Forskning visar på att patienter önskar kontinuitet, då de upplever att det bidrar till känslan av trygghet och närhet. Det ger sjuksköterskan möjlighet att lära känna personen och en möjlighet att bättre följa upp gjorda åtgärder. Syfte Syftet med denna studie var att beskriva vilka faktorer som har samband med patientens upplevelse av kontinuitet i vården. Metod Studien har genomförts som en litteraturstudie. Resultat Resultatet visade att det var viktigt för kontinuiteten att de fick träffa en sjuksköterska som de kände sedan tidigare och att det var samma sjuksköterska vid alla vårdtillfällen. Det var även viktigt att sjuksköterskan de träffade var uppdaterad på deras medicinska historia. En viktig faktor som höjde kontinuiteten var om patienten hade en kronisk sjukdom, då de patienterna oftare kräver regelbunden uppföljning med fler besök hos vården. Patienterna upplevde större kontinuitet om vården utfördes av sjuksköterska istället för av andra vårdgivare Sjuksköterskorna var mer anpassningsbara, flexibla och tog sig mer tid med patienten. Slutsats Studien visar att kontinuitet är något som patienter upplever som viktigt när de möter vården men det saknas forskning om hur vården ska organiseras, för att kontinuiteten ska upplevas bättre ur ett patientperspektiv, balanserat mot organisationens behov av att spara tid och pengar. / Research shows that patients wants continuity, as they feel it adds to the feeling of security and closeness That it gives the nurse the opportunity to get to know the person and an opportunity to better follow up actions. Aim The aim of this study was to investigate the factors that influence patient perception of continuity of care. Method This study was conducted as a literature review. Result The results showed that it was important for the continuity that they got to meet a nurse they knew from before, and it was the same nurse at every appointment. It was also important that who they met, was up to date on their medical history. An important factor that increased continuity was if the patient has a chronic disease, which increases the need to require regular follow-up with more visits to health care. Patients experienced greater flexibility of care performed by a nurse instead of a doctor, the nurses took more time with the patient and that it was more effective. Conclusion The study shows that continuity is important when patients recieve care, but there is no research about how care should be organized, for continuity to be perceived better from a patient perspective, balanced against the needs of the organization to save time and money.

This thesis considers three physician scheduling problems in health care systems. Specifically, we focus on improvements to current physician scheduling practices through the use of mathematical modeling. In the first part of the thesis, we present a physician shift scheduling problem focusing on maximizing continuity of care (i.e., ensuring that patients are familiar with their treating physicians, and vice versa). We develop an objective scoring method for measuring the continuity of a physician schedule and combine it with a mixed integer programming model. We apply our methods to the problem faced in the pediatric intensive care unit at Children's Healthcare of Atlanta at Egleston, and show that our schedule generation approach outperforms manual methods for schedule construction, both with regards to solution time and continuity. The next topic presented in this thesis focuses on two scheduling problems: (i) the assignment of residents to rotations over a one-year period, and given that assignment, (ii) the scheduling of residents' night and weekend shifts. We present an integer programming model for the assignment of residents to rotations such that residents of the same type receive similar educational experiences. We allow for flexible input of parameters and varying groups of residents and rotations without needing to alter the model constraints. We present a simple model for scheduling 1st-year residents to night and weekend shifts. We apply these approaches to problems faced in the Department of Surgery Residency Program at Emory University School of Medicine. Rotation assignment is made more efficient through automated schedule generation, and the shift scheduling model allows us to highlight infeasibilities that occur when shift lengths exceed a certain value, and we discuss the impact of duty hour restrictions under limitations of current scheduling practices. The final topic of this thesis focuses on the assignment of physicians to various tasks while promoting equity of assignments and maximizing space utilization. We present an integer programming model to solve this problem, and we apply this model to the physician scheduling problem faced in the Department of Gynecology and Obstetrics at Emory University Hospital and generate high quality solutions very quickly.

