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  • Suffering related to care among older patients on perioperative care pathways

    Major changes have taken place in the treatment of surgical patients. The changes mean shorter stays in hospital in connection with surgical treatment, including for older patients. These patients can be exposed to suffering beyond the illness itself and the treatment. In this article, we chose to use the terms ‘unnecessary suffering related to care’ and ‘unnecessary suffering’.

    Eriksson describes ‘suffering related to care’ as a violation of the patient’s dignity, absence of care, condemnation, punishment and the exercising of power (1). Dahlberg’s term ‘unnecessary suffering’ is described as negative encounters with healthcare personnel that make patients vulnerable, and this suffering is caused by a lack of care (2).

    Everyone wants to be well looked after, receive considerate nursing care and be treated with understanding, dignity and respect by the health service (3, 4). However, patients sometimes encounter healthcare personnel who subject them to indignities, and by so doing cause them to suffer. Healthcare personnel can be rude and disrespectful, and they can ignore and humiliate patients and treat them as if they are invisible (2, 5–7).

    Albina gives an example of an older man being subjected to serious violations of dignity in the form of physical touching and offensive language in connection with an operation (8). Willassen et al. refer to an example of a patient’s pain being ignored, and give examples of offensive language in the form of negative comments about the patient’s body (9).

    Care pathway

    In our study, the nurses refer to patients aged 60+. The World Health Organization (WHO) defines people between the ages of 60 and 75 as ‘early elderly’, and people over 75 as ‘late elderly’. Older patients are often moved to convalescence wards or their home shortly after surgery, and this process is referred to as a care pathway, treatment pathway, treatment loop or trauma chain (10).

    A surgical care pathway is normally divided into three phases: preoperative, intraoperative and postoperative. The preoperative phase is the time from which it is decided that the patient should be operated until the patient arrives in the operating theatres. This period involves preparations for patients and staff. In the operating theatre, the patients are taken care of by the surgical team, which mainly consists of a surgeon, theatre nurses, an anaesthetist and a nurse anaesthetist (3, 11, 12).

    Perioperative nursing care

    The term ‘perioperative nursing’ was adopted in the USA in the 1970s. Lindwall and von Post define perioperative nursing as the nursing actions and nursing activities performed by theatre nurses and nurse anaesthetists during the pre-, intra- and postoperative phases of surgery, normally in operating theatres (13).

    In the Nordic countries, the qualifications and areas of responsibility of these specialist nurses vary, and the scope of work for perioperative nurses can vary from hospital to hospital and from country to country (14). In its broadest sense, perioperative nursing can nowadays include contact with and caring for the patient at outpatient clinics, recovery units, day surgery operating theatres and contact with the patient via telephone before and after surgery (14).

    Responsibility to protect the patient

    Theatre nurses and nurse anaesthetists work in a multidisciplinary surgical team along with doctors, engineers and porters, and the entire team has a duty to work in a caring manner (4). Theatre nurses have a special responsibility for protecting patients from embarrassment and ensuring that they do not suffer indignities when they are naked or defenceless (4).

    Research such as ours on suffering related to care throughout the treatment pathway is new. It is important to learn more about the nurses’ perspectives of the suffering inflicted on patients in the perioperative phase in order to develop the nursing care.

    Objective of the article

    The purpose of this article is to describe nurses’ experiences with suffering related to care that is inflicted on patients. The findings in this article appeared in a study we conducted on patient safety and older patients (15).

    Method

    Design

    We chose a qualitative method with semi-structured interviews, and a content analysis of the data material was performed (16).

    Sample

    We interviewed 15 nurses working in small and large urban municipalities. These nurses worked in operating theatres, nursing homes and the community nursing service. In order to strengthen and enrich the study and gain an inside perspective from the entire course of the patient’s care pathway, we chose a combination of a focus group interview with four participants, five interviews with two participants and one individual interview. Table 1 shows detailed information about the participants.

    Table 1. Information on the nurses who participated in the study

    Data collection

    We contacted managers in hospitals and local authorities, who arranged contact with the nurses we interviewed. The interviews were conducted during the period March 2014 to September 2015. The main questions concerned patient safety for older patients undergoing surgery. We used an interview guide that we devised based on literature and the authors’ experiences.

    The interviews comprised of a total of 23 questions. The questions were open-ended, and we also asked for further details when the nurses described experiences in which patients had been subjected to offensive language or neglect, or had been ignored. We also asked if the nurses could give us examples of such incidents. We conducted a total of seven interviews: one interview with one participant, five interviews with two participants and one focus group interview.

    Four nurses participated in the focus group interview: two worked in a nursing home and two were part of the community nursing service. The third author was the moderator in this interview, and her task was to get the participants to talk to each other and to manage the social dynamics so that everyone was heard. The second author conducted all the interviews, while the first author took notes and asked supplementary questions (16). Table 2 shows details of the interviews.

    Table 2. Information on the seven interviews

    Analysis

    After the interviews, we prepared summaries and noted the main impressions. The first author transcribed all the interviews apart from one. We performed a qualitative content analysis of the data material (17, 18). This method of analysis was chosen because it is considered to be suitable for examining participants’ experiences, attitudes, motives and thoughts, as well as for examining some of the topics in more depth.

    The first and second authors listened to the recordings and read through the texts several times. The statements were then broken down into meaning units, which were then condensed, coded and thematised (17, 18).

    The first author had the main responsibility for the analysis, but regular meetings were held with all the authors where analyses, interpretations and text were reviewed and analysed. Table 3 gives examples of how the statements were broken down into meaning units, condensed meaning units and codes, and how these were sorted into sub-themes and main themes.

    Table 3. Examples of how main themes were extracted from raw data

    Ethical considerations

    We provided written and oral information about the study to the managers and informants. The nurses signed an informed consent form. They stated their age, qualifications and number of years in the profession prior to interview, with the exception of the first interview, where this information was provided during the interview itself.

    We informed the nurses that the study was voluntary and that they had the right to withdraw without giving a reason. Four informants withdrew on the day we had arranged to conduct the interviews. The study was reported to the Norwegian Centre for Research Data (project number 37833).

    Results

    The nurses in the study had experienced that suffering related to care, such as disrespectful behaviour, was being inflicted on patients, and that healthcare personnel neglected patients who were trying to get their attention. Conflicts of values made it particularly difficult for the nurses to discuss the suffering inflicted on patients with colleagues and management.

    Disrespectful behaviour towards patients

    The nurses from nursing homes gave examples of patients with cognitive impairments and dementia diagnoses being subjected to offensive language. They also provided examples of staff non-conformance notices being submitted because personnel had acted inappropriately towards patients.

    You do see patients’ dignity being violated, particularly in relation to offensive language, by the nurses and doctors in the surgical team, and it’s very difficult to address the issue.

    Theatre nurses

    The theatre nurses described incidences of violations of dignity by both nurses and doctors in the surgical team. This related to swearing and other language that the nurses considered to be inappropriate. One theatre nurse described it as follows:

    ‘You do see patients’ dignity being violated, particularly in relation to offensive language, by the nurses and doctors in the surgical team, and it’s very difficult to address the issue.’

    Another theatre nurse said the following:

    ‘The nurse anaesthetist actually sedated a patient so that they didn’t have to experience the surgeon’s inappropriate language. I don’t think we’re the only hospital in Norway that has this problem.’

    Several theatre nurses claimed that offensive language towards patients was a common problem in many operating rooms and that it was difficult to raise the issue with colleagues.

    Lack of appropriate pain relief

    The nurses reported that older patients did not always receive appropriate pain relief. One nurse employed in the community nursing service said the following:

    ‘Violations of dignity in relation to pain. I’ve experienced that a lot, where a patient’s claims of pain are treated with scepticism.’

    Nurses from the community nursing service and nursing homes had witnessed the stigmatisation of patients with substance abuse problems. They had also experienced patients not being given appropriate pain relief after surgery. One nurse said the following:

    ‘Unfortunately, it’s perhaps all too common for us to have a high threshold for providing any medication. There’s probably a reluctance to give morphine, for example, because you then need to keep a closer eye on the patient when we’re understaffed, and nurses may also be afraid that the patient will fall.’

    A nurse in the convalescence ward said that a patient told the doctor that he had received poor pain relief after surgery. It transpired from his medical records that the patient had not received any of the pain medication that had been prescribed for use as needed. The nurse made the following observation:

    ‘Not providing medicine when needed, that’s totally wrong. Maybe we’re afraid of giving too much pain relief as there’s been a lot of press coverage about patients being sedated, so it’s a very complicated issue.’

    Patients trying to get the nurses’ attention were ignored or neglected

    In the interviews, nurses described how patients who try to get the nurses’ attention are neglected. The nurses working in nursing homes said that patients were ignored, and that they did not get help when they pressed the alarm button. One said the following:

    ‘They’ve been ignored. When someone presses the alarm button it’s registered as a non-conformance, and no one goes to see to them.’

    Nurses described it as very difficult for patients and an affront to their dignity when they do not receive help when they are in pain or discomfort, or need assistance for other reasons.

    Discussion

    This article highlights suffering related to care that is inflicted on older patients undergoing surgical treatment and care. In the study, we find disrespectful behaviour towards patients, lack of pain relief and neglect on the part of the healthcare personnel when patients try to get their attention. Vulnerable groups, such as patients in a state of confusion or with cognitive impairments, were particularly at risk, as were older patients with substance abuse problems.

    Studies, including from operating theatres, show that patients are subjected to serious and unacceptable violations of dignity (7, 9). Albina gives examples of serious violations of dignity in a patient receiving perioperative nursing care. She points out that patients undergoing surgery are in a particularly vulnerable situation because they are anaesthetised (8).

    It can be difficult to get healthcare personnel to talk about such reprehensible behaviour. According to Eriksson, patients can feel spiritual and mental distress as a result of humiliation by fellow human beings. They may also feel a sense of guilt in relation to their treatment or illness. These are feelings that are manifested within the patient, but they can also occur due to the judgmental attitude of nursing staff (1).

    Conflicts of values arise when nurses witness rude behaviour by other healthcare personnel.

    Lindwall and von Post describe how patients suffer during humiliating actions. They explain that if healthcare personnel really want to protect a patient’s dignity, they must force themselves to see what they do not want to see. Furthermore, they argue that conflicts of values arise when nurses witness rude behaviour by other healthcare personnel. They conclude that it is necessary to discuss and reflect on such reprehensible behaviour, which causes the patients to suffer and leaves them feeling humiliated (19).

    Perioperative care involves theatre nurses and nurse anaesthetists safeguarding patient care. Their role is to protect patients from suffering beyond that caused by the surgical procedure. Dahlberg and Martinsen describe how perioperative nurses are there to protect patients from violations of dignity and ensure that they are not subject to any unnecessary suffering (2, 4).

    Nordtvedt believes that moral sensitivity is characterised by identifying and intercepting the morally relevant features of a situation. To illustrate a situation where nurses should be particularly careful with patients, he uses the example of protecting a patient’s dignity when exposed (20). Theatre nurses are well-versed in such situations in connection with the surgical positioning of patients, i.e. placing them in a particular physical position to enable the operation to be carried out. The theatre nurse must safeguard the patient’s integrity and dignity by preventing their body from being exposed (20).

    Guidelines on professional ethics state that the nurse must safeguard the individual patient’s dignity and integrity, and that the patient has the right to comprehensive nursing care, the right to shared decision-making and the right not to be subjected to indignities (21). According to the legislation, healthcare personnel must perform the work in a way that meets the requirement for professionally responsible and caring nursing (13). Our study shows that serious violations of dignity have occurred and that suffering related to care has been inflicted on patients.

    Disrespectful behaviour towards patients

    Nurses have a professional, ethical and legal responsibility to speak out against violations of patients’ dignity and to not participate in or tolerate unacceptable behaviour (3, 21, 22). The nurses described how they felt uncomfortable when such undesirable events occurred, which concurs with the findings of Lindwall and von Post (13).

    The nurses had experienced difficult situations and had chosen to give the patients extra sedatives to make them sleep. They wanted to spare patients from verbal outbursts by members of the surgical team. This method of protecting vulnerable patients is debatable, but nurses can feel pressure to act and resolve the situation in the best way possible.

    It is important that healthcare personnel have good collaboration skills and that they find good ways to communicate. It is not uncommon for conflicts to arise in the operating room. In the worst case, conflicts can pose a risk to a patient’s safety, or the patient can feel violated (13, 14).

    Our findings are consistent with Willassen et al. (15), who describe undignified care and violations of dignity in perioperative practices and conclude that there is a need for reflection and discussion on ethics and dignity in the field. They further conclude that these issues need to be discussed in study programmes in order to raise awareness of attitudes and help change these for the benefit of patients, staff and students (9).

    There are many different explanations for disrespectful behaviour towards patients. It can be blamed on work-related stress factors, physical or mental illness, abuse, thoughtlessness or fear of making a mistake (18). Power hierarchies, fear of reprisal or bullying are some of the reasons why healthcare personnel are unable to deal with these difficult situations. Various communication problems also cause adverse events (15).

    Nordtvedt believes that there are many explanations for how a moral breakdown can occur. He cites power hierarchies, blind obedience, emotional numbness, ideology, sadism and lack of empathy as causes of moral breakdown (23). The degree of openness in the patient safety climate will determine how easy staff think it is to talk about risks and adverse events in the workplace (24).

    In the USA, professional development courses for nurses and doctors whose conduct poses a risk to patient safety have long been used as a tool for behavioural change. Early feedback from staff and managers is important for the employee to understand the impact of his or her behaviour (25).

    Lack of appropriate pain relief

    Our findings show that patients do not always receive appropriate pain relief following surgical procedures. The nurses gave examples of individual patients being stigmatised. The examples concerned drug addicts and are taken from nursing homes and the community nursing service.

    The lack of appropriate pain relief for vulnerable patient groups after surgery is a serious situation that leads to suffering for the patients. Pain-based behaviour, pain-based emotions and experiences of pain differ from patient to patient, and they are also contingent on culture (26).

    It is essential to develop greater collaboration across treatment levels.

    Failure to give patients appropriate pain relief represents a serious lack of care (1). Possible solutions for nurses may be to update their knowledge of pain and pain-based behaviour and emotions in different cultures, participate in learning networks and form a closer working relationship with pharmacists and doctors. Pain relief can help prevent falls among older patients.

    Multidisciplinary collaboration, annual medication reviews and home care rehabilitation all play a major role in fall prevention. Fall prevention in healthcare institutions is a priority area for the Norwegian patient safety programme (27).

    Closer collaboration between the specialist health service and the primary health service, better nursing documentation, the use of interpreters and the sharing of necessary information when patients are moved between different levels in connection with surgical procedures are all crucial (28). It is essential to develop greater collaboration across treatment levels.

    Patients trying to get the nurses’ attention were ignored or neglected

    The nurses from the nursing homes provided examples of patients not receiving help when they pressed the alarm button. Dahlberg also refers to examples where patients do not have access to the alarm button and are therefore unable to call for help when needed (2).

    Report no. 13 to the Storting, ‘Quality and Patient Care’, states that patients’ families are concerned about the lack of dignity, care, trust and safety for frail people over the age of 80 living at home. They do not receive help at the agreed time, and there are not enough qualified staff (24). The families are often a source of strength for older patients when they are admitted to a hospital or nursing home and when they receive home nursing care.

    Martinsen gives an example where a woman with cancer who is in the last week of her life was denied assistance from a nurse to find a more comfortable position. The woman pressed the alarm button, but did not get help. The nurse acted shamelessly and used the fact she was busy as an excuse for not helping a vulnerable patient in severe pain (28). Malmedal points out that bad attitudes and poor management, lack of knowledge and tight financial frameworks may be the reasons behind patients not receiving help (6).

    Conclusion

    We collected data across health service levels. In the study, there are examples of disrespectful behaviour, lack of appropriate pain relief and neglect when the patients tried to get the staff’s attention, and the findings suggest that unnecessary suffering is inflicted on older patients. The nurses’ most important task is to alleviate suffering and promote good health. Nurses, managers and other healthcare personnel must work together to prevent more suffering being inflicted on older patients, particularly when continuity in the nursing is a challenge.

    The study shows the importance of person-centred care, better collaboration between the different service levels and better pain management. Perioperative nurses must communicate with the patient throughout the entire course of the patient’s care pathway, and not just at the time of surgery.

    The nurses’ most important task is to alleviate suffering and promote good health.

    The study also shows that the primary and specialist health services should include Lindwall and von Post’s perioperative dialogue model. This model places the focus on patient dignity, which includes contact with patients and their families, and dialogue between staff within and between units. Openness and discussion in connection with violations of dignity in the working environment are needed to improve the safety climate. It is crucial that nurses discuss how to deal with such situations.

    More research is needed in this area, which also encompasses patients’ and their families’ experiences of suffering related to care that is inflicted in connection with surgery. Nurses should lead the way in promoting a caring environment for patients and staff, and they must have the courage to address adverse events. By not reporting unacceptable behaviour, they are allowing such attitudes and behaviour to continue.

    We thank the informants who participated in the study and the managers who helped us gain access to the field. We also thank the Norwegian Association of Operating Room Nurses for providing project funds, which made the study possible.

    References

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    28.     Naustdal A, Netteland G. Sjukepleiedokumentasjon i eit elektronisk samhandlingsperspektiv. Oslo: Sykepleien Forskning. 2012;3(7):270–7. DOI: 10.4220/sykepleienf.2012.0133.

    Patients move quickly between different units during the surgical pathway. Older patients in particular are at risk of suffering related to care such as violations of dignity, neglect and poor pain management.

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    Sammendrag

    Background: Older patients who are admitted to hospital for surgery are moved quickly between different levels in the health service. These patients can be exposed to unnecessary suffering related to care, which can become an additional burden and impede convalescence.

    Objective: To describe nurses’ experiences with suffering related to care that is inflicted on older patients undergoing surgical procedures.

    Method: The study has a qualitative, exploratory design and comprises a total of seven interviews. We conducted one focus group interview, five qualitative in-depth interviews with two informants in each group and one individual interview with one nurse. Fifteen nurses participated, who either worked in the community nursing service, nursing homes or operating theatres.

    Results: The nurses who participated had experienced nurses behaving disrespectfully towards older patients. Conflicts of values arose in the interaction between patients and healthcare personnel, and it was difficult to discuss unethical behaviour with managers or colleagues. Patients did not always receive appropriate pain relief and did not always receive help when they pressed the alarm button or asked for help.

    Conclusion: Older patients are at risk of suffering related to care in the form of violations of dignity, neglect and lack of appropriate pain relief during the surgical pathway, where patients are moved quickly between different units. Suffering that is unnecessarily inflicted on patients can be prevented by talking to the patient and his or her family. Ethically responsible management requires good communication and ethical reflection with colleagues on observed violations of dignity.  

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  • Stigmatisation and shame – a qualitative study of living with obesity

    The study describes how people with obesity experience stigmatisation and shame. Adults with a body mass index (BMI) of more than 25 are considered to be overweight, and those with a BMI over 30 are classed as obese (1). In 2016, 13 per cent of the world’s adult population has obesity. According to a Norwegian public health report from 2017, approximately 1 in 4 middle-aged men and 1 in 5 women have obesity (2).

    Malterud and Ulriksen define stigma as an intersubjective phenomenon that is constructed via interaction with an individual’s immediate surroundings (3). Weight stigma is defined as ‘the social rejection and devaluation that accrues to those who do not comply with prevailing social norms of adequate body weight and shape’ (4). Weight-based stigmas can lead to social devaluation and discrimination and can manifest themselves in most interpersonal relationships (5).

    According to Luoma, shame is the emotional core of the experience of stigmatisation (6). Shame is a self-related and self-evaluating emotion that is connected to a form of self-awareness in which one no longer owns one’s own body (7). In self-stigmatisation, the socially devalued status of an overweight person is internalised (8).

    The World Health Organization claims that obesity is one of the most pressing health challenges today (1). Throughout the world, there is a cultural understanding of obesity as a moral failure that leads to impaired health and quality of life. Brewis et al. argue that the way in which shame and discrimination are linked to obesity will gradually undermine public health efforts (9).

    Earlier research

    The norm in Western societies is to be slim, and those who suffer from obesity are constantly confronted with this ideal (10–13). Society’s rhetoric in the description of obesity is itself stigmatising, with wording such as ‘an obesity epidemic’, ‘the fight against obesity’ and ‘the war on the obesity epidemic’ (14, 15). People with obesity are regarded as a medical, financial and social liability in society (14, 15).

    At an individual level, people with obesity are often portrayed as less physically attractive, undisciplined and greedy individuals who should be ashamed of themselves. Someone who is overweight is often regarded as lazy and having a weak character (3, 15). An additional burden also exists in the form of a moral imperative on the individual to treat and take preventive action against obesity (15).

    People with obesity find that society’s body norms are also reflected in the gaze of professional helpers. This reinforces the stigma and shame (16). They feel they are excluded for being abnormal, and avoid contact with the health service (12, 14, 17).

    It is not possible for people with obesity to escape the cultural message. Thus, the experience of being overweight can overshadow their entire life and become ‘the very scene of life’ (3). Anyone who does not have the ideal body can perceive stigmatisation as a signal that he or she does not quite fit in, which can make them feel that they are not a fully-fledged human being (16, 18).

    Kahan and Puhl (5) claim that weight-based stigmatisation and shame are underreported as a health challenge. The subject of weight stigma is largely absent both at the individual level of treatment and in the national discourse, as well as in health-promoting measures and political priority areas (19). The first step in facilitating health-promoting measures for this vulnerable group is to learn more about their experiences of weight stigma and the associated repercussions on health (19).

