Résumé: Les signes de détérioration clinique chez les patients hospitalisés ne sont pas toujours détectés ou interprétés adéquatement, occasionnant des arrêts cardiaques, des transferts vers les unités de soins intensifs et des décès évitables. Afin de bien reconnaître les signes de détérioration clinique, les infirmières doivent avoir un raisonnement clinique adéquat. Évaluer le raisonnement clinique d’infirmières en contexte de détérioration clinique pourrait aider à identifier les difficultés associées à la reconnaissance de ses signes. A l’heure actuelle, il n’y a pas d’instrument de mesure disponible pour ce faire. Le test de concordance de script (TCS) est un instrument de mesure du raisonnement clinique qui pourrait être développé dans ce but. Cette étude méthodologique vise à élaborer un TCS évaluant le raisonnement clinique d’infirmières en contexte de détérioration clinique en milieu hospitalier et à évaluer ses qualités sychométriques, soit sa fidélité et sa validité, ainsi que son appréciation. Un TCS de 22 scénarios cliniques (88 items) a été conçu, puis administré à 47 infirmières au baccalauréat en sciences infirmières et 21 infirmières expertes. Douze des étudiantes ont rempli le test à nouveau pour un test-retest. Après son optimisation, il contenait 20 scénarios et 68 items. Il a obtenu un coefficient alpha de Cronbach de 0,76. L’étude de sa stabilité temporelle a révélé un coefficient de corrélation intra-classe modéré de 0,554 (p < 0,05). Les indices de la validité du contenu pour la pertinence et la clarté du TCS ont été de 0,99. Le TCS a aussi démontré une différence statistiquement significative dans les scores des deux groupes d’infirmières (p < 0,01) et une relation linéaire positive entre les scores moyens et l’expertise clinique (p < 0,01). Finalement, son appréciation générale a été jugée bonne. Cette étude a rendu disponible un TCS fidèle, valide et apprécié pour évaluer le raisonnement clinique infirmier en contexte de détérioration clinique en milieu hospitalier. Des études restent à faire pour déterminer si le TCS permet de déceler l’effet d’interventions éducatives.||Abstract: Hospitalised patients may present warning signs of clinical deterioration that are not always detected or well interpreted leading to preventable heart attack, intensive care unit transfer or even death. In order to recognize clinical signs of deterioration, nurses must have well developed clinical reasoning skills. Assessing nurse's clinical reasoning skills in situations of clinical deterioration could help to identify difficulties associated with the detection of its signs. At the present time no such tool for this purpose exists. Script concordance test (SCT) is a tool used to assess clinical reasoning that could be constructed for this purpose. This methodological study aims to develop a SCT to assess nurse's clinical reasoning in situations of clinical deterioration as well as to validate its psychometrics qualities, its validity, its reliability and the appreciation of the SCT. A SCT of 22 clinical situations (88 items) was developed. It was then completed by 47 nurses who were students undergoing their bachelor of nursing studies and by 21 expert nurses. Twelve students took the SCT twice to establish a test re-test. The SCT demonstrated good psychometrics qualities. After optimization, it had 20 clinical situations and 68 items. The SCT had a Cronbach's alpha coefficient of 0.76. The study of temporal stability demonstrated a moderate intra-class correlation coefficient of 0.554 (p < 0.05). Content validity generated indices of 0.99 both for relevance and clarity of the entire tool. TCS has also distinguished a statistically significant difference in the scores of the two groups of nurses (p < 0.01) and a positive linear relationship between mean scores and clinical expertise (p < 0.01). Finally, its overall appreciation is good. This study has made it possible to measure nurses' clinical reasoning skills in situations of in-hospital clinical deterioration using a reliable, valid and appreciated SCT. Other studies are needed to see if the SCT can detect the effect of educative interventions.

