"Parents are our greatest asset but also our greatest challenge": A Qualitative Study of Anesthesia Staff's Experiences of Parental Presence During Anesthesia Induction.

PURPOSE: The perioperative period is a stressful experience for both the child and their parents. Anesthesia staff generally have a positive attitude to the parental presence in the operating room. They can be a powerful resource in creating a caring environment, but they are challenged by limited time to establish a relationship. The present study describes the anesthesia staff's experience of parental presence during their child's anesthesia induction. DESIGN: A descriptive design with a phenomenological approach. METHODS: A total of 22 anesthesia staff from four Swedish hospitals were interviewed. The study has been carried out using a reflective lifeworld research (RLR) approach. FINDINGS: The following four constituents describe anesthesia staff's experiences of parental presence: a conditional presence; a relationship that is secondary; a shared but two-part responsibility; and a need to demonstrate professionalism. CONCLUSIONS: Parental presence is natural and essentially irreplaceable, as it creates security for the child. However, the results show that parental presence is not free of obligations and expectations. Designing for good perioperative care is important, and the staff plays a key role in cooperating with the parents to improve the quality of care.

I saw myself as an important piece of a jigsaw puzzle: Parents experiences of their child's anaesthesia induction.

Anxiety in children, as well as their parents, is common in high-tech environments such as an operating room. This study aimed to describe parents' experiences of being present when their child is being anaesthetised. Twenty-four parents were interviewed and data were analysed using a descriptive phenomenological approach. Findings show that being present at a child's anaesthesia and surgery is a long, continuous process that begins at home. Parents struggle to face strong emotions in a special and frightening environment, focussing on their child's well-being while trying to remain control in this situation. Security and trust are vital, but it's challenging to relinquish control in an uncertain situation. Professional caregivers can promote trust and participation, but an awareness that something can go wrong affects parents on a deep level. In conclusion, parental presence at induction of anaesthesia is important but can be overwhelming and anxiety-inducing for some parents. Parents should be seen as a resource rather than a disturbance. Overall, the healthcare system should prioritise parents' involvement and seek to create an environment where they feel supported and included.

Exposed - a semantic concept analysis of its origin, meaning change over time and its relevance for caring science.

PURPOSE: A patient is vulnerable and exposed due to illness, relies on and surrender to other people. In caring this means a special dependency. The aim of this study was to describe the origin of the concept 'exposed', to elucidate how the definition of this term has changed over time, and to outline its relevance in caring science. METHOD: A semantic concept analysis in two phases was conducted. RESULTS: The findings show that over time, the degree of binding of the following synonyms has become stronger; unprotected/defenseless, naked/bare, pressed/jostled and unsafe/unprotected and can easily be transferred to a clinical nursing context. CONCLUSIONS: This study provides a deeper understanding of the concept 'exposed' semantically. Being exposed is a profound experience for patients who need to be seen as the person they really are. A life-world led care has an existential power that can support professionals, strengthen patients' health processes, and alleviate the patient's suffering.

Prediction of Postoperative Delirium After Cardiac Surgery with A Quick Test of Cognitive Speed, Mini-Mental State Examination and Hospital Anxiety and Depression Scale.

Purpose: To evaluate if preoperative assessment with A Quick Test of Cognitive Speed (AQT) could increase the accuracy of predicting delirium after cardiac surgery compared to Mini-Mental State Examination (MMSE), and examine if a composite of variables, including cognitive function and depressive symptoms, could be useful to predict delirium. Patients and Methods: Cardiac surgery was performed in 218 patients (mean age 72 years). Preoperative evaluation involved AQT, MMSE and Hospital Anxiety And Depression Scale (HADS). Postoperative delirium was assessed using Nursing Delirium Screening Scale (Nu-DESC) and Confusion Assessment Method-ICU (CAM-ICU). Logistic regression was performed to detect predictors of postoperative delirium and receiver operator characteristic curves (ROC) with area under the curve (AUC) to determine the accuracy. Results: Postoperative delirium occurred in 47 patients (22%) who had lower MMSE scores (median (range), 27 (19-30) vs 28 (20-30), p=0.009) and slower AQT (median (range), 76 (48-181) vs 70 (40-182) seconds, p=0.030) than patients without delirium. Predictive power measured as AUC (95% CI) was 0.605 (0.51-0.70) for AQT and 0.623 (0.53-0.72) for MMSE. Logistic regression (OR, 95% CI) showed MMSE <27 points (2.72, 1.27-5.86), AQT >70 sec (2.26, 1.03-4.95), HADS-D >4 points (2.60, 1.21-5.58) and longer cardiopulmonary bypass-time (1.007, 1.002-1.013) to be associated with postoperative delirium. Combining these parameters yielded an AUC of 0.736 (0.65-0.82). Conclusion: The ability of predicting delirium using AQT was similar to MMSE, and only slightly higher by combining AQT and MMSE. Adding HADS-D and cardiopulmonary bypass-time to MMSE and AQT increased the predictive power to a borderline acceptable discriminatory value. Preoperative cognitive tests and screening for depressive symptoms may help identify patients at risk of postoperative delirium. Yet, there is still a need to establish useful preoperative tests.