    Objective of the study

    The study explores how people with obesity experience stigmatisation and shame. Knowledge can help improve the health service’s approach to this group, and increase society’s understanding. The objective of the study is to gain a deeper understanding of how people living with obesity experience stigmatisation and shame.

    Method

    The study is based on a phenomenological-hermeneutical epistemology perspective and has an exploratory design. Qualitative research interviews were conducted, which helped to provide insight into the individual’s lifeworld (20). The hermeneutic aspect of the project represents an interpretive approach (21).

    Gadamer claims that the interpretation of meaning is the human way of being in the world, and the study explores the deeper meaning. New understandings can arise when we are open to the unknown and are willing to challenge our own preconceptions (22). The author is a nurse with an interest in health-promoting processes, which influences her preconceptions.

    Participants and data collection

    The study is based on qualitative in-depth interviews conducted on 18 people who suffer from obesity. The participants represent a convenience sample and were recruited at the start of a three-week lifestyle change course at a Norwegian rehabilitation institution. The course leader at the clinic provided written information about the research project to all participants. Of the 30 people who were invited to participate in the study, 18 agreed. They informed the staff at the clinic, who forwarded their telephone numbers to the author.

    The participants were contacted, and the time and place of the interview were agreed. Fifteen women and three men participated in the project. The information letter explained informed consent and gave details concerning anonymity. The inclusion criteria were a BMI over 30, age 18–75 years and an interest in expressing themselves orally. The research project was assessed and approved by the Regional Committees for Medical and Health Research Ethics (REC number 2015/1720).

    The author conducted the interviews, which lasted between 30 and 90 minutes. An open approach was adopted in the interviews: ‘Describe what living with obesity is like for you. How do you view yourself?’

    In order to prepare participants for the fact that the interview would touch on sensitive issues and emotions, the information letter described how bodies and weight gain can be difficult to talk about as doing so may make some people feel vulnerable.

    Analysis

    The transcribed interviews were analysed using Kvale and Brinkmann’s qualitative analysis method with three levels of interpretation (20). Each interview was reviewed in its entirety to gain an overall understanding of what it was about. The first step in the analysis and level of interpretation was to identify the individual’s self-understanding. Meaning-bearing units in the dataset were extracted and arranged under provisional category titles that closely resembled the quotes.

    The second step of the analysis and level of interpretation was to provide a reasonable, general interpretation of what the participants said. Using careful abstraction, the participants’ self-understanding was reformulated, and new themes were created, which are presented in the findings. The themes were generated as part of a hermeneutic process whose validity was verified as the parts and the whole fell into place (22).

    The findings illustrate obese people’s experiences of stigmatisation by culture, society and immediate surroundings, and how the stigma is an integral part of them that brings with it a sense of shame. In the third level of interpretation, the empirical data leads us to relevant theory that can deepen and broaden the understanding of the data. The theoretical understanding and further interpretation of the data are explained in the discussion section.

    Results

    The analysis of the transcribed material shows that the interviewees’ comments describe three perspectives on how stigmatisation and shame are created and sustained:

    • Pressure from society
    • Offensive behaviour in immediate surroundings
    • Self-devaluation

    Stigmatisation and shame are expressed directly in the material and are also interpreted from the descriptions.

    Pressure from society

    People with obesity feel pressure and a sense of shame as a result of society’s focus on body image. This group is particularly exposed and susceptible to enormous pressure, as the size of a person’s body is always visible. The message from society cannot be ignored and robs them of the freedom to be themselves and have their own thoughts about themselves:

    ‘What is it that makes me reproach myself? It has a lot to do with society. There is a focus on exercise and dieting that is totally insane. There is the sense that society nowadays has a very narrow mindset.’

    This cultural pressure manifests itself in various ways: ‘Am I less successful and less gifted, not wise enough to realise that I should lose weight?’

    The health service conveys a similar message in its approach to people with obesity: ‘It only makes me feel more guilty when I’m told that I shouldn’t eat this and that. Being taught about what it is to be overweight is stupidity. Those of us who are overweight know perfectly well what is wrong. We can see our extra kilos. I believe that both the health service and the majority of the population believe that this is self-inflicted.’

    Try buying sportswear when you weigh 137 kilos.

    People with obesity feel that there is no place for them in the public domain. They do not feel welcome: ‘Try buying sportswear when you weigh 137 kilos. When you go to the gym, the training equipment specifies a maximum body weight!’

    They have a fear of being redundant: ‘I’m afraid of being pushed out of my job, not counting, not being given training or responsibilities. I want to show that I count. I think about that a lot.’

    Offensive behaviour in immediate surroundings

    Most of the interviewees feel that they are being continuously monitored by the people around them. Other people’s feelings towards people with obesity are reflected in how they look at and talk to this group – through verbal and non-verbal communication. These experiences leave their mark on people with obesity and add to the shame they deal with in everyday life:

    ‘If I go to a cafe, they’re watching every bite you take. It’s a bit like “being fat is stupid because taking that piece of cake is stupid.” If I had been them, I would no doubt have thought: “Oh my God, she’s so fat! Why is she taking that piece of cake, can’t she just leave it?” You recognise the look. They can’t hide their condescending attitude.’

    Although the impressions from the outside world can be strong, people are starting to rally against the idea of being defined by society. Action is needed to reduce the vulnerability of those who are living with obesity. Dealing with it through self-ridicule reinforces their vulnerability: ‘I've always laughed it off, but I feel fake and weird afterwards. So I’ve now started saying that I don’t appreciate it, and then it gets very quiet, embarrassing and silly.’

    Another says the following: ‘I joke about myself, joking about it to them, but am sad inside.’

    Obese people feel that they need to answer for their body and the extra kilos: ‘That’s good that you’ve lost weight. You need to keep it off now.’

    They find it annoying when people praise them for losing weight. ‘It’s as if they’re saying: “You’re on your way to becoming a fully-fledged human being now”.’

    Others are reminded of their weight on a daily basis: ‘Yes, there’s a few extra kilos there since the last time I saw you; yes, you’re doing well; how fat you’ve gotten.’

    Self-devaluation

    People living with obesity are also shaped by their own self-understanding, which creates a certain disdain for themselves and their bodies:

    ‘Thinking about what they think just makes me depressed. I view myself as horribly fat and bulky, someone who has failed, with a weakness. But I’ve had a job, and I haven’t failed at all. My first evaluation of anyone is: ‘Are you fat, or are you thin? Do you work out?ʼ So I think that others are also focussed on that. It affects my self-esteem.’

    Participants express in different ways that they are a burden to themselves and others: ‘When I went out with my friends, I was thinking: “It must ruin their chances of getting a man when they’re with me, being the way I am”.’

    Feeling less attractive creates a self-fulfilling prophecy and makes them withdraw.

    Obese people’s bodies and appearance are continuously being judged. Feeling less attractive creates a self-fulfilling prophecy and makes them withdraw: ‘When I’m fat, I feel less attractive. I probably don’t behave like I’m attractive either. I do after all tend to keep myself to myself! I haven’t managed to maintain my social life. Everything depends on my weight. If I’m invited to a club and I feel that I’m the wrong weight, I won’t go.’

    Their own foundation is a breeding ground for shame: ‘I feel a kind of hopelessness. Shame and hopelessness are connected here and are a big part of my personality. But how am I going to change it? I could give up. Why should I struggle with this? Can’t I have a good life instead, for the rest of my life, being as ugly as I am, and now soon to depart this world.’

    The shame is exacerbated by hiding what they eat: ‘I think that I’ll only have one slice, but I plan to eat more when the others have gone to bed. It’s associated with shame, it’s bad. When I comfort eat, I get a feeling of self-loathing.’

    Shame and pride fight for space: ‘The dream is to feel that you are completely normal in appearance, someone who blends in, and no one reacts, no one thinks: “Oh God, look at that belly or those thighs or that backside or those arms, look at her eating, oh dear!” I want to be completely normal. Yes, thinner and more elegant! So that I can hold my head up a bit and feel a bit of pride in my appearance as well. I do feel some pride in who I am on the inside.’

    Discussion

    The objective of the study was to explore the correlations between stigmatisation and shame, and their impact on people who are living with obesity. On the basis of the findings, I will discuss the possibilities for preventing and managing stigma and shame at the individual level and at the societal level.

    A key feature of the findings is that the devaluing voice from society and the immediate surroundings is dominant and can lead to internalised stigma. The internalisation is reflected in the way that the participants talk about themselves: overweight people are stupid, less gifted, unsuccessful, failures. Obesity is a deviation from the normative body, and people who experience self-stigma view themselves as having a devalued social identity (6, 15).

    The study also shows that the impact of weight stigma and shame on the participants’ health is a challenge that they described using words such as hopelessness, sadness, resignation, not being counted, being a burden on their immediate surroundings and withdrawal and isolation. Studies confirm that self-stigma leads to a sense of worthlessness and isolation, with loss of self-actualisation (3, 6, 23).

    In the phenomenology of the body (24), an individual with obesity is an exposed object for the other (7). The pre-reflective embodiment as a form of innocence and immediate being-in-the-world can be lost, and the person loses their spontaneity. Pre-reflective embodiment refers to the relationship we have with our body, which we do not normally give any thought to, but with which it is possible to have a conscious relationship. Shame leads to a person losing sight of the future (7, 23).

    Having to act in accordance with culture

    People with obesity cannot escape the cultural context, but must find a way to cope with the influence of culture (3). Their efforts to move forward so that life can be lived is expressed in the findings as an endeavour in self-understanding: ‘I want to count, I have begun to speak up, I want to be completely normal and be proud of my appearance.’ But they also exhibit a resigned attitude: ‘How am I supposed to change this?’

    There is a longing to have the normalised body, whilst simultaneously expressing a sense of hopelessness and powerlessness. Welz claims that individuals cannot shed the sense of shame on their own; it has to be done in a dialogue with others (25). Fuchs argues that it is crucial to maintain a metaperspective: ‘Taking a metaperspective on situations that cause shame and guilt helps to cope with the self-devaluation [...]. The capability of adopting a metaperspective depends on an open interpersonal space which allows for freedom of self-distance.’ (7, p. 234, 240).

    The informants in the study describe hurtful shame, but there are also traces of pride associated with their inner qualities.

    The informants in the study describe hurtful shame, but there are also traces of pride associated with their inner qualities. It is essential to highlight these elements of pride as building blocks to entering a freer space with themselves, their bodies and their lives. Using the Danish philosopher Kierkegaard’s writings about love, Lippitt illustrates how healthy self-love represents a kind of pride (26).

    Shame can paralyse us and prevent us from living a full life, while self-love can help us liberate ourselves from shame. By doing so, we open ourselves up to future possibilities (26).

    Extensive weight discrimination

    Weight discrimination is a global health challenge and is found in recruitment, educational institutions, the mass media and the health service. Social measures are needed to address this widespread health threat (9). A broader effort is required in society to combat weight stigma than has been the case so far, according to Puhl and Suh (19).

    Weight discrimination is a global health challenge and is found in recruitment, educational institutions, the mass media and the health service.

    Malterud and Ulriksen argue that, as part of the qualitative care for people with obesity, health policy and the field of medicine must acknowledge the body weight prejudices that exist in our culture. In doing so, they will enable those affected to mobilise their own health resources (3). Future obesity prevention initiatives and treatments must give greater empowerment to people living with obesity instead of reinforcing stigma, shame and guilt (19).

    Implications for clinical practice

    Healthcare personnel are well positioned to contribute to health-promoting change processes, both at the individual level and at the societal level (4). The health challenges associated with stigma and shame and the consequences of these challenges cannot be solved without preventative efforts in a societal perspective.

    Medvedyuk claims that the focus of health research and the health service makes victims of obese people. It is therefore essential that healthcare personnel set aside these cultural and negative norms and treat such patients with openness and without prejudice (27). Changing the focus of society and treatment services from weight reduction to greater efforts to address how people are affected by obesity can help reduce stigmatisation (5).

    Weaknesses of the study

    The study’s findings help us understand some of the correlations between and consequences of stigma and shame, but cannot be generalised as they stand. Vulnerability in connection with stigma and shame is experienced by everyone differently. The sense of shame is concealed within the stigma and is expressed both explicitly and implicitly in the interviews (6). The validity of the study is enhanced by the rich data provided in the interviewees’ descriptions (20). Earlier research also emphasises correlations and consequences, which further validates the findings.

    Conclusion

    Internalised stigma can crystallise into shame processes, thereby limiting quality of life. The ability to overcome shame as a result of self-stigma lies in developing a resistance to shame, something that can only be achieved in a dialogue with others.

    As healthcare professionals, we play an important role in supporting those who suffer from obesity and in enabling them to view themselves as fully-fledged human beings. We also have a responsibility to highlight this aspect of obesity in the public domain and thus help society as a whole to be accepting of obese people.

    References

    1.       Verdens helseorganisasjon (WHO). Obesity and overweight [Internet]. WHO; 16.02.2018 [cited 09.01.2019]. Available at: http://www.who.int/mediacentre/factsheets/fs311/en/

    2.       Folkehelseinstituttet. Overvekt og fedme i Noreg [internett]. Oslo: Folkehelseinstituttet; 2017 [updated 04.10.2017; cited 09.01.2019]. Available at: https://www.fhi.no/nettpub/hin/levevaner/overvekt-og-fedme/

    3.       Malterud K, Ulriksen K. «Norwegians fear fatness more than anything else» – a qualitative study of normative newspaper messages on obesity and health. Patient Educ Couns. 2010;81(1):47–52. DOI: 10.1016/j.pec.2009.10.022

    4.       Tomiyama AJ, Carr D, Granberg EM, Major B, Robinson E, Sutin AR, et al. How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Medicine. 2018;16(1):123. DOI: 10.1186/s12916-018-1116-5

    5.       Kahan S, Puhl R. The damaging effects of weight bias internalization. Obesity. 2017;25(2):280–1. DOI: 10.1002/oby.21772

    6.       Luoma JB, Platt MG. Shame, self-criticism, self-stigma, and compassion in Acceptance and Commitment Therapy. Current Opinion in Psychology. 2015 april;2:97–101. DOI: 10.1016/j.copsyc.2014.12.016

    7.       Fuchs T. The phenomenology of shame, guilt and the body in body dysmorphic disorder and depression. Journal of Phenomenological Psychology. 2002;33(2):223–43. DOI: 10.1163/15691620260622903

    8.       Pila E, Sabiston CM, Brunet J, Castonguay AL, O'Loughlin J. Do body-related shame and guilt mediate the association between weight status and self-esteem? J Health Psychol. 2015;20(5):659–69. DOI: 10.1177/1359105315573449

    9.       Brewis A, SturtzSreetharan C, Wutich A. Obesity stigma as a globalizing health challenge. Global Health. 2018;14(1):20. DOI: 10.1186/s12992-018-0337-x

    10.     Moola FJ, Norman ME. On judgement day: Anorexic and obese women’s phenomenological experience of the body, food and eating. Feminism & Psychology. 2017;27(3):259–79. DOI: 10.1177/0959353516672249

    11.     Lewis S, Thomas S, Blood R, Castle D, Hyde J, Komesaroff P. How do obese individuals perceive and respond to the different types of obesity stigma that they encounter in their daily lives? A qualitative study. Soc Sci Med. 2011;73(9):1349–56. DOI: 10.1016/j.socscimed.2011.08.021

    12.     Owen-Smith A, Donovan J, Coast J. «Vicious Circles»: The development of Qualitative Health Research. 2014;24(9):1212–20. DOI: 10.1177/1049732314544908

    13.     Grønning I, Scambler G, Tjora A. From fatness to badness: the modern morality of obesity. Health. 2013;17(3):266–83. DOI: 10.1177/1363459312447254

    14.     Brown-Bowers A, Ward A. Treating the binge or the (fat) body? Representations of fatness in a gold standard psychological treatment manual for binge eating disorder. Health. 2017;21(1):21–37. DOI: 10.1177/1363459316674788

    15.     Throsby K. «How could you let yourself get like that?» Stories of the origins of obesity in accounts of weight loss surgery. Soc Sci Med. 2007;65(8):1561–71. DOI: 10.1016/j.socscimed.2007.06.005

    16.     Christiansen WS, Karlsen TI, Larsen IB. Materiell og profesjonell stigmatisering av mennesker med sykelig overvekt. Nordisk tidsskrift for helseforskning. 2016;13(2). DOI: http://dx.doi.org/10.7557/14.4195

    17.     Barber SW. Being large: an interpretive phenomenological enquiry into the lived world of problematic weight. (Doctoral thesis.) Middlesex: New School of Psychotherapy and Counselling; 2016.

    18.     Merrill E, Grassley J. Women's stories of their experiences as overweight patients. J Adv Nurs. 2008;64(2):139–46. DOI: 10.1111/j.1365-2648.2008.04794.x

    19.     Puhl R, Suh Y. Health consequences of weight stigma: implications for obesity prevention and treatment. Current Obesity Report. 2015;4(2):182–90. DOI: 10.1007/s13679-015-0153-z

    20.     Kvale S, Brinkmann S. Det kvalitative forskningsintervju. Oslo: Gyldendal Akademisk; 2009.

    21.     Thagaard T. Systematikk og innlevelse. En innføring i kvalitativ metode. Bergen: Fagbokforlaget; 2013.

    22.     Gadamer HG. Sannhed og metode. 2. ed. Århus: Academia; 2007.

    23.     Shaughnessy MJ. Integrative literature review on shame. Nursing Science Quarterly. 2018;31(1):86–94. DOI: 10.1177/0894318417741120

    24.     Merleau-Ponty M. Phenomenology of perception. London: Routledge; 2002.

    25.     Welz C. Shame and the hiding self. Passions in context: International Journal for the History and Theory of Emotions. 2011 aug;(2).

    26.     Lippitt J. True self-love and true self-sacrifice. International Journal for Philosophy of Religion. 2009;66(3):125–38. DOI: 10.1007/s11153-009-9201-5

    27.     Medvedyuk S, Ali A, Raphael D. Ideology, obesity and the social determinants of health: a critical analysis of the obesity and health relationship. Critical Public Health. 2018;28(5): 573–85. DOI: 10.1080/09581596.2017.1356910

    Healthcare personnel should treat obese people with openness and without prejudice. By doing so, they can help them develop a resistance to shame.

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    English
    Sammendrag

    Background: Those who suffer from obesity can feel stigmatised and shamed by society, which can prevent them from living life to the full.

    Objective: We need a deeper understanding of obese people’s experiences with stigmatisation and shame, of how stigma and shame are created and sustained, and the impacts of shame on this group. The health service needs insight into how stigmatisation leads to shame, and the consequences of shame for the individual.

    Method: The study has a phenomenological-hermeneutic approach and an exploratory design. We conducted qualitative in-depth interviews with 18 obese people. The interviews were analysed using Kvale’s phenomenological-hermeneutic method.

    Results: People living with obesity experience stigma both from society in general and from their immediate surroundings in particular. Internalised stigma creates shame, which can severely impact on how obese people view and perceive themselves. The shame can impact on self-actualisation.

    Conclusion: Shame resulting from self-stigma can be overcome by developing a resistance to being defined by shame. The sense of shame cannot be shed by an individual in isolation. It is therefore important for healthcare personnel to have an insight into the impacts of stigma and shame in order to adopt attitudes that reduce the shame. Social and health policy measures are also required to reduce stigmatisation.

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  • Perceptions of postnatal care after emergency caesarean sections

    Many women in Norway unexpectedly undergo surgery just as they embark on life as a new mother. In 2017, 16 per cent of all births in Norway were by caesarean section, and 65 per cent (5870) of these were emergency procedures (1). However, the caesarean section rate in Norway is among the lowest in the western world (2).

    Since the 1960s, new mothers have been handed an increasing degree of responsibility for their own child during their stay in the maternity ward, while the number of routine observations and interventions has been reduced (3). This development stems from the view that giving birth is a natural process, but also from a wish within the health service to prioritise patients who are seriously ill (4).

    In Norway, new mothers tend to stay in hospital for two or three days after a normal birth, and early departure is desirable (5). Report no. 12 to the Storting, ‘A Happy Event’, pointed to the need for systematic collection of service user experiences and information from medical personnel in order to learn what aspects of postnatal care ought to be improved (4).

    In 2016, a nation-wide survey of service users’ perceptions of antenatal, birthing and postnatal care found that the least favourable reports concerned the postnatal stay in hospital (6). When asked whether they had received sufficient information about their own physical health after the birth, as many as 19 per cent of respondents answered ‘not at all’ or ‘to a small extent’, while 27 per cent answered ‘to some extent’ (6).

    Possible complications

    A caesarean section may give rise to complications such as endometritis, embolism (7) and operating wound infections. The risk of re-admission to hospital is higher after a caesarean section than after a vaginal delivery (8, 9), particularly among women who have undergone emergency surgery (10). All forms of caesarean section are associated with poorer health and quality of life compared to spontaneous vaginal deliveries (11).

    Studies describe dissatisfaction and insufficient postnatal follow-up in hospital (9, 12–14) and point out that postnatal care is a low-priority area that has a lower status than birthing care amongst healthcare personnel (13). According to Fenwick et al. (15), women who give birth by emergency caesarean section sometimes experience a difficult postpartum period. Many feel that they receive insufficient physical assistance at the hospital.

