Critical incidents and post-traumatic stress symptoms among experienced registered nurses during the COVID-19 pandemic: A cross-sectional study.

Background: Registered nurses working on the frontline during the COVID-19 pandemic encountered significant challenges, including exposure to critical incidents. Critical incidents refer to sudden unexpected clinical events that surpass an individual's ability to cope, leading to considerable psychological distress, which could potentially result in the development of post-traumatic stress disorder symptoms. Research has shown a high prevalence of post-traumatic stress disorder symptoms among healthcare workers, particularly those in close contact with COVID-19 patients. Objective: To assess the levels of post-traumatic stress symptoms among registered nurses in relation to exposure to working conditions during the COVID-19 pandemic, such as how much their work was affected by the pandemic, re-deployment, working hours hindering sufficient recovery between shifts and critical incidents. Design: Cross sectional study. Settings: The registered nurses working in multiple health care services covering all 21 geographic regions in Sweden. Participants: A total of 1,923 registered nurses, who are part of a Swedish national cohort and have been followed since their nursing education, were invited to participate in a survey in late September 2021 (15 to 19 years post graduation). Methods: The data were analyzed using descriptive statistics, unpaired t-tests, and one-way analysis of variance. Cohen's d was employed to quantify differences in mean levels between subgroups. Results: The response rate were 56.5 %. Over 50 % of experienced registered nurses reported significant disruptions to their work environments. In total, 85 % of registered nurses were exposed to at least one critical incident in their work during the pandemic, with 60 % facing organisational changes and nearly 50 % experiencing emotionally distressing situations. The exposure to work situations involving critical incidents consistently demonstrated strong associations with higher levels of post-traumatic stress disorder symptoms compared to those not exposed, with effect sizes ranging from moderate to high. Conclusions: This study underscores the profound impact that working conditions, such as redeployment and exposure to critical incidents, have on the mental health of registered nurses. We offer valuable insights into registered nurses' pandemic-related challenges, highlighting the need for support and interventions to prevent and manage critical incidents, ultimately promoting their well-being. We also highlight the significance of thorough workforce readiness planning for future pandemics and other challenging health care scenarios, such as staff shortage.

Callers' Descriptions of Stroke Symptoms during Emergency Calls in Victims Who Have Fallen or Been Found Lying Down: A Qualitative Content Analysis.

Early identification of stroke symptoms is essential. The rate of stroke identification by call-takers at emergency medical communication centres (EMCCs) varies, and patients who are found in a lying down position are often not identified as having an ongoing stroke. OBJECTIVES: this study aimed to explore signs and symptoms of stroke in patients who had fallen or were found in a lying position. DESIGN: a retrospective exploratory qualitative study design was used. METHOD: a total of 29 emergency calls to EMCCs regarding patients discharged with a stroke diagnosis from a large teaching hospital in Stockholm, Sweden, in January-June 2011, were analysed using qualitative content analysis. RESULTS: during the emergency calls, the callers described a sudden change in the patient's health status including signs such as the patient's loss of bodily control, the patient's perception of a change in sensory perception, and the callers' inability to communicate with the patient. CONCLUSIONS: The callers' descriptions of stroke in a person found in a lying position are not always as described in assessment protocols describing the onset of a stroke. Instead, the symptom descriptions are much vaguer. Therefore, to increase identification of stroke during emergency calls, there is a need for an increased understanding of how callers describe stroke symptoms and communicate with the call-takers.

Using High-Fidelity Virtual Reality for Mass-Casualty Incident Training by First Responders - A Systematic Review of the Literature.

