte-americana Infant/Toddler Environment Rating Scale Revised Edition, utilizada internacionalmente para avaliar a qualidade do atendimento oferecido para crianças de 0-30 meses. Essa escala é composta por 39 itens agrupados em sete subescalas, que contemplam diversas dimensões do ambiente de creches: Espaço e mobiliário (5 itens); Rotinas de cuidado pessoal (6); Falar e compreender (3); Atividades (10); Interação (4); Estrutura do programa (4); Pais e equipe (7). Tais itens servem de guia para observações feitas nas várias áreas da creche, durante atividades rotineiras de uma turma de crianças e sua(s) educadora(s); com base nas condições observadas e nas descrições dos indicadores de qualidade da escala, o avaliador atribui pontuação de 1 (inadequado) a 7 (excelente) para cada item. Esta pesquisa englobou quatro etapas: (1)análise semântica; (2)treinamento e familiarização com a escala; (3)verificação da discriminabilidade; (4)verificação da concordância entre aplicadores treinados. Na Etapa 1, seis participantes avaliaram se as sentenças escritas nos indicadores de qualidade da escala expressavam claramente o que deveria ser observado. Dos 466 indicadores, 80% foram considerados compreensíveis por todas as participantes; os 93 indicadores considerados com dificuldades de compreensão semântica passaram por revisão e 57% foram reescritos. Na Etapa 2 (treino através de vídeo e aplicação da escala em três turmas, uma de creche universitária e duas de creche filantrópica), o índice de acordo obtido entre dois aplicadores na terceira turma (82%) permitiu encerrar o treinamento. Na Etapa 3, a escala foi aplicada em quatro turmas de creches com tipos diferentes de gestão (universitária, municipal, filantrópica e particular) a escala discriminou níveis diferentes de qualidade, conforme o escore total obtido (E.T.): as turmas Universitária (E.T.=4,97) e Municipal (E.T.=3,33) apresentaram nível de qualidade suficiente e as turmas Filantrópica (E.T.=2,7) e Particular (E.T.=1,57), nível de má qualidade. Na Etapa 4, dois aplicadores treinados avaliaram, simultânea e independentemente, duas turmas, uma de creche municipal e outra universitária; o Coeficiente de Correlação Intraclasse indicou uma concordância quase perfeita (0,83) e substancial (0,66), respectivamente para cada turma; a análise de concordância sugeriu um nível satisfatório de precisão da escala. As avaliações realizadas identificaram, em cada turma, aspectos positivos da qualidade do atendimento e aspectos que necessitam de melhorias, os quais foram apresentados às coordenadoras das creches, favorecendo reflexões/discussões sobre qualidade do atendimento e oferecendo a elas subsídios para trabalhar com as educadoras; pois, para promover um ambiente institucional de qualidade é importante que a equipe discuta e reflita sobre aspectos positivos já presentes e aqueles que necessitam de planejamento para serem implantados. Desta maneira, a escala pode ser um instrumento útil na promoção de qualidade do atendimento infantil em creches brasileiras. / At the moment that day care center was incorporated to Brazilian educational system, the State come across with the challenge of establishing quality parameters and criteria for evaluation of services provided to children of 0-6 years. Thus, assessment the environmental quality of day care center by an instrument could help in this task. Because of the nonexistence of Brazilian instruments, this research aimed to verify the suitability for our context of translated version of the North American scale Infant/Toddler Environment Rating Scale - Revised Edition, used internationally to assess the quality of services offered for children of 0-30 months. This scale consists of 39 items grouped into seven subscales, which include various dimensions of day care center environment: Space and furnishings (5 items), Personal care routines (6); Speaking and understanding (3) Activities (10); Interaction (4) Program structure (4) Parents and staff (7). These items serve as a guide for observations made in various areas of day care center, during routine activities of a group of children and their teacher(s); based on observed conditions and descriptions of quality indicators of the scale, the evaluator assigns scores of 1 (inadequate) to 7 (excellent) for each item. This study included four phases: (1) semantic analysis, (2) training and familiarization with the scale, (3) verification of the scales discrimination, (4) verification of agreement between trained evaluators. In the Phase 1, six participants judged if the written phrases of quality indicators of the scale expressed clearly what should be observed. Of the 466 indicators, 80% were considered understandable by all participants, the 93 indicators considered not understandable underwent revision and 57% have been rewritten. In the Phase 2 (training through video and application of scale in three playrooms, a playroom of an university day care center and two playrooms of a philanthropic day care center), the agreement between two evaluators in the third playroom (82%) allowed finishing the training. In Phase 3, the scale was applied in four playrooms of day care centers with different types of management (university, public, private and philanthropic) - the scale discriminated different levels of quality, according to the total score obtained (T.S.): the playrooms University (T.S. = 4.97) and Public (T.S.