Patients' position in care transitions : an analysis of patient participation and patient-centeredness

Introduction: Patients with chronic diseases need care transitions between primary and hospital care when facing severe exacerbation or acute illness. Such transitions are associated with risks, potentially adverse events and patient suffering. To improve care transitions, patients’ and healthcare professionals’ experiences and perspectives of patient participation and patient-centeredness need to be explored. Aim: The general aim of this thesis is to improve the knowledge and understanding of patient participation and patient-centeredness in handovers between primary and hospital care. Methods: The thesis comprises four papers about patients with chronic diseases (asthma, diabetes mellitus I or II, chronic heart failure, chronic obstructive pulmonary disease) and/or polypharmacy, and the healthcare professionals who treated the patients in the hospital and the primary healthcare. The study was conducted in five European countries: the Netherlands, Spain, Poland, Italy and Sweden. Both qualitative (papers I, II, and III) and quantitative (paper IV) methodology are used. Paper I is a content analysis of individual interviews with 23 Swedish patients. Paper II is a secondary analysis of both individual and focus group data of 90 patients from the five countries. Paper III is a meta-synthesis of both individual and focus group data of 90 patients and 258 healthcare professionals from the five countries. Paper IV includes medical records of 22 Swedish patients by review and assessment of their handover records. Results: Patients participated through both verbal activities (information exchange) and non-verbal activities (e.g. transfer of medication lists, referrals, and discharge notes). Patients’ activity varied from taking responsibility for handover, via shared responsibility, to being passive. The patients’ capacity for participation was reduced by health condition and health illiteracy, and strengthened by personality, experience and social network. Patients felt empowered by the knowledge they received through participation. Patients and healthcare professionals experienced both patient-centered handovers (patient needs addressed and discussed; responsive relations in which personalized information was provided; having continuity of care) as well as non patient-centered handovers. Organizational factors such as lack of time; emergent needs of other patients; and shift work forced the healthcare professionals to discharge patients without needs properly assessed; in discharge encounters held in a rush or without encounters; and by healthcare professionals who had not treated the patient at the ward. Conclusions: Based on the findings, improved handovers – ensuring that information reaches the next setting – would mean having formal discharge encounters, and empowering patients with information, education and clarification of the handover process. In such cases, the patients can participate in handovers through exchange of information about their self-management, care and treatment in the present encounter, the next encounter and the handover between those. Organizational factors contribute to healthcare professionals’ patient-centeredness, and patient-centeredness seems to increase patients’ participation in handovers. The interactive aspects should be encouraged, an organization providing allocated time and recourses, and a following patient-centered attitude of the healthcare professionals could benefit all involved stakeholders resulting in patient-centered handovers with participating patients

Har du roligt lilla vän? : En diskursiv undersökning om hur dramapedagoger uppfattar sin yrkesroll

Syftet med uppsatsen är att undersöka hur dramapedagoger uppfattar och framställer sin yrkesroll. Undersökningen är kvalitativ och använder fenomenologi som vetenskapsteoretisk utgångspunkt. För att skaffa material har en workshop och en intervju genomförts, båda inspirerade av metoderna fokussamtal och föreställningskartor. En kortare mejlintervju har också utförts med alla informanterna. Materialet har analyserats fenomenologiskt och det resulterade i sex kate-gorier av uppfattningar om den dramapedagogiska yrkesrollen. Vidare analys av kategorierna och de uppfattningar som kopplades till respektive kategori utfördes med inspiration från diskurspsykologin. Resultatet presenteras i en dramatiserad empiri. Två fiktiva dramapedagoger som skapats utifrån den diskursiva analysen samtalar i resultatdelen med en journalist kring hur de uppfattar sin yrkesroll. En av dramapedagogerna representerar den rådande diskursen inom dramapedagogyrket och en representerar den utmanande diskursen. Undersökningsresultatet visar att det kan vara svårt att urskilja vad som är dramapedagogens yrkesidentitet och vad som är syfte och mål med det dramapedagogiska arbetet, i den rådande diskursen. I den utmanande diskursen anas en mer konkret beskrivning av yrket och yrkesrollen. Sammanlagt nio dramapedagoger har deltagit i undersökningen och kriteriet för att kallas dramapedagog i studien har varit att man har/har haft en anställning som dramapedagog

