A guided single session intervention to reduce intrusive memories of work-related trauma: a randomised controlled trial with healthcare workers in the COVID-19 pandemic.

BACKGROUND: Intrusive memories of psychologically traumatic events bring distress both sub-clinically and clinically. This parallel-group, two-arm randomised controlled trial evaluated the effect of a brief behavioural intervention on reducing intrusive memories in frontline healthcare workers exposed to traumatic events during the COVID-19 pandemic. METHODS: Participants with at least two intrusive memories of work-related trauma in the week before recruitment were randomised 1:1 to an imagery-competing task intervention (n = 73) or attention-based control task (n = 71). The number of intrusive memories was assessed at baseline and 5 weeks after the guided session (primary endpoint). RESULTS: The intervention significantly reduced intrusive memory frequency compared with control [intervention Mdn = 1.0 (IQR = 0-3), control Mdn = 5.0 (IQR = 1-17); p < 0.0001, IRR = 0.30; 95% CI = 0.17-0.53] and led to fewer post-traumatic stress-related symptoms at 1, 3 and 6 month follow-ups (secondary endpoints). Participants and statisticians were blinded to allocation. Adverse events data were acquired throughout the trial, demonstrating safety. There was high adherence and low attrition. CONCLUSIONS: This brief, single-symptom, repeatable digital intervention for subclinical-to-clinical samples after trauma allows scalability, taking a preventing-to-treating approach after trauma. TRIAL REGISTRATION: 2020-07-06, ClinicalTrials.gov identifier: NCT04460014.

Factors predictive of hospital admission for children via emergency departments in Australia and Sweden: an observational cross-sectional study.

BACKGROUND: Identifying factors predictive of hospital admission can be useful to prospectively inform bed management and patient flow strategies and decrease emergency department (ED) crowding. It is largely unknown if admission rate or factors predictive of admission vary based on the population to which the ED served (i.e., children only, or both adults and children). This study aimed to describe the profile and identify factors predictive of hospital admission for children who presented to four EDs in Australia and one ED in Sweden. METHODS: A multi-site observational cross-sectional study using routinely collected data pertaining to ED presentations made by children < 18 years of age between July 1, 2011 and October 31, 2012. Univariate and multivariate analysis were undertaken to determine factors predictive of hospital admission. RESULTS: Of the 151,647 ED presentations made during the study period, 22% resulted in hospital admission. Admission rate varied by site; the children's EDs in Australia had higher admission rates (South Australia: 26%, Queensland: 23%) than the mixed (adult and children's) EDs (South Australia: 13%, Queensland: 17%, Sweden: 18%). Factors most predictive of hospital admission for children, after controlling for triage category, included hospital type (children's only) adjusted odds ratio (aOR):2.3 (95%CI: 2.2-2.4), arrival by ambulance aOR:2.8 (95%CI: 2.7-2.9), referral from primary health aOR:1.5 (95%CI: 1.4-1.6) and presentation with a respiratory or gastrointestinal condition (aOR:2.6, 95%CI: 2.5-2.8 and aOR:1.5, 95%CI: 1.4-1.6, respectively). Predictors were similar when each site was considered separately. CONCLUSIONS: Although the characteristics of children varied by site, factors predictive of hospital admission were mostly similar. The awareness of these factors predicting the need for hospital admission can support the development of clinical pathways.

A New Perspective on Missed Nursing Care in the Emergency Department: A Descriptive Cross-Sectional Study.

