A qualitative study on diverse experiences of medication safety among foreign-born persons living in Sweden.

BACKGROUND: The ongoing global migration has led to multicultural societies, with many migrants who do not speak the official language in the host country. This could contribute to communication problems with staff in healthcare and a risk to patient safety. Research on patient safety in medication use in migrants is an under-researched area. The aim was to explore diverse foreign-born people's experiences and perceptions of self-management of medication and determine if home-based practice patterns have implications on medication safety, and what factors may support safe medication use. METHODS: A qualitative explorative study, with individual semi-structured interviews and participant observations in the patients' home. Qualitative content analysis was applied. RESULTS: A purposeful sample of 15 foreign-born persons identified by healthcare staff as having language difficulties in Swedish that may pose a safety risk in connection with medication use at home, was selected. Three categories were identified. The first category showed respondents being dependent on another person, having experiences of not receiving information about their medications due to language barriers, having difficulties getting access to the healthcare centre and feeling distrusted/misunderstood. The second category showed respondents being independent and self-motivated Although they struggled, they managed to get access/contact with the healthcare centre themselves and felt understood/listened to by the staff. The last category concerned factors that facilitating medication use; such as having a medication list in the respondents' own language and offering a choice of language on the answering machine at the healthcare centre. Although they knew it was impossible to get an interpreter at the pharmacy, they felt safe knowing there was always a solution for receiving understandable information. CONCLUSION: The findings highlighted that language barriers can complicate the communication between migrants and the healthcare, which can affect the medication safety. Understanding of this group is essential to improve the cooperation between patients and staff, leading to culturally congruent care. This knowledge should be used in healthcare to understand the gap in communication to increase patient safety. Further research from other angles, e.g. pharmacy/healthcare staff and relatives is needed to identify and evaluate facilitation to improve the outcome of the intended medication treatment.

Evaluation of patient participation in relation to the implementation of a person-centered nursing shift handover.

BACKGROUND: It has been suggested that nursing shift-to-shift handover should be a more team-based dialogue with and for the patient rather than about a patient. AIM: The aim of this study was to evaluate patient participation in relation to the implementation of the person-centered handover (PCH). METHOD: A pretest-posttest design was used without a comparison group, including patients from nine units in a university hospital at pretest (n = 228) and after implementing PCH (posttest, n = 253) per the framework integrated-Promoting Action on Research Implementation in Health Services. The PCH is inspired by an Australian bedside handover model. The Patient Preferences for the Patient Participation tool was used to rate the preference for and experience of participation on 12 items, combined into three levels of preference-based participation (insufficient-fair-sufficient). RESULTS: There were no differences regarding experience or preference-based participation between patients at pretest-posttest; however, posttest patients experienced participation in the item Reciprocal communication to a lesser extent than the pretest patients. Only 49% of the posttest group received PCH; of those not receiving PCH, some would have wanted PCH (27%), while some would have declined (24%). Patients receiving PCH had sufficient participation (82%), to a greater extent, regarding the item Sharing one's symptoms with staff than patients at pretest (72%). Patients receiving PCH also had sufficient participation, to a greater extent, than patients at posttest who did not receive, but would have wanted PCH, regarding four items: (1) sharing one's symptoms with staff, (2) reciprocal communication, (3) being told what was done, and (4) taking part in planning. LINKING EVIDENCE TO ACTION: Most patients want to be present at PCH. Therefore, nurses should ask for the patients' preferences regarding PCH and act accordingly. Not inviting patients who want PCH could contribute to insufficient patient participation. Further studies are needed to capture what assistance nurses would want in identifying and acting in alignment with patient preferences.

Swedish Registered Nurse Anesthetists' Understanding of Difficult Airway Algorithms.

