Reducing risks in complex care transitions in rural areas: a grounded theory

PURPOSE

Although previous research indicates that care transitions differ between rural and urban areas, the knowledge of challenges related to care transitions in rural areas appears limited. This study aimed to provide a deeper understanding of what registered nurses' perceive as the main concerns in care transitions from hospital care to home healthcare in rural areas, and how they handle these during the care transition process.

METHODS

A Constructivist Grounded Theory method based on individual interviews with 21 registered nurses.

RESULTS

The main concern in the transition process was "Care coordination in a complex context". The complexity stemmed from several environmental and organizational factors, creating a messy and fragmented context for registered nurses to navigate. The core category "Actively communicating to reduce patient safety risks" was explained by the three categories- "Collaborating on expected care needs", "Anticipating obstacles" and "Timing the departure".

CONCLUSIONS

The study shows a very complex and stressed process that includes several organizations and actors. Reducing risks during the transition process can be facilitated by clear guidelines, tools for communication across organizations and sufficient staffing.

Relatives' experiences of care encounters in the general ward after ICU discharge: a qualitative study

BACKGROUND

Care encounters at general wards have many reasons, and the complexity differs. Some arriving at the ward are relatives of discharged intensive care unit patients', who are usually more fragile than others due to what had happened to them. Research indicates that care encounters leave relatives dissatisfied. There is a lack of studies describing how relatives of adult patients experience the transfer from the intensive care unit.

AIM

The purpose of this study was to describe relatives' experiences of care encounters with nurses during their loved ones' stay in the general ward after being discharged from the intensive care unit.

METHODS

A qualitative descriptive design with an inductive approach was used. Semi-structured individual interviews were conducted with relatives [n = 14) of patients from different hospitals in Sweden. Data were analysed using content analysis.

RESULTS

Relatives expressed feeling a huge responsibility for ensuring the quality of care for their loved ones. It was essential to encounter available, committed, and compassionate nurses in the general ward after being transferred from the intensive care unit. The theme 'longing for trust and struggling to be involved in their loved one's care' was illustrated in the two subthemes of 'wanting to be seen as an important piece of the puzzle' and 'being vigilant and worrying about the quality of care'.

CONCLUSION

The relatives of patients experience their needs as unfulfilled in care encounters with nurses at the general ward after transfer from ICU. In order to meet the needs of relatives, nurses require well-developed non-technical skills to establish a compassionate interaction founded on trust and respect for the individual. Future research should investigate how relatives' needs can be met in practice. New nursing innovations are necessary to structure encounters with patients and relatives transitioning from the intensive care unit.

A reflexive thematic analysis of ambulance nurses' experience of facilitating child-centered care

INTRODUCTION

Ambulance nurses' (ANs) feel less confident treating children. According to the United Nations Convention on Child Rights, there is a provision to safeguard children's rights. Child-Centered Care (CCC) strives to lift children's voices in healthcare.

AIM

To describe ambulance nurses' experiences of facilitating child-friendly care.

METHOD

A qualitative approach with Reflexive Thematic Analysis was performed on seventeen individual semi-structured interviews.

RESULT

One overarching theme, caring with the child in center, and three themes were developed: adapting to follow the child's lead, being reliable by balancing the trust, stepping back and supporting.

DISCUSSION

The ANs' communication with the children was honest and straightforward. Letting the child and the parents perform the care together reduced the child's anxiety. Guided participation was used by ANs, expanding the child's initiative.

CONCLUSION

The ANs work according to CCC, but unknowingly. It is important and beneficial to elevate the CCC to a conscious level. The ANs could refer to CCC in training new colleagues, reflecting on cases, and incorporating the Child Act in their work.

Quality of care during rural care transitions: a qualitative study on structural conditions

BACKGROUND

Registered nurses are critical for the delivery of high-quality healthcare during care transitions from hospital to home. Older co-morbid patients are most vulnerable during these transitions. A growing population of older adults with a higher prevalence of diseases implies increased demands on healthcare and its quality, which is affected by the environment where healthcare is provided. One can draw inferences on the quality of care when classified into structure, process, and outcome. This study explored registered nurses' perspectives on structural conditions that promote or hinder good quality care during transitions from hospital to home healthcare in rural areas.

