Nutrition intervention goals from the perspectives of patients at risk of malnutrition: A qualitative study.

BACKGROUND: Nutrition counselling is characterised by a collaborative approach where the patient and the dietitian establish goals that promote health and self-management. Little is known about goal-setting in nutrition interventions of patients at risk of malnutrition. The present study aims to describe the perspectives and needs of patients at risk of malnutrition regarding goals of nutrition interventions. METHODS: Semi-structured interviews were conducted with 15 patients from three primary care centres and one hospital in mid-Sweden selected through purposive sampling. Interview transcripts were analysed using reflexive thematic analysis following the six-phase guidelines of Braun and Clarke to identify patterns of shared meaning and themes in the data. RESULTS: The findings highlight that the participants rarely reflected on their personal goals of the nutrition intervention. Instead, they strived to maintain strength and energy, with the nutrition counselling being seen as supportive in managing nutrition impact symptoms. They described discrepancies between their perspectives and the dietitian's regarding weight goals and the diet prescribed to gain weight. CONCLUSIONS: The study findings suggest that elucidating patients' goals is key to counteracting the discrepancies between the dietitians' clinically oriented goals and patients' perspectives. Goal-setting is part of the dietitian's structured working process, whereas the patient's lifeworld is complex and unstructured. To provide person-centred nutrition care, new strategies and tools are needed to facilitate collaborative goal-setting. These approaches will bridge the gap between clinical goals and patients' individual needs, promoting better alignment and improved outcomes.

Development and psychometric properties of a short version of the Patient Continuity of Care Questionnaire.

INTRODUCTION: Hospitalization due to cardiac conditions is increasing worldwide, and follow-up after hospitalization usually occurs in a different healthcare setting than the one providing treatment during hospitalization. This leads to a risk of fragmented care and increases the need for coordination and continuity of care after hospitalization. Furthermore, international reports highlight the importance of improving continuity of care and state that it is an essential indicator of the quality of care. Patients' perceptions of continuity of care can be evaluated using the Patient Continuity of Care Questionnaire (PCCQ). However, the original version is extensive and may prove burdensome to complete; therefore, we aimed to develop and evaluate a short version of the PCCQ. METHODS: This was a psychometric validation study. Content validity was evaluated among user groups, including patients (n = 7), healthcare personnel (n = 15), and researchers (n = 7). Based on the results of the content validity and conceptual discussions among the authors, 12 items were included in the short version. Data from patients were collected using a consecutive sampling procedure involving patients 6 weeks after hospitalization due to cardiac conditions. Rasch analysis was used to evaluate the psychometric properties of the short version of the PCCQ. RESULTS: A total of 1000 patients were included [mean age 72 (SD = 10), 66% males]. The PCCQ-12 presented a satisfactory overall model fit and a person separation index of 0.79 (Cronbach's α: .91, ordinal α: .94). However, three items presented individual item misfits. No evidence of multidimensionality was found, meaning that a total score can be calculated. A total of four items presented evidence of response dependence but, according to the analysis, this did not seem to affect the measurement properties or reliability of the PCCQ-12. We found that the first two response options were disordered in all items. However, the reliability remained the same when these response options were amended. In future research, the benefits of the four response options could be evaluated. CONCLUSION: The PCCQ-12 has sound psychometric properties and is ready to be used in clinical and research settings to measure patients' perceptions of continuity of care after hospitalization. PATIENT OR PUBLIC CONTRIBUTION: Patients, healthcare personnel and researchers were involved in the study because they were invited to select items relevant to the short version of the questionnaire.

Taking control of one's everyday life - a qualitative study of experiences described by participants in an occupational intervention.

