A qualitative study of leaders' experiences of handling challenges and changes induced by the COVID-19 pandemic in rural nursing homes and homecare services.

BACKGROUND: The COVID-19 pandemic had a major impact on healthcare services globally. In care settings such as small rural nursing homes and homes care services leaders were forced to confront, and adapt to, both new and ongoing challenges to protect their employees and patients and maintain their organization's operation. The aim of this study was to assess how healthcare leaders, working in rural primary healthcare services, led nursing homes and homecare services during the COVID-19 pandemic. Moreover, the study sought to explore how adaptations to changes and challenges induced by the pandemic were handled by leaders in rural nursing homes and homecare services. METHODS: The study employed a qualitative explorative design with individual interviews. Nine leaders at different levels, working in small, rural nursing homes and homecare services in western Norway were included. RESULTS: Three main themes emerged from the thematic analysis: "Navigating the role of a leader during the pandemic," "The aftermath - management of COVID-19 in rural primary healthcare services", and "The benefits and drawbacks of being small and rural during the pandemic." CONCLUSIONS: Leaders in rural nursing homes and homecare services handled a multitude of immediate challenges and used a variety of adaptive strategies during the COVID-19 pandemic. While handling their own uncertainty and rapidly changing roles, they also coped with organizational challenges and adopted strategies to maintain good working conditions for their employees, as well as maintain sound healthcare management. The study results establish the intricate nature of resilient leadership, encompassing individual resilience, personality, governance, resource availability, and the capability to adjust to organizational and employee requirements, and how the rural context may affect these aspects.

A resilience perspective on healthcare personnels' experiences of managing the COVID-19 pandemic: a qualitative study in Norwegian nursing homes and come care services.

BACKGROUND: The COVID-19 pandemic led to new and unfamiliar changes in healthcare services globally. Most COVID-19 patients were cared for in primary healthcare services, demanding major adjustments and adaptations in care delivery. Research addressing how rural primary healthcare services coped during the COVID-19 pandemic, and the possible learning potential originating from the pandemic is limited. The aim of this study was to assess how primary healthcare personnel (PHCP) working in rural areas experienced the work situation during the COVID-19 outbreak, and how adaptations to changes induced by the pandemic were handled in nursing homes and home care services. METHOD: This study was conducted as an explorative qualitative study. Four municipalities with affiliated nursing homes and homecare services were included in the study. We conducted focus group interviews with primary healthcare personnel working in rural nursing homes and homecare services in western Norway. The included PHCP were 16 nurses, 7 assistant nurses and 2 assistants. Interviews were audio recorded, transcribed and analyzed using thematic analysis. RESULTS: The analysis resulted in three main themes and 16 subthemes describing PHCP experience of the work situation during the COVID-19 pandemic, and how they adapted to the changes and challenges induced by the pandemic. The main themes were: "PHCP demonstrated high adaptive capacity while being put to the test", "Adapting to organizational measures, with varying degree of success" and "Safeguarding the patient's safety and quality of care, but at certain costs". CONCLUSION: This study demonstrated PHCPs major adaptive capacity in response to the challenges and changes induced by the covid-19 pandemic, while working under varying organizational conditions. Many adaptations where long-term solutions improving healthcare delivery, others where short-term solutions forced by inadequate management, governance, or a lack of leadership. Overall, the findings demonstrated the need for all parts of the system to engage in building resilient healthcare services. More research investigating this learning potential, particularly in primary healthcare services, is needed.

Migrant Somali women's experiences with their first contact with the labor ward prior to admission: A qualitative study.