INTRODUCTION: This descriptive cross-sectional study describes missed nursing care, quality of care, and patient safety rated by nursing staff in emergency departments. Required patient care that is omitted or delayed (missed nursing care) is associated with poorer quality of care and increased risk for adverse events, but studies are scarce in the emergency setting. METHODS: Emergency registered nurses and nursing assistants (N=126) at 2 Swedish emergency departments participated in the study. The MISSCARE survey-Swedish version was used for data collection. RESULTS: Emergency nursing staff assessed that nursing care is frequently missed in the emergency department. More than half of the 24 nursing care items were reported as missed by over 50% of the participants, and registered nurses rated most items significantly higher compared to nursing assistants. Half of the nursing staff perceived quality of care to be good, but nearly the same proportion perceived patient safety as poor. Registered nurses viewed both quality and safety worse than nursing assistants. DISCUSSION: The present study found very high levels of missed nursing care in most nursing items. Results indicate that nursing staff in emergency departments need to prioritize between the tasks and that some tasks may not be relevant in the context. The emergency setting focuses primarily on identifying signs of urgency, assessing patients, performing interventions, and diagnostics. However, even items that seemed to be prioritized, such as reassessment of vital signs, had a surprisingly high level of missed nursing care in comparison to in-hospital wards.

Differences between Registered Nurses and nurse assistants around missed nursing care-An observational, comparative study.

BACKGROUND: From a nursing perspective, tasks that are not carried out, and the consequences of this, have been studied for over a decade. The difference between Registered Nurses (RNs) and nurse assistants (NAs) regarding qualifications and work tasks, and the profound knowledge around RN-to-patient ratios, warrants investigating missed nursing care (MNC) for each group rather than as one (nursing staff). AIM: To describe and compare RNs and NAs ratings of and reasons for MNC at in-hospital wards. METHODS: A cross-sectional study with a comparative approach. RNs and NAs at in-hospital medical and surgical wards for adults were invited to answer the MISSCARE Survey-Swedish version, including questions on patient safety and quality of care. RESULTS: A total of 205 RNs and 219 NAs answered the questionnaire. Quality of care and patient safety was rated as good by both RNs and NAs. Compared to NAs, RNs reported more MNC, for example, in the item 'Turning patient every 2 h' (p < 0.001), 'Ambulation three times per day or as ordered' (p = 0.018), and 'Mouth care' (p < 0.001). NAs reported more MNC in the items 'Medications administered within 30 min before or after scheduled time' (p = 0.005), and 'Patient medication requests acted on within 15 min' (p < 0.001). No significant differences were found between the samples concerning reasons for MNC. CONCLUSION: This study demonstrated that RNs' and NAs' ratings of MNC to a large extent differed between the groups. RNs and NAs should be viewed as separate groups based on their different knowledge levels and roles when caring for patients. Thus, viewing all nursing staff as a homogenous group in MNC research may mask important differences between the groups. These differences are important to address when taking actions to reduce MNC in the clinical setting.

Missed nursing care during the COVID-19 pandemic: A comparative observational study.

AIM: To evaluate frequencies, types of and reasons for missed nursing care during the COVID-19 pandemic at inpatient wards in a highly specialized university hospital. BACKGROUND: Registered nurse/patient ratio and nursing competence are known to affect patient outcomes. The first wave of the COVID-19 pandemic entailed novel ways for staffing to meet the expected increased acute care demand, which potentially could impact on quality of care. METHODS: A comparative cross-sectional study was conducted, using the MISSCARE Survey. A sample of nursing staff during the first wave of the COVID-19 pandemic (n = 130) was compared with a reference sample (n = 157). RESULTS: Few differences between samples concerning elements of missed care and no significant differences concerning reasons for missed care were found. Most participants perceived the quality of care and the patient safety to be good. CONCLUSION: The results may be explained by three factors: maintained registered nurse/patient ratio, patients' dependency levels and that nursing managers could maintain the staffing needs with a sufficient skill mix. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing managers impact on the occurrence of MNC; to provide a sufficient registered nurse/patient ratio and skill mix when staffing. They play an important role in anticipatory planning and during infectious disease outbreaks.

Nursing staff ratio and skill mix in Swedish emergency departments: A national cross-sectional benchmark study.

