Nursing intensity and nurse staffing in perioperative settings

The goal of this study was to design and test a nursing intensity (NI) instrument in perioperative settings to produce information concerning patients’ care needs. This information is intended to be used for knowledge-based management purposes when applying optimal nurse staffing. In Phase I, a Delphi method with two rounds (n=55) was used to define the core elements of perioperative nursing. Then those core elements were tested to evaluate NI during the pre-, intra-, and postoperative phases of the surgical patient’s care process (n=308 patients). In Phase II, the core elements were implemented in an instrument, and further testing was carried out in different perioperative settings (n=876 patients). In Phase III, an integrative review was con-ducted to find out how nurse staffing had been executed in perioperative settings. According to the results, the core elements of perioperative nursing describing patient’s safety or patient’s physiological needs were seen as the most crucial. A principal component analysis revealed that a patient’s care needs vary from the intraoperative to postoperative phases of perioperative nursing. Patients in a high ASA class more frequently had high intraoperative NI points, but patients in a low ASA class did not automatically have fewer intraoperative care needs. The length of stay in the post-anesthesia care unit (PACU) and the type of follow-up unit could be predicted with intraoperative NI. Scant evidence was found concerning nurse staffing in perioperative settings. The need to take into account patients’ care needs showed up in some papers, but these were not expressed in an assessable form. Staffing models in relation to perioperative nursing-sensitive outcomes were not found. This study offers an instrument for evaluating NI in perioperative settings. This information produced can be utilized for nurse staffing and nurse staff allocation purposes. More research is needed that focuses more on the detailed use of information based on NI. Its potential to serve as a knowledge-based management tool also needs clarifying in future studies

Nursing Students’ Learning about an Empowering Discourse In Patient Education

The main purpose of this study was to describe and evaluate nursing students' learning about an empowering discourse in patient education. In Phase 1, the purpose was to describe an empowering discourse between a nurse and a patient. In Phase 2, the purpose was first to create a computer simulation program of an empowering discourse based on the description, and second, the purpose was to evaluate nursing students’ learning of how to conduct an empowering discourse using a computer simulation program. The ultimate goal was to strengthen the knowledge basis on empowering discourse and to develop nursing students’ knowledge about how to conduct an empowering discourse for the development of patient education. In Phase I, empowering discourse was described using a systematic literature review with a metasummary technique (n=15). Data were collected covering a period from January 1995 to October 2005. In Phase 2, the computer simulation program of empowering discourse was created based the description in 2006–2007. A descriptive comparative design was used to evaluate students’ (n=69) process of learning empowering discourse using the computer simulation program and a pretest–post-test design without a control group was used to evaluate students’ (n=43) outcomes of learning. Data were collected in 2007. Empowering discourse was a structured process and it was possible to simulate and learned with the computer simulation program. According to students’ knowledge, empowering discourse was an unstructured process. Process of learning empowering discourse using the computer simulation program was controlled by the students and it changed students’ knowledge. The outcomes of learning empowering discourse appeared as changes of students’ knowledge to more holistic and better-organized or only to more holistic or better-organized. The study strengthened knowledge base of empowering discourse and developed students to more knowledgeable in empowering discourse.Siirretty Doriast

Machine Learning and Clinical Text. Supporting Health Information Flow

Fluent health information flow is critical for clinical decision-making. However, a considerable part of this information is free-form text and inabilities to utilize it create risks to patient safety and cost-­effective hospital administration. Methods for automated processing of clinical text are emerging. The aim in this doctoral dissertation is to study machine learning and clinical text in order to support health information flow.First, by analyzing the content of authentic patient records, the aim is to specify clinical needs in order to guide the development of machine learning applications.The contributions are a model of the ideal information flow,a model of the problems and challenges in reality, and a road map for the technology development. Second, by developing applications for practical cases,the aim is to concretize ways to support health information flow. Altogether five machine learning applications for three practical cases are described: The first two applications are binary classification and regression related to the practical case of topic labeling and relevance ranking.The third and fourth application are supervised and unsupervised multi-class classification for the practical case of topic segmentation and labeling.These four applications are tested with Finnish intensive care patient records.The fifth application is multi-label classification for the practical task of diagnosis coding. It is tested with English radiology reports.The performance of all these applications is promising. Third, the aim is to study how the quality of machine learning applications can be reliably evaluated.The associations between performance evaluation measures and methods are addressed,and a new hold-out method is introduced.This method contributes not only to processing time but also to the evaluation diversity and quality. The main conclusion is that developing machine learning applications for text requires interdisciplinary, international collaboration. Practical cases are very different, and hence the development must begin from genuine user needs and domain expertise. The technological expertise must cover linguistics,machine learning, and information systems. Finally, the methods must be evaluated both statistically and through authentic user-feedback.Siirretty Doriast

