The starting point of the present thesis is nurses’ reported experiences of disagreements with physicians for pushing life sustaining treatment too far. The overall aim was to describe and compare nurses’ and physicians’ perspectives on the boundaries for life-sustaining treatment and to evaluate whether ethics rounds could promote mutual understanding and stimulate ethical reflection. A mixed methods design with qualitative and quantitative data was used, including interviews and questionnaires. The health professionals’ experiences/perceptions were based on known patients foremost from general wards, but also intensive care units, at four Swedish hospitals. The first two studies treated the perspective on boundaries for life-sustaining treatment and the last two evaluated philosopher- ethicist led ethics rounds. Analysis of data was performed using a phenomenological approach and content analysis as well as comparative and descriptive non-parametric statistics. In the first study, the essence of the physicians’ decision-making process to limit life-sustaining treatment for ICU patients, was a process of principally medical considerations in discussions with other physicians. In the second study, there were more similarities than differences between nurses’ and physicians’ opinions regarding the 714 patients studied. The physicians considered limited treatment as often as the nurses did. The ethics rounds studies generated mixed experiences/perceptions. It seemed that more progress was made toward the goal of promoting mutual understanding than toward the goal of stimulating ethical reflection. Above all, the rounds seemed to meet the need for a forum for crossing over professional boundaries. The most salient finding was the insight to enhance team collaboration, that the interprofessional dialogue was sure to continue. Predominating new insights after rounds were interpreted as corresponding to a hermeneutic approach. One of nurses’ negative experiences of the ethics rounds was associated with the lack of solutions. Based on the present findings, one suggestion for improvement of the model of ethics rounds is made with regard to achieving a balance between ethical analyses, conflict resolution and problem solving. In conclusion, the present thesis provides strong evidence that differences in opinions regarding boundaries for life-sustaining treatment are not associated with professional status. The findings support the notion of a collaborative team approach to end-of-life decision-making for patients with diminished decisionmaking capacity. There is an indication that stimulation of ethical reflection in relation to known patients may foremost yield psychosocial insights. This could imply that social conflicts may overshadow ethical analysis or that ethical conflicts and social conflicts are impossible to distinguish.

[pt] Os laboratórios analíticos de universidades e instituições de pesquisa privadas sem fins lucrativos estão expostos a um ambiente competitivo bem como à descontinuidade e contingenciamento de recursos financeiros oferecidos pelos órgãos de fomento. Objetivando a auto-sustentabilidade operacional, esses laboratórios estão buscando fontes de recursos próprios com a oferta crescente de prestação de serviços especializados a diferentes setores industriais. Contudo, as atividades de prestação de serviço são distintas quando comparadas às atividades de P&D&I, pois as primeiras são caracterizadas pela necessidade imediata ou de curto prazo e as últimas são caracterizadas pelo longo prazo. Neste contexto, torna-se necessário avaliar o trade-off entre ambientes competitivos e cooperativos (serviços e pesquisa) e estabelecer estratégias competitivas sustentáveis, além de práticas e técnicas de gestão que garantam a eficiência operacional sem prejuízo da qualidade e do nível de atendimento do laboratório analisado. O objetivo geral deste trabalho é, portando, analisar o desempenho do LabDRX da PUC-Rio em um cenário auto-sustentável através de um modelo de simulação de eventos discretos. Conclui-se que em tal cenário o desempenho do Laboratório atende a política de atendimento acordada com as categorias de clientes, desde que se faça a implementação conjunta de limitação dos pedidos de urgência na disciplina de fila do sistema e do aumento de capacidade com uma proposta de inovação em processo, o Distance Rietveld. A metodologia apresentada neste trabalho pode ser adaptada para outros laboratórios semelhantes que procurem sustentabilidade operacional através de prestação de serviços tecnológico para indústria. / [en] Private non-profit universities and research institutes have their analytical laboratories exposed to a competitive environment, as well as to discontinuity and limitation of financial resources offered by funding agencies. Aiming to operational self-sustainability, these laboratories are searching complementary resources by increasing the offer of specialized services to different industrial sectors. However, service activities are distinct from R&D&I activities, because the former are characterized by immediate or short-term need and the latter, by long-term need. In this context, it becomes necessary to evaluate the trade-off between competitive and cooperative environments (services and research), and to establish sustainable competitive strategies, as well as management practices and techniques that assure operational efficiency without quality losses or decrease in the service level. The objective of this work is, therefore, to analyze the performance of LabDRX at PUC-Rio in a self-sustainable scenario through discrete-event simulation. It was found that, in the self- sustainable scenario considered, the performance of the Laboratory satisfies the contracting policy agreed with the customer categories, as long as one makes simultaneous implementation of a limited urgent queue discipline and a capacity increase through an innovation proposal: Distance Rietveld. The methodology presented in this work can be adapted for many other similar laboratories searching for operational sustainability by offering technological services to industry.

