To handle the unexpected - the meaning of caring in pre-hospital emergency care

Prevalence and clustering of NANDA-I nursing diagnoses in the pre-hospital emergency care setting: A retrospective records review study

AIM

To determine the prevalence and clustering of NANDA-International nursing diagnoses in patients assisted by pre-hospital emergency teams.

DESIGN

Retrospective descriptive study of electronic record review.

METHODS

Episodes recorded during 2019, including at least a nursing diagnosis, were recovered from the electronic health records of a Spanish public emergency agency (N = 28,847). Descriptive statistics were used to characterize the sample and determine prevalence. A two-step cluster analysis was used to group nursing diagnoses. A comparison between clusters in sociodemographic and medical problems was performed. Data were accessed in November 2020.

RESULTS

Risk for falls (00155) (27.3%), Anxiety (00146) (23.2%), Acute pain (00132), Fear (00148) and Ineffective breathing pattern (00032) represented 96.1% of all recorded diagnoses. A six-cluster solution (n = 26.788) was found. Five clusters had a single high-prevalence diagnosis predominance: Risk for falls (00155) in cluster 1, Anxiety (00146) in cluster 2, Fear (00148) in cluster 3, Acute pain (00132) in cluster 4 and Ineffective breathing pattern (00032) in cluster 6. Cluster 5 had several high prevalence diagnoses which co-occurred: Risk for unstable blood glucose level (00179), Ineffective coping (00069), Ineffective health management (00078), Impaired comfort (00214) and Impaired verbal communication (00051).

CONCLUSION

Five nursing diagnoses accounted for almost the entire prevalence. The identified clusters showed that pre-hospital patients present six patterns of nursing diagnoses. Five clusters were predominated by a predominant nursing diagnosis related to patient safety, coping, comfort, and activity/rest, respectively. The sixth cluster grouped several nursing diagnoses applicable to exacerbations of chronic diseases.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Knowing the prevalence and clustering of nursing diagnoses allows a better understanding of the human responses of patients attended by pre-hospital emergency teams and increases the evidence of individualized/standardized care plans in the pre-hospital clinical setting.

IMPACT

What problem did the study address? There are different models of pre-hospital emergency care services. The use of standardized nursing languages in the pre-hospital setting is not homogeneous. Studies on NANDA-I nursing diagnoses in the pre-hospital context are scarce, and those available are conducted on small samples. What were the main findings? This paper reports the study with the largest sample among the few published on NANDA-I nursing diagnoses in the pre-hospital care setting. Five nursing diagnoses represented 96.1% of all recorded. These diagnoses were related to patients' safety/protection and coping/stress tolerance. Patients attended by pre-hospital care teams are grouped into six clusters based on the nursing diagnoses, and this classification is independent of the medical conditions the patient suffers. Where and on whom will the research have an impact? Knowing the prevalence of nursing diagnoses allows a better understanding of the human responses of patients treated in the pre-hospital setting, increasing the evidence of individualized and standardized care plans for pre-hospital care.

REPORTING METHOD

STROBE checklist has been used as a reporting method.

NO PATIENT OR PUBLIC CONTRIBUTION

Only patients' records were reviewed without further involvement.

Patient experience of non-conveyance in the EMS of Southwest Finland: a descriptive survey study

BACKGROUND

Emergency Medical Services are dispatched more frequently than before. However, many non-urgent patients do not need ambulance transportation to a healthcare facility after evaluation and treatment on scene. This study explored the experiences of non-conveyed patients. Our research questions were: (1) How have non-conveyed patients experienced the service received from EMS? (2) Does a patient's age, gender, or time of the emergency call impact the patient's experience?

METHODS

This descriptive survey study examined non-conveyed Emergency Medical Services patients in the Wellbeing Services County of Southwest Finland. The study period was from March 1, 2023, to March 31, 2023. The study population was 1017. They received a questionnaire that was sent by mail. The questionnaire was formed based on questions previously used in four different questionnaires. We received 247 answers (24.3% response rate). Percentages, medians with interquartile ranges, and non-parametric tests were used in the descriptive analyses.