AIM: The aim of this study is to describe ratio and skill mix for nursing staff in Swedish emergency departments over a specific 24-h period. BACKGROUND: The link between number of patients per nursing staff and missed nursing care is well described within the in-hospital setting, showing association with negative outcomes such as increased mortality. Potential association within the emergency department setting is still unexplored. METHOD: This is a national descriptive cross-sectional benchmark study. RESULTS: The majority (n = 54; 89%) of Swedish emergency departments participated. The patients-per-registered nurse ratio varied between the shifts, from 0.3 patients to 8.8 patients (mean 3.2). The variation of patients per licenced practical nurse varied, from 1.5 to 23.5 patients (mean 5.0). The average skill mix was constant at around 60% registered nurses and 40% licenced practical nurses. CONCLUSION: The varying ratios for patient per registered nurse and licenced practical nurse in Swedish emergency departments are noteworthy. Furthermore, the patient flow and nursing staff numbers did not match one another, resulting in higher nursing staff ratios during the evening shift. IMPLICATIONS FOR NURSING MANAGEMENT: Findings can be used to improve rosters in relation to crowding, to manage the challenging recruitment and retention situation for nursing staff and to improve patient safety.

Translation, culture adaption and psychometric testing of the MISSCARE Survey-Swedish version.

AIM: To translate the MISSCARE Survey into Swedish and establish its validity and reliability by evaluating its psychometric properties. BACKGROUND: Missed nursing care is defined as any aspect of required nursing care that is omitted or delayed. The consequence of missed nursing care is a threat to patient safety. The MISSCARE Survey is an American instrument measuring missed nursing care activities (part A) and its reasons (part B). METHODS: The translation was accomplished according to World Health Organization guidelines, focusing on a culture adaptation. Acceptability, construct validity, test-retest reliability and internal consistency were analysed. The Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) was used as reporting checklist. RESULTS: The translation and culture adaptation needed several revisions. A total of 126 nurses answered the test and retest which showed acceptability of missing data. The factor analysis revealed a lack of fit to data for the original factorial structure in part B, while further analysis provided results suggesting a modification based on omitting six items. The internal consistency for part B and its subscales showed good results. CONCLUSIONS: The MISSCARE Survey-Swedish version is a reliable and valid instrument, with good psychometric properties. RELEVANCE TO CLINICAL PRACTICE: More reliable language versions of the instrument enable national and international comparisons that could be valuable for nursing managers and/or directors of nursing who are responsible for quality of care and patient safety in the strategic care planning process.

Associations Between Crowding and Ten-Day Mortality Among Patients Allocated Lower Triage Acuity Levels Without Need of Acute Hospital Care on Departure From the Emergency Department.

STUDY OBJECTIVE: We describe the association between emergency department (ED) crowding and 10-day mortality for patients triaged to lower acuity levels at ED arrival and without need of acute hospital care on ED departure. METHODS: This was a registry study based on ED visits with all patients aged 18 years or older, with triage acuity levels 3 to 5, and without need of acute hospital care on ED departure during 2009 to 2016 (n=705,699). The sample was divided into patients surviving (n=705,076) or dying (n=623) within 10 days. Variables concerning patient characteristics and measures of ED crowding (mean length of stay and ED occupancy ratio) were extracted from the hospital's electronic health records. ED length of stay per ED visit was estimated by the average length of stay for all patients who presented to the ED during the same day and shift and with the same acuity level. The 10-day mortality after ED discharge was used as the outcome measure. Multivariable logistic regression analyses were conducted. RESULTS: The 10-day mortality rate was 0.09% (n=623). The event group had larger proportions of patients aged 80 years or older (51.4% versus 7.7%) and triaged with acuity level 3 (63.3% versus 35.6%), and greater comorbidity (age-combined Charlson comorbidity index median interquartile range 6 versus 0). We observed an increased 10-day mortality for patients with a mean ED length of stay greater than or equal to 8 hours versus less than 2 hours (adjusted odds ratio 5.86; 95% confidence interval [CI] 2.15 to 15.94) and for elevated ED occupancy ratio. Adjusted odds ratios for ED occupancy ratio quartiles 2, 3, and 4 versus quartile 1 were 1.48 (95% CI 1.14 to 1.92), 1.63 (95% CI 1.24 to 2.14), and 1.53 (95% CI 1.15 to 2.03), respectively. CONCLUSION: Patients assigned to lower triage acuity levels when arriving to the ED and without need of acute hospital care on departure from the ED had higher 10-day mortality when the mean ED length of stay exceeded 8 hours and when ED occupancy ratio increased.

Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival.

AIMS: To describe out-of-hospital cardiac arrest (OHCA) in Sweden from a long-term perspective in terms of changes in outcome and circumstances at resuscitation. METHODS AND RESULTS: All cases of OHCA (n = 59,926) reported to the Swedish Cardiac Arrest Register from 1992 to 2011 were included. The number of cases reported (n/100,000 person-years) increased from 27 (1992) to 52 (2011). Crew-witnessed cases, cardiopulmonary resuscitation prior to the arrival of the emergency medical service (EMS), and EMS response time increased (P < 0.0001). There was a decrease in the delay from collapse to calling for the EMS in all patients and from collapse to defibrillation among patients found in ventricular fibrillation (P < 0.0001). The proportion of patients found in ventricular fibrillation decreased from 35 to 25% (P < 0.0001). Thirty-day survival increased from 4.8 (1992) to 10.7% (2011) (P < 0.0001), particularly among patients found in a shockable rhythm and patients with return of spontaneous circulation (ROSC) at hospital admission. Among patients hospitalized with ROSC in 2008-2011, 41% underwent therapeutic hypothermia and 28% underwent percutaneous coronary intervention. Among 30-day survivors in 2008-2011, 94% had a cerebral performance category score of 1 or 2 at discharge from hospital and the results were even better if patients were found in a shockable rhythm. CONCLUSION: From a long-term perspective, 30-day survival after OHCA in Sweden more than doubled. The increase in survival was most marked among patients found in a shockable rhythm and those hospitalized with ROSC. There were improvements in all four links in the chain of survival, which might explain the improved outcome.

Pain rating in the ED-a comparison between 2 scales in a Swedish hospital.

BACKGROUND: Pain is common at an emergency department (ED). Two common scales used to rate intensity are the visual analog scale (VAS) and the numeric rating scale (NRS), but it remains unknown which is superior to use in the ED. AIM: The aim of the study is to compare correlations between values on the VAS and the NRS in patients visiting the ED as well as to assess the patients' preference of scale. METHODS: Patients who visited the ED due to chest pain, abdominal pain, or an orthopedic condition during autumn 2012 were enrolled onto a cross-sectional study with a consecutive sample. Patients rated their pain using the VAS and NRS scales. They answered an open-ended oral questionnaire regarding their preference and their estimation of the sufficiency of the scales. Data were analyzed with significance test. RESULTS: In all, 217 patients (70% of eligible, 94% of invited) participated. The pain scores generated from the NRS and the VAS were found to strongly correlate (mean difference, 0.41; 95% confidence interval, 0.29-0.53). Most patients found the NRS easier to use than the VAS (61% and 22%, respectively; P < .001). Furthermore, a majority reported that the NRS reflected/described their pain better than the VAS (53% and 26%, respectively; P < .01). CONCLUSION: Because values on the NRS correspond well to values on the VAS, values rated with different scales over time might be comparable. Because a majority of the patients found the NRS scale simpler to use and preferred it over the VAS, it might be more appropriate to use in the ED.

Do-Not-Attempt-Cardiopulmonary-Resuscitation (DNACPR) decisions in patients admitted through the emergency department in a Swedish University Hospital - An observational study of outcome, patient characteristics and changes in DNACPR decisions.