BACKGROUND: Sick leave due to stress-related ill-health is increasing and is often caused by occupational imbalance. These types of issues tend to affect both the ability to work and cope with everyday life, as well as the overall experience of health, negatively. There is still little knowledge on how to prepare people and workplaces for the return-to-work process after participation in a work rehabilitation program due to stress and occupational ill-health. Therefore, this study aimed to describe what is needed to achieve a balanced everyday life that includes paid work as experienced by individuals who had participated in a ReDO® intervention due to occupational imbalance and ill-health. METHODS: The concluding notes from 54 informants' medical records were used for qualitative content analysis. The informants had participated in an occupational therapy group intervention to promote occupational health and regain full work capacity. RESULTS: The analysis resulted in one major theme and four categories describing how the informants perceive that they must take control of their everyday life as a whole. By doing so, they need to work with structurization and prioritization, social interaction, boundary setting, and occupational meaningfulness. CONCLUSION: The study indicates a highly relational process, where it is impossible to divide life into private and work, and presupposes balance in everyday life in multiple dimensions. Its contribution includes the formulation of perceived needs in the transition between intervention and return to work and could, through further research, be used to generate a more effective and sustainable return- and rehabilitation models.

Routine conversations about violence conducted in Swedish child health services-A mixed methods study of nurses' experiences.

AIM: To evaluate an intervention where nurses in child health care services routinely talk to and inform parents about violence. METHODS: The intervention included providing information during home visits and individual conversations with mothers and fathers/partners in connection with screening for parental depression. A convergent mixed-methods design was used with a documentation form for each child (n = 475) and results from focus group interviews with nurses. Quantitative data were analysed using descriptive statistics and qualitative with manifest content analysis. RESULTS: Almost all families participated in the intervention; individual conversations were conducted with nearly all the mothers, and to a somewhat lesser extent with the fathers/partners. Initially, the nurses felt slightly uncomfortable about these conversations, but described experiencing development and professionalisation in their role of talking about violence. Parents' reactions were generally positive and they expressed appreciation for this topic being raised. CONCLUSION: The results show that the intervention has been carried out successfully. The newborn period is a phase in which mothers and fathers are interested and receptive to knowledge and support in sensitive matters. Prerequisites for implementation were the preparation phase for the nurses, the use of routine questioning and a questionnaire as a basis for the conversations.

The voice of the profession: how the ethical demand is professionally refracted in the work of general practitioners.

BACKGROUND: Among the myriad voices advocating diverging ideas of what general practice ought to be, none seem to adequately capture its ethical core. There is a paucity of attempts to integrate moral theory with empirical accounts of the embodied moral knowledge of GPs in order to inform a general normative theory of good general practice. In this article, we present an empirically grounded model of the professional morality of GPs, and discuss its implications in relation to ethical theories to see whether it might be sustainable as a general practice ethic. METHODS: We observed and interviewed sixteen GPs and GP residents working in health care centres in four Swedish regions between 2015-2017. In keeping with Straussian Grounded Theory, sampling was initially purposeful and later theoretically guided, and data generation, analysis and theoretical integration proceeded in parallel. The focal concept of this article was refined through multidimensional property supplementation. RESULTS: The voice of the profession is one of four concepts in our emerging theory that attempt to capture various motives that affect GPs' everyday moral decisionmaking. It reflects how GPs appreciate the situation by passing three professional-moral judgments: Shall I see what is before me, or take a bird's-eye view? Shall I intervene, or stay my hand? And do I need to speak up, or should I rather shut up? By thus framing the problem, the GP narrows down the range of considerations, allowing them to focus on its morally most pertinent aspects. This process is best understood as a way of heeding Løgstrup's ethical demand. Refracted through the lens of the GP's professional understanding of life, the ethical demand gives rise to specific moral imperatives that may stand in opposition to the express wishes of the other, social norms, or the GP's self-interest. CONCLUSIONS: The voice of the profession makes sense of how GPs frame problematic situations in moral terms. It is coherent enough to be sustainable as a general practice ethic, and might be helpful in explaining why ethical decisions that GPs intuitively understand as justified, but for which social support is lacking, can nevertheless be legitimate.

Associations between continuity of care, perceived control and self-care and their impact on health-related quality of life and hospital readmission-A structural equation model.