RESULTS

Non-conveyed patients were very satisfied with the paramedics' expertise and behavior, their ability to meet their individual needs, the sense of safety provided by the paramedics, and the instructions given to the patients. Time to receive help (19% rated 3 or less on a scale from 1 to 5), how paramedics introduced themselves (16.5%), and satisfaction with non-conveyance decisions (14.6%) were more frequently rated lower than other areas. Further, pain management stood out in the less favorable evaluations. Still, patients' experiences of the service were positive. The age group, gender, or time of the emergency call were not associated with patient experience.

CONCLUSIONS

Patients were very satisfied with the paramedics' interpersonal skills. A more focused approach to pain management and developing EMS to ensure faster patient outreach and clearer explanations of non-conveyance decisions could further enhance the patient experience.

Ambulance clinicians' understanding of older patients' self-determination: A vignette study

BACKGROUND

Older patients are often vulnerable and highly dependent on healthcare professionals' assessment in the event of acute illness. In the context of ambulance services, this poses challenges as the assessment is normally conducted with a focus on identifying life-threatening conditions. Such assessment is not fully satisfactory in a patient relationship that also aims to promote and protect patient autonomy.

AIM

To describe ambulance clinicians' understanding of older patients' self-determination when the patient's decision-making ability is impaired.

RESEARCH DESIGN

A qualitative design with an inductive approach, guided by descriptive phenomenology.

PARTICIPANTS

In total, 30 ambulance clinicians, comprised of 25 prehospital emergency nurses, 1 nurse and 4 emergency medical technicians participated in 15 dyadic interviews.

ETHICAL CONSIDERATIONS

The research was conducted in accordance with the Declaration of Helsinki, and permission was granted by the Swedish Ethical Review Authority.

FINDINGS

The findings are presented in two themes: (1) Movement between explicit and implicit will; and (2) Contradictions about the patient's best interests. The clinicians' interpretations are based on an understanding of the patient's situation using substitute decision-making in emergency situations and conversations that reveal the patient's explicit wishes. Sometimes the clinicians collaborate to validate the patient's implicit will, while they at other times subordinate themselves to others' opinions. The clinicians find themselves in conflict between personal values and organisational values as they try to protect the patient's self-determination.

CONCLUSION

The results indicate that older patients with an impaired decision-making ability risk losing the right to self-determination in the context of ambulance services. The clinicians face challenges that significantly affect their ability to handle the older patient's unique needs based on a holistic perspective and their ability to be autonomous.

Factors influencing witnesses' perception of patient safety during pre-hospital health care from emergency medical services: A multi-center cross-sectional study

AIM

To determine the factors related with the perception of feeling safe during pre-hospital emergency care.

METHODS

A multi-centred, cross-sectional study. Data collection from April 2021 to March 2022, in the Centro de Emergencias Sanitarias 061 (Andalusia, Spain).

INCLUSION CRITERIA

witnesses of health care by emergency medical services.

EXCLUSION CRITERIA

minors, or communication barriers.

OUTCOME VARIABLE

Witness Perceived Safety Scale ESPT10. The variables studied were related with sociodemographic data, the request for health care, the patient, the hospital transfer and patient safety incidents. A multivariate linear regression model was constructed for the dependent variable. The study followed STROBE statement.

RESULTS

Responses were obtained from 1400 witnesses. The linear regression model showed that the score on the scale increased as the witnesses felt more satisfied (B = 1.302; p < 0.001). On the contrary, the score was lower when the witness reported a patient safety incident (B = -2.856; p < 0.001 and B = -3.166; p < 0.001), or when the assistance took place in a public space (B = -0.722; p = 0.017).

CONCLUSIONS

The level of satisfaction, the occurrence of a patient safety incident, and the place of health care are related factors with the perception of the witnesses. The Witness Perceived Safety Scale ESPT10 could be considered a valid and useful patient safety indicator.

"You have to live with some risk, it's part of the profession". Specialist ambulance nurses' perceptions of assignments involving ongoing lethal violence

BACKGROUND

As a result of several violent terrorist incidents, authorities in Sweden have shifted from previous approaches of being certain that it is safe for the ambulance service to enter the scene, to a one where "safe enough" is sufficient, potentially making it possible to save more lives. The aim was therefore to describe specialist ambulance nurses' perceptions of the new approach to assignments involving incidents with ongoing lethal violence.

METHODS

This interview study employed a descriptive qualitative design with a phenomenographic approach in accordance with Dahlgren and Fallsberg.

