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Hintergrund: Die COVID-19-Pandemie ist eine Ausnahmesituation ohne Präzedenz und erforderte zahlreiche Ad-hoc-Anpassungen in den Strukturen und Prozessen der akutstationären Versorgung.
Ziel: Ziel war es zu untersuchen, wie aus Sicht von Führungspersonen und Hygienefachkräften in der Pflege die stationäre Akutversorgung durch die Pandemiesituation beeinflusst wurde und welche Implikationen sich daraus für die Zukunft ergeben.
Methoden: Qualitative Studie bestehend aus semistrukturierten Interviews mit fünf Verantwortlichen des leitenden Pflegemanagements und drei Hygienefachkräften in vier Krankenhäusern in Deutschland. Die Interviews wurden mittels qualitativer Inhaltsanalyse ausgewertet.
Ergebnisse: Die Befragten beschrieben den auf die prioritäre Versorgung von COVID-19-Fällen hin umstrukturierten Klinikalltag. Herausforderungen waren Unsicherheit und Angst bei den Mitarbeiter_innen, relative Ressourcenknappheit von Material und Personal und die schnelle Umsetzung neuer Anforderungen an die Versorgungleistung. Dem wurde durch gezielte Kommunikation und Information, massive Anstrengungen zur Sicherung der Ressourcen und koordinierte Steuerung aller Prozesse durch bereichsübergreifende, interprofessionelle Task Forces begegnet.
Schlussfolgerungen: Die in der COVID-19-Pandemie vorgenommenen Anpassungen zeigen Entwicklungspotenziale für die zukünftige Routineversorgung auf, z. B. könnten neue Arbeits- und Skill Mix-Modelle aufgegriffen werden. Für die Konkretisierung praktischer Implikationen sind vertiefende Analysen der Daten mit zeitlichem Abstand erforderlich.
Objective: Many different assessment tools are used to assess functioning in rehabilitation; this limits the comparability and aggregation of respective data. The aim of this study was to outline the development of an International Classification of Functioning, Disability and Health (ICF)-based interval-scaled common metric for 2 assessment tools assessing activities of daily living: the Functional Independence Measure (FIMTM) and the Extended Barthel Index (EBI), used in Swiss national rehabilitation quality reports.
Methods: The conceptual equivalence of the 2 tools was assessed through their linking to the ICF. The Rasch measurement model was then applied to create a common metric including FIMTM and EBI.
Subjects: Secondary analysis of a sample of 265 neurological patients from 5 Swiss clinics.
Results: ICF linking found conceptual coherency of the tools. An interval-scaled common metric, including FIMTM and EBI, could be established, given fit to the Rasch model in the related analyses.
Conclusion: The ICF-based and interval-scaled common metric enables comparison of patients and clinics functioning outcomes when different activities of daily living tools are used. The common metric can be included in a Standardized Assessment and Reporting System for functioning information in order to enable data aggregation and comparability.
Keywords: Barthel Index; Functional Independence Measure; Rasch Measurement Model; activities of daily living; outcome assessment (healthcare); psychometrics; quality in healthcare; rehabilitation.
In this study, an experimental apparatus is used to excite four U-tube-shaped liquid pistons connected in series, and to study their behaviour. Some of the gas spaces are heated to induce piston oscillations; in others, gas expansion is utilised to produce a refrigeration effect. It was discovered that the liquid piston surface would become unstable and turbulent at relatively low gas charge pressures (2 bar–3 bar). Cylindrical polyethylene floats were employed at each piston surface in order to reduce the area of the free surface of each piston and allow experiments to be conducted over a wide range of operating conditions. Experiments were carried out using gas charge pressures in the range of 1 bar–6 bar. The resulting liquid piston oscillations were measured and analysed to assess the impact of any developing piston instability. Evidence of a liquid piston acceleration limit, likely resulting from the Rayleigh-Taylor instability phenomenon, is consistently observed during the experiments. The use of submerged polyethylene piston floats is found to increase the surface stability and enable maximum accelerations of 25 ms−2 to 30 ms−2.
In March 2019, German-speaking scientists and scholars calling themselves Scientists for Future, published a statement in support of the youth protesters in Germany, Austria, and Switzerland (Fridays for Future, Klimastreik/Climate Strike), verifying the scientific evidence that the youth protestors refer to. In this article, they provide the full text of the statement, including the list of supporting facts (in both English and German) as well as an analysis of the results and impacts of the statement. Furthermore, they reflect on the challenges for scientists and scholars who feel a dual responsibility: on the one hand, to remain independent and politically neutral, and, on the other hand, to inform and warn societies of the dangers that lie ahead.
Aquifers are typically perceived as rather stable habitats, characterized by low biogeochemical and microbial community dynamics. Upon contamination, aquifers shift to a perturbed ecological status, in which specialized populations of contaminant degraders establish and mediate aquifer restoration. However, the ecological controls of such degrader populations, and possible feedbacks between hydraulic and microbial habitat components, remain poorly understood. Here, we provide evidence of such couplings, via 4 years of annual sampling of groundwater and sediments across a high-resolution depth-transect of a hydrocarbon plume. Specialized anaerobic degrader populations are known to be established at the reactive fringes of the plume. Here, we show that fluctuations of the groundwater table were paralleled by pronounced dynamics of biogeochemical processes, pollutant degradation, and plume microbiota. Importantly, a switching in maximal relative abundance between dominant degrader populations within the Desulfobulbaceae and Desulfosporosinus spp. was observed after hydraulic dynamics. Thus, functional redundancy amongst anaerobic hydrocarbon degraders could have been relevant in sustaining biodegradation processes after hydraulic fluctuations. These findings contribute to an improved ecological perspective of contaminant plumes as a dynamic microbial habitat, with implications for both monitoring and remediation strategies in situ.
Implementation of robotic devices in nursing care. Barriers and facilitators: an integrative review
(2020)
Background: Robots in healthcare are gaining increasing attention; however, their implementation is challenging due to the complexity of both interventions themselves and the contexts in which they are implemented. The objective of this integrative review is to identify barriers to and facilitators of the implementation of robotic systems in nursing.
Methods: Articles published from 2002 to 2019 reporting on projects to implement robotic devices in nursing care were searched on Medline (via PubMed), CINAHL and databases on funded research projects (Community Research and Development Information Services and Technische Informationsbibliothek) and in journals for robotic research in November 2017 and July 2019 for an update. No restrictions regarding study designs were imposed. All included articles underwent quality assessments with design-specific critical appraisal tools. Barriers to and facilitators of implementation were classified using the Context and Implementation of Complex Interventions framework.