INTRODUCTION: First responders' training and learning regarding how to handle a mass-casualty incident (MCI) is traditionally based on reading and/or training through computer-based scenarios, or sometimes through live simulations with actors. First responders should practice in realistic environments to narrow the theory-practice gap, and the possibility of repeating the training is important for learning. High-fidelity virtual reality (VR) is a promising tool to use for realistic and repeatable simulation training, but it needs to be further evaluated. The aim of this literature review was to provide a comprehensive description of the use of high-fidelity VR for MCI training by first responders. METHODS: A systematic integrative literature review was used according to Whittemore and Knafl's descriptions. Databases investigated were PubMed, CINAHL Complete, Academic Search Ultimate, Web of Science, and ERIC to find papers addressing the targeted outcome. The electronic search strategy identified 797 potential studies. Seventeen studies were deemed eligible for final inclusion. RESULTS: Training with VR enables repetition in a way not possible with live simulation, and the realism is similar, yet not as stressful. Virtual reality offers a cost-effective and safe learning environment. The usability of VR depends on the level of immersion, the technology being error-free, and the ease of use. CONCLUSIONS: This integrative review shows that high-fidelity VR training should not rule out live simulation, but rather serve as a complement. First responders became more confident and prepared for real-life MCIs after training with high-fidelity VR, but efforts should be made to solve the technical issues found in this review to further improve the usability.

Newly employed nurses' transition into their new role in the ambulance service- a qualitative study.

BACKGROUND: Nurses are essential to ensure safe and high-quality care worldwide. The World Health Organization (WHO) forecasts a shortfall of 5.9 million nurses by the year 2030, and in the ambulance service, the turnover rate ranges between 20% and 30%. With this study, we seek to increase knowledge by exploring the transition of newly employed experienced nurses into their roles in the ambulance service using the Meleis theory of transition. Through understanding transition, support for newly employed nurses can be developed, turnover rates can decrease, and in the long term, patient safety may increase. DESIGN: The study employed a qualitative approach. METHODS: Eighteen newly employed experienced nurses were individually interviewed four times during their first six months of employment. Deductive qualitative content analysis was used to analyse the data. The reporting of this research adheres to the COREQ checklist. RESULTS: The results show that the transition process for newly employed nurses in the ambulance service encompassed all five aspects of Meleis' transition theory: Awareness, Engagement, Change and Difference, Time Span, and Critical Points. The transition period varied among the participants, and it was also observed that not all nurses went through a transition in line with Meleis' theory. Additionally, there were findings that nurses highlighted the impact of the ambulance service culture on their transition. CONCLUSIONS: The findings provide a more profound insight into how newly employed nurses with previous experience as nurses navigate their roles and transition into a new profession in a new context. An ambulance service where the organisation is aware of the newly employed nurses' transition processes and what the transition entails can develop and promote a supportive and permissive culture within the ambulance service. For newly employed nurses who are adequately supported, health transitions are more likely to occur, which may increase retention and in the long term increase patient safety. The insights gained from the study can empower ambulance organisations to improve their introduction programmes and offer enhanced support for newly employed experienced nurses entering the ambulance service.

Finnish emergency medical services managers' and medical directors' perceptions of collaborating with patients concerning patient safety issues: a qualitative study.

OBJECTIVES: This study aimed to describe emergency medical services (EMS) managers' and medical directors' perceptions of collaborating with patients concerning patient safety issues in the EMS. DESIGN: The study used a descriptive qualitative approach. Five focus groups and two individuals were interviewed using a semi-structured guide with open-ended questions. The data were analysed using reflexive thematic analysis. Consolidated criteria for Reporting Qualitative research was used to guide the reporting of this study. SETTING: EMS organisations from Finland's five healthcare districts. PARTICIPANTS: EMS medical directors (n=5) and EMS managers (n=14). Purposive sampling was used. RESULTS: Two main themes, 'Patient safety considered an organisational responsibility' and 'EMS patients' opportunities and obstacles to speaking up', were generated from the data. Under the main theme, 'Patient safety considered an organisational responsibility', were three subthemes: patient safety considered part of the quality in EMS, system-level models for handling and observing patient safety in EMS, and management's ability to find a balance when using patients' feedback for patient safety development. Under the other main theme were four subthemes: 'social and feedback skills of EMS personnel and management', 'managements' assumptions of patients' reasons for not speaking up', 'EMS organisations' different but unsystematic ways of collecting feedback' and 'management's openness to develop patient participation'. CONCLUSIONS: The nature of the EMS organisations and EMS assignments could affect a patient's participation in developing patient safety in EMS. However, EMS managers and medical directors are receptive to collaborating with patients concerning patient safety issues if they have sufficient resources and a coherent way to collect patient safety concerns. The management is open to collaborating with patients, but there is a need to develop a systematic method with enough resources to facilitate the management's collaborating with patients.

