Orientador: Sérgio Resende Carvalho / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-20T10:38:02Z (GMT). No. of bitstreams: 1 Azevedo_BrunoMarianideSouza_M.pdf: 1198343 bytes, checksum: 8fce30161987b520756ccd86a5562aef (MD5) Previous issue date: 2012 / Resumo: Fazendo uma passagem breve pela história da saúde pública brasileira desde o século XX e fazendo um paralelo com os movimentos em torno dos currículos das escolas médicas, reflete-se um pouco sobre os diversos agenciamentos que afetam a construção dos currículos de Medicina e suas relações com o Sistema Único de Saúde. Marcadamente, nos últimos dez anos, as mudanças nos currículos (formal e paralelo) são incentivadas por diretrizes, projetos e políticas governamentais diversos. Em 2001, enquanto Campinas faz uma série de transformações na forma de fazer gestão e atenção à saúde, inicia um novo currículo do curso de Medicina da Unicamp. Tal mudança curricular assume a Atenção Básica como importante cenário de ensino-aprendizagem, levando alunos a quase todas as regiões da cidade. Neste cenário, o que se passa nesse encontro da universidade com o serviço, entre alunos, docentes, gestores, trabalhadores e usuários, do projeto institucional dos serviços com o projeto educativo? É um encontro que provoca incômodo, conflito e dissenso, que traz novos sentidos para as práticas dos serviços e das universidades. Aponta para importância que tal relação traz para a formação dos trabalhadores, para a reflexão e qualificação da gestão, para a mudança da prática médica. Refletindo o que se entende por gestão em saúde e por integração ensino-serviço e tomando o apoio de conceitos trazidos pela filosofia da diferença, esta investigação utiliza-se de métodos como diários de campo, grupos focais e oficinas com gestores, trabalhadores, docentes e alunos envolvidos com o estágio de Planejamento e Gestão/Saúde Coletiva do 5º ano de Medicina da Unicamp para construir uma interpolação de olhares sobre tal acontecimento, mapeando as linhas de forças e poderes instituídos que atravessam essa relação. No processo, a pesquisa constrói a história de criação e desenvolvimento deste estágio, identifica as tensões constitutivas deste campo de trabalho, ensino e aprendizagem, dialogando com as potências e dificuldades de cada segmento. Por fim, traçam-se algumas considerações que tal estudo pode trazer tanto para o currículo, quanto para os serviços de saúde e a relação entre eles, a qual, essencialmente deve ser dialógica e radicalmente cogerida / Abstract: A reflection on the different agencies how they affect Med schools' curricula and how they relate to the Unified Health System (SUS) is made through a brief analysis of Brazilian's public health history since the XX century and a parallel analysis of said curricula. It has become patent that, in the past ten years, changes in the curricula (formal and parallel ones) have been driven by different directives, projects and governmental politics. In 2001, as Campinas goes through a series of changes in how public health is seen and managed, a new curriculum is enforced in Unicamp's Medicine program. Such change assumes Basic Attention as important in the teaching-learning context, taking students to almost all parts of town. That being said, what happens in this encounter between the University and public service, between students, professors, administrators, workers and users, between the institution's service project and the educational project? This encounter brings about conflict, unease and different opinions, which in turn redefines practices in the public service and in universities. It points to how important this relationship between agencies, curricula and the SUS is to the formation of workers, to the reflection and qualifity of the administration, to the changes in the medical practice. Reflecting on what health management and integration of teaching and service mean, supported by concepts from the philosophy of difference, this research uses methods such as field journals, focal groups and workshops with managers, workers, professors and students involved in the Planning and Management / Collective Health internship in the 5th year of Unicamp's Medicine program to create a connection between viewpoints on this situation by tracing social forces and instituted powers crossing this relation. In the process, this research builds the history of the creation and development of such stage, identifies tensions that form this field of work, teaching and learning, in relation to each segment's strong points and short comings. Finally, this study points to things that might be considered not only in the curriculum, but also in health services and in their relations, which must be, in essence, a dialogue and which should be radically co-managed / Mestrado / Política, Planejamento e Gestão em Saúde / Mestre em Saude Coletiva

