Mid Sweden University

There are challenges faced by many countries around the world related to an increasing number of elderly people and a shortage of health care personnel. The purpose of this paper was to explore the extent to which the magnet model and core values of TQM offer complementary perspectives with the intention of providing a good working environment for health care professionals and better quality of care for elderly people. The magnetic forces were analysed versus the core values/cornerstones of TQM. The results show similarities that reinforce the quality of care and a good working environment for health care professionals.

Background: Transitional care encompasses to ensure high-quality healthcare from illness onset through hospitalization to returning home. Relatives of intensive care patients are notably vulnerable to adverse emotional and psychological effects due to the sudden, life-threatening nature of their next of kins' conditions. Unfortunately, limited research explores the experiences of relatives in transitional care contexts. Therefore, the aim of this study was to explore the experiences of relatives as they navigate the process of transitional care, encompassing the journey from home to hospital, from intensive care to general ward settings, and the eventual return to their homes. 

Method: A qualitative research design was used, semi-structured individual interviews with 14 participants who had experience with transitional care, spanning from intensive care to general care, and their return home. Data were analyzed using reflexive thematic analysis as described by Braun and Clarke. 

Preliminary Findings: In the context of transitional care, relatives perceive themselves as frequently becoming invisible and subsequently abandoned by the healthcare system. Relatives perceived that they went in and out of being a part of the care- sometimes invited, other times, they were not, which led to fluctuations in their involvement and confusion regarding how the healthcare system operated.

Background: Being a family member to someone who suffers from a serious illness can change one's perspectives about life. A sudden and severe illness can result in a demanding journey that involves acute admission to hospital, intensive care, post-care, and finally, returning home. Aim: To describe the experience of staying beside a next of kin throughout the healthcare journey, from the onset of illness at home, to the intensive care unit, post-care, and returning home. Methods: The study employed a qualitative design, with data collected via semi-structured interviews and analysed using reflexive thematic analysis. A purposive sampling was used to recruit participants (n = 14), who had experiences of staying beside a next of kin throughout the healthcare journey from the onset of illness to discharge from the hospital. Findings: Family members’ experiences were captured under the overarching theme Journey through an emotional turmoil and the themes Entering a new world, Continuing the journey towards something unknown, and Striving for the new normal at home. They described going through a non-linear process, characterised by transitions or changes in several aspects. The transitions included shifts in the roles that the family members played, in the various environments they found themselves in, and in the progression of the patient's illness or injury. Conclusion: The study suggested that family members with a next of kin who experienced life-threatening situations undergo challenging transitions. The informal caregiver role placed on family members of intensive care unit-survivors significantly impacts their lives and the healthcare systems should prioritise providing high-quality support to family members throughout the entire healthcare journey. Elevating the importance of nursing care within the healthcare system can contribute to delivering holistic care and facilitating transitions. Further research should focus on understanding the support that family members perceive as necessary to facilitate their transition and enhance their well-being. 

Bakgrund: Vårdmöten kan ha många orsaker och vara av olika komplexitet. Till vårdavdelningar kommer bland annat närstående till patienter som har förflyttats från intensivvårdsavdelning. På grund av den livsavgörande händelsen de varit med om kan dessa närstående vara mer sköra än andra. Forskning har visat att de kan uppleva vårdmöten otillfredsställande. Det finns otillräckligt med studier som beskriver hur närstående till vuxna patienter upplever förflyttningen från intensivvård till allmän vård.

Syftet: Att beskriva närståendes upplevelser av vårdmöten med sjuksköterskor under vårdtiden på allmän vårdavdelning efter förflyttning från intensivvårdsavdelning.

Metod: En kvalitativ beskrivande design med en induktiv ansats. Semi-strukturerade individuella intervjuer utfördes med närstående (n = 14) till patienter vid fem sjukhus i Sverige. Data analyserades med innehållsanalys.

Resultat: Närstående upplevde ett stort ansvar för att säkerställa att deras anhörig fick vård av god kvalitet. För närstående var det väsentligt att få möta tillgängliga, engagerade och medkännande sjuksköterskor på vårdavdelningen. Temat ’Längtan efter tillit och strävan efter att involveras i sin anhörigs vård’ illustrerades i två underteman ’Önskan att vara en viktig del i pusslet’ och ’Vara vaksam med oro över vårdens kvalitet’.

