Dans cette thèse, nous avons travaillé sur les différents versants de la technique de dissection sous-muqueuse et les problèmes que pose ce geste quasi chirurgical dans des unités d'endoscopie initialement médicales. Tout d'abord, nous avons travaillé sur la formation à la technique en développant un modèle d'apprentissage sur colon de bovin plus adapté à la situation européenne où les lésions colo-rectales sont les plus fréquentes. Ce modèle de rectum de bovin, simple à trouver et à préparer permet une formation dans des conditions plus proches de la paroi colique humaine que celles offertes par l'estomac de cochon. Un travail à plus grande échelle évaluant les bénéfices d'une aide à l'apprentissage par un logiciel interactif dédié mené sur ce modèle avec 37 étudiants français et japonais est en cours d'analyse et sera publié prochainement. Ensuite, nous avons réfléchi à la stratégie de la procédure pour la rendre plus simple en évaluant précocement la technique du tunnel pour la dissection des lésions œsophagiennes. Cette stratégie permet de maintenir une traction sur les bords lésionnels et nous offrent une sorte de triangulation en élargissant physiquement la zone de travail. Cette stratégie est devenue un standard pour les résections œsophagiennes dans de nombreuses équipes. Enfin, nous avons travaillé conjointement avec la société Nestis® au développement d'un outil permettant d'optimiser la procédure de dissection sous-muqueuse en associant les bénéfices des bistouris bi fonction (injectant et coupant avec le même outil}, de la haute pression pulsée et des solutions macromoléculaires visqueuses. Le système Nestis® permet pour la première fois cette association et a démontré son intérêt en termes de sécurité et de performance par rapport à la méthode classique utilisant l'aiguille et un bistouri électrique conventionnel. Avec cet outil bi fonction, il n'est plus nécessaire de changer d'instrument puisque toutes les étapes de la procédure sont désormais réalisées avec un seul et même outil. D'autres projets sont déjà prévus avec ce matériel pour étudier ses bénéfices et sa sécurité en dissection colique humaine qui est réputée comme la plus difficile compte tenu de la finesse de la paroi. Enfin, ce matériel offre la possibilité d'injecter sous pression des principes actifs qui pourrait dans le futur permettre de prévenir la survenue de sténoses œsophagiennes ou diriger la cicatrisation. Nous avons ainsi travailler avec la pharmacie de l'hôpital Edouard Herriot pour stabiliser la solution macromoléculaires de mélange de glycérol pour permettre son utilisation en pratique quotidienne / First of all, we worked on the training for unexperienced operators by developing a bovine colon model more adapted to the European situation where colo-rectal lesions are the most common. This model of rectum from bovine, easy to find and to prepare allows training in conditions most close to the human colonic wall than those offered by the pig stomach. Furthermore, such models allows to teach the initial skills but avoiding the risk of adverse events for the first procedures in humans. A future work evaluating the benefits of a learning support by a dedicated interactive software on this model with 37 french and Japanese students is now being analyzed and will be reported soon. Then we thought about the strategy of the procedure in order to make it more simple using the tunnel technique to perform ESD for the esophageal lesions. This strategy helps to maintain traction on the edges and offers a sort of triangulation physically expanding the working space. This strategy has become a standard for esophageal resections in many teams and we still work to improve its efficacy. Finally, we worked jointly with Nestis® Company to develop a tool to optimize the submucosal dissection procedure by combining the benefits of the catheters bi function (injecting and cutting with the same tool), but adding high pulsed pressure and capability to inject viscous macromolecular solutions. The Nestis® system allows for the first time this association and demonstrated his interest in terms of security and performance compared with the conventional method using the needle and a conventional electrocautery device. With this bi function tool, it is not necessary to change instrument frequently since all stages of the procedure are now done with a single device. Other projects are already included with this material to explore its benefits and its safety in human colonic dissection that is deemed as the most difficult due to the thinner wall. Finally, this material offers the possibility to inject pressurized active drugs which could be used in the future to prevent the occurrence of esophageal strictures or to direct healing. We also worked with the hospital Edouard Herriot pharmacy to stabilize the solution glycerol mix to allow its use in daily practice in our unit

