Ethics rounds in the ambulance service: a qualitative evaluation.

BACKGROUND: It is a common ethical challenge for ambulance clinicians to care for patients with impaired decision-making capacities while assessing and determining the degree of decision-making ability and considering ethical values. Ambulance clinicians' ethical competence seems to be increasingly important in coping with such varied ethical dilemmas. Ethics rounds is a model designed to promote the development of ethical competence among clinicians. While standard in other contexts, to the best of our knowledge, it has not been applied within the ambulance service context. Thus, the aim of this study was to describe ambulance clinicians' experiences of participating in ethics rounds. METHODS: This was a qualitative descriptive study, evaluating an intervention. Data were collected through sixteen interviews with ambulance clinicians who had participated in an intervention involving ethics rounds. The analysis was performed by use of content analysis. RESULTS: Two themes describe the participants' experiences: (1) Reflecting freely within a given framework, and (2) Being surprised by new insights. The following categories form the basis of the themes; 1a) Gentle guidance by the facilitator, 1b) A comprehensible structure, 2a) New awareness in the face of ethical problems, and 2b) Shared learning through dialogue. CONCLUSION: Incorporating structured ethics rounds seems to create a continuous development in ethical competence that may improve the quality of care in the ambulance service. Structured guidance and facilitated group reflections offer ambulance clinicians opportunities for both personal and professional development. An important prerequisite for the development of ethical competence is a well-educated facilitator. Consequently, this type of ethics rounds may be considered a useful pedagogical model for the development of ethical competence in the ambulance service.

Ethics education to support ethical competence learning in healthcare: an integrative systematic review.

BACKGROUND: Ethical problems in everyday healthcare work emerge for many reasons and constitute threats to ethical values. If these threats are not managed appropriately, there is a risk that the patient may be inflicted with moral harm or injury, while healthcare professionals are at risk of feeling moral distress. Therefore, it is essential to support the learning and development of ethical competencies among healthcare professionals and students. The aim of this study was to explore the available literature regarding ethics education that promotes ethical competence learning for healthcare professionals and students undergoing training in healthcare professions. METHODS: In this integrative systematic review, literature was searched within the PubMed, CINAHL, and PsycInfo databases using the search terms 'health personnel', 'students', 'ethics', 'moral', 'simulation', and 'teaching'. In total, 40 articles were selected for review. These articles included professionals from various healthcare professions and students who trained in these professions as subjects. The articles described participation in various forms of ethics education. Data were extracted and synthesised using thematic analysis. RESULTS: The review identified the need for support to make ethical competence learning possible, which in the long run was considered to promote the ability to manage ethical problems. Ethical competence learning was found to be helpful to healthcare professionals and students in drawing attention to ethical problems that they were not previously aware of. Dealing with ethical problems is primarily about reasoning about what is right and in the patient's best interests, along with making decisions about what needs to be done in a specific situation. CONCLUSIONS: The review identified different designs and course content for ethics education to support ethical competence learning. The findings could be used to develop healthcare professionals' and students' readiness and capabilities to recognise as well as to respond appropriately to ethically problematic work situations.

Older patients' autonomy when cared for at emergency departments.