Results: After removing all duplicates, the search revealed 11 204 studies, of which 17 met the inclusion criteria and were included in the synthesis. The majority of the studies dealt with the implementation of robots designed to support individuals, either living at home or in nursing homes (n=11). The studies were conducted in Europe, the USA and New Zealand and were carried out in nursing homes, individual living environments, hospital units and laboratories. The quality of reporting and quality of evidence were low in most studies. The most frequently reported barriers were in socioeconomic and ethical domains and were within the implementation outcomes domain. The most frequently reported facilitators were related to the sociocultural context, implementation process and implementation strategies.
Discussion: This review identified barriers to and facilitators of the implementation of robotic devices in nursing within different dimensions. The results serve as a basis for the development of suitable implementation strategies to reduce potential barriers and promote the integration of elements to facilitate implementation.
PROSPERO registration number: CRD42018073486.
Abstract
Objectives: To develop a common reference metric of functioning, incorporating generic and health condition-specific disability instruments, and to test whether this reference metric is invariant across 2 health conditions.
Design: Psychometric study using secondary data analysis. Firstly, the International Classification of Functioning, Disability and Health (ICF) Linking Rules were used to examine the concept equivalence between the World Health Organization Disability Assessment Schedule (WHODAS 2.0), Health Assessment Questionnaire (HAQ), and Functional Independence Measure (FIMTM). Secondly, a scale-bank was developed using a reference metric approach to test-equating, based on the Rasch measurement model.
Participants: Secondary analysis was performed on data from 487 people; 61.4% with rheumatoid arthritis and 38.6% with stroke.
Results: Three sub-domains of the WHODAS 2.0 and all items of the HAQ and FIMTM motor mapped on to the ICF chapters d4 Mobility, d5 Self-care and d6 Domestic life. Test-equating of these scales resulted in good model fit, indicating that a scale bank and associated reference metric across these 3 instruments could be created.
Conclusion: This study provides a transformation table to enable direct comparisons among instruments measuring physical functioning commonly used in rheumatoid arthritis (HAQ) and stroke (FIMTM motor scale), as well as in people with disability in general (WHODAS 2.0).
Keywords: FIM; Functional Independence Measure; HAQ; Health Assessment Questionnaire; WHODAS 2.0; World Health Organization Disability Assessment Schedule; outcome assessment; rheumatoid arthritis; stroke; psychometrics.
Introduction
Mobility limitations have a multitude of different negative consequences on elderly patients including decreasing opportunities for social participation, increasing the risk for morbidity and mortality. However, current healthcare has several shortcomings regarding mobility sustainment of older adults, namely a narrow focus on the underlying pathology, fragmentation of care across services and health professions and deficiencies in personalising care based on patients’ needs and experiences. A tailored healthcare strategy targeted at mobility of older adults is still missing.
Objective
The objective is to develop multiprofessional care pathways targeted at mobility sustainment and social participation in patients with vertigo/dizziness/balance disorders (VDB) and osteoarthritis (OA) .
Methods
Data regarding quality of life, mobility limitation, pain, stiffness and physical function is collected in a longitudinal observational study between 2017 and 2019. General practitioners (GPs) recruit their patients with VDB or OA. Patients who visited their GP in the last quarter will be identified in the practice software based on VDB and OA-related International Classification of Diseases 10th Revision. Study material will be sent from the practice to patients by mail. Six months and 12 months after baseline, all patients will receive a mail directly from the study team containing the follow-up questionnaire. GPs fill out questionnaires regarding patient diagnostics, therapy and referrals.
Ethics and dissemination
The study was approved by the ethical committee of the Ludwig-Maximilians-Universität München and of the Technische Universität Dresden. Results will be published in scientific, peer-reviewed journals and at national and international conferences. Results will be disseminated via newsletters, the project website and a regional conference for representatives of local and national authorities.
The objective of this research project is to develop a solar-powered refrigerator in the lower capacity range of up to 5 kW of cooling power. With the use of liquid pistons and one of the most efficient thermodynamic cycles known, the Stirling cycle, this product has the potential to outperform rival solar cooling technologies while providing inexpensive, reliable, quiet, environmentally-friendly, and efficient solar cooling for residential use, due to its straightforward manufacturing, simple design and inert working gas. Presented in this paper are the newest results of the theoretical and experimental investigation into deducing the key design parameters and system configuration of the so-called Liquid Piston Stirling Cooler (LPSC), which will help lead to optimal performance. Computer models of the complex unconstrained system have been constructed and validated using the modelling software Sage and shown to replicate system behavior with reasonable accuracy in experiments. The models have been used to predict system improvements and identify limitations imposed by the use of liquid pistons. The results to date provide a unique insight into a relatively little studied area in Stirling cycle research.
The classical results of the binomial and negative binomial probability distribution are generalized by means of homogeneous Discrete Time Markov Chains to series of stochastically independent random trials. These have not only two possible outcomes but two groups of them -- different kinds of successes and failures with occurrence probabilities depending on the outcome of the previous trial. This generalization allows a uniform view of occupation time, first passage time and recurrence time. Our results are consequently derived and presented in matrix form, the probabilities as well as the moments. They can be applied to all Discrete Time Markov Chains, especially in computer capacity planning, performability and economics.
Due to the application of elastic interlayers for acoustic decoupling, wood screws to connect timber elements are stressed beneath axial and shear loads additionally by a bending moment. The equations to calculate the load carrying capacity of wood-wood-connections according to the Eurocode 5, lose their validity in case of application of interlayers with low shear resistance. Furthermore, the increasing flexibilities of the joints should be considered for a realistic static modelling.
Aim of the present work is to analyze the mechanical load bearing characteristics of wall-ceiling-connections of cross laminated timber with and without elastic interlayers. On the basis of experiments as well as analytical approaches, the load-deformation-behavior is discussed and contrasted to the current standards.
