Patients' Participation as It Appears in the Nursing Documentation, When Care Is Ruled by Standardized Care Plans

This study aimed to describe inpatients with myocardial infarction and their participation in care as documented in the nursing records when standardized care plans are used in care. The use of standardized care plans not only has increased the quality of medical treatment but has also overlooked patients' opportunities to participate in their own care. There is a lack of knowledge about how standardized care plans influence patients' participation in nursing care. Data were collected from thirteen patients' records with diagnoses of myocardial infarction. Participation in the decision-making process and participation associated with “sharing with others” were searched for in the analysis. The analytical process was guided by content analysis. The findings were grouped into two categories: patients' intermediary participation and patients' active participation. The main results indicated that patients' intermediary participation depended on healthcare professionals' power to rule the nursing care situation

Methodological strategies in resilient health care studies: An integrative review

Resilient healthcare research focuses on everyday clinical work and a system’s abilities to adopt or absorb disturbing conditions as opposed to risk management approaches, which are based on retrospective analyses of errors. After more than a decade of theoretical development and a large quantity of empirical work, the field of resilience is beginning to recognize the methodological challenges related to operationalizing and designing studies of complexity. This paper reviews a sample of empirical articles on studies of resilient healthcare to describe and synthesize their methodological strategies. The review found that data collection by resilient healthcare studies has predominantly been conducted at the micro level (e.g. frontline clinical staff). Data sources at the meso level (i.e. hospital/institution) have been limited, and no studies were found that collected macro-level data. We argue that the methodological focus in the field should increase its embrace of complexity and the adaptive capacities of the system as a whole by integrating data sources at the micro, meso, and macro levels. To improve the methodological designs, we argue that the resilience construct, in which the complexity of multiple levels is integrated, must be developed. Improving the transparency and quality of future resilient healthcare research might be accomplished by reporting thorough descriptions of analytical strategies, in-depth descriptions of research design and sampling strategies, and discussing internal and external validity and reflexivity.publishedVersio

Communication about medication management during patient-physician consultations in primary care: a participant observation study

Objective - To explore communication about medication management during annual consultations in primary care. Design: passive participant observations of primary care consultations. Setting - Two primary care centres in southern Sweden. Participants - Consultations between 18 patients (over the age of 60 years) with chronic diseases and 10 general practitioners (GPs) were observed, audio-recorded, transcribed and analysed using content analysis. Results - Four categories emerged: communication barriers, striving for a shared understanding of medication management, evaluation of the current medication treatment and the plan ahead and behavioural changes in relation to medication management. Misunderstandings in communication, failure to report changes in the medication treatment and use of generic substitutes complicated mutual understanding and agreement on continued treatment. The need for behavioural changes to reduce the need for medication treatment was recognised but should be explored further. Conclusion - Several pitfalls, including miscommunication and inaccurate medication lists, for safe medication management were identified. The purpose of annual consultations should be clarified, individual treatment plans could be used more actively during primary care consultations and efforts are needed to improve verbal communication and information continuity

Mapping registered nurse anaesthetists' intraoperative work: tasks, multitasking, interruptions and their causes, and interactions: a prospective observational study

Introduction Safe anaesthesia care is a fundamental part of healthcare. In a previous study, registered nurse anaesthetists (RNAs) had the highest task frequency, with the largest amount of multitasking and interruptions among all professionals working in a surgical team. There is a lack of knowledge on how these factors are distributed during the intraoperative anaesthesia care process, and what implications they might have on safety and quality of care. Objective To map the RNAs' work as done in practice, including tasks, multitasking, interruptions and their causes, and interactions, during all phases of the intraoperative anaesthesia work process. Methods Structured observations of RNAs (n=8) conducted during 30 procedures lasting a total of 73 hours in an operating department at a county hospital in Sweden, using the Work Observation Method By Activity Timing tool. Results High task intensity and multitasking were revealed during preparation for anaesthesia induction (79 tasks/hour, 61.9% of task time spent multitasking), anaesthesia induction (98 tasks/hour, 50.7%) and preparation for anaesthesia maintenance (86 tasks/hour, 80.2%). Frequent interruptions took place during preoperative preparation (4.7 /hour), anaesthesia induction (6.2 /hour) and preparation for anaesthesia maintenance (4.3 /hour). The interruptions were most often related to medication care (n=54, 19.8%), equipment issues (n=40, 14.7%) or the procedure itself (n=39, 14.3%). RNAs' work was conducted mostly independently (58.4%), but RNAs interacted with multiple professionals in and outside the operating room during anaesthesia. Conclusion The tasks, multitasking, interruptions and their causes, and interactions during different phases illustrated the RNAs' work as done, as part of a complex adaptive system. Management of safety in the most intense phases-preparing for anaesthesia induction, induction and preparing for anaesthesia maintenance-should be investigated further. The complexity and adaptivity of the nature of RNAs' work should be taken into consideration in future management, development, research and education.</p

