An Integrative Systematic Review of Promoting Patient Safety Within Prehospital Emergency Medical Services by Paramedics: A Role Theory Perspective.

Timely and effective prehospital care significantly impacts patient outcomes. Paramedics, as the frontline providers of emergency medical services, are entrusted with a range of critical responsibilities aimed at safeguarding the well-being of patients from the moment they initiate contact in the out-of-hospital environment to the time of handover at healthcare facilities. This study aimed to understand the multifaceted roles of paramedics in promoting patient safety within the context of prehospital emergency medical services. A systematic review with an integrative approach using the Whittemore and Knafl's framework was performed examining qualitative, quantitative, and mixed-methods research, then conducting data assessment, quality appraisal, and narrative research synthesis. Literature search encompassed PubMed (including MEDLINE), Scopus, Cinahl, ProQuest, Web of Science, and EMBASE, with the aim of retrieving studies published in English in the last decade from 2013 to 2023. To conceptualize the roles of paramedics in ensuring patient safety, the review findings were reflected to and analyzed through the role theory. The preliminary exploration of the database yielded 2397 studies, ultimately narrowing down to a final selection of 16 studies for in-depth data analysis and research synthesis. The review findings explored facilitators and obstacles faced by paramedics in maintaining patient safety in terms of role ambiguity, role conflict, role overload, role identity, and role insufficiency in the dynamic nature of prehospital care. It also highlighted the diverse roles of paramedics in ensuring patient safety, which encompassed effective communication and decision making for the appropriate management of life-threatening emergencies. The effectiveness of paramedics in playing their roles in promoting patient safety relies on acknowledging the contributions of paramedics to the culture of patient safety; training and educational initiatives focused on enhancing their decision-making abilities and both their non-technical and technical competencies; developing relevant guidelines and protocols; improving collaboration between paramedics and other healthcare peers; optimizing environmental conditions and equipment; fostering a supportive work environment.

Gaming the system to care for patients: a focused ethnography in Norwegian public home care.

BACKGROUND: With its emphasis on cost-reduction and external management, New Public Management emerged as the dominant healthcare policy in many Western countries. The ability to provide comprehensive and customized patient-care is challenged by the formalized, task-oriented organization of home-care services. The aim of this study is to gain deeper understanding of how nurses and the patients they care for, relate to and deal with the organizational systems they are subjected to in Norwegian home care. METHODS: The focused ethnographic design is based on Roper and Shapira's framework. Data collection consisted of participant observation with field notes and semi-structured interviews with ten nurses and eight patients from six home care areas located in two Norwegian municipalities. RESULTS: Findings indicate cultural patterns regarding nurses' somewhat disobedient behaviors and manipulations of the organizational systems that they perceive to be based on economic as opposed to caring values. Rigid organization makes it difficult to deviate from predefined tasks and adapt nursing to patients changing needs, and manipulating the system creates some ability to tailor nursing care. The nurses' actions are founded on assumptions regarding what aspects of nursing are most important and essential to enhance patients' health and ensure wellbeing - individualized care, nurse-patient relationships and caring - which they perceive to be devalued by New Public Management organization. Findings show that patients share nurses' perceptions of what constitute high quality nursing, and they adjust their behavior to ease nurses' work, and avoid placing demands on nurses. Findings were categorized into three main areas: "Rigid organizational systems complicating nursing care at the expense of caring for patients", "Having the patient's health and wellbeing at heart" and "Compensating for a flawed system". CONCLUSIONS: Our findings indicate that, in many ways, the organizational system hampers provision of high-quality nursing, and that comprehensive care is provided in spite of - not because of - the system. The observed practices of nurses and patients are interpreted as ways of "gaming the system" for caring purposes, in order to ensure the best possible care for patients.

The nurse-patient relationship in the New Public Management era, in public home care: A focused ethnography.

AIM: The aim of this study was to gain deeper understandings of nurse-patient relationships in the New Public Management era, by exploring beliefs and practices of nurses and patients in Norwegian public home care. BACKGROUND: Organization of Norwegian home care services is based on New Public Management-ideologies, which have led to a rigidly formalized and task-oriented nursing practice that may jeopardize individual nursing care. Nurse-patient relationships have several positive effects on patients' health and well-being, but organizational boundaries and time pressure affect the quality of relationships. DESIGN: Focused ethnography. METHODS: Data were collected between November 2015-July 2016 using participant observation and semi-structured interviews with 10 nurses and eight patients in six different home care areas, in two Norwegian municipalities. Data analysis was based on Roper and Shapiras framework. FINDINGS: Findings demonstrate the continued importance of nurse-patient relationships in contemporary home care, while identifying extensive variations in the degree of closeness and emotional involvement. Organizational boundaries, time constraints, high workload, and disharmony between nurses "competence and patients" complex illnesses, influence practice in ways that reduce the significance of nurse-patient relationships and affect conditions under which they develop and evolve. Facing a system nurses perceive to function suboptimal, they govern practices based on their own professional assessments, and findings indicate cultural patterns in the way both nurses and patients prioritize to safeguard nurse-patient relationships. CONCLUSION: Home care cultures based on traditional nursing values continue, despite New Public Management influences, but a transition into New Public Management culture may, over time, influence the quality of nurse-patient relationships and meanings attributed to them.