= 3.33) had sufficient level of quality and the playrooms Philanthropic (T.S.= 2.7) and Private (T.S.= 1.57), level of poor quality. In Phase 4, two trained evaluators assessed, at the same time and independently, two playrooms, a playroom of a public day care center and another university; the intraclass correlation coefficient indicated an almost perfect correlation (0.83) and substantial agreement (0.66), respectively for each class, the analysis of agreement suggested a satisfactory level of accuracy of the scale. The evaluations identified, in each class, the positive aspects of quality of service and aspects that need improvement, which were presented to the day care centers coordinators, encouraging reflections and discussions about quality of service and offering them subsidies for working with educators; because, to promote the quality of institutional environments is important that the team discuss and reflect on positive aspects already present and those that require planning to be implemented. Thus, the scale may be a useful tool in promoting quality of service provided to children in Brazilians day care centers.

<p>Istraživanje prikazano ovim radom imalo je za cilj da opi&scaron;e mentalno zdravlje<br />dece na hraniteljstvu ranog &scaron;kolskog uzrasta i da sagleda kakvu ulogu u aktuelnom<br />stepenu njihovog psihosocijalnog funkcionisanja ima kvalitet brige koji im je pružen u<br />hraniteljskoj porodici. Kvaliteta staranja o detetu je konceptualizovan iz okvira teorije<br />afektivne vezanosti kao posvećenost hranitelja detetu na sme&scaron;taju i podrazumeva nivo<br />emocionalne investiranosti i motivisanosti hranitelja da sa detetom uspostavi emotivno<br />blizak, stabilan i trajan odnos.<br />U uzorak istraživanja je uključeno 82 dece na sme&scaron;taju u hraniteljskim<br />porodicama, uzrasta od 5 do 11 godina, koji su &scaron;tićenici Centra za socijalni rad Grada<br />Novog Sada i vi&scaron;e op&scaron;tinskih centara na teritoriji Vojvodine (Novi Bečej, Bačka<br />Topola, Mali Iđo&scaron; i Vrbas), bez ozbiljnijih smetnji u psihomotornom razvoju i koja u<br />aktuelnoj hraniteljskoj porodici borave najmanje dva meseca. U uzorku je podjednak<br />broj dečaka i devojčica, pri čemu dominiraju deca koja su na sme&scaron;taju u standardnim<br />(nesrodničkim) hraniteljskim porodicama (90.2 %), u odnosu na srodničke.<br />Podaci o mentalnom zdravlju dece su prikupljani uz pomoć dve skale za procenu<br />dečije psihopatologije koje su popunjavale hraniteljice: Liste provere dečijeg pona&scaron;anja<br />za decu od 6-18 godina (Child Behavior Checklist for ages 6-18, CBCL/6-18,<br />Achenbah &amp; Reskorla, 2001) i Liste za procenu dece u socijalnoj za&scaron;titi uzrasta od 4-11<br />godina (Assessment Checklist for Children for ages 4-11, ACC, Tarren-Sweeney,<br />2007). Podaci o mentalnom zdravlju su prikupljani i za kontrolni uzorak dece koja<br />odrastaju u biolo&scaron;kim porodicama, ujednačenom po broju, polnoj i uzrasnoj strukturi sa<br />uzorkom dece na hraniteljstvu, kao i u odnosu na pol roditelja koji pruža podatke<br />(majke). Za operacionalizovanje i procenjivanje kvaliteta staranja o detetu od strane<br />hranitelja je kori&scaron;ćen polustrukturirani intervju &ldquo;To je moje čedo&rdquo; (&ldquo;This Is My Baby&rdquo;<br />interview&rdquo;, TIMB, Bates &amp; Dozier, 1998) koji se sastoji od standardizovanih pitanja u<br />vezi hraniteljicinih osećanja prema detetu i njihovog međusobnog odnosa i daje uvid u<br />tri dimenzije: prihvatanja deteta na sme&scaron;taju kao svog (eng. acceptance), posvećenosti u<br />podsticanju njegovog rasta i razvoja bez emotivne &ldquo;zadr&scaron;ke&rdquo; (eng. commitment) i<br />svesnosti o uticaju uspostavljenog odnosa sa detetom na detetov emocionalni i socijalni<br />razvoj, aktuelno i u budućnosti (eng. awareness of influence).