Le but de cette étude exploratoire est de déterminer si le test de concordance de script est un instrument capable de mesurer le raisonnement clinique d’étudiantes en formation et s’il peut déceler des différences entre le raisonnement clinique des novices et des expertes de la profession. Un TCS adapté au domaine des sciences infirmières et portant sur des champs particuliers de la pédiatrie a été administré à des candidates revendiquant différents niveaux d’expérience : des expertes du domaine (n=15), des infirmières (n=40) et des étudiantes de troisième année de formation (n=30). D’une durée de 20 minutes, le test a été pratiqué en ligne; il comptait 15 scénarios et 45 items au total. Les scores des étudiantes étaient significativement inférieurs aux scores des infirmières et des expertes. Le TCS est un instrument fiable et utile lorsqu’il s’agit de déterminer, en termes de raisonnement clinique, une différence de niveau entre la novice et l’experte.

BACKGROUND: Patient navigators have been shown to reduce cancer disparities among racial/ethnic minorities by improving timely diagnosis and treatment of cancer. We sought to determine if race/ethnicity and language concordance of patients and their navigator improved time to diagnostic resolution of breast and cervical cancer screening abnormalities. METHODS: Demographic data on patients and navigators from the Boston Patient Navigation Research Program were used to assess concordance by race, ethnicity, and language. Kaplan-Meier survival curves and Cox proportional hazards regression models examined the association of race/ethnicity and language concordance on time to definitive diagnosis of cancer screening abnormalities. All analyses were performed separately for breast and cervical groups. RESULTS: There were 1257 patients and 23 navigators in this study. In the breast group (n=655), 44% of patient-navigator pairs were concordant by race/ethnicity and 75% were language concordant. In the cervical group (n=602), 70% of patient-navigator pairs were race/ethnicity concordant and 87% were language concordant. There was no association with race/ethnicity concordance and time to diagnostic resolution for the breast group, aHR 1.19 (95% CI: 0.97, 1.46) or cervical group, aHR 1.23 (95% CI: 0.99, 1.53). However, in the stratified analysis, race/ethnicity concordance was associated with timelier resolution for minority women with breast and cervical cancer screening abnormalities but not for Whites. For cervical cancer screening abnormalities resolving in less than 90 days, language concordance was also associated with timelier resolution, aHR of 1.46 (95% CI: 1.18, 1.80) but there was no association in the breast group. In the subgroup analysis of Spanish concordance there was also an association of timelier resolution for those with cervical cancer screening abnormalities resolving in less than 90 days. CONCLUSION: Patient-navigator race/ethnicity concordance is associated with timelier diagnostic resolution of breast and cervical cancer screening abnormalities among minority women. Language concordance is also associated with timelier resolution in participants with cervical cancer screening abnormalities despite the availability and use of interpreters. Given poorer cancer outcomes among minority women, the use of patient navigators that are diverse by race/ethnicity and multilingual may help address barriers to care and improve health outcomes among low-income minorities.

Made available in DSpace on 2015-07-22T20:50:30Z (GMT). No. of bitstreams: 0 Previous issue date: 2008-07-30. Added 1 bitstream(s) on 2015-08-11T03:25:54Z : No. of bitstreams: 1 Publico-10999.pdf: 828663 bytes, checksum: 3120eb8cbe0dd912fe745f6d65d0f09e (MD5) / A avaliação da competência para o raciocínio clínico em situações de incerteza ainda é pouco pesquisada. Os testes escritos mais usados na educação médica são os testes de múltipla escolha. Embora estes sejam capazes de avaliar a capacidade para se lidar com problemas bem definidos, reconhece-se que, na prática, a maioria das situações contém incertezas. A tomada de decisões nesses contextos é um dos pilares da competência profissional. Compreender como isso se desenvolve pode contribuir com propostas de ensino com ênfase no aprimoramento dessa competência. Para tanto, a avaliação do raciocínio clínico em contextos de incerteza foi desenvolvida a partir da teoria de scripts, a qual explica o processo de raciocínio clínico, com base na metodologia descrita por Charlin et al. (2000). Os objetivos dessa pesquisa foram: desenvolver, aplicar e analisar um teste de concordância de scripts (TCS) com temas em geriatria. Um grupo de