Bakgrund: Då en patient får en diagnos eller sjukdom kan vården vara inriktad på kuration eller palliation. Vård med kurativ inriktning syftar till att bota sjukdom medan palliativ vård syftar till att lindra genom stödjande åtgärder. Att genomgå en transition är något som påverkar människans alla dimensioner. En av sjuksköterskans uppgifter är att stödja patienten genom transitioner, för att kunna göra det krävs en förtroendefull relation mellan patient och sjuksköterska. Syfte: Syftet var att belysa patienters upplevelser av transitionen från kurativ till palliativ vård. Metod: Metoden som använts är en litteraturöversikt som syftar till att skapa en överblick över det valda kunskapsområdet. Resultatet har författarna skapat av tio kvalitativa originalartiklar som identifierades i databaserna: Cinahl Complete, Pubmed och Medline. Resultat: Analysen resulterade i fyra huvudteman och tre subteman. Med det första temat “Vårdrelationen” och subtemana “Behovet av att få information” och “Stödet från sjuksköterskan” beskrivs patienters upplevelser av att få information och att bli introducerad till palliativ vård och upplevelsen av stödet från vårdpersonalen. Det andra temat “Från att vara självständig till att bli beroende” skildrar patienters upplevelse av förändrade och en rädsla för att bli en börda för någon annan: Det senare framgår av subtemat ”Rädslan för att bli en börda för andra”.  Det tredje temat “Tankar om framtiden” handlar om patienters upplevelser och tankar om framtiden vid transitionen från kurativ till palliativ vård. Det fjärde temat “Upplevelser av att anpassa sig till sin nya situation” beskriver patienters upplevelse av att försöka anpassa sig till sin nya situation. Diskussion: Utifrån Meleis transitionsteori diskuterades resultatet som var relaterat till patienternas upplevelse av transitionen från kurativ till palliativ vård. Att få information har varit viktigt för patienterna i denna transition, något som även transitionsteorin bekräftar. I diskussionen lyfte författarna även problematiken kring rollförändringar och upplevelsen av hopp. / Background: When a patient receives a diagnosis or contracts a disease, treatment can be focused on curation or palliation. Care with a curative orientation aims to cure the disease, whilst palliative care aims to relieve through supportive measures. Undergoing a transition affects all human dimensions. One of the nurse's tasks is to support the patient through transitions, doing so requires a trusting relationship between patient and nurse. Aim: The aim was to highlight patients´ experiences through the transition from curative to palliative care. Method: The method used was a literature review that aims to create an overview of the chosen field of knowledge. The authors created the result using ten original articles from the databases: Cinahl Complete, PubMed and Medline. Results: The result of the literature overview shows four main themes and four subthemes. The first theme "The nursing relationship" has two subthemes "The need to get information" and "The patients´ experience of the support from the nurse" describes patients´ experience of getting information and introduction to palliative care and the experience of the support from the nurse. The second theme "From independent to dependent" portrays patients' experience of changing roles and a fear of becoming a burden to someone else with one subtheme "The fear of being a burden to someone else". The third theme "Thoughts on the Future" is about patients' experiences and thoughts about the future during the transition from curative to palliative care. The fourth theme "Experiences of adapting to their new situation," describes patients' experiences of trying to adapt to their new situation. Discussion: Based on Meleis transition theory the results were discussed and related to the patient's experience of the transition from curative to palliative care. Getting the information has been important for the patients in this transition, which also confirms by the transition theory. The authors highlighted the problem of role changes and the experience of hope in the discussion.

