"Just pee in the diaper" - a constructivist grounded theory study of moral distress enabling neglect in nursing homes.

BACKGROUND: A growing body of evidence shows that many nursing home residents' basic care needs are neglected, and residents do not receive qualitatively good care. This neglect challenges nursing staff´s professional and personal ideals and standards for care and may contribute to moral distress. The aim of this study was to investigate how nursing staff manage being a part of a neglectful work culture, based on the research question: "How do nursing home staff manage their moral distress related to neglectful care practices?" METHODS: A qualitative design was chosen, guided by Charmaz´s constructivist grounded theory. The study was based on 10 individual interviews and five focus group discussions (30 participants in total) with nursing home staff working in 17 different nursing homes in Norway. RESULTS: Nursing staff strive to manage their moral distress related to neglectful care practices in different ways: by favouring efficiency and tolerating neglect they adapt to and accept these care practices. By disengaging emotionally and retreating physically from care they avoid confronting morally distressing situations. These approaches may temporarily mitigate the moral distress of nursing staff, whilst also creating a staff-centred and self-protecting work culture enabling neglect in nursing homes. CONCLUSIONS: Our findings represent a shift from a resident-centred to a staff-centred work culture, whereby the nursing staff use self-protecting strategies to make their workday manageable and liveable. This strongly indicates a compromise in the quality of care that enables the continuation of neglectful care practices in Norwegian nursing homes. Finding ways of breaking a downward spiralling quality of care are thus a major concern following our findings.

Neonatal mortality and video assessment of resuscitation in four district hospitals in Pemba, Tanzania.

BACKGROUND: We aimed to assess risk factors for neonatal mortality, quality of neonatal resuscitation (NR) on videos and identify potential areas for improvement. METHODS: This prospective cohort study included women in childbirth and their newborns at four district hospitals in Pemba, Tanzania. Videos were analysed for quality-of-care. Questionnaires on quality-of-care indicators were answered by health workers (HW) and women. Risk factors for neonatal mortality were analysed in a binomial logistic regression model. RESULTS: 1440 newborns were enrolled. 34 newborns died within the neonatal period (23.6 per 1000 live births). Ninety neonatal resuscitations were performed, 20 cases on video. Positive pressure ventilation (PPV) was inadequate in 15 cases (75%). Half (10/20) did not have PPV initiated within the first minute, and in one case (5.0%), no PPV was performed. PPV was not sustained in 16/20 (80%) newborns. Of the 20 videos analysed, death occurred in 10 newborns: 8 after resuscitation attempts and two within the first 24 h. Most of HW 49/56 (87.5%) had received training in NR. CONCLUSIONS: Video analysis of NR revealed significant deviations from guidelines despite 87.5% of HW being trained in NR. Videos provided direct evidence of gaps in the quality of care and areas for future education, particularly effective PPV. IMPACT: Neonatal mortality in Pemba is 23.6 per 1000 livebirths, with more than 90% occurring in the first 24 h of life. Video assessment of neonatal resuscitation revealed deviations from guidelines and can add to understanding challenges and aid intervention design. The present study using video assessment of neonatal resuscitation is the first one performed at secondary-level hospitals where many of the world's births are conducted. Almost 90% of the health workers had received training in neonatal resuscitation, and the paper can aid intervention design by understanding the actual challenges in neonatal resuscitation.

Video Tutorials to Empower Caregivers of Ill Children and Reduce Health Care Utilization: A Randomized Clinical Trial.