Risk factors for reoperation due to periprosthetic joint infection after elective total hip arthroplasty: a study of 35,056 patients using linked data of the Swedish Hip Arthroplasty Registry (SHAR) and Swedish Perioperative Registry (SPOR).

BACKGROUND: In Sweden, the incidence of a prosthetic joint infection (PJI) after a planned Total Hip Arthroplasty (THA) is 1.3%, but the worldwide incidence of PJI after THA is unknown. This study explores associations between reoperation due to PJI and potential risk factors. METHODS: Primary elective THA surgery registered in both the Swedish Hip Arthroplasty Registry (SHAR) and the Swedish Perioperative Registry (SPOR) between 1 January 2015 and 31 December 2019 were included in this registry study, resulting in a total study population of 35,056 cases. The outcome variable was reoperation as the result of PJI within a year after surgery. Data were analysed using a multivariable Cox regression model. RESULTS: Reoperation due to PJI occurred in 460 cases (i.e., 1.3% of the study population). Each year of age increased the risk with 2% (HR 1.02 Cl 1.01, 1.03 P = < 0.001). Compared to men, women had significantly less risk for reoperation (HR 2.17 Cl 1.79, 2.53 P = < 0.001). For patients with obesity (BMI > 30), the risk increased considerably compared to underweight, normal weight, or overweight patients (HR 1.89 Cl 1.43, 2.51 P = < 0.001). The risk also increased by 6% for every 10 min of operative time (HR 1.06 Cl 1.02, 1.09 P = < 0.001). Patients having general anaesthesia had greater risk compared to those with spinal anaesthesia (HR 1.34 Cl 1.04, 1.73 P = 0.024). Finally, a lateral approach showed higher risk of reoperation than a posterior approach (HR 1.43 Cl 1.18, 1.73 P = < 0.001). CONCLUSION: Recognition of the several risk factors identified in this study will be important for the perioperative management of patients undergoing THA.

The interplay between children, their parents and anaesthesia staff during the child's anaesthesia - An observational study.

AIMS AND OBJECTIVES: To interpret and understand the interplay between children, their parents, and anaesthetic staff to gain a greater understanding of children being anaesthetised. BACKGROUND: Anaesthesia induction is a stressful procedure for the child and parents in the technologically advanced environment in the operating room (OR). Anaesthesia staff are a key resource for ensuring safety and interplays, but the meeting is often short, intensive, and can affect the child and the parent. DESIGN: A qualitative observational design with a hermeneutic approach. METHODS: Twenty-seven non-participant observations were conducted and videotaped when children were being anaesthetised. The SRQR checklist was used. RESULTS: The result is presented as a theatre play with three headings; the scene, the actors, and the plot. The scene was not designed for the child or the parent's comfort and could lead to anxiety and insecurity. Four themes described the interplays: The need to be inviting and to be invited, The need for varying compliance, The need for mutual dependence, and The need to give and to receive emotional support. The plot could lead to uncertainty, and the interplay could change between being caring and uncaring depending on the actors. CONCLUSIONS: The technologically advanced environment in the OR constituted an emotional obstacle, but the anaesthesia staff themselves can be a powerful resource creating a caring environment. The outcome of the plot may depend on the anaesthesia staff's bearing. RELEVANCE TO CLINICAL PRACTICE: A caring approach in the OR requires a willingness from the anaesthesia staff to invite the child to participate and find a balance between helping the parents to find their place in the OR and support them in supporting their child. The findings can start reflections in the unit on how to create a more caring environment.