AIM: The aim of this study is to examine whether a conceptual model including the associations between continuity of care, perceived control and self-care could explain variations in health-related quality of life and hospital readmissions in people with chronic cardiac conditions after hospital discharge. DESIGN: Correlational design based on cross-sectional data from a multicentre survey study. METHODS: People hospitalized due to angina, atrial fibrillation, heart failure or myocardial infarction were included at four hospitals using consecutive sampling procedures during 2017-2019. Eligible people received questionnaires by regular mail 4-6 weeks after discharge. A tentative conceptual model describing the relationship between continuity of care, self-care, perceived control, health-related quality of life and readmission was developed and evaluated using structural equation modelling. RESULTS: In total, 542 people (mean age 75 years, 37% females) were included in the analyses. According to the structural equation model, continuity of care predicted self-care, which in turn predicted health-related quality of life and hospital readmission. The association between continuity of care and self-care was partly mediated by perceived control. The model had an excellent model fit: RMSEA = 0.06, 90% CI, 0.05-0.06; CFI = 0.90; TLI = 0.90. CONCLUSION: Interventions aiming to improve health-related quality of life and reduce hospital readmission rates should focus on enhancing continuity of care, perceived control and self-care. IMPACT: This study reduces the knowledge gap on how central factors after hospitalization, such as continuity of care, self-care and perceived control, are associated with improved health-related quality of life and hospital readmission in people with cardiac conditions. The results suggest that these factors together predicted the quality of life and readmissions in this sample. This knowledge is relevant to researchers when designing interventions or predicting health-related quality of life and hospital readmission. For clinicians, it emphasizes that enhancing continuity of care, perceived control and self-care positively impacts clinical outcomes. PATIENT OR PUBLIC CONTRIBUTION: People and healthcare personnel evaluated content validity and were included in selecting items for the short version.

Understanding adolescent males' poor mental health and health-compromising behaviours: A factor analysis model on Swedish school-based data.

AIM: The aim was to develop a factor model of the clustering of poor mental-health symptoms and health-compromising behaviours (HCBs) in adolescent males. METHODS: The study was based on two cross-sectional school-based Swedish surveys in 2011 (response rate 80%, N=2823) and 2014 (response rate 85%, N=2358), both of which comprised questionnaires from males aged 15-16 and 17-18 years. A factor model was developed by exploratory factor analysis on the 2011 survey and validated by confirmatory factor analysis on the 2014 survey. RESULTS: Four aspects of poor mental health and HCBs emerged in the exploratory factor analysis: (a) deviancy as a tendency to substance use and delinquency, (b) unsafety as an inclination towards feelings of unsafety in different environments, (c) gloominess as a tendency towards pessimism and feeling unwell and (d) pain as an inclination to experience physical pain. The model was validated with good model fit. Age did not affect the model structure, but older adolescent males were more influenced by deviancy and gloominess and less by unsafety compared to their younger peers. Conclusions: Separating symptoms of poor mental health and HCBs into four areas - deviancy, unsafety, gloominess and pain - brings new perspectives to the understanding of adolescent males' health. To the best of our knowledge, our factor model is the first to include unsafety and pain in this context. Whenever a comprehensive approach to the health of adolescent males is needed in the clinic or in the field of public health, this factor model may provide guidance.

Perceived needs for team-based visits in Swedish child healthcare services exceed its existence-A mixed-methods study targeting healthcare professionals.

AIM: To investigate both quantitatively and qualitatively the differences between participation in team-based visits (TBVs) and perceived needs for TBVs from the perspectives of healthcare professionals, in the context of the Swedish 3-tier national Child Healthcare programme. METHODS: A study-specific questionnaire, including multiple-choice questions with fixed and free-text response options, was developed, and used. To capture healthcare professionals' experiences and find explanations for the quantitative results in qualitative data, a convergent parallel mixed-methods study design was used. Descriptive statistics and McNemar's test were used to analyse the quantitative data, and content analysis was used to analyse the qualitative data. RESULTS: Healthcare professionals perceived the need for TBVs in the Swedish Child Healthcare Services (CHS) to a high extent. The largest difference between the perceived need for TBVs and experienced TBVs was for indications associated with psychosocial problems. The quantitative findings were explored by the qualitative findings. Both individual and organisational factors influenced TBVs. CONCLUSION: Perceived needs for TBVs in Swedish CHS exceed its existence. Healthcare professionals require TBVs delivered by interprofessional teams, in line with proportionate universalism. Accordingly, organisational structures (e.g. colocation and clear instructions on how to distribute TBVs) and human resources (e.g. psychologists and social worker) are needed.