METHODS

We conducted a reflexive thematic analysis of interviews with 21 registered nurses experienced in care transitions from hospital to home healthcare in a rural area of Sweden. We based the theoretically driven analysis on Donabedian's definition of structures regarding the quality of care.

RESULTS

The structural conditions were represented by three themes; (I) "Distances and inaccessibility" explains physical matters such as geographical (in)accessibility, bed (un)availability and electronic aids. (II) "Competence of the actors" explains continuity, knowledge and collaboration among the individuals involved. (III) "Levels of organizational governance" explains laws, expectations, values, and agreements regarding care transitions. All themes involved promoting and hindering factors, mutually influencing aspects of the others.

CONCLUSIONS

Care actors, educators, managers, and decision-makers need to understand how structures in the physical, social and symbolic environment interactively affect the quality of care during care transitions since understanding this is a prerequisite for improvements. These aspects must be considered to optimize conditions for high-quality care transitions from hospital to rural home healthcare and implemented continuously to improve transitions within the respective organization and inter-organizationally. According to this study, these aspects are critical in a rural context due to structural care quality influencers such as geographical challenges, difficulties in finding competent staff members, development of technical devices, and access to the Internet.

Success Factors for Quality and Safety of Intensive Care Unit Transitional Care – Listening to the Sharp End

Purpose: The purpose of this paper was to present success factors for increasing quality and safety of intensive care unit (ICU) transitional care as described by co-workers at the sharp end using the core values of total quality management (TQM) as a theoretical lens. Methodology/Approach: The study had a qualitative design, with data from nine interdisciplinary focus group discussions, including co-workers from the intensive care and general wards. Data were sorted into TQM core values and analysed using qualitative content analysis. Findings: Quality and safety in transfer processes requires a holistic view, avoiding silos, shared arenas for collaboration, and evidence-based methodologies and tools for safe transfers. Research Limitation/Implication: A limitation of this study is that it only portrays the challenges encountered by two hospitals during the process of transitional care in the ICU. Originality/Value of paper: By using TQM core values as a theoretical lens, we could present a usable, holistic picture of success factors and how to improve the transfer process.

Meanings of carers’ lived experience of “regulating oneself” in forensic psychiatry

Purpose

This study aimed to illuminate the essential meanings of carers’ lived experience of regulating themselves when caring for patients with mental illnesses in forensic inpatient care.

Methods

Qualitative analysis was used to analyse data from narrative interviews with open-ended questions conducted with nine carers, which were analysed using a phenomenological-hermeneutic approach.

Results

Findings revealed three themes, “preserving oneself as a carer,” “building an alliance with the patient” and “maintaining stability in the community.” Carers not only regulated emotions related to patients but also the ward to facilitate a caring climate. For carers, encounters with patients meant facing expressions of suffering that evoked unwanted emotions. Regulating one’s emotions also meant being emotionally touched and facing one’s vulnerability.

Conclusion

Regulating oneself was a strategy used by carers to get closer to the patient and establishing a trusting relationship. Regulating oneself meant becoming aware of one’s shortcomings, not projecting them onto others, which may impair establishing relationships with patients and fulfilling the aim and caring task of forensic psychiatry. This study stresses the importance of carers being guided to manage their conflicting emotions and vulnerabilities and finding courage and an approach that allows a permissive climate of self-reflection.

Encountering patients with anorexia nervosa - An emotional roller coaster. nurses’ lived experiences of encounters in psychiatric inpatient care

Purpose

The aim of this study was to illuminate the meaning of nurses’ lived experiences of encounters with adult patients with anorexia nervosa in psychiatric inpatient care.

Methods

A qualitative phenomenological hermeneutical design was used. Personal interviews with a narrative approach were conducted with 11 nurses with experience of encountering patients with anorexia nervosa in psychiatric inpatient care.

Results

Three key themes were revealed: Being overwhelmed by emotions consisting of three subthemes: Bearing feelings of incomprehension, Navigating emotions, and Being disappointed and frustrated; Seeking strength to cope consisting of three subthemes: Relying on colleagues and routines, Feeling hope and motivation, and Building inner security; and Trying to build relations consisting of two subthemes: Getting closer to the patient and Relating to relatives.