For African Americans, literacy has historically been rooted in passion, collaboration, and social justice. This study explores two distinct sites of historical African American literacy development: literary societies of the 1800s and print culture of the Harlem Renaissance. Notably, literacy and culture were fundamentally intertwined during these times, creating an urgency and inspiration for literary pursuits not often seen today. In an effort to rekindle this reverence and utility for literacy in classrooms today, a culturally sustaining pedagogy is called for. Culturally sustaining pedagogy seeks to leverage students’ cultural knowledge and skills. By culturally aligning curriculum and instruction, educators position students to experience the transformative power of literacy—a transformative power that was evident in African American literary societies and through the Harlem Renaissance print culture. This study seeks to merge historical and contemporary approaches to literacy development to reconceptualize literacy education and engagement for all students.

Vården som utförs på intensivvårdsavdelningar präglas av övervakningsutrustning vilket kan medföra svårigheter för de närstående att komma nära den som vårdas. De gånger när livsuppehållande behandling inte räcker till tar vården en annan riktning och övergår till palliativ vård på IVA. Som omvårdnadsansvarig för patienten befinner sig intensivvårdsjuksköterskan ofta nära de närstående. För att kunna främja mötet med närstående behövs en förmåga att kunna sätta sig in i de närståendes livsvärld. Studiens syfte var att belysa intensivvårdssjuksköterskans upplevelse av att möta närstående till patienter där livsuppehållande behandling avvecklats och övergår till palliativ vård på IVA. För att besvara studiens syfte har sex intensivvårdssjuksköterskor intervjuats. För att genomföra intervjuerna tillämpades en intervjuguide med öppna frågor. Data analyserades med kvalitativ innehållsanalys, vilket resulterade i åtta subkategorier och tre kategorier. Studiens resultat visar att interaktionen mellan närstående och intensivvårdssjuksköterskan påverkas av övervakningsutrustningen samt om mötet sker på flerbäddsrum. Att ha en relation med de närstående och att vara delaktig i brytpunktsamtalet upplevdes som viktiga faktorer för intensivvårdssjuksköterskans bemötande med närstående. En förutsättning för att kunna balansera närvaro med distans i mötet med de närstående är att intensivvårdsjuksköterskan har en förmåga att själv reflektera över existentiella frågor. Vidare framkommer det att intensivvårdssjuksköterskan upplever sig vägleda de närstående genom ett svårt skede i livet. / Program: Specialistsjuksköterskeutbildning med inriktning mot intensivvård

El desarrollo de la presente tesis tiene como objetivo disminuir el déficit de la infraestructura educativa primaria, mediante el desarrollo de módulos autosustentables en el distrito de Asunción de la provincia y departamento de Cajamarca; la cual forma parte de los sectores rurales del Perú con una altitud superior a los 2200 msnm de la sierra peruana del departamento de Cajamarca. En la tesis propuesta se plantea el desarrollo de módulos educativos que se adapten a los requerimientos y a la geografía del lugar, adecuándose a las condiciones climáticas y a la difícil accesibilidad. Este proyecto está destinado a beneficiar a la población del Distrito de Asunción, dotándola de infraestructura educativa cuya principal característica será la de ofrecer espacios adecuados para el desarrollo de las actividades propias de su función mediante módulos de fácil instalación. Estos módulos tendrán una vida útil de 10 años aproximadamente y estarán equipados para aprovechar los recursos naturales de la zona (captación de agua pluvial y también energía solar) de tal manera que sean edificaciones amigables con el entorno; aprovechando e integrándose al medio ambiente. / The objective of this thesis is to reduce the deficit of the primary educational infrastructure, through the development of self-sustaining modules in the Asunción district of the province and department of Cajamarca; which is part of the rural sectors of Peru with an altitude higher than 2200 meters above sea level in the Peruvian highlands of the department of Cajamarca. The thesis proposes the development of educational modules that adapt to the requirements and geography of the place, adapting to climatic conditions and difficult accessibility. This project is intended to benefit the population of the Asunción District, providing with educational infrastructure whose main characteristic will be to offer adequate spaces for the development of the activities of its function through easy-to-install modules. These modules will have a useful life of approximately 10 years and will be equipped to take advantage of the natural resources of the area (rainwater collection and solar energy) so that they are buildings that are friendly to the environment; taking advantage and integrating into the environment. / Tesis

The use of information technology (IT) is becoming an essential component within the commercial sector. While large number of companies have adopted IT applications to achieve competitive advantage, and number of studies have been done on competitive advantage through an IT application, it is not clear what the impact of an IT application on competitive advantage is. The purpose of this study was to examine the impact of an IT application on competitive advantage and how to create and sustain competitive advantage through an IT application. For that purpose, this study adopted Sethi and King's (1994) instrumental tool, while the theory of resource based view of the firm (RBV) was the theoretical underpinning for the investigation of how to create and sustain competitive advantage through an IT application. In other words, this study examined how an IT application impacts the seven dimensions which are attributes of competitive advantage through an IT application, and how a firm's resources and capabilities, which are measured in three dimensions. moderate the impact of an IT application on competitive advantage. The three dimensions were identified from the review of literature concerning on the theory of RBV. / Ph. D.

Bakgrund: Då det inte längre finns en kurativ behandling för en patient som intensivvårdats är det av betydelse att föra diskussioner kring avbrytande av livsuppehållande behandling. Avbrytandet innefattar flertalet aspekter som intensivvårdssjuksköterskan i olika grad kan påverka.  Syfte: Syftet med denna studie var att beskriva intensivvårdssjuksköterskors erfarenheter av att avbryta livsuppehållande behandling.  Metod: Kvalitativ studie där tio intensivvårdssjuksköterskor intervjuades med semistrukturerade frågor.  Resultat: Tre teman med fem subteman framkom; Betydelsen av att kommunicera, När det är dags att avbryta samt Viljan att göra gott. Intensivvårdssjuksköterskorna belyste betydelsen av en tvärprofessionell kommunikation för att främja teamarbetet. Närstående ska involveras tidigt i vårdförloppet då det ökar upplevelsen av delaktighet. Vårdmiljön ansågs inte anpassad för palliativ vård men anpassades i den mån det är möjligt. Patientens önskemål kring sin vård ska beaktas. Intensivvårdssjuksköterskorna beskrev att ett tidigare beslut gällande avbrytande av livsuppehållande behandling skulle kunna förhindra onödigt lidande. Ångest- och smärtlindrande läkemedel var avgörande vid vård i livets slutskede. Konklusion: En förbättrad kommunikation tvärprofessionellt ansågs minska patientens lidande. Involvering av patient och närstående främjar delaktighet. Vårdmiljön ansågs inte gynnsam för palliativ vård men anpassades i den mån det var möjligt. Genom att intensivvårdssjuksköterskor delar med sig av sina erfarenheter kan patientens hälsa främjas och lidande reduceras. / Background: When there no longer is a curative treatment for an intensive care patient it is important to discuss the aspects of withdrawing life-sustaining treatment. The withdrawal of treatment includes several aspects that the intensive care nurse in various ways can affect.  Aim: The aim of this study was to describe intensive care nurses experiences' in withdrawing life-sustaining treatment.  Method: A qualitative design with ten intensive care nurses that were interviewed with semi-structured questions.  Results: Three themes and five subthemes emerged; The importance of communicating, When it is time to withdraw treatment and The will to do good. Interprofessional communication was considered promoting teamwork. Relatives' involvement increases the experience of participation. The intensive care environment is not considered adapted for palliative care. The patients wishes regarding their care must be taken into consideration. The intensive care nurses described that an earlier decision regarding withdrawal of life-sustaining treatment could prevent unnecessary suffering. Drugs to reduce anxiety and pain was crucial in end-of-life care.  Conclusion: Improved interprofessional communication was considered to reduce the patient's suffering. Involvement of patients and relatives promoted participation. The care environment was not considered favorable for palliative care but was adapted as far as possible. By sharing intensive care nurses' experiences, the patient's health can be promoted and suffering reduced.