Data collection in helicopter emergency medical services

Prehospital critical care, especially helicopter emergency medical services (HEMS), is a costly but vital part in the chain of survival for a critically deteriorated patient. The quality assessment and outcome measures of this service are important for targeting the limited resources accurately. Clinical registries are a key element of this system follow-up and quality assurance. In addition, they are a vast resource for scientific objectives. Therefore, the data reliability in these clinical registries needs to be assured. The aims of this thesis were to evaluate the accuracy and reliability of clinical data collection in a national HEMS service. In addition, to study the accuracy of prognostication based on prehospital patient classification and registry data. And finally, to revise a prehospital patient scoring system, the HEMS Benefit Score, to meet the modern standards of prehospital emergency medical services. This scoring is used in all Finnish HEMS units to evaluate the benefit of prehospital emergency medical services for patients treated on HEMS missions. Inter-rater reliability was evaluated among HEMS clinicians as they registered written mission scenarios into the FinnHEMS database. Furthermore, the accuracy of prognostication was evaluated in a retrospective patient population of 6219 HEMS patients. Finally, a revision for the HEMS Benefit Score was performed with Delphi method. The overall inter-rater reliability of data collected from the written mission scenarios was on an adequate level, however, vital signs documentation was shown to be poor. In addition, documentation of time-related parameters had a moderate inter-rater reliability. Patient scoring and classification indicated an overall poor inter-rater reliability among study participants. Prognostication in the HEMS setting had a moderate accuracy, and both futile and non-futile patients were treated with similar intensity. The revision of the HEMS Benefit Score resulted in a restructured and modernised version of a scoring for prehospital use, the EMS Benefit Score. As a conclusion, the reliability and accuracy of data collection among Finnish HEMS clinicians is on an adequate level. The reliability of a prehospitally set futile prognosis is at least questionable, therefore, decisions to limit treatment in a prehospital setting should be made with caution. Delphi method was established as a suitable process for implementation of a prehospital scoring system.Tiedon keruu ensihoidon helikopteritoiminnassa Lääkärijohtoiset ensihoidon helikopteriyksiköt (HEMS) ovat tärkeä osa kriittisesti sairastuneiden potilaiden hoitojärjestelmää. Jotta rajallisia resursseja voidaan kohdistaa oikealla tavalla, on tärkeää arvioida HEMS-toiminnan laatua ja vaikuttavuutta. Kliiniset laaturekisterit ovat olennainen osa toiminnan laadun arviointia, ja rekisterit toimivat myös tieteellisen tutkimuksen pohjana. Tästä syystä kliinisiin rekistereihin kerätyn tiedon luotettavuus tulee varmistaa. Tämän väitöskirjan tavoitteena oli tutkia kansallisissa HEMS-yksiköissä toimivien ensihoitolääkärien ja ensihoitajien kirjauskäytäntöjen luotettavuutta ja yhtenäisyyttä. Lisäksi tutkittiin potilaiden luokittelun ja ennustearvion osuvuutta HEMS-tehtävissä. Väitöskirjan viimeisenä osaprojektina päivitettiin kansallisten HEMS-yksiköiden käyttämä pisteytysjärjestelmä, HEMS Benefit Score, vastaamaan nykyaikaisia ensihoidon käytäntöjä. HEMS Benefit Score on ensihoidon yksittäiselle potilaalle tuottamaa hyötyä arvioiva pisteytysjärjestelmä, joka on käytössä kaikissa suomalaisissa HEMS-yksiköissä. Kirjausten luotettavuutta tutkittiin kuvitteellisten ensihoidon tehtävien avulla. Luotettavuutta arvioitiin erikseen sekä tehtäväkohtaisten muuttujien että potilasluokitus- ja pisteytysjärjestelmien osalta. Väitöskirjan kolmannessa osatyössä tutkittiin ennustearvion luotettavuutta 6219 potilaan retrospektiivisessä tutkimusasetelmassa. Viimeisessä osatyössä HEMS Benefit Score päivitettiin Delphimenetelmää käyttäen. Tulosten perusteella kirjaamisen luotettavuus oli kaiken kaikkiaan kohtalaisella, mutta peruselintoimintojen kirjaamisen osalta huonolla tasolla. Väitöskirjassa tutkittujen pisteytysjärjestelmien luotettavuus osoitettiin olevan vaihtelevaa vastaajien välillä. Ennustearvion teko onnistui kohtalaisen luotettavasti, ja sekä toivottomaksi arvioituja että todennäköisesti selviytyviksi arvioituja potilaita hoidettiin yhtä intensiivisesti. Väitöskirjan tulosten perusteella ensihoidossa asetetun toivottoman ennusteen osuvuus ei ole merkittävän korkea, joten päätöksiin rajoittaa hoitoa jo ensihoitotilanteessa tulisi suhtautua varovaisuudella. HEMS Benefit Score päivitettiin Delphi-menetelmällä vastaamaan nykyaikaisia hoitokäytäntöjä, ja nimettiin uudelleen EMS Benefit Scoreksi

