Information in the transition to the late palliative phase is not a well-studied area, especially not from the perspective of patients and family members. The aim of this thesis was to describe how cancer patients, family members and physicians experience information during the transition from a curative or early palliative phase to a late palliative phase, i.e. when tumour-specific treatment could not be offered. Cancer patients (n=30) admitted to palliative hospital based home care, family members (n=20) of cancer patients, and physicians (n=30) working with cancer patients in different settings were included in order to create a maximum variation sampling. Tape-recorded, semi-structured interviews and qualitative, phenomenographic analyses were done in all the studies. Patients described the physician as an expert (study I), an important person during this event, despite characterising him/her in different ways ranging from the empathetic professional to the rough and ready expert. Their relationship with the physician was also stressed. Their own resources, i.e. a sense of well being, a sense of security and individual strength, and their previous knowledge, were important components regarding their ability to take part in the communication (study II). Patients interpret words and phrases carefully and can perceive them as forewarnings, as being emotionally trying, and as fortifying and strengthening (study III). The overall message could be interpreted as either focused on quality if life, on treatment or on death and threat. Family members wanted to protect the patient during this period and could be very active and prominent in their protective role (study IV). However, other family members described themselves as being in the background more or less involuntarily. Family members also felt that there were expectations regarding their behaviour, either that they should take over in terms of communication, or that they should restrict their participation. When giving information, the physicians had a clear goal - to make the patient understand while being as considerate toward the patient as possible. However, the strategies for reaching this goal differed and included: explaining and convincing, softening the impact and vaguely suggesting, preparing and adapting. Some physicians had a main strategy while others mixed different strategies depending on the context. The experience of receiving and providing information about discontinuing tumour specific treatment is like crossing a border, where patients experience the behaviour of the physician and the words they express of great significance. Family members assume the role of protectors. Physicians use different strategies in order to help patients cross the border. / On the day of the public defence the status of the article II was: In press and the title was: Patient interpretation of verbal expressions when given information about ending cancer treatment.; the status of article V was: Submitted.

This study employed a design-based research methodology to develop a theoretically sound approach for designing instructional treatments. The instruction of interest addressed the broad issue of physician wellness among medical school faculty, with particular emphasis on physician self-diagnosis and self-care. The theoretically sound approach comprised a domain theory and design framework. The domain theory was posited subsequent to an examination of the literature, and subjected to expert examination through three cycles of instructional treatment development. The design framework for crafting the treatment was created from components of existing frameworks, and evolved with the cycles of development. The instructional treatment was designed to be delivered to a web browser from a server using a Python microframework to preserve the anonymity of the end user. Experts in three relevant knowledge domains verified that the instructional treatment embodied the domain theory, and was suitable for use as a practical instructional treatment. Subsequently, a limited-time pilot deployment was initiated among practicing faculty physicians (N=273) to solicit user feedback. Responses were obtained through a survey instrument created for the purpose and hosted on a remote website. Although the response rate was low (12%), the responses were encouraging and useful for guiding future research and treatment development.