Slutsats: Närståendes delaktighet är nödvändig för att bygga upp livet efter sjukhusvistelsen för både dem själva och patienten. Deras oro och bekymmer gällande förflyttningen behöver tas på allvar och inkluderas i vårdplaneringen för att säkerställa deras välbefinnande. Sjuksköterskor behöver avancerade icke-tekniska färdigheter i att skapa vårdmöten byggda på tillit och respekt för närstående. Framtida forskning bör undersöka hur närståendes behov kan mötas i praktiken. Fortsatt omvårdnadsforskning är nödvändig för att strukturera möten med patienter och närstående som förflyttas från intensivvårdsavdelning; ett sätt kan vara att utveckla och använda specifika vårdplaner för mottagande av närstående.

Background

Care encounters at general wards have many reasons, and the complexity differs. Some arriving at the ward are relatives of discharged intensive care unit patients’, who are usually more fragile than others due to what had happened to them. Research indicates that care encounters leave relatives dissatisfied. There is a lack of studies describing how relatives of adult patients experience the transfer from the intensive care unit.

Aim

The purpose of this study was to describe relatives’ experiences of care encounters with nurses during their loved ones’ stay in the general ward after being discharged from the intensive care unit.

Methods

A qualitative descriptive design with an inductive approach was used. Semi-structured individual interviews were conducted with relatives [n = 14) of patients from different hospitals in Sweden. Data were analysed using content analysis.

Results

Relatives expressed feeling a huge responsibility for ensuring the quality of care for their loved ones. It was essential to encounter available, committed, and compassionate nurses in the general ward after being transferred from the intensive care unit. The theme ‘longing for trust and struggling to be involved in their loved one’s care’ was illustrated in the two subthemes of ‘wanting to be seen as an important piece of the puzzle’ and ‘being vigilant and worrying about the quality of care’.

Conclusion

The relatives of patients experience their needs as unfulfilled in care encounters with nurses at the general ward after transfer from ICU. In order to meet the needs of relatives, nurses require well-developed non-technical skills to establish a compassionate interaction founded on trust and respect for the individual. Future research should investigate how relatives’ needs can be met in practice. New nursing innovations are necessary to structure encounters with patients and relatives transitioning from the intensive care unit.

Aim: To explore the meaning of ‘safety’ as it applies to critical care nurses during daily care practice in the intensive care setting.

Design: A qualitative study design was employed.

Methods: The study enlisted 18 critical care nurses and nurse leaders from three hospitals in Sweden. Interview data were collected in 2017 and in 2024. The data were examined using reflexive thematic content analysis.

Results: The meaning of safety within critical care settings was illustrated by the themes ‘Sustaining a safety mindset’, ‘Fostering commitment to patient safety’, ‘Showing individual accountability and continuous learning’ and ‘Managing complexity while prioritising safety standards’. Safe care practice in daily practice also involved adaptability and resilience in response to changing circumstances or unexpected events, ensuring thoroughness and allowing for a return to regular routines when conditions permitted, thereby preventing incomplete care. Core competencies in safety encompassed both technical and non-technical skills, such as the ability to assess and use technology, remain vigilant and thorough, plan ahead, prioritise and identify, and follow through on nursing interventions, all while working in a team and allocating sufficient time for patients.

Conclusion: Sustaining a safe mindset over time is both challenging and essential. Further research should focus on how tofoster a sustained safety mindset. A more proactive approach to learning may be achieved by reflecting on and discussing things that have worked well even in challenging circumstances.

Implications for the Profession and/or Patient Care: This study enriches our understanding of practising safe care in intensive care. It furnishes the nursing profession with a deeper theoretical grasp of proactive safety efforts, encompassing various factors that can mitigate risks in a technologically advanced environment.

Background When cure is no longer possible, medical care should aim for a transition to palliative care regardless of disease. Patients with incurable cancer are often treated with palliative chemotherapy (PCT), starting with the intent to prolong life and increase quality of life. Eventually, in the late stages of the disease, the patient reaches a transition phase when further PCT neither prolongs life nor adds any predominantly positive effects.

Aim of the thesis

Study I: To analyse the proportion of patients with incurable cancer who received palliative chemotherapy during the last month of life, and to identify their discriminative characteristics.

Study II: To develop a questionnaire assessing performance status in palliative chemotherapy, and to test its psychometric properties.