RESULTS

Five categories containing conceptual descriptions were developed from the analysis: Collaboration, Unsafe environments, Resources, Unequipped and Risk taking and self-protection.

CONCLUSIONS

The findings highlight the need to ensure that the ambulance service is a learning organisation, where clinicians with experience of an ongoing lethal violence event can pass on and share their knowledge with colleagues to prepare mentally for such an event. Potentially compromised security in the ambulance service when dispatched to ongoing lethal violence incidents needs to be addressed.

A phenomenological interview study with patients being non-conveyed in the ambulance service

BACKGROUND

Non-conveyed patients (i.e. patients who are not transported to a hospital after being assessed by ambulance clinicians) represent a significantly increasing proportion of all patients seeking ambulance care. Scientific knowledge about patients' non-conveyance experiences is sparse. This study describes the lived experiences of non-conveyed patients in an ambulance care context.

METHODS

A reflective lifeworld research (RLR) approach founded on phenomenology is used. Data is derived from nine in-depth interviews with patients not conveyed by the ambulance service in a major Swedish region.

RESULTS

Patients' lived experiences of becoming acutely ill or injured and not conveyed by ambulance to a hospital are characterised by several dynamic movements: losing and regaining situational and bodily control, dependence and autonomy, external competence and inner knowledge, handing over and regaining responsibility, and fear and security.

CONCLUSIONS

Patients' lived experiences of non-conveyance are complex and versatile. Although non-conveyed patients initially experience strong fear and the loss of situational and bodily control, they gradually feel more secure when experiencing confirmation and trust, which evolves into insecurity and uncertainty. The non-conveyance situation's complexity from a patient's perspective implies the need for ambulance organisations to take measures to prevent further suffering. Non-conveyed patients must be taken seriously in their unique situations, requiring ambulance clinicians to reflect and act with a conscious ethical perspective before, during and after their visit.

Altruism in Paramedicine: A Scoping Review

While altruism has been studied in healthcare professions such as nursing and medicine, the exploration of the characteristics of altruism, as related to paramedicine and emergency care in Australia, is limited. This scoping review explores altruism in paramedicine from the perspective of the paramedic as practitioner, learner, and educator as seen through the lens of the paramedic and the patient. Also discussed is the positive impact of altruism on the patient experience of care. A scoping review was used to assess the availability of data related to altruism in paramedicine. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews was used to guide the process. Search categories were orientated around the subject (altruism) and discipline (paramedicine). A total of 27 articles are included in this scoping review. Initial searching identified 742 articles; after duplicate removal, 396 articles were screened with 346 excluded. Fifty articles were full-text reviewed and 23 excluded. The final 27 were extracted following full-text screening. None of the articles are specific to altruism in paramedicine. The data related to the practice of altruism in paramedicine are extremely limited. The preponderance of data arise from Europe and North America which, due to crewing and service differences, may impact the practice of altruism in different regions. Recent changes to the scope of paramedic practice, workload, education, and case acuity may influence behaviour regarding altruism, compassion, caring, and associated caring behaviours. The practice and education of paramedics including altruism, compassion, caring and caring behaviours in the Australasian setting warrants further research.

Prehospital Impact on Family Members of Road Traffic Accident

Background  Prehospital care is nonexistent in most rural and semiurban areas. The implementation of golden hour care is still unachieved. The psychosocial problems of family members who accompany the traumatic brain injury (TBI) survivors after road traffic accidents (RTA) are not given attention during prehospital care. Therefore, the current study was aimed to understand the prehospital psychosocial impact on family members.

Methodology  A cross-sectional study was conducted at the Emergency and Trauma Care Centre at National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru between July 2017 to April 2018. Forty-five ( n = 45) referred family members providing care for trauma survivors were purposively recruited in the study. Structured checklists were administered to measure the psychological reactions and psychosocial problems experienced by the family members during prehospital care. Data analysis was analyzed using the R software 3.0.1 version.

Results  TBI survivor's mean age was found to be 33 years (33.09 ± 13.20), of which males were 23 (51.1%) and females were 22 (48.9%), respectively. The result depicted first aid was provided by unskilled people after an average of 41 minutes (41 ± 30). The results further showed that family members had experienced agitation (100%), shock (82.2%), fatigue and headache (75.6%), depression (66.7%), feeling of hopelessness (55.6%) helplessness, and lack of support from family and financial constraints (48.9%) during prehospital care.