INTRODUCTION: The first contact with the labor ward is a crucial moment in any birth and can be especially challenging when the woman has a migrant background. The aim of the study was to explore migrant Somali women's experiences with their first contact with the labor ward prior to admission, in Norway. METHODS: In this qualitative study, data were collected through semi-structured individual interviews and Systematic Text Condensation was the method used to analyze the data. Ten Somali-born women who had given birth in Norway were included. RESULTS: The migrant Somali women's first contact with the labor ward prior to admission was challenging, due to one-way communication, poor health literacy, and a fear of interventions or adverse outcomes. To improve care, the migrant Somali women highlighted a need for: 1) flexibility, tailored information and practical guidance before birth; and 2) face-to-face assessment in early labor. CONCLUSIONS: The findings in this study indicate that the needs of laboring migrant Somali women are not fully met by antenatal or pre-hospital maternity care services. To improve the critical first contact with the labor ward for migrant Somali women, this study suggests that antenatal care services offer practical guidance on whom to contact and what to expect at the hospital in early labor. Face-to-face assessment of maternal and fetal well-being should be the first choice of care for Somali women in early labor who are unfamiliar with the healthcare system after immigration. Interpretation services need strengthening and our findings support a need for increased continuity of care.

A planned but vulnerable pathway towards self-management following day surgery. Orthopaedic patients' experiences.

INTRODUCTION: An increasing share of surgical activity is organised as day surgery, thus giving more responsibility for care to patients and their next of kin. PURPOSE: To obtain increased understanding of orthopaedic day surgery patients' experiences with self-management. METHODS: A descriptive interview study. Eleven men and five women aged 18-78 years, who had undergone arthroscopic knee surgery in rural Norway participated in qualitative individual interviews during autumn 2018. Systematic text condensation was used as analysis strategy. RESULTS: The main theme a planned but vulnerable pathway towards self-management and five subthemes were highlighted. The interviewees were satisfied with most aspects of the day surgery. However, challenges in adapting oral and written information to self-management postdischarge, a need for further self-management support at home, and strenuous travel increased the strain. CONCLUSION: The written and oral information and support that was planned and provided by the hospital did not meet the patients' needs for self-management support postdischarge. The day surgery care pathway seemed to lack effective educational interventions for strengthening the patients' self-efficacy and control and to have potential for improvements.

Hospital physicians' views on discharge and readmission processes: a qualitative study from Norway.

OBJECTIVES: To explore hospital physicians' views on readmission and discharge processes in the interface between hospitals and municipalities. DESIGN: Qualitative case study. SETTING: The Norwegian healthcare system. PARTICIPANTS: Fifteen hospital physicians (residents and consultants) from one hospital, involved in the treatment and discharge of patients. RESULTS: The results of this study showed that patients were being discharged earlier, with more complex medical conditions, than they had been previously, and that discharges sometimes were perceived as premature. Insufficient capacity at the hospital resulted in pressure to discharge patients, but the primary healthcare service of the area was not always able to assume care of these patients. Communication between levels of the healthcare service was limited. The hospital stay summary was the most important, and sometimes only, form of communication between levels. The discharge process was described as complicated and was affected by healthcare personnel, by patients themselves and by aspects of the primary healthcare service. Early hospital discharges, poor communication between healthcare services and inadequacies in the discharge process were perceived to affect hospital readmissions. CONCLUSION: The results of this study provide a better understanding of hospital physicians' views on the discharge and hospital readmission processes in the interface between the hospital and the primary healthcare service. The study also identifies discrepancies in governmental requirements, reform regulations and current practices in municipalities and hospitals.

Nursing home leaders' and nurses' experiences of resources, staffing and competence levels and the relation to hospital readmissions - a case study.