    Objective of the study

    We are aware that there are mental as well as physical aspects to the concept of health, and that its interpretation is culturally and historically conditioned. It is therefore challenging to distinguish between physical and mental health following a caesarean section, where bodily challenges and existential experiences are closely intertwined.

    It is nevertheless useful to explore how women perceive the care that is provided for their physical health after an emergency caesarean section, because caesarean sections carry a higher risk of physical complications. The objective of the study was therefore to investigate how women perceived the physical health care that was provided in the maternity ward following an emergency caesarean section.

    Method

    Design and sample

    We chose a qualitative design for the study as this is well suited for shedding light on the women’s experiences (16, 17). Using social media, we recruited a convenience sample (16) consisting of ten women. Those who wished to take part, contacted the first author and recruitment took place on an ongoing basis. Posters displayed at child health clinics in one local authority area did result in women coming forward, but these were not included in the sample because their details were received too late in the study period.

    We included women who had given birth by emergency caesarean section in the period 2014–2016 and who had spent the initial postpartum period in hospital. The women were between 27 and 40 years of age, and all had been married or in a cohabiting partnership at the time of the birth. Nine women were ethnic Norwegians, while one was from a non-western background. All had a higher education. Seven women were primipara, while three were secundipara who had previously also delivered by emergency caesarean section.

    We conducted individual semi-structured interviews (17) from October to November 2016. Six of the informants chose to be interviewed in their own home while four were interviewed in a meeting room at a public library. The interviews lasted between 20 and 76 minutes (40 minutes on average). Five women were accompanied by their infant during the interview, and one of them had their partner present for 5 minutes.

    We made use of an interview guide and started the interviews with an open-ended question, asking the women to describe their transfer from the recovery unit to the maternity ward. The interview guide further included a question about the course of events that followed the decision to undertake an emergency caesarean section. These open-ended questions proved to be good conversation-starters.

    The interview guide also included questions about assistance received with personal hygiene, mobilisation, pain relief and follow-up of the operation wound. After conducting the first interview, we added themes that referred to the value of the partner’s presence and to midwifery follow-up. The interviews were recorded, and the resultant audio files were transcribed verbatim.

    Data analysis

    Two of the authors analysed the material by means of systematic text condensation (STC), which is a four-step thematic cross-case analysis method (16). We started the analytic work by reading all interviews in order to gain an overall perspective and identify provisional themes.

    The second step involved the identification and coding of meaning units. We proceeded to focus on one code group at a time, sorting the content into subgroups that represented different nuances of the phenomenon. These were then condensed. Finally, we synthesised the condensates into a single analytic text per code group, adding appropriate quotes that shed light on the text.

    Figure 1. The four analytic steps of systematic text condensation

    Ethical considerations

    The project was carried out in compliance with the Declaration of Helsinki (18). The informants received written information about the study in advance, they signed a consent form prior to being interviewed, and they were informed that they were free to withdraw from the study without giving a reason at any stage before the data had been fully processed.

    The Regional Committees for Medical and Health Research Ethics (REC) found that the study fell outside the scope of Norwegian legislation on health research (REC number 2016/1105). The study was approved by the Norwegian Centre for Research Data (NSD) (project number 49227). The relevant local authority approved the poster that was displayed at child health clinics.

    Results

    Our analysis identified four themes: the post-surgery experiences of new mothers, perceptions of continuity and midwifery presence, the importance of knowledge and good information, and the value of a partner’s presence.

    Figure 2. The study’s themes

    The post-surgery experiences of new mothers

    The informants described various degrees of pain after the caesarean section. One woman who had undergone a caesarean section on a previous occasion, explained that the pain was more frightening the first time around, because she had been worried that her wound would open. Another woman who had been unable to fall asleep on the third night after her operation was made to feel like a drug addict when the midwife told her that she no longer should be needing morphine.

    Some were so focused on the child that they took no notice of their own pain until it became overwhelming, and one informant felt like a primal female who defied her pain to look after her child. For others, the pain led to a feeling of helplessness, that rendered them incapable of caring for their child.

    One informant felt like a primal female who defied her pain to look after her child.

    The informants talked about a great need for sleep, rest and respite. Family rooms were important to many in ensuring that they received sufficient sleep and rest, while others chose to go home in order to satisfy this need. The chance of staff providing respite was a key factor in this respect, and it was important to them that they would have excess energy by the time they returned home.

    The informants talked about a feeling of happiness when the operation was over, and everything had gone well. Nevertheless, they felt that postnatal staff ‘forgot’ about them and their situation and that breastfeeding and breastfeeding assistance became the sole focus. In the words of one of the women:

    ‘And when she wasn’t at work, that really nice one, it was like everything was done with. It was all about breastfeeding from then on. People seemed to be really concerned with that! But no-one focused their attention on me anymore.’ (Interview 4)

    Perceptions of continuity and midwifery presence

    Some of the informants described the postnatal personnel as positive and accessible, and they explained that it had been easy to ring the bell for assistance. One woman felt that the midwife took particularly good care of her on the first day and assisted her with personal care and mobilisation, thereby making her feel safe and cared for. Others described midwives who encouraged and pressurised them to get out of bed, which they considered to be positive.

    There was close midwifery follow-up on the first day, but this was subsequently reduced. Most of the women considered this to be a natural course of events, but one of them had felt that this was difficult. She had been feeling increasingly unwell, but staff had considered her pain to be caused by wind. Two days after being discharged from hospital she was re-admitted with complications. The postnatal personnel had failed to spot the complications, and neither her blood pressure nor her temperature had been measured during her postnatal stay in the maternity ward.

    The informants also talked about inadequate follow-up routines, and some of them had been lying for hours without receiving attention after being transferred from the recovery unit. They felt it was difficult to bother healthcare personnel unnecessarily when they were busy. Some had experienced that staff had no time to provide assistance when they rang for help, and they would have liked the midwives to have taken the initiative to look in on them.

    I am positive we didn’t see them at all for a good 24 hours. No-one dropped by.
    Informant

    The informants felt confused by constantly having to relate to new midwives, and not knowing who was responsible for them. They therefore tried to manage by themselves. A first-time mother who went home after two days described the lack of accessible staff in these terms:

    ‘Perhaps a slightly greater presence? You shouldn’t have to ask all the time; they should drop by every now and again and make sure that everything is all right. I felt that you were left to your own devices, as it were, and that it’s more difficult to try to grab their attention than if they had dropped by of their own accord and asked how things were. I am positive we didn’t see them at all for a good 24 hours. No-one dropped by.’ (Interview 3)

    The importance of knowledge and good information

    When the women were informed of what was going to happen, they felt safe, and it was easier for them to be physically active. However, they emphasised that receiving concurring information from different midwives instilled a sense of confidence. One informant explained that she had received information about mobilisation from the physiotherapist. Others missed out on that particular communication because it was the weekend, or because they were otherwise engaged when the physiotherapist called in.

    The women were looking for information about how to deal with their operating wound and how to change dressings after returning home, and they felt it was strange that they were expected to take a lot of responsibility for their own medication while they were still on the maternity ward. They were handed a 24-hour dose of medicines and had to request further drugs when the containers were empty. They were asking themselves whether the midwives kept a check on the medication.

    One woman had not been told why she was no longer receiving blood-thinning jabs, another reported that staff had forgotten to give her a prescription for drugs that she was meant to continue taking after returning home. When her legs started to swell, she related this to the medication that had been forgotten about and was gripped by a fear of dying.

    The caesarean section was entirely unexpected for most of the primiparous women, and they described how they had skipped the chapter on caesarean sections when they were preparing to give birth. Moreover, for several of the women, their stay in the maternity ward was their first encounter with the hospital, and some felt that they existed in a bubble of morphine that made it impossible to take on board the information given. They explained that the healthcare personnel had to repeat everything:

    ‘It is easy to forget that this may be the only time that someone is in touch with the health service. Perhaps you thought you would be delivering your baby the normal way, and then suddenly they have operated on you. It’s like an extra added bit that you may simply not have the capacity to take in. That you have to get one of those things that the elderly use, a dosette box, or it may have to be made even clearer […] And particularly the things that are supposed to be taken as required. Because you don’t know what you need. The pain. What is normal, and what is not normal? It’s not easy to know.’ (Interview 8)

    The value of a partner’s presence

    The majority of the women were made to feel safer by the fact that their partner was able to stay overnight with them on the maternity ward. They explained that it was important to them to be together as a couple, since the partner had also been through a lot before the child was born. It was also a comfort that there were two people to remember information provided by staff. Many had a family room at their disposal during parts of their stay and they pointed out that this made it easy to ask the partner for assistance with things they were unable to do themselves, such as moving from one place to another, collecting food, changing nappies and lifting the child.

    Some had found that when their spouse left the ward, staff expected the women to be able to manage by themselves.

    The women were concerned that their partners ought to be better cared for by postnatal personnel, and one informant explained that her spouse had been made to feel unwelcome when he was collecting food from the canteen. Some had found that when their spouse left the ward, staff expected the women to be able to manage by themselves. For one of the women, this made her stay in the maternity ward so difficult and painful that she chose to go home in order to receive the necessary help.

    Not all the women felt a need to be accompanied by someone during their stay in the maternity ward. Some women felt it was unproblematic to ask staff for assistance and considered that they had received the help and respite they needed. However, many accentuated the fact that the assistance provided by their partner was readily available.

    Several informants believed that their experience of staying in the maternity ward would have been different if they had been there without their partner, since they felt that their partner had been of greater assistance to them than the ward staff. In the words of one of them:

    ‘I’m a bit like, I don’t want to be a nuisance. But then I had […]. They told us straight that they had forgotten about us because we were doing so well on our own. But that was only because of my partner. He saw to everything.’ (Interview 6)

    Discussion

    This study describes the postnatal experiences of ten women following an emergency caesarean section. Our discussions examine these experiences in the light of patient safety theory.

    The Norwegian Knowledge Centre for the Health Services defines patient safety in these terms: ‘Protection against unnecessary harm caused as a consequence of health care that the health service has provided or failed to provide’ (19). Severinsson et al. point to the importance of a systematic approach to the development of a patient safety culture, in order to prevent human suffering (20).

    Patient safety culture is made up of several subthemes, such as leadership, teamwork, communication and learning, and must be fair, evidence based and patient focused (21). When Currie and Richens investigated how midwives perceive patient safety culture, they found that patient safety may be compromised by pressures to ensure that women are moved swiftly on through the delivery and postnatal wards (22).

    Failed to take on board the women’s needs

    Our informants explained that they had felt a need for rest, respite and adequate pain relief, but that staff appeared to be more concerned with breastfeeding than with their post-surgical recovery. They explained that it was difficult to lift the child. Similar findings were described in a study conducted by Hillans (23), in which 68 per cent of the women who had undergone an emergency caesarean section felt it was difficult to lift the child and to move around. They did not receive any acknowledgement of these difficulties from the midwives.

    It is thought-provoking that neither the midwives nor the women themselves recognised their physical needs. The fact that the surgical procedure is referred to as a caesarean section may cause staff to consider it a less serious procedure than the surgical intervention it is (23). One study showed that after undergoing a caesarean section, women felt that regaining normality was their top priority as they sought to inhabit their new maternal role; concealing their physical needs after the operation is one way of doing this (15).

    It is important for midwives to know that women who have delivered by caesarean section sometimes downplay their own complaints. In the interest of patient safety, the midwife needs to focus on the woman – she needs to be patient-oriented. The guidelines on postnatal care (5) do not include a chapter specifically on caesarean sections. They only describe basic postnatal care procedures.

    It is important for midwives to know that women who have delivered by caesarean section sometimes downplay their own complaints.

    In Norway, the incidence of emergency and elective caesarean sections is rising. In order to safeguard a high standard of follow-up for this patient group, it would therefore, in our view, be useful for the guidelines to include a good description of postnatal care for women who have given birth by caesarean section.

    Long periods without receiving attention

    The informants described how important it is that postnatal healthcare personnel make themselves accessible and provide good care. They had found that while they received close follow-up on the first day after surgery, the level of attention was then reduced, and they were left to their own devices for long periods. They felt uncomfortable about bothering busy maternity staff, and some felt that healthcare personnel had expected them to manage by themselves when their partner had gone home.

    The women who had undergone an emergency caesarean section on a previous occasion were generally happier with the follow-up that they received. Two of the women had received counselling and had drawn up a plan for their postnatal hospital care. Hjälmhult and Økland (14) found that postpartum women received little help or practical support from staff, and that the women felt they were not treated as individuals. Similar findings are described in other studies (24–28).

    Our informants explained that they had endured hours without receiving attention from postnatal personnel immediately after transfer from the recovery unit. One informant was even told that the ward was busy, and that the staff had forgotten about her.

    According to Thorstensson et al. (25), women were left to their own devices for hours without receiving attention, whether delivery had been vaginal or by caesarean section. This is disconcerting considering the fact that women who have undergone a caesarean section have an elevated risk of complications. At the same time, the rate of birthing women with risk factors is rising (29, 30), which means that there is a general need for better postnatal care.

    One of our informants felt increasingly unwell during her postnatal stay in hospital, but neither her blood pressure nor her temperature was measured. She returned home in poor health and was re-admitted after two days due to complications associated with the caesarean section. Complications associated with caesarean sections and surgical deliveries are undesirable incidents that may jeopardise patient safety, particularly when the complications are not identified before discharge from hospital and the follow-up responsibility is left to the woman herself and a potential partner.

    The clinical guidelines issued by the National Institute for Health and Care Excellence (NICE) specify that fit and healthy women should be discharged from hospital no earlier than 24 hours after a caesarean section, but that prior to discharge they must be monitored in hospital with a view to complications (7). Postnatal personnel must be available and trained to undertake the required observations.

    Good help and support provided by the partner

    Studies show that women’s satisfaction with their postnatal stay in hospital increases if their partner can stay with them (26). Our study highlights the partner’s presence as being highly valuable for women who have given birth by caesarean section. Some informants were unable to imagine how they would have coped on the postnatal ward without the assistance of their partner, while others chose to go home to make sure they would receive adequate assistance and respite.

    The informants’ descriptions of how important it is to receive help, support and care from their partner gives the impression that the partner’s presence is of great value. Patient safety should be part of the ward culture rather than dependent on the presence of relatives. However, the practical assistance that a relative is able to provide for a new mother who is recovering from surgery is a weighty argument for prioritising family rooms for these couples.

    Strengths and weaknesses of the study

    All of the authors are midwives with either a masters or doctoral degree on top of many years’ experience of work in delivery and maternity wards, including professional development. One author is still working as a midwife in clinical practice, while two are training midwifery students. Our work experience has impacted on our understanding of the data.

    We used semi-structured interviews to gain insight into the women’s experiences (16), combined with thematic cross-case data analysis. This method was useful and pragmatic given our relatively large body of data (16), and the informants talked willingly about their postnatal experiences. This enabled us to collect a rich material that contributed to shedding light on the study’s research question.

    Three women had experience of more than one caesarean section. They found it unproblematic to distinguish between the caesarean sections but talked about their experiences in relation to both operations.

    The women we recruited contacted us after seeing a social media post shared by midwifery colleagues and others among their personal Facebook networks. The use of social media and snowball sampling (16), i.e. that the informants communicated the information to other potential recruits, meant that the sample was somewhat homogeneous, since all informants were resourceful women with a higher education.

    On the other hand, it is a strength of the study that both primiparous and secundiparous women took part. The inclusion of more women with an immigrant background would have strengthened the study’s external validity, as there is a higher risk of emergency caesarean section among immigrant women (30).

    Conclusion

    The study shows that women who had given birth by emergency caesarean section experienced inadequate care for their physical health after surgery. Although the postnatal women felt no pressure to go home early, several experienced that midwifery help and support was not always available to the extent that they needed it. Some endured long periods without receiving attention, little assistance was forthcoming once their partner had gone home, medicines were forgotten about and complications were overlooked.

    There is a need for further research to be carried out on the quality of postnatal care provided in Norwegian hospitals. There is also a need to investigate the consequences of inadequate follow-up after delivery by caesarean section for the mother, the child and the wider family.

    References

    1.       Folkehelseinstituttet. Keisersnitt utført, standardstatistikk. Medisinsk fødselsregister, 2017. Available at: http://statistikkbank.fhi.no/mfr/(downloaded 02.05.2019).

    2.       Betrán A, Ye J, Moller A-B, Zhang J, Gülmezoglu A, Torloni M. The increasing trend in caesarean section rates: global, regional and national estimates: 1990–2014. PLoS One. 2016;11(2):e0148343. DOI: 10.1371/journal.pone.0148343.

    3.       Venheim MA, Reinar LM. Barselomsorg. In: Brunstad A, Tegnander E, eds. Jordmorboka. Oslo: Akribe; 2010. p. 535–46.

    4.       Meld. St. nr. 12. (2008–2009). En gledelig begivenhet : om en sammenhengende svangerskaps-, fødsels- og barselomsorg. Oslo: Helse- og omsorgsdepartement; 2009.

    5.       Helsedirektoratet. Nasjonal retningslinje for barselomsorgen – Nytt liv og trygg barseltid for familien. Oslo; 2013.

    6.       Sjetne IS, Holmboe O. Brukererfaringer med fødsels- og barselomsorgen i 2016 (PasOpp-rapporter), Folkehelseinstituttet. PasOpp-rapport December 2017. Available at: https://www.fhi.no/globalassets/dokumenterfiler/rapporter/pasopp/2017/fodsel-og-barsel/brukererfaringer-med-fodsels--og-barselomsorgen-i-2016.-nasjonale-resultater.pdf(downloaded 21.06.2018).

    7.       NICE – National Institute for Health and Care Excellence. Care after caesarean section. 2012. Available at: https://pathways.nice.org.uk/pathways/caesarean-section#path=view%3A/pathways/caesarean-section/care-after-caesarean-section.xml&content=view-node%3Anodes-care-of-the-woman(downloaded 20.06.2018).

    8.       Declercq JE, Barger RM, Cabral JH, Evans JS, Kotelchuck JM, Simon JC, et al. Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births. Obstetrics & Gynecology. 2007;109(3):669–77.

    9.       Borders N. After the afterbirth: a critical review of postpartum health relative to method of delivery. Journal of Midwifery & Women's Health. 2006;51(4):242–8.

    10.     Armson BA. Is planned cesarean childbirth a safe alternative? CMAJ: Canadian Medical Association Journal. 2007;176(4):475–6.

    11.     Petrou S, Kim SW, McParland P, Boyle EM. Mode of delivery and long-term health-related quality-of-life outcomes: a prospective population-based study. Birth. 2016;44(2): 110–9.

    12.     Barimani M, Oxelmark L, Johansson SE, Langius-Eklof A, Hylander I. Professional support and emergency visits during the first 2 weeks postpartum. Scandinavian Journal of Caring Sciences. 2014;28(1):57–65.

    13.     Fahey JO, Shenassa E. Understanding and meeting the needs of women in the postpartum period: the perinatal maternal health promotion model. Journal of Midwifery & Women’s Health. 2013;58(6):613–21.

    14.     Hjälmhult E, Økland T. Hva barselkvinner er opptatt av den første tiden hjemme med en nyfødt. Sykepleien Forskning. 2012;7(3):224-30. DOI:
    10.4220/sykepleienf.2012.0128.

    15.     Fenwick S, Holloway I, Alexander J. Achieving normality: The key to status passage to motherhood after a caesarean section. Midwifery. 2009;25(5):554–63.

    16.     Malterud K. Kvalitative forskningsmetoder for medisin og helsefag. 4. ed. Oslo: Universitetsforlaget; 2017.

    17.     Kvale S, Brinkmann S. Det kvalitative forskningsintervju. 3. ed. Oslo: Gyldendal Akademisk; 2015.

    18.     WMA, World Medical Association. Helsinkideklarasjonen 2013. Available at: https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/(Nedlastet 20.06.2018).

    19.     Helsedirektoratet. Pasientskader i Norge [Internet]. Oslo: Helsedirektoratet; 2012 [updated 29.01.2019, cited 15.01.2019]. Available at: http://www.pasientsikkerhetsprogrammet.no/om-oss/om-pasientsikkerhetsprogrammet/pasientskader-i-norge.

    20.     Severinsson IE, Haruna M, Rönnerhag M, Berggren I. Patient safety, adverse healthcare events and near-misses in obstetric care – a systematic literature review. Open Journal of Nursing. 2015;5:1110–22.

    21.     Sammer CE, Lykens K, Singh KP, Mains DA, Lackan NA. What is patient safety culture? A review of the literature. Journal of Nursing Scholarship. 2010;42(2):156–65.

    22.     Currie L, Richens Y. Exploring the perceptions of midwifery staff about safety culture. British Journal of Midwifery. 2009;17(12):783–90.

    23.     Hillan EM. Issues in the delivery of midwifery care. Journal of Advanced Nursing. 1992;17(3):274–8.

    24.     Ellberg L, Högberg U, Lindh V. ‘We feel like one, they see us as two’: new parents’ discontent with postnatal care. Midwifery. 2010;26(4):463–8.

    25.     Thorstensson S, Andersson A, Israelsson S, Ekström A, Wahn EH. To build a bridge between two worlds: Mothers' experiences of professional support at the maternity ward. Health Care for Women International. 2016;37(10):1067–81.

    26.     Barimani M, Vikstrom A. Successful early postpartum support linked to management, informational, and relational continuity. Midwifery. 2015;31(8):811–7.

    27.     Hildingsson IM, Sandin-Bojö A-K. ‘What is could indeed be better’ – Swedish women’s perceptions of early postnatal care. Midwifery. 2011;27(5):737–44.