The voice of the self: a typology of general practitioners' emotional responses to situational and contextual stressors.

OBJECTIVE: To develop a comprehensive typology of emotional reactions associated with stress among general practitioners (GPs), grounded in their own experiences. DESIGN: Data was generated using observations and unstructured interviews, using Straussian grounded theory as the overarching methodology. The typology was built using multidimensional property supplementation. SETTING: Eleven health care centres in urban and rural communities in four Swedish regions. SUBJECTS: Sixteen GPs and GP residents. MAIN OUTCOME MEASURES: Characteristics of GPs' emotional reactions in everyday work situations. RESULTS: Accounts of negative emotions connected to stress revealed four principal personal needs of the GP: trust, efficacy, understanding, and knowledge. Simultaneous threats to more than one of these needs invariably increased the level of tension. From these more complex accounts, six second-order needs could be identified: integrity, judgment, pursuit, authority, autonomy, and competence. The most extreme encounters, in which all four principal needs were threatened, were characterised by the experience of being reduced into an assistant. CONCLUSION: The considerable resilience of GPs may belie some of the pressures that they are facing while being far from a fail-safe defence against being diverted from purposeful and morally responsible action. Our typology distinguishes between different forms of stress that may affect how GPs carry out their work, and connects to the vast literature on GP wellness. The results of this study could be used to develop tools for self-reflection with the aim of countering the effects of stress, and are potentially relevant to future research into its causes and consequences.Key pointsWhat is known•Stress among GPs may have severe consequences for themselves and their patients, and levels of stress appear to be increasing.What this article adds•Stressful situations threaten at least one of four principal needs of the GP: trust, efficacy, understanding, and knowledge.•More complex threats increase the level of tension and bring out second-order needs: integrity, judgment, pursuit, authority, autonomy, and competence.•The wealth of literature on GP stress can be clearly understood through the lens of our four-dimensional typology.

Confidentiality matters! Adolescent males' views of primary care in relation to psychosocial health: a structural equation modelling approach.

OBJECTIVE: To investigate to what degree adolescent males (1) value confidentiality, (2) experience confidentiality and are comfortable asking sensitive questions when visiting a general practitioner (GP), and (3) whether self-reported symptoms of poor mental health and health-compromising behaviours (HCB) affect these states of matters. DESIGN: Cross-sectional. SETTING: School-based census on life, health and primary care in Region Sörmland, Sweden. SUBJECTS: 2,358 males aged 15-17 years (response rate 84%). MAIN OUTCOME MEASURES: The impact of poor mental health and HCBs on adolescent males' valuing and experiencing private time with the GP, having professional secrecy explained, and being comfortable asking about the body, love and sex, analysed with structural equation modelling. RESULTS: Almost all respondents valued confidentiality regardless of their mental health or whether they engaged in HCBs: 86% valued spending private time with the GP, and 83% valued receiving a secrecy explanation. Among those who had visited a GP in the past year (n = 1,200), 74% had experienced private time and 42% a secrecy explanation. Three-quarters were at least partly comfortable asking sensitive questions. Adolescent males with HCBs were more likely to experience a secrecy explanation (approximative odds ratio [appOR] 1.26; p = 0.005) and to be comfortable asking about sex than their peers (appOR 1.22; p = 0.007). Respondents reporting experienced confidentiality were more comfortable asking sensitive questions (appOR 1.25-1.54; p ≤ 0.010). CONCLUSION: Confidentiality matters regardless of poor mental health or HCBs and makes adolescent males more comfortable asking sensitive questions. We suggest that GPs consistently offer private time and explain professional secrecy.Key PointsConfidentiality for adolescent males has been scantily studied in relation to mental health and health-compromising behaviours.In this study, most adolescent males valued confidentiality, regardless of their mental health and health-compromising behaviours.Health-compromising behaviours impacted only slightly, and mental health not at all, on experiences of confidentiality in primary care.When provided private time and an explanation of professional secrecy, adolescent males were more comfortable asking the GP sensitive questions.

