Introduction 

In a cancer pathway, it is not only the patient who is affected, but also those close to them (1). The partner is an important resource and, in many cases, takes on increased responsibility and more caregiving tasks (2–4). Tasks can be related to practical, emotional, physical and/or social aspects, and some could have been performed by healthcare personnel (5). 

A study shows that caregiving tasks at home can take up to 20 hours per week, such as practical chores and follow-up on doctor appointments (6). Some tasks can cause stress and be so demanding that they have an adverse effect on the caregiver’s own quality of life (7–9). However, many describe the caregiving role as meaningful and report that it strengthens their bond with the person who is ill and brings them closer (10). 

Nevertheless, the caregiving role can also affect their ability to work (11, 12), i.e. their self-assessed ability to perform job tasks as required (13). Many family caregivers therefore face challenges in balancing their working life with caregiving duties at home (1, 8, 11, 12). 

The Norwegian Directorate of Health’s Family Caregiver Survey shows that one-third of the working population have been negatively affected by caregiving, with reduced efficiency, productivity and concentration (4). This finding is also confirmed in a US study, where one in three family caregivers of a cancer patient had to leave their job due to the strain (14). 

Changes in employment can lead to changes in finances (1, 14–16). Meanwhile, the workplace and colleagues can help an employee maintain their identity, social network and ‘normal’ daily life (10). Consequently, a family caregiver’s job can serve as a sanctuary and an important arena for their social life (4, 17).

The employer’s sympathy for the family caregiver’s situation and ability to make accommodations are important factors that can help caregivers to continue working (10, 18–20).

Studies show that family caregivers with jobs that offer flexibility and accommodations are more likely to continue working and experience less stress (18–21). However, a Norwegian study shows that only one in four employers have procedures for supporting employees in caregiving situations (22).

The Norwegian health and welfare services have developed several support schemes to assist family caregivers (23) but few are aware of what is available (13). Care allowance is a little-used financial support scheme for family caregivers, designed to replace lost wages for up to 60 days’ absence from work (1). The scheme enables family caregivers to stay home and care for their loved one, but the financial support is terminated if the patient is admitted to an institution. The extent of family caregivers’ sick leave in Norway is unknown (21).

According to Norway’s National Insurance Act, sick pay is only for those who are unable to work due to a disability that is clearly due to their own illness or injury. ‘Incapacity for work caused by social or financial problems’ is not grounds for sick pay (24, section 8-4).

Objective of the study

Overall, there is very little Norwegian research on partners’ experiences of caregiving for a spouse/cohabitant with cancer while continuing to work (21). The purpose of this study was to explore the experiences of surviving partners of cancer patients, with a particular focus on how it felt to be in a caregiving role while continuing to work.

Method

We employed a qualitative design in this study and conducted individual in-depth interviews using a semi-structured interview guide (Appendix 1 – in Norwegian). The article is part of a larger project at the Norwegian Institute of Public Health on how cancer affects families, called Cancer in Families (FAMCAN).

Recruitment, inclusion criteria and sample

The participants were recruited from the Norwegian Cancer Society’s user panel. In January 2024, the Norwegian Cancer Society distributed an electronic survey. Recipients who met the pre-specified inclusion criteria were asked to leave their contact information for the research team. 

The inclusion criteria were as follows: at the time of interview, participants must have had a partner who had recently died from cancer, participants were of working age and in employment. The Norwegian Cancer Society reviewed the responses and then forwarded the email addresses and phone numbers of 12 eligible participants to FAMCAN’s project manager. 

The information was shared with the first two authors, who then contacted the individuals to provide more details about the study and ask them to participate. One person chose not to participate, but the remaining 11 consented. The interviews were arranged over the phone.

Data collection

The participants were spread across a large geographic area in Norway in six different counties. Seven interviews were conducted remotely via Teams, two were by phone and two were held in person in February 2024. The conversations lasted between 30 and 60 minutes, and audio recordings were made. 

We used a semi-structured interview guide (Appendix 1 – in Norwegian), which was devised in a collaboration between the Norwegian Cancer Society, the Norwegian Institute of Public Health and OsloMet – Oslo Metropolitan University. The interview guide consisted of pre-defined questions and was structured based on the objective of the study, existing research and the researchers’ professional experience. FAMCAN’s users provided feedback on the interview guide.

The first two authors were present at all the interviews and alternated as moderators. This ensured that all topics were covered and that both could contribute with follow-up questions to gain a deeper understanding of the participants’ experiences. The subsequent discussion on the findings also contributed to reflection and intersubjectivity, meaning relative agreement on how the participants described their experiences.

Table 1 gives a brief description of the informants. The time from the partner’s death to the interview varied from about three months to three years. 

Data analysis

We employed Braun and Clarke’s six-step reflexive thematic analysis to analyse the data (25, 26). In the first step, the audio recordings were reviewed and manually transcribed by the first authors, giving a total of 110 pages. All transcriptions were read thoroughly by all the authors to familiarise themselves with the data. In the second step, we organised the data into codes (N = 23).

This led us to the third step in the analysis process: development of themes (Table 2). Codes that were similar to each other were grouped together. The themes were developed based on patterns in the data, such as similarities, differences, frequency and correspondence, but also based on the authors’ background understanding and experiences from the interviews.

In the fourth step, the themes and subthemes were redefined and discussed repeatedly in light of the codes from step two. Finally, the themes were defined and named (fifth step) and then presented in the results chapter (sixth step).

Ethical considerations

The project was reported to Sikt – Norwegian Agency for Shared Services in Education and Research (reference number 907772/24). It did not need to be reviewed by the Regional Committee for Medical and Health Research Ethics (REK) because we did not use information about third parties or health data. The study therefore fell outside the scope of the Health Research Act. We conducted a risk and vulnerability analysis (RVA). 

Audio recordings were stored in an encrypted format for 90 days using the data collection tool Nettskjema, and then deleted. We immediately de-identified the data and subsequently anonymised them in order to protect confidentiality and safeguard data protection. During transcription, participants’ dialects were transcribed into standard Norwegian (bokmål) to prevent the data from being recognisable. Ordinary personal information and anonymised transcriptions were stored with a key password in a dedicated project area in the Services for Sensitive Data (TSD) at the Norwegian Institute of Public Health. 

We initially provided written information about consent to participate in an information letter. We then repeated this orally before the interview. Participants were informed about their right to withdraw, according to the guidelines of the Declaration of Helsinki (27). Participants’ oral consent was thus given in the audio recording. 

To protect those who were potentially in a vulnerable situation, we chose to recruit participants whose partner had already died (retrospective perspective). Some of the questions were nevertheless distressing as the participants had to relive difficult situations to answer them. We made it clear that they could choose not to answer certain questions, and request a break or withdraw without consequence.

Results

Our main findings were that many participants experienced (1) work limitations due to having a seriously ill partner. However, several of them emphasised (2) the joy (and benefit) of continuing to work while (3) acting as a family caregiver. 

The interviews revealed that the majority found it challenging to work while in the caregiving role. They noted that workplace flexibility and accommodations were crucial for them being able to continue working while caring for and supporting their partner. Working was important because it gave the participants the opportunity to switch off and recharge. Figure 1 illustrates the main results and shows themes and subthemes from the analysis.

Reduced ability to work and difficulty prioritising

The majority of participants reported a reduced cognitive capacity, which led to limitations in their work capacity, including difficulty concentrating. They forgot things more often and felt more tired:

‘My memory isn’t what it used to be, I’m not as patient, I can’t concentrate, I’m a lot slower at things, it’s harder to get going.’

Many participants also found it challenging to set priorities. They had an internal struggle in the face of expectations, both at work and at home. The dynamics at home affected their ability to perform tasks at work, and vice versa, making the balancing act very difficult in some cases:

‘No, it wasn’t easy to balance things, to be really positive, encouraging and cheerful. I didn’t manage to balance it or keep my head above water.’

They found it challenging to combine work with caregiving tasks at home, both practically and mentally. Three participants expressed it as follows:

‘There aren’t enough hours in the day, and maybe you’re not the best version of yourself either. When you need more energy, more calm, and more understanding for your husband and children, you don’t have it.’

‘But I wasn’t sure how things were going at home when I was at work.’

‘I used to have everything under control, but that’s not always the case now.’

It became more difficult for participants to manage their duties at work and perform satisfactorily. This was often related to their partner’s health and the extent of their caregiving tasks. Many had to scale back their work commitments by working fewer hours, taking time off or taking sick leave. In the early stages of their partner’s illness, this particularly applied to participants in jobs with fixed working hours and few opportunities for flexibility. 

In the later stages, many more reduced their working hours. Some felt that the sick leave system worked well, while others expressed a desire for a different arrangement because they themselves were not actually ill:

‘I wish there was something that said, ‟If you are in this extreme situation, you could get something that is not sick leave”. Because I’m not sick, I wasn’t sick, but I wasn’t functioning well.’

Two participants had fixed working hours (see Table 1) and had to change their work situation. They faced financial challenges both during and after their partner’s illness. Several applied for a care allowance but found that the payments stopped once their partner was hospitalised. The system was perceived as rigid and inadequate for dealing with the unpredictable nature of illness: 

‘I think it’s a paradox, with the welfare state we live in, and such good systems for all sorts of things, I think the idea that you can do a good job at work when your partner is in hospital with incurable cancer, it’s just not possible. You should be able to be there with them.’

Psychosocial and financial benefits of continuing to work

Working was extremely valuable for the majority of our participants. At work, the family caregivers could be themselves for a short time. They could talk to colleagues about other things and take a break from their caregiving role and their partner’s illness. For some, physically being at work and receiving support from colleagues became important: 

‘I was able to switch off when I was at work, and I could sort of ‘forget’ about everyday life for a little while. It allowed me to regain some energy and strength. It was like I had recharged my batteries in a way.’ 

Another benefit of continuing to work during their partner’s illness was that their finances and income remained unchanged. This applied to a total of nine participants. 

Caring for partner while continuing to work 

Participants in more flexible jobs felt supported and received understanding from their employers. They were given a great deal of freedom and extensive accommodations were made, such as working from home more often or flexible working hours, with the ability to log on and off as needed: 

‘My employer [is] amazing. I could take time off and just let them know. And as [x] got worse, I was also granted leave to stay home.’ 

Many emphasised that workplace accommodations and flexibility made it possible to provide care at home while still carrying out some of their duties at work: 

‘Given the job I have, I could be at home a lot more than perhaps others whose partners have cancer.’

Discussion

This study examines the experiences of surviving partners of cancer patients. The study also explores their experiences of acting as a family caregiver while continuing to work.

Importance of workplace flexibility and the joy of working

Our findings show that employees’ ability to work is impaired when they have a sick partner. They feel it is more difficult to work effectively. Their mental capacity in particular is reduced, which aligns with previous research (7, 8, 14, 15). Several participants reported feeling tired and being torn between being a good partner and a productive employee, in line with the key findings of the Family Caregiver Survey (4). 

Participants with considerable workplace flexibility and/or accommodations were more likely to work almost normally, at least in the early stages of their partner’s illness. They reported being better able to manage their work tasks because they had the flexibility to choose when and where to complete them. This finding is consistent with previous research, which shows that flexibility increases the likelihood of family caregivers continuing to work (18, 19). 

Flexibility also helped several participants manage both their caregiving role and their responsibilities as employees. Many expressed that workplace flexibility meant they could be involved in the medical follow-up of their partner’s illness, such as attending doctor’s appointments, which was in line with other findings (20). 

This argument is further supported by the fact that participants without flexible workplaces had to reduce their working hours, take sick leave or take time off because they were unable to manage both home and work responsibilities. They were unsure whether sick leave was a good solution, as they were not necessarily the ones who were ill. Studies show that this type of sick leave is often based on a mental health diagnosis (28). 

It was also problematic for several participants who used up their sick leave when their partner was sick and were left without any when they became ill themselves after their partner died.

In line with previous findings (4, 17), participants valued having a job as it meant they could get a break. Previous research (17) also shows that the workplace can serve as a sanctuary for self-care, maintaining a social network and an opportunity to get some breathing space. Having some time away from their partner also enabled them to contribute more in their caregiving role. A previous study showed that family caregivers who did not work were more stressed than those who did work (18). This finding corresponds with the experiences of participants in our study who had little or no workplace flexibility and who reported a greater extent of physical and mental strains.

The finances of the majority of participants were unaffected. This finding does not fully align with previous research (1, 14–16). Our sample predominantly described having a flexible work situation (Tables 1 and 2). It is possible that those with less flexible work situations might have responded differently. Future research should consider prospective designs and registry data in order to include a representative sample of partners with flexible and less flexible jobs. 

Care tasks and perceptions of support

The health service should have guidelines for protecting and supporting family caregivers (23), but half of these caregivers spend considerable time performing and/or coordinating services (4). Family caregivers are entitled to help at home, such as technical aids, practical assistance or healthcare services in addition to respite care (29). 

We found that caregivers described the experience of spending time with their partner as invaluable as it brought them closer together. This is in line with previous research (6). However, many faced challenges when their partner had significant care needs. Participants described situations where they helped with tasks such as personal care, nursing and mobilisation. For some, it became difficult to leave the house because they had to stay with their partner.

Several participants called for more support and welfare schemes to manage the daily life of being both an employee and a family caregiver. Guidance from healthcare personnel can help prevent additional stress for caregivers (23, 30), such as on techniques for moving patients, nutritional advice, or emotional support (30–33). The latter is particularly important for nurses who interact with family caregivers (34), but many of our participants felt that the clinical nurses and cancer coordinators were often unavailable due to high workloads. 

We asked participants specifically about the care allowance scheme in the interviews. Participants had either heard about the scheme through an acquaintance or found information about it online, but it was often discovered too late, as was found in earlier studies (1). Participants who received the care allowance but had it revoked when their partner was hospitalised described this as very frustrating. 

Since sick pay is not primarily for caregivers, we did not ask participants about this directly. However, several participants had received sick pay. Whether the caregiving role was so demanding that it caused them to become ill themselves or if they simply found the sick pay scheme to be the most accessible option is not clear, and further investigation is needed.

Strengths and limitations of the study

The study included participants from the Norwegian Cancer Society’s user panel, representing various parts of Norway. A potential limitation of the study is that our participants may have been more affected by living with someone with cancer compared to other partners, as they had chosen to be members of the Norwegian Cancer Society and its user panel. 

It may also be a strength that the participants were likely to have been particularly interested and engaged, resulting in rich and contrasting descriptions. The interviewers’ lack of experience with data collection may have limited the number of follow-up questions, which could have resulted in more in-depth data. 

However, the first two authors had been trained in communicating with patients and their families. This may have had a reassuring effect during the interviews, which in turn encouraged the informants to share detailed descriptions of very personal experiences. 

We conducted the interviews digitally, via phone or in person. Without these flexible options, the recruitment of participants would have been a challenging process. In remote meetings, it can be difficult to establish a good rapport and it is harder to observe body language. In contrast, the distance may feel comfortable and safe for some participants. Allowing participants to choose the interview format, along with the relatively short duration of the interviews and the absence of travel costs, were all strengths. 

A retrospective perspective gives participants time to reflect on their experiences as a caregiver and what information and support they felt was lacking in this situation. One limitation is that the findings may not be completely reliable, as memories and emotions can change over time. The strength of the information was assessed throughout, with all authors involved in developing the themes through shared reflections, known as researcher triangulation. 

It is difficult to know whether saturation was achieved. In our study, we only had access to 11 participants, and all were interviewed. It is possible that we would have received different answers and/or drawn different conclusions if more participants had been available. We consider it a limitation that only two men were included in the sample and that most participants had highly flexible jobs.

Conclusion

Cancer affects many people and therefore has an impact on a significant number of family members. We found that while it is crucial for partners to provide care and support to their ill spouse/cohabitant, continuing to work can be a challenge. However, work provided a breathing space and respite from their everyday life at home. Those with less flexible jobs who took sick leave in the early stages of their partner’s illness had more difficulty finding a sanctuary and were under a greater strain. 

The experiences of partners of seriously ill cancer patients may also be relevant for family caregivers of individuals with other diseases. Several participants called for user-friendly support services and relevant support schemes for family caregivers. This feedback could be important for employers, clinicians, patient organisations and those responsible for shaping family caregiver policies.

Funding

This study received funding from the DAM Foundation and the Norwegian Cancer Society. 

Acknowledgments 

We extend our sincere thanks to the participants who shared their experiences with us. This article would not have been possible without you. 

Irma Taslidza and Gunhild Eide Myhre share first authorship.

The authors declare no conflicts of interest.

Open access CC BY 4.0

Introduction

The Nordic Institute for Studies in Innovation, Research, and Education (NIFU) has studied clinical placements in nursing education in Norway. They found that the quality of the placements is crucial for students achieving the learning outcomes of the study programme (1). 

Learning outcomes refer to what a person knows, can do and is able to accomplish as a result of a learning process. They are expressed in terms of knowledge, skills and general competence, and describe the qualification level students should have attained upon completing their education (2, 3). Clinical placements in the master’s programme in intensive care nursing are an important component in students’ competency development, accounting for 45 of the total 120 ECTS credits and covering a total of 30 weeks (4).

In the ‘Operation Clinical Placement 2018–2020’ project, Nokut investigated the quality of clinical placements in higher education within health studies during the period 2018–2020. The project revealed that clinical placements play a crucial role in helping students develop the competencies required for their future careers (5, 6). 

The project also showed that one of the ways that clinical placements differ from practical job training is the opportunity they provide for students to reflect on their clinical experience within a theoretical framework (7). However, the quality of clinical placements is often considered variable and inconsistent (5). 

Earlier research indicates that the quality of clinical placements can be linked to the structure of the content, the supervision that students receive and the cooperation between the university and the field of practice (2, 5, 8–10).

Academic supervisors and supervisors/coordinators in clinical practice emphasise the importance of a close cooperation between educational institutions and the field of practice. This cooperation is a key factor for improving the quality of clinical placements (11, 12). The field of practice aims to provide a welcoming environment for the students, but familiarity with the learning outcomes and content of study programmes varies (11). 

Meanwhile, educational institutions aim to work together on planning and developing the content of study programmes with a view to ensuring up-to-date and practice-oriented learning. Close cooperation in integrating theory with practice is considered an important factor for improving the quality of clinical placements (2, 5, 7–12). 

Universities Norway suggests that ‘new clinical placement models be developed, tested, evaluated and exchanged in an equal partnership between educational institutions and the field of practice’ (2, p. 6). Collaborative projects like this can bridge the gap between the field of practice and universities and help improve clinical placements for students (9). 

New clinical placement models have been tested in the bachelor’s programme in nursing (13, 14) and in mental health care (15). However, we have not identified any studies evaluating new models for clinical placements in the master’s programme in intensive care nursing.

In cooperation with the Cardiac Intensive Care Unit (CICU) at Oslo University Hospital (OUS), the master’s programme in intensive care nursing at OsloMet developed a clinical placement model aimed at improving the structure of the clinical placement content, strengthening student supervision and promoting closer cooperation between the university and clinical practice (16). 

Objective of the study

The objective of the study was to evaluate a clinical placement model for students in a master’s programme in intensive care nursing. The research question was: ‘What are students’ experiences with a structured competency development programme for clinical placements?’

Method

The clinical placement model included a competency development programme for patient care in acute cardiovascular conditions and is intended solely for the clinical placements at CICU. To ensure that students achieved the desired learning outcomes in the clinical placement (Table 1), and to create variation in the learning process, the project group employed various didactic methods: 

• E-learning with a combination of interactive information pages and short video clips, where the third author provided instruction on topics in a relevant hospital setting.
• Reflection groups led by the first and second authors, with a review of a patient case in which students applied relevant research and experiential knowledge.
• Structured training in cardiac rhythm analysis, including practice in analysing various heart arrhythmias.
• One-on-one supervision in patient situations with a supervisor.

The purpose of the various methods was to foster motivation, engagement, practical application, variation, individualisation and cooperation (Table 2 and Figure 1). 

The programme was implemented in the department in February 2020. The project group that developed the programme consisted of all three authors. At the time, the first and last authors held the roles of student coordinator and clinical nurse specialist at CICU, respectively, and represented the clinical placement department. The second author represented OsloMet in the project. 

Design and method

We aimed to capture the students’ individual experiences with the competency development programme. We therefore chose a qualitative design method with semi-structured in-depth interviews, and reported the findings in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) (17). 

Interviews

We used an interview guide with open-ended questions based on the learning outcomes of the study programme. The guide was developed from the study programme description and the national curriculum for intensive care nursing (Table 1) (18, 19). 

The last author conducted the interviews alone in the spring and autumn of 2020 and the spring of 2021. Unlike the first and second authors, who were part of the students’ supervision team, he had no close relationship with the students in clinical placement.

The interviews were held at the hospital immediately after the students had completed their clinical placements and received the result of their assessment. The interviews lasted between 30 and 60 minutes. Audio recordings were made but no field notes were taken.

Sample

The study participants were students in the master’s programme in intensive care nursing. They carried out clinical placements at CICU during the project period, from February 2020 to March 2021. The students spent between five and seven weeks in the department. Students in the master’s programme in intensive care nursing are registered nurses with at least two years of clinical experience in the somatic specialist health service. 

During the project period, 14 students completed the competency development programme. Thirteen of these agreed to participate in the study and were subsequently interviewed. 

Analysis

The interview recordings were transcribed verbatim. The first and second authors analysed the interview transcripts using Braun and Clarke’s reflexive thematic analysis of qualitative data (20). 

The analysis process is not linear and involves moving back and forth between the various phases of analysis: 1) Familiarisation with the data, 2) Generating initial codes, 3) Identifying themes, 4) Reviewing themes, 5) Defining and naming themes, and 6) Reporting the findings (Table 3).

Ethics

The study was defined as part of a quality improvement initiative at OUS. Sikt – Norwegian Agency for Shared Services in Education and Research did not therefore need to be notified, but it was reported to the hospital trust’s data protection officer. The data protection officer at OUS recommended approval of the study (reference number 20/02076). 

Participants were informed about the study on their first day of clinical placement. The interviewer repeated this information before the interview started. The students provided voluntary and informed written consent. They were informed that they could withdraw from the study at any time without giving a reason and that all data collected would be de-identified. 

Results

We identified five main themes in the analysis:

1. Students felt prioritised
2. Students gained an overview of the department’s activities
3. Students found there to be structure and continuity in the supervision
4. Students felt self-assured
5. Students found that their competencies and preparedness to respond effectively improved

Students felt prioritised

The students noted that the department seemed well-prepared to receive them and that their assigned supervisors were familiar with the learning outcomes of the study programme. They felt that learning situations were specially facilitated for them, whereby they were allowed to participate in relevant patient cases: 

‘The entire setup was notable – in a good way. I quickly got the impression that the department had prepared for our arrival. It stood out from other departments I’ve been in, also in my bachelor studies.’ (Student 1)

Students gained an overview of the department’s activities

CICU is a specialised department with several types of patient categories, where patients’ needs for monitoring and treatment vary. It can take time for students to familiarise themselves with the department’s core activities and understand what kind of patient care is needed. 

The students felt that the content of the competency development programme helped clarify the department’s core activities. They were able to use e-learning before the clinical placement started. This gave them a good insight into the patient population and the relevant care needed for patients with an ST elevation myocardial infarction (STEMI) and acute heart failure: 

‘We should use e-learning before we arrive […] I’ve done it twice, but I think it’s a good idea to do it first to understand the entire workflow in the department and the treatment.’ (Student 2)

In the reflection groups, they also described the supervision as important to understanding the treatment chain and what patient care is needed. After the group supervision, the students felt it was easier to understand and contribute to patient care: 

‘The group supervision on STEMI was great because we’d been in clinical practice and seen patients. When we had the group supervision we could ask questions about the treatment we’d seen and experienced in practice. It was good to see if we had understood it correctly.’ (Student 3)

Students found there to be structure and continuity in the supervision

Several students emphasised that the competency development programme had a positive effect on the structure and continuity of the supervision. Knowing what to focus on and thus having the opportunity to make the necessary preparations helped them achieve the learning outcomes of the study programme. They also felt that the competency development programme facilitated a more coherent approach to clinical practice. Furthermore, the students found that the content of the competency development programme was varied and educational, with different didactic methods being used: 

‘The way it is structured ensures that you get through your learning objectives. In earlier clinical placements, I’ve found that you can set as many goals as you want but end up with completely different patients, and things quickly become very fragmented.’ (Student 4)

Because of the defined content in the programme, students found that the clinical supervisors were able to ensure continuity in the content and taxonomy of supervision: 

‘The programme makes it easier for clinical supervisors to help me experience the things I should, and not just be assigned tasks like personal care or things I already know. I don’t have to fight to create learning situations that I need. The supervisor is more aware of what learning situations I need.’ (Student 2) 

E-learning enabled students to refresh their knowledge throughout their clinical placement: 

‘The videos were really educational. You could watch them repeatedly. The content in the videos was very clear. Very well explained. It helps when you watch them again, a hundred times, then it sticks.’ (Student 5) 

In terms of other structural factors, students characterised the cooperation between the department and the university as positive: 

‘It’s great that the university and clinical practice cooperate on the organisation of clinical placements and what we need to do.’ (Student 8)

Students felt self-assured

They pointed out the importance of feeling self-assured during clinical placement in order to actively participate in providing patient care. Factors that fostered self-assurance included the following:

• The department was prepared and welcoming.
• E-learning enabled students to prepare themselves.
• The content of the clinical placement was clearly defined and organised. 

Student 1 noted the following: ‘For me as a student, it was very reassuring that you had set up a plan for us. How we would systematically go through things, like STEMI and cardiogenic shock.’

Student 6 expressed the following: ‘After going through the patient case for acute coronary disease in group supervision, I felt more self-assured in the PCI [percutaneous coronary intervention] lab. I felt braver about getting involved.’

Students found that their competencies and preparedness to respond effectively improved

The students felt that their competencies improved through, for example, acquiring knowledge and skills in patient care for STEMI and acute heart failure. They felt that the content of the competency development programme helped them form a comprehensive understanding of the patient’s problems and needs. E-learning provided them with an overview of the knowledge and skills the department expected them to acquire. 

Through group supervision, they gained a deeper understanding and had the opportunity to reflect on their own experiences in patient situations: 

‘I remember sitting at the end of the day thinking how much I had learned about seeing the whole picture. Recognising the patient’s basic needs. I had to reflect on what might complicate the situation. The learning was more in-depth.’ (Student 1)

The patient’s condition, such as in the case of STEMI for example, can change suddenly. In the interviews, it emerged that the competency development programme helped to highlight the complications that could arise when treating patients. This made the students feel that they were prepared to respond effectively and carry out the recommended interventions:

‘You’re aware of all the complications of the treatment being given in general, so I became even more aware of what could go wrong. I really like having an overview of that, because then it’s much easier to prepare yourself for it, what you’re thinking, what equipment to bring with you.’ (Student 6)

Discussion

The results show that the students had positive experiences with the competency development programme. They felt that the structured content in the clinical placement, continuity in supervision and close cooperation between the university and clinical practice helped them achieve the learning outcomes. 

Structure

The structure of clinical placements impacts on quality (2, 5, 8–10). Structure refers to how the various elements of clinical placements are integrated into a cohesive whole and how this whole is organised. 

The competency development programme helped students gain a comprehensive understanding of the care needed for patients with acute and/or critical coronary disease. The students thus felt they achieved the learning outcomes of the study programme. According to Norway’s Ministry of Education and Research, clinical placements should facilitate the achievement of study programmes’ learning outcomes (10). 

Research shows differing opinions on the effect of e-learning in developing competencies (21–23). However, the students in this study found e-learning useful as it served as a knowledge resource that could be accessed throughout their clinical placement. 

Self-assurance promotes learning, including in clinical placement. Self-assurance in clinical placement stems from being acknowledged and supported, and having a well-organised structure, mutual expectations and predictability. Predictability is linked to clarity and structure. Students who are self-assured are more willing to take an active role in their learning and therefore make better use of their resources and work more consciously toward their learning outcomes (24). 

According to the students in the study, the structure and systematic approach of the competency development programme was reassuring. The fact that the department was prepared and welcoming also contributed to this experience. The structured organisation of the clinical placements made them feel prepared, enabling them to take an active part in patient care. 

Supervision

The quality of supervision that students receive affects the overall quality of their clinical placement (1, 2, 5, 8–10). To achieve the learning outcomes of their study programme, students need competent supervisors. The clinical supervisors assigned to students play a crucial role in their learning process. 

The students found that the competency development programme helped familiarise their clinical supervisors with the study programme’s learning outcomes. As a result, learning situations were arranged and adapted according to the students’ needs. The students experienced structure and continuity in their supervision. 

The opportunity to reflect on patient situations that students have encountered is important for ensuring that clinical placements serve as educational experiences rather than just practical job training (7, 9, 25). However, finding time for reflection during patient care is not always possible. The physical and mental condition of patients with an acute and/or critical illness may limit this opportunity. 

Groups of three to four students were taken out of the department for two full days of group supervision. The students in the study reported that these supervision sessions provided a space for reflection, allowing them to connect theory with practice. They worked through patient cases with their academic and clinical supervisors, which helped confirm their understanding of what they had learned and highlight any knowledge gaps.

Reflection groups with few students, led by an academic supervisor and/or clinical supervisor, can provide a space for students to engage in professional reflection during their clinical placement. This form of supervision can motivate students and help them connect theory with practice (9, 25). 

Allocating time for reflection may mean that students experience fewer patient situations, but none of the study participants raised concerns about this.

Cooperation between educational institutions and the field of practice

The interviews revealed that the students viewed the cooperation between the university and clinical practice in a positive light. According to Hatlevik and Havnes, students perceive their studies to be of a higher quality when there is a clear connection between what they are taught at university and what happens in clinical practice (26). 

Hatlevik asserts that this connection is crucial for students achieving the learning outcomes of their study programme and ensuring continuity and quality in their education (27). He also claims that a connection between theory and practice can be established by explaining how theoretical knowledge informs various aspects of professional practice (27). 

Group supervision in the competency development programme is an example of this. In the group supervision, challenges from clinical practice were discussed in light of theory with professionals from both the university and clinical practice. The students reported that the group supervision helped them gain a more comprehensive understanding of the patient’s situation and the care they needed. This gave them the confidence to become actively involved in patient situations.

Clinical supervisors are calling for closer cooperation with educational institutions. Dialogue about the curriculum, learning outcomes and other framework conditions helps create a more comprehensive understanding for students, better preparing them for the professional challenges they will face in clinical practice (2, 28). 

The cooperation between the university and clinical practice helped ensure that students perceived their clinical supervisors as well-prepared, with a good understanding of the learning outcomes for the clinical placement, thereby fostering students’ competency development. 

Strengths and weaknesses of the study

The study has a number of strengths:

1. We interviewed students in three different cohorts of the competency development programme over a period of 13 months.
2. The participants were interviewed immediately after completing their clinical placement, when the competency development programme was still fresh in their minds. This may have reduced the risk of bias.
3. The interviewer was well acquainted with the study programme’s content and learning outcomes for the clinical placement, as well as the field of study and the content of the competency development programme.

None of the students reported having negative experiences in relation to the competency development programme. However, the study has several potential weaknesses that may have unintentionally contributed to more favourable findings: 

1. The study participants were students, which may have created an imbalanced power dynamic between the researchers and the participants. The project group consisted of representatives from the university and clinical practice, which are the entities responsible for assessing whether the students have passed their clinical placement. We therefore conducted the interviews after the students had completed their clinical placement and been informed of the result of their assessment. The interviewer was not involved in the student assessments. However, we cannot rule out the possibility that the students felt under pressure to be positive.
2. The interviewer played a central role in the e-learning videos. This may have made it difficult for the students to criticise that part of the competency development programme. Otherwise, the interviewer had no other relationship with the students during their clinical placements.
3. We developed and implemented the competency development programme and then researched our own field. We cannot rule out the possibility that our preunderstanding may have influenced the results.
4. The COVID-19 pandemic started shortly after the competency development programme was implemented. This led to some minor changes in the programme, such as one of the reflection groups being held remotely instead of in person. The interviews were held in person at the hospital, as planned. We cannot rule out the possibility that the pandemic may have impacted on the results.

Conclusion

The study shows that the students felt the clinical placement model helped them achieve the learning outcomes of the study programme. The structure and content of the competency development programme fostered self-assurance in the students and continuity in the supervision, and integrated theory and practice through the cooperation between the university and clinical practice. 

A structured programme for clinical placements can help students view the placements as meaningful and as a suitable setting for achieving the learning outcomes of their study programme. We believe the results may be transferable to undergraduate, graduate and postgraduate nursing students.

Funding

The clinical placement model was developed with the help of partner funding from Oslomet. 

During the study, the first and last authors held the roles of student coordinator and clinical nurse specialist at CICU, respectively, and represented the clinical placement department. 

The authors declare no conflicts of interest.

Open access CC BY 4.0

Introduction

The percentage of older people in society is growing and in turn, the number of people with complex health needs will increase (1). Local authorities have assumed several tasks that were previously assigned to hospitals. In the primary health care service, the out-of-hours emergency service (OOH service) is the first stage of the chain of emergency care. The EMCC call handlers have direct contact with patients and their families who ring the OOH service, and they have an advisory function for other actors in the primary health care service (2). 

Calls to the OOH service about older patients are often characterised by the patients having general, unspecific symptoms, and it is sometimes difficult to determine their cause (3).

EMCC operators who handle emergency calls must map and assess the patient’s medical situation, decide the level of urgency, initiate action and give guidance and medical advice (2). The operators must have relevant professional medical training at a bachelor’s degree level, additional training as an operator and relevant clinical practice (4). 

However, there are no guidelines on what constitutes relevant clinical practice or its duration. Normally registered nurses (RNs) act as EMCC operators and answer emergency calls. Consequently, they are the first to assess the situation (5). 

EMCC operators have a heavy responsibility. Their decisions can impact patient treatment and safety as well as decide the outcome for the patient (6). A review study shows that decision-making in time-critical situations is a complex process in which many different factors must be evaluated (7). 

In a short period of time, the nurse must systematically map the patient’s situation and obtain relevant information in order to make a correct and confident decision (2). The target set in the regulation on emergency medical services is that all calls should be answered within two minutes (4). 

The quality of information obtained by the nurse depends on good communicative abilities (2). It also depends on the nurse being concentrated and attentive (8). Insufficient information can threaten patient safety (9). The caller’s ability to communicate is also important. Shim (10) demonstrates that health competence, attitudes and behaviour all affect the outcome. 

In addition to assessing the actual situation, nurses must also reach a consensus with the caller about the right level of health care, and act as a gate-keeper for the health services (11). During the conversation, the nurse has no opportunity to make a clinical assessment based on visual cues. Consequently, the task becomes more challenging and requires the nurse to have extensive medical knowledge to be able to identify the patient’s needs. In order to safeguard patient safety, greater attention must be paid to these decision processes (12).

Several decision support tools have been developed with the aim of ensuring that patients are triaged consistently. In Norway, the most frequently used tools are the Norwegian Index for Emergency Medical Assistance, the decision support tool for telephone triage (legevaktindeks) and the Manchester triage system (2). 

However, as there is no requirement that these tools should be used, the practice varies. Studies report that the decision support tool is not always seen as a support because the patient’s problem may be reduced to symptoms (13, 14). Thus it can be difficult to obtain a comprehensive view of the patient’s problems (14). In these studies, nurses related that diffuse and complex issues required most knowledge, while such conversations also took most time and led to greatest insecurity (13, 14). 

Hansen and Hunskaar (15) found in their study that nurses felt it was easier to assess the most urgent cases because in less urgent cases, the patient’s symptoms could appear vague. Earlier studies have also shown that assessing diffuse symptoms correctly requires both expertise and time (11). Moreover, this entails complex decision processes (16–18) that demand both knowledge and experience. 

Decision support tools may be perceived as inadequate. A Norwegian cross-sectional study by Haraldseide et al. (3) discussed older people’s contact with the OOH service. They pointed out that the decision support tool should incorporate the characteristics of geriatric illnesses better, and that the emergency nurses should have more training in interpreting older people’s symptoms (3).

The objective of the study

As mentioned above, earlier research shows that assessing patients on the telephone is a complex task, especially when the symptom profile is diffuse. At the same time, there is little research describing how EMCC nurses experience having to assess these patients and make decisions over the telephone. 

Such knowledge can provide a solid foundation for quality-enhancing measures that will increase patient safety. The objective of this study, therefore, was to examine nurses’ experiences of assessing patients at the EMCC.

Method

Design

The study had an explorative, descriptive design. We used individual interviews as a data collection method, as this method is suited to performing in-depth investigations of people’s experiences (19). The article adheres to the Consolidated criteria for reporting qualitative research (COREQ) checklist for qualitative studies (20).

Recruitment and sample

The participants were recruited from two EMCCs in Eastern Norway and two in Northern Norway. Heads of section in the four local authorities identified possible informants on the basis of the inclusion criteria: nurse with at least two years’ experience at the EMCC and a minimum FTE of 50 per cent. This gave a strategic sample of participants who could provide new insights and wider understanding of the topic, illuminating the study (21).

Twelve nurses were interested in participating. They received written and oral information about the study, and all of them consented to participate. The sample consisted of eleven women and one man between the ages of 24 and 70. To preserve anonymity, all the informants are registered as women in Table 1, which provides demographic information.

Data collection 

The first and second authors carried out six interviews each during February 2023. Both authors are female master’s degree students with limited research experience but with broad experience from the OOH service. The interviews lasted approximately 45 minutes, and were conducted in a suitable room at the informants’ workplace. The interviewer took notes during the process. The interviews were recorded using an audio-recorder, and then transcribed. 

We used a thematic interview guide in all the interviews. The guide was devised by all the authors based on the objective of the study, previous research and their own experiences. It consisted of five main topics with twenty questions. 

The main topics were as follows: ‘Motivation for starting as a call handler’, ‘Induction training and positive aspects of the work’, ‘Daily work tasks’, ‘Experiences associated with triage’, ‘Experiences linked to the use of aids’, and ‘Challenges or wishes for change’. 

The first author tested the interview guide in a pilot interview. We then evaluated and adjusted it in line with what worked or did not work in the interview situation. Both interviewers were keen to have a natural conversation with the informants. As a result, we could ask questions in a different order and be open to other topics that the informants regarded as important and that were relevant to the study’s research question.

In the course of the interviews, topics emerged that we wanted to explore further. These were shared with the other interviewer and included in the interview guide. 

Data analysis

We analysed the data by using reflexive thematic analysis as described by Braun and Clarke (21). Reflexive thematic analysis entails that the researcher acknowledges their own prior understanding and reflects underway on how their own experiences may impact on the analysis (21). The analytic method consists of six steps. Table 2 shows what we did at each step of the process and which of the authors was involved.

Table 3 shows examples of the analysis process – from transcribed text to theme and sub-theme.

Ethical considerations

The study was reported to the Norwegian Agency for Shared Services in Education and Research (Sikt), reference number 925316. The heads of section at the different EMCCs gave us permission to carry out the study. 

Prior to the interviews, we obtained written informed consent from the informants, and informed them that participation was voluntary and that they were free to withdraw from the study at any point. The informants were reminded that they should not share confidential information. 

All personally identifiable information was anonymised in the transcription and audio recordings were deleted after the transcription. The collected data were stored in accordance with the guidelines of the institution responsible for the data, i.e. Lovisenberg diaconal college. 

Results

In the analysis process, we identified two overarching themes that describe the nurses’ experiences of assessing patients at the EMCC (Table 4). The themes are explored further in this chapter.

Feeling insecure when alone with such a heavy responsibility 

Insecurity linked to their own assessments and fear of making mistakes

The informants in the study said that being an EMCC operator was a varied and exciting experience. However, all of them described having felt insecure when they were alone with certain assessments. Assessing questions about complex health problems felt frightening because they were afraid they had insufficient knowledge and might make mistakes. 

One informant described what it had been like to be a novice operator: ‘I was always scared that I’d made a mistake, misunderstood the patient, or that I didn’t know enough about what they were calling about.’ (Informant 1) 

Informants 2, 4 and 11 pointed out the need for more training and follow-up. They called into question the low requirements that were set and whether the limited call handler training they received was professionally sound: ‘I often think about the heavy responsibility we have. We’re kind of supposed to know about all kinds of patients, diagnoses and symptoms after five days training, I don’t understand how it can be lawful.’ (Informant 1) 

The insecurity they felt meant that several of them chose to refer the patient for a consultation at the OOH service, so as to avoid being alone with the responsibility: ‘I always have to think about watching my back when assessing whether patients should be called in to the OOH service so as to be in the clear.’ (Informant 4)

Meanwhile several informants felt under pressure not to refer too many patients, and believed that they played an important role as gatekeepers to the emergency service. 

Their work at the EMCC was also described as unpredictable. It was impossible to be prepared for the telephone conversations in advance: ‘You never know who’s going to call, you can never prepare yourself.’ (Informant 6)

The informants had to be ready to assess patients of all ages with different types of symptoms. Based on the insecurity and unpredictability of the work, half of the informants said that they wanted to have supervision and support in their clinical assessments: ‘I feel more confident when I don’t have to make the assessment on my own, when I can check with others at work. Have I made the correct decision? There should be regular supervision, in my opinion.’ (Informant 3)

Even though they could consult colleagues, there was no formal supervision, and the informants felt alone with the responsibility. ‘You’re so alone, you’re the only person to hear what they’re saying. You’re the one who has to make the decisions initially.’ (Informant 7)

All informants described a fear or concern related to making errors because of the heavy responsibility they had for the life and health of individual patients: ‘I’m not confident about having this big responsibility alone, and it’s strange that there’s no greater focus on this.’ (Informant 2)

The fear of making mistakes also applied to the personal burden they had to bear if they make a wrong assessment: ‘I think if I make a wrong assessment, it’s my personal responsibility. That’s also a burden.’ (Informant 8) 

For this reason, several informants said that they needed to be exempted from responsibility: ‘It also gives a sense of security to know that I’m more in the clear if I’ve followed the triage system, because I’m aware of the huge responsibility we have.’ (Informant 1) 

The informants described how this fear of making mistakes could last over time because they were never told whether their assessments were correct. As a rule, patients continued on the health service pathway without the OOH service being informed of what had happened afterwards. Therefore their ability to evaluate their own work was limited. 