This paper concerns the development and validation of Finite Element Methods (FEM) to simulate the dynamic response of a dowelled-joist timber floor. This is a solid floor comprised of timber joists connected using timber dowels with individual assemblies connected using inclined metal screws. The focus is on the structural dynamics in the low-frequency range up to 200 Hz which is the relevant range for impact sound insulation and vibration serviceability. Dowel connections between the joists that formed each assembly were modelled using either rigid or spring connectors in the FEM models. The validation against experimental modal analysis showed that both approaches were valid in terms of the eigenfrequencies, Modal Assurance Criterion (MAC) and the spatial-average velocity with point excitation. Whilst the FEM model with spring connectors had a higher number of correlated modes in the MAC analysis, this required removal of many spurious modes before predicting the response. The validated models were used to demonstrate the potential in predicting assessment parameters for vibration serviceability that are contained in EN 1995-1-1 (Eurocode 5). This predictive approach to the evaluation of vibration serviceability has the advantage in that it can be used for non-standard timber floors with non-standard boundary conditions or floor plans.
We examine the interaction in the market for physician services when the total budget for reimbursement is fixed. Physicians obtain points for the services they render. At the end of the period the budget is divided by the sum of all points submitted, which determines the price per point. We show that this retrospective payment system involves – compared to a fee-for-service remuneration system – a severe coordination problem, which potentially leads to the “treadmill effect”. We argue that when market entry is possible, a budget can be efficiency enhancing, if in addition a price floor is used.
Predictive Modeling (PM) techniques are gaining importance in the worldwide health insurance business. Modern PM methods are used for customer relationship management, risk evaluation or medical management. This article illustrates a PM approach that enables the economic potential of (cost-)effective disease management programs (DMPs) to be fully exploited by optimized candidate selection as an example of successful data-driven business management. The approach is based on a Generalized Linear Model (GLM) that is easy to apply for health insurance companies. By means of a small portfolio from an emerging country, we show that our GLM approach is stable compared to more sophisticated regression techniques in spite of the difficult data environment. Additionally, we demonstrate for this example of a setting that our model can compete with the expensive solutions offered by professional PM vendors and outperforms non-predictive standard approaches for DMP selection commonly used in the market.
We present a numerical and experimental design study for reducing conducted common mode noise for frequencies below 10MHz generated in switching cells comprising sub-nH commutation loops. Compared to conventional methods of adding external gate resistors our approach does not degrade efficiency. A parallel plate loop design (characterized by a minimum loop inductance and small board area usage) is found suboptimal in terms of conducted EMI compared to a micro-strip line loop geometry. The net ground impedance rather than the net ground inductance is found to mainly contribute to the observed EMI noise.
Wide-bandgap semiconductors such as Silicon Carbide (SiC) or Gallium Nitride (GaN) enable fast switching and high switching frequencies of power electronics. However, this potential can not be exploited due to limitations caused by parasitic elements of packaging and interconnections. This paper shows a possibility to minimize parasitic elements of a half-bridge switching cell with 650 V GaN dies integrated into a printed circuit substrate. A sub-nH commutation loop of 0.5 nH inductance gives superior switching characteristics compared to circuits with packaged dies. Simulation and experimental results of an inverse double pulse test confirm our expectations. This study further reveals additional benefits of the proposed technology in terms of mechanical stability and thermal interfacing to heat sinks compared to circuits with packaged dies.
Power cycling and temperature endurance test of a GaN switching cell with substrate integrated chips
(2019)
We present a reliability study of a half-bridge switching cell with substrate integrated 650 V GaN HEMTs. Power Cycling Testing with a ΔTj of 100 K has revealed thermo-mechanically induced failures of contact vias after more than 220 kcycles. The via failure mode of contact opening is confirmed by reverse-bias pulsed IV-measurements to be primarily triggered by a ΔTj imposed thermal gradient and not by a high Tj. The chip electrical characteristics, however, remained unaffected during Power Cycling. Furthermore, a High Temperature Storage test at 125 °C for 5000 h has shown no changes in the electrical performance of substrate integrated GaN HEMTs.
This paper proposes an ultra-low inductance half-bridge switching cell with substrate integrated 650V GaN bare dies. A vertical parallel-plate waveguide structure with 100 μm layer thickness results in a commutation loop inductance of 0.5 nH resulting in a negligible drain-source voltage overshoot in the inductive load standard pulse test. On the other hand reliable circuit operation requires an assessment of the isolation strength of the thin dielectric layer in the main commutation loop, because critical high local electric fields might occur between the pads. Measurements of the dielectric breakdown voltage followed by a statistical failure analysis provide a characteristic life of 14.7 kV and a 10% quantile of 13.5kV in the Weibull fitted data. This characteristic life depends strongly on the ambient temperature and drops to 4.1kV at 125°C. Additionally, ageing tests show an increasing in dielectric breakdown voltage after 500h, 1000h and 2000h at 125°C high-temperature storage due to resin densification processes.
The dynamic behavior and position stability of servo drives are influenced by many parameters. One major influencing parameter is the pulse width modulation (PWM) frequency. With inverters based on wide bandgap semiconductors, the PWM frequency can be increased. This enables a substantial increase in the current control bandwidth. The paper focuses on the influence of the PWM frequency on the dynamics of control loops and position stability, which are derived from theoretical correlations. The theory is verified using a test bench for high dynamic and position stability. The test bench is equipped with a voice coil motor and power electronic with gallium nitride (GaN) power semiconductors for switching frequencies of 100kHz and over. The achieved position stability, measured with a laser-based comparator at the tool center point, is lower than "+-1nm" with a standard deviation of "0.16nm" at a PWM frequency of "f_PWM=100kHz".
A discrete-time design method for a robust current controller of a servo drive has been developed. It takes the sampling time, the processing dead time and the dynamic behavior of the A/D converter into account. The theoretical calculations are verified using a test stand for high dynamics. The test stand includes a voice coil motor and power electronics with Gallium Nitride (GaN) power semiconductors for switching frequencies of more than 100 kHz. The bandwidth of the current control loop can be improved from typically 1 kHz to 1.5 kHz with insulated-gate bipolar transistor (IGBT) power semiconductors in state-of-the-art motion control systems to 10 kHz and more.
A calculation method for a robust servo controller design depending on the sampling time and the processing dead time was developed for mechanically stiff drives. With a test stand for high dynamic and high positioning accuracy, the theoretical calculations for the high bandwidth improvements are verified. The test stand includes a voice coil motor and a power electronic with Gallium Nitride (GaN) power semiconductors for switching frequencies of more than 100kHz.