Importance: Young children often fall ill, leading to concern among their caregivers and urgent contact with health care services. Objective: To assess the effectiveness and safety of video tutorials to empower caregivers in caring for acutely ill children. Design, Setting, and Participants: Caregivers calling the out-of-hours Medical Helpline 1813 (MH1813), Emergency Medical Services Capital Region, Denmark, and their children aged 0.5 to 11.9 years were randomized to video tutorials (intervention) or telephone triage by a nurse or physician (control) from October 2020 to December 2021 and followed up for 72 hours blinded to the intervention. Data were analyzed from March to July 2022. Intervention: The intervention group had the call disconnected before telephone triage and received video tutorials on managing common symptoms in acutely ill children and when to seek medical help. Caregivers could subsequently call MH1813 for telephone triage. Main outcomes and measures: The primary outcome was caregivers' self-efficacy, reported in an electronic survey the following day. Secondary outcomes were satisfaction, child status, assessment by a general practitioner or physician at the hospital, telephone triage, and adverse events during the 72-hour follow-up period. Results: In total, 4686 caregivers and children were randomized to intervention (2307 participants) or control (2379 participants), with a median (IQR) child age of 2.3 (1.3-5.1) years and 53% male distribution in both groups (2493 participants). Significantly more caregivers in the intervention group reported high self-efficacy (80% vs 76%; crude odds ratio [OR], 1.30; 95% CI, 1.01-1.67; P = .04). The intervention group received fewer telephone triages during follow-up (887 vs 2374 in the control group). Intention-to-treat analysis showed no difference in secondary outcomes, but per-protocol subanalysis showed fewer hospital assessments when caregivers watched video tutorials (27% vs 35%; adjusted OR, 0.67; 95% CI, 0.55-0.82). Randomization to video tutorials did not increase adverse outcomes. Conclusions and relevance: In this randomized clinical trial, offering caregivers video tutorials significantly and safely increased self-efficacy and reduced use of telephone triage. Children had fewer hospital assessments when caregivers watched videos. This suggests a future potential of health care information to empower caregivers and reduce health care utilization. Trial Registration: ClinicalTrials.gov Identifier: NCT04301206.

The impact of the Safe Delivery Application on knowledge and skills managing postpartum haemorrhage in a low resource setting: a cluster randomized controlled trial in West Wollega region, Ethiopia.

BACKGROUND: Postpartum haemorrhage is one of the leading causes of maternal mortality in low-income countries. Improving health workers' competencies in obstetric emergencies in low-income settings, has been recognized as an important factor in preventing maternal mortality and morbidity. mHealth interventions in maternal and newborn health care has shown the potential to improve health service delivery. Strong study designs such as randomized controlled trials are missing to estimate the effectiveness of the mHealth interventions. METHODS: Between August 2013 and August 2014, 70 health facilities in West Wollega Region, Ethiopia were included and randomized to intervention or control in a cluster randomized controlled trial. At intervention facilities birth attendants were provided with a smartphone with the SDA installed. Of 176 midwives and "health extension workers," 130 completed at 12 months follow-up. At baseline and after 6- and 12-months participants were assessed. Knowledge was tested by a Key Feature Questionnaire, skills by an Objective Structured Assessment of Technical Skills in a structured role-play scenario. RESULTS: Baseline skills scores were low and comparable with a median of 12/100 in the intervention and the control group. After 6 months skills had doubled in the intervention group (adjusted mean difference 29.6; 95% CI 24.2-35.1 compared to 1·8; 95% CI - 2.7 to 6.3 in the control group). At 12 months skills had further improved in the intervention group (adjusted mean difference 13.3; 95% CI 8.3-18.3 compared to 3.1; 95% CI - 1.0 to 7.3 in the control group). Knowledge scores also significantly improved in the intervention group compared to the control (adjusted mean difference after 12 months 8.5; 95% CI 2.0-15.0). CONCLUSION: The Safe Delivery App more than doubled clinical skills for managing postpartum haemorrhage among birth attendants making it an attractive tool to reduce maternal mortality. TRIAL REGISTRATION: Clinicaltrial.gov Identifier NCT01945931. September 5, 2013.

Maternal mortality caused by postpartum haemorrhage is a major public health concern in many low-income countries. Having access to skilled health care professionals during pregnancy and childbirth can prevent maternal deaths related to postpartum haemorrhage. mHealth interventions like the Safe Delivery App (SDA), a smartphone application, has shown the potential to improve the quality of care in emergency situations related to childbirth in low-income health system settings.This study examines the SDA as a training/education tool for improving health workers' competencies and performances in managing postpartum haemorrhage. The SDA contained animated instruction videos on how to prevent and treat postpartum haemorrhage and a list of essential drugs and basic equipment.In Ethiopia, 70 health facilities and 176 birth attendants were included in a randomized controlled trial. The intervention group received a smartphone with the SDA installed and half a day of introduction to the use of the app. Birth attendants' skills and knowledge in managing postpartum haemorrhage in the control and the intervention group were tested at baseline, 6 and 12 months after intervention.Our study found that the SDA is an effective tool to improve and sustain birth attendants' knowledge and skills in the management of postpartum haemorrhage in a rural, low-resource health system setting in Ethiopia, which confirms findings in other non-randomized studies examining the SDA on the management of postpartum haemorrhage.

