Essential Emergency and Critical Care: a consensus among global clinical experts.

BACKGROUND: Globally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients are often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low cost and low complexity for the identification and treatment of critically ill patients across all medical specialties. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19. METHODS: In a Delphi process, consensus (>90% agreement) was sought from a diverse panel of global clinical experts. The panel iteratively rated proposed treatments and actions based on previous guidelines and the WHO/ICRC's Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent and feasible package of clinical processes plus a list of hospital readiness requirements. RESULTS: The 269 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 requirements, plus additions specific for COVID-19. CONCLUSION: The study has specified the content of care that should be provided to all critically ill patients. Implementing EECC could be an effective strategy for policy makers to reduce preventable deaths worldwide

Cultural competence in nursing

The overall aim of this thesis is to explore, analyze and clarify how cultural competence is understood. This is explored from the perspective of nurses, nursing students, nurse educators, and nurse researchers in relation to the Swedish care context. The field of transcultural nursing and cultural competence was founded in the United States in the 1950s in response to an increased awareness of cultural diversity arising from immigration. In Sweden an interest in transcultural nursing and cultural competence has emerged only recently and therefore knowledge in this area is quite sparse. In Study I, an instrument for measuring cultural competence was translated, adapted and evaluated for use in Sweden. By following guidelines in the literature, this process was carefully laid out and the content and internal structure of the instrument was evaluated. The findings indicated that the instrument did not meet appropriate validity and reliability levels, and the evaluation of the content indicated a weak relation between the instrument and the constructs. Therefore, it was concluded that the instrument could not be used in Sweden. In Study II, the aim was to analyze the core components found in the descriptions of the most frequently cited theoretical frameworks of cultural competence. Nine theoretical frameworks of cultural competence were analyzed using a documentary analysis method. The data were analyzed using qualitative content analysis. The findings revealed four themes that characterized cultural competence: an awareness of diversity among human beings; an ability to care for individuals; nonjudgmental openness for all individuals and; enhancing cultural competence as a longterm continuous process. In Study III, the aim was to identify the core components of cultural competence from a Swedish perspective. The Delphi technique was used and 24 experts took part in the study. The first round was conducted with qualitative interviews and was followed by three rounds with questionnaires. In total, consensus was reached on 118 core components that were grouped into five categories, with 17 associated subcategories. These categories are: cultural sensitivity; cultural understanding; cultural encounter; understanding of health, ill-health and healthcare; and social and cultural context. In the final study, Study IV, qualitative interviews were conducted with 10 nursing students, five with an immigrant background and five with a Swedish background, to explore their experiences of communication in cross-cultural care encounters. The interviews were analyzed using the framework approach. Four themes were identified: conceptualizing cross-cultural care encounters; difficulties in communication; strategies employed; and factors influencing communication. The synthesis of the findings from the four studies is illustrated in Figure 1 as the common patterns in the constituent elements of cultural competence in the Swedish context, which are identified as: the nurse s cultural awareness, personal beliefs and values; cultural assessment; and cross-cultural communication. The thesis concludes that transcultural nursing and cultural competence is about nurses being able to take the patient s cultural background, beliefs, values and traditions into consideration in nursing care. Cultural competence should not only be employed when caring for immigrants or ethnic minority groups, but also in encounters with all patients

Congenital cataract in newborns : A qualitative study on parents' experiences of the surgery and subsequent care