Tasks, multitasking and interruptions among the surgical team in an operating room: a prospective observational study

Objectives: The work context of the operating room (OR) is considered complex and dynamic with high cognitive demands. A multidimensional view of the complete preoperative and intraoperative work process of the surgical team in the OR has been sparsely described. The aim of this study was to describe the type and frequency of tasks, multitasking, interruptions and their causes during surgical procedures from a multidimensional perspective on the surgical team in the OR.Design: Prospective observational study using the Work Observation Method By Activity Timing tool.Setting: An OR department at a county hospital in Sweden.Participants: OR nurses (ORNs) (n=10), registered nurse anaesthetists (RNAs) (n=8) and surgeons (n=9).Results: The type, frequency and time spent on specific tasks, multitasking and interruptions were measured. From a multidimensional view, the surgical team performed 64 tasks per hour. Communication represented almost half (45.7%) of all observed tasks. Concerning task time, direct care dominated the surgeons’ and ORNs’ intraoperative time, while in RNAs’ work, it was intra-indirect care. In total, 48.2% of time was spent in multitasking and was most often observed in ORNs’ and surgeons’ work during communication. Interruptions occurred 3.0 per hour, and the largest proportion, 26.7%, was related to equipment. Interruptions were most commonly followed by professional communication.Conclusions: The surgical team constantly dealt with multitasking and interruptions, both with potential impact on workflow and patient safety. Interruptions were commonly followed by professional communication, which may reflect the interactions and constant adaptations in a complex adaptive system. Future research should focus on understanding the complexity within the system, on the design of different work processes and on how teams meet the challenges of a complex adaptive system.</p

Novel Biochemical Markers of Psychosocial Stress in Women

Background: Prolonged psychosocial stress is a condition assessed through self-reports. Here we aimed to identify biochemical markers for screening and early intervention in women

Burnout and sleep

Burnout and Sleep The overall aim of this thesis was to describe the physiological characteristics of sleep in persons with burnout and the relation between sleep and a number of physiological stress markers. The aim was also to evaluate the diurnal pattern of subjective sleepiness and fatigue across workday and weekend, and to describe the experiences of time preceding burnout from a life world perspective. This thesis focuses on burnout in white-collar workers; one group on sick-leave (I, II) and one with high burnout scores (pre-burnout) but still at work (III, IV). The Shirom- Melamed Burnout Questionnaire SMBQ was used for selection of participants with a mean of >4,75 on the total score (range 1-7) as upper limit and <2,5 as cut off for the two control groups. A combination of methods was used interviews, sleep and wake diaries, questionnaires, blood and saliva samples, and polysomnograpic (EEG, EOG, EMG) measures of sleep. The analyses included; t tests, chi2, analysis of variance, ANOVA, and covariance, ANCOVA, correlations, Pearson s r, stepwise regression analyses (study II-IV), and phenomenological analysis (study I). Study I describes the complex interaction between the person and his/her life world during the process of burning out. Study II evaluated whether subjective sleep complaints in burnout individuals on sick leave was related to disturbed sleep architecture and impaired homeostatic processes. Physiological and subjective aspects of sleep before a workday and a day off were investigated in study III. The diurnal pattern of sleepiness on workday and weekend was evaluated in study II and III, and the diurnal pattern of mental fatigue was evaluated in study II as well as occupational fatigue. Additionally, the burnout groups (II III) were described with respect to work stress, mood, recovery and burnout related variables. Study IV was a correlation study where the relation between sleep fragmentation and a number of physiological stress parameters, as well as possible predictors in daily life was evaluated. The most important finding is that sleep was impaired on all essential sleep variables in the burnout group on sick-leave (II). In the pre-burnout group (III) the main findings was an increased frequency of arousals, and the relatively moderate sleep fragmentation was related to of a number of risk factors for CVD and the metabolic syndrome (IV). Also unclear boundaries between work and leisure time and tension/irritability were associated with the sleep fragmentation. The burnout group on sick leave was sleepier than the controls for most point in time, with levels comparable to night or early morning shifts, and mental fatigue was equally elevated (except for weekday evenings). The pattern of sleepiness and mental fatigue was consistent across days. The high and low burnout groups were equally sleepy during workdays but differed during days off, indicating impaired recovery in the high burnout group. The time preceding burnout (I) was experienced as being trapped between never-ending demands on the one hand and stimulating challenges on the other. Cutting off important areas of life enhanced the strong focus on responsibilities, protected their self-images and impeded sleep and recovery. Acceptance of the situation was the turning point from where a new reconstruction of life could emerge. These findings suggest that sleep disruptions and impaired recovery seem to be characteristics of burnout, resulting in fatigue, and that inability to unwind the stress system may be a mediating factor. With this knowledge interventions for sleep improvement on company or population level seems important, and effective treatment of sleep disorders in order to prevent or relieve burnout is needed, as is a deeper understanding of how fatigue is experienced in health and illness