PURPOSE: To explore Swedish registered nurse anesthetists' (RNAs') different ways of understanding difficult airway algorithms. DESIGN: A qualitative study design, using a phenomenographic approach, was chosen to describe variations in RNAs' understanding of difficult airway algorithms. METHODS: Individual interviews were conducted with eighteen RNAs working at three hospitals in Sweden. The data were analyzed using a qualitative method. FINDINGS: Three ways of understanding algorithms were identified: (1) Algorithms constitute a plan not communicated at the clinic; (2) Algorithms constitute a shared plan to improve teamwork; (3) Algorithms constitute a plan for how to think and work systematically. CONCLUSIONS: According to the RNAs, airway management algorithms should be discussed more openly at the workplace. RNAs expressed their desire to have a shared algorithm and to use it as a tool during team simulations. Airway algorithms were seen as constituting a plan for how to think and work systematically to improve patient safety.

Parents' needs of support following the loss of a child to cancer: a Swedish, prospective, longitudinal, multi-centre study.

Introduction: Parents' needs of support following the loss of a child to cancer and whether these needs are met are not fully known. This study aimed to describe parents' needs, opportunity, and benefit of support from healthcare professionals and significant others from shortly after, up to five years after bereavement.Material and methods: Data were collected at nine months (T5, n = 20), eighteen months (T6, n = 37), and five years after the child's death (T7, n = 38). Parents answered questions via telephone about need, opportunity, and benefit of talking to psychologists, social workers, partners, and friends. Needs were examined in relation to parent and child characteristics, including sex, age, and parent posttraumatic stress symptoms (PTSS).Results: The proportion reporting a need of support from psychologists varied from 56% and 46% at T5 to 20% and 6% at T7 (mothers and fathers, respectively). All mothers and 90% of fathers reported a need of support from social workers at T5. At T7, the corresponding percentages were 30% and 6%. More mothers than fathers reported a need of support from friends at T7 (p = .001). The proportion reporting a need of support from psychologists, social workers, and friends decreased over time (all p ≤ .050). Parents reporting a higher level of PTSS were more likely to report a need of support from social workers at T6 (p = .040) and from psychologists (p = .011) and social workers (p = .012) at T7. Opportunities for support from healthcare professionals varied, most reported need of and opportunity for support from significant others. Almost all reported benefit from received support.Conclusion: Bereaved parents need and benefit of support from healthcare professionals and significant others. Results show a need for improved access to psychosocial services, even at five years post bereavement. Large-scale studies are needed to better understand the associations between parent and child characteristics and support needs.

Caring in nursing homes to promote autonomy and participation.

BACKGROUND:: Autonomy and participation are threatened within the group of older people living in nursing homes. Evidence suggests that healthcare personnel act on behalf of older people but are still excluding them from decision-making in everyday care. OBJECTIVE:: The purpose was to describe registered nurses' experience of caring for older people in nursing homes to promote autonomy and participation. RESEARCH DESIGN:: A descriptive design with a phenomenological approach was used. Data were collected by semi-structured individual interviews. Analysis was inspired by Giorgi's method. PARTICIPANTS AND RESEARCH CONTEXT:: A total of 13 registered nurses from 10 nursing homes participated. ETHICAL CONSIDERATIONS:: Ethical approval was obtained from the Regional Research Ethics Committee. Informed consent was achieved and confidentiality guaranteed. FINDINGS:: The essence of caring for older people in nursing homes to promote autonomy and participation consisted of registered nurses' awareness of older people's frailty and the impact of illness to support health and well-being, and awareness of acknowledgement in everyday life and trusting relationships. Paying attention to older people by being open to the persons' wishes were aspects that relied on registered nurses' trusting relationships with older people, their relatives and surrounding healthcare personnel. The awareness reflected challenges in caring to promote older people's right to autonomy and participation in nursing homes. Registered nurses' strategies, hopes for and/or concerns about development of everyday life in nursing homes were revealed and mirrored their engagement in caring for older people. DISCUSSION AND CONCLUSION:: Awareness of older people's frailty in nursing homes and the importance of maintained health and well-being were described as the main source for promoting autonomy and participation. Everyday life and care in nursing homes needs to be addressed from both older people's and healthcare personnel's perspectives, to promote autonomy and participation for residents in nursing homes.

Registered nurses' perspectives of work satisfaction, patient safety and intention to stay - A double-edged sword.