<br />Rezultati istraživanja ukazuju da deca na hraniteljstvu u poređenju sa svojim<br />vr&scaron;njacima koji odrastaju u biolo&scaron;kim porodicama, ispoljavaju značajno vi&scaron;e problema<br />mentalnog zdravlja, pri čemu prednjače problemi sa pažnjom, smetnje afektivne<br />vezanosti u vidu nediskriminativnog, pseudozrelog i nesigurnog pona&scaron;anja u<br />5<br />interpersonalnim relacijama, eksternalizujući problemi (agresivno pona&scaron;anje, kr&scaron;enje<br />pravila), abnormalni obrasci ishrane (čuvanje, skladi&scaron;tenje i krađa hrane) i<br />samopovređivanje. Mentalno zdravlje dece je determinisano nepovoljnim razvojnim<br />okolnostima koje prethode sme&scaron;taju ali i kvalitetom brige koja im je pružena u<br />hraniteljskoj porodici, pa se kod dece o kojima brinu hraniteljice visokog nivoa<br />prihvatanja i posvećenosti beleži manje emocionalnih problema, problema u pona&scaron;anju i<br />odnosu sa drugima. Rezultati ukazuju i na moderirajuće efekte kvaliteta staranja, u<br />smislu da je stepen prihvatanja i posvećenosti od strane hraniteljica posebno značajan za<br />decu koja su pre sme&scaron;taja u hraniteljsku porodicu imala visoko rizično iskustvo, čineći<br />ih znatno vulnerabilnijim u okolnostima niskog kvaliteta brige, kao &scaron;to i okolnosti<br />visokog kvaliteta staranja u ovoj grupi dece ostvaruju najintenzivniji protektivni i<br />kompenzatorni efekat.<br />Rezultati su diskutovani u svetlu teorije afektivne vezanosti, u smislu potvrde<br />kvaliteta staranja kao protektivnog činioca koji podstiče rezilijentnost dece i implikacija<br />relevantnih za praksu socijalnog rada u oblasti hraniteljstva.</p> / <p>The purpose of the research presented in this paper is to describe the mental<br />health of children in foster care at early school-age and to analyse the role that the<br />quality of care they receive in foster family plays in the current level of their<br />psychosocial functioning. The quality of child care has been conceptualized from the<br />framework of the attachment theory as the commitment of foster carers to the foster<br />children and it implies a level of emotional investment and motivation of the foster<br />carers to establish an emotionally close, stable and permanent relationship with the<br />child.<br />The research sample involved 82 foster children, aged 5 to 11, who are in the<br />care of the Centre for Social Work of the City of Novi Sad and several municipal<br />centres in the territory of Vojvodina (Novi Bečej, Bačka Topola, Mali Iđo&scaron; and Vrbas),<br />who are without serious difficulties in psychomotor development and who have been<br />with the current foster family for at least two months. The sample included the same<br />number of boys and girls, and the majority were children in standard (non-kinship)<br />foster families (90.2 %), as opposed to kinship foster families.<br />Information about the mental health of the children was collected using two<br />scales for the assessment of psychopathology in children, which were filled out by<br />foster mothers: Child Behaviour Checklist for ages 6-18 (CBCL/6-18, Achenbah &amp;<br />Reskorla, 2001) and Assessment Checklist for Children for ages 4-11 (ACC, Tarren-<br />Sweeney, 2007). Information about the mental health was also collected for the control<br />sample of children who live with biological families, identical in number, gender and<br />age structure with the sample of children in foster care, as well as in relation to the<br />gender of the parent providing the information (mother). In order to operationalize and<br />assess the quality of child care, the research used the semi structured interview &ldquo;This Is<br />My Baby&rdquo; (TIMB, Bates &amp; Dozier, 1998) which contains standardized questions in<br />relation to the foster mother&rsquo;s feelings towards the child and their mutual relationship<br />and it also provides insight into three dimensions: acceptance of foster child as her own,<br />commitment in encouraging their growth and development without emotional<br />&ldquo;reservations&rdquo; and the awareness of influence of the established relationship with the<br />child on the child&#39;s emotional and social development, now and in the future.<br />The results of the research indicate that the children in foster care, as compared<br />to their peers growing up with biological families, display significantly more mental<br />health problems, and the most frequent ones are attention problems, attachment related<br />difficulties in the form of indiscriminate, pseudo mature and insecure interpersonal<br />8<br />behaviours, externalising problems, aggressive and rule-breaking behaviour, eating<br />problems, food maintenance behaviour and self-injury. The mental health of the<br />children is determined by the unfavourable development circumstances prior to<br />placement in foster care, but also by the quality of care that they receive in foster<br />family, and so the children in the care of foster mothers with a high level of acceptance<br />and commitment display fewer emotional, behavioural and interpersonal problems. The<br />results also indicate the moderation effects of the quality of care, in the sense that the<br />level of acceptance and commitment by the foster mothers is of particular significance<br />for the children who had high-risk experience before they were placed in foster family,<br />which made them significantly more vulnerable in the circumstances of low-quality<br />care, just like the circumstances of high-quality care with this group of children<br />produced a more intensive protective and compensatory effect.