Making Neglect Invisible: A Qualitative Study among Nursing Home Staff in Norway.

BACKGROUND: Research shows that nursing home residents' basic care needs are often neglected, potentially resulting in incidents that threaten patients' safety and quality of care. Nursing staff are at the frontline for identifying such care practices but may also be at the root of the problem. The aim of this study was to generate new knowledge on reporting instances of neglect in nursing homes based on the research question "How is neglect reported and communicated by nursing home staff?" METHODS: A qualitative design guided by the principles of constructivist grounded theory was used. The study was based on five focus-group discussions (20 participants) and 10 individual interviews with nursing staff from 17 nursing homes in Norway. RESULTS: Neglect in nursing homes is sometimes invisible due to a combination of personal and organizational factors. Staff may minimize "missed care" and not consider it neglect, so it is not reported. In addition, they may be reluctant to acknowledge or reveal their own or colleagues' neglectful practices. CONCLUSION: Neglect of residents in nursing homes may continue to occur if nursing staff's reporting practices are making neglect invisible, thus proceeding to compromise a resident's safety and quality of care for the foreseeable future.

Herpes simplex virus infection among neonates suspected of invasive bacterial infection: a population-based cohort study.

OBJECTIVE: To estimate the incidence of neonatal herpes simplex virus (HSV) infection and the number of neonates with suspected invasive bacterial infection (IBI) needed to treat (NNT) with acyclovir to ensure prompt treatment of invasive HSV infections. DESIGN: A nationwide population-based cohort study. SETTING: All neonatal and paediatric emergency departments in Denmark from 1 January 2010 to 31 December 2019. PATIENTS: Neonates aged 0-28 days with HSV infection. MAIN OUTCOME MEASURES: The main outcome measures were incidence and NNT. The NNT was calculated based on neonates with invasive HSV infection whose onset symptoms resembled IBI and the estimated number of Danish neonates who received antibiotics for suspected IBI. RESULTS: Fifty-four neonates with HSV infection were identified, that is, an incidence of 9 per 100 000 live births. Twenty presented with symptoms resembling IBI, all within the first 14 days of life. Of 18 (78%) neonates, 14 had elevated C reactive protein, 14 of 19 (74%) had elevated alanine aminotransferase and 11 of 17 (65%) had thrombocytopaenia. The estimated NNTs with empiric acyclovir at postnatal ages 0-3, 4-7 and 8-14 days were 1139 (95% CI 523 to 3103), 168 (95% CI 101 to 726) and 117 (95% CI 48 to 198), respectively. CONCLUSIONS: The incidence of neonatal HSV infection was higher than in previous decades; however, the estimated NNT with empiric acyclovir was high. Therefore, we propose not to treat all neonates suspected of IBI with empiric acyclovir, as current European guidelines suggest. However, HSV should be considered in neonates with signs of infection, especially after the third postnatal day and in neonates with high alanine aminotransferases and thrombocytopaenia.

Risk factors of stillbirths in four district hospitals on Pemba Island, Tanzania: a prospective cohort study.