The following Thesis deals with problems concerning human resources management in the area of Health Care and its failures. Furthemore, it seeks for the reasons for such failures, analyzes the legal background and compares it with the day-to-day life of hospitals. The goal of this Thesis is to reveal the real roots of the ongoing crisis, which was demonstrated e.g. by so called Děkujeme, odcházíme campaign, and to find out possible solutions to stabilize the Health Care system and minimaze the risk of lose of health care professionals.

Screening to detect diseases early is attractive as it can improve the prognosis and decrease costs, but it is often a problematic concept and there are several pitfalls. Many healthy individuals have to be investigated to avoid a disease in a few, which results in a dilemma because to save a few, many are exposed to a procedure that could potentially harm them. Other examples of problems associated with screening are latent diseases and over-treating. The question of optimal design of a screening program is another source of uncertainty for decision-makers, as a screening program may potentially be implemented in very different ways. This highlights the need for structured analyses that weigh benefits against the harms and costs that occur as consequences of the screening. The aim of this thesis is, therefore, to explore, develop and implement methods for health economic evaluations of screening programs. This is done to identify problems and suggest solutions to improve future evaluations and in extension policy making. This aim was analysed using decision analytic cost-effectiveness analyses constructed as Markov models. These are well-suited for this task given the sequential management approach where all relevant data are unlikely to come from a single source of evidence. The input data were in this thesis obtained from the published literature and were complemented with data from Swedish registries and the included case studies. The case studies were two different types of screening programs; a program of screening for unknown atrial fibrillation and a program to detect colorectal cancer early. Further, the implementation of treatment with thrombectomy and novel oral anticoagulants were used to illustrate how factors outside the screening program itself have an impact on the evaluations. As shown by the result of the performed analyses, the major contribution of this thesis was that it provided a simple and systematic approach for the economic evaluation of multiple screening designs to identify an optimal design. In both the included case studies, the screening was considered costeffective in detecting the disease; unknown atrial fibrillation and colorectal cancer, respectively. Further, the optimal way to implement these screening programs is dependent on the threshold value for cost-effectiveness in the health care sector and the characteristics of the investigated cohort. This is because it is possible to gain increasingly more health benefits by changing the design of the screening program, but that the change in design also results in higher marginal costs. Additionally, changes in the screening setting were shown to be important as they affect the cost-effectiveness of the screening. This implies that flexible modelling with continuously updated models are necessary for an optimal resource allocation.

Introduktion: Den nyutexaminerade sjuksköterskan har under tre år samlat på sig teoretisk kunskap och ska nu ge sig ut i arbetslivet och ge god och patientsäker vård. Hur första tiden i yrket upplevs har betydelse för hur den kommande rollen som professionell sjuksköterska blir. Syfte:Att beskriva hur nyutexaminerade sjuksköterskor upplever första åretsom legitimerad sjuksköterska. Metod:Litteraturstudie med systematisk datainsamling och urval med tio vetenskapliga artiklar. Resultat:Den första tiden i yrket visade sig innebära nervositet, stress och en känsla av att vara otrygg. De nyutexaminerade sjuksköterskorna upplevde under de första månaderna i yrket en frustration. Detta på grund av brist averfarenhetsbaserad kunskap och att deras prestationer inte matchar med förväntningarna från patienter såväl som kollegor. Slutsatser:För att övergången skall vara tillfredsställande måste många delar fungera under första året. Arbetsintroduktion, handledning och kollegor gjorde stor inverkan på hur första året upplevdes. En vanligt förekommande uppgift är att nyutexaminerade sjuksköterskor upplever brist på klinisk kunskap, denna kunskap utvecklas med hjälp av erfarenhet i yrket. Litteraturstudien visar att nyutexaminerade är i behov av stöd och support för att få en bra start i yrket. Därför anses det vara av vikt att stötta varandra under första tidenför att öka trivseln och undvika att sjuksköterskor slutar

