Transitional care model for older adults with multiple chronic conditions: An evaluation of benefits utilising an umbrella review.

AIMS: To synthesise and describe the combined evidence from systematic reviews of interventions using elements from the Transitional Care Model, on the content and timeframe of the interventions and the related improvement of outcomes for older patients with multiple chronic conditions. BACKGROUND: The population of older patients with multiple chronic conditions is increasing worldwide and trajectories are often complicated by risk factors. The Transitional Care Model may contain elements to support transitions between hospital and home. DESIGN: An umbrella review. REVIEW METHODS: A comprehensive search in five electronic databases was performed in April 2021 based on the search terms: 'Patients ≥60 years,' 'multi-morbidity,' 'Transitional care model,' 'Transitional care,' and 'Systematic review.' PRISMA guidelines was used. RESULTS: Five systematic reviews published from 2011 to 2020 comprising 62 intervention studies (59 randomised controlled trials and three quasi-experimental trials) were included in the review. The synthesis predominantly revealed significant improvements in decreasing re-admissions and financial costs and increasing patients' quality of life and satisfaction during discharge. CONCLUSION: The results of the review indicate that multiple elements from the Transitional Care Model have achieved significant improvements in older patients' transitions from hospital to home. Especially a combination of coordination, communication, collaboration and continuity of care in transitions, organised information and education for patients and pre-arranged structured post-discharge follow-ups. IMPACT: The transition from hospital to home is a complex process for older patients with multiple chronic conditions. A specific focus on coordination, continuity, and patient education should be implemented in the discharge process. Nurses with specialised knowledge in transitional care are needed to ensure safe transitions. PATIENT AND PUBLIC CONTRIBUTION: The umbrella review is part of a larger research program which involved a patient expert advisory board, which participated in discussing the relevance of the elements within the umbrella review.

Nordic nurses' areas of research during and related to the COVID-19 pandemic. A scoping review with recommendations for evidence-based practice.

BACKGROUND: The knowledge of the landscape of COVID-19 research performed by nurses in hospitals and health services is scarce. It is important to identify, map and share knowledge and thus provide a better understanding of the important research performed by nurses. AIMS: To provide a comprehensive overview of Nordic nurses' focus areas of research during and related to the COVID-19 pandemic and to extract knowledge on recommendations for future evidence-based practice. METHODS: The electronic databases of MEDLINE (via PubMed), CINAHL (via EBSCO) and Scopus (via Elsevier) were searched for studies describing all areas of nursing during and related to the COVID-19 pandemic conducted in the Nordic countries. Studies conducted by a nurse as the first or last author and published from March 2020 to March 2022 were included in the scoping review. The protocol for the review is registered at Open Science Framework (https://osf.io/f8kuq). RESULTS: Of 8412 studies found in the comprehensive search, 119 studies met the inclusion criteria. The studies were written by nurses from Denmark (42%), Sweden (31%), Norway (20%), Finland (6%) and Iceland (1%). The majority of studies (39%) covered patients' and relatives' experiences of visiting restrictions and social distancing and relatives' communications with healthcare professionals. Twenty-six per cent of included studies covered healthcare professionals' experiences of caring for patients infected with COVID-19, working during the pandemic and suffering from the consequences of both. LINKING EVIDENCE TO ACTION: The recommendations of evidence-based practice for future pandemics show that social distancing for disease prevention must be provided while considering the human consequences of social distancing. Special training is also recommended for healthcare professionals caring for COVID-19 patients accompanied by psychosocial support for their mental well-being. Additionally, virtual contact is an important supplement to personal treatment and face-to-face contact during social restrictions.

SHOULD I STAY OR SHOULD I GO-A rapid qualitative study of principal deteriorating factors experienced by nurses relating to their intentions to leave their current position in a medical hospital department.