Diabetes care provided by national standards can improve patients' self-management skills: A qualitative study of how people with type 2 diabetes perceive primary diabetes care.

BACKGROUND: The increasing incidence of type 2 diabetes mellitus [T2DM] has resulted in extensive research into the characteristics of successful primary diabetes care. Even if self-management support and continuity are increasingly recognized as important, there is still a need for deeper understanding of how patients' experiences of continuity of care coincide with their needs for self-management and/or self-management support. OBJECTIVE: To gain a deeper understanding of how people with T2DM perceive Swedish primary diabetes care and self-management support. METHODS: This qualitative study used focus groups as the means for data collection. Participants were identified through a purposive sampling method differing in age, sex, diabetes duration and latest registered glycated haemoglobin level. Twenty-eight participants formed five focus groups. Qualitative content analysis was applied to interview transcripts. RESULTS: The main theme emerging from the focus group data was that diabetes care provided by national standards improved self-management skills. Two themes that emerged from the analysis were (a) the importance of a clarification of structures and procedures in primary diabetes care and (b) health-care staff 'being there' and providing support enables trust and co-operation to enhance self-management. CONCLUSIONS: Individual patients' self-management resources are strengthened if the importance of providing relational continuity, management continuity and informational continuity is considered. Patients also need assistance on 'how' self-management activities should be performed. PATIENT CONTRIBUTION: Prior to the study, one pilot focus group was conducted with patients to obtain their perspectives on the content of the planned focus groups; thus, patients were involved in both planning and conduct of the study.

Healthcare professionals' perceptions about interprofessional teamwork: a national survey within Swedish child healthcare services.

BACKGROUND: Globally, interprofessional teamwork is described as a key method to promote health and prevent illness in children, namely, to achieve the goals of Child Healthcare Services (CHS). However, how teamwork should be designed within CHS to achieve the goals is unclear. This study aimed to investigate healthcare professionals' perceptions about 1) taking part in interprofessional teamwork, 2) team characteristics, and 3) whether the perceptions were related to professional affiliation or workplace. METHODS: A national cross-sectional survey was conducted using a web-based study-specific questionnaire sent to all accessible nurses, physicians, and psychologists in Swedish CHS (n = 3552). The response rate was 31.5%. To identify possible associations, logistic regressions were conducted. RESULTS: Almost all respondents, 1096/1119 (97.9%), reported taking part in some type of interprofessional teamwork within the Swedish CHS. Among those, the most common was team-based visits (82.2%). It was perceived that performing team-based visits resulted in fulfilled goals, expertise exceeding individual team members' competences, provision of high-quality care, and meeting children's and families' needs, to a greater extent, than if not performing team-based visits. Correspondingly, working as a team in parental groups was perceived as resulting in fulfilled goals, meeting the needs of children and their families, and continuity within the team to a greater extent than if not working together in a team. Professional affiliation was associated with different perceptions and types of teamwork. Family Centers were positively associated with all types of teamwork as well as continuity within the team. CONCLUSIONS: Healthcare professionals' perceptions about team characteristics were associated with professional affiliation, workplace, and type of teamwork (defined as team activities) within the CHS. Professionals within Swedish CHS, taking part in team-based visits and in interprofessional teamwork in parental groups, perceived that the team fulfilled its goals and met the needs of children and families to a greater extent than professionals not taking part in these types of teamwork. Professionals at Family Centers were more likely to work in teams in different ways. Knowledge about interprofessional teamwork for individuals and groups in Swedish CHS might also be valuable in other healthcare settings, dealing with complex needs.