Study III: To explore challenging situations experienced by registered nurses when administering palliative chemotherapy to patients with incurable cancer.

Study IV:  To investigate whether routine use of the Performance Status in Palliative Chemotherapy (PSPC) questionnaire in PCT would affect the proportion of patients receiving PCT during the last month of life, hospital admissions, notifications of performance status, documented decisions of ceasing PCT in the medical records, and/or place of death. A secondary aim was to gather registered nurses’ experiences of PSPC in clinical use.

Methods In Studies I and IV, information from the medical records of deceased patients with epithelial cancers was used in descriptive analyses of the proportions of patients receiving PCT in counties in northernmost Sweden. A quantitative design was chosen, using non-parametric statistical methods. In Study II, a brief patient-completed questionnaire assessing performance status was developed and psychometrically tested. In Study III, data from research interviews with registered nurses were analysed qualitatively with a narrative thematic approach.

Results Studies I and IV showed that about 25% of patients receiving PCT were treated during the last month of life. This group of patients had more hospital admissions, were less likely to die at home, and had fewer instances of documentation of the decision to cease PCT. The questionnaire developed in Study II was shown to have acceptable psychometric qualities such as reliability, validity, and sensitivity to detect deterioration in performance status. Study IV showed that the questionnaire gave nurses valuable information about patients’ performance status. The results also showed that 97% of nurses and 48% of physicians documented their patients’ performance status in the medical records. Study III demonstrated that when nurses administered PCT they considered futile, they could experience dilemmas created by the unforeseeable outcomes of PCT or stemming from insufficient communication between nurses, patients, next-of-kin, and physicians.

Conclusions Administration of PCT can create dilemmatic situations for both the patient and medical staff when approaching end-of-life. This is underlined by the finding that some 25% of treated patients received their last round of PCT as late as during the last month of life. The decisions to cease PCT were less likely to be documented for patients who had received PCT within a month before death. Nurses described situations where they felt they were in the middle of the decision-making process regarding whether or not to continue PCT. They found the treatments were given on the authority of someone else; the physician’s recommendation or the patient’s and/or relatives’ request.

The unpredictability of PCT was a continuous theme in the work described in this thesis, emphasizing the necessity of individually assessing every patient before PCT in order to minimize the risk of futile treatments. The attempt to develop a reliable and valid questionnaire for systematic assessment of performance status has increased future possibilities to monitor this parameter in PCT when approaching end-of-life. The questionnaire developed as part of this thesis has provided nurses with increased knowledge of patients’ performance status. If routinely used, it may help decrease the proportion of patients receiving PCT during the last month of life, though this remains to be rigorously proven. Further research efforts are needed to progress in the task of optimizing rather than maximizing the use of PCT when approaching end-of-life.

Background: When death ends a life, the impact of caring for person who suffered a period of illness or diseasecontinues for significant others who are left to grieve. They should be offered support to avoid complicated grief.This can be provided in different ways and individually or in groups. This study aims to describe significant others’experiences of participation in bereavement groups.Methods: Ten bereavement groups that each met five times offered support for the significant others of deceasedloved ones who had been cared for by a palliative-care team. After the five meetings, the grieving members (n =46)completed written comments about the role of the groups; they also commented one year after participating (n =39).Comments were analyzed with qualitative content analysis with a directed approach using the theory of a good deathaccording to the 6S’s: self-image, self-determination, social relationships, symptom control, synthesis and summation,and surrender.Results: Bereavement groups were found to be a source for alleviating grief for some significant others, but not allexperienced relief. Moreover, grief was found to persist during participation. Another finding involved the impact ofthe role of the palliative home-care team on bereavement support. To evaluate the experience of participating in abereavement group, the use the 6S’s as a model was a strength of the analysis. Bereavement groups could enhancethe self and offer relief from grief. Participation was described as social relationships that offered a sense of coherenceand understanding in grief. The effects of participation were more meaningful close to the loss and could lose efficacyover time. Bereavement support provided before a loved one’s death was seen as valuable.Conclusion: Overall, the bereavement groups eased the grief of significant others close to the death of their lovedone. However, moving forward, several of the significant others were not sure that their participation eased their grief.To identify persons who may remain in a state of complicated grief, a routine of planned contacts with the bereavedshould begin before death and be followed up later than six months after the death of a loved one.