especialistas formou o painel de referência para a construção do escore do teste. O teste também foi aplicado em um grupo de estudantes de graduação. Da comparação dos resultados obtidos pelos dois grupos, chegou-se a indícios de validade do instrumento, que foi capaz de diferenciar o raciocínio clínico de acordo com o nível de experiência dos examinandos. As análises de consistência interna e de estudos G forneceram interpretações que se aproximaram da complexidade contida em um escore que busca avaliar a competência profissional. Os coeficientes de alfa de Cronbach e G foram calculados e discutidos segundo as qualidades e as limitações psicométricas dos resultados alcançados. Com isso, comprovou-se que o teste de concordância de script, com situações em geriatria, desenvolvido em língua portuguesa, em uma instituição de ensino brasileira, pode ser uma alternativa de avaliação do raciocínio clinico em contextos de incerteza. / Assessment of competency for clinical reasoning in contexts of uncertainty is still little studied. The assessment methodologies most applied in medical course are the multiple choice questions. Although these questions are appropriate to evaluate the capacity to solve well defined problems, it is recognized in practice most of situations are under uncertainty. Decision making in these situations becomes one of the supports of the professional competency. To understand how this process develops can contribute with educational propositions emphasizing the improvement of this competency. Therefore, a written test for the assessment of the clinical reasoning process in contexts of uncertainty could be helpful. For this purpose, it was developed an instrument of assessment based on the script cognitive theory that explains the clinical reasoning process, according to the description by Charlin et al. (2000). The purposes of this study were to develop, apply and analyze a script concordance test (SCT) in geriatrics. A group of experts constituted the reference panel for the construction of the test´s score. After that, the instrument was solved by a group of medical students. Comparing the results for both groups, it was achieved evidences of validation for the approach, which result was able to discriminate the clinical reasoning in agreement with the experience level of the examinees. Internal consistency and G test analyzes gave meanings close to the complexity of a score to measure a professional competency. Cronbach´s alphas and G coefficients were calculated and discussed to support psychometric qualities and limitations of results. Therewith, it has confirmed the script concordance test with geriatrics situations, developed in Portuguese, at a brazilian educational institution, can be an alternative to the assessment of clinical reasoning in contexts of uncertainty / TEDE / BV UNIFESP: Teses e dissertações

Submitted by Maria Creuza Silva (mariakreuza@yahoo.com.br) on 2014-07-16T20:12:35Z No. of bitstreams: 1 Dissertação Patricia Almeida Moreno. 2010.pdf: 828032 bytes, checksum: 344cf314c0512a27470bf97bf1f721c9 (MD5) / Approved for entry into archive by Maria Creuza Silva (mariakreuza@yahoo.com.br) on 2014-07-16T20:32:56Z (GMT) No. of bitstreams: 1 Dissertação Patricia Almeida Moreno. 2010.pdf: 828032 bytes, checksum: 344cf314c0512a27470bf97bf1f721c9 (MD5) / Made available in DSpace on 2014-07-16T20:32:56Z (GMT). No. of bitstreams: 1 Dissertação Patricia Almeida Moreno. 2010.pdf: 828032 bytes, checksum: 344cf314c0512a27470bf97bf1f721c9 (MD5) / Objetivo: Comparar o estado antropométrico dos idosos negros a partir do IMC obtido pela altura estimada e a altura convencional. Metodologia: Trata-se de um estudo transversal realizado em amostra populacional de negros dos distritos sanitários (DS) Barra- Rio vermelho e Liberdade, na cidade de Salvador-Ba, sendo a população final do estudo constituída por 383 indivíduos com idade ≥ 60 anos. As variáveis do estudo foram: medidas antropométricas ― peso, altura e altura do joelho, índice de massa corpórea, cor autorreferida, escolaridade, nível socioeconômico. Utilizou-se o teste t-student pareado para analisar as diferenças de médias das medidas antropométricas e o teste de qui-quadrado para analisar as diferenças de proporções dos estratos do diagnóstico nutricional à partir do IMC convencional e do IMC estimado. Para a classificação da concordância de IMC´s foram calculados os valores de Kappa. Resultados: Dos idosos estudados 60,8% estavam na faixa etária 60-69 anos, predominando o sexo feminino (69,2%). A análise de concordância do IMCE apresenta para magreza em homens e mulheres 72,0% e 83,4%, respectivamente. Os valores observados