Nurse anesthetist attitudes towards parental presence during anesthesia induction- a nationwide survey.

AIMS: To describe nurse anesthetists' attitudes towards the importance of parental presence during their child's anaesthesia induction and to explore associating factors. DESIGN: A cross-sectional design. METHODS: Nurse anesthetists from 55 Swedish hospitals were asked to participate (n = 1,285). A total of 809 completed the questionnaire, Families' Importance in Nursing Care-Nurses' Attitudes (FINC-NA) during 2018. Data were analysed by descriptive statistics and multiple linear regression analysis. RESULTS: Nurse anesthetists generally had a positive attitude towards the importance of parental presence. They reported a more positive attitude in family as a resource in nursing care (median = 40) followed by family as a conversational partner (median = 25), family not as a burden (median = 17) and family as its own resource (median = 13). Multiple linear regression analyses showed that working in a district hospital, working only with children, having routines/memorandum about parental presence, being a woman, allowing both parents to be present in their child's anaesthesia and greater experience of children's anesthesia, were associated with a more positive attitude. CONCLUSION: This nationwide survey contributes important knowledge for understanding nurse anesthetists' attitudes and the result shows that nurse anesthetists generally have a positive attitude towards the importance of parents. Areas of improvement were, however, identified; the nurses tend to not value family as its own resource and family as a conversational partner highly. IMPACT: Nurse anesthetists have a crucial role in children's anesthesia care since the quality of parental presence experience depends on a positive attitude from the nurses. Parental involvement is important to establish a child-centered anaesthesia care, which should be highlighted in the education of nurse anesthetists. Parental involvement should also be addressed in healthcare policies and routines should be established.

Covering surgical instruments with single- or double-layer drape pending surgery: an experimental study in a perioperative setting.

BACKGROUND: Surgical site infections (SSI) constitute a severe threat to surgery patients. The surgical environment must be as free of contaminating microorganisms as possible. Using sterile surgical instruments while performing surgery is an absolute necessity for ensuring quality of care in perioperative settings. AIM: To compare bacterial contamination of agar plates after 15 h on set surgical instrument tables covered with a single- or double-layer drape. METHODS: An experimental design was used consisting of set instrument tables with six agar plates on each table: four instrument tables were covered with a single-layer drape and four instrument tables were covered with a double-layer drape. This set-up was repeated on nine occasions during the period of data collection, making 76 set instrument tables in total. As a control, one instrument table was uncovered on four of those occasions. RESULTS: The double-layer drape cover showed a significantly (P = 0.03) lower number of colony forming units (CFU) per agar plate than the single-layer drape covering. As expected, the uncovered instrument tables were highly contaminated. DISCUSSION: Our results indicate that it is good practice to cover instruments properly with at least a single-layer drape before a surgical procedure. If there is difficulty achieving optimal conditions while setting the instrument tables (e.g. positioning the patient for general anaesthesia), it is a better option to set the instrument tables earlier and cover them with a double-layer drape. These precautions will help protect the patient from harm and unnecessary SSI by lowering microbiological burden, a key factor in developing SSI.

I'm afraid! Children's experiences of being anesthetized.

INTRODUCTION: Children experience anesthetization as stressful, and many preoperative measures have been tested for reducing their anxiety. There is, however, little research about children's own experiences and thoughts about being anesthetized. AIMS: The aim of the present study was thus to explain and understand the meaning of being anesthetized as experienced by children. METHODS: A qualitative lifeworld hermeneutic approach was used. Data were collected through nonparticipant video observations, field notes, and interviews. The participants were children (n = 28) aged 4-13 years who required general elective minor surgery performed in four Swedish hospitals. RESULTS: The four interpreted themes describe the children's experiences of being anesthetized: Being powerless, Striving for control, Experiencing an ambiguous comprehensibility, and Seeking security. The children struggled with anxiety as a result of their inability to protect themselves from perceived external threats while being anesthetized. In order to meet their needs, it would be beneficial for them to receive appropriate information in a calm, supportive, and protective environment. CONCLUSION: The reasons for children experiencing anxiety when being anesthetized are multifaceted, and this study highlights the importance of listening to each child's own voice and striving to create an individually adapted caring and safe environment with as much protection as possible.

