The use and application of intensive care unit diaries: An instrumental multiple case study.

AIMS AND OBJECTIVES: The study aim was to explore the use of an Intensive Care Unit (ICU) diary within four different ICUs units in Sweden and thereby contribute to practice guidelines regarding the structure, content and use of an ICU diary. BACKGROUND: ICU diaries are used to aid psychological recovery among critical care patients, but differences remain in diary writing both within and across countries. Few studies have focused on the combined views and experiences of ICU patients, family members and nursing staff about the use of ICU diaries. DESIGN: An instrumental multiple case study design was employed. METHODS: Three focus groups interviews were carried out with 8 former patients and their family members (n = 5) from the research settings. Individual interviews were carried out with 2 patients, a family member and a nurse respectively. Observations, field notes, documentary analysis and conversations with nursing staff were also conducted. Consolidated criteria for reporting qualitative research (COREQ) was followed. RESULTS: The qualitative findings firstly consisted of a matrix and descriptive text of the four ICU contexts and current practices. This highlighted that there were similarities regarding the aims and objectives of the diaries. However, differences existed across the case study sites about how the ICU diary was developed and implemented. Namely, the use of photographs and when to commence a diary. Second, a thematic analysis of the qualitative data regarding patients' and family members' use of the ICU diary, resulted in four themes: i) the diary was used to take in and fully understand the situation; ii) the diary was an opportunity to assimilate warm, personalised and human care; iii) the diary was used to manage existential issues; and iv) the diary was a tool in daily activities. CONCLUSIONS: Analysis of the instrumental case study data led to the identification of core areas for inclusion in ICU diary practice guidelines.

Chemotherapy-induced Emesis: Experienced Burden in Life, and Significance of Treatment Expectations and Communication in Chemotherapy Care.

OBJECTIVE: Because antiemetics have become more effective and integrative therapies such as acupuncture are used in combination with antiemetics, people receiving chemotherapy for cancer today might expect less emesis than in the past. It is not previously described if and how people receiving modern antiemetics during chemotherapy experience emesis. The objective of this study was to describe experiences regarding emesis among persons undergoing emetogenic chemotherapy, and how it affects their quality of life, daily life and work. A further aim was to describe views on the significance of treatment expectations and communication with healthcare personnel while undergoing chemotherapy for cancer. METHOD: Fifteen participants (median age 62 years, n = 1 man and n = 14 women, with breast (n = 13) or colorectal (n = 2) cancer) undergoing adjuvant or neo-adjuvant highly or moderately emetogenic chemotherapy were interviewed individually. The data were then analyzed using inductive thematic analysis. RESULTS: Three themes described the participants' experiences: "Your whole life is affected, or continues as usual," covering descriptions of emesis limiting some participants' everyday lives, while others experienced no emesis at all or had found ways to manage it. Overall, participants described satisfaction with their antiemetic treatment. "Experiences and expectations more important than information", that is, the participants reported wanting all the information they could get about possible adverse effects of treatment, although they believed previous experiences were more important than information in creating expectations about treatment outcomes. The participants reported that being seen as a unique person was of utmost importance: "Meet me as I am." This creates trust in healthcare personnel and a feeling of safety and security in the situation. CONCLUSIONS: These findings underline the importance of person-centered care and support in creating positive treatment expectations. Future research is called for regarding the potential antiemetic effects of positive communication regarding strengthening positive treatment expectations during emetogenic chemotherapy.

Parents' experiences of the significance of interpersonal interactions for becoming parents and a family during neonatal intensive care.

PURPOSE: To describe parents' experiences of the significance of interpersonal interactions for becoming parents and a family during neonatal intensive care. DESIGN AND METHODS: We employed a qualitative descriptive design with semi-structured family interviews. Ten families were included from four neonatal intensive care units (NICU) in Sweden. Results were evaluated using thematic analysis. RESULTS: The results were presented as two themes: 1) Interactions within the family, and 2) Interactions between parents and staff. Analyses revealed that interpersonal interactions could both facilitate and hinder development in becoming a parent and a family. CONCLUSION: Interactions within the family and with the staff have an important function in the process of becoming a parent and a family. This process would benefit from a systemic approach, focusing on the family as a unit, as unique individuals, and as parents with unique needs and experiences. PRACTICE IMPLICATIONS: Our findings can facilitate changes to reduce the separation between family members (mother-father-newborn-siblings) during their stay in NICU; guiding parents to take care of their child, while being sensitive and balancing their situation as to where they are in their process; supporting the family through joint conversations by listening to the parents and their expectations and experiences both in the NICU and at home; and encouraging parents to do everyday things together outside NICU like an ordinary family.

A piece of a puzzle-Patient and psychologist experiences of the Affect School as additional treatment in a Swedish eating disorder unit.

BACKGROUND: Emotion dysregulation has been shown to be a transdiagnostic characteristic of eating disorders. The Affect School aims to enhance emotional awareness and the ability to perceive and express emotions. This study was conducted as part of an RCT where patients with various eating disorders were randomised to participation in the Affect School as a supplement to treatment. AIM: To explore Affect School participants' and leaders' experiences of the Affect school at an Eating Disorder outpatient unit in Sweden. METHOD: Nine patients with eating disorder diagnoses and three Affect School leaders at an eating disorder outpatient clinic in Sweden were interviewed for their experiences of the intervention. The interviews were analysed with Thematic Analysis. RESULT: Eight themes were revealed at the analysis, five from the participants: "Worries about group participation", "Not alone anymore and gaining new insights about oneself", "Shared stories can also be painful", "Relationships outside the Affect School as a foundation for affective work", and "A change is coming", and three from the leaders:"Affect awareness is important in eating disorders", "Group meetings create opportunities and challenges", and "The Affect School setup needs more customisation". CONCLUSION: The results suggested that the Affect School provided an acceptance for experiencing all sorts of affects. Both leaders and participants considered working with affects necessary, although participants reported no changes in their life situation or condition after the intervention but considered the intervention as part of a process with gradual results. Being part of a group and sharing experiences was experienced as positive by participants and leaders, but the model could be further developed to better adapt to patients with an eating disorder.

Young adults' needs when seeking first-line healthcare: A grounded theory design.

BACKGROUND: Healthcare outpatient visits have increased in recent years, and young adults are often given as an explanatory factor for many avoidable visits. OBJECTIVE: The objective of this study was to explore how young adults perceive seeking first-line healthcare. DESIGN AND SETTING: The study utilized a grounded theory design with data collection at primary healthcare centres and emergency departments in southeast Sweden. METHOD: Data were collected during individual interviews and patient observations with subsequent interviews during the years 2017-2018. The analysis was performed using grounded theory. RESULTS: The main concern when young adults are seeking healthcare is that their worries are taken seriously. It is a four-part process: becoming aware of, verifying, communicating, and receiving an opinion about one's symptoms. The process includes external factors, clarity of symptoms, behavioural approaches, healthcare know-how, enabling self-management, and prior healthcare experience(s). When communicating symptoms, the clearer the symptoms, the less there needs to be communicated. When symptoms are unclear, the importance of different behavioural approaches and healthcare know-how increases. When receiving a medical opinion about symptoms, young adults want to learn how to self-manage their symptoms. Depending on previous healthcare experience, the healthcare visit can either harm or help the patient in their healthcare-seeking process. CONCLUSION: This study reflects several insights in the healthcare-seeking process from a young adult perspective. Based on the results, we suggest that healthcare providers focus on the final step in the healthcare-seeking process when giving their medical opinion about symptoms. Having extra minutes to give support for future self-care regardless of diagnosis could increase positive healthcare experiences and increase future self-care among young adults.

Experiences of paediatric emergence delirium - from parents' and a child's perspective.

BACKGROUND: Emergence delirium is a complex behaviour of perceptual disturbances that may occur after general anaesthesia in children. These children often exhibit delusions, confusion, restlessness and involuntary physical activity. They cry and are almost impossible to console. Research has mainly focused on comparing different medication agents in the occurrence of and dealing with emergence delirium. However, less is known about parents' experiences of emergence delirium during the recovery process, and there is hardly any research concerning the children's experiences. AIMS: The primary aim of this study was to describe parents' experiences and reflections during their child's emergence delirium behaviour when recovering from anaesthesia. A secondary aim was to describe children's experiences of having been in this condition. METHOD: A qualitative research approach with thematic analysis was applied. The study was conducted at two county hospitals in southern Sweden. A total of 16 parents and one child were interviewed. RESULTS: Watching their child demonstrate emergence delirium made parents feel as if they were encountering an incomprehensible scenario. They experienced fear and insecurity and had feelings of powerlessness and guilt. Information and previous experience turned out to offer relief, and being seen by the healthcare staff when they, in their vulnerability, failed to reach or console their child, gave hope and energy. The child confirmed the unexpected and uncontrolled behaviour described by parents. She clearly remembered being 'wild' and out of control. CONCLUSION: Emergence delirium must be extensively considered in children undergoing general anaesthesia. It is of great importance for healthcare staff to be aware of the parental difficulties it may cause and what is experienced as relieving, such as receiving information and staff members being available, responsive and supportive during the wake-up period.

Young adults' healthcare utilisation and healthcare needs: Perceptions and experiences of healthcare providers.

BACKGROUND: Health care in many countries entails long waiting times. Avoidable healthcare visits by young adults have been identified as one probable cause. OBJECTIVE: The aim of this study was to explore healthcare providers' experiences and opinions about young adults' healthcare utilisation in the first line of care. METHOD: This study used latent qualitative conventional content analysis with focus groups. Four healthcare units participated: two primary healthcare centres and two emergency departments. This study included 36 participants, with 4-7 participants in each group, and a total of 21 registered nurses and 15 doctors. All interviews followed an interview guide. RESULTS: Data were divided into eight categories, which all contained the implicit theme of distribution of responsibility between the healthcare provider and the healthcare user. Young adult healthcare consumers were considered to be highly influenced by external resources, often greatly concerned with small/vague symptoms they had difficulty explaining and unable to wait with. The healthcare provider's role was much perceived as being part of a healthcare structure-a large organisation with multiple units-and having to meet different priorities while also considering ethical dilemmas, though feeling supported by experience. CONCLUSION: Healthcare personnel view young adults as transferring too much of the responsibility of staying healthy to the healthcare system. The results of this study show that the discussion of young adults unnecessarily seeking health care includes an underlying discussion of scarcity of resources. PATIENT OR PUBLIC CONTRIBUTION: The conduct of this study is based on interviews with young adult patients about their experiences of seeking healthcare.

Parents' experiences of family health conversations after having a child in need of neonatal intensive care.

BACKGROUND: When a newborn child requires neonatal intensive care, it is often the beginning of a journey of stress and worry for the parents. Such situations could cause difficulties in problem-solving and communication within the family and result in decreased family functioning. Studies have shown that nurse-led interventions in the form of Family Health Conversations promote family's well-being and functioning and strengthen their relationships. However, this model has not previous been used and evaluated with families who have a child in need of neonatal intensive care. AIM: To describe parents' experiences of participating in Family Health Conversations after having a child in need of neonatal intensive care. METHOD: Family interviews were conducted with 12 families from three neonatal intensive care units in southern Sweden, six months after a Family Health Conversations intervention. Data were analysed using qualitative content analysis. FINDINGS: The parents experienced the Family Health Conversations as an opportunity to co-create a comprehensive picture of what had happened after their child was born. Parents shared their experiences of the Family Health Conversations in terms of feeling validated and strengthened as individuals, as a couple, and as a family. They found the conversations to be supportive to their well-being and to processing experiences and becoming equipped for the future. The parents reported that it was valuable to talk with conversational leaders who had knowledge in neonatal care and who thereby understood what the parents were talking about. This provided a different type of support compared with other conversational contacts. CONCLUSION: These results highlight the importance of having an early onset of family conversations in order to help the parents to cope with their challenges and improve their well-being.

Development and validation of an ICU-specific pressure injury risk assessment scale.

BACKGROUND: Critically ill patients are at high risk for pressure injury (PI) due to critical illness combined with multiple interventions and therapies. It is hence important to gain more knowledge about the risk factors associated with pressure injury development and methods for decreasing its prevalence. AIMS: To develop and validate a clinical useful ICU-specific PI risk assessment scale based on the RAPS. METHOD: The study was designed as a prospective instrument development and validation study. The Risk Assessment Pressure Ulcer Scale (RAPS), which in Sweden is a commonly used PI risk assessment scale, was used as a starting point. Development was then performed in different steps; adaption of items and response options to ICU care, discussion with ICU staff members to enhance clinical relevance and usability, test of interrater reliability, revision of instrument, a new test with 300 patients followed by statistical evaluation. RESULTS: The final version of the RAPS-ICU consists of six items: failure of vital organs, mobility, moisture, sensory perception, level of consciousness and special treatment in the form of mechanical ventilation, continuous dialysis and/or inotropic drugs. A total score was reached by summing all responses. Each of the items was found to be significant associated with PI development as well as the total score (p < 0.001). The total score also showed a high interrater reliability (ICC = 0.96), good sensitivity and acceptable specificity with AUC = 0.71 and ICU staff perceived the RAPS-ICU as relevant and easy to use in clinical practice. CONCLUSION: The RAPS-ICU is a valid and clinically useful tool to identify patients at risk to develop pressure injury at ICU.

Corrigendum to "What do patients rate as most important when cared for in the ICU and how is this met? - An empowerment questionnaire survey" in Journal of Critical Care 40 (2017) 83-89.

This study aimed to explore what patients rate as being of the greatest importance and less important, when being cared for in the intensive care unit (ICU). The aim was also to examine the extent to which these topics are met. In the Patient Empowerment Questionnaire (PEQ-ICU), patients were first asked to rate the importance of 28 items, and then how often those topics were met during their stay in the ICU. Having trust/confidence in staff, Receive visits from next of kin, Staff being positive to visitors, Receive pain relief, Staff showing human warmth, and Staff trying to strengthen my life spirit were the items that most patients evaluated as being of the greatest importance. The items Staff being positive to visitors, Receiving pain relief and Receive visits from next of kin, were the items most frequently c onsidered as "always met", while the items Have influence and Receive help to look forward were less often met. It was found that there is a potential for improvement in helping the ICU patients to maintain contact with reality, remind them about their importance to someone or something, and what they could look forward to when becoming healthier and returning to ordinary life.

Nursing staff's experiences of intensive care unit diaries: a qualitative study.

BACKGROUND: Diaries as an intervention to aid psychological recovery among intensive care patients have been used for about 20 years, and findings tend to be positive. The provision of a diary directed at the patient may clarify the story of the intensive care unit (ICU) even for the family members and the family members of non-survivors. Members of nursing staff are the primary authors, but how they themselves experience the use of ICU diaries has been minimally explored. AIMS AND OBJECTIVES: This study aimed to explore how nursing staff experienced the use of ICU patient diaries. DESIGN: Qualitative design using focus group interviews. METHODS: A qualitative methodology was used. Six focus group interviews were conducted with 27 nursing staff recruited from one university and two county hospitals. The data were analysed via thematic content analysis. FINDINGS: One overarching theme, 'An effort to do good in words and actions', and four interconnected themes were derived from the analysis. By creating the diary, nursing staff had to deal with a variety of ethical and practical dilemmas, but feedback from patients, family members and ICU follow-up services reinforced the feeling of doing good. This overarching feeling of beneficence encouraged diary authoring and increased motivation and commitment to strive towards excellent patient care. To sustain the use of ICU diaries, collegiate and organizational support was deemed essential. CONCLUSIONS: Nursing staff strived to do good in words and actions for patients and their families when writing the diaries. Positive feedback from patients, family members and ICU follow-up services reinforced feelings of doing good, which served to enhance work satisfaction and a commitment to good-quality nursing care. Experiential-based education was recommended to help sustain ICU diary writing. RELEVANCE TO CLINICAL PRACTICE: Nursing staff requested mentoring and group discussions concerning the format, content and communication channels of the diary.

Evaluating Pictures of Nature and Soft Music on Anxiety and Well-Being During Elective Surgery.

BACKGROUND: Patients going through surgery being awake often have a sense of anxiety and need support to relax. OBJECTIVE: The aim of this study was to investigate whether looking at pictures of natural scenery could reduce anxiety and pain and increase relaxation and well-being being awake during the elective surgery. METHODS: This three-arm, randomized intervention study consisted of one group viewing pictures of natural scenery, one group listening to soft instrumental music, and one control group without distraction, all adult patients (n=174). The State Trait Anxiety Inventory short form and a visual analogue scale on well-being were used as well as sedation treatment if necessary. RESULTS: No differences related to anxiety after surgery were found among the three groups. When controlling for the effect of sedative treatment, however, patients without sedation had a lower degree of anxiety postoperatively (p=0.014). Younger patients had a higher degree of anxiety and lower degree of postoperative relaxation and well-being. CONCLUSION: Viewing pictures of natural scenery while being awake during elective surgery is as relaxing as listening to soft instrumental music. Offering nature scenery pictures for patients to view could be relaxing during the elective surgery.

A psychometric evaluation of the Pediatric Anesthesia Emergence Delirium scale.

BACKGROUND: Emergence delirium and emergence agitation have been a subject of interest since the early 1960s. This behavior has been associated with increased risk of injury in children and dissatisfaction with anesthesia care in their parents. The Pediatric Anesthesia Emergence Delirium Scale is a commonly used instrument for codifying and recording this behavior. AIMS: The aim of this study was to psychometrically evaluate the Pediatric Anesthesia Emergence Delirium scale, focusing on the factor structure, in a sample of children recovering from anesthesia after surgery or diagnostic procedures. The reliability of the Pediatric Anesthesia Emergence Delirium scale was also tested. METHODS: One hundred and twenty-two children younger than seven years were observed at postoperative care units during recovery from anesthesia. Two or 3 observers independently assessed the children using the Pediatric Anesthesia Emergence Delirium scale. RESULTS: The factor analysis clearly revealed a one-factor solution, which accounted for 82% of the variation in the data. Internal consistency, calculated with Cronbach's alpha, was good (0.96). The Intraclass Correlation Coefficient, which was used to assess interrater reliability for the Pediatric Anesthesia Emergence Delirium scale sum score, was 0.97 (P < .001). The weighted kappa statistics were almost perfect in 4 of 5 items, with substantial agreement in the fifth (P < .001). CONCLUSION: The one-factor solution and the satisfactory reliability in terms of internal consistency and stability support the use of the Pediatric Anesthesia Emergence Delirium scale for assessing emergence delirium in children recovering from anesthesia after surgery or diagnostic procedures. The kappa statistics for the Pediatric Anesthesia Emergence Delirium scale items essentially indicated good agreement between independent raters, supporting interrater reliability.

Patient perceptions of specialised hospital-based palliative home care: a qualitative study using a phenomenographical approach.

BACKGROUND: Specialised palliative care is given around the clock to palliative patients who have severe symptoms or special needs. AIM: The aim of this study was to describe patients' perceptions of what it is like to be cared for by a specialised palliative care team within hospital-based palliative home care (HPHC). METHOD: A qualitative method with semi-structured interviews was used. Fourteen patients enrolled in HPHC at a unit for specialised palliative care linked to the hospital in the southeast of Sweden participated. The analysis was performed with a phenomenographical approach. RESULTS: Four description categories were identified: 'it is safe to receive care at home,' 'support and commitment', 'having access to a multiprofessional team', and 'how HPHC changes everyday life'. To be cared for by HPHC was perceived as safe, and the patients thought that having access to competent staff who supported them around the clock had improved their care and daily life. CONCLUSION: The need for specialised palliative care will likely grow with an ageing population and this form of care was perceived as functioning well.

Health-promoting conversations-A novel approach to families experiencing critical illness in the ICU environment.

AIMS AND OBJECTIVES: To identify and describe the outcomes of a nurse-led intervention, "Health-promoting conversations with families," regarding family functioning and well-being in families with a member who was critically ill. BACKGROUND: Families who have a critically ill family member in an intensive care unit face a demanding situation, threatening the normal functioning of the family. Yet, there is a knowledge gap regarding family members' well-being during and after critical illness. DESIGN: The study used a qualitative inductive-descriptive design. METHODS: Eight families participated in health-promoting conversations aimed to create a context for change related to the families' identified problems and resources. Fifteen qualitative interviews were conducted with 18 adults who participated in health-promoting conversations about a critical illness in the family. Eight participants were patients (six men, two women) and 10 were family members (two male partners, five female partners, one mother, one daughter, one female grandchild). The interviews were analysed by conventional content analysis. RESULTS: Family members experienced strengthened togetherness, a caring attitude and confirmation through health-promoting conversations. The caring and calming conversations were appreciated despite the reappearance of exhausting feelings. Working through the experience and being confirmed promoted family well-being. CONCLUSION: Health-promoting conversations were considered to be healing, as the family members take part in sharing each other's feelings, thoughts and experiences with the critical illness. RELEVANCE TO CLINICAL PRACTICE: Health-promoting conversations could be a simple and effective nursing intervention for former intensive care patients and their families in any cultural context.

Family members' experiences with intensive care unit diaries when the patient does not survive.

OBJECTIVE: The aim of the study was to explore how family members experienced the use of a diary when a relative does not survive the stay in the intensive care unit (ICU). METHOD: A qualitative method with a hermeneutic approach was used. Nine participants who read/wrote eight diaries in total were interviewed. The collected data were analysed using a hermeneutic technique inspired by Geanellos. FINDINGS: The analysis revealed an overall theme 'the diary was experienced as a bridge connecting the past with the future', which was a metaphor referring to the temporal aspect where there was the period with the diary up until the patient's death and then the postbereavement period. The diary contributed to both a rational and emotional understanding of the death of the patient and disclosed glimmers of light that still existed before the illness deteriorated. Further, the diary bridged the space between family members themselves and between family and nursing staff. It helped to maintain a feeling of togetherness and engagement in the care of the patient which family members found comforting. CONCLUSION: Family members of nonsurvivors had a need to have the ICU time explained and expressed. The diary might work as a form of 'survival kit' to gain coherence and understanding; to meet their needs during the hospital stay; and, finally, to act as a bereavement support by processing the death of the patient.

Empowerment in critical care - a concept analysis.

OBJECTIVE: The purpose of this paper was to analyse how the concept of empowerment is defined in the scientific literature in relation to critical care. As empowerment is a mutual process affecting all individuals involved, the perspectives of not only patients and next of kin but also staff were sought. METHOD: A literature review and a concept analysis based on Walker and Avant's analysis procedure were used to identify the basic elements of empowerment in critical care. Twenty-two articles with a focus on critical care were discovered and included in the investigation. FINDINGS: A mutual and supportive relationship, knowledge, skills, power within oneself and self-determination were found to be the common attributes of empowerment in critical care. The results could be adapted and used for all parties involved in critical care - whether patients, next of kin or staff - as these defining attributes are assumed to be universal to all three groups, even if the more specific content of each attribute varies between groups and individuals. CONCLUSION: Even if empowerment is only sparsely used in relation to critical care, it appears to be a very useful concept in this context. The benefits of improving empowerment are extensive: decreased levels of distress and strain, increased sense of coherence and control over situation, and personal and/or professional development and growth, together with increased comfort and inner satisfaction.

Family members' experiences of keeping a diary during a sick relative's stay in the intensive care unit: a hermeneutic interview study.

OBJECTIVE: The aim of the study was to explore family members' experiences with keeping a diary during a sick relative's stay in the ICU. DESIGN: A qualitative method with a hermeneutic approach was used. Eleven participants, who recorded nine diaries in total, were interviewed. The collected data were analysed using a hermeneutic approach inspired by Gadamer. RESULTS: The analysis revealed a meta-theme: 'it [writing in the diary] felt like contact' which was created by a feeling of togetherness and the opportunity to communicate with the patient. Keeping a diary likely meets the needs of family members in several ways because it becomes a way to be present at the patient's bedsides, to provide caregiving, to maintain hope and to relay cogent information. However, concerns regarding negative aspects of diary keeping were also raised; for example, the diary created feelings of stress, guilt and failure and exposed intimate details. CONCLUSION: The diary symbolised the maintenance of relationships with the patients and was a substitute for the usual opportunities for communication. Furthermore, it was instrumental in meeting the needs of the majority of family members in several ways. Nevertheless, the diary did have negative effects for certain individuals, which highlights the importance of an individualised approach.

Staff empowerment in intensive care: nurses' and physicians' lived experiences.

AIM: The purpose of the study was to describe empowerment from the perspective of intensive care staff. What makes intensive care staff experience inner strength and power? BACKGROUND: Intensive care staff are repeatedly exposed to traumatic situations and demanding events, which could result in stress and burnout symptoms. A higher level of psychological empowerment at the workplace is associated with increased work satisfaction and mental health, fewer burnout symptoms and a decreased number of sick leave days. METHOD: Open-ended interviews were conducted with 12 intensive care unit (ICU) staff (four registered nurses, four enrolled nurses and four physicians) in southern Sweden. Data were analysed using a phenomenological method. FINDINGS: Intensive care staff were found to be empowered both by internal processes such as feelings of doing good, increased self-esteem/self-confidence and increased knowledge and skills, and by external processes such as nourishing meetings, well functioning teamwork and a good atmosphere. CONCLUSION: Findings show that not only personal knowledge and skills, but also a supporting atmosphere and a good teamwork, has to be focused and encouraged by supervisors in order to increase staff's experiences of empowerment. Staff also need a chance to feel that they do something good for patients, next of kin and other staff members.