de Kappa elevados para magreza e sobrepeso em ambos os sexos indicam que o IMC cuja altura foi estimada pelo Knee-height tem boa concordância com aquele obtido a partir de medidas convencionais de peso e altura. Tanto para a altura convencional, quanto para a altura estimada houve uma redução da altura média com o aumento da idade. Conclusão: Diante dos resultados encontrados, sugere-se, então, que na prática nutricional da assistência ao idoso, seja considerada a medida do joelho na estimativa da altura para efeito de cálculo do IMC e considerando que esta técnica é de baixo custo e de fácil aplicação pode ser utilizada em ambiente ambulatorial, domiciliar ou hospitalar. / Objective: To compare the anthropometric status of elderly blacks from BMI obtained by the estimated height and conventional height. Methodology: This was a cross-sectional study in a population sample of black health districts (DS) Barra-Rio Vermelho and Liberdade in the city of Salvador-BA, and the final study population consisted of 383 individuals aged ≥ 60 years. The study variables were: anthropometric measurements - weight, height and knee height, body mass index, self-reported color, education, socioeconomic level. We used the paired Student t test to analyze differences in mean values of anthropometric measures and chi-square test to analyze differences in proportions of the strata of nutritional diagnosis from the conventional BMI and BMI estimated. For classification concordance of BMI's were calculated Kappa values. Results: Of the elderly studied 60.8% were aged 60-69 years, predominantly female (69.2%). Concordance analysis of IMCE presents for men and women were 72.0% and 83.4%, respectively. It was observed that the high Kappa values for thinness and overweight in both sexes indicate that BMI whose height was estimated by Knee-height is in good agreement with that obtained from conventional measurements of height and weight. Both for the conventional height, the estimated height to the height was reduced with increasing average age. Conclusion: Considering the results, it is suggested, then, that in practice the nutritional care of the elderly, is considered as the estimation of knee height to calculate BMI and considering that this technique is inexpensive and easy application can be used in an outpatient setting, home or hospital.

Submitted by Valquíria Barbieri (kikibarbi@hotmail.com) on 2018-04-11T20:19:04Z No. of bitstreams: 1 DISS_2014_Marisa Cristina Lários Vieira.pdf: 621828 bytes, checksum: 6fb30defa70375c6da6f1e09459a02a0 (MD5) / Approved for entry into archive by Jordan (jordanbiblio@gmail.com) on 2018-04-26T17:54:43Z (GMT) No. of bitstreams: 1 DISS_2014_Marisa Cristina Lários Vieira.pdf: 621828 bytes, checksum: 6fb30defa70375c6da6f1e09459a02a0 (MD5) / Made available in DSpace on 2018-04-26T17:54:43Z (GMT). No. of bitstreams: 1 DISS_2014_Marisa Cristina Lários Vieira.pdf: 621828 bytes, checksum: 6fb30defa70375c6da6f1e09459a02a0 (MD5) Previous issue date: 2014-12-18 / CNPq / A análise de congruência em comunidades é utilizada para verificar se grupos biológicos apresentam padrões de distribuição semelhantes ao longo de um gradiente ambiental. Quando ocorre congruência entre os grupos, é possível a seleção de um grupo biológico para monitorar outros, denominado grupo substituto. Nesse contexto, avaliei a congruência entre sete grupos biológicos, para a seleção de um possível grupo substituto. Avaliei também a influência dos fatores espacias e ambientais no padrão de congruência entre os grupos. Os dados foram coletados em um sítio de pesquisa de longa duração no Pantanal brasileiro nos anos de 2006 e 2007 no período da seca. Os grupos biológicos utilizados foram: plantas herbáceas, plantas lenhosas, anuros, aves, morcegos, aranhas e pequenos mamíferos. A congruência entre os grupos foi avaliada utilizando o teste de Mantel, e aquele que apresentou a maior média de coeficiente de correlação (r) foi considerado o melhor grupo substituto. Através da partição de variância, avaliei a influência dos fatores ambientais e espaciais na estruturação da comunidade e sua influência na congruência. Como variáveis ambientais, utilizei dados da estrutura física do solo (silte e argila), inundação (duração e amplitude), altitude e estrato da vegetação, e como preditores espaciais usei mapas de autovetores de Moran. O grupo de plantas lenhosas apresentou a maior média de coeficiente de correlação, seguido por herbáceas, aranhas, anuros, aves e pequenos mamíferos. O maior valor de congruência foi encontrado entre herbáceas e plantas lenhosas, e o menor, entre morcegos e herbáceas. Os preditores ambientais que mais influenciaram