A phenomenological interview study with patients being non-conveyed in the ambulance service.

BACKGROUND: Non-conveyed patients (i.e. patients who are not transported to a hospital after being assessed by ambulance clinicians) represent a significantly increasing proportion of all patients seeking ambulance care. Scientific knowledge about patients' non-conveyance experiences is sparse. This study describes the lived experiences of non-conveyed patients in an ambulance care context. METHODS: A reflective lifeworld research (RLR) approach founded on phenomenology is used. Data is derived from nine in-depth interviews with patients not conveyed by the ambulance service in a major Swedish region. RESULTS: Patients' lived experiences of becoming acutely ill or injured and not conveyed by ambulance to a hospital are characterised by several dynamic movements: losing and regaining situational and bodily control, dependence and autonomy, external competence and inner knowledge, handing over and regaining responsibility, and fear and security. CONCLUSIONS: Patients' lived experiences of non-conveyance are complex and versatile. Although non-conveyed patients initially experience strong fear and the loss of situational and bodily control, they gradually feel more secure when experiencing confirmation and trust, which evolves into insecurity and uncertainty. The non-conveyance situation's complexity from a patient's perspective implies the need for ambulance organisations to take measures to prevent further suffering. Non-conveyed patients must be taken seriously in their unique situations, requiring ambulance clinicians to reflect and act with a conscious ethical perspective before, during and after their visit.

The complexity of kidney disease and diagnosing it - cystatin C, selective glomerular hypofiltration syndromes and proteome regulation.

Estimation of kidney function is often part of daily clinical practice, mostly done by using the endogenous glomerular filtration rate (GFR)-markers creatinine or cystatin C. A recommendation to use both markers in parallel in 2010 has resulted in new knowledge concerning the pathophysiology of kidney disorders by the identification of a new set of kidney disorders, selective glomerular hypofiltration syndromes. These syndromes, connected to strong increases in mortality and morbidity, are characterized by a selective reduction in the glomerular filtration of 5-30 kDa molecules, such as cystatin C, compared to the filtration of small molecules <1 kDa dominating the glomerular filtrate, for example water, urea and creatinine. At least two types of such disorders, shrunken or elongated pore syndrome, are possible according to the pore model for glomerular filtration. Selective glomerular hypofiltration syndromes are prevalent in investigated populations, and patients with these syndromes often display normal measured GFR or creatinine-based GFR-estimates. The syndromes are characterized by proteomic changes promoting the development of atherosclerosis, indicating antibodies and specific receptor-blocking substances as possible new treatment modalities. Presently, the KDIGO guidelines for diagnosing kidney disorders do not recommend cystatin C as a general marker of kidney function and will therefore not allow the identification of a considerable number of patients with selective glomerular hypofiltration syndromes. Furthermore, as cystatin C is uninfluenced by muscle mass, diet or variations in tubular secretion and cystatin C-based GFR-estimation equations do not require controversial race or sex terms, it is obvious that cystatin C should be a part of future KDIGO guidelines.

Prehospital nursing students' experiences of patient safety culture in emergency medical services-A qualitative study.