Professionally challenging to assess patients over the telephone

Communicating with the caller – a challenging piece of detective work 

Although all the informants said it was professionally exciting to work at the EMCC, they also found it challenging: ‘I like the range and breadth you find at the EMCC with patients from 0 to 100 years old. It’s difficult but rewarding to be on the phone doing the assessments.’ (Informant 2)

All the informants described the level of urgency as the most important factor in the conversations. They found it challenging to assess patients over the telephone because they could neither see them nor examine them physically. In addition, they usually had no access to other information about the patient than what was given during the conversation. 

Consequently, a difficult and important part of the job was to ask the right questions in order to form the most accurate picture of the patient: ‘You should have a lot of experience before you man the EMCC phones, it’s a great disadvantage not being able to see the patient, not being able to examine them physically or get a complete picture of the patient and their situation, so experience is absolutely essential.’ (Informant 4) 

The informants described the telephone calls as a demanding piece of detective work. They explained that they usually had to sort the information they obtained from the conversations to find out what the patient needed: ‘You have twenty calls describing absolutely classical influenza symptoms, so how do you manage to pick out the one where sepsis is involved?’ It’s difficult. Terribly difficult. Beyond difficult. No one presents things in the same way.’ (Informant 8) 

Several of the informants said that they had to have good clinical competence to be able to judge from the conversation whether the matter was urgent or not. As well as listening to what was said, they also listened to the voice and breathing: ‘You hear from the voice register – is the patient calm or stressed? Are they able to use full sentences? It’s difficult to put everything into words really. Because you probably get more of a general picture.’ (Informant 12)

The informants put emphasis on calming the caller to gain their trust and create a safe frame round the conversation: ‘You must create a verbal relationship to promote rich communication that builds trust. Set limits so that you get the information, quickly. Clear, authoritative and confident.’(Informant 3)

Meanwhile several informants said it could be challenging to work out what the patient needed. It might be difficult to understand each other, with different mother tongues and different ways of expressing themselves. Some conversations could also affect the informants emotionally, especially when the caller was angry or frightened. It became challenging to avoid provoking them while at the same time asking more questions. 

Such conversations were challenging, and you needed to summon up your courage to deal with them: ‘You must have experience, remain calm and be brave enough to stand your ground. It’s difficult. The only way to deal with this is to have competence and knowledge. Give them solid professional reasons for your assessment.’ (Informant 10) 

Complex assessments – the need for competence and experience

All the informants stated that patients with diffuse and clinically complex symptoms were especially difficult to assess. The general clinical view of the patient is the deciding factor, and it is thus important to obtain background information. The available decision support tools were a vital supplement in the assessments, acting both as a reminder and an assurance of quality. 

However, some informants expressed the view that the use of the tools alone was not enough to ensure good assessments of patients with complex health problems: ‘The index alone is not enough, I have to use everything I’ve got – all my experience and training.’ (Informant 6) 

The tools did not capture the complexity of the case, and the assessments therefore might be incorrect: ‘I have found the triage support tool useful, but it resulted in an awful lot of people being called in urgently to the OOH service, and we really don’t have the resources for that in the health service.’ (Informant 5) 

Consequently, all the informants pointed out that good assessments of these patients depend on the operator having broad knowledge and a high degree of competence. Although it was challenging and demanding, it was also professionally rewarding to assess patients with so many different health issues. 

To deal with all these calls, several informants believed that you needed personal qualities such as confidence in your own role, good local knowledge and the ability to trust your own gut feeling.

Moreover, some believed that they needed qualities such as patience, humility and openness: ‘You must have patience, you must be able to understand why you maybe get a telling-off – because that can happen. You must understand people’s reaction processes. Fear or grief can cause that kind of reaction, for example.’ (Informant 9)

Discussion

In this study, we examined nurses’ experiences of assessing patients at the EMCC, which they found challenging and made them feel insecure. The nurses said that they were frightened of making mistakes. This was linked to their fear that their understanding of the situation was inadequate, and they misinterpreted it. 

Difficulties in understanding the situation may be associated with various obstacles in the communication between the caller and the nurse, such as vague descriptions of symptoms and language-related challenges (22). Earlier studies have pointed out that the fear of making mistakes can result in the overuse of limited health resources (23, 24), which this study also indicates. 

There is a growing need for health services. Meanwhile, there is already a shortage of resources (11), and it is therefore important to avoid unnecessary use of the health services. By implementing measures to increase the EMCC nurses’ confidence, it may be possible to reduce unnecessary use of the OOH service. 

A 2023 study (25) points out that over-triaging may affect the workflow at the OOH service in a negative way. It may result in more concurrency conflicts and challenges in prioritising between calls with the same level of urgency, which in turn can be stressful for the health personnel (25). 

The danger of under-triaging is that the patient does not receive the necessary health care at the right time. If necessary treatment is delayed, this may have fatal consequences (26). This risk becomes particularly evident when communication is by telephone. 

Sole responsibility led to insecurity

Our study also found that nurses were insecure when it came to having sole responsibility for asking the necessary questions, identifying health needs and making correct assessments of the patient. This responsibility is seen as a significant challenge. The informants described challenging conversations, uncertainty about whether they had understood the caller and assessed the situation correctly, and well as time pressure at the EMCC. 

This can be compared with a Norwegian study that investigated how new doctors experienced the clinical assessment of patients. The study described how newly qualified doctors in particular felt discomfort and uncertainty about whether they had made the correct assessments, a feeling echoed by a number of experienced doctors. This feeling of insecurity affected them both physically and mentally (27). 

Another study exploring nurses’ experiences of dealing with challenging telephone conversations at the EMCC found that such conversations could create anxiety and emotional reactions in nurses even long after the conversation ended (22). 

Support from colleagues and evaluation are important after challenging conversations

A Swedish study from the emergency medical service (24) emphasises that emotional support is important after challenging conversations. The informants in our study mentioned the importance of support from colleagues and expressed a wish for closer cooperation and supervision. 

Earlier studies (22, 23) support the finding that the individual can derive benefit from reflection, discussions and feedback from colleagues after challenging conversations. Receiving confirmation that your thinking is correct can make nurses feel more confident in their work (28). 

The informants in our study would also like their call handing to be evaluated so that they could feel more confident about their own assessments. Such confirmation could help them process and learn from the situation they have experienced (23). 

Due to strict personal data legislation in Norway, it is difficult for the OOH service to find out about patient outcomes. Consequently, we must find other ways of giving the nurses feedback, for example through the supervision of their colleagues. 

Different tools and measures help the nurses 

A Norwegian study examining the quality of EMCC triage assessments pointed out that it would be a learning experience if the same nurse that took the call, was to meet the patient on arrival at the OOH service centre (15). This quality improvement measure could be trialled at several OOH services. 

The nurses in this study said it was difficult to assess patients’ health needs when they were unable to see them. Earlier research has shown that nurses form a mental picture of the patient and that they use this picture as well as their clinical knowledge and decision support tools to map the situation during the telephone conversation (29). 

We also found that the nurses felt it was challenging to assess diffuse symptoms. Moreover, the support tools did not always provide an answer since they require a clear symptom and are not adapted to complex health conditions. 

The strengths and weaknesses of the study

The first and second authors have experience as EMCC nurses. Research in one’s own field can be challenging as it easy to be blind to experiences other than one’s own. Consequently, we made active choices during the entire process from the formulation of the questions in the interview guide to the selection of themes and codes. We acknowledge that our experience and prior knowledge of the EMCC directly impacts on the data when we use this method (30). 

The researchers’ prior understanding will affect the questions and their interpretation. The interviews were carried out by two different people with different attitudes and prior understandings. This may produce dissimilar results. We have taken active measures to avoid excessive bias, for example by sharing our perceptions after each interview. 

The last author, who had no experience from the EMCC, asked critical questions and participated actively in the planning of the study, the analysis process and the presentation of the results. 

Another weakness may be that the heads of section identified potential informants for the study. They may have chosen informants who they felt were particularly interested or who would present their workplace in the best possible manner. Meanwhile, the results show that most participants also pointed out work-related challenges. This indicates that the sample did not influence the results of the study in any particular direction. 

Conclusion

The findings in this study show that nurse may find it professionally challenging and personally demanding to make assessments at the EMCC. The informants had a feeling of insecurity at work. They were frightened of making mistakes and shouldering the responsibility alone, and they described a need for structured training and supervision. 

The study sheds light on the human aspects of working at the EMCC. The findings may indicate that nurses have a need for support and cooperation in relation to the assessments they make at the EMCC. This indicates a need to facilitate support and supervision from colleagues to enable them to handle challenging conversations better and evaluate assessments, giving them more confidence in their own assessments. 

Acknowledgements

The authors want to thank all the twelve nurses who were willing to share their unique experiences of working at an emergency medical communication centre. The first and second authors also wish to thank Elisabeth Østensen for her patient, thoughtful supervision of two practitioners on their academic journey. We couldn’t have done it without you! 

The authors declare no conflicts of interest.

Open access CC BY 4.0

Introduction 

The nurse has a unique role and pivotal function in helping the patient to deal with and master different transitions, and preventing the negative impacts a transition may have on health and illness (1–3). A transition may have negative, health-related consequences, but care measures can improve the quality of transitions and thus influence the outcome (1, 2, 4–8).

The patient’s condition, nursing-related factors and organisational aspects are some of the elements that affect the outcome of transitions for patients with cancer (8). 

Patients with terminal cancer are in continuous state of transition due to a rapidly progressing disease and bodily changes (9). This means that these patients may need palliative care, nursing and treatment from both the primary and specialist health services (10). 

They risk being moved to different places, with another group of health personnel assuming responsibility for their treatment and care (9). Such a transition may make patients and their families feel insecure. Therefore not only do they need information and practical support but also to be involved in the planning of the transition (8, 11–13).

Ensuring the quality of patient transitions is a familiar and long-standing challenge (14). The goal has been to achieve seamless patient transitions between the primary and specialist health services. Although various national measures have been implemented to ensure their quality, adverse events nevertheless still occur (14, 15). 

The ‘Cancer patient pathway’ was intended to be implemented in the different health services by the end of 2023. The purpose is to give the patient reassurance and predictability. The intervention includes three joint meetings with conversations about the patient’s life situation over and beyond the cancer treatment. Moreover, the patient must receive follow-up after being informed of the cancer diagnosis. The first conversation is initiated by the health trust while the second and third conversations are initiated by the primary health service (16–18). 

Research emphasises the importance of collaboration between nurses and other health personnel at different levels of the health service (7). Close collaboration between nurses, patients and their family is important in creating trust and reassurance in the home setting (19). When the hospital fails to provide sufficient information about the prognosis or treatment targets, it is challenging to take over the care of the patient (20). Differing views about what information should be emphasised in the exchange between community nurses and specialist health care nurses may make cooperation difficult (21, 22).

If there is little time for planning, dialogue and interaction, the danger of adverse events increases (19, 21–23). Inadequate planning of the discharge entails additional work afterwards (21, 22, 24). Research shows that interventions can improve patient safety, but this does not necessarily mean that they will make the patient more satisfied (25). We need more knowledge about the care of patients with cancer at the transition stage as this may lead to more satisfied patients and prevent re-admissions to hospital (8). 

Transitions are described as ‘a passage from one life phase, condition or status to another’ (2, p. 25). Afaf Meleis’ transitions theory can make nurses more aware of what promotes good patient transitions (7). The main focus of the theory is to promote well-being and coping strategies by identifying critical points or risk areas during the transition. In this way, we can avoid deterioration in the condition of those undergoing a transition, and give their families greater understanding of what a transition entails (4). 

Meleis describes different types of transition, such as developmental, health-related, organisational and situational (5, 26). Discharge from a hospital can be regarded as a transitional experience that requires the nurse’s attentiveness (1, 26). The transitions theory provides a framework for clinicians to describe the critical needs of patients during hospitalisation, discharge, restitution and transfer. This may have implications for nursing practice (5). Our discussion of the study’s findings is informed by Afaf Meleis’ transitions theory.

The objective of the study 

The objective of the study was to gain greater insight into nurses’ experiences of the transfer of patients with terminal cancer from hospital to home 

Method

Design

The study has an explorative qualitative design with focus group interviews (27–29). 

Recruitment and sample

We recruited a strategic sample (28) of nurses who had experience of the discharge and reception of patients with terminal cancer. 

The participants were recruited from four wards in a large hospital in Norway and three of the local authorities that form part of the health trust in question. Managers and cancer coordinators were excluded. 

The ward managers and the various municipal home care services were the first author’s contacts, and they passed on information about the study to their staff. Those who wished to participate contacted the first author by email or text message. As it was challenging to recruit a sufficient number of participants from the specialist health service, we also used snowball recruitment (27), whereby nurses in the first author’s circle of acquaintances informed their own circle about the study, and they in turn informed others. 

Those who wished to participate contacted the first author directly via email or text message, and then received written information about the study by email. We recruited two informants in this way. 

A total of 15 nurses agreed to participate. Two of these withdrew: one withdrew when the first author contacted them to arrange a date for the focus group interview, and the other withdrew the day before the focus group interview. A further two participants were unable to attend because none of the alternative interview dates suited them. A total of eleven nurses attended the two focus group interviews (Table 1). They were aged from 24 to 52 years, with a median age of 42. Their work experience ranged from 6 months to 26 years. 

Data collection

We devised a semi-structured interview guide with three themes (28, 29): ‘Risk factors in patient transitions’, ‘The nurse’s role and responsibilities’, and ‘Safe discharge’. Each theme had related questions. We conducted a pilot focus group interview with four nurses from the first author’s workplace to practice carrying out an interview and to check whether the questions in the guide elucidated the theme fully. No changes were made in the interview guide. 

Next we carried out two focus group interviews – the first with six participants from the home care services, and the second with five participants from the hospital. The pilot and the two focus group interviews were conducted by the first author and a co-moderator (28) in a hospital meeting room. 

The interviews lasted 59 and 65 minutes, respectively. The themes in the interview guide were presented in the same manner in all the interviews. The questions that had been prepared in advance were hardly required because the informants largely kept to the various themes in the interview guide when talking to each other. At the end, they were all asked the last backup question in the interview guide: ‘Lastly, is there anything else you believe is important that hasn’t been mentioned in this interview?’

At the end of the interviews, the co-moderator summarised the essence of what had been discussed, and the informants could give feedback. The focus group interviews were digitally audio-recorded and transcribed by the first author. Table 2 presents the interview guide. 

Analysis

The interviews were analysed using systematic text condensation – a thematic cross-case analysis consisting of four steps (28). We used highlighter pens to colour code text on paper, then the meaning units were cut out and sorted. 

Step 1 consisted of acquiring a total impression. First the transcribed interviews were read and reread several times to gain a total impression of the entire dataset. In addition, eight preliminary themes were identified. 

At step 2, we identified meaning units. The material was then systematically reviewed to identify what was relevant to the research question. We set aside the material that was not found relevant. As a result of this process, the preliminary themes were reduced from eight to four code groups. 

At step 3, we abstracted the content of the individual meaning units. These were processed and sorted into sub-groups based on the nuances observed. We summarised the sorted information by condensing the content of the sub-group and using pertinent quotations. 

At step 4, we synthesised the meaning of the content. Finally, we formulated an analytical text for each sub-group, and assessed the pertinent quotations to check if they still illustrated the analytical text. Throughout the analytical process, we evaluated the titles of the code group and sub-groups, and refined these in order to capture the content (28). Table 3 gives an example of the analytical steps for one theme. 

Ethical considerations

The study was reported to Sikt, the Norwegian Agency for Shared Services in Education and Research, reference number 146020. Participation in the study was voluntary, and we obtained written informed consent. The participants recruited by the snowball method received information and a consent form by email, and the remaining participants received this from their supervisor. They sent their written consent to the first author. We processed all information and data material in line with the guidelines for research ethics (30). 

The audio files were deleted after transcription. The transcribed material did not contain any personally identifiable data. The first author is affiliated with the institution where the study was conducted. Three of the informants knew the first author through her position as a coordinator at the Regional Centre of Excellence for Palliative Care, but they had no personal relationship. The informants who withdrew had no knowledge of or relationship with the first author. 

Results 

As the entire process of facilitating and implementing patient transitions was characterized by randomness, the overarching theme of the study was ‘An unpredictable process’. Both hospital and community nurses found it impossible to predict whether the necessary aids would be in place in the patient’s home, if the discharge report would be available when the patient was discharged, and if prescriptions for the prescribed medications had been written. 

The analysis resulted in the following two main categories: ‘Unsystematic planning’ and ‘Tacit expectations’, each with two sub-groups (Figure 1). 

Unsystematic planning 

There were variations in how the planning of a patient transition was carried out and documented. The different hospital wards had different procedures for documenting the planning and progress of a patient transition in the patient record. When progress was not documented systematically, this was extremely challenging. Reading through several documents in the patient record to find the right information could be time-consuming. Even though there were clear procedures for how this work was to be accomplished, these were not always followed: 

‘We have a discharge plan, but I think it’s quite poor. It’s almost better that one person has the main responsibility, someone who is more involved than all the others. […] People forget to use it [the discharge plan]. It’s not always updated. What has been done? What hasn’t been done? So there’s a bit of a muddle at the end. And with the high turnover of personnel, shifts, all kinds of things. […] I think there’s kind of a capacity problem really’ (Participant 10 from the hospital).

Acquiring an overview is challenging

The hospital nurses emphasised that they needed information from various actors, such as the attending doctor at the hospital, the patient’s GP, the hospital and community nurses, the patients and their families: 

‘There are conversations with the patient about applying for home care services, for example. Then we must help them with the application and see that it’s sent. And we must have a meeting with the local authority, organise things, and adapt the home with the help of the local authority. Communicate with the local authority about when the patient is to be discharged. It’s a big area, and there’s a lot to cover. A lot of tasks to do when preparing for people with late-stage cancer to stay comfortably at home’ (Participant 7 from the hospital). 

A hectic workplace setting

Both hospital and community nurses described the planning of patient transitions as time-consuming. The hospital nurses found that they had only a short time to prepare for a patient transition: 

‘Maybe a reason for things often being forgotten is that we have too much to do. A lot has to be done at the same time. Then you forget it, because we’re not programmed machines’ (Participant 9 from the hospital).’ 

The hospital nurses found that insufficient time was set aside for work on patient transitions. Consequently, this was often done in between other tasks. The community nurses also usually found that they needed more time with patients than was allocated:

‘Patients are allocated services. But 20 minutes for conversation, what happened to that? You’re expected to do this at the same time as caring for a PICC line or other tasks. I think that’s a shortcoming’ (Participant 4 from the home care services).

Community nurses had a feeling that they were only given time to carry out practical tasks when visiting patients. They wanted to give the patient all-round care but were under pressure because the time allocated was insufficient. 

Tacit expectations 

The nurses’ expectations of what should be done by the home care services or the hospital were not clarified. The hospital nurses expected the community nurses to correct errors or shortcomings that were identified after the patient transition, although this was really the responsibility of the hospital. 

The community nurses expected that as much as possible had been arranged before the patient came home, but with no dialogue about what this entailed for the individual patient. When expectations were not made clear, or services were promised that could not be provided, this could lead to frustration and disappointment not only for patients and their families but also for those working in the home care services: 

‘When expectations of the role of the home care services are made clear, in other words “what support can we provide, and what are we unable to do” – that we’re not all-rounders who can sort of fix everything. So it’s disappointing for patients that maybe we can’t do it all’ (Participant 1 from the home care services).

Both the hospital and community nurses described patient transitions as successful when it was clear what patients and their families wanted, who was involved, what tasks were to be done prior to discharge, and who was responsible for carrying them out.

A lack of information

The varying quality of the exchange of information between hospital and community nurses could lead to unpredictable planning of patient transitions. Community nurses only had access to information provided via electronic care messages and telephone calls.

The nurses often needed to talk together because the electronic care messages did not bring out the nuances in the patient’s situation in the same way as an oral exchange. When home care services received patients with complex health problems, liaison meetings were held. 

It was important for the home care services to have updated information about the patient and the discharge report in particular. When preparing for the patient’s return home, they usually called the hospital nurses directly if anything was unclear. On several occasions they had discovered that the hospital’s information about the patient did not correspond with what they themselves experienced when they met the patient in their home. Then they spent a considerable amount of time trying to contact the person who had the information they needed, since many actors were involved: 

‘If you need a prescription, who do you then call? Do you call the GP, the palliative team or the [hospital] department? So it should have been made clear whether the GP is included or not. And as for the palliative team, they’re only available from 8am to 4pm, right? After that you must contact the ward’ (Participant 2 from the home care services). 

Compensating for shortcomings 

When there were errors or shortcomings in patient transitions, these were often rectified because the community nurses informed the hospital or put them right themselves: 

‘We get phone calls about all sorts of things. But I feel that we often manage to fix it ourselves. We haven’t done the job properly, haven’t sent all the paperwork or followed the procedures. But it works out, the home care services get in touch’ (Participant 10 from the hospital).

Community nurses often felt they were on their own with the work of unravelling and solving problems related to patient transitions when there were deficiencies. With no specific contacts to turn to, nurses often felt that they were alone. When equipment or medications were lacking, the community nurses themselves procured these in order to avoid negative consequences for the patient. 

‘Maybe the patient is sent home without the right equipment. […] Sometimes we’ve had to go to the hospital or medical assistive equipment centre and collect things during working hours. Just so we can save the situation’ (Participant 6 from the home care services). 

Efforts to obtain equipment or medications might result in nurses having no time to eat lunch. In some cases it meant that they had to work overtime to make up for the lost working hours. Afternoons, evenings, public holidays and holiday periods were mentioned as being difficult times for the discharge of patients from hospital.

Discussion 

To achieve a smooth patient transition, it is vital to be aware that this entails change, and that there are critical points in the change process (4). In this study, two critical points stood out: information exchange and unclear expectations. 

Information exchange

This study identified the unpredictability of the entire process of patient transitions from hospital to home. There was a considerable lack of clarity, and the hospital and community nurses expressed a strong need for a better overview of the information exchange between them. Much of this could be both unstructured and undocumented. Earlier studies also point out challenges in relation to information exchange and the information that is relevant and important in the handover (21, 22, 31). 

Community nurses find that important information may be lost in the communication between hospital and local authority (19). This finding is similar to findings in our study, which also showed that important information about the patient may be lost in the communications gap between ward nurses in hospital. An earlier study sheds light on the insecurity patients and their families may experience in connection with transitions. It also demonstrates that health personnel may fail to provide information about what the imminent transition entails, and who the patient or their family can contact if necessary after discharge from the hospital (12). 

Meleis’ theory, which highlights awareness of the changes that are important for patients and their families as well as nurses in transitions, can shed light on these findings (4, 5). Moreover, findings in our study indicate that the informal and unsystematic exchange of information in telephone calls poses a risk that important information will not be documented, and will then be lost.

Different medical record systems and a lack of mutual access to these may pose a challenge (31). The written exchange of information between the specialist and primary health services takes place via electronic care messages. Brattheim et al. (32) point out that these promote closer cooperation across health levels, but poor-quality messages lead to a need for supplementary oral communication. 

The study of Lundereng et al. (21) mentions that nurses were not always confident that the other party had read and understood the message content, and therefore they double-checked by telephone. Access to electronic communication between the medical record systems is discontinued when the patient is discharged from hospital (31). 

Our findings also indicate that in some cases the hospital and community nurses were unable to bring out the nuances in an electronic care message in the same way as in an oral exchange. This did not necessarily mean that the messages were inaccurate but that an informal conversation was needed to bring out the nuances in the patient’s situation. 

Unclear expectations

Allen (33) describes the nurse’s coordinating role as an invisible function that is not noticed until something fails. This invisible function serves to tie all the loose ends together so that patients and their families experience the various health services as coordinated and coherent (3). 

The nurse’s coordinating function is vital in maintaining the quality of care in patient transitions. However, we need to clarify what this involves in terms of tasks and practice. Knowledge of transitions theory can provide a sound framework that enables the nurse to be aware of the critical points in a transition. Moreover, applying the theory can promote the wellbeing and coping skills of the patient and prevent negative impacts on health and illness during transitions (1, 2, 5). 

According to Meleis and Trangenstein (1), the nurse has a unique role and key function in helping patients to manage and cope with transitions, partly because they must make the patient and those involved aware of what a transition may entail (4, 5). 

The degree of personal involvement in a transition will depend on how aware the patient is of the changes and experiences the transition entails. These depend on the individual and require the nurse to chart what the patient experiences when they are discharged from hospital to home. 

The patient pathway in the home may be the solution for the critical points we have identified in this study as it has guidelines for the systematic mapping, coordination and follow-up of the patient (16). 

However, it is too early to say if this will serve the purpose. Critical voices claim that the care pathway is a tool suited to the treatment focus of hospitals. They assert that holistic patient pathways cannot be standardised in the same way, since these do not involve a diagnosis but an individual overall health status and function that forms the basis of the local authority’s planning and provision of services (34). 

Another challenge, which the Norwegian Cancer Society has highlighted (35), is that the patient pathway in the home is a recommendation that health trusts and local authorities cannot be instructed to use. 

The study’s strengths and weaknesses 

The focus group interview is an efficient way of collecting qualitative data. Good interaction in the group can produce rich data through an exchange of opinions where the individual must put forward clear arguments to support their views. A weakness may be that some participants may dominate the discussion, whilst others do not make themselves heard (27). 

A weakness of the study is that our dataset is associated with a particular geographical area. This could have been avoided by recruiting informants from other hospitals and local authorities in Norway. A third focus group interview with informants from both the primary and specialist health services might have produced a richer dataset. Moreover, as the first author conducted the research in their own field, this may have impacted on the study’s validity. 

However, a strength of the study is that the co-moderator is an experienced researcher, and the second author has contributed to the various steps of the analysis process. Systematic text condensation does not require there to be one overarching theme as the analysis cross-cuts individual themes (28). However, as the themes in this study belonged together, they were grouped under one overarching theme. 

Conclusion

Nurses in both the specialist and primary health services found that patient transitions from hospital to home were characterised by unsystematic planning, and it was challenging for nurses in their busy workday to gain an overview of the necessary information when preparing for a patient transition. 

Both parties had certain expectation of what the other party could or should do in these transitions, but these were not clearly formulated. The community nurses in particular perceived shortcomings in patient transitions. To ensure that the patient was cared for, they compensated for these inadequacies by carrying out tasks that should have been performed in hospital.

Clinical practice should acknowledge that a patient’s needs may change in a different context. The differences in the working situation of nurses in the primary and specialist health services must also be recognised. 

Acknowledgements

Thanks to the informants who shared their experiences. Without you, this article would not have come to fruition. Thanks also to Bente Ervik, PhD – manager and cancer nurse at the Regional Centre of Excellence for Palliative Care, University Hospital of North Norway HF – who shared her knowledge of interview techniques prior to the pilot focus interview, and contributed as a co-moderator in the pilot and focus group interviews. 

The authors declare no conflicts of interest.

Open access CC BY 4.0

Introduction

Opioid dependence is a severe disorder that affects the physical, mental and social aspects of life (1). It is characterised by an inability to regulate the use of substances like heroin despite the adverse consequences (2). People with opioid dependence are more likely to receive disability benefits, and they have a four to seven times higher risk of premature death (3–9). They also report a lower quality of life compared to the general population (10–13). 

High overdose figures indicate that people with a substance use disorder (SUD) do not receive adequate help, and in 2023, there were 363 drug-related deaths in Norway (14). Most of these were linked to heroin and other opioids. In the National Overdose Strategy 2019–2022, the Norwegian Directorate of Health introduced measures to prevent lethal overdoses and improve the quality of life for this patient group (15). These measures included better access to opioid agonist treatment (OAT) and the development of heroin-assisted treatment (HAT).

HAT is a five-year pilot project that is being evaluated by the Section for Clinical Addiction Research (RusForsk) at Oslo University Hospital, among others. This study of HAT in Bergen was conducted as a master’s project at the Western Norway University of Applied Sciences in collaboration with RusForsk. HAT was launched in Oslo and Bergen in the winter of 2022 as part of the existing OAT provision.

HAT patients attend an outpatient clinic twice daily to take medically prescribed heroin (diacetylmorphine), administered by injection or tablet, as an alternative to other substitution medications. The treatment has a higher intensity than other forms of OAT. Patients are assigned a primary nurse who follows up on their daily treatment. Patients can also receive psychosocial support from a social worker or psychologist at the clinic. The treatment is aimed at patients with opioid dependence who have not had sufficient results from standard OAT (16). 

HAT is available in countries such as Denmark, Switzerland, Germany and the Netherlands. International research shows that the treatment has a positive, stabilising effect (17, 18), that heroin improves quality of life more effectively than methadone, that the treatment leads to a higher level of satisfaction (12, 19), and that it can reduce the use of illicit heroin (18, 20). However, HAT has been a controversial treatment method both in Norway and other countries.

There are few qualitative studies on quality of life and HAT internationally (21, 22). Considerable quantitative research has been conducted on dependency and patients’ quality of life; however, more qualitative research has been called for that includes the user’s perspective and a subjective approach to quality of life (10, 21, 23). This study contributes to such knowledge. 

Objective of the study

The first and second authors worked together on the master’s study on which this article is based. The study was one of the first contributions to research on HAT in a Norwegian context. The aim was to generate knowledge about HAT as a treatment method and its potential impact on the quality of life for patients in Bergen. The research question for the study was as follows:

How do HAT patients feel that the treatment impacts on their quality of life?

‘Quality of life’ has many definitions, but in this article, we focus on it as a subjective psychological phenomenon, defined as mental well-being and an individual’s experience of feeling good (24). A good quality of life is when a person’s conscious cognitive experiences, such as evaluations, thoughts and perceptions, are positive, while negative affective experiences, such as emotional states, indicate a poor quality of life (24).

RusForsk recently published an article addressing patient satisfaction with HAT in Bergen and Oslo (25). The article is based on parts of the same data collected for our study by the first and second authors. 

Method

Sample and recruitment

Only ten patients were enrolled in HAT when we began recruiting for the study. We therefore formed a strategic sample from this group, and included the six who gave their consent to participate, made up of an equal number of women and men. The median age of the participants is 43 years.

At the time of recruitment, the second author was employed in the HAT programme. In her professional capacity, she informed the patients about the study, obtained consent and arranged interviews. We will later discuss how this asymmetrical power dynamic may have impacted on the data.

Interviews

The first and second authors each conducted semi-structured, individual interviews with three participants. The interviews were held one month and six months after treatment started. One participant withdrew from treatment and was unable to participate in the second round of interviews, resulting in a total of eleven interviews.

The interview guide was devised by RusForsk, and we included our own questions about quality of life, such as: ‘How does HAT impact on your quality of life?’ The most suitable time and place to conduct the interviews was at the clinic after the participants had taken their dose of medically prescribed heroin, as they would not be experiencing withdrawal symptoms at that point. The interviews lasted between 15 and 60 minutes. Each interviewer made audio recordings of their own interviews and transcribed them verbatim.

Data analysis

The first and second authors carried out reflexive thematic analysis on the qualitative data, as described by Braun and Clarke (26–28). This six-phase analytical method entails creating codes and developing themes from across the dataset. We adopted an inductive approach and sought to develop codes and themes that reflected both the positive and negative aspects of HAT that could impact on the participants’ quality of life.

The focus in this analysis method is on the researcher being reflexive, i.e. subjective, curious and critical of their own preunderstandings. Throughout the process, we discussed how our preunderstandings and experiences from working in the field of substance use could impact on the analysis in the study. 

Research ethics considerations

This study was part of RusForsk’s research project, which has been approved by the Regional Committee for Medical and Health Research Ethics (REK), reference number 195733. The research project has also been approved by the data protection officer at Oslo University Hospital and at Haukeland University Hospital. We adhered to RusForsk’s and Oslo University Hospital’s research protocols for data collection and storage to protect participants’ privacy and ensure secure data management. Pseudonyms are used in excerpts from the interviews. 

Results

The thematic diagram (Figure 1) shows the findings of the analysis, setting out two main themes: ‘HAT – a long-awaited intervention that improves quality of life’ and ‘HAT – a high-intensity intervention that demands a lot from patients’. The subthemes from the first round of interviews are shown in the upper part of the diagram, while the subthemes from the second round of interviews are positioned in the lower part.

HAT – a long-awaited intervention that improves quality of life

The first main theme that was constructed from the analysis describes the experiences and feelings in relation to HAT that help to improve the participants’ quality of life. The participants said that they applied to take part in HAT due to their heroin dependency, the offer of free heroin administered legally in a safe environment, and a desire for a better and more stable life. The four subthemes are briefly described below.

The subtheme ‘A less burdensome life’ focuses on the direct consequences of HAT, such as the sense of liberation from the stress and anxiety of looking for their next fix every day. Other consequences include reduced use of illegal substances and less involvement in criminal activities. They also no longer have to fund their heroin use from within an environment that could cause them psychological and physical harm. 

These factors in turn led to better finances, improved health and more time in their daily lives. We interpret this finding as an improved life situation that entails a better quality of life: 

‘How much easier everyday life became for me after I started here. When I think about it, how much time I actually spend looking for my next fix, and whole days go by just trying to stay well, and that constant search, you know.’ (Tore, first interview)

‘Finally able to relax’ addresses the more indirect consequences of heroin dependency and how it can be all-consuming without proper help. The daily supply of heroin that participants received in HAT gave them a sense of safety and predictability. HAT also gives them a routine and stability in life, where the time they would otherwise have spent looking for their next fix can be used for enjoyable activities. Life becomes more relaxed, leading to an improved quality of life: 

‘I just notice how much easier it is to get out now and get things done at home, and I eat more, and yes, I feel a bit more relaxed.’ (Tore, first interview)

‘Healthier, freer and understood’ addresses the indirect emotional consequences of HAT. This subtheme includes the feeling that life has improved, of better self-esteem, of finding more meaning and belonging, of recognising the heroin dependency and feeling freer and healthier. They felt healthier due to the positive effects and minimal adverse effects of the medically prescribed heroin, along with experiencing fewer withdrawal symptoms throughout the day:

‘Things have really only gone in the right direction, or the direction I had hoped. I appreciate being part of this, and yes, as I said, it makes things much better and easier, I’m a bit healthier and more active, and I get things done.’ (Tore, second interview)

‘Sustained consequences – life is on the up’ is the subtheme from the second round of interviews. Shortly after starting HAT, the participants were more focused on the direct consequences of the medically prescribed heroin they were given. After six months, they were more concerned with the implications of HAT for their lives. Most of the positive aspects related to the quality of life that were identified in the first round of interviews continued into the second round.

HAT – a high-intensity intervention that demands a lot from patients

The second main theme that was constructed from the analysis describes experiences and feelings in relation to HAT that may hinder quality of life. Examples of these include encountering other substance users at the HAT clinic, being faced with ignorant attitudes from the staff, and the frequent attendance required. The four subthemes are briefly described below.

‘The difficult encounters’ addresses the interactions with other HAT patients and staff. At the HAT clinic, participants will be in the presence of other substance users, some of whom they may have a bad relationship with. They asked to be separated from other substance users and expressed concern about the inclusion of those who might exploit the programme. They also felt that the staff imposed sanctions and made unreasonable demands. Some of the staff lacked understanding and knowledge about dependency, as well as the effects and motivations behind each patient’s use of heroin:

‘I’m not going to tell them [the staff] if I have a relapse with pills; they can figure it out for themselves. I could get punished for saying something like that. They put you in a position, and on top of that they expect you to manage fine, when the reason I took [another substance] was to top up the dose I had.’ (Lisa, first interview)

‘The important heroin’ refers to the perception that heroin is so essential that the informants prioritise attending the clinic even though the frequency of visits is challenging and prevents them for planning other activities. Many of the informants, particularly those who live far away, find that being so tied to the clinic is exhausting and that it restricts their freedom. Some expected a stronger effect from the medically prescribed heroin: 

‘It’s the fact that you have to come here twice, you always have to be thinking about it.’ (Ruth, first interview)

In the subtheme ‘An insufficient time window’, the informants described rigid opening hours that did not align with their needs and rhythms. They expressed a desire to have the option of a third dose of heroin and a meal at the clinic. The HAT clinic in Bergen does not offer either of these, which they found limiting.

‘Life has changed, and yet it hasn’t’ is the subtheme from the second round of interviews. The negative aspects from the first round of interviews were still present after six months of HAT. The informants shared more about how their dependency affected their daily lives, such as use of additional substances to numb unpleasant feelings and painful experiences from life in the drug community, in relation to violence and exploitation. HAT does not address aspects such as this that reduce quality of life. Life is still difficult. 

The results show that the informants have both positive and negative affective and cognitive experiences related to HAT. They describe how the medically prescribed heroin makes them feel joyous, euphoric, safe, a sense of belonging and recognised. These are examples of positive affective experiences. They are more satisfied with their lives because HAT gives them stability and routine. They have better self-esteem and feel healthier and freer. These are examples of positive conscious cognitive experiences. The informants also reported that HAT helps reduce negative affective experiences such as anxiety, fatigue, shame and stress. 

However, they also found HAT to be exhausting and time-consuming. It involves involuntarily meeting other substance users. These are examples of negative conscious cognitive experiences. Both the positive and negative aspects of HAT highlighted by the informants correspond with results from international studies (21, 22).

Discussion

The results show that medically prescribed heroin is a major, important and somewhat positive part of the informants’ lives. They illustrate the complexity of substance use disorders in the context of heroin use being generally perceived in a one-dimensional negative light and sobriety being idealised. However, the aim of receiving HAT is not sobriety or recovery from dependency, but rather to gain access to medically prescribed heroin and manage the dependency in a responsible manner within the framework of the healthcare system. Nevertheless, as the results show, these frameworks can be perceived as rigid and insufficiently adapted to the patients’ needs. 

Quality of life and dependence

Drug use has a powerful effect on the brain’s dopamine release and gives the brain a major boost compared to other natural dopamine-releasing activities. Over time, this can alter the brain’s motivation and reward system, thereby increasing the motivation for further consumption. As a result, the positive affective experience associated with heroin use becomes so intense that it can overshadow most aspects of the lives of individuals with an SUD (7, 29, 30, 31). 

When informants cite heroin as the most important aspect of what they perceive as a better quality of life, it should be understood in this context. Access to medically prescribed heroin in HAT also means that informants no longer need to worry about withdrawal symptoms or the stress of funding illegal heroin use. 

Medically prescribed heroin in HAT gives an immediate positive affective experience of euphoria and reduces negative cognitive experiences of suffering from withdrawal symptoms and the stress and anxiety associated with looking for the next fix. Both the act of taking heroin itself and the safety and predictability of the HAT clinic supplying them with medically prescribed heroin lead to the perception of a better quality of life. The informants are relieved of the uncertainty and risk of taking illicit heroin, and the use of medically prescribed heroin is monitored and takes place in a safe environment. 

The informants also said that, with HAT, heroin use is reframed as medical care as opposed to a criminal act. This can help reduce the shame associated with SUD and increase the feeling that opioid dependency is recognised by the healthcare system and society in general (32). 

The informants also highlighted that HAT means they no longer need to seek out the drug community to obtain illicit heroin. This is described as one of the reasons for their improved quality of life. While meeting the physiological need for heroin is important, it seems that this alone is insufficient for them to distance themselves from the drug community. 

HAT improves quality of life – real or not? 

Treatment for SUD is complex. On the one hand, patients’ physiological dependence must be treated with medication to adjust their tolerance levels and prevent withdrawal symptoms. Meanwhile, the psychosocial aspect of dependency needs a sufficient focus in the treatment process. This group of patients needs help to change behaviour patterns and habits that feed their condition. 

The findings of this study are consistent with international quantitative research in which HAT patients are more satisfied with the medication than those receiving other forms of opioid substitution treatment (19). 

However, the qualitative interviews provide deeper insight, showing that while patients may be satisfied with the medication, the lack of a comprehensive treatment provision makes it difficult to improve their overall life situation. This point aligns with an international literature review recommending a stronger focus in clinical practice on the quality of life of those receiving treatment for opioid dependency (10).

The informants described how they found the daily attendance exhausting and that it could get in the way of them pursuing enjoyable activities. This can negatively affect their perceptions of quality of life. Self-fulfilment is considered an important aspect of a good quality of life (24, 33). The intensity of HAT seems to limit patients’ opportunities to engage in any activity other than the treatment. 

The frequent visits to the HAT clinic mean that the informants involuntarily spend time with other substance users, which can trigger a craving to take drugs to regulate negative emotions. Some informants also feel that the staff do not sufficiently understand their dependency and the effects of heroin. These factors can make it difficult for the informants to avoid feeling shame about their dependency. The shame associated with SUD is often both the cause and effect of substance use (34). There is a risk that the clinic environment perpetuates cravings and feelings of shame. 

Stabilisation from a single daily dose of medication, without experiencing the usual high, can also present challenges. The high often serves a purpose beyond its biological and chemical effects, including keeping unpleasant feelings, such as anxiety, shame and guilt, at bay. 

As patients develop a tolerance to heroin and stabilise their dosage, they may find that the heroin becomes solely a means of preventing withdrawal symptoms. Negative emotions may not necessarily be suppressed any longer, and the heroin’s utility may decrease. This can make navigating everyday life a challenge that calls for some extra support. The dependency becomes more complex, and treatment must offer something more. HAT as a purely medication-based treatment can lead to an oversimplified view of SUD as a disease. Consequently, this treatment approach may be inadequate for addressing the non-medical needs of patients that are essential for improving their quality of life.

The shift from heroin as an intoxicant to a medicine has significant implications. The psychosocial and social education aspects can be overshadowed by the medical need to control its administration and the assessment of whether it is medically justified. 

It is important to remember that this treatment is intended for active users with an opioid dependency who have not had satisfactory results from standard OAT: the most vulnerable and hardest to treat. They cannot be expected to be continuously stabilised, as neither dependency nor stabilisation are a linear process. Staff can better support patients by recognising this reality and reducing their own need for control.

Building relationships, preventing the use of additional substances and addressing other challenges become easier if psychosocial follow-up is emphasised, prioritised and further developed to meet the patients’ complex needs beyond the medical. The nurses’ expertise should also be utilised for effective psychosocial follow-up, as they work most closely with the patients.