AIM: To describe job satisfaction in registered nurses (RNs), their intention to stay at their current workplace and in the profession and to explore patient safety in relation to these. BACKGROUND: Nurse turnover presents a serious challenge to health care that may be predicted by factors related to the work environment. METHOD: Descriptive design with 25 qualitative interviews. RESULTS: Five categories were identified: RNs feel satisfied when providing person-centred care; RNs enjoy the variability of the nursing job, but want control; RNs feel frustrated when care is put on hold or left undone; RNs depend on team collaboration and the work environment to assure patient safety; intention to stay depends on the work environment and a chance for renewal. CONCLUSION: Registered nurses' job satisfaction could be described as a double-edged sword. Although the profession is described as a positive challenge, work overload threatens both job satisfaction and patient safety. IMPLICATIONS FOR NURSING MANAGEMENT: Our findings suggest that nursing leadership can increase RNs' intention to stay by meeting their needs for appreciation, a better work environment, competence development and professional career development.

Struggling for a feasible tool - the process of implementing a clinical pathway in intensive care: a grounded theory study.

BACKGROUND: Clinical pathways can enhance care quality, promote patient safety and optimize resource utilization. However, they are infrequently utilized in intensive care. This study aimed to explain the implementation process of a clinical pathway based on a bottom-up approach in an intensive care context. METHODS: The setting was an 11-bed general intensive care unit in Sweden. An action research project was conducted to implement a clinical pathway for patients on mechanical ventilation. The project was managed by a local interprofessional core group and was externally facilitated by two researchers. Grounded theory was used by the researchers to explain the implementation process. The sampling in the study was purposeful and theoretical and included registered nurses (n31), assistant nurses (n26), anesthesiologists (n11), a physiotherapist (n1), first- and second-line managers (n2), and health records from patients on mechanical ventilation (n136). Data were collected from 2011 to 2016 through questionnaires, repeated focus groups, individual interviews, logbooks/field notes and health records. Constant comparative analysis was conducted, including both qualitative data and descriptive statistics from the quantitative data. RESULTS: A conceptual model of the clinical pathway implementation process emerged, and a central phenomenon, which was conceptualized as 'Struggling for a feasible tool,' was the core category that linked all categories. The phenomenon evolved from the 'Triggers' ('Perceiving suboptimal practice' and 'Receiving external inspiration and support'), pervaded the 'Implementation process' ('Contextual circumstances,' 'Processual circumstances' and 'Negotiating to achieve progress'), and led to the process 'Output' ('Varying utilization' and 'Improvements in understanding and practice'). The categories included both facilitating and impeding factors that made the implementation process tentative and prolonged but also educational. CONCLUSIONS: The findings provide a novel understanding of a bottom-up implementation of a clinical pathway in an intensive care context. Despite resonating well with existing implementation frameworks/theories, the conceptual model further illuminates the complex interaction between different circumstances and negotiations and how this interplay has consequences for the implementation process and output. The findings advocate a bottom-up approach but also emphasize the need for strategic priority, interprofessional participation, skilled facilitators and further collaboration.

Impact of a child's cancer disease on parents' everyday life: a longitudinal study from Sweden.

BACKGROUND: A child's cancer disease may disrupt the daily life of the affected family for a long period. The aim was to describe restrictions on parents' leisure activities and work/studies during and after the child's treatment. METHODS: This study used data from a cohort of mothers and fathers (n = 246) of children diagnosed with cancer. Data was collected five times from two months after diagnosis to one year after end of treatment. Reports of restrictions were evaluated over time, between mothers and fathers, and in relation to parent-reported child symptom burden (The Memorial Symptom Assessment Scale) and partial post-traumatic stress disorder (PTSD) (The PTSD Checklist-Civilian Version). RESULTS: Two (51%) and four (45%) months after diagnosis, about half reported that their leisure activities were restricted at least some of the time. Corresponding percentages for restrictions on work/studies were 84% and 77%. One year after end of treatment, the great majority reported that their leisure activities (91%) and/or work/studies (76%) were never/seldom restricted. During treatment, more mothers than fathers reported restrictions on work/studies all/most of the time. After end of treatment, gender was only related to reports of restrictions among parents not reporting partial PTSD. More parents who reported being restricted all/most of the time also reported partial PTSD and/or a greater symptom burden for the child. CONCLUSION: Parents report frequent restrictions on everyday life during treatment. One year after end of treatment, parents report only a limited impact of the child's cancer on their leisure activities and work/studies. More parents who report restrictions also report partial PTSD and/or a greater child symptom burden. The effect of gender on restrictions varies depending on reports of partial PTSD. Future studies of gender differences regarding the impact of a child's cancer on parents' everyday life should thus consider mothers' and fathers' level of psychological distress.

