Chapter 24 Working Together in the Aftermath of an Unforeseen Event

"The frame of this chapter is how clinicians and leaders employed in psychiatric departments in hospitals experience and cope with patients who commit suicide while undergoing treatment. The major focus is the phenomenon which in the Bow-tie model is called “stabilization”. To explore this phenomenon in an empirical analysis, two concepts of samhandling are introduced, these being coordination and cooperation. These two concepts are used in an interpretation of what eight leaders and clinicians report on how they handle working together after a patient during treatment in a psychiatric hospital has unexpectedly committed suicide. The findings are that leaders and clinicians have different views on what stabilization is. Stabilization to the leaders seems to be something they can handle by using mandatory organizational procedures of coordination. To the clinicians (psychologists and psychiatrists) however, stabilization is less straightforward. Professional stabilization is, to them, more important than organizational stabilization, and it requires another form of interaction – namely, cooperation. Cooperation is, in its simplest and purest form, a symmetrical way of working together, based on equality in competence and an unforced relation between the parties. For the purpose of professional stabilization, this is the form of interaction preferred by the clinicians. However, these findings are tentative and more research is needed to elaborate why leaders and clinicians respond as they do after a patient suicide.

Chapter 24 Working Together in the Aftermath of an Unforeseen Event

"The frame of this chapter is how clinicians and leaders employed in psychiatric departments in hospitals experience and cope with patients who commit suicide while undergoing treatment. The major focus is the phenomenon which in the Bow-tie model is called “stabilization”. To explore this phenomenon in an empirical analysis, two concepts of samhandling are introduced, these being coordination and cooperation. These two concepts are used in an interpretation of what eight leaders and clinicians report on how they handle working together after a patient during treatment in a psychiatric hospital has unexpectedly committed suicide. The findings are that leaders and clinicians have different views on what stabilization is. Stabilization to the leaders seems to be something they can handle by using mandatory organizational procedures of coordination. To the clinicians (psychologists and psychiatrists) however, stabilization is less straightforward. Professional stabilization is, to them, more important than organizational stabilization, and it requires another form of interaction – namely, cooperation. Cooperation is, in its simplest and purest form, a symmetrical way of working together, based on equality in competence and an unforced relation between the parties. For the purpose of professional stabilization, this is the form of interaction preferred by the clinicians. However, these findings are tentative and more research is needed to elaborate why leaders and clinicians respond as they do after a patient suicide.

Sammenhenger mellom tilgang til nærmiljøkvaliteter, aktivitetsdeltakelse og sosioøkonomisk status blant voksne i Norge : en tverrsnittstudie med bruk av GIS som metode

Bakgrunn: Fysisk aktivitet fremmer helse og trivsel, kan forebygge sykdom og subjektive plager og gir flere friske leveår. Samtidig ser vi at kun tre av ti voksne i Norge imøtekommer Helsedirektoratets anbefalinger for fysisk aktivitet. Grupper med høyere inntekt og høyere utdanning er mer fysisk aktive og en rekke faktorer i vårt nærmiljø kan potensielt påvirke muligheten for aktivitetsdeltakelse. Ved å sette fokus på determinanter for helse slik som inntekt, utdanning og nærmiljøkvaliteter kan man øke forståelse for hvordan planlegging kan være med å utjevne sosiale forskjeller. Formål: Formålet med denne masteroppgaven er å få økt kunnskap om sammenhenger mellom tilgang til nærmiljøkvalitetene grøntområder og aktivitetsfasiliteter, aktivitetsdeltakelse og sosioøkonomisk status blant voksne i Norge. Med økt innsikt i disse sammenhengene kan man lettere utvikle nærmiljøkvaliteter som stimulerer til økt aktivitetsdeltakelse og imøtekommer sosioøkonomiske utfordringer for å utjevne sosiale forskjeller i helse. Metode: Studiedesignet for denne masteroppgaven er en kvantitativ tverrsnittstudie. Utvalget er hentet fra spørreskjema og data ble koblet med geografiske data som beskriver de fysiske nærmiljøkvalitetene. Spørreskjemaet er fra Friluftslivets Fellesorganisasjon, nå Norsk Friluftsliv (FRIFO) hvor spørsmål om aktivitetsvaner i organisert idrett og grøntområder er hentet ut. Nærmiljøvariablene aktivitetsfasiliteter, grøntområder og skog er beregnet ved hjelp av geografiske informasjonssystemer (GIS). Variablene inntekt og utdanning legger grunnlaget for å studere sosioøkonomisk status. Dataene ble statistisk analysert ved hjelp av lineære regresjonsanalyser og enveis variansanalyse. Hovedfunn: Resultatene i studien viser signifikante sammenhenger mellom sosioøkonomisk status og tilgang til nærmiljøkvaliteter. Det kan tyde på at de med økt inntekt har bedre tilgang til aktivitetsfasiliteter og at økt utdanning gir bedre tilgang til grøntområder og skog. Studien viser at aktivitet i organisert idrett kan øke ved økt utdanning og at økt utdanning kan gi mindre tilgang til grøntområder. Studien viser ingen signifikante sammenhenger mellom deltakeres tilgang til nærmiljøkvalitetene og aktivitetsdeltakelse. Konklusjon: Resultatene i denne studien tilsier at det bør planlegges for nærmiljøkvaliteter som tar hensyn til ulike sosioøkonomiske grupper og aktivitetsmønstre. Samtidig har denne studien satt søkelys på faktorer ved selvrapport data og objektive målemetoder hvor der er behov for ytterligere kunnskap. Studien peker på et behov for langsgående studier for å kunne si mer om studiens tematikk. Et sektorovergripende samarbeid er nødvendig for å skape aktivitetsvennlige nærmiljø for alle.Background: Physical activity promotes health and well-being, can prevent diseases and subjective illness and provide more healthy life years. At the same time, only three out of ten adults in Norway meets the national recommendations for physical activity. Groups with higher income and higher education are more physically active and there are several factors in our built environment that can potentially affect the possibility of activity participation. By focusing on determinants of health such as income, education and built environmental qualities, we can increase our understanding of how planning can help to reduce social inequalities. Purpose: The purpose of this master's thesis is to provide knowledge about the relationship between access to facilities and green areas, participation in activity and socio-economic status among adults in Norway. Increased knowledge and insight into these relations, could be of importance for developing built environment qualities that stimulates activity participation and meet socioeconomic challenges. Method: This master's thesis applies a quantitative cross-sectional study design. The sample derived from questionnaire data obtained from Friluftslivets Fellesorganisasjon, now Norsk Friluftsliv (FRIFO). The questionnaire from FRIFO covered questions about activity habits in organized sports and green areas, income and education, which were selected for the purposes of this study. The questionnaire data were linked with geographical data describing the built environmental qualities. The variables relating to the built environments activity facilities, green areas and forests were calculated using geographical information systems (GIS). In the analyzes of data, statistical methods such as linear regression analyzes, and one-way analysis of variance were used. Main findings: The results show no significant associations between participants' access to environmental qualities and activity participation. There are significant correlations between socioeconomic status and access to built environmental qualities. The results show that those with a medium income have better access to activity facilities than those with low income. The study also shows that access to green areas are reduced as education increases. Those under education also has a significantly higher activity in organized sports. Conclusion: The results of this study indicate that that socio-economic groups and activity patterns should be considered in environmental planning. The study points to the importance of factors in self-reported data and objective measurement methods, where additional knowledge is needed. This study also highlights the need for longitudinal studies on the particular topics. A cross-sectoral collaboration is necessary to create an active local environments for everyone.M-FO