na estrutura da comunidade vegetal foram os ligados à inundação, e grupos da fauna apresentaram maior influência da vegetação. Deste modo, concluo que o grupo plantas lenhosas é capaz de representar a diversidade dos demais grupos, simplificando o monitoramento ambiental. / The congruence analysis in communities is used for check if biological groups show the same patterns of distribution along an environmental gradient. When occurs congruence between groups is possible the selection of one biological group for to monitor others, called surrogate. In this context, I evaluated the congruence between seven biological groups for selection of one possible group. I also evaluated the influence of spatial and environment factors in pattern of congruence between of these groups. Datasets was collected in a longterm research site in the Brazilian Pantanal in 2006 and 2007 during dry season. The biological groups used were: herbaceous plants, woody plants, frogs, birds, bats, spiders and small mammals. The congruence between groups was evaluated using Mantel test, and one who showed the bigger average of correlation coefficient (r) was considered the best surrogate. Through of partitioning of variation, evaluated the influence of spatial and environmental factors in community structure and your influence in congruence. How environmental variables, I used the physical structure data of soil (silt and clay), flood (duration and amplitude), altitude and stratum of vegetation, and as spatial predictors used maps eigenvectors Moran. The woody plants group showed the better average of correlation coefficient, followed for herbaceous, spiders, frogs, birds and small mammals. The higher value of congruence was found between herbaceous and woody plants, and the lower, between bats and herbaceous. The environmental predictors that has more influence in the community structure are linked the flood, and groups of fauna showed higher influence of vegetation. This way, I conclude that woody plants group is able of represent the biodiversity of others groups, simplifying the environmental monitoring.

Abstract In this thesis, I studied the patterns in the assemblage composition as well as the biogeography and ecology of spring macroinvertebrates and bryophytes in Finland. My main objectives were to assess the importance environmental variables to macroinvertebrate and bryophyte assemblage composition in springs at the level of multiple spatial scales. In addition, I assessed the importance of springs in the boreal mire landscape, and sought the ecological and environmental determinants of a key species in boreal springs. In a large-scale study, I also examined the concordance between macroinvertebrates and bryophytes across boreal ecoregions, and assessed how macroinvertebrate assemblage variation corresponds to terrestrially-based ecoregions. Locally, spring macroinvertebrate assemblage structure displays high variation between different kinds of mesohabitats within springs, highlighting the importance of careful sampling of all habitat types in spring surveys. Helocrenes and other aquatic-terrestrial ecotone habitats harbour the highest species diversity and most spring-dependent species among spring habitat types. Further, spring-influenced mire patches were shown to have distinct cranefly assemblages in the mire landscape and to harbour higher cranefly diversity than mire types with lower trophic status, emphasising the importance of springs for mire biodiversity. Regionally, a red-listed spring-dependent caddisfly species appeared to be a surrogate for a high spring conservation value, indicating high overall species diversity and the occurrence of additional red-listed species. On a large geographical scale, intersecting the boreal ecoregions, a pattern of gradual change of benthic macroinvertebrate assemblage composition from south to north was detected, largely corresponding to terrestrially-derived ecoregions. However, the physical attributes of springs also need to be taken into account in bioassessment studies. Macroinvertebrate assemblage variation also correlated with physical habitat-scale variables, but not with changes in water chemistry. In contrast, spring bryophyte assemblages showed a distinct response to variation in water chemistry, but not to variation in physical habitat characteristics. Bryophytes and insect assemblages were concordant with each other on the large geographical scale, although the concordance was rather weak. Because of their different kind of responses to the physical and chemical variables, insects and bryophytes of springs are poor surrogates for each other in boreal springs.