Conclusion

Our findings illuminate the “emotional roller-coaster” which nurses are embedded in during their daily work experiences. Being able to balance one’s professional role, seeing the person behind the patient, and the illness is important in all nurse-patient encounters. An examination of nurses’ lived experiences can contribute new and important knowledge, an in-depth understanding of the nurses’ work situation, and can help identify any need for increased knowledge.

"You Know Where the Boundary Is When You Cross It" - A Phenomenological Understanding of Vulnerability as Experienced by Carers in Forensic Inpatient Care

In forensic nursing, carers must balance caring and limiting actions in encounters with patients. Interpreting suffering in others raises awareness of one's own vulnerability. Hence, the aim of this study was to describe the phenomenon of vulnerability as experienced by carers in forensic inpatient care. Nine participants were recruited at a major forensic hospital, and their narratives were analysed with a reflective lifeworld approach. The findings revealed that vulnerability was both a strength and a burden. Vulnerability comprised becoming aware of one's boundaries, being genuine and protecting oneself. Dealing with vulnerability enables carers to open up to patients.

Social processes in academic-community partnership in health care. A grounded theory study

Background

International and national guidelines state that palliative care should be offered to everyone who needs it. To promote the implementation of palliative care in nursing homes, a partnership collaboration was initiated with the goal of implementing high quality palliative care. The partnership consisted of three partner groups: a project group from a non-profit organisation providing health care, managers at the nursing homes and an academic partner. The aim was to explore the social processes within academic-community partnership in a collaboration project.

Methods

Digital focus group discussions were conducted with 16 participants, representing all three partner groups. One individual digital interview was also carried out. A constructivist perspective of a grounded theory approach was used for data analysis.

Results

The core category, partnership positioning, covers the social processes of the academic-community partnership in a collaboration project to implement and evaluate health-promoting interventions in clinical health care. The core category was found to have four categories: Pre-positioning, Co-positioning, Re-positioning and GoOn-positioning. The process of partnership positioning is conceptualised in a model.

Conclusions

Our findings indicate that a new partnership in an implementation project needs holistic, systemic thinking. To enhance implementation in a collaborative project involving different professionals and actors a plan is required to facilitate positioning activities. The process, the roles and the components need to be clearly defined and documented, and the management of a system requires knowledge of the interrelationships between all the components within the system. The development of a conceptual model of Partnership Positioning contributes to knowledge concerning the social dynamic processes which can be applied to support future academic-community collaboration and/or implementation projects.

Trial registration

Not applicable. The present study has not been considered as a clinical trial.

The path of compassion in forensic psychiatry

We aimed to deepen our understanding of the concept of compassion in caring for patients with mental illness in forensic psychiatric inpatient care settings. Qualitative analysis was used to illuminate themes from interviews conducted with 13 nurses in a prior study. The audiotaped interviews, which had been transcribed verbatim, were analyzed following a hermeneutic approach. Results revealed the main theme of "being compassionate in forensic psychiatry is an emotional journey" and three themes. Overall, compassion was seen as a changeable asset, but also an obstacle when absent; sensitivity to one's own vulnerability is necessary to overcome that obstacle.

Controlling emotions-nurses' lived experiences caring for patients in forensic psychiatry

Purpose: Nurses working in forensic psychiatry often encounter offenders who have a severe mental illness, which may cause ethical challenges and influence nurses' daily work. This study was conducted to illuminate the meaning of nurses' lived experiences of encounters with patients with mental illnesses in forensic inpatient care. Methods: This qualitative study employed narrative interviews with 13 nurses. Interviews were audiotaped and transcribed verbatim and analysed following a phenomenological-hermeneutic approach. Results: Four key themes were revealed: "Being frustrated" (subthemes included "Fighting resignation" and "Being disappointed"), "Protecting oneself" (subthemes included "To shy away," "Being on your guard," and "Being disclosed"), "Being open-minded" (subthemes included "Being confirmed," "Developing trust," and "Developing compassion"), and "Striving for control" (subthemes included "Sensing mutual vulnerability" and "Regulating oneself"). Further, working in forensic psychiatry challenged nurses' identity as healthcare professionals because of being in a stressful context. Conclusions: Dealing with aggressive patients with severe mental illnesses threatens nurses' professional identity. Nurses must attempt to empathize with patients' experiences and respond accordingly. Utilizing strategies rooted in compassion such as self-reflection, emotional regulation, and distancing themselves when necessary may enable nurses to more effectively respond to patients' needs.