Existing scholarship on modern Tibetan writing takes the 1980s as its point of “birth” and presents this period as marking a “rupture” with traditional forms of literature. This study seeks to go beyond such an interpretation by foregrounding the persistence of Tibet’s artistic past and oral traditions in the literary creativity of the present. An appreciation of genres, styles, concepts and techniques derived from Tibet’s rich and diverse oral art forms and textual traditions exposes the inadequacy of a simple “rupture” perspective. Whilst acknowledging the novel features of modern Tibetan literary creations this work draws attention to hitherto neglected aspects of continuities within the new. It reveals the innovative presence of Tibetan kāvya poetics, the mgur genre, biography, the Gesar epic and other types of oral compositions within modern Tibetan poetry and fiction. It also brings to prominence the complex and fertile interplay between orality and the Tibetan literary text. All these aspects are demonstrated by bringing the reader closer to Tibetan literature through the provision of original English translations of various textual and oral sources. Like any other national literature modern Tibetan literary production is also informed by socio-political and historical forces. An examination of unexplored topics ranging from popular music, Tibet’s critical tradition and cultural trauma to radical and erotic poetries shows a variety of issues that fire the imagination of the modern Tibetan writer. Of all these concerns the most overriding is the Tibetan nation, which pervades both fictional and poetic writing. In its investigation into modern Tibetan literature this thesis finds that Tibet as a nation - constituted of history, culture, language, religion, territory, shared myths and rituals, collective memories and a common sense of belonging to an occupied land - is inescapable. Embracing a multidisciplinary approach drawing on theoretical insights in literary theory and criticism, political studies, sociology and anthropology, this research demonstrates that, alongside past literary and oral traditions, the Tibetan nation proves to be an inevitable attribute of modern Tibetan literature.

Graphicacy is the fundamental human capability of communicating through still images. Graphicacy has been described as the fourth ace within education, alongside literacy, numeracy and articulacy. However, it has been neglected, both within education and the research field. This thesis investigates graphicacy and students learning, structured around 3 objectives: establishing what graphicacy is and how it is used in the school curriculum; demonstrating the wider significance of design and technology teaching and learning by collecting evidence of the importance of graphicacy across the curriculum; and establishing how the abilities to understand and create images affect students learning. A literature review was conducted focused on three areas. Firstly, identifying the meaning of graphicacy, elements contained within it and relevant prior studies including its use in different subject areas and image use within teaching. This formed the foundations for a new taxonomy of graphicacy. Secondly, the levels of drawing and developmental stages children go through were investigated and the need for further research on children s abilities aged 11 to 14 was identified. The well balanced arguments concerning the nature versus nurture debates are described. Thirdly, the methodology used to measure graphicacy, and map the results to reflect levels of different competencies were reviewed. A naturalistic and often opportunistic approach was followed in this research. The research methodology was based on the analysis of textbooks and later, on research within practice. The research included the development, validation and use of the taxonomy of graphicacy; case studies in Cyprus, the USA and England on identifying graphicacy use across the curriculum; and the creation of continuity and progression descriptors through the analysis of students work. This work covered: rendering, perspective drawing, logo designing, portrait drawing and star profile charts. Research methodologies developed and implemented for conducting co-research and the Delphi studies are also described. Through interviews with experts, the taxonomy was validated as an appropriate research tool to enable the identification of graphicacy use across the curriculum. These research studies identified links between design and technology and all other subject-areas studied. Similar patterns of graphicacy use were identified across 3 schools, one in Cyprus, USA and the UK. Photographs were the most commonly used graphicacy element across all subject areas studied. Design and technology within England was found to use the widest variety of graphicacy elements, providing evidence towards research objective 3; establishing how the ability to understand and create images affects students learning. Continuity and progression (CaP) descriptors were created for each area covered by this research. The success of the CaP descriptors relied on the technical complexity involved in the creation of each image. Some evidence was found concerning the limits of natural development and how nurture can further develop graphicacy skills. In addition, co-research as a methodology, its limitations and potentials are identified.