BACKGROUND: High nurse turnover in hospitals is a worldwide problem with dire consequences for patient care such as increased mortality and a decrease in patient safety. A specific effort to retain nurses is urgently needed due to the many vacant nursing positions, especially across the Medical hospital departments. AIM: To identify the principal deteriorating factors experienced by nurses relating to their intentions to leave the medical department at a university hospital. METHODS: A rapid qualitative research methodology was used. Participants comprised 22 registered nurses employed in five university hospital medical department units. The Rigorous and Accelerated Data Reduction (RADaR) technique was therefore used for data collection through qualitative semi-structured interviews and analysis. COREQ was used for reporting the study. RESULTS: The RADaR analysis detected a downward spiral of five principal deteriorating factors influencing nurses' intentions to leave their position in the medical department. The factors were resignations from several nursing colleagues combined with too few and inexperienced nurses present during shifts, additional tasks assigned, a management refraining from improving the problematic issues, leading to decisive consequences for patient care and a declining feeling of professional care. CONCLUSIONS: The lack of nurses in the department caused missed nursing care, which affected the nurses' job satisfaction and intentions to leave their positions. Future research initiatives must focus on evaluating successful interventions to maintain the nurses in the positions. Further knowledge, is also needed, to investigate how we can change the downward spiral to a story of retention success.

Community nurse specialists' translation of newly learned knowledge in primary healthcare: A mixed methods study.

AIM: To investigate how graduates of a Nurse Specialist Education in Community and Primary Healthcare Nursing programme self-assess their competencies and possibilities to translate knowledge into practice. METHODS: A mixed methods design based on the triangulation convergence model was used. Thirty-four community nurse specialists, who had graduated from a Nurse Specialist Education in Community and Primary Healthcare Nursing programme, participated in a cross-sectional survey and of these; seven nurses participated in a semi-structured interview. Data from the survey were analysed using descriptive statistics and data from the interviews underwent a thematic analysis. All results were combined and compared according to the study design. FINDINGS: The combined comparison of the results from the survey and the findings from the interviews showed, how the community nurse specialists self-assessed their competencies in direct clinical practice, professional development, ethical decision-making, clinical leadership, cooperation and collaboration, and critical thinking as high. However, they experienced very few opportunities to translate their new knowledge in practice due to low alignment between the statutory purpose of the education and their own expectations. CONCLUSIONS: Competent clinical nurses working in community care settings who completed an education in advanced community care experienced few opportunities to use their new knowledge in practice. The community nurse specialists' expectations of how to use their new knowledge in practice after graduation does not align with the statutory order of the specialist education, which is directed towards combining direct and specialised patient care with coordination of care trajectories for the most fragile patients. It is important to include the managers in coordination of the community nurse specialists' usage of their new knowledge in practice.

Creating a practice-related culture for research: A qualitative study of engaging clinical nurses in utilization of developmental and research-based knowledge in hospital settings.

AIM: To describe academic nurses' experiences engaging clinical nurses in utilizing and implementing developmental and research-based knowledge in hospital settings. METHODS: This study used a descriptive qualitative design. Fourteen academic nurses at Masters or PhD level from three different regions of Denmark participated in the study, relating their successful experiences engaging clinical nurses in utilizing and implementing developmental and research-based knowledge. Data were collected in February 2020 through qualitative semi-structured interviews and analysed using a qualitative manifest content analysis. RESULTS: The main theme revealed was that academic nurses were 'Working towards creating a practice-related culture for research' to engage clinical nurses. This was supported by three subthemes: 'Focusing on evidence-based practice knowledge', 'Facilitating knowledge through a pedagogical approach' and 'Aiming for future changes'. CONCLUSIONS: The academic nurses experienced their engagement of clinical nurses and the subsequent change of practice in patient care and nurses' workflows in the department settings, as successful due to the academic nurses' pedagogical actions to educate clinical nurses and due to the academic nurses' practice-related approach to research and implementation.

Searching for a new normal-Hospital-employed researchers' experiences during the COVID-19 pandemic.

BACKGROUND: This study focuses on hospital-employed researchers, a relatively new staff group. Their job descriptions vary, which may lead to lack of clarity or preparedness regarding their roles and core tasks during a crisis such as COVID-19. AIM: The aim of this study was to explore hospital-employed healthcare researchers' experiences of work during the COVID-19 pandemic. DESIGN: A qualitative design based on Graneheim and Lundman's latent content analysis of two focus groups with researchers in clinical practice was chosen to explore researchers' experiences of work during the COVID-19 pandemic. METHODS: Fifteen hospital researchers participated in two focus groups, divided into predoctoral and postdoctoral researchers. Focus groups were conducted in May 2020 during the COVID-19 pandemic, using the voice over IP service, Skype®, due to risk of contagion. FINDINGS: 'Searching for a new normal during the COVID-19 pandemic' was the main theme during the latent content interpretation, with subthemes of (i) balancing calm and insecurity, (ii) negotiating core tasks and (iii) considering the future. CONCLUSION: The 15 researchers tried to balance calm and insecurity within work and family, on standby for the hospital's contingency plan, and in their research tasks. This led them to negotiate their core tasks and to reflect on the changes and consequences for their positions as researchers in clinical practice in the future.