AIMS AND OBJECTIVES: To describe prehospital nursing students' experiences of patient safety culture in emergency medical services during their internship. BACKGROUND: Patient safety culture in the emergency medical services is a complex phenomenon including more than organisational policies and practices and professionals' technical skills. DESIGN: The descriptive qualitative approach used the Sharing Learning from Practice to improve Patient Safety Learning Event Recording Tool, which includes both open-ended and structured questions. METHODS: Purposeful sampling was used, and data were collected from graduating prehospital nursing students (n = 17) from three Finnish Universities of Applied Sciences. Open-ended questions were reviewed using thematic analysis, and frequencies and percentages were derived from structured questions. COREQ guidelines were used to guide this study. RESULTS: Four themes were identified during the thematic analysis: environmental and other unexpected factors in emergency medical services, working practices and professionalism in emergency medical services, teamwork in emergency medical services and feelings related to patient safety events in emergency medical services. Patient safety events described by students were seldom reported in the healthcare system or patient files. According to the students, such events were most likely related to communication, checking/verification and/or teamwork. CONCLUSIONS: This study shows that prehospital nursing students can produce important information about patient safety events and the reasons that contributed to those events. Therefore, emergency medical services organisations and managers should use students' observations to develop a patient safety culture in emergency medical services. RELEVANCE TO CLINICAL PRACTICE: Understanding how prehospital nursing students have experienced patient safety culture during their internships on ambulances can support educational institutions, together with emergency medical services organisations and managers, to improve policies for students to express patient safety concerns as well as patient safety successes.

Paramedics' perceptions of job demands and resources in Finnish emergency medical services: a qualitative study.

BACKGROUND: Paramedics' fatigue is rising. Stress factors show increased risk for burnout, fatigue, leaving the profession, decreased performance and risk for patient safety. Meanwhile, paramedics' strong community of practice, autonomy and a sense of professional respect are important factors in forming psychological resilience. We aimed to explore Finnish paramedics' perceptions of job demands and resources. METHODS: Our study design was descriptive, inductive with a constructivist approach. Using reflexive thematic analysis, we analyse open-ended questions, from a web-based survey and essays written by Finnish paramedic masters-degree students. The study followed the SRQR checklist. RESULTS: We identified paramedics' job demands as stress from a high workload, environmental factors and emotional burden. Performance expectations and a sense of inadequacy were further noted, as well as an organizational culture of hardiness, presenting lack of support and sense of inequality. Paramedics' job resources were pressure management strategies, which were expressed as positive coping mechanisms, agency to affect workload and professional self-actualization, expressed as psychologically safe work community, professional pride and internal drive to professional development. CONCLUSIONS: Finnish paramedics exhibit resources and demands related to uncertainty and emotional burden as well as cultural hardiness and psychological safety in communities. PATIENT OR PUBLIC CONTRIBUTION: This study was done based on survey data collected and analysed by the authors. No patient or public contribution was utilized for this study.

Developing new possibilities for interprofessional learning- students' experience of learning together in the ambulance service.

BACKGROUND: It is known that setting and context matters, and contextual factors influence interprofessional education (IPE). Activities developed in a new setting should therefore be evaluated to determine students' experiences and learning. IPE in the ambulance service may present a new setting for interprofessional learning (IPL). AIM: The aim of this study was to explore undergraduate students' experiences of collaboration and learning together during their clinical rotation in the ambulance service. STUDY DESIGN AND METHOD: A mixed convergent parallel design was used to describe nursing and medical students' experiences of collaboration and learning together during their clinical rotation in the ambulance service during autumn 2019. Two group interviews with nursing students (n = 20; response rate 80%) were conducted and the medical students (n = 40; response rate 72.5%) answered a self-assessment questionnaire regarding their IPE. The group discussions were analysed using an inductive thematic analysis and descriptive statistics were used to describe the medical students' self-assessed experiences and competencies in interprofessional collaboration. RESULTS: In the context of the ambulance service, some of the challenges included, the team vary daily, a context that can be unpredictable, and the team being required to make decisions in various situations with limited support. The context presented good opportunities to learn together, since they faced a broad variety of situations and had opportunities to follow patients through the chain of care. CONCLUSION: The students' experiences show that the ambulance service offers possibilities for IPL. The ambulance service enhanced the students' learning in an unfamiliar environment, encouraging them to develop collaborative learning strategies and situational leadership regardless of established hierarchical structures and stereotypes that are sometimes present in other parts of the health care service. ETHICAL APPROVAL: By the Swedish Ethical Review Authority. No: 2019-03595.