    28.     Fenwick J, Butt J, Dhaliwal S, Hauck Y, Schmied V. Western Australian women's perceptions of the style and quality of midwifery postnatal care in hospital and at home. Women and Birth. 2010;23(1):10–21.

    29.     Folkehelseinstituttet. Fakta om fruktbarhet, fødsealder og helse. Oslo: Folkehelseinstituttet; 2016. Available at: https://www.fhi.no/fp/gravide-og-fodende-kvinners-helse/fruktbarhet-fodealder-og-helse---fa/(downloaded 02.05.2019).

    30.     Sorbye IK, Daltveit AK, Sundby J, Stoltenberg C, Vangen S. Caesarean section by immigrants' length of residence in Norway: a population-based study. European Journal of Public Health. 2015;25(1):78–84.

    Women who had given birth by caesarean section often downplayed their own complaints, felt left to their own devices and received invaluable assistance from their partner.

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    English
    Sammendrag

    Background: In Norway and other European countries, women are less satisfied with the postnatal care they receive than with the antenatal and birthing care. Postnatal care in Norway is changing, with the number of nights in hospital being reduced, including for women who have undergone a caesarean section.

    Objective: To investigate women’s perceptions of the physical health care they received in the maternity ward following an emergency caesarean section.

    Method: Qualitative study involving a convenience sample consisting of ten women who had given birth by emergency caesarean section. We conducted semi-structured, individual interviews and analysed the data using systematic text condensation.

    Results: The analysis highlighted four themes: the post-surgery experiences of new mothers, perceptions of continuity and midwifery presence, the importance of knowledge and good information, and the value of a partner’s presence.

    Conclusion: The study shows that women who had given birth by emergency caesarean section felt that they received poor physical health care in the maternity ward.

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  • Factors associated with post-stroke fatigue

    Every year, approximately 15 000 people have a stroke in Norway (1). Fatigue often occurs as a subjectively experienced state following a stroke accompanied by a substantially reduced capacity for activity, known as post-stroke fatigue (PSF) (2, 3). Around 10 per cent of the Norwegian population suffer from exhaustion or fatigue (4), but the prevalence of PSF is higher (3).

    A stroke is the most common cause of disability in the elderly, but appropriate and early rehabilitation increases the likelihood of regaining everyday functions (1). Many patients experience considerable progress as a result of targeted rehabilitation, but studies show that PSF can last for several years (5, 6). Studies have also shown that PSF can occur at different points in time following a stroke (7).

    PSF is associated with impaired quality of life, a reduced degree of coping (8), a reduced capacity to perform daily tasks (9) and loss of control (10).

    What is fatigue?

    Schillinger and Becker (3) suggest that fatigue can be defined as ‘a subjective experience of protracted or recurrent tiredness and a reduced capacity for mental and/or physical activity’. PSF is a state that is characterised by exhaustion and a considerable depletion of energy that often occurs without prior physical or mental exertion (3).

    The cause of PSF is unknown, but there is likely to be a complex causal explanation (11). It is not clear what medical and socio-demographic factors are associated with PSF as findings in earlier studies are contradictory (3, 8, 12, 13). However, PSF is often associated with pain and sleep disorders (8) and is closely associated with depression (8, 9, 14) and anxiety (8, 10, 14).

    It is uncertain whether socio-demographic factors such as age, gender, marital status, living situation (living alone or not), education and returning to paid work are associated with PSF (3, 8). Previous research findings are also contradictory in terms of the association between PSF and neuropsychological factors, such as the stroke location, type and severity (3, 8).

    How is fatigue measured?

    The prevalence of PSF shown in earlier studies varies. Three systematic review articles covering 71, 16 and 22 studies respectively show a prevalence of 51–72 per cent (3), 29–70 per cent (12) and 25–35 per cent (13) for PSF. The review articles point out that different definitions of PSF are used and that prevalence measurements vary depending on which operationalisation of PSF is used.

    There are several measuring instruments for measuring fatigue (15), but none specifically for PSF. Fatigue is a subjective experience that can only be reported by the patient, and instruments for self-reporting are therefore used. Different scales are often used to measure PSF, but there is no set threshold for fatigue (3), which can complicate the interpretation of data from this type of measuring instrument.

    Objective of the study

    The cause of PSF is unclear, treatment is limited and figures on the prevalence of PSF vary considerably (3). Earlier research has identified a clear need for more research in order to secure the best possible follow-up for patients (3, 8, 16). Knowledge of how many and which patients are struggling with PSF is therefore needed so that these patients can receive targeted treatment.

    The objective of this study is to investigate whether there is an association between PSF and socio-demographic, medical and clinical characteristics in a Norwegian sample.

    Method

    Design and sample

    This study is a cross-sectional study using randomised controlled trial (RCT) data to investigate the effect of a psychosocial intervention on stroke patients (17). The sample in the cross-sectional study consists of stroke patients recruited from 11 hospitals in Southeast Norway during the period November 2014 to November 2016.

    A total of 353 patients met the inclusion criteria and consented to taking part in the study (Figure 1). Thirty-one participants dropped out between the recruitment phase and the data collection, and one participant failed to answer questions about fatigue. A total of 321 participants were therefore included in our cross-sectional study.

     Figure 1. Flowchart for recruiting participants

    Data collection and instruments

    We collected the data 4–6 weeks after the patient’s stroke, using a structured questionnaire in individual interviews. The questionnaire was made up of six measuring instruments (17). In this cross-sectional study we have only used one of these instruments to measure fatigue and one to measure depression. The data were collected by nurses and ergonomists who are trained in using the measuring instruments.

    In addition to data on fatigue and depression, we also collected data on socio-demographic characteristics, such as age, gender, marital status, living situation, education, care responsibilities, pre- and post-stroke work situation, as well as medical and clinical data on the severity, type and location of the stroke, rehabilitation services and health problems prior to the stroke.

    We measured the prevalence of fatigue and operationalised PSF using a shortened version of the Fatigue Questionnaire (FQ), which consists of one closed question: ‘Do you often feel tired, indisposed and lacking energy?’. Patients who answered in the affirmative were asked a follow-up question about the duration of the symptoms, with the response options ‘less than 1 week’, ‘less than 1 month’, ‘1–3 months’, ‘3–6 months’ and ‘6 months or more’ (4, 18).

    The keywords ‘often’, ‘tired’, ‘indisposed’ and ‘lacking energy’ and the reported duration of these symptoms relate to the definition of fatigue as a protracted and recurrent experience of lacking energy and a reduced capacity for activity compared to before the stroke (3).

    We measured depression using the Yale-Brown single item screening questionnaire (Yale), which consists of one question: ‘Do you often feel sad or depressed?’. The response options were ‘yes’ and ‘no’ (19). Yale is an instrument for screening depression that is validated for stroke patients. The instrument is considered to have satisfactory sensitivity and specificity compared to more comprehensive instruments for identifying depression (19).

    In the acute phase at the hospital, medical staff assessed the severity of the stroke according to the National Institutes of Health Stroke Scale (NIHSS). NIHSS consists of 11 clinical observations that are quantified and tallied up on a scale from 0–42. The higher the score, the higher the degree of disability (20).

    Analysis and coding

    We used descriptive statistics to describe the sample in this study. Multivariate logistic regression analysis was used with PSF (0 = ‘no, no reported fatigue’, 1 = ‘yes, recently occurring fatigue’) as the dependent variable. PSF was operationalised with ‘1 = yes’ on the variable FQ if the fatigue symptoms occurred recently (<3 months’ duration). Participants who reported fatigue symptoms for a longer duration (>3 months) (n = 35) were excluded from the logistic regression analysis.

    Based on earlier research into factors that may be associated with PSF (3, 8, 12, 13, 21), we included the following variables as independent variables in the logistic regression: age at admission, gender (1 = male), care responsibilities for others (1 = yes), previous health problems (1 = yes), stroke type (0 = infarction, 1 = cerebral haemorrhage), severity of stroke (total score on NIHSS) and depression (1 = yes).

    The post-stroke work situation (0 = in work, 1 = retired/receiving welfare benefits/ unemployed, 2 = on sick leave) was included in the model in order to check for potential confounding. The sample for the logistic regression analysis only includes patients with complete medical and clinical data (n = 209). We set the level of significance in all the statistical analyses to 0.05. Statistical analyses were performed in SPSS version 25.

    Ethical considerations

    The study was approved by the Regional Committees for Medical and Health Research Ethics (REC number 2013/2047) and registered with the Data Protection Officer (registration number 2014/1026) for the health trusts that were involved in the recruitment process in the study. The participants gave voluntary consent to taking part in the study and were free to withdraw at any time without giving a reason or facing consequences in respect of further medical follow-up.

    Results

    Description of the sample

    The sample in this study was made up of 59.2 per cent men and 40.8 per cent women, with a total mean age of 66.3 years. The proportion who had care responsibilities for their own children or someone else close to them was 22.7 per cent (Table 1).

    In 91 per cent of cases, blood clotting was the cause of the stroke, while 9 per cent were due to a cerebral haemorrhage. Overall, the median score for the stroke severity was NIHSS 3, and the interquartile range was 1–6. Only 19.3 per cent reported no previous health problems. A total of 22.4 per cent reported depression 4–6 weeks after the stroke. Participants reported that they made extensive use of rehabilitation services 4–6 weeks after the stroke. Only 34.3 per cent reported that they did not receive any form of rehabilitation (Table 2).

    Table 1. Description of the demographic characteristics of the sample
    Table 2. Description of medical and clinical characteristics of the sample

    Prevalence and factors associated with PSF

    The prevalence of PSF was 43.6 per cent. Of those who reported PSF, 55 per cent were men and 45 per cent were women, with a mean age of 65.3 years. A total of 10.9 per cent of the participants reported pre-stroke fatigue, i.e. fatigue before the stroke, while 45.5 per cent did not experience fatigue 4–6 weeks after the stroke.

    The logistic regression analysis showed that four factors were associated with PSF when we controlled for the other factors in the model (Table 3). Patients who reported having health problems before the stroke were nearly five times more likely (OR = 4.99; 95% CI 2.07–12.01; p <0.001) to report PSF compared to patients who did not report previous health problems.

    Patients who reported depression 4–6 weeks after their stroke were more than four times more likely (OR = 4.47; 95% CI 2.01–9.93; p <0.001) to report PSF compared to patients who did not report depression. Those with care responsibilities for others were more than 2.5 times more likely (OR = 2.86; 95% CI 1.28-6.36; p = 0.01) to report PSF compared to those who did not have care responsibilities.

    For each point in the NIHSS score, the patient was 1.16 times more likely to report PSF (OR = 1.16; 95% CI 1.07-1.26; p <0.001). The patient’s gender, age, work situation and type of stroke had no statistically significant association with PSF in this model.

    Table 3. Factors associated with post-stroke fatigue (PSF*)

    Discussion

    Prevalence of PSF

    A total of 43.6 per cent of participants reported PSF 4–6 weeks after their stroke. This figure concurs with the prevalence of PSF shown in previous studies (12, 13). Studies show that PSF may increase over time. One study found that the prevalence of PSF increased from the date of admission to three months after the stroke (7). Another study showed that the prevalence at admission, and six and twelve months after the stroke was 52, 64 and 70 per cent respectively (22).

    A total of 43.6 per cent of participants reported PSF 4–6 weeks after their stroke.

    The measurement period of 4–6 weeks after the stroke may explain the medium to low prevalence in our study compared to previous studies, but it may also mean that previous studies used other criteria for PSF.

    The definition of PSF is not standardised in the research literature, and there are no specific measuring instruments for PSF (3). The large variance in the prevalence of PSF from earlier studies (3) may be because the term ‘post-stroke fatigue’ is defined and operationalised in different ways.

    Fatigue is often described as tiredness or lack of energy, which is associated with biological, psychological and social factors (11). Earlier studies hypothesise that the term PSF should be defined more uniformly, for example, by distinguishing between physical and mental fatigue (23). The prevalence of PSF appears to be somewhat lower in, for example, Asia (35 per cent) than in Europe (13), which indicates that social factors may be linked to the experience of fatigue.

    Other pre-stroke health problems increased the risk of PSF

    In this study, we found that patients who reported other pre-stroke health problems were almost five times more likely to report PSF. There is currently insufficient research on the types of health problems that are predictors of PSF, but both depression and pre-stroke fatigue are factors that have been shown to have an association with PSF (24, 25). Researchers have been aware of a possible association between premorbid factors and PSF for some time.

    A study conducted in 2005 found that pre-stroke fatigue was the factor that made it most likely to experience PSF, but that a higher stroke severity and post-stroke depression were also among the most important factors for experiencing PSF (24). The association of both a higher stroke severity and post-stroke depression with PSF concurs with our findings.

    Pre-stroke fatigue may be an important factor for PSF, but our study does not show a significant finding that it is associated with PSF as we did not measure pre-stroke fatigue as a separate factor.

    Higher severity of stroke increased the risk of PSF

    Earlier research suggests little association between stroke severity and PSF (3). Findings from our study showed that stroke severity was a significant factor that increased the risk of PSF, with each point in the NIHSS score increasing the risk of PSF by 1.16. However, several previous studies do not show to any extent that medical and clinical factors are important for experiencing PSF (3, 8).

    A Norwegian systematic literature review concluded that stroke severity has either no association or a questionable association with PSF, since none of the studies in the review found any significant association between the severity of a stroke and PSF (3). However, one study found that stroke severity proved to be a factor that had a significant association with PSF (24).

    These contradictory findings may be due to differences in study design, the operationalisation of fatigue or the sample size. The findings in our study indicate that the higher severity of the stroke may be significant for PSF. The type of stroke has an uncertain association with PSF (3), and we also found no association between these factors in our study.

    Depression closely associated with PSF

    The results of this study showed a strong association between fatigue and depression 4–6 weeks after the patient’s stroke. The likelihood of reporting PSF was more than four times greater if depression was reported at the same time. This finding is consistent with earlier research, which has shown that depression is widespread among those who experience PSF (14, 26, 27).

    A total of 22.4 per cent reported depression. The proportion who reported PSF at the same time was 59.7 per cent, and the prevalence was only 16.7 per cent among those who did not report PSF. There is no doubt a complex explanation as to why depression occurred so often with fatigue. Fatigue and depression are probably different parts of the same spectrum with similar causal explanations (11).

    Lack of energy is often included as a criterion in different definitions and measurements of depression. It is therefore possible that the instruments measure different parts of a phenomenon in the same domain. Part of the covariance may be a reflection of linguistic challenges in the measuring instruments. Fatigue is characterised by a reduced capacity to perform daily tasks, which in turn can lead to depression and impaired quality of life (9).

    The likelihood of reporting PSF was more than four times greater if depression was reported at the same time.

    Patient’s concerns about their prospects can also impact on fatigue, and some patients may be more at risk of PSF due to health problems prior to the stroke. Depressive symptoms and pre-stroke fatigue are both factors that have been found to have a possible correlation with PSF (25).

    It is interesting to compare the associations between the patient’s health before the stroke and PSF with the findings of this study. The findings showed that the prevalence of post-stroke depression was higher among those who also reported experiencing fatigue before the stroke, compared to those who did not report PSF. However, the prevalence of post-stroke depression was highest among those who reported experiencing fatigue more recently after the stroke (Table 2). There is an unclear distinction between the three phenomena of fatigue, depression and anxiety after a stroke (14).

    Associations between life situation and PSF

    PSF may have an important association with psychosocial factors. In our study, we found that having care responsibilities for others was a significant factor that increased the risk of PSF. One explanation for the association between care responsibilities and PSF is the stress levels involved in an acutely ill patient caring for him/herself whilst also caring for others, such as children, a spouse or someone else close to them.

    This association indicates that PSF should be viewed in the context of the stroke patient’s life situation (21). The work situation was shown to have no effect on whether patients in our sample experienced PSF.

    In our study, we found that having care responsibilities for others was a significant factor that increased the risk of PSF.

    The impact of age on PSF has previously been studied, but the association is unclear (3). One study found that older people experience PSF more often than young people (22), and it has also been found that the prevalence is higher among younger stroke patients (28). Our findings show no association with age.

    The fact that pre-stroke health problems and stroke severity increased the risk of PSF in this study suggests that biological factors may play a role in increasing the likelihood of experiencing PSF. A social factor such as having care responsibilities for others and experiencing post-stroke depression increased the risk of PSF. This shows that PSF can be a complex phenomenon. It is unclear whether PSF primarily has a medical causal explanation, or whether there are psychosocial and environmental factors that increase the likelihood of experiencing PSF (11).

    Strengths and weaknesses of the study

    Operationalisation of fatigue

    The instrument and the question formulation we have chosen to operationalise fatigue serve as a guide for how PSF is interpreted in this study. Selecting one response option in structured questionnaires can be difficult, and this may have led to over or underreporting. The question formulation may, in turn, affect whether PSF is measured correctly in terms of how the phenomenon actually affects the patient.

    The way we defined the duration of the fatigue symptoms may be a weakness of the study, as the response options given to the patient do not define ‘before’ or ‘after’ the stroke very precisely. We could have achieved greater precision if there had been more response options for the questions concerning duration.

    Defining and operationalising the term PSF can be a challenge in that there is no validated instrument for measuring the phenomenon of PSF, i.e. fatigue after a stroke. PSF can manifest itself in different ways in contexts other than after a stroke. In our study, it was appropriate to distinguish between the patients who unambiguously reported protracted fatigue (>3 months), as we wanted to investigate fatigue that occurred after a stroke. We cannot rule out the possibility that those who reported fatigue of a longer duration interpreted the question about fatigue in the same way as those who experienced recently occurring fatigue. Nor can we ignore the possibility that the results would have been different if we had used other instruments.

    Defining and operationalising the term PSF can be a challenge in that there is no validated instrument for measuring the phenomenon of PSF.

    Although there is still uncertainty about the best way to measure PSF, this study generated new knowledge about which patients experienced fatigue 4–6 weeks after a stroke, and may therefore help to identify which patients may be at risk of impaired quality of life after a stroke (6, 9, 10).

    The span of the reported confidence intervals (95% CI) from the logistic regression analysis (Table 3) is relatively broad. This is probably due to the fact that a small sample gives greater variation around the true estimate. This means that even if the results are statistically significant, the estimated odds ratio for each of the variables should be interpreted with caution.

    Representativeness of the sample

    Following the recruitment protocol at each hospital presented a number of challenges. This may have meant that some patients who met the inclusion criteria were not asked to participate, which in turn may have led to unintentional bias in the sample. Some patients did not want to participate in the study, partly because they were too ill. The patients who had more severe outcomes and more pronounced fatigue may have chosen not to participate in the study because they thought it was too demanding.

    Another reason why patients did not want to participate in this study was that they felt too healthy. When patients feel too ill to participate in a study, it can lead to bias in the sample, or mean that only the healthiest patients are represented in the study. Compared to the population registered in the stroke register (29), the participants in our study are 10 years younger on average. The proportion of women is 5 per cent lower, and the proportion who had a minor stroke (NIHSS <6) is 5 per cent higher.

    Data collection by means of a structured questionnaire in individual interviews can lower the patient’s threshold for completing the questionnaire, resulting in a higher completion rate. This type of approach helps to gather more complete data and prevents data omissions. It also reduces the possibility of misunderstanding the questionnaire.

    One of the strengths of this study is that it uses data from a multi-centre study that has recruited patients from several different hospitals in the country. Furthermore, we include a large number of participants in the study. These elements increase the generalisability of the results to other stroke patients.

    Conclusion

    In our study, the prevalence of fatigue in patients 4–6 weeks after a stroke was 43.6 per cent. The following factors increased the risk of PSF in the sample: health problems before the stroke, depression after the stroke, care responsibilities for someone close and higher severity of stroke (measured by NIHSS).

    Nurses and healthcare personnel need to know who is particularly at risk of PSF so that these patients can be given the appropriate follow-up at the right time. It is therefore important to know the prevalence of PSF and the factors associated with PSF. However, more research is needed on PSF.

    Thank you to Manuela Zucknick, a statistician in the Department of Biostatistics, University of Oslo, for helping with the quality assurance of statistical analyses and interpretations.

    Our study was funded with support from South-Eastern Norway Regional Health Authority (project number 2013086) and the European Commission’s seventh framework programme (FP7-PEOPLE-2013-COFUND) (agreement number 609020 – Scientia Fellows). The University of Oslo and Oslo University Hospital, Ullevål, have contributed research time and administrative support to the study.

    References

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    2.       Kirkevold M, Christensen D, Andersen G, Johansen S, Harder I. Fatigue after stroke: manifestations and strategies. Disabil Rehabil. 2012;34(8):665–70.

    3.       Schillinger A, Becker F. Fatigue/utmattelse etter traumatisk hjerneskade og hjerneslag. Tidsskr Nor Legeforen. 2015;135:331–5.

    4.       Loge JH, Ekeberg O, Kaasa S. Fatigue in the general Norwegian population: normative data and associations. J Psychosom Res. 1998;45(1):53–65.

    5.       Elf M, Eriksson G, Johansson S, von Koch L, Ytterberg C. Self-reported fatigue and associated factors six years after stroke. PLoS One. 2016;11(8):e0161942.

    6.       Lerdal A, Gay CL. Fatigue in the acute phase after first stroke predicts poorer physical health 18 months later. Neurology. 2013;81(18):1581–7.

    7.       Delva II, Lytvynenko NV, Delva MY. Post-stroke fatigue and its dimensions within first 3 months after stroke. Wiad Lek. 2017;70(1):43–6.