Ce travail est une confrontation. Une rencontre entre familles réelles et familles fictionnelles par écran interposé, afin de comprendre comment l’expérience fictionnelle interagit avec l’expérience de la vie. À cet effet, nous avons mené une enquête auprès de sept familles du Nord-Pas-de-Calais et avons choisi trois séries significatives en matière de représentations familiales, fortement plébiscitées par toutes les chaînes du groupe M6 et dont les circonstances de diffusion les réunissent à plus d’un titre : La petite maison dans la prairie (NBC, 1974-1984), Malcolm in the middle (FOX, 2000-2006) et Desperate Housewives (ABC, 2004-2012). Les résultats de l’enquête montrent que ces trois séries constituent une ressource permanente curative, qui sert de point de départ à une construction, voire une reconstruction de soi, que la nostalgie apparaît comme un moteur d’action, lequel amène à la composition singulière de situations, de décors de scène, de décoration d’intérieur, de pratiques variées et à la confection d’un patrimoine familial. Pour le dire autrement,l’expérience de la fiction rappelle constamment l’expérience de la vie et provoque, déclenche,de nouvelles expériences que souvent, les familles s’assurent de se transmettre de génération en génération. L’attachement à la fiction est un attachement à la vie personnelle et la chaîne joue un rôle sensible dans ce processus. / This work proposes to implement a confrontation between real families and fictional familiesby interposing a screen in between them in order to understand how a fictional experienceinteracts with life experience. We have interviewed seven families from the Nord-Pas-de-Calais region of France. We have chosen three shows that are integral in familyrepresentation. They enjoy great popularity on the M6 TV group’s various channels andexhibit similar airing strategies: The Little House on the Prairie (NBC, 1974-1984), Malcomin the Middle (FOX, 2000-2006) and Desperate Housewives (ABC, 2004-2012). The ideathat we offer is that these three shows establish a permanent curative resource which is thebase of the individual’s self-construction. We may also go as far as to call it a reconstructionof oneself. Nostalgia seems to inspire action which leads to the construction of situations, setdesign, interior decoration, various practices and the creation of a family heritage. In otherwords: the experience of fiction serves as a constant reminder of the experience of life whichtriggers and inspires new experiences that families often pass down from generation togeneration. The shows in this corpus play a role in the creation of one’s family-relatedidentity and memories. An attachment towards fiction equates to an attachment to personallife. The network’s part in this process is substantial.

Submitted by Cássia Santos (cassia.bcufg@gmail.com) on 2016-09-26T11:13:04Z No. of bitstreams: 2 Tese - Lucimeire Fermino Lemos - 2016.pdf: 4325729 bytes, checksum: 57073bf305b5938110d79f20752057a7 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2016-09-26T11:55:01Z (GMT) No. of bitstreams: 2 Tese - Lucimeire Fermino Lemos - 2016.pdf: 4325729 bytes, checksum: 57073bf305b5938110d79f20752057a7 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Made available in DSpace on 2016-09-26T11:55:01Z (GMT). No. of bitstreams: 2 Tese - Lucimeire Fermino Lemos - 2016.pdf: 4325729 bytes, checksum: 57073bf305b5938110d79f20752057a7 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2016-06-21 / Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEG / Health records are important for keeping effective communication among all professionals involved in the process of taking care as well as for legitimating the team actions in the face of patients and families. The records must be clear and objective because they are sources of information for judicial, research, teaching, billing and auditing issues. This study has an objective to analyze the records of procedures of Level II Curative in medical records of hospitalized patients, from the nurses’ perspective, before and after the pedagogical intervention, in a Brazilian teaching hospital in the Midwest region. It was a descriptive study with both qualitative and quantitative research and was developed in many stages. The first stage included the nurses’ profiles and the identification of the main reasons why the nursing actions were not recorded. The second stage was the analysis of the records before and after the pedagogical action, which was the third stage. At last, the nurses were interviewed about their perception of the importance of the records for billing. It was observed among the sample of nurses the predominance of women (87,2%), post-graduated (82,1%) and statuary civil servants (80,4%). Even though 53,6% of the nurses said that they do not have double employment relationships, 46,4% said they do. The nurses said that it was not possible to record the procedures due to lack of time (50%), work overload (20%), lack of human resources and access to the records (12,5%), interruptions and lack of guidance (2,5%). The objective of the intervention was to discuss the importance of health records, and specially, in relation to the level II curative. 