<br />Results are discussed in the light of the attachment theory, in terms of<br />confirmation of the quality of care as a protective factor which encourages the resilience<br />of children, as well as the implications relevant to the social work practice in the field of<br />foster care.</p>

Background: To achieve better health outcomes it is important to identify those aspects of health care delivery system that determines patient satisfaction. The health care planners must therefore be cognizant of the opinions and expectations of those who utilize health care facilities to achieve better health outcomes. This also applies to maternal satisfaction. The study aimed to measure mothers satisfaction with maternity care and its association with various socio-demographic characteristics. Method: The study presented here is a quantitative cross-sectional study that utilizes secondary data from facility-based survey conducted in 12 different tertiary hospitals of Nepal and included client exit interviews  (n=43756). The maternal satisfaction association with different exposures and potential confounders was determined using multivariate logistic regression analysis. Statistical Package for Social Sciences (SPSS) was used for data analysis. Results:. Better information and counselling is seen to be associated with higher satisfaction and recommendation [AOR: 1.67 [1.60-1.75]] and [1.68[1.57-1.80], respectively. Higher level of delivery preparation indicates lower overall satisfaction [AOR: 0.70 [0.66-0.74]]. Mothers were seen to be less satisfied with the religious and cultural aspects of the maternal health services. Mothers age and sex of child was not seen to be significant with any outcome. Conclusion: Better information and counselling indicates more satisfaction and recommendation. Mothers delivery preparation is seen as a significant predictor of their overall satisfaction; therefore, this should be a part of education and information strategy for mothers from the different backgrounds.

Text in English / Aim: The aims of this study were to investigate the treatment outcomes of patients with MDRTB and its determinants at referral hospitals in Ethiopia. The study also aims to develop a conceptual model for enhancing treatment of patients with MDR-TB in Ethiopia. Design and methods: A concurrent mixed methods design with quantitative dominance was used to investigate treatment outcomes of patients with MDR-TB and its determinants. Results: A total of 136 (n=136) patients with MDR-TB participated in the study, 74 (54%) were male and 62 (46%) were female. Forty-one (31%) of the patients had some co-morbidity with MDR-TB at baseline, and 64% had body mass index less than 18.5kg/m2. Eight (6%) of the patients were diagnosed among household contacts. At 24 months, 76/110 (69%) of the patients had successfully completed treatment, but 30/110 (27%) were died of MDR-TB. Multivariable logistic regression revealed that the odds of unfavourable treatment outcomes were significantly higher among patients with low body mass index (BMI <18.5kg/m2) (AOR=2.734, 95% CI: 1.01-7.395; P<0.048); and those with some co-morbidity with MDR-TB at the baseline (AOR=4.260, 95%CI: 1.607-11.29; p<0.004). The majority of the patients were satisfied with the clinical care they received at hospitals. But as no doctor was exclusively dedicated for the MDR-TB centre, patients could not receive timely medical attention and this was especially the case with those with emergency medical conditions. The caring practice of caregivers at the hospitals was supportive and empathic but it was desperate and alienating at treatment follow up centres. Patients were dissatisfied with the quality and adequacy of the socio-economic support they got from the programme. Despite the high MDR-TB and HIV/AIDS co-infection rate, services for both diseases was not available under one roof. Conclusions: Low body mass index and the presence of any co-morbidity with MDR-TB at the baseline are independent predictors of death among patients with MDR-TB. Poor communication between patients and their caregivers and inadequate socio-economic support were found to determine patients’ perceived quality of care and patients’ satisfaction with care given for MDR-TB. / Health Studies / D. Litt et Phil. (Health Studies)