BACKGROUND: More than 2 million third-trimester stillbirths occur yearly, most of them in low- and middle-income countries. Data on stillbirths in these countries are rarely collected systematically. This study investigated the stillbirth rate and risk factors associated with stillbirth in four district hospitals in Pemba Island, Tanzania. METHODS: A prospective cohort study was completed between the 13th of September and the 29th of November 2019. All singleton births were eligible for inclusion. Events and history during pregnancy and indicators for adherence to guidelines were analysed in a logistic regression model that identified odds ratios [OR] with a 95% confidence interval [95% CI]. RESULTS: A stillbirth rate of 22 per 1000 total births in the cohort was identified; 35.5% were intrapartum stillbirths (total number of stillbirths in the cohort, n = 31). Risk factors for stillbirth were breech or cephalic malpresentation (OR 17.67, CI 7.5-41.64), decreased or no foetal movements (OR 2.6, CI 1.13-5.98), caesarean section [CS] (OR 5.19, CI 2.32-11.62), previous CS (OR 2.63, CI 1.05-6.59), preeclampsia (OR 21.54, CI 5.28-87.8), premature rupture of membranes or rupture of membranes 18 h before birth (OR 2.5, CI 1.06-5.94) and meconium stained amniotic fluid (OR 12.03, CI 5.23-27.67). Blood pressure was not routinely measured, and 25% of women with stillbirths with no registered foetal heart rate [FHR] at admission underwent CS. CONCLUSIONS: The stillbirth rate in this cohort was 22 per 1000 total births and did not fulfil the Every Newborn Action Plan's goal of 12 stillbirths per 1000 total births in 2030. Awareness of risk factors associated with stillbirth, preventive interventions and improved adherence to clinical guidelines during labour, and hence improved quality of care, are needed to decrease the stillbirth rate in resource-limited settings.

Legitimizing neglect - a qualitative study among nursing home staff in Norway.

INTRODUCTION: Residents in nursing homes do not always get qualitatively good nursing care, and research shows that residents' basic care needs are sometimes neglected. Neglect in nursing homes is a challenging and complex issue, yet a preventable one. Nursing home staff are at the frontline of detecting and preventing neglect but may also be the ones causing it. It is essential to understand why and how neglect happens in order to recognize, expose, and prevent its occurrence. Our aim was to generate new knowledge on the processes leading to and allowing neglect to continue in Norwegian nursing homes, by studying how nursing home staff perceive and reflect on when nursing home residents are neglected in their daily practice. METHODS: A qualitative exploratory design was used. The study was based on five focus group discussions (20 participants, total) and ten individual interviews with nursing home staff from 17 different nursing homes in Norway. The interviews were analysed according to Charmaz constructivist grounded theory. RESULTS: In order to make neglect an acceptable practice, nursing home staff apply different strategies. These strategies were identified as when the staff legitimize neglect by neglecting neglect, when the staff are not recognizing their own behaviour as neglectful, as expressed in their actions and language, and normalizing missed care when resources are lacking and nursing staff are rationing care. CONCLUSIONS: The gradual shift between judging actions as neglectful or not are made possible when nursing home staff legitimize neglect by not recognizing their practice as neglective, thus neglecting neglect or when they are normalizing missed care. Increased awareness and reflections on these processes may be a way of reducing the risk of and preventing neglect in nursing homes.

Simulation-based training in paediatric emergency medicine.

Managing critically ill children is a rare and challenging event requiring training to ensure adequate and timely quality of care. Thus, health professionals train for pediatric emergencies in a simulated setting. Virtual reality (VR) is a promising modality for simulation, and current evidence highlights the potential of VR for simulating pediatric emergencies. However, more studies are needed to determine the aspects of VR design and implementation that support transfer of learning.

Vaccination timeliness of preterm infants hospitalised in a neonatal intensive care unit in Denmark.

AIM: In Denmark, preterm infants are recommended to receive childhood vaccinations without correction for gestational age. This study aimed to describe the timeliness of the Danish Childhood Vaccination Program in preterm infants during the first 13 months of life and to evaluate possible determinants of delay. METHODS: This retrospective cohort study included preterm infants admitted to a level III neonatal intensive care unit between October 2019 and October 2020. Clinical data were retrieved from medical records and the Danish Vaccination Register. Timely vaccination was defined corresponding to chronological age of 3-, 5- and 12 months, within a time interval of 30 days before to 29 days after the expected date. RESULTS: Analyses included 365 infants. Timely vaccination occurred in 91%, 83% and 67% of preterm infants for the first, second and third vaccination, respectively, and timeliness was highest if born before gestational age 28 weeks. Gestational age 28-31 + 6 weeks and delayed former vaccinations negatively influenced the timeliness of the following vaccinations. CONCLUSION: Most preterm infants received the first vaccination timely; however, timeliness decreased with each subsequent vaccination. Efforts to improve timeliness should focus on counselling healthcare personnel and parents to follow the recommendations for the first and the following vaccinations.