The Importance of Context and Organization Culture in the Understanding of Nurses' Barriers Against Research Utilization: A Systematic Review.

BACKGROUND: Numerous studies have explored nurses' perceived barriers to research utilization. In this study, considerations of how to break down the barriers are discussed in order to find new ways to develop and strengthen evidence-based practice. AIMS: The objective of the study was to identify nurses' perceptions of barriers to research utilization in clinical practice between the years of 2000 and 2018 and across continents by reviewing studies that used the Barriers to Research Utilization (BARRIERS) scale (Appl Nurs Res, 4, 1991, 39). DESIGN: A systematic review of observational studies based on Joanna Briggs specific guidelines. METHODS: A systematic search to identify and select eligible studies was conducted in PubMed, CINAHL, PsycInfo, and SCOPUS during January 2019. Google Scholar was also searched to identify additional studies using the Funk et al. (Appl Nurs Res, 4, 1991, 39) BARRIERS scale. An instrument for quality appraisal was constructed for this paper by combining two similar and previously used cross-sectional study checklists (Int J Sociol Soc Policy, 23, 8, 2003; Implement Sci, 5, 32, 2010). Descriptive statistics were performed using IBM SPSS Statistics (version 25). RESULTS: The 27 included studies were conducted in 16 countries across five continents and 11,276 nurses participated. Seven of the top 10 barriers were comprised of organizational factors. These organizational barriers were consistent over time and the five continents, with 56% of the listed top 10 barriers falling under the organizational category. From the year 2000 to 2008, the majority of the studies were conducted in Europe and Australia. However, for the next 10 years (2008-2018), the majority of studies were conducted in Asia, Africa, and North America. LINKING EVIDENCE TO ACTION: To break down the nurses' barriers to research utilization, our future practice and research focus will be to conduct intervention studies focusing on the effect of facilitators and contextual environment, as well as developing nursing research cultures in clinical practice with support from the nursing management.

Leading unique cultures in departments with low turnover of nurses. A positive deviance approach study.

AIM: To investigate nurse leaders' experiences and strategies for turnover in relation to culture and work environment in hospital departments with low nurse turnover. BACKGROUND: Nursing shortage is a global problem, and numerous turnover strategies have been utilized to attempt to address this shortage. DESIGN/METHODS: Four regional hospital departments with the lowest nurse turnover were included. Data were constructed with nine nurse leaders through individual interviews and were analysed using directed content analysis. RESULTS: The findings presented in two categories, 'The culture is unique' and 'Maintaining, protecting or re-establishing a unique culture', summarize how leaders navigated authentically in different contexts, operationalizing clear values and visions both for their departmental culture and in turnover strategies. CONCLUSION: Even though all the nurse leaders interviewed were concerned about the current recruitment situation, they were confident in their leadership roles, targeted towards supporting the unique culture in their departments. IMPLICATIONS FOR NURSING MANAGEMENT: Leaders with clear cultural awareness and visions for the context in which they operate may be positively associated with lower turnover of nurses. Including the perspectives of leaders from departments with low turnover of nurses has the potential to create new knowledge about improving nurse retention.

Cancer patients' perceptions of factors influencing their decisions on participation in clinical drug trials: A qualitative meta-synthesis.

AIMS AND OBJECTIVES: To examine cancer patients' perceptions of factors that may influence their decisions on participating in phase I-III clinical drug trials. BACKGROUND: The number of cancer participants in clinical drug trials has increased rapidly in Denmark in recent years. The rights, safety and well-being of patients considering participation are protected by the international, ethical and scientific principles. A meta-synthesis was conducted to enable health professionals to support cancer patients who are considering trial participation in accordance with the above principles. DESIGN: Meta-synthesis. METHODS: A qualitative meta-synthesis, as described by Sandelowski and Barroso, was conducted based on a literature search in PubMed, CINAHL, EMBASE and PsycINFO. Nine reports were found eligible and were included. The PRISMA checklist was used. RESULTS: A framework was developed, and patients' perceptions of the factors influencing their decisions were identified, namely patients' perceptions of their relatives, the physician, the hope of therapeutic benefit, altruism, having other options and living with cancer. CONCLUSIONS: This study shows that cancer patients' decisions on participation in clinical drug trials are influenced by their perceptions of trust towards the physician, their relatives' attitudes and the consequences participation might have for their families. Patients are motivated to participate due to the hope of therapeutic benefit and for altruistic reasons. The factors influencing their decisions to participate include a cost-benefit consideration, which in turn may be subject to the patient's perception of having other options available besides participation. This may be related to the patient's attitude towards living with cancer, and the decision can be a way of trying to cope with the psychological aspects of living with cancer. RELEVANCE TO CLINICAL PRACTICE: The results of this meta-synthesis offer insight into patients' perceptions of what may influence their decisions, and they enable health professionals to support patients making such decisions.

Caught between a rock and a hard place: An intrinsic single case study of nurse researchers' experiences of the presence of a nursing research culture in clinical practice.

AIMS AND OBJECTIVES: To explore how nurse researchers in clinical positions experience the presence of a nursing research culture in clinical practice. BACKGROUND: Higher demands in the hospitals for increasing the quality of patient care engender a higher demand for the skills of health professionals and evidence-based practice. However, the utilisation of nursing research in clinical practice is still limited. DESIGN: Intrinsic single case study design underlined by a constructivist perspective. METHODS: Data were produced through a focus group interview with seven nurse researchers employed in clinical practice in two university hospitals in Zealand, Denmark, to capture the intrinsic aspects of the concept of nursing research culture in the context of clinical practice. A thematic analysis was conducted based on Braun and Clarke's theoretical guideline. RESULTS: "Caught between a rock and a hard place" was constructed as the main theme describing how nurse researchers in clinical positions experience the presence of a nursing research culture in clinical practice. The main theme was supported by three subthemes: Minimal academic tradition affects nursing research; Minimal recognition from physicians affects nursing research; and Moving towards a research culture. CONCLUSIONS: The nurse researchers in this study did not experience the presence of a nursing research culture in clinical practice, however; they called for more attention on removing barriers against research utilisation, promotion of applied research and interdisciplinary research collaboration, and passionate management support. RELEVANCE TO CLINICAL PRACTICE: The results of this case study show the pressure which nurse researchers employed in clinical practice are exposed to, and give examples on how to accommodate the further development of a nursing research culture in clinical practice.

The SICAM-trial: evaluating the effect of spouses' involvement through case management in older patients' fast-track programmes during and after total hip replacement.

AIM: The aim of this study was to evaluate the effect of spouses' involvement in older patients' care trajectories, using case management as intervention in total hip replacement through fast-track programmes. BACKGROUND: Patients need their spouses to be involved in their fast-track programmes and this involvement is often associated with improvements in patient outcomes. However, the effect of spouses' involvement in older patients' fast-track programmes has not yet been investigated. DESIGN: A two-group quasi-experimental design with pre-test and repeated post-test measures was conducted in an orthopaedic ward of a Danish Regional Hospital from February 2014-June 2015. Spouse-patient dyads were initially recruited for the control group (n = 14), receiving usual care; dyads for the intervention group (n = 15) were recruited afterwards, receiving case management intervention elements before, during and after admission. METHODS: Face-to-face interviews on questionnaires were conducted with spouses and patients at baseline, 2 weeks and 3 months after discharge, measuring spouses' caregiver satisfaction, difficulties and level of anxiety and patients' functional and nutritional status, pain and level of depression. RESULTS: The results showed that there were no differences between the groups with regard to any of the outcome measures. However, statistically significant improvements were found in the patient groups on functional status, pain and depression and in the groups of spouses on caregiver satisfaction. CONCLUSION: The case management intervention seemed to have an effect in patient and spousal groups; however, this improvement could also have been caused by the effect of fast-track treatment.

'Nursing research culture' in the context of clinical nursing practice: addressing a conceptual problem.

AIM: To report an analysis of the concept of nursing research culture in the context of clinical nursing practice. BACKGROUND: Nursing research culture should be valued for its contribution to improving patient care and should be considered as a routine hospital activity. However, the demand for efficiency, nurses' barriers to research use and the lack of definition of the concept of nursing research culture make it difficult to establish. DESIGN: Concept analysis. DATA SOURCES: Data were collected through a literature review in PubMed, CINAHL and PsycINFO during March 2016. METHODS: Walker and Avant's eight-step framework for concept analysis. RESULTS: Five defining attributes of nursing research culture in the context of clinical nursing practice were identified: strong monodisciplinary nursing professionalism, academic thinking and socialization, research use as a part of daily nursing practice, acceptance by colleagues and management and facilitation of resources from management and organization. CONCLUSION: Although the method of concept analysis has been criticized and heavily debated, the development of nursing research cultures based on the defining attributes and antecedents of the concept will be important to emphasize evidence-based clinical nursing care. Further research should support the development and the implementation of nursing research culture in clinical nursing practice.

Systematic review describing the effect of early mobilisation after dysvascular major lower limb amputations.

AIMS AND OBJECTIVES: To assess the effect of early mobilisation of patients after dysvascular lower limb amputation and to compare the effectiveness of different mobilisation regimens. BACKGROUND: Patients who have undergone dysvascular major lower limb amputations are at high risk of postoperative complications, which include loss of basic functions, and early mobilisation interventions might prevent these complications. DESIGN: Systematic review. METHODS: Systematic searches were performed on PubMed (including MEDLINE), CINAHL and EMBASE databases to identify studies investigating the effects of (early) mobilisation interventions in dysvascular lower limb-amputated patients. Data collection and quality assessment were performed using the Cochrane Effective Practice and Organization of Care Review Group data collection checklist and the Cochrane Handbook for Systematic Reviews of Interventions, respectively. RESULTS: Five studies were included in the review: four pre- to post-case studies and one randomised controlled study. However, none of these studies were of high quality. Four studies investigated early mobilisation promoted by immediate postoperative prosthesis. One study investigated whether reorganizing care increases mobilisation and thereby functional outcome. CONCLUSIONS: This systematic review reveals a lack of evidence to determine whether early mobilisation interventions are beneficial to this vulnerable patient group. Nevertheless, ambulation from the first postoperative day with temporary prosthesis is possible among the heterogeneous population of dysvascular lower limb-amputated patients if the necessary interdisciplinary team is dedicated to the task. RELEVANCE TO CLINICAL PRACTICE: Mobilisation is a fundamental care task often missed for several reasons. Moreover, mobilisation of the newly amputated patient is complex, and knowledge of effective strategies to promote postoperative mobilisation in this vulnerable population is desired. Nurses are urged to take responsibility for this fundamental care task and to engage the necessary collaborative interdisciplinary team to develop, implement and evaluate ambitious early mobilisation interventions.

A discussion of differences in preparation, performance and postreflections in participant observations within two grounded theory approaches.

This paper presents a discussion of the differences in using participant observation as a data collection method by comparing the classic grounded theory methodology of Barney Glaser with the constructivist grounded theory methodology by Kathy Charmaz. Participant observations allow nursing researchers to experience activities and interactions directly in situ. However, using participant observations as a data collection method can be done in many ways, depending on the chosen grounded theory methodology, and may produce different results. This discussion shows that how the differences between using participant observations in classic and constructivist grounded theory can be considerable and that grounded theory researchers should adhere to the method descriptions of performing participant observations according to the selected grounded theory methodology to enhance the quality of research.

An evaluation of orthopaedic nurses' participation in an educational intervention promoting research usage--a triangulation convergence model.

AIMS AND OBJECTIVES: To describe the orthopaedic nurses' experiences regarding the relevance of an educational intervention and their personal and contextual barriers to participation in the intervention. BACKGROUND: One of the largest barriers against nurses' research usage in clinical practice is the lack of participation. A previous survey identified 32 orthopaedic nurses as interested in participating in nursing research. An educational intervention was conducted to increase the orthopaedic nurses' research knowledge and competencies. However, only an average of six nurses participated. DESIGN: A triangulation convergence model was applied through a mixed methods design to combine quantitative results and qualitative findings for evaluation. METHODS: Data were collected from 2013-2014 from 32 orthopaedic nurses in a Danish regional hospital through a newly developed 21-item questionnaire and two focus group sessions. Data were first analysed using descriptive statistics (stata 12.0) and qualitative manifest content analysis. Second, the results were compared, contrasted and interpreted using international literature. RESULTS: The nurses experienced the intervention as a new way to focus on nursing research in practice. However, some nurses were not able to see the relevance of research usage in clinical practice. Nursing research was not a top priority for the nurses and their personal barriers for research usage during their working day were prioritising patients' and colleagues' well-being. Their colleagues' and head section nurses' lack of acceptance regarding participation in the teaching session was a contextual barrier for the nurses. CONCLUSION: The nurses were interested in participating in the intervention. However, some felt restricted by the research-practice gap and by diverse personal and contextual barriers. RELEVANCE TO CLINICAL PRACTICE: The knowledge derived from this study has high clinical and practical relevance and is currently used to facilitate the nurses' research usage in the orthopaedic department setting, by working around the perceived barriers.

Integrating nurse researchers in clinical practice - a challenging, but necessary task for nurse leaders.

AIM: To create awareness among nurse leaders, of what they may need to consider, when integrating nurse researchers as advanced nurse practitioners (ANP) at PhD-level among their staff. BACKGROUND: In a time of transition nurse leaders may be challenged by the change towards evidence-based clinical nursing, including integrating nurse researchers in ANP positions. METHODS: A collective case study including three ANPs took place at a large regional hospital in Denmark. The cases were first analysed by focusing on the generic features, functions and skills of ANPs, and second by focusing on the approaches to evidence-based practice seen in the cases. RESULTS: Regardless of same position, formal level of research expertise and overall responsibility, different approaches related to each ANPs professional profile, interest, academic ambitions and personality were seen. CONCLUSION: Nurse leaders must ensure a process where the content and expectations of the particular role are mutually clarified and adjusted to the individual ANP and to the specific context, in order to create a harmonious match. IMPLICATIONS FOR NURSING MANAGEMENT: In order to clarify expectations regarding the inclusion of nurse researchers as ANPs at PhD level, the paper provides firm recommendations that may guide the process.

Spouses' involvement in older patients' fast-track programmes during total hip replacement using case management intervention. A study protocol of the SICAM-trial.

AIM: To present the protocol of a two-group quasi-experimental study of spouses' involvement through case management (The SICAM-trial) in older patients' fast-track programmes during total hip replacement. BACKGROUND: Patients in fast-track programmes are required to take an active part in their treatment and rehabilitation. Spouses of older patients can often provide valued practical and emotional support, reducing stress, pain and length of stay - yet they are seldom invited to participate in a supporting role. DESIGN: A two-group quasi-experimental design with pre-test and repeated post-test measures (protocol approved in November 2012). METHODS: A total of 120 patients aged 65 years or older going through a fast-track programme for a total hip replacement and their spouses will be recruited from one Danish orthopaedic ward. We will initially include the control group for data collection and subsequently include the intervention group to avoid contamination of the control group. A case manager will be recruited to perform the case management intervention. Data will be collected from both groups at baseline, 2 weeks and 3 months after surgery. Outcome measures for patients include: functional status, nutrition, pain, depression and healthcare consumptions; and for spouses: caregiver satisfaction and difficulties and anxiety. CONCLUSION: The intervention will give further evidence on the need for relatives' participation in the patients' fast-track programmes and the results will contribute to education of the health professionals in their need to include relatives in fast-track programmes. The study was funded by the Novo Nordisk Foundation and the Regional Health Scientific Foundation of Sealand.

Maintaining Unity - relatives in older patients' fast-track treatment programmes. A grounded theory study.

AIM: To generate a substantive grounded theory of relatives' pattern of behaviour in older patients' fast-track treatment programmes during total hip or knee replacement. BACKGROUND: Fast-track treatment programmes are designed to make total hip and knee replacements more efficient through recovery improvements. The support of relatives during older patients' trajectory is important. However, knowledge is needed on the relatives' pattern of behaviour to strengthen their involvement in fast-track treatment programmes. DESIGN: We used a Glaserian grounded theory approach based on a systematic generation of theory from data to explain the latent pattern of behaviour of relatives. METHODS: Data were collected from 2010-2011 in orthopaedic wards at two Danish university hospitals and consisted of 14 non-participant observations, 14 postobservational interviews and five interviews. Seven relatives of patients over 70 years of age participated. The constant comparative method was the guiding principle for simultaneous data collection, data analysis and coding, while theoretically sampling and writing memos. FINDINGS: Maintaining Unity emerged as the relatives' pattern of behaviour through which they resolved their main concern: preventing the patients from feeling alone. The relatives resolved their main concern through three interchangeable behavioural modes: Protecting Mode, by providing loving and respectful support; Substituting Mode, with practical and cognitive support; and an Adapting Mode, by trying to fit in with the patients' and health professionals' requirements. CONCLUSION: The substantive theory of Maintaining Unity offers knowledge of relatives' strong desire to provide compassionate and loving support for the older patients during fast-track treatment programmes.

Inhibiting Interference--a grounded theory of health professionals' pattern of behaviour related to the relatives of older patients in fast-track treatment programmes.

AIM: To generate a grounded theory explaining health professionals' pattern of behaviour and experience related to the relatives of older patients in fast-track treatment programmes during total joint replacement. BACKGROUND: Health professionals uphold standardised care for patients, and effect on quality is seen when relatives support patients during total joint replacement. Since health professionals often have problematic relationships with relatives, knowledge is needed of the health professionals' pattern of behaviour in relation to relatives of older patients in fast-track treatment programme. DESIGN: Grounded theory according to Glaser's methodology was used to generate substantive theory of health professionals' pattern of behaviour. METHODS: Data were collected from 2010 to 2011 by 44 health professionals in orthopaedic wards at two Danish hospitals. Data from nonparticipant observations, formal interviews, group interviews, informal interviews and written information material were collected, coded and analysed through the constant comparative method. FINDINGS: Inhibiting Interference emerged as health professionals' pattern of behaviour through which they resolved their main concern, striving for maintenance of the fast-track treatment programme and principles. Their main concern was resolved by a main strategy: Focusing on Principles, by striving for patients' full compliance during the trajectory, followed by two strategies of social control: Accepting Compliant Motivators, by involving well-informed relatives, and Avoiding Disobedient Doubters, by excluding relatives who do not comply with programme principles. CONCLUSION: In the health professionals' strive to maintain programme principles, relatives were perceived as interferences, if noncompliant with trajectory rules, resulting in exclusion with consequences for their potential of being resources for patients.

Opting out of cardiac rehabilitation in local community healthcare services: Patients' perspectives and reflections.

RATIONALE: Despite cardiac rehabilitation and medical treatment being integrated parts of the pathway of patients with cardiovascular disease, as well as the well-establish positive effect, cardiac rehabilitation remains underutilised. In recent years, cardiac rehabilitation has increasingly been moved from the hospitals to the community healthcare services. This transition may be challenging for patients with cardiovascular disease. AIM: To investigate reflections and perspectives of patients opting out of cardiac rehabilitation in community healthcare services to improve participation and adherence to cardiac rehabilitation in the future. RESULTS: A total of eight patients opting out of cardiac rehabilitation participated in individual interviews. Opting out of cardiac rehabilitation is defined as never enroled or did not complete cardiac rehabilitation. The Interpretive Description methodology was used in the analysis where two themes and six subthemes were identified: (1) 'Structural and organisational factors' with three subthemes; Being a patient in the healthcare system, Enroling into CR when it is meaningful, and Getting back to work is vital, and (2) 'Patients' internal factors' with three subthemes; Feeling a desire to regain control, Seeing yourself as recovered, and Being aware of own needs. The analysis indicates that patients' decision to opt out of CR was multidimensional and based on a combination of factors. CONCLUSION: Ensuring that the healthcare professionals in the community have sufficient information regarding the patient and a clear communication plan between the healthcare professionals and the patient may reduce the transition causing confusion and frustrations for patients. Incorporating a vocational element in CR and ensuring that employers understand the importance of CR may hamper returning to work as a challenge to CR. Ensuring timely CR referral and enrolment and a transition coordinator may reduce the challenge of patients not viewing CR as meaningful. However, further studies are needed to fully understand how CR could become meaningful for patients opting out of CR.