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.

Non-conveyance of older adult patients and association with subsequent clinical and adverse events after initial assessment by ambulance clinicians: a cohort analysis.

BACKGROUND: Older adults (age ≥ 65 years) represent a significant proportion of all patients who are not transported to hospital after assessment by ambulance clinicians (non-conveyed patients). This study aimed to fill the knowledge gap in the understanding of the prevalence of older adult non-conveyed patients and investigate their characteristics and risk factors for subsequent and adverse events with those of younger non-conveyed patients comparatively. METHODS: This population-based retrospective cohort study included all adult non-conveyed patients who availed the ambulance service of Region Stockholm, Sweden in 2015; they were age-stratified into two groups: 18-64 and ≥ 65 years. Inter-group differences in short-term outcomes (i.e. emergency department visits, hospitalisations, and mortality within 7 days following non-conveyance) were assessed using multivariate regression analyses. RESULTS: Older adult patients comprised 48% of the 17,809 non-conveyed patients. Dispatch priority levels were generally lower among older non-conveyed patients than among younger patients. Non-conveyance among older patients occurred more often during daytime, and they were more frequently assessed by ambulance clinicians with nonspecific presenting symptoms. Approximately one in five older adults was hospitalised within 7 days following non-conveyance. Patients presenting with infectious symptoms had the highest mortality risk following non-conveyance. Oxygen saturation level < 95% or systolic blood pressure > 160 mmHg had significantly higher associations with hospitalisation within 7 days following non-conveyance in older adult patients. CONCLUSIONS: Older adult patients have an increased risk for adverse events following non-conveyance. In combination with a complex and variating presentation of symptoms and vital signs proved difficult for dispatch operators and ambulance clinicians to identify and assess, the identified risks raise questions on the patient safety of older adult non-conveyed patients. The results indicate a system failure that need to be managed within the ambulance service organisation to achieve higher levels of patient safety for older non-conveyed patients.

Finnish paramedics' professional quality of life and associations with assignment experiences and defusing use - a cross-sectional study.

BACKGROUND: Paramedics experience traumatic events and social emergencies during assignments while also being subjected to verbal and physical threats. Consequently, they are at risk for burnout and secondary traumatic stress, factors inherent to professional quality of life. Defusing and peer-support potentially decrease such symptoms; however, perceived defusing needs and use are not always balanced. Our aim was to explore Finnish paramedics' professional quality of life, using the Professional Quality of Life Scale, with associations to EMS assignment experiences as well as formal and informal defusing need and use over a 12-month period. METHODS: A quantitative study of 257 Finnish paramedics using a cross-sectional design. Study outcomes were secondary traumatic stress (STS), compassion satisfaction (CS), and burnout (BO) scores using the modified 9-item Short Professional Quality of Life scale (ProQOL). Likert-type scales were used to collect participants' recollections of assignment experiences and defusing from a 12-month period. Associations were explored using Spearman's correlation coefficients. RESULTS: Short ProQOL score medians were STS 4.00 (IQR 3), BO 6.00 (IQR 3) and CS 13.00 (IQR 3). STS and BO correlated to experiences of social emergencies and traumatic events while BO correlated to experiences of threat situations (r = 0.206, p = .001). Paramedics perceived a need for defusing in general associated with STS (r = 0.178, p < .001) and participated in informal defusing. Participation in defusing of any form did not associate with ProQOL scores. CONCLUSIONS: Finnish paramedics' more frequent experiences of social emergencies, traumatic events, and paramedic-directed threat situations were associated with higher levels of STS and BO. STS was also associated with paramedics' increased need for defusing and use of informal peer defusing, although neither STS, BO or CS scores associated to any defusing form. Managing paramedics STS and BO, while fostering CS, could therefore be a future research focus.

Exploring safety culture in the Finnish ambulance service with Emergency Medical Services Safety Attitudes Questionnaire.

BACKGROUND: Emergency Medical Services (EMS) is, by its nature, a challenging context that may create risks for both patients and employees. It is also known that an organisation's safety culture has an influence on both patient and employee safety. Finnish EMS organisations lack knowledge of how their safety culture is perceived by their employees. AIM: This study aims to test the psychometric properties of the Emergency Medical Services Safety Attitudes Questionnaire (EMS-SAQ) in a Finnish EMS setting. We also explore the connections between individual- and organisation-based characteristics and safety attitudes in the Finnish EMS. METHODS: A cross-sectional survey study design was used. The EMS-SAQ was used to collect data via social media. The instrument measures six domains of workplace safety culture: safety climate, teamwork climate, perceptions of management, job satisfaction, working conditions and stress recognition. The 5-point Likert scale was converted to a 100-point scale and mean ≥ 75 was dichotomized as a positive. Confirmatory factor analysis (CFA) was carried out to validate the EMS-SAQ in a Finnish setting. Other results were analysed by using non-parametric tests. RESULTS: 327 responses were included in the analysis. CFA showed that the total EMS-SAQ model had acceptable goodness-of-fit values in the Finnish EMS setting. Total mean scores for each safety culture domain were identified non-positively (mean score < 75); safety climate 60.12, teamwork climate 60.92, perceptions of management 56.31, stress recognition 64.55, working conditions 53.43 and job satisfaction 70.36. Higher education was connected to lower job satisfaction and the teamwork climate within the individual characteristics. All organisation-based characteristics caused at least one significant variation in the safety culture domain scores. Working area significantly affected (p < 0.05) five out of the six safety culture domain scores. CONCLUSIONS: The EMS-SAQ is a valid tool to evaluate safety culture among the Finnish EMS organisations; it offers a novel method to evaluate safety and patient safety within the Finnish EMS organisations. According to the findings, the organisation-based characteristics more likely had an impact on safety attitudes than did the individual-based characteristics. Therefore, it is suggested that the Finnish EMS organisations undertake safety culture development at the organisational level.

Soluble urokinase plasminogen activator receptor and lactate as prognostic biomarkers in patients presenting with non-specific chief complaints in the pre-hospital setting - the PRIUS-study.

BACKGROUND: Emergency Medical Services (EMS) are faced daily with patients presenting with non-specific chief complaints (NSC). Patients presenting with NSCs often have normal vital signs. It has previously been established that NSCs may have a serious underlying condition that has yet to be identified. The aim of the current study was to determine if soluble urokinase plasminogen activator receptor (suPAR) and lactate could be used to identify serious conditions among patients presenting with NSCs to the EMS. The secondary aim was to describe the prognostic value for mortality in the group. METHOD: A blinded prospective observational cohort study was conducted of patients brought to the ED by ambulance after calling the national emergency number 112 and who were assessed as having NSC by the EMS. Biomarkers were measured during index EMS assessment before transportation to the ED. Patients were followed via EMS and hospital electronic health records. Descriptive and logistic regression analyses were used. RESULTS: A total of 414 patients were included, with a median age of 82 years. A serious condition was present in 15.2% of the patients. Elevated suPAR above 3 ng/ml had a positive likelihood ratio (LR+) of 1.17 and a positive predictive value (PPV) of 17.3% as being predictive of a prevalent serious condition. Elevated suPAR above 9 ng/ml had LR+ 4.67 and a PPV of 16.7% as being predictive of 30-day mortality. Lactate was not significantly predictive. CONCLUSION: Pre-hospital suPAR and lactate cannot differentiate serious conditions in need of urgent treatment and assessment in the ED among patients presenting with non-specific chief complaints. suPAR has shown to be predictive of 30-day mortality, which could add some value to the clinical assessment. TRIAL REGISTRATION: NCT03089359. Registered 20 March 2017, retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03089359 .

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.