Caregivers' perceptions of aggressive behaviour in nursing home residents living with dementia: A meta-ethnography.

AIM: To explore how formal caregivers perceive and interpret aggressive behaviour in nursing home residents living with dementia, by synthesizing knowledge from published qualitative studies. BACKGROUND: Nursing home caregivers are exposed to aggressive behaviour from residents living with dementia. The way caregivers perceive aggressive behaviour may affect their feelings and actions related to situations and thus nursing care. Knowledge about caregivers' perceptions of aggressive behaviour has previously not been synthesized. DESIGN: Noblit and Hare's interpretative meta-ethnography. DATA SOURCES: A systematic literature search in CINAHL, PubMed and Scopus supplemented by manual search strategies, were completed. Nine studies from five countries, published between 2001 - 2015, met the research objective and inclusion criteria and were included. FINDING: Five themes describing formal caregivers' perceptions and interpretation of residents' aggressive behaviour emerged: "A manifestation of the disease"; "a way to express themselves and their needs"; "a reaction to caregivers" attitude and approach"; "a reaction to a stressful and demanding environment"; and "an unavoidable situation that seems impossible to solve". Themes were synthesized into the metaphor: 'tailoring using unpredictable patterns' and visualized in a model. CONCLUSION: Caregivers perceive and interpret aggressive behaviour related to the resident's illness and person, the caregiver's attitude and approach, or a demanding environment. Further research and theoretical development is important, as shown by different perceptions and interpretations, as well as central definitions in research publications. The study informs evidence-based practice and health-policy by showing the importance of developing reflective relational nursing care, knowledge, and competence in nursing homes.

The nurse-patient relationship as a story of health enhancement in community care: A meta-ethnography.

AIM: To explore and improve our understanding of how nurse-patient relationships can enhance patients' health by synthesizing knowledge from published qualitative studies from both patients' and nurses' perspectives in community care. BACKGROUND: While primary research showing the health benefits of the nurse-patient relationship has been reported, this knowledge has not previously been synthesized. DESIGN: Meta-ethnography. DATA SOURCES: A comprehensive search of five relevant databases, without year limitation, was completed. Inclusion criteria were: peer-reviewed studies exploring patient and/or nurse perspectives in community care settings, using a qualitative approach and published in English in any country. REVIEW METHOD: Noblit and Hare's meta-ethnographic approach. RESULTS: Ten primary studies published between 1997 - 2014 met the research objective and inclusion criteria and were appraised as high quality using CASP. Included studies reported similar findings and reciprocal translational analysis was possible. Six core themes were identified: entering the patient's world; trusting and telling; identifying different needs and uncovering change; patients becoming masters of their own health; patients experiencing health in illness; and nurses going the distance. The core themes were synthesized into a metaphor of "the nurse-patient relationship as a story of health enhancement", which illustrates the meaning of the "common story" they create together. CONCLUSION: The findings help us better understand how the nurse-patient relationship may enhance the patient's health, not only with regard to illness, physical condition and treatment but also physical, emotional, mental and social well-being. The nurse-patient relationship also has the potential to strengthen the patient's own resources towards maintaining health.

Ethical challenges in neonatal intensive care nursing.

BACKGROUND: Neonatal nurses report a great deal of ethical challenges in their everyday work. Seemingly trivial everyday choices nurses make are no more value-neutral than life-and-death choices. Everyday ethical challenges should also be recognized as ethical dilemmas in clinical practice. RESEARCH OBJECTIVE: The purpose of this study is to investigate which types of ethical challenges neonatal nurses experience in their day-to-day care for critically ill newborns. RESEARCH DESIGN: Data were collected through semi-structured qualitative in-depth interviews. Phenomenological-hermeneutic analysis was applied to interpret the data. PARTICIPANTS AND RESEARCH CONTEXT: Six nurses from neonatal intensive care units at two Norwegian hospitals were interviewed on-site. ETHICAL CONSIDERATIONS: The study is designed to comply with Ethical Guidelines for Nursing Research in the Nordic Countries and the Helsinki declaration. FINDINGS: Findings suggest that nurses experience a diverse range of everyday ethical challenges related to challenging interactions with parents and colleagues, emotional strain, protecting the vulnerable infant, finding the balance between sensitivity and authority, ensuring continuity of treatment, and miscommunication and professional disagreement. DISCUSSION: A major finding in this study is how different agents involved in caring for the newborn experience their realities differently. When these realities collide, ethical challenges arise. Findings suggest that acting in the best interests of the child becomes more difficult in situations involving many agents with different perceptions of reality. CONCLUSION: The study presents new aspects which increases knowledge and understanding of the reality of nursing in a neonatal intensive care unit, while also demanding increased research in this field of care.