    8.       Ponchel A, Bombois S, Bordet R, Hénon H. Factors associated with poststroke fatigue: a systematic review. Stroke Res Treat. 2015;2015:347920.

    9.       Mandliya A, Das A, Unnikrishnan JP, Amal MG, Sarma PS, Sylaja PN. Post-stroke fatigue is an independent predictor of post-stroke disability and burden of care: a path analysis study. Top Stroke Rehabil. 2016;23(1):1–7.

    10.     Wu S, Barugh A, Macleod M, Mead G. Psychological associations of poststroke fatigue: a systematic review and meta-analysis. Stroke. 2014;45(6):1778–83.

    11.     Ormstad H, Eilertsen G. A biopsychosocial model of fatigue and depression following stroke. Medical Hypotheses. 2015;85(6):835–41.

    12.     Nadarajah M, Goh HT. Post-stroke fatigue: a review on prevalence, correlates, measurement, and management. Top Stroke Rehabil. 2015;22(3):208–20.

    13.     Cumming TB, Packer M, Kramer SF, English C. The prevalence of fatigue after stroke: A systematic review and meta-analysis. Int J Stroke. 2016;11(9):968–77.

    14.     Galligan NG, Hevey D, Coen RF, Harbison JA. Clarifying the associations between anxiety, depression and fatigue following stroke. J Health Psychol. 2015;21(12):2863–71.

    15.     Mead G, Lynch J, Greig C, Young A, Lewis S, Sharpe M. Evaluation of fatigue scales in stroke patients. Stroke. 2007;38(7):2090–5.

    16.     Kutlubaev MA, Mead GE, Lerdal A. Fatigue after stroke – perspectives and future directions. Int J Stroke. 2015;10(3):280–1.

    17.     Kirkevold M, Bragstad LK, Bronken BA, Kvigne K, Martinsen R, Gabrielsen EH, et al. Promoting psychosocial well-being following stroke: study protocol for a randomized, controlled trial. BMC Psychol. 2018;3(1):12.

    18.     Chalder T, Berelowitz G, Pawlikowska T, Watts L, Wessely S, Wright D, et al. Development of a fatigue scale. J Psychosom Res. 1993;37(2):147–53.

    19.     Watkins C, Lightbody C, Sutton C, Holcroft L, Jack C, Dickinson H, et al. Evaluation of a single-item screening tool for depression after stroke: a cohort study. Clin Rehabil. 2007;21(9):846–52.

    20.     Adams Jr HP, Davis PH, Leira EC, Chang K-C, Bendixen BH, Clarke WR, et al. Baseline NIH Stroke Scale score strongly predicts outcome after stroke. Neurology. 1999;53(1):126–31.

    21.     Martinsen R, Kirkevold M, Sveen U. Younger stroke survivors' experiences of family life in a long-term perspective: a narrative hermeneutic phenomenological study. Nurs Res Pract. 2012;2012(Article ID 948791):11.

    22.     Schepers VP, Visser-Meily AM, Ketelaar M, Lindeman E. Poststroke fatigue: course and its relation to personal and stroke-related factors. Arch Phys Med Rehabil. 2006;87(2):184–8.

    23.     Hubacher M, Calabrese P, Bassetti C, Carota A, Stöcklin M, Penner I-K. Assessment of post-stroke fatigue: the fatigue scale for motor and cognitive functions. Eur Neurol. 2012;67(6):377–84.

    24.     Choi-Kwon S, Han SW, Kwon SU, Kim JS. Poststroke fatigue: characteristics and related factors. Cerebrovasc Dis. 2005;19(2):84–90.

    25.     Lerdal A, Bakken LN, Rasmussen EF, Beiermann C, Ryen S, Pynten S, et al. Physical impairment, depressive symptoms and pre-stroke fatigue are related to fatigue in the acute phase after stroke. Disabil Rehabil. 2011;33(4):334–42.

    26.     Kim JS. Post-stroke mood and emotional disturbances: pharmacological therapy based on mechanisms. J Stroke. 2016;18(3):244–55.

    27.     Kouwenhoven SE, Kirkevold M, Engedal K, Kim HS. Depression in acute stroke: prevalence, dominant symptoms and associated factors. A systematic literature review. Disabil Rehabil. 2011;33(7):539–56.

    28.     Lerdal A, Gay C, Lee K. Curvilinear relationship between age and post-stroke fatigue among patients in the acute phase following first-ever stroke. Int J Phys Med Rehabil. 2013;1(5).

    29.     Fjærtoft H, Indredavik B, Mørch B, Phan A, Skogseth-Stephani R, Varmdal R. Årsrapport 2016 – med plan for forbedringstiltak. 2017; St. Olavs hospital HF: Nasjonalt sekretariat for Norsk hjerneslagregister, Seksjon for medisinske kvalitetsregistre, Norsk Hjerneslagregister. Available at: https://stolav.no/Medisinskekvalitetsregistre/Norsk-hjerneslagregister/%C3%85rsrapport2016-Norsk-hjerneslagregister.pdf(downloaded 13.10.2018).

    When nurses and healthcare personnel are able to identify which patients are particularly at risk of post-stroke fatigue, patients can be given the appropriate follow-up at the right time.

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    Sammendrag

    Background: Fatigue is a pronounced symptom that often affects stroke patients. Fatigue is described as persistent tiredness, exhaustion and reduced capacity for activity, and is often associated with impaired quality of life. Earlier studies show a large variation in associated factors and the prevalence of post-stroke fatigue (PSF).

    Objective: To investigate whether there is an association between PSF and socio-demographic, medical and clinical characteristics in a Norwegian sample.

    Method: A cross-sectional study of 321 stroke patients recruited from 11 hospitals in Norway in the period 2014–2016. We collected data using a structured questionnaire in individual interviews held 4–6 weeks after the patient’s stroke. Fatigue was measured using a shortened version of the Fatigue Questionnaire (FQ). We used multivariate logistic regression analysis in this study.

    Results: The prevalence of PSF was 43.6 per cent in this study. Previous health problems (OR, odds ratio = 4.99), depression (OR = 4.47), care responsibilities for others (OR = 2.86) and the severity of the stroke (OR = 1.16) were factors that increased the risk of fatigue 4–6 weeks after a stroke.

    Conclusion: The study supports earlier findings that PSF is widespread. The study identified four factors that increased the likelihood of reporting fatigue 4–6 weeks after a stroke. Knowledge of the prevalence of PSF and the factors associated with PSF is crucial for nurses and other healthcare personnel being able to identify which patients may need follow-up in connection with PSF.

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  • What factors prevent young adults from showing up for their addiction treatment?

    Between 10 and 60 per cent of those who embark on an interdisciplinary specialised addiction treatment programme drop out of the programme before completion (1). Among these dropouts there is greater probability of re-hospitalisation, poorer physical and mental health, and relapses (2). In order to increase the completion rate, the Norwegian Ministry of Health and Care Services granted project funding in 2014 to each of the regional health authorities.

    The department for substance abuse and addiction treatment at the Hospital for Southern Norway (SSHF) was awarded funding for a treatment dropout project that, among other things, examined the transition period between receiving treatment in the hospital department and admission to a private in-patient institution. This part project defined ‘treatment dropout’ as the discontinuation of treatment before completion, the turning down of an offer of a place, and the failure to turn up at the start of the treatment programme.

    The department for substance abuse and addiction treatment offers a range of different treatments, and most patients who continue on a long-term therapy programme are referred to a private in-patient institution in the voluntary sector. The various private institutions employ different methodologies and provide treatment programmes of between six and twelve months’ duration. In 2013, the average waiting period between the offer of a place and treatment start-up was 72 days (3).

    Different patient pathways

    Patients follow different pathways before admission to a private institution. They may be referred by their GP, the local authority’s addiction service, the Norwegian Labour and Welfare Administration or the specialist health service. When their application is submitted to the assessment team at the department for substance abuse and addiction treatment, the team decide whether the patient is entitled to treatment, and what level of treatment is appropriate. The application is then forwarded for assessment by the private institution in question. Patients are free to choose among the options available at the level of treatment for which they receive an offer.

    The transition from one place of treatment to another may put the patient in a vulnerable situation.

    The transition from one place of treatment to another may put the patient in a vulnerable situation. The part project conducted at the department for substance abuse and addiction treatment found that 48 per cent of patients dropped out during the period of transition from one institution to another (3). The high dropout rate prompted a need to obtain more knowledge from patients about the factors that prevented them from turning up.

    Earlier research on the topic

    Government guidelines emphasise the importance of allowing service user experiences to play a bigger part in the development of good and efficient services (4). User involvement and a good alliance between the patient and the therapist are considered keys to preventing treatment dropout (5). Nonetheless, few studies have investigated the patients’ own perceptions and experiences associated with dropping out of treatment programmes.

    A recent review article showed that, with the exception of increased vulnerability with lower age, no patient-related factors could be said to unequivocally explain the programme dropout rate. Only six of the 122 studies had investigated factors relating to the therapist. These studies showed that a close alliance between the therapist and the patient may lead to lower treatment dropout rates.

    The review article authored by Brorson et al. asks for more research into treatment processes, for example patient satisfaction levels (1).

    We have found no studies that investigate the failure to turn up for treatment seen from the patients’ perspective. Studies that have investigated the reasons why patients discontinue their treatment before completion, cite factors such as dissatisfaction with the treatment programme and a lack of flexibility in the planning phase (6, 7).

    Studies that have investigated patient perceptions of treatment received, refer to various needs and opinions, but involvement, therapeutic alliances and being taken seriously and being respected were recurring themes (8–10).

    The study’s objective

    The study’s objective was to gain further insight into what factors prevent young adult patients from showing up for addiction treatment in a private in-patient institution.

    Method

    The study has a qualitative design. Since we wanted a deeper insight into the stories of individual service users, we made use of semi-structured life story interviews, characterised by questions that are neither completely open-ended nor completely closed-ended (11). We drew up an interview guide that focused on topics we wanted answers to: the informants’ experiences in the process leading up to hospitalisation, their positive and negative experiences and their reasons for failing to turn up.

    Sample

    Our informants had to have capacity to consent in order to be included in the sample; also, they could not be too affected by drugs to complete the interview, nor could they be admitted for treatment or imprisoned.

    In order to identify suitable informants, we conducted searches in the hospital’s patient records. Out of 20 people, six met the criteria and the first author contacted them by phone. We managed to contact five informants, all of whom wanted to be interviewed. However, two of the informants did not turn up, and after a further check of patient records for potential informants the first author contacted two people who had been admitted for in-patient treatment. Both wished to take part in the study, and both turned up for an interview.

    The sample included three males and two females between the ages of 18 and 30. Their respective treatment pathways had been different until they applied for treatment at one of four private institutions in 2013. All had a long track record of receiving help with their addiction problem, and all had previous experience of treatment in a private institution.

    At the time of their referral to a private institution in 2013, they were all receiving some form of assistance from agencies such as the specialist health service, the Norwegian Labour and Welfare Administration, the local authorities, their GP or the child welfare service, and one of these agencies had applied for them to be admitted. Three of the informants were drug dependent at the time of referral, one had stayed off drugs for a few weeks, while one had been clean for a longer period of time.

    At the time of the interview, two of the informants were receiving the treatment they wanted, one was receiving stable drug-assisted treatment, while two had stayed clean for months.

    The informants conveyed that the opportunity to pass on their story was important to them, in order to help other people experience a better treatment process than they had done.

    Conducting the interviews

    The first and second authors conducted the interviews. They were conducted at different premises according to the wishes of the informants and they lasted for 50 to 80 minutes. Several informants mentioned that the presence of a user representative during the interview was a positive aspect. We made audio recordings that were later transcribed by ourselves; the material made up a total of 115 pages of text. The text was then read and analysed by all authors.

    Analysis

    The first author conducted the analysis by means of systematic text condensation according to Malterud’s (12) four-step model. We started by reading through the interviews from what Malterud (12) calls a bird’s eye perspective in order to form an impression of relevant themes. We then re-read the interviews, coded and sorted them by putting text fragments together as we found appropriate under each theme heading. All text that did not fit into a category was put to one side.

    We went on to re-write the text fragments in less verbatim language, combining fragments with similar content. We retained quotes that might serve to complement the content. Afterwards, each theme was again reviewed, and each text fragment re-assembled under each theme. In the end, all authors reviewed all interviews again to see if the descriptions matched what the informants had said. The analysis generated three main themes.

    Ethical aspects

    We submitted the study to the Regional Committees for Medical and Health Research Ethics (REC) and it was concluded that project authorisation was not required. The study has been approved by the Norwegian Centre for Research Data (NSD).

    The informants received verbal and written information about the study. Confidentiality was maintained by storing all data on a password protected memory stick placed in locked storage. Only the authors had access to the memory stick. All data were anonymised to ensure that no individuals could be identified.

    The informants signed a consent declaration and were able to withdraw from the study at any time without giving a reason, and without consequence to any treatment they may have been receiving. Nobody chose to withdraw. All informants had access to someone to talk to in the aftermath of the study.

    Results

    The results show that the informants felt there was inadequate service user involvement, they felt anxious and upset, and their motivation was dwindling during the waiting period. There was also a sense of being pressurised into accepting the treatment offer, and this stopped them from turning up for treatment.

    Insufficient involvement

    All the informants had envisioned what kind of help they needed to free themselves of their addiction. Four of them had conveyed their needs and wishes before their application for treatment had been submitted. However, they had all found that their application had been for a different programme or institution than the one they wanted:

    ‘I really wanted to be admitted to one specific institution, I suppose, but then the support services applied to have me admitted elsewhere. They felt that’s where I ought to go, so I ended up not […] I turned down the offer, you see.’

    The informants had been given a variety of reasons why their wishes had not been granted: the institution’s waiting time was too long, they were not ready for that particular type of treatment or follow-up, they did not fulfil the criteria, or the help they wished for, did not exist.

    Neither heard nor seen

    The fact that they were not granted the assistance they wanted, meant that they felt their needs were neither listened to nor believed. They were left with a sense that the treatment they were granted was insufficiently adjusted to the individual:

    ‘I think they’re doing what their textbook says is the right thing to do, sort of. They probably did what they thought was right based on how they were used to doing things, but in my opinion that’s not necessarily right, at least not in our case.’

    They were left with a sense that the treatment they were granted was insufficiently adjusted to the individual.

    According to four of the informants, a recurring theme throughout their treatment pathway was that they had not been listened to nor taken notice of. One of them complained as follows:

    ‘I have heard several […] It’s really that they’re not listened to when they say something, and actually, those who are honest about what they hear and see; of course, there are those who try it on, but most of the people who admit themselves, they do so because they want to try, but when their voices aren’t being listened to, then things aren’t that easy.’

    Distrust on the part of the support system

    Several informants had found that the support system had little confidence in their ability to achieve what they wanted to achieve. One of them described the way she sensed this distrust:

    ‘[…] and again, you need to try to trust people and support them, rather than like “but what if this and that happens”. Yeah, sure, that sort of thing is quite stressful.’

    One of the informants, who was pregnant and on drugs, encountered an exaggerated trust in her own ability to stop taking drugs of her own accord. For her, it would have been important that the treatment service realised she was lying about managing by herself.

    Angry and desperate

    Four of the informants described how angry they felt when they were not listened to or taken seriously. One of the informants, who had been clear about what help he needed, described it in these terms:

    ‘What I remember is the feeling I was left with when I was reaching out for help, and then I didn’t get any help. I remember getting bloody pissed off. Then there’s no point, I thought. I might as well continue the way I am. I’m not getting any help even if I’m asking for it.’

    The fact that he was neither heard nor taken seriously, meant he felt there was no point in asking for more help.

    I’m not getting any help even if I’m asking for it.
    Informant

    Uncertainty, anxiety and dwindling motivation

    The informants experienced uncertainty, anxiety and dwindling motivation in the time leading up to their admission. For many, the waiting period was too long and they felt they were not receiving sufficient follow-up. One of them had stayed off drugs for a long time and was uncertain how long he would be able to keep it up:

    ‘The problem was really that all my motivation went down the pan, and then I would have to mobilise all over again […] I was like really annoyed that I had to wait for such a long time, ‘cause I didn’t know how long I would manage to stay clean before I was to be admitted.’

    In addition, he felt he was receiving little follow-up from the institution he was being admitted to. All things combined, this meant he lost his motivation for treatment.

    Loss of confidence

    Another informant became anxious and lost her confidence in her own ability to go through with the treatment:

    ‘I panicked, really. I think I became fearful of giving up the dope, of addressing some of the feelings I knew I had to address […], ‘cause I really believed that perhaps I wouldn’t be up to it. So I lost my confidence.’

    The informants also felt they were receiving insufficient information during the waiting period. One of them said:

    ‘In fact, it would have been really good if they told you a bit about the place you’re going to, and what the programme is and a little about how things work, ‘cause I’ve never known any of that stuff whenever I’ve gone somewhere.’

    Another informant had received some information but didn’t feel receptive. A lack of information had a negative impact on their motivation.

    Feeling pressurised to accept the offer of a place

    Four of the informants had felt pressurised into accepting when they were offered a place in the institution that had been suggested by the support service, even if this was not the one that they themselves had wanted. The reason given by several informants was that they had not felt ready for this type of treatment.

    One of the informants talked about how in 2013 and on several other occasions she had been pressurised into accepting treatment in an institution. She had accepted so that she would not lose custody of her children:

    ‘[…] maybe I wasn’t receptive the other times I was receiving treatment; I was doing it just because I felt I had to, because I had been given an ultimatum – they would take away my kids if I didn’t.’

    The pressure applied by the care system had made her make a half-hearted attempt at ridding herself of her addiction.

    A sense of being pressurised by the Norwegian Labour and Welfare Administration

    Another informant talked of financial pressure, and how he had felt that the Norwegian Labour and Welfare Administration had the upper hand:

    ‘The Social had me in a hold so to speak, they could stop the money coming in if I didn’t stick to the plan, and I was totally dependent on the cash, I never managed to hang on to a job or anything, to get an income. So I had to do what I had to do, in a way, to get the money.’

    Four of the informants had declined an offer of a place. They had chosen to go their own way in their effort to free themselves of their substance addiction, although they felt that they were receiving little support from the support system, and that it was a struggle to find approval for their own wishes.

    Discussion

    The study’s objective was to gain insight into the factors that prevent young adult patients from turning up for addiction treatment in private in-patient institutions. The results show that they experienced inadequate service user involvement, uncertainty, anxiety and dwindling motivation while waiting for admission, and that they felt pressurised into accepting an offer of treatment.

    The service user has a right to be involved

    The findings show that the informants felt their opportunity for user involvement was inadequate. On an individual level, service user involvement means that patients are kept involved by being asked to choose between safe and available treatment and examination options, and that their opinions must carry considerable weight. This involvement is an entitlement enshrined in law and forms a part of the obligation to provide safe and appropriate services (13).

    The informants’ experiences appear to be at odds with the requirement for service user involvement, which is a finding reflected in other studies (8–10). There are several challenges ahead before the potential for service user involvement has been fully exhausted (14). The user involvement requirement represents a change to the notion that patients should adjust to the services rather than the other way around (15).

    Moreover, the expert role assumed by healthcare personnel must change. Staff object to involving substance abuse patients with their own addiction treatment and argue that the substance abusers’ ‘chaotic’ lifestyle, and the addiction itself, will limit the individual’s capacity to participate (16).

    However, studies show positive results from involving service users with treatment provided by the interdisciplinary specialised addiction services: patients stay on their treatment programmes for longer, the level of heroin use is reduced, there is less crime, and the patients’ empowerment increases (16–18).

    Felt they were not taken seriously

    Several informants talked of anger and despair when they felt that their wishes were not listened to, and that they were not taken seriously. The few studies that have examined what patients consider to be the key to a good treatment offer, show that a high rate of satisfaction is associated with staff taking patients seriously (8–10).

    Being taken seriously, and being respected, is considered to be particularly important for people who suffer from substance addictions because many have experienced disdain and a lack of respect (8).

    The informants felt that they were pressurised into accepting an offer of treatment they did not want. Patient empowerment prevents a sense of powerlessness in patients who feel they have little control of their own lives in their encounters with the support system (15).

    The informants felt that they were pressurised into accepting an offer of treatment they did not want.

    A recent publication features the stories of 14 individuals and their struggle to rid themselves of their drug addiction. Their stories support the notion that for the support system to help people free themselves of their addictions, the most effective approach is to allow the individual’s preferences, values and contexts to form the starting point (19).

    A good alliance is characterised by the therapist and patient working as a team in full agreement about the goals and targets, and about how they should be working together. Several studies show that the quality of the relationship between the therapist and the patient is one of the best treatment outcome indicators (1, 20, 21).

    Essential to provide motivation and prevent treatment drop-out

    The informants referred to minimal follow-up and dwindling motivation while waiting to be admitted. Motivation is key to all change processes. Fluctuating levels of motivation are to be expected; ambivalence and resistance to change form part of the process that leads to freedom from addiction (22). Becoming drug free is a change process that takes years to achieve, and that needs constant attention (20).

    Other studies have also found that patients drop out of treatment programmes because they are not ready (23). However, dropping out of a programme does not necessarily mean an end to all treatment (24). Good treatment may involve providing patients with follow-up and support as they go through their processes, in a way that is adjusted to the patient’s pace, needs and targets, and which takes account of their resources and dreams (19).