Introduction: Medication errors are a major cause of illness and hospitalization of patients throughout the world. This study examines the situation regarding medication errors in the Armed Forces Hospital, Kuwait since no literature exists of any such studies for this country. Several types of potential errors were studied by physicians, nurses and pharmacists. Their attitudes to the commission of errors and possible consequences were surveyed using questionnaires. Additionally, patient medical records were reviewed for possible errors arising from such actions such as the co-administration of interacting drugs. Methods: This study included direct observations of physicians during the prescribing process, pharmacists while they dispensed medications and nurses as they distributed and administered drugs to patients. Data were collected and compiled on Microsoft Excel spreadsheet and analyses were performed using SPSS. Where applicable, results were reported as counts and/ or percentages of error rates. Nurses, pharmacists and physicians survey questionnaires: From the 200 staff sent questionnaires a total of 149 respondents comprising nurses (52.3%), physicians (32.2%) and pharmacists (16.1%) returned the questionnaires a total response rate of 74.5%. All responses were analyzed and compared item-by-item to see if there were any significant differences between the three groups for each questionnaire item. All three groups were most in agreement about their perception of hospital administration as making patient safety a top priority with regard to communicating with staff and taking action when medication errors were reported (all means 3.0 and p > 0.05). Pharmacists were most assured of administration support when an error was reported whereas nurses were least likely to see the administration as being supportive ( p < 0.001), and were more afraid of the negative consequences associated with reporting of medication errors (p = 0.026). Although nurses were generally less likely to perceive themselves as being able to communicate freely regarding reporting of errors compared to pharmacists there was no significant difference between the two groups. Both however were significantly different from physicians (p< 0.001). Physicians had the most favorable response to perceiving new technology as helping to create a safer environment for patients and to the full utilization of such technologies within the institution in order to help prevent medical errors. Scenario response - Responses to two scenarios outlining possible consequences, should a staff member commit a medication error, tended to be very similar among the three groups and followed the same general trend in which the later the error was discovered and the more grievous the patient harm, the more severe would be the consequences to the staff member. Interestingly, physicians saw themselves as less likely to suffer consequences and nurses saw themselves as more likely to suffer consequences should they have committed a medication error. All three groups were more likely to see themselves as facing dismissal from their job if the patient were to die. RESULTS OF ALL THREE OBSERVATIONS: Result of Nursing observations: For 1124 doses studied, 194 resulted in some form of error. The error rate was 17.2% and the accuracy was 82.8%. The commonest errors in a descending order were: wrong time, wrong drug, omission, wrong strength/ dose, wrong route, wrong instruction and wrong technique. No wrong drug form was actually administered in the observational period. These were the total number of errors observed for the entire month period of the study. IV Result of Pharmacist observations: A total of 2472 doses were observed during the one month period. Observations were done for 3 hours per day each day that the study was carried out. The study showed that there were 118 errors detected which were in the following categories respectively: 52 no instructions, 28 wrong drug/unordered, 21 wrong strength/dose, ignored/omission 13, shortage of medication 3 and expired date 1. Result of Prescribers in Chart review for drug-drug interactions: The analysis of the drug-drug interactions showed that out of a total of 1000 prescriptions, 124 had drug-drug interactions. None were found to fall into the highest severity rating i.e. 4 (contraindicated). Only twenty-one interactions were rated 3 (major), 87 interactions were rated moderate and 15 interactions were rated minor according the modified Micromedex scale. Patient education: All health care such as physician, pharmacist, and nurses have a responsibility to educate patient about their medication use and their health conditions to protecting them from any error can occur by wrong using drugs. Conclusion This study has contributed to the field of medication errors by providing data for a Middle Eastern country for the very first time. The views and opinions of the nurses, pharmacists and physicians should be considered to enhance the systems to minimize any errors in the future.

Several longitudinal studies show that over time the American public has become more approving of euthanasia and suicide for terminally ill persons. Yet, these previous findings are limited because they derive from biased estimates of disaggregated hierarchical data. Using insights from life course sociological theory and recently developed cross-classified mixed effects logistic regression, I better account for this liberalization process by disentangling the age, period, and cohort effects that contribute to longitudinal changes in these attitudes. Findings indicate that while attitudes toward euthanasia and suicide have liberalized over time, they remained relatively stable over the past 10 years. Furthermore, this study finds significant age effects in which the probability of agreement to euthanasia and suicide steadily decreases throughout the life course. Contrary to previous research, this study finds that when controlling for age and period effects, there are no significant birth-cohort effects that contribute to longitudinal changes in these attitudes.