Gallium Nitride (GaN) semiconductor devices are promised to be a good alternative to Silicon (Si) semiconductors in future motor inverters for variable frequency drives (VFDs). They combine low on state resistance and low switching losses with a high blocking voltage capability. Compared to actual inverters based on insulated gate bipolar transistors (IGBTs) the pulse width modulation (PWM) frequency for efficient operation can be increased by a factor of 5 to 10, extending the PWM frequency range up to 500 kHz. This allows the use of motor filters with small component size. As a result, high motor efficiency, low torque ripple, high control bandwidth and nearly ideal sinusoidal output voltages are achieved. Therefore this inverters can be used for high speed spindle motors and dynamic servo drives. This paper focus on the design of a hybrid sine wave filter consisting of an analog and a digital part. The filter is optimized to achieve low power loss and high current control bandwidth. A 3-phase GaN motor inverter operating at 200 kHz PWM frequency at 400 V DC-link voltage verifies the system design.
A gate drive circuit for gallium nitride (GaN) enhancement mode (e-mode) transistors is presented, which avoids parasitic turn-on of the power devices in the halfbridge configuration. New e-mode GaN devices turn on at very low threshold voltages between 1V and 2V. This makes the transistors highly sensitive to spurious turn-on and thus reduces the required safety margin of the gate drive signals. To avoid this parasitic turn-on, a very low gate loop impedance is required. This prevents the halfbridge against bridge shorts during the switching events and guarantees stable gate drive control with increased switching efficiency. The new gate drive circuit is developed in a SPICE simulation environment and verified in a prototype setup by a double pulse test. The simulation matches very well with the experimental result and demonstrates the suppression of parasitic semiconductor turn-on with the proposed gate drive. Furthermore the dissipated switching energy is reduced, compared to a standard gate drive circuit. High DCDC converter efficiency of 98.67% at 1kW output power is achieved by using the driving circuit for a buck converter prototype with 200kHz switching frequency.
Increasing the switching frequency has been one of the most beneficial advancements in modern power electronics. This trend has been enabled by progress in power semiconductors resulting in increased power densities, efficiencies and control dynamics. The aim of this study is to analyze the influence of three different circuit carrier technologies on switching power loss of 650 V hardswitching GaN devices. Limitations and solutions for half-bridge circuits operating at MHz-switching are investigated by modeling and experiments on a prototype.
An accurate SPICE model is proposed in this paper to calculate the power losses of high voltage converter systems. This supports power circuit optimization in the very first design stage. The parasitic package inductances and the nonlinear voltage dependent semiconductor capacitances are taken into account. In addition the high frequency behavior of the power inductor is investigated. A detailed loss breakdown is done to analyze the main sources of power loss and their physical reasons. The simulation results of the converter waveforms and of its efficiency match very well to the experimental results. The prototype boost converter shows a top efficiency greater than 98.3 % at a switching frequency of 1 MHz and an output voltage of 400 V at the maximum output power of 1 kW.
A Parametric Layout Study of Radiated Emission from High-Frequency Half-Bridge Switching Cells
(2016)
We present a numerical modeling study of radiated emission from half-bridge switching cells based on the method of moments (MoM). A low loop inductance cell design enables high-speed switching of power semiconductors which is demonstrated on a prototype circuit. The layout is further optimized for low radiated emission by variation of the heat sink placement. This is achieved by the heat sink attached to the phase terminal. The performance of the structure in terms of loop impedance, electric field radiation and sensitivity to cable attachments are numerically studied. Emission peaks arising from loop resonances can be reduced by over 20 dB with damping elements in the switching cell. The improved EMI performance of the proposed structure is attributed to decoupling of the loop current from the heat sink structure.
Recent development of GaN power transistors with blocking voltages up to 650V enables novel power electronics applications with outstanding performance in high-frequency operation. This paper demonstrates a class E power amplifier with 13.56MHz switching frequency for inductively coupled DC power supplies. Continuous wave output power up to 200W is achieved with 95% Power Added Efficiency (PAE).
Background
Joint contractures in frail older people are associated with serious restrictions in participation. We developed the Participation Enabling CAre in Nursing (PECAN) intervention, a complex intervention to enable nurses to promote participation in nursing home residents with joint contractures. The aim of this study was to examine the feasibility of the implementation strategy and to identify enablers and barriers for a successful implementation.
Methods
The implementation of PECAN was investigated in a 6-month pilot cluster-randomised controlled trial (c-RCT). As a key component of the implementation strategy, nominated nurses were trained as facilitators in a one-day workshop and supported by peer-mentoring (visit, telephone counselling). A mixed-methods approach was conducted in conjunction with the pilot trial and guided by a framework for process evaluations of c-RCTs. Data were collected using standardised questionnaires (nursing staff), documentation forms, problem-centred qualitative interviews (facilitators, therapists, social workers, relatives, peer-mentors), and a group discussion (facilitators). A set of predefined criteria on the nursing home level was examined. Quantitative data were analysed using descriptive statistics. Qualitative data were analysed using directed content analysis.
Results
Seven nursing homes (n = 4 intervention groups, n = 3 control groups) in two regions of Germany took part in the study. Facilitators responded well to the qualification measures (workshop participation: 14/14; workshop rating: “good”; peer-mentor visit participation: 10/14). The usage of peer-mentoring via telephone varied (one to seven contacts per nursing home). Our implementation strategy was not successful in connection with supplying the intervention to all the nurses. The clear commitment of the entire nursing home and the respect for the expertise of different healthcare professionals were emphasised as enablers, whereas a lack of impact on organisational conditions and routines and a lack of time and staff competence were mentioned as barriers.
Conclusion
The PECAN intervention was delivered as planned to the facilitators but was unable to produce comprehensive changes in the nursing homes and subsequently for the residents. Strategies to systematically include the management and the nursing team from the beginning are needed to support the facilitators during implementation in the main trial.
Trial registration
German clinical trials register, DRKS00010037. Registered 12 February 2016.
Objective: To evaluate the metric properties of distinct measures of psychological personal factors comprising feelings, beliefs, motives, and patterns of experience and behaviour assessed in the Swiss Spinal Cord Injury Cohort Study (SwiSCI), using Rasch methodology.
Methods: SwiSCI Pathway 2 is a community-based, nationwide, cross-sectional survey for persons with spinal cord injury (SCI) (n = 511). The Rasch partial credit model was used for each subscale of the Positive Affect Negative Affect Scale (PANAS), Appraisal of Life Events Scale (ALE), Purpose in Life test – Short Form (PIL-SF), and the Big Five Inventory-K (BFI-K).