Team-based visits within Swedish child healthcare services: a national cross-sectional study.

Complex healthcare needs can be met through effective interprofessional collaboration. Since 2014, Swedish Child Healthcare Services (CHS) include universal team-based visits with a nurse and a physician who perform such visits at the age of 4 weeks, 6 months, 12 months, and 2.5 to 3 years, as well as targeted team-based visits to address additional needs. The aim of this study was to describe the prevalence of team-based visits in the Swedish CHS and possible associations between team-based visits and contextual factors that may affect its implementation. A national cross-sectional survey was conducted using a web-based questionnaire distributed to all reachable nurses, physicians, and psychologists (n =3,552) engaged in the CHS. Data were analyzed using descriptive statistics and binary and multivariate logistic regressions. The response rate was 32%. Team-based visits were reported by 82% of the respondents. For nurses and physicians, the most frequent indication was specific ages, while for psychologists it was to provide parental support. Respondents working at Family Centers were more likely to perform team-based visits in general, at 2.5 to 3 years and in case of additional needs, compared to respondents working at Child Health Centers (CHC) and other workplaces. In conclusion, team-based visits are well implemented, but the pattern differs depending on the contextual factors. Targeted team-based visits and team-based visits at the age of 2.5 to 3 years are most unequally implemented.

How general practitioners decide on maxims of action in response to demands from conflicting sets of norms: a grounded theory study.

BACKGROUND: The work of general practitioners (GPs) is infused by norms from several movements, of which evidence based medicine, patient-centredness, and virtue ethics are some of the most influential. Their precepts are not clearly reconcilable, and structural factors may limit their application. In this paper, we develop a conceptual framework that explains how GPs respond, across different fields of interaction in their daily work, to the pressure exerted by divergent norms. METHODS: Data was generated from unstructured interviews with and observations of sixteen Swedish GPs (who have by definition more than five years of experience after license to practice) and family medicine residents (with less than five years of experience) between 2015 and 2017. Straussian Grounded Theory was used for analysis. RESULTS: We found that GPs' maxims of action can be characterised in terms of dichotomous responses to demands from four distinct sets of norms, or "voices": the situation, the self, the system, and the profession. From the interactions between these voices emerge sixteen clusters of maxims of action. Based on the common features of the maxims in each cluster, we have developed a conceptual framework that appears to be rich enough to capture the meaning of the ethical decisions that GPs make in their daily work, yet has a high enough level of abstraction to be helpful when discussing the factors that influence those decisions. CONCLUSIONS: Our four-dimensional model of GPs' responses to norms is a first step toward a middle-range theory of quality from GPs' perspective. It brings out the complexity of their practice, reveals tensions that easily remain invisible in more concrete accounts of their actions, and aids the transferability of substantive theories on GPs' ethical decision making. By explaining the nature of the ethical conflicts that they experience, we provide some clues as to why efforts to improve quality by imposing additional norms on GPs may meet with varying degrees of success.

Social support, self-rated health and low mood in people on sick leave due to heart failure: a cross-sectional study.

AIMS: The aim of this study was to investigate social support in relation to self-rated health and the prevalence of low mood in people on sick leave due to heart failure. METHODS: A cross-sectional design was used, and 590 individuals on sick leave due to heart failure in Sweden responded to the postal questionnaire. The questions therein concerned received and needed functional and structural support from managers, work colleagues, families and friends. Multivariate analyses were conducted. RESULTS: The variables of income and needed support from family contributed significantly and negatively to self-rated health. Those who perceived that they needed more support from their manager reported experiencing low mood more frequently. CONCLUSIONS: The results showed a negative relation between manager support and low mood. Thus, support from managers and perceptions of low mood during sick leave are negatively associated, however, we do not know anything about the causality of this association. The results also indicated that needed support from family was negatively associated with self-rated health. The results also highlighted a multidimensional frailty in people with heart failure that needs to be recognized in future research as well as in clinical practice.

Struggling for a feasible tool - the process of implementing a clinical pathway in intensive care: a grounded theory study.

