Development and validation of a survey designed to measure patient experience of and preference for surgical wound care discharge education: A pilot study.

AIM OF THE STUDY: To develop and undertake validation testing of a survey designed to measure patients' experiences of and preferences for surgical wound care discharge education. MATERIALS AND METHODS: A literature review and content analysis was undertaken on patients' experiences of and preferences for surgical wound care discharge education. Four themes were uncovered in the literature (wound care discharge education, preferences for discharge education delivery, participation in wound care decisions and patient ability to manage their surgical wound to prevent wound complications), which guided item generation. Three types of validity testing occurred including: 1) face validity testing by the research team; 2) content validity testing (using Delphi study) with an international panel of experts including patients, clinicians and researchers; and 3) content validity (using pilot-testing) of the survey with seven patients from the target population. RESULTS: Initially 106 items were generated from the literature, and of these, 55 items were subjected to content validity testing by an international panel of 41 experts. After two Delphi rounds, 18 items were retained. Most patients provided limited and very minor feedback during pilot-testing. However, pilot-testing resulted in a revised survey administration plan to deliver the survey via telephone, including adding prompts and preambles to items. CONCLUSION: An 18-item survey comprised of three groups of items and an individual item was rigorously developed. The survey requires further testing among a larger sample of patients to confirm the items reflect important aspects of patients' experiences of and preferences for surgical wound care discharge education.

Patient and family experience 2 years after necrotizing soft-tissue infection: A longitudinal qualitative investigation.

AIMS: The study aims were to provide a comprehensive description of the short- and long-term experience of necrotizing soft-tissue infections from the patient and family perspective. Further, to describe how unmet needs related to diagnosis, treatment and rehabilitation are experienced. And finally, to present patient and family recommendations for improvements. DESIGN: The study had a longitudinal qualitative multi-centre two-country design. METHODS: Qualitative content analysis was applied to 87 semi-structured interviews involving 50 participants from Denmark and Sweden. In most interviews, patient and family were interviewed separately. Data were collected in 2015-2018. This is the fifth and final paper reporting the study. FINDINGS: After initial inductive coding, we constructed a matrix of four timepoints (pre-admission, acute admission, after 6 months and after 2 years) describing physical, psychological and social responses and recommendations for improvement. We analysed deductively according to timepoints and predefined categories describing patient and family responses to life with necrotizing soft-tissue infections. The study suggested that physical recovery was obtained before psychological recovery. The aftermath of job loss and lacking social services amplified the burden. Patients still recovering experienced lack of understanding from family, friends and professionals that failed to recognize the complexity of their suffering. CONCLUSIONS: Half of the patients in our study reported making a full recovery while the remaining described issues still unresolved 2 years after intensive care unit discharge. Predisposing factors and symptoms align with other studies of critical illness. During the acute stage, patients receive state-of-the art treatment and care, but as time passes, rehabilitation becomes less available and less patient-centred. IMPACT: The study will increase nurses' understanding of patient and family suffering and complexity of long-term survival of necrotizing soft-tissue infections. PATIENT OR PUBLIC CONTRIBUTION: From the planning stage of the study, we collaborated with a necrotizing soft-tissue infection survivor.

Factors affecting nurses' decision to undergo a specialist education and to choose a specialty.

AIMS: The aims of the study were to identify factors affecting nurses' decision to undergo specialist education and choose a specialty and to describe differences between specialization areas with different types of care. DESIGN: A descriptive cross-sectional design. METHODS: A survey was conducted among specialist nurse students in three nursing colleges in Sweden (n = 227). Instruments such as Big Five Inventory and RAND-36 and items earlier used by Bexelius and Olsson were included. Survey data were analysed by using descriptive and analytical statistics, and for open-ended question qualitative content analysis was used. RESULTS: Wage benefit during the education was regarded by 47% as an incentive to start studies. Most of the specialist nurse students considered an opportunity for new tasks (75%), new areas of responsibility (75%), intellectual challenges (72%) and higher wages (71%) to be of high importance when choosing a specialty. However, the students in specialization areas with transitory care-rated challenges regarding the practical skills (84%) and the occurrence of acute events (82%) higher. CONCLUSION: Although higher wages were important to make nurses feel that they will get value from the education, there were also other important aspects, such as opportunity for new tasks, new areas of responsibility and intellectual challenges that influenced nurses' willingness to undergo a specialist education. Our findings provide employers with the useful information to guide and influence nurses' decisions to enter specialist education and their choice of specialist area.

Wound specific quality of life after blast or gunshot injury: Validation of the wound QoL instrument.

BACKGROUND: Acute blast or gunshot wounds have a negative effect on the patients' health related quality of life (HRQoL). No validated instrument exists to assess the HRQoL of patients with such wounds. Therefore, we aimed to test and validate a subscale of an existing HRQoL instrument among patients with acute blast or gunshot wounds. METHODS: We used data from a randomized controlled trial comparing negative pressure wound therapy with standard treatment of civilian adults with acute extremity blast or gunshot wounds. We evaluated the reliability (internal consistency, stability) and validity of the body subscale of the Wound QoL instrument using the World Health Organisation 20 question self-reporting questionnaire as gold standard. RESULTS: A total of 152 participants were included in the study. The participants were predominantly (93.4%) male, and median age was 29.0 years (IQR 21.0-34.0). The internal consistency was acceptable while a test-retest analysis indicated instability in the Wound QoL instrument. The content validity of the instrument was considered satisfactory; however, the criterion validity was found to be insufficient. CONCLUSIONS: Our results indicate that Wound QoL is a promising instrument for the assessment of wound specific HRQoL among patients with acute blast or gunshot wounds. Further testing and validation is needed.

Experiences of Acute Surgical Care During the Coronavirus Disease 2019 Pandemic Among Patients and Their Next of Kin.

INTRODUCTION: Since March 2020, the coronavirus disease 2019 pandemic has affected healthcare systems worldwide. It is largely unknown how acutely ill surgical patients and their next of kin have perceived the hospital care during the ongoing pandemic. Therefore, we aimed to explore their experiences. MATERIAL AND METHODS: We performed 12 interviews with patients who had undergone acute abdominal surgery in a public acute care hospital in Sweden during March to June 2020. In addition, we interviewed 10 of the patients' next of kin. We analyzed the interviews using content analysis. RESULTS: Our analysis resulted in two themes: "Worries about seeking acute care" and "The surgical care worked adequately, even though the system was overloaded." The participants experienced that the hospital maintained its functionality during the ongoing pandemic. Both the patients and their next of kin experienced insufficient information by the hospital, especially during the initial acute phase and at discharge, which led to a perceived loss of control. The implemented ban on visitors was found to have had both positive and negative effects for the patients, whereas the next of kin's experiences focused on the difficulties with not being able to visit. CONCLUSIONS: Our findings indicate that the challenges of communication with patients and their next of kin are exacerbated during a crisis such as a pandemic. In addition, a ban on visitors might have both positive and negative aspects. Therefore, we propose individualized routines for visits to acute surgical patients when possible.

Moral Distress Among Operating Room Personnel During the COVID-19 Pandemic: A Qualitative Study.

INTRODUCTION: The ongoing COVID-19 pandemic has necessitated the reallocation of healthcare resources, and a minimization of elective activities. Healthcare personnel involved in COVID-19 care have been negatively affected by the associated excess stress. The existing COVID-19 research has focused on the experiences among healthcare personnel in general, and not particularly on the operating room team members, who have often been relocated to overburdened workplaces. Therefore, we aimed to explore the experiences in this particular group. METHODS: This study has a qualitative inductive design based on interviews with a strategic sample of 12 operating room team members: surgeons, anesthesiologist, specialist nurses, and nurse assistants. The interviews were analyzed using content analysis. RESULTS: Three themes were identified: "Feeling safe in the familiar and anxiety in the unknown", "To be the ones left behind", and "The possibility for recuperation in a seemingly everlasting situation". The participants described working hard, although their efforts were experienced as not enough according to their moral ideals. We interpreted this as feelings and signs of moral distress, a commonly described concept in previous studies during the COVID-19 pandemic, and a risk for burn out. CONCLUSIONS: The operating room team members emphasized the negative stress of being in the unknown, performing work tasks in an unfamiliar place and situation, and experiencing conflicting feelings of relief and guilt. Organizational strategies toward a functional leadership and support should be emphasized. Such strategies might reduce the risk of psychological consequences such as burn out.

Health-related quality of life and prosthesis use among patients amputated due to peripheral arterial disease - a one-year follow-up.

PURPOSE: A major amputation affects the patients' independence, well-being and HRQoL. However, prosthesis use and the impact on the patient's HRQoL are scarcely described. The aim was to compare HRQoL between walker and non-walker amputees. Secondary aim was to evaluate prosthesis use and habits. METHOD: Ninety-eight patients with a major amputation due to peripheral arterial disease were included during 2014-2018. They were interviewed using EQ-5D-3L (HRQoL), Stanmore Harold Wood mobility grade (prosthesis use) and Houghton scale (prosthesis habits). RESULTS: Seventy-three patients completed the one-year follow-up, out of them 56 got a prosthesis. Twenty-three used it to walk both inside and outside. EQ-5D-3L at follow-up was increased in all patients in comparison to baseline (0.16 versus 0.59, p < 0.001). Patients walking with prosthesis had the largest improvement (0.12 versus 0.78, p < 0.001). A sub-analysis aiming to study the importance of independent movement showed an improved HRQoL at follow-up among those classified as prosthesis-user (p<0.001) and walker (p<0.001), but not among non-prosthesis users (p = 0.245). CONCLUSION: Learning how to use, not exclusively to walk with, a prosthesis after an amputation is important for the patients' HRQoL. At follow-up, patients using their prosthesis to walk or to move to a wheelchair, showed an improved HRQoL compared to baseline.IMPLICATIONS FOR REHABILITATION Walking ability with a prosthesis is important for the patient's perceived HRQoL after an amputation.Rehabilitation of amputees should focus on independence and movability and not only on walking ability.Wider use of prescribing prostheses after an amputation also to those predicted as non-walkers, may increase the number of patients with independence and improved HRQoL.When using their prosthesis for independent movement, patients who were otherwise unable to walk due to their amputation were able to achieve HRQoL comparable to walking amputees.

Patient safety during joint replacement surgery: experiences of operating room nurses.

BACKGROUND: Avoidable complications for surgical patients still occur despite efforts to improve patient safety processes in operating rooms. Analysis of experiences of operating room nurses can contribute to better understanding of perioperative processes and flow, and why avoidable complications still occur. AIM: To explore aspects of patient safety practice during joint replacement surgery through assessment of operating room nurse experiences. METHOD: A qualitative design using semistructured interviews with 21 operating room nurses currently involved in joint replacement surgery in Sweden. Inductive qualitative content analysis was used. RESULTS: The operating room nurses described experiences with patient safety hazards on an organisational, team and individual level. Uncertainties concerning a reliable plan for the procedure and functional reporting, as well as documentation practices, were identified as important. Teamwork and collaboration were described as crucial at the team level, including being respected as valuable, having shared goals and common expectations. On the individual level, professional knowledge, skills and experience were needed to make corrective steps. CONCLUSION: The conditions to support patient safety, or limit complication risk, during joint replacement surgery continue to be at times inconsistent, and require steady performance attention. Operating room nurses make adjustments to help solve problems as they arise, where there are obvious risks for patient complications. The organisational patient safety management process still seems to allow deviation from established practice standards at times, and relies on individual-based corrective measures at the 'bedside' at times for good results.

An Interprofessional E-Learning Resource to Prepare Students for Clinical Practice in the Operating Room-A Mixed Method Study from the Students' Perspective.

The operating room is a challenging learning environment for many students. Preparedness for practice is important as perceived stress and the fear of making mistakes are known to hamper learning. The aim was to evaluate students' perspectives of an e-learning resource for achieving preparedness. A mixed methods design was used. Students (n = 52) from three educational nursing and medical programs were included. A questionnaire was used to explore demographics, student use of the e-learning resource, and how the learning activities had helped them prepare for their clinical placement. Five focus group interviews were conducted as a complement. Most students (79%) stated that the resource prepared them for their clinical placement and helped them to feel more relaxed when attending to the operating room. In total, 93% of the students recommended other students to use the e-learning resource prior to a clinical placement in the operating room. Activities containing films focusing on practical procedures were rated as the most useful. We conclude that an e-learning resource seems to increase students' perceived preparedness for their clinical practice in the operating room. The development of e-learning resources has its challenges, and we recommend student involvement to evaluate the content.

Debriding effect of amino acid-buffered hypochlorite on hard-to-heal wounds covered by devitalised tissue: pilot study.

OBJECTIVE: Wounds such as lower extremity ulcers are serious, costly and frequently hard to heal. Guidelines conclude that new dressings and treatments generally fail to show superiority compared with standard of care. Several mechanisms are probably responsible for impaired healing of hard-to-heal wounds, including inflammation and infection. Amino acid-buffered hypochlorite has presumed antiseptic and antibacterial properties and has been shown to be useful in the treatment of diabetic foot ulcers (DFUs). We evaluated the debriding effect of amino acid-buffered hypochlorite (ChloraSolv) on full skin hard-to-heal lower extremity ulcers covered with devitalised tissue (≥50%), with six applications over 5 weeks and follow-up at 12 weeks. METHOD: This was an open-label, single-arm, multicentre, pre-market pilot investigation. We recruited subjects with a lower extremity ulcer, covered with devitalised tissue (≥50%), who were candidates for cleansing and debridement/desloughing. There was a weekly application of the investigational device for five weeks. Follow-up for wound status evaluation was performed at 12 weeks from baseline. RESULTS: We evaluated 57 subjects (33 males, 24 females, median age 73 years, range 51-90 years) (intention-to-treat). Of these, 61.4% had a leg ulcer and 38.6% a foot ulcer. The median wound size at baseline was 7.7cm2 (range 2.1-52cm2) with devitalised tissue coverage of 76.5%. After 5 weeks, a decrease of 72.7% in devitalised tissue was seen, and 71.4% of the subjects showed a decrease in devitalised tissue of ≥50% (evaluated independently using PictZar). At 12 weeks' follow-up the decrease in devitalised tissue was 84.4%. Wound-related pain was reported by ten subjects, resulting in 17 adverse events (AEs). Among these, 12 AEs from eight subjects were recorded as possibly or probably related to the investigational device and one AE was reported to have a causal relationship with the investigational device. CONCLUSION: This clinical study suggests that amino acid-buffered hypochlorite can be effective and well tolerated in the treatment of hard-to-heal lower extremity ulcers to dissolve and remove devitalised tissue.

Assessing the quality of life of people with chronic wounds by using the cross-culturally valid and revised Wound-QoL questionnaire.

The Wound-QoL is an often used reliable and valid measure, originally developed in Germany. It has been sequentially translated and validated for other languages/countries, for the measurement of health-related quality of life (HRQoL) in patients with chronic wounds. However, a study from the United States postulated its benefits from further adaptations. Furthermore, some patients struggled to provide an answer for some of the items. We aimed to test the cross-cultural structure and psychometric performance of the questionnaire to suggest necessary revisions. This cross-sectional analysis of existing data sets included 1185 patients from Germany, the US, the Netherlands, Spain, Sweden, and Israel. Patients in the U.S. Wound Registry completed the Wound-QoL during routine care. Different studies comprised the data collection in the other countries. Almost half of the patients were women (48.4%). Furthermore, 42.6% were diagnosed with leg ulcers. Their average age was 66 years. We used a confirmatory factor analysis and an unconstrained graded response model. We revised and shortened the Wound-QoL from 17 to 14 items. In addition, we supported the cross-cultural metric invariance of the revised Wound-QoL questionnaire. The new version with 14 items and three dimensions revealed good psychometric properties with Cronbach's alpha (α) of 0.913 for the total score, and 0.709-0.907 for different dimensions. Furthermore, we provided strict invariance for different clinical variables. In conclusion, the revised Wound-QoL is a reliable and cross-cultural instrument to measure the HRQoL on patients with chronic wounds. Future studies should analyse the revised Wound-QoL for convergent validity with generic HRQoL questionnaires as well as for determining its sensitivity to clinical change.

Risk factors for reamputations in patients amputated after revascularization for critical limb-threatening ischemia.

OBJECTIVE: Despite vascular intervention, patients with critical limb-threatening ischemia (CLTI) have a high risk of amputation. Furthermore, this group has a high risk for stump complications and reamputation. The primary aim of this study was to identify risk factors predicting reamputation after a major lower limb amputation in patients revascularized because of CLTI. The secondary aim was to investigate mortality after major lower limb amputation. METHODS: There were 288 patients who underwent a major ipsilateral amputation after revascularization because of CLTI in Stockholm, Sweden, during 2007 to 2013. The main outcome was ipsilateral reamputation. RESULTS: Of 288 patients, 50 patients had a reamputation and 222 died during the 11-year follow-up. Patients with ischemic pain as an indication for primary amputation had nearly four times higher risk for a reamputation compared with those with a nonhealing ulcer (subdistribution hazard ratio, 3.55; confidence interval, 1.55-8.17). Higher age was associated with an increased risk for death in the multivariable analysis (hazard ratio, 1.03; confidence interval, 1.02-1.04). CONCLUSIONS: Patients with ischemic pain as an indication for amputation have an elevated risk of reamputation. Ischemic pain may be indicative of a more extensive and proximal ischemia compared with patients with foot tissue loss. An extended evaluation of the preoperative circulation before amputation may facilitate the choice of amputation level and could lead to a reduction of reamputations.

Patient experience of necrotising soft-tissue infection from diagnosis to six months after intensive care unit stay: A qualitative content analysis.

INTRODUCTION: Necrotizing soft tissue infection (NSTI) is a severe, life-threatening condition requiring immediate diagnosis and treatment to avoid widespread tissue destruction and death. Current research seeks to explain the complex interaction between patient and disease agent, whereas only few studies have addressed the patient perspective. OBJECTIVE: The present study aimed to describe the patient experience of NSTI in the first six months after diagnosis. METHODS: The study had a qualitative design with patient involvement. We interviewed 27 NSTI survivors at six months after diagnosis and applied content analysis to capture their experiences. Patients were recruited from two referral centers in Sweden and one in Denmark. FINDINGS: We identified three categories representing chronological stages of the illness trajectory depicting pivotal patient experiences: regaining awareness in the intensive care unit, transitioning to the ward, and returning home to normal life. Fear of infection or reinfection permeated all stages of the trajectory. Each stage was characterized by ambivalence: at first the relief of being alive and distress of serious illness, then the relief of independence and distress of abandonment, and finally the relief of being home and distress of still being dependent on others. CONCLUSION: Fear of infection and reinfection during and after hospitalization characterized lives of NSTI survivors and their family. This fear was potentially debilitating in daily life, working life and social life. Healthcare professionals need to be aware of these modifiable factors to help alleviate the concerns of patient and family throughout the illness trajectory.

Risk factors for amputation are influenced by competing risk of death in patients with critical limb ischemia.

OBJECTIVE: Patients with critical limb ischemia (CLI) have a high risk of amputation and death. Death is a competing risk that affects the estimated amputation risk. Our aim was to find the specific risk factors for amputation for patients with CLI using competing risk analyses and compared these results with those from standard Cox regression analysis. METHODS: Patients who had undergone revascularization for CLI (2009-2013, with follow-up data until 2017) in Stockholm were identified from the Swedish National Registry for Vascular Surgery. The main outcome was major amputation. The risk factors for amputation were assessed using competing risk analysis and compared with the risk factors for amputation-free survival identified using Cox proportional hazards regression analysis. RESULTS: Of 855 patients with CLI, 178 had required a major amputation and 415 had died during the 8-year follow-up period. In the competing risk regression, age (subdistribution hazard ratio [sub-HR], 0.98; 95% confidence interval [CI], 0.97-1.00), ambulatory status (independent vs bedridden; sub-HR, 4.10; 95% CI, 2.14-7.86), and ischemic wound vs rest pain (sub-HR, 3.03; 95% CI, 1.72-5.36) were associated with amputation, considering death as a competing risk. In contrast, Cox regression analysis identified female vs male (hazard ratio [HR], 0.77; 95% CI, 0.64-0.94), age (HR, 1.02; 95% CI, 1.01-1.03), renal impairment (HR, 2.08; 95% CI, 1.61-2.67), ambulatory status (independent vs bedridden; HR, 3.45; 95% CI, 2.30-5.18), and ischemic wound vs rest pain (HR, 2.41; 95% CI, 1.78-3.25) as risk factors. CONCLUSIONS: The risk factors associated with amputation differed when analyzing the data using competing risk regression vs Cox regression. The differences between the analyses indicated that a risk exists for biased estimates using standard survival methods when a strong competing risk such as death is present.

Signs, symptoms and diagnosis of necrotizing fasciitis experienced by survivors and family: a qualitative Nordic multi-center study.

BACKGROUND: Necrotizing soft tissue infection is the most serious of all soft tissue infections. The patient's life is dependent on prompt diagnosis and aggressive treatment. Diagnostic delays are related to increased morbidity and mortality, and the risk of under- or missed diagnosis is high due to the rarity of the condition. There is a paucity of knowledge regarding early indications of disease. The aim of the study has thus been to explore patients' and families' experiences of early signs and symptoms and to describe their initial contact with the healthcare system. METHODS: A qualitative explorative design was used to gain more knowledge about the experience of early signs and symptoms. Fifty-three participants from three study sites were interviewed. The framework method was used for data analysis. RESULTS: Most of the participants experienced treatment delay and contacted healthcare several times before receiving correct treatment. The experience of illness varied among the participants depending on the duration of antecedent signs and symptoms. Other important findings included the description of three stages of early disease progression with increase in symptom intensity. Pain experienced in necrotizing soft tissue infections is particularly excruciating and unresponsive to pain medication. Other common symptoms were dyspnea, shivering, muscle weakness, gastrointestinal problems, anxiety, and fear. CONCLUSION: Our study adds to the understanding of the lived experience of NSTI by providing in-depth description of antecedent signs and symptoms precipitating NSTI-diagnosis. We have described diagnostic delay as patient-related, primary care related, or hospital related and recommend that patient and family narratives should be considered when diagnosing NSTI to decrease diagnostic delay.

Operating Room Nurses' Perceptions of the Clinical Learning Environment: A Survey Study.

BACKGROUND: Authors commonly agree that the clinical learning environment significantly affects student learning. Studies of how operating room nurses perceive the clinical learning environment during their specialist studies are sparse. METHOD: This study aimed to examine newly graduated operating room nurses' perceptions of the clinical learning environment during their specialist education. Fifty newly graduated operating room nurses answered a questionnaire gaging their perceptions of clinical education. RESULTS: Most participants perceived the clinical learning environment as good and highly associated with the supervisor's ability to supervise, enjoy supervision, and show interest in the participants' degree project. The management at the clinical setting, which was perceived to emphasize the importance of supervision, time allocated especially for supervision, and perceived cooperation between the University and hospital, also had an impact. CONCLUSION: Social interactions and structures within the operating room affect how the clinical learning environment is perceived. J Contin Educ Nurs. 2018;49(9):416-423.

Experiences of family caregivers the first six months after patient diagnosis of necrotising soft tissue infection: A thematic analysis.

BACKGROUND: Necrotising soft tissue infection, or necrotising fasciitis, is a rapidly progressing disease requiring immediate diagnosis and treatment consisting of antimicrobial therapy, hyperbaric oxygen, debridement surgery and treatment in the intensive care unit. The harrowing illness trajectory affects the family caregivers potentially producing long-term psychological issues. OBJECTIVES: We aimed to explore the experiences and coping strategies of family caregivers during the first six months after patient diagnosis of necrotising soft tissue infection. METHODS: Our study had a prospective, explorative, qualitative design using semi-structured interviews and thematic analysis to understand necrotising soft tissue infection as an intrinsic and instrumental case. Family caregivers (n = 25) were recruited at three university hospitals in Denmark and Sweden. FINDINGS: We identified three chronological themes describing issues of importance to the family caregivers. In the intensive care unit: Coping with illness and intensive care; In the ward: Coping with injury and post-intensive care and At home: Coping with recovery and new home life. CONCLUSION: Challenges facing family caregivers of necrotising soft tissue infections survivors are still under-recognised. Healthcare professionals need to ensure that families and stakeholders throughout the patient trajectory have access to and co-create timely information and care plans to bridge the knowledge gap across care environments and to relieve family responsibility.

Translation and Validation of a Wound-specific, Quality-of-life Instrument (The Wound-QoL) in a Swedish Population.