E-health and e-welfare of Finland : Check Point 2022

The report provides an overview of progressive nationwide activities towards better e-services in Finland. The information system services of social welfare and health care are monitored by systematic gathering, analysis, and use of data, which allows the tracking of the progress of operations and the realisation of goals. In 2020 and 2021, six data collections were carried out to produce data for the monitoring of the Finnish ‘Information to support well-being and service renewal, eHealth and eSocial Strategy’. Some of the results presented in the report are also openly available in database cubes

Stigma toward people with mental disorders

The aim of this study was to gain an understanding of the stigma toward people with mental disorders in health care and society. The study was carried out as a mixed methods study that included four phases. First, the perceptions and associated factors of self-stigma among clients (n=898) in outpatient psychiatric services were investigated. Second, the topic of stigma in the curriculums of general nurse education programs at universities of applied sciences (n=11) was investigated. Third, the stigmatizing attitudes and associated factors that primary health care nurses (n=218) had toward people with mental disorders are described. Fourth, a systematic literature review of 55 studies and a meta-analysis of 45 interventions were performed, aiming to describe interventions to reduce stigma and effectiveness of domains of the interventions. Quantitative data were analyzed with statistical methods, and qualitative data also with narrative analysis. According to the results of four phases, first, self-stigma exists among clients with mental disorders. Clients with affective disorders have higher self-stigma than those with psychotic disorders. Long durations of illness and depressive symptoms were also associated with self-stigma. Second, in nursing education at universities of applied sciences, the descriptions of stigma varied in the the different curriculums regarding stigma. Stigma was included only to a limited extent in the content of the courses; only two curriculums out of eleven curriculums included a clear description of stigma. Third, in primary health care, nurses had both positive and stigmatizing attitudes toward people with mental disorders. Positive attitudes were associated with nurses being older and having additional training in the field of mental health. Fourth, descriptions of interventions were at times unstructured and limited. The effectiveness of the interventions to reduce stigma proved to be effective in domains. Stigma toward people with mental disorders is a multifaceted phenomenon that can be viewed from many angles in health care and society. More actions are needed to prevent self-stigma. Therefore, students should be educated about stigma and health care professionals should have