Ambulatory surgery centers (ASCs) play an important role in providing surgical and diagnostic services in an outpatient setting. They can be owned by physicians who staff them. Previous studies focused on patient “cherry picking” and over-utilization of services due to physician ownership. Few studies examined the relationship between physician ownership and quality of care. Using a retrospective cohort of patients who underwent colonoscopy, this study examined the effect of physician ownership of ASCs on the occurrence of adverse events after outpatient colonoscopy. Agency theory is used to as a conceptual framework. Depending on the extent to which consumers are able to assess quality of care differences across health care settings, physician ownership can function as a mechanism to improve quality or as a deterrent to quality. Four adverse event measures are used in this study: same day ED visit or hospitalization, 30-day serious gastrointestinal events resulting in ED visit or hospitalization, 30-day other gastrointestinal events resulting in ED visit or hospitalization, and 30-day non-gastrointestinal events resulting in ED visit or hospitalization. Physician ownership status is determined based on a court decision in California in 2007. Data sources include the State Ambulatory Surgery Databases (SASD), State Inpatient Databases (SID), Emergency Department Databases (SEDD), State Utilization Data Files, the Area Resource File (ARF), and HMO/PPO data from Health Leaders. After controlling for confounding factors, the study found that colonoscopy patients treated at a physician-owned ASC had similar odds of experiencing same day ED visit or hospitalization and 30-day non-gastrointestinal events resulting in ED visit or hospitalization as those treated in a hospital-based outpatient facility. But the former had significantly higher odds of experiencing 30-day serious gastrointestinal events and 30-day other gastrointestinal events resulting in ED visit or hospitalization. The results are robust to changes in propensity score adjustment approach and to the inclusion of a lagged quality indicator. They suggest that physician ownership of ASCs was not associated with better quality of care for colonoscopy patients. As more complex procedures are shifted from hospital-based outpatient facilities to ASCs, expanded efforts to monitor and report quality of care will be worthwhile.

Critical Access Hospitals (CAHs) – the predominant type of hospital operating in rural areas – play an integral role in the US healthcare system, providing care for over 7 million rural residents each year who might otherwise have no local access to urgent care or inpatient services. This dissertation examines three aspects of care delivery in CAHs – effectiveness, cost/efficiency, and access – each of which has separate implications for policy and practice. The first study addresses effectiveness and evaluates the performance of CAHs on specific patient safety indicators compared to small Prospective Payment System (PPS) hospitals. A total of 35,674 discharges from 136 non-federal general hospitals with fewer than 50 beds were included in the analyses: 14,296 from 100 CAHs and 21,378 from 36 PPS hospitals. Outcome measures included six bivariate indicators of adverse events of surgical care that were developed from Agency for Healthcare Research and Quality Patient Safety Indicators. Multiple logistic regression models were developed to examine the relationship between hospital adverse events and CAH status. The results indicated that compared to PPS hospitals, CAHs are less likely to have any observed (unadjusted) adverse event on all six indicators, four of which are statistically significant. After adjusting for patient mix and hospital characteristics, CAHs perform better on three of the six indicators. Accounting for the number of discharges eliminated the differences between CAHs and PPS hospitals in the likelihood of adverse events across all indicators except one. Tele-emergency (tele-ED) services can address several challenges facing emergency departments (EDs) in rural areas. The second study investigates access and characterizes the impact of a rural-ED-based telemedicine program on discharge disposition in terms of patient transfer, local hospital admission, and routine discharge. This study tests the hypothesis that telemedicine enhances access by allowing patients to receive care in the local community, and does so by looking at the probability of transfer and local admissions before and after telemedicine was implemented in CAHs. The results indicate that in the post-telemedicine period, patients were 38% less likely to be admitted to the local inpatient facility than to be routinely discharged [aOR=0.62, 95%CI=(0.57,0.67)] after adjusting for age, sex, race, time of visit, clinical diagnosis, CPT code, number of diagnoses, and admitting hospital. The