Background: This study analyses the potential discriminative characteristics for patients with incurable cancer who received palliative chemotherapy during their last month of life.

Patients and methods: The study includes all patients with epithelial cancer treated with palliative chemotherapy who died in 2008 in northern Sweden. Demographic parameters and care utilization data were registered. Data were analyzed using nonparametric methods.

Results: Of 374 included patients, 87 (23%) received chemotherapy during the last month of life. These patients had a significantly shorter survival time from first palliative treatment to death, were admitted more frequently to hospital, more often lacked a documented decision to cease treatment, and died less frequently at home.

Conclusions: The results indicate covariations between palliative chemotherapy treatments in the last month of life and unfavorable patient outcomes. As almost one of four patients with incurable cancer received their last round of palliative chemotherapy <31 days before death, there is a potential for improved routines.

BACKGROUND: Earlier studies have shown that up to 43% of patients with incurable cancer are treated with palliative chemotherapy in the last month of their lives. Although pretreatment blood tests are acceptable, the patient's general condition may not permit further palliative chemotherapy treatment (PCT). Presently, there is no patient self-assessment tool available to monitor performance status during PCT.

OBJECTIVES: To describe the development process of the Performance Status in Palliative Chemotherapy (PSPC) questionnaire, and the testing of its psychometric properties.

METHODS: The questionnaire was developed by the authors based on the Eastern Cooperative Oncology Group Performance Status Rating (ECOG PSR) scale as well as their clinical experience with PCT. Adult patients who were diagnosed with epithelial cancers (n = 118) were enrolled to test the PSPC questionnaire for reliability, sensitivity for change, and validity.

RESULTS: After stepwise modifications of the PSPC questionnaire, psychometric tests revealed acceptable values for reliability (via a test-retest method), sensitivity for change (via a comparison of patients with progressive disease over time), and validity (via a comparison of the PSPC vs the Edmonton Symptom Assessment System [ESAS]).

LIMITATIONS: At this stage of questionnaire development, we are unable to conclude whether the PSPC is superior to the conventional ECOG PSR in the evaluation of performance status and the prediction of chemotherapy response.

CONCLUSION: Psychometric tests suggest that the PSPC questionnaire may be a useful patient-completed tool in the late stages of cancer disease to routinely monitor performance status in palliative chemotherapy treatments so as to minimize the risk of inflicting more harm than good.

Purpose Palliative chemotherapy treatment (PCT) offered late in the cancer disease trajectory may be problematic. It is not easy to accurately calculate whether the potential benefits will outweigh the side-effects. This study investigates whether routine use of the Performance Status in Palliative Chemotherapy questionnaire (PSPC) affects the proportions of patients receiving PCT during the last month of life, care utilization, and documentation routines. A secondary aim was to gather registered nurses' experiences of the PSPC in routine use. Methods Eighty incurable patients with cancer who had used the PSPC before PCT were compared to 160 matched controls, using non-parametric tests. Nurses' reflections on the PSPC were collected and reviewed. Results No significant differences were found between users and non-users of the PSPC in terms of proportions receiving PCT during the last month of life. Higher proportions of patients older than 74 years received PCT than in previous studies (40% versus 17%). Nurses considered the questionnaires to be a valuable complement to verbal information when trying to acquire an accurate picture of patients' performance status. Conclusion At this point in the development of the PSPC we did not find any significant decreases in the proportion of patients receiving PCT during the last month in life. However, as the nurses valued the PSPC, it can be used as a complementary tool in assessment of performance status until further research is conducted.

Abstact: Background: Bereavement groups are believed to be beneficial as preventive interventions to reduce the development of complicated grief for people at risk after the death of a significant other. This study aimed to investigate whether measurable effects on grief, anxiety, and depression could be detected in those participating in bereavement groups compared to non-participating controls. Methods: Questionnaires covering the Texas Revised Inventory of Grief (TRIG), the Hospital Anxiety and Depression Scale (HADS), and background questions were handed out pre-intervention, five weeks and one year post-intervention to bereaved caregivers invited to bereavement groups. The results were analysed with non-parametric methods. Results: A total of 124 individuals answered the questionnaires, and were divided into three categories: participants, non-participants unable to participate, and non-participants not wanting to participate in bereavement groups. At the one-year follow up, participants and those unable to participate reported higher levels of grief and were more anxious than those not wanting to participate. Depression did not differ between the groups. Conclusions: Participation in bereavement groups did not produce any effects on grief, anxiety, or depression in comparison to non-participants who were unable to participate. Non-participants who did not want to participate reported lower levels of grief and anxiety than the other two groups.