45,2% of the nurses of this institution took part in this event. In the analysis of the records, before and after the intervention, it was possible to observe the increase of the records of the curatives (82,3%), the detailing of the quantity of curatives per patient (69,9%), the classification of the wounds (63,5%), the description of the materials used in the procedures (67,3%), and also the scheduling (74%) and the checking (71,4%). The data shows that the quantity of material used maintained still. However, there was a rise of curative prescription by the nurses (79,4%) and a fall of curative prescription by the doctors (18,3%). It was also possible to observe that the performed and not prescribed procedures or prescribed and not verified procedures, in both cases, were not billed. Nevertheless, the hospital overturn related to this procedure has an increase, from July 2015. The interviews with the nurses showed that they take the responsibility in the treatment of wounds for themselves. However, it is necessary to standardize the prescriptions and the evolutions of the procedure. The complete record of this intervention is important to safeguard the institution in case of auditing. In conclusion, nurses have an important role in recording the wound treatment. The obligation of recording should be reinforced due to the quality of the service and the profession´s visibility as well as for a better material and input control and billing. / Os registros em saúde são importantes tanto para garantir comunicação efetiva entre todos os profissionais envolvidos no processo de cuidar, quanto para legitimar as ações da equipe junto ao usuário e família. Devem ser claros, e objetivos, pois servem de fonte de informações para questões jurídicas, de pesquisa, ensino, faturamento e auditoria. Este estudo teve por objetivo analisar os registros do procedimento curativo (curativo grau II) nos prontuários de pacientes internados, em um hospital universitário de Goiás, na perspectiva dos enfermeiros, antes e após um treinamento, em hospital de ensino da região Centro-Oeste do Brasil. Tratouse de estudo descritivo, de natureza mista, quanti-qualitativa, desenvolvido em várias etapas. A primeira etapa compreendeu a caracterização do grupo de enfermeiros e a identificação dos principais motivos para a falta de registro das ações de enfermagem. Na segunda etapa, a análise do prontuário procurou em dois momentos, antes e após ação educativa (terceira etapa), identificar o registro. Por último, em entrevista com enfermeiros, verificou-se sua percepção quanto à importância dos registros para o faturamento. Na amostra dos enfermeiros, observou-se predominância feminina (87,2%), de pós-graduados, (82,1%), com vínculo estatutário (80,4%). Embora 53,6% tenham alegado não ter duplo vínculo empregatício, chama a atenção 46,4% alegarem esta condição. Os enfermeiros referem ainda que nem sempre é possível a efetuação dos registros, relatando como motivos: falta de tempo (50%), sobrecarga de trabalho (20%), falta de recursos humanos e acesso à papeleta (12,5%), e interrupções e falta de orientação (2,5%). Realizou-se atividade interventiva, que teve por objetivo tratar de assunto referente à importância do registro em saúde, e especificamente em relação ao curativo grau II, e contou com a participação de 45,2% dos enfermeiros desta instituição. A análise dos prontuários antes a após a intervenção, verificou o aumento dos registros de prescrição de curativos (82,3%), discriminação da quantidade de curativos por paciente (69,9%), classificação das feridas (63,5%), descrição dos materiais utilizados (67,3%), além do aprazamento (74%) e checagem (71,4%). Não se verificou alteração relacionada ao registro da quantidade de materiais. Evidenciou-se aumento das prescrições do procedimento por enfermeiros (79,4%) e diminuição pelos médicos (18,3%). O estudo permitiu ainda identificar procedimentos executados e não prescritos ou prescritos e não checados, em ambos os casos não faturados. Apesar disto, o faturamento do hospital, no que se refere a este procedimento, apresentou aumento a partir de julho de 2015. A entrevista com enfermeiros evidenciou que este profissional assume para si a responsabilidade do tratamento de feridas, mas ainda é necessária a padronização das prescrições e evoluções referentes a este cuidado. O registro completo da intervenção é importante para que a instituição se resguarde em caso de auditoria. O enfermeiro tem papel importante no registro do tratamento de feridas. Deve ser reforçada a obrigatoriedade do registro, tanto para a qualidade do atendimento prestado e visibilidade da profissão, quanto para o melhor controle de materiais e insumos e do faturamento relacionado a este procedimento.