BACKGROUND: Thirty-day hospital readmissions represent an international challenge leading to increased prevalence of adverse events, reduced quality of care and pressure on healthcare service's resources and finances. There is a need for a broader understanding of hospital readmissions, how they manifest, and how resources in the primary healthcare service may affect hospital readmissions. The aim of the study was to examine how nurses and nursing home leaders experienced the resource situation, staffing and competence level in municipal healthcare services, and if and how they experienced these factors to influence hospital readmissions. METHOD: The study was conducted as a comparative case study of two municipalities affiliated with the same hospital, chosen for historical differences in readmission rates. Nurses and leaders from four nursing homes participated in focus groups and interviews. Data were analyzed within and across cases. RESULTS: The analysis resulted in four common themes, with some variation in each municipality, describing nurses' and leaders' experience of the nursing home resource situation, staffing level and competence and their perception of factors affecting hospital readmissions. The nursing home patients were described as becoming increasingly complex with a subsequent need for increased nurse competence. There was variation in competence and staffing between nursing homes, but capacity building was an overall focus. Economic limitations and attempts at saving through cost-cutting were present, but not perceived as affecting patient care and the availability of medical equipment. Several factors such as nurse competence and staffing, physician coverage, and adequate communication and documentation, were recognized as factors affecting hospital readmissions across the municipalities. CONCLUSION: Several factors related to nurses' and leaders' experience of the resource situation, staffing and competence level were suggested to affect hospital readmissions and the municipalities were similar in their answers regarding these factors. Patients were perceived as more complex with higher patient mortality forcing long-term nursing homes to shift towards an acute care or palliative function, and short-term nursing homes to function as "small hospitals", requiring higher nurse competence. Staffing, competence and physician coverage did not seem to have adjusted to the new patient group in some nursing homes.

Exploring physicians' decision-making in hospital readmission processes - a comparative case study.

BACKGROUND: Hospital readmissions is an increasingly serious international problem, associated with higher risks of adverse events, especially in elderly patients. There can be many causes and influential factors leading to hospital readmissions, but they are often closely related, making hospital readmissions an overall complex area. In addition, a comprehensive coordination reform was introduced into the Norwegian healthcare system in 2012. The reform changed the premises for readmissions with economic incentives enhancing early transfer from secondary to primary care, making research on readmissions in the municipalities more urgent than ever. General practitioners (GPs) and nursing home physicians, have traditionally held a gatekeepers function in hospital readmissions from the municipal healthcare service, as they are the main decision-makers in questions of hospital readmissions. Still, the GPs' gatekeeper function is an under-investigated area in hospital readmission research. The aim of the study was to increase knowledge about factors that lead to hospital readmissions among elderly in municipal healthcare, with special attention to GPs' and nursing home physicians' decision making. METHOD: The study was conducted as a comparative case study. Two municipalities affiliated with the same hospital, but with different readmission rates were recruited. Twenty GPs and nursing home physicians from each municipality were recruited and interviewed. Forty hours of observation were conducted during the huddles in one long-term and one short-term nursing home in each municipality. RESULTS: Seven themes describing how different factors influence physicians' decision-making in the hospital readmission process in two municipalities were identified. Poor communication, continuity and information flow account for hospital readmissions in both municipalities. Several factors, including nurse staffing and competence, patients and their families, time constraints and experience affected physicians' decision-making. CONCLUSION: Communication, continuity and information flow contributed to hospital readmissions in both municipalities. The cross-case analysis revealed slight differences between municipalities. More research focusing on GPs' and nursing home physicians' decision-making, nursing home nurses and home care nurses' experience of hospital readmissions and discharges is needed.

What characterizes women who want to give birth as naturally as possible without painkillers or intervention?

OBJECTIVE: To describe the characteristics of pregnant women who wish to have as natural a birth as possible without analgesics and without intervention. STUDY DESIGN: National cohort study. SETTING: Norwegian Institute of Public Health. POPULATION: 55,859 pregnant women booked for antenatal care in Norway 1999-2007. METHODS: Data on women's interest in natural birth and a set of possible predictors were retrieved from a questionnaire completed at the 30th week of pregnancy and linked to the Medical Birth Registry of Norway. MAIN OUTCOME MEASURE: Natural birth and the characteristics of pregnant women with such preferences. RESULTS: Interest in natural childbirth was consistently expressed by 72%. Positive experience from previous pregnancies, first birth or third or later birth, no fear of giving birth, and reporting positive intra-psychic phenomena are significantly associated with the wish for natural birth. CONCLUSIONS: Positive experiences from previous childbirths and no fear of giving birth are the strongest factors associated with a wish for as natural birth as possible and should be taken into consideration in public health.