Risk factors for neonatal sepsis in Sub-Saharan Africa: a systematic review with meta-analysis.

OBJECTIVES: To identify the risk factors for neonatal sepsis in Sub-Saharan Africa. DESIGN: Systematic review and meta-analysis. DATA SOURCES: PubMed, Embase, Web of Science, African Index Medicus and ClinicalTrials.gov were searched for observational studies from January 2010 to August 2020. SETTING: Sub-Saharan Africa, at all levels of healthcare facilities. PARTICIPANTS: 'Neonates' (<28 days of age) at risk of developing either clinical and/or laboratory-dependent diagnosis of sepsis. OUTCOME MEASURES: Identification of any risk factors for neonatal sepsis. RESULTS: A total of 36 studies with 23 605 patients from secondary or tertiary level of care facilities in 10 countries were included. Six studies were rated as good quality, 8 as fair and 22 as poor. Four studies were omitted in the meta-analysis due to insufficient data. The significant risk factors were resuscitation (OR 2.70, 95% CI 1.36 to 5.35), low birth weight <1.5 kg (OR 3.37, 95% CI 1.59 to 7.13) and 1.5-2.5 kg (OR 1.36, 95% CI 1.01 to 1.83), low Apgar score at the first minute (OR 3.69, 95% CI 2.34 to 5.81) and fifth minute (OR 2.55, 95% CI 1.46 to 4.45), prematurity <37 weeks (OR 1.91, 95% CI 1.27 to 2.86), no crying at birth (OR 3.49, 95% CI 1.42 to 8.55), male sex (OR 1.30, 95% CI 1.01 to 1.67), prolonged labour (OR 1.57, 95% CI 1.08 to 2.27), premature rupture of membranes (OR 2.15, 95% CI 1.34 to 3.47), multiple digital vaginal examinations (OR 2.22, 95% CI 1.27 to 3.89), meconium-stained amniotic fluid (OR 2.72, 95% CI 1.58 to 4.69), intrapartum maternal fever (OR 2.28, 95% CI 1.18 to 4.39), foul-smelling vaginal discharge (OR 3.31, 95% CI 2.16 to 5.09) and low socioeconomic status (OR 1.93, 95% CI 1.11 to 3.35). We found considerable heterogeneity in the meta-analysis of 11 out of 15 identified risk factors. CONCLUSION: Multiple risk factors for neonatal sepsis in Sub-Saharan Africa were identified. We revealed risk factors not listed by the WHO guidelines. The included studies overall had high risk of bias and high heterogeneity and thus, additional research of high quality is needed. PROSPERO REGISTRATION NUMBER: CRD42020191067.

[Herpes simplex virus infection in newborns].

Neonatal herpes simplex disease (HSV) is a rare but life-threatening infection associated with high rates of morbidity and mortality. Recent studies indicate that the incidence rate has continued to rise over the past decades, while the mortality remains unchanged. Early clinical suspicion of HSV and parenteral antiviral treatment of acute disease is essential for the prognosis. The subsequent use of suppressive therapy with oral acyclovir has further enhanced the long-term prognosis. This review presents evidence of risk factors, clinical presentation, prevention, and management of HSV in newborns.

Essential newborn care practices for healthy newborns at a district hospital in Pemba, Tanzania: a cross-sectional observational study utilizing video recordings.