Chapter 1 investigates whether physicians' financial incentives influence health care supply, technology diffusion, and resulting patient outcomes. In 1997, Medicare consolidated the geographic regions across which it adjusts payments for physician services, generating area-specific price shocks that are plausibly exogenous with respect to health care demand. Areas with higher payment shocks experience significant increases in health care supply. On average, a 2 percent increase in payment rates leads to a 5 percent increase in care provision per patient. Elective procedures such as cataract surgery respond twice as strongly as less discretionary services like dialysis. Higher reimbursements also increase the pace of technology diffusion, as non-radiologists acquire magnetic resonance imaging scanners more readily when prices increase. The magnitudes of our empirical findings imply that changing provider incentives explain up to one third of recent growth in spending on physician services. The incremental care has no significant impacts on mortality, hospitalizations, or heart attacks. In chapter 2, we analyze bargaining between health care providers and private insurers in the shadow of large public insurance programs. Using several distinct sources of variation in Medicares payment rates, we find robust evidence that private insurers adapt to Medicare pricing. The relationship between private and public prices is both significantly positive and significantly less than one-for-one. The results reject both the strong view that private insurers mimic Medicare and views that emphasize cost-shifting as the predominant feature of these markets. Private responses to Medicare payments are larger in states with more competitive insurance markets. The evidence is consistent with models in which Medicares payment rates serve as a basis for negotiations between insurers and provider networks. Chapter 3 revisits the standard user cost model of housing prices and concludes that the predicted impact of interest rates on prices is much lower once the model is generalized to include mean-reverting interest rates, mobility, prepayment, elastic housing supply, and credit-constrained home buyers. The modest predicted impact of interest rates on prices is in line with empirical estimates, and suggests that lower real rates can explain only one-fifth of the rise in prices from 1996 to 2006. / Economics

Sjuksköterskor ifrågasätter ibland sin närvaro under ronden och för motivation krävs förståelse för yrkesrollens betydelse. Trots rondens potential för vårdutveckling saknar den erkännande som ett viktigt forskningsområde. Syftet var att studera ronden som företeelse på sjukhus. En litteraturstudie grundad på 13 artiklar utfördes. Resultatet belyser att ronden skedde på rutin, aldrig ställdes in samt innehade främst tre funktioner: planering och utvärdering av patientvården, en pedagogisk funktion samt en samordnande funktion. Rondens upplägg påverkade patienters upplevelse och delaktighet. Sjuksköterskor kände sig ofta exkluderade, hade svårigheter att förmedla information och bidrog sällan till beslutsfattandet. Sjuksköterskans bidrag under ronden var nödvändigt och höjde patientsäkerheten. Gemensamma verktyg för kommunikation, dokumentation och riskanalyser inom vårdteamet har utvecklats för att förbättra ronden. Det förekom att patienter och vårdpersonal var missnöjda med upplägget av ronden och i båda grupperna fanns de som kände oro under ronden samt hade bristfällig kunskap om dess innebörd och syfte. Ronden bör därför lyftas i utbildningen och studenter tränas i att kommunicera med andra inom vårdteamet. Yrkesverksamma bör främja patienters delaktighet och förståelse under ronden. Kommande forskning bör utgå från ett omvårdnadsperspektiv och riktas mot hur ronden kan användas som ett effektivt arbetsverktyg och hur teamarbete kan uppmuntras. / Nurses sometimes question their presence during the ward round and understanding of the importance of their professional role is required as motivation. In spite of the ward rounds’ potential for care development it lacks recognition as an important research area. The aim was to study the ward round as a phenomenon. A literature review was conducted using 13 papers. The findings reveal that the ward round was conducted as a routine part and was never cancelled. It consisted of mainly three functions; planning and evaluation of the patient care, a pedagogical function and a coordinating function. The format affected patients experience and participation. Nurses often felt excluded, experienced difficulties in providing information and rarely contributed to decision making. Nurses’ contribution in the ward round was essential and increased patient safety. Common tools for communication, documentation and risk analysis within the care team have been developed to improve the ward round. There were patients and staffs who were dissatisfied with the format and there existed anxiousness during the ward round and lack of knowledge about the meaning and purpose in both groups. The ward round needs to be highlighted in education and students need to practice communication with other care team members. Professionals should promote patient participation and understanding during the ward round. Future research should include a nursing perspective and address how the ward round could be used as an effective tool and how to promote teamwork.