Dead wood and the presence of two mosses indicating forest continuity

Studiens syfte är att undersöka arterna Buxbaumia viridis och Nowellia curvifolia för att kunna förutse var man hittar dessa signalarter. Detta gjordes genom att död liggande ved undersöktes i Ycke naturreservat samt en närliggande brukas skog, Östergötlands län. Resultaten visar att faktorerna som är avgörande för B. virids är markkontakt och nedbrytningsklass. B. viridis föredrar att växa på lågor i de högre nedbrytningsklasserna (4-7) och med stor andel markkontakt, över 80 %. N. curvifolia beror på diameter (över 60cm), nedbrytningsklass (3-4) och längd (över 30m). Baserat på dessa resultat, kan signalarter lättare upptäckas utan en fullskalig inventering av skogen.Young trees dominate Swedish forests, which today have a shortage of downed dead wood, key biotopes, and an overall lack of high natural values. By using the mosses Buxbaumia viridis and Nowellia curvifolia the general state of a forest can be assessed. These species indicate high natural values, with a continuity of dead wood in different stages of decay. By investigating ground-lying dead wood, one can predict if the mosses occur in the area or not. This is useful for maintenance of the forests and the preservation of biological diversity. The purpose of this study was to study the species B. viridis and N. curvifolia in Ycke natural reserve in Östergötland, southern Sweden, and learn how to predict where these species occur. The results showed that ground contact (over 80 %) and stage of decay (stage 4-6) of logs were important to B. viridis, with test values 30- 50 times as high as the other test values. To N. curvifolia, the diameter of the logs was the most important. Decay stage and length of the log were also important factors to N. curvifolia. Based on these results, these indicator species can more easily detected without a full scale inventory of the forest

Att bevittna,benämna och baka en kaka : En studie av uppfattningar om gott kollegialt samspel, ur några undersköterskors perspektiv

Denna kvalitativa studie har med utgångspunkt i det sociokulturella perspektivet undersökt fenomenet samspel mellan kollegor. Studiens syfte var att undersöka uppfattningar om gott kollegialt samspel, utifrån några undersköterskors perspektiv, och urvalsgruppen bestod av sju yrkesverksamma undersköterskor från fem olika arbetsplatser. För att genomföra studien användes en fenomenologisk ansats och metoden fokusgruppssamtal och empirin analyserades tematiskt. Studiens resultat utgjordes av fem gemensamma teman, som kallades samspelsnycklar: Att investera och se varandra i arbetet, Att sträva efter att vara ett lag, Att arbeta utifrån tillit och jämlika samspelsvillkor, Att kunna förmedla och variera arbetsattityd, Att kunna ge och be om hjälp med respekt. Resultatet analyserades med begrepp från Wengers teori Communities of practice och genom det framkom att uppfattningar om ett gott kollegialt samspel i omvårdnadspraktiken kan sägas innehålla samma grundfaktorer som utgör en etablering och utveckling av en praktikgemenskap. Detta på grund av att det i alla samspelsnycklarna förekommer utsagor som kan förstås genom Wengers begrepp område, gemenskap och praktik. Resultatet kan även förstås utifrån det sociokulturella perspektivets antagande att språket är ett centralt medierande redskap för lärande i en social kontext.  This qualitative study has, on the basis of the sociocultural perspective, examined the phenomenon of interaction between colleagues. The study's purpose was to examine perceptions of good interaction, based on some enrolled nurses ' perspective and the selection group consisted of seven professional enrolled nurses from five different workplaces. The study used a phenomenological approach and focus group discussions, and the research data was thematically analyzed. The results of the study consisted of five core themes, called interaction keys: Investing and see each other at work, To endeavor to be a team, To work on the basis of trust and equal interaction terms, To convey, and vary work attitude, To be able to provide and receive assistance with respect. The results were analyzed using the concepts from Wenger's theory Communities of practice, and thru that it was revealed that perceptions of a good collegial interaction in enrolled nursing practice can be said to contain the same basic elements that constitute and develops a Community of practice. This is because all interaction keys include statements that can be understood by Wenger's concept area, fellowship and internship. The result can also be understood on the basis of the sociocultural perspective's assumption that language is an essential mediating tool for learning, in a social context