Conclusion  Psychosocial interventions need to be provided during prehospital care by trained medical and psychiatric social work professionals to address the need of family members during the crisis.

Caring approach for patients with chest pain - Swedish registered nurses' lived experiences in Emergency Medical Services

Purpose: Encountering patients with chest pain iscommon for Registered Nurses (RNs) in Emergency Medical Services (EMS) who are responsible for the patient’s medical and nursing care . From a lifeworld perspective, bodily illness is related to existential suffering, requiring knowledge to asses the situation from a holistic perspective . The aim of this study is to describe the caring approach when RNs encounter patients with chest pain.

Methods: A phenomenological methodology to capture RNs’ lived experiences was chosen. Seven qualitative in-depth interviews were conducted at three ambulance stations in Sweden.

Results: The essence of the caring approach while encountering patients with chest pain comprises two constituents; “trust based on confidence and competence” and “the collegial striving towards the best possible care”. Trust is two-parted; trust in oneself, and striving towards gaining the patient’s trust . Competence and experience when combined, develop into confidence especially in stressful situations. The caring approach is nurtured in a well-functioning collegial team.

Conclusions: This study contributes to understanding the caring approach based on the specific patient’s lifeworld in holistic EMS care. By trusting oneself, the patient, and one’s colleague, RNs in EMS shift focus from medical-orientated care to a holistic lifeworld caring approach. . More research is needed on trust as a phenomenon in EMS, both from caregivers’ and patients’ perspectives.

A Communicative Intervention to Improve the Psychoemotional State of Critical Care Patients Transported by Ambulance

BACKGROUND

Communication is key to understanding the emotional state of critical care patients.

OBJECTIVE

To analyze the effectiveness of the communicative intervention known as CONECTEM, which incorporates basic communication skills and augmentative alternative communication, in improving pain, anxiety, and posttraumatic stress disorder symptoms in critical care patients transported by ambulance.

METHODS

This study had a quasi-experimental design with intervention and control groups. It was carried out at 4 emergency medical centers in northern Spain. One of the centers served as the intervention unit, with the other 3 serving as control units. The nurses at the intervention center underwent training in CONECTEM. Pretest and posttest measurements were obtained using a visual analog scale to measure pain, the short-version State-Trait Anxiety Inventory to measure anxiety, and the Impact of Event Scale to measure posttraumatic stress disorder symptoms.

RESULTS

In the comparative pretest-posttest analysis of the groups, significant differences were found in favor of the intervention group (Pillai multivariate, F2,110 = 57.973, P < .001). The intervention was associated with improvements in pain (mean visual analog scale score, 3.3 pretest vs 1.1 posttest; P < .001) and posttraumatic stress disorder symptoms (mean Impact of Event Scale score, 17.8 pretest vs 11.2 posttest; P < .001). Moreover, the percentage of patients whose anxiety improved was higher in the intervention group than in the control group (62% vs 4%, P < .001).

CONCLUSION

The communicative intervention CONECTEM was effective in improving psychoemotional state among critical care patients during medical transport.

Registered nurses’ experiences of assessing patients with mental illness in emergency care: A qualitative descriptive study

Patients with mental illness are exposed and experience themselves as not being taken seriously in emergency care. Registered nurses need to assess patients with mental illness from a holistic perspective comprising both a physical and an existential dimension. The aim of the study was to describe registered nurses’ (RNs) experiences of assessing patients with mental illness in emergency care. Twenty-eight RNs in prehospital and in-hospital emergency care were individually interviewed. The interviews were analysed descriptively. The design followed the COREQ-checklist. One main theme ‘A conditional patient assessment’ and two themes; ‘A challenged professional role’ and ‘A limited openness for the patient’, comprising in turn four sub-themes emerged. Although the RNs showed willingness to understand the mental illness aspects of their patients, they were insufficient in their assessments. This implies the importance of developing emergency care RNs’ competence, knowledge and self-confidence in assessments and care of patients with mental illness.