Swedish outcomes of the Overall Assessment of the Speaker's Experience of Stuttering in an international perspective.

Aim: The purpose of the present project was to translate the Overall Assessment of the Speaker's Experience of Stuttering (OASES) to Swedish, and to compare the results with available international data.Method: The Swedish versions of OASES-A, OASES-T and OASES-S were administered to 80 adults, 27 teenagers and 32 children who stutter, respectively. The overall impact scores and the impact scores for each of the four sections of the instrument were analyzed in relation to other studies involving the OASES.Results: The results revealed that all three Swedish versions of OASES had normally distributed outcomes and that they were reliable and valid. The overall impact scores for adults (2.33), teenagers (2.60) and children (2.28) all fell within Impact Rating Moderate. The mean overall impact score for OASES-A-S was significantly lower than corresponding data from USA, Australia and Japan (p < .01). There was no difference between Swedish and American teenagers, or between Swedish and American or Dutch schoolchildren.Conclusion: There seems to be cultural differences in the experience of negative consequences associated with stuttering. This suggests that cultural aspects should be carefully considered in assessment, treatment, and research involving individuals who stutter.

Intraoperative prevention of Surgical Site Infections as experienced by operating room nurses.

Aim: This study examines how OR nurses experience intraoperative prevention of SSIs. Introduction: Infections related to surgical procedures create both great patient suffering and high costs for society. Therefore, prevention of Surgical Site Infections (SSIs) should be a high priority for all surgical settings. All details of intraoperative care need to be investigated and evaluated to ensure best practices are evidence-based. Methods: This study uses the Reflective Lifeworld Research (RLR) approach, which is grounded in phenomenology. Participants were OR nurses with at least one year of clinical experience. In total, 15 participants from seven hospitals made contact and were included in this interview study. Results: Prevention of SSIs takes both head and hand. It requires long-term, continuous, and systematic work in several parallel processes, both intellectually and organisationally. The hierarchical tradition of the operating room is often ambiguous, shielded by its safe structures but still restricted by traditional patterns. Confident relations and resolute communication within the team generate favorable conditions for preventing SSIs. Conclusions: By setting up mutual platforms and forums for quality development, increasing legitimacy for OR nurses and establishing fixed teams, prevention of SSIs will continue to improve, ensuring the patients' safety during intraoperative care.

PP4397/FlgZ provides the link between PP2258 c-di-GMP signalling and altered motility in Pseudomonas putida.

Bacteria swim and swarm using rotating flagella that are driven by a membrane-spanning motor complex. Performance of the flagella motility apparatus is modulated by the chemosensory signal transduction system to allow navigation through physico-chemical gradients - a process that can be fine-tuned by the bacterial second messenger c-di-GMP. We have previously analysed the Pseudomonas putida signalling protein PP2258 that has the capacity to both synthesize and degrade c-di-GMP. A PP2258 null mutant displays reduced motility, implicating the c-di-GMP signal originating from this protein in control of P. putida motility. In Escherichia coli and Salmonella, the PilZ-domain protein YcgR mediates c-di-GMP responsive control of motility through interaction with the flagellar motors. Here we provide genetic evidence that the P. putida protein PP4397 (also known as FlgZ), despite low sequence homology and a different genomic context to YcgR, functions as a c-di-GMP responsive link between the signal arising from PP2258 and alterations in swimming and swarming motility in P. putida.

Supporting patients learning to live with diabetes: a phenomenological study.

This article describes a study of the phenomenon of supporting patients who are learning to live with diabetes, from a diabetes specialist nurse (DSN) perspective. Guided by principles of reflective lifeworld research, data from six interviews (four in groups and two individual) with 16 DSNs were analysed. The results show that, in order to support learning, DSNs use a self-critical approach with the insight that they should not take over responsibility for their patients' diabetes. The DSNs support, encourage and challenge the patients to self-reflect and take responsibility based on patients' own goals and needs. To provide support, DSNs need to assume a tactful, critically challenging approach, dare to confront patients' fears and other emotions and have the insight to know that the responsibility for learning and integration of the condition lies with the patient. To be able to support patients in this way, it is necessary that the DSN is mentored and supported in this role.