Submitted by Kenia Bernini (kenia.bernini@ufpel.edu.br) on 2016-08-31T20:31:30Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Susana_Santos_Dode_Dissertação.pdf: 5238315 bytes, checksum: 637aad85a9291b9360a07eb1e1aeceeb (MD5) / Approved for entry into archive by Aline Batista (alinehb.ufpel@gmail.com) on 2016-09-05T19:30:00Z (GMT) No. of bitstreams: 2 Susana_Santos_Dode_Dissertação.pdf: 5238315 bytes, checksum: 637aad85a9291b9360a07eb1e1aeceeb (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Approved for entry into archive by Aline Batista (alinehb.ufpel@gmail.com) on 2016-09-05T19:30:22Z (GMT) No. of bitstreams: 2 Susana_Santos_Dode_Dissertação.pdf: 5238315 bytes, checksum: 637aad85a9291b9360a07eb1e1aeceeb (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Made available in DSpace on 2016-09-05T19:30:52Z (GMT). No. of bitstreams: 2 Susana_Santos_Dode_Dissertação.pdf: 5238315 bytes, checksum: 637aad85a9291b9360a07eb1e1aeceeb (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2016-06-23 / Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul - FAPERGS / A grande quantidade de material arqueológico metálico depositado nas instituições de guarda do sul do Brasil e do Uruguai, provenientes de campos de batalha e a constante perda desses materiais e das informações associadas a eles, tem sido motivo de preocupação dos gestores destas instituições. Este trabalho visa contribuir para a conservação e a musealização desses materiais, bem como conscientizar seus gestores, e pesquisadores em arqueologia da importância da presença do conservador arqueológico em todas as etapas que envolvem a pesquisa arqueológica. A metodologia empregada constou de revisão bibliográfica, aplicação de procedimentos de conservação curativa e preventiva em uma série de materiais provenientes de campo de batalha, que se encontrava em risco decorrentes do péssimo estado de armazenamento nas respectivas instituições. Os procedimentos resultaram na recuperação desses materiais que se encontram em condições de serem estudados por futuras gerações de pesquisadores e apresentados para a sociedade em geral. / There is a large amount of archaeological metallic material stocked safeguard institutions in the south of Brazil and Uruguay. They come mostly from battlefield sites and the loss of information associated with them has been a constant worry for managers in those institutions. This work intent to contribute for the conservation and the musealization of those materials, and also to create an awareness for the managers in order to maintain the presence of an archaeologist and/or conservator in these places and participation in all the stages that encompass the archaeological research. The methodology used was a bibliographic revision, the application of curative and preventive conservation procedures in a series of materials from a battlefield site that were in risk due to the big storage issues in their respective institutions. The procedures resulted in a recovery of those materials that are now in a condition to be studied by the next generations of researchers and presented to the public in general

Bakgrund: Idag drabbas många av cancersjukdom men tack vare tidig upptäckt botas många. Under sjukdomstiden påverkas även patientens maka/make/partner av cancersjukdomen. Anhöriga som stöttar sin partner kan ha en ökad risk att drabbas av egna hälsorelaterade problem.  Syfte: Syftet var att belysa anhörigas upplevelser av att stötta en partner i kurativt skede av cancersjukdom.  Metod: Resultatet består av tolv vetenskapliga artiklar som analyserades och delades in i sju teman. Roys Adaptationsmodell har använts för att diskutera resultatet. Artiklarna samlades in via databaserna CINAHL och PUBMED med urvalet 2007-2017.   Resultat: Resultatet visade på att anhörigas behov blev åsidosatta under partnerns sjukdomstid.  Deras identitet påverkades då de anpassade tillvaron för att kunna fokusera på sin partners vård. Rollfördelningen i parrelationen förändrades och anhöriga fick ta mer ansvar. En för stor börda på de anhöriga kunde ha stor påverkan på deras hälsa men många anhöriga upplevde att de kom sin partner närmare under sjukdomstiden.                    Diskussion: De fyra anpassningslägena i Roys modell påverkar varandra och är svåra att separera. Detta visar på att det är viktigt att ha en helhetssyn på människan. Vi anser att det är viktigt att vården uppmärksammar anhörigas behov och situation och erbjuder stöd för att undvika framtida ohälsa. / Background: A large number of individuals are affected by cancer disease every year, but due to improved treatment and early discovery many are cured. The illness, also affect the patient´s significant other and may increase their risk of own health-related problems. Aim: The aim was to describe significant others´ experiences when supporting a partner in curative phase of cancer disease. Method: The results are based on twelve scientific articles and categorized in seven themes. The Roy Adaptation model was used to discuss the result. Data were collected from the CINAHL and PUBMED databases, including articles from the years 2007-2017. Results: The results show that significant others´ own needs were put aside during their partner´s illness. Their identities were affected as they were adapting their everyday life to be able to support their partner. A partner´s illness also changed the couple’s roles as the couples responsibility changed within the relationship. If the significant other experienced the support as burdensome their health could be negatively affected. Significant others´ experienced their relationship to their partner to improve during the illness. Discussion: The four adaptation modes by Roy are related to each other and are hard to distinguish and the holistic view of each person is important. We conclude that it is important that the health care system also acknowledges the significant other´s needs and situations and thereby provide support needed to elude future health issues.