BACKGROUND: Clinical pathways can enhance care quality, promote patient safety and optimize resource utilization. However, they are infrequently utilized in intensive care. This study aimed to explain the implementation process of a clinical pathway based on a bottom-up approach in an intensive care context. METHODS: The setting was an 11-bed general intensive care unit in Sweden. An action research project was conducted to implement a clinical pathway for patients on mechanical ventilation. The project was managed by a local interprofessional core group and was externally facilitated by two researchers. Grounded theory was used by the researchers to explain the implementation process. The sampling in the study was purposeful and theoretical and included registered nurses (n31), assistant nurses (n26), anesthesiologists (n11), a physiotherapist (n1), first- and second-line managers (n2), and health records from patients on mechanical ventilation (n136). Data were collected from 2011 to 2016 through questionnaires, repeated focus groups, individual interviews, logbooks/field notes and health records. Constant comparative analysis was conducted, including both qualitative data and descriptive statistics from the quantitative data. RESULTS: A conceptual model of the clinical pathway implementation process emerged, and a central phenomenon, which was conceptualized as 'Struggling for a feasible tool,' was the core category that linked all categories. The phenomenon evolved from the 'Triggers' ('Perceiving suboptimal practice' and 'Receiving external inspiration and support'), pervaded the 'Implementation process' ('Contextual circumstances,' 'Processual circumstances' and 'Negotiating to achieve progress'), and led to the process 'Output' ('Varying utilization' and 'Improvements in understanding and practice'). The categories included both facilitating and impeding factors that made the implementation process tentative and prolonged but also educational. CONCLUSIONS: The findings provide a novel understanding of a bottom-up implementation of a clinical pathway in an intensive care context. Despite resonating well with existing implementation frameworks/theories, the conceptual model further illuminates the complex interaction between different circumstances and negotiations and how this interplay has consequences for the implementation process and output. The findings advocate a bottom-up approach but also emphasize the need for strategic priority, interprofessional participation, skilled facilitators and further collaboration.

Balancing intertwined responsibilities: A grounded theory study of teamwork in everyday intensive care unit practice.

This study aimed to describe and explain teamwork and factors that influence team processes in everyday practice in an intensive care unit (ICU) from a staff perspective. The setting was a Swedish ICU. Data were collected from 38 ICU staff in focus groups with registered nurses, assistant nurses, and anaesthetists, and in one individual interview with a physiotherapist. Constant comparative analysis according to grounded theory was conducted, and to identify the relations between the emerged categories, the paradigm model was applied. The core category to emerge from the data was "balancing intertwined responsibilities." In addition, eleven categories that related to the core category emerged. These categories described and explained the phenomenon's contextual conditions, causal conditions, and intervening conditions, as well as the staff actions/interactions and the consequences that arose. The findings indicated that the type of teamwork fluctuated due to circumstantial factors. Based on the findings and on current literature, strategies that can optimise interprofessional teamwork are presented. The analysis generated a conceptual model, which aims to contribute to existing frameworks by adding new dimensions about perceptions of team processes within an ICU related to staff actions/interactions. This model may be utilised to enhance the understanding of existing contexts and processes when designing and implementing interventions to facilitate teamwork in the pursuit of improving healthcare quality and patient safety.

Being in a critical illness-recovery process: a phenomenological hermeneutical study.