Results: The measures were unidimensional, with the exception of the positive affect items of the PANAS, where pairwise t-tests resulted in 10% significant cases, indicating multidimensionality. The BFI-K subscale agreeableness revealed low reliability (0.53). Other reliability estimates ranged between 0.61 and 0.89. Ceiling and floor effects were found for most measures. SCI-related differential item functioning (DIF) was rarely found. Language DIF was identified for several items of the BFI-K, PANAS and the ALE, but not for the PIL-SF.
Conclusion: A majority of the measures satisfy the assumptions of the Rasch model, including unidimensionality. Invariance across language versions still represents a major challenge.
Ein zweistufiger Operationsverstärker wird parallel in einer 180nm CMOS Technologie in der Entwicklungsumgebung von Cadence ADE und in MATLAB/Simulink in einem modellbasierten Ansatz entworfen und simuliert. Für den Entwurf in MATLAB/Simulink wird das Kleinsignalersatzschaltbild der physikalischen Schaltung verwendet. Mit Hilfe der Co-Simulation zwischen Cadence und MATLAB/Simulink wird das Verhalten simuliert und ausgewertet. Die Ergebnisse aus beiden Modellen stimmen überein, wodurch festgestellt werden kann, dass die Co-Simulation erfolgreich war.
Für eine Einführung in die fertigungstechnischen Grundlagen der Aufbau- und Verbindungstechnik sind im Wahlfach „Leiterplattentechnik Praktikum“ an der Technischen Hochschule (TH) Rosenheim Inhalte der Prozesstechnik und des Leiterplattendesigns miteinander kombiniert. Zu Beginn der Veranstaltung zeichnen die Praktikumsteilnehmer ein Layout für eine Leiterbahn-Teststruktur, welche anschließend im Haus gefertigt wird. Nach der Fertigung folgt eine elektrische und optische Charakterisierung zur Kontrolle der Prozessqualität. Die praxisnahe Erstellung eines einlagigen Layouts für eine LED-Taschenlampe auf Basis eines vorgegebenen Schaltplans und innerhalb einer begrenzten Platinenfläche sowie dessen Fertigung befähigen die Kursteilnehmer später, eigene Layouts für elektronische Schaltungen selbstständig zu entwickeln. Die anspruchsvolle, teilautomatische Bestückung einer zweilagigen, vorgegebenen SMT(Surface Mount Technology)-Leiterplatte, die ein FM-Radio mit Capacitive Touch-Steuerung bildet, rundet die erfolgreiche Qualifizierung in der Leiterplattentechnik ab.
Background:
Care pathways (CPWs) are complex interventions that have the potential to reduce treatment errors and optimize patient outcomes by translating evidence into local practice. To design an optimal implementation strategy, potential barriers to and facilitators of implementation must be considered.
The objective of this systematic review is to identify barriers to and facilitators of the implementation of CPWs in primary care (PC).
Methods:
A systematic search via Cochrane Library, CINAHL, and MEDLINE via PubMed supplemented by hand searches and citation tracing was carried out. We considered articles reporting on CPWs targeting patients at least 65 years of age in outpatient settings that were written in the English or German language and were published between 2007 and 2019. We considered (non-)randomized controlled trials, controlled before-after studies, interrupted time series studies (main project reports) as well as associated process evaluation reports of either methodology. Two independent researchers performed the study selection; the data extraction and critical appraisal were duplicated until the point of perfect agreement between the two reviewers. Due to the heterogeneity of the included studies, a narrative synthesis was performed.
Results:
Fourteen studies (seven main project reports and seven process evaluation reports) of the identified 8154 records in the search update were included in the synthesis. The structure and content of the interventions as well as the quality of evidence of the studies varied.
The identified barriers and facilitators were classified using the Context and Implementation of Complex Interventions framework. The identified barriers were inadequate staffing, insufficient education, lack of financial compensation, low motivation and lack of time. Adequate skills and knowledge through training activities for health professionals, good multi-disciplinary communication and individual tailored interventions were identified as facilitators.
Conclusions:
In the implementation of CPWs in PC, a multitude of barriers and facilitators must be considered, and most of them can be modified through the careful design of intervention and implementation strategies. Furthermore, process evaluations must become a standard component of implementing CPWs to enable other projects to build upon previous experience.
Objective
To analyze the content of outcome measures commonly used to assess health in patients with fibromyalgia (FM) by linking the items of the instruments with the International Classification of Functioning, Disability and Health (ICF) in order to evaluate the adequacy of currently used measures.
Methods
Questionnaires used in FM were identified in a structured literature search. All concepts included in the items of the questionnaires were linked to ICF categories, according to previously published linking rules, by 2 independent health professionals. The percentages of linked ICF categories addressing the different ICF components were calculated.
Results
Generic and symptom‐specific instruments were included. From the 296 items contained in all 16 instruments, 447 concepts were extracted and then linked to 52 ICF categories of the component body functions, 1 category of the component body structure, 40 categories of the component activities and participation, and 9 categories of the component environmental factors. More than half of the concepts identified were linked to body function, fewer were linked to activities and participation, and only concepts of 4 instruments were linked to the ICF component environmental factors.
Conclusion
Many concepts were linked to the categories in the ICF component body functions. While linking to the broad category, purportedly similar instruments often covered widely varying areas of function at more fine‐grained levels of detail. Some categories, such as environmental factors, were barely covered by any of the instruments and might constitute an important aspect of health deserving better coverage and future development.
Objective: Research has shown that comparatively few adults with Asperger Syndrome (AS) participate in the competitive work force. The purpose of this study was to gain in-depth knowledge about contextual factors, which contribute to successful labor market participation in some adults with AS. Participants: This study was conducted by indepth-interviewing six adults with AS working in the competitive job market in Switzerland. Methods: A developmental and hermeneutic narrative approach was used for data collection and analysis. Two in-depth narrative interviews were conducted with each participant. A narrative analysis according to the theories of Paul Ricoeur was performed. Results: Results showed that participants received pre-vocational requisites during their childhood through parents and friends that provided a feeling of security in social contexts. For participants, a supportive school setting resulted in academic achievements. The narratives reveal participants' capacities for understanding and adapting to social norms. Participants' understanding of their own needs was essential to the successful labor market participation. However, disclosure is rare and social stigma is still present. Conclusions: This study showed that successful labor participation of adults with AS can be enhanced through adequate social support already in the early stages of an individual's lifetime.