PURPOSE: Having a child with congenital cataract that requires surgery, contact lens treatment, and frequent medication is a life-altering experience. The aim of this study was to provide more in-depth knowledge of parents' experiences of diagnosis, surgery, and subsequent care, in order to find the areas for improvement. METHODS: Data were collected via semi-structured interviews with parents recruited from St. Erik Eye Hospital, Sweden. The children were operated for congenital cataract before 3 months of age and were aged 12-24 months at the time of the interviews. The interviews were analysed using qualitative content analysis with an inductive approach. RESULTS: Three themes emerged from the data: living in a turbulent time before the diagnosis, coping during the time of initial treatment, and managing the responsibility of their child's visual development. All parents expressed confidence in the operating unit. However, there was a clear need for reliable information on the condition, the surgery, and likely the long-term outcome in the time between receiving the preliminary diagnosis at the maternity ward and getting it confirmed by a paediatric ophthalmologist. CONCLUSION: Much of the parents' concern in this turbulent time is linked to poor information before the visit to the eye hospital. We, therefore, recommend earlier contact with the eye hospital, preferably at the time of writing the referral. Moreover, the possibility of providing up-to-date information via alternative information channels such as smartphone apps should be investigated

Experiences of parents whose school‐aged children were treated with therapeutic hypothermia as newborns: A focus group study

Abstract Aim To describe parents' past and present experiences of their newborn infant's therapeutic hypothermia (TH) treatment after perinatal asphyxia 10–13 years after the event. Background Newborn infants are treated with TH following perinatal asphyxia to improve neurodevelopmental outcomes. Design A qualitative descriptive design using focus groups (FGs). Methods Twenty one parents to 15 newborn infants treated with TH between 2007 and 2009 participated in five FGs. The FGs were transcribed verbatim and analysed using framework approach. The SRQR checklist was followed for study reporting. Results Two main categories were identified: hardships and reliefs during TH treatment and struggles of everyday life. Both categories include three subcategories, the first: (1) concern and gratitude for the unrecognized treatment, (2) insufficiency of information and proposed participation and (3) NICU nurses instilled security and hope. The second with subcategories: (1) unprocessed experiences of the TH treatment, (2) later challenges at school and (3) existential and psychological challenges in everyday life. Conclusion TH of their newborns affected the parents psychologically not only during the treatment, but lasted months and years later. Information and communication with health care professionals and school management were inefficient and inadequate. The parents' concerns could be prevented by an improved identification and understanding of the problems and the needs of the infants and their families before discharge. Relevance for Clinical Practice Through more personalized and efficient preparation and communication by the nursing staff before discharge, many of the parents' worries and problems could be reduced. Check‐up of parents' needs of psychosocial support before and after discharge and offering counselling should become routine. Also, nurses at Well‐Baby Clinics and in school health care should receive knowledge about TH treatment and the challenges the children and the parents experience. Patient or Public Contribution Participation of parents was limited to the data provided through interviews

Treatment of alcohol dependence in Swedish primary care : perceptions among general practitioners

OBJECTIVE: To describe general practitioners' (GPs) attitudes to the management of patients with alcohol dependence in primary care and current treatment routines and their view on a new treatment approach; internet-based Cognitive Behavioral Therapy (iCBT). DESIGN: A qualitative interview study with ten GPs participating in a randomized controlled trial. The interviews were analyzed using qualitative content analysis. SETTING: The participating GPs were recruited via purposeful sampling from primary care clinics in Stockholm. SUBJECTS: The GPs were participants in an RCT investigating if iCBT when added to treatment as usual (TAU) was more effective than TAU only when treating alcohol dependence in primary care. RESULTS: The GPs found alcohol important to discuss in many consultations and perceived most patients open to discuss their alcohol habits. Lack of training and treatment options were expressed as limiting factors when working with alcohol dependence. According to the respondents, routines for treating alcohol dependence were rare. CONCLUSION: GPs believed that iCBT might facilitate raising questions about alcohol use and thought iCBT may serve as an attractive treatment option to some patients. The iCBT program did not require GPs to acquire skills in behavioral treatment, which could make implementation more feasible.KEY POINTSAlcohol dependence is highly prevalent, has a large treatment gap and is relevant to discuss with patients in many consultations in primary care.This study is based on interviews with 10 GPs participating in a randomized controlled trial comparing internet-based Cognitive Behavioral Therapy (iCBT) for alcohol-dependent patients to treatment as usual.GPs viewed alcohol habits as important to discuss and they perceived most patients are open to discuss this.The access to iCBT seemed to increase GPs' willingness to ask questions about alcohol and was viewed as an attractive treatment for some patients.The iCBT program did not require GPs to acquire skills in behavioral treatment, which might be timesaving and make implementation more feasible