During the 1980s, it was frequently claimed that spatial patterns of archaeological and contemporary settlements were closely related to the social nature of the societies which had created and modelled them (Hietala 1984; Hillier & Hanson 1984). Despite a decade of alternative claims, such theories are still widely accepted although in many cases the emphasis has shifted from economic factors to symbolic or social ones. The presence of a class-based social system is one of the major characteristics of Iranian society during the Sasanian era (224-651 CE). This social system was based upon the official religion of Sasanians - Zoroastrianism - and had a major impact on most aspects of Iranian society during this period. The far-reaching impact of this social system on architectural space and urban infrastructure is clearly representative of a class-based society. The collapse of the Sasanian world, accelerated by Arab invasions (641 CE), severely reduced the dominance of Zoroastrianism within Iran, heralding a fundamental change in the social life of its people. These changes, accompanied by the acceptance of a new religion, have been the focus of several researchers over the last decades (Kennedy 2001). In contrast to Sasanian society, Early Islamic social structure was characterised as one of equality and its urban forms as ones with little differentiation as typified by Medina (Zarrinkub 1993). The aim of this dissertation is to test the above assumptions and models with reference to a single urban site - the city of Barn. Selected due to its Pre-Islamic and Islamic occupations, its excellent state of preservation allows a full testing of the above assumptions through archaeological analysis. The results of this research indicate a continuation of patterns of Sasanian space and society into the Islamic period. In addition, the space and society of Bam, documented in this research, provides an important step towards a further understanding of the social and spatial organisation of Sasanian and Early-Islamic cities, as well as providing a foundation for additional research in this field.

Land is a critical element in the formation of, maintenance and continuance of Native identity to tribes in North America. Since time immemorial, Native people have occupied these landscapes in a manner than can perhaps be best described as "persistent." Native views of the land can differ significantly from those of a Western, or Anglo-American tradition. And when managers of these lands come from a Western tradition, dissimilar views on how these lands should be used can become very problematic for Native people. This research examines how five tribes (Pueblo of Acoma, the Hopi Tribe, Pueblo of Laguna, Navajo Nation and Pueblo of Zuni) view their identity and future cultural continuity as their ancestral homelands are inundated by competing uranium mining interests that threaten to destroy the Mount Taylor landscape of northern New Mexico.

Vårdpersonal och allmänheten uttrycker ofta negativa attityder till patienter som är överviktiga. Antalet patienter som genomgår en operation för sin övervikt ökar för varje år. Det är en omvälvande operation för patienten och patienter söker mycket information innan operationen. Den perioperativa dialogen, en ideal arbetsmodell har tidigare prövats på andra patientgrupper men inte på patienter som skall genomgå en operation för sin övervikt.  Syfte med studien var att beskriva patienters upplevelse av sin övervikt och hur kontinuiteten i den perioperativa dialogen kan ge lindrat lidande i samband med operation för övervikt. Studien har en hermeneutisk design. Data samlades in med hjälp av den perioperativa dialogen som dokumenterats vid sjuksköterskans möte med 26 patienter. Data tolkades genom hermeneutisk texttolkning. Resultatet beskrivs i två huvudteman Att leva i en överviktig kropp och Kontinuiteten i den perioperativa dialogen skapar möjligheter för lindrat lidande. Övervikten hindrar patienter i det dagliga livet både fysiskt och psykiskt, vilket tär på krafter och erfars som en lidande kropp. Genom den perioperativa dialogens kontinuitet lindras oro och tryggheten ökar, patienter upplever att de får vara med och planera, påverka och genomföra sin vård. Delaktighet minskar oron och därmed lidandet för patienten. Den perioperativa dialogen borde vara en självklarhet eftersom förtroende och trygghet skapas genom kontinuitet och patienten får möjlighet att bevara sin autonomi.  