Introduction:
Occupation-based approaches are a hallmark of excellence in occupational therapy practice. This article focuses on the disjuncture between how women with rheumatoid arthritis go about their daily lives, that is to say their occupations, and what is addressed during routine visits at a specialized rheumatology outpatient clinic.
Method:
Institutional ethnography was employed as a method of inquiry to identify the occupations and related issues that were or were not accounted for in health records and addressed within institutional processes. Interviews and participant observations were conducted with seven women with rheumatoid arthritis who were mothers. Hospital records were analysed as texts mediating between the women's daily lives and the rheumatology outpatient clinic.
Findings:
The analysis revealed that despite the diversity in the ways that the women managed their daily lives, the things that they did were viewed, understood, and addressed only within the boundaries of the standardizing relations that ruled practice in this clinical setting. Institutional processes grounded in biomedical concepts such as functional status or disease activity, as well as clinical assessments that depict these concepts, both shape and limit opportunities for occupational therapists to advance and enact occupation-based practice.
Conclusion:
In this setting, the complexity of the participants' daily lives and the occupations they engage in remain unaddressed.
Background
The International Classification of Functioning, Disability and Health (ICF) can serve as reference for standardized documentation of health in clinical practice.
Purpose
This study aims to bridge the gap between the ICF and occupational therapy specific concepts, represented by occupational therapy models and their derived assessments.
Method
Occupational therapy assessments in relation to their models were systematically linked to the ICF, and a compatibility analysis was conducted. To strengthen reliability of the linkings, feedback from the respective assessment hosts was obtained.
Findings
Linking tables were developed for the Assessment of Motor and Process Skills, the Canadian Occupational Performance Measure, and the Model of Human Occupation Screening Tool. Similarities and differences between the ICF and the three assessments and their associated models show how they differ from and complement each other.
Implications
The findings of this study lay the foundation for standardized documentation in occupational therapy and enhance the practicability of the ICF.
Background: Current health systems are increasingly challenged to meet the needs of a growing number of patients living with chronic and often multiple health conditions. The primary outcome of care, it is argued, is not merely curing disease but also optimizing functioning over a person’s life span. According to the World Health Organization, functioning can serve as foundation for a comprehensive picture of health and augment the biomedical perspective with a broader and more comprehensive picture of health as it plays out in people’s lives. The crucial importance of information about patient’s functioning for a well-performing health system, however, has yet to be sufficiently appreciated.
Methods: This paper argues that functioning information is fundamental in all components of health systems and enhances the capacity of health systems to optimize patients’ health and health-related needs.
Results and conclusion: Beyond making sense of biomedical disease patterns, health systems can profit from using functioning information to improve interprofessional collaboration and achieve cross-cutting disease treatment outcomes.
- Implications for rehabilitation
- Functioning is a key health outcome for rehabilitation within health systems.
- Information on restoring, maintaining, and optimizing human functioning can strengthen health system response to patients’ health and rehabilitative needs.
- Functioning information guides health systems to achieve cross-cutting health outcomes that respond to the needs of the growing number of individuals living with chronic and multiple health conditions.
- Accounting for individuals functioning helps to overcome fragmentation of care and to improve interprofessional collaboration across settings
Objective
To validate the International Classification of Functioning, Disability and Health (ICF) Generic-6 in daily routine clinical practice in Mainland China. Specific objectives were to analyze (1) interrater reliability, (2) convergent validity, (3) known group validity, and (4) predictive validity of the ICF Generic-6.
Design
Multicenter prospective cohort study.
Setting
Fifty hospitals from 20 provinces of Mainland China.
Participants
A total of 4510 patients from departments of rehabilitation, orthopedics, neurology, cardiology, pneumology, and cerebral surgery of the participating hospitals with different health conditions were included in this study.
Intervention
Not applicable.
Main Outcome Measures
The assessment was undertaken by nurses with ICF Generic-6 in combination with a numeric rating scale. Interrater reliability was evaluated with intraclass correlation coefficients (ICC). Convergent validity was evaluated with Spearman correlation coefficients between ICF Generic-6 and Medical Outcomes Short Form (SF)-12 items. Known group validity was examined by comparing discharge scores between different discharge destinations. Predictive validity was determined by using ICF Generic-6 baseline scores for estimating length of hospital stay with a loglogistic survival model with gamma shared frailty and cost of in-hospital treatment with a mixed effects generalized linear regression model of the gamma family.
Results
The interrater reliability of items and score of ICF Generic-6 was good with ICCs ranging from 0.67-0.87. ICF Generic-6 items were further correlated with respective SF-12 items. Discharge scores of patients differed significantly by discharge destination. The ICF Generic-6 admission score was a significant predictor of length of stay and treatment cost.
Conclusions
The ICF Generic-6 administered in combination with a 0-10 numeric rating scale is a reliable and valid tool for the collection of minimal information on functioning across various clinical settings.
Objectives: To examine metric properties and responsiveness of the International Classification of Functioning, Disability and Health (ICF) Generic Set when used in routine clinical practice to assess functioning.
Design: Prospective multicentre study.
Setting: 50 hospitals from 20 provinces of Mainland China.
Participants: 4510 adult inpatients admitted to the departments of Pulmonology, Cardiology, Neurology, Orthopaedics, Cerebral Surgery or Rehabilitation Medicine.
Main outcome measures: The ICF Generic Set (ICF Generic 6 Set) applied with an 11-point numeric rating scale (0-no problem to 10-complete problem) was fit to the Partial Credit Model (PCM) to create an interval score of functioning.
Results: PCM assumptions were found to be fulfilled after accounting for Differential Item Functioning. With an average improvement by 7.86 points of the metric ICF Generic 6 score (95% CI 7.53 to 8.19), the ICF Generic 6 Set proved sensitive to change (Cohen’s f2=0.41). Ceiling and floor effects on detecting change in functioning were cancelled or reduced by using the metric score.
Conclusion: The ICF Generic 6 Set can be used for the assessment of functioning in routine clinical practice and an interval score can be derived which is sensitive to change.