    Methodology consideration

    The study includes a small number of informants, and all of them were recruited because they had received treatment at the same hospital and failed to turn up for treatment at a private institution in 2013. The study cannot be used for generalisation purposes but must be seen as a contribution to gaining further knowledge about the factors that prevent young patients from turning up for treatment.

    The study’s strength is that we used the same interview guide for all informants. The guide’s open-ended questions gave informants an opportunity to talk freely. Their experiences and perceptions varied. All of them were keen and had formed many thoughts and opinions on the topic. However, the experiences featured in the informants’ accounts were not recent, which may have affected the results.

    It was also a strength that a user representative was involved with the design and implementation of the study, to ensure that both the ‘professional view’ and the ‘service user view’ were represented throughout the process. The authors’ preconceptions will inevitably influence the interviews and the analysis process, and we sought to achieve reflexivity since all authors are working within the field.

    The informants said that the presence of a service user representative instilled a sense of safety in them. This may have caused the informants to give different answers than if the first author had conducted the interviews on her own.

    Conclusion

    The factors that prevented the informants from turning up for treatment at the private institution, were a sense of inadequate user involvement, dwindling motivation and being pressurised to accept a treatment they did not want.

    The study shows that there is an increased need to implement service user involvement and to strengthen the focus on individualised treatment. It also shows that a good relationship between the therapist and the service user is important, as is close follow-up during transition periods. There is a need for further research to shed light on the service users’ own experiences and perceptions of treatment they receive within the interdisciplinary specialised addiction treatment service.

    References

    1.          Brorson H, Arnevik EA, Rand-Hendriksen K, Duckert F. Drop-out from addiction treatment: a systematic review of risk factors. Clin Psychol Rev. 2013;33(8):1010–24.

    2.          Stark MJ. Dropping out of substance abuse treatment: A clinically oriented review. Clinical Psychology Review. 1992;12(1):93–116.

    3.          Gallefoss L, Årseth AL. Drop-out prosjektet. Delrapport 2. Pasientforløp og drop-out i overgang fra Avd. for rus- og avhengighetsbehandling (ARA) Sørlandet Sykehus HF til videre behandling i private døgninstitusjoner. Kristiansand: Sørlandet sykehus HF, Avdeling for rus- og avhengighetsbehandling; 2016.

    4.          St.prp. nr. 1 (2007–2008). Oslo: Helse- og omsorgsdepartementet; 2008. Available at: https://www.regjeringen.no/no/dokumenter/stprp-nr-1-2007-2008-/id483671/sec1 (downloaded 08.01.2019).

    5.          Helsedirektoratet. Nasjonal faglig retningslinje for behandling og rehabilitering av rusmiddelproblemer og avhengighet. Oslo; 2016. Available at: https://helsedirektoratet.no/retningslinjer/behandling-og-rehabilitering-av-rusmiddelproblemer-og-avhengighet (downloaded 02.11.2015).

    6.          Ball SA, Carroll KM, Canning-Ball M, Rounsaville BJ. Reasons for dropout from drug abuse treatment: Symptoms, personality, and motivation. Addictive Behaviors. 2006;31:320–30.

    7.          Laudet AB, Stanick V, Sands B. What could the program have done differently? A qualitative examination of reasons for leaving outpatient treatment. Journal of Substance Abuse Treatment. 2009;37:182–190.

    8.          Dahle KA, Iversen HH. Hva er viktig for pasienter innen rusbehandling? Notat fra Kunnskapssenteret. Oslo: Nasjonalt kunnskapssenter for helsetjenesten; 2011.

    9.          Nordfjærn T, Rundmo T, Hole R. Treatment and recovery as perceived by patients with substance addiction. Journal of Psychiatric and Mental Health Nursing. 2009;17(1):46–64.

    10.        Hackman A, Brown C, Yang Y, Goldberg R, Kreyenbuhl J, Lucksted A, et al. Consumer satisfaction with inpatient psychiatric treatment among persons with severe mental illness. Community Mental Health Journal. 2007;43:551–64.

    11.        Kvale S, Brinkmann S. Det kvalitative forskningsintervju. Oslo: Gyldendal Akademisk; 2010.

    12.        Malterud K. Kvalitative metoder i medisinsk forskning. En innføring. Oslo: Universitetsforlaget; 2003.

    13.        Helsedirektoratet. Veileder om rehabilitering, habilitering, individuell plan og koordinator. Oslo; 2015. Available at: https://helsedirektoratet.no/retningslinjer/rehabilitering-habilitering-individuell-plan-og-koordinator (downloaded 08.01.2019).

    14.        Torjussen E, Harwiss HL, Havenes IA. Brukermedvirkning i TSB – en myte? : en nasjonal kartlegging av brukermedvirkning i Tverrfaglig spesialisert behandling av ruslidelser (TSB). Oslo: Oslo universitetssykehus; 2014:1. Available at: https://oslo-universitetssykehus.no/seksjon/nasjonal-kompetansetjeneste-for-tverrfaglig-spesialisert-rusbehandling-tsb/Documents/SkriftserieNrENTilNett.pdf (downloaded 25.03.2019)

    15.        Dahl T. Brukeren som veileder. Ambulant brukerstyrt tilnærming. Oslo: Gyldendal Akademisk; 2011.

    16.        Fischer J, Neale J. Involving drug users in treatment decisions: an exploration of potential problems. Drugs Educ. Prev. Policy. 2008;15(2):161–75.

    17.        Nabitz U, van der Brink W, Walburg J. A quality framework for addiction treatment programs. Addict. Behav. 2005;30:1254–60.

    18.        Ning AM. Games of truth: rethinking conformity and resistance in narratives and heroin recovery. Med. Anthropol. 2005;24(4):349–82.

    19.        Landheim A, Wiig FL, Brendbekken M, Brodahl M. Biong S. Et bedre liv. Historier, erfaringer og forskning om recovery ved rusmiddelmisbruk og psykiske problemer. Oslo: Gyldendal Akademisk; 2016.

    20.        Meier PS, Donmall MC, McElduff P, Barrowclough C, Heller RF. The role of the early therapeutic alliance in predicting drug treatment dropout. Drug and Alcohol Dependence. 2006;83(1):57–64.

    21.        Miller MR, Moyers TB. The forest and the trees: Relational and specific factors in addiction treatment. Addiction. 2014;110:401–13.

    22.        Biong S, Ytrehus S. Helsehjelp til personer med rusproblemer. Oslo: Akribe; 2012.

    23.        Palmer RS, Murphy MK, Piselli A, Bali SA. Substance abuse treatment drop-out from client and clinical perspectives. Substance Use Misuse. 2013;44(7):1021–38.

    24.        Nordheim K, Walderhaug E, Alstadius S, Kern-Godal A, Arnevik E, Duckert F. Young adults’ reasons for dropout from residential substance use disorder treatment. Qual Soc Work. 2018;17(1):24–40. DOI: 10.1177/1473325016654559.

    Patients fail to turn up for their treatment in private institutions if they feel inadequately involved, suffer dwindling motivation or feel pressurised into accepting the treatment.

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    Sammendrag

    Background: Between 10 and 60 per cent of those who embark on an interdisciplinary specialised addiction treatment programme drop out of the programme before completion. The transition from one place of treatment to another is frequently found to be a vulnerable period, and we know from clinical experience that there is a dropout risk when patients are referred from one institution to another.

    A treatment dropout project at the department for substance abuse and addiction treatment at the Hospital for Southern Norway found that 48 per cent of patients under 30 years of age dropped out of the programme during the period of transition from one place of treatment to another (3). The high dropout rate prompted a need to obtain more knowledge from the patients about why they failed to show up for treatment. Few existing studies have looked into the perceptions and experiences of this patient group in connection with treatment dropout.

    Objective: The study’s objective was to gain further insight into what factors prevent young adult patients from showing up for addiction treatment in private in-patient institutions within the interdisciplinary specialised addiction treatment service.   

    Method: The study has a qualitative design. We conducted semi-structured life story interviews with five informants who had failed to show up for addiction treatment in a private institution. We analysed the data by means of systematic text condensation.

    Results: The results highlight a sense of inadequate involvement, uncertainty, anxiety and dwindling motivation during the waiting period and a feeling of being pressurised into applying for and accepting the treatment offer.

    Conclusion: The findings suggest that there is a need within the interdisciplinary specialised addiction treatment service to increase the knowledge about service user involvement and to strengthen the focus on individualised treatment, relationships and close follow-up during transition periods. There is a need for further research that sheds light on the service users’ own perceptions and experiences in connection with the treatment they receive within the interdisciplinary specialised addiction treatment service.

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  • Native language nurses and second language nurses document information in patient records differently

    In this article, we direct our attention to patient record documentation carried out by nurses with Norwegian as their native language and nurses with Norwegian as a second language. Nurses must use clear and succinct language in patient record documentation in order to avoid misunderstandings and errors. Nurses who have been educated in countries other than Norway and nursing students with Norwegian as a second language may face linguistic challenges both during their education and in professional life (1, 2).

    Students who pursue a programme of study in a country in which they must use a second language during their education often find that the transition from upper secondary school to nursing studies, for example, is linguistically challenging (1). Nurses using a second language may find the interaction with patients and colleagues challenging, and they may have a different interpretation of the role of the nurse (2).

    Studies of patient record documentation

    Studies that do not distinguish between native language nurses and second language nurses generally show that the quality of patient record documentation varies (3–5), and that the nurses find that formulating nursing plans is challenging (6). The quality of the patient record may be affected by fragmentary language (7), and the records may be incomplete with, for example, a lack of information about the effect of nursing measures (8).

    A study from a German university hospital (9) pointed in part to considerable deficiencies in the patient records. The researchers revealed that there was a lack of correspondence between what was said in the oral report and what was documented in the patient record, and that there were errors in important information, or that this information was lacking altogether.

    Advantages and disadvantages for second language nurses

    International nurses and second language nursing students who follow a programme of nursing education in a different country may face linguistic, professional and culturally-related challenges. Canadian studies show that internationally trained nurses face challenges in using English as an academic language when they take further education and when they encounter unexpected formal requirements (10).

    Various factors, either combined or singly, have a positive impact on nurses’ integration and professional practice. Factors such as financial resources, general language skills and work-related linguistic proficiency are highlighted (11).

    An Australian study (12) shows that purposeful enhanced interaction with experienced nurses and with patients helps to improve the communicative skills of second language nurses and their interaction with patients and other nurses. In relation to linguistic adaptation, the study emphasises the importance of how the nurse sees him/herself and how well-prepared he/she is before working in another country. Their manner of communication affects the expectations of patients and other healthcare personnel towards them.

    Publications that identify problems linked to communication with second language nurses apparently use the term ‘language’ only in connection with oral communication (2, 13). Written documentation is not discussed even though it has a legal significance which does not apply to oral communication (14).

    The objective of the study

    In our article, we focus on the fully trained nurse who has completed a course of professional education and who satisfies language requirements. We have not found studies that examine linguistic similarities and differences between documentation recorded by native language nurses and second language nurses, either in Norway or internationally.

    Currently, over 10 per cent of 100 000 nurses, midwives and public health nurses in Norway do not come from Norway originally.

    The absence of such studies is surprising considering that in some countries, a relatively large proportion of nurses do not speak the country’s official language as their mother tongue. Currently, over 10 per cent of 100 000 nurses, midwives and public health nurses in Norway do not come from Norway originally (15).

    In order to ensure quality and continuity, an adequate, relevant, precise and comprehensible language repertoire, that allows for the inclusion of the patient’s views, is essential (16). The aim of the pilot study was to explore differences and similarities in scope and linguistic precision between the handover reports of native language nurses and second language nurses.

    Method

    We employed an exploratory approach to examine the nurses’ language skills. We identified their linguistic register and use of grammatical structures.

    Setting and sample

    Handover reports must help to ensure continuity and teamwork around the patient (4, 14). The charge nurses in four wards collected written, anonymised reports from day shifts at a large hospital in the eastern part of southern Norway. Reports from day shifts are normally more comprehensive than reports from evening and night shifts.

    In the hospital’s electronic documentation system, handover reports are referred to as ‘Note/evaluation’, hereinafter referred to as ‘reports’. The inclusion criteria were that the nurses should have Norwegian as their mother tongue or Norwegian as their second language. They could not have any other Scandinavian language as their mother tongue, be permanent employees or have no higher education.

    The managers also gathered information about how long the nurses had been employed in Norway, and where they had taken their final nursing examination.

    Data collection

    A member of hospital management contacted five clinic heads and requested permission to carry out the study. Four agreed to participate and arranged for a contact person for the individual ward. The contact persons received further written and oral information from the first author about the objective of the project and the mode of procedure.

    The contact persons obtained written consent from the nurses allowing them to collect the reports the nurses had written and use them in the project. Prior to giving consent, the nurses had received written information about the objective of the project and how the results were to be used. The charge nurse of each individual ward anonymised people and patient-identifying information.

    We collected ward reports between June 2015 and January 2016. We sought to ensure that none of the reports covered periods when there are frequently a number of agency nurses on duty or double shifts, such as Christmas, Easter and the summer holidays. We chose the same shift and omitted defined periods in order to prevent imbalances between the two groups of nurses.

    Altogether we collected 129 reports written by 20 nurses who were native speakers and 20 nurses who were second language speakers. The material we received from the charge nurses turned out to include reports from evening and night shifts. These reports were removed from the material that finally consisted of reports written by 17 nurses who were native speakers and 17 nurses who were second language speakers, representing 57 and 56 reports respectively.

    Ten of the nurses who were second language speakers were educated as nurses in Norway, while the other seven had nursing education from other countries. The majority of nurses who were native speakers had worked from one to three years as nurses. Second language speakers had longer professional experience on average. The majority had worked in a permanent position from two to fifteen years.

    For reasons of anonymisation, we do not present the results by ward or place of education, i.e. whether the place of education was in Norway or elsewhere.

    Analysis

    First we carried out an analysis in order to identify categories across twelve functional areas that the nurses were expected to use in the reports:

    • Communication and senses
    • Knowledge, development or mental health challenges
    • Respiration and circulation
    • Nutrition, fluid and electrolyte balance
    • Elimination
    • Skin, tissue and wounds
    • Activity and functional status
    • Pain, sleep, rest and well-being
    • Sexuality and reproduction
    • Social needs
    • Spiritual and cultural needs, and lifestyle challenges
    • Miscellaneous, doctor-delegated activities and observations

    In this phase, we first organised the material on the basis of official expectations regarding patient record documentation (14). Then we used text condensation based on a grounded theory approach (17).

    This resulted in the following six cross-cutting categories: 1) Nurse’s assessments and nursing diagnoses, 2) Nurse’s measures and actions, 3) Communication between patient and nurse, 4) Cooperation and communication with other healthcare personnel, 5) Notes that related to family, relatives and friends, and 6) Number-related information units such as blood pressure, fever, degree of pain and time.

    In order to facilitate a comparison of the two groups of nurses, we summarised the number of times each nurse recorded information in each category, and then calculated the average number of information units per report. For example, nurses who were native speakers recorded 108 cases of ‘Communication between patient and nurse’ in the 57 reports. We calculate this as an average of 1.9 per report. The group of nurses who recorded most information in each category was set at 100 per cent, making it possible to show the relative difference between native speakers of Norwegian and speakers of Norwegian as a second language.

    In-depth analysis of skin, tissue and wounds

    Hospital patients are vulnerable to infections (18) and wounds (19). Both professional and linguistic competence is needed to be able to express precisely how a wound appears along a timeline, i.e. the past and present state of the wound, what action has been taken in the preceding shift(s), and also reference to any follow-up that is necessary in the ensuing shift(s).

    Consequently, we conducted an in-depth analysis of the functional area ‘Skin, tissue and wounds’ in order to examine the linguistic level of precision through the use of nuanced language. We investigated expressions used to describe variation in different assessments, measures and actions, descriptions of time and changes as well as communication and cooperation.

    We decided to compare the patient record documentation of the two groups of nurses based on: 1) Register of blood-related vocabulary, 2) Register of colour symptoms ranging from light to dark, 3) Register of various documented measures or actions, 4) Register of various documented types of dressings, 5) Terms expressing condition of patient and changes over time, and 6) Cooperation and communication with other healthcare personnel and the patient.

    Category 6 was included since cooperation and communication are intended to strengthen the quality of patient follow-up as well as including one-way communication in the form of direct messages to the next shift.

    Ethics

    The project was quality assured and was assessed and approved by the hospital’s data protection official for research. The nurses consented to our use of the reports they had written in the analysis. They had removed all patient-identifying information from the reports we received.

    We informed the nurses that it would not be possible to identify individual wards in publications. The same applied to individual nurses and groups of nurses as well as to their national or cultural background.

    Results

    A main finding is that native language nurses record more information than second language nurses in the following categories: ‘Nurse’s assessments and nursing diagnoses’, ‘Nurse’s measures and actions’, ‘Communication between patient and nurse’, and ‘Interaction with other healthcare personnel’.

    Second language speakers recorded more information in the ‘Family, relatives and friends’ category than native speakers. In the ‘Number-related information units’ category, native speakers documented slightly more. Table 1 shows the differences in the scope of the information with examples of how the two groups of nurses record patient information.

    Table 1. The scope of information in the main categories for nurses who are native speakers and nurses who are second language speakers.

    Figure 1 shows the relative difference in the scope of the main categories between the two groups’ patient record documentation.

    Figure 1. Differences in the scope of documentation

    Second language speakers have lower linguistic precision

    In a detailed analysis of linguistic precision, we found that second language speakers recorded information in 37 out of the 56 reports (66 per cent), but that native language speakers had provided documentation in 51 out of the 57 (89 per cent). Second language speakers have less linguistic precision with fewer nuances. This is, for instance, revealed when they document observations of wound care and change of dressing. Native speakers use a register of ten different words related to observation of dressings, while we identified only one description among second language speakers.

    Second language speakers have less linguistic precision with fewer nuances.

    Table 2 shows differences in nuances and specificity in the documentation. There are also differences between the two groups when describing symptoms using colour and nuanced conditions – native speakers use twice as many descriptions. The register of different measures and actions shows that native language speakers use twice as many descriptions – altogether twelve as opposed to six for second language speakers.

    Table 2. Examples of the linguistic precision and language nuances of nurses who are native speakers and those who are second language speakers

    Nurses who are native language speakers document cooperation to a greater extent

    The type of dressing gives additional information about the wound and the treatment given. Second language speakers specify this in two out of 14 notes that include dressings, in contrast to 13 out of 28 notes made by native speakers. The notes of the former reflect to a minimal degree the change and development aspect that is critical to the skin, tissue and wound category, for example the condition of the skin or the wound during the previous shift and the type of change prior to the shift in question.

    Native language speakers document far more on cooperation and communication with other healthcare personnel and with patients. We identified twelve notes with documentation of various forms of communication and cooperation. In contrast, second language speakers had two notes in this category and both were direct requests to future shifts and did not concern communication with patients.

    Figure 2 shows graphically the difference in register of the two groups of nurses’ descriptions and actions.

    Figure 2. Differences in language repertoire

    Discussion

    A main finding is that nurses who are native speakers and nurses who are second language speakers record information to a different degree, and the linguistic precision differs. In four out of six categories, the latter document less than the former. In one category, second language speakers document more, and in one category the amount of documentation is relatively similar.

    The detailed analysis of skin, tissue and wounds shows that native language nurses consistently use more detailed and more nuanced language in all categories.

    A main finding is that nurses who are native speakers and nurses who are second language speakers record information to a different degree.

    However, the findings also reveal that the documentation of native language nurses can also be deficient, as other studies have also shown (20). Competence and cultural circumstances that are significant for how second language speakers regard their roles and responsibilities may explain some of the differences we uncovered (2).

    Second language speakers have a narrower linguistic register

    Nurses who are second language speakers have a narrower linguistic register when it comes to using nouns, adjectives and verbs in their descriptions of symptoms and actions. They include little information from before or after the shift on which they report.

    There is a comprehensive body of research on second languages, i.e. learning, acquisition and application. This is not uniform, but it confirms that developing a richer linguistic register in terms of mastering good oral and written communication is a process that takes many years (21).

    Henriksen (22) refers to such differences between the language acquisition and learning of native and non-native speakers, and provides an explanation. When learning a second language, a number of people can function well after a short time when using everyday language, but it can take several years to acquire a functional, professional language. These experiences also tally with the experiences of nurses in Norway who are second language speakers (2).

    Refer to time differently

    We revealed differences when it came to expressing time factors, sequence and changes in the condition of skin, tissue and wounds. There may be various reasons for the differences. They may be associated with the fact that second language nurses record less information than native language nurses, and therefore refer less to time-related factors.

    Another possibility is that the differences may be linked to professional competence, but they may also be connected to the linguistic background of the nurse. The tense of a verb depends on whether it refers to something which has happened or something which is happening now, whether it describes an actual condition or is something the nurse must take into account in the future – for example during the next shift.

    We revealed differences when it came to expressing time factors, sequence and changes in the condition of skin, tissue and wounds.

    The recording of information that concerns the current shift largely requires verbs in the present simple, present perfect or past simple tenses, i.e. ‘eats’, ‘has eaten’ or ‘ate’ respectively, and adverbs of time such as ‘this morning’ and ‘12 noon’ and the like. Notes intended for the next nurse on duty make it natural for the reporting nurse to express the future using verbs such as ‘shall’, ‘can’, ‘must’ and ‘should’, and expressions of time such as ‘this evening’ or ‘next week’.