Utan kontinuiteten i den perioperativa vården försvinner patientens möjlighet till delaktighet i sin vård. / Health professionals and the public often have negative attitudes towards patients who are overweight. The number of patients undergoing surgery for their obesity is increasing every year. A surgery for obesity is a major change for the patient and patients seek a lot of information before surgery. The perioperative dialogues have been tried in other patient groups before but not in patients with overweight. The overall aim of the study was to describe how anesthesia and theatre nurses through the continuity of the perioperative dialogue can alleviate suffering of the patient during a surgery for obesity. The study has a hermeneutic design. Data were collected with the help of the perioperative dialogue as documented on the nurse's meeting with 26 patients. Data were interpreted through a hermeneutic text interpretation.The results are described in two main themes To live in an overweight body and Continuity in the perioperative dialogue creates opportunities for the alleviation of suffering. Obesity hinders patients in daily life both mentally and physically, which is putting a strain on their forces, and is experienced as a suffering body. Through the perioperative dialogue continuity reduces anxiety and increases safety. Patients feel that they may be involved in planning, influencing and implementing their care. This participation reduces anxiety and therefore the suffering for the patient. The perioperative dialogue should be obvious as the confidence and safety created by the continuity and patients should be able to maintain its autonomy. Without continuity in the perioperative care disappear the patient's ability to participate in their care. / Den perioperativa dialogen - ett applicationsmoment som skapar kontinuitet

Résumé : La qualité des services est considérée de plus en plus comme un paramètre essentiel de la conception des services sociosanitaires (MSSS, 2005). Selon les divers modèles théoriques de la qualité des services (Donabedian, 1980; Kroger, 2007; OMS, 2004), la continuité des services en constitue une composante importante, surtout pour une organisation des services qui se veut de plus en plus intégrée. La continuité est abordée ici en s'appuyant sur la définition tridimensionnelle qu'en donnent Reid, Haggerty & McKendry, (2003). Elle est relationnelle, ce qui implique l'existence de rapports significatifs entre professionnels et usagers. Elle est informationnelle, ce qui suppose de rendre accessibles aux professionnels les informations requises pour l'exercice de leurs fonctions. Enfin, il faut ajouter la dimension d'approche, laquelle renvoie à la cohérence des diverses actions accomplies pour le bien-être et au bénéfice de l'usager. Le dossier clinique se présente comme une fenêtre par laquelle les trois objets que sont la qualité des services, l'intégration des services et la continuité des services peuvent se révéler et s'articuler. Pourtant, peu de recherches ont analysé le dossier clinique spécifiquement sous cet angle, privilégiant plutôt les études portant sur sa conformité à certaines normes (audits) ou l'utilisation des dossiers cliniques dans une optique de triangulation des données. La présente étude aborde le dossier clinique en tant qu'observatoire de la continuité. Cette position s'explique par les contextes social et scientifique actuels, qui considèrent la continuité comme une dimension transversale de la qualité (Kroger et al. 2007) et la voient comme à la fois une condition et un effet de l'intégration des services. Notre étude vise à repérer et à catégoriser des indices de continuité des services tels qu'on les retrouve dans des dossiers cliniques d'usagers inscrits en gestion de cas, et ce, dans le but de contribuer à l'accroissement de la qualité dans les services dispensés aux personnes âgées. En identifiant les façons dont les professionnels inscrivent des traces de continuité dans les dossiers cliniques des usagers et en dégageant les composantes de la continuité qui sont présentes dans les rédactions, la pertinence de l'usage des dossiers cliniques dans l'analyse de la continuité est précisée et quelques pistes méthodologiques d'analyse de la continuité des services peuvent être esquissées. Nous avons procédé à l'analyse de 16 dossiers cliniques de personnes âgées de 75 ans et plus, qui vivent dans deux territoires où existent des réseaux intégrés de services et qui sont inscrites en gestion de cas depuis au moins six mois. L'information contenue dans les dossiers cliniques des usagers a été extraite à l'aide d'outils conçus à cette fin spécialement pour notre étude. L'approche qualitative que nous mettons à contribution opère un double mouvement analytique de déduction et d'induction des formes de continuité que l'on retrouve dans les dossiers cliniques. Précisons que cette étude s'inscrit dans le cadre d'une plus grande recherche portant sur la fragilité (IRSC team onfrailty) que dirigent François Béland et André Tourigny. Nos résultats indiquent que les dossiers cliniques se révèlent un excellent observatoire de la continuité, bien que ce soit avec une pertinence variable selon la dimension retenue. Ainsi, le principal obstacle à la continuité informationnelle réside dans la difficulté à maintenir à jour les documents standardisés (OÉMC et PIAS, notamment). De même, la continuité relationnelle a pu être appréhendée en termes de permanence de la présence des