Sjuksköterskeyrket är det äldsta traditionellt, professionella kvinnliga yrket inom vården. Sjuksköterskan kan bidra till en bra samverkan genom sin omvårdnadskunskap och yrkeskompetens. Syftet med studien var att belysa faktorer av betydelse för samarbetet mellan sjuksköterska och läkare som kan inverka på en välfungerande samverkan mellan de båda professionerna. Metoden är utförd som en litteraturstudie där sammanställning av forskning inom aktuellt område har genomförts genom systematiska sökningar i olika databaser. I resultatet framkom fem kategorier av viktiga faktorer för samverkan mellan läkare och sjuksköterskor, dessa var traditionella hierarkiska strukturer, respekt och jämställdhet, kunskap, kommunikation, samt strategier för förbättrad samverkan. Sjuksköterskor upplevde sig underordnade under läkare beroende på ojämlikheter som uppstår genom bristande respekt och dåliga kunskaper om andra professioners ansvarsområden. Kommunikation framhölls som en avgörande faktor för en positiv samverkan mellan sjuksköterskor och läkare. Sjuksköterskans kunskaper i att informera, planera, organisera och kommunicera verbalt och skriftligt visade sig ha stor betydelse för hur relationen utvecklade sig mellan olika professioner. Grunden för en bra relation mellan sjuksköterska och läkare är att kunna kommunicera och använda sig av olika strategier för att främja samverkan positivt. Sjuksköterskan kan bidra till att förbättra olika faktorer i samverkan professionerna. / Nursing profession is the oldest traditional female occupation in medical care. The nurse can contribute to a good collaboration by her nursing knowledge and professional competence. The aim of this study was to illuminate factors of meaning between nurse and physician that has impact on collaboration between those professions. The method was a literature study where research was compiled within the topical area and conducted by systematical searches in different databases. The result shows different categories that appeared to be important factors for collaboration between nurses and physicians. Categories shown were traditional hierarchical structures, respect and equality, knowledge, communication and different strategies for improved collaboration. Several nurses experienced that subordination of nurses depended on inequalities that comes from lack of respect and bad knowledge about each others professional occupations. Communication was pointed out as a conclusive factor that contributed to a positive collaboration between the nurse and the physician. Nurses knowledge about informing, planning, organizing, and communicating both in oral and in writing was of importance for developing collaboration between different professions. The foundation for a good relationship between nurse and physician is to be able to communicate and to use different strategies in order to promote collaboration in a positive manner. Nurses have the ability to improve different factors of collaboration between the professions.

Syfte: Undersöka hur sjuksköterskor och läkare upplever att samarbetet dem emellan fungerar, hur sjuksköterskor och läkare anser olika faktorer hos den andra yrkesgruppen påverka samarbetet mellan dem och hur faktorerna påverkar arbetet och dess resultat. Metod: Kvantitativ studie med deskriptiv statistik. Enkäter med slutna svarsalternativ. Respondenterna bestod av 24 sjuksköterskor och 17 läkare. Resultat: Läkare tenderar i högre grad än sjuksköterskor att anse att samarbetet dem emellan fungerar bra. Båda yrkesgrupperna ansåg att den viktigaste egenskapen hos motparten för ett fungerande samarbete, är att ha kunskaper inom sin specialitet. Bland sjuksköterskorna var det den egna arbetsinsatsen och resultatet av patientvården som påverkades mest av ett gott samarbete, medan läkarna ansåg trivseln i arbetsgruppen påverkades mest. Slutsats: Fler läkare än sjuksköterskor anser att samarbetet yrkesgrupperna emellan fungerar väl. Kunskap inom sin specialitet är den viktigaste faktorn för ett fungerande samarbete. Ett fungerande samarbete mellan sjuksköterskor och läkare har stor betydelse för trivseln i arbetsgruppen, för den egna arbetsinsatsen och för resultatet av vården för patienten. / Objective: Explore nurses and physicians experience about how collaboration between them works, how nurses and physicians consider various factors among the opposite professional group affect collaboration between them and how the factors can affect their work and its outcome. Method: Quantitative study with descriptive statistics. Questionnaires with close-ended questions. Respondents consisted of 24 nurses and 17 physicians. Results: Physicians are more likely than nurses to consider collaboration between them works well. Both professional groups considered the most important characteristic in the opposite profession for a well-functioning collaboration, is to have knowledge in the current specialty. Among the nurses one’s own work effort and the outcome of the patient care were the factors that got most affected by a good collaboration, while the physicians rated well-being in the working group highest. Conclusion: Physicians are more likely than nurses to consider collaboration between them works well. To have knowledge in one’s own specialty is the most important factor for a well-functioning collaboration. A well-functioning collaboration between nurses and physicians are of great importance for well-being in the working group, for one´s own work effort and for the outcome of the patient care.