Specialist Ambulance Nurses' Perceptions of Nursing: A Phenomenographic Study

Although nursing is the main area of interest in the curriculum of the specialist ambulance nursing program in the advanced level of education, there has been reported a lack of knowledge about nursing in within the ambulance service. The aim was to explore specialist ambulance nurses' perceptions of nursing, which were explored by employing a phenomenographic approach. The study comprises individual interviews with 19 strategically selected specialist ambulance nurses. The results showed seven descriptive categories emerged detailing the variations in how the specialist ambulance nurses perceive, understand, and conceptualize the phenomenon of nursing in the Swedish Ambulance Service. Four categories revealed the specialist ambulance nurses' qualitatively different perceptions of nursing, i.e., their role and responsibility, while three showed perceived barriers to assuming their role and responsibility, comprising culture and leadership, conditions, and framework. The seven categories are outlined in the outcome space. In conclusion, there is a very wide variety of perceptions of ambulance nursing within the Swedish Ambulance Service. There is a need for implement the nursing process both in the Specialist Nursing Pre-hospital Emergency Care education curriculum and within clinical practice. Further, there is a necessity to develop and implement nursing guidelines in the ambulance.

Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study

Background

There is widespread concern about the pressure on emergency and urgent services in the UK, particularly emergency ambulances, emergency departments and same-day general practitioner appointments. A mismatch between supply and demand has led to interest in what can be termed ‘clinically unnecessary’ use of services. This is defined by the research team in this study as ‘patients attending services with problems that are classified as suitable for treatment by a lower urgency service or self-care’. This is a challenging issue to consider because patients may face difficulties when deciding the best action to take, and different staff may make different judgements about what constitutes a legitimate reason for service use.

Objectives

To identify the drivers of ‘clinically unnecessary’ use of emergency ambulances, emergency departments and same-day general practitioner appointments from patient and population perspectives.

Design

This was a sequential mixed-methods study with three components: a realist review; qualitative interviews (n = 48) and focus groups (n = 3) with patients considered ‘clinically unnecessary’ users of these services, focusing on parents of young children, young adults and people in areas of social deprivation; and a population survey (n = 2906) to explore attitudes towards seeking care for unexpected, non-life-threatening health problems and to identify the characteristics of someone with a tendency for ‘clinically unnecessary’ help-seeking.

Results

From the results of the three study components, we found that multiple, interacting drivers influenced individuals’ decision-making. Drivers could be grouped into symptom related, patient related and health service related. Symptom-related drivers were anxiety or need for reassurance, which were caused by uncertainty about the meaning or seriousness of symptoms; concern about the impact of symptoms on daily activities/functioning; and a need for immediate relief of intolerable symptoms, particularly pain. Patient-related drivers were reduced coping capacity as a result of illness, stress or limited resources; fear of consequences when responsible for another person’s health, particularly a child; and the influence of social networks. Health service-related drivers were perceptions or previous experiences of services, particularly the attractions of emergency departments; a lack of timely access to an appropriate general practitioner appointment; and compliance with health service staff’s advice.

Limitations

Difficulty recruiting patients who had used the ambulance service to the interviews and focus groups meant that we were not able to add as much as we had anticipated to the limited evidence base regarding this service.

Conclusions

Patients use emergency ambulances, emergency departments and same-day general practitioner appointments when they may not need the level of clinical care provided by these services for a multitude of inter-related reasons that sometimes differ by population subgroup. Some of these reasons relate to health services, in terms of difficulty accessing general practice leading to use of emergency departments, and to population-learnt behaviour concerning the positive attributes of emergency departments, rather than to patient characteristics. Social circumstances, such as complex and stressful lives, influence help-seeking for all three services. Demand may be ‘clinically unnecessary’ but completely understandable when service accessibility and patients’ social circumstances are considered.

Future work

There is a need to evaluate interventions, including changing service configuration, strengthening general practice and addressing the stressors that have an impact on people’s coping capacity. Different subgroups may require different interventions.

Study registration

This study is registered as PROSPERO CRD42017056273.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 15. See the NIHR Journals Library website for further project information.

'Clinically unnecessary' use of emergency and urgent care: A realist review of patients' decision making

Background

Demand is labelled ‘clinically unnecessary’ when patients do not need the levels of clinical care or urgency provided by the service they contact.

Objective

To identify programme theories which seek to explain why patients make use of emergency and urgent care that is subsequently judged as clinically unnecessary.

Design

Realist review.

Methods

Papers from four recent systematic reviews of demand for emergency and urgent care, and an updated search to January 2017. Programme theories developed using Context‐Mechanism‐Outcome chains identified from 32 qualitative studies and tested by exploring their relationship with existing health behaviour theories and 29 quantitative studies.