Being Facilitators in a Challenging Context-School Personnel's Experiences of Caring for Youth with Diabetes Type 1

PURPOSE

The purpose of the study was to describe school personnel's experiences of caring for youth with diabetes type 1.

DESIGN AND METHODS

A qualitative design was chosen for this study. Data were collected with individual interviews that were subjected to inductive qualitative content analysis. The sample consisted of 24 school personnel (teachers, principals and school nurses) from Swedish schools. All had experience with youth aged 6 to 18 years old with diabetes type 1.

RESULTS

School personnel experienced caring for youth with diabetes type 1 as "Being facilitators in a challenging context" and described establishing trusting relationships, finding strategies to support self-care, feeling uncertain and incapable in need of education, and dealing with unclear responsibility.

CONCLUSIONS

School personnel (teachers, principals and school nurses) are key professionals supporting youth with diabetes type 1 and self-care in school. Lack of education and unclear responsibility created feelings of uncertainty and insecurity for school personnel and a need for mandatory education of school personnel regarding T1DM and self-care, including legislation was identified.

IMPLICATIONS

Mandatory education should be provided for all school personnel regarding diabetes type 1, self-care and current legislation. A liason position in form of a nurse specialist should manage the education.

Ward visits- one essential step in intensive care follow-up. An interview study with critical care nurses' and ward nurses'

OBJECTIVE

The aim of this study was to describe critical care nurses' and ward nurses' perceptions of the benefits and challenges with a nurse-led follow-up service for intensive care-survivors at general wards.

BACKGROUND

Patients recently transferred from intensive care to the general ward are still vulnerable and require complex care. There are different models of intensive care follow-up services and some include ward visits after transfer from intensive care. Research methodology/design: This study had a qualitative design. Data from 13 semi-structured interviews with Swedish critical care nurses and ward nurses were analysed using qualitative content analysis.

FINDINGS

The findings consisted of one theme, namely, "Being a part of an intra-organisational collaboration for improved quality of care", and four subthemes: "Provides additional care for the vulnerable patients, "Strengthens ward-based critical care", "Requires coordination and information", and "Creates an exchange of knowledge". The nurse-led follow-up service detected signs of deterioration and led to better quality of care. However, shortage of time, lack of interaction, feedback and information about the function of the follow-up service led to problems.

CONCLUSION

The findings indicate that ward visits should be included in the intensive care follow-up service. Furthermore, intra-organisational collaboration seems to be essential for intensive care survivors' quality of care.

Nurses' experiences of prehospital care encounters with children in pain

BACKGROUND

Pain relief in children is a complex issue, partly an ethical dilemma and due to a lack of nursing competence. There are few studies regarding prehospital care encounters with children in pain.

AIM

The aim of this study was to describe nurses' experiences in prehospital care encounters with children in pain and the specific related challenges.

METHOD

This study has a qualitative design. Eighteen Swedish nurses participated in three focus group interviews analysed using qualitative content analysis.

FINDINGS

The findings consist of a theme, "A challenge to shift focus and adjust to the child", and three categories describing prehospital care encounters with children in pain: "Being receptive and focusing on care," "Developing a trusting relationship," and "Providing professional nursing care." Caring for children in pain was stressful for the nurses. The nurses described how they had to shift focus and used different methods to build trust, such as playfulness, making eye contact, attracting curiosity, and using the parents to create trust. The also had to adjust to the child regarding dosages and materials.

CONCLUSION

Nurses has to be practically, mentally, and theoretically prepared to care for children with prehospital pain. It is essential to evaluate the administration of adequate pain relief to children, and more evidence-based knowledge is necessary concerning the different modes of administering pain-relieving drugs to prehospital children.