Patients' experiences with at-home preoperative skin disinfection before elective hip replacement surgery.

The aim of the study was to describe patients' experiences with preoperative skin disinfection carried out in their home before elective hip replacement surgery with the aim of lowering the microbial burden and avoiding surgical site infections. The literature was reviewed for relevant studies. Optimal preparations before surgery depend on patients being able to assimilate preoperative information and instructions. The study was based on 14 interviews with patients who had undergone elective hip replacement surgery. Data were analysed with qualitative manifest content analysis according to Graneheim and Lundman (2004). The main categories of findings were: patients' experience of obstacles and limitations, the importance of supportive surroundings, and personal resources as strength when performing preoperative skin disinfection. The findings of this study agree with earlier studies showing a lack of compliance to preoperative skin disinfection. The findings also suggest reasons for non-compliance. Preoperative skin disinfection involves many important steps that need to be accomplished to ensure the maximum effect on microbial burden on skin surface. These steps can be difficult for some patient groups. Perioperative dialogue is one way to identify patients' individual needs and to help patients participate in the process. The study concludes that patients who carried out skin disinfection at home before surgery have a great responsibility to prepare themselves. The challenge for perioperative nurses who work with preoperative information is to identify and individually guide those patients who need extended support so that all patients with elective hip replacement surgery receive the same quality of care. Further research should focus on how caregivers discover individuals with extended needs and on identifying the kind of support that is effective to achieve optimal conditions for hip replacement surgery.

Patients' experiences of support for learning to live with diabetes to promote health and well-being: A lifeworld phenomenological study.

Learning to live with diabetes in such a way that the new conditions will be a normal and natural part of life imposes requirements on the person living with diabetes. Previous studies have shown that there is no clear picture of what and how the learning that would allow persons to incorporate the illness into their everyday life will be supported. The aim of this study is to describe the phenomenon of support for learning to live with diabetes to promote health and well-being, from the patient's perspective. Data were collected by interviews with patients living with type 1 or type 2 diabetes. The interviews were analysed using a reflective lifeworld approach. The results show that reflection plays a central role for patients with diabetes in achieving a new understanding of the health process, and awareness of their own responsibility was found to be the key factor for such a reflection. The constituents are responsibility creating curiosity and willpower, openness enabling support, technology verifying bodily feelings, a permissive climate providing for participation and exchanging experiences with others. The study concludes that the challenge for caregivers is to create interactions in an open learning climate that initiates and supports reflection to promote health and well-being.

Methodological support for the further abstraction of and philosophical examination of empirical findings in the context of caring science.

Phenomena in caring science are often complex and laden with meanings. Empirical research with the aim of capturing lived experiences is one way of revealing the complexity. Sometimes, however, results from empirical research need to be further discussed. One way is to further abstract the result and/or philosophically examine it. This has previously been performed and presented in scientific journals and doctoral theses, contributing to a greater understanding of phenomena in caring science. Although the intentions in many of these publications are laudable, the lack of methodological descriptions as well as a theoretical and systematic foundation can contribute to an ambiguity concerning how the results have emerged during the analysis. The aim of this paper is to describe the methodological support for the further abstraction of and/or philosophical examination of empirical findings. When trying to systematize the support procedures, we have used a reflective lifeworld research (RLR) approach. Based on the assumptions in RLR, this article will present methodological support for a theoretical examination that can include two stages. In the first stage, data from several (two or more) empirical results on an essential level are synthesized into a general structure. Sometimes the analysis ends with the general structure, but sometimes there is a need to proceed further. The second stage can then be a philosophical examination, in which the general structure is discussed in relation to a philosophical text, theory, or concept. It is important that the theories are brought in as the final stage after the completion of the analysis. Core dimensions of the described methodological support are, in accordance with RLR, openness, bridling, and reflection. The methodological support cannot be understood as fixed stages, but rather as a guiding light in the search for further meanings.

Manoeuvring between anxiety and control: patients' experience of learning to live with diabetes: a lifeworld phenomenological study.