General practitioners' experiences as nursing home medical consultants.

OBJECTIVE: To describe general practitioners' experiences of being the principal physician responsible for a nursing home. METHOD: Fifteen general practitioners assigned to a nursing home participated in semi-structured qualitative interviews. Data were analysed using systematic text condensation. RESULT: Medical assessment is the main duty of general practitioners. Advance care planning together with residents and family members facilitates future decisions on medical treatment and end-of-life care. Registered Nurses' continuity and competence are perceived as crucial to the quality of care, but inadequate staffing, lack of medical equipment and less-than-optimal IT systems for electronic healthcare records are impediments to patient safety. CONCLUSION: The study highlights the importance of advance care planning together with residents and family members in facilitating future decisions on medical treatment and end-of-life care. To meet the increasing demands for more complex medical treatment at nursing homes and to provide high-quality palliative care, there would seem to be a need to increase Registered Nurses' staffing and acquire more advanced medical equipment, as well as to create better possibilities for Registered Nurses and general practitioners to access each other's healthcare record systems.

Balancing intertwined responsibilities: A grounded theory study of teamwork in everyday intensive care unit practice.

This study aimed to describe and explain teamwork and factors that influence team processes in everyday practice in an intensive care unit (ICU) from a staff perspective. The setting was a Swedish ICU. Data were collected from 38 ICU staff in focus groups with registered nurses, assistant nurses, and anaesthetists, and in one individual interview with a physiotherapist. Constant comparative analysis according to grounded theory was conducted, and to identify the relations between the emerged categories, the paradigm model was applied. The core category to emerge from the data was "balancing intertwined responsibilities." In addition, eleven categories that related to the core category emerged. These categories described and explained the phenomenon's contextual conditions, causal conditions, and intervening conditions, as well as the staff actions/interactions and the consequences that arose. The findings indicated that the type of teamwork fluctuated due to circumstantial factors. Based on the findings and on current literature, strategies that can optimise interprofessional teamwork are presented. The analysis generated a conceptual model, which aims to contribute to existing frameworks by adding new dimensions about perceptions of team processes within an ICU related to staff actions/interactions. This model may be utilised to enhance the understanding of existing contexts and processes when designing and implementing interventions to facilitate teamwork in the pursuit of improving healthcare quality and patient safety.

Awake intubation creates feelings of being in a vulnerable situation but cared for in safe hands: a qualitative study.

BACKGROUND: Awake fiberoptic intubation is an alternative procedure for securing the airway and is a recommended option when a difficult airway is expected. The aim of the present study was to describe patient experiences with this procedure. METHODS: A qualitative, descriptive design was used and patients were recruited from three county hospitals and one university hospital in Sweden. Data was collected by semi-structured interviews with 13 patients who underwent awake fiberoptic intubation. A qualitative content analysis extracted theme, categories, and subcategories. RESULTS: From the patient statements, one main theme emerged, feelings of being in a vulnerable situation but cared for in safe hands, which were described in five categories with 15 subcategories. The categories were: a need for tailored information, distress and fear of the intubation, acceptance and trust of the staff's competence, professional caring and support, and no hesitation about new awake intubation. The patients felt they lacked information about what to expect and relied on the professionals' expertise. Some patients felt overwhelmed by the information they were given and wanted less specific information about the equipment used but more information about how they would be cared for in the operating room. Undergoing awake intubation was an acceptable experience for most patients, whereas others experienced it as being painful and terrifying because they felt they could not breathe or communicate during the procedure itself. CONCLUSIONS: Tailored information about what to expect, ensuring eye contact and breathing instruction during the procedure seems to reduce patient distress when undergoing awake fiberoptic intubation. Most of the patients would not hesitate to undergo awake intubation again in the future if needed.

Standardised care plans for in hospital stroke care improve documentation of health care assessments.

AIMS AND OBJECTIVES: To compare stroke unit staff members' documentation of care in line with evidence-based guidelines pre- and postimplementation of a multi-professional, evidence-based standardised care plan for stroke care in the electronic health record. BACKGROUND: Rapid and effective measures for patients with stroke or suspected stroke can limit the extent of damage; it is imperative that patients be observed, assessed and treated in accordance with evidence-based practice in hospital. DESIGN: Quantitative, comparative. METHODS: Structured retrospective health record reviews were made prior to (n 60) and one and a half years after implementation (n 60) of a multi-professional evidence-based standardised care plan with a quality standard for stroke care in the electronic health record. RESULTS: Significant improvements were found in documentation of assessed vital signs, except for body temperature, Day 1 post compared with preimplementation. Documentation frequency regarding body temperature Day 1 and blood pressure and pulse Day 2 decreased post compared with preimplementation. Improvements were also detected in documented observations of patients' micturition capacity, swallowing capacity and mouth status and the proportion of physiotherapist-documented aid assessments. Observations of blood glucose, mobilisation ability and speech and communication ability were unchanged. CONCLUSIONS: An evidence-based standardised care plan in an electronic health record assists staff in improving documentation of health status assessments during the first days after a stroke diagnosis. RELEVANCE TO CLINICAL PRACTICE: Use of a standardised care plan seems to have the potential to help staff adhere to evidence-based patient care and, thereby, to increase patient safety.

Is the competence of Swedish Registered Nurses working in municipal care of older people merely a question of age and postgraduate education?

OBJECTIVES: Previous studies suggest that not only education but also personal aspects such as experience of working as a registered nurse (RN) and age can influence competence. The objective was to explore the educational and self-rated competence of RNs and their duties within the care of older people. METHODS: A cross-sectional descriptive design was used. All RNs in two counties in Sweden were asked to complete a written questionnaire: a study specific questionnaire with educational and work related questions using the Nurse Competence Scale. The response rate was 61% (n 344). RESULTS: Higher self-rated satisfaction with own professional competence was related to older age, more years after nursing education and possessing at least one postgraduate education in specialist nursing. Educational needs were related to younger age and fewer years since nursing graduation. Education within elder care, including education about drugs was rated the most urgently needed area of education. The most frequently reported tasks were found in the domain helping role, whereas ensuring quality was less present in their daily work. CONCLUSIONS: Educational level, age and years of experience had an impact on RNs' self-perceived competence, which is in accordance with previous descriptions of the concept competence. It seems imperative that RNs working in care of the old and with the demands placed on them are given the opportunity to take a postgraduate specialist education in order to gain a competence level in their desired area of work. It is also important that RNs working in care of the old get tailored education in line with the requirements the organisation places on them.

Life memories and the ability to act: the meaning of autonomy and participation for older people when living with chronic illness.

There is a lack of knowledge about how older people living with chronic illness describe the meaning of autonomy and participation, indicating a risk for reduced autonomy and participation in their everyday life. The purpose of this study was to describe the meaning of autonomy and participation among older people living with chronic illness in accordance with their lived experience. The design was descriptive with a phenomenological approach guided by Giorgi's descriptive phenomenological psychological method. Purposive sampling was used, and 16 older people living with chronic illness who lived in an ordinary home participated in individual interviews. The findings showed that the meaning of autonomy and participation among the older people emerged when it was challenged and evoked emotional considerations of the lived experience of having a chronic illness. It involved living a life apart, yet still being someone who is able, trustworthy and given responsibility--still being seen and acknowledged. The meaning of autonomy and participation was derived through life memories and used by the older people in everyday life for adjustment or adaption to the present life and the future. Our conclusion is that autonomy and participation were considered in relation to older people's life memories in the past, in their present situation and also their future wishes. Ability or disability is of less importance than the meaning of everyday life among older people. We suggest using fewer labels for limitations in everyday life when caring for older people and more use of the phrase 'ability to act' in different ways, based on older people's descriptions of the meaning of autonomy and participation.

A nationwide postal questionnaire survey: the presence of airway guidelines in anaesthesia department in Sweden.

BACKGROUND: In Sweden, airway guidelines aimed toward improving patient safety have been recommended by the Swedish Society of Anaesthesia and Intensive Care Medicine. Adherence to evidence-based airway guidelines is known to be generally poor in Sweden. The aim of this study was to determine whether airway guidelines are present in Swedish anaesthesia departments. METHODS: A nationwide postal questionnaire inquiring about the presence of airway guidelines was sent out to directors of Swedish anaesthesia departments (n = 74). The structured questionnaire was based on a review of the Swedish Society of Anaesthesia and Intensive Care voluntary recommendations of guidelines for airway management. Mean, standard deviation, minimum/maximum, percentage (%) and number of general anaesthesia performed per year as frequency (n), were used to describe, each hospital type (university, county, private). For comparison between hospitals type and available written airway guidelines were cross tabulation used and analysed using Pearson's Chi-Square tests. A p- value of less than 0 .05 was judged significant. RESULTS: In total 68 directors who were responsible for the anaesthesia departments returned the questionnaire, which give a response rate of 92% (n 68 of 74). The presence of guidelines showing an airway algorithm was reported by 68% of the departments; 52% reported having a written patient information card in case of a difficult airway and guidelines for difficult airways, respectively; 43% reported the presence of guidelines for preoperative assessment; 31% had guidelines for Rapid Sequence Intubation; 26% reported criteria for performing an awake intubation; and 21% reported guidelines for awake fibre-optic intubation. A prescription for the registered nurse anaesthetist for performing tracheal intubation was reported by 24%. The most frequently pre-printed preoperative elements in the anaesthesia record form were dental status and head and neck mobility. CONCLUSIONS: Despite recommendations from the national anaesthesia society, the presence of airway guidelines in Swedish anaesthesia departments is low. From the perspective of safety for both patients and the anaesthesia staff, airway management guidelines should be considered a higher priority.

Registered nurses' experiences on job satisfaction in nursing home settings.

AIM: To describe what registered nurses' experience to be important to job satisfaction in nursing home settings. DESIGN: This is a qualitative study based on data from individual interviews. METHODS: Sixteen registered nurses working in nursing homes were interviewed, and their responses were analysed with systematic text condensation. RESULTS: A total of six categories were developed to describe various aspects of job satisfaction among registered nurses at nursing homes: meaningfulness is essential, to possess control and manageability is central, a possibility to balance daily challenges with professional development, supportive leadership is imperative, the nursing team's competence and companionship, and being confident in one's own profession. CONCLUSION: In the present study, meaningfulness was essential to job satisfaction, and work was experienced to be meaningful and engaging when the demands were manageable, the workload controllable, and when the registered nurses felt supported by management and co-workers. Conversely, if the demands were too high, the workload was beyond their control and the nurses felt unsupported, then the work felt meaningless and thus unsatisfactory.

The Sukaribit Smartphone App for Better Self-Management of Type 2 Diabetes: Randomized Controlled Feasibility Study.

BACKGROUND: A new app, Sukaribit, was designed to enable contact between the caregiver and the patient with the intent to improve self-care and glycemic control (hemoglobin A1c [HbA1c]). OBJECTIVE: This study investigated the feasibility of the study methodology and the intervention in preparation for a larger effectiveness study. METHODS: Adults with type 2 diabetes were recruited in this randomized controlled feasibility study with a mixed methods design. The intervention group (n=28) tried Sukaribit for 2 months. They were encouraged to report blood glucose levels and medications, and they received feedback from a physician. The control group (n=31) received standard care. Both groups were evaluated with pre and postmeasurements of glycemic control (HbA1c), diabetes distress, physical activity, and self-care. Feasibility was evaluated against 5 progression criteria regarding recruitment, study methods, and active participation. RESULTS: Of the 5 progression criteria, only 2 were met or partially met. The recruitment process exceeded expectations, and data collection worked well for self-reported data but not for HbA1c measured with a home testing kit. The participants were less active than anticipated, and the effect sizes were small. Only the number of blood glucose tests per day was positively affected by the intervention, with 0.6 more tests per day in the intervention group. CONCLUSIONS: Recruitment of participants to a future fully powered study may work with minor adjustments. The collection of HbA1c using home testing constituted a major problem, and an alternative strategy is warranted. Finally, the app was not used as intended. In order to proceed with a larger study, the app and study procedures need improvement.

Challenges of safe medication practice in paediatric care--a nursing perspective.

AIM: To explore nurses' experiences of handling medications in paediatric clinical practice, with a focus on factors that hinder and facilitate safe medication practices. METHODS: Twenty nurses (registered nurses) from four paediatric wards at two hospitals in Sweden were interviewed in focus groups. The interviews were analysed using content analysis. RESULTS: Six themes emerged from the analysed interviews: the complexity specific for nurses working on paediatric wards is a hindrance to safe medication practices; nurses' concerns about medication errors cause a considerable psychological burden; the individual nurse works hard for safe medication practices and values support from other nurse colleagues; circumstances out of the ordinary are perceived as critical challenges for maintaining patient safety; nurses value clear instructions, guidelines and routines, but these are often missing, variable or changeable; management, other medical professionals, the pharmacy, the pharmaceutical industry and informatics support need to respond to the requirements of the nurses' working situations to improve safe medication practices. CONCLUSION: Weaknesses were apparent in the long chain of the medication-delivery process. A joint effort by different professions involved in that delivery process, and a nationwide collaboration between hospitals is recommended to increase safe medication practices in paediatric care.

The ethics of coercive treatment of people with dementia.

The aim of the present study was to describe how registered nurses in nursing homes ensure legal security, good and safe nursing care and uphold the dignity of nursing home residents with severe dementia without violating residents' integrity. Semi-structured interviews were conducted with 10 charge nurses in a county in central Sweden. The transcribed interviews were examined using manifest and latent content analyses. The manifest analysis identified actual local routines involving coercive treatment and registered nurses' descriptions of complications and alternative measures. The latent analysis resulted in three themes describing nursing strategies: one with coercive treatment, one with coercive treatment under specific circumstances and one to prevent coercive treatment. Interpretations of legal terms regarding coercive treatment and inadequate gerontological nursing training and understaffing seem to preserve the use of coercive treatment.

Implementation of a multi-professional standardized care plan in electronic health records for the care of stroke patients.

AIMS: To compare staff opinions about standardized care plans and self-reported habits with regard to documentation, and their perceived knowledge about the evidence-based guidelines in stroke care before and after implementation of an evidence-based-standardized care plan (EB-SCP) and quality standard for stroke care. The aim was also to describe staff opinions about, and their use of, the implemented EB-SCP. BACKGROUND: To facilitate evidence-based practice (EBP), a multi-professional EB-SCP and quality standard for stroke care was implemented in the electronic health record (EHR). METHOD: Quantitative, descriptive and comparative, based on questionnaires completed before and after implementation. RESULTS: Perceived knowledge about evidence-based guidelines in stroke care increased after implementation of the EB-SCP. The majority agreed that the EB-SCP is useful and facilitates their work. There was no change between before and after implementation with regard to opinions about standardized care plans, self-reported documentation habits or time spent on documentation. CONCLUSIONS: An evidence-based SCP seems to be useful in patient care and improves perceived knowledge about evidence-based guidelines in stroke care. IMPLICATIONS FOR NURSING MANAGEMENT: For nursing managers, introduction of evidence-based SCP in the EHR may improve the prerequisites for promoting high-quality EBP in multi-professional care.