Identifying the core components of cultural competence: findings from a Delphi study

Aims. To identify the core components of cultural competence from a Swedish perspective. Background. The cultural diversity of Swedish society raises challenges for nursing practice. Nurses need to be culturally competent, i.e. demonstrate the effective application of knowledge, skills and attitudes to practice safely and effectively in a multi-cultural society. Existing frameworks of cultural competence reflect the socio-cultural, historical and political context in which they were developed. To date, there has been no research examining cultural competence within a Swedish context. Design. A Delphi survey. Methods. A purposive sample of 24 experts; (8 nurses, 8 researchers, 8 lecturers) knowledgeable in multicultural issues, was recruited. Interviews were undertaken to identify the knowledge, skills and attitudes that formed the components of cultural competence. Content analysis yielded statements which were developed into a questionnaire. Respondents scored questionnaire items in terms of perceived importance. Statements which reached consensus were removed from questionnaires used in subsequent rounds. Three rounds of questionnaires were distributed during 2006. Results. 118 out of 137 components reached a consensus level of 75%. The components were categorized into five areas; cultural sensitivity, cultural understanding, cultural encounters, understanding of health, ill-health and healthcare, and social and cultural contexts with 17 associated sub-categories. Conclusions. There are some similarities between the issues raised in the current study and existing frameworks of cultural competence from the USA and the UK. However, Swedish experts placed less emphasis on ethnohistory and on developing skills to challenge discrimination and racism. Relevance to clinical practice. This study identified the core components of cultural competence important to nurses practising within a multi-cultural society such as Sweden. Acquisition of the knowledge, skills and attitudes identified should enable nurses to meet the needs of patients from different cultural backgrounds. The components of cultural competence can form the basis of nursing curricula.</p

Treating alcohol use disorders in primary care - a qualitative evaluation of a new innovation : the 15-method

OBJECTIVE: This study aims to explore how the characteristics of an innovation, the 15-method, a stepped care model for treatment of alcohol use disorders in primary care was perceived. METHODS/DESIGN/SETTING/SUBJECT: General practitioners and heads of primary care units (n = 10) that delivered the 15-method in a randomized controlled trial participated in individual interviews at two occasions in Stockholm, Sweden. Data were analyzed with theoretical thematic analysis, using Diffusion of Innovation Theory. RESULTS: The participants described that offering the 15-method met a need among their patients. Participants were positive towards the training and the manual for the method. They mentioned a previous lack of routines to work with alcohol use disorders. The 15-method was described as easy to use. It would however be more feasible to implement in a team of different professions, rather than among general practitioners only. Priorities made by regional health care managers were described as important for the implementation, as well as financial incentives. A barrier to implementation was that alcohol screening was perceived as difficult. While the 15-method was perceived as effective in reducing the patients' alcohol use and cost effective, participants expressed uncertainty about the long-term effects. CONCLUSIONS: The 15-method provides structure for treatment of alcohol use disorders and is described by general practitioners and heads as a promising approach. Being able to offer treatment for alcohol dependence may increase the uptake of alcohol interventions in primary care. KEY POINTS Little attention has been given to develop treatment models for alcohol use disorders that are adapted to primary care settings. This study describes how an innovation, the 15-method, a stepped care model for treatment of alcohol use disorders in primary care was perceived. The 15-method provides structure for treatment of alcohol use disorders in primary care and is described by general practitioners and heads as a promising approach. Being able to offer treatment for alcohol dependence may increase the uptake of alcohol interventions in primary care

Treat me nice! –a cross-sectional study examining support during the first year in the emergency medical services

