Evaluating a targeted person-centred pain management intervention programme in lumbar spine surgery - a controlled segment-specific before-and-after interventional design.

BACKGROUND: Postoperative pain management in lumbar spine surgery care remains a challenge. The aim of this study was to evaluate the impact of a person-centred postoperative pain management intervention programme on lumbar spine surgery patients on postoperative pain, shared decision-making, and satisfaction with postoperative pain management. METHODS: The study was performed with a controlled before-and-after interventional design in an orthopaedic unit at a university hospital. Person-centred pain management for patients undergoing spine surgery was developed in co-creation by a multi-professional team and implemented throughout the care pathway. The usual care group (pre-intervention) served as a comparison to the intervention group. Pain intensity, shared decision-making in pain management, and patient satisfaction with results of pain management, served as patient-reported measures, collected using the International Pain Outcomes questionnaire and analysed using descriptive statistics. RESULTS: The intervention showed no benefit for patients' pain and satisfaction, while shared decision-making in pain management was significant lower in the intervention group than in the conventional group. The per-protocol analysis showed no significant differences between groups. CONCLUSION: The initial assumption of the study, that the implementation of a co-created structured person-centred care pathway would improve patient-reported outcomes, was not confirmed. The periodically low fidelity to the intervention due to organizational constraints (due to sub-optimal organizational conditions and managerial support) may have affected the results.

Patient-Centerdness in the Perioperative Period-A Rapid Review of Current Research.

PURPOSE: The indication of surgery is a critical moment in a person's life implying different needs, feelings, or fears. The aim of the current literature review was to elucidate the prevailing utilization of the concepts 'patient-centerdness' and 'person-centerdness' within the perioperative period. DESIGN: A rapid review design. METHODS: Literature searches were conducted in the databases PubMed, Scopus (Elsevier), American Psychological Association PsychInfo (Ovid), Embase (Ovid), CINAHL (Ovid), and Cochrane Library in December 2022. Rayyan software was used to assess the articles. Joanna Briggs Institute critical appraisal tools were used to evaluate the quality of the included articles. Thematic analysis was used to identify themes across the articles. FINDINGS: The electronic database searches identified 1,967 articles. A total of 12 articles were assessed in full text against the inclusion and exclusion criteria, and finally, a total of seven articles were included. The articles originated from six countries, employed disparate methodological approaches, and featured a heterogeneous array of participants representing various health care settings. Patient-centerdness held the mantle as the most prominently used concept across the seven articles, whereas person-centerdness emerged as the least frequently explored concept. One theme was identified across the articles; Preparedness. This was related to shared decision-making and information pre, peri- and postoperative. CONCLUSIONS: This rapid review suggests that patient preparedness, particularly through shared decision-making and providing information, is a recurring theme in the limited studies on patient- or person-centerdness in the perioperative context. The fact that only one single study focuses on person-centered care underscores the pressing need for a comprehensive re-evaluation of modern perioperative care.

Using nudges to promote clinical decision making of healthcare professionals: A scoping review.

Nudging has been discussed in the context of policy and public health, but not so much within healthcare. This scoping review aimed to assess the empirical evidence on how nudging techniques can be used to affect the behavior of healthcare professionals (HCPs) in clinical settings. A systematic database search was conducted for the period January 2010-December 2020 using the PRISMA extension for Scoping Review checklist. Two reviewers independently screened each article for inclusion. Included articles were reviewed to extract key information about each intervention, including purpose, target behavior, measured outcomes, key findings, nudging strategies, intervention objectives and their theoretical underpinnings. Two independent dimensions, building on Kahneman's System 1 and System 2, were used to describe nudging strategies according to user action and timing of their implementation. Of the included 51 articles, 40 reported statistically significant results, six were not significant and two reported mixed results. Thirteen different nudging strategies were identified aimed at modifying four types of HPCs' behavior: prescriptions and orders, procedure, hand hygiene, and vaccination. The most common nudging strategy employed were defaults or pre-orders, followed by alerts or reminders, and active choice. Many interventions did not require any deliberate action from users, here termed passive interventions, such as automatically changing prescriptions to their generic equivalent unless indicated by the user. Passive nudges may be successful in changing the target outcome but may go unnoticed by the user. Future work should consider the broader ethical implications of passive nudges.