Optimum construction worker (CW) performance is required to achieve project delivery within project parameters. It is not always the case as CWs are regularly exposed to hazards, involved in accidents, their productivity is poor, they suffer from ill health, suffer from work-related musculoskeletal disorders (WMSDs) and contractors lack resources to allocate towards H&S. However, the lack or the absence of health and safety (H&S) measures, which the aforementioned depend on, has a negative impact on workers’ performance. Two descriptive surveys were conducted among professional construction project managers (CPMs) registered with the South African Council for Project and Construction Management Professions (SACPCMP) and general contractors (GCs) registered with the East Cape Master Builders Association (ECMBA). Interviews were also conducted with CPMs registered with the SACPCMP residing in the Nelson Mandela Bay metropolitan area. The salient findings include: • Accidents, which occur on construction sites, impact workers’ performance; • Inadequate H&S implementation affects both CW skills and motivation, which in turn affects their performance; • Poor constructability is relevant to H&S and CWs’ skills; • Provision and maintenance of welfare facilities are commonly inadequate and affect workers’ performance, and • Projects do not benefit from the adequate financial provision for H&S. It was concluded that exposure to hazards, poor site conditions, inadequate provision of welfare facilities, WMSDs, and insufficient financial provision for H&S affect workers’ performance by either incapacitating or demotivating them. Recommendations include : CPMs should make better use of their influence on clients; they should improve communication channels between project stakeholders; legislators need to raise awareness regarding H&S and worker welfare, and training and education institutions need to empower workers and professionals with H&S knowledge.

Thesis evaluates the possible use of approaches for crisis management in restructuring of health facility. Thesis combines expertise and approaches in crisis management as a V concept for restructuring of the Tomas's Bata Hospital in Zlín. Crisis management approaches are adapted to the regulatory requirements of health sector. It is also assessed whether it is possible to use all approaches in decision making with a large number of stakeholders in decision making process.