How does preference for natural childbirth relate to the actual mode of delivery? a population-based cohort study from Norway.

BACKGROUND: In Norway, intervention in childbirth has increased from 3 percent in 1967 to 37 percent in 2006. The objectives of this study were, first, to estimate to which extent women who expressed a preference for natural birth actually were delivered vaginally without interventions, and second, to estimate the influence that emotions and maternal background factors have on the mode of delivery. METHODS: We used data from 39,475 pregnancies of participants in the Norwegian Mother and Child Cohort Study in which the pregnant woman had expressed a preference for natural birth, and linked these data with the pregnancy outcome as registered in the population-based Medical Birth Registry of Norway during 2000 to 2006. The influence of maternal factors on the mode of delivery was estimated with log-binomial regression models, stratified by parity. RESULTS: Among primiparas, 29.3 percent delivered vaginally without interventions (natural birth), 56.1 percent gave birth vaginally with interventions, and 14.5 percent had a cesarean section. The strongest predictor for actually having a natural birth was age below 25 years, having more than 12 years' education, carrying a single fetus, and having a low score for anxiety and depression. Among multiparas, 61.1 percent gave birth vaginally without interventions, 30.6 percent vaginally with interventions, and only 8.3 percent had a cesarean section. The effects of maternal age, education, and anxiety or depression on the outcome were smaller for multiparas than for primiparas. CONCLUSIONS: The chance of actually having a natural birth for women with a preference for a natural birth is much greater for multiparas than for primiparas. The factors that influence the chance of having a natural birth are different for primiparas and multiparas.

What characterizes women in Norway who wish to have a caesarean section?

AIMS: The aim of this study was to describe the characteristics of pregnant women who wish to have a caesarean section. METHODS: Data were collected as part of the Norwegian Mother and Child Cohort Study conducted by the Norwegian Institute of Public Health. Pregnant women booked for antenatal care in Norway between 1999 and 2006 were invited to participate in the study. Data on women's interest in mode of delivery and a set of associated variables were gathered from a questionnaire completed by 55,859 women at 30 weeks of pregnancy. RESULTS: A wish for caesarean section was expressed by 10% of the women, and 33% thought that the woman herself should be allowed to decide whether to have a caesarean section or not. A negative experience from a previous labour, a second birth, an age>35, a low level of education, being single, being unemployed, having an assisted conception, expecting more than one foetus, experiencing urinary and bowel incontinence before current pregnancy, experiencing pelvic pain, having a fear of childbirth and reporting negative intra-psychic phenomena were significantly associated with a wish for caesarean section. CONCLUSIONS: At 30 weeks of pregnancy, one out of 10 women in a sample of Norwegian women would choose a caesarean section. Negative experiences from previous pregnancies and fear of giving birth are two of the strongest factors associated with a wish for a caesarean section and should be taken into consideration.

Risk and security in childbirth.

Risk and security are often defined as being complementary. Security is based on risk calculations, which undergo constant change. An increasing number of abnormalities can be uncovered in the human body, and more and more people are defined as being at risk for various diseases or at risk as child bearers. The aim of this paper is to examine the notion of risk, and to understand it in different ways as it is applied to childbirth. General and professional perspectives on risk are different; views vary as to what constitutes acceptable risk, and the association between normalcy and complications is socially and culturally determined. Figures for risk and reliability are not objective values. The safe and the risky are anchored in certain symbol systems. Alternative and dialogic notions have been introduced in conversations and thinking about risk, and medicalism and paternalism have been questioned. This questioning has thus far had little influence on clinical practice. The two opposite perspectives of risk and security in the area of pregnancy and birth should be taken into consideration. The childbearing woman has preferences of her own. Dialog with the health professional and information about professional facts and professional uncertainty should be offered.