Patient safety culture in home care settings in Sweden: a cross-sectional survey among home care professionals.

BACKGROUND: The connection between a weak patient safety culture and adverse patient events is well known, but although most long-term care is provided outside of hospitals, the focus of patient safety culture is most commonly on inpatient care. In Sweden, more than a third of people who receive care at home have been affected by adverse events, with the majority judged to be preventable. The aim of this study was to investigate the patient safety culture among care professionals working in care at home with older people. METHODS: This cross-sectional study used a purposive sample of 66 municipal care workers, health care professionals, and rehabilitation staff from five municipal care units in two districts in western Sweden who provided care at home for older people and had been employed for at least six months. The participants completed the Hospital Survey on Patient Safety Culture (HSOPSC) self-report questionnaire, which assessed aspects of patient safety culture-norms, beliefs, and attitudes. Logistic regression analysis was used to test how the global ratings of Patient safety grade in the care units and Reporting of patient safety events were related to the dimensions of safety culture according to the staff's professions and years of work experience. RESULTS: The most positively rated safety culture dimension was Teamwork within care units (82%), which indicates good cooperation with the closest co-workers. The least positively rated dimensions were Handoffs and transitions among care units (37%) and Management support (37%), which indicate weaknesses in the exchange of patient information across care units and limited support from top-level managers. The global rating of Patient safety grade was associated with Communication openness and Management support (p < 0.01 and p = 0.03, respectively). Staff with less work experience evaluated the Patient safety grade higher than those with more work experience. CONCLUSIONS: This study suggests that improvements are needed in care transitions and in support from top-level managers and that awareness of patient safety should be improved in staff with less work experience. The results also highlight that an open communication climate within the care unit is important for patient safety.

Seeking lifestyle counselling at primary health care centres: a cross-sectional study in the Swedish population.

BACKGROUND: Millions of people follow an unhealthy lifestyle in terms of tobacco consumption, hazardous use of alcohol, poor eating habits, and insufficient physical activity. Healthy lifestyles can to a large extent prevent and/or delay progression of non-communicable diseases. Factors influencing persons health-seeking behaviour regarding unhealthy lifestyles are of importance for sustainable health-promotive and disease-preventive work in primary health care. Generally, lifestyle interventions within primary health care are seen as feasible, but rarely reach all members of the general population. Few studies have been conducted about the likelihood among the general population to voluntarily contact a primary health care centre for support regarding lifestyle changes. The present study therefore aimed to investigate the general population's likelihood of contacting a primary health care centre regarding their lifestyles, and factors associated with a lower such likelihood. METHODS: A probability sample of adults living in Sweden (n = 3 750) were invited to participate in a cross-sectional survey regarding how societal developments affect attitudes and behaviours of the adult Swedish population. Data were collected between September and December 2020. Participants completed a questionnaire about lifestyle changes, and the data were analysed using descriptive statistics, Chi-square test and logistic regression analysis. RESULTS: The response rate was 52.0% (n = 1 896). Few persons responded that they would be likely to contact a primary health care centre for support regarding their lifestyles. Factors predicting a lower likelihood of contacting primary health care included few yearly visits to a primary health care centre, male sex, and living in a rural area. CONCLUSIONS: Primary health care centres are not the first choice for lifestyle counselling for the majority of adults living in Sweden. We have identified factors predicting low likelihood of using the support available at these centres. In order to work with sustainable and visible health-promotive and disease-preventive strategies at primary health care centres, these settings need to find valid methods to involve and collaborate with the members of the general community, to meet the needs of a population struggling with unhealthy lifestyles.

District nurses' perspectives on health-promotive and disease-preventive work at primary health care centres: A qualitative study.

BACKGROUND: Health promotion and disease prevention are of utmost importance for sustainable health care and primary health care. District nurses play a key role in primary health care centres, where they meet people suffering from, and/or having risk factors for, non-communicable diseases. AIM: The study aim was to describe district nurses' perspectives on their health-promotive/disease-preventive work at primary health care centres. METHODS: Interviews were conducted with 16 district nurses at primary health care centres in Sweden. An interpretive descriptive approach was employed for the analysis. FINDINGS: The district nurses integrated a focus on health-promotive and disease-preventive work into every patient encounter, which manifested through four intertwined themes: finding opportunities and striving for visibility; building relationships; considering patients' life situations; and inviting patients to share responsibility. Our findings show how, through a flexible approach, the district nurses strived for equal health and care for all, and how the care was built on a shared responsibility between the district nurse and patient, where district nurses aimed to empower patients to take action for their own health. CONCLUSION: The district nurses described health-promotive endeavours, in line with person-centred care in prioritising building relationships with patients, starting from their lived experience. They spoke of barriers, at both micro and macro levels, to health-promotive/disease-preventive work. These included language barriers, the impact of the media, and the overall organisation of primary health care. The work at primary health care centres should be restructured to clarify the district nurse's role, and to strengthen community outreach, and thereby improve individuals' access to support in lifestyle changes.

Barriers for Inter-Organisational Collaboration: What Matters for an Integrated Care Programme?

Introduction: Inter-organisational collaboration is challenging but essential in managing the complex and comprehensive needs of frail older people. Therefore, there is a need to investigate the influence of different barriers to inter-organisational collaboration when implementing an integrated care programme. The aim of this study was to investigate both inpatient and outpatient staff views on the factors they deemed to be influential to inter-organisational collaboration for an integrated care programme. Methods: The study was a cross-sectional study and included staff from hospitals, primary care and municipal health and social care. Results: There were no significant differences between staff from inpatient and outpatient care in measuring factors that may cause difficulties for inter-organisational collaboration. Staff views diverged significantly on all factors, such as educational level at long physical distances, laws and regulations, knowledge of each others work settings, experience from inter-organisational collaboration, different professions, variations in professional status and power, psychosocial factors such as positive work environment and interpersonal chemistry. Discussion: A multidisciplinary team culture and avenues for inter-organisational collaboration need to be developed for improved care continuity. Conclusion: The staffs' educational level influenced what was perceived as barriers to inter-organisational collaboration, and may guide future development of integrated care programmes.

A sense of being rejected: Patients' lived experiences of cancelled knee or hip replacement surgery.

BACKGROUND: Growing care queues, reduced access to care and cancelled surgery are realities for some patients being treated with total hip or knee replacement surgery in Sweden. Most of the patients on the waiting lists have experienced pain and limited motion for a varying period of time, with a negative effect on their everyday lives. Overbooked surgical schedules are already contributing to the lengthy waiting times, but, with the addition of cancellations, longer waiting times will increase still further and may affect patients' well-being. METHODS: In the present study, we aimed to illuminate the experience of having planned surgery cancelled, based on narratives from 10 participants. The interview transcriptions were analysed using a phenomenological hermeneutic approach. RESULTS: The comprehensive analyses revealed that the participants described the agony of being deselected and the additional impression of being excluded. Metaphors of being damaged and feeling physical pain were used and the interpretations referred to the cancellations as unpleasant. Additionally, the important relationship and the trust between the health workers and the patient were negatively affected by the cancellation. CONCLUSION: After the cancellation, the participants expressed being vulnerable and from their perspective the cancelled surgery affected them deeply; in fact, much more than the healthcare workers appeared to understand. Therefore, information around the cancellation must be given respectfully and with dignity, in a dialogue between the patient and the healthcare workers. Taken together, to enable an opportunity to be involved in the continued care. The cancellations should be seen as an interruption, in which the patients' chance of living a pain-free, active life is postponed.

Perceptions of providing safe care for frail older people at home: A qualitative study based on focus group interviews with home care staff.

BACKGROUND: Providing safe care is a core competence in healthcare. The concept usually refers to hospitals but, consistent with the increasing importance of integrated care, the provision of safe care needs to be extended to the context of home care, and more research is needed concerning home healthcare providers' perspectives in this context. AIM: The aim of this study was to describe care providers' perceptions of providing safe care for frail older persons living at home. METHOD: A qualitative methodology was chosen. In total, 30 care providers agreed to participate. Data were collected through five focus group interviews and analysed using a phenomenographic approach. RESULTS: Three themes regarding care providers' perceptions of providing safe care emerged from the data: 'safe care is created in the encounter and interaction with the older person', 'safe care requires responsibility from the caregiver' and 'safe care is threatened by insufficient organisational resources'. The findings show that providing safe care is an endeavour that requires a holistic view among the care providers as well as effective collaboration within the team, but insufficient competence or a lack of time can make it difficult to safeguard the psychological and existential needs of older persons. CONCLUSION: Providing safe care in home environments encompasses more than just risk reduction. The findings highlight the importance of establishing and integrating team-based and person-centred care into home care settings. Traditional communication structures for inpatient care also need to be adapted to the cross-disciplinary work in municipalities. Care providers should be given the opportunity to develop and maintain their competences and to prioritise relationship-oriented care.

What constitutes feeling safe at home? A qualitative interview study with frail older people receiving home care.

Aim: To highlight experiences of what constitutes feeling safe at home among frail older people receiving home care. Design: Qualitative descriptive study. Methods: The sample consists of 12 individual recorded interviews with frail older people in their homes. Interviews were transcribed verbatim and analysed using qualitative content analysis. The data collection was performed in spring 2018. Results: The analysis resulted in three categories: "Having a feeling of 'at-homeness'" describes the older people's surrounding environment and their efforts to maintain independence; "being able to influence" describes the importance for older people to shape their care by being in control and having an opportunity for self-determination in the context of home care; and "being able to trust staff" relates to expecting staff's knowledge and skills and to appreciating the staff's ability to create positive relations.

Striving to be in close proximity to the patient: An interpretive descriptive study of nursing practice from the perspectives of clinically experienced registered nurses.

This paper explores essential characteristics of current nursing practice from the perspectives of clinically experienced registered nurses in various fields of health care in Sweden. Nursing practice has been the subject of much debate in the past and because of its complexity as well as continuous changes in society it is important to continue the debate. A qualitative study, including 16 group interviews with altogether 74 participants, was conducted. Nursing practice was viewed as a multifaceted field. The participants struggled to define nursing but were able to describe it using concrete examples. The analysis, using interpretive description, identified current practice as essentially consisting of: 'A practice pervaded by comprehensive responsibility', 'A practice that recognises a patient's unique needs', 'A practice based on multifaceted knowledge' and 'A practice that mediates between traditional values and changing demands'. Current nursing practice can be understood as striving to be in close proximity to the patient, but in tension with pervasive requirements and societal changes. Going forward, it is necessary to continue to reflect on and discuss the nature of nursing practice in an interprofessional context. Studies from primary and home care are also needed to broaden the understanding of nursing practice.

Comprehensive geriatric assessment of frail older people: ideals and reality.

We explored different professionals' views on and experiences of comprehensive geriatric assessment (CGA) of frail older people. Forty-six professionals working in hospitals, primary care, or municipal health and social care participated in 10 focus groups. Professional groups comprised of occupational therapists, physiotherapists, nurses, physicians, and social workers. Participants shared an ideal image of how the CGA of frail elderly people should be conducted. Experience-based competence was more often used as an assessment tool than standardized tests. The ideal image contrasted with reality, listening to the needs expressed, with the person's problems, needs, and priorities in the foreground, as described by the categories: a need that can be met; different perspectives on needs; needs can be hidden; and needs assessment is affected by the collaboration around the person, by the context, and by the dialogue. The health and social care professionals' first priority is to make a person-centred tailor-made comprehensive geriatric assessment and not be bound to instruments. Clear guidelines need to be developed, stating which profession assesses what, when and how in order to ensure that person-centred needs are assessed including structures and procedures for how communication and collaboration within the team as well as between the organizations are achieved in order to perform a good person-centred CGA.

Fathers' experiences of being in change during pregnancy and early parenthood in a context of intimate partner violence.

OBJECTIVE: Intimate partner violence (IPV) is a large public health problem with far-reaching consequences for those involved. The aim of this study was to explore fathers' experiences of change during pregnancy and early parenthood in the context of IPV. METHODS: The methodological approach in this interview study was hermeneutics, based on a lifeworld perspective. Ten men, who had subjected their partners to violence during the childbearing period, and had become fathers within the previous 6 years, participated. RESULTS: The analysis revealed four themes: beginning to acknowledge that you are inflicting violence, receiving confirmation that you are more than just a perpetrator of violence, becoming aware of the child, and the desire to receive support in the process of learning how to become a father. Levinas' concept "the face of the other" is used to interpret the findings. CONCLUSION: This study contributes to a more nuanced and expanded picture of IPV. It shows that men who inflict violence want to be and learn how to be fathers. We need more knowledge about how to stop violent acts and support these men in the process of fatherhood.

Combining garden therapy and supported employment - a method for preparing women on long-term sick leave for working life.

Women are overrepresented among the group people suffering from long-term illness. In addition to their illness, suffering long-term sick leave leads to economical restraints as well social distress. There are gaps in our understanding of the challenges these women face. There is also lack of knowledge about how these challenges can be effectively addressed in rehabilitation. This deficiency is problematic from an ethical, justice and a caring perspective. In this study, changes in health-related quality of life (HRQoL) among women on long-term sick leave were investigated during and after participating in a rehabilitation programme combining two validated methods, Garden Therapy and Supported Employment (SE). The study also discusses difficulties in realising research related to vulnerable under-privileged people. From a population of 329 women who had reported their interest to participate, 245 were randomised to the programme. Of these 144 accepted participation in the research project and of these 123 women accepted to answer the SF-36 questionnaire. The participants were between 21 and 62 years with poor physical and mental health. They had received public financial support from <1 year to >10 years. The SF-36 measurement was carried out at baseline, after completion of Garden Therapy and after completion of SE. The results are based on data of respondents who participated at all the three occasions (n = 52). When comparing HRQoL baseline with the following occasions, the participants' General Health (GH), Vitality (VT), Social Functioning (SF) and mental health had improved significantly. The Four Leaf Clover (FLC) programme could be an appropriate method for reducing socially induced suffering. However, to conduct intervention studies where vulnerable persons are involved, it is off vital importance to consider whether the participants have the strength to complete the intervention.

The meaning of learning to live with medically unexplained symptoms as narrated by patients in primary care: a phenomenological-hermeneutic study.

BACKGROUND: Although research about medically unexplained symptoms (MUS) is extensive, problems still affect a large group of primary care patients. Most research seems to address the topic from a problem-oriented, medical perspective, and there is a lack of research addressing the topic from a perspective viewing the patient as a capable person with potential and resources to manage daily life. The aim of the present study is to describe and interpret the experiences of learning to live with MUS as narrated by patients in primary health-care settings. METHODS: A phenomenological-hermeneutic method was used. Narrative interviews were performed with ten patients suffering from MUS aged 24-61 years. Data were analysed in three steps: naive reading, structural analysis, and comprehensive understanding. FINDINGS: The findings revealed a learning process that is presented in two themes. The first, feeling that the symptoms overwhelm life, involved becoming restricted and dependent in daily life and losing the sense of self. The second, gaining insights and moving on, was based on subthemes describing the patients' search for explanations, learning to take care of oneself, as well as learning to accept and becoming mindful. The findings were reflected against Antonovsky's theory of sense of coherence and Kelly's personal construct theory. Possibilities and obstacles, on an individual as well as a structural level, for promoting patients' capacity and learning were illuminated. CONCLUSIONS: Patients suffering from MUS constantly engage in a reflective process involving reasoning about and interpretation of their symptoms. Their efforts to describe their symptoms to healthcare professionals are part of this reflection and search for meaning. The role of healthcare professionals in the interpretative process should be acknowledged as a conventional and necessary care activity.

Norwegian nurse-midwives' perspectives on the provision of antenatal diabetes care in an outpatient setting: A qualitative study.

BACKGROUND: There is limited research related to nurse-midwives' accounts of their provision of antenatal diabetes care in hospital outpatient settings. This study explored the perspectives and experiences of eight Norwegian nurse-midwives regarding the provision of the midwifery aspect of an antenatal consultation as part of the diabetes specialist team. METHODS: A qualitative descriptive study was used. Eight nurse-midwives aged between 37 and 58 years, representing four Norwegian hospital outpatient clinics, participated in individual interviews. Transcribed interviews were analysed in accordance with a qualitative thematic analysis. RESULTS: Three main themes were developed: "Approaching the women as persons in order to frame strengths and normalcy", "Managing different tasks judiciously" and "Balancing conflicting values". Some of the barriers were found to be related to the organisation of care, such as short timeframes with a medical focus, which overshadowed or forced the normalcy aspects of childbearing into the background. Managing risk and evidence-based knowledge were demanding tasks to fulfil in a judicious way. Some midwives experienced ambiguity while being forced to prioritise medical factors over woman-focused care while running others' errands, an act of balancing conflicting values. CONCLUSIONS: The contextual conditions related to the organisation present barriers for pregnant women to receive woman-focused care beyond the medical approach. The midwifery contribution in this care setting should be clearly recognised and defined so that women can capitalise on the different professionals and their expert competencies and contributions in this setting.

Communicating bodily changes: physicians' ways of enabling patient understanding in gastrointestinal cancer consultations.

OBJECTIVE: To explore how physicians communicatively enable patients' understanding of bodily changes in gastrointestinal cancer care consultations. METHOD: Two datasets were used. The first consisted of transcribed video-recorded palliative care consultations with three oncologists and six patients diagnosed with advanced gastrointestinal cancer, in the context of outpatient palliative care. The second dataset was audio-recorded transcriptions from diagnostic consultations with six surgeons and seven patients diagnosed with colorectal cancer, in the context of cancer surgery. An inductively driven and iterative analysis of interaction was performed, guided by Wetherell et al. (2001). RESULTS: Two overarching communicative strategies were identified: (1) "visualizing strategies," with the dimensions: visible strategies (visualizing with what you actually or potentially can see), sensory strategies (visualizing with what is possible to feel), and imaginative strategies; and (2) "contrasting strategies," with the dimensions: contrasting subjective experiences and contrasting between the patient and other people. SIGNIFICANCE OF RESULTS: The visualizing and contrasting communicative strategies form parts of physicians' tacit and experience-based knowledge. The strategies employed by physicians reveal clear potentials to enable patients' understanding and sense making of bodily changes. However, these strategies need to be explicated and problematized as parts of both consultation practice and basic medical education. By means of increased awareness, physicians can more easily identify turning points in patients' levels of understanding, thereby enriching ordinary medical consultations with reflected pedagogical strategies and skills in how to dialogue in a person-centered manner.

Patient participation in discharge planning conference.

INTRODUCTION: There is a need for individualized discharge planning to support frail older persons at hospital discharge. In this context, active participation on their behalf cannot be taken for granted. The aim of this study was to elucidate patient participation in discharge planning conferences, with a focus on frail older persons, supported by the theory of positioning described by Harré & van Langenhove. METHODS: The study was designed as a case study based on audio-recordings of multidisciplinary discharge planning conferences and interviews with health professionals elucidating their opinions on preconditions for patient participation in discharge planning. The analysis has been performed using qualitative content analysis and discourse analysis. Data collection took place during 2008-2009 and included 40 health professionals and 13 frail older persons in hospital or municipal settings. RESULTS: Findings revealed four different positions of participation, characterized by the older person's level of activity during the conference and his/her appearance as being reduced (patient) or whole (person). The positions varied dynamically from being an active person, passive person, active patient, or passive patient and the health professionals, next-of-kin, and the older persons themselves contributed to the positioning. CONCLUSIONS: The findings showed how the institutional setting served as a purposeful structure or a confinement to patient participation.

Women's experiences of important others in a pregnancy dominated by intimate partner violence.

BACKGROUND: Being exposed to intimate partner violence (IPV) during pregnancy is a difficult and complex situation. Despite this, there are few studies describing women's own needs for help and support. AIM: The aim of this study is to gain a deeper understanding of women's experiences of important others in relation to changing their life situation in a pregnancy dominated by IPV. METHODS: The study has a qualitative phenomenological design. The data were collected through in-depth interviews with seven Norwegian women, who were exposed to IPV during pregnancy. FINDINGS: Being pregnant and exposed to violence in relation to important others means confronting present life, life history and future life. The essence implies striving for control in an uncontrolled situation, where other people might be experienced as both a rescuer and a risk. This is further described in four constitutions: the child needs protection; my mother is always present for me; an exhausted run for help; and a reduced, but important social network. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: For women exposed to violence, pregnancy can offer an opportunity for change. Midwives play a unique role in relation to care and continuity in this phase of life, as they can support pregnant women, help to identify their needs, possibilities for action and advise them about appropriate services. Midwives can encourage and support women to find people whom they can trust and who can offer assistance. It is vital that midwives ask about the women's relationship to the baby and their social networks, especially the relationship with their mothers. Ethical considerations: During the whole study process, guidelines for research on violence against women were followed, to respect the integrity, security and confidentiality of the participants. The study is ethically approved.

Experts' encounters in antenatal diabetes care: a descriptive study of verbal communication in midwife-led consultations.

Aim. We regard consultations as cocreated communicatively by the parties involved. In this paper on verbal communication in midwife-led consultations, we consequently focus on the actual conversation taking place between the midwife and the pregnant woman with diabetes, especially on those sequences where the pregnant woman initiated a topic of concern in the conversation. Methods. This paper was undertaken in four hospital outpatient clinics in Norway. Ten antenatal consultations between midwives and pregnant women were audiotaped, transcribed to text, and analyzed using theme-oriented discourse analysis. Two communicative patterns were revealed: an expert's frame and a shared experts' frame. Within each frame, different communicative variations are presented. The topics women initiated in the conversations were (i) delivery, time and mode; (ii) previous birth experience; (iii) labor pain; and (iv) breast feeding, diabetes management, and fetal weight. Conclusion. Different ways of communicating seem to create different opportunities for the parties to share each other's perspectives. Adequate responses and a listening attitude as well as an ambiguous way of talking seem to open up for the pregnant women's perspectives. Further studies are needed to investigate the obstacles to, and premises for, providing midwifery care in a specialist outpatient setting.

Experiences of being exposed to intimate partner violence during pregnancy.

In this study a phenomenological approach was used in order to enter deeply into the experience of living with violence during pregnancy. The aim of the study was to gain a deeper understanding of women's experiences of being exposed to intimate partner violence (IPV) during pregnancy. The data were collected through in-depth interviews with five Norwegian women; two during pregnancy and three after the birth. The women were between the age of 20 and 38 years. All women had received support from a professional research and treatment centre. The essential structure shows that IPV during pregnancy is characterized by difficult existential choices related to ambivalence. Existential choices mean questioning one's existence, the meaning of life as well as one's responsibility for oneself and others. Five constituents further explain the essential structure: Living in unpredictability, the violence is living in the body, losing oneself, feeling lonely and being pregnant leads to change. Future life with the child is experienced as a possibility for existential change. It is important for health professionals to recognize and support pregnant women who are exposed to violence as well as treating their bodies with care and respect.

Person-centered care--ready for prime time.

Long-term diseases are today the leading cause of mortality worldwide and are estimated to be the leading cause of disability by 2020. Person-centered care (PCC) has been shown to advance concordance between care provider and patient on treatment plans, improve health outcomes and increase patient satisfaction. Yet, despite these and other documented benefits, there are a variety of significant challenges to putting PCC into clinical practice. Although care providers today broadly acknowledge PCC to be an important part of care, in our experience we must establish routines that initiate, integrate, and safeguard PCC in daily clinical practice to ensure that PCC is systematically and consistently practiced, i.e. not just when we feel we have time for it. In this paper, we propose a few simple routines to facilitate and safeguard the transition to PCC. We believe that if conscientiously and systematically applied, they will help to make PCC the focus and mainstay of care in long-term illness.