Background: Time utilisation among primary care professionals has been affected by structural changes and reorganisation performed in Swedish primary care over several decades. The work situation is complex with a heavy administrative work load. The overall aim with this thesis was to describe time utilisation among staff in Swedish primary care and to investigate associations with perceived psychosocial work environment and legitimacy of work tasks. Methods: A multicentre, descriptive, cross-sectional study design was used including all staff categories in primary care i.e. registered nurses, primary care physicians, care administrators, nurse assistants and allied professionals (physiotherapists, occupational therapists, psychologists, counsellors, dieticians and chiropodists) at eleven primary care centres located in southeast Sweden. The data collection consisted of a questionnaire including a subjective estimate of workload, the Bern Illegitimate Tasks Scale (BITS) and the Copenhagen Psychosocial Questionnaire (COPSOQ). Also, a time study was performed, where the participants reported their work time based on three main categories; direct patient work tasks, indirect patient work tasks and other work tasks, each with a number of subcategories. The participants reported time spent on different work tasks, day by day during two separate weeks. Response rates were 75% for the questionnaire and 79% for the time study. Results: In paper I the time study revealed that health professionals at the primary care centres spent 37% of their work time with direct patient work tasks. All professions estimated a higher proportion of time spent directly with patients than they reported in the time study. Physicians scored highest on the psychosocial scales of quantitative demands, stress and role conflicts. The proportion of administrative work tasks was associated with role conflicts, the more administration the more role conflicts. Findings in paper II were that more than a quarter of physicians scored above the cut-off value for BITS regarding unnecessary work tasks, which was significantly more than the proportion observed in all other professions in the survey. Across all staff groups, a perception of having to perform illegitimate work tasks was associated with experiencing negative psychosocial work environment and with high proportion of administrative-related work tasks. Conclusions: Swedish primary care staff spend a limited proportion of their work time directly with patients and primary care physicians perceive the psychosocial work environment in negative terms to a greater extent than all other staff members. Allocation of work tasks has an influence on the perceived psychosocial work environment. The perception of having a large number of illegitimate work tasks affects the psychosocial work environment negatively, which might influence the perception the staff have of their professional roles. Perception of high proportion of unreasonable work tasks is associated with a high proportion of non-patient-related administration. This thesis illuminates the importance of decision makers thoroughly considering the distribution and allocation of non-patient related work tasks among staff in primary care, in order to achieve efficient use of personnel resources and favourable working conditions. Hopefully, the results of this study will contribute to further development of primary care so that medical competence will benefit patients as much as possible. / Bakgrund: Under de senaste decennierna har det i svensk primärvård varit omfattande omorganisationer, vilket har påverkat arbetstidens innehåll. Arbetssituationen är komplex och omfattningen av administration har ökat. Det övergripande syftet med föreliggande studie var att beskriva arbetstidens innehåll bland personal i svensk primärvård och att undersöka samband mellan upplevd psykosocial arbetsmiljö och arbetsuppgifternas legitimitet. Metod: Studien har genomförts som en deskriptiv multicenterstudie med tvärsnittsdesign och inkluderade sjuksköterskor, läkare, vårdadministratörer, undersköterskor och övriga professioner (fysioterapeuter, arbetsterapeuter, psykologer, kuratorer, dietister och fotvårdsspecialister) vid elva vårdcentraler i sydöstra Sverige. Studien inleddes med att deltagarna ombads att besvara ett frågeformulär vars första del bestod av en skattning av hur arbetsuppgifterna var fördelade. Frågeformuläret innehöll också frågor om illegitima arbetsuppgifter; Bern Illegitimate Tasks Scale (BITS) och psykosocial arbetsmiljö; Copenhagen Psychosocial Questionnaire (COPSOQ). Därefter gjordes en tidsstudie där deltagarna fick registrera tidsåtgången för olika arbetsuppgifter, varje dag under två separata veckor. Arbetsuppgifterna delades upp i tre huvudkategorier; direkt patientarbete, indirekt patientarbete och övrigt arbete. Varje huvudkategori hade flera underkategorier. Svarsfrekvensen var 75% för frågeformuläret och 79% för tidsstudien. Resultat: Resultatet från delarbete I visar att personal i primärvård ägnade 37% av arbetstiden direkt med patienter. Alla professioner skattade den direkta patienttiden till större andel än vad tidsstudien visade. Läkare upplevde sämst psykosocial arbetsmiljö avseende kvantitativa krav, stress och rollkonflikter. Det förelåg ett samband mellan andelen administrativa arbetsuppgifter och rollkonflikter, ju mer administration desto mer rollkonflikter. I delstudie II visade resultatet att mer än en fjärdedel av läkarna upplevde en hög nivå av illegitima arbetsuppgifter avseende onödiga arbetsuppgifter, vilket var signifikant mer jämfört med andra professioner. För personalgruppen som helhet framträdde ett samband mellan upplevelsen av att ha mycket illegitima arbetsuppgifter och upplevelse av negativ psykosocial arbetsmiljö samt med hög andel administrationsrelaterade arbetsuppgifter. Konklusion: Personal i primärvård ägnar en begränsad andel av arbetstiden åt direkt patientarbete och läkare upplever sämre psykosocial arbetsmiljö än övriga professioner. Arbetstidens fördelning mellan olika arbetsuppgifter påverkar den psykosociala arbetsmiljön. Upplevelsen av att utföra en stor andel illegitima arbetsuppgifter påverkar den psykosociala arbetsmiljön negativt, vilket kan ha inverkan på hur personalen uppfattar sin professionella roll. Upplevelsen av att ha mycket oskäliga arbetsuppgifter har samband med hög andel icke patientrelaterad administration. Avhandlingen belyser vikten av att beslutsfattare noga överväger fördelningen av icke patientrelaterade arbetsuppgifter bland personal i primärvård, för att möjliggöra effektiv användning av personalresurserna och för att främja goda arbetsförhållanden. Förhoppningen är också att studiens resultat ska bidra till fortsatt utveckling av primärvården så att den medicinska kompetensen kommer patienterna till nytta i så stor omfattning som möjligt.