Le but de cette étude exploratoire est de déterminer si le test de concordance de script est un instrument capable de mesurer le raisonnement clinique d’étudiantes en formation et s’il peut déceler des différences entre le raisonnement clinique des novices et des expertes de la profession. Un TCS adapté au domaine des sciences infirmières et portant sur des champs particuliers de la pédiatrie a été administré à des candidates revendiquant différents niveaux d’expérience : des expertes du domaine (n=15), des infirmières (n=40) et des étudiantes de troisième année de formation (n=30). D’une durée de 20 minutes, le test a été pratiqué en ligne; il comptait 15 scénarios et 45 items au total. Les scores des étudiantes étaient significativement inférieurs aux scores des infirmières et des expertes. Le TCS est un instrument fiable et utile lorsqu’il s’agit de déterminer, en termes de raisonnement clinique, une différence de niveau entre la novice et l’experte.

BACKGROUND: The United States maternal mortality ratio (MMR) has increased in the past few decades and disparities that negatively impact birthing individuals of color persist. While there are many potential causes for health inequity, distinct factors such as obstetric racism, lack of informed and shared decision-making approaches, and lack of continuous birthing support can prevent positive birthing outcomes. The present study investigates the impact of doula support on perinatal mood disorders while also evaluating potential differences in racial/cultural concordance and cultural competence in the context of the doula-patient relationship, in a Northeastern U.S. urban setting. METHODS: Seven focus group discussions (FGDs) were conducted amongst prenatal and postpartum patients (n=9) and actively practicing doulas (n=18). Participants shared their thoughts and lived experiences related to doula support during the perinatal period through open-ended questions. Researchers transcribed qualitative data from FGDs and analyzed them using a modified grounded theory approach. RESULTS: Five major themes emerged from qualitative data analysis: (1) doula support can reduce stress during the perinatal period, (2) doulas can make the process of seeking out mental health support more efficient, (3) cultural competency in doula care is a learning process (4) racial concordance does not guarantee successful doula-patient relationships, and (5) doulas play an important role in the decision-making process. CONCLUSIONS: The presence of doula support can combat perinatal mood disorders through two pathways identified in the present study. Although there may be distinct differences between culturally competent versus culturally congruent doula-patient relationships, matching by race or culture is not the solution to a fulfilling relationship. Doulas practicing cultural competence and cultural humility – regardless of client background – can make a meaningful impact on the perinatal experience and long-term mental health outcomes. / 2022-11-10T00:00:00Z

Le test de concordance de script (TCS) est un outil qui vise à mesurer le raisonnement clinique (RC) des apprenants en contexte d’incertitude en comparaison à celui des experts. La nature de cet instrument fait en sorte que le processus de détermination des scores est névralgique et influence ainsi l’interprétation de ces derniers. Le but de cette recherche à caractère exploratoire était d’examiner l’impact de trois méthodes de détermination des scores sur les propriétés métriques des scores obtenus avec un TCS. Nous avons réalisé une analyse secondaire de données recueillies entre 2010 et 2014 auprès de 160 étudiants inscrits dans un programme de médecine familiale à l'Université de Liège en Belgique. Ainsi la théorie classique des tests et le modèle de Rasch ont été mis à contribution. Selon les résultats obtenus, la méthode selon la bonne réponse n’est pas recommandée. En revanche, la méthode des scores combinés très utilisée dans le contexte du TCS n’a pas prouvé, selon nous, sa supériorité sur la méthode avec pénalité de distance. D’autres études s’avèrent nécessaires pour approfondir ces résultats.