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Att organisera en trygg och sammanhållen vårdkedja mellan IVA och allmän vårdavdelning.: En grundad teori om organisation, vård och samarbete i förflyttningsprocessen
Mid Sweden University, Faculty of Human Sciences, Department of Health Sciences.
2012 (Swedish)Doctoral thesis, comprehensive summary (Other academic)
Abstract [sv]

Det övergripande syftet med avhandlingen var att generera en grundad teori om huvudproblemet i förflyttningsprocessen mellan intensivvårdsavdelningar (IVA) och allmänna vårdavdelningar, det vill säga den vård som ges; före, under och efter det att patienter förflyttats från intensivvård till allmän vårdavdelning. Avhandlingen består av 4 delstudier (I- IV) som ligger till grund för en slutlig övergripande teori. Datainsamling har skett med hjälp av fokusgruppsdiskussioner, individuella intervjuer, observationer samt en enkät. Data inhämtades från tre sjukhus och fyra IVA-avdelningar samt sex allmänna vårdavdelningar. Olika personalgrupper och närstående har varit i fokus beroende på delstudiens syfte. I de olika delstudierna har Grundad Teori (GT) (I, II, III) och mixed method (IV) använts som metod. De fyra delstudierna har slutligen syntetiseras till en övergripande Grundad Teori.

 

Avhandlingen visar att samspelet kring IVA-patienters förflyttningar påverkas av sjukhusets organisations- och säkerhetskultur och hur vårdkedjan organiserats. Det som upplevdes vara huvudproblemet för de inblandade var att organisera en trygg och sammanhållen vårdkedja mellan IVA och allmän vårdavdelning. Detta inkluderade att på ett patientsäkert sätt överbrygga de olikheter och det glapp som fanns mellan vården och vårdkulturen på den personaltäta, högteknologiska intensivvårdsavdelningen jämfört med vården och den vårdkultur som återfanns på de allmänna vårdavdelningarna.   Resultatet i den övergripande teorin visade att ett centralt behov hos såväl personal som hos närstående, är att uppleva kontroll och delaktighet i förflyttningsprocessen (kärnkategori). Detta behov kunde tillgodoses genom att det fanns och delgavs rutiner och strategier för vården före, under och efter förflyttning, att upprätta ett kliniköverskridande samarbete, genom kompetens och kunskap, att resurser fanns och genom att ge en personcentrerad vård. Om personal och närstående upplevde egen kontroll och delaktighet i förflyttningsprocessen bidrog detta till att reducera oro och osäkerhet och till att underlätta samverkan och samordning mellan IVA och allmän vårdavdelning. När den egna kontrollen och delaktigheten däremot uteblev, ökade istället de negativa upplevelserna av ett stort glapp mellan IVA och de allmänna vårdavdelningarna och desto mer negativt framstod skillnaderna vara mellan de olika enheterna och istället uppstod ett revirtänkande och misstro mellan personalgrupperna på de inblandade avdelningarna. 

Det fanns ett behov av ett gott samarbetsklimat samt en god organisations- och säkerhetskultur för en sammanhållen vårdkedja. Utöver detta påverkades också förflyttningprocessen av om avdelningen byggt upp en god lärandemiljö med fungerande teamwork och rutiner och strategier kring patientomflyttningar. För att kunna ge god vård genom vårdkedjan behövdes också resurser. Personalens intentioner var att ge god, personcentrerad vård genom hela processen men de fick oftast balansera dessa intentioner mot bristande resurser och de förutsättningar som gavs, i form av personalbrist, bristande vårdplatser och avsaknad av planering. Vårdkedjan mellan IVA och allmänna vårdavdelningar kräver en organisation och en kultur som främjar individers egen kontroll och delaktighet. Dessutom krävs det planering och strategier som främjar patientsäkerhet, samordning och kontinuitet samt en tydlig nedtrappningsfas av den högteknologiska vården. Resultatet visar vidare att sjuksköterskor och andra i vårdteamet kring den svårt sjuke patienten har en stor pedagogisk utmaning i att kvalitetssäkra informationsflödet och kunskapsöverföringen om vad som skall hända i processen för närstående och för patienter.

Place, publisher, year, edition, pages
Sundsvall: Kopieringen , 2012. , 99 p.
Series
Mid Sweden University doctoral thesis, ISSN 1652-893X ; 133
Keyword [sv]
Förflyttningsprocess, grundad teori, hälso- och sjukvårdsorganisation, intensivvård, omvårdnad, patientomflyttning, säkerhetskultur, vårdkedja
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:miun:diva-17092ISBN: 978-91-87103-30-8 (print)OAI: oai:DiVA.org:miun-17092DiVA: diva2:557248
Public defence
2012-10-19, M 108, campus Åkroken, Sundsvall, 11:29 (Swedish)
Opponent
Supervisors
Available from: 2012-09-28 Created: 2012-09-27 Last updated: 2012-10-10Bibliographically approved
List of papers
1. Struggle with a gap between intensive care units and general wards
Open this publication in new window or tab >>Struggle with a gap between intensive care units and general wards
2009 (English)In: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 4, no 3, 181-192 p.Article in journal (Refereed) Published
Abstract [en]

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.