Långsiktiga investeringar i hemsjukvård skapar förutsättningar för säker vård

Ett hållbart sjukvårdsystem kännetecknas av att (människor i) organisationen har förmåga att förutse och upptäcka risker och snabbt kan anpassa sin verksamhet till komplexa situationer på ett för patienten säkert sätt. För att skapa patientsäkerheten i hemsjukvård där många professioner och vårdgivare är involverade behöver vi veta mer om HUR detta går till. I denna fallstudie identifieras förutsättningar för att skapa säker vård inom specialiserad hemsjukvård (ASIH). Kännetecken på ett hållbart system visar sig i organisationens förmåga att skapa frihetsgrader för personalen att i skarpt läge prioritera och skräddarsy lösningar. Exempel på organisationens förmåga att hantera olika målkonflikter och balansera sina resurser nära gränsen för säkerhet beskrivs. Studien visar att hållbara sjukvårdssystem bygger på långsiktiga investeringar och systematiskt lärande på olika nivåer i systemet. Bakgrund och syfte Hälso- och sjukvården har blivit alltmer komplex och präglas av avancerad teknik och potenta behandlingar. Den medicinska och tekniska utvecklingen har medfört att avancerad vård idag kan ges i hemmen, exempelvis med apparater för syrgasbehandling, dialys, blodtransfusion eller smärtlindring. Det innebär att patienter med en komplex sjukdomsbild, oftast äldre personer med multimorbiditet i allt större grad kan behandlas i hemmet. Den ökade valfriheten och möjligheten att vårdas hemma har ofta idealiserats eftersom den anses öka patienters och närståendes livskvalitet. Men det kan även medföra nya risker. Många vårdgivare och professioner har tillträde till patientens hem och en sammanhållen vårdplan går lätt förlorad. Därför accentueras frågor om hur ledarskap och organisation påverkar patientsäkerhetsarbetet. Även frågor om ansvarsstrukturer, maktförhållanden, samt förekomsten av ett proaktivt förhållningssätt i relation till risker blir aktuella. Denna studie ingår i ett på gående forskningsprogram som syftar till att få en bättre förståelse för hur risker identifieras och hanteras i vård av patienter med komplex sjukdomsbild, när den utförs i eller nära patientens hem. Vi studerar hur vårdsystemen utformas på ett sätt så att det skapar förutsättningar för yrkesutövarna i "the sharp end" att bedriva en säker vård. Metod: Denna fallstudie genomfördes vid enheter som bedriver Avancerad Sjukvård i Hemmet (ASIH) inom Stockholms län. Studien är explorativ och vi använder etnografiska metoder för att identifiera centrala processer på individ och organisationsnivå. Vi genomför deltagande observationer med följande tekniker: semistrukturerade observations protokoll, ljudinspelningar, fältanteckningar samt korta individuella intervjuer med nyckelpersoner. Upprepade individuella intervjuer samt fokusgruppsintervjuer genomfrös med patienter, chefer och medlemmar i det multiprofessionella vårdteamet för att fördjupa materialet. Datainsamling och analys sker i iterativa cykler utifrån principer för teorigenererande forskningsmetod som innebär att nya frågor genereras ur dataanalysen som grund för nästa observation/fokusintervju. Transkriberat material från intervjuer och observationer analyseras med kvalitativa forskningsmetoder. Resultatet beskriver kännetecken i systemet som bidrar till hållbar och säker vård. Under oförutsedda händelser framkom olika strategier för att förenkla och effektivisera arbetet innanför systemets säkerhetsgränser. Kännetecken på systemets hållbarhet visas genom organisationers förmåga att skapa frihetsgrader för personalen att i skarpt läge prioritera och skräddarsy lösningar. Exempel på strategier och investeringar på olika nivåer i organisationen framkom. Investeringar, i vissa fall genomförda sedan lång tid tillbaka, utgjorde en grund för förmågan att hantera målkonflikter och snabbt fatta autonoma beslut i akuta situationer. Slutsatser Ett hållbart sjukvårdssystem skapas genom långsiktiga investeringar på olika nivåer, och ett systematiskt lärande i organisationen. Dessa investeringar kommer till uttryck som frihetsgrader för människor i organisationen att agera effektivt och säkert, när ett system utsätts för ovanlig belastning. Resultaten från studien kan öka kunskapen om förutsättningar för säker vård för patienter med komplexa vårdbehov i sina privata hem.SEMINARIUM: Sjukvård på bortaplan, om att skapa säker hemsjukvård</p

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