AIMS AND OBJECTIVE: The aim of this study was to describe and interpret the essential meaning of the lived experiences of being in a critical illness-recovery process after a life-threatening condition. BACKGROUND: The critical illness-recovery process after a life-threatening condition takes several years and does not only include patients' experiences during intensive care. Previous research has mainly focused on what critically ill patients recall. However, from a phenomenological point of view, experiences are more than memories alone. To plan and perform relevant health care and social support for patients who have survived a life-threatening condition, a more profound understanding about their lived experiences is needed. DESIGN AND METHOD: In this qualitative study, a phenomenological hermeneutical approach was used. Interviews were conducted with seven patients, two to four years after they had received care in an intensive care unit in Sweden. RESULTS: The comprehensive understanding of the results shows that the critical illness-recovery process after a life-threatening condition means an existential struggle to reconcile with an unfamiliar body and with ordinary life. This can be understood as an 'unhomelikeness' implying a struggle to create meaning and coherence from scary and fragmented memories. The previous life projects, such as work and social life become unfamiliar when the patient's fragile and weak body is disobedient and brings on altered sensations. CONCLUSIONS: Patients who survive a life-threatening condition have an immense need for care and support during the entire critical illness-recovery process, and also after the initial acute phase. They need a coherent understanding of what happened, and support to be able to perform their changed life projects. RELEVANCE TO CLINICAL PRACTICE: Supporting and caring for patients' recovery from a life- threatening condition involves recognising the patients' struggle and responding to their existential concerns.

Being on sick leave due to heart failure: self-rated health, encounters with healthcare professionals and social insurance officers and self-estimated ability to return to work.

Younger people with heart failure often experience poor self-rated health. Furthermore, poor self-rated health is associated with long-term sick leave and disability pension. Socio-demographic factors affect the ability to return to work. However, little is known about people on sick leave due to heart failure. The aim of this study was to investigate associations between self-rated health, mood, socio-demographic factors, sick leave compensation, encounters with healthcare professionals and social insurance officers and self-estimated ability to return to work, for people on sick leave due to heart failure. This population-based investigation had a cross-sectional design. Data were collected in Sweden in 2012 from two official registries and from a postal questionnaire. In total, 590 subjects, aged 23-67, responded (response rate 45.8%). Descriptive statistics, correlation analyses (Spearman bivariate analysis) and logistic regression analyses were used to investigate associations. Poor self-rated health was strongly associated with full sick leave compensation (OR = 4.1, p < .001). Compared self-rated health was moderately associated with low income (OR = .6, p = .003). Good self-rated health was strongly associated with positive encounters with healthcare professionals (OR = 3.0, p = .022) and to the impact of positive encounters with healthcare professionals on self-estimated ability to return to work (OR = 3.3, p < .001). People with heart failure are sicklisted for long periods of time and to a great extent receive disability pension. Not being able to work imposes reduced quality of life. Positive encounters with healthcare professionals and social insurance officers can be supportive when people with heart failure struggle to remain in working life.

Effects of dog-assisted intervention on behavioural and psychological symptoms of dementia.

AIM: To evaluate the effect of a dog-assisted intervention on the behavioural and psychological symptoms of residents with dementia during a six-month period. METHOD: The study was conducted in eight nursing homes in Sweden. A total of 33 residents with dementia, 20 in the intervention group and 13 in the control group, were recruited. The Cohen-Mansfield Agitation Inventory (CMAI) and the Multi-Dimensional Dementia Assessment Scale (MDDAS) were used to assess the effects of a dog-assisted intervention on participants' behavioural and psychological symptoms. The intervention comprised ten sessions, lasting between 45 and 60 minutes, once or twice a week. Descriptive statistics were used to analyse background data, comparisons between groups at baseline were performed using the Mann-Whitney U test, and the Wilcoxon rank sum test was used to test differences in groups over time. RESULTS: In the intervention group changes from baseline to follow up immediately after the intervention were not significant, possibly because of the small sample size. Some positive tendencies were observed: the CMAI mean score for physical non-aggressive behaviours decreased from 18.5 at baseline to 15.3 at follow up immediately after the intervention; lower scores indicate fewer symptoms. Mean and median MDDAS scores for behavioural symptoms decreased from 15.3 and 13.5 respectively at baseline to 13.1 and 12.0 respectively at follow up immediately after the intervention; lower scores indicate fewer symptoms. The CMAI mean score for verbal agitation increased significantly (P=0.035) from 17.2 at baseline to 20.6 at follow up six months after the intervention. CONCLUSION: Dog-assisted intervention may provide an alternative or a complement to pharmacological treatments to reduce behavioural symptoms in people with dementia, but its value and place in care require further evaluation.