Perceptions and experiences of skilled birth attendants on using a newly developed strap-on electronic fetal heart rate monitor in Tanzania

Background: Regular fetal heart rate monitoring during labor can drastically reduce fresh stillbirths and neonatal mortality through early detection and management of fetal distress. Fetal monitoring in low-resource settings is often inadequate. An electronic strap-on fetal heart rate monitor called Moyo was introduced in Tanzania to improve intrapartum fetal heart rate monitoring. There is limited knowledge about how skilled birth attendants in low-resource settings perceive using new technology in routine labor care. This study aimed to explore the attitude and perceptions of skilled birth attendants using Moyo in Dar es Salaam, Tanzania. Methods: A qualitative design was used to collect data. Five focus group discussions and 10 semi-structured indepth interviews were carried out. In total, 28 medical doctors and nurse/midwives participated in the study. The data was analyzed using qualitative content analysis. Results: The participants in the study perceived that the device was a useful tool that made it possible to monitor several laboring women at the same time and to react faster to fetal distress alerts. It was also perceived to improve the care provided to the laboring women. Prior to the introduction of Moyo, the participants described feeling overwhelmed by the high workload, an inability to adequately monitor each laboring woman, and a fear of being blamed for negative fetal outcomes. Challenges related to use of the device included a lack of adherence to routines for use, a lack of clarity about which laboring women should be monitored continuously with the device, and misidentification of maternal heart rate as fetal heart rate. Conclusion: The electronic strap-on fetal heart rate monitor, Moyo, was considered to make labor monitoring easier and to reduce stress. The study findings highlight the importance of ensuring that the device’s functions, its limitations and its procedures for use are well understood by users

Acquiring Knowledge about the Use of a Newly Developed Electronic Fetal Heart Rate Monitor: A Qualitative Study Among Birth Attendants in Tanzania

In an effort to reduce newborn mortality, a newly developed strap-on electronic fetal heart rate monitor was introduced at several health facilities in Tanzania in 2015. Training sessions were organized to teach staff how to use the device in clinical settings. This study explores skilled birth attendants’ perceptions and experiences acquiring and transferring knowledge about the use of the monitor, also called Moyo. Knowledge about this learning process is crucial to further improve training programs and ensure correct, long-term use. Five Focus group discussions (FGDs) were carried out with doctors and nurse-midwives, who were using the monitor in the labor ward at two health facilities in Tanzania. The FGDs were analyzed using qualitative content analysis. The study revealed that the participants experienced the training about the device as useful but inadequate. Due to high turnover, a frequently mentioned challenge was that many of the birth attendants who were responsible for training others, were no longer working in the labor ward. Many participants expressed a need for refresher trainings, more practical exercises and more theory on labor management. The study highlights the need for frequent trainings sessions over time with focus on increasing overall knowledge in labor management to ensure correct use of the monitor over time