Overcoming Reluctance towards High Fidelity Simulation - A Mutual Challenge for Nursing Students’ and Faculty Teachers

BACKGROUND: One strategy to develop nursing students’ clinical judgment are the use of high-fidelity patient simulation (HFS). The aim of the study was twofold. Firstly, the aim of this study was to describe the nursing students’ experiences while participating in HFS, and secondly to describe faculty teachers’ reflections about nursing students’ need in HFS and the related teaching challenges.METHOD: Data was collected in focus group discussions and individual interviews, analyzed using thematic qualitative content analysis.FINDINGS: The nursing students’ experienced HFS as being thrown into an uncertain, exposure situation. This were for some, reason for reluctance. The teachers challenge was motivating and coaching the students throughout a demanding teaching situation. DISCUSSION: Students’ ability to perform in HFS is influenced by self-perceived efficacy, own attitudes and responsibility for one’s learning, which are a challenge for the teachers.CONCLUSION: HFS methodology can be useful to identify gaps and strengths in students’ professional transition towards becoming registered nurses. Overcoming reluctance towards HFS is a mutual challenge for faculty teachers and nursing students. By entering the scenario with a positive mindset, nursing students can improve their ability to perform clinical judgments.

Learning to manage vasoactive drugs-A qualitative interview study with critical care nurses

OBJECTIVE

Being a nurse in an intensive care unit entails caring for seriously ill patients. Vasoactive drugs are one of the tools that are used to restore adequate circulation. Critical care nurses often manage and administer these potent drugs after medical advice from physicians.

AIM

To describe the experiences of critical care nurses learning to manage vasoactive drugs, and to highlight the competence required to manage vasoactive drugs.

RESEARCH METHODOLOGY/SETTING

Twelve critical care nurses from three hospitals in Sweden were interviewed. Qualitative content analysis was applied.

RESULTS

The theme "becoming proficient requires accuracy, practice and precaution" illustrated how critical care nurses learn to manage vasoactive drugs. Learning included developing cognitive, psychomotor, and effective skills. Sources for knowledge refers to specialist education combined with practical exercises, collegial support, and accessible routine documents. The competence required to manage vasoactive drugs encompassed well-developed safety thinking that included being careful, in control, and communicating failures. Specific skills were required such as titrating doses, being able to analyse and evaluate the technological assessments, adapting to the situation, and staying calm.

CONCLUSION

Learning to manage vasoactive drugs requires a supportive introduction for novices, collegial support, lifelong learning, and a culture of safety.

Svensk översättning, kvalitativ relevansvärdering och kvantitativ reliabilitetstestning av Lasater Clinical Judgment Rubric

Newly graduated nurses show lacking skills and competences regarding the ability to make appropriate clinical assessment of acute, complex care situations. There is also a lack of translated, qualitative relevance-evaluated and reliability-tested rubrics in the Swedish language. The purpose of this method article was to translate, and conduct a relevance evaluation and reliability test of the identified Lasater Clinical Judgment Rubric (LCJR). In this article, the Swedish translation LCJR (S) is presented. The results showed that the LCJR (S) was both qualitatively relevant and quantitatively reliable. We claim that there are several advantages to systematic use LCJR (S) for assessment of nursing students’ clinical judgement in laboratory simulation environments with acute patient situations.

Struggle with a gap between intensive care units and general wards

Nursing critically ill patients includes planning and performing safe discharges from Intensive Care Units (ICU) to the general wards. The aim of this study was to obtain a deeper understanding of the main concern in the ICU transitional process-the care before, during, and after the transfer of ICU patients. Interviews were conducted with 35 Swedish nurses and analysed according to grounded theory. The main concern was the nurses' "struggling with a gap." The "gap" was caused by differences in the altered level of care and contributed to difficulties for nurses encountering an overlap during the transitional care. The categories: sheltering, seeking organizational intertwining and striving for control are related to the core category and were used to generate a theory. The nurses sought improved collaboration, and employed patient-centred routines. They wanted access to necessary tools; they relayed or questioned their own competence and sought assurance of the patients' ability to be transferred. If the nurses felt a loss of control, lack of intertwining and lack of collaboration, they sheltered their patients and themselves. Intertwining was more difficult to perform, but actually even more important to do. With knowledge about ICU transitional care, collaboration, routines, and with an organization that provides an educational environment, the process could be improved.

A personal digital assistant application (MobilDent) for dental fieldwork data collection, information management and database handling

OBJECTIVE

To develop a personal digital assistant (PDA) application for oral health assessment fieldwork, including back-office and database systems (MobilDent).