third study addresses cost and efficiency by modeling the financial implications of using the same telemedicine program to avoid transfers and estimating the costs and benefits associated with tele-ED implementation in CAHs. Analysis is based on 9,048 tele-ED encounters generated by the Avera eEmergency program in 85 rural hospitals across seven states between October 2009 and February 2014. For each non-transfer patient, physicians indicated whether the transfer was avoided because of tele-ED activation. The cost-benefit analysis is conducted from the hospital, patient, and societal perspectives, and includes technology costs, local hospital revenues, and patient-associated savings. The results show that 1,175 avoided transfers could be attributed to tele-ED. From a rural hospital perspective, tele-ED costs around $1,739 to avoid a single transfer but saves approximately $5,563 in avoided transportation and indirect patient costs. From a societal perspective, tele-ED results in a net savings of $3,823 per avoided transfer while accounting for tele-ED technology costs, hospital revenues, and patient-associated savings. This study highlights various stakeholder perspectives on the financial impact of tele-ED in avoiding patient transfers in rural EDs. Telemedicine has the potential to reduce the number of transfers of ED patients and generate some revenue for rural hospitals despite associated technology costs, while incurring substantial patient savings.

<p>The development and provision of equitable and acceptable standard of health services to all segments of the population has been the major objective of the 1993 Ethiopian National health policy. However, community based studies on satisfaction with public health care facilities reveal that the majority of the population are not satisfied with the services provided predominantly as a result of the long waiting times. Studies done on private health facilities on the contrary reveal that patients are satisfied with the service delivered within short waiting times in these clinics. Even though the speculated waiting time is thought to be long among the public health care facilities and short in private clinics, the actual waiting and service times have not been measured and compared. Aim: To determine the waiting and service times among the public and private health care facilities and measure the perceptions of &ldquo / acceptable&rdquo / waiting time among the providers and clients. Materials and methods: A cross sectional observational study using quantitative techniques was carried out amongst patients and staff at selected public and private health care facilities in Gondar District. Stratified sampling method was used to select facilities. All patients visiting the selected facilities and all staff who provided service to patients on the day of the study were included in the time-delimited sample. Data was collected by research assistants and health workers from all patients attending the health care facility by registering the arrival and departure time of each patient to the facility and to each service point on a patient flow card. Then data was cleaned and captured by a specific Waiting and Service Time database. Descriptive statistics was done on waiting and service times for each facility and this was summarized for each public and private health facility by using tables and graphs. Finally a comparison was made for private and public health facilities by using Wilcoxon-mann-whitney non parametric tests.</p>

Client satisfaction is an outcome measure of quality care. Therefore, health care providers (HCP) have a responsibility to provide quality care services in order to satisfy clients’ health needs. The aim of this study was to establish the satisfaction level of persons with disabilities regarding health services provided at primary health care centres (PHCC) in Ndola, Zambia. The study employed a crosssectional descriptive design and quantitative research method. The sample comprised 200 male and female persons with disabilities aged between 18-65 years old, selected using a convenience sampling technique. The clients were health care service beneficiaries from four PHCCs and four community based rehabilitation centres (CBR). The self-administered General Practice Assessment Questionnaire (GPAQ) was used to collect data on client satisfaction.The results showed that majority of clients were dissatisfied with availability of health services. There was a significant association between care providers’ skills and clients’ satisfaction level at p<0.0001. There is need to increase and assign specifically trained health professionals to health centres. Besides this, a multi-disciplinary approach that incorporates other professionals might help to deliver quality care services to persons with disabilities.

The overall aim of this thesis was to describe quality of care from different perspectives in the psychiatric setting, to develop an instrument for measuring quality of care from the in-patient perspective and to use this instrument empirically. A qualitative descriptive design involving a phenomenographic analysis was used in Studies I, III and IV, and a descriptive and comparative design with statistical analysis in Study II. In Study I, 20 patients were interviewed. The results showed that quality of care was perceived as a positive, normative concept namely as good quality of care. Five descriptive categories emerged: the patient’s Dignity is respected; the patient’s sense of Security with regard to care; the patient’s Participation in care; the patient’s Recovery; and the patient’s care Environment. In addition, two conceptions that had not explicitly emerged in previous studies on quality of care were identified: Being helped to reduce the shame and Being looked upon as like anyone else. In Study II a definition of quality of care from a patient perspective was formulated on the basis of the results in Study I. A two-part instrument the Quality in Psychiatric Care (QPC) was developed for measuring the patients’ expectations regarding quality of care (QPC-1) and their subsequent experience of it (QPC-2). One hundred and sixteen patients answered both parts of the instrument. Overall, the quality of care was rated high in both parts. However, experienced quality of care was significantly lower than the patient’s expectations in all the dimensions of the instrument: Total dimension, Dignity, Security, Participation, Recovery and Environment. Patients who perceived that the time of discharge was consistent with the stage of their illness experienced significantly higher Recovery; patients with good psychiatric health also experienced this, but had in addition significantly higher levels of Participation. This new instrument exhibited too high Cronbach’s alpha values (QPC-1 0.87–0.98, QPC-2 0.85–0.98), which means the instrument needs to be further tested in order to improve its psychometric properties. Twelve next of kin were interviewed in Study III. The next of kin described quality of care mainly from their own perspective, but also to a large extent from the patient’s perspective as well. They described it in both positive and negative terms. Five descriptive categories resulted: Dignity, Security, Participation, Recovery and Health-promoting surroundings. Good relations and communication between staff, patients and next of kin emerged as the central factors regarding the quality of care. The next of kin asked for information about mental illnesses and wanted to co-operate and participate in the patient’s care. They avoided telling others about their family member’s psychiatric illness because of a feeling of shame and guilt. In Study IV, 20 care staff and care associates were interviewed. They described quality of care both from the patient’s perspective and from a professional perspective. They perceived the concept as a positive one and as being of great importance for the patient’s health and life situation. Four descriptive categories resulted: the patient’s Dignity is respected; the patient’s Participation in the care; the patient’s Recovery; and the patient’s care Environment plays an important role. The main contribution of this thesis with regard to the concept of quality of care in the psychiatric setting is its emphasis on the significance of the different perspectives described above, as such knowledge is vital when planning and implementing and evaluating quality of psychiatric care. In addition, the descriptive categories that emerged in this thesis clearly highlight the importance of interpersonal relationships in the care situation. The new instrument (QPC) needs psychometric testing before it routinely can be used as a self-rating instrument for the purpose of improving psychiatric inpatient care and help guide the proper allocation of care resources.

Patients and next of kin in intensive care often experience powerlessness, anxiety and distress and intensive care staff are repeatedly exposed to traumatic situations and demanding events. Empowerment has been described as a process of overcoming a sense of powerlessness and a model through which people may develop a sense of inner strength through connections with others. The aim of this thesis was to describe empowerment as experienced by patients, next of kin and staff in intensive care and to compare patient's experiences with staff and next of kin beliefs. Empowerment is reflected in this thesis as experiences of inner strength and power and of participation/self-determination. The study was based on open-ended interviews with 11 patients, 12 next of kin and 12 staff members from two intensive care units in southern Sweden. A phenomenological perspective was applied in three studies, while a qualitative content analysis was used in the forth study. Findings showed that nourishing relationships were of crucial importance, and contributed to every participant's experiences of empowerment regardless of whether he/she was an intensive care patient, a next of kin or a staff member. Patients were found to be strengthened and empowered by a positive environment where their own inherent joy of life and will to fight was stimulated, where they felt safe and a sense of value and motivation were encouraged and where they were taken seriously and listened to. Next of kin were extremely important to