Abstract Background Working in the emergency medical service (EMS) can be extremely varying and sometimes physically and psychologically demanding. Being new in this context can be a great challenge. This study aim to describe what ambulance nurses consider to be important support during the first year in the EMS. Methods Three hundred and eighty-nine eligible participants that had graduated from the prehospital emergency care program were identified via university registrations office in Sweden. The eligible participants received a study specific questionnaire via mail consisting of 70 statements about support during the first year. The perceived importance of each statement were graded on a 7-point Likert scale. The gradings were analysed using descriptive statistics and frequencies, mean and SD were calculated. Results Two hundred and thirty questionnaires were returned fully completed, giving a response rate of 59%. Fourteen statements regarding desirable support were rated with mean values > 6.00 and SD < 1.00 and considered as being the most important during the first year in the EMS. The important supports regarded; colleagues and work environment, management and organisation, experience-based knowledge, introduction period, practical support, and theoretical support. Most statements regarded culture and climate and the way the newcomers wanted to be treated. Conclusion It was concluded that an important way to support newcomers in the EMS is to treat them ‘nice’. This can be achieved by creating an open climate and a welcoming culture where the new professionals feel trusted and treated with respect, created ways to work structurally, have applicable medical guidelines, and for newcomers to receive feedback on their actions

Effects of exercise in non-treatment seeking adults with alcohol use disorder: a three-armed randomized controlled trial (FitForChange).

BACKGROUND: Most individuals with alcohol use disorder (AUD) do not seek treatment. Stigma and the desire to self-manage the problem are likely explanations. Exercise is an emerging treatment option but studies in non-treatment seeking individuals are lacking. We compared the effects of aerobic exercise, yoga, and treatment as usual (phone-based support) on alcohol consumption in non-treatment seeking adults with AUD. METHODS: Three-group parallel, single blind, randomized controlled trial. 140 physically inactive adults aged 18-75 diagnosed with AUD were included in this community-based trial. Participants were randomized to either aerobic exercise (n = 49), yoga (n = 46) or treatment as usual (n = 45) for 12-weeks. The primary study outcome was weekly alcohol consumption at week 13 (Timeline Follow-back). RESULTS: A significant decrease in weekly alcohol consumption was seen in all three groups: aerobic exercise, yoga group and TAU. The between group changes were not statistically significant at follow-up. Per-protocol analyzes showed that the mean number of drinks per week reduced more in both TAU and yoga compared to aerobic exercise. CONCLUSIONS: Participation in a 12-week stand-alone exercise program was associated with clinically meaningful reductions in alcohol consumption comparable to usual care (phone counseling) by an alcohol treatment specialist

We need support! A Delphi study about desirable support during the first year in the emergency medical service.

BACKGROUND: New and inexperienced emergency medical service (EMS) professionals lack important experience. To prevent medical errors and improve retention there is an urgent need to identify ways to support new professionals during their first year in the EMS. METHODS: A purposeful sample and snowball technique was used and generated a panel of 32 registered nurses with 12-48 months of EMS experience. A Delphi technique in four rounds was used. Telephone interviews were undertaken in round one to identify what desirable support professionals new to the EMS desire during their first year. Content analysis of the transcribed interviews yielded items which were developed into a questionnaire. The experts graded each item in terms of perceived importance on a 5-graded likert scale. Consensus level was set at 75%. Items which reached consensus were removed from questionnaires used in subsequent rounds. RESULTS: Desirable support was categorized into eight areas: Support from practical skills exercises, support from theoretical knowledge, support from experiences based knowledge, theoretical support, support from an introduction period, support from colleagues and work environment, support from management and organization and other support. The experts agree on the level of importance on 64 of a total of 70 items regarding desirable support. One item was considered not important, graded 1 or 2, 63 items were considered important, graded 4 or 5. CONCLUSION: Even with extensive formal competence the EMS context poses challenges where a wide variety of desirable forms of support is needed. Support structures should address both personal and professional levels and be EMS context oriented