    Notes that refer to the preceding shift require the nurse to use past forms such as the past simple ‘ate’ or the past perfect tense to show that something happened before something else, for example, ‘had just eaten when he felt pain’. The verb tense used in this example was previously referred to as the pluperfect. Even foreign languages that are closely related to Norwegian, such as English, German, French and Spanish, express the past fairly differently.

    Languages such as Vietnamese and Chinese (Mandarin) do not express the past by means of different verb endings like Norwegian ( åpner – åpnet/åpna) or changes in the vowel ( stå – sto), but use time markers, for example ‘this morning’ and ‘during the visit’ (23). Such language differences can explain some of the findings. Therefore, the linguistic challenges we have revealed may vary according to the native language of the nurse, or where he/she completed their nursing education.

    The fact that Norwegian is a foreign language not spoken by many people may make a difference for nurses who have probably learned it as adults. They have been exposed to Norwegian for a far shorter length of time and to a lesser degree than to world languages such as English and Spanish. This may lead to considerable challenges in communication with patients and in interaction with other healthcare personnel. However, on the basis of the findings in the study, we have no evidence to comment on such challenges.

    The employer is responsible for the training

    We cannot draw conclusions as to whether there is any correlation between language skills and possible deficiencies in the direct treatment and follow-up of patients. The objective of the study has not been of a normative character – i.e. meant to evaluate whether one group of nurses is better than the other. We have focused on describing linguistic similarities and differences.

    There may be reason to reflect on the findings in a broader cultural context, with information culture in the foreground (16). Precision in descriptions and a smaller register of words and expressions to describe professional assessments, actions and measures may then be significant.

    Regardless of the reason for these linguistic challenges, the employer has a duty to ascertain that the language skills of second-language speakers are on a level that ensures that they can record information accurately and succinctly so that nursing services are sound (24).

    Developing nursing terminology

    International efforts have been made to develop terminology for use in nurses’ patient record documentation, which may alleviate some of the challenges (25, 26). Efforts are being made nationally to develop and introduce nursing terminology, and the Norwegian Directorate of eHealth recommends the use of the ICNP (International Classification for Nursing Practice). When the nurses used specialist terminology, the content was more complete (27).

    However, nursing diagnoses can be seen as enriching, linguistic constructions (6). Therefore, we need studies that address whether the use of specialist terminology helps to support nurses who are second language speakers.

    Limitations of the study

    The study has several limitations. We do not know if the differences are caused by language proficiency alone or by nursing competence and cultural background in addition (1). More knowledge is needed about the actual quality of patient record documentation through more comprehensive and robust studies. An interview survey giving more in-depth insight is also recommended.

    Our study builds on a limited number of handover reports. Since we found no previous studies on this topic, we used a method that enabled us to compare the scope and linguistic nuances of the two groups. The fact that we analysed the material across functional areas is a strength because it gives a deeper understanding of the nuances.

    Ten of the second-language speakers had completed their nursing education in Norway while the remaining seven were educated in other countries. We found small differences when comparing these groups so we chose to include them in the same group. However, the findings must be seen in light of the fact that we were unable to control for the characteristics of the informants. The body of material was too small.

    The findings must also be considered in light of the fact that we have no information about how many patients were represented in the reports. In addition, we had to take ethical considerations into account. Since the number of informants in the sample is small, we cannot state the country of origin of nurses with Norwegian as a second language due to anonymity requirements.

    The fact that nurses who are second language speakers have a smaller vocabulary in writing does not mean that we can draw conclusions about the quality of their direct patient care or their competence as nurses. We do not know whether there was an oral information transfer between the shifts and whether this helps to compensate for deficiencies in written information. However, an oral report does not necessarily solve all the language challenges (9).

    Nor do we know whether the participants in this study felt pressurised to participate. If cultural factors indicate that they feel inferior (2), this may mean that our group is not representative. Furthermore, we have no information about the content or quality of the reports written by the nurses who chose not to participate, and this may affect the results.

    Conclusion

    Native language nurses and second language nurses record almost the same amount of numerical information but there are clear differences between the groups in terms of their language repertoire and register. Nurses who are native speakers use a larger and more nuanced repertoire than those who are second language speakers. The study does not provide a basis for concluding that nurses who are native speakers record nursing information flawlessly.

    The study should be followed up by a larger and more broadly based study in the specialist and primary health services and in the education sector. It is a managerial responsibility to ensure that employees receive language and professional follow up to prevent risk to patients. The study can help to implement relevant measures that may make patient record documentation easier for a growing group of nurses that Norway needs.

    Thanks to quality assurance staff at the hospital for their help in the implementation of the project, and to Else Ryen for vital input in the final phase.

    Lasse Morten Johannesen died before the article was published. The article is published in agreement with his family.

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    22.     Henriksen B. Research on L2 learners' collocational competence and development – a progress report. In: Bardel C, Lindqvist C, Lauffer B, eds. L2 vocabulary acqusition, knowledge and use – new perspectives on assessment and corpus analysis 2: Eurosla Monographs series. Italia: University of Modena and Reggio Emilia; 2013. p. 11–29.

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    Nurses with Norwegian as their mother tongue use a larger, and more nuanced repertoire in handover reports than those with Norwegian as a second language. However, they document numerical information in almost the same way. 

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    Background: In recent decades, there has been an increase in the labour migration of nurses across country borders. Managers have a responsibility for ensuring that staff have the necessary language skills. We have not identified any studies that compare patient records written by nurses who are native language speakers with those written by second language nurses.

    Objective: The objective of the study was to explore differences and similarities in the scope and linguistic precision of the handover reports of nurses who are native speakers and those of second language nurses.

    Method: We used an exploratory design to assess 113 handover reports, of which 57 were written by 17 nurses with Norwegian as their mother tongue, and 56 were written by 17 nurses with a different mother tongue.

    Results: Nurses who are native speakers for the most part documented more information than second language nurses. However, second language nurses documented almost as much numerical information as well as more information about family and relatives. The findings revealed that they had a smaller repertoire and lower linguistic precision.

    Conclusion: Nurses who are native speakers and nurses who are second language speakers recorded almost the same amount of numerical information, but there were clear differences between the groups in respect of their language repertoire and register. The former use a larger and more nuanced repertoire than the latter. The study does not provide a basis for concluding that nurses who are native speakers record nursing information flawlessly, but it can help to initiate measures that may make patient record documentation easier for a growing group of nurses that Norway needs.

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  • How intensive care patients’ family members can play a more active role

    Intensive care treatment is constantly changing. The changes affect the interaction between healthcare personnel, patients and patients’ families (1, 2). While the public health service’s treatment responsibilities are mandatory, family members can provide crucial support for the patient, including during intensive care treatment (1, 3).

    The situation and efforts of family members have not been sufficiently elucidated in earlier research (1, 3, 4). The aim of this study is therefore to examine their situation in connection with heart surgery patients with a prolonged stay in intensive care.

    A planned heart surgery trajectory involves 24 hours in an intensive care unit, where the patients are extubated after a few hours. Most patients are weak at this point. They are then transferred to intermediate monitoring for 24 hours, followed by a few days in a ward, and then transferred to a local hospital where necessary. In cases where a patient’s stay in intensive care needs to be prolonged, the nature of the trajectory changes and has several similarities with a general stay in intensive care.

    Earlier research

    Research on families of intensive care patients has centred around perceptions of crises and reactions to stress that can pose a health risk to the patients’ families. The most important needs of the family members are identified as open and honest information, the opportunity to spend time with the patient, assurance that the patient is being taken care of, hope, updates on the patient’s condition and the need for comfort and support.

    These findings are confirmed in several studies and appear to be well-documented (4–8). How well the families’ needs are taken care of is primarily documented through measurements of family satisfaction (9, 10). The intensive care setting is part of everyday life for the staff, but is a unique experience for the patients and their families. Patients, their families and the staff can therefore have different interpretations of the same events (2, 6).

    There is limited knowledge about families’ experiences in several contexts – about how these experiences are influenced by society, the culture, the type of health service and by various underlying reasons why patients need intensive care treatment. The focus of research in the field has been based on the situation of the bereaved (4). Thus, families’ experiences with intensive care survivors and with other types of intensive care stays are not as well documented (2, 10).

    Guidelines

    Families can find the intensive care environment to be an alien, stressful and hectic world characterised by complex treatment using a great deal of technology. Families are exposed to high noise levels, limited physical space in rooms with several beds, extensive visiting restrictions, waiting times for visits without appropriate facilities and strong impressions from the concentration of intensive care patients in large rooms (11–13).

    In response to these challenges in the intensive care environment, guidelines have been drawn up for patient and family-oriented care in intensive care units, where a family-friendly structure includes waiting rooms, single rooms and flexible visiting hours (11, 12). The guidelines allow the patients’ families to be involved during the intensive care stay, and ensure that the families’ needs in a difficult situation are recognised and met by the healthcare personnel (3, 6, 12).

    Objective of the study

    Despite over 30 years of research on the subject and ongoing debate, particularly in relation to visiting hours, there are still unanswered questions about families’ experiences with the different structures of intensive care units, and how the families perceive the interplay between the patients and the healthcare personnel within different frameworks and space solutions.

    Earlier research has called for studies that can provide more knowledge about structure and interaction in the intensive care setting (9, 14), with a view to helping healthcare personnel to make better provision for patients’ families.

    The purpose of our study was therefore to provide knowledge on family members’ experiences and perceptions in connection with intensive care stays following heart surgery in a unit with single rooms and flexible visiting hours.

    Method

    The complexity of family members’ experiences and our ambition to ascertain their perspectives led us to using a qualitative research design based on the Corbin and Strauss (15) approach to grounded theory (GT). In line with an exploratory basis, we chose an inductive design. We performed the data analysis in accordance with the principles of constructivist grounded theory (CGT) (15).

    GT is traditionally based on symbolic interactionism combined with pragmatic philosophy. GT studies seek explanations, processes, experiences and knowledge of how situations are handled. Analysis of the interplay between action, structure and interaction is central.

    CGT represents a continuation of GT, with a goal of improving knowledge about various possible interpretations of reality in a given context, where the researcher is regarded as a co-participant as opposed to a neutral discoverer of objective findings (15).

    We recruited family members through patients who had undergone heart surgery and had been in an intensive care unit for more than 24 hours. The unit is part of a relatively new hospital with single rooms, waiting rooms, rooms for private conversations and no fixed visiting hours.

    The data were collected through semi-structured interviews with family members of heart surgery patients who had survived intensive care. The stay in intensive care was longer than is normally expected following standard heart surgery. Table 1 shows the interview guide.

    Table 1. Interview guide

    Sample

    Our ambition was to recruit ten informants, but this was not possible within the timeframe of the project. The interviews were conducted two to six months after the hospital stay, when we assumed that the situation was probably clearer for the patients and that the family had had time to reflect on events.

    We contacted the patients in writing in order to recruit the person they chose as their closest family member over the age of 18.

    Due to the risk of confusing the researcher role with the role of intensive care nurse or healthcare personnel, the letters were sent by the hospital without us knowing who was contacted. We first learned the identity of the participants when they responded with their contact details.

    The study was approved by the Regional Committee for Medical and Health Research Ethics (REC) (project number 2014/1144) and the participants’ written consent was obtained.

    Data

    The data include material from interviews with four spouses and two adult children; a total of four women and two men. The first author, who is an intensive care nurse with many years of experience with heart surgery patients in intensive care, interviewed the informants. Four of the interviews were conducted in the informant’s home and two were held at office premises.

    The interviews lasted between 1.25 and 1.75 hours, and were recorded on audio tapes and transcribed in full text. In order to strengthen credibility, we summarised the main points at the end of the interviews by asking questions such as ‘Have I understood you correctly...?’.

    The analysis included the transcription of interviews, memo writing and a writing process in line with GT, coding of the material and further analysis with the development of concepts and categories (15). One of the co-authors read through the transcripts, and both co-authors took part in the analysis and writing process.

    In the open coding process, the purpose was to break down the data into smaller and more manageable units. We therefore created matrices to gain an overview. See the example in Table 2.

    Table 2. Sample matrix

    Open coding, matrices, notes from interviews and transcription enabled us to structure the data using axial coding in different themes and categories, then, in line with a circular work method, to return to the data to validate the analysis (15). Table 3 illustrates the analysis process.

    Table 3. Analysis of the data

    During the analysis process, we noted both typical and anomalous findings and focused our attention on alternative explanations (15). After each interview, we changed and controlled concepts and categories in the data in line with the GT principle of constant comparison (15).

    The aim was to strengthen the credibility of our interpretation of the data since the goal was to elucidate the situation from the informants’ perspective. We also enhanced the credibility of the categories and concepts by presenting relevant quotes from the transcripts.

    Results

    The analysis produced two main themes: family members sought and fostered a sense of security by providing support and care for the patient whilst in intensive care. The second theme was that the combination of a family-friendly structure with single rooms, flexible visiting hours and positive perceptions of healthcare personnel in the intensive care unit enabled the families to play a supportive and active role during visits.

    Fostering a sense of security

    The most important aspect for the family members was to seek a sense of security, primarily for the patient, but also for themselves and other relatives. The informants felt that they were in a ‘bubble’, where all the attention was directed towards the patient’s well-being, and found that they were able to muster the energy and strength to support the patient during the intensive care stay. The primary agenda of the families was to serve as a supportive presence:

    ‘Then the tears started without him saying anything. So, yes, he felt that we were there. Because he said that it was good to see me: ‘Good that you’re here’, he said. And that was enough to make me want to stay.’

    The most important aspect for the family members was to seek a sense of security, primarily for the patient, but also for themselves and other family members.

    Intensive care stays varied from a few days up to two weeks, and both planned and emergency cases were represented in the family members’ narratives. The day of surgery, however, entailed unbearable tension for them.

    Some patients recovered quickly after undergoing a new intervention, while others were subject to complications and an uncertain prognosis. The family members also told of respiratory treatment and various forms of impaired consciousness. They visited the patients at least once a day.

    During the course of the clinical pathway, family members had visited the patient in one or more hospitals, and their time was taken up with travelling, work and family obligations. Being a family member of a seriously ill patient was a challenge. They likened the twists and turns in the clinical pathway and the patient’s uneasiness to being on ‘an emotional rollercoaster’.

    Varying degrees of security within the same family

    Some family members barely managed to visit, and were described by the informants as ‘completely shattered’. The informants tried to hide their own uneasiness from the patient during visits. Some had a strong reaction to the first encounter with the patient in the intensive care unit, which was reinforced by the fact that they were not prepared for the patient’s changed appearance and level of consciousness. One family member described a visit to a previously healthy person after an emergency operation, as follows:

    ‘Many people are shocked by their own reactions when they see their mother or grandmother in such a situation and are overwhelmed when they encounter the intensive care unit for the first time, with the monitoring equipment, breathing apparatus and a close relative caught up in something that changed their skin colour from normal to grey during the course of a day.’

    Protecting the patient entailed avoiding talking about disturbing topics of conversation, leaving the unit when they observed that the patient was tired, not obstructing the staff’s patient care work and trying to act calm in front of the patient:

    ‘I now have to show my mother that I’m worried, but not so worried that she’s worried about me being worried! That’s the kind of balancing act that family members need to maintain, because I saw how scared and badly affected she was then.’

    Observing that the patient felt soothed by their presence seemed to reassure family members, and this strengthened their belief in their own efforts. The informants signalled a confirmatory family togetherness: this was something they would get through together. They encouraged the patient and distracted them from uneasiness and discomfort. Outside the hospital, they carried out tasks that the patient would normally undertake, cared for other family members, and updated social networks about the patient’s condition.

    Scope for active presence

    The environment in the intensive care unit was new and unknown to the informants, who described a quiet place with a calm atmosphere, and they were not frightened by the environment. Flexible visiting hours and single rooms made it easy for the family members to be present in the patient’s room:

    ‘How can I put it - I just went straight in. Getting access was no problem for us, we came straight in every time!’

    ‘We didn’t need to wait around much, we were in his room. He did have a single room after all.’

    ‘Being in a single room as opposed to a room with several other patients makes a huge difference. So I found it incredibly positive. In a way, it made my role easier; you have nothing else to focus on apart from the patient and the treatment. And that’s exactly what you want to be in focus when visiting a hospital.’

    There were opportunities for safe, ‘private’ time, when the healthcare personnel took a step back, but continued to monitor the patient. The staff were mostly described as ‘nice’, and the informants felt welcome in the unit. However, the dialogue with the healthcare personnel in the patient’s room showed signs of restraint to some extent. As well as shielding the patient from uneasiness, family members were focussed on communicating with and caring for the patient.

    Desire for more information from healthcare personnel

    The family members were also conscious of not obstructing the staff’s patient care work. The informants therefore called on the healthcare personnel to take the initiative more often to provide information, not just about the patient, but about which professionals they had talked to, the daily routine, suitable visiting times and the healthcare personnel’s expectations of the families.

    In addition, the informants made the following suggestions for the healthcare personnel: give the families a short briefing on the patient’s condition before a visit, have a brief conversation with them after the visit, and hold information meetings after the initial shock phase has passed. Conversations and meetings outside the patient’s room would also give families the opportunity to talk about their situation and their own reactions.

    The informants were reassured by the fact that heart surgery is regarded as a routine operation nowadays, and by confirmation that the planned clinical pathway was mostly adhered to. Complications and significant deviations from the planned clinical pathway following surgery raised new, unanswered questions for some of the informants. Lack of information may have been the reason for these questions going unanswered, but in some cases, they may have misunderstood or forgot what they had been told:

    ‘We were told that quite a few patients had this operation and that it went well. We hoped so. We didn’t really get any explanation, they said that all the tests were fine. But I immediately thought that that’s no doubt something I’ll hear about later.’

    Trust linked to information

    A close link existed between whether the family members received information and whether they perceived the healthcare personnel as competent. How the staff conveyed information was the determining factor in whether the overall impression inspired trust:

    ‘Just how much of an overview I felt I had, I’m not sure. I had the impression that they were in control of the situation. That was really the most important thing for me. Medical jargon and all of that is not too important. The fact that I don’t remember everything the surgeon told me is not his fault.’

    Trust was central to the informants’ narratives.

    Trust was central to the informants’ narratives. Family members generally had a high level of trust in the health service, but in this particular setting they found the trust to be forced:

    ‘You are totally dependent on the people who are around you, and whether those machines work. You just need to believe that everything will work! You can’t just start expecting or looking for mistakes, you just have to have faith, you know?’

    After observing that the patient was being taken care of, the informants found that their general confidence in the health service was maintained. This certainty helped them to trust that the patient was in good hands when they themselves were not present.

    Support from healthcare personnel

    The informants wanted information from doctors and nurses, but some thought that the healthcare personnel should concentrate primarily on the patient. Some family members took care of each other and therefore did not need support from the staff if the patient survived the intensive care treatment. Others wanted support, and they received the support they needed from the healthcare personnel, but the experiences varied:

    ‘For my own part, I think I was in shock, I wasn’t able to initiate contact myself. So I suppose if there had been someone there who had approached me and sat down and chatted, I think it would’ve helped.’

    Informants who received support from healthcare personnel found it reassuring:

    ‘As a family member of a patient, you’re very vulnerable. You need to be there for the person who is sick. It’s therefore good to get some comfort and understanding from the experts, and for them to realise that you’re a bit fragile, that you actually need to hear that things are going well. It’s small things like that that take away the fear of all the tubes. That they take the time, that they look you in the eye, maybe even give you a little smile.’

    The families’ experiences with the roles of the healthcare personnel varied, but they all wanted to be able to help the patient feel a greater sense of security through a supportive presence and care.

    Discussion

    During the patient’s prolonged stay in intensive care following heart surgery, it was important for the family members to make the patient feel more secure by serving as a calming, confirmatory, protective and encouraging presence.

    Positive experiences with the health service and trust-inspiring healthcare personnel, no waiting times, flexible visiting hours and a calm atmosphere with opportunities for privacy in single rooms enabled families to play an active role, with a self-defined, patient-oriented agenda.

    Role of the family

    Engaged family members with a strong belief in the importance of their own role challenge traditional perspectives on family roles (16, 17), where families’ capacity and efforts in relation to the intensive care patient have received little attention (1, 3, 14).

    Even in Norway, families have been regarded more as visitors than as a resource for the patients (18). Defining families as passive visitors or as resources can have an impact on the interaction between the families and the healthcare personnel.

    Even in Norway, families have been regarded more as visitors than as a resource for the patients.

    The findings are in line with research on families of intensive care patients concerning the emphasis on the sense of security, the healthcare personnel’s expertise and patient care, honest information and the importance of a family-friendly structure (4–8, 12).

    Families’ efforts are worthwhile

    The informants’ desire to be there for the patients has been identified in earlier research (4, 7, 8, 19). Studies have emphasised that participation is important for the families’ own health (20, 21), but there is less of a focus on the importance of the family members’ efforts for the patients. The informants’ hopes and positive expectations for the heart surgery may have made it easier for them to assume an active role.

    Research has shown that the burden on families is less in cases of intensive care treatment following planned surgery than for emergency intensive care (22). Meanwhile, the importance of families’ efforts for seriously ill intensive care patients has been documented in research (3, 23), which shows that the treatment context may have an impact, but is not a prerequisite for the family members taking an active role.

    Expectations that the patient should recover from heart surgery and intensive care meant that some informants did not consider themselves to be a target group for support from healthcare personnel. All they wanted was information, since family members took care of each other. The importance of healthcare personnel’s support and care for families has almost been taken for granted, and is therefore not discussed to any great extent.