“I Was Relieved to Know That My Baby Was Safe”: Women’s Attitudes and Perceptions on Using a New Electronic Fetal Heart Rate Monitor during Labor in Tanzania

To increase labor monitoring and prevent neonatal morbidity and mortality, a new wireless, strap-on electronic fetal heart rate monitor called Moyo was introduced in Tanzania in 2016. As part of the ongoing evaluation of the introduction of the monitor, the aim of this study was to explore the attitudes and perceptions of women who had worn the monitor continuously during their most recent delivery and perceptions about how it affected care. This knowledge is important to identify barriers towards adaptation in order to introduce new technology more effectively. We carried out 20 semi-structured individual interviews post-labor at two hospitals in Tanzania. A thematic content analysis was used to analyze the data. Our results indicated that the use of the monitor positively affected the women’s birth experience. It provided much-needed reassurance about the wellbeing of the child. The women considered that wearing Moyo improved care due to an increase in communication and attention from birth attendants. However, the women did not fully understand the purpose and function of the device and overestimated its capabilities. This highlights the need to improve how and when information is conveyed to women in labor

Electrocardiographic Criteria for Left Ventricular Hypertrophy in Children

Previous studies to determine the sensitivity of the electrocardiogram (ECG) for left ventricular hypertrophy (LVH) in children had their imperfections: they were not done on an unselected hospital population, several criteria used in adults were not applied to children, and obsolete limits of normal for the ECG parameters were used. Furthermore, left ventricular mass (LVM) was taken as the reference standard for LVH, with no regard for other clinical evidence. The study population consisted of 832 children from whom a 12-lead ECG and an M-mode echocardiogram were taken on the same day. The validity of the ECG criteria was judged on the basis of an abnormal LVM index, either alone or in combination with other clinical evidence. The ECG criteria were based on recently established age-dependent normal limits. At 95% specificity, the ECG criteria have low sensitivities (<25%) when an elevated LVM index is taken as the reference for LVH. When clinical evidence is also taken into account, the sensitivity improved considerably (<43%). Sensitivities could be further improved when ECG parameters were combined. The sensitivity of the pediatric ECG in detecting LVH is low but depends strongly on the definition of the reference used for validation

Chronic fatigue syndrome: identifying zebras amongst the horses

There are currently no investigative tools or physical signs that can confirm or refute the presence of chronic fatigue syndrome (CFS). As a result, clinicians must decide how long to keep looking for alternative explanations for fatigue before settling on a diagnosis of CFS. Too little investigation risks serious or easily treatable causes of fatigue being overlooked, whilst too many increases the risk of iatrogenic harm and reduces the opportunity for early focused treatment. A paper by Jones et al published this month in BMC Medicine may help clinicians in deciding how to undertake such investigations. Their results suggest that if clinicians look for common psychiatric and medical conditions in those complaining of prolonged fatigue, the rate of detection will be higher than previously estimated. The most common co-morbid condition identified was depression, suggesting a simple mental state examination remains the most productive single investigation in any new person presenting with unexplained fatigue. Currently, most diagnostic criteria advice CFS should not be diagnosed when an active medical or psychiatric condition which may explain the fatigue is identified. We discuss a number of recent prospective studies that have provided valuable insights into the aetiology of chronic fatigue and describe a model for understanding chronic fatigue which may be equally relevant regardless of whether or not an apparent medical cause for fatigue can be identified

Association of adiposity and mental health functioning across the lifespan:Findings from understanding society (The UK household longitudinal study)

Background: Evidence on the adiposity-mental health associations is mixed, with studies finding positive, negative or no associations, and less is known about how these associations may vary by age. Objective: To examine the association of adiposity -body mass index (BMI), waist circumference (WC) and percentage body fat (BF%)- with mental health functioning across the adult lifespan. Methods: Data from 11,257 participants (aged 18+) of Understanding Society: the UK Household Longitudinal Study (waves 2 and 3, 5/2010-7/2013) were employed. Regressions of mental health functioning, assessed by the Mental Component Summary (MCS-12) and the General Health Questionnaire (GHQ-12), on adiposity measures (continuous or dichotomous indicators) were estimated adjusted for covariates. Polynomial age-adiposity interactions were estimated. Results: Higher adiposity was associated with poorer mental health functioning. This emerged in the 30s, increased up to mid-40s (all central adiposity and obesity-BF% measures) or early 50s (all BMI measures) and then decreased with age. Underlying physical health generally accounted for these associations except for central adiposity, where associations remained statistically significant from the mid-30s to50s. Cardiovascular, followed by arthritis and endocrine, conditions played the greatest role in attenuating the associations under investigation. Conclusions: We found strong age-specific patterns in the adiposity-mental health functioning association that varied across adiposity measures. Underlying physical health had the dominant role in attenuating these associations. Policy makers and health professionals should target increased adiposity, mainly central adiposity, as it is a risk factor for poor mental health functioning in those aged between mid-30s to 50 years