BACKGROUND: Older patients in emergency care often have complex needs and may have limited ability to make their voices heard. Hence, there are ethical challenges for healthcare professionals in establishing a trustful relationship to determine the patient's preferences and then decide and act based on these preferences. With this comes further challenges regarding how the patient's autonomy can be protected and promoted. AIM: To describe nurses' experiences of dealing with older patients' autonomy when cared for in emergency departments (EDs). RESEARCH DESIGN: This study adopted reflective lifeworld theory and a phenomenological design. PARTICIPANTS AND RESEARCH CONTEXT: A total of 13 open-ended interviews were performed with nurses working at two EDs in Sweden. ETHICAL CONSIDERATIONS: The study was reviewed by the Ethical Advisory Board in South East Sweden and conducted according to the Declaration of Helsinki. All participants gave consent. FINDINGS: Nurses' experiences of dealing with older patients' autonomy in EDs are characterized by moving in a conflicting uphill struggle, indicating obscure thoughts on how patient autonomy can be protected in an ethically challenging context. The phenomenon is further described with its meaning constituents: 'Being hampered by prioritization under stress', 'Balancing paternalism and patient autonomy', 'Making decisions without consent in the patient's best interests' and 'Being trapped by notions of legitimate care needs'. CONCLUSION: Stressful work conditions and lacking organizational strategies in EDs contribute to nurses maintaining unjustified paternalistic care, regardless of the patient's ability and medical condition, and questioning who has legitimacy for participating in decisions about care. The nurses' protection and promotion of older patients' autonomy is dependent on the opportunity, ability and willingness to create a patient relationship where the patient's voice and preferences are valued as important. Consequently, strategies are needed to improve patient autonomy in EDs based on the idea of 'relational autonomy'.

Staff strategies for dealing with care situations at an emergency department.

INTRODUCTION: Overcrowding is a common international problem at Emergency Departments often due to those patients get recommendations or referrals from other health professionals to seek care at the emergency department. Crowding brings with it an amount of adverse consequences for both patients and staff, and knowledge about staff's strategies of dealing with this caring situation is limited. AIM: The aim of the present study was thus to describe staffs' strategies to deal with the caring situations at an emergency department. METHOD: Secondary analysis has been made of 18 qualitative interviews grounded in a lifeworld perspective. The interviews were analysed by qualitative content analysis. FINDINGS: The results showed that the staff at the ED worked in twofold directions using both proactive and reactive strategies in order to deal with the care situation when caring for patients at ED. The proactive strategy is optimising conditions, controlling patient flow and being boundary. The reactive strategy is about customising the conversation and holding an open approach. CONCLUSION: In conclusion, the proactive strategy is to make what you decided for unseen circumstances. The reactive strategy is then about less anticipation of the encounter, waiting for the patient to act and react to it. IMPLICATION: The result can have implications with respect to developing and improving care at crowded Emergency departments. Knowledge about strategies creates a fundament for developing visible sustainable structure for patient flow in making work patient safety for patients, staff and organisation.

Factors contributing to serious adverse events in nursing homes.

AIMS AND OBJECTIVES: To identify the most common serious adverse events that occurred in nursing homes and their most frequent contributing factors to the improvement of safe nursing care. BACKGROUND: There is a need to improve safe nursing care in nursing homes. Residents are often frail and vulnerable with extensive needs for nursing care. A relatively minor adverse event in nursing care can cause serious injury that could have been preventable. DESIGN: This was a retrospective study, with a total sample of data regarding adverse events (n = 173) in nursing homes, concerning nursing care reported by healthcare providers in Sweden to the Health and Social Care Inspectorate. The reports were analysed with content analysis, and the frequencies of the adverse events, and their contributing factors, were described with descriptive statistics. RESULTS: Medication errors, falls, delayed or inappropriate intervention and missed nursing care contributed to the vast majority (89%) of the serious adverse events. A total of 693 possible contributing factors were identified. The most common contributing factors were (i) lack of competence, (ii) incomplete or lack of documentation, (iii) teamwork failure and (iv) inadequate communication. CONCLUSIONS: The contributing factors frequently interacted yet they varied between different groups of serious adverse events. The resident's safety depends on the availability of staff's competence as well as adequate documentation about the resident's condition. Lack of competence was underestimated by healthcare providers. RELEVANCE TO CLINICAL PRACTICE: Registered nurses and assistant nurses need to have awareness of contributing factors to adverse events in nursing care. A holistic approach to improve patient safety in nursing homes requires competence of the staff, safe environments as well as resident's and relative's participation.

Early detection and management of symptoms using an interactive smartphone application (Interaktor) during radiotherapy for prostate cancer.

PURPOSE: Patients undergoing radiotherapy for prostate cancer suffer from a variety of symptoms which influence health-related quality of life. We have developed an application (Interaktor) for smartphones and tablets for early detection, reporting and management of symptoms, and concerns during treatment for prostate cancer. The study evaluates the effect on symptom burden and quality of life when using the application for real-time symptom assessment and management during radiotherapy for localized prostate cancer. METHODS: A non-randomized controlled study was used at two university hospitals in Sweden where 64 patients constituted a control group and 66 patients made up an intervention group. The intervention group was asked to report symptoms via the application daily during the treatment as well as 3 weeks after. The EORTC QLQ-C30 and its module PR25 and the Sense of Coherence questionnaire were administered at three time points in both groups. RESULTS: The intervention group rated significantly lower levels of fatigue and nausea at the end of radiotherapy. Moreover, they had significantly less burden in emotional functioning, insomnia, and urinary-related symptoms at the end of treatment as well as 3 months later compared with the control group. In the multivariate analyses, with education and sense of coherence as covariates, the intervention group still significantly rated emotional functioning (p = 0.007), insomnia (p = 0.017), and urinary-related symptoms (p = 0.008) as better than the control group at T2. CONCLUSION: Study findings suggest that Interaktor could be an efficient mHealth tool for facilitating supportive care needs during cancer treatment.

Patients' strategies to deal with their situation at an emergency department.

INTRODUCTION: The care in the emergency department (ED) is often characterised by high standards of efficiency and rapid treatment and the encounter between patient and staff can be described as both short and fragmented. Research within this field has mostly been performed with quantitative measurements and patients are both satisfied and vulnerable in their care at an ED. There is a lack of qualitative studies about patient's strategies to deal with their situation. AIM: The aim was to describe patient's strategies for dealing with their situation at an ED. METHODS: Secondary analysis has been made of 13 qualitative interviews grounded in a lifeworld perspective. The interviews were analysed by qualitative content analysis. RESULTS: The results showed that patients' strategies to deal with the situation at the ED are passive or active. The passive strategy is being patient and the active strategies varied in terms of having hidden tactics, using visible tactics and using families as support. CONCLUSION: These findings increase the importance of gaining knowledge about these strategies so that the staff at the ED can support the patients so they do not have to use them.

Older patients' perceptions of the Swedish ambulance service: A qualitative exploratory study.

BACKGROUND: As worldwide life expectancy increases, the Swedish Ambulance Service is likely to be affected by the demographic shift towards a larger proportion of older persons. An older population tends to increase the demand for ambulances, indicating a need to illuminate older patients' perspective. Thus, the aim of this study was to explore older patients' perceptions of the Swedish Ambulance Service. METHODS: This interview study employed a descriptive qualitative design with a phenomenographic approach in accordance with Dahlgren and Fallsberg. RESULTS: Three main descriptive categories emerged to describe the underlying conceptions in the interviews; A double-edged encounter, Trust is created by perceived competence, and Safety through accessibility in vulnerable situations. CONCLUSION: Older patients described trust in ambulance clinicians as a prerequisite for feeling safe enough to share their feelings and allow a bodily examination. However, they also criticized the care provided because they questioned the need for certain actions.

Questionnaire for patient participation in emergency departments: development and psychometric testing.

AIM: The aim of the study was to develop and test the psychometric properties of a patient participation questionnaire in emergency departments. BACKGROUND: Patient participation is an important indicator of the quality of healthcare. International and national healthcare policy guidelines promote patient participation. While patients cared for in emergency departments generally express dissatisfaction with their care, a review of the literature fails to reveal any scientifically tested instruments for assessing patient participation from the perspective of patients. METHODS: A methodological study was conducted involving a convenience sample of 356 patients recently cared for in emergency departments in Sweden. Data were collected in 2008 and analysed for construct and criterion validity, also homogeneity and stability reliability. RESULTS: A 17-item questionnaire was developed. Two separate factor analyses revealed a distinct 4-factor solution which was labelled: Fight for participation, Requirement for participation, Mutual participation and Participating in getting basic needs satisfied. Criterion validity testing showed 9 out of 20 correlations above 0.30 and, of these, three were moderate correlations of 0.62, 0.63 and 0.70. Cronbach's alpha coefficient ranged from 0.63 to 0.84 and test-retest varied between 0.59 and 0.93. CONCLUSION: The results signify evidence of acceptable validity and reliability, and the questionnaire makes it possible to evaluate patient participation in emergency department caring situations. In addition, it produces data which are usable by a diverse range of healthcare professionals.

Patient participation in the emergency department: an evaluation using a specific instrument to measure patient participation (PPED).

AIM: This study aimed at evaluating patient participation from the perspective of patients who received care in emergency departments, with a separate examination of the relationship between participation and age, gender, education and priority level. BACKGROUND: International and national guidelines encourage patient participation. High patient participation is required to ensure a high quality of care. No studies evaluating patient participation at an emergency department have been published. METHODS: An evaluating study, with the Patient Participation Emergency Department questionnaire, was conducted at emergency departments in Sweden. A consecutive sample of 356 patients participated. Data were collected in 2008: participants were 49% women and with an average age of 56 years. The statistical methods used were Student's t-test, one-way ANOVA and Spearman correlation. RESULTS: The results revealed that patients experienced good requirement for participation such as time and information. Mutual participation demonstrated a reasonable level, but patient participation is low in two dimensions (Fight for participation, Participation in getting basic needs satisfied). Young and well-educated patients fought more to participate in their care and gained less attention for basic needs than older and less well-educated patients. CONCLUSIONS: Patient participation in a mutual care situation between patients and healthcare professionals requires further improvement to ensure that patients are satisfied and do not have to struggle and fight to participate in their care.

Patient participation in emergency care - a phenomenographic analysis of caregivers' conceptions.

AIMS AND OBJECTIVES: The aim of this study was to describe caregivers' conceptions of patient participation in an emergency care unit. BACKGROUND: Patient participation is an important goal in health care. Patients who are given the opportunity to participate in care situations are able to influence care in a way that is more beneficial to them. Patients' participation in caring has been studied in different contexts, but little health care research has been conducted into patient participation in the emergency care unit. Patients treated in emergency care units sometimes express dissatisfaction with their care situation and it would therefore be important to find out how caregivers in emergency care experience patient participation. DESIGN: A phenomenographic research method based on life world theory was used in the study. METHOD: Data were collected from 11 caregivers with experience of working in an emergency department. The caregivers were from different professions: three physicians, four nurses and four auxiliary nurses. RESULTS: The caregivers' conceptions of patient participation can be divided into three different descriptive categories: caregivers offer the opportunity for participation, patients demand participation and mutual participation. CONCLUSIONS: The study adds knowledge that caregivers' different qualitative conceptions of patient participation are mainly conditional from caregivers. RELEVANCE TO CLINICAL PRACTICE: Mutual participation is perceived occasionally and often unexpectedly, when the right circumstances occur, despite international and national guidelines that lay down the need for patient participation.

Patient participation in the intensive care unit.

OBJECTIVE: Patient participation in healthcare is important for optimizing treatment outcomes and for ensuring satisfaction with care. The purpose of the study wasto explore critical care nurses' perceptions of patient participation for critically ill patients. DESIGN AND SETTINGS: Qualitative data were collected in four separate focus group interviews with 17 nurses from two hospitals. The interviews were analyzed using qualitative content analysis. FINDINGS: Initially, the nurses stated that patient participation in the intensive care unit (ICU) was dependent on the patient's health condition and consciousness. However, during the interviews three descriptive categories emerged from their experience, that is: passive patient participation, one-way communication and nurse/patient interaction. CONCLUSION: In the ICU, the possibilities for patient participation in nursing care are not only dependent on the patient's health condition but also on the nurse's ability to include patients in various care actions despite physical and/or mental limitations. When the patient is not able to participate, nurses strive to achieve participation through relatives' knowledge and/or other external sources of information.