Results

Six mechanisms, based on ten interrelated programme theories, explained why patients made clinically unnecessary use of emergency and urgent care: (a) need for risk minimization, for example heightened anxiety due to previous experiences of traumatic events; (b) need for speed, for example caused by need to function normally to attend to responsibilities; (c) need for low treatment‐seeking burden, caused by inability to cope due to complex or stressful lives; (d) compliance, because family or health services had advised such action; (e) consumer satisfaction, because emergency departments were perceived to offer the desired tests and expertise when contrasted with primary care; and (f) frustration, where patients had attempted and failed to obtain a general practitioner appointment in the desired timeframe. Multiple mechanisms could operate for an individual.

Conclusions

Rather than only focusing on individuals' behaviour, interventions could include changes to health service configuration and accessibility, and societal changes to increase coping ability.

Clinical reasoning in the emergency medical services: an integrative review

Clinical reasoning is the process of gathering and understanding information conducted by clinicians in the emergency medical services (EMS) so as to make informed decisions. Research on clinical reasoning spans several disciplines, but a comprehensive view of the process is lacking. To our knowledge, no review of clinical reasoning in the EMS has been conducted.

AIM

The aim was to investigate the nature, deployment, and factors influencing EMS clinicians' clinical reasoning by means of a review.

METHOD

Data was collected through searches in electronic databases, networking among research teams, colleagues and friends, "grey literature," and through ancestry searches. A total of 38 articles were deemed eligible for inclusion and were analyzed using descriptive thematic analysis. The analysis resulted in an overarching finding - namely, the importance for EMS clinicians to adjust for perceived control in unpredictable situations. Within this finding, 3 themes emerged in terms of EMS clinicians' clinical reasoning: (1) maintaining a holistic view of the patient; (2) keeping an open mind; and (3) improving through criticism. Seven subthemes subsequently emerged from these three themes.

RESULTS

This review showed that EMS clinicians' clinical reasoning begins with the information that they are given about a patient. Based on this information, clinicians calculate the best route to the patient and which equipment to use, and they also assess potential risks. They need to be constantly aware of what is happening on the scene and with the patient and strive to control the situation. This striving also enables EMS clinicians to work safely and effectively in relation to the patient, their relatives, other clinicians, associated organizations, and the wider community. A lack of contextually appropriate guidelines results in the need for creativity and forces EMS clinicians to use "workarounds" to solve issues beyond the scope of the guidelines available. In addition, they often lack organizational support and fear repercussions such as litigation, unemployment, or blame by their EMS or healthcare organization or by patients and relatives.

CONCLUSION

Clinical reasoning is influenced by several factors. Further research is needed to determine which influencing factors can be addressed through interventions to minimize their impact on patient outcomes.

Common core content in education for nurses in ambulance care in Sweden, Finland and Belgium

There is no consensus regarding the required education content and competence needed for professionals working in the emergency medical services and only a few countries in Europe staff ambulances with registered nurses. This study aimed to identify common core content in Swedish, Finnish and Belgian university curricula in the education on advanced level for registered nurses in ambulance care and to describe the teachers' perception of the necessary content for the profession as a registered nurse in ambulance care. A deductive research design was used. Three Universities, one from each country; Sweden, Finland and Belgium, participated. Data was generated from curricula and interviews with teachers and analyzed with different approaches of qualitative content analysis. The results showed commonness with respect to core content; the emphasis was mainly on medical knowledge but the content concerning contextual subjects differed between the three universities. The teachers, however, aimed for the students' to acquire a broad competence in clinical reasoning by implementing theory into practice, as well as developing the students' personal aptitude and instilling a scientific awareness. The results suggest that it is possible to create a common curriculum for training of RNs for working in ambulance care.

Quality Is in the Eye of the Beholder-A Focus Group Study from the Perspective of Ambulance Clinicians, Physicians, and Managers

Quality within all areas of healthcare should be systemically monitored and ensured. However, the definition of quality is complex and diverse. In the ambulance service (AS), quality has traditionally been defined as response time, but this measurement eliminates the possibility of addressing other characteristics of quality, such as the care provided. This study aimed to explore what constitutes quality in the context of the ambulance service as experienced by ambulance clinicians, physicians, and managers. A focus group study was conducted with 18 participants. The three focus groups were analyzed with the focus group method developed by Kreuger and Casey. The participants highlighted patient involvement, information and care, as well as adherence to policies, regulations, and their own standards as representing quality in the AS. This study demonstrates that quality is in the eye of the beholder. As quality seems to be viewed similarly by patients and ambulance clinicians, physicians, and managers, stakeholders should aim for a paradigm shift where patients' experience of the care is just as important as various time measures.