På varje arbetsplats uppstår det konflikter av olika slag. En del av dessa konflikter är av en mildare variant som medarbetarna på egen hand lyckas lösa, men det finns även svårlösta konflikter som på sikt kan påverka arbetsmiljön och medarbetarna negativt. I sociala verksamheter som äldreomsorg och hemtjänst handskas enhetschefer medkonflikthanteringar i sina arbetsgrupper. Det är därmed viktigt att en konflikt hanteras så fort som möjligt eftersom den annars kan bli svårlöst. En ouppklarad konflikt kan i regel leda till att personalen tappar sin arbetsglädje, motivation och energi, något som inte enbart påverkarverksamheten och övrig personal, utan även skapar en lidande situation för brukarna som tillhör verksamheten. I samhällsdebatten är konflikthantering ett omdiskuterat ämne där höga krav ställs på chefer. Chefen befinner sig oftast i en komplicerad situation där missnöje från både personalen och de överordnade finns. Ju känsligare situationen och konflikten är, desto svårare blir konflikthanteringen för chefen. Detta då varje handling från chefens sida tycks av andra ha en underliggande betydelse. Trots detta, förväntas chefen dock hantera och lösa konflikten. Denna studie har som syfte att klarlägga vad för roll en chef har vid konflikthantering. För att besvara frågeställningen har en kvalitativ metod använts, med mål att skildra informanternas känslor samt upplevelser gällande konflikter och dess hantering. Uppsatsen har sin grund i fem intervjuer med enhetschefer inom äldreomsorgen och hemtjänsten. Studien utgår utifrån semistrukturerade intervjuer, med mål att samla empiri. Slutresultatet framförde att enhetscheferna handskas med konflikter på liknande sätt, medsamma utgångspunkt att lösa konflikten omgående. Även om det inte finns någon handlingsplan i konflikthantering, ansåg informanterna att en närvarande chef kan hindra en konflikt från att bli urartad.

This qualitative study describes relationships problems highlighted by individuals with an autism diagnosis and professionals at Vuxenhabiliteringen (adult disability services). It also captures the individuals’ and professionals’ opinion of how to work with these particular problems. Nine people were interviewed for this study. The interviews were semi-structured and systems Theory in Social Work were used to understand the organisational tension between where support for relationship problems for people with an autism diagnosis should lie. An autism diagnosis is linked to problems in social-emotional reciprocity, for example difficulties to initiate or respond to social interactions, inflexible adherence to routines and difficulties with sensory input. Several themes emerged regarding relationship problems; structure and planning, communication, understanding, sex and intimacy and partners’ own difficulties. Professionals reported that a number of services are currently being offered, such as diagnose information, talking therapy, help with planning and structure, among others. Professionals expressed that including the partner more, working more jointly with other professionals and starting a relationship group to share experiences could improve services. The support that neurodiverse participants asked for were couple’s therapy, information and education about sex, relationships and men. Relationship support can be given by VUH through the services already offered and by expanding them further. More research is needed to understand relationship issues in relation to an autism diagnosis.  Keywords: Relationship, autism, neurodiversity, Vuxenhabiliteringen, health care, organisation, couple’s therapy, relationship difficulties Sökord: Relationer, autism, neurodiverse, Vuxenhabiliteringen, Hälso och sjukvård, organisation, parterapi, relationssvårigheter Author: Jessica Vannoorenberghe Word count: 16846

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