Patients' Perspective on Participation in Care With or Without the Support of a Smartphone App During Radiotherapy for Prostate Cancer: Qualitative Study.

BACKGROUND: Patients with prostate cancer are often cared for as outpatients during radiotherapy, which can be an aggravating circumstance for patient participation. There is a need to evaluate whether an interactive smartphone app could enable participation in care, specifically during treatment for prostate cancer. The interactive app (Interaktor) used in this study is developed in codesign with patients and health care professionals; it includes daily reports of symptoms, a risk assessment model, evidence-based self-care advice, along with the provision of immediate access to clinicians. OBJECTIVE: The aim of this study was to explore how patients with prostate cancer perceived their participation with or without the support of the smartphone app during radiotherapy. METHODS: A total of 28 prostate cancer patients receiving adjuvant radiotherapy were interviewed about their perceived participation in their own care. All the patients interviewed in this study participated in an intervention study where the control group received standard care that comprised having access to a contact nurse to turn to with any concerns during their treatment. In addition to standard care, the patients in the intervention group received the app downloaded in a smartphone. The patients' age ranged between 57 and 77 years; 17 patients used the smartphone app. The interviews were analyzed with directed qualitative content analysis. RESULTS: The four dimensions of patient participation, which include mutual participation, fight for participation, requirement for participation, and participation in getting basic needs satisfied, were confirmed as valid perspectives in the interviews with the patients with prostate cancer, irrespective of whether they used the smartphone app. However, the patients who had used the smartphone app described it as a facilitating factor, especially for mutual participation. CONCLUSIONS: Using innovative ways to communicate with patients, such as an interactive app for symptom management with contact with health care in real time, can successfully help achieve increased patient participation in care.

Symptoms and self-care following pancreaticoduodenectomy: Perspectives from patients and healthcare professionals - Foundation for an interactive ICT application.

PURPOSE: Poor prognosis and a problematic recovery period after pancreaticoduodenectomy means that patients may benefit from early detection of symptoms and support for self-management. Interactive Information and Communication Technology tools can be used for this purpose, but the content needs to be relevant to patients as well as healthcare professionals. To facilitate development of the content of an application for this purpose, the aim of this study was to explore common symptoms and self-care in the first six months after pancreaticoduodenectomy, as identified by patients and healthcare professionals. METHOD: Data were collected through individual interviews with patients (n = 14), along with two focus group interviews and one individual interview with healthcare professionals (n = 10). Data were analysed using qualitative content analysis. RESULTS: Common symptoms after surgery were those related to eating, bowel function and emotional wellbeing, along with fatigue and pain. Some self-care activities and advice were mentioned in the interviews. The patients often experienced a lack of advice on self-care at discharge. CONCLUSIONS: The results render knowledge of the symptoms it is important to be aware of and to assess regularly after pancreaticoduodenectomy. The results also contribute to knowledge about specific self-care related to these symptoms, even though it was not extensively described, and further research is needed to define evidence-based self-care advice.

Patient participation in emergency care - a phenomenographic study based on patients' lived experience.

International guidelines promote patient participation in health care. When patients participate in their care they experience greater satisfaction. Studies have shown that patients in emergency departments express dissatisfaction with their care, and it was therefore important to study how patients understand and conceptualize their participation. The aim of this study was to describe patients' qualitatively different conceptions of patient participation in their care in an emergency department. Based on a lifeworld perspective, nine interviews were performed with patients in an emergency department. The phenomenographic analysis shows that participation by patients means contact with the emergency department staff in three categories of conceptions: being acknowledged; struggling to become involved; and having a clear space. The different conceptions of patient participation give us a deeper understanding of how patients may experience their care, and this result may provide a foundation for developing nursing practice and the quality of health care in line with international guidelines.