access to regular additional mental health training. Effective interventions for stigma reduction decrease stigma among people with mental disorders and increase positive attitudes held by nurses. More research is needed to increase awareness and strengthen understanding about stigma toward people with mental disorders.Mielenterveyshäiriötä sairastaviin ihmisiin kohdistuva stigma Tutkimuksen tavoitteena oli saada ymmärrystä stigmasta (häpeäleima), joka kohdistuu mielenterveyshäiriötä sairastaviin ihmisiin terveydenhuollossa ja yhteiskunnassa. Tutkimus toteutettiin monimenetelmätutkimuksena neljässä vaiheessa. Ensimmäisessä vaiheessa selvitettiin psykiatrian avohoidossa olevien mielenterveysasiakkaiden (n=898) näkemyksiä itsestigmasta ja yhteydessä olevia tekijöitä. Toisessa vaiheessa selvitettiin sitä, miten stigman opetus kohdistuu sairaanhoitajakoulutuksen opetussuunnitelmiin ammattikorkeakouluissa (n=11). Kolmannessa vaiheessa kuvattiin perusterveydenhuollossa työskentelevien hoitajien (n=218) leimaavia asenteita mielenterveysasiakasta kohtaan ja yhteydessä olevia tekijöitä. Neljännessä vaiheessa toteutettiin systemaattinen kirjallisuuskatsaus (55 tutkimusta) kuvaamaan interventioita ja meta-analyysin avulla tarkasteltiin interventioiden (n=45) osa-alueiden vaikuttavuutta stigman vähentämisessä. Määrälliset aineistot analysoitiin tilastollisilla menetelmillä ja laadulliset aineistot myös narratiivista analyysia käyttäen. Tulosten perusteella ensinnäkin mielenterveysasiakkaalla esiintyi itsestigmaa; mielialahäiriötä sairastavilla asiakkailla itsestigmaa oli enemmän kuin psykoosia sairastavilla asiakkailla. Itsestigmaan oli yhteydessä myös pitkä sairaudenkesto ja masennusoireet. Toiseksi opetussuunnitelmien kuvaukset vaihtelivat stigman osalta. Stigman opetus sisältyi vähäisessä määrin opetussuunnitelmiin; vain kahdessa opetussuunnitelmassa löytyi selvä kuvaus stigmasta. Kolmanneksi perusterveydenhuollossa hoitajilla oli sekä myönteisiä että leimaavia asenteita mielenterveysasiakasta kohtaan. Myönteisempiin asenteisiin olivat yhteydessä hoitajan vanhempi ikä ja mielenterveysalan lisäkoulutus. Neljänneksi stigmaa vähentäviä interventioita oli kuvattu vaihtelevasti. Interventioiden eri osa-alueet osoittautuivat vaikuttaviksi menetelmiksi stigman vähentämisessä. Stigma on monitasoinen ilmiö, jota voi tarkastella useasta eri kulmasta terveydenhuollossa ja yhteiskunnassa. Tarvitaan lisää toimia mielenterveysasiakkaiden itsestigman välttämiseksi. Stigmaan liittyvä koulutus sairaanhoidon opiskelijoille ja säännöllisesti tarjottu mielenterveysalan lisäkoulutus terveydenhuollon ammattilaisille on tärkeää. Vaikuttaviksi osoittautuneet interventiot vähentävät stigmaa ja lisäävät hoitajien myönteisiä asenteita. Tarvitaan lisää tutkimusta stigman tietoisuuden lisäämiseksi ja ymmärtämiseksi

Relationship of neuropsychiatric symptoms with falls, psychotropic drug use and quality of life among people with dementia

Background: Dementia is characterized not only by cognitive and functional decline, but also by neuropsychiatric symptoms (NPSs). These affect almost all people with dementia during the course of the disease. NPSs are associated with impaired health-related quality of life (HRQoL) and admission to long-term care. People with dementia have an elevated risk of falling. Fall risk has been associated with impaired mobility, some NPSs such as depression and anxiety, and the use of psychotropic drugs. In long-term-care settings the prevalence of use of any psychotropic drug has been reported to be very high. There is a scarcity of studies on the interplay between NPSs, psychotropics, falls, and HRQoL Objectives: This study, comprised of four sub-studies, was aimed at examining the relationships between NPSs, falls, psychotropic drug use and HRQoL among people with dementia. The relationship between NPSs and falls was explored in two different populations: home-dwelling older adults with Alzheimer’s disease (AD) (Study I), and institutionalized older adults with cognitive impairment (Study IV). Study I concerned how long-term exercise modifies the risk of falling in community-dwelling people with AD and NPSs. Study IV was carried out to explore whether or not psychotropic drug use modifies the relationship between NPSs and falls. Study III concerned the association between NPSs and HRQoL, and, further, how the severity of dementia modifies this relationship. In addition, Study II concerned temporal trends in the prevalence of use of psychotropics and opioids, and sedative load in long-term-care settings over a 14-year period in relation to the residents’ dementia status. Participants: Study I was a secondary analysis of a randomized controlled trial, FINALEX. All the participants from the original FINALEX trial whose spousal caregivers had completed the Neuropsychiatric Inventory (NPI) at baseline and who had had at least three months of follow-up were included in this study (n=179). Study II is based on Helsinki Nutrition and Medication studies conducted in 2003–2018. It comprised four cross-sectional studies in institutional settings in Helsinki. The participants were residents in nursing homes (NHs) in 2003 (n=1987), 2011 (n=1576), and 2017 (n=791) and in assisted-living facilities (ALFs) in 2007 (n=1377), 2011 (n=1586), and 2017 (n=1752). The participants of Studies III and IV were a random sample of long-term-care residents aged 65 years and older in Helsinki (n=532). Measures: NPSs were measured with the NPI. In Studies III and IV participants were placed in three groups: no significant NPSs (NPI points 0–3), low-NPS burden (4–12 points) and high-NPS burden (NPI >12 points). The severity of dementia was measured by using Clinical Dementia Rating (CDR). HRQoL was measured by using the 15D instrument. Falls were recorded in daily-falls diaries in Study I and collected from medical records in Study IV over a one-year period. Data on demographics, diagnoses and medication were collected from medical records. Types of medication were classified according to Anatomical Therapeutic Chemical (ATC) classification. Results: Mean ages ranged from 78 to 84 years in four large samples. The participants had a high number of comorbidities and were given a high number of drugs (mean range 6.9-8.6). The severity of cognitive impairment varied. Most of the participants in Study I had mild to moderate dementia (CDR 0.5–2), whereas almost all long-term-care residents had moderate to severe dementia (CDR 2–3) (Studies II–IV). In Studies I and IV falls had a clear relationship with NPSs measured by the total NPI score. In Study I the incidence of falls increased linearly with NPI score in the control group. The fall rate was 2.87 per person-years (95% Cl 2.43–3.35) in the control group, whereas the exercise intervention group showed no such relationship with NPI score and had a fall rate of 1.48 per person-years (95% Cl 1.26–1.73). In Study IV the NPI total score had a curvilinear association with the incidence rate of falls per person-years. Using the no-significant-NPSs group as a reference, the low-NPS-burden group had an IRR per SD for falls of 1.64 (95% Cl 1.27–2.12), whereas in the high-NPS-burden group the IRR per SD was 2.43 (95% Cl 1.91–3.08). Psychotropics did not modify the relationship between NPSs and falls. Psychosis and hyperactivity subsyndromes were associated with higher IRRs of falls, whereas apathy and affective symptoms were not. In Study III the severity of NPSs was significantly associated with better HRQoL (15D measures). This seemed to be related to better physical functioning and greater