BACKGROUND: High-quality essential newborn care (ENC) can improve newborn health and reduce preventable newborn mortality. The World Health Organization recommends specific ENC interventions. Video recordings have potential as a tool for assessment of clinical care also in low and middle-income countries. OBJECTIVE: To use video observations of healthy newborns to describe ENC practices in a low-income setting and compare actual clinical practice with WHO recommendations. METHOD: This is a cross-sectional observational study. Video records of neonatal interventions to 324 healthy newborns were assessed. They were obtained at baseline of a pre-post intervention study during a 10-week study period in Pemba, Tanzania. Data also included postnatal structured questionnaires. Eight ENC interventions and quality indicators were defined as per the WHO recommendations. Descriptive statistics were used to summarize ENC practices and maternal and neonatal characteristics. RESULTS: None of the newborns received all eight recommended ENC interventions. The median duration of separation from the mother was 25 minutes and 15 seconds (ranging from 22 seconds to 3 hours and 36 minutes), 51% of the newborns received proper thermal care during the separation. Twenty-one percent had sufficient umbilical cord care, 8% were stimulated for breathing, 69% were observed at least once by healthcare staff and 9% did undergo suctioning. None of the newborns received antibiotic ointments or vitamin K. CONCLUSION: Video recording of healthy newborns was feasible. The study identified omission of key ENC practices including proper thermal care, skin-to-skin contact and establishment of breastfeeding within the first hour of life, vitamin K administration as well as application of unnecessary practices such as excessive suctioning of breathing newborns.

Video recording as an objective assessment tool of health worker performance in neonatal resuscitation at a district hospital in Pemba, Tanzania: a feasibility study.

OBJECTIVES: To assess the feasibility of using video recordings of neonatal resuscitation (NR) to evaluate the quality of care in a low-resource district hospital. DESIGN: Prospective observational feasibility study. SETTING: Chake-Chake Hospital, a district hospital in Pemba, Tanzania, in April and May 2019. PARTICIPANTS: All delivering women and their newborns were eligible for participation. MAIN OUTCOME MEASURES: Motion-triggered cameras were mounted on resuscitation tables and provided recordings that were analysed for quality of care indicators based on the national NR algorithm. Assessment of feasibility was conducted using Bowen's 8-point framework for feasibility studies. RESULTS: 91% (126 of 139) of women and 96% (24 of 26) of health workers were comfortable or very comfortable with the video recordings. Of 139 newborns, 8 underwent resuscitation with bag and mask ventilation. In resuscitations, heat loss prevention measures were not performed in half of the cases (four of eight), clearing the airway was not performed correctly in five of eight cases, and all newborns were suctioned vigorously and repeatedly, even when not indicated. In a quarter (two of eight) of cases, the newborn's head was not positioned correctly. Additionally, two of the eight newborns needing ventilation were not ventilated within the first minute of life. In none of the eight cases did ventilation appear to be performed effectively. CONCLUSIONS: It proved feasible to use video recordings to assess quality of care during NR in a low-resource setting, and the method was considered acceptable for the delivering women and health workers. Recordings of eight resuscitations all demonstrated deviations from NR guidelines.

The right antibiotic for the right neonate? A prospective observational cohort study at a district hospital in Pemba, Tanzania.

BACKGROUND: The highest neonatal mortality is in Sub-Saharan Africa, where neonatal sepsis accounts for approximately 50%. At Pemba Island, Tanzania, we examined the use of prophylactic antibiotics in neonates and related it to WHO guidelines and compared clinical signs of infection with the use of antibiotic treatment; furthermore, we aimed to investigate all use of antibiotic treatment in the neonatal period. METHOD: This prospective observational cohort study was performed from 1 January 2022 to 15 April 2022 at a district hospital on Pemba Island, Tanzania. Women admitted in early established or active labour, and their neonates, were eligible for inclusion. We used questionnaires for mother and health worker and examined the neonates 2 h after birth. Follow-up was made at discharge or at 18 h of life, and days 7 and 28. RESULTS: We included 209 women and their 214 neonates. The neonatal mortality was 5 of 214 (23 per 1000 live births). According to WHO guidelines 29 (13.6%) had ≥ 1 risk factor for infection. Of these, three (10.3%) received prophylactic antibiotic treatment; only one (3.4%) received the correct antibiotic drug recommended in guidelines. Thirty-nine (18.2%) neonates had ≥ 1 clinical indicator of infection and 19 (48.7%) of these received antibiotic treatment. A total of 30 (14.0%) neonates received antibiotics during the study period. Twenty-three (76.7%) were treated with peroral antibiotics. CONCLUSION: Adherence to WHO guidelines for prophylactic antibiotic treatment to prevent neonatal infection was low. Further, only half of neonates with clinical signs of infection received antibiotics.