Bakgrund: När en kurativ behandling inte längre kan rädda liv och orsakar lidande, kan patienter behöva övergå till palliativ vård. Brytpunktssamtal markerar en ändring i vårdens mål och upplägg, såsom vid en övergång från kurativ till palliativ vård. Problem: Om patienternas behov av brytpunktssamtal inte uppmärksammas så riskerar brytpunktssamtalet att försenas eller utebli, vilket kan orsaka lidande. Syfte: Att sammanställa sjuksköterskans erfarenheter av brytpunktssamtal vid övergång från kurativ till palliativ vård. Metod: En litteraturstudie. Resultat: Tolv kvalitativa artiklar analyserades vilket genererade sex teman, att vara patienternas och närståendes företrädare, faktorer som försenade eller förhindrade brytpunktssamtal som beskrevs i underteman osäkerhet om prognosen, svårigheten att prata om döendet, den botande kulturen, en hemlig prognos, sjuksköterskans auktoritet och Patientens oförutsedda lidande. De andra teman var en oklar roll, bristande brytpunktssamtal, närståendes delaktighet och vikten av att fånga upp patient och närstående. Dessa presenteras i en modell som belyser sjuksköterskans arbetet med patienter som behöver övergå till palliativ vård utifrån en tidslinje, det vill säga innan, under och efter brytpunktssamtal. Slutsats: Aktuellt studie har bidragit med kunskap om faktorer som gör att patienter inte erbjuds brytpunktssamtal liksom hur patientens självbestämmande åsidosätts under samtalet. Studie visade även sjuksköterskans viktiga roll. Resultatet betonade vikten av omvårdnad oavsett var patienterna befinner sig under processen av övergång från en kurativ behandling till palliativ vård. Resultatet bevisade även att sjuksköterskan i sin professionella roll kunde bidra med omvårdnadsåtgärder som kan förbättra brytpunktssamtalets kvalitet. / Background: When curative treatment can no longer save lives and cause suffering, patients may need to switch to palliative care. Breaking point conversations mark a change in the care's goals and structure, such as in a transition from curative to palliative care. Problem: If the patients' need for a breaking point conversation is not noticed, the breaking point conversation risks being delayed or absent, which can cause suffering. Purpose: To compile the nurse's experiences of breaking point conversations during the transition from curative to palliative care. Method: A literature study. Results: Twelve qualitative articles were analyzed, which generated six themes, to be the patients 'and relatives' representative, factors such as delayed or absent breaking point conversation described in subtopics uncertainty about the prognosis, difficulty talking about dying, healing culture, secret prognosis, nurse authority and the patient's unforeseen suffering. The other themes were an unclear role, deficient breaking point conversation, the involvement of relatives and the importance of capturing patients and relatives. These are presented in a model that sheds light on the nurse's work with patients who need to switch to palliative care based on a timeline, i.e., before, during and after breaking point conversations. Conclusion: The current study has contributed with knowledge about factors that prevent patients from being offered a breaking point conversation, as well as how the patient's self-determination is disregarded during the conversation. The study also showed the nurse's important role. The results emphasized the importance of nursing regardless of where the patients are during the process of transition from a curative treatment to palliative care. The result also proved that the nurse in his or her professional role could contribute with nursing measures that can improve the quality of the breaking point conversation.

The study aimed to explore and describe factors which impacted on the satisfaction of patients using the curative component of primary health care in the Ekurhuleni Metropolitan area. A qualitative, explorative and contextual design was followed in this study. Focus group interviews were used to collect data from clients, nurse clinicians and community health committee members. Findings indicated that there was lack of facilities, resources and supplies, lack of safety and security measures, negative attitudes of nurse clinicians, lack of community involvement and lack of clinic management involvement. Suggestions were made by the groups on how to improve the curative primary health care service and intervention strategies were identified from the suggestions made. The implementation of these strategies will help with the improvement of the service delivery at the clinic for primary health care. / Health Studies / (M.A. (Health Studies)

Bakgrund: Ur ett historiskt perspektiv har det inom intensivvård skett stora förändringar över tid. I och med denna utveckling har patienter idag bättre förutsättningar till överlevnad och fortsatt liv. Detta medför dock att det i högre grad uppstår etiska frågor på intensivvårdsavdelningarna vilka berör livsuppehållande behandling, medicinsk meningslös behandling, att bibehålla patientens autonomi samt omvårdnad i livets slutskede. Syfte: Syftet med studien var att få ökad förståelse för intensivvårdssjuksköterskors upplevelser av etiskt svåra situationer som kan uppstå när intensivvård för svårt sjuka patienter inte är kurativ. Metod: En kvalitativ intervjustudie med ett ändamålsenligt urval genomfördes. Inklusionskriterierna var specialistsjuksköterskeexamen samt minst två års erfarenhet av intensivvård. Data bearbetades utifrån kvalitativ innehållsanalys. Resultat: Ett tema och tre kategorier formades utifrån data som insamlats. Tema: En vilja att göra gott, men vad är det? Kategorier: Att ha tillgång till avancerad vård löser inte alla problem. Att vara den som verkställer åtgärder som man inte alltid förstår eller samtycker med. Att bemöta närstående är en viktig men komplicerad del av vårdandet. Det funna resultatet visade på svårigheter som intensivvårdssjuksköterskorna stötte på i den högspecialiserade vården som är inriktad på att upprätthålla vitala funktioner hos patienter samt att rädda liv. Svårigheter uppstod när de förstod att patientens liv inte skulle gå att räddas, i mötet med närstående och i samspelet med läkarna samt intensivvårdssjuksköterskans egna känslor kring handlingar och fenomen. Konklusion: Intensivvårdssjuksköterskorna upplever att etik ofta stå tillbaka till förmån för att rädda livet på patienten. De medicinska perspektiven är högst rankade på intensivvårdsavdelningen, detta trots att de etiskt svåra situationerna ständigt är närvarande. I de mest krävande patientmötena underlättar det för intensivvårdssjuksköterskan att hen är väl förankrad i besluten som har tagits, förstår beslutet samt känner förtroende för och har uppbackning av läkaren. Även det kollegiala samspelet med andra yrkesgrupper kan stödja intensivvårdssjuksköterskan i de etiskt svåra situationerna.

This thesis describes the life of a family with a dying child. The objective of the thesis is to describe the experience of its members after the diagnosis has been decided, during treatment and after the child's decease. It discusses the phases of going through the disease and death of one's own child for the parents and other close persons and how such a critical event in a family's life changes its values and attitudes. The theoretical part of this thesis deals with experiencing of all stages of the child's disease by their closest persons and with the psychology of the ill child. In this context, it briefly describes the history and idea of care of the incurably ill and the possibility of family support provided by non- governmental organizations. The practical part of the thesis contains the findings of the qualitative research conducted using the phenomenology approach on how the parents supported the child in the terminal stage of their disease, what they went through during this difficult time of life and how they remember that time after certain time has elapsed. Respondents include the parents or closest persons of children aged over one year that deceased as a result of a malignant disease.