Background

Palliative care requires major nursing interventions as well as medical interventions; thus, both district nurses and doctors are vital to the palliative team. Sparsely populated rural areas are characterised by large geographic distances with the nurses and doctors located far away from each other. If collaboration does not work, this can create challenges for district nurses when managing patients’ symptoms. The aim of this study was to describe district nurses’ experiences of collaborating with doctors-in-charge during palliative home care in sparsely populated rural areas.

Method

Semi-structured interviews were conducted with 10 district nurses. Inductive content analysis was used to analyse the data.

Results

The experiences of the district nurses are described under the overarching theme of Experiences of acting asthe patient’s advocate, which is divided into two categories: Feeling secure in oneself and the other person and Feeling alone when collaboration breaks down.

Conclusion

Consensus and coherence, or lack there of, between district nurses and doctors affect how collaboration is experienced. Positive experiences are generated when the district nurse and the doctor share a holistic approach, while collaboration is experienced as dysfunctional when the doctor’s decisions are not consistent with what the nurse judges to be beneficial to the patient. An understanding of how collaboration across long distances isexperienced in rural areas is necessary to enhance collaboration.

Palliative chemotherapy treatments (PCT) are becoming more common for patients with incurable cancer; a basic challenge is to optimize tumour response while minimizing side-effects and harm. As registered nurses most often administer PCT, they are most likely to be confronted with difficult situations during PCT administration. This study explores challenging situations experienced by nurses when administering PCT to patients with incurable cancer.

Methods

Registered nurses experienced in administering PCT were asked in interviews to recall PCT situations they found challenging. Inspired by the narrative tradition, stories were elicited and analysed using a structural and thematic narrative analysis.

Results

A total of twenty-eight stories were narrated by seventeen nurses. Twenty of these were dilemmas that could be sorted into three storylines containing one to three dilemmatic situations each. The six dilemmatic situations broadly related to three interwoven areas: the uncertainty of the outcome when giving potent drugs to vulnerable patients; the difficulty of resisting giving PCT to patients who want it; and insufficient communication between nurses and physician.

Conclusion

Nurses who administer PCT are engaged in a complex task that can give rise to a number of dilemmatic situations. The findings may be interpreted as meaning that at least some situations might be preventable if the knowledge and insight of all team members – nurses, physicians, patients, and relatives – are jointly communicated and taken into account when deciding whether or not to give PCT. Forming palliative care teams early in the PCT trajectory, could be beneficial for staff and patients.

Palliative Care in Sparsely Populated Rural Areas -Collaboration between District Nurses and Doctors U. Näppä1, I. Winqvist1, E. Nässén2

1Mid Sweden University, Department of Health Sciences, Östersund,Sweden, 2Östersund Hospital, Region of Jämtland Härjedalen, Researchand Development Unit, Östersund, Sweden

Background/aims: Palliative care requires major nursing interventions as well as medical interventions, thus the district nurse and the doctor are both central to the palliative team. Sparsely populated rural areas are characterized by large geographic distances and can mean that the different professionals are located a long way from each other, which can pose a challenge to collaboration. The aim of this study was to describe district nurses’ experiences of collaborating with the doctor in charge during palliative home care in sparsely populated rural areas.

Methods: Semi-structured interviews were carried out with ten district nurses. The material was analyzed using inductive content analysis.

Results: The experiences of the district nurses are described under the overarching theme of Experiences of acting as the patient advocate, which is divided into two categories. The category Positive experiences of collaboration generated the sub-categories Pride, Confidence, Support and Mutuality. The category Negative experiences of collaboration generated the sub-categories Inadequacy, Frustration and Shortage of time. Consensus and coherence, or lack thereof, between district nurses and doctors affects how collaboration is experienced. When the doctor shares the district nurse’s holistic approach this generates positive experiences, while collaboration is experienced as negative when the doctor does not make decisions in accordance with what the nurse judges to be beneficial to the patient.

Conclusions: These experiences are probably not unique to this situation and can possibly explain the interprofessional collaboration in other contexts involving interaction between the nursing and the medical professions. An understanding of how collaboration is experienced is necessary to bring about enhanced collaboration, thus an equivalent analysis of doctors’ experiences is therefore suggested for future research.