Supporting health literacy using an interactive app for symptom management during radiotherapy for prostate cancer.

OBJECTIVE: Patients' ability to self-monitor symptoms and engage in self-care activities is dependent upon their level of health literacy. Health literacy and self-care ability was compared in men with prostate cancer undergoing radiotherapy that used an app for symptom management with a control group. METHODS: Included were an intervention group (n = 66), who used an app for symptom reporting and support for self-care, and a control group (n = 64). Outcomes were Functional Health Literacy, Communicative and Critical Health Literacy and Appraisal of Self-Care Agency (ASA-A). RESULTS: The intervention group had improved regarding "ability to select information needed from a variety of information sources" (p = .020), "ability to determine the information credible" (p = .041), and "being able to plan and decide what to do to improve health" (p = .004). No inter-group difference was found for ASA-A. CONCLUSIONS: With the support of an app for reporting and managing symptoms, important advanced health literacy skills of selecting, determining, and judging information credible may improve. PRACTICE IMPLICATIONS: Patients undergoing treatment for prostate cancer may benefit from an individualized approach, such as an app, for communication with health care providers and as a source of health information to make decisions about their own health.

Multi-method versus single method appraisal of clinical quality indicators for the emergency medical services.

BACKGROUND: Quality Indicator (QI) appraisal protocol is a novel methodology that combines multiple appraisal methods to comprehensively assess the 'appropriateness' of QIs for a particular healthcare setting. However, they remain inadequately explored compared to the single appraisal method approach. OBJECTIVES: To describe and test a multi-method QI appraisal protocol versus the single method approach, against a series of QIs previously identified as potentially relevant to the prehospital emergency care setting. METHODS: An appraisal protocol was developed consisting of two categorical-based appraisal methods, combined with the qualitative analysis of the discussion generated during the consensus application of each method. The output of the protocol was assessed and compared with the application and output of each method. Inter-rater reliability (IRR) of each particular method was evaluated prior to group consensus rating. Variation in the number of non-valid QIs and the proportion of non-valid QIs identified between each method and the protocol were compared and assessed. RESULTS: There was mixed IRR of the individual methods. There was similarly low-to-moderate correlation of the results obtained between the particular methods (Spearman's rank correlation = 0.42, P < 0.001). From a series of 104 QIs, 11 non-valid QIs were identified that were shared between the individual methods. A further 19 non-valid QIs were identified and not shared by each method, highlighting the benefits of a multi-method approach. The outcomes were additionally evident in the group discussion analysis, which in and of itself added further input that would not have otherwise been captured by the individual methods alone. CONCLUSION: The utilization of a multi-method appraisal protocol offers multiple benefits, when compared to the single appraisal approach, and can provide the confidence that the outcomes of the appraisal will ensure a strong foundation on which the QI framework can be successfully implemented.

Patients' perceptions of safety in emergency medical services: an interview study.

BACKGROUND: Research on patient safety in emergency medical services (EMS) has mainly focused on the organisation's and/or the EMS personnel's perspective. Little is known about how patients perceive safety in EMS. This study aims to describe the patients' experiences of their sense of safety in EMS. METHODS: A qualitative design with individual interviews of EMS patients (n=21) and an inductive qualitative content analysis were used. RESULTS: Patients' experiences of EMS personnel's ability or inability to show or use their medical, technical and driving skills affected the patients' sense of safety. When they perceived a lack of professionalism and knowledge among EMS personnel, they felt unsafe. Patients highlighted equality in the encounter, the quality of the information given by EMS personnel and the opportunity to participate in their care as important factors creating a sense of safety during the EMS encounter. Altogether, patients' perceptions of safety in EMS were connected to their confidence in the EMS personnel. CONCLUSIONS: Overall, patients felt safe during their EMS encounter, but the EMS personnel's professional competence alone is not enough for them to feel safe. Lack of communication or professionalism may compromise their sense of safety. Further work is needed to explore how patients' perceptions of safety can be used in improving safety in EMS.