National Category
Nursing
Identifiers
urn:nbn:se:miun:diva-10260 (URN)10.1080/17482620903072508 (DOI)000271013900006 ()2-s2.0-70349860265 (Scopus ID)
Available from: 2009-10-30 Created: 2009-10-30 Last updated: 2016-10-18Bibliographically approved
2. How can nurses facilitate patient’s transitions from intensive care?: A grounded theory of nursing
Open this publication in new window or tab >>How can nurses facilitate patient’s transitions from intensive care?: A grounded theory of nursing
2012 (English)In: Intensive & Critical Care Nursing, ISSN 0964-3397, E-ISSN 1532-4036, Vol. 28, no 4, 224-233 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: Intensive care patients often experience feelings of powerlessness and vulnerabilitywhen being transferred from an intensive care unit to a general ward. The aim of this study wasto develop a grounded theory of nurses care for patients in the ICU transitional care process.Methods: Group interviews, individual interviews and participant observations were conductedwith 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 contextsof 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 ‘‘beingperceptive 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 wereforced to ‘‘balance between patient needs and the caregivers’ resources’’ and consequentlywere compromising their care.Conclusions: To facilitate an ICU-patient’s transition, individual care planning is needed. Itis also essential that the patients are adequately prepared for the change to facilitate thetransitional care. Knowledge about transitional needs, empowerment and patient-educationseems to be important issues for facilitating transitions.

Keyword
Critical care; Discharge; Healthcare transitions; Person-centered care
National Category
Health Sciences
Identifiers
urn:nbn:se:miun:diva-17094 (URN)10.1016/j.iccn.2012.01.002 (DOI)2-s2.0-84863838714 (Scopus ID)
Available from: 2012-09-27 Created: 2012-09-27 Last updated: 2012-10-22Bibliographically approved
3. To reduce technology prior discharge from intensive care –important but difficult?: A grounded theory
Open this publication in new window or tab >>To reduce technology prior discharge from intensive care –important but difficult?: A grounded theory
2013 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 27, no 3, 506-515 p.Article in journal (Refereed) Published
Abstract [en]

Aim: The aim of this study was to provide a deeperunderstanding of the experience of intensive care staffregarding the reduction in the use of medical technologyprior to patients’ transfer from the ICU.Background: The goal of ICU transitional care, provided forintensive care patients before, during and after the transferfrom the ICU to another care unit, is to ensure minimaldisruption and optimal continuity of care for the patient.To smooth this transition, there is a need to prepare for aless technological environment and therefore also a needfor a gradual reduction in the use of monitoring equipment.Method: Group interviews and individual interviews, togetherwith participant observations, were conducted withICU staff in two hospitals in Sweden. The data wereanalysed using classic grounded theory.Results: The main concern was the ICU staff’s ambiguityregarding whether and how to reduce the use of medicaltechnology devices. Insecurity about weaning patientsfrom medical equipment combined with a lack of standardizedroutines made it difficult for staff to reduce thetechnical support. The core category describes how theambiguity was solved primarily by ’prioritizing control’.However, this often caused the ICU staff to use advancedtechnology while the patients were in the ICU until theward staff arrived, even if this should have been handledotherwise. 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 forguidance and a shared understanding’ and ’weighing advantageswith more v s less technology’.Conclusion: It is important to consider ICU staff ambiguityconcerning the reduction in technology and to establishstrategies for a safe and structured transitional phase withstep-down procedures in which technology and monitoringis gradually reduced prior to transfer from ICU.

Keyword
continuity of care, grounded theory, patient discharge, patient transfer, intensive care, health care technology, patient safety, step-down unit
National Category
Health Sciences
Identifiers
urn:nbn:se:miun:diva-17095 (URN)10.1111/j.1471-6712.2012.01063.x (DOI)000321625800003 ()2-s2.0-84880287552 (Scopus ID)
Available from: 2012-09-27 Created: 2012-09-27 Last updated: 2013-11-22Bibliographically approved
4. Important quality aspects in transfer process
Open this publication in new window or tab >>Important quality aspects in transfer process
2014 (English)In: International journal of health care quality assurance/MCB University Press, ISSN 0952-6862, Vol. 27, no 2, 123-139 p.Article in journal (Refereed) Published
Abstract [en]

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.

Place, publisher, year, edition, pages
Emerald Group Publishing Limited, 2014
Keyword
Critical care, intensive care, transfer process, transition, length-of-stay, relatives, quality in care
National Category
Health Sciences
Identifiers
urn:nbn:se:miun:diva-17097 (URN)10.1108/IJHCQA-09-2012-0090 (DOI)2-s2.0-84897031560 (Scopus ID)
Available from: 2012-09-27 Created: 2012-09-27 Last updated: 2014-04-16Bibliographically approved

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