Depression is a nebulous term that is used in a variety of ways to account for a range of experiences usually characterized by low mood, lethargy, diminished pleasure from activities, among others. One prevalent way of making sense of depression in North America is through a biomedical discourse that constructs depression as resulting from an imbalance of neurotransmitters in the brain. Such an explanatory discourse supports antidepressants as the treatment of choice for depression, despite controversy associated with this discourse and disputes about the effectiveness and appropriateness of antidepressants for the treatment of most presentations of depression. In spite of challenges Western physicians face in diagnosing and treating depression, its management overwhelmingly occurs in primary care. Models of primary care treatment decision-making range from those that frame physicians as the principal decision maker (paternalism) to those that feature patients as more autonomous deciders (patient-directed approaches). Existing in the centre of the treatment continuum is a range of joint approaches that feature a more equal relationship between physician and patient. Over the last several decades, paternalism as the traditional approach to treatment decision-making has given way to joint approaches that are heralded as the best ways to manage complex disorders that involve multiple treatment approaches with variable risks and benefits, as depression is often framed. Requests for antidepressants can be considered either patient-directed or joint approach actions, depending on how they are presented. Research on this topic typically focuses on statistical analyses of whether or not patient requests for antidepressants are granted, and whether they help or hinder treatment. Little research has focused on qualitative explorations of how patients and physicians construct accounts about requests themselves. For Study 1, Dr. McMullen and I interviewed 11 family physicians and asked them whether they experienced, and how they managed, patient requests for antidepressants. I used a discursive analytic approach in analyzing the data from the interviews and argue that (a) physicians framed patients as autonomous treatment decision-makers while defining limits on these decisions, and (b) they framed denials of what they characterized as inappropriate requests for antidepressants through patient-centered (and persuasive) approaches to refusal. For Study 2, I interviewed 11 patients about their experiences requesting antidepressants from their physicians. Using a discursive analytic approach, I argue that (a) patients provided accounts of employing what can be considered a soft sell approach in requesting antidepressants, while framing their physician’s contribution to decision-making as necessary and important, and that (b) unexpected outcomes which followed requests for antidepressants (i.e., not having their request endorsed by their physician or having their request fulfilled too readily by their physician) can be understood as discrepancies between the patients’ preferred level of involvement in the process of decision-making and what they encountered. The results of Studies 1 and 2 suggest that these interviewees enacted a physician+ joint approach to treatment decision-making by constructing accounts of requests for antidepressants in ways that largely favour the physician as the lead role within a broadly joint approach to decision-making. Despite attempts to avoid conceptualizations of being overly directive or uninvolved in the process of decision-making, physician and patient interviewees framed conflict as inevitable and offer hints as to how conflict might be avoided or mitigated. To the extent that both patients and physicians are attempting to get their respective needs met from one another within the primary care consultation, I frame their accounts as evidence of a mutual or reciprocal persuasion that is characteristic of more equal relationships. Finally, I bring together some of the controversies associated with treating depression with antidepressants in a primary care setting and raise broader questions about the role of the general practitioner in the management of depression.

The refugee population within the United States is very dynamic, creating new challenges for county boards of health every day. To assist refugee groups in their transition to life in America, their needs must be thoroughly understood. County officials must also recognize their own limitations and be able to overcome them. Appropriate coordination with community resources relieves boards of health of some of the burden. However, county officials must also ensure that services provided in their domain are exceptional. This project aims to aid in this process for the DeKalb County Board of Health (DCBOH) and incoming refugees. A physician directory was created to improve the coordination between the DCBOH and community resources. In addition, a health manual geared towards informing refugees was updated and prepared for distribution.