    Earlier research has shown that families of intensive care patients suppress their own needs because they are so focussed on the patient’s situation (4, 7, 8, 20). While some family members do not feel a need for support, other members of the same family may react differently to the patient’s illness and intensive care stay and will consequently have a greater need for involvement from healthcare personnel. Families differ in terms of caring for the patient, participation, reactions to the patient’s illness and the need for support.

    The informants wanted updates on the patient’s condition. For some, confirmatory information after heart surgery was sufficient, but not when the clinical pathway took a different direction. It has previously been shown that deviations from the described treatment pathway increase family members’ need for explanations (24). When the use of standardised clinical pathways in the health service becomes more widespread, reactions and needs in relation to pathway deviations may also be a relevant issue for families of other patient groups.

    Trust in the health service

    The informants generally trusted the health service. They felt that their trust in healthcare personnel in the unit was justified. Families’ observations of how healthcare personnel took care of the patient and the families’ contact with the staff confirmed that the patient was in safe hands. The importance of families experiencing that patients are well taken care of is consistent with research showing that families are reassured by care, expertise and dedication in healthcare personnel (4, 5, 8, 20, 21).

    When the informants believed that the healthcare personnel were in control, it compensated for an incomplete picture of the pathway. The importance of trust in healthcare personnel may explain research results showing that even though the majority of informants did not understand the content of what was communicated to them, they were nevertheless satisfied with the supply of information (25).

    Research also shows that relatives often refrain from asking for clarification when they trust the healthcare personnel (26). This finding is in contrast to research results from intensive care units that give very limited access to visitors, and where restrictions and waiting have led to considerable frustration for families and created more uncertainty (17).

    Family members protected the patient

    An important task for the informants was to protect the patient, which we interpret as shielding the patient and sparing their feelings. According to research on patients’ families living in countries with low levels of societal trust, protection took on a different meaning in that it entailed monitoring the healthcare personnel’s treatment and care for the patients.

    They assumed that the healthcare personnel did more for the patients when the families were present (27). Consequently, family members assumed a role similar to a guard, or an advocate-like role, in order to safeguard the patient’s interests (3, 16, 17, 20, 23, 28), while our informants trusted that the patients were well taken care of whether a family member was present or not.

    Ambitions to protect the patient conflicted with the informants’ desire to ask staff questions. Research has shown that families refrain from asking questions for reasons of protection; to spare the patient from disturbing topics of conversation in the patient’s room (7, 8, 29).

    They assumed that healthcare personnel who perform patient care cannot dedicate too much attention to families. The studies point to a need for alternative arenas for communication with families of intensive care patients (13, 19, 24).

    More satisfied with single rooms

    The informants thought that the single-room structure made it easy for them to care for and support the patients during their stay in intensive care. There is little research on intensive care units with single rooms, but satisfaction surveys before and after the reorganisation of the room structure show that satisfaction increases when there is an opportunity for privacy and when more emphasis is placed on improving the atmosphere in the unit (30).

    The results from these studies are in contrast to research in which the intensive care unit environment is described as frightening and noisy (10, 11). Although the environment is portrayed as quieter, encounters with a critically ill family member can nevertheless have a strong impact on relatives and they will therefore still have a need for preparatory information (4, 13, 31).

    Family members’ perceptions of their presence in the intensive care unit differed, but this finding is not well-documented in earlier research (4). According to Olsen et al., intensive care patients often worry that some family members cannot bear to visit (32). Such findings can highlight variations in experiences and perceptions, not only between families, but also within the same family.

    This appears to be more of an active role and less of a recipient role than shown in earlier research.

    Family members’ experiences showed that a modern, family-friendly structure and confidence-inspiring experiences with healthcare personnel helped families to take on a supportive and active role. This appears to be more of an active role and less of a recipient role than shown in earlier research.

    Reflections on method

    The interviews generated rich data on families’ experiences and perceptions. The perspectives and voices of family members emerged, including in relation to matters we did not include in the interview guide. For example, the informants placed a great deal of emphasis on the importance of trust in the health service in general and in the healthcare personnel they had contact with during the clinical pathway. We discussed the findings based on relevant research, and we have reason to believe that the findings are relevant for relatives’ experiences in a similar context.

    The number of informants was lower than planned as we concluded recruitment after nine months, with six informants. This is a weakness of the study. Despite our ambitions to recruit more informants, we believe that the data on family members’ experiences include both common and more varied experiences, which strengthened the analysis of the findings (15, 33). In principle, the number of informants is assessed according to whether the data adequately elucidate the issue.

    The fact that the sample consisted of informants who were taken from a limited population, where the informants had experiences from a limited and defined field, can justify a downward adjustment of the requirement for the number of informants (33).

    We concluded that the sample of informants was composed of different familial roles, gender and geographic location, that the data basis was sufficient, and that we achieved saturation in the data. However, it is possible that the patients recruited family members based on different familial roles, but who nevertheless had several things in common, and that the findings reflected this.

    The findings are based on an interpretation of the interview material. The interviewer undertook a dual role as a researcher and a professional practitioner. We avoided mixing professional roles and research roles in the interview setting by excluding patients for whom the first author, who is also an intensive care nurse, had been responsible. The role of intensive care nurse may nevertheless have influenced the informants and meant that they under-communicated criticism.

    One of the strengths of the study is the first author’s and one of the co-author’s extensive knowledge of the field. Nevertheless, their occupational affiliation carries a risk of bias and insufficient distance to the field in the interpretation of data (15). We attempted to reduce this risk by involving a co-author in all parts of the research process who did not have the same affiliation.

    The data are based on the informants’ narratives following the intensive care stay, which may have impacted on the findings, both in terms of the recollection and the assessment of the course of events. Small details can easily be forgotten, but it is uncertain whether forgotten information affects the quality when complex experiences and perceptions are being conveyed.

    The informants were made up of the patients’ spouses of both sexes and adult children of both sexes. It is unknown whether the variation in familial roles and gender had a bearing on our findings, but we believe that family roles and family dynamics, in addition to individual reactions in the same families, should be elucidated through research.

    Conclusion

    Family members found that it was possible to feel a sense of security despite tension and uncertainty during the intensive care period. Trust in healthcare personnel, information, expectations of heart surgery and a family-friendly structure provided the basis for a more active role by family members than that described in earlier research.

    Family members felt that their efforts made them an important resource for the intensive care patients. This finding challenges traditional perspectives on the roles of patients’ families, where family members are primarily ascribed a passive recipient role as a visitor. The findings point to considerable variation in the reaction patterns within the same family, which is an under-researched area and should be explored further.

    We would like thank the patients who recruited a family member, as well as the family members who participated in the study.

    We would also like to thank the Cardiothoracic Intensive Department and Department of Cardiothoracic Surgery at St. Olav’s hospital.

    Finally, we thank the Norwegian Nurses Organisation’s Association of Intensive Care Nurses (NSFLIS) for allowing the first author to attend the writing seminar in 2017.

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    A calm atmosphere with single rooms, flexible visiting hours and trust in the healthcare personnel can help the family members to serve as a resource for heart surgery patients with a prolonged stay in intensive care.

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    Sammendrag

    Background: Family members can provide crucial support for the patient, including during stays in an intensive care unit, but the family members’ situation and efforts have not been sufficiently elucidated in earlier research. The focus has been on identifying the family members’ needs and their satisfaction with how healthcare personnel meet these needs.

    Visiting hours in intensive care units have traditionally been restricted. Multi-bed wards were sometimes considered overwhelming, with limited opportunities for privacy. Little research is available on family members’ experiences with single rooms and flexible visiting hours.

    Objective: We wanted to obtain more knowledge about families’ experiences in connection with prolonged stays in intensive care units following heart surgery in a unit with single rooms and flexible visiting hours.

    Method: A grounded theory-based study, including semi-structured interviews with six family members of intensive care patients. The data were analysed in accordance with constructivist grounded theory (CGT).

    Results: Patients’ family members sought and fostered a sense of security by being present for the patient and helping the patient to get through the intensive care treatment. They found that single rooms, short waiting times, flexible visiting hours, information, trust in healthcare personnel, privacy and a calm atmosphere in the unit enabled them to play an active role in which they could support and protect the patients.

    Family members had a strong desire to make the patient and other relatives feel more secure in an uncertain, unfamiliar, busy and challenging situation characterised by fluctuating hope and emotions. During visits, they were primarily concerned with supporting the patient and protecting them from their own reactions and difficult topics of conversations. Strong impressions and concern for the patient sometimes made it difficult to comprehend important information given by healthcare personnel.

    Conclusion: Family members wanted to play a role in making the patients feel more secure during their stay in intensive care, and they felt that their efforts were an important resource. A calm atmosphere, trust in the healthcare personnel and private visits with the patients made it possible for them to support and care for the patients. The findings challenge traditional perspectives on the roles of patients’ families, where families are ascribed a passive recipient role as a visitor.

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  • Prehospital healthcare personnel are apprehensive about paediatric airway management

    Airway obstruction may well be one of the most frequent causes of death in children (1), but acute illness can also bring respiratory problems (2). It is therefore important that prehospital healthcare personnel are proficient in applying techniques that clear the airways of patients (2–4). Prehospital healthcare personnel include paramedics, nurses, ambulance workers and doctors.

    In children, the epiglottis is sharper and the larynx is located higher than in adults, and the dimensions are smaller. The techniques, however, are generally the same (4). Several factors can help to prevent undesirable incidents in children; one of them is enhanced knowledge and skills among healthcare personnel.

    Cross-professional interaction

    Prehospital healthcare personnel have a unique opportunity to prevent undesirable incidents by practising how to deal with serious illness by applying simple, life-saving measures in the acute phase. For anaesthetists, ambulance personnel and doctors to be able to implement life-saving measures and prevent the development of serious illness or complications, they must work to a high professional standard and have the adequate level of professional and interactive competence (5).

    Cross-professional interactive skills are required for the treatment of patients to be effective and to achieve a broad platform of competencies (6–8). It is therefore essential that healthcare personnel have the required skills and are familiar with the necessary procedures and equipment for use in emergency situations.

    Prehospital work in rural areas

    Report to the Storting (white paper) no. 13 (6) makes it clear that there is a growing need for a range of skills within the healthcare sector, yet approximate 30 per cent of workers in the primary health service are unskilled. It is unclear which sectors are represented, and whether the content of this report may put the standard of prehospital work at risk. However, it may be necessary to enhance prehospital competencies, particularly in rural areas.

    It may be necessary to enhance prehospital competencies, particularly in rural areas.

    According to the Official Norwegian Report NOU 2015:17 (9), a shortage of trained healthcare personnel in remote areas may come to represent a challenge to the management of illness and injuries outside of hospital. The Health Directorate’s report on the need for paramedic competence (10) points out that there will be a demand for healthcare personnel with skills across a range of levels, and that there is a need for enhanced competencies in the ambulance service, currently and in the future.

    Proficiency requirements

    Research confirms that all members of staff are expected to maintain their skills in basic paediatric airway management as well as their familiarity with essential medical equipment such as bag valve masks, medication and intubation (1, 3–4). Emergency healthcare personnel should be proficient in basic airway management and practise implementing the procedures (4, 11).

    There is no documentation to suggest that intubation is a life-saving prehospital measure, but there is sufficient documentation to indicate that basic airway management saves lives (11). It is vital that first-aiders feel confident in their work and provide effective life-saving first aid when the minutes count (3). This assertion is supported by Goldmann and Ferson (12), who point out that basic airway management is a first-line treatment and requires ongoing skills training.

    Objective of the study

    The study’s objective is to enhance our knowledge of prehospital healthcare personnel’s insights into the professional and interactive competencies that are available in the workplace with respect to paediatric airway management.

    The research question

    ‘What is the experience of prehospital healthcare personnel with respect to professional and interactive competencies in acute paediatric airway management in rural areas?’ 

    Method

    Design

    We have employed a qualitative design in this study. This design is well suited for research that seeks to explore experiences and opinions (13). We made use of focus groups in order to draw on a range of experiences and gain a wider understanding of the topic from the different professions employed by the ambulance service.

    Sample

    Staff at the Clinic of Emergency Medicine and Prehospital Care and at one municipal Accident and Emergency Department in Central Norway were invited to take part in the study. We selected a random sample of ambulance stations and medical centres. Information letters were sent to the managers of twelve random ambulance stations, three medical centres and the Norwegian air ambulance service.

    Seven ambulance stations with considerable geographic spread, and one medical centre, enlisted for the study. A total of 25 informants accepted our invitation to take part, but only 20 made themselves available for interview. The informants were from a cross-professional background and between 21 and 49 years of age. Their work experience ranged from 2 to 24 years. Current employment in the prehospital services was the only informant inclusion criterion. Table 1 shows the number of informants included from the various professions.

    Table 1. Professions represented in the sample

    Data collection

    We conducted three focus group interviews in the spring of 2017, involving five, seven and eight informants respectively. We obtained the participants’ consent declarations and mapped their experience, training and age. The interviews were conducted at three different ambulance stations. Interview duration was 30 to 50 minutes, with each interview ending in a concluding summary.

    We used a Dictaphone for recording purposes, and the first author transcribed the interviews immediately afterwards. All data were erased at the end of the project. We made use of an interview guide with the following four open-ended questions:

    • What competencies do you consider to be important in order to optimise the treatment of children?
    • What is your experience of cross-professional collaboration in such circumstances?
    • Tell us about your familiarity with or skills in using the technical medical equipment for children.
    • Tell us about the sort of courses and practice sessions you have attended in paediatric airway management or in the use of equipment.  

    Analysis

    We based our analysis on an inductive approach; the findings became meaningful through a process of interpretation and abstraction (14). Our analysis of the interview transcripts was inspired by Giorgi’s (15) analytic strategy. The first and last authors conducted the analysis without using any computer software. The four stages of the analytic strategy were implemented as follows:

    Total impression. Repeated close readings of the transcribed material allowed us to form a total impression.  

    Identifying meaning units. We divided the text into a number of meaning units, each with a unique colour code.

    Abstraction and condensation of the text. This process helped us to develop two meaning units: a) communication and interaction in prehospital work with children, and b) prehospital professional development. Each of the meaning units were then condensed into four sub-categories, two per unit. These were used as headings for our Results chapter.

    Synthesising the meaning of the text. Critical conceptualisation of the text highlighted helpful quotes and drew out the essence of the interviews.

    Table 2. The analytic process

    Results 

    Communication and interaction in prehospital work with children

    Communication when the minutes count

    ‘Being clear, and thinking out loud, could be vital to avoiding misunderstandings’, said one informant who received the backing of several others. In their opinion, good communication between prehospital healthcare personnel and other resources, such as the emergency calls service (AMK), the air ambulance service and the accident and emergency department, is essential to ensuring that patients receive good treatment.

    Staff should be imaginative and seek to distract children from the most critical aspects of the situation.

    They also pointed out that healthcare personnel should be flexible in all emergency situations involving children, because ‘parents often come rushing out and fling their kid into the arms of the first person they see’, in the words of one informant. Several informants pointed out that prehospital personnel cannot therefore be locked into a pre-planned distribution of work. It was also made clear that staff should be imaginative and seek to distract children from the most critical aspects of the situation.

    Cross-professional interaction

    The informants agreed that good cross-professional collaboration was key to their work, but it was considered to be down to personalities whether this collaboration worked well. They also reported that they could draw on significant assistance from the emergency calls service, the air ambulance service, accident and emergency departments and hospitals, even if they were not in the immediate vicinity.

    Several informants reported that their experience with collaborative interaction was good. One of them said: ‘I have never been rebuffed when asking for assistance.’ This informant pointed out that although they have access to all collaborative partners, it is essential that the ambulance personnel are able to work independently.

    This independence was essential because the geographic distances involved are vast, and time may be short. Moreover, because many local authorities depend on inter-municipal partnership agreements, there may be no accident and emergency Department available at certain times. Whenever an Accident and Emergency Department is available, this is considered a helpful resource and a confidence boost for the ambulance personnel.

    The informants emphasised that doctors have wider experience with children and are therefore more skilled at distinguishing between the healthy and the poorly, and between incidents that carry little risk and those that are potentially serious.

    Prehospital professional development

    The need for professional development

    Some of the informants pointed out that it was impossible for them to learn practical skills by reading about them when there was no opportunity to practise or receive skills training to boost their experience. They said they needed procedural training and added that they wanted internships at hospitals with organised practical skills training. In the words of one of the informants: ‘I want training in the correct use of bag valve masks.’

    The informants felt that the individual staff members were given too much responsibility for their own learning. They argued that having to take responsibility for their own learning would lead to considerable individual differences in skill levels.

    The informants felt that the individual staff members were given too much responsibility for their own learning.

    They went on to point out that they are entitled to have time set aside for professional training during working hours, but that it is left to the individual station manager to decide how much time is earmarked for such training. An internal reference book with clear procedures was a good aid, particularly in emergency situations involving children.

    Professional development undertaken

    Several informants were concerned that they did not automatically receive feedback once the patient had been transferred to hospital, or that they had no right to see the patient’s records due to confidentiality regulations. The informants maintained that a lack of feedback can be an obstacle to learning from experience and hold back professional development.

    Furthermore, several informants emphasised that they should be offered to attend courses and other skills-enhancing programmes, and that several such measures should be made mandatory. ‘Us ambulance workers have completed our online training, and today this is the only re-certification programme available’, said one informant. Several informants were keen to point out that courses and annual skills checkouts had boosted their confidence and improved their skills: ‘Increase the requirements we need to meet and make us better at our job.’

    Some informants pointed out that a certain level of baseline knowledge was necessary in order to understand the body’s anatomy and the effect of medication: ‘There is often only one person with medication management authority on duty in the ambulance service. Much of the responsibility is therefore resting on the shoulders of this one person.’ Some of the informants missed having an instructor with specialist expertise: ‘We have no practical checkouts for children.’

    Discussion 

    Handling emergency situations

    Several informants mentioned that a lack of confidence in the work situation may be a cause of stress, which is supported by Smith and Roberts (17). They maintain that stress, in turn, can lead to a loss of confidence. Prehospital healthcare personnel should be confident in their work in order to cope with stress in emergency situations. Terrified parents and distressed children who find themselves in a crisis constitute a stress factor for ambulance personnel, according to Bohnström et al. (18).

    How ambulance personnel handle stress in emergency situations has also been the subject of studies conducted by LeBlanc et al. (19), who maintain that ambulance personnel often found themselves in highly stressful situations. They also point out that it is necessary to prepare prehospital healthcare personnel for acute stress situations and that an appropriate level of competence is required (19).

    Calm communication is important

    The informants pointed out that clear, calm, simple and targeted communication, particularly in emergency situations, was essential in order to optimise the treatment. According to Rehn et al. (11), calm dialogue with parents and children makes for a better approach and is more reassuring, thus representing a good investment in the treatment. They go on to point out that communication is a skill that can be acquired through practice.

    According to O’Malley et al. (20), there may be communication challenges associated with dealing with terrified parents and frightened children. Information is easily forgotten in a shock phase and should therefore be repeated. Some informants maintained that talking to the child in a pleasant, amiable way can generate calm and trust, which may be the start of an optimal treatment chain.

    According to Richardsen (2), and Grønseth and Markestad (21), it can also be reassuring if healthcare personnel explain what is being done to the child. Children generally have a limited capacity to describe discomfort and pain. This challenge increases the need for observation, and observation is essential for correct prioritisations to be made.

    Communicating with children

    Communicating with children is different to communicating with adults. Healthcare personnel must engage with the child at the child’s own level, using simple words and explanations: calmly and considerately, but in a focused tone of voice and a relaxed posture that signals neither stress nor anxiety. Using the equipment in a creative and playful way may help to establish trust, which in turn enhances communication (22).

    The informants gave several examples of things that might help to defuse the situation and distract the child, including the use of a plastic cup rather than a mask in oxygen treatment, inflating rubber gloves, demonstrating on a teddy or using humour and stories.

    A conscious choice of words

    Levetown (23) asserts that it may be a useful and life-saving approach to choose words and expressions clearly and consciously, and that relatives expect to receive information. The various professions have their own terminology, which is difficult to understand for patients and their relatives. Communication must be adjusted to the receiver, and it is important to be clear in conversation and to use simple words in order to avoid misunderstandings.

    According to Aggarwal et al. (24), approximately 70 per cent of incidents are caused by a failure in communication and interaction. This includes communication with colleagues as well as with the child or with parents. LeBlanc et al. (19) emphasise that the most common intervention in emergency medicine is precise communication.

    Several informants were keen to see good cross-professional collaboration, and many wanted more training. Team training across professional boundaries can help to improve collaboration (25, 26).

    Professional and interactive competencies within the service

    Parents whose children suffer from respiratory problems may find the situation extremely distressing. They expect to encounter competent healthcare personnel. It is essential that prehospital healthcare personnel are confident in their work and provide effective, life-saving assistance when the minutes count. Such confidence is in line with the minimum requirements for basic prehospital airway management (3).

    In critical situations it is essential that healthcare personnel have sufficient professional and interactive competence (4). An Official Norwegian Report (NOU) (9) points out that health trusts must ensure that staff who provide emergency medical services meet specific requirements and that the trusts are obliged to provide the necessary training and practice. They are also obliged to ensure that all parts of the health service meet a certain set of requirements. 

    The informants said that feedback was not automatically forthcoming once the patient had been transferred to hospital, largely due to confidentiality regulations. Hospital culture focuses on the patient’s treatment and health in general. Prehospital training is therefore not a key issue in a hospital setting. It is not clear whether confidentiality regulations are in fact the root cause.

    The informants claