Patients' experiences of the caring encounter in health promotion practice: a qualitative study in Swedish primary health care.

BACKGROUND: Previous studies have reported that organizational structures and cultures in primary health care are obstacles to district nurses doing successful work in health promotion practice (HPP). Because organizational structures are not easily changed, Jean Watson's Attending Nurse Caring Model (ANCM) was introduced and piloted at a primary health care center in Sweden, aiming to transform HPP so as to empower district nurses and increase their work satisfaction. AIM: To investigate patients' experiences of the caring encounter in HPP after introduction of the ANCM in Swedish primary health care, the aim being to explore the essential components of the caring encounter between patients and district nurses. METHODS: A descriptive and qualitative research design was used. Data collection was performed using individual face-to-face interviews with twelve patients at risk for developing CVD. Data analysis consisted of both deductive content analysis, using a categorization matrix based on the ANCM and, subsequently, inductive latent content analysis. RESULTS: The findings were abstracted into three themes: 1.'Feeling the deepest essence of being cared for': to be respected and being put at the center of the encounter; 2. 'Feeling acceptance and worth': being treated with openness and permissive attitudes, 3. 'Being in a supportive atmosphere that promotes hope': to feel trust and being trusted in the encounter, and being empowered by hope. The unifying main theme of the caring encounter was abstracted as 'Experiencing human dignity'. CONCLUSION: The present study revealed that the essence of the caring encounter between patients and district nurses in HPP is to be unconditionally accepted in an environment that inspires hope and encouragement. The ANCM seems to be a promising model to use for strengthening the caring encounter and supporting CVD patients in making healthy lifestyle choices. However, further studies of qualitative and quantitative designs are needed to investigate what the ANCM can contribute to HPP in Swedish primary health care.

Perspectives of a tailored lifestyle program for people with severe mental illness receiving housing support.

PURPOSE: The purpose of the present study was to describe the acceptability of the lifestyle program PHYS/CAT and to get information about the tools used for assessment of functional exercise capacity, cognitive performance, and self-health-related quality of life. DESIGN AND METHODS: The findings are based on focus groups and the researchers' experiences of conducting the program as well as using the assessment tools. FINDINGS: The acceptability of the program and the assessment tools was mainly satisfactory. PRACTICE IMPLICATIONS: The program with relational, educational, and supportive dimensions may be a promising tool to be integrated into daily nursing care.

Meeting the needs? Perceived support of a nurse-led lifestyle programme for young adults with mental illness in a primary health-care setting.

Being a young adult with mental illness challenges all aspects of health, including an increased risk for developing lifestyle-related diseases. There is a lack of lifestyle programmes in primary health care that target physical, mental, and social needs for young adults with mental illness. The aim of the present study was to describe the experiences of young adults with mental illness receiving support from a nurse-led lifestyle programme, and how this support was related to their life context, including challenges and coping strategies. Two focus groups and six individual interviews were performed with 13 young adults (16-25 years), and analysed using a qualitative content analysis. The findings showed that the young adults experienced challenges in their daily lives, including psychiatric symptoms, lack of social understanding, and loneliness. The study indicated that the programme could support lifestyle habits with its components of supportive interpersonal relationships, awareness of coping strategies, understanding of health and illness, and cognitive support (e.g. schedules and reminders). However, the programme could not meet everyone's needs for new social relationships or more comprehensive support. Even so, this nurse-led programme provides health information-management strategies that could easily be integrated in a primary health-care setting.

Educational nurse-led lifestyle intervention for persons with mental illness.

Although persons with severe mental illness face an increased risk of mortality and of developing negative health outcomes, research has shown that lifestyle interventions can sufficiently support their health. In response, this study examined a nurse-led lifestyle intervention developed in cooperation with members of municipal and county councils to gauge its impact on the quality of life, cognitive performance, walking capacity, and body composition of persons with severe mental illness. Lasting 26 weeks and involving 38 persons with severe mental illness, the intervention prioritised two components: the interpersonal relationships of persons with severe mental illness, staff, and group leaders and group education about physical and mental health. Pre-post intervention measurements of quality of life collected with the Manchester Short Assessment of Quality of Life, cognitive performance with the Frontal Systems Behaviour Scale, walking capacity with a 6-min walk test, and body composition in terms of waist circumference and body mass index were analysed using a nonparametric test Wilcoxon signed-rank test. Results suggest that the intervention afforded significant improvements in the health-related variables of quality of life, cognitive performance, walking capacity, and waist circumference for persons with severe mental illness. However, long-term studies with control groups and that examine parameters related to cardiovascular risk factors are essential to ensure the sustained impact of the intervention.

Health Promotion in Practice-District Nurses׳ Experiences of Working with Health Promotion and Lifestyle Interventions Among Patients at Risk of Developing Cardiovascular Disease.

OBJECTIVE: Health Promotion Practice (HPP) has the objective to promote a healthier lifestyle and reduce the risk of disease. The aim of this study was to examine district nurses׳ experiences of working with health preventive actions among patients with risk factors for cardiovascular disease (CVD), and to identify facilitators and obstacles in HPP. DESIGN/SETTING: The study was carried out with a qualitative approach where individual semistructured interviews were performed with a total of 12 district nurses in primary care. Data transcripts were analyzed with a manifest content analysis. FINDINGS: Five categories were identified. Firstly, informants regarded HPP as the core essence of their work. Secondly, counseling and coaching were reported as crucial elements in working with HPP. Thirdly, informants identified tools such as motivational interviewing (MI) to facilitate HPP. In the fourth category facilitators and barriers of HPP appeared, consisting of both positive and negative attitudes and presence as well as lack of organizational culture and structure. Finally, some informants were dissatisfied with HPP and viewed it as compulsory or as a burden, while others were satisfied and experienced it as a stimulating challenge. CONCLUSION: This study identified that HPP is the core of the district nurses׳ work to promote a healthier lifestyle in individuals with CVD. Organizational structures and culture need to be improved in order to support district nurses to successfully work with HPP. To optimize health promotion and strengthen patients׳ self-care, it is recommended that HPP include holistic elements of care.

High-fidelity simulation: Assessment of student nurses' team achievements of clinical judgment.

Nursing educators have the challenge of preparing nursing students to handle complex patient care situations in real life, but much remains unknown about the ability to make clinical judgments. In this study, high-fidelity simulation (HFS) was used at a Swedish university to find answers about pre-licensure nursing students' success in clinical judgment in terms of team ability and relationships with theoretical achievements, and personal and scenario circumstances. The matrix Lasater Clinical Judgment Rubric (LCJR) was used to analyze and score the students' ability in teams to notice, interpret and respond to complex care situations. Overall, the results showed the student teams in their first meeting with HFS in a complex care situation achieved low clinical judgment points; most teams were in the stages of Beginning and Developing. For attaining high team achievements the majority of the students in the team should theoretically be "high performance". Being observers and having HFS experience before nursing education was significant too. However, age, health care experience, and assistant nurse degrees were of secondary importance. Further research at universities regionally, nationally, and internationally is needed.

Assessing the Construct Validity and Reliability of School Health Records Using the 'Health Dialogue Questionnaire' in the Eleventh Grade.

BACKGROUND AND AIMS: The aim for this study was to assess the construct validity and reliability of the Health Dialogue Questionnaire (HDQ©) for eleventh grade in school through comparison of the HDQ© with Paediatric Quality Of Life Inventory (PedsQL™), Local monitoring of youth policy questionnaire (LUPP®), Health behaviour in Swedish school-aged children (HBSC©), Equal health (EH©) and The Swedish Survey Youth on Alcohol Consumption (SSYAC©). METHODS: Cross-sectional samples of eleventh graders from the academic year 2009/2010 was used from the HDQ© (n = 2752), the HBSC© (n = 2090), the PedsQL™ (n = 666), the "LUPP®" questionnaires (n = 2400), EH© (n = 258), and SSYAC© (n = 1748) in the academic year 2009/2010. A comparison between HDQ© and the different proxies was done. Exploratory and confirmatory factor analyses were performed as well as a Multitrait-Multimethod Matrix (MTMM), in order to evaluate the construct validity and reliability of HDQ©. RESULTS: An average disagreement between HDQ© and proxies with 10 percentages was found. Exploratory factor analysis of HDQ© on the 2009/2010 sample suggested a four factor solution (girls factor solution 65% of total variance explained, and in the boys' solution 59% of total variance explained). A second sample 2010/2011 of eleventh graders were used for the confirmatory solution. Almost perfectly similar four factor solutions with were found (girls 58% of total variance explained and boys 56% of the total variance explained). Using MTMM the reliability was generally high and HDQ© and showed agreeable validity. DISCUSSION AND CONCLUSIONS: The HDQ© questionnaire is a reliable and valid instrument for measuring eleventh graders self-reported-health in school.

Reducing or increasing violence in forensic care: a qualitative study of inpatient experiences.

Semi-structured interviews with 13 forensic psychiatric inpatients that had decreased their assessed risk of violence were analyzed using interpretive description. The main contribution from this study is a detailed description of patients' own strategies to avoid violence. Participants described having an ongoing inner dialog in which they encouraged themselves, thereby increasing their self-esteem and trying to accept their current situation. An unsafe and overcrowded ward with uninterested and nonchalant staff increased the risk of aggressive behavior. In the process of decreasing violence, the patients and the forensic psychiatric nursing staff interacted to create and maintain a safe environment.

Exploring the influence of Internet-based caregiver support on experiences of isolation for older spouse caregivers in rural areas: a qualitative interview study.

BACKGROUND: Many older spouse caregivers are tied to the home by their caring duties and feel isolated. The values of supporting older caregivers are well known. In rural areas with long distances and decline in essential services, attending caregiver support groups can be difficult. Using Internet-based services can provide an opportunity for rural caregivers to participate in caregiver support, regardless of geographical distances and without the need for physical presence. AIMS AND OBJECTIVES: This study aimed to explore how Internet-based caregiver support may influence the experience of isolation among older spouse caregivers in rural areas. DESIGN: An intervention study where 63 older rural caregivers received an Internet-based caregiver support service. METHOD: A qualitative interview study based on 31 interviews with open-ended questions, analysed using latent content analysis. FINDINGS: Two themes represent the findings from the study: Expanding the concept of place and Developing networks. Even though participants still spent their days in the house, they experienced that daily life was being spent in a variety of places, both physically, virtually and emotionally. The Internet-based support service provided them with a tool to reconnect with family and develop new friends. CONCLUSIONS: Internet-based caregiver support may reduce the experience of isolation for spouse caregivers in rural areas. Nurses played a crucial part in the development, by encouraging, educating and inspiring caregivers and supporting their independence. IMPLICATIONS FOR PRACTICE: Internet-based services ought to be an option for caregiver support in rural areas as it may reduce feelings of isolation for older spouse caregivers.

Correlations Between Clinical Judgement and Learning Style Preferences of Nursing Students in the Simulation Room.

BACKGROUND: Health care educators account for variables affecting patient safety and are responsible for developing the highly complex process of education planning. Clinical judgement is a multidimensional process, which may be affected by learning styles. The aim was to explore three specific hypotheses to test correlations between nursing students' team achievements in clinical judgement and emotional, sociological and physiological learning style preferences. METHODS: A descriptive cross-sectional study was conducted with Swedish university nursing students in 2012-2013. Convenience sampling was used with 60 teams with 173 nursing students in the final semester of a three-year Bachelor of Science in nursing programme. Data collection included questionnaires of personal characteristics, learning style preferences, determined by the Dunn and Dunn Productivity Environmental Preference Survey, and videotaped complex nursing simulation scenarios. Comparison with Lasater Clinical Judgement Rubric and Non-parametric analyses were performed. RESULTS: Three significant correlations were found between the team achievements and the students' learning style preferences: significant negative correlation with 'Structure' and 'Kinesthetic' at the individual level, and positive correlation with the 'Tactile' variable. No significant correlations with students' 'Motivation', 'Persistence', 'Wish to learn alone' and 'Wish for an authoritative person present' were seen. DISCUSSION & CONCLUSION: There were multiple complex interactions between the tested learning style preferences and the team achievements of clinical judgement in the simulation room, which provides important information for the becoming nurses. Several factors may have influenced the results that should be acknowledged when designing further research. We suggest conducting mixed methods to determine further relationships between team achievements, learning style preferences, cognitive learning outcomes and group processes.

Transitions in the Swedish school system and the impact on student's positive self-reported-health.

BACKGROUND: To explore three school based transitions and their impact on positive self-reported-health (SRH), pre-school to elementary school (6-10 y), elementary school to junior high school (10-13 y), and junior high school to upper secondary school/high school (13-16 y), in a long-term longitudinal population based study. METHODS: The study followed three cohorts through one school transition each. A longitudinal study with data from 6693 Health Dialogue questionnaires were used. Data were collected in the middle of Sweden during 2007-2012 with school children age 6-16 years old. RESULTS: Several significant factors were identified with an impact for a positive self-reported-health among children age 6-16 y; not feeling sad or depressed, afraid or worried, positive school environment (schoolyard and restrooms), not bullied, good sleep, daily physical activity and ability to concentrate. There was no single factor identified, the factors differed according to gender and age. CONCLUSION: The study have identified several gender and age specific factors for successful school transitions relevant for a positive SRH. This is valuable information for school staff, parents and school children and provides a possibility to provide support and assistance when needed.

Important quality aspects in the transfer process.

PURPOSE: Admission to and transfer from an intensive care unit affects not only the patient but also his or her relatives. The authors aimed to investigate relatives' perceptions of quality of care during a patient's transfer process from an intensive care unit to a general ward. DESIGN/METHODOLOGY/APPROACH: The study had a mixed method design that included quantitative data and answers to open questions. The participants were 65 relatives of patients who received care in an ICU. They were recruited from two hospitals in Sweden. FINDINGS: A majority perceived the transfer process as important, but analysis also showed that the participants rated it as an area for improvements. The relatives wanted participation, personal insight and control, respectful encounters, proximity, reassurance, continuous quality, reconnection and feedback. The relatives' participation in the transfer process was perceived as inadequate by 61 per cent, and the support that was received after the ICU discharge was perceived as inadequate by 53 per cent. The patients' length of stay in the ICU affected the relatives' perceptions of the quality of care. Overall, the relatives seemed to desire that the transfer process includes a continuous care, a competent staff, available information throughout the transfer process and personal involvement in the care, both before and after the transfer from the ICU. RESEARCH LIMITATIONS/IMPLICATIONS: The conclusion of this study is that relatives' needs and seeking for a well-planned ICU transitional process organisation with continuous quality before and after transfer, informational strategies that encourage the relatives to be involved and an organisation with competence throughout the healthcare chain are vital for quality. PRACTICAL IMPLICATIONS: The conclusion of this study is that relatives' needs and seeking for a well-planned ICU transitional process organisation with continuous quality before and after transfer, informational strategies that encourage the relatives to be involved and an organisation with competence throughout the healthcare chain are vital for quality. ORIGINALITY/VALUE: The findings have important implications for nursing and nursing management. A relative's perception of the quality of care before and after transfer from ICU may be a valuable source to evaluate the ICU transitional care.

Reaching a turning point--how patients in forensic care describe trajectories of recovery.

In Sweden, the duration of treatment is increasing for patients admitted to forensic psychiatric care. To reduce the length of stay, it is important for the forensic rehabilitation and recovery process to be effective and safe. Not much is known about how the process of recovery and transition begins and how it is described by the forensic patients. The purpose of this study was to explore how forensic patients with a history of high risk for violence experienced the turn towards recovery. A qualitative content analysis was used to analyse interviews with 10 patients who had decreased their assessed risk for violence on the risk assessment instrument HCR-20 and who were successfully managed a lower level of security. Three themes were identified: (i) the high-risk phase: facing intense negative emotions and feelings (ii) the turning point phase: reflecting on and approaching oneself and life in a new way (iii) the recovery phase: recognising, accepting and maturing. In the high-risk phase, chaotic and overwhelming feelings were experienced. The turning point phase was experienced as a sensitive stage, and it was marked by being forced to find a new, constructive way of being. The recovery phase was characterised by recognising personal circumstances in life, including accepting the need for structure, a feeling of maturity and a sense of responsibility for their own life. In order to ensure a successful recovery, the forensic nursing staff needs to recognise and support processes related to treatment motivation and turning points. Recommendations for best nursing practice are given accordingly.

Decreased risk for violence in patients admitted to forensic care, measured with the HCR-20.

AIM: The aim of this study was to explore if patients admitted to forensic psychiatric care decreased their assessed risk for violence over time, to identify patients who decreased their assessed risk for violence exceptionally well (30% or more) on the clinical (C) and risk management (R) scales in the (HCR-20), and to compare them in terms of demographic data. METHODS: The HCR-20 risk assessment instrument was used to assess the risk for violence in 267 patients admitted to a Swedish forensic psychiatric clinic between 1997 and 2010. Their assessments at admission were compared with a second, and most recent, risk assessment. RESULTS: The risk for violence decreased over time. Demographic criteria had no impact on differences on decreased risk. Only two factors, namely gender and psychopathy showed a difference. Risk factors associated with stress and lack of personal support were the items that turned out to be the most difficult to reduce. CONCLUSION: The results show that risk prevention in forensic care does work and it is important to continue to work with risk management. The study highlights the importance of a careful analysis of the patient's risk for violence in order to work with the patient's specific risk factors to reduce the risk.

To reduce technology prior discharge from intensive care--important but difficult? A grounded theory.

AIM: The aim of this study was to provide a deeper understanding of the experience of intensive care staff regarding the reduction in the use of medical technology prior to patients' transfer from the ICU. BACKGROUND: The goal of ICU transitional care, provided for intensive care patients before, during and after the transfer from the ICU to another care unit, is to ensure minimal disruption and optimal continuity of care for the patient. To smooth this transition, there is a need to prepare for a less technological environment and therefore also a need for a gradual reduction in the use of monitoring equipment. METHOD: Group interviews and individual interviews, together with participant observations, were conducted with ICU staff in two hospitals in Sweden. The data were analysed using classic grounded theory. RESULTS: The main concern was the ICU staff's ambiguity regarding whether and how to reduce the use of medical technology devices. Insecurity about weaning patients from medical equipment combined with a lack of standardized routines made it difficult for staff to reduce the technical support. The core category describes how the ambiguity was solved primarily by 'prioritizing control'. However, this often caused the ICU staff to use advanced technology while the patients were in the ICU until the ward staff arrived, even if this should have been handled otherwise. Why and how the ICU staff used the strategy of 'prioritizing control' is further explained in the categories 'being affected by cultural/contextual aspects', 'searching for guidance and a shared understanding' and 'weighing advantages with more v s less technology'. CONCLUSION: It is important to consider ICU staff ambiguity concerning the reduction in technology and to establish strategies for a safe and structured transitional phase with step-down procedures in which technology and monitoring is gradually reduced prior to transfer from ICU.

How can nurses facilitate patient's transitions from intensive care?: a grounded theory of nursing.

OBJECTIVES: Intensive care patients often experience feelings of powerlessness and vulnerability when being transferred from an intensive care unit to a general ward. The aim of this study was to develop a grounded theory of nurses care for patients in the ICU transitional care process. METHODS: Group interviews, individual interviews and participant observations were conducted with nurses in two hospitals in Sweden and were analysed using grounded theory. RESULT: The substantive theory shows the process of nursing care activities - from the contexts of the ICU and the general ward. The main concern was to achieve a coordinated, strengthening, person-centered standard of care to facilitate patient transitions. The core category "being perceptive and adjustable" was a strategy to individualise, that was related to the other categories; "preparing for a change" and "promoting the recovery". However, the nurses were forced to "balance between patient needs and the caregivers' resources" and consequently were compromising their care. CONCLUSIONS: To facilitate an ICU-patient's transition, individual care planning is needed. It is also essential that the patients are adequately prepared for the change to facilitate the transitional care. Knowledge about transitional needs, empowerment and patient-education seems to be important issues for facilitating transitions.

Left alone--Swedish nurses' and mental health workers' experiences of being care providers in a social psychiatric dwelling context in the post-health-care-restructuring era. A focus-group interview study.

The professional role of nurses and mental health workers in social psychiatry is being re-defined towards a recovery, client-focused perspective. Approximately 0.7 percent of the adult population in Sweden suffers from severe mental illness leading to a need for community services. The primary aims of the Mental Health Reform in 1995 in Sweden were to improve the quality of life for people with severe, long-term mental illness and, through normalization and integration, enhancing their opportunities to communicate with and participate in society. This study examines nurses' and mental health workers' views and experiences of being care providers in a municipal psychiatric group dwelling context when caring for clients suffering from severe mental illness. Three focus group interviews were made and thematic content analysis was conducted. Four themes were formulated: 'Being a general human factotum not unlike the role of parents', 'Having a complex and ambiguous view of clients', 'Working in a mainly 'strangled' situation', and 'Feeling overwhelming frustration'. The staff, for instance, experienced a heavy workload that highly involved themselves as persons and restricted organization. The individual relational aspects of the nursing role, the risk of instrumentalizing the staff due to an organizational economical teleopathy (meaning a pathological desire to react goals), and the high societal demands on accomplishing the Mental Health Reform goals are discussed. To redefine the professional role of nurses and mental health workers in the community, in Sweden known as municipality, they need support in the form of continuously education, supervision, and dialogue with politicians as well as the public in general.

Struggle with a gap between intensive care units and general wards.

Nursing critically ill patients includes planning and performing safe discharges from Intensive Care Units (ICU) to the general wards. The aim of this study was to obtain a deeper understanding of the main concern in the ICU transitional process-the care before, during, and after the transfer of ICU patients. Interviews were conducted with 35 Swedish nurses and analysed according to grounded theory. The main concern was the nurses' "struggling with a gap." The "gap" was caused by differences in the altered level of care and contributed to difficulties for nurses encountering an overlap during the transitional care. The categories: sheltering, seeking organizational intertwining and striving for control are related to the core category and were used to generate a theory. The nurses sought improved collaboration, and employed patient-centred routines. They wanted access to necessary tools; they relayed or questioned their own competence and sought assurance of the patients' ability to be transferred. If the nurses felt a loss of control, lack of intertwining and lack of collaboration, they sheltered their patients and themselves. Intertwining was more difficult to perform, but actually even more important to do. With knowledge about ICU transitional care, collaboration, routines, and with an organization that provides an educational environment, the process could be improved.

Nurses' attitudes towards older residents with long-term schizophrenia.

BACKGROUND: In institutional care, a symptom-oriented approach is a frequently used but seldom-discussed method for treating people with severe mental illness. AIM: To investigate whether nurses' approach could be explained with reference to a client's individual clinical picture or the fact that they had a diagnosis of schizophrenia. METHODS: An exploratory study of the staff's view of a caring approach for a fictitious older long-term schizophrenic resident was conducted. All nurses working in the field of psychiatry at seven different units in one municipality in northern Sweden were an integral part of the study. The units were divided into two groups and classified as 'dwelling' or 'support'. The 'dwelling group' was characterized by nurses working at traditional group dwellings, and the 'support group' by nurses working in small teams and visiting people with long-term mental illness in their homes. Responses were received from 62 women and 23 men, of whom 14 were Registered Nurses and 69 were Enrolled Nurses. A questionnaire was used, developed from a case description of a 68-year-old woman with typical symptoms of severe cognitive decline, with problematic behaviour and a diagnosis of long-term schizophrenia. FINDINGS: The main finding was that nurses with long experience became less sensitive in their relationship with the resident than less experienced nurses. There appeared to be a tendency for long work experience to have a negative effect on nurses' attitudes towards the resident. CONCLUSIONS: The nurses could be interpreted as being caught in a moral dilemma between ends and means. This dilemma could be represented on the one hand as the 'conformist mode', with an acceptance of ends and means, and on the other hand as the 'innovation mode', with acceptance of ends but with few legitimate means to achieve them.