patients' experiences of safety, value, human warmth and motivation, and patients were strengthened when their next of kin were acknowledge and welcomed by staff. Next of kin in intensive care were strengthened and empowered by a caring atmosphere in which they received continuous, straightforward and honest information that left room for some hope and in which closeness to the patient was facilitated and medical care was experienced as the best possible. Some informants were also empowered by family support and/or participation in caring for the patient. Intensive care staff were empowered by both internal processes such as feelings of doing good, increased self-esteem/self-confidence and increased knowledge and skills, and by external processes such as nourishing meetings, excitement and challenge, well functioning teamwork and good atmosphere. When comparing patient experiences with staff and next of kin beliefs, there was agreement regarding joy of life and will to fight being essential to patients' experiences of inner strength and power, but staff and next of kin seemed to see this as a more constant individual viewpoint or characteristic than the patient did. Next of kin, and especially staff, seemed to regard the patient as more unconscious and unable to participate in the communication and interaction process than the patient him/herself experienced. A mutual and friendly relationship was experienced by the patients as highly empowering, while a more professional relationship was emphasized by the staff. These findings could serve as a basis for reflection about patient, next of kin and staff experiences of strength and power and if empowerment is seen as a dimension in quality of care, the findings from this thesis ought to be taken into consideration to increase the quality of care in intensive care. / Patienter och närstående inom intensivvård upplever ofta maktlöshet, oro och inre stress. Upplevelser från intensivvårdstiden har visat sig kunna påverka patienters och närståendes psykologiska välbefinnande under lång tid, även efter det fysiska tillfrisknadet. Intensivvårdspersonal utsätts mer eller mindre frekvent för svåra och traumatiska händelser, vilket kan orsaka stress och utbrändhetssymtom. Empowerment har beskrivits som en process för att övervinna upplevelser av maktlöshet eller en modell genom vilken människor kan utveckla en känsla av inre styrka. Syftet med denna avhandling var att beskriva patienters, närståendes och personals upplevelser av empowerment inom intensivvård. Syftet var också att jämföra patienters upplevelser med vad närstående och personal tror att de upplever. Med empowerment avses här upplevelser av inre kraft och styrka samt av delaktighet/självbestämmande. Avhandlingen är baserad på öppna intervjuer med 11 patienter, 12 närstående och 12 personal vid två intensivvårdsavdelningar i södra Sverige. Alla intensivvårdspatienter upplevde att den egna livsgnistan och kämparvilja var avgörande för deras upplevelser av inre kraft och styrka och inverkade på deras möjlighet att tillfriskna. Livsgnistan och kämparviljan påverkades i sin tur av vad som hände runt omkring patienterna. En positiv atmosfär där de kände sig trygga, betydelsefulla och blev lyssnade på, stärkte deras livsgnista och kämparvilja, liksom extra omsorg, uppmuntran och stärkt motivation. Närstående spelade en viktig roll i att förstärka patienternas upplevelser av trygghet, värde och motivation och öka deras upplevelse av inre kraft och styrka. Atmosfären hade stor betydelse för närståendes upplevelser av kraft och styrka och de påverkades mer av hur något utfördes än av vad som utfördes. Det var viktigt för närstående att känna att det fanns både en kapacitet och en vilja att hjälpa och lindra och de upplevde det stärkande att känna att personalen brydde sig såväl om patienten som om dem. En kontinuerlig, rak och ärlig information som lämnade rum för hopp, tillsammans med möjlighet att få vara nära den svårt sjuke familjemedlemmen samt en upplevelse av att patienten fick bästa möjliga medicinska vård, upplevdes av närstående som stärkande. Några stärktes även av stöd från andra familjemedlemmar och av att få vara delaktiga i vården. Vårdpersonalen fick kraft och styrka både av interna och externa processer. Exempel på stärkande interna processer var upplevelsen av att göra gott, av att ha kunskaper och färdigheter för att klara de uppgifter och utmaningar man ställdes inför, samt av att känna sig trygg både i sig själv (självkänsla) och i det man gjorde (självförtroende). Närande möten med närstående och patienter, spänning och utmaningar, välfungerande teamarbete och en positiv atmosfär är exempel på externa processer som bidrog till personalens upplevelse av inre kraft och styrka. När patienternas upplevelser jämfördes med vad närstående och personal trodde att de upplevde, fanns en samsyn i att patienternas egen livsgnista och kämparvilja hade stor betydelse för deras upplevelse av kraft och styrka. Närstående och personal betraktade emellertid patientens livsgnista och kämparvilja som ett tämligen statiskt karaktärsdrag, medan patienterna själva menade att livsgnistan och kämparviljan i hög utsträckning påverkades av atmosfären runt omkring dem och av hur de blev bemötta. Närstående och personal, tycktes betrakta patienterna som mer omedvetna och oförmögna att kommunicera och samverka med omgivningen än vad patienterna själva upplevde. Patienterna upplevde det som ytterst stärkande när de fick känna sig som medlemmar i vårdteamet och inte ”bara som en patient”.