As the student population in U.S. public schools becomes more diverse, with an increase of students of color and from low socioeconomic backgrounds, it is critical that the opportunity gaps in our education system are addressed to provide an equitable education for urban youth. To mitigate these gaps, there is a need for an experienced urban teacher workforce, but urban schools face staffing challenges that make this difficult. There is an exceptional need for Latina/o teachers, who demonstrate positive impacts on Latina/o students, the largest minority population nationwide, however, the retention rate amongst Latina/o teachers is lower than that of other demographics. This phenomenological qualitative research study explored the personal and professional factors that sustain Latina veteran urban teachers in a predominantly Latina/o school district through the development of testimonios. Data was collected through a survey, instructional documents, and interviews to produce the individual testimonios of each participant’s history as a Latina veteran urban teacher and a cross-case analysis of the participants’ shared experiences. The findings demonstrated that Latina veteran urban teachers possessed la chispa, the spark, for serving students who share their cultural and linguistic identity. These teachers ignited, fueled, and preserved their chispa through various personal and professional factors, including a commitment to serving urban students, a dedication to continuous professional growth, and the support from personal and professional networks. These findings can inform teacher preparation programs and school systems on how to prepare and sustain Latina teachers for long-term careers in urban education.

Physicians encounter significant difficulty when faced with decisions related to withdrawal of life-sustaining therapy (WLST) in patients with devastating brain injury (DBI). The complexity of this decision-making process is multifactorial, including practitioner- and patient-specific variables, as well as surrogate decision-maker bias, inaccuracies in scoring systems, and inconsistencies in guidelines endorsed by professional societies; these issues all contribute to the significant uncertainty of these situations and variability in treatment paradigm. Solutions are complex; however, analyzing WLST with an urban bioethical lens — which emphasizes the principles of solidarity, agency, and social justice — can enhance physicians’ ability to navigate this uncertainty and ensure that potential solutions are patient-centered. / Urban Bioethics

Wall-bounded turbulent flows such as plane Couette flow, channel, pipe flows and boundary layer flows are fundamental problem of interest that we often meet in many scientific and engineering situations. The goal of the present thesis is to investigate the origin of large-scale streaky motions observed in the wall-bounded turbulent flows. Under a hypothesis that the large-scale streaky motions sustain with a process similar to the well-known near-wall self-sustaining cycle, the present thesis have pursued on four separate subjects: (i) non-modal amplification of streaks, (ii) the secondary instability of the finite amplitude streaks, (iii) existence of a self-sustaining process at large scale and (iv) turbulent skin friction reduction by forcing streaks. First, using a linear model with turbulent mean flow and the related eddy viscosity, it is shown that the streaks are largely amplified by harmonic and stochastic forcing. The largely amplified streaks undergo the secondary instability and it has been associated with the formation of the large-scale motions (bulge). The existence of a self-sustaining process involving the amplification and instability of streaks at large scale is proved by quenching the smaller-scale energy carrying eddies in the near-wall and logarithmic regions. Finally, it is shown that artificially forcing of large-scale streaks reduce the turbulent skin friction up to 10\% by attenuating the near-wall streamwise vortices.