AIMS: The aims were to examine patient and hospital characteristics associated with Do-Not-Attempt-Cardiopulmonary-Resuscitation (DNACPR) decisions for adult admissions through the emergency department (ED), for patients with DNACPR decisions to examine patient and hospital characteristics associated with hospital mortality, and to explore changes in CPR status. METHODS: This was a retrospective observational study of adult patients admitted through the ED at Karolinska University Hospital 1 January to 31 October 2015. RESULTS: The cohort included 25,646 ED admissions, frequency of DNACPR decisions was 11% during hospitalisation. Patients with DNACPR decisions were older, with an overall higher burden of chronic comorbidities, unstable triage scoring, hospital mortality and one-year mortality compared to those without. For patients with DNACPR decisions, 63% survived to discharge and one-year mortality was 77%. Age and comorbidities for patients with DNACPR decisions were similar regardless of hospital mortality, those who died showed signs of more severe acute illness on ED arrival. Change in CPR status during hospitalisation was 5% and upon subsequent admission 14%. For patients discharged with DNACPR decisions, reversal of DNACPR status upon subsequent admission was 32%, with uncertainty as to whether this reversal was active or a consequence of a lack of consideration. CONCLUSION: For a mixed population of adults admitted through the ED, frequency of DNACPR decisions was 11%. Two-thirds of patients with DNACPR decisions were discharged, but one-year mortality was high. For patients discharged with DNACPR decisions, reversal of DNACPR status was substantial and this should merit further attention.

A longitudinal, retrospective registry-based validation study of RETTS©, the Swedish adult ED context version.

BACKGROUND: Triage and triage related work has been performed in Swedish Emergency Departments (EDs) since the mid-1990s. The Rapid Emergency Triage and Treatment System (RETTS©), with annual updates, is the most applied triage system. However, the national implementation has been performed despite low scientific foundation for triage as a method, mainly related to the absence of adjustment to age and gender. Furthermore, there is a lack of studies of RETTS© in Swedish ED context, especially of RETTS© validity. Hence, the aim the study was to determine the validity of RETTS©. METHODS: A longitudinal retrospective register study based on cohort data from a healthcare region comprising two EDs in southern Sweden. Two editions of RETTS© was selected; year 2013 and 2016, enabling comparison of crude data, and adjusted for age-combined Charlson comorbidity index (ACCI) and gender. All patients ≥ 18 years visiting either of the two EDs seeing a physician, was included. Primary outcome was ten-day mortality, secondary outcome was admission to Intensive Care Unit (ICU). The data was analysed with descriptive, and inferential statistics. RESULTS: Totally 74,845 patients were included. There was an increase in patients allocated red or orange triage levels (unstable) between the years, but a decrease of admission, both to general ward and ICU. Of all patients, 1031 (1.4%) died within ten-days. Both cohorts demonstrated a statistically significant difference between the triage levels, i.e. a higher risk for ten-day mortality and ICU admission for patients in all triage levels compared to those in green triage level. Furthermore, significant statistically differences were demonstrated for ICU admission, crude as well as adjusted, and for adjusted data ten-day mortality, indicating that ACCI explained ten-day mortality, but not ICU admission. However, no statistically significant difference was found for the two annual editions of RETTS© considering ten-day mortality, crude data. CONCLUSION: The annual upgrade of RETTS© had no statistically significant impact on the validity of the triage system, considering the risk for ten-day mortality. However, the inclusion of ACCI, or at least age, can improve the validity of the triage system.

Missed nursing care in the critical care unit, before and during the COVID-19 pandemic: A comparative cross-sectional study.