Caring science research in the ambulance services: an integrative systematic review

BACKGROUND

The ambulance services are associated with emergency medicine, traumatology and disaster medicine, which is also reflected in previous research. Caring science research is limited and, since no systematic reviews have yet been produced, its focus is unclear. This makes it difficult for researchers to identify current knowledge gaps and clinicians to implement research findings.

AIM

This integrative systematic review aims to describe caring science research content and scope in the ambulance services.

DATA SOURCES

Databases included were MEDLINE (PubMed), CINAHL, Web of Science, ProQDiss, LibrisDiss and The Cochrane Library. The electronic search strategy was carried out between March and April 2015. The review was conducted in line with the standards of the PRISMA statement, registration number: PROSPERO 2016:CRD42016034156.

REVIEW METHODS

The review process involved problem identification, literature search, data evaluation, data analysis and reporting. Thematic data analysis was undertaken using a five-stage method. Studies included were evaluated with methodological and/or theoretical rigour on a 3-level scale, and data relevance was evaluated on a 2-level scale.

RESULTS

After the screening process, a total of 78 studies were included. The majority of these were conducted in Sweden (n = 42), fourteen in the United States and eleven in the United Kingdom. The number of study participants varied, from a case study with one participant to a survey with 2420 participants, and 28 (36%) of the studies were directly related to patients. The findings were identified under the themes: Caregiving in unpredictable situations; Independent and shared decision-making; Public environment and patient safety; Life-changing situations; and Ethics and values.

CONCLUSION

Caring science research with an explicit patient perspective is limited. Areas of particular interest for future research are the impact of unpredictable encounters on openness and sensitivity in the professional-patient relation, with special focus on value conflicts in emergency situations.

Association between the reported intensity of an acute symptom at first prehospital assessment and the subsequent outcome: a study on patients with acute chest pain and presumed acute coronary syndrome

BACKGROUND

To decrease the morbidity burden of cardiovascular disease and to avoid the development of potentially preventable complications, early assessment and treatment of acute coronary syndrome (ACS) are important. The aim of this study has therefore been to explore the possible association between patients' estimated intensity of chest pain when first seen by the ambulance crew in suspected ACS, and the subsequent outcome before and after arrival in hospital.

METHODS

Data was collected both prospectively and retrospectively. The inclusion criteria were chest pain raising suspicion of ACS and a reported intensity of pain ≥4 on the visual analogue scale.

RESULTS

All in all, 1603 patients were included in the study. Increased intensity of chest pain was related to: 1) more heart-related complications before hospital admission; 2) a higher proportion of heart failure, anxiety and chest pain after hospital admission; 3) a higher proportion of acute myocardial infarction and 4) a prolonged hospitalisation. However, there was no significant association with mortality neither in 30 days nor in three years. Adjustment for possible confounders including age, a history of smoking and heart failure showed similar results.

CONCLUSION

The estimated intensity of chest pain reported by the patients on admission by the ambulance team was associated with the risk of complications prior to hospital admission, heart failure, anxiety and chest pain after hospital admission, the final diagnosis and the number of days in hospital.

TRIAL REGISTRATION

ClinicalTrials.gov 151:2008/4564 Identifier: NCT00792181. Registred 17 November 2008 'retrospectively registered'.

Specialist ambulance nurses' experiences of births before arrival

BACKGROUND

Working as an ambulance nurse means interacting with and caring for acutely ill and injured patients. It can even involve births before arrival to the hospital (BBA), which are rare but increasing due to the centralization of maternity wards.

AIM

This study describes the experiences of specialist ambulance nurses with BBA.

METHOD

A qualitative study was conducted, and nine specialist ambulance nurses who had assisted with one or more prehospital births were interviewed. Data were analysed with thematic content analysis.

FINDINGS

The analysis revealed three categories that were compiled into a theme of feeling fright and exhilaration. The findings showed that BBA causes feelings of anxiety and stress. The experience is also associated with joy and relief when the baby is born. Childbirth is a situation for which specialist ambulance nurses feel less prepared, lack of knowledge, and wish for more education.