Total opioid-free general anaesthesia can improve postoperative outcomes after surgery, without evidence of adverse effects on patient safety and pain management: A systematic review and meta-analysis.

BACKGROUND: Opioid-based treatment is used to manage stress responses during surgery and postoperative pain. However, opioids have both acute and long-term side effects, calling for opioid-free anaesthetic strategies. This meta-analysis compares adverse events, postoperative recovery, discharge time from post-anaesthesia care unit, and postoperative pain, nausea, vomiting, and opioid consumption between strict opioid-free and opioid-based general anaesthesia. METHODS: We conducted a systematic review and meta-analysis. We searched PubMed, Embase, Cinahl, Cochrane Library, selected reference lists, and Google Scholar. We included randomised controlled trials (RCTs) published between January 2000 and February 2021 with at least one opioid-free study arm, i.e. no opioids administered preoperatively, during anaesthesia induction, before skin closure, or before emergence from anaesthesia. RESULTS: The study comprised 1934 patients from 26 RCTs. Common interventions included laparoscopic gynaecological surgery, upper gastrointestinal surgery, and breast surgery. There is firm evidence that opioid-free anaesthesia significantly reduced adverse postoperative events (OR 0.32, 95% CI 0.22 to 0.46, I2  = 56%, p < 0.00001), mainly driven by decreased nausea (OR 0.27, (0.17 to 0.42), p < 0.00001) and vomiting (OR 0.22 (0.11 to 0.41), p < 0.00001). Postoperative opioid consumption was significantly lower in the opioid-free group (-6.00 mg (-8.52 to -3.48), p < 0.00001). There was no significant difference in length of post-anaesthesia care unit stay and overall postoperative pain between groups. CONCLUSIONS: Opioid-free anaesthesia can improve postoperative outcomes in several surgical settings without evidence of adverse effects on patient safety and pain management. There is a need for more evidence-based non-opioid anaesthetic protocols for different types of surgery as well as postoperative phases.

Comparison of two different intratympanic corticosteroid injection protocols as salvage treatments for idiopathic sudden sensorineural hearing loss.

PURPOSE: We aimed to investigate the effect of interval length and total count of intratympanic steroid (ITS) injections in salvage treatment of patients with idiopathic sudden sensorineural hearing loss (ISSNHL). METHODS: This retrospective case-control study included 64 patients with ISSNHL, who were treated with ITS injections as salvage therapy at a tertiary referral centre. From September 2019 to December 2020, 32 patients received up to four injections every 2-4 days (revised-protocol group). These patients were 1:1 matched to patients, who received up to three injections at 1-week intervals between January 2014 and August 2019 (initial-protocol group). Hearing outcomes of the two groups were compared. RESULTS: Both ITS salvage treatment protocols resulted in a statistically significant hearing improvement (p < 0.05). The initial-protocol declined hearing thresholds by 12 ± 11.7 dB (p < 0.001, d = 1, P = 99%). Mean hearing function was improved by 13.4 ± 19.1 dB in the revised-protocol group [p < 0.001, d = 0.7, P = 98%]. A clinically significant hearing improvement (> 10 dB) was seen in 18 patients (58.1%) in the initial-protocol group and in 14 patients (41.9%) in the revised-protocol group. A comparison of the hearing outcomes between protocol groups revealed no statistically significant differences (p > 0.05). CONCLUSION: These results indicate that a shorter injection interval does not lead to better hearing outcomes in ITS salvage treatment for ISSNHL. Moreover, fewer ITS injections may reduce costs, physical/mental stress of the patients and lower the risk of persistent tympanic perforations.

Preservation of nasal turbinates in endoscopic, anterior skull base surgery-yes, we can!