Background

In palliative care, registered nurses provide advanced nursing care to relieve patients’ symptoms and increase their quality of life based on physical, mental, social and existential dimensions. Conversations, often about existential issues, are an important part of nursing and can affect quality of life positively. Confidential conversations between patients and nurses occur naturally while other nursing activities are being performed. Despite their great importance for palliative care these are rarely described.

Aim

To gain a deeper understanding of how nurses in palliative care experience and describe confidential conversations with patients.

Method

Secondary analysis of data from 17 open-ended face-to-face interviews with registered nurses in palliative care was conducted. Qualitative content analysis using an inductive approach was used to gain a deeper understanding and analyse the latent content.

Results

The confidential conversation was considered an important part of palliative care and is the nurse’s responsibility. This responsibility was described as complex and placed various demands on the nurses, both personal and professional. A prerequisite for the conversation was the interpersonal relationship. The conversation allowed the patient to process important matters not previously addressed or put into words. It had no predetermined content, was unplanned and entirely on the patient’s terms. For nurses the conversation could be experienced both as draining and a source of power and strength. The nurses also described safeguarding the patient through the conversation.

Conclusion

Nurses’ confidential conversations with patients are essential in palliative care and must be highlighted more to increase the quality of palliative care. The confidential conversations often have an existential content and are challenging for the nurses. Therefore, nurses need time, knowledge, and supervision to increase their conversation skills.

Bakgrund: I palliativ omvårdnad identifierar, bedömer och bemöter sjuksköterskan fysisk, social, psykisk och existentiell hälsa för såväl patient som närstående samt planerar, genomför och utvärderar åtgärder. Samtal är en viktig omvårdnadshandling med syfte att förbättra patienternas livskvalitet och möjliggöra en värdig död. Samtalen om existentiella frågor har positiva effekter på livskvalitet och samtalet erbjuder existentiellt stöd i olika åldrar och sjukdomsgrupper vid obotlig sjukdom som exempelvis cancer, organsvikt, demenssjukdom. Det finns olika former av samtal i palliativ vård. Sjuksköterskans förtroliga samtal som ofta sker spontant vet vi lite om Det förtroliga samtalet finns inte heller explicit beskrivet som begrepp i vårdvetenskaplig forskning. Syfte: Att få en djupare förståelse för innebörden av förtroliga samtal i palliativ vård utifrån sjuksköterskors och patienters perspektiv. Metod: Kvalitativ ansats med sjuksköterskor och patienter som i intervjuer beskriver sina erfarenheter av förtroliga samtal. Resultat: Analys av insamlade data med sjuksköterskor pågår och beräknas avslutas hösten 2022. Rekrytering och insamling av data med patienter beräknas påbörjas hösten 2022. Preliminära resultat i delstudie I visar att samtalen är en viktig del i den palliativa omvårdanden och sjuksköterskans självklara ansvar. Såväl ansvaret som samtalet i sig beskrivs som komplext och ställer olika typer av krav på sjuksköterskan. I samtalet kan patienten med palliativ vårdbehov få möjlighet att bearbeta saker som inte tidigare bearbetats och sätta ord på det som behöver sättas ord på. Samtalet inte har något förutbestämt innehåll, sker ofta i anslutning till någon annan omvårdnadssituation och sker helt på patientens villkor då det är patienten somhåller i taktpinnen. Betydelse: Samtal är mycket viktig del av omvårdnaden, trots det upplever vårdpersonal av olika skälutmaningar i att genomföra samtal. Personalens vilja att hjälpa, lindra symtom och plågor samt att främja en värdig död är ofta en stark drivkraft. I förtroliga samtal med en sjuksköterska får patienter möjlighet att hantera sin situation, sin sjukdom, sina förluster, sitt beroende av hjälp och stöd samt sin livssituation vilket kan leda till ökad livskvalitet och känsla av oberoende och värdighet. Kontexten palliativ vård är viktig i det förtroliga samtalet, där livets sista tid, döendet och döden är närvarande. Studien med patienter kommer att ligga till grund för en digital interaktiv utbildningsintervention om existentiella samtal riktad till vårdpersonal. Det är centralt att medarbetare i teamet runt patienter med palliativ vårdbehov har kunskaper, förmåga och mod att initiera och samtala kring patienters existentiella tankar och funderingar vid obotlig sjukdom.