Hard-to-heal wounds can compromise patient quality of life (QoL); thus, assessing QoL is an important aspect of wound management. The aim of this study, conducted from August 2015 to July 2016, was to translate a wound-specific instrument, the Wound-QoL, into the Swedish language and context and validate its ability to assess QoL in a population of patients with wounds of various etiologies. The Wound-QoL, derived from 3 existing wound care QoL instruments, is a paper-and-pencil tool comprised of 17 Likert-style questions addressing 3 categories (Body, Psyche, and Everyday Life) to provide a global score. The instrument was translated into Swedish and its psychometric properties (reliability, validity, responsiveness, and ceiling and floor effect) were tested in a convenience sample of 88 Swedish outpatients (64 men [73%], mean age 67 [range 27-96] years) with hard-to-heal wounds (mean duration 10 months) of varying etiologies. Participants completed the questionnaires at baseline in the beginning of the study and at 6 weeks; they also had the opportunity to comment on the questionnaire. Reliability was analyzed using Cronbach's alpha coefficient (0.70 or higher was considered acceptable). Criterion validity was examined using a generic European QoL instrument, considered the gold standard, as the comparator. Descriptive statistical analysis was performed for presentation of the demographic and wound variables. Standardized response mean was used to assess internal responsiveness. All tests were 2-sided with 95% confidence interval; the results were considered significant at P <.05. QoL scores of the study population in the different domains measured with the Wound-QoL instrument varied from 1.11 to 1.72. Reliability was excellent, with internal consistency of 0.78-0.92 and test-retest stability of 0.80-0.88; standardized response mean showed small to moderate sensitivity; and validity was found to be slightly moderate to moderate. No signs of ceiling or floor effect could be detected. The Swedish version of the Wound-QoL instrument was found to be a reliable and valid tool for measuring health-related QoL in patients with hard-to-heal wounds in Sweden and demonstrated the potential to be used in a clinical setting to detect QoL issues during wound treatment. Further psychometric studies need to be performed to validate the instrument in patient groups with acute wounds, with different wound treatments, and for patients treated in nonspecialized wound care settings such as home care.

The patient's experience of amputation due to peripheral arterial disease.

It is not uncommon that patients with peripheral arterial disease (PAD) need to undergo a lower limb amputation, with or without previous revascularization attempts. Despite that, the patient's experience of the amputation has been scarcely studied. The aim of this qualitative study was to describe the patient's experience of amputation due to PAD. Thirteen interviews were conducted with vascular patients who had undergone a lower limb amputation at tibia, knee, or femoral level. Data were analyzed with content analysis. Our findings of the patient's experiences during the amputation process resulted in three themes with additional time sequences: the decision phase "From irreversible problem to amputation decision", the surgical phase "A feeling of being in a vacuum," and the rehabilitation phase "Adaptation to the new life". One main finding was that the patients felt abandoned during the surgical period. Despite that, most of the participants were satisfied with the decision, some of them even regretted that they had not undergone an amputation earlier in the process. It is important for the patient's well-being to develop a partnership with the surgeon to increase a feeling of being participating in the care. Vascular patients need better information on lower limb amputation, and its consequences so as to be better prepared for the whole process. To increase the patient's quality of life and reduce unnecessary suffering, amputation may be presented earlier in the process as a valuable treatment option.

Images of suffering depicted in diaries of family caregivers in the acute stage of necrotising soft tissue infection: A content analysis.

OBJECTIVES: Severe necrotising soft tissue infections (NSTI) are rare life threatening rapidly progressing bacterial infections requiring immediate diagnosis and treatment. The aim of the study was to explore the experience of family caregivers of patients with necrotising soft tissue infection during the acute stage of disease. METHODS: Our study had a qualitative descriptive binational design using qualitative content analysis to explore diaries written by close family members (n=15). Participants were recruited from university hospitals in Denmark and Sweden. FINDINGS: Three main categories emerged: Trajectory, Treatment, and Patient & Family. The first helped us construct an overview of the NSTI trajectory showing issues of importance to patient and family caregivers. The following categories were analysed further to describe four themes central to the family caregiver experience: craving information, needing to be near, suffering separation and network taking over. CONCLUSIONS: Necrotising soft tissue infections are uncommon causing shock and concern. Centralised treatment might involve physical separation of patient and family during the acute stage of illness. Family accommodations near the patient and accessibility to adequate communication devices at the bedside are recommended. Health professionals need to keep in mind the importance of information and reassurance on the wellbeing of the family and ultimately of the patient.