Research shows that people with diabetes want their lives to proceed as normally as possible, but some patients experience difficulty in reaching their desired goals with treatment. The learning process is a complex phenomenon interwoven into every facet of life. Patients and healthcare providers often have different perspectives in care which gives different expectations on what the patients need to learn and cope with. The aim of this study, therefore, is to describe the experience of learning to live with diabetes. Interviews were conducted with 12 patients afflicted with type 1 or type 2 diabetes. The interviews were then analysed with reference to the reflective lifeworld research approach. The analysis shows that when the afflicted realize that their bodies undergo changes and that blood sugar levels are not always balanced as earlier in life, they can adjust to their new conditions early. The afflicted must take responsibility for balancing their blood sugar levels and incorporating the illness into their lives. Achieving such goals necessitates knowledge. The search for knowledge and sensitivity to changes are constant requirements for people with diabetes. Learning is driven by the tension caused by the need for and dependence on safe blood sugar control, the fear of losing such control, and the fear of future complications. The most important responsibilities for these patients are aspiring to understand their bodies as lived bodies, ensuring safety and security, and acquiring the knowledge essential to making conscious choices.

Nurses' lived experiences of intensive care unit bed spaces as a place of care: a phenomenological study.

BACKGROUND: The environment of an intensive care unit (ICU) is, in general, stressful and has an impact on quality of care in terms of patient outcomes and safety. Little is known about nurses' experiences, however, from a phenomenological perspective with regard to the critical care settings as a place for the provision of care for the most critically ill patients and their families. AIM: The aim of this study was to explore nurses' lived experiences of ICU bed spaces as a place of care for the critically ill. DESIGN AND METHODS: A combination of qualitative lifeworld interviews and photos --photovoice methodology --was used when collecting data. Fourteen nurses from three different ICUs participated. Data were analysed using a phenomenological reflective lifeworld approach. FINDINGS: An outer spatial dimension and an inner existential dimension constitute ICU bed spaces. Caring here means being uncompromisingly on call and a commitment to promoting recovery and well-being. The meanings of ICU bed spaces as a place of care comprise observing and being observed, a broken promise, cherishing life, ethical predicament and creating a caring atmosphere. CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE: The architectural design of the ICU has a great impact on nurses' well-being, work satisfaction and the provision of humanistic care. Nurses need to be involved in the process of planning and building new ICU settings. There is a need for further research to highlight the quality of physical environment and its impact on caring practice.

Patient-nurse anesthetist interaction during regional anesthesia and surgery based on video recordings.

PURPOSE: The purpose of this study was to interpret and describe the patient-nurse anesthetist (NA) interaction during regional anesthesia. DESIGN: Video recordings conducted during orthopedic surgery at a surgical clinic in Sweden formed the basis for the study, in which three patients and three NAs participated. METHODS: A hermeneutic analysis was conducted on the data. FINDING: The findings of the analysis demonstrated that the NA was in either "present" presence or "absent" presence in the awake patient's visual field during surgery. The NA's professional actions at times dominated the patient's existential being in the intraoperative situation. The findings conveyed insights about the patient-NA interaction that open up possibilities for nurses to understand and reflect upon their own practice in an expanded way. CONCLUSIONS: Using video recordings for reflections enables development of professional skills that positively influence the care quality for patients during regional anesthesia.

Genetic dissection of a motility-associated c-di-GMP signalling protein of Pseudomonas putida.

Lack of the Pseudomonas putida PP2258 protein or its overexpression results in defective motility on solid media. The PP2258 protein is tripartite, possessing a PAS domain linked to two domains associated with turnover of c-di-GMP - a cyclic nucleotide that controls the switch between motile and sessile lifestyles. The second messenger c-di-GMP is produced by diguanylate cyclases and degraded by phosphodiesterases containing GGDEF and EAL or HD-GYP domains respectively. It is common for enzymes involved in c-di-GMP signalling to contain two domains with potentially opposing c-di-GMP turnover activities; however, usually one is degenerate and has been adopted to serve regulatory functions. Only a few proteins have previously been found to have dual enzymatic activities - being capable of both synthesizing and hydrolysing c-di-GMP. Here, using truncated and mutant derivatives of PP2258, we show that despite a lack of complete consensus in either the GGDEF or EAL motifs, the two c-di-GMP turnover domains can function independently of each other, and that the diguanylate cyclase activity is regulated by an inhibitory I-site within its GGDEF domain. Thus, motility-associated PP2258 can be added to the short list of bifunctional c-di-GMP signalling proteins.