Sorg och glädje: en kvalitativ studie om fem kvinnors upplevelser och hanterande av att bli kroniskt sjuka i samband med att de fick barn

This essay aims to investigate how women who fall ill in Rheumatoid Arthritis, during or just after their pregnancy, experience and cope with this. The main questions were 1. What experiences did the women have from receiving their diagnosis? 2. How has the motherhood and the sickness affected one another? 3. How did the women cope with the problems they faced? 4. What kind of support were the women in need of? 5. What support did they receive? A qualitative method was used and five interviews were made. Coping theory and crisis theory were used. The interviews showed that the women experienced mainly practical difficulties. They also had difficulties dealing with the fact that they had a chronic sickness. They experienced that the sickness affected them in both a negative and a positive way. They had made new experiences which were good for both them and the child. Having to take care of the child also helped them to manage the difficulties. But the sickness also brought problems. The women coped with their problems both by making up new solutions to their practical problems and by the help that they received from their families and friends

Planning for the Discharge, not for Patient Self-Management at Home – An Observational and Interview Study of Hospital Discharge

Introduction and objective: Despite recent interest in care transitions, little is known about how patients are prepared for the self-management tasks following the hospitalization. The objective of the study was to explore how discharge information is prepared and provided to patients in the transition from hospital to home. Method: The discharge process at three hospitals in Sweden was observed over 12 days spread over ten weeks. In total, 30 discharge encounters were observed followed by interviews with patients and professionals. Data were analysed using qualitative content analysis. Results: Much time, effort and resources were used to prepare the discharge; home-going teams and registered nurses planned the practical and social aspects of the discharge and the physicians compiled a plain-language discharge letter. Less focus was given on the actual discharge information to the patients. The discharge encounters lasted for a median of 4:46 minutes and the information had a retrospective focus with information on the hospitalization period, though omitting self-management tasks and life-style advice. Conclusion: The discharge letter constitutes the basis for all patient information at discharge. The focus of the discharge encounter needs to be extended beyond mere information to include patient understanding, motivation and skills for self-management at home

Exploring patient safety in Swedish specialised home healthcare : an interview study with multidisciplinary teams and clinical managers

OBJECTIVE: Home healthcare is the fastest growing arena in the healthcare system but patient safety research in this context is limited. The aim was to explore how patient safety in Swedish specialised home healthcare is described and adressed from multidisciplinary teams' and clinical managers' perspectives. DESIGN: An explorative qualitative study. SETTING: Multidisciplinary teams and clinical managers were recruited from three specialised home healthcare organisations in Sweden. METHODS: Nine focus group interviews with multidisciplinary teams and six individual interviews with clinical managers were conducted, in total 51 participants. The data were transcribed verbatim and analysed using qualitative content analysis. RESULTS: Patient safety was inherent in the well-established care ideology which shaped a common mindset between members in the multidisciplinary teams and clinical managers. This patient safety culture was challenged by the emerging complexity in which priority had to be given to standardised guidelines, quality assessments and management of information in maladapted communication systems and demands for required competence and skills. The multiple guidelines and quality assessments that aimed to promote patient safety from a macro-perspective, constrained the freedom, on a meso-level and micro-level, to adapt to challenges based on the care ideology. CONCLUSION: Patient safety in home healthcare is dependent on adaptability at the management level; the team members' ability to adapt to the varying conditions and on patients being capable of adjusting their homes and behaviours to reduce safety risks. A strong culture related to a patient's value as a person where patients' and families' active participation and preferences guide the decisions, could be both a facilitator and a barrier to patient safety, depending on which value is given highest priority