[Bite wounds from dogs, cats and humans].

Bite wounds are common in the emergency departments in Denmark. As a result of the Covid-19 pandemic, more people are adopting pets and the number of hours spent at home with pets are increasing. This will probably result in more bite wounds and therefore, it is as important as ever for emergency doctors to be able to treat bite wounds appropriately. In this review, we summarise the most common types of bite wounds, how to make a thorough physical examination, what to focus on in the anamnesis, and how to treat bite wounds including when to suture and the indications for prophylactic antibiotics.

'I want to get back!' A qualitative study of long-term critically ill patients' inner strength and willpower: Back home after long-term intensive care.

AIMS AND OBJECTIVES: To provide insights into what promotes and challenges inner strength and willpower in formerly critically ill patients back home after a long-term ICU stay. BACKGROUND: Critically ill patients demand great resources during an ICU stay, some experience great challenges after discharge from hospital. Knowledge about how health professionals can promote former long-term critically ill patients' inner strength and willpower after discharge is essential, but still missing. DESIGN: A qualitative, hermeneutic-phenomenological approach using in-depth interviews with former long-term ICU patients. METHODS: Seventeen long-term ICU patients were interviewed 6-20 months after ICU discharge. The consolidated criteria for reporting qualitative research was used (COREQ,2007). RESULTS: Back home after hospital discharge, some former patients coped well while others suffered heavy burdens mentally and physically, along with economic problems. They handled their challenges differently: some found comfort and insight by reading their diary written by their ICU nurses, while several were struggling alone experiencing a lonesome silent suffering; these called for a follow-up support by the healthcare system. CONCLUSION: Long-term ICU patients' inner strength and willpower are vital salutogenic resources supporting the fight back to one's former independent life. However, physical, mental and economic challenges drain their inner strength to go on and succeed. Several long-term ICU patients need health-promoting follow-up support after hospital discharge. RELEVANCE TO CLINICAL PRACTICE: This study disclosed a lonely and silent suffering indicating a need for development of systematical health-promoting follow-up programmes including salutogenic components such as health-promoting conversations, diaries and web-based recovery programme along with a cell phone app.

[Indirect effects of the COVID-19 pandemic on mortality of mothers and children in low- and middle-income countries].

The COVID-19 pandemic may not only increase mortality due to the virus but also due to the indirect effects. The disease continues to ravage health and economic metrics globally, which is likely to increase maternal and under five-year child mortality in low- and middle-income countries. This review highlights key areas of concern for maternal and under five-year child mortality due to the indirect effects of the COVID-19 pandemic in low- and middle-income countries.

A qualitative study of long-term ICU patients' inner strength and willpower: Family and health professionals as a health-promoting resource.

AIMS AND OBJECTIVES: To explore how the presence of family and health professionals influences long-term critically ill patients' inner strength and willpower as an incitement to keep fighting for recovery. BACKGROUND: This study reports long-term critically ill patients' experiences of family and health professionals as health-promoting resources in terms of significance for their inner strength and willpower. Earlier research on this topic is scarce. DESIGN: A qualitative, hermeneutic-phenomenological approach, within the context of Antonovsky's salutogenic theory. METHODS: Seventeen long-term critically ill patients were interviewed once, at 6-18 months after ICU discharge. The consolidated criteria for reporting qualitative research (COREQ) were used (Supplementary File 1). RESULTS: Four main themes identified how family and staff promoted and challenged the patient's inner strength and willpower: (a) the importance of family and friends; my family was surrounding me, (b) staff contributions, (c) challenges to inner strength and willpower in relation to family and (d) loneliness and indifferent care. CONCLUSION: This study brings new knowledge from the long-term critically ill patient's view about the impact of family, friends and nurses on the patient's inner strength and willpower. All impact is experienced positively and negatively. RELEVANCE TO CLINICAL PRACTICE: Knowledge from the long-term critically ill patient's view is vital in nurse-patient interactions to facilitate liberation of inner strength and willpower.