DESIGN

System design, construction and implementation of PDA, back-office and database systems.

METHODS

System requirements for MobilDent were collected, analysed and translated into system functions. User interfaces were implemented and system architecture was outlined. MobilDent was based on a platform with. NET (Microsoft) components, using an SQL Server 2005 (Microsoft) for data storage with Windows Mobile (Microsoft) operating system. The PDA devices were Dell Axim.

RESULTS

System functions and user interfaces were specified for MobilDent. User interfaces for PDA, back-office and database systems were based on. NET programming. The PDA user interface was based on Windows suitable to a PDA display, whereas the back-office interface was designed for a normal-sized computer screen. A synchronisation module (MS Active Sync, Microsoft) was used to enable download of field data from PDA to the database.

CONCLUSIONS

MobilDent is a feasible application for oral health assessment fieldwork, and the oral health assessment database may prove a valuable source for care planning, educational and research purposes. Further development of the MobilDent system will include wireless connectivity with download-on-demand technology.

Intestinal pHi studied with continuous saline tonometry during ischaemia and reperfusion in the pig

OBJECTIVE

To evaluate continuous saline tonometry for detection of progressive intestinal ischaemia and reperfusion in a porcine model.

DESIGN

In eight anaesthetised pigs, small bowel mucosal pCO2 was recorded by means of two identical equipments for continuous saline tonometry and a standard tonometry balloon during ischaemia and reperfusion.

RESULTS

Both systems of saline tonometry functioned stably during the four hour protocol ischaemia, although not significant until after 45 min for one of the tonometers.

CONCLUSION

The equipment for continuous saline tonometry has a good reactivity, an accuracy comparable with standard tonometry.

Validation of a novel method for continuous saline tonometry in a porcine model

Only intermittent and semi-continuous tonometric measurement of gastric and intestinal pHi is possible with the equipment available today. Earlier we developed a system for continuous saline tonometry and tested it in vitro. To assess the in vivo reliability of this method for continuous gastrointestinal saline tonometry, a standard tonometer for measurement of intestinal pCO2 and corresponding pHi was modified to allow continuous perfusion of physiological saline in a closed system and tested in a porcine model. In 11 anaesthetized and haemodynamically stable pigs, two continuous tonometry balloons were inserted into the distal small bowel, and a standard tonometry balloon was used as reference. To test long-term function of the continuous tonometers the research protocol lasted for eight hours. The two continuous saline tonometers performed well, and after an equilibration time of three hours the mean pHi values were stable between 7.35 and 7.43 and between 7.32 and 7.39 respectively. The standard tonometer measured stable pHi values. These preliminary studies indicate that continuous saline tonometry performs well over eight hours with a small bias and a good precision.

GENEUS, a computer system for DNA and protein sequence analysis containing an information retrieval system for the EMBL data library

We describe a comprehensive computer system, GENEUS, for extensive DNA, RNA and protein sequence analysis. The analysis system is developed for the DEC VAX/VMS computer and uses the EMBL Nucleic Acid Sequence Data Library. Help information is available on-line on terminal screen. To speed up system handling, a qualifier oriented user communication is employed. All results are stored on files making them accessible to the computer editor. An information retrieval system for the EMBL Nucleotide Sequence Data Library is also described. A defined data-base interface allows connection to other analysis programs.+

Search algorithm for pattern match analysis of nucleic acid sequences

A new type of search algorithm to find biological information inherited in nucleic acid sequences was developed. The algorithm is of pattern match type and is based on the fact that genetic information often is a function of a predictable statistical occurrence of the four bases within parts of the sequence. The search algorithm compares the known statistical pattern of bases in e.g. a promoter, with an unknown sequence and calculates the statistical significance of the match at all positions in the unknown sequence. The program was tested on 54 published prokaryotic promoters. 44 or 49 could be found with 1 or 4 false answers, respectively. The program was also used on plasmid pBR322. All promoters functioning in an in vitro transcription system were found (tet, anti-tet, p4, bla and ori) except the so called p5 promoter. A search for donor and acceptor sites was performed in a human HLA genomic sequence that contains six introns. Five of the possible six donor and acceptor sites were found.