vitality. Residents with severe dementia (CDR 3) had worse HRQoL than residents with mild-to-moderate dementia (CDR <3). There was a significant interaction between NPI and CDR scores (p=0.037 for NPI, p<0.001 for CDR and p<0.001 for interaction). In Study II the prevalence of use of all psychotropics decreased significantly in NHs (from 81% to 61%), whereas in ALFs there was no such trend (from 65% to 64%). There was a significant increase in opioid use in both settings. Residents with dementia used fewer psychotropics and opioids than those without dementia in both settings and at all time points. Conclusions: Neuropsychiatric symptoms and their severity are associated with fall risk. Evaluation of NPSs, especially NPS severity and neuropsychiatric subsyndromes, should be part of comprehensive assessment when aiming to prevent falls in long-term-care residents with cognitive impairment. Exercise has the potential to reduce the risk of falls associated with NPSs. The severity of NPSs and dementia are both important factors determining HRQoL. NPSs have a distinct impact on HRQoL at different stages of dementia. The prevalence of psychotropic use has decreased over the last 14 years in NHs in Helsinki, but at the same time the rates of opioid use have increased in both NHs and ALFs, leading to a high overall sedative load among long-term-care residents.Muistisairaudet tunnetaan muistin heikentymisestä. Vähemmän on puhuttu muistisairauksien neuropsykiatrisista oireista, vaikka niitä esiintyy lähes kaikilla muistisairauteen sairastuneilla jossakin vaiheessa sairautta. Tavallisimpia neuropsykiatrisia oireita ovat masennus, levottomuus, ahdistuneisuus, apatia ja näkö- tai kuuloharhat sekä harhaluulot. Neuropsykiatriset oireet yhdistyvät heikompaan terveyteen liittyvään elämänlaatuun ja lisääntyneeseen pitkäaikaishoidon tarpeeseen. Muistisairailla on suurempi kaatumisriski kuin ei-muistisairailla. Kaatumisriskiä lisäävät heikentynyt liikkumiskyky sekä psyykelääkkeiden käyttö. Tutkimusnäyttö neuropsykiatristen oireiden yhteydestä kaatumisriskiin on vähäistä. Väitöskirjatutkimuksen tavoitteena oli tutkia neuropsykiatristen oireiden yhteyksiä kaatumisiin, psyykelääkkeiden käyttöön ja terveyteen liittyvään elämänlaatuun muistisairailla ihmisillä. Neuropsykiatristen oireiden yhteyksiä kaatumisiin selvitettiin sekä kotona että pitkäaikaishoidossa asuvilla muistisairailla. Lisäksi tutkimus selvitti kuinka pitkäaikainen säännöllinen liikunta ja psyykelääkkeiden käyttö muokkaavat kaatumisriskiä. Tutkimus kartoitti myös neuropsykiatristen oireiden ja terveyteen liittyvän elämänlaadun yhteyttä ja kuinka muistisairauden vaikeusaste on siihen yhteydessä. Neuropsykiatrisia oireet selvitettiin NPI mittarilla (Neuropsychiatric Inventory) ja muistisairauden vaikeusaste mitattiin CDR- mittarilla (Clinical Dementia Rating). Terveyteen liittyvää elämänlaatua mitattiin 15D mittarilla. Yksi osatöistä tutki psyykelääkkeiden, vahvojen kipulääkkeiden ja väsyttävän lääkekuorman muuttumista pitkäaikaishoidossa 14 vuoden seuranta-ajalla muistisairailla ja ei-muistisairailla. Tutkittavien keski-ikä oli 78-84 vuotta neljässä eri aineistossa. Tutkittavilla oli useita pitkäaikaissairauksia ja pysyviä lääkityksiä. Säännöllisessä käytössä oli keskimäärin 6.9-8.6 lääkettä. Tutkittavien muisti oli lievemmin heikentynyt kotona asuvilla muistisairailla, kun taas pitkäaikaishoidossa lähes kaikilla oli vaikea-asteinen muistin heikentymä. Kaatumiset ja vammat lisääntyivät merkitsevästi neuropsykiatristen oireiden vaikeutuessa. Eri käyttäytymisen oireet vaikuttivat kaatumisen riskiin eri tavoin. Aistiharhat, harhaluulot, levottomuus ja ärtyneisyys olivat yhteydessä suurempaan kaatumisen riskiin. Psyykelääkkeiden käyttö ei muuttanut neuropsykiatristen oireiden ja kaatumisten välistä yhteyttä. Pitkäaikainen, säännöllinen vuoden kestävä liikuntaharjoittelu vähensi merkittävästi neuropsykiatrisiin oireisiin yhdistyvää kaatumisriskiä. Sekä neuropsykiatristen oireiden että muistisairauden vaikeusaste vaikutti terveyteen liittyvään elämänlaatuun. Psyykelääkkeiden käytön esiintyvyys on vähentynyt viimeisen 14 vuoden aikana vanhainkodeissa Helsingissä, mutta samalla vahvojen kipulääkkeiden käyttö on lisääntynyt, johtaen siihen, että keskushermostoon vaikuttavia väsyttäviä lääkkeitä käytetään yhä paljon pitkäaikaishoidossa. Tutkimuksen perusteella voidaan todeta, että neuropsykiatriset oireet ovat itsenäinen riskitekijä kaatumisille. Neuropsykiatristen oireiden arviointi tulisi ottaa osaksi kokonaisvaltaista arviota, kun muistisairaiden kaatumisriskiä halutaan pienentää. Liikuntaharjoittelulla voidaan vähentää neuropsykiatrisiin oireisiin yhdistyvää kaatumisriskiä