Methodological considerations

In this study, we have focused on reflexivity, remaining mindful of how we as researchers have influenced the research process and the results. Three aspects of the project have been particularly important: interviewing informants under the influence of a substance, our experiences as nurses from working in the field of substance use, and the second author’s dual role as both an employee at the HAT clinic and a researcher. 

The interview situation and interviewing active substance users who could be considered intoxicated, was no easy task in terms of the ideal qualitative research interview. We encountered reluctance, polite rejection, hypersensitivity and a lack of both interest and experience in discussing life. It was often difficult to decipher what was being said. These factors raise questions about the validity and quality of the data. 

We believe the data provide important insights and are representative of the informants’ reality. When researching this patient group, it is also necessary to consider that the group is under the influence of the substance they are dependent on. We treated the informants differently from interview subjects who are not part of a marginalised group or under the influence of substances; we would have challenged the latter group more.

It is reasonable to question whether the informants felt pressured into participating in the study. The second author had a dual role as an employee at the HAT clinic and a researcher, and was also the one who provided information, obtained consent and arranged the interviews. The participants were told that participation and the information they provided in interviews would not affect their treatment. Nevertheless, they may have consciously or subconsciously wanted to make a good impression on the second author. 

They may also have presented HAT in a more positive than negative light because they hoped that it would become an established provision after the pilot project period. These factors, along with the possibility that the data may not adequately represent HAT in Oslo, should be considered when evaluating the study’s data and results. Nevertheless, the study provides important and unique insights into how HAT impacts on patients’ quality of life.

Conclusion

The study’s results show that HAT has a positive impact on the informants’ perceived quality of life, particularly in terms of the access to medically prescribed heroin and because they no longer need to spend time and effort on looking for their next fix. However, several aspects of HAT could be improved to better meet the patients’ needs. This relates to the fact that HAT in Bergen is not equipped to facilitate a comprehensive treatment provision, where relationship-building, social education and psychosocial support are central. 

There are indications that HAT in Oslo is better structured for a comprehensive treatment provision (25). Better utilisation of nurses’ expertise in these areas in HAT in Bergen would be beneficial. 

However, the positive aspects of HAT outweigh the negative ones for the patients. Furthermore, HAT can help reduce the stigma and shame that this group experiences through recognition and validation of the opioid dependency and use. When the administration of heroin shifts from the streets to the clinic, use becomes safer, and the number of lethal overdoses can be reduced.

One of the goals of HAT is to improve participants’ quality of life. Overall, HAT is an important initiative for enhancing the quality of life for this group. However, if HAT becomes too medicalised, it could result in patients merely functioning, without necessarily achieving the important changes that are needed to improve their life.

We have identified potential for improvement in HAT in Bergen. We believe that HAT’s mandate and objectives need to be more clearly defined. This would allow for an evaluation of whether and how HAT in Bergen can be further adapted to patients’ needs and to a holistic approach for each participant. This would enhance the patients’ quality of life and better equip them to make positive changes in their lives. 

Conflicts of interest

During the study, Christina Dahl Andersen was employed in a 60% position in the heroin-assisted treatment (HAT) programme.

Open access CC BY 4.0

Introduction

Quality and efficiency are two important pillars for the health service of the future, and digital tools are essential to achieving this (1). The World Health Organization (WHO) suggests that there is a need to change how healthcare services are delivered, and highlights the importance of person-centred care when developing new ways of delivering health care (2). 

The Norwegian health authorities have a focus on patients and service users being more involved in their own care. They also want to develop digital tools to improve the working conditions of healthcare personnel (3).

The health service is under substantial pressure, and future shortages of healthcare personnel will put further pressure on health services (4). Digitalisation may be a solution to future challenges, but whether digital technology will ease or add to the burdens of staff and patients is uncertain (4). More knowledge is still needed on how we can exploit the potential of eHealth (5).

The potential for remote patient monitoring in cancer care

RPM enables healthcare personnel to monitor patients at home (6). Service users measure their own vital signs and complete self-reported questionnaires that are then sent to healthcare personnel, who can subsequently respond and take the appropriate action (6).

Cancer patients often experience adverse side effects from their illness and treatment (7). RPM for cancer patients in the form of self-reporting can improve symptom relief and quality of life (7) and increase survival rates (8). Using RPM can also facilitate communication between healthcare personnel and patients, strengthen user involvement, improve time efficiency, enhance service quality and reduce resource use (9).

Although RPM can yield positive outcomes for cancer patients and healthcare personnel, implementation and uptake in the health services present challenges (9). A literature review points to a need for more knowledge on how RPM can be implemented and optimised. The literature review recommends exploring how work processes should be reorganised and what role nurses can play in utilising digital tools in cancer care (5).

Nurses’ focus on person-centred care 

Health services across the world are increasingly focussed on person-centred care (2), where user involvement and shared decision-making are key aspects (10). To this end, Norwegian health authorities aim to create a health service in which the patient plays a more participatory role (3).

Nurses who feel that they are practising person-centred care are more satisfied with their jobs than other nurses and are more likely to stay in their job. However, the organisation of healthcare services, in which the focus is on operational factors and performance management, can make it challenging for nurses to provide good comprehensive care (11).

RPM for cancer outpatients

A Norwegian hospital entered into an innovation partnership with a technology company with the aim of developing an RPM system for cancer patients to improve the working day of healthcare personnel and patient care at an outpatient clinic. Nurses, doctors and nursing associates participated in the development process, which resulted in the Nimble app. Following an initial trial period from 2020 to 2021, during which around 100 patients tested the solution, the hospital decided to purchase the app and initiated the implementation process in spring 2022. 

Nimble consists of different versions for patients and healthcare personnel and can be used on a mobile phone, tablet or computer. In the app, patients are asked to register symptoms and side effects in a self-reported questionnaire prior to a consultation or treatment, and this is then sent to the hospital.

Patients can also communicate with healthcare personnel via secure messaging such as a chat function. The solution also includes video consultations that can be initiated by healthcare personnel. Nimble is synchronised with the patient record system and can transmit data to an electronic chart.

The introduction of Nimble has led to changes in how nursing care is organised and entails new routines for nurses and nursing associates. A new role has been created, RPM manager, where a nurse has overall responsibility for checking that all alerts are followed up. If a patient sends a questionnaire in which some of the symptoms are outside the reference range, or if a message is received in the chat function, an alert is triggered for nurses and nursing associates. This appears as a red dot in the app. 

The nursing associates respond to questionnaires and messages and contact a nurse or doctor if alerts are outside their area of ​​expertise. Each nurse must check Nimble daily to monitor their primary patients. The log-in procedure is the same as for the hospital’s ICT systems.

Self-reported values within the normal range, such as no fever or side effects, self-reported blood pressure within the normal range and stable weight, are used as a basis for organising chemotherapy or immunotherapy, which will then be ready for the patient to start when they arrive at the outpatient clinic. 

Objective of the study

The objective of the study was to explore nurses’ experiences with RPM for cancer outpatients being treated with medication. We also wanted to investigate how the tool impacts on the nurses’ working day and interaction with patients.

Method

The study has an exploratory qualitative design with an inductive approach. Data were collected in semi-structured focus group interviews, and the COREQ checklist was used to promote clear reporting of the research (12).

Sample and setting

The informants were recruited from an outpatient clinic at a hospital in Norway that treats patients with cancer and blood disorders, and experience with RPM was one of the inclusion criteria. Potential informants received information about the study from their manager. Those interested received oral and written information from the first author.

Out of 26 potential informants, 17 expressed an interest in participating. We interviewed 11 informants based on their availability at the time of the focus groups and operational considerations in the department. An operations coordinator divided the informants into three focus groups, independently of the first author.

The informants were women and men aged 30–63, with a median age of 48 years, who had been using the app for at least six months. They were nine oncology nurses and two other nurses, all with extensive experience in cancer care.

Data collection

We collected data based on a semi-structured interview guide (Appendix 1 (in Norwegian)) in three focus group interviews with a total of 11 nurses. Two of the groups each had four informants and one group had three. The interview guide was developed based on the authors’ preunderstandings, previous research and discussions. We pilot-tested the interview guide before the interviews. The first author, who conducted the interviews, had a collegial relationship with the informants.

The interviews were conducted at the informants’ workplace in autumn 2022 and lasted between 40 and 55 minutes. Informants were asked all the questions in the interview guide in addition to follow-up questions. They were given the opportunity to shed light on other topics that did not emerge when following the interview guide. Audio recordings were made of the interviews, and these were subsequently transcribed verbatim. 

Data analysis

The first author coded and analysed the data together with the last author, using Braun and Clarke’s reflexive thematic analysis. This a six-step systematic process in which the researcher critically examines their own role in the research process (13).

We started by identifying meaning units, which were coded. We then developed subcategories, which ultimately formed the basis for the main themes. Table 1 shows excerpts from the analysis. 

Ethics and ethical considerations

Participation was voluntary. The participants received oral and written information in advance and consented to participation in writing. The study was reported to Sikt (the Norwegian Agency for Shared Services in Education and Research), reference number 802570. The audio recordings were collected via the dictaphone app Nettskjema-diktafon before being encrypted and sent to Nettskjema.no. The audio files were downloaded and stored in an approved location in accordance with routines at the University of South-Eastern Norway. They were then transcribed verbatim, and the transcripts were de-identified and treated confidentially.

The first author has been involved in implementing RPM in the informants’ workplace and her prior knowledge, experiences, thoughts and attitudes have influenced the research process, potentially limiting the emergence of new insights (14). 

In order to ensure that the informants’ experiences come to light and that the emerging themes are not a construct of the first author’s biases, the analysis process was carried out together with the last author, who has no relationship to the informants. Additionally, the themes were presented to the informants after the analysis to check that they recognised the content.

Results

The informants described how RPM impacted their working day and the interaction with patients. The following three themes emerged from the analysis: 1) Change – challenging, but creates possibilities, 2) Impact on the working day – a double-edged sword and 3) Relationships in the digital world – proximity and accessibility (Figure 1).

Change – challenging, but creates possibilities

The informants described the changes that RPM had brought about in their working day. ‘Something else new’ was a recurring phrase in the focus group interviews, and the nurses talked about a constantly changing health service. The informants initially feared that using the app would be time-consuming:

‘Something else new, and maybe more work as well, when will there be time for it? I thought more work and something else new’ (Informant 3).

They emphasised that it was challenging to deal with changes, especially when there was already so much work. However, they also saw that RPM has future potential and considered it part of the evolution of the health service. They described RPM as a new way of working. They wanted to preserve human contact and stressed that RPM was not comparable to physical meetings. 

Several informants also described how the self-reported questionnaires effectively assessed health status and side effects, and met the nurses’ need for information. The nurses also reflected on whether their own relationship to and interest in digital technology could impact on how quickly they adopt the new solution.

The informants valued the opportunity to contribute to the app development. They considered it essential that eHealth developers understand users’ needs, and described the collaboration with the developers as important for user friendliness.

Impact on the working day – a double-edged sword

The informants stated that RPM can aid their work and serve as a useful tool in their working day, but that it also created extra work.

The informants found that the app can help streamline their tasks. They pointed out that the self-reported questionnaires that patients completed the day before treatment provided the nurses with sufficient information to pre-order treatment such as chemotherapy and immunotherapy, which they described as time-saving. This results in shorter hospital visits, which is beneficial for both the patient and the outpatient clinic. One informant expressed it as follows:

‘Less time in the chair, more efficient from our perspective. And less time at the hospital for the patient’ (Informant 9).

The informants found that the self-reported questionnaire and the messaging function could also prevent unnecessary hospital visits. This benefitted both the nurses and the patients, as they could spend their time on something else and save on travel costs.

The informants felt that the messaging function created flexibility and gave them better control of their time. Several mentioned that they experienced fewer interruptions from phone calls and that it was beneficial to be able to respond to messages when it suited them. They could then consult with a colleague or the duty doctor before responding, enabling them to provide more informed feedback to the patient. The informants said that the app ensured quality-assured communication about important information and changes to medication dosage.

The informants also said that alerts in the app can lead to extra work and stress, as they are time-consuming to deal with, and no time is allocated for them alongside other tasks:

‘Nevertheless, these messages can take up quite a bit of time. They can generate a lot of work. Seeing that red dot on Nimble and knowing that I need to act on it during the day makes me a bit stressed, and I have to find time for it in a busy working day, but it usually works out, and I can choose when to do it. But still, it can be yet another thing that adds to the stress’ (Informant 6).

Some of the informants expressed that the app increases the flow of information, and that they have to deal with all the messages that come in. Some described how having to deal with multiple patient histories was burdensome.

Relationships in the digital world – proximity and accessibility

The informants described how the app makes them more accessible to patients. They said that patients who never used to call were now more likely to get in touch via the messaging function.

The nurses said that the app had the potential to improve the quality of service, and that increased accessibility is reassuring for the patients and allows nurses to monitor patients at home between treatments. The informants initially feared that they would feel less connected to the patients when using the technology, but after using the app, they found it was possible to use the technology to build a good relationship. One informant described it as follows:

‘You might think that digital communication makes you feel less connected to the patient, but I don’t really think that’s the case. If it’s someone I know, someone I’m monitoring, and have established a connection with, then they feel a bit like ‘my’ patient, and I also think that the patients feel they connect with me through the messaging function. Because I know the patient’ (Informant 6).

The informants also said that they felt the messaging function could provide more personal patient follow-up, described by one informant as follows:

‘I think it can almost feel even more personal, when they send a message, they write ‘Hi [name of the nurse]’, so it almost becomes even more personal than if they phone and get through to some random person on the other end, as it were’ (Informant 7).

However, the informants stressed that it was important to establish face-to-face contact beforehand in order to build a good relationship via the app.

Discussion

The main findings of the study highlighted how RPM for cancer patients impacted on the informants’ working day and the interaction with patients. The informants found the changes in work routines brought about by RPM to be challenging, but they also felt that the tool created possibilities. The informants found that the self-reported questionnaire and messaging function offered benefits such as increased flexibility, the opportunity to work more efficiently, and time-savings for both themselves and the patients.

The greater accessibility has also increased the flow of information, causing stress and extra work. The informants initially feared that RPM might have a negative impact on the nurse-patient relationship; however they found that the tool facilitated more personalised monitoring, contributing to person-centred care. 

Changing practice through the introduction of technology

The informants had experienced several technology-related changes in recent years. Although they considered RPM to be part of this development, they found change processes challenging. Technology is advancing at a rapid pace and is changing the way nurses work and interact with patients (15). Healthcare personnel often face a high level of work pressure and have to prioritise which tasks to spend time on (16).

The informants also said they had identified potential in the app that could make certain aspects of their work easier. This finding is consistent with research showing that healthcare personnel are more likely to adopt a new digital solution if they believe it will have a positive effect on work routines (17), is user-friendly and has benefits (18).

The informants highlighted the importance of the collaboration with the developers and linked it to the app’s perceived user-friendliness and benefits. This type of collaboration is described in the literature as ‘co-creation’, where different actors and professions come together in an equal partnership to find new solutions (19). This can serve as an arena for staff learning and reflection, which can have a positive effect on the implementation process (20).

User involvement can prevent resistance (21) and facilitate successful change (16). The informants’ experiences with user involvement can also be observed in person-centred care, where the nurse’s professional autonomy is crucial for job satisfaction, as it includes being part of the decision-making about nursing practice (11). 

As the informants themselves experienced, digital competence impacts on how they relate to digital tools. Healthcare personnel’s age, gender and experience influence acceptance and use of digital tools (18). A high level of digital competence is associated with a positive view of technology, while a low level is linked to concerns about patient safety and own competence (22).

People with advanced technological expertise reap greater benefit from digitalisation, while those with more limited knowledge find that it creates extra work (23). This may suggest that authorities and hospital management should take more of an interest in the importance of digital competence in relation to acceptance of digital innovation. They should focus on training and information, tailor solutions to needs and facilitate employees’ adoption of the solutions (17). 

Since nurses can be key contributors in transforming healthcare services, it is important to leverage their visions and knowledge when developing care practices (24).

Possibilities and challenges linked to RPM

The informants highlighted several examples of how RPM impacted on their working day. They were able to work more efficiently and flexibly, which improved the workflow. In line with earlier research, the nurses found that the self-reported questionnaires provided useful information about the patient (9).

RPM streamlined the work and saved time for both patients and nurses (25). Furthermore, the nurses found that the messaging function allowed them to provide better feedback than in a phone call because they could consult with colleagues before responding.

The informants found there to be several positive aspects of RPM. However, they also said that the alerts from the app could lead to extra work and stress. Although technology is typically introduced to improve working conditions, it can also have unintended adverse effects, such as increasing the workload rather than easing it (23).

For the nurses in this study, this meant having to deal with more information. RPM results in more frequent and a higher volume of information about patients, which in turn reveals that more patients need treatment or follow-up (22). As a result, nurses need to spend time on patients beyond the scheduled appointments (9).

The nurses noted that digital tools can impact on their work in various ways. This can be explained by the complexity of hospitals, which consist of a multitude of occupational groups (4), and the multifaceted challenges faced by cancer patients (26). It is therefore difficult to find a solution that meets everyone’s needs, which suggests that future research should focus on cultural and human factors related to the implementation of digital tools (16). 

The patient-nurse relationship with RPM

Oncology nurses highly value their interpersonal relationships with patients (27). The informants initially feared that the app would make them feel less connected to the patients. This finding is in line with other research indicating that nurses fear that digital tools could negatively affect the nurse-patient relationship (22), that technology might diminish their ability to provide holistic person-centred care, create distance and render the care more impersonal (28). 

However, the informants in our study found that the app could facilitate a closer relationship, and highlighted the importance of the messaging function for achieving a closer dialogue. Nevertheless, face-to-face interaction is crucial for creating a digital relationship (22), which the informants also pointed out. The informants said that RPM cannot replace physical meetings, which is consistent with previous research. Clinical observations and non-verbal cues from the patient are lost (24), which places demands on the skills and expertise of the nurses (28).

The context for interaction is central to person-centred care (11). The informants described the app as a new setting and way of interacting with the patient. In line with research, the informants found that digital tools support person-centred care by strengthening the relationship between the patient and the healthcare personnel (29) and through empowerment and better communication between the healthcare personnel and the patient. Furthermore, digital tools can improve quality of life and physical and mental well-being (30). 

These are values ​​that nurses should base their practices on when adopting digital tools, as oncology nurses have a duty to safeguard ethical and professionally responsible application of innovations, health technology and digital competence (26). It is therefore important that the staff have sufficient knowledge and information about the advantages and disadvantages of RPM, and that they understand the reasons behind the implementation of the tool (16).

Strengths and weaknesses

A weakness of the study is that the focus group interviews only consisted of 11 nurses and that it was conducted in just one outpatient department. This may affect the transferability of the results to other occupational groups and settings. However, several of the findings are consistent with other studies of healthcare personnel’s experiences with RPM, which can strengthen the study’s validity.

The first author works at the same place as the informants, which led her to be particularly mindful of distinguishing between her professional and researcher role. To avoid the possibility of informants agreeing to participate in the study because of a collegial relationship, the first author was not involved in recruiting the informants or in assembling the focus groups. 

The fact that the first author conducted the interviews and knew the informants may have made the informants feel secure enough to share information, but it may also have caused them to withhold information. The informants were given the opportunity to read through the results and indicate their recognition of the themes that had emerged, which can support the study’s credibility.

Conclusion

The study suggests that nurses have mixed opinions about using an app to monitor cancer patients. The nurses found that using the app streamlined the work and reduced phone interruptions, thus improving the workflow.

The tool can provide flexibility in the working day and have a positive impact on the nurse-patient relationship. However, RPM can also lead to an increased flow of information, which the nurses can find burdensome. The study further indicates that the collaboration between nurses and developers of e-Health technology can yield a useful and user-friendly solution. 

RPM can be a valuable addition to the care of cancer patients receiving outpatient treatment. In order to achieve this, it is important that nurses are involved in tailoring the digital solution to their working day. Resources must also be allocated for new tasks that arise from this new way of organising nursing practices. 

The authors declare no conflicts of interest.

Open access CC BY 4.0

Introduction

In the past ten years, local authorities have taken on more responsibility within the health and care service. The ageing population is expected to increase considerably by 2040 (1). One of the consequences is that the demand for nurses in primary care is also rising (2). Kristiansen et al. (3) emphasise the importance of local authorities both recruiting and retaining newly qualified nurses. Meanwhile, it has emerged that students do not find primary care work as appealing as working in the specialist health service (3, 4). 

Surveys show that only two out of ten newly qualified nurses list nursing homes or home care services as their first choice (4, 5). The students’ experiences from clinical placement seem to influence their choice of workplace once they are qualified nurses (4, 5).

NOKUT’s report and analysis of the Norwegian National Student Survey 2018 (6) shows that clinical placements help to enhance students’ sense of belonging to the workforce. Students encounter learning situations and gain insight into their future work as a nurse. Clinical placements are a key setting for developing knowledge, skills and general competencies. For students, knowledge and learning can present differently in a practical setting compared to an academic one, and there can be a major disconnect between theoretical knowledge and practical application. One characteristic of professional degrees such as nursing is that they cover a range of different courses or subjects, and learning takes place both at the educational institution and out in the field (5–10). 

According to Hovdenak and Risør (11), professional knowledge is formal, rational and abstract; yet it is also concrete because it can be applied. Theoretical perspectives provide a basis for reflection, interpretation and analysis, which underpin practical action. It is therefore essential to foster students’ understanding of the importance of different theoretical perspectives and their practical application in the field. 

For students, the validity of the knowledge base stems from its relevance to practice, as described by Grimen (8). Grimen argues that a fruitful approach is to view this knowledge base as a set of meaningful wholes that may not necessarily be well integrated from a theoretical perspective. The coherence is instead based on practical syntheses in which different pieces of knowledge are combined because they form meaningful components of professional practice, understood as a practical whole.

Hatlevik and Havnes (9) highlight how a sense of coherence is something that can be created and discovered when students actively engage with and reflect on the contradictions they encounter (9), such as those experienced in inspirational practical training.

According to the new programme description for the bachelor’s degree in nursing at Oslo Metropolitan University (OsloMet) (12), first-year students are required to complete a mandatory one-week learning activity in their first semester, which takes the form of inspirational practical training at a nursing home, before undertaking a six-week clinical placement at a nursing home in their second semester. The purpose is to give first-year students an early insight into professional practice and hands-on experience with nursing tasks in a nursing home. 

Inspirational practical training is supervised but not assessed (12). Terms such as ‘observational practice’ and ‘guest placements’, as described in the curriculum for the bachelor’s degree in nursing from 2008 (13), seem to be synonymous with what we refer to as ‘inspirational practical training’. 

A mandatory learning activity in the course SYKPRA 60 (12) for third-year students is to plan and carry out mentoring of first-year students during their inspirational practical training, in collaboration with the practice supervisor and academic supervisor (12). 

Several studies (14–20) focus on peer learning in which ‘older’ students mentor first-year students in simulation centres and clinical settings. The studies also show that peer mentoring is a pedagogical method that is often valued by students and that reduces the stress of supervision for those being mentored. The students who were mentored found the training to be a valuable learning experience when they were actively involved and included in various tasks in the clinical setting (21).

Students’ interactions and experiences with peer mentorship have been thoroughly studied (22). However, systematic and unsystematic database searches reveal few studies that explore first-year students’ experiences with nursing in peer-mentored inspirational practical training in nursing homes. One exception is the study by Lillekroken et al. (23), which shows that first-year students were inspired by and learned a lot from being mentored by third-year students.

To provide students with high-quality learning activities related to clinical practice, more knowledge on this topic is needed. The objective of this study was to explore experiences during such inspirational practical training. 

Research question in the study

We posed the following research question: ‘What are first-year students’ perceptions of nursing based on peer-mentored inspirational practical training in a nursing home?’

Method

We used the COREQ (consolidated criteria for reporting qualitative research) guidelines in our study (Appendix 1).

Design

The study is qualitative and has an exploratory and descriptive design. Data were collected from eight focus group interviews with first-year students. We chose focus group interviews because this method allows for an in-depth exploration of participants’ perceptions, opinions and experiences (24).

Recruitment and sample

All first-year students (N = 488) from the 2022 cohort at the Department of Nursing and Health Promotion (SHA3) at OsloMet were invited to participate. Students were recruited in two rounds because the cohort completed their inspirational practical training in two rounds. 

Recruitment was conducted via emails to students and announcements in OsloMet’s digital platform. The email included brief information about the background, objective and design of the study. The students were also informed about giving their consent to participate and that they could withdraw from the study at any time without repercussions. During study group sessions, students were reminded orally to respond to the email. Some participants withdrew before the interviews started because the time and place were not convenient.

A total of 488 students were invited to participate and 53 accepted. Participants ranged in age from 19 to 54 years, and only seven were men. Most had no work experience in the health service, but some had up to 13 years of clinical experience in the care of older patients. 

Conducting the research interviews

The interviews were conducted within a week of the students completing their inspirational practical training, between October and November 2022. The interview guide was devised prior to data collection and consisted of five phases: 1) identifying the prerequisites for using semi-structured interviews, 2) searching for existing knowledge on the topic, 3) formulating a preliminary semi-structured interview guide, 4) pilot-testing the interview guide, and 5) presenting the final semi-structured interview guide (25). 

The interview guide included open-ended questions about the students’ experiences with peer mentoring in clinical practice, their perceptions of clinical practice in a nursing home setting, and their understanding of the nurses’ tasks in clinical practice (Appendix 2 – in Norwegian). The interviews were held in meeting rooms on campus. One of the authors led the interview, while another acted as a co-moderator. 

The interviews lasted between 30 and 55 minutes, and the group composition varied from three to twelve participants. We aimed to ensure that everyone had the opportunity to express their views. In the dialogue between focus group members, new perspectives and opinions emerged on the topics we aimed to explore. We made audio recordings of the interviews and transcribed these. 

Ethical considerations

The study was registered with Sikt – the Norwegian Agency for Shared Services in Education and Research, reference number 334855. The interview transcripts were deidentified, and the audio files were deleted immediately after transcription. The coded quotes are recognisable to the researchers but are only linked to the interview participant number, not to the individual.

Participants signed the consent form before the interviews began, after receiving the necessary information about the study and being informed that they could withdraw at any time without repercussions for their academic progress. 

Participants did not receive financial compensation for the interviews, and none of them withdrew once the interview had started, or afterwards.

Analysis

The analysis is based on Kvale and Brinkmann’s (26) three interpretative contexts. First, all the authors read the interview transcripts to form an overall impression of the text. We then discussed the material without going into details, but highlighted and noted keywords that described meaning units in the interviews. Next, we worked together to identify meaning units across the text material. 

This process led to the creation of codes. These codes were discussed within the project group, and the first, second and last authors organised them into eight codes. The text was then structured under the various codes.

Finally, the text was summarised and reorganised to ensure it addressed the research question in the study. The analysis resulted in three themes, each represented by headings derived from the text that capture its meaning.

Preunderstandings

The study is a collaboration between six employees working on the bachelor’s degree in nursing in the same academic year. Four are associate professors, one is a senior lecturer and one is an assistant professor. We have between 1 and 25 years of experience in educational institutions. 

We also have varying levels of experience in researching the relevant field. This diversity enabled us to read and interpret the data from different perspectives, resulting in valuable insights. All authors led one or more interviews and transcribed them. The first, second and last authors worked most closely with the analysis and discussion, with input from their co-authors.

Inspired by the concept of ‘information power’ (27), we continuously evaluated the number of focus group interviews to ensure a rich dataset. The evaluation included assessing factors such as alignment between the objective, sample specificity and analysis method of the study. After eight focus group interviews, we concluded that the data collected provided sufficient information for a coherent exploration of various aspects (27). 

Results

The analysis resulted in three main themes that reflect the first-year students’ experiences of what nursing entails in a nursing home setting. These themes are supported by quotes from various participants, whose focus group and participant number are denoted after each quote, e.g. (FG5, S5), which means focus group 5, student 5.

Nursing is about checking that everyone is doing well

The first-year students described nursing in nursing homes as multifaceted, with nurses having a major responsibility. Nursing tasks observed by the students included administering medication, documentation, reporting and ensuring that the residents were doing well. Another nursing task was maintaining a comprehensive overview. Several participants noted that the nurse’s main responsibility was to ensure the well-being of the residents. One of the participants expressed it as follows: ‘Nursing is about keeping track of the well-being of patients, that’s where the main responsibility lies’ (FG5, S5). 

Furthermore, the students described values like respect as pivotal to the nurses’ work in nursing homes: ‘Respect for the resident […] that we shouldn’t treat anyone differently’ (FG4, S1). Some students also emphasised the ethical perspective in nursing, where they believe care and the resident’s autonomy are central:

‘It’s crucial that residents’ families see your skills and professionalism so they can trust that you’re treating their loved one properly. It helps reassure them that their father, mother, or whoever, is doing well.’ (FG2, S2)

The first-year students described the importance of good communication skills for nurses being able to uphold these values. This also applies in relation to colleagues, other occupational groups and management. One of the students stated: ‘Good communication skills. Not least with colleagues, management and in interdisciplinary teamwork’. (FG2, S3) 

Many of nurses’ tasks in a nursing home are directly patient related. The students also observed that planning and managing the work in the department are important tasks. Nurses serve as advisors, but they are also the ones who remain one step ahead in preventing adverse events.

The first-year students described nursing as the work of meeting the residents’ basic needs. Several recounted episodes where they either observed or helped with residents’ personal care. Many noticed that this was carried out thoroughly and that observational and communication skills were applied, along with knowledge of hygiene principles.

Experiencing nursing first hand

Although several of the first-year students had previous experience from nursing homes, they still felt that they had gained new insights and perspectives during the inspirational practical training. They mainly highlighted procedural tasks and how these can be performed correctly. Some of them also reported learning tips from the third-year students that were not found in textbooks but were used in practice. 

Several first-year students stated that the inspirational practical training helped prepare them for upcoming clinical placements and their future careers. They gained an understanding of what nursing entails in the nursing home setting and how nursing care was carried out in the daily work: 

‘We attended a morning meeting. The head of department was there as well. I thought it was quite educational. Seeing how they communicated with each other. We got to hear how the residents had been doing, and whether there was anything we needed to think about.’ (FG1, S4) 

Some described the inspirational practical training as fun, explaining that it gave them the opportunity to experience a learning environment that was different from university and the simulation and skills unit. By putting into practice at the nursing home the knowledge they had learned in seminars, lectures and the simulation and skills unit, they felt they developed a deeper understanding of what nursing entails. Others highlighted the importance of being present in the department: ‘Meeting a resident and saying “I’m a student, is it okay if I take your blood pressure?” made it feel very real’. (FG6, S2) 

It became clear to several first-year students that the nurses and third-year students understood why they were performing the various tasks in the nursing home. This became apparent when they explained why they carried out certain actions, such as weighing the residents. In this context, the first-year students felt they too were able to recognise the connections and understand the reasons behind the actions, based on their theoretical knowledge: 

‘I now understand the point of the weighing. That they do it once a month. I get it now, you see things in context. If I’d been employed at a nursing home, I would’ve just accepted “oh yes, we weigh them once a month.” I wouldn’t have questioned it. Now I do ask questions because we have the theory. There’s a connection.’ (FG3, S1) 

It was not so apparent to others how different types of knowledge are combined and applied in the work of caring for residents, and they believed that nursing in a nursing home mostly involves providing basic care and assistance. Some felt, for example, that they had not been involved in many nursing tasks. 

They also stated that tasks related to meeting residents’ basic needs, such as personal care, are not really nursing tasks: ‘You deal with their personal care, and then you’re done. But that’s not really nursing’. (FG8, S8) 

As a result, they believed that nursing cannot be learned in a nursing home setting alone. Others made the same point, highlighting that ‘you think more about nursing in hospitals and such like. Giving injections and jabbing patients with needles and things like that’. (FG8, S10)

Framework for important learning points 

Third-year students are free to decide what first-year students should participate in and learn about during inspirational practical training. However, there are contextual factors at the different nursing homes that also influence this, such as physical space, the health status of patients and time: 

‘We tried to get involved with the personal care, but since there were so many of us, it was too much with four new people in a dementia ward. So we just had to let the third-year students do what they needed to do while we waited.’ (FG5, S4) 

The third-year students who plan and carry out the mentoring set a framework for what they consider important for first-year students to learn. Despite the first-year students believing that personal care is a core aspect of the work, they reported that some third-year students ‘spared them’ from participating in this because they perceived it as merely a routine task. 

Some third-year students told first-year students that working in a nursing home is boring and that it demotivates them in terms of their profession. One first-year student pondered on the third-year students’ views on working in a nursing home: ‘They told us that being there made them feel discouraged because they felt it wasn’t what nursing was about’. (FG8, S10)

Discussion

Knowledge and competence in nursing

The findings show that first-year students experience nursing as a varied profession with a broad range of tasks. Nursing duties involve meeting patients’ basic needs and performing procedural tasks. They also pointed to other areas of nurses’ scope of practice, such as planning and leading the work in the department.

A characteristic of professional practice such as nursing is that the tasks often require a heterogeneous knowledge base (28). The nurse’s competence lies in knowing when and how to apply and combine knowledge. 

The findings show that several first-year students recognised that the nurses and third-year students possessed professional knowledge about whey they performed the variety of tasks at the nursing home and were able to explain why they implemented certain measures, such as weighing the residents. In such cases, the first-year students were also able to link this to their own theoretical knowledge. One possible synergy is that the first-year students were encouraged to look at their previously acquired knowledge and skills, such as weighing the residents, from a new perspective. 

Grimen’s (8) point of departure is that the demands of professional practice mean that pieces of knowledge that are not necessarily linked by theory, can still form a meaningful whole. According to Grimen’s terminology, when complex pieces of knowledge are integrated into nursing practice, practical syntheses are formed.

According to Hatlevik and Havnes (9), however, this requires the professional practitioner, in this case the first-year student, to be able to understand potential connections and articulate them in the relevant situation and context. The descriptions from the first-year students reveal a complexity in the relationship between theory and practice. One example is the first-year students’ descriptions of precision and adaptation when performing personal care. They illustrate how nurses are expected to apply their knowledge and skills, regardless of whether it is in interactions with residents or their families, or colleagues, and that this requires discretionary assessments. 

This is consistent with Grimen (8). In other words, different professional perspectives, according to Havnes (10), will be relevant or be made relevant in nursing practice depending on the situation. There will always be a degree of uncertainty, therefore, about which practical syntheses are relevant in a given situation. Assessments of what is considered relevant may also vary. 

The relational role of nurses also seems to become clearer for several of the first-year students. For example, they described a nurse at a nursing home as both a coordinator of interdisciplinary work and as a source of reassurance and a link to the institution for the residents’ families. Communication and interaction with residents are based on values such as respect and autonomy, and are pivotal to nursing practice. 

In line with Nortvedt (29), the first-year students’ descriptions revealed some of the distinctive features of care, namely the attitude and attentiveness in nursing practice that embody care. Haugan (30) highlights how attentiveness is the essential ‘tool’ in a caregiver–patient relationship. In the words of Martinsen (31), it is about being attentively present.

First-year students’ experiences with learning in clinical practice

The findings show that some first-year students believed that nursing in nursing homes is not advanced enough for them to learn nursing. This may be because they believe they do not have the professional expertise to ‘see’ the diversity in relevant nursing challenges in the nursing home. 

Hovdenak and Risør (11) point out that theoretical perspectives enable reflection, interpretation and analysis as a basis for action. However, they also require the first-year students to understand how they can apply the different theoretical perspectives to practice. Nor is relevance to practice an inherent quality of the knowledge, as observed by Hatlevik (32); relevance is created through the application of knowledge. 

Nowadays, nursing home residents often have complex comorbidities (30, 33). The first-year students therefore need guidance to recognise what they are observing and experiencing in situations with residents, so they can understand how knowledge gains relevance and validity in clinical situations. Conversely, those guiding the students must also be capable of showing them the way (19, 20). 

Wiggen notes that if the students, in our case first and third-year students, are not adequately prepared, the outcome may be that they are unable to reflect on practice, and consequently do not learn anything (6). 

The findings show that some of the first-year students believe that nursing cannot be learned in a nursing home setting alone. They associate nursing and nursing tasks with the hospital setting. Some types of knowledge require a physical presence where the knowledge is being applied (8). In this context, the knowledge is embedded in our actions. It is subjective, sensory and concrete, such as adapting personal care and nursing techniques to the patient or resident. 

According to Grimen (8), action is a way of articulating knowledge that is as fundamental as verbal expression. It is therefore important that first-year students gain insight into the diversity of the nursing profession through inspirational practical training and real-world interactions with patients and residents. However, our findings show that some first-year students consider the flow of actions in nursing practice to be unproblematic, and they have few issues or questions. As a result, their ability to reflect is not challenged. Alvsvåg (34) emphasises that in such cases, the situation will pass without further consideration. 

The study’s findings suggest that it was chiefly the third-year students who decided which aspects of nursing first-year students gained insight into in the nursing home. The first-year students described the importance of being involved in personal care situations. 

In contrast, some first-year students mentioned in the interviews that they had been spared from personal care tasks, as the third-year students felt it was too basic and uninteresting. International literature shows that many nurses and nursing students believe that addressing patient’s basic needs is common sense. They do not see it as part of their job – there is nothing complicated about it, it does not require any special education and/or knowledge, and it is not important (35). 

Such attitudes have led to poor nursing care, or what Richards and Borglin (36) refer to as ‘shitty nursing’, with adverse effects on the quality of nursing care.

The first-year students’ reflections suggest that some third-year students allowed their peer mentoring role to become overly subjective by focussing only on the aspects of nursing they considered relevant, such as medication administration or other procedural tasks like measuring vital signs. 

Benner’s (37) interpretation of the Dreyfus brothers’ five-stage model highlights the progression from a novice with little experience to an expert with rich experience. Our findings may align with this five-stage model, suggesting that the third-year students are not sufficiently sensitive to the first-year students’ needs, potentially reflecting the characteristics of a novice in this context. Peer mentoring could therefore ‘hinder’ first-year students’ exploration of nursing as a discipline and profession. 

Conclusion

The first-year students have a watchful and diverse view of nursing in their first encounter with clinical practice. They recognise the complexity of the field and nursing practice and start to form an understanding of its relevance based on the knowledge they have acquired. Some also realise that clinical placements in a nursing home alone will not be sufficient but that they could be useful for learning various aspects of nursing’s scope of practice. 

However, successful inspirational practical training will depend on the framework for the physical capacity of the clinical placements, as well as how well prepared both the first and third-year students are. The findings of this study will be relevant for the future planning of inspirational practical training. It would also be interesting to investigate the experiences of third-year students in this training.

The authors declare no conflicts of interest.

Open access CC BY 4.0

Introduction

Over the past ten years, the role of social media in our daily lives has increased significantly. Everyone in the age group 16–34 years in Norway uses image-sharing platforms (1). Today, the average age of first-time mothers is 30 (2), placing them within the age group of the most frequent users of social media. Women actively turn to social media during pregnancy and the postpartum period to gather information and receive emotional support (3, 4).

During pregnancy and the postpartum period, women are in a vulnerable phase of their life (5). This vulnerability can be intensified by increased social media use, which is associated with lower levels of psychological well-being and a more negative self-image (4). In this phase of life, women tend to reflect more on their body image and appearance due to the major and rapid changes they experience (6). 

Body image is based on an individual’s perception, thoughts and feelings about their own body (7). A negative body image during and after pregnancy increases the risk of adverse outcomes, such as depression, dietary issues and a shorter breastfeeding duration (8, 9). However, studies have shown that pregnant women generally have a significantly more positive body image than non-pregnant women (10).

According to social comparison theory (11), we compare ourselves to others to objectively evaluate ourselves, and such comparisons affect our relationships and emotions. Objectification is the act of degrading someone to the status of a mere object or reducing them to their physical attributes. Women in particular are subjected to this, for example in the media (12). 

Objective of the study

The objective of this study was to explore whether social media influences women’s body image during pregnancy and the postpartum period. Social media is a relatively new phenomenon, and there is limited research on how it affects the body image and mental health of this group of women. Summarising recent research on this topic could help fill the existing knowledge gap.

In our increasingly digitalised society, it would be beneficial for midwives and other healthcare personnel to gain more insight into the impact of social media on women’s health and well-being from the perspective of health promotion and prevention.

Our research question was as follows:

‘What influence does social media have on pregnant and postpartum women’s body image?’

Method

We performed a systematic literature search in the databases CINAHL, Pubmed, PsycINFO, Web of Science and Oria in November 2023 and February 2024. In a systematic literature review, a clearly formulated research question is established before initiating a systematic search in databases (13). We used a format based on the PICOT template to help develop a research question prior to performing the searches (Table 1).

Search strategy

We developed keywords that we considered relevant for identifying sufficient and current scientific literature. The search terms were body image, social media and pregnancy.

In our search for relevant research literature, we examined the title, abstract and keywords of all 995 results in the databases. We ended up with 48 articles that appeared to be relevant. Of these, only 15 were suitable for full-text reading, as they met our inclusion and exclusion criteria. A total of seven articles that specifically addressed the topic were ultimately included, consisting of two qualitative and five quantitative studies. The selection process is presented in a PRISMA flowchart (14) (Figure 1). 

The articles we included were individual studies of pregnant women or women who had given birth in the past 12 months, and social media. Table 2 shows our inclusion and exclusion criteria, which provided the framework for our searches. 

Appendix 1 (partly in Norwegian) shows our search history from November 2023. No new scientific articles were identified in February 2024.  

Quality assessment of articles included

Quality assessment entails a structured review of the strengths and weaknesses of the scientific article. We used the Critical Appraisal Skills Programme (CASP) tool in our critical review of qualitative studies and quantitative randomised controlled trials (RCTs) (15). For cross-sectional studies, we used the Joanna Briggs Institute Critical Appraisal Tools (16). Six articles were considered high quality, while one was deemed to be medium quality. Table 3 provides insight into our quality assessment.

Analysis method

We used the thematic analysis method, which involved identifying themes that directly reflect our research question, based on the findings in the articles (13). The authors worked together to discuss and identify themes. We then compared the findings in the articles and identified three overarching themes. Table 4 shows the themes developed from the data analysis. 

Results

Different portrayals contribute to differing perceptions of body image

Research shows that social media use and dependence on technological devices are associated with a negative body image among pregnant women and concerns about how their bodies look after childbirth (17). 

Pregnant and postpartum women report being exposed to unrealistic and unattainable portrayals of pregnant women and new mothers on social media. Women talk of a focus on the perfect, slim body on social media, both during pregnancy and after childbirth, and how this focus negatively affects them. However, women also protect themselves by being critical to the content posted and limiting the time spent on social media (18). 

Research shows that social media portrayals of slim and athletic women’s bodies contribute to negative emotions among women about their own body (19).

A total of 41% of the participants in the study by Liechty et al. (19) said that portrayals in social media had a negative influence, while 33% had mixed feelings. Furthermore, it was revealed that 46% felt negatively about their body as a result of being exposed to idealised images of pregnant and postpartum women:

‘I don’t like, anytime when you’re talking about “in sixth months” it’s just, like that’s too short a time. There is a lot of healing that needs to happen after you have a baby and maybe for some people they can go that fast, but I just feel that’s unrealistic. I feel like that’s what makes us all depressed because after 6 months we don’t look like her […]’ (19, p. 854).

The study by Tang et al. (20) found that exposure to body-focused images and videos of women who had recently given birth had a negative effect on postpartum women’s body image. Body dissatisfaction was most common in the intervention group, which was exposed to body-focused content, compared to the control group, which was exposed to realistic images. 

Another study found that participants who were exposed to images of slim and athletic pregnant and postpartum women reported a more negative body image (21). 

Hicks and Brown (22) reported that 47% of participants felt anxious about their own bodies during pregnancy when using Facebook. Sixty-seven per cent felt envious of how their friends looked while pregnant, and 61% reported being envious of how celebrities looked during pregnancy. Only 8% reported feeling self-assured about their bodies during pregnancy. It was found that the level of body dissatisfaction, combined with increased concern about how the body looked after childbirth, increased proportionally with the amount of time pregnant women spent on Facebook. Pregnant women who did not use Facebook were more positive about their bodies than those who did use the platform. 

Another study similarly showed that reducing media consumption had a positive effect on pregnant and postpartum women’s body image (19). 

During pregnancy and after childbirth, women report that they are less negatively affected by social media portrayals of the female body in these stages when they recognise that much of it is unrealistic (18). In the study by Liechty et al. (19), 54% of the women said they were not affected by media images. These women were critical of portrayals in social media, felt supported by their friends and family and were aware that all bodies are different: 

‘I definitely wanna compare myself … I feel like I wanna live up to that and then like I should live up to that, and it’s just overwhelming because anyone who has a baby in Hollywood, like immediately loses all the weight … but then after remembering, like, the things that matter most … then I realise, “Ok, I shouldn’t worry about that, I don’t care”’ (19, p. 855).

Becker et al. (21) found that positive emotions related to body image arose when women were exposed to realistic images of pregnant women and women who had recently given birth. Similarly, Liechty et al. (19) showed that 26% of participants reported that realistic portrayals in social media had a positive influence on their body image. 

Body-focused comparisons as a result of social media use

Pregnant and postpartum women feel that social media can stimulate comparisons. Women often compare themselves to other women on social media who have the ideal appearance, i.e. women who do not experience significant weight gain during pregnancy or who quickly regain their pre-pregnancy body after childbirth (19): 

‘I see lots of moms who are posting … they just look really skinny … and I look like this. … I feel bad just cause I want to be back in my normal size and everyone else seems to be doing it …’ (19, p. 856).

Women’s lives are often glamorised on social media, and how they are portrayed deviates from reality. Much of the content posted on social media has a body-focused perspective and does not reflect women’s actual lives: 

‘I think sometimes people see Facebook as a way to compare yourself with other people and sometimes you don’t get the real picture of what is happening in people’s lives …’ (19, p. 857). 

Research shows that pregnant and postpartum women experience negative emotions when they see portrayals of slim and athletic women in the media. These negative emotions stem from comparisons of themselves with the women in the images, leading them to feel pressure or an expectation to look the same (19): 

‘I think that the message it is sending is that…keeping your figure…is what’s important,...So I just feel like the message is who cares about your baby, or how healthy your pregnancy is going – just make sure you look good.’ (19, p. 856).

Women report that after giving birth, they compare their bodies to those of other women on social media. They feel pressure from society to post unrealistic images of their bodies and fear they will fail to live up to ideals and expectations (18): 

‘You might be more influenced than you think. There is after all a reason why you feel like you should get back to normal as quickly as possible. It’s because you’re influenced by other new mums who look great a few weeks after giving birth, you know. And then you look at yourself after four months, and you still have that slightly flabby belly.’ (18, p. 79 – our translation).

The study by Nagl et al. (23) found that 42% of new mothers compared themselves in particular with close friends on social media. Comparisons with celebrities on social media were less frequent, but as many as 93% of the women who reported comparing themselves to celebrities did so in an upward direction, i.e. they compared themselves to someone they perceived as better than themselves (11). 

Frequent use of social media is associated with body dissatisfaction after childbirth because women compare themselves with unrealistic, idealised content (23). 

Sharing content on social media is associated with competition to resemble the idealised images of pregnant women’s bodies (17). It has been shown that the more time pregnant women spend on Facebook, the more they compare their own bodies to others. This leads to competition to look good while pregnant (22). As many as 67% of the pregnant women in the study by Hicks and Brown (22) felt pressure to look like the idealised pregnant bodies seen on social media.  

Influence on lifestyle

In the study by Zeeni et al. (17), pregnant women’s social media use was found to be strongly associated with healthy eating habits. However, the study also revealed that factors such as age, body mass index (BMI), parity, trimester, use of dietary supplements and rapid weight gain during pregnancy had no impact on the outcome of eating habits. 

Nagl et al. (23) also found a link between social media and diet among postpartum women. However, their findings showed a more negative influence: body dissatisfaction resulting from social media use was associated with higher levels of eating restraint and dietary concerns among postpartum women. 

Similarly, the study by Tang et al. (20) showed that when postpartum women were exposed to body-focused images on social media, they developed a strained relationship with food. It was also found that this type of exposure inspired them to be more physically active. However, this inspiration was short-lived and did not result in changes in their activity levels.  

Discussion 

Forming body image through social media

Our findings show that exposure to body-focused social media posts can lead to body dissatisfaction among pregnant and postpartum women (17–22). According to objectification theory, women are reduced to objects that are expected to satisfy society’s expectations of how the female body should look. Body dissatisfaction occurs when women feel they do not meet the ideal (12). 

Our study shows that increased use of social media is linked to a more negative body image among pregnant and postpartum women (19, 22). Previous studies indicate that a negative body image among these groups can contribute to antenatal and postnatal depression, shorter duration of breastfeeding and increased use of formula milk (8, 24). In the context of objectification theory, depression, shame and anxiety in women can be a result of body objectification (12). 

Our study found that less frequent social media use had a positive effect on body image for women during and after pregnancy. Studies have shown that women who check Instagram repeatedly throughout the day evaluate their physical appearance far more than women who do not use Instagram (19, 22). According to Cohen et al. (25), a similar pattern is observed with exposure to appearance-related posts on Facebook. Other research shows that the use of image-sharing platforms is associated with body dissatisfaction (26, 27). 

Our findings show that social media can also have a positive effect on women’s body image during pregnancy and in the postpartum period (19, 21). This is supported by the study by Tiggemann et al. (28), which demonstrates that exposure to images of fuller-figured bodies can promote a positive body image among women. Cohen et al. (29) found that young women who are exposed to social media posts that embrace the female body’s variety of shapes and sizes can develop a more positive body image.

Our results indicate that some women feel that portrayals in social media have no impact on their body image. This depends on their awareness that social media images can be altered and do not always reflect reality. Support from friends and family is also essential (18, 19). Rodgers et al. (30) also found that support and encouragement from family and friends, with an emphasis on physical function, had a positive effect on women’s body image. 

Social media stimulates appearance-focused comparisons

Our findings suggest that pregnant and postpartum women often experience negative emotions when they see images of other women in similar situations on social media (18–20, 22, 23). Social comparison theory explains how comparisons can trigger both positive and negative emotions, depending on whether the comparison is upward or downward (7, 11). Research indicates that comparisons with images perceived as closer to the ideal are associated with a more negative body image (31).

Our results further show that negative emotions resulting from comparisons stem from a perceived societal pressure to look slim and athletic, both during and after pregnancy (18, 19). This finding aligns with objectification theory, which posits that negative emotions related to comparison arise from unrealistic societal standards and ideals of the female body (12).

Our findings show that pregnant and postpartum women compare themselves to women on social media who have not gained much weight during pregnancy and who quickly regain their pre-pregnancy body after childbirth (19). One woman in the study by Loftås and Råheim (18) reported feeling pressure to return to her pre-pregnancy body as quickly as possible after giving birth.

Tiggemann and Anderberg (32) discovered that comparisons with idealised images of women on social media can contribute to a more negative body image. They also found that women can improve their body image by comparing themselves to realistic images of other women (32).

Our results indicate that pregnant women who use social media feel as though they are in some sort of competition, where their bodies should resemble the idealised images of pregnant women as much as possible. This leads to negative emotions (17, 22). According to social comparison theory, individuals will adjust their level of aspiration to align more closely with that of others if they perceive it to be better than their own (11). 

Changes to eating habits as a result of social media use

Our findings show that social media can positively influence healthy eating habits in pregnant women (17). In contrast, Rodgers et al. (30) highlight how sociocultural pressure to look slim during and after pregnancy, such as portrayed in social media for example, can contribute to restrained eating and strict exercise routines during pregnancy. Our results also indicate that social media can lead to a strained relationship with food in women who have recently given birth (20, 23).

In light of objectification theory, comparisons with idealised images of other women’s bodies can lead to body dissatisfaction, thus contributing to the development of eating disorders (12). This theory is further supported by research on women in general, which indicates that upward comparisons with social media images are associated with restrained eating and eating disorders (26, 31). 

Implications for clinical practice

Midwives play a crucial role in promoting women’s health and well-being, both at the individual and public health level. It is reasonable to assume that guidance and counselling in antenatal care can raise awareness of social media’s influence and foster realistic expectations of the female body during pregnancy and after childbirth. By doing this, midwives can help women protect themselves from the negative consequences of exposure to unrealistic social media posts. 

Methodology

A strength of the study is that the systematic literature searches were conducted in five different databases. We worked together on the thematic analysis to strengthen the study’s internal validity. The search method is thoroughly described, making our findings verifiable.

Social media is a more or less global phenomenon. It is therefore reasonable to assume that our findings have transferability to the broader female population, which strengthens the study’s external validity. Our study shows that social media and pregnant and postpartum women is an under-researched area. This area of research is relatively new, which strengthens the relevance of the study.

Conclusion

Our findings suggest a complex relationship between social media use and body image among pregnant and postpartum women. Social media can have both a positive and negative effect, depending on the content women are exposed to and how critical they are of this. The use of social media in this phase of life leads to social comparison, which can impact women’s eating habits.

Our study identifies a need for further research in this area. This study provides a basis for future research that could help shape guidelines and interventions that support women’s health and well-being during this phase of life. 

The authors declare no conflicts of interest.

Open access CC BY 4.0

Introduction

Healthcare-associated infections (HAIs) are infections that occur in a patient in a hospital or healthcare institution. HAIs are prevalent and often lead to suffering and mortality among nursing home residents (1, 2). Many of these infections are treated with antibiotics and widespread use contributes to antimicrobial resistance (3). The United Nations (UN) considers antimicrobial resistance to be one of the top global public health problems (4).

In nursing homes, nurses play a crucial role in limiting the unnecessary prescription of antibiotics and the spread of antibiotic resistance (5, 6). The most effective strategy for reducing widespread use of antibiotics is to decrease the number of infections (3, 7).

An important aspect of infection prevention is monitoring the number of infections (8, 9). This can provide us with information and knowledge about the frequency and types of infections. Early detection of an infection outbreak is essential so that preventive measures can be implemented before the infection spreads further (5, 10). 

The World Health Organization (WHO) believes that infection surveillance should be a top priority in institutions (8). In the Norwegian Ministry of Health and Care Services’ action plan for improving infection control in order to reduce HAIs 2019–2023, one of the goals is to improve infection surveillance in hospitals and primary care institutions (5).

The goals outlined in the action plan have not yet been realised. Norway monitors many conditions and has quality registries for these. However, there is no system for continuous infection surveillance in healthcare institutions (5). The Norwegian Institute of Public Health conducts a prevalence survey twice a year (NIOS-PIAH), which asks how many patients have the four most common HAIs on the measurement day (2).

The response rate has been low over time, even though participation is mandatory for nursing homes. In November 2023, only 47.5% of nursing homes in Norway participated. The survey revealed that 3.5% of nursing home residents had an HAI. Of these, 1.7% had urinary tract infections, 0.9% respiratory tracts infections, and 0.7 and 0.1% had skin and wound infections or post-surgical wound infections, respectively (2). 

During the COVID-19 pandemic, morbidity and mortality rates increased among older adults, with nursing home residents being particularly vulnerable (11, 12). Most nursing home residents are older, and the natural ageing process can lead to a weakened immune system and reduced physical and cognitive abilities (13–15). 

Advancing age also increases the risk of multiple and chronic diseases, which can lead to frailty (13). This combination makes nursing home residents particularly prone to infection (14, 15), and there is little that can be done to avoid these risk factors. They also tend to experience more severe outcomes from infections, such as prolonged hospital stays, suffering, and death (2, 9, 16, 17). Norway’s Cause of Death Registry shows that infections are the third most common cause of death in healthcare institutions outside the hospital setting (18). Many of these infections could have been prevented (2, 9, 16). 

This study is the first to map infection incidence and antibiotic use in a sample of nursing homes over time in Norway. The objective of the study was to monitor infections in nursing homes over an extended period in order to examine the prevalence of various types of infections, the types of antibiotics most frequently used in nursing homes, and how sociodemographic variables associated with the prevalence of infections changed during the pandemic.

Method

Design

This study is a quantitative prospective study using weekly reporting forms to monitor infection prevalence in nursing homes over an 18-month period. Data were collected between February 2021 and August 2022.

Sample and recruitment 

In December 2020, 17 nursing homes hosting clinical placement students from Oslo Metropolitan University (OsloMet) received information about the study via email, along with an invitation to participate. In January 2021, we contacted the nursing homes again by phone to provide additional information about the study and reiterate our invitation to take part.

Reporting forms and data collection 

Nursing home wards selected staff to submit weekly reports on infections and antibiotic use via the digital platform Nettskjema.no. The responses were sent directly to the Services for Sensitive Data (19). 

The reporting form included questions about how many residents currently had an infection or had had an infection in the past week, their sex and age (≤ 84 or ≥ 85), as well as when and where (at the nursing home or not) the infection began, the type of infection, whether they had more than one infection, and whether antibiotics were used to treat the infection. If they had received antibiotics, we asked about the type of antibiotic, the start date and the estimated duration of the treatment.

The reporting form was devised specifically for the project, based on the clinical experience of the authors and the staff at a nursing home ward. The form was pilot tested by the department head and the nurses in one ward before the study began. Based on their feedback, we revised the wording of some questions and added several antibiotic options to make the form easier and faster to complete.

The wards received an email reminder the following week if they had not submitted a report. We called the wards if several weekly reports were missing.

In addition to the reporting form, the wards were sent a questionnaire on sociodemographic variables twice during the study period: in the summer of 2021 and 2022. This form contained questions about the type of ward (long-term or short-term), the total number of beds and residents, residents’ age (≤ 84 or ≥ 85) and sex, the number of full-time equivalents (FTEs), and the number of nursing FTEs. 

Data analysis

Statistical analyses were performed in Stata version 16. We reviewed the reports in their entirety. Weeks with missing reports were recorded as missing. Healthcare personnel could select the category ‘Other’ for both infection and antibiotic type, and provide free-text responses.

Under ‘Infections’, the ‘Other’ category included 50 different types of infections, while under ‘Antibiotic’, the category consisted of 26 different types. The ‘Unknown focus’ category under ‘Infections’ indicates that healthcare personnel had found an infection but were uncertain about the type.

Descriptive analyses were performed, including cross tabulation. We conducted fixed-effects linear regression analyses to examine which sociodemographic variables could be associated with infection prevalence and how these variables changed over the course of the study. The 18 months were divided into three periods, each spanning six months. 

All significant variables in bivariate analyses at one of the three time points were incrementally included in a multiple regression analysis for each time period. The number of infections reported each week was used as the dependent variable. An interaction term between ‘Ward type’ and ‘Percentage of nursing positions’ was included in the regression analysis.

A significant result indicates that the effect of the number of nurses (percentage of nursing positions) on the number of infections differs depending on the ward type. The variable ‘Occupancy rate’ indicates the percentage of the ward’s beds that are occupied, and the variable ‘Percentage of nursing positions’ refers to the number of FTEs. P-values < 0.05 were considered statistically significant.

Ethical considerations 

This study is part of a larger project that has been reviewed and assessed by the Regional Committee for Medical and Health Research Ethics (REK), reference number 196911 and 226694/REK South-East. Sikt – the Norwegian Agency for Shared Services in Education and Research found that the project complied with data protection regulations, reference number 118936. 

Nursing home residents and their families received a letter giving them information about the study and informing them that they could opt out of data being collected on them for the study and that they could withdraw at any time. Before the study could commence, the department head or quality manager at each nursing home received an information letter and had to sign a cooperation agreement for each ward in the study. 

Results

A total of 22 nursing home wards from 9 different nursing homes wished to participate in the study. The wards consisted of 3 short-term care units and 19 long-term care units in 2021, and 2 short-term care units and 17 long-term care units in 2022. Two wards were closed in the spring of 2022, resulting in two fewer wards in 2022. 

In the summer of 2021, 15 of the wards were organised into several small groups with their own kitchen. All residents had their own toilet, while seven wards were a single large ward with shared toilets for several or all residents. In the summer of 2022, 15 wards still had small groups and individual toilets for residents, while the number with a single large ward and shared toilets was reduced to five. Table 1 shows sociodemographic variables.

During the 83 weeks of reporting, we received 1391 weekly reports. Each ward submitted an average of 63 reports, but there was significant variation, ranging from 31 to 81.

Infections in nursing homes

Over the 18-month data collection period, 1625 infections were reported. Of all new infections, 91.8% originated in the nursing home, while only 8.2% were contracted prior to admission to the nursing home. In the short-term care units, this percentage was higher: 19.7–27.8. It was reported that 30.0% of the infections lasted more than one week. The most common infections were urinary tract infections, followed by respiratory tract and skin infections (Figure 1). 

Antibiotic use in nursing homes

The different infection types were generally treated with antibiotics, and 88.2% of all new infections were treated with antibiotics. Urinary tract infections were treated with antibiotics in 98.2% of cases, skin infections in 92.5% and respiratory tract infections in 75.9% of cases. The exception was gastrointestinal infections, where 61.8% of the infections were not treated with antibiotics. 

The active ingredients trimethoprim-sulfamethoxazole, amoxicillin and mecillinam were used the most. Figure 2 shows the distribution of the various active ingredients, colour-coded to highlight which antibiotics are standard in primary care (20, 21). 

The category ‘Other’ consists of 20 different antibiotics, all of which were used fewer than 10 times. ‘Combination of different types’ can refer to either two different medications or a single-pill combination. 

The most common treatment for respiratory tract infections was amoxicillin (34.2%), followed by phenoxymethylpenicillin (19.9%). Urinary tract infections were treated with pivmecillinam in 32.5% and trimethoprim-sulfamethoxazole in 27.1% of cases. Skin infections were most frequently treated with dicloxacillin (47.3%), followed by the ‘Other’ category (26.0%).

Gastrointestinal infections (76.9%), sepsis (33.3%), infections of unknown focus (26.3%), and the general infection category ‘Other’ (40.0%) were most frequently treated with antibiotics from the general antibiotic category ‘Other’. This category consisted of different types of antibiotics, each of which was reported fewer than ten times. 

Sociodemographic variables associated with the prevalence of infections during the study

The results from the regression analyses show different significant findings across the three six-month periods. The results indicate that high infection rates occur simultaneously with a high number of hospital admissions, which is the only variable that continues to be significant throughout the entire period (Table 2).

The incremental inclusion of variables showed that the interaction term between ‘Ward type’ and ‘Percentage of nursing positions’ was the most important variable for explaining the change in the number of infections. Over the three time periods, this variable accounted for 11.99, 12.64 and 18.10% (adjusted R-squared) of the change in infection prevalence, respectively. In the last period, the hospital admissions variable was the most significant for explaining infection prevalence, accounting for 20.83%.

Discussion

This study is the first in Norway to monitor infections and antibiotic use in a sample of nursing homes over an 18-month period. It describes the prevalence of various types of infections and the antibiotics most frequently used in nursing homes.

Most infections originate in nursing homes

A full 88% of all identified infections in this study originated in nursing homes, and many of these could likely have been avoided with better infection prevention (9, 16). In 2022, Norway’s Cause of Death Registry showed that infectious diseases, COVID-19, influenza and pneumonia were the cause of 3161 of the 24 809 deaths in healthcare institutions outside the hospital setting. This makes infections the third most common cause of death in healthcare institutions outside the hospital setting, surpassed only by tumours and cardiovascular diseases (18). 

Unlike tumours and cardiovascular diseases, most infections are contagious and can be prevented in nursing homes. Nursing home residents are generally vulnerable due to their advanced age, multimorbidity (13–15) and reduced intrinsic capacity. This makes nursing home residents particularly susceptible to infections and the severe consequences of these (2, 9, 16, 17).

In addition, older adults often experience atypical symptoms and can find it difficult to convey relevant symptoms to healthcare personnel (15, 22). These factors combined can lead to delayed initiation of necessary treatments as well as a more severe course of disease, such as hospitalisation, sepsis and death (15). Hand hygiene is the most important and cost-effective measure we have to prevent the spread of infection (8).

Previous findings from this research project have shown just 58% hand hygiene adherence in nursing homes (23), but multimodal interventions could improve this (24). However, the transmission of infection is complex, and good hand hygiene alone will not prevent all infections. Continuous infection surveillance will enable a rapid response with appropriate infection control measures, thus reducing the number of residents infected. 

Antibiotic use in nursing homes

The antibiotics most commonly used in our study were largely consistent with those most frequently prescribed to patients over the age of 75 in 2020, as reported in the Norwegian Prescription Database (25). Broad-spectrum antibiotics are the standard treatment for various infections (20), which may explain the prominence of several broad-spectrum antibiotics in our study.

It was not possible in our study to investigate whether antibiotics were prescribed with the correct indication. Errors and unnecessary use of antibiotics contribute to increased development of resistance, with broad-spectrum antibiotics fostering greater resistance than narrow-spectrum antibiotics (26). 

One of the differences in our study from the Norwegian Prescription Database is that neither methenamine nor nitrofurantoin is frequently used. Neither of these antibiotics has been subscribed more than ten times during the 18-month period and they are therefore classified in the ‘Other’ category in this study. In the Norwegian Prescription Database, methenamine and nitrofurantoin were the sixth and eighth most used antibiotics in 2020 in the over 75 age group (25).

Methenamine, with the most recognised brand name Hiprex, is classified as an antibacterial agent with antiseptic properties. It is used for long-term prevention of chronic recurrent urinary tract infections (27). A 2016 study showed that Norway had the highest methenamine use in the EU/EEA (28).

The low reported use of this medication in our study is therefore surprising. One possible reason may be that nursing home doctors have become more restrictive in prescribing the medication. Research on the preventive effect of methenamine has been inconclusive (29). Consequently, there has not been a clear recommendation to use methenamine (30). 

However, compelling evidence has recently emerged indicating that the medication may have a preventive effect, but only if the urine has the correct pH level and the substance it converts into, formaldehyde, is present at a certain concentration and remains in the bladder for a specific duration. It is not therefore expected that patients with permanent urinary catheters will benefit from methenamine (29). 

Nursing home doctors may have taken this into account, which could explain the reduced use. However, it remains unclear whether the reduced use of methenamine has led to an increase in the use of another antibiotic. Methenamine is an antiseptic agent, and there is currently no evidence that it leads to increased antimicrobial resistance (30). Consideration should therefore be given to whether the use of methenamine is more beneficial than the increased antimicrobial resistance that stems from recurrent urinary tract infections treated with antibiotics (31).

Another reason for the low reported methenamine use could be that the nursing homes in the study did not think to include preventive antibiotic treatment. Although the reports have shown a few instances of preventive treatment, there have been fewer than ten cases per antibiotic, and this has not therefore been highlighted in the study. 

Number of infections varied throughout the data collection period

Many infections exhibit a seasonal trend, with a higher incidence in winter (32). It was therefore interesting to observe the seasonal effects on the number of infections in this study. The interaction term was the primary explanatory variable in the model, indicating that the interplay between ward type and the number of nursing positions was significant. In the middle six months, wards with more nursing positions also had a higher number of infections. We can interpret this to mean that nurses are more likely to detect and report infections.

Ward type is the significant finding with the greatest association with infection incidence. In the last six months, infections increased in short-term care units, which may be due to a higher number of patients being admitted with infections in these units. 

In the middle six months, the short-term care units had fewer infections than the long-term care units. It is difficult to know why, but various factors related to the pandemic may have impacted on our results. In the first six months of this study, there were fewer infections and deaths in Norway than would normally be expected (33), and this is likely due to the COVID-19 vaccine and stringent restrictions.

During the middle six months, infections and hospital admissions both increased in the autumn, which led to further lockdowns (34). Norway experienced an excess mortality of 11.8% in 2022 (33) in the last six months of the study, when the number of infections and hospital admissions during the pandemic peaked (34). 

COVID-19 may have impacted on the organisation of nursing homes, leading to more patients who would normally be admitted to short-term care units being admitted to hospital or a dedicated COVID-19 ward instead. Hospital admissions are the only explanatory variable that remains significant across all three time periods. 

However, the incremental inclusion of variables in the regression analysis shows that hospital admissions have a different explanatory power in the model and are the primary explanatory variable in the last six months. These findings support the interpretations above. Although nursing homes are now dealing with many infections independently and administering more intravenous therapy (35), an increasing number of residents are in such poor health that they require hospitalisation for proper treatment (15).

Strengths and weaknesses

The use of self-reporting questionnaires in the study was a limitation that led to incomplete reporting many weeks from some wards. Additionally, the reports may have been influenced by the person submitting them. Consequently, they do not necessarily reflect the full picture. 

Although most reports were submitted in the same week they pertained to, retrospective reporting was also possible. This may have led to recall bias, as the staff might not accurately have remembered how many infections occurred going back in time.

Another weakness of the study is that we did not follow individual residents over time, so we do not know their outcomes or if certain residents experienced recurrent infections. 

COVID-19 may also have had an impact on the results as it entailed periods with higher infection rates than normal but also stringent restrictions to prevent transmission. The consequence was periods with fewer infectious diseases than usual in the Norwegian population. 

Nevertheless, the strength of the study lies in its weekly reporting over an 18-month period, which allowed us to observe the infection rate over time rather than just presenting a snapshot. The study includes various nursing home wards from nine different nursing homes. It also encompassed all types of infections and was not limited to the most common HAIs. 

Conclusion

The findings from this study show that most infections in nursing home residents originated in the nursing home. Infections can cause suffering for nursing home residents, leading to hospitalisation and increasing the risk of death. Many of these infections could have been avoided with better infection prevention measures. Continuous infection surveillance in nursing homes must be prioritised to quickly control potential outbreaks. 

The high proportion of infections treated with antibiotics in our study is surprising. Increased knowledge and awareness of recommended treatments for infections in nursing homes may help reduce the high use of antibiotics in these institutions. Reducing antibiotic use is a national goal and could also help to decrease antibiotic resistance.

Funding

This study is part of a doctoral project funded by the Norwegian Nurses Organisation, reference number 4207. 

The authors declare no conflicts of interest.

Open access CC BY 4.0

Introduction 

This study was conducted in a rural context in Norway’s northernmost county, Troms and Finnmark. Rural areas are characterised by large geographical areas with low population density, large distances to the nearest hospital and limited healthcare services (1). The demographic evolution in rural municipalities is reflected in the growing ageing population and an increase in the number of people receiving medical treatment in nursing homes following the Coordination Reform (2, 3). Since 2016, local authorities have been required to provide municipal acute bed units (MABUs) (4, 5). 

MABUs were incorporated into nursing homes in numerous rural municipalities. The MABU provision in nursing homes constitutes a limited number of beds for patients with acute illnesses, worsening of chronic illnesses, or the need for observation or investigation of undiagnosed conditions. Patients with mild to moderate mental and substance use disorders are also treated here. The duration of stay is typically limited to three to five days. 

There are no clear guidelines for which patient groups can be treated in MABUs. There is a standard of care requirement in the provision and for it to serve as an equivalent alternative to hospital admission. All patients admitted to MABUs must be examined immediately by a nurse and within a reasonable time by a doctor. 

The need for further follow-up by a doctor is assessed based on the patient’s condition, the treatment or interventions initiated and the expertise of the nurse. The use of scoring tools, such as NEWS (National Early Warning Score) or the Norwegian TILT (Early Identification of Life-threatening Conditions), will be useful for evaluating the patient’s clinical status as well as in the communication between the nurse and the doctor (4–7).

A knowledge summary from 2015 reveals a need for more research on MABUs from a professional clinical perspective, with a focus on the nurses’ new experiences and duties in relation to the development and implementation of the MABU provision (8).

Nursing research on MABUs in a rural context is limited. An observational study from 2018 summarises the first four years after the introduction of MABUs in nursing homes in rural Norway (9). One of the findings was that most patients admitted to MABUs are older adults with complex medical conditions. The need for acute hospital admissions decreased slightly during this period, from 2013 to 2016.

One qualitative study included nurses working in MABUs in both urban and rural areas. The nurses reported that the shortage of staff with nursing competence impacted on the quality of care for the older patients. The study revealed a need for general nursing competence in order to help meet patients’ basic needs, as well as advanced skills in managing complex conditions and situations (10).

A cross-sectional study (11) shows a low nursing staff level and limited availability of doctors in nursing home units with MABUs in rural areas, despite the increase in responsibilities and complexity of duties. The study reveals major variations in doctors’ presence and availability. A low doctor presence can lead to nurses taking on more responsibility, and the quality of care depends on the individual nurse’s competence and cooperation skills.

A qualitative study in which doctors were interviewed about nurses’ competence needs in MABUs highlights three areas: broad medical knowledge, advanced clinical skills, and ethical qualifications and a holistic approach, where nurses precisely and systematically report the patients’ condition to the doctor (12).

Other studies describe the importance of nurses’ organisational knowledge of and familiarity with primary care systems and resources when introducing MABUs (13, 14). 

Several studies describe MABUs as a pathway to a higher level of care for older patients. Frail older MABU patients with functional impairments often require extended stays in an institution (9, 10, 15). 

In international studies from rural acute care settings, nurses report challenges with the generalist role and the steep learning curve. They are afraid of making mistakes in critical situations. Stress has led several of them to consider leaving their jobs (16–18). 

Nurses in rural areas often work alone, without access to interdisciplinary resources or specialists with whom they can discuss the challenges of the job. They therefore need to be competent generalists but also possess specialised skills to handle such a broad scope of practice with limited resources. This role is described in the literature as a generalist specialist (18, 19). 

A 2017 knowledge summary reveals a need for further research to deepen the understanding of nursing practice in a rural context in Norway (19).

Objective of the study

The objective of the study was to gain insight into nurses’ experiences with MABUs in nursing homes in rural municipalities in Troms and Finnmark. We aimed to gather information on the following:

1. The challenges nurses face when working with MABU patients
2. The nurses’ need for competence and resources following the introduction of MABUs

Method 

The study has a qualitative, descriptive design. Data were collected through individual, semi-structured interviews with nurses working in nursing homes with MABU patients. 

Context

We collected data in three rural municipalities in the Norwegian county of Troms and Finnmark. There are a total of five beds in MABUs in nursing homes across these three municipalities. All MABU beds in the study are linked to short-term care units within nursing homes. 

Municipality 1 is a host municipality. It accepts patients from two municipalities and is part of an intermunicipal cooperation for emergency primary care at weekends and holidays. Municipality 2 is part of an intermunicipal cooperation for emergency primary care in which the service is carried out in a neighbouring municipality during evenings, nights, weekends and holidays. Municipality 3 has its own emergency primary care. During the day, the doctor on duty in emergency primary care is responsible for MABU patients and conducts daily rounds. 

The medical practice is located in close proximity to the nursing home in all three municipalities. The five MABU beds serve a catchment area of 7177 km², with 16 740 inhabitants. For comparison, Oslo is 454 km² and has 699 827 inhabitants (20). Table 1 provides an overview of the context of the study.

Sample and interviews

We conducted six individual interviews in January and February 2022. The participants worked at three different nursing homes, primarily in short-term care units, although there were also long-term beds linked to these units. Through strategic sampling, department heads recruited nurses based on specified inclusion criteria outlined in information provided to potential participants. Inclusion criteria were at least one year of experience with MABU patients in nursing homes and a minimum of two years of experience in the primary care service within the relevant municipality. 

The sample consisted of five women and one man, aged 35 to 59 years. Participants had between 10 and 35 years of nursing experience, mainly in primary care. On average, they had 3.8 years of experience with MABUs in nursing homes. Two participants held a master’s degree in nursing, one had specialised in geriatrics, and one was a midwife.

The first author conducted the semi-structured interviews at the participants’ workplace. The interview guide was based on the first author’s experience in rural primary care and identified knowledge gaps in earlier research (8, 10, 19). 

The interview guide consisted of 13 questions about how the MABU provision is organised in nursing homes, available personnel resources and medical equipment, training and competence needs, admission criteria, the nurse’s responsibilities when admitting and following up patients, challenges in the service, and cooperation with doctors and other health services. Participants were encouraged to describe experiences from practice that could shed light on the topic. 

Analysis 

Audio recordings were made of the interviews (21) and these were transcribed by the first author. The analysis is based on Malterud’s (22) four-step systematic text condensation. In the first step, we read the raw data and notes from the interviews to form an overall impression and consider possible themes. 

We then identified, sorted and condensed meaning units. The condensates formed the basis for subthemes and themes. In the fourth step, we shared insights about the phenomena that emerged in the analysis and abstraction process, and summarised commonalities and variations from the descriptions (Table 2). 

Ethics

The Norwegian Centre for Research Data, now known as Sikt – Norwegian Agency for Shared Services in Education and Research, evaluated the study, reference number 569341. The informants received written information about the project and the collection and storage of data, as well as the steps taken to protect privacy and anonymity. They were also informed that they could withdraw from the project at any time. The participants gave informed consent to participate. Before the interviews began, we provided an oral summary of the information, and the participants were given the opportunity to ask questions (23). 

Results

We identified three main themes during the data analysis: 1) Nurses’ competence needs and opportunities for knowledge development, 2) Sole responsibility in nursing homes and the importance of collegial support, and 3) Doctors’ availability and large geographical distances in Troms and Finnmark. Following direct quotes, participants are referred to as D1, D2, D3, D4, D5 and D6.

Nurses’ competence needs and opportunities for knowledge development

The participants described a need for competence in multiple specialist fields due to the increased variety of medical conditions in patients since the introduction of MABUs. One participant described the variation in the patient group as follows: ‘There can be very drunk teenagers needing supervision, pregnant women with hyperemesis gravidarum [severe morning sickness] requiring fluid supplementation, fall injuries, and there are lots of people with infections, so there’s everything’. (D2) 

Nurses’ skills in observing and assessing acute and complex medical conditions

The participants reported that older patients in MABUs often have multimorbidity. They also emphasised the importance of accurate and systematic observations when assessing the patient’s condition and determining how to treat them. With regard to the complexity of the medical conditions, one participant said the following: ‘If the patient has pre-existing heart and kidney failure as well as diabetes, there are several factors affecting their health beyond just the infection they were admitted for’. (D1) 

Several participants described how they needed to consider various factors beyond the patient’s diagnosis and treatment plan upon admission. All had experienced patients being admitted with incorrect or unconfirmed diagnoses. One participant recounted: ‘The doctor thought he was just unwell and needed intravenous fluids and help with ADL [activities of daily living], managing his stoma and COPD medications. But it turned out to be ongoing bleeding’. (D3) 

The participants further described the benefit of having experience and familiarity with the patient and their medical history, which aids the early detection of changes in disease progression. One participant explained how knowing the patient and their previous health issues meant that they assessed the situation differently and more seriously: ‘I had known this man before, and nausea and vomiting were not typical for him’. (D4) 

Patients with a COPD diagnosis were referred to as ‘repeat visitors’ in the MABU. The participants described the challenges of dealing with both physical and mental symptoms in these patients, noting that treatment options in the nursing home are limited if the patient’s condition deteriorates. 

Sharing knowledge and professional development after the introduction of MABUs

The participants explained that knowledge is primarily developed through practical experience, reflection and discussions among colleagues about diagnoses and problems that arise. One participant described how the MABU has contributed to professional growth: ‘I would say you develop professionally. There’s more professional development compared to working in a regular nursing home. The patient turnover rate is higher, and there are more unresolved and acute problems, so I think the learning curve is steeper’. (D4) 

One participant described the learning process as follows: ‘It’s been a bit like learning by doing really. I don’t think we’ve had any special training, other than some instruction on using a bladder scanner that was purchased’. (D1) 

The participants from one municipality mentioned that they had attended a course on emergency medicine since the MABU was introduced and had access to e-learning courses.

Sole responsibility in nursing homes and the importance of collegial support

The participants felt that their range of responsibility was extensive because they are often the only nurse on duty and are responsible for all nursing care in the nursing home, with 50–60 patients in addition to MABU patients. Some participants also described having responsibilities outside the nursing home during night shifts.

Alone on duty and collegial support

The participants expressed feelings of vulnerability during evening, night and weekend shifts due to low nursing staff levels and the burden of sole responsibility. The sole responsibility was described as follows: ‘So it’s mostly just you, there’s no one else to rely on’. (D1)

One participant mentioned a standing agreement to contact an off-duty colleague if they are left to address a problem on their own and need advice or practical help: ‘Nurses can call each other [...], and we also have a private group on Messenger: ‘Support Group for Nurses’. (D3)

The participants described competent nursing associates on the wards, but emphasised that it is primarily the nurse’s responsibility to make clinical assessments and contact a doctor in relation to patient-facing work.

Night shifts and responsibility for the community

Several participants highlighted night shifts as the most challenging due to the sole responsibility and conflicting demands: ‘On night shifts, I’m basically on my own at work in the two wards. So getting MABU patients […] is definitely challenging. You can only be in one place at a time’. (D4) 

Nurses’ responsibilities beyond the nursing home when on night shift were described as part of the job when they are the only nurse on duty in the municipality: ‘So when we log into our phones, we have to log into the more rural parts of the municipality, the central parts of the municipality, the assisted living facilities and short-term care units’. (D6) 

This responsibility involves handling multiple phone calls and forwarding requests from other service providers in the municipality, as well as responding to patient alarms and enquiries from patients receiving home care. Patients, their families and the emergency primary care doctor can all contact the nurse for advice or practical assistance. One participant described how they had to trust their own judgement, have faith in their own experience and feel secure in their nursing role. This makes it easier to cope with sole responsibility: ‘You really need to trust in yourself, be bold, so it’s challenging for newly qualified nurses who come here’. (D5) 

MABU patients are more time-consuming and require more resources

All participants stated that no additional personnel were allocated when the MABU provision was introduced in the nursing homes. They explained that caring for MABU patients is more time-consuming and resource-intensive due to their condition and the need to always have a nurse present for clinical observations. One participant said the following: ‘We have a shortage of resources when it comes to MABUs. We should have more nurses on weekends and at night, but it’s not just a matter of getting more nurses’. (D5) 

The participants described the nurse’s role and responsibilities in relation to MABUs as pivotal to patient safety and the overall provision: ‘A major shortage of nurses would make it difficult to manage the MABU beds’. (D2)

Doctors’ availability and large geographical distances in Troms and Finnmark

The participants generally reported that the cooperation with the emergency primary care service was effective, but noted that it can be challenging when the doctor is busy for an extended period or is unable to attend in person because of an intermunicipal cooperation and large distances.

A good plan for medical follow-up

Participants from one municipality said that their emergency primary care service is located in a neighbouring municipality during evening, night and weekend shifts. They described this as challenging, noting that, in practice, it is impossible to have a doctor attend a patient due to the geographical distance: ‘If I need a doctor to physically come here, that’s a problem. I don’t really see that as an option’. (D4) 

Participant 3 explained that it can be difficult for the nurse with responsibility for the patient as well as for the doctor, who has to assess the situation over the phone. All participants said there were challenges when the doctor is busy for an extended period and that a good plan needs to be in place to follow up MABU patients. Two participants suggested making more use of video conferencing, which allows the doctor to see and talk to the patient and involve them in assessments and decision-making when they are not physically present.

Geographical distances and patient transport

All participants characterised geographical distances, long journeys to the hospital and large distances within the municipality as burdensome for older patients. They felt that patients are grateful when offered a place in the local MABU. 

One participant mentioned that weather conditions can prevent travel outside the community to the hospital, forcing patients to remain in the MABU while waiting for the weather to improve: ‘In winter, if roads are closed and ferries are cancelled, it’s definitely a challenge for the patient to stay here longer’. (D6)

Discussion

The objective of the study was to generate knowledge on the professional and practical challenges of nurses in MABUs in nursing homes in rural Norway. This knowledge provides insight into the competence needed to care for MABU patients and demonstrates how nurses in rural areas perform their duties when resources are scarce.

Generalist-specialist competence and knowledge development

Our study shows that there is considerable variation in the clinical condition, complexity and diagnoses of MABU patients. Since the MABU provision was introduced, more younger patients and a wider range of conditions have been treated in nursing homes. This has created a need for competence in more fields, such as geriatrics, emergency nursing, psychiatry and substance use.

Clinically assessing patients and their disease progression can be challenging for both doctors and nurses. The report entitled ‘Emergency Medical Care for the Elderly’ describes atypical symptoms of acute illness and injury in older adults. The consequences can include delayed or inadequate evaluation and treatment, as well as increased mortality (24). Healthcare personnel need to be attentive, have strong observational skills and have a broad knowledge base (10, 17, 18, 19, 25). 

Knowledge is primarily developed through practical experience with patients who have complex medical conditions and multimorbidity, as well as through professional discussions about diverse patient cases. Reflection and the sharing of experiences foster knowledge development in individuals. Similar experiences are described in other studies from rural settings (10, 16, 18). A better competence-enhancement plan, supported by mandated programmes with available financial and human resources, could have met some of the needs described by the participants.

Sole responsibility, personnel resources and patient safety

All participants in this study described challenges associated with being the only nurse on duty at the nursing home due to the broad scope of responsibilities and conflicting demands. Sole responsibility is a well-known phenomenon in rural nursing, where a nurse is the only one on duty or responsible for a particular area, with a doctor available only under certain circumstances (17–19).

Nurses in rural areas are often responsible for a large number of patients and administrative duties, with minimal support from a broader professional network. This can be challenging, particularly for newly qualified nurses (11, 16–18). The combination of sole responsibility and the expectation to develop generalist-specialist competence is a challenge for nurses in rural settings (17, 18, 30, 32).

Nurses are sometimes called on to assist in difficult situations during their time off. How nurses support each other in small communities has also been described in previous studies (18, 31, 33).

The participants described feeling particularly vulnerable on evening, night and weekend shifts due to low nursing staff levels and having sole responsibility. Low staffing levels, combined with a perceived lack of competence and time pressure, can impact on the quality of healthcare services and patient safety, leading to adverse events. The increasing presence of unskilled staff in nursing homes and home care services means that nurses constantly have to prioritise where to utilise their expertise in terms of patients and duties, which can make their job even more challenging (9, 11, 26). 

Several studies from rural areas describe how workplace stress and concerns about making mistakes can lead nurses to leave their jobs (17, 18, 27). 

Failure to provide additional staff in nursing homes following the introduction of MABUs can create stress factors that, in turn, increase the risk of burnout and employee attrition in the health sector, as observed after the COVID-19 pandemic (28, 29).

Rural cooperation

This study sheds light on the challenges of intermunicipal cooperation and the limited doctor availability following introduction of the MABU provision. In rural nursing practice, the lack of medical support in difficult patient situations is framed in relation to the challenges of having sole responsibility.

Based on the nurses’ experiences with doctor cooperation in this study, as well as previous research from a doctor’s perspective, effective cooperation can be summarised as follows: sufficient exchange of information, a good treatment plan, indications for further contact with the doctor, and clear agreements on further medical follow-up. If the same nurse and doctor follow the patient throughout their treatment it is easier to observe changes in the patient’s condition. 

Scoring tools can serve as an aid in assessments and observations, enabling the precise and systematic reporting of a patient’s condition to the doctor by the nurses. When the doctor is unable to attend a patient in person, video conferencing via a secure network can strengthen patient involvement (34). Effective doctor-nurse cooperation improves the quality and standard of care of the service provision and is an important part of the Coordination Reform and the intentions behind it (6, 12). 

Strengths and weaknesses of the study

The first author works within the context described in the study. Personal understandings of nursing in the research field are a strength of the study, but this requires awareness of preunderstandings. The findings and analysis were discussed with the second author, whose familiarity with the research field strengthens the validity of the study. 

All participants have extensive experience in the research field. Several have a specialisation and a master’s degree, which strengthens the reliability of the data. A further strength of the study is the participants’ descriptions of many similar challenges across the various municipalities. 

Despite the small sample size, the findings provide insights that may resonate with nurses working in departments with an MABU in other rural areas of Norway.

Conclusion

The findings of this study provide insight into the responsibilities and duties of nurses within patient care in MABUs in nursing homes in Troms and Finnmark. Patients admitted with acute and complex conditions represent a challenge to the nurses’ observational, assessment and action competence. 

Participants have not experienced increased staffing levels despite the greater scope of responsibility and complexity of the service provision. Cooperation with the emergency primary care service can be challenging when the doctor cannot be physically present in difficult patient situations. Nurses are therefore facing increased pressure at work, particularly when they have sole responsibility during evening, night and weekend shifts. 

All participants state that there is a need for more nurses and systematic, competence-enhancing measures in nursing homes with an MABU. This will help nurses feel that they are delivering a professional standard of care, which aligns with findings from other studies on this subject in Norway (10–12, 15).

The authors declare no conflicts of interest.

Open access CC BY 4.0

Introduction

Sleep is an important element of human functioning and can affect us both physically and mentally (1, 2). How much sleep we need varies from person to person. Nevertheless, the recommended sleep duration remains relatively constant at 7–9 hours per night from the age of 20 (2). Sleep quality is partly influenced by the circadian rhythm, which is regulated by a nucleus in the brain called the suprachiasmatic nucleus (2). 

Shift work disrupts the circadian rhythm, and both sleep duration and sleep quality are negatively affected. This can contribute to a range of issues, such as heart disease, diabetes and mental disorders (2). Sleep quality is a complex concept and includes factors such as sleep quantity, sleep latency, sleep disturbances, depth of sleep and habitual sleep efficiency (3). 

The Working Environment Act (4, section 10-8[1]) stipulates a minimum rest time of 11 hours between two work periods. This is in line with the EU’s Working Time Directive, which is applicable in Norway (5, Chapter 2, Article 3). However, the Working Environment Act allows for the rest period to be reduced, by agreement, to eight hours (4, section 10-8[3]). The most common short rest period is between evening and day shifts (6). Short rest periods and night shifts can be associated with poorer performance and sleep quality. Improving sleep quality may reduce the risk of errors (7, 8). 

Shift work has a more negative impact on sleep duration and sleep quality among older shift workers than younger ones, particularly with short rest periods between evening and day shifts, as well as with night work (9-11). Research shows that the likelihood of experiencing good or poor sleep does not depend on the number of years of work experience (9, 10). However, there is evidence that the longer intensive care nurses have been working shifts, the higher their tolerance for sleep problems (11). 

A systematic literature review of shift work and nurses’ health showed that shift work exacerbates sleep problems (12). Nurses report a high prevalence of sleep problems, which can lead to poorer health, quality of patient care and job satisfaction (6, 11, 13, 14). In a Norwegian study of intensive care nurses, 70% of participants reported poor sleep quality (11). Significant differences in sleep quality have also been observed among nurses across hospital departments (8).

There is little research on the relationship between sleep quality and job satisfaction, but some findings suggest that better sleep quality leads to higher job satisfaction, and vice versa (15, 16). A Swedish study found that short rest periods negatively affect nurses’ sleep quality and shift rota satisfaction (17).

However, no studies appear to have explored the relationship between sleep quality and nurses’ shift rota satisfaction. A systematic literature review showed that employees who are able to influence their working day are more satisfied and are less likely to leave the labour force (18).

Objective of the study

The objective of this study was therefore to

• assess the sleep quality of nurses on hospital wards in the specialist health service, and
• investigate the relationships between sleep quality and various demographic and work-related factors. 

Method

Design

In this descriptive cross-sectional study, data were collected via a questionnaire. This data collection method is well-suited for examining the relationships between factors at a specific point in time (19). The questionnaire included demographic and work-related questions, as well as a measurement of sleep quality.

Recruitment 

The questionnaire was distributed via the ‘Sykepleieforskning’ (Nursing research) Facebook group, which had around 10 000 followers. We collected the data by distributing the survey twice: first on 28 December 2020, and then on 24 January 2021, before closing the questionnaire for responses on 4 February 2021. 

Posts in the Facebook group were shared a total of 42 times. Responses to the questionnaire were collected via Nettskjema.no, the University of Oslo’s digital platform (20).

Measuring sleep quality

In this study, we used the Pittsburgh Sleep Quality Index (PSQI) as the primary outcome measurement for sleep quality (3). The PSQI consists of dichotomous questions and multiple-choice questions across seven standardised components: sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleeping medication and daytime dysfunction (3, 21).

Each component is scored from 0 to 3, and the global score is measured on a scale from 0 to 21. A global score for the components of > 5 indicates poor sleep quality, meaning the participant has significant challenges in at least two components or moderate challenges in three or more components (3).

The PSQI was developed to provide a reliable, valid and standardised measure of sleep quality. Globally, the PSQI has been validated for many populations, including healthy adolescents and adults, as well as those with somatic and mental disorders (22). The PSQI is frequently used in research to measure nurses’ sleep quality (7–11, 23) and has been translated to Norwegian and validated among nursing home staff and students (21).

The original version of the PSQI has a Cronbach’s alpha of 0.83, and the Norwegian validated version has a Cronbach’s alpha of 0.77 (3, 21). In our study, the Cronbach’s alpha is 0.71, which indicates acceptable internal consistency in the study (19, 24).

Data collection, coding of variables and data analysis

The questionnaire included two screening questions for inclusion in the study: participants had to indicate that they consented to participate in the study and that they were working as nurses on a specialist health service ward. The sociodemographic and work-related variables in the study were as follows: sex, age, workplace (type of ward and regional health authority), work experience, percentage of full-time position, rest time between evening and day shifts, number of evening and night shifts per month and working time arrangements, involvement in shift planning and shift rota satisfaction.

All work-related variables were multiple-choice questions with a free text field option. The workplace was coded as medical, surgical and other types of wards, along with the specific regional health authority the nurses worked in. The percentage of full-time position was coded as full time (100%) or part time (< 100%). 

Working time arrangements were denoted as single-shift rota, two-shift rota or three-shift rota and were further coded into two groups: all those working a three-shift rota (day, evening and night) and those working only one or two of the shift types. Involvement in shift planning and shift rota satisfaction were coded as dichotomous variables with the categories ‘small/very small/zero degree’ and ‘large/very large degree’ of involvement or satisfaction. The PSQI was coded according to the tool’s instruction manual (3).

The results are presented as descriptive statistics: categorical data as absolute numbers and percentages, and continuous data as median with range or mean with standard deviation (SD), depending on normal distribution. 

Differences between categorical variables were analysed using Pearson’s chi-square test, with one exception where we used Fisher’s exact test because the expected value was five or less in the matrix. Group differences between good and poor sleep quality in continuous variables were analysed using Mann-Whitney’s U test, as the variables were not normally distributed. 

A linear regression model was used to examine possible associations between sleep quality and demographic and work-related factors. Participants for whom there was not a complete dataset were excluded from this analysis (3.4%, 8/235).

All variables were included in a univariable analysis. All variables that showed an association with sleep quality in the univariable analysis (p < 0.200), in addition to age, were included in a multivariable model. The variables were included simultaneously, thus controlling for the effects of other variables in the model (19).

The association is expressed as unstandardised beta coefficients, and the uncertainty of the estimates is given as a 95% confidence interval. The significance level is set at p < 0.05. The statistical analysis was performed using IBM SPSS Statistics version 28 for Mac (25).

Research ethics considerations

Participants were informed about the objective of the study and the time each participant would be required to spend on it. We told them that participation was voluntary and that the study was anonymous, and explained how the data would be used. Since we did not collect any direct or indirect personal information, Sikt – the Norwegian Agency for Shared Services in Education and Research found that the study was not subject to reporting (reference number 834431).

Results 

The survey received a total of 259 responses. Of these, 235 participants (90.7%) reported that they were working as a nurse on a hospital ward in the specialist health service, and they were included in the study. The participants had a median age of 31 years (range 22–63 years). The gender distribution was 90.6% female (213/235) and 9.4% male (22/235). 

All counties in Norway were represented, with the highest number from Oslo and the fewest from Nordland. Over half (55.3%, 130/235) worked in South-Eastern Norway Regional Health Authority. The median work experience was 6 years (range 1–36 years). A total of 81.2% of participants (190/235) worked in a three-shift rota, while 61.1% (143/235) worked full time. Rest time between evening and day shifts varied between 8 and 10 hours, with 87.7% of participants (206/235) reporting a rest period of 9 hours.

In the sample, 51.5% of participants (120/235) reported that they were involved in drawing up their own shift rota to a small, very small or zero degree. A total of 59.6% (140/235) stated that they were satisfied with their shift rota to a large or very large extent. Demographic and work-related data are presented in more detail in Table 1.

Differences between groups of good and poor sleep quality

Table 1 shows how sociodemographic and work-related data are distributed between the groups who reported good sleep quality and the groups with poor sleep quality. There was no difference across ages or between the sexes in terms of self-reported sleep quality. Neither were there any differences in work experience, percentage of full-time position, rest time between evening and day shifts, number of evening or night shifts, working time arrangements or involvement in shift planning. 

A correlation was found between sleep quality and shift rota satisfaction. In the group of participants with poor sleep quality, 56.7% (115/203) were satisfied with their shift rota to a large or very large degree. In the group with good sleep quality, 78.1% (25/32) were satisfied with their shift rota (p = 0.021).

Nurses’ sleep quality

Table 2 presents the PSQI scores in the sample. The average PSQI score was 9.38 (SD 3.42, range 3–19). The mean scores for the PSQI components varied from 0.41 to 2.03. Among the components, sleep latency (mean 2.03, SD 0.93) had the highest score, indicating that many participants experienced long sleep onset times. 

The use of sleep medication (mean 0.41, SD 0.81) had the lowest score, suggesting that few participants used any form of medication to help with sleep onset. The proportion of participants who reported poor sleep quality (PSQI > 5) was 86.4% (203/235).

Relationship between sociodemographic and work-related factors and sleep quality 

In the linear regression model examining the relationship between sociodemographic and work-related factors and sleep quality, a complete dataset was available for analysis for 96.6% of participants (227/235) (Table 3). Following the univariable analysis, sex, rest period, involvement in shift planning and shift rota satisfaction were included in the multivariable analysis. In the multivariable analysis, rest period, involvement in shift planning and shift rota satisfaction were associated with sleep quality (p < 0.050): for each additional hour of rest time, the PSQI score decreased by –1.26 (confidence interval [CI]: –2.4 to –0.1, p = 0.031). 

The score of participants who were involved in drawing up their own shift rota was 1.17 (CI: 0.2 to 2.1, p = 0.014) higher than those who were not. For participants who experienced shift rota satisfaction, the PSQI score was –1.30 (CI: –2.3 to –0.3, p = 0.008) lower than for those who were not satisfied. The regression model as a whole explained 12.8% of the variance in reported sleep quality (R² = 0.128, adjusted R² = 0.109, p < 0.001).

Discussion

The objective of this study was to assess nurses’ sleep quality and the potential sociodemographic and work-related factors associated with sleep quality. The study participants were nurses working on wards in hospitals throughout Norway. The instrument used to measure sleep quality is well-established and frequently used in sleep quality research.

The main finding of the study was a very high proportion of participants with poor sleep quality. Other important findings were that participants who were satisfied with their shift rota reported better sleep quality than those who were not satisfied. Participants who were involved in drawing up their own shift rota reported poorer sleep quality than those who were not. Furthermore, longer rest periods between evening and day shifts were associated with better sleep quality.

Sleep quality of nurses on hospital wards in the specialist health service

The participants in our study had considerably lower mean PSQI scores and sleep quality compared to previous Norwegian research on nursing home staff (mean 5.70; SD 3.42; PSQI > 5 = 44.6%) and intensive care nurses (mean 7.5; SD 3.0; PSQI > 5 = 69.7%) (11, 21). 

In addition to the global score being higher, the mean score in our study was higher on all components compared to nursing home staff in a Norwegian study (21). In an Italian study that measured sleep quality among nurses on hospital wards, the proportion with poor sleep quality was 88%, which is in line with the results of our study (7).

In an Iranian study, differences in sleep quality were also found among nurses on different types of wards (8). These results may suggest that nurses on hospital wards in the specialist health service have poorer sleep quality than comparable shift-working populations studied in Norway, and that sleep quality can vary across hospital departments.

Our study sample shows a bias in the gender distribution. However, it is close to the gender distribution among nurses employed in the health service in Norway in 2020 (26), and among nurses in the studies with nursing home staff and intensive care nurses (11, 21). The Italian study had a somewhat lower proportion of female participants (84.3%) (7). Neither sex nor age could be associated with sleep quality in our study.

In our study, there was no difference between the various working time arrangements and sleep quality. Previous research has not reached a consensus on which working time arrangements yield the best sleep quality. An Iranian study found that nurses with three-shift rotas had better sleep quality than nurses working just a single-shift rota (15), which is in contrast to findings for intensive care nurses in Norway (11).

The discrepancies in findings indicate a need for further studies in this area in order to compare participants’ different working time arrangements and sleep quality. 

Shift rota satisfaction

Almost 80% of the participants in our study who reported having good sleep quality also stated that they were satisfied with their shift rota. The finding that nurses with high shift rota satisfaction experience better sleep quality aligns with results from a longitudinal study of Swedish nursing students who went on to work as nurses: short rest periods negatively affected both sleep quality and shift rota satisfaction, albeit only slightly (17). 

Involvement in shift planning

A somewhat surprising finding in our study was that participants who indicated that they are involved in drawing up their own shift rota have poorer sleep quality than those who are not. Our data do not provide a causal explanation for this, and we were unable to find any research on this topic. It may relate to individual nurses’ ability to draw up optimal shift rotas – a field in which managers, health and safety personnel and union representatives typically have more expertise. 

The Working Environment Act stipulates that if working hours are at different times of the day, the shift rota is to be drawn up in collaboration with union representatives, rather than unilaterally by the employer (4, section 10-3). Nevertheless, it could be argued that this result contradicts findings from a systematic literature review of the reasons people leave the labour force (18), which recommends that employers give employees the opportunity to be closely involved in shaping their working day (18). The result in our study is therefore difficult to explain, as employees who are involved in drawing up their shift rota are in a better position to adapt their shifts to their lives outside of work.

Rest time between evening and day shifts

None of the participants’ rest time between evening and day shifts exceeded the statutory minimum of 11 hours as provided for in the Working Environment Act (4, section 10-8[1]). Analysis of the number of hours in rest periods between evening and day shifts found very little difference in good and poor sleep quality between the groups with. However, a high proportion reported having nine hours of rest between these shifts.

Participants scored high in the PSQI component ‘sleep latency’, indicating that the sample population, on average, took more than 30 minutes to fall asleep at least once or twice a week. In the multivariable analysis, shorter rest periods were negatively associated with sleep quality, aligning with findings from studies involving nurses in Italy, Sweden and Norway, in which reduced sleep quality is associated with short rest periods (12, 17, 27).

Strengths and weaknesses of the study

Using the PSQI as a tool for measuring sleep quality is the subject of ongoing debate. Its use has been described as a strength in research because it provides a reliable, valid and standardised measure of sleep quality (10). However, it has been shown to be unsuitable for measuring the sleep quality of shift workers, as there are three key factors that can vary considerably from one week to another among this group: nocturnal sleep onset, sleep disturbances and sleep duration (23). 

A majority of the participants worked three-shift rotas (81.2%). Over 40% of participants in our study and over 60% of participants in a corresponding Italian study reported good sleep quality, which was not in accordance with the global PSQI score results (7). 

This finding may indicate that the threshold for good and poor sleep quality in the PSQI may be too low for shift-working nurses. Furthermore, the recruitment method employed in our study may have contributed to nurses with poor sleep quality being more inclined to participate in the study. 

In our study, we categorised working time arrangements into two groups: three-shift rotas and two/single-shift rotas. This means that some participants with short rest periods between shifts are analysed together with participants who do not have short rest periods. A Taiwanese study found that shift workers who only work night shifts have shorter sleep duration than nurses with other working time arrangements (28). 

Norwegian nurses have been shown to have a higher prevalence of insomnia when working two-shift rotas compared to when they only work night shifts (27). Our categorisation of working time arrangements may, therefore, have contributed to a bias in the groups when examining differences in reported sleep quality and the various working time arrangements. 

Furthermore, it is a weakness of the study that we do not have information on participants’ levels of burnout, or mental health and insomnia, since these factors have been shown to affect shift workers’ sleep after a shift (28). If participants had responded to questions about their own sleep quality with a one-month interval, this would have provided a better basis for identifying which disturbances are temporary and which are long-term (3).

Research shows that differences have been found between women and men in terms of how they describe sleep quality. Women score higher (29) and view sleep quality as a combination of sleep disturbances and daytime dysfunction, while men relate sleep quality to sleep duration and sleep efficiency. The lack of differences between the sexes in our study may be related to the low number of male participants (9.4%, 22/235). The results of our study cannot, therefore, be generalised to male nurses. 

Data were collected between late December 2020 and late January 2021. The COVID-19 pandemic had been ongoing for about a year at that time, and the pressure on the health service was particularly high. The tool for measuring sleep quality asks for responses to be related to the past month and does not account for any long-term variations in daily life, and this may have impacted on the results of our study. 

Wang et al. examined the validity and reliability of the PSQI among doctors and nurses working with COVID-19 patients in Wuhan, China, at the start of the pandemic (30). The findings of the study indicate that the PSQI was reliable and valid for research on healthcare personnel, including during the pandemic (30).

The data for our study were collected during a period that included a national holiday, when workloads and capacity in the health service are lower than usual. No account was taken of possible reduced activity in either the questions or analyses, but the deviation from normal activity may have impacted on participants’ self-reporting of sleep quality over the past month.

Although the linear regression model in the study was statistically significant (p < 0.001), it explained only 12.8% of the variance in reported sleep quality. This result indicates that much of the variation in sleep quality cannot be explained by the included variables but by unknown factors outside the scope of the study.

Conclusion

The results of this study clearly indicate that nurses on hospital wards in the Norwegian specialist health service have poorer sleep quality than other comparable groups. For nurses on hospital wards in the specialist health service, it appears that rest time, involvement in shift planning and shift rota satisfaction are factors associated with sleep quality, and should therefore be the subject of future studies.

The author declares no conflicts of interest.

Open access CC BY 4.0

Introduction

Mental health problems in children and adolescents are one of the most significant public health challenges faced by Norwegian local authorities (1). The primary care services play a key role in health-promoting and preventive work, and also have a responsibility in the treatment of mental health problems in this population (2). However, there are considerable variations in the type of treatment provision in primary care (2), even though increased pressure on the specialist health service means that more individuals with moderate and severe mental disorders are dealt with in the low-threshold services in primary care (3 ). 

Nurses play an important role in helping children and their families (4), both in various low-threshold teams for mental health and in statutory services such as child health centres and the school health service (2). Nurses in Norway report that they spend more than half of their time on tasks related to mental health (5). In addition to the follow-up offered by the school health service for children with mental health issues and disorders, the national clinical guidelines encourage practitioners to consider whether parents should also be informed and included (6). 

The importance of family involvement in health services for children and adolescents is widely supported by research (7) and is emphasised in several national guidelines and manuals (1, 8). The child welfare reform in Norway of 1 January 2022 makes it mandatory for the municipal services to work preventively with families and the child’s environment (9), both because proper support from parents can protect the child from developing mental health issues (10), and because neglect is a risk factor for developing physical and mental disorders (11). 

Sameroff’s transactional model illustrates how children and parents mutually shape each other over time, and how negative development in the child can be reversed by helping parents change their interpretation of or behaviour towards their child (12). Parents may therefore play an important role as participants in their child’s treatment (13). Moreover, for many parents, their involvement is important for their own health and sense of coping (14). 

Within the nursing profession, it appears that attention has moved increasingly from individually centred to family-centred nursing. Several studies point to the advantages of family-centred care (FCC), where the entire family is regarded as recipients of treatment and care (7). Nurses have a generally positive attitude to involving the family (15), but most studies have been conducted among hospital nurses (15). 

The few studies that have been conducted in low-threshold services (16–20) show that for nurses in the school health service, most parent contact takes place in telephone conversations (16), and that the contact is mainly problem-based and deals with risk factors for the child’s health or well-being (20). 

In Norway, family-centred care has been studied in mental health services for adults (21, 22), but has received little attention in the services for children and adolescents. In studies investigating the work of the Norwegian school health service with mental health issues, however, public health nurses express the importance of involving the family and strengthening the role of parents (5, 23).

Despite positive attitudes to family involvement, there are still challenges in implementing family-centred care in practice (24). Implementation of new knowledge is a frequently studied topic (25), and several theoretical models and frameworks have attempted to describe what characterises successful implementation processes (24). 

The ‘Knowledge-to-Action’ framework (26) illustrates the importance of closeness between the field of research and the users. It shows how knowledge should be tailored to users’ needs and barriers identified in the context in which the new knowledge is to be implemented (26). For routines and tools for family involvement to function well in the low-threshold services, it may therefore be important to know what characterises the services’ work with families. 

The purpose of this study is therefore to answer the following research question:

‘What is the extent of nurses’ parent contact in low-threshold services for children and adolescents, and which factors related to the nurses and services are associated with parent contact?’

Method

This cross-sectional study is based on data from a questionnaire survey undertaken by the Regional Centre for Child and Adolescent Mental Health, Eastern and Southern Norway (RBUP) in 2019 (27). The aim of the survey was to identify the mental health services available for children and adolescents in primary care. 

The target group was municipal employees who offer mental health care for children and adolescents between 5 and 18 years of age, with no requirement for referral, that are easy to access, and that are primarily intended for children with mild and moderate mental health issues. The data were collected via an online questionnaire (Appendix 1 – in Norwegian only) that was sent out in spring 2019. The questionnaire survey was assessed by the Norwegian Centre for Research Data (NSD), now called Sikt – the Norwegian Agency for Shared Services in Education and Research, as being compliant with data protection legislation, reference number 331014.

Sample

We recruited participants for the survey by emailing 1270 municipal employees in low-threshold mental health services in all Norwegian counties. One reminder was sent, and we encouraged recipients to forward the email to other relevant respondents. Participants were also recruited via RBUP’s website, RBUP’s Facebook page and the website of the Norwegian Resource Centre for Community Mental Health (NAPHA). 

The data collection took place from 21 February 2019 to 21 May 2019. To date, one article has been published from the data material, which relates to the psychologists in the survey (27). Of the 992 respondents in the survey, 406 had a nursing background. Of these, 243 (59.9 per cent) responded to the questions about parent contact (Figure 1). These nurses comprise the sample in this study.

Variables 

To investigate parent contact, we posed the following questions: ‘ attend the appointments together with the child?’ and ‘How often do you work solely with parents/guardians?’. The variable is a five-category variable, and the response alternatives were ‘never’, ‘seldom’, ‘occasionally’, ‘often’ and ‘always’. 

The participants were asked about gender, age, number of years of relevant professional experience and whether they had specialist education or postgraduate education. The education variable was dichotomised to ‘education beyond a three-year bachelor’s degree’ (‘yes’/’no’).

The participants were asked whether they had training in 16 different manual-based tools that are often used in mental health work with children and adolescents. Of these, nine are considered to be parental counselling tools: De utrolige årene [The incredible years], Tuning into kids, Tuning into teens, Circle of Security, International Child Development Programme (ICDP), Multisystemic therapy, Parent Management Training Oregon (PMTO/TIBIR), Treatment Foster Care Oregon (TFCO) and Functional Family Therapy (FFT). 

They also had the opportunity to add any other manual-based tools. The variable was dichotomised to ‘have training in parental counselling tools’ (‘yes’/‘no’).

The participants were asked which service they worked in. The variable was dichotomised to ‘works in the school health service’ (‘yes’/‘no’). They were also asked ‘Which of these groups is the service you work in primarily aimed at?’ and were asked to select one or more of the alternatives ‘infants and young children (0–4 years)’, ‘children (5–12 years)’ and ‘adolescents(13–18 years)’. The variable was dichotomised to ‘work solely with adolescents’ (‘yes’/‘no’).

To map time resources, the participants where asked ‘how often would you like to have had more time/more sessions with the child and/or the family?’. The variable was dichotomised to ‘yes’ (‘often’ and ‘very often’) and ‘no’ (‘very seldom’, ‘seldom’ and ‘occasionally’). 

The participants were asked whether the service they work for is part of a family centre or the Family’s House, a service model used by several municipalities to coordinate services for children, adolescents and families. The variable was dichotomised to ‘yes’ (‘yes’) and ‘no’ (‘no’ and ‘don’t know’). 

Analysis

Results from descriptive statistics are reported as mean and standard deviation and in absolute and relative numbers. To investigate the associations between different variables and parent contact, we used the chi-square test and ordinal logistic regression analysis with parent contact as the five-category dependent variable. 

By using ordinal logistic regression with a five-category dependent variable, we utilised the information available in the data, rather than dichotomising the variable and using normal (binary) logistic regression. The odds ratio in ordinal logistic regression has the same interpretation as in binary logistic regression (28). A two-tailed p-value less than or equal to 0.05 is considered to indicate statistically significant findings. We analysed the data in SPSS version 28.

Results

Description of the sample

Table 1 shows demographic data for the respondents. When we compared those who completed the survey with those who did not complete the full survey, we found more participants who worked solely with adolescents and in the school health service among those who completed it (Appendix 2 – in Norwegian only). 

The extent of nurses’ parent contact

The results shown in Table 2 show variation in the extent of parent contact. Telephone contact was the most frequently used way to involve parents, and 94 per cent of the nurses in the study reported that they occasionally, often or always had telephone parent contact. Just over 63 per cent reported that they occasionally, often or always saw parents and children together at appointments. Around 30 per cent of the participants reported that they never or seldom saw parents and children together at appointments, or that they only worked with parents.

Factors associated with parent contact

Factors associated with nurses’ parent contact

The results in Table 3 show that the likelihood of nurses reporting that they see parents and children together at appointments increased with the nurse’s age, experience and postgraduate education, but education was only statistically significant with regard to telephone contact in the adjusted analysis.

The nurses’ training in parental counselling tools is the factor that appeared to be most strongly associated with parent contact. The nurses with training in such tools were more than twice as likely as other nurses to report that they often had parent contact.

Factors associated with parent contact in the services

The results show that nurses who worked solely with adolescents reported having parent contact to a far smaller extent than the rest of the sample (Tables 3 and 4). 

The nurses who worked in the school health service reported having parents present in appointments less frequently, either with or without the children (Table 3 and 4). 

The percentage who reported that they frequently had parents and children attend appointments together, was five times higher in the rest of the sample than for the nurses who worked in the school health service (Table 4). We did not find large differences in the other variables between nurses in the school health service and the other services (Appendix 2 – in Norwegian only).

The nurses who wished for more time or more sessions with the children and/or their families reported having parents at appointments more often than the rest of the sample (Table 3). 

Discussion

The objective of the study was to examine the extent to which nurses in low-threshold services have parent contact and which factors impact on this contact. Overall, the results show that the type and frequency of parent contact varied. Over 94 per cent of nurses had telephone contact and over 63 per cent had parents present in sessions. This is much higher than a US study in which 77 per cent of nurses had parent contact by telephone and only 18 per cent had parents present at in-person appointments.

The relatively high degree of parent contact may be due to the increased focus on mental health and family-centred work in recent years. (1, 8). 

Despite nurses’ positive attitudes to family involvement, a third of the nurses in low-threshold services reported that parents were seldom or never present in conversations, either with or without the child. This suggests that there may be differing practices for how and to what extent parents are involved, both among nurses and across services. 

Training in manual-based tools

The data in this study do not give an indication of whether the nurses are engaged in supportive or therapeutic work. However, the factor most strongly associated with parent contact among the nurses was training in manual-based parental counselling tools. 

This finding aligns with other studies that have shown that training in family-centred methods fosters positive attitudes to family involvement (15), and that public health nurses are more likely to contact parents and invite them to family sessions after receiving training in family-centred conversation tools (29). 

Since nurses are more likely to carry out the parts of family-centred care they consider necessary (30), knowledge about the benefits of family involvement may also be important. Criticism has been levelled at nursing education in Norway for lacking a family perspective (31). 

Given that only 26 per cent of nurses in low-threshold services reported having training in parental counselling tools, there appears to be a need to raise competence levels in family-centred work. Training in manual-based tools could potentially bolster competence (29). Consideration should also be given at a national level as to how nursing education in Norway can help enhance competence and increase the number of tools used in family-centred care. 

The largest portion of nurses in our sample had a public health nursing education or other additional training, which it is assumed will impact on their work. Education and experience, however, did not show such a clear association with parent contact. This finding is somewhat surprising, since several other studies found that higher education can lead to increased confidence and better skills in family care (19). Studies also show that less experienced nurses express uncertainty about family involvement (18, 19).

However, some studies have found no association between education and experience and positive attitudes to family involvement (17). It is conceivable that factors such as training in parental counselling tools or type of postgraduate education may have impacted on the results. Public health nurses have expressed a lack of tools when dealing with children with mental health issues (5, 17, 20), which has been found to be associated with a greater tendency to view the family as a burden (17).

Thus, competence in mental health may also impact on the frequency of nurses’ parent contact. Supervision for the least experienced nurses could be useful for promoting family-centred work, while more knowledge is needed about what aspects of education and experience affect the degree of family involvement. 

Less contact with parents of adolescents

The study found several factors in the services to be associated with parent contact. Nurses working with children had more parent contact than those who work solely with adolescents, which is consistent with previous research (17). This may be because, under Norwegian law, children over the age of 12 have the right to influence what information is given to their parents (5, 32).

Public health nurses have expressed fears that conversations with parents may damage the relationship of trust with the child, leading them to prioritise the child’s wishes for confidentiality (20). Many parental counselling tools are also aimed at younger children, which can make nurses unsure about counselling parents of adolescents. More research is needed on the factors that impact on the degree of parental contact in adolescent health care.

The results show that parents are much less frequently present in conversations with nurses in the school health service than nurses in other low-threshold services, and those working as part of the Family’s House have conversations solely with parents more often. Differing frameworks and guidelines may partly explain this gap, and other studies have confirmed this to be an important factor (15, 25).

According to national guidelines, the main focus of the school health service is preventive and health-promoting work (6). Some local authorities have indicated that they involve family centres in cases requiring more follow-up (2). The advice in national guidelines for the school health service to involve parents can be perceived as weak (6). Users, primary care services and the specialist health service have all expressed a lack of clear directives or frameworks describing what can be expected from mental health services for children and adolescents in primary care (2). Different cultures of family involvement may also partly explain the difference in parent contact between the school health service and other services (15, 25). For instance, schools may be perceived as more of ‘the child’s space’, whereby children more often contact services without their parents’ involvement (33). 

Based on our data, we cannot form a conclusion as to why public health nurses choose to include parents often or seldom. Moreover, the reasons children seek out the public health nurse in the school health service vary. Contact with children may consist of either a single conversation or multiple sessions. In cases related to friendships or matters of the heart, it may not always be appropriate or necessary to involve the parents. However, it is worth noting that healthcare personnel in different services involve parents to varying degrees, even though they have similar professional backgrounds and are supposed to follow the same national guidelines for working with patients’ families (8).

The results may indicate a need for local routines and procedures for family-centred work. This also applies when considering whether the frameworks under which the low-threshold services operate are aligned with national guidelines and strategies for working with patients’ families.

Time as a factor in family-centred work

Lastly, the study results suggest that nurses who expressed a desire for more time with children or families more frequently reported involving parents in in-person conversations. Lack of time is highlighted as a significant barrier to implementation (24, 25), and it is possible that the nurses who express a desire for more time are those who already spend extra time on conversations with parents. This is merely an assumption, as the reason why these nurses feel they have too little time is unknown. 

Some nurses have expressed that family work is more time-consuming than individual follow-up (22), while others stated that family intervention is a time-saving and efficient way to gain an overview and provide help (28). These findings may indicate differences in how families are involved. 

The results may also suggest that nurses have different perceptions of how much time family involvement requires. More studies are therefore needed to examine experiences with different family interventions. Since Norwegian public health nurses signal that they have a heavy workload (5), it is crucial to consider that time is an important resource that must be prioritised.

The associated factors we found in the study align with several aspects that implementation research identifies as facilitators or barriers (24). The ‘Knowledge-to-Action’ framework emphasises the importance of tailoring knowledge tools and interventions to local conditions and identified barriers (26). It is therefore important that management and staff in the various services understand the prerequisites for evidence-based care (26). 

The fact that several service-related factors are associated with parent contact strengthens the argument that changes are also needed within each service and organisation for new knowledge to be implemented (24). Family-centred work should not only be anchored in national guidelines but also in the various service frameworks, local procedures and working methods (15, 25).

For knowledge development to meet users’ needs and contexts, it is also important that priority is given at a national level to knowledge development within low-threshold services. The planned initiative to establish a national centre of excellence for child health centres and the school health service can be an important step in this direction (34). 

Methodology considerations

The larger sample size compared to similar previous studies was a strength of the study (16–19). However, cross-sectional studies cannot provide causal explanations between variables. Neither does the study elucidate the content of parent contact, whether practical information was involved, health assessments or guidance, or whether the content differed between telephone and in-person conversations.

A possible bias in the sample could be that participants were not randomly selected and that those who responded to the surveys might have been those who were most interested in the topic. The use of non-validated questions may be a weakness, as it is possible that the questions may have been misinterpreted. Using more objective quantifiers and response categories based on frequencies could have provided more valid data (35). 

It is also possible that responses from school health service staff were based on all children who use the service, not just those with mental health issues.

Conclusion

The study shows variation in how and to what extent nurses in low-threshold services have parent contact. Factors related to both the nurses and the services are associated with the frequency of nurses’ parent contact. The findings suggest a need for more knowledge and tools in family-centred work, as well as clearer frameworks for services and local routines for family involvement.

An important step going forward could be to consider the content of nursing education and develop the national research community for low-threshold services. Knowledge about and tools for family involvement must be tailored to the needs and conditions of low-threshold services in order to strengthen family-centred work aimed at children and adolescents in primary care. 

More studies are needed with larger, representative samples to explore how the various low-threshold services work with parents and families. Qualitative studies exploring nurses’ experiences with what hinders and promotes parental involvement are also needed, as is knowledge about the experiences of children, adolescents and parents with family involvement.

There is a further need for intervention studies examining how various family-centred interventions can aid nurses in their work with children and adolescents. The overarching goal should be for the child’s and family’s situation to guide decisions about when to involve parents, rather than factors related to individual nurses or services. 

The authors declare no conflicts of interest.

Open access CC BY 4.0

Introduction

Breast cancer is the most common form of cancer among women in Norway and internationally, and is the third most deadly cancer type among women in Norway (1, 2). All women resident in Norway in the age group 50–69 years are invited to participate in BreastScreen Norway every two years (3). The aim of mammography screening is to discover breast cancer at an early stage of the disease trajectory and reduce mortality from the disease. 

The World Health Organization (WHO) recommends screening for breast cancer for all women in a given age group, irrespective of country of origin (4). Female immigrants in Norway receive the same mammography screening service as women born in Norway; however, participation is lower among immigrants, irrespective of country of origin and socioeconomic status (5, 6). These findings are consistent with studies in other countries (7). 

The largest immigrant group in Norway is from Poland, and currently more than 100 000 immigrants from Poland live in the country (8). The Polish immigrants visit their GP less frequently when they feel ill than was the case when they lived in Poland (9), and have lower participation for mammography, cervical and colorectal screening (5, 10, 11).

Mammography screening is also offered to women in Poland. From November 2023, women in the age group 45–74 years have been offered free mammography screening every two years without referral through the National Health Fund that manages the Polish health service (12). 

Before November 2023, the mammography screening service applied to the same target group as in Norway: women in the age group 50–69 years. Participation in mammography screening in Poland is lower than in Norway. While participation in Norway has reached more than 75 per cent for Norwegian-born women and 51 per cent for immigrants from Poland, participation in breast cancer screening in Poland is reported to be 37 per cent (5, 13). 

Even though a service exists, its availability is limited by its location, hours of operation, costs, whether the service is accepted by the target group, as well as other factors (14). If the availability of mammography screening is systematically poorer for immigrants than for Norwegian-born women, it may mean that the service provision is not equitable; in other words that it is of poorer quality, is less accessible or yields poorer results for immigrants than for Norwegian-born women (15). The aim should therefore be to achieve the same participation level for all groups invited to participate.

Health literacy among Polish immigrants was surveyed in 2020–2021 (16). The survey showed that one in three Polish immigrants in Norway were at or below the lowest level of general health literacy. This level means that they will most likely face challenges in understanding what the doctor says, understanding information and treatment options, as well as finding information about treatment and diseases. It is therefore quite conceivable that Polish immigrants may experience difficulties in understanding and utilising healthcare services in Norway. 

Health literacy can be understood as how health information is identified and transformed into knowledge and action (17). Sørensen et al. (18) point to four competencies associated with health literacy: accessing, understanding, appraising and applying health information. Health knowledge and health understanding appeared to be highly relevant concepts when we read through the interview transcripts. Health literacy was therefore chosen as the theoretical framework.

The objective of this study was to explore factors that may impact on Polish female immigrants’ participation in BreastScreen Norway.

Method

We conducted a qualitative study based on interviews with seven women born in Poland and resident in Norway at the time of the interviews. The interviews were conducted in the period from June to November 2021. The women were interviewed about colorectal cancer, breast cancer and screening. In addition to these seven women, we also interviewed three men about colorectal cancer and colorectal screening. Findings from the part of the study that dealt with colorectal screening are published in a separate article (19). 

This article deals with the data on breast cancer and mammography screening. 

Implementation and data collection 

This study was designed and initiated by the first and last author. The interviews were conducted by the first and fourth author. The first author is a male doctor whose main language is Norwegian. The fourth author is a female sociologist who speaks Norwegian but whose main language is Polish. The interviews with Norwegian-speaking participants were conducted by the first author, and the interviews with Polish-speaking participants were conducted by the fourth author.

The participants constituted a convenience sample (20), but we nevertheless achieved variation in terms of education, employment status, length of residence in Norway, Norwegian language skills and affiliation to the Norwegian-Polish community (Table 1). As we wished to interview participants who were in the target group, both for mammography and colorectal screening, the participants were in the age group 50–60 years. Some of them were recruited through the interviewers’ own networks. Other participants were recruited through the largest web portal for Poles in Norway: ‘Moja Norwegia’.

The ongoing COVID-19 pandemic was a challenge for the interview process. It was difficult for our Polish-speaking interviewer to travel to Norway, and it was also considered unacceptable to meet the participants in person. The interviews were therefore conducted by telephone, meaning that we were unable to observe non-verbal communication. However, our Polish-speaking interviewer was able to observe the COVID-19 restrictions and safely conduct interviews from Poland with women in Norway. We were able to interview women from large parts of southern Norway. 

The interviews were semi-structured and based on an interview guide (20) (Figure 1). The participants were informed that we were not looking for right or wrong answers, but that we wanted a dialogue to understand their viewpoints. The Polish transcriptions were translated to Norwegian by Tolkenett. 

Analysis

We analysed the data using systematic text condensation as described by Malterud (21). The second author led the analysis as part of their master's degree in health sciences, specialising in oncology nursing. The transcriptions were read repeatedly before text of interest was coded and sorted into code groups. The second and third authors discussed the code groups and identified meaning units. The content from the meaning units was then extracted and condensed. 

Finally, the findings were grouped together into interpretive syntheses with final themes. We reviewed the final themes and accompanying analytical text and checked them against the original interviews and/or the translated transcriptions. In the presentation of the results, we have given the participants pseudonyms. Several were offered the opportunity to read through their transcript, but none accepted. 

Ethical considerations

The data protection officer at Oslo University Hospital approved the study (reference number 20/15902). In line with the endorsement from the data protection officer, the interviewers ensured that the participants understood the content of the consent form before we obtained oral consent to participate. All transcriptions and translations that were used in this study were de-identified by removing names and other directly identifiable information. 

Results

We present our findings through five themes that have an impact on Polish female immigrants’ participation in mammography screening (Figure 2).

Knowledge about breast cancer

The women appeared to be knowledgeable about breast cancer and were familiar with the risk factors for developing breast cancer. They mentioned diet, lifestyle, genes and chance or bad luck. Several mentioned that the breast cancer screening programme and breastfeeding can prevent the development of breast cancer. 

Nevertheless, several women felt unsure whether they knew enough about breast cancer. Some seemed ambivalent with regard to obtaining more knowledge, as described by Hanna:

‘I don’t know [whether I want to know more about breast cancer]. To be honest, it doesn’t make much difference to me. The important thing is whether I’m healthy or not. Things that I consider unnecessary, I just don’t engage.’ 

Most of the women, however, wanted more information about breast cancer. Maja wanted better communication about the seriousness of cancer, so that more women undergo mammography and discover the disease at an early stage.

Many associated cancer with fear and serious illness. Katja explained:

‘People think that if you get cancer, you will never get well, and you will only live for a few months.’ 

Several of the other women also described similar negative thoughts about cancer. For example, they said that the very word ‘cancer’ caused worry and gave rise to fear. 

Examinations for breast cancer

A number of the women examined their own breasts, some regularly, others more sporadically. Most were aware of BreastScreen Norway. Some had heard about the service because they had been invited to participate. One participant who had previously had breast cancer had not heard of the programme. 

Maja had not heard of the programme before she was invited, and she found it to be a beneficial and supportive service. However, she perceived the tone of the invitation as nagging, and that it arrived out of the blue. She felt obliged to have an examination she had not previously heard of.

The women had different views on the purpose and importance of BreastScreen Norway. Maria was very positive and explained enthusiastically:

‘I would have run and had the examination straight away.’ 

However, she explained about an earlier occasion when she was busy and set aside the invitation to BreastScreen Norway. She did not find it again until several months later: 

‘I wasn’t worried about it, so I simply forgot it. I put the letter away and found it again several months later.’ 

The negative comments generally concerned how the participants believed other Polish women thought. Fear of the result was suggested as the reason why some women did not participate in mammography screening, as Katja put it: 

‘People think that cancer is scary, and that it’s better not to know.’

Laura thought that many Poles think that mammography is dangerous and can lead to breast cancer. Milena explained that if a woman is unwilling to participate in screening, it can be difficult to persuade her. 

Cross-border health care 

Transnationalism can be described as a spectrum of human activities that take place across national borders (22). Transnationality was expressed in how the participants related to the health service in Norway versus Poland. Most of the women reported that they primarily used the Norwegian health service. For some, participating in the BreastScreen Norway was a given, as described by Milena:

‘Of course I am part of the screening programme in Norway. I don’t have a GP in Poland, so I have all my examinations done here.’ 

However, Milena explained, like other participants, that there were other health examinations that she undertook in Poland, for example if the waiting time in Norway was long. Julia described the screening service in Poland as very accessible:

‘I went as a tourist. I went there on holiday and came across a mobile mammogram bus. They were right there, and the examination was free.’ 

Hanna reported that she was offered mammography screening both in Poland and in Norway, but that she only made use of the Norwegian service. Another woman reported that she had previously made use of the health service in Poland, even though she lived in Norway, but that she now used the Norwegian health service. 

Katja explained that even though there is a screening service in Poland, Polish women do not use it. Milena, on the other hand, told us that all the women she knew, both in Poland and Norway, participated in mammography screening. 

Promoters and barriers

The women described several factors that promoted or acted as barriers to participation in BreastScreen Norway. Most of the participants believed that language could prevent participation, and that an invitation letter in their own mother tongue could motivate women to participate. Hanna explained: 

‘It would be perfect if they could see a person’s nationality somewhere in the system, and then use Polish in the invitation.’ 

She nevertheless believed that it is possible to understand the importance of the invitation, even though it is in Norwegian, since the word ‘mammography’ is in the letter and there are good translation apps. Hanna described how linguistic challenges could make it difficult to navigate the health service. She did not feel completely conversant in Norwegian and had attempted to order an interpreter for the examination but was told that she was not entitled to this. 

Several participants expressed a wish for more information about the examination. Laura wanted the invitation letter to contain information on possible benefits and drawbacks of mammography screening. Some possible drawbacks were perceived differently by the women. While Julia reported pain for several days after the examination, Maria questioned whether pain was a barrier at all, as she herself did not regard the examination as painful. Not all the participants were aware that there are drawbacks, as illustrated by Maria:

‘Drawbacks? I don’t know anything about drawbacks [of mammography screening].’

Maja did not believe it was necessary to be informed about the drawbacks of screening in the invitation. She felt that it could be counterproductive.

Several of the women maintained that involvement of GPs could encourage participation in BreastScreen Norway, as illustrated by Hanna:

‘GPs should send information in Polish and Norwegian, and include some scary pictures of breast cancer.’ 

Others also called for pictures. While some believed that pictures of cancer could encourage women to attend for screening, Laura suggested sending a picture of what a screening examination entailed, to create an idea of what to expect.

Information about BreastScreen Norway 

The women described BreastScreen Norway as a well-organised, supportive service. Many ideas were put forward on how to persuade more Polish women to participate in the programme. Some suggested requesting confirmation that the invitation was received. Others considered the service so important that participation should not be optional, as suggested by Laura:

‘They [the mammography programme] should write that it is mandatory for Polish people.’ 

A number of participants described how they proactively retrieved information from several public and private sources in order to obtain the information they needed. Hanna explained:

‘The most important thing to do is to keep your eyes and ears open’. 

Most of the participants expressed a desire for information about breast cancer and mammography screening from their GP. They wanted information about cancer and screening through several public channels such as TV, radio and newspapers. Internet portals for Poles in Norway were also suggested as an information channel.

Discussion

In this study involving qualitative interviews with seven immigrant women from Poland, we explored factors that may impact on Polish immigrant women’s participation in BreastScreen Norway. By using health literacy as a theoretical framework, we identified several factors that may be relevant for their participation in the programme. 

Many immigrants from Poland compare the screening service in their home country with that in Norway (23). This may have resulted in some participants using the Polish screening service, especially before they became familiar with the Norwegian health service. Although Polish immigrants in Norway have a low rate of participation in BreastScreen Norway compared to women born in Norway, they still have a higher average participation rate than in the Polish screening programme (5, 13). 

Even though a service exists, it can nevertheless be unavailable for the target group. The service must also be understood and accepted by the recipient, be physically accessible, acceptable in terms of cost, and suitable (14). 

Studies from other countries in this respect have identified a number of barriers to mammography screening among immigrants, at individual, social or cultural, and system level (24, 25). Examples are costs, transport, difficulties in navigating the health service, language problems, lack of translations, lack of a social network, cultural norms, insufficient knowledge and scheduling conflicts. Some of these factors were also highlighted in our study, as we discuss in the following paragraphs. 

A Danish study of immigrants from Somalia, Turkey, India, Iran, Pakistan, and Arabic-speaking countries showed that even with knowledge about breast cancer and mammography screening, participation for screening was not prioritised (26). 

The Danish study emphasised that the women strived to maintain transnational links and were busy with everyday tasks, which gave little space for worrying about breast cancer. The same may apply to the women in our study. They knew about breast cancer and screening, but might still forget to attend the screening, or they felt that the invitation had a nagging tone. 

Language problems were often highlighted as barriers to participation in screening programmes (27). The need for translated information for immigrant groups has also been emphasised in other studies as a barrier to participating in various screening programmes in Norway (19, 28–31). BreastScreen Norway recently conducted a randomised controlled trial, where immigrants from five language groups, including Polish, received an invitation to mammography screening either only in Norwegian or in both Norwegian and their assumed mother tongue (32). 

The study showed no difference in participation among immigrants from Poland for those who received the invitation only in Norwegian compared to those who also received the same information in Polish. This finding may indicate that the translation of written information alone is not sufficient to increase participation, and should be supplemented with other measures. 

The participants in the same study and in a study with Pakistani women (31) proposed alternative information methods to increase participation for mammography screening, including involving GPs and using other information channels than the written information that is sent. On the websites of the Norwegian Cancer Registry and BreastScreen Norway there is information on the benefits and drawbacks of participating in screening, as well as videos with oral information in several languages (33).

The study provides valuable insight into how immigrants from Poland relate to mammography screening. The study has a number of limitations. Two of the women had undergone treatment for cancer, one of them for breast cancer. We therefore assume that the participants in the study were more concerned about cancer than immigrants from Poland in general. 

The low number of participants also represents a limitation. The participants were part of a group of ten men and women, where both sexes were interviewed about colorectal cancer and colorectal screening, while only the women were interviewed about breast cancer and mammography screening. 

We originally planned to conduct twelve interviews, but after ten interviews we considered that they were providing little new information. The interviews were translated multiple times, which poses the risk that meaning may be lost. However, the first and fourth author quality assured the findings described by the second author, and confirmed that they are consistent with the interviews. 

All the participants in our study had been living in Norway for a long time, which is also a weakness. Moreover, we wished to interview Polish women with a short period of residence but were unable to find women who had lived in Norway for less than seven years. We included participants with varying proficiency in Norwegian and different affiliations to Norwegian society. Although the women had a relatively long period of residence, they represented a broad-based sample with many different viewpoints, providing a rich data set.

Conclusion

With health literacy as the theoretical framework, our findings shed light on various factors that may impact on Polish female immigrants’ participation in BreastScreen Norway. The participants’ knowledge about BreastScreen Norway varied, but they considered it an important health intervention. To encourage more Polish immigrants to attend BreastScreen Norway, they suggested, among other things, translating information and using alternative information channels. 

These approaches can supplement the information that potential participants in cancer screening programmes receive, and can be used to increase the immigrants’ opportunity to make an informed choice to participate in BreastScreen Norway. Our findings will be used by BreastScreen Norway in their efforts to revise the information material that is sent to women invited to mammography screening. Our findings are also interesting for healthcare personnel and decision-makers working to achieve equitable health services. 

Acknowledgements

We wish to thank Paula Berstad for making this study possible through the ImmigrantScreen project. We also wish to thank all the women who took time to participate in the interviews and share their important and insightful reflections with us. 

Funding

The study is part of a project supported by the Norwegian Cancer Society (reference 213396–2019).

Conflict of interest

Sameer Bhargava has participated in a Norwegian expert panel for triple-negative breast cancer under the auspices of Gilead. This work was completed in mid-January 2024. He will receive financial compensation of NOK 20 000 for this.

Open access CC BY 4.0

Introduction

It is estimated that up to 80% of hospital patients require intravenous cannulation (1). Peripheral intravenous catheterisation (PVC) is used for a variety of interventions: medications, fluid therapies, blood transfusions and nutrition (1, 2). PVC is therefore the most common invasive clinical procedure performed by nurses in the hospital setting (3). 

Previous studies have shown that possible complications, difficulties in establishing venous access and the rate of failed PVC attempts vary (4), due to factors related to the patient or catheter, as well as the skills of the person inserting the catheter (1). Patients often experience increased pain when repeated attempts are needed to establish intravenous access. The size of the catheter does not affect pain levels (5). 

Research shows that although PVC is a common nursing procedure in clinical practice, the procedure is complex and can be challenging for nurses to perform (6). Nurse anaesthetists have specialised expertise in establishing intravenous access (7, 8), particularly in patients who have neither visible nor palpable veins, often referred to as ‘DIVA’ (difficult intravenous access) patients (9). 

To assess the difficulty of a patient’s venous access, a validated scoring tool called the A-DIVA scale has been developed (10). The difficulty level for venous access is ranked from 0–5 based on the following variables: a history of difficult intravenous access, expected difficult intravenous access, inability to detect a dilated vein by palpating and/or visualising the extremity, and a diameter of less than 3 millimetres in the selected vein. The A-DIVA score indicates whether there is low, moderate or high risk for difficult intravenous access (10). 

Two or more failed skin punctures are defined as difficult PVC. One-third of adult patients are estimated to have difficult venous access (6, 9). Failure to establish intravenous access can lead to delays in necessary treatment (11). 

To establish intravenous access, there are two well-established methods: traditional PVC and ultrasound-guided PVC (USGPVC). The traditional method is based on direct visualisation and palpation of a peripheral vein. Using ultrasound makes it possible to locate a suitable vein using an ultrasound device. USGPVC has been shown to be a good alternative to the traditional method in patients with difficult venous access (12).

Several studies have also shown that USGPVC can reduce the number of skin punctures and the time required for PVC in patients with difficult venous access (13–16). If a patient is defined as having easy venous access (low A-DIVA score), the traditional method is considered the most effective method (16). 

Several international studies comparing USGPVC with the traditional method for PVC in adult patients have shown that USGPVC reduces the number of skin punctures in patients with difficult venous access (17, 18). None of the aforementioned studies were conducted in Norway. In hospitals in this country, nurse anaesthetists are often called on to establish intravenous access. This occurs when nurses in surgical and medical wards assess the patient as having difficult venous access. 

Objective of the study

The objective of this study was therefore to investigate whether USGPVC results in fewer skin punctures than the traditional method when nurse anaesthetists are called on to establish intravenous access in patients in surgical and medical wards. We also wanted to examine whether there is a difference in time usage between traditional PVC and USGPVC. We therefore formulated a hypothesis related to our primary outcome measurement, which was the number of skin punctures, and a hypothesis for our secondary outcome measurement, which was time usage: 

1. There is a difference in the number of skin punctures between traditional PVC and USGPVC. 
2. There is a difference in time usage between traditional PVC and USGPVC.

Method

Design and setting

This study has a pragmatic, randomised controlled two-arm study design and was conducted in accordance with the CONSORT Statement for Randomised Trials of Nonpharmacologic Treatments (19). 

The study was carried out between June and September 2022 at a local hospital in Central Norway, which serves approximately 74 555 inhabitants over the age of 18. The practice at the hospital in the study is that ward nurses call on nurse anaesthetists from the anaesthesiology department for assistance in establishing intravenous access in patients with difficult venous access. 

Over the course of one year, the nurse anaesthetists at the hospital were involved in 1658 PVC procedures in other departments. The hospital has 153 beds, distributed between medical and surgical wards. 

Before the study commenced, all nurse anaesthetists undertook training in USGPVC. The training programme consisted of one hour of theory and practical guidance, training in the A-DIVA scale, practising with ultrasound on a vein phantom, and a minimum of one USGPVC on a patient under supervision. 

Sample

The inclusion criteria in our study were: 1) nurse anaesthetists who had completed training in USGPVC, and 2) adult patients over 18 years old who the nurses in the hospital’s surgical and medical wards assessed as having difficult venous access. 

The exclusion criteria in the study were nurse anaesthetists who had not completed training in USGPVC and patients who were critically ill or in isolation for an infectious disease. We also excluded patients who it was deemed unethical to include after the nurse anaesthetists had gone through the A-DIVA scoring assessment. 

The study participants who were nurse anaesthetists were recruited by the first and second authors. Nurse anaesthetists who met the inclusion criteria were given written and oral information about the purpose of the study and informed that participation was voluntary. Those who wished to participate in the study gave written consent. 

The patients in the study were recruited by the nurse anaesthetists who were called on to establish venous access. It was the nurse anaesthetists who informed the patients about the study and its objective. They also indicated that participation was voluntary and that there would be no negative consequences for the patients if they chose not to participate. Patients who wanted to participate gave oral consent in accordance with the recommendations from the Regional Committee for Medical and Health Research Ethics (REK).

Intervention group

PVK procedures that were randomised to the intervention group were conducted using USGPVC. 

Control group 

In the control group, the traditional method for PVC was used, involving visualisation and palpation of the vein. 

Randomisation 

The randomisation was carried out by having the nurse anaesthetists draw a sealed, opaque envelope from the anaesthesiology department when they were called from a medical or surgical ward to carry out PVC on a patient. The envelopes contained information about which method should be used – USGPVC or the traditional method. They also contained a registration form that the nurse anaesthetists were to fill out after completing the PVC procedure. 

All envelopes were filled, sealed and then mixed up by one of the researchers. The second researcher then numbered all the envelopes from 1 to 100. These two processes were conducted independently of each other. The nurse anaesthetists were instructed to take the envelope with the lowest number when they were allocated a PVC procedure. The envelope was not opened until the patient had been informed about the study and had given oral consent to participate and had undergone the A-DIVA scoring assessment. 

Data collection

We collected data using the registration form developed for this study. The data included the number of skin punctures, time usage, A-DIVA scores, type of catheter, location of the catheter, patients’ sex and age, the patient’s ward, and the nurse anaesthetists’ length of service. The A-DIVA score was ranked from low (0-1), moderate (2-3) or high (4-5) risk for difficult venous access.

Primary outcome measurement 

The primary outcome measurement of the study was the number of skin punctures that the nurses anaesthetists needed to establish venous access. This is a recognised outcome measurement that has been used in similar studies (14–16). 

Secondary outcome measurement

The secondary outcome measurement in the study was time usage, including preparation time in the anaesthesiology department when retrieving equipment, going to and from the ward, the actual location of the catheter and tidying up afterwards.

Sample size 

The sample size (20) was calculated based on the primary outcome measurement, which was the number of skin punctures, with a test power of 90% and a significance level of 5% (14–16). 

From the aforementioned studies, the results of the number of successful skin punctures on the first attempt in patients assessed as having difficult venous access were combined. The calculated sample size was n = 46 in each group. To account for potential exclusions from the study, such as PVC procedures with registration forms that were incorrectly filled in or incomplete, we included 50 PVC procedures in each group. 

Statistical analyses

We analysed the data using the statistical software SPSS, version 27 (21). A one-sample t-test was employed to investigate whether there was a difference in the number of skin punctures (primary outcome measurement) between the intervention group and the control group. We employed Mann-Whitney’s U test to examine whether there was a difference in time usage between the intervention group and the control groups (secondary outcome measurement) since the data were not normally distributed (20). If the p-value was less than 0.05, we considered the difference between the groups to be statistically significant.

Ethical considerations 

The study was conducted in accordance with the Declaration of Helsinki (22). The study has been approved by the Regional Committee for Medical and Health Research Ethics (REK), reference number 455676, and by the Data Access Committee (DAC) at the local hospital, reference number 2022/2331 – 17683/2022. Parts of the study were funded through research grants from Nord-Trøndelag Hospital Trust. All participants were informed about the objective of the study. The patients gave oral consent to participate in accordance with the decision from REK, while the nurse anaesthetists gave written consent. 

Results

A total of 20 out of a possible 29 nurse anaesthetists participated in the study, and 171 PVC procedures were registered during the study period. Of these, 71 were excluded (Figure 1), either because the nurse anaesthetists deemed it unethical to include the patient in the study, or due to the procedure involving children or patients in isolation for an infectious disease, or time-sensitive PVC procedures.

The results show that the majority of the patients included were women (62.8%). The median age of the patients was 72 years, with a range spanning from 19 to 92 years. Most of the catheters were pink (1.1 mm), and the most common location was the forearm (Table 1). The analyses also indicated that the patients included had a mean A-DIVA score of 2.16, indicating a low to moderate risk for difficult venous access (9).

The analyses examining the differences between the intervention group and the control group are presented in Table 2. The t-test showed no statistically significant difference in the number of skin punctures between the groups, with an average of 1.3 and 1.2 skin punctures per patient in the intervention group and control group, respectively (p = 0.235). 

There was also no statistically significant difference in the A-DIVA score based on the difficulty of venous access for patients in the intervention group (A-DIVA 2.5) and the control group (A-DIVA 1.8) (p = 0.291). However, Mann-Whitney’s U test indicated a statistically significant difference in time usage between the two groups, with USGPVC taking longer, at 14.82 minutes, compared to the traditional method, which took 10.15 minutes (p = 0.001).

Discussion

The objective of this study was primarily to investigate whether the use of USGPVC results in fewer skin punctures than the traditional method when nurse anaesthetists are called on to establish intravenous access for patients in surgical and medical wards. However, no statistically significant difference was found in the number of skin punctures between USGPVC and the traditional method. 

Our findings align with another study (16), which shows that USGPVC is not a more suitable method for patients with defined simple venous access, i.e. an A-DIVA score between 0 and 3 (10). Furthermore, we found that USGPVC took longer to perform than the traditional method. 

It also transpired that the venous access for patients in our study had a low to moderate A-DIVA score. Based on the findings in this study, the traditional method of PVC rather than USGPVC should be used for patients with simple venous access. The traditional method takes less time and is just as effective as USGPVC. 

Several factors were involved in the calculation of time usage, making it difficult to compare our study with other studies. These factors included physical distances within the hospital, preparation of equipment, the nurse anaesthetists’ level of experience in using ultrasound, and the patient’s condition.

Findings from our study are consistent with results from other studies (23, 24) showing that nurse anaesthetists spend a significant amount of time performing PVC procedures in other departments. This finding is important in terms of ensuring optimal use of hospital resources. If ward nurses are given additional training and more opportunities to practise PVCs, it may result in fewer painful procedures and subsequent complications for patients with genuinely difficult venous access.

Additionally, nurse anaesthetists could make better use of their expertise (6). The results in this study may indicate that the nurses in the wards did not feel confident enough to perform PVC, even though the venous access for the patients, per definition, had a low to moderate A-DIVA score.

Strengths and weaknesses of the study

The study was conducted at a local hospital where the practice is that ward nurses can call on nurse anaesthetists for assistance in establishing intravenous access if they assess the patient as having difficult venous access. We therefore assumed that our sample of patients would have difficult venous access, as the ward nurses had assessed them as having such. However, this assumption turned out to be incorrect, as the sample’s mean A-DIVA score of 2.16 corresponds to a low to moderate risk of difficult venous access (10).

There is therefore a need for further research on how nurses assess the difficulty of venous access as well as their own skills and competence in performing PVC. Studies should also be carried to explore whether the traditional method or USGPVC is better suited when patients have a high A-DIVA score. A potential risk in the latter study is that patients could be subjected to multiple skin punctures during PVC.

The design of the study is one of its strengths (20). We used simple randomisation, which means that all PVC procedures had an equal chance of being assigned to the control group (traditional method) or the intervention group (USGPVC), resulting in comparable groups. This randomisation therefore strengthens the validity of the study, as the groups being compared are nearly identical, allowing us to determine whether the traditional method, which is the current standard, or USGPVC is the most suitable method.

However, one of the weaknesses of all randomised controlled trials is that they are conducted under controlled and standardised conditions, which do not necessarily reflect clinical practice (25). Nevertheless, this study was designed and carried out in a way that closely mirrors everyday practice in the hospital. Ward nurses can contact nurse anaesthetists when they need assistance with PVC. We therefore consider the results of this study to have high practical and clinical utility. 

Another potential weakness of this study is that the nurse anaesthetists excluded a relatively large number of patients due to high A-DIVA scores and ethical considerations. This resulted in the patients in this sample having venous access that was defined as ‘simple/moderate’, i.e. an A-DIVA score between 0 and 3, and not difficult venous access according to A-DIVA. We discussed this exclusion criterion with REK before the study began and, in consultation with REK, determined that such a criterion was necessary to avoid causing unnecessary discomfort and pain to the patients.

Unfortunately, the data collected did not include detailed information on why patients were excluded, but many nurse anaesthetists commented on the registration form that they felt it was irresponsible not to be able to choose the method they believed was best when patients had a high A-DIVA score. 

In 35 of the 37 excluded cases with a high A-DIVA score, the nurse anaesthetists chose to use USGPVC. This indicates that the clinical assessments of nurse anaesthetists align with research in the field, which shows that USGPVC is the best method for patients with very difficult venous access (14–17).

Another weakness of the study was the reliance of one of the inclusion criteria on the nurses’ subjective assessment of difficult venous access, without using a validated scoring tool. The results show that the nurses’ subjective assessment was an insufficient measure of ‘difficult venous access’, and meant we were unable to study USGPVC in patients with a validated score for difficult venous access.

For future studies on the use of USGPVC and the traditional method, researchers should therefore consider defining the inclusion criterion for ‘difficult venous access’ as A-DIVA ≥ 4 (10), in order to investigate whether USGPVC is more effective than the traditional method in patients with a high A-DIVA score.

The nurse anaesthetists in our study had extensive experience and training in traditional PVC, but their level of experience in using USGPVC varied. Some of the nurse anaesthetists had only received the training necessary to take part in this study, while others had been using USGPVC for several years.

In order to protect the privacy of the study participants, we did not collect data on the nurse anaesthetists’ level of experience. The department is relatively small and transparent. However, on average, the nurse anaesthetists in this study had less practical experience and training in using USGPVC, i.e. fewer hours, compared to nurse anaesthetists in other studies (14–16), where both the experience level required and the success rate were higher.

Implications for practice

The results in this study show that the traditional method for PVC is just as effective as USGPVC in patients with easy to moderately difficult venous access (A-DIVA score 0–3). The traditional method was also quicker to perform and is therefore recommended for patients with a low A-DIVA score. 

Although the sample in our study did not exhibit ‘difficult venous access’, meaning that we were unable to definitively state that USGPVC is best suited for a high A-DIVA score, other studies have shown this (14–16). Discussion is therefore needed on whether training in USGPVC should be mandatory for nurse anaesthetist students, as using ultrasound for PVC can entail fewer skin punctures and less pain for patients with difficult venous access. 

Consideration should also be given to whether undergraduate nursing students should be given more training in PVC. Furthermore, efforts should be made to ensure that ward nurses also have the opportunity to practise PVC (6). 

Conclusion

This randomised controlled trial found no statistically significant difference in the number of skin punctures between USGPVC and the traditional method. However, the findings indicate that when patients have difficult venous access, nurse anaesthetists prefer to use ultrasound for PVC. 

The authors declare no conflicts of interest.

Open access CC BY 4.0

Introduction

Both the World Health Organization (WHO) (1) and the International Confederation of Midwives (ICM) (2) recommend involving women receiving antenatal and intrapartum care in decision-making. In Norway, a woman’s right to be involved in health decision-making is enshrined in law (3). 

Women have the right to be involved in the choice of examination and treatment methods and to receive sufficient and tailored information to help them understand the state of their health and the content of the healthcare provided, including potential risks and adverse effects. Healthcare services should be designed in collaboration with the woman to the greatest extent possible, and her opinion should be given weight. As a general rule, health care should only be provided with the woman’s consent. Informed consent is only valid if she has understood the content and significance of the information (3). 

This study focuses on women’s right to be involved in the decision-making and to informed consent in normal childbirth. Separate rules apply to acute situations. 

How can we understand the right to be involved in decision-making in the context of childbirth? In a comment on the legislation (4), the Norwegian Directorate of Health states that the right to be involved in decision-making requires interaction between the patient and the healthcare personnel. However, it also emphasises that the patient’s right to be involved in the choice of appropriate examination and treatment methods does not negate healthcare personnel’s medical responsibility in the situation. 

For a woman in labour, this means, for example, that she has the right to be involved in the choice of pain relief methods and other examination and treatment methods, as long as the choice is medically justifiable. However, she cannot freely choose a caesarean section over a vaginal birth. In situations where it is difficult to foresee the consequences of different treatment options, the need for information, advice and guidance from healthcare personnel for the woman to make a medically justifiable choice becomes greater (4). In the context of childbirth, the midwife plays an important support role for the woman. 

Involvement in decision-making is an underexamined topic in Norwegian government documents on intrapartum care, but the clinical guidelines on quality in intrapartum care (Et trygt fødetilbud – kvalitetskrav til fødselsomsorgen), which are under revision, establish women’s legal right to be involved in decision-making and to information during childbirth (5). 

In contrast, involvement in the form of shared decision-making was introduced in evidence-based guidelines, procedures and recommendations for antenatal, intrapartum and postpartum care many years ago in England (6). In terms of intrapartum care, this means that women are involved in decision-making processes, supported in evaluating different options and given the opportunity to express her own wishes and views (7), such as choosing a birthing position or pain relief method. 

Previous research shows that inadequate information and poor communication, as well as the sense of being excluded, can lead to a traumatic childbirth experience (8). To ensure a positive birth outcome, the woman should feel that she is actively participating in the decision-making process. A study by Kloester et al. (9) describes midwives’ strong desire to protect women’s rights and provide woman-centred care. Nevertheless, women’s rights are not always well protected due to a lack of knowledge, fear of accusations and legal action, and heavy workloads. 

Furthermore, a study by Kennedy et al. (10) shows that consent during labour, as it is practised today, is not in accordance with legislation and clinical guidelines. The study shows that healthcare personnel want to offer women options but find a mismatch between wishes and practice. In order to be able to protect women’s right to consent, healthcare personnel need to update their knowledge on the legislation regarding consent (10). The study discusses whether midwives unconsciously use nonverbal persuasion and points out that only women who are willing to fight for their rights are able to resist the pressure from healthcare personnel (10).

A systematic literature review highlights the lack of studies addressing informed choice and decision-making in antenatal and intrapartum care in traditional hospital settings (11). The authors found that many primary studies include women who have chosen a home birth or unassisted birth – women who have made a conscious decision not to give birth in a traditional setting for various reasons (11). The purpose of our study was to explore midwives’ experiences with protecting women’s right to be involved in the decision-making and to informed consent in childbirth in Norwegian maternity institutions. 

Method

We employed a qualitative method and an exploratory design to investigate the midwives’ experiences (12, 13). Individual interviews and thematic analysis were considered suitable for collecting and analysing the data. We used the COREQ checklist (14) to quality assure the execution of the study. 

Recruitment

We recruited informants using convenience sampling and held individual interviews based on a semi-structured interview guide (13). Recruitment began in August 2022 with a post in the Facebook group for midwives in Norway (Jordmødre i Norge), and five midwives expressed an interest. Due to the poor response, the request for participants was reposted in September 2022, but no new participants emerged. Through snowball sampling (13), we then asked our informants to share information with colleagues who might be interested. We also emailed and phoned maternity units throughout Norway, which resulted in four more participants. 

Sample and data collection 

The sample consisted of nine midwives. The inclusion criteria were that they had to have been employed at a Norwegian maternity unit within the last five years. Due to the geographical distances, and as per the participants’ preferences, all informants except one were interviewed via Zoom or Teams. 

The interviews were held between September and November 2022 and lasted between 27 and 65 minutes. The authors were each assigned separate interviews, but the first interview was conducted by two of the authors. An interview guide (Table 1) consisting of seven questions was used. An audio recording was made of the interviews and this was transcribed verbatim by the interviewer. 

The midwives were employed at three of Norway’s four health trusts. They were currently or previously employed in delivery rooms, maternity wards or maternity clinics. Three of the midwives were aged 30–40 years, one was in the 40–50 age group, three were in the 50–60 age group, and two were in the 60–70 age group. Their length of service varied from 8 to 30 years.

Analysis

The authors performed a joint analysis of the data using systematic text condensation (STC), a cross-sectional thematic analysis method consisting of four steps (13). 

In the first analysis step, we read all the interview transcripts to form an overall impression, and identified six preliminary themes. These were then revised and reduced to three preliminary themes that served as the basis for code groups. In the second analysis step, we labelled meaning units and sorted them into the relevant code groups. In the third step, we organised these meaning units into subgroups and then condensed them. Finally, each condensed unit was transformed into analytical text (13). The code groups and subgroups are presented in Table 3.

Ethical considerations

The project was reported to the Norwegian Centre for Research Data (NSD), now called Sikt – the Norwegian Agency for Shared Services in Education and Research, reference number 936542. As the purpose of the study was to examine midwives’ experiences, we determined that the project fell outside the scope of the Health Research Act and that there was therefore no needed to notify the Regional Committee for Medical and Health Research Ethics.

The study was conducted in line with the recommendations in the Declaration of Helsinki (15). The midwives were sent written information about the study before they agreed to participate. One participant gave oral consent. The midwives who were interviewed via Teams or Zoom consented by logging on to the Teams or Zoom link. They were informed of their right to withdraw from the study without giving a reason, up until completion of the data analysis.

Results

The midwife’s adaptation and handling of information

The midwives felt that information should be provided at the right time, giving the woman time to reflect on what was said and enabling her to give informed consent. Time pressures forced them into harsh prioritising. When faced with choosing critical care, providing information took a back seat. The midwives were in a better position to provide useful information to women giving birth at a time when the department was quiet compared to when it was busy. The women accepted the procedures suggested if they were given information and explanations. 

However, it was challenging for the midwives to provide information and obtain consent in the later stages of labour when the pain was more intense. The midwives prioritised giving information between contractions and reiterated it as necessary. During the pushing stage, the information they provided was brief. The best approach was to prepare the women well in advance of the birth. Ideally, information about the women’s rights, as well as the benefits and drawbacks of interventions, should be provided as part of the antenatal care: 

‘If you’re going to explain it in a way that she’ll truly be able to give her consent, you need to do it well in advance. It’s too late once the head is crowning.’ (Informant 2) 

Some midwives were surprised by what their colleagues chose to spend time explaining, but they understood that perceptions of situations could differ. They emphasised the importance of ‘sensing’ how receptive the woman was, and tailored the information they provided accordingly. 

The midwives found that women who understood the reason behind something being done in the delivery room were less afraid. They therefore tried to avoid using complicated words and phrases. They noted that when a woman was scared, providing information that she was able to understand was challenging. In cases of information overload, when the woman was losing her focus, the midwives allied themselves with her partner: 

‘I often find that the woman’s partner can be a team player because they aren’t as overwhelmed as the woman. So, working with the partner is a good idea.’ (Informant 1) 

The midwives made sure that the information they provided aligned with what they themselves considered best practice, in the hope that the woman would cooperate. When the midwives recommended interventions, they rarely mentioned adverse effects and drawbacks in order to avoid alarming the women. If a woman did not ask about adverse effects, the midwives did not mention them. Some did inform the women of drawbacks but were mindful of how they phrased it. One midwife gave an example of how she would never phrase things: 

‘I’m making an incision now just to be on the safe side. It will hurt more, and will be more painful to heal than a second-degree tear.’ (Informant 3) 

She was aware that by withholding information about the drawbacks it would be easier to gain approval for performing an episiotomy (an incision made in the perineum to prevent uncontrolled large tears, particularly when a quick delivery is needed).

The midwife is caught between procedures and the women’s right to involvement in decision-making

The midwives sometimes felt compelled to perform procedures they disagreed with. They found that clinical management expected more monitoring than was recommended in research, such as requiring admission cardiotocography (CTG) for all women. Most of the midwives felt they had to be loyal to their employer in order avoid a reprimand. 

One midwife used to tell women, ‘This is the department’s procedure, that’s why I’m doing it this way’ (Informant 2). She rarely faced resistance, as most people assumed the hospital knew best. The midwives explained that it would be the midwives themselves who would suffer the consequences if they failed to follow the procedure. However, the more experienced midwives often chose to deviate from the procedure to enable the woman to be involved in decision-making. They justified this by saying they were more confident in their abilities than newly qualified colleagues and were less afraid of being reprimanded: 

‘Adhering to procedures while also protecting the woman’s right to be involved in the decision-making and to informed consent is, I would say, a bit of a utopian expectation.’ (Informant 9) 

It was difficult to fulfil a woman’s wishes and protect her rights in addition to taking responsibility for her child, while also adhering to the department’s practices. Sometimes, for medical reasons, the midwives had to perform procedures against a woman’s wishes. 

One challenge that was mentioned was that if a woman did not want to be catheterised but had two litres of urine in her bladder, the midwife would not give up until the woman understood the consequences of not being catheterised. Some midwives were afraid of doing something wrong or overlooking something, and they believed this was driven by a need for control that possibly stemmed from fear. They performed interventions that were not part of the procedure, ‘just in case’: 

‘In any case, I think we focus more on covering our backs than on allowing them to have a say and make informed choices.’ (Informant 3)

The midwives questioned whether the women actually had a real choice. Several reflected on how they phrased their language. They often presented measures during labour as suggestions or recommendations, because as soon as they formulated the proposed measure as a question, they had to consider the possibility of the woman refusing. One such example was: ‘I’m now going to [...] because [...].’ They then performed the procedure without asking the woman. One midwife described this as a form of coercion and thought it would have been a better experience for the woman if she had been given the opportunity to take part in the decision-making: 

‘I present it as part of our standard practices, this is how we do things here. I don’t ask directly if she agrees.’ (Informant 6)

The joint responsibility of the midwife and the patient for involvement in decision-making in childbirth

Women who had attended antenatal classes were more aware of their rights and the opportunity to influence the childbirth process with a birth plan. Some of the midwives applauded this, while others found it problematic. One midwife thought that colleagues who questioned it perhaps felt that their professional competence was being challenged. Another believed that it was primarily the most experienced and authoritative midwives who found the use of a birth plan problematic. 

Birth plans were challenging when women had a very fixed idea about what they wanted, and all the midwives emphasised the importance of women being flexible during labour. There was no point in planning the birth in detail, as childbirth is inherently unpredictable. However, most of the midwives believed that antenatal classes and birth plans were effective tools for facilitating women’s involvement in decision-making. One informant said the following: 

‘She herself has a responsibility for her labour progressing, so she needs to be informed about what we want to do and why. If she wants to lie on her back in labour for eight hours, let her get on with it.’ (Informant 6) 

All informants agreed that there was potential for improvement in relation to their own and the department’s knowledge of the legislation on women’s rights during childbirth. One question raised was, ‘What would I want if I was in this situation?’ Many felt that introspection and effort were needed to change established behaviours. Suggestions for improvement included holding training days on the patient’s involvement in decision-making. Several highlighted the value of sharing experiences, thoughts and perspectives with each other. 

The midwives expressed uncertainty about the legislation and were unable to quote any of its content. Some were more up to date than others, but most engaged with the legislation at a subconscious level; they reasoned that women have the right to be involved in decision-making and to give informed consent: 

‘At some point, I’ve probably known something about patients’ rights. But the laws on that are not foremost in my mind.’ (Informant 5)

Discussion

Right to information – a challenge in clinical practice?

Women in labour have the right to tailored information (3), but the midwives in the study rarely mentioned adverse effects and drawbacks of various interventions in order to avoid alarming the women. One of the midwives described this as a form of coercion. When a suggestion is framed as a question, it opens up the possibility of the woman responding with either yes or no. If the woman declined the proposed intervention, the midwife was faced with a dilemma. This dilemma was avoided by refraining from providing the woman with sufficient information to make an informed choice. Consequently, she deprived the woman of the opportunity to be involved in decision-making and to make a real choice. 

This finding is consistent with other research indicating that it is not standard procedure to provide information about the benefits and drawbacks, and that this practice may be linked to midwives’ reluctance to involve women in the decision-making (16). Another explanation could be that providing detailed information is time-consuming. In order to make an informed choice, the woman needs time to reflect on the information she is given, which can be challenging in a busy department. Although shared decision-making is not yet common practice in Norwegian maternity wards, documents on intrapartum care recognise women’s legal right to receive information during childbirth (5). 

Providing the women with adequate information can give them a greater opportunity to be involved in decision-making, helping them avoid becoming a passive participant in their own childbirth process (8). Furthermore, studies show that healthcare personnel’s reluctance to provide information (16–18) can contribute to traumatic childbirth experiences (8, 19). Trying to shield women by withholding information can therefore be counterproductive to the midwives’ intentions.

Active involvement in decision-making – a real possibility?

According to Joseph-Williams et al. (20), women may be trapped in their desire to be a ‘good’ patient, where they are passive and compliant and take up little space. The study shows that healthcare personnel believe it is their job to make decisions on the patient’s behalf, as they know what is best for them. Similar findings were reported by the midwives in our study and are supported by research indicating that some women do not actually want to be involved in health decision-making (21).

In contrast, other studies show that while healthcare personnel may believe a woman does not want to be involved in decision-making, the reality might be that she does. However, she is being deprived of this opportunity because she has been given inadequate information (8) or does not wish to bear sole responsibility (19). 

The midwives in the study reported how some women used a birth plan to be actively involved in the decision-making during labour. Devising a birth plan after consulting with the midwife and maintaining an open dialogue about it during labour has been shown to enhance the birth experience (22), foster greater involvement in the decision-making and promote a sense of control (23, 24).

All the midwives agreed that birth plans are a useful tool for childbirth, but they also raised concerns about some women setting specific demands and wishes that are unrealistic. The midwives felt that if the women’s wishes in the birth plan were too detailed, they were less inclined to adapt. This could be professionally challenging for experienced midwives. 

This finding is consistent with other studies (25, 26), which show that experienced midwives in Norway have a strong identity linked to the midwifery profession. They often viewed the women’s expectations during childbirth as a long ‘wish list’ of demands that could be perceived as offensive, and they felt that the women doubted their midwifery knowledge and experience. This tension can pose a challenge to the midwife’s professional autonomy and hinder effective collaboration between the midwife and the patient.

The quote above from Informant 6, regarding the shared responsibility for labour progressing, illustrates the importance of information, communication and collaboration during childbirth. Although the women have a legal right to be involved in decision-making, the midwife has a professional responsibility in the situation. The midwife must balance the woman’s wishes and rights with her own duty to provide appropriate medical care. 

Clinical guidelines and procedures – basis for negotiation?

The midwives in the study sometimes felt compelled to perform procedures they considered inappropriate. They felt they had to be loyal to their employer, and that it would be commented on if they did not adhere to procedures. Several studies indicate that midwives feel pressured into adhering to the department’s practices and procedures, even when this undermines the patient’s right to be involved in the decision-making and to informed consent (16, 27, 28).

The study by Feeley et al. (16) found that midwives engaged in negotiations with the women to find a compromise between fulfilling the woman’s wishes and adhering to the department’s practices. This finding is consistent with our own results. Midwives found the situation challenging because they felt that internal procedures and clinical guidelines did not adequately address women’s right to be involved in the decision-making during childbirth. Nevertheless, they tended to adhere more to the department’s procedures and clinical guidelines than to the legislation. A British study shows that no facilitation is made for midwives to protect women’s rights while simultaneously following departmental guidelines (28). 

In our study, several experienced midwives chose to deviate from the department’s procedures to enable the women to be involved in decision-making, for example by omitting the routine use of admission CTG. They justified this by saying they were more confident in their abilities than newly qualified colleagues and were willing to take responsibility for their decisions. Similar findings are seen in a study that describes how the midwife’s autonomy is more crucial than departmental procedures for ensuring a normal birth (25).

It is interesting to note that the midwives who chose to deviate from or only partly adhere to procedures at larger maternity wards were regarded as ‘alternative’ by their colleagues (25), while the midwives concerned perceived themselves as a reassuring presence for the women in their care. This finding raises thought-provoking questions about what constitutes ‘valid’ knowledge in the midwifery profession, as well as the understanding of the midwife’s autonomy versus the woman’s rights during childbirth.

Strengths and weaknesses of the study

The authors are midwives with experience in intrapartum and postpartum care, professional development and education. Our interest in the topic arose after observing how practices regarding the protection of women’s right to be involved in decision-making and to informed consent differed across clinical settings. We recognise that women are becoming increasingly aware of their rights during childbirth, but challenges often arise when trying to balance the requirement for medically justifiable care with the women’s right to be involved in decision-making.

Qualitative design and individual interviews were suitable methods for shedding light on the study’s research question (13). Similarly, a cross-sectional thematic analysis was an appropriate choice given the scope of our data (13). However, our limited research experience may have impacted on the quality of the interviews, particularly our ability to follow up on important points in the first interviews.

Using social media in the recruitment process enabled us to effectively communicate information about the study to a wide audience of midwives. One of the strengths of the study was the participation of midwives from large and small maternity units across three of Norway’s four health trusts. However, the recruitment was challenging. This could be due to a lack of interest in the topic, or perhaps a reluctance to comment on it, but it could also be related to our choice to recruit via social media.

The closed Facebook group for midwives in Norway (Jordmødre i Norge) has over 3000 members and is frequently used to recruit participants for various studies. We cannot ignore the possibility that the volume of requests has led to ‘fatigue’ within the group, as members mostly need to participate in the research in their leisure time. We also cannot rule out the possibility that midwives who were particularly interested in the topic contacted us with a desire to participate, which may represent a bias in our sample.

Conducting the interviews via Zoom and Teams enabled us to recruit participants from across the country. The midwives could respond from the comfort of their own homes, making it easier to fit the interview into their busy daily routines. The participants reported feeling comfortable with digital video platforms, having grown accustomed to them over the years of the pandemic. However, we cannot ignore the fact that it can be easier to establish a good rapport and identify non-verbal cues in in-person interviews compared to remote interviews.

Conclusion

The midwives found it challenging to protect the women’s right to be involved in the decision-making and to informed consent during childbirth. Balancing the protection of women’s rights while being expected to adhere to the department’s practices was particularly challenging. 

The study also revealed a need to improve practices and update clinical guidelines and procedures, with a strong focus on opportunities for patient involvement and shared decision-making. Greater involvement in decision-making can contribute to a more positive childbirth experience and give a woman a greater sense of ownership over her own childbirth process.

The authors declare no conflicts of interest.

Open access CC BY 4.0

Introduction

Hip fractures (HF) are an emerging worldwide public health challenge for the increasing geriatric population with an estimated annual global incidence of 14.2 million hip fractures in 2019 and an expected rise of 50% in 2050 (1, 2). In Norway, the annual hip fracture incidence is 166 per 100 000 inhabitants, and among the highest worldwide (3). Surgical treatment is mandatory for all patients except moribund patients, class V according to the American Society of Anesthesiologists (ASA) classification (4). 

In Norway, the mean age of patients undergoing surgery for HF is 80 years, and 66% are women (3, 5). At hospital admission, hip fracture patients often experience severe pain. Acute confusion occurs in approximately 40% of older HF patients and uncontrolled pain is thought to increase the risk of developing delirium (6, 7). 

Regional nerve blocks are a recommended supplement to oral and intravenous pain management to avoid side effects of the latter, including delirium, nausea, vomiting, rebound pain and altered mental state (4, 8). For example, in Lim et al.’s retrospective study of 252 hip fracture patients, regional nerve blocks reduced the incidence of delirium by about 45% (9). In particular, the ultrasound-guided fascia iliaca compartment block (US-FICB) has gained popularity in recent years, due to its relatively simple and safe application (10). 

In a retrospective cohort study with 98 patients, US-FICB at hospital admission reduced opioid consumption and length of hospital stay in geriatric hip fracture patients to a statistically significant degree (11). However, the literature is conflicting: for example, in Salottolo et al.’s observational cohort study with 517 geriatric hip fracture patients, fascia iliaca compartment blocks neither decreased opioid consumption nor the incidence of delirium (12).

Our institution has implemented a fast-track system for geriatric hip fracture patients, which included the routine application of an FICB without ultrasound guidance by the orthopaedic surgeon on duty. However, there was some evidence for a superior analgetic effect of ultrasound guided FICB, compared to a non-instrumental method, often referred to as the ‘landmark approach’ (13, 14). 

Additionally, the use of ultrasound guidance can significantly reduce the incidence of local anaesthetic systemic toxicity (LAST) in older patients (15). 

Nevertheless, the abundance of hip fracture patients, combined with the limited availability of orthopaedic surgeons and anaesthesiologists, can compromise a swift and efficient US-FICB application. Nurse anaesthetists are highly qualified personnel and experienced with ultrasound-guided procedures. They can be a valuable resource to ensure adequate pain management in that fragile patient population. Gawthorne et al. demonstrated equal results and complication rates for US-FICB performed by nurses compared to medical doctors (6). 

In our institution, nurse anaesthetists have performed US-FICB since 2019 with about 750 procedures in 2023 alone. Except for one case of a transient blood pressure drop without further consequences, no complications were reported. Given that a predominant number of hip fracture patients are female and recent neurobiological studies indicate notable differences in pain perception between the sexes, differentiating between male and female patients is of significance for optimising pain management strategies (16).

This study aims to evaluate the analgetic effect of nurse anaesthetist-administered US-FICB on pain intensity at rest and pain intensity during movement, differentiated by the patient’s age and sex. Furthermore, we aim to describe possible factors for the success of the procedure.

Method

Study design

Prospective observational study, compliant with the ‘Strengthening the Reporting of Observational Studies in Epidemiology’ (STROBE) guidelines (17).

Ethical aspects

The current study was approved by the Regional Ethics Committee (reference REK 2021/265106), and Akershus University Hospital’s data protection officer (reference 2021_159 21/0898). Patients provided informed written consent. Patients were not refused supplemental oral pain medication and received the same level of care as in guideline-based routine clinical practice.

Setting and eligibility criteria

Patients over 18 years of age admitted to Akershus University Hospital with a radiologically verified isolated hip fracture between September and December 2021 were eligible for the study. Hip fracture was defined as either femoral neck fracture or trochanteric fracture, including subtrochanteric fracture, classified as 31-A1-3 and 31-B1-3 according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) and the Orthopaedic Trauma Association (OTA): Detailed inclusion and exclusion criteria are summarised in Table 1. 

The initial physical examination was performed by the orthopaedic surgeon, who reconfirmed the diagnosis and set up a treatment plan, including the prescription of the US-FICB. The patient’s pain intensity was recorded by staff nurses using a numeric rating scale (NRS) ranging from 0–10, where 0 indicated no pain and 10 represented the worst pain imaginable. Pain at rest was documented both before and after the US-FICB procedure. 

For the assessment of pain during movement, upon initial assessment, pain intensities were gauged when patients actively moved in bed. Nurse anaesthetists performed the US-FICB according to a standardised procedure implemented in our hospital. In brief, 20 ml of 0.9 mg/ml sodium chloride and 20 ml of ropivacaine 5mg/ml solution were mixed into a 40 ml solution and subsequently injected beneath the fascia iliaca, approximately 1–2 cm lateral to the femoral nerve under ultrasound guidance. See Figure 1. 

The details of the procedure are described in Appendix 1. All five nurse anaesthetists participating in the study had previously received four hours of theoretical training and had performed a minimum of 20 US-FICB procedures under supervision. After 60 minutes, staff nurses measured pain intensity using the NRS at rest and during movement again. Pain during movement after US-FICB was recorded by inserting a wedge underneath the patient’s femur, resulting in 20˚ hip and 40˚ knee flexion. In addition to NRS for pain measurement, the age and sex of the patient were recorded.

Success in pain relief was defined as the minimal clinically important difference (MCID) of ≥ 1.5 difference on the NRS, in accordance with Bijur’s MCID study for using NRS for pain measurement on 195 older patients (18). 

Data analysis

The primary outcome in the present study was the change in pain intensity (NRS) before and after the US-FICB. Data were analysed with descriptive statistics for the whole study sample and for females and males, respectively. A two-tailed paired Student’s T-test was performed for the NRS scores recorded before and after US-FICB. Significant differences were assumed at alpha ≤ 0.05. A posthoc power analysis was provided for each Student’s T-test. 

Logarithmic regression: the study population was divided into a ‘success’ and ‘no-success’ group, depending whether US-FICB reduced pain intensity with a minimum of 1.5 points on NRS or not. This was performed for both pain at rest and pain during movement. We postulated that the US-FICB procedure was especially efficient in patients with high initial NRS scores. Hence, we hypothesised that pain intensity measured before administering US-FICB could independently predict the chance of success for the treatment.

Two logarithmic regressions were modelled, one for pain at rest and one for pain with movement. The independent variables were age, sex and pain intensity assessment (NRS) before administering US-FICB. The dependent variable was the success of the procedure for pain at rest and pain during movement, respectively, as defined above.

Data were analysed with Stata 16 (Statacorp LLC, College Station, TX, USA). 

Results

Descriptive statistics

A total of 35 eligible patients were included and received US-FICB from nurse anaesthetists. No adverse events were reported. Data from two patients were not included in the analysis due to missing NRS recordings. Out of 33 patients with complete datasets, 21 were female (63.6%). 

The mean age was 78.6 years (95% CI: 74.6–82.7). Pain intensity (NRS) was normally distributed, except for pain intensity during movement before administering US-FICB. There was no association between the sexes in initial pain intensity, neither at rest nor during movement, but the sample size was underpowered (1-β=36.5%). Nor did we find any statistically significant difference between the sexes in pain reduction after US-FICB. 

Pain intensity on the NRS scale was lower after US-FICB for pain at rest for females and for pain during movement for both sexes, to a statistically significant and clinically important extent. Further details are summarised in Table 2.

Stratifying (success/no success)

A reduction of minimum 1.5 NRS points for pain intensity was recorded in 17 patients for pain at rest, and in 23 patients for pain during movement. Patients who reported a minimum 1.5-point decrease in the NRS after the US-FICB (defined as success) reported a higher NRS score, i.e. more pain at rest before the procedure (6.3; 95% CI: 5.1–7.4), compared to patients whose NRS decreased by less than 1.5 points (3.3; 95% CI: 1.8–4.8). That difference of three NRS points was statistically significant, and the sample was adequately powered for this question (Student’s T-test; p<0.01; 1-β=93%).

Logarithmic regression

NRS scores at rest before US-FICB were associated with the success of the procedure (odds ratio 1.6; 95% CI: 1.1–2.3; p<0.01). However, for pain experienced during movement, NRS scores before US-FICB were not significantly associated with success (OR 0.98; 95% CI: 0.7–1.4; p=0.9), nor were age and sex. A high score for pain intensity at rest before nerve block increases the probability of pain reduction of more than 1.5 points after ultrasound-guided fascia iliaca compartment block (US-FICB) (Figure 2). 

Discussion

In this prospective observational study with 33 hip fracture patients, ultrasound-guided fascia iliaca compartment block provided a clinically important analgetic effect for pain at rest in women and pain during movement in both sexes. Furthermore, a higher baseline NRS at rest was an independent predictor for clinically important pain relief by US-FICB. That finding indicates that patients experiencing a higher initial pain intensity are more likely to benefit from US-FICB. 

The advantages of fascia iliaca compartment blocks have been described in previous literature. Verbeek et al. concluded that regional nerve blocks relieve dynamic pain effectively and increase patient satisfaction (19). Furthermore, patients are also described as tolerating the positioning for spinal anaesthesia better after FICB (20, 21).

The mean NRS reduction for pain intensity during movement in our study was 2.6 and 69.7% of patients experienced a clinically important analgetic effect for pain during movement. This finding is in line with the observational study by Ridderikhof et al. with supra-inguinal FICB, with a mean NRS reduction of 2.5; and 59% of patients improving more than 1.5 points (22). 

Guay and Kopp found a 2.5 NRS score reduction thirty minutes after both FICB and femoral nerve block (23). In Gawthorne et al.’s prospective cohort study, US-FICB resulted in a mean NRS reduction of 3.7 (SD: 2.9) and 3.3 (SD: 2.6), when performed by either medical doctors or emergency department nurses. However, neither of these papers differentiated between pain at rest and during movement, which makes a direct comparison to our study challenging (6). 

Wennberg et al.’s findings from their case-control study of 135 patients indicate a better effect of US-FICB for movement-evoked pain, compared to pain at rest (25). We also found a statistically significant higher NRS reduction for movement-evoked pain compared to pain at rest 60 minutes after US-FICB. 

Pain during movement is important to assess and treat because it can impede motion, which is essential for post-operative mobilisation and the prevention of respiratory and circulatory complications (24).

In our study, NRS recordings both at rest and during movement suggest that female participants report higher pain intensity than their male counterparts. In their review paper, Palmeira et al. demonstrate how sex hormones, genetics, and psychosocial and cultural differences affect pain perception (26). One finding was that men generally express a greater tolerance for pain, while women show a greater willingness to report pain (16, 26). 

In our study, we did not detect significant differences between the sexes. However, our study material was not adequately powered for this question. As already outlined by Templeton et al., future studies should include a sufficient number of patients for the generation of adequately powered stratified data for both sexes (27).

In our study, US-FICB achieved a significantly higher mean NRS reduction in patients reporting a higher initial pain intensity. Some authors have excluded patients with initial NRS ≤3, potentially affecting the results. (28). The minimally clinically important difference (MCID) for NRS recording was previously found to be 1.5 points (18). 

Limitations

This observational study has inherent limitations compared to randomised controlled trials, such as the lack of a control group and a non-blinded design. Unfortunately, the time and resource limitations related to a master’s thesis, and delay at the regional ethics committee limited the available timeframe for data acquisition, resulting in the limited sample size. This may affect the internal and external validity of the results. 

That is why we performed a post-hoc power analysis on all statistical tests, showing that our study was sufficiently powered for the majority of the statistical tests (see Table 2). Finally, previous history of chronic pain or chronic pain medication might be confounders for which we have no data.

Patients with nurse-diagnosed delirium and cognitive impairment were excluded, even though this patient group comprises a significant portion of all hip fracture patients. No formal screening and/or assessment tools for cognitive impairment and delirium were applied.

Seven patients report more pain at rest after US-FICB. One patient reports increased pain both at rest and during movement post-procedure. Possible explanations include statistic outliers and other potentially confounding patient-related factors which were not documented, such as anxiety, previous opioid (ab)use, or pain stimuli between the two NRS registrations, such as the moving of the patient from the stretcher to the hospital bed. Neither of these possible explanatory events was recorded during the scope of the study.

Given the resources dedicated to this investigation, only a single follow-up NRS registration after 60 minutes was performed. Ropivacaine achieves its onset of action within a timeframe of less than 15 minutes. Under ideal circumstances, multiple NRS registrations within 60 minutes might have revealed patients with non-clinically important responses to US-FICB earlier. 

Additional registrations, e.g. after four hours, eight hours, and at the time of surgery could have provided more data about the longer-term effect of US-FICB. Ultimately, this study lacks data for the orally administered pain medication, which could potentially have influenced the NRS registrations. 

In studies that examine clinical methods delivered by multiple providers, inherent inter-provider variability can introduce potential confounding factors. However, this study involves patients admitted unexpectedly at any time, making it challenging to have one or two dedicated nurse anaesthetists constantly available for the procedure.

Furthermore, NRS for pain with movement was recorded by two different methods before and after US-FICB. While pain with movement before US-FICB was defined as the patient’s spontaneous movements in bed, the pain after US-FICB was provoked by sliding a 20˚ wedge underneath the patient’s thigh. That methodological difference might potentially impair the validity of the results.

Finally, the sample size of 33 patients with complete datasets might limit the external validity of the results. The four-month timeframe was chosen with respect to the given resources dedicated to this study. Still, our principal findings correlate well with previous studies with significantly larger sample sizes (6).

Conclusion

US-FICB performed by nurse anaesthetists is a valuable tool for pain management with hip fracture patients, and our data indicate that it can have a clinically important analgetic effect, especially for pain during movement. Furthermore, it seems that US-FICB is particularly useful for patients with high initial pain intensity. 

Larger studies, preferably randomised-controlled trials will be necessary to elucidate lingering issues, with a focus on the patient’s sex and the difference between pain at rest and movement-evoked pain. Finally, upcoming investigations should include cognitively impaired patients by applying existing tools for pain assessment in this patient group.

In the future, nurse anaesthetists will be required to master the use of ultrasound as a tool in clinical practice, hopefully for nerve blocks as well, to the benefit of an increasingly frail hip fracture patient population. 

Acknowledgements

The authors would like to thank Prof. Marit Leegaard at Oslo Metropolitan University for her supervision and guidance.

The authors declare no conflicts of interest.

Open access CC BY 4.0

Introduction

Sepsis leads to organ failure due to a dysregulated immune response to common infections, including bloodstream infections (BSIs) (1, 2). As sepsis patients are often in need of organ support (3), sepsis is one of the most common reasons for admission to an intensive care unit (ICU) (4) and the most common cause of death in hospitals (5). 

Even with intensive care, sepsis mortality remains high, accounting for 11 million lives lost annually across the world (1). In population-based data, the overall mortality within 30 days for patients with infection and a positive blood culture is reported to be 15.8% (6). 

For adult survivors, severe sepsis is associated with both functional and mental limitations (7), demanding a long and comprehensive individualised recovery process, with care delivered by multidisciplinary team members (3). Guidelines recommend that patients with critical illness start rehabilitation as early as clinically possible (8), and early rehabilitation in the ICU is a well-proven treatment to improve functional outcomes (9, 10). 

Recent sepsis guidelines also recommend referral to a post-critical illness follow-up programme, if available (3). These guidelines state that evidence on effects of rehabilitation after the critical care phase is scarce, highlighting the need to gather evidence from different healthcare delivery systems (3). 

During holiday periods, post-acute sepsis patients’ rehabilitation trajectories may be limited by a lack of staff members or even by unavailability of rehabilitation facilities. However, the impact of multidisciplinary rehabilitation wards closed during holidays and sepsis patients’ trajectories – including length of stay, discharge destination and long-term outcomes – is still unknown (11).

This study aimed to understand the impact of closing specialised rehabilitation wards during holidays on patients’ length of stay, discharge destination and survival over a 10-year period. 

Method

Study design and study population

In this registry-based cohort study, data were extracted from the Nord-Trøndelag Hospital Trust’s (HNT HF) hospital-based Sepsis Registry at Levanger Hospital, Norway (12): a community hospital for approximately 100,000 inhabitants. All patients aged ≥18 years who had their first admission and were included in the Sepsis Registry between 2003 and 2013 were included in this study.

The Sepsis Registry and local routines

The HNT HF Sepsis Registry is a medical quality and research register established in 1994 for surveillance purposes. At the time of sepsis suspicion, all patients underwent a standard clinical examination to decide on a diagnosis. Blood cultures were drawn prospectively at the time of suspicion and routinely assessed by a microbiologist to evaluate the possibility for contamination. 

All patients with clinically suspected sepsis and confirmed BSI in two sets of blood culture bottles (BACTEC 9240 Vacutainer Culture Bottles until 2010, hereafter BACTEX FX (13)) were included in the Sepsis Registry. Clinical variables from electronic medical records were obtained by a trained research team and quality checked by an experienced consultant in infection medicine. All patients received information regarding inclusion in the registry and were given the option to withdraw.

Dependent on treatment needs, the sepsis patients were either admitted to a general medical ward, a monitoring unit (MU) or an ICU for more specialised care. After medical treatment, patients in need of interdisciplinary specialised rehabilitation were commonly transferred to a rehabilitation ward at the same hospital. 

Since its opening at the end of 2002, the rehabilitation ward has been closed during holidays: for four weeks in July/August and during Christmas and Easter each year (see details in Appendix 1). In the present study, the holiday period is defined as one week before the rehabilitation ward closes until one week after reopening (patients admitted in this period are usually affected by the closed ward).

Data collection

Baseline and clinical variables – including length of stay, discharge destinations and survival – were retrieved from the Sepsis Registry. Data on discharge destination was not available before 2008. Functional status before sepsis hospitalisation was recorded as ‘independent’ when the patient lived at home without assistance, ‘partly independent’ if the patient lived at home with some assistance and ‘dependent’ if the patient either lived at home and received help with most daily life activities or in a nursing home or similar institution (14). 

We also calculated the Charlson Comorbidity Index (CCI) (15) and the Sequential Organ Failure Assessment (SOFA) score (2). The SOFA score is a validated scoring system that measures the degree of acute organ failure in six organs (respiratory, cardiovascular, hepatic, coagulation, renal and neurological systems) (2). 

Statistical analyses

Descriptive statistics are reported as median and interquartile range (IQR) for continuous variables and as count and percentage for categorical variables. Groups were compared for baseline differences using the t-test for continuous variables, the Wilcoxon–Mann–Whitney test for ordered categorical variables and the Pearson chi-squared test for dichotomous variables. Length of stay was calculated as the number of full days from the date of hospital admission to the date of hospital discharge. 

Since means could be more relevant than medians when estimating costs and the need for health workers (16, 17), both medians with IQR and means with standard deviations (SDs) are presented for the length of stay, since the data were right-skewed. The differences in length of stay were assessed using the independent samples t-test, not assuming equal variances. This version of the t-test is robust to deviance from normality (18). 

For discharge destination and survival at 30 and 90 days, the Pearson chi-squared test was used. Survival time was assessed from the time of the first admission to death (end of follow-up 31 December 2021). We used Cox regression to assess differences in survival between groups adjusted for age, sex, baseline functional status, comorbidity and SOFA score. The proportional hazard assumption was confirmed by visual inspection of Schoenfeld residual plots and log-log plots. We regarded a two-sided p-value <0.05 to represent statistical significance, and 95% confidence intervals are reported where relevant. Data were analysed using SPSS 27 and Stata 17.

Ethics and approvals

This study was approved by the HNT HF’s Data Access Committee (reference 2021/1221 - 9248/2021) and the Regional Committee for Medical and Health Research Ethics, Health Region IV in Norway (REK reference 230377). 

Results

Of the 1,893 eligible patients, a total of 1,552 were included in the analysis. A flowchart for the inclusion process is presented in Figure 1. Of these, 481 patients were hospitalised during the holiday periods, while 1,071 patients were hospitalised outside the holiday periods. Baseline characteristics for patients admitted to the hospital during versus outside holiday periods are presented in Table 1, and there were no statistically significant differences between the groups. 

The severity of illness and treatment characteristics were also similar for patients admitted to the hospital during holiday periods versus outside holiday periods (Table 2).

Length of hospital stay

The median length of stay was 9 days (IQR 5–17) for patients hospitalised during the holiday periods, compared with 7 days (IQR 5–12) for patients hospitalised outside the holiday periods (p<0.001). The mean length of stay was 14.5 days (SD 16.9) and 11.2 days (SD 13.3), respectively (mean difference of 3,3 days, 95% CI 1.6–5.0 days, p<0.001). As seen in Figure 2, there was a subtle, gradual decrease in the length of stay from 2003 to 2013, and the differences varied over the years.

A subgroup analysis was performed on the 332 patients who were admitted to the MU and ICU, where 102 (30.7%) were hospitalised during the holiday periods and 230 (69.3%) were hospitalised outside the holiday periods. In this subgroup, the median length of stay was 13.5 days (IQR 7–28.3) during the holiday periods, compared with 9 days (IQR 5–16) outside the holiday periods (p<0.001). 

The mean length of stay during the holiday periods was 22.8 days (SD 23.4), compared with 15.2 days (SD 18.1) outside the holiday periods, with a mean difference of 7.6 (95% CI 2.5–12.8, p=0.004). The length of stay over time is shown in Figure 3.

Discharge destination

Discharge destination was recorded from 2008, thus we have complete data for 601 patients (n=414 (68.9%) outside the holiday periods and n=187 (31.3%) during the holiday periods). The distribution of discharge destinations between groups did not differ (p=0.739). Of the patients hospitalised during the holiday periods, 60.4% (113/187) were discharged to their residence versus 58.0% (240/414) of the patients hospitalised outside the holiday periods (p=0.571). 

Further, 17.6% (33/187) were discharged to a nursing home or rehabilitation facility in the municipality during the holiday periods versus 16.7% (69/414) (p=0.767) outside the holiday periods. Transfer to another hospital occurred in 4.8% (9/187) in the holiday periods versus 4.3% (18/414) (p=0.799) outside the holiday periods. Discharge to a district medical centre occurred in 17.1% (32/187) of the patients during the holiday periods versus 21.0% (87/414) (p=0.266) outside the holiday periods.

Survival

A total of 13.5% (65/481) of the patients hospitalised during the holiday periods died within 30 days, compared with 15.1% (162/1071) in the other group (p=0.406). The proportion who died within 90 days was 21.8% (105/481) during the holiday periods, compared with 21.7% (232/1071) outside the holiday periods (p=0.941). 

The hazard ratio (HR) for survival did not differ between groups; moreover, the patients hospitalised during holiday periods had an HR of 1.01 (95% CI 0.89-­1.15) for death when adjusted for baseline characteristics, compared to the reference group that was admitted with sepsis during non-holiday periods (p=0.843). This estimate did not change with adjustment for two or more organ failures during hospital stay, as measured by a categorical SOFA score (value 0 if 0–1 organ failures, value 1 if 2 or more organ failures).

Discussion

In this study, we found that the sepsis patients admitted to the hospital during the holiday periods had a median 2 days longer and mean 3.3 days longer hospital stay, compared to patients who were hospitalised in non-holiday periods. In sepsis patients in need of MU or ICU treatment, the length of stay was a median 4.5 days and mean 7.6 days longer during the holiday periods. However, there were no differences in discharge destinations or survival between the two groups. 

Previous studies in intensive care have reported positive outcomes for general patients and sepsis patients receiving early rehabilitation (9, 10, 19). Severe sepsis is associated with both physical and cognitive deficits (7), and the required rehabilitation can be complex. Thus, sepsis patients may have considerable potential for improvement. 

Since prolonged length of stay is associated with an increased risk of complications and mortality (20, 21), the complication rates could have been increased during holiday periods, although this was not assessed in the present study. In addition, one study shows that rehabilitation provided on a general ward can be suboptimal and that some deaths following ICU discharge can be avoided (22). 

However, we did not find any differences in survival between the groups in our study, and this may reflect a successful implementation of sepsis care bundles that secure good quality care both during and outside of the holiday periods. It is important to note the severe burden of sepsis that was demonstrated in our study: 1 out of 7 died within 30 days and one fifth after 90 days. The 30-day mortality rate corresponds to data from Denmark (6).

An increased length of stay may also lead to a delayed start of necessary interdisciplinary rehabilitation (23) and be a burden for the patients. However, a small study demonstrated ward-based rehabilitation to be feasible if interprofessional coordination is ensured: the study found no difference in outcome with or without treatment in a specialised rehabilitation ward for sepsis patients (24). 

Our study supports these findings. Nevertheless, there might be a risk of higher patient occupancy at the other wards due to closed rehabilitation wards, which could result in less time for healthcare workers to follow up on all patients. Further studies should therefore assess the outcome of all patient groups to obtain an overall overview of the consequences of closed rehabilitation wards. 

Increased patient occupancy in the wards could also contribute to the need for extra personnel at work, and the cost of bed days at the medical ward, the MU or the ICU might be higher than at the rehabilitation ward. However, keeping a rehabilitation ward closed during holidays may also save costs, and further studies are needed to investigate the economic aspects of this issue. 

A subtle decrease in hospital stay was found from 2003 to 2013 in our study, which corresponds to data from both Denmark and the United States (6, 25). This may reflect more efficient treatment over time or an increased incidence of discharge to an external health institution (6) where the treatment can be continued. However, the difference in length of stay between the two groups varied over the years and seemingly decreased towards the end of the period. This could potentially be explained by natural fluctuations, but it may also be a result of the 2012 Norwegian Coordination Reform (26). 

This reform aimed to place responsibility upon the municipalities for patients ready for discharge, which has shown to decrease hospital stay and increase stay in municipal care (27). Based on this, the outcome in our study regarding discharge destination might have been different if the study had more recent data. In 2017, the national patient safety programme for early detection and treatment of sepsis was also implemented, and future studies should investigate whether this trend continues (28). 

Strengths and limitations

A strength of our study is the large sample size and the use of population-based data, leading to a high degree of external validity. However, it is possible that the most critically ill patients are most affected by holiday closures, since they are at higher risk of functional disability. Consequently, the study may have yielded different results if only this group of patients had been included. 

A limitation of our study is the use of historical data. At the time, sepsis was characterised by the systemic inflammatory response syndrome (SIRS) in response to an infection (Sepsis 2-definition) (2). However, sepsis is an evolving field in critical care, and limitations with this definition were later recognised. The Sepsis 3 definition was introduced in 2016 and identifies sepsis as a dysregulated host response to infection resulting in life-threatening organ dysfunction (2). 

Considering the refined definition of sepsis, it is possible that a study utilising more recent data could have included patients with more severe illness. Regardless, since this study has a substantial sample size and the estimates for survival between the groups did not change with adjustments for SOFA score, the potential influence this has on the outcomes is likely minimal. We also find the topic to be highly relevant. 

Prioritising rehabilitation for sepsis survivors might be imperative, given the escalating incidence of sepsis (29) and concurrent decline in mortality rates (30). Studies have shown that only two thirds of the non-ICU sepsis patients and half of ICU sepsis patients have resumed work at two years (31). Efficient rehabilitation not only addresses the physical and cognitive impairments experienced by sepsis survivors, but could also contribute to expedited recovery, potentially reducing the burden on healthcare resources.

Conclusion

We found that closing a rehabilitation ward during holidays prolonged the length of hospital stay in patients with sepsis but did not affect discharge destinations or survival. This may lead to increased risk of complications and be a burden for sepsis patients. Further studies are needed to investigate the economic aspects of this issue.

Acknowledgements 

We want to thank the clinicians and other employees involved with the HNT HF Sepsis Registry for their support and for contributing to the data collection in this research project. This work was partly supported by grants from the HNT HF. The funder played no role in the design, interpretation or decision to publish the analysis presented herein.

Funding

This work was partly supported by grants from Nord-Trøndelag Hospital Trust. The funder played no role in the design, interpretation, or decision to publish the analysis presented herein.

Conflicts of interest

Lise Tuset Gustad declare a conflict of interest as she is editor-in-chief (EIC) in Sykepleien Forskning. She did not participate in the handling or decision-making process concerning this submission. The manuscript was overseen by an appointed EIC to ensure impartiality and fairness in the review and editorial process.

Open access CC BY 4.0

Introduction

The incidence of food allergies has increased in recent decades. This has an impact on public health. Cow’s milk and eggs are the two foods that most commonly cause allergic reactions in infants and toddlers (1). According to the World Allergy Organisation (WAO) estimate, the incidence of cow’s milk protein allergy in infants is between 2 and 4.5% (2). The allergy is largely transitory. Over 75% of children diagnosed with cow’s milk protein allergy tolerate cow’s milk protein by the age of three (3). 

Cow’s milk protein allergy has been well described in terms of incidence, symptoms and investigation, but there are few studies that focus on the parents’ perspective. Research shows that parents of children with egg and cow’s milk protein allergy have lower self-efficacy compared to parents who deal with other food allergies (4). Parents of children with multiple food allergies have stated that cow’s milk protein allergy required more planning than other allergies and had a greater adverse effect on them, both socially and emotionally (5). 

The parents’ perspective has been better investigated for children with general food allergies. It has also been well described for those whose children have had anaphylactic reactions to foods, which is rarely the case with cow’s milk protein allergy. Compared to other parents, the parents of children with food allergies have poorer mental health and a lower quality of life (6). Mothers have withdrawn socially due to the child’s food allergy, and this has impacted on their perception of quality of life (6). 

Food allergies are managed by avoiding the foods that cause allergic reactions. It is difficult to avoid certain foods in a diet, so personalised training is required. In children, dietary restrictions can lead to diverging development paths in terms of weight and length, due to the risk of insufficient intake of nutrients. Children with cow’s milk protein allergy are at risk of iodine, calcium and vitamin D deficiency (7).

According to the national clinical guidelines (8), health promotion and preventive work are the two most important tasks of the local authorities’ child health centres. Their objectives include promoting the healthy development of infants and toddlers and providing parental support, follow-ups and referrals. It is strongly recommended that the child’s diet is mapped by healthcare personnel and that the family should receive personalised dietary guidance from when the child is born (9). Parents of children with food allergies struggle when they realise that they have insufficient knowledge and are receiving inadequate support from healthcare personnel. This can diminish their trust in healthcare personnel (6). 

Objective and research question

The study’s objective was to gain practice-oriented knowledge that could help improve the healthcare services provided for parents of children with cow’s milk protein allergy. I sought a deeper understanding of mothers’ experiences of caring for infants and toddlers who have been diagnosed with cow’s milk protein allergy. To this end, I drew up three research questions:

• Do mothers find that they are emotionally affected by their child’s cow’s milk protein allergy? 
• How do mothers perceive their encounters with healthcare personnel in general, and public health nurses in particular, when their child suffers from cow’s milk protein allergy? 
• What are mothers’ experiences of adapting to a diet free from cow’s milk protein?

Method

This study has a qualitative approach based on interpretive description, which is well suited for healthcare research that focuses on problems encountered in clinical practice. The goal is to gain knowledge that will benefit the field of practice (10). 

Recruitment and sample

In August 2021, I shared an informative poster about the study with the Facebook group ‘Barn med melkeallergi’ (children with milk allergy), in order to recruit informants. Research shows that recruitment via Facebook can be useful, particularly in the case of specific or rare medical conditions (11). The criteria for inclusion were ‘having a child with cow’s milk protein allergy diagnosed by a doctor’, and ‘having sufficient proficiency in the Norwegian language to understand the informative note and to be interviewed in Norwegian’. 

Soon after publishing the poster, I received messages from 25 mothers who were interested in the project. Most of them gave a brief description of their own situation when they got in touch. On this basis, I selected participants with a view to achieving variation in the number of allergic children per family, the severity of allergy symptoms and their geographic location in Norway. Eleven mothers were invited to take part, eight of whom accepted. Table 1 shows the participants’ demographic data. 

Collecting the data

The interviews were conducted by the author via Uninett’s Zoom platform, which meets the requirements of the General Data Protection Regulation (GDPR) and relevant Norwegian legislation (12). I followed the Zoom procedures adopted by VID Specialized University for research interviews (13). 

The questions in the interview guide were open-ended and inspired by themes from earlier research. The phrasing of the questions, and their sequence, were adjusted after a pilot interview. Follow-up questions about experiences at the child health centre were added, as this issue has not been studied previously in a Norwegian context. In the period between September and December 2021, I conducted eight individual semi-structured interviews, each lasting 30–70 minutes. The interviews were recorded on an audio recorder and immediately transcribed. 

Analysis

Interpretive description is an inductive research approach that allows data to be analysed according to a range of analytic methodologies (10). After careful reading, I reduced the volume of transcripts by means of empirically close codes according to Tjora’s (14) method: Stepwise-Deductive Induction (SDI). The steps from raw data to main themes are presented in Table 2. Each empirically close code and code category was created inductively and tested deductively. In line with the SDI method, a new category level, called a main theme, was created (14). 

Ethical considerations

The study was assessed by Sikt − the Norwegian Agency for Shared Services in Education and Research, reference number 429927, and approved by the Regional Committees for Medical and Health Research Ethics (REK), reference number 218883. The informants received written and oral information about the study. Participation was voluntary, and they were informed about their right to withdraw from the study without giving a reason. They posted their written informed consent before the interview took place. The informants’ confidentiality has been protected throughout the research process.

Results

The analysis gave three main findings: (1) It is demanding to care for an infant who is unwell, (2) Insufficient competence in healthcare personnel can lead to a breakdown of trust and (3) Navigating a world free of cow’s milk protein on your own is all-consuming. 

It is demanding to care for an infant who is unwell 

None of the mothers had heard of cow’s milk protein allergy before their child was diagnosed. First-time parents found that the initial period was marked by uncertainty. Although they knew that infants cry, gulp and sleep to varying degrees, they did not know what to expect or what was normal. They described how challenging and tiring it was when the child expressed pain and distress for extended periods of time, and needed to be held close and comforted throughout the day and night. 

The mothers suffered from sleep deprivation and stress, which adversely affected their relationship with their partner. They took sick leave during their period of statutory maternal leave and developed symptoms of post-natal depression, like despondency, social withdrawal and unhappiness: 

‘It was really tough! We were at the point of leaving each other, me and my partner. […] We were completely run down, both of us. So it was really hard going.’ (informant 3)

The baby’s expressed distress, crying and gulping, described by many mothers as vomiting, led to several of them choosing to avoid social settings, like taking part in postnatal groups. Several mothers reported that they had initially assumed the infant was suffering from colic. When the child failed to gain weight, or there was blood in the faeces, or they developed a rash immediately after the first intake of baby porridge, the mothers realised it had to be something else. 

They later talked about unhappy memories and felt upset that the joy of the postpartum period, which should be cherished, had been lost due to the baby’s distress and pain.

Insufficient competence in healthcare personnel can lead to a breakdown of trust 

The mothers had repeatedly expressed a worry about their infant’s health in various consultations with public health nurses and doctors in both the primary and specialist health service. The infants’ symptoms were largely downplayed, particularly at the child health centre: 

‘She [the public health nurse] had like a refrain she kept repeating, like: “Yes, but all children are different, all children are different, everything is normal”.’ (informant 5) 

When the healthcare personnel failed to recognise the infant’s symptoms, this gave the mothers a sense of having to fight to be believed and to get the referrals they needed. When cow’s milk protein allergy was eventually put forward as a possible diagnosis, they felt left to their own devices without being provided with further information or follow-up by healthcare personnel.

None of the mothers felt that the doctor at the child health centre was involved with the allergy investigation or follow-up. There was a wide range of perceptions of GPs’ attitudes. Some felt that their GP was highly involved with the follow-up, while other GPs were perceived to be entirely disinterested or unaware of how the allergy affected the mothers’ everyday lives. 

Even when food provocation tests were to be conducted, some of the mothers felt that they received no information or guidance from the doctor in charge. Those with the longest experience of having a child with allergies described it as sheer luck the times they had met healthcare personnel with in-depth knowledge about cow’s milk protein allergy. 

The mothers who felt they had received help at an early stage and good follow-up from personnel outside the child health centre setting described a good relationship with their public health nurse. Even if they found that the public health nurses had inadequate knowledge about cow’s milk protein allergy, they were able to benefit from other aspects, like supportive conversations. Most of the mothers found that cow’s milk protein allergy was never a topic for discussion during consultations at the child health centre. Some were advised to google the answers themselves. 

The mothers also used their own networks and spent countless hours on the internet to acquire basic knowledge about cow’s milk protein allergy. When the healthcare personnel did not meet their expectations in terms of up-to-date knowledge about cow’s milk protein allergy, the mothers experienced a breakdown of trust in them. This made them feel doubtful, and they stopped making use of the child health centre services to the extent they had originally wanted: 

‘I have no confidence in them. Of course, they [the public health nurses] are nice and sweet, but I don’t think they have any knowledge, up-to-date knowledge.’ (informant 1)

Half the mothers had consulted private practitioners for allergy investigation and follow-up, since they felt there was little help forthcoming from the primary health service. Even if the mothers had told their doctor that they needed a referral to a nutritionist, this was only provided for mothers with premature babies, except for one mother who was referred to ‘The Milk School’ (15) at Oslo University Hospital, Ullevål. ‘The Milk School’ was described as very useful, but it was felt that the referral had come too late. 

Navigating a world free of cow’s milk protein on your own is all-consuming

The breastfeeding mothers, who themselves embarked on a diet free of cow’s milk protein on behalf of their child, described the initial phase as all-consuming. They were having to navigate in a world free from cow’s milk protein on their own, whilst also caring for a child who continued to suffer from symptoms. Finding safe foods was time-consuming, and they spent considerable time planning meals throughout the day. For some of the mothers, the situation became so challenging that they chose to stop breastfeeding. 

The mothers were also worried about making mistakes that would cause more suffering for their child, and they felt that the restrictions had major implications for their diet. Alternative foods were also costly and affected large parts of their daily life: 

‘I felt it was almost like studying for a bachelor’s degree. I had to read up on everything […] There is milk protein in Zendium toothpaste, I found, and I felt that, gosh! It was difficult and dispiriting to start with.’ (informant 8)

The mothers became skilful in handling the dietary constraints, which gradually became part of their new daily routine. They continued to worry about whether the child’s diet was sufficiently nutritious. They experienced repeated mishaps when their food was prepared by others. In parallel, the mothers experienced a growing need for control in order to protect their child. 

Daycare and birthday celebrations became challenging arenas where the mothers felt their children were vulnerable to mishaps or had no access to food of a standard that matched everyone else’s. The mothers constantly had to inform other people and remain vigilant because others failed to grasp the severity and extent of the dietary restrictions. 

Travelling involved detailed meal planning. Even after direct contact with hotels, the food on offer was inadequate. Allergen markings on restaurant menus were also not reliable. They soon found that society in general had insufficient knowledge about the difference between lactose intolerance and cow’s milk protein allergy. 

Discussion

Daily life was hugely affected by the infant’s allergy symptoms and management of the allergy. The strain of living with an infant who is unwell could cause symptoms of postnatal depression in the mothers, lead to periods of sick leave, or bring parents to the verge of a relationship breakdown. 

Similar findings are described by Feng et al. (16) and Moen et al. (6), who showed that mothers, in particular, experienced anxiety, depression and a diminished quality of life when their child suffered from a food allergy. Having to adhere to strict dietary constraints meant that the family restricted their social interactions, and this gave them a sense of diminished quality of life (6). 

The management of food allergies has received considerable attention in recent years. Nevertheless, the parental mental health challenges associated with caring for children with food allergies have not received the same level of recognition (16).

Breastfeeding is associated with self-efficacy in the maternal role and can be linked to the child’s allergy symptoms

Lower self-efficacy levels have been found among parents of children with egg and cow’s milk protein allergy compared to parents of children with other food allergies. This was associated with the type of food that had to be avoided, not the severity of symptoms (4). 

Mothers whose firstborn child developed symptoms of cow’s milk protein allergy encountered particularly big challenges. Seven of the mothers who took part in the study found that their infant reacted to cow’s milk protein through breast milk. The mothers therefore experienced a direct link between their own diet and the infant’s manifestation of allergy symptoms. The ability to breastfeed is a significant factor that has a direct impact on a mother’s self-efficacy in her maternal role (17). 

Frustration and grief arise when expectations of competence and support from healthcare personnel are not being met

My study shows a more significant breakdown of trust between the mothers and the healthcare personnel than has been previously demonstrated in earlier studies. Research shows that parents’ trust in healthcare personnel is reduced when they encounter inadequate recognition and insufficient assistance with the management of food allergies in children (6). 

When healthcare personnel had insufficient knowledge about symptoms, the mothers felt that their infant’s allergy was diagnosed later than necessary. They also found that healthcare personnel were lacking in understanding, and provided insufficient follow-up before, during and after the diagnostic process. This led to a breakdown of trust in the healthcare personnel. 

There was also a clear expectation that the public health nurses and the doctor at the child health centre would have in-depth knowledge about cow’s milk protein allergy because they attend to virtually all children. Public trust in child health centres is high (18). Moreover, public health nurses have a close relationship with families with children. By working with the parents, they can help identify signs of food allergy in infants (19). 

Under the child health centre programme, the mothers had frequent contact with public health nurses. Trust collapsed in the public health nurses who had downplayed the symptoms at an early stage, or who showed little interest in or provided little support with managing the allergy. This emotional collapse of trust was described during the interviews as irreparable, even after the diagnostic process, because the mothers later experienced a lack of follow-up and support. This finding matches earlier research showing that parents have felt they receive little support and advice from the child health centre with managing the child’s food allergies (20).

When healthcare personnel demonstrated competence in relation to cow’s milk protein allergy, the mothers believed it was based on previous experiences with other patients. It therefore appeared to them that the knowledge did not stem from guidelines or training. In 2021, in an effort to ensure that patients with food allergies are dealt with by healthcare personnel with appropriate knowledge, the regional centres for asthma, allergy and hypersensitivity published, with their collaborative partners, a practical guide to managing food allergies: ‘Praktisk veileder i håndtering av matallergi’ (21). 

Several informants described frustration and grief because their postnatal period had been ruined by insufficient assistance from healthcare personnel. Feng et al. (16) write that diagnosing food allergies is no longer sufficient; the parents’ mental health must also be acknowledged. 

Dietary restrictions can affect the nutritional status of both mother and child

While the mothers had a keen wish to be referred to a nutritionist, they found that healthcare personnel assumed it was easy to adhere to a diet free from cow’s milk protein, and that consequently a referral was not necessary. Research has shown that adhering to a diet free from cow’s milk protein is a massive challenge, and that parents consider the dietary restrictions to be burdensome. Finding alternative foods is also very time-consuming, and plant-based products are often more expensive (5). 

Sugunasingha et al. (22) point out that there is little doubt that parents of children with food allergies have an unmet need for information. Were this need to be fulfilled, the parents’ stress would probably be reduced and their quality of life improved. Although several educational interventions have been explored, none of these methods can be fully recommended due to the low methodological quality of these studies. Future studies should have a more robust methodological design (22). 

Leaving the entire nutritional responsibility to the parents is a risk, particularly since children with dietary restrictions often have an insufficient and unbalanced intake of nutrition (7). 

This fact is supported by the practical guide to managing food allergies (21), which emphasises that a nutritionist or other skilled health worker should take part in the investigation and follow-up of cow’s milk protein allergy. Furthermore, breastfeeding mothers should take dietary supplements to compensate for the inadequate intake of dairy produce (21). However, none of the mothers had received personalised dietary guidance at the child health centre, and more than half of them were never referred to a nutritionist.

Strengths and weaknesses of the study

By recruiting via Facebook and conducting the interviews on the Zoom platform, I was able to include mothers from a wide geographic area, with different family sizes and levels of experience with managing cow’s milk protein allergy in their own children. However, I am uncertain why parents chose to join the Facebook group. It is possible that this group of parents have experiences that are different to those who do not choose to join this group. This may be a weakness of the study. 

A potential constraint is that participation in the study required technical skills. Individual interviews were an appropriate data collection method, particularly since the informants were sharing sensitive information about themselves and their children. The informants had different experiences, and the interviews provided rich answers to the research questions. 

Conclusion

Cow’s milk protein allergy is a complex allergy that often requires extensive dietary restrictions. These constraints have a direct impact on family life and on the mothers’ self-efficacy. The mothers who contacted healthcare personnel for advice often felt that they were not taken seriously. They found that their concerns were downplayed. The child’s symptoms were not acknowledged, and they had an unmet need for information. 

They also experienced a low level of follow-up from healthcare personnel in the public health service, and felt that the diagnostic process was too protracted. The mothers were left with deep-seated frustration and grief because the postnatal period was marked by the allergy symptoms. 

Healthcare personnel should be aware of the repercussions of a diet free from cow’s milk protein for the child’s growth, the mothers’ mental health and family life. Through the national child health centre programme, public health nurses have a significant role to play in providing guidance and information about infant nutrition. 

No single educational intervention currently stands out as significantly superior to others in meeting the parents’ need for information. Nevertheless, it is important that healthcare personnel who attend to infants and toddlers have expertise on cow’s milk protein allergy so that they can identify the symptoms and provide referrals, guidance and practical advice to the families as the child develops. 

Future studies should investigate dietary restrictions and breastfeeding, or explore the perspectives of fathers, healthcare personnel or daycare staff. 

The author declares no conflicts of interest.

Open access CC BY 4.0

Introduction 

Highly qualified staff are the most important input factor in hospitals. It has been and will remain a challenge to manage human resources to ensure that patients receive high-quality, safe treatment and that public resources are used efficiently (1). The concept of the Magnet hospital emerged in the United States in the 1980s in a study that aimed to identify common features of hospitals that attract and retain registered nurses (RNs) (2). 

Since then, the Magnet hospital concept has been examined in a number of studies, almost exclusively in the United States. The common features identified have proven to be beneficial to the hospitals’ overall operation in terms of clinical, financial and organisational outcomes. The latter includes enhancing recruitment and stability of nursing staff levels (3). 

The American Nurses Credentialing Center can provide accreditation as a recognised Magnet hospital to individual hospitals, conditional on the fulfilment of criteria that can be summed up in five main principles: transformational leadership; structural empowerment; exemplary professional practice; new knowledge, innovation and improvements; and empirical quality results (4). 

Research and method development have primarily been carried out in the United States, and it is relevant to ask whether findings from studies in the United States can be replicated in Europe. Two international, EU-funded studies have used a method developed in the United States to study the management of RNs at hospitals in Europe. Data has been collected regarding RNs’ perceptions of working conditions and well-being. 

Furthermore, organisational information on hospitals’ patient outcomes, number of beds and number of stays has been collected. Knowledge that can help underpin efficient management of nursing resources in hospitals is valuable to RNs as a group and to society as a whole, in the light of current and future needs for qualified health personnel. 

The Norwegian Nurses Organisation has provided financial support for Norwegian participation in both studies. Lovisenberg Diaconal Hospital, hereafter referred to as Lovisenberg, participated in both studies. 

RN4CAST: Registered Nurse forecasting in Europe (2009–2011)

RNs at 486 hospitals in 12 European countries, including 35 hospitals in Norway, participated in the cross-sectional study RN4CAST (2009–2011). The main objective of RN4CAST was to contribute to better planning and management of nursing resources in Europe (5). Compared to the other countries, the national results in Norway were consistently good (6, 7). However, there were large differences between individual hospitals and different types of hospitals within Norway. Among the Norwegian hospitals, the best results were achieved by private hospitals run by non-profit organisations (8). 

Magnet4Europe (2020–2024)

In the intervention study Magnet4Europe (M4E, 2020–2024), over 60 hospitals in six countries participated. The intervention consisted of introducing changes in line with the main principles of Magnet hospitals. Each individual hospital decided which of these was to be a priority, based on information from gap analyses in some cases. In the course of the transition process, empirical measurements were gathered, using, for example, employee surveys. A baseline measurement was carried out at the start of 2021, before the intervention began (9). 

In M4E, both RNs and doctors (US: physicians) were included in the employee survey. Lovisenberg is the only Norwegian hospital participating in Magnet4Europe, and a research article describes the local interventions that have been implemented (10).

The two surveys collected data on RNs’ assessments of different aspects of the work environment, separated by a twelve-year interval. The aim of this article is to compare the responses of RNs working at Lovisenberg to questions that were posed in both surveys in 2009 and 2021. 

Method 

Data collection for RN4CAST in 2009 included a comprehensive survey on working conditions, well-being, patient safety and quality. Some of the questions were reused in the M4E study, in which the first of three surveys was conducted in spring 2021 during the COVID-19 pandemic. We compared the questions that were the same in both 2009 and 2021. 

A group of eight items were derived from the Nursing Work Index (NWI). The NWI was developed during the early studies of Magnet hospitals in the US. The instrument covers characteristics such as cooperation, development opportunities and management, which the studies of Magnet hospitals indicated were important for a workplace to be a good place for RNs to work. The respondent rates the presence of a particular characteristic at their own workplace, using a scale from 1 (strongly disagree) to 4 (strongly agree). 

Signs of emotional exhaustion were measured using the Emotional Exhaustion subscale in the Maslach Burnout Inventory (MBI-EE). The nine questions in the subscale describe feelings connected to work. The response requires the respondent to note how frequently they feel a certain way, from 0 (never) to 6 (every day). The score that is represented here is an average of the nine questions, where there was a response to all questions (12, 13).

In both 2009 and 2021, items concerning patient safety, the frequency of missed nursing care, general assessments and individual background variables were included. 

All RNs who had direct contact with patients in the medical and surgical wards for adult patients, including intensive care units, participated. RNs in small part-time positions were excluded. In 2009, the minimum cut-off point was 20% (of a full-time position), while in 2021 it was 30%. 

In autumn 2009, the local representative of the Norwegian Nurses Organisation distributed paper copies of the survey. This was followed up by locally initiated measures to increase the response rate. It was not possible to send direct reminders to individuals. In spring 2021, the survey was conducted online. The employees, (including doctors who participated on this occasion), were contacted via email and could register on an Internet-based platform where the questions were presented electronically. The hospital sent three reminders and thank-you messages to all included via email. Various measures were implemented to promote participation and raise awareness concerning the survey. The responses from RNs in 2009 and 2021 were compared using descriptive statistics. 

Differences in the respondents’ ages and length of work experience, as well as the results of the patient safety questions, were tested using the Student’s t-test for independent samples. The remaining differences were tested using Pearson’s chi-squared test. We conducted the analyses using IBM SPSS software, version 29. We selected a limit of p ≤ 0.05 for statistical significance.

The data protection routines in RN4CAST were submitted to the data protection officer for research at the Norwegian Centre for Research Data (NSD), now known as Sikt – the Norwegian Agency for Shared Services in Education and Research (reference number 22537). In M4E, some of the questions focused on health. The survey was assessed by the Regional Committee for Medical and Health Research Ethics (REK South-East D, reference number 166980). We obtained relevant data concerning the number of beds and patient turnover from Lovisenberg’s internal records.

Results

Data from the surveys

In 2009, 168 printed questionnaires were distributed, which received a total of 108 (64.3%) responses. In 2021, 218 (82.8%) RNs registered and responded to the survey. Except for the size of the positions of those who worked part-time and the number of years of nursing experience, the differences between the known characteristics of the two groups of respondents were not statistically significant. See the comparison in Table 1. A closer analysis of the data showed that in 2021, the oldest RNs had far more work experience than those surveyed in 2009, and this pushed the average up. 

In the responses to the eight items from the NWI, the general tendency is that the proportion of positive answers (completely agree / agree) was largest in 2021 (Table 2). The biggest difference concerned the question about immediate supervisors, with an increase in the proportion of positive responses of 13 percentage points (p = 0.002). 

In relation to having sufficient staff to get the work done, the proportion of positive responses was 1 percentage points higher in 2021 than 2009. However, the proportion of respondents who answered ‘strongly agree’ as opposed to ‘agree’, was considerably higher, with an increase of 13 percentage points (p = 0.008). The proportion of positive responses to the question about cooperation between RNs and doctors was 8 percentage points higher in 2021 than in 2009, while the p value was just above the chosen limit for statistical significance (p = 0.057). 

For the whole hospital, the number of patients per RN ‘on their most recent shift’ was 4.5 in 2009 and 3.6 in 2021 (p = 0.010). The average number of patients per RN in the two surveys was 4.8 and 3.4 respectively in surgical wards, 5.2 and 4.2 in medical wards and 1.5 in intensive wards in both surveys. See Appendix 1 [in Norwegian] for more details.

On a common list of nine potential missed nursing care activities, the frequency was quite similar in the two surveys. In 2009, no respondents reported necessary pain management as missed. In 2021, the percentage was 7% (p = 0.003). See Table 3 for a complete list of results. 

Five questions on patient safety were comparable (see Table 4). The tendency in the mean scores was unchanged or somewhat better in 2021. There was a positive change in terms of discussing errors to prevent reoccurrence, with an increase from 3.7 to 4.0 (p < 0.001). 

The level of emotional exhaustion (MBI-EE) was the same. The mean and standard deviation in 2009 was 1.89 and 0.91 respectively. In 2021, it was 1.95 and 1.25 (p = 0.664). The extent of working overtime remained the same for Lovisenberg as a whole, with different results in the individual departments (Appendix 2 – in Norwegian). There was no change in the percentage of RNs who intended to leave the next year (2009: 17.0%; and 2021: 19.0%, p = 0.395), nor was there in the percentage among those who intended to leave Lovisenberg and also quit the nursing profession entirely (2009: 8.7%, and 2021: 11.4%, p = 0.190). 

In regard to the five ‘on the whole’ questions (Table 5), there was a general tendency towards a lower score in 2021 than in 2009. In the respondents’ general assessment of the quality of nursing care, the proportion positive responses was 7 percentage points lower in 2021 than in 2009 (p = 0.004), and in regard to whether they would recommend the hospital to family and friends, the proportion was 11 percentage points lower (p = 0.005). In response to the question about how certain the respondent was that patients would be able to cope after being discharged, the proportion positive responses was 11 percentage points lower in 2021 than in 2009 (p = 0.008). 

Data from other sources

Registration practices have changed during the period, which makes it difficult to compare figures that relate to operation in the two years in question. The standard number of beds was 158 in 2009 and 153 in 2020 (the closest year with complete figures); in both years, 12 beds in the palliative care unit were included. The number of admissions to the hospital was 10,208 in 2009 and 10,252 in 2020. In the surgical clinic, the average length of stay fell from 3.2 in 2009 to 2.0 in 2020, and there was a corresponding drop in the medical clinic from 5.6 to 3.9. 

The hospital’s personnel data information system cannot provide comparable information regarding the number of full-time equivalents for RNs in 2009 and 2021 (or the closest year).

Discussion

In this secondary analysis of survey data, we have compared responses from RNs at Lovisenberg in 2009 and 2021. The results are mixed and do not confirm that everything was better before or that everything is better now.

Working conditions and working hours

Responses to the questions from the NWI showed that RNs felt that working conditions were better in 2021 in relation to specific matters such as cooperation with doctors and their immediate supervisor, and staffing levels (Table 2). The responses to the number of patients per RN (Appendix 1 – in Norwegian) indicate that staffing levels have also increased. We have not been able to find administrative figures to support this, but the impression of increased staffing levels at the local level corresponds with the national tendency in the development of the larger occupational groups in the specialist health service, although the figures here too are uncertain (1, Chapter 4.2.3). 

In 2017, the hospital introduced a leadership training programme consisting of four seminars over a nine-month period. The target group includes the managers of the clinical departments. This initiative perhaps partly explains why the RNs were more satisfied with their immediate supervisor in 2021 than in 2009. 

The percentage of RNs working overtime at Lovisenberg as a whole remained unchanged. It is worth noting that the 2021 survey was conducted during the COVID-19 pandemic, when the hospital had a higher level of preparedness. This may have influenced the results, but we have no information to assume how. At department level, it appears that there has been a change, but the differences between 2009 and 2021 are not statistically significant (Appendix 2 – in Norwegian). 

Missed nursing care

In relation to missed nursing care (Table 3), the situation remained unchanged except for pain management. The increased frequency of missed pain management in 2021 may be connected to the fact that pain management options were more advanced and resource-intensive than in 2009, or that RNs’ knowledge and/or their expectations regarding efficient pain management had increased. 

The similarity in the ranking of the various missed nursing care tasks is thought-provoking. In both surveys, comfort/talk with patients was the activity most frequently reported as missed (in 2021, completely or partly missed) on the most recent shift, while missed pain management was reported by the lowest number of respondents. Whether this is an indication of the normalisation of missed nursing care in the daily work at the hospital is an open question. When time is insufficient, is comforting/talking with patients the first activity that is omitted, followed by developing or updating patient plan of care/care pathways or oral hygiene as numbers two or three? 

The introductory text to the question on missed nursing care was as follows: ‘On the most recent day/shift you worked, which of the following nursing care activities were necessary but left undone (in 2021, added ‘fully or partially’) because of time constraints? Mark all that apply…’ It is not known whether the addition to the text in 2021 influenced the responses.

Burnout

The burnout level (MBI-EE) measured among RNs at Lovisenberg was unchanged and is lower than previously reported scores using the MBI variant Human Services Survey (13). Recent international findings indicate that burnout among RNs increased during the COVID-19 pandemic (14, 15). 

Patient safety and general quality assessments

During the patient safety campaign (2011–2013) and patient safety programme (2014–2018), systematic interventions were implemented to reduce the frequency of patient injuries. In the surveys, the responses to the questions on patient safety remained unchanged from 2009 to 2021, with one exception (Table 4). Any possible explanations for this are speculative. For example, it may be that patient safety per se has improved between 2009 and 2021. At the same time, RNs have a more acute awareness and higher expectations of good patient safety, which makes it less likely that they will give a positive description. 

The RNs reported better working conditions in 2021 than in 2009. Nevertheless, the responses to three of the five ‘on the whole’ questions were poorer in the most recent survey (Table 5). We do not have the data to enable us to interpret this observation, and explanations may be both numerous and complex. We cannot rule out the possibility that the results were affected by differences in how the survey was conducted. It may also be the case that the understanding of responsible nursing practice has actually changed in the interval between surveys. 

The available resources for providing nursing care services were perceived as better in relation to important aspects. With regard to RNs, we can say with certainty that there was a larger proportion of older RNs, and therefore RNs with more work experience, at Lovisenberg in 2021 than in 2009. The proportion of RNs with a postgraduate education was the same. We have some data on the activities that RNs carry out using available resources. 

The objective of the Coordination Reform in 2012 was to enhance cooperation between the specialist and primary care services. Shorter stays in hospitals in 2021 meant that patients in wards had not progressed as far in their care pathways and had a more extensive need for nursing care when they were discharged than was the case in 2009. Faster patient turnover means more frequent discharges, and a greater need for follow-up leads to a need for better organisation of necessary nursing care and treatment after discharge. Moreover, the collection of data in spring 2021 occurred after almost a year of emergency preparedness across the entire health service in connection with the COVID-19 pandemic. 

Strengths and weaknesses of the study

A strength of the study is that the surveys captured the perspectives of RNs. Many other surveys on working conditions have been developed for employees in general. Subsequently, the approach here means that the collected data is more relevant in relation to the challenges faced by RNs in their daily work environment.

In secondary analyses, the collected data is used for other purposes than the initial one. This means that the data is rarely the most relevant for the problem statement in question. The questions in RN4CAST/Magnet4Europe have international origins. Furthermore, it has been concluded previously that there is a need for a closer assessment of the relevance of the translated instruments in a Norwegian context, such as the NWI in these two surveys (16). 

When data is collected using translated instruments, it may mean that the data is not of optimal relevance for bedside RNs in Norwegian hospitals. Analyses based on such data may still have value if there are no better alternatives. From a research ethics point of view, it is positive to use data that has already been collected in order to illuminate further hypotheses, where possible. A key objection to the study is that there are only two measuring points with a twelve-year interval. 

We have not collected data that might have made it possible to examine how representative the respondent groups were. The response rate in the survey is good or very good compared to surveys involving similar topics and target groups. One review article referred to 675 studies of patient safety culture, in which the authors found that the response rate varied between 4.2 and 100%, with an average of 66.5% (17).

The surveys have small samples, with only 108 respondents in 2009. For example, responses to the question on the number of patients per RN were based on the most recent shift (Appendix 1 – in Norwegian). Staffing levels vary between departments and shifts – day, evening and night – and the responses could have been grouped accordingly. However, this would have resulted in such small groups of respondents that the results would have been too uncertain to have any value. 

We cannot rule out the possibility that RNs have responded strategically to questions, for example, regarding nurse staffing levels. The question was framed in the same way in both surveys, and any tendency to respond in a way that suits the group best would probably apply in both cases. There are no comparable ‘objective’ statistics for these two years, a factor that may have provided more reliable and detailed information. 

We have found evidence that staffing levels and management are better than before, but at the same time, RNs have described quality in general as poorer. There may be many explanations for this and they may be complex. We cannot rule out the possibility that the results were affected by differing data collection routines in the surveys in 2009 and 2021. It may also be the case that the norms for acceptable practice have changed in the interval between surveys. The high (and increasing) level of documentation required for treatment and nursing care is often described as a time thief that steals time from interactions with patients. 

The findings in the study cannot be generalised as valid for other Norwegian hospitals. Lovisenberg is operated on a non-profit, charitable basis in line with its contract with the South-Eastern Norway Regional Health Authority, and it is run according to diaconal principles. All surgery carried out is elective. The medical clinic has the role of local hospital for districts in inner Oslo and has special competence in palliative care. Lovisenberg’s results in RN4CAST were in the top tier of Norwegian hospitals. 

As far as we know, this is the only study that compares results over a period of time using descriptions of RNs’ daily work environment in hospitals in Norway. The study itself indicates indirectly a general lack of information that can help to inform good decision-making within human resources management. With today’s technological solutions, it should be possible to establish a national representative sample to monitor the situation in occupational groups that are indispensable in the health service. Monitoring should be based on information that is relevant to the respective groups’ daily work environment, not just the health authorities’ financial bottom line.

The complete data set from Lovisenberg in 2021 will be used together with the two follow-up surveys from spring 2022 and autumn 2023, in line with the main objectives of Magnet4Europe (9).

Conclusion 

To compare snapshots of RNs’ daily work environment at Lovisenberg in 2009 and 2021, we have used data collected during two international studies. We found that the description of many of the factors were the same in the two surveys. Some working conditions were described as being better in 2021 than in 2009, but where differences were found, the ‘on the whole’ assessments were somewhat poorer in the most recent survey. 

Acknowledgements

Thanks to all the RNs who responded to the surveys, to RNs Christine Raaen Tvedt PhD and Monica Bukkøy Kjetland for their indispensable efforts in data collection in 2009 and 2021 respectively. Thanks to Per Arne Holman for operational data on Lovisenberg and to peer reviewers for valuable input to the manuscript.

Funding

The international studies were funded by the EU. RN4CAST: Framework Programme 7, Grant Agreement 223468. Magnet4Europe: Horizon 2020, Grant Agreement 848031. The Norwegian Nurses Organisation (NSF) has contributed with financial support to RN4CAST and Magnet4Europe. NSF has not played a role in the design, execution or reporting of the studies.

The authors declare no conflicts of interest. 

Open access CC BY 4.0

Introduction

In recent years, the subject of ‘boys and body image’ has been regularly debated in the media (1–3). In their own life stories, adolescents describe a desire and struggle to have a body that aligns with societal ideals, which favour a slim but muscular, sculpted and well-proportioned body (3–7).

The proliferation of social media exposes adolescents to gender-specific advertising that portrays a one-dimensional view of the body and appearance. Nearly half of all those in Norway aged 13–18 have been targeted by advertising on how to lose weight or gain muscle (8). 

The annual Ungdata survey of youth in Norway has shown that adolescents experience significant pressure in relation to body and appearance, academic performance, athletic prowess and social media (9). Significant pressure in relation to body and appearance was reported by 25% of girls and 23% of boys (9). They described the body pressure and school-related pressure as exhausting and challenging (5, 7, 10).

Girls as well as boys experience a large discrepancy between their own body and the ideal body, which can further reinforce body dissatisfaction and body pressure (5, 11, 12). Body pressure is defined as the feeling that the body should look a certain way (13). On social media, influencers and fitness idols describe exercise and diet methods that will supposedly help to achieve these ideals (14–16). 

In the Norwegian living conditions survey on sports and outdoor activities, 58% of the population aged 16 and over reported that they exercise or engage in physical activity several times a week. The younger generation primarily exercised to improve their appearance, while the older generation exercised to improve their health, get fresh air and experience nature (17).

In recent years, considerable research has been conducted, both nationally and internationally, on adolescents’ relationship with their bodies. Most studies have been quantitative and have found high levels of body dissatisfaction and body pressure among girls (4, 10, 18). Previous research and media articles have been dominated by girls’ experiences and perceptions (4, 5, 19).

Studies of boys show that a significant proportion report body dissatisfaction, mainly related to body shape, muscle tone and muscle mass (4, 11, 14). Just as many boys as girls struggle with disordered eating and exercise behaviours, body pressure and body dissatisfaction, but far fewer boys seek help from the school health service or other first-line services (34). 

Meanwhile, boys have been under-represented in relevant research, and their experiences with body pressure and body dissatisfaction have been under-communicated and taboo (20–22). The purpose of this study was therefore to explore boys’ reflections on body image. This knowledge will inform the development of a more attractive health service provision for boys and young men.

Method

Our study is qualitative with a descriptive design. We conducted nine semi-structured, individual in-depth interviews. 

Recruitment and sample

We asked seven public health nurses in upper secondary schools in a city in Norway for assistance in recruiting informants. Three declined due to time constraints. The remaining four obtained consent from their respective schools. Information about the study was distributed to several classes and pupils. Those who wanted to participate were encouraged to get in touch.

Six informants were recruited. Three more were recruited via the snowball method, where informants who have been interviewed ask their fellow pupils to participate in the study. This method ensures motivated informants and is time-efficient (23).

Pupils who needed an interpreter or follow-up by a school psychologist or public health nurse were excluded. This was to ensure that language barriers or additional personal stresses did not influence the responses.

The participants signed a consent form, and the interviews were arranged. The final sample consisted of nine boys aged 16–19 from four upper secondary schools. Three of the informants were in the general studies programme, three were studying sports and physical education, and three were taking the building and construction vocational line of study (Table 1).

Data collection

We conducted the interviews in November 2019 with the help of a semi-structured interview guide that had been adjusted slightly following quality assurance in a pilot study. The interview guide consisted of introductory short-answer questions followed by more probing open-ended questions for reflection (Table 2). The order of the questions varied according to the development and dynamics of the conversations.

The interviews were conducted during school hours in specially arranged, sound-insulated interview rooms to prevent distractions. The interviews lasted between 60 and 90 minutes. We recorded the conversations and transcribed them verbatim.

Data analysis

The data were analysed using the stepwise deductive-inductive method (SDI) (23) (Figure 1). 

The study followed the first four steps of the model: generating data, processing raw data through coding, categorising codes and developing concepts. The study had a limited scope and it was not therefore relevant to develop theory. We instead used an adapted version of the model. Rather than theory development, our goal was to gain a new and expanded understanding of the subject.

The raw data resulted in 197 codes, which were analysed in various steps, condensed and categorised into seven code groups. These were further condensed to three main thematic categories, also referred to as concepts (Table 3). In the analysis, we identified recurring patterns, and interviews were conducted until thematic saturation was achieved. 

Ethical considerations

The study was reported to the Norwegian Centre for Research Data (NSD), now called Sikt – the Norwegian Agency for Shared Services in Education and Research (reference number 419077). Informants were recruited on a voluntary basis and provided written informed consent. The data collected were anonymised.

Results

We identified three concepts through the analysis: 1) Own body and the ideal body, 2) The importance of the ideal body and 3) Body pressure or motivation. 

Own body and the ideal body

The informants described their own body and appearance as ‘fine’, ‘okay’ and ‘adequate’, followed by specific wishes for change:

‘[…] but I wish I was a bit taller’ (Peter), ‘I want to broaden my shoulders’ (Thomas), and ‘I need to work on my thighs’ (Noah).

The informants mentioned height, shoulder width and a well-developed upper body as factors that contribute to satisfaction. Informants in a more advanced stage of puberty were more positive in their descriptions than those in an earlier stage.

The informants with late onset of puberty considered their development to be delayed or stagnant, and they became more dissatisfied as the height and muscles of their peers increased. However, they were optimistic about how they would develop based on their understanding of genetics and typical developmental patterns. The majority referred to the ideal body as ‘the dream body’, and they described it in the same way: 

‘Starting under the head; the shoulders should be quite broad. The collarbone should be pronounced, you should have large biceps and triceps, and not too thin forearms, preferably with visible veins on the arms. And you should also have wings, a broad back, a six-pack and fairly large calves’ (Leo).

The informants described the ideal body as athletic, slim, sculpted and ‘properly masculine’. Several informants referred to the American actor and bodybuilder Arnold Schwarzenegger when describing the dream body: ‘I think all boys my age dream of looking like Arnold Schwarzenegger’ (Markus).

All informants emphasised the importance of balance and moderation when it came to muscle growth and muscle appearance. A body that is too big or too muscular had a strong negative connotation and was referred to as ‘unsavoury’ and ‘juiced up’. They referred to people with such an appearance as ‘stupid’ or ‘not very smart’. 

Half of the informants associated an untrained body with characteristics such as irresponsibility, laziness and/or psychological and social insecurity: ‘He has little self-control, he’s not as disciplined and doesn’t work as hard and things like that. Maybe he struggles mentally or socially with friends. He’s probably hanging out in the wrong environment’ (Jamal).

The remainder described an untrained body through the person’s interests: ‘They probably have other interests and don’t care about exercise’ (Leo). 

The importance of the ideal body

The informants described a well-trained and muscular body as a positive identity marker that reflects desired personal attributes such as hard-working, dedicated and disciplined: ‘He takes a lot of responsibility, because it takes a lot to get a nice body’ and ‘You’re seen as more successful’ (Tim).

The informants felt that body and appearance were important for first impressions: ‘When you meet new people, new boys, you introduce yourself by way of your appearance. Being big and strong gives you a certain status’ (John).

However, several informants discuss this attention in a negative light: ‘You get scanned, stared at in the canteen. It’s a bit stressful’ (Markus). 

The informants said that the ideal body ensures recognition and respect from others: ‘The perfect body means that many people notice me, look up to me and like me. The body gives me status’ (Tim). However, there was competition between the boys: ‘All my mates work out, so there’s a bit of competition, yeah, I have to catch up if they get bigger than me’ (Frank).

The informants also emphasised that the body was crucial for attracting attention from girls: ‘A fit body gets a fit lady’. All assumed that an attractive appearance would improve their options and increase their chances of getting a girlfriend.

According to the informants, body and appearance were important for social positioning. They expressed it as ‘a gateway to desirable social arenas and environments’.

One informant linked appearance to future employment: ‘A well-trained person knows how to stay in control, so can have control over others in a work context’ (Frank). More than half of the informants drew a parallel between the ideal body and success: ‘Look around you; there are more good-looking successful business leaders than ugly ones. That’s just how it is’ (Leo).

Two informants related the dream body and a muscular appearance to respect and security: ‘I train to get muscles, you know, you have to be big to be able to thrash someone’ (Jamal). Both had described challenging times as a child. The three informants in vocational education linked the desire for a strong, muscular body to the need for muscle strength to meet the physical demands of future employment. 

Body pressure or motivation

In the body image reflections, the term ‘body pressure’ was used repeatedly: ‘There’s definitely body pressure. Having a big, muscular body with a six-pack and attractive ab crack and all that’ (Thomas).

Body pressure was mainly described as a negative feeling: ‘There’s a bit of pressure. I have to catch up with those who’ve gotten bigger than me, and it gets a bit stressful’ (Tim).

They described the desire for progress and quick results as stressful. ‘I can definitely say that I start to really depend on making progress and getting results. It’s exhausting – not so much physically, but more mentally’ (Frank).

Despite their stress, they did not consider it relevant to contact first-line services to discuss the issue or obtain advice. This kind of help was viewed in a negative light: ‘Boys want to be manly, and it’s not manly to talk about your feelings’ and ‘Boys have to be able to fix their own problems’ (Jamal).

Meanwhile, a third of the informants thought that body pressure was somewhat positive as it leads to a healthier diet, regular exercise and social interaction at the gym: ‘I think everyone can feel body pressure at times, and that’s healthy. Yeah, it’s healthier to be thin and do exercise than to be so overweight that you can’t walk straight’ (Frank). 

The positive effect of exercise on sleep quality and the sense of well-being was also discussed. Several described the gym as an important and informal social arena that promotes a sense of belonging.

All informants did strength training and cited increasing muscle growth and altering their appearance as the most motivating factors for the training:

‘I train to look good, and the health benefit is less important. I don’t care too much about my health, I’m young, I go out drinking, and I’ve had periods where I’m smoking and things like that’ (Markus).

Exercise was seen as a necessary measure in response to body pressure. It was also described as a positive activity that gives structure to daily life:

‘With the training, I go there and have peace, and it gives me something to do every day instead of hanging around doing stupid things’ (Jamal). 

They also described diet and nutrition as crucial to achieving the body ideal. The level of knowledge varied and was mainly based on advice and recommendations from friends, older siblings, and influencers and sports idols on social media. All informants except one had used or were currently using dietary supplements regularly. They differentiated between legal and illegal substances. Two-thirds of the informants were strongly opposed to the use of, for example, anabolic androgenic steroids due to a fear of side effects: ‘I will never resort to pills and doping. Dietary supplements and shakes are things I’ve tried and will definitely try again’ (Noah).

Some had a more liberal or ambiguous attitude towards doping. 

Discussion

The purpose of the study was to explore boys’ reflections on body image. We identified three concepts ‘Own body and the ideal body’, ‘The importance of the ideal body’ and ‘Body pressure or motivation’, and discuss the topic based on these.

The informants were satisfied with their own body and appearance. All of them had specific goals for how they wanted their body to look. The ideal body can be understood as a positive identity marker that reflects personal characteristics. A body that aligns with societal ideals was considered important for attracting a potential girlfriend. What was even more important was recognition by their peers, respect, and social belonging and positioning. 

The dream body

The informants’ body image reflections were consistent, and they used general terms and emotionally neutral words like ‘okay’. Their descriptions of the ideal body aligned with the current male body ideal, which is slim, muscular, sculpted and capable of sustained physical performance. These findings are consistent with research reports from Sweden, the United Kingdom and the United States, which also found that young boys aspired to a masculine, muscular physique that aligns with the ideals of Western culture, characterised by broad shoulders, a narrower waist, and a well-proportioned body with a low fat percentage (4, 10, 19, 24).

Body ideals are constantly changing (12, 25), and have recently shifted towards a mesomorphic ideal, which values ​​well-defined muscles, a well-developed chest and shoulder area and a narrow waist and hip area. A smaller proportion of body fat is desired than before, and adolescents’ role models and idols have become both thinner and stronger over the last 30 years (1, 14, 16, 26). 

A balance in muscle growth and body appearance is favoured. A body that deviates from this by being too large or too muscular is viewed in a negative light and associated with negative personal characteristics by the informants. Sæle refers to deviations from body ideals as ‘the shame of our time’ (27). Research from the United States, Australia and the United Kingdom found that an overly large and muscular body is associated with self-absorption, lower intelligence and low education, and is not compatible with a prestigious job (4, 11, 14, 28).

In this study, the associations with a less well-trained body were less negative and were attributed to these people having other interests or being lazy or insecure. Boys at an early stage of puberty were less satisfied with their bodies than boys at a more advanced stage. International research findings consistently demonstrate that many boys are dissatisfied with their appearance due to insufficient height and muscle growth in relation to their perception of the dream body (21, 24, 29).

Other research found similar results and showed that early onset of puberty leads to greater satisfaction than later onset. Overall, puberty takes boys closer to their dream body through the increase in muscle mass (5, 10). This highlights the importance of covering topics such as normal development and body dissatisfaction in puberty education in primary and lower secondary schools.

Body and appearance as identity markers

The informants referred to the body as an important identity marker that reflects desirable and coveted personal characteristics such as hard-working, dedicated, goal-oriented and disciplined. This perception is supported by other research, which shows that an attractive body and appearance is a reflection of personal characteristics (26, 28, 30, 31).

The pursuit of the dream body can be understood in terms of hegemonic masculinity and the male ideal (26, 32). Hegemonic masculinity is described as a practice in which a social elite sets the standards and norms for the prevailing ideals (26, 28, 29, 32). The elite contribute to, legitimise and reproduce the social relations and trends that perpetuate the dominance of certain men over other men. Body and appearance function as symbolic capital and a gateway to desirable social environments (26, 28, 29, 31). 

The informants’ perceptions of the dream body align with this hegemonic male ideal, where the body provides access to desirable and coveted high-status environments. Nielsen describes today’s body ideal as far more hegemonic and homogenised, with girls placing the emphasis on aesthetic aspects of the body, while boys are more concerned with the functional aspects, such as strength and sporting prowess (33).

In our survey, a strong body is also described as important for gaining respect and remaining safe in childhood. A strong body signals physical superiority. The informants in the building and construction vocational line of study also mentioned that muscle strength is important for their future careers in manual labour.

The informants said that body and appearance were crucial for making a good first impression. People are weighed up, ranked and positioned socially based on their body and appearance after just a few seconds of observation. An attractive exterior helps secure the desired positioning and recognition from friends, acquaintances and potential girlfriends. These findings are consistent with other research, which emphasises the value of recognition by friends as motivation for achieving the dream body (4, 31).

The informants in our study said that trying to make a good first impression was stressful and exhausting, leading to additional pressure. According to Sæle, when body shape is perceived as reflecting certain character traits in a person, body pressure will also be greater and more complex (12, 27, 31). 

Negative associations concerning the body and appearance

All informants had experienced body pressure. National and international research confirms a high prevalence of body pressure among adolescents and young adults (10, 18, 20). Body pressure is described in our study and others as a negative feeling characterised by low mood, dispiritedness, as well as pressure and stress related to progress and changes in body-related behaviours (6, 14, 20).

Seeking help from first-line services was rarely considered and was described as unmasculine and unmanly. Hargreaves and Tiggemann suggest that this is because boys are experiencing body dissatisfaction whilst also contending with a social taboo against expressing emotions (1). However, previous research shows that good access to and positive interactions with public health nurses and first-line services increase the likelihood of boys subsequently making contact if they are having problems (34). It is therefore important that the public health nurse is present at the school, where regular meeting points such as group sessions and themed gatherings are a key priority throughout primary and lower secondary education.

The informants’ widespread use of dietary supplements can be partly a result of the desire for quick results, reading advice and recommendations on social media, and accessibility. Their reason for not using doping agents was a fear of side effects. However, informants who followed strict exercising and diet regimes seemed to have an ambiguous attitude towards doping.

Eik-Nes found that young men with a strong focus on building muscle are four times as likely to resort to muscle-building supplements, both legal and illegal. Twenty-two per cent reported such use in the past year (10, 14, 30). This highlights the health risks faced by the target group in this study.

Other research points to how public health nurses play a key role in providing new and up-to-date information on the topic as part of their preventive efforts. This can help change and correct adolescents’ assumptions, which may be based on poor knowledge (34). 

Strengths and limitations 

It is a strength of the study that the informants represent a heterogeneous group in terms of ethnicity, line of study and socio-economic background. The target group, boys aged 16–19, is under-represented in other research compared to girls (5, 10, 20). This strengthens the study’s relevance. The results align with other national and international research (4, 24, 35) and can therefore provide insight into boys’ reflections on body image. Due to the small sample size, the results cannot be generalised. 

Conclusion

The informants were generally satisfied with their own body and appearance. Their descriptions of the ideal body were consistent. They considered body and appearance to be important identity markers that were important for recognition and social belonging. Body pressure was a common experience that mainly had a negative association. However, some informants found that body pressure motivated and disciplined them, leading them to make choices that had positive health effects.

The study shows that the informants’ onset of puberty and pubertal development impacted on their degree of satisfaction with their body. It also shows how the masculine ideal is favoured and how the desire for the ideal body is related to expectations and hopes for recognition, respect, social positioning and future employment. This knowledge is important in the health promotion and prevention efforts aimed at pubescent boys.

Our findings highlight the need for access in schools to a public health nurse who can educate groups about puberty development, body pressure, body dissatisfaction, exercise, muscle growth and dietary supplements. This could help make the school health service more appealing for boys.

Acknowledgements

The authors would like to thank all the informants, the public health nurses who facilitated the study, and the school for its positive attitude. 

The authors declare no conflicts of interest.

Open access CC BY 4.0