intervenants dans le dossier clinique de l'usager, même si la qualité de la relation entre le professionnel et l'usager n'y est pas explicite. Enfin, s'agissant de la continuité d'approche, la fragmentation du dossier clinique et l'absence de description des processus de prise de décision clinique rendent son évaluation plus problématique. Une bonne partie du caractère incomplet du dossier clinique pourrait être facilement comblée, ce qui aurait pour effet de placer les pratiques de rédaction utilisées par les professionnels en phase avec les changements qui surviennent dans la conception de la qualité et dans l'organisation des services||Abstract : The quality of services is more and more often viewed as a parameter which plays a crucial role in the conception of socio-sanitary services. According to the diverse theoretical models that seek to define the concept of quality of care (Donabedian, 1980; Kröger, 2007; OMS, 2004), continuity of services represents an important dimension of the quality of care, specifically for a services organization that sees itself as a structure that is more and more integrated. Our point of view on continuity is based essentially on the tridimensional definition of continuity given by Reid, Haggerty & McKendry, (2002). Firstly, relational continuity implies the existence of significant relationships that take place between professionals and services users. Secondly, informational continuity supposes that the professionals involved have access to the information they need in order to accomplish their tasks. Thirdly, management continuity refers to the coherence between the various actions that are undertaken by diverse professionals for the benefit and well-being of services users. The clinical record can be likened to a window through which three objects, the quality of services, the integration of services, and the continuity of services, can appear and form a structure. However, very few researches tried to understand the clinical record in that specific perspective, preferring to focus their attention on the study of audits and on utilization of clinical records in a perspective of data triangulation. Our study considers the clinical record as an observatory of the continuity. The adoption of this specific point of view is best explained by the existing social context and scientific context, which consider the continuity as a cross-sectional dimension of the quality as well as both a cause and an effect of the services integration. Our study aims to identify and categorize the continuity indicators that appear in the clinical records of the services users that were admitted in case management, with the objective of increasing the quality of services provided to the elderly population. In identifying the different ways by which some professionals leave their marks of continuity in the clinical records and recognizing the elements that define continuity and that those professionals take into account when writing their observation notes, the relevance of using clinical records in order to understand the concept of continuity of services is duly confirmed, and some methodological tracks to enhance the study of the continuity of services can be made. We analysed the clinical records of 16 older people aged 75 and more who are living in a territory where there is an integrated services network and who were admitted in case management since at least six months. Data that were contained in the users' clinical records were extracted using instruments that were specialty created for our study. With its double analytic process of deduction and induction, the qualitative approach we utilize seeks to understand the dimensions of the continuity that are present in the clinical records. Our study is part of a bigger research on frailty, namely the CIHR Team in Frailty and Aging, which is led by François Béland and André Tourigny. Our results show that the clinical records represent a very good observatory of continuity, but with more or less relevance depending of the dimension of the continuity that is involved. Thus, the most important obstacle to informational continuity lies in the fact that it is difficult to keep the standardized documents up to date. Similarly, the relational continuity was evaluated taking into account the permanency of the professionals' presence in the clinical records, but the quality of the relationship between professionals and users is not explicit. Finally, concerning the management continuity, the fragmentation which characterizes the clinical record and the absence of description of the decision-making process render the estimation of management continuity much more hazardous. A good part of the sketchy nature of the clinical record could easily be taken care of and completed, which would have the effect of putting the professionals' recording habits in phase with the changes that take place in the conception of the quality and in the services organization.

Regarding class transovers, there is a common problem when teachers of the first grade take over a new class. The problem is that the new teachers do not receive enough information about the pupils’ earlier knowledge from their development in school. It is also known that the writing education is one of the most important duties for teachers to teach pupils. The ability of writing thoughts into words is a source of communication between the writer and the reader. An undeveloped writing ability will cause a lack of communication for the pupils. The purpose of this study is to examine how individualizing is done at the transitions from pre-school to first grade. The study also explores how and with which methods teachers work with an individualized writing education in the subject Swedish in first grade. The study will also examine the possibilities and difficulties that can occur at an individualized writing education. I prepared three following questions to answer the aim of this study: How does the individualizing in class transfers look like from pre-school to first grade? How and with which methods teachers individualize the writing education in first grade? Which possibilities and difficulties can occur with an individualized writing education? The study is based on interviews with four pre-school teachers and four first grade teachers to get answers for this study’s aim. The study is also based on theories about transfers and individualized education. The results showed that pre-school teachers and first grade teachers do not have a clue about how the other teacher works with the pupils. The study shows that first grade teachers do not receive the information they need to individualize the education for the pupils. The results also show that all the teachers have a positive attitude to individualizing in the education, but are unable to plan individualized lessons and assignments for each student because of their lack of time and big classes.

Stroke is one of the major causes of eating difficulties (EDs). It is one of the leading causes of death and disability and one of the most important factors contributing to health-care costs. There is a clear association between EDs after stroke and undernutrition, where studies have shown that structured screening of eating function among stroke patients can predict nutritional problems as well as need for subsequent institutional care. Reliable and valid instruments that can identify EDs exist, but there is lack of knowledge on how persons experience living with EDs after stroke. Stroke unit care is evidence-based and grounded in multidisciplinary collaboration and continuity of care. The overall aim of this thesis is to explore and describe EDs after stroke as represented by health care professionals in patient records (PRs) and transferred information, and as described by persons living with EDs after stroke. An additional aim is to explore methodological aspects related to the inclusion of persons with EDs and communication impairment in research studies. Both quantitative and qualitative methods were used. Two studies used descriptive designs (I, II), one an explorative design (III) and one applied a methodological discussion (IV). In one of the studies PR data were used (I), in another study data were derived from three sources: PRs, screening of patients and interviews with nurses (II). Persons with EDs after stroke participated in Study III while literature, empirical data and researchers' experiences served as the data in study IV. Data were analysed by categorisation of phrases (I), content analysis (II) and descriptive statistics (I, II), by qualitative analysis (III) and by processing of literature and empirical findings in two research groups (IV). The main findings from the studies on representation of stroke care in PRs (I, II) showed that, despite that >50% of patients in Study I and all patients in Study II had EDs, there were few signs of multidisciplinary collaboration dealing with this problem. Unsystematic screening for swallowing difficulties was routine, whereas screening for nutritional risk and EDs was lacking (I, II). Multidisciplinary discharge summaries proved to have low quality and entailed little information on patients' eating ability (I). The two EDs most frequently documented were swallowing and lack of energy to complete a meal (I,II). EDs were described in vague terms (I, II). In Study II, all patients had swallowing difficulties and most patients had lack of energy to complete a meal. The electronic information transfer tool held information on eating ability for most patients (II), but the nursing staff in residential home care perceived deficiencies in that information, even identifying several EDs not reported at discharge (II). Experiences from persons living with EDs after stroke were presented in one main theme: Striving to live a normal life, including three sub-themes: Abandoned to learn on one's own (little support from health care professionals to learn to handle eating), Experiencing losses (loss of eating functions and loss of valued activities) and Feeling dependent in mealtime situations (III). One major finding from the methodological exploration (IV) is that creative approaches and suitable methods for inclusion of participants with EDs and communication impairment into qualitative studies can be found in the fields of aphasiology and learning disabilities. Another major finding from Study IV is that researchers need good communication skills as well as knowledge in neuropsychology. A general conclusion is that screening for EDs should be routine in stroke care and that a multidisciplinary terminology to express EDs must be developed to provide accurate information transfer. Health care professionals need to enhance their knowledge in nutrition and provide support to stroke patients with EDs with the goal that they can eat and perform meal-related activities in accordance with their habits before the stroke. To gain access to the experiences of persons with EDs and communication impairment researchers need to test participatory approaches when planning for inclusion of those persons.