Background: Patients with palliative care needs live with the reality of limited time due to illness or age, eliciting emotional and existential responses. A failure to address their existential needs can lead to significant suffering. A person-centred approach is paramount to effectively address these needs, emphasising holistic care and effective communication. Although existing communication models focus on predefined frameworks, a need exists to explore more spontaneous and confidential conversations between patients and nurses. Confidential conversations have the potential to build therapeutic relationships and provide vital emotional support, highlighting the need for further research and integration into palliative care practice. This study aims to more deeply understand the meaning of confidential conversations for patients with palliative care needs. Methods: In-depth interviews were conducted with 10 patients in the context of specialised palliative care. A hermeneutic analysis was used to gain a deeper understanding of the meanings of the conversations. Results: The patients had varying experiences and wishes concerning confidential conversations. They strived for self-determination in finding confidants, seeking trust and comfort in their interactions with nurses. Trust was crucial for creating a safe space where patients could express themselves authentically. In shared belonging, confidential conversations with a nurse provided validation and relief from life’s challenges. Experiences of feeling unheard or rejected by a nurse could intensify loneliness, prompting individuals to withdraw and remain silent. Regardless of the motives behind their choices, it was crucial that patients felt respect and validation in their decisions. Their autonomy could thus be recognised, and they felt empowered to make decisions based on their unique preferences. Conclusions: Patients value trust and understanding, particularly in confidential conversations with nurses, which offer solace, validation and empowerment. However, indifference can increase patients’ suffering, fostering self-doubt and reluctance to engage further. To address this, health care can prioritise empathic communication skills, offer ongoing support to nurses, and promote continuity in care through investment in training and resources. Additionally, adopting a person-centred approach in confidential conversations is crucial, considering patients’ varying preferences. 

Background

Leadership is vital for well-coordinated healthcare, as it affects the quality of care and patient safety. The flow of activities between organizations and departments is challenging for coordination and collaboration in healthcare. Nursing leaders are essential in creating appropriate structures and processes that support improving patient outcomes of transitional care in a rural context.

Aim

To explore nursing leaders' concerns about creating quality care in transitions from hospital care to home healthcare in rural areas and how they experience their roles and responsibilities for improving this process.

Methods

A constructivist grounded theory methodology was used. Data were collected mainly through individual interviews with twenty hospital- and rural municipal care nursing leaders.

Results

Nursing leaders' main concern about creating quality care in transitions was  A lack of consensus. The core category explaining their approach when having different goals was Focusing on one’s responsibilities by working within organizational downpipes. As they only considered themselves able to influence their operations, they focused on setting the culture of their unit and guarding their resources to watch over patient safety and the work environment. Three categories further explained this: I) Promoting nursing competence by recruiting and training nurses in their unit, II) Ensuring continuous care flow by collaborating up and down within one's organization and clarifying rights and obligations, (III) Evaluating collaboration by investigating collaboration-related unwanted events in close misses and incident reports in each unit.

Conclusion

The theory of bureaucratic caring may explain that there are different target images at different units. Seamless care transitions are challenging when nursing leaders lack a view outside their organizational boundaries. Increased patient participation becomes a prerequisite as they are the only ones involved throughout the care transition.

Background

Registered nurses are critical for the delivery of high-quality healthcare during care transitions from hospital to home. Older co-morbid patients are most vulnerable during these transitions. A growing population of older adults with a higher prevalence of diseases implies increased demands on healthcare and its quality, which is affected by the environment where healthcare is provided. One can draw inferences on the quality of care when classified into structure, process, and outcome. This study explored registered nurses’ perspectives on structural conditions that promote or hinder good quality care during transitions from hospital to home healthcare in rural areas.

Methods

We conducted a reflexive thematic analysis of interviews with 21 registered nurses experienced in care transitions from hospital to home healthcare in a rural area of Sweden. We based the theoretically driven analysis on Donabedian’s definition of structures regarding the quality of care.

Results

The structural conditions were represented by three themes; (I) “Distances and inaccessibility” explains physical matters such as geographical (in)accessibility, bed (un)availability and electronic aids. (II) “Competence of the actors” explains continuity, knowledge and collaboration among the individuals involved. (III) “Levels of organizational governance” explains laws, expectations, values, and agreements regarding care transitions. All themes involved promoting and hindering factors, mutually influencing aspects of the others.

Conclusions

Care actors, educators, managers, and decision-makers need to understand how structures in the physical, social and symbolic environment interactively affect the quality of care during care transitions since understanding this is a prerequisite for improvements. These aspects must be considered to optimize conditions for high-quality care transitions from hospital to rural home healthcare and implemented continuously to improve transitions within the respective organization and inter-organizationally. According to this study, these aspects are critical in a rural context due to structural care quality influencers such as geographical challenges, difficulties in finding competent staff members, development of technical devices, and access to the Internet.

Bakgrund: Sjuksköterskans roll är viktig vid överflyttning av patienter från en vårdgivare till en annan. Äldre personer med komplexa vårdbehov löper stor risk vid vårdövergångar och sköra äldre tenderar känna oro i samband med dessa processer. Återinskrivningsrisken är högre vid utskrivning till ordinärt boende än till särskilt boende, vilket även skiljer sig mellan glesbygds- och tätortsbosatta, till nackdel för de glesbygdsbosatta. Få tidigare studier förklarar sjuksköterskans perspektiv på vårdövergångar från sjukhusvård till hemsjukvård i ordinärt boende i gles landsbygd.

Syfte: Att ge en djupare förståelse för sjuksköterskors uppfattningar av vårdkvalitet vid vårdövergångar från sjukhusvård till hemsjukvård i gles landsbygd.

Frågeställningar: Vad uppfattar sjuksköterskor vara det huvudsakliga bekymret i vårdövergångar från sjukhusvård till hemsjukvård i gles landsbygd och hur hanteras detta?

Metod: En konstruktivistisk grundad teori-Metod: baserad på individuella intervjuer med 21 legitimerade sjuksköterskor med erfarenhet av vårdövergångar från sjukhus till hemsjukvård i glesbygd.

Resultat: Det huvudsakliga bekymret vid vårdövergångar var "Vårdkoordination i en komplex process". Komplexiteten härrörde från flera miljömässiga och organisatoriska faktorer, vilket skapade en rörig och fragmenterad kontext för sjuksköterskorna att navigera inom. Kärnkategorin ”Att aktivt kommunicera för att reducera patientsäkerhetsrisker” förklarades närmre av de tre kategorierna – ”Samarbeta kring förväntade vårdbehov”, ” Förutse hinder” och ”Tajma avgången”. Underlåtenhet att utföra dessa aktiviteter förknippades med ökad risk för vårdskador i flera avseenden.

Diskussion: Fynden visar hur kommunikation och samarbete är nyckelfaktorer för vårdkvaliteten i övergångsprocessen. Ett proaktivt arbetssätt underlättar i gles landsbygd där långa avstånd medför längre tid från beslut till genomförande. Den konstanta interaktionen mellan kategorierna sammanknöts av den teoretiska koden ”Att konstant prioritera”. Beslutsfattare måste ha i åtanke vilka risker kopplat till organisation och vårdövergångar som kan uppstå i glesbygdsmiljö, för att möta behoven hos sköra äldre personer och deras anhöriga.

Slutsats: Studien visar en mycket komplex och stressad process som omfattar flera organisationer och aktörer. Riskreducering kan underlättas av tydliga riktlinjer, verktyg för kommunikation och tillräcklig bemanning.

Purpose: Although previous research indicates that care transitions differ between rural andurban areas, the knowledge of challenges related to care transitions in rural areas appearslimited. This study aimed to provide a deeper understanding of what registered nurses’perceive as the main concerns in care transitions from hospital care to home healthcare inrural areas, and how they handle these during the care transition process.

Methods: A Constructivist Grounded Theory method based on individual interviews with 21registered nurses.

Results: The main concern in the transition process was “Care coordination in a complexcontext”. The complexity stemmed from several environmental and organizational factors,creating a messy and fragmented context for registered nurses to navigate. The core category“Actively communicating to reduce patient safety risks” was explained by the three categories–“Collaborating on expected care needs”, “Anticipating obstacles” and “Timing the departure”.

Conclusions: The study shows a very complex and stressed process that includes severalorganizations and actors. Reducing risks during the transition process can be facilitated byclear guidelines, tools for communication across organizations and sufficient staffing.