Background: The International Classification of Functioning, Disability and Health is the international standard for describing and monitoring functioning. While the categories, the units of the classification, were not designed with measurement in mind, the hierarchical structure of the classification lends itself to the possibility of summating categories into some higher order domain. Focusing on the chapters of d4 Mobility, d5 Self-Care and d6 Domestic Life, this study seeks to ascertain if qualifiers rating of categories (0-No problem to 4-Complete problem) within those chapters can be summated, and whether such derived measurement is consistent with estimates obtained from well-known instruments which purport to measure the same constructs.
Methods: The current study applies secondary analysis to data previously collected in the context of validating Core Sets for stroke, rheumatoid arthritis, and osteoarthritis. Data included qualifier-based ratings of the categories in the Core Sets, and the physical functioning sub-scale of the Short-Form 36, and the World Health Organization Disability Assessment Schedule 2.0. To examine qualifier-comparator scale item agreement Kappa statistics were used. To identify whether appropriate gradients of the comparator scales were observed across qualifier levels, an Independent Sample Median Test of the ordinal scores was deployed. To investigate the internal validity of the summated ICF categories, the Rasch model was applied.
Results: Data from 2,927 subjects from Europe, Australasia, Middle East and South America were available for analysis; 36.3% had experienced a stroke, 35.8% osteoarthritis, and 27.9% had rheumatoid arthritis. The items from the Short-Form 36 could not match directly the qualifier categories as the former had only 3 response options. The Kappa between World Health Organization Disability Assessment Schedule 2.0 items and categories was low. For all qualifiers, a significant (<0.001) overall gradient was observed across the comparator scales. Only in few of the World Health Organization Disability Assessment Schedule 2.0 items could no discrete level be detected. The aggregation of the qualifiers at the Chapter and higher order levels mostly revealed fit to the Rasch model. Almost all ICF qualifiers showed ordered thresholds suggesting that the current structure and response options of the qualifiers worked as intended.
Conclusions: The findings of this study provide supporting evidence for the use of the professionally rated categories and associated qualifiers to measure functioning.
Implication for Rehabilitation
- This study provides evidence that functioning data can be collected directly with the International Classification of Functioning, Disability and Health (ICF) by using the ICF categories as items and the ICF qualifiers as rating scale.
- The findings of this study show the aggregated ratings of ICF categories from the chapters d4 Mobility, d5 Self-care, and d6 Domestic life capture a broader spectrum of the construct than the corresponding summated items from the SF36-Physical Function sub-scale and the corresponding items of the World Health Organization Disability Assessment Schedule 2.0.
- This study illustrates the potential of building quantitative measurement by aggregating ICF categories and their qualifier ratings into meaningful domains.
Living with spinal cord injury in Mongolia: A qualitative study on perceived environmental barriers
(2020)
Context: Environmental factors play a key role in the lives of individuals with a spinal cord injury (SCI). This study identifies environmental barriers and their impacts on daily lives as perceived by individuals living with SCI in Mongolia.
Design: A qualitative study with semi-structured interviews was conducted. A topic guide for the interviews was structured around the components of the International Classification of Functioning, Disability, and Health.
Setting: Urban and rural areas of Mongolia.
Participants: A purposive sample of 16 persons with traumatic SCI.
Interventions: Not applicable.
Outcome Measures: Not applicable.
Results: Seven categories of environmental barriers were mentioned, such as poor access to the physical environment, absence of wheelchair-friendly transportation, negative societal attitudes, inadequate health and rehabilitation services, lack of access to assistive devices and medicines, limited financial resources for healthcare, and inaccurate categorization of disabilities in laws. These barriers were claimed to have an impact on physical and psychological health, limit activities, and restrict participation in almost all areas of life.
Conclusion: This study contributes to the identification of targets for interventions aimed at improving the lived experience of persons with SCI in a low-resource context. The findings reveal that while the Mongolian government already has laws and policies in place to improve access to the physical environment, transportation, assistive devices and employment, much more has to be done in terms of enforcement. Specialized SCI care and rehabilitation services are highly demanded in Mongolia.
Abstract
Objective: Since the 1990s the Functional Independence Measure (FIM™) was believed to measure 2 different constructs, represented by its motor and cognitive subscales. The practice of reporting FIM™ total scores, together with recent developments in the understanding of the influence of locally dependent items on fit to the Rasch model, raises the question of whether the FIM™ 18-item version can be reported as a unidimensional interval-scaled metric.
Design: Rasch analysis of the FIM™ using testlet approaches to accommodate local response dependency.
Patients: A calibration sample containing 946 cases of data from 11,103 patients undergoing neurological or musculoskeletal rehabilitation in Switzerland in 2016.
Results: Baseline analysis and the traditional testlet approach showed no fit with the Rasch model. When items were grouped into 2 testlets, fit to the Rasch model was achieved, indicating unidimensionality across all 18 items. A transformation table to convert FIM™ raw ordinal scores to the corresponding Rasch interval scaled values was created.
Conclusion: This study provides evidence that FIM™ total scores represent a unidimensional set of items, supporting their use in clinical practice and outcome reporting when applying the respective transformation table. This provides a basis for standardized reporting of functioning.
Lay Abstract
The aim of this study was to look in detail at the FIM™, an assessment tool often used for patients undergoing rehabilitation. Some users report the FIM™ as 2 scores: one related to motor tasks, the other to cognitive tasks; others recommend reporting it as a single score including both motor and cognitive tasks. This study explored whether it is statistically meaningful to sum all the points into a single FIM™ total score. The results support the current practice of summing the points into a single total score for patients undergoing musculo-skeletal and neurological rehabilitation. The results also allowed an interval scale to be derived from the FIM™, enabling a broad range of calculations to be made using the FIM™ score, such as calculating the change in FIM™ outcomes from the time a patient is admitted to a rehabilitation clinic until their discharge.
Background
Limitations in upper limb functioning are common in Musculoskeletal disorders and the Disabilities of the Arm, Shoulder and Hand scale (DASH) has gained widespread use in this context. However, various concerns have been raised about its construct validity and so this study seeks to examine this and other psychometric aspects of both the DASH and QuickDASH from a modern test theory perspective.
Methods
Participants in the study were eligible if they had a confirmed diagnosis of Rheumatoid Arthritis (RA). They were mailed a questionnaire booklet which included the DASH. Construct validity was examined by fit to the Rasch measurement model. The degree of precision of both the DASH and QuickDASH were considered through their Standard Error of Measurement (SEM).
Results
Three hundred and thirty-seven subjects with confirmed RA took part, with a mean age of 62.0 years (SD12.1); 73.6% (n = 252) were female. The median standardized score on the DASH was 33 (IQR 17.5–55.0). Significant misfit of the DASH and QuickDASH was observed but, after accommodating local dependency among items in a two-testlet solution, satisfactory fit was obtained, supporting the unidimensionality of the total sets and the sufficiency of the raw (ordinal or standardized) scores.
Conclusion
Having accommodated local response dependency in the DASH and QuickDASH item sets, their total scores are shown to be valid, given they satisfy the Rasch model assumptions. The Rasch transformation should be used whenever all items are used to calculate a change score, or to apply parametric statistics within an RA population.
Significance and innovations
Most previous modern psychometric analyses of both the DASH and QuickDASH have failed to fully address the effect of a breach of the local independence assumption upon construct validity.
Accommodating this problem by creating ‘super items’ or testlets, removes this effect and shows that both versions of the scale are valid and unidimensional, as applied with a bi-factor equivalent solution to an RA population.
The Standard Error of Measurement of a scale can be biased by failing to take into account the local dependency in the data which inflates reliability and thus making the SEM appear better (i.e. smaller) than the true value without bias.
Background: The Extended Barthel Index (EBI), consisting of the original Barthel Index plus 6 cognitive items, provides a tool to monitor patients’ outcomes in rehabilitation. Whether the EBI provides a unidimensional metric, thus can be reported as a valid sum-score, remains to be examined.
Objective: To examine whether the EBI can be reported as unidimensional interval-scaled metric for neurological and musculoskeletal rehabilitation.
Methods: Rasch analysis of a calibration sample of 800 cases from neurological or musculoskeletal rehabilitation in 2016 in Switzerland.
Results: In the baseline analysis no fit to the Rasch Model was achieved. When accommodating local dependencies with a testlet approach satisfactory fit to the Rasch Model was achieved, and an interval scale transformation table was created.
Conclusion: The results support the reporting of adapted EBI total scores for both rehabilitation groups by applying the interval scaled transformation table presented in this study.
Study design
Mapping of the National Spinal Cord Injury Model System (SCIMS) Database (NSCID) to the International Classification of Functioning, Disability and Health (ICF).
Objectives
To link the content of the latest two versions of the NSCID to the ICF; more specifically (1) to compare the content of the current NSCID 2016–2021 version to its predecessor (NSCID 2011–2016) using the ICF as a neutral reference framework, and (2) to compare the content contained in the NSCID 2016–2021 version with relevant ICF Sets.
Setting
The forms of the NSCID 2016–2021 and 2011–2016 versions were linked to the ICF and contrasted. Comparability of the current version of the NSCID with the ICF Core Set for Spinal Cord Injury (SCI) in the post-acute and long-term context and the two generic ICF sets— ICF Generic-7 and ICF Generic-30 was then examined.
Methods
ICF Linking Rules and descriptive statistics.
Results
The current NSCID 2016–2021 version covers functioning as classified in the ICF with 8 ICF categories more comprehensively than its predecessor does. More than 50% of ICF categories contained in the two ICF Generic Sets were covered. The coverage of the brief ICF Core Sets for SCI by the NSCID 2016–2021 was more than 50%, but the coverage of the comprehensive core sets was low. Results showed the best coverage in the ICF component Activities and Participation.
Conclusions
This study emphasizes how the ICF and its Sets can serve as a reference framework to foster comparability of existing data sets from both clinical practice and research.
Background
Modification of the home environment, together with rehabilitative interventions, is important for maximizing the level of functioning after an individual with disability undergoes rehabilitation in the hospital.
Objectives
We developed a simple screening scale – the home environment checklist (HEC) – to identify any mismatch between an individual's abilities and their home environment to help clinicians monitor the appropriateness of the home environment to which individuals with disability will be discharged. We also examined the psychometric properties of the HEC.
Methods
The HEC was developed by a multidisciplinary panel of rehabilitation experts using information routinely collected in rehabilitation clinics before discharge. The reliability of the checklist was assessed in 60 individuals undergoing rehabilitation. The inter-rater agreement and internal consistency of the scale were assessed by weighted kappa statistics and Cronbach's alpha, respectively. Rasch analysis was performed with 244 rehabilitation individuals to evaluate the internal construct validity, and the known-groups validity was confirmed by a comparison of the daily activity levels of 30 individuals with disabilities under rehabilitation to the HEC score.
Results
The HEC was developed as a simple, 10-item checklist. The weighted kappa statistics ranged from 0.73 to 0.93, indicating excellent inter-rater reliability. Cronbach's alpha was 0.92, indicating high internal consistency. Rasch analysis with a testlet approach on 3 subscales demonstrated a good fit with the Rasch model (χ2 = 13.2, P = 0.153), and the demonstrated unidimensionality and absence of differential item functioning supported the internal construct validity of the HEC. HEC scores were significantly different (P < .01) among individuals with disability and 3 levels of restrictions in their activities (no limitation, home-bound, and bed-bound), which demonstrates the known-groups validity of the HEC.
Conclusions
The HEC has good reliability and validity, which supports its utility in rehabilitation clinics.
Making one's own choices is an important part of leading a fulfilling life within society. However, people with IDs often face significant obstacles when making their own decisions. Article 12 (Equal recognition before the law) of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) aims to ensure firstly that people with IDs and others with compromised capacity are nonetheless recognized as legal individuals, and secondly that assistance is provided in the form of supported decision‐making in order to exercise this resulting legal capacity. It is unclear whether current national legislation in any country satisfies these requirements in practice. This study utilizes institutional ethnography to reveal how decision‐making is coordinated in practice for people with mild to moderate IDs living in supported residential environments in England, and to determine whether these processes are compliant with Article 12 of the CRPD. Data collection was based on observations, semi‐structured interviews, and documentary analysis, involving 29 participants including people with mild to moderate IDs. The results point to the complexity of supported decision‐making and identify three main categories of decision‐making: spontaneous decisions, mid‐term decisions, and strategic decisions. The data also show that people with mild to moderate IDs are able to exercise their legal capacity through support decision‐making in their everyday life. Immediate and informal supported decision‐making exists in daily practice for people with mild to moderate IDs living in supported residential environments. Although there are structures in place for implementing supported decision‐making, various barriers persist that limit the overall efficacy and consistency of the realization of supported decision‐making, for example, multiple use of mental capacity assessments. Such practices move away from the supported decision‐making model toward substituted decision‐making.