CONCLUSION

Specialist ambulance nurses face challenges in the pre-hospital care environment during BBA, with long distances, a lack of equipment aboard the ambulance, and no assistance from midwives. To feel secure in the complex role that is required when assisting with a BBA, specialist ambulance nurses should be given the opportunity to receive scenario training.

Patient participation during and after a self-management programme in primary healthcare - The experience of patients with chronic obstructive pulmonary disease or chronic heart failure

OBJECTIVE

Patient participation is facilitated by patients' ability to take responsibility for and engage in health issues. Yet, there is limited research as to the promotion of these aspects of patient participation in long-term healthcare interactions. This paper describes patient participation as experienced by patients with chronic obstructive pulmonary disease (COPD) or chronic heart failure (CHF); the aim was to describe if and how a self-management programme in primary healthcare influenced patient participation.

METHODS

Patients who had participated in a self-management programme were interviewed in nine focus groups (36 patients). Data was analysed using qualitative content analysis.

RESULTS

Patients described equality in personal interactions, opportunities to share and discuss, and a willingness to share and learn to facilitate patient participation in a self-management programme. Consequently, patient participation was promoted by a match between the individuals' personal traits and the context.

CONCLUSION

Features facilitating patient participation by means of sharing and assimilating knowledge and insights should be included in self-management programmes and in the care for patients with COPD and CHF.

PRACTICE IMPLICATIONS

A self-management programme can complement regular primary care regarding enhanced understanding of one's disease and support patient participation and the patient's own resources in self-management.

Perceptions of paramedics and emergency staff about the care they provide to people who self-harm: Constructivist metasynthesis of the qualitative literature

OBJECTIVE

Presentations of self-harm to paramedic and emergency staff are increasing, and despite being the first professionals encountered, patients who self-harm report the quality of care and attitudes from these staff are unsatisfactory. Understanding this care may provide opportunities to improve services. The aim of this study is to enhance knowledge building and theory generation in order to develop practice and policy through a metasynthesis of qualitative research relating to perceptions of paramedic and emergency care for people who self-harm.

METHODS

The metasynthesis draws on Evolved Grounded Theory Methodology (EGTM). A search was undertaken of CINAHL, MEDLINE, OVID and Psych INFO, and grey literature. Subject headings of 'self-harm' were used alongside key words 'suicide', 'paramedic' 'emergency', 'overdose', 'pre-hospital' mental health, ambulance, perceptions of care, emergency.

RESULTS

A total of 1103 papers were retrieved; 12 were finally included. No papers investigated paramedic care for self-harm. The following metaphors emerged: (a) frustration, futility and legitimacy of care; (b) first contact in the pre-hospital environment: talking, immediate and lasting implications of the moral agent; (c) decision making in self-harm: balancing legislation, risk and autonomy; (d) paramedics' perceptions: harnessing professionalism and opportunities to contribute to the care of self-harm.

CONCLUSION

Paramedics are often the first health professional contact following self-harm, yet limited qualitative literature has explored this encounter. Metaphors revealed in this paper highlight challenges in decision making and legislation, also opportunities to improve care through professionalization and tailored education.

Elderly patients' participation in emergency medical services when offered an alternative care pathway

As organizational changes in the healthcare system are in progress, to enhance care quality and reduce costs, it is important to investigate how these changes affect elderly patients' experiences and their rights to participate in the choice of healthcare. The aim of this study is to describe elderly patients' lived experience of participating in the choice of healthcare when being offered an alternative care pathway by the emergency medical services, when the individual patient's medical needs made this choice possible. This study was carried out from the perspective of caring science, and a phenomenological approach was applied, where data were analysed for meaning. Data consist of 11 semi-structured interviews with elderly patients who chose a healthcare pathway to a community-based hospital when they were offered an alternative level of healthcare. The findings show that the essence of the phenomenon is described as "There was a ray of hope about a caring encounter and about being treated like a unique human being". Five meaningful constituents emerged in the descriptions: endurable waiting, speedy transference, a concerned encounter, trust in competence, and a choice based on memories of suffering from care. The conclusion is that patient participation in the choice of a healthcare alternative instead of the emergency department is an opportunity of avoiding suffering from care and being objectified.