OBJECTIVE: To evaluate the frequency, type and indications of nasal turbinate (NT) resection during endoscopic, anterior skull base surgery and to analyze factors that may have an impact on the need of NT removal. METHODS: In this retrospective cohort study, 306 subjects (150 males and 156 females, mean age 55.4 ± 15.3 years) who underwent multidisciplinary, transnasal, endoscopic tumor surgery of the anterior skull base using 4-handed techniques between 2011 and 2019 at the Department of Otorhinolaryngology, Medical University of Graz, were included. RESULTS: In the majority of interventions (n = 281/306; 91.8%), all NT were preserved. Significant factors influencing the need of NT resections turned out to be type of endoscopic approach (p < 0.001; V = 0.304), sagittal (p = 0.003; d = 0.481) and transversal (p = 0.017; d = 0.533) tumor diameter, tumor type (p < 0.001; V = 0.355) and tumor location (p < 0.001; V = 0.324). CONCLUSIONS: NT can be preserved in the majority of patients undergoing tumor resection in anterior, transnasal, skullbase surgery and routine resection of NT should be avoided. Variables that have an impact on the need of NT resections are types of endoscopic approaches, sagittal and transversal tumor extension and tumor type. These factors should be considered in planning of surgery and preoperative information of patients.

Distinct Chemokine Receptor Expression Profiles in De Novo DLBCL, Transformed Follicular Lymphoma, Richter's Trans-Formed DLBCL and Germinal Center B-Cells.

Chemokine receptors and their ligands have been identified as playing an important role in the development of diffuse large B-cell lymphoma (DLBCL), follicular lymphoma, and Richter syndrome (RS). Our aim was to investigate the different expression profiles in de novo DLBCL, transformed follicular lymphoma (tFL), and RS. Here, we profiled the mRNA expression levels of 18 chemokine receptors (CCR1-CCR9, CXCR1-CXCR7, CX3CR1 and XCR1) using RQ-PCR, as well as immunohistochemistry of seven chemokine receptors (CCR1, CCR4-CCR8 and CXCR2) in RS, de novo DLBCL, and tFL biopsy-derived tissues. Tonsil-derived germinal center B-cells (GC-B) served as non-neoplastic controls. The chemokine receptor expression profiles of de novo DLBCL and tFL substantially differed from those of GC-B, with at least 5-fold higher expression of 15 out of the 18 investigated chemokine receptors (CCR1-CCR9, CXCR1, CXCR2, CXCR6, CXCR7, CX3CR1 and XCR1) in these lymphoma subtypes. Interestingly, the de novo DLBCL and tFL exhibited at least 22-fold higher expression of CCR1, CCR5, CCR8, and CXCR6 compared with RS, whereas no significant difference in chemokine receptor expression profile was detected when comparing de novo DLBCL with tFL. Furthermore, in de novo DLBCL and tFLs, a high expression of CCR7 was associated with a poor overall survival in our study cohort, as well as in an independent patient cohort. Our data indicate that the chemokine receptor expression profile of RS differs substantially from that of de novo DLBCL and tFL. Thus, these multiple dysregulated chemokine receptors could represent novel clinical markers as diagnostic and prognostic tools. Moreover, this study highlights the relevance of chemokine signaling crosstalk in the tumor microenvironment of aggressive lymphomas.

Older adults' provision of informal care and support to their peers - A cornerstone of swedish society: Demographic characteristics and experiences of social isolation.

BACKGROUND: Family members provide the majority of informal care for older adults in Sweden. Nevertheless, by providing a range of assistance, peers often emerge as a central to counter social isolation among older adults. Therefore, there is a need to know more about what informal care provision by older adults to their peers means for different groups of older adults. AIM: This study investigated the types of informal care and support that older adults provide to their peers in Sweden, and how these types of care and support are associated with demographic characteristics and social isolation. We also compared older adults who provide informal care and support with those who do not. METHOD: For this purpose, we used a national online survey named "Involuntary loneliness among senior citizens" answered by 10,044 older adults enrolled in the Swedish Citizen Panel. We adopted a mixed-method design to analyse the survey data, including free-text options (n = 2155) and numerical data. Social isolation was assessed using a score built from the social loneliness items of the UCLA Loneliness Scale. RESULTS: In our population, 21.5% of the older adults were providing informal care and support to their peers. Practical/instrumental help was frequently offered by younger participants (<75 years), men and respondents who were less socially isolated. On a general level, the factors that were positively associated with giving informal care and support to peers were older age, being male, retired, married/living in a relationship, living in an urban area/big city and exhibiting greater isolation. Focusing specifically on social support shows that older participants (>80) and those experiencing less social isolation (score < 24) were more engaged in social activities.  CONCLUSION: This paper is unique in exploring the informal peer-caregiver's perceptions of isolation. Data were collected during the COVID-19 pandemic; this highlights the need to recognise informal care and support between older adults and to acknowledge their contributions as an essential component of Swedish civil society, especially during a societal crisis.

Attitudes towards oldest-old adults (age ≥80 years): A survey and international comparison between Swedish and Austrian nursing students.

BACKGROUND AND RATIONALE: Ageism in nursing, particularly regarding oldest-old adults (age ≥80 years), adversely affects patient safety and care quality. Nurse education can reduce ageist attitudes. Swedish and Austrian nursing students' attitudes towards adults age ≥80 years have not been assessed. AIMS: To analyse attitudes towards adults age ≥80 years among nursing students from universities in Sweden and Austria. DESIGN: A prospective cross-sectional survey including the four-factor, 26-item validated Ageing Semantic Differential scale and demographic questions. METHODS: A pen-and-paper survey was administered to nursing students at the Medical University of Graz, Austria (May-June 2019); an online survey was conducted at the University of Gothenburg, Sweden (January-June 2020). Demographic data were analysed descriptively; means and individual item ratings were calculated for each country. Multiple logistic regression was performed for each factor of the instrument: (1) Instrumentality, (2) Autonomy, (3) Acceptability and (4) Integrity. Six independent variables were included in the regression analysis. RESULTS: In total, 136 Austrian and 222 Swedish students responded (88% women). Compared with Austrian students, Swedish students were older and had more positive attitudes about oldest-old adults. Swedish students' median factor ratings (7-point scale) were 3.62 (Factor 1), 3.50 (Factor 2), 2.71 (Factor 3) and 3.80 (Factor 4). Austrian students' median ratings were 4.25 (Factor 1), 3.83 (Factor 2), 3.28 (Factor 3) and 4.00 (Factor 4). Regression analyses showed that the variables country, older family member/acquaintance, and age were associated with the different factors. DISCUSSION: Compared with Austrian students, Swedish students' attitudes towards oldest-old adults were more favourable. We discussed the findings at individual, interpersonal/intergroup and societal/cultural levels and present implications for education and research. CONCLUSIONS: Nurse education should address ageism as a multilevel phenomenon, and include the person-centred care perspective. Further research comparing nursing students' attitudes from different cultures is needed.

Intratympanic Triamcinolone Acetonide as a Salvage Treatment for Idiopathic Sudden Sensorineural Hearing Loss.

INTRODUCTION: Intratympanic steroid (ITS) injections represent an increasingly used salvage treatment option for patients with idiopathic sudden sensorineural hearing loss -(ISSHL) after systemic treatment. The most effective corticosteroid for this treatment modality still remains unclear. Triamcinolone acetonide has been used for ITS treatment in various clinical settings. However, there are limited clinical data of its usage in the therapeutic management of ISSHL. The aim of this study was to determine the efficacy of intratympanic triamcinolone acetonide injections as a salvage treatment for ISSHL. METHODS: We conducted a retrospective chart review on patients affected by ISSHL with insufficient hearing recovery after primary systemic corticosteroid therapy and who were treated with intratympanic triamcinolone acetonide as a salvage therapy between January 2014 and August 2019. The patients were divided into groups according to their degree of hearing recovery, and we evaluated potential predictors of hearing recovery. Audiometric results were then compared to historic studies using dexamethasone or methylprednisolone. RESULTS: One-hundred and fifty-two patients received up to 3 intratympanic injections with triamcinolone acetonide at 1-week intervals. The mean hearing improvement due to ITS salvage treatment was 15.9 ± 18.9 dB. Complete hearing recovery was noted in 15 patients (9.9%), while 73 patients (48%) obtained partial recovery, and 64 patients (42.1%) had no recovery. Primary systemic treatment delay, hearing improvement by primary systemic treatment, and severity of initial hearing loss were identified as significant predictors of hearing improvement. The first of the 3 injections resulted in the greatest hearing improvement. CONCLUSION: The use of triamcinolone acetonide in ITS salvage treatment resulted in similar hearing improvements as the use of the commonly used corticosteroids, namely, dexamethasone and methylprednisolone. Longer treatment delays, lower hearing improvement by primary systemic treatment, and higher initial hearing loss are associated with poorer prognoses of hearing recovery.

"Care is not care if it isn't person-centred": A content analysis of how Person-Centred Care is expressed on Twitter.

BACKGROUND: Person-Centred Care (PCC) has been the subject of growing interest in recent decades. Even though there is no conceptual consensus regarding PCC, many health-care institutions have implemented elements into their care. OBJECTIVE: This study aimed to investigate the PCC topics presented by different stakeholder groups on Twitter and to explore the perceptions of PCC within the content of the tweets. METHOD: Tweets with mentions of PCC in various translations were collected through a Twitter Application Programming Interface in October 2019. The tweets were analysed using quantitative and qualitative content analysis. RESULTS: Five stakeholder groups and ten topics were identified within 1540 tweets. The results showed that the PCC content focused on providing information and opinions rather than expressing experiences of PCC in practice. Qualitative content analysis of 428 selected tweets revealed content on a vision that all care should be person-centred but that the realization of that vision was more complicated. CONCLUSIONS: Twitter has shown to be a quick and non-intrusive data collection tool for uncovering stakeholders' expressions concerning PCC. The PCC content revealed that stakeholders feel a need to 'educate' others about their perception of PCC when experiences and real-life applications are missing. More action should be taken for the implementation of PCC rather than circulating PCC vision without operationalization in care. PUBLIC CONTRIBUTION: The public provided the data through their posts on Twitter, and it is their perception of PCC that is studied here.

Nudging healthcare professionals in clinical settings: a scoping review of the literature.

BACKGROUND: Healthcare organisations are in constant need of improvement and change. Nudging has been proposed as a strategy to affect people's choices and has been used to affect patients' behaviour in healthcare settings. However, little is known about how nudging is being interpreted and applied to change the behaviour of healthcare professionals (HCPs). The objective of this review is to identify interventions using nudge theory to affect the behaviour of HCPs in clinical settings. METHODS: A scoping review. We searched PubMed and PsycINFO for articles published from 2010 to September 2019, including terms related to "nudging" in the title or abstract. Two reviewers screened articles for inclusion based on whether the articles described an intervention to change the behaviour of HCPs. Two reviewers extracted key information and categorized included articles. Descriptive analyses were performed on the data. RESULTS: Search results yielded 997 unique articles, of which 25 articles satisfied the inclusion criteria. Five additional articles were selected from the reference lists of the included articles. We identified 11 nudging strategies: accountable justification, goal setting, suggested alternatives, feedback, information transparency, peer comparison, active choice, alerts and reminders, environmental cueing/priming, defaults/pre-orders, and education. These strategies were employed to affect the following 4 target behaviours: vaccination of staff, hand hygiene, clinical procedures, prescriptions and orders. To compare approaches across so many areas, we introduced two independent dimensions to describe nudging strategies: synchronous/asynchronous, and active/passive. CONCLUSION: There are relatively few studies published referring to nudge theory aimed at changing HCP behaviour in clinical settings. These studies reflect a diverse set of objectives and implement nudging strategies in a variety of ways. We suggest distinguishing active from passive nudging strategies. Passive nudging strategies may achieve the desired outcome but go unnoticed by the clinician thereby not really changing a behaviour and raising ethical concerns. Our review indicates that there are successful active strategies that engage with clinicians in a more deliberate way. However, more research is needed on how different nudging strategies impact HCP behaviour in the short and long term to improve clinical decision making.

The impact of implementing a person-centred pain management intervention on resistance to change and organizational culture.

BACKGROUND: Resistance to change and organizational culture are essential factors to consider in change management in health care settings. Implementation of structural change remains a challenge. There is a lack of studies providing information on the impact of implementation processes on the organization. The aim of this study was to describe the impact of implementing a systematic change process concerning postoperative person-centred pain management on resistance to change and organizational culture in an orthopaedic spine surgery unit. METHODS: The study was set in an orthopaedic spine surgery unit at a university hospital. Person-centred bundles of care for postoperative pain management of spine surgery patients were developed in co-creation by a multi-professional expert group and implemented throughout the care pathway. The intervention was underpinned by theories on organizational culture and inspired by principles of person-centred care. Quantitative data were collected using the Resistance to Change Scale and the Organizational Culture Assessment Instrument and analysed using descriptive statistics. RESULTS: The findings showed a low resistance to change decreasing during the study. The organizational culture shifted from a result-oriented to a formalized and structured culture after the implementation. The culture preferred by the staff was team-oriented and participation-focused throughout the study. The discrepancy between the current and preferred cultures remained extensive over time. CONCLUSION: It is challenging to describe the influence of the development and implementation of a postoperative pain management program on organizational culture as well as in terms of resistance to change, in a complex health care setting. In the current study the unit was under organizational strain during the implementation. Albeit, the important discrepancy between the current and preferred organizational culture could imply that structural changes aren't enough when implementing person-centred pain management structures and needs to be combined with relational aspects of change.

Epistemic injustices in clinical communication: the example of narrative elicitation in person-centred care.

The increasing popularity of the term 'person-centred' in the healthcare literature and a wide range of ideals and practices it implies point to the need for a more inclusive and holistic healthcare provision. A framework developed in a Swedish context suggested narrative elicitation as a key practice in transition to person-centred care. Initiating clinical communication by inviting people to tell their stories makes persistent yet often subtle problems in clinical communication visible. By drawing upon an observational study on narrative elicitation and vignette-based focus group interviews with nurses, our aim is to trace 'credibility deficits' (Fricker 2007. Epistemic Injustice. Power and the Ethics of Knowing. Oxford: Oxford University Press) and 'credibility excesses' (Medina 2011, Social Epistemology, 25, 1, 15-35, 2013, The Epistemology of Resistance: Gender and Racial Oppression, Epistemic Injustice, and the Social Imagination. Oxford: Oxford University Press) in narrative elicitation. We argue that narrative elicitation may be one way to tackle epistemic injustices by giving voice to previously silenced groups, yet it is not enough to erase the effects of 'credibility deficits' in clinical communication. Rather than judging individual professionals' success or failure in eliciting narratives, we underline some extrinsic problems of narrative elicitation, namely structural and positional inequalities reflecting on narrative elicitation and the credibility of patients. 'Credibility excesses' can be useful and indicative to better understand where they are missing.

Patients' experiences of everyday living before and after transcatheter aortic valve implantation.

BACKGROUND: Aortic stenosis (AS) is the most common valvular disease in western countries. Unless treated, it is associated with a poor prognosis. Surgical aortic valve replacement, the gold-standard approach, aims to increase survival and improve quality of life. In recent years, though, transcatheter aortic valve implantation (TAVI) has become the treatment of choice in elderly, high-risk patients who are denied open surgery. To date, however, little is known about their personal psychological experience after undergoing TAVI. AIM: This study aimed to explore patients' experiences during everyday life before and after TAVI. METHOD: Altogether, 14 elderly Swedish patients (9 women, 5 men), treated with TAVI, were interviewed between 2 and 6 months after the implantation. The interviews were analysed using qualitative content analysis. RESULTS: Analysis of the participants' experiences was divided into two domains: before and after, that is, life with AS vs. life after TAVI. From these domains, four categories were derived: (1) adapting to the deteriorating self; (2) feeling disconnected; (3) reconstruction of self; and (4) processing disappointment. CONCLUSIONS: Transcatheter aortic valve implantation involves not only adding years to life but also adding life to years. The urge to live an autonomous life in a social context with others is an important argument for undergoing a TAVI procedure. Despite severe illness and demanding rehabilitation, elderly TAVI patients have the ability to regain independence and rebuild their lives when they base their decision to undergo TAVI on personal goals. These findings might be helpful when implementing person-centred care.

Managerial and organisational prerequisites for the integration of palliative care in the intensive care setting: A qualitative study.

AIM: To explore the association of organizational structures when integrating palliative care in intensive care units. BACKGROUND: Palliative care within intensive care settings has been widely recognized as an area requiring improvement when caring for patients and their families. Despite this, intensive care units continue to struggle to integrate palliative care. METHODS: A qualitative descriptive methodology was used. Data were collected through research interviews with 15 managers and 36 health care professionals working in intensive care. The data were analysed adopting constant comparative analysis. RESULTS: This study provides insight into a diverse range of perspectives on organizational structure in the context of facilitation and the challenges posed. Three themes were identified: Do not resuscitate policy as a gateway to palliative care, facilitating family members to enable participation and support and barriers for palliative care in intensive care unit as a result of intensive care organization. CONCLUSIONS: In fostering a sustainable organizational culture and practice development in intensive care, the findings indicate the need for specific palliative care policies and implementation strategies tailored according to context. IMPLICATIONS FOR NURSING MANAGEMENT: Management has a responsibility to facilitate dialogue within any multidisciplinary team regarding palliative care and, in particular, to focus on 'do not resuscitate' policies as a gateway into this conversation.

Registered nurses' experiences of working in the intensive care unit during the COVID-19 pandemic.

BACKGROUND: During the pandemic, increased numbers of patients requiring intensive care unit (ICU) admission required an increase in ICU capacity, including ICU staffing with competence to care for critically ill patients. Consequently, nurses from acute care areas were called in to staff the ICU along with experienced intensive care nurses. AIMS AND OBJECTIVES: To describe Swedish registered nurses' experiences of caring for patients with COVID-19 in ICUs during the pandemic. DESIGN: Mixed method survey design. METHODS: An online questionnaire was distributed through social media to registered nurses who had been working in the ICU during the COVID-19 outbreak. Data were collected for 1 week (May 2020) and analysed using content analysis and descriptive statistics. RESULTS: Of the 282 nurses who participated, the majority were ICU nurses (n = 151; 54%). Half of the nurses specialized in ICU reported that they were responsible for the ICU care of three or more patients during the pandemic (n = 75; 50%). Among non-intensive care nurses, only 19% received introduction to the COVID-19 ICU (n = 26). The analysis of data regarding nurses' experiences resulted in three categories: tumbling into chaos, diminished nursing care, and transition into pandemic ICU care. Participants described how patient safety and care quality were compromised, and that nursing care was severely deprioritized during the pandemic. The situation of not being able to provide nursing care resulted in ethical stress. Furthermore, an increased workload and worsened work environment affected nurses' health and well-being. CONCLUSIONS: The findings from the present study indicate that nurses perceived that patient safety and quality of care were compromised during the pandemic. This resulted in ethical stress among nurses, which may have affected their physical and psychosocial well-being. RELEVANCE TO CLINICAL PRACTICE: The COVID-19 pandemic had a severe impact on nurses' work environment, which could result in burnout and staff turnover.

The potential and pitfalls of narrative elicitation in person-centred care.

BACKGROUND: Revitalized interest in narrative has informed some recent models of patient and person-centred care. Yet, scarce attention has been paid to how narrative elicitation is actually used in person-centred care practice and in which ways it is incorporated into clinical routine. AIM: We aimed to identify facilitators and barriers for narrative elicitation and setting goals in a particular example of person-centred care practice (University of Gothenburg Centre for Person-centred Care, GPCC) where narrative elicitation is considered as a method of setting goals for the patient. METHODS: Observation of 14 admission interviews including narrative elicitation on an internal medicine ward in Sweden where person-centred care was implemented. Five focus group vignette-based interviews with nurses (n = 53) were conducted to assess confirmation of the emerging themes. RESULTS: The inductive analysis resulted in three themes about the strategies to elicit patients' narratives: (a) Preparing for narrative elicitation, (b) Lingering in the patient's narrative, and (c) Co-creating, that is, the practitioner's and third parties' engagement in the patient's narration. Even though there were obstacles to eliciting narratives and setting lifeworld goals in a medical setting, narrative elicitation was often useful to turn general and medical goals into more specific and personal goals. CONCLUSIONS: Narrative elicitation is neither a simple transition from traditional medical history taking nor a type of structured interview. It entails skills and strategies to be practiced. On the one hand, it revitalizes ethical considerations about clinical relationship building. On the other hand, it can help patients articulate lifeworld goals that are meaningful and important for themselves.

Factors influencing the integration of a palliative approach in intensive care units: a systematic mixed-methods review.

BACKGROUND: While a palliative approach is generally perceived to be an integral part of the intensive care unit (ICU), the provision of palliative care in this setting is challenging. This review aims to identify factors (barriers and facilitators) influencing a palliative approach in intensive care settings, as perceived by health care professionals. METHOD: A systematic mixed-methods review was conducted. Multiple electronic databases were used, and the following search terms were utilized: implementation, palliative care, and intensive care unit. In total, 1843 articles were screened, of which 24 met the research inclusion/exclusion criteria. A thematic synthesis method was used for both qualitative and quantitative studies. RESULTS: Four key prerequisite factors were identified: (a) organizational structure in facilitating policies, unappropriated resources, multi-disciplinary team involvement, and knowledge and skills; (b) work environment, including physical and psychosocial factors; (c) interpersonal factors/barriers, including family and patients' involvement in communication and participation; and (d) decision-making, e.g., decision and transition, goal conflict, multidisciplinary team communication, and prognostication. CONCLUSION: Factors hindering the integration of a palliative approach in an intensive care context constitute a complex interplay among organizational structure, the care environment and clinicians' perceptions and attitudes. While patient and family involvement was identified as an important facilitator of palliative care, it was also recognized as a barrier for clinicians due to challenges in shared goal setting and communication.

Volumetric Investigation of Sphenoid Sinus in an Elderly Population.

The aims of this study were to determine the sphenoid sinus volume in an Austrian population, evaluate the relationship between volume and different types of pneumatization and investigate possible age-related sphenoid sinus volume degeneration in the elderly. A total of 50 human cadaver including 25 male and 25 female samples (=100 sphenoid sinuses, age range 65-100, mean age 84.52 ±â€Š9.50) were selected to obtain volume and anatomical variants of pneumatization by using sphenoid sinus casts, made of quadrofunctional hydrophilic addition reaction silicone. The mean sphenoid sinus volume was 4.79 ±â€Š2.39 cm. Males showed statistically significant larger sinus volumes than females (P = 0.048). The volume differed statistically significant for the different types of pneumatization (P < 0.001). The combined type of sphenoid sinus pneumatization presented the largest volume with 7.20 cm, followed by lateral, clival, sphenoid body, presellar, and conchal sinus type with 5.72, 5.63, 4.25, 2.08, and 0.5 cm, respectively. No significant correlation between age and sphenoid sinus volume was found (P = 0.707). This study highlights the close relationship between volume and morphology of sphenoid sinus and confirms ethnic variability. Moreover, our data shows no age-related volume degeneration.