OBJECTIVES: Todescribe and evaluate reported missed nursing care in the critical care context during different phases of the COVID-19 pandemic in Sweden. RESEARCH METHODOLOGY: A comparative cross-sectional design was used, comparing missed nursing care in three samples: before the COVID-19 pandemic in 2019, during the second wave of the pandemic in spring 2020, and during the third wave of the pandemic in fall 2021. SETTING: The study was conducted at critical care units at a university hospital, Sweden. MAIN OUTCOME MEASURES: The MISSCARE Survey-Swedish version was used to collect data along with two study-specific questions concerning perception of patient safety and quality of care. RESULTS: Significantly more overtime hours and number of days absent due to illness were reported during the pandemic. The nurse/patient ratio was above the recommended level at all data collection time points. Most missed nursing care was reported in items concerning basic care. The most reported reasons for missed nursing care in all samples concerned inadequate staffing, urgent situations, and a rise in patient volume. Most nurses in all samples perceived the level of patient safety and quality of care as good, and the majority had no intention to leave their current position. CONCLUSION: The pandemic had a great impact on the critical care workforce but few elements of missed nursing care were affected. To measure and use missed nursing care as a quality indicator could be valuable for nursing managers, to inform them and improve their ability to meet changes in patient needs with different workforce approaches in critical care settings.

Thoracic injuries in trauma patients: epidemiology and its influence on mortality.

BACKGROUND: Thoracic injuries are common among trauma patients. Studies on trauma patients with thoracic injuries have reported considerable differences in morbidity and mortality, and there is limited research on comparison between trauma patients with and without thoracic injuries, particularly in the Scandinavian population. Thoracic injuries in trauma patients should be identified early and need special attention since the differences in injury patterns among patient population are important as they entail different treatment regimens and influence patient outcomes. The aim of the study was to describe the epidemiology of trauma patients with and without thoracic injuries and its influence on 30-day mortality. METHODS: Patients were identified through the Karolinska Trauma Register. The Abbreviated Injury Scale (AIS) system was used to find patients with thoracic injuries. Logistic regression analysis was performed to evaluate factors [age, gender, ASA class, GCS (Glasgow Coma Scale), NISS (New Injury Severity Score) and thoracic injury] associated with 30-day mortality. RESULTS: A total of 2397 patients were included. Of those, 768 patients (32%) had a thoracic injury. The mean (± SD, range) age of all patients (n = 2397) was 46 (20, 18-98) years, and the majority (n = 1709, 71%) of the patients were males. There was a greater proportion of patients with rib fractures among older (≥ 60 years) patients, whereas younger patients had a higher proportion of injuries to the internal thoracic organs. The 30-day mortality was 11% (n = 87) in patients with thoracic injury and 4.3% (n = 71) in patients without. After multivariable adjustment, a thoracic injury was found to be associated with an increased risk of 30-day mortality (OR 1.9, 95% CI 1.3-3.0); as was age ≥ 60 years (OR 3.7, 95% CI 2.3-6.0), ASA class 3-4 (OR 2.3, 95% CI 1.4-3.6), GCS 1-8 (OR 21, 95% CI 13-33) and NISS > 15 (OR 4.2, 2.4-7.3). CONCLUSION: Thoracic injury was an independent predictor of 30-day mortality after adjustment for relevant key variables. We also found a difference in injury patterns with older patients having a higher proportion of rib fractures, whilst younger patients suffered more internal thoracic organ injuries.

Patient safety, quality of care and missed nursing care at a cardiology department during the COVID-19 outbreak.

AIM: To evaluate missed nursing care and patient safety during the first wave of the COVID-19 pandemic at in-patient cardiology wards. DESIGN: A cross-sectional design with a comparative approach. METHOD: Registered nurses and nurse assistants at a cardiology department were invited to answer the MISSCARE Survey-Swedish version, and questions on patient safety and quality of care during the COVID-19 pandemic. The data were compared with a reference sample. RESULTS: A total of 43 registered nurses and nurse assistants in the COVID-19 sample and 59 in the reference sample participated. The COVID-19 sample reported significantly more overtime hours and more absence from work due to illness in comparison with the reference sample. The patient safety and quality of care were perceived significantly worse, 76.7% (N = 33) versus 94.7% (N = 54), and 85.7% (N = 36) versus 98.3% (N = 58, respectively. The COVID-19 sample reported more missed nursing care in wound care and in basic nursing.

A first remotely-delivered guided brief intervention to reduce intrusive memories of psychological trauma for healthcare staff working during the ongoing COVID-19 pandemic: Study protocol for a randomised controlled trial.

Addressing the mental health needs of healthcare staff exposed to psychologically traumatic events at work during the COVID-19 pandemic is a pressing global priority. We need to swiftly develop interventions to target the psychological consequences (e.g., persistent intrusive memories of trauma). Interventions for healthcare staff must be brief, flexible, fitted around the reality and demands of working life under the pandemic, and repeatable during ongoing/further trauma exposure. Intervention delivery during the pandemic should be remote to mitigate risk of infection; e.g., here using a blend of digitalized self-administered materials (e.g., video instructions) and guided (remote) support from a researcher. This parallel groups, two-arm, randomised controlled trial (RCT) with healthcare staff working during the COVID-19 pandemic is the first evaluation of whether a digitalized form of a brief cognitive task intervention, which is remotely-delivered (guided), reduces intrusive memories. Healthcare staff who experience intrusive memories of work-related traumatic event(s) during the COVID-19 pandemic (≥2 in the week before inclusion) will be randomly allocated (1:1) to receive either the cognitive task intervention or an active (attention placebo) control, and followed up at 1-week, 1-month, 3-months, and 6-months post-intervention. The primary outcome will be the number of intrusive memories reported during Week 5; secondary and other outcomes include the number of intrusive memories reported during Week 1, and other intrusive symptoms. Findings will inform further development and dissemination of a brief cognitive task intervention to target intrusive memories.

Registered nurses' thinking strategies on malnutrition and pressure ulcers in nursing homes: a scenario-based think-aloud study.

AIM: The aim of this study was to explore the thinking strategies and clinical reasoning processes registered nurses use during simulated care planning for malnutrition and pressure ulcers in nursing home care. BACKGROUND: Clinical reasoning is an essential component of nursing practice. Registered nurses' thinking strategies and clinical reasoning have received limited attention in nursing science. Further research is needed to understand registered nurses' clinical reasoning, especially for prevention of malnutrition and pressure ulcers as they are important quality indicators of resident care in nursing homes. DESIGN: A qualitative explorative design was used with a think-aloud interview technique. METHODS: The transcribed verbalisations were analysed with qualitative deductive content analysis. Data were collected during six months in 2007-2008 from 30 registered nurses at nine nursing homes in Norway. RESULTS: The registered nurses used a variety of thinking strategies, but there were differences in the frequency of use of the different strategies. The three most commonly used thinking strategies were 'making choices', 'forming relationships' and 'drawing conclusions'. None of the nurses performed a structured risk assessment of malnutrition or pressure ulcers. Registered nurses started with assessing data from the scenarios, but after a short and elementary assessment they moved directly to planning. CONCLUSION: Many different thinking strategies were used in registered nurses' clinical reasoning for prevention of malnutrition and pressure ulcers. The thinking strategy 'making choices' was most commonly used and registered nurses' main focus in their reasoning was on planning nursing interventions. RELEVANCE TO CLINICAL PRACTICE: This study showed that most of the registered nurses go directly to planning when reasoning clinically about residents in nursing homes. A lack of systematic risk assessments was identified. The insight gained from this study can be used to recommend improvements in tools designed for nursing homes to support the registered nurses.

An updated national survey of triage and triage related work in Sweden: a cross-sectional descriptive and comparative study.

BACKGROUND: Triage and triage related work has been performed in Swedish Emergency Departments (EDs) since the mid-1990s. According to two national surveys from 2005 to 2011, triage was carried out with different triage scales and without guidelines or formal education. Furthermore, a review from 2010 questioned the scientific evidence for both triage as a method as well as the Swedish five level triage scale Medical Emergency Triage and Treatment System (METTS); nevertheless, METTS was applied in 65% of the EDs in 2011. Subsequently, METTS was renamed to Rapid Emergency Triage and Treatment System (RETTS©). The hypothesis for this study is that the method of triage is still applied nationally and that the use of METTS/RETTS© has increased. Hence, the aim is to describe the occurrence and application of triage and triage related work at Swedish Emergency Departments, in comparison with previous national surveys. METHODS: In this cross-sectional study with a descriptive and comparative design, an electronic questionnaire was developed, based on questionnaire from previous studies. The survey was distributed to all hospital affiliated EDs from late March to the middle of July in 2019. The data was analysed with descriptive statistics, by IBM SPSS Statistics, version 26. RESULTS: Of the 51 (75%) EDs partaking in the study, all (100%) applied triage, and 92% used the Swedish triage scale RETTS©. Even so, there was low concordance in how RETTS© was applied regarding time frames i.e., how long a patient in respective triage level could wait for assessment by a physician. Additionally, the results show a major diversion in how the EDs performed education in triage. CONCLUSION: This study confirms that triage method is nationally implemented across Swedish EDs. RETTS© is the dominating triage scale but cannot be considered as one triage scale due to the variation with regard to time frames per triage level. Further, a diversion in introduction and education in the pivotal role of triage has been shown. This can be counteracted by national guidelines in what triage scale to use and how to perform triage education.

Digitalizing a Brief Intervention to Reduce Intrusive Memories of Psychological Trauma for Health Care Staff Working During COVID-19: Exploratory Pilot Study With Nurses.

BACKGROUND: The COVID-19 pandemic has accelerated the worldwide need for simple remotely delivered (digital) scalable interventions that can also be used preventatively to protect the mental health of health care staff exposed to psychologically traumatic events during their COVID-19-related work. We have developed a brief behavioral intervention that aims to reduce the number of intrusive memories of traumatic events but has only been delivered face-to-face so far. After digitalizing the intervention materials, the intervention was delivered digitally to target users (health care staff) for the first time. The adaption for staff's working context in a hospital setting used a co-design approach. OBJECTIVE: The aims of this mixed method exploratory pilot study with health care staff who experienced working in the pandemic were to pilot the intervention that we have digitalized (for remote delivery and with remote support) and adapted for this target population (health care staff working clinically during a pandemic) to explore its ability to reduce the number of intrusive memories of traumatic events and improve related symptoms (eg, posttraumatic stress) and participant's perception of their functioning, and to explore the feasibility and acceptability of both the digitalized intervention and digitalized data collection. METHODS: We worked closely with target users with lived experience of working clinically during the COVID-19 pandemic in a hospital context (registered nurses who experienced intrusive memories from traumatic events at work; N=3). We used a mixed method design and exploratory quantitative and qualitative analysis. RESULTS: After completing the digitalized intervention once with remote researcher support (approximately 25 minutes) and a brief follow-up check-in, participants learned to use the intervention independently. All 3 participants reported zero intrusive memories during week 5 (primary outcome: 100% digital data capture). Prior to study inclusion, two or more intrusions in the week were reported preintervention (assessed retrospectively). There was a general pattern of symptom reduction and improvement in perceived functioning (eg, concentration) at follow-up. The digitalized intervention and data collection were perceived as feasible and rated as acceptable (eg, all 3 participants would recommend it to a colleague). Participants were positive toward the digital intervention as a useful tool that could readily be incorporated into work life and repeated in the face of ongoing or repeated trauma exposure. CONCLUSIONS: The intervention when delivered remotely and adapted for this population during the pandemic was well received by participants. Since it could be tailored around work and daily life and used preventatively, the intervention may hold promise for health care staff pending future evaluations of efficacy. Limitations include the small sample size, lack of daily intrusion frequency data in the week before the intervention, and lack of a control condition. Following this co-design process in adapting and improving intervention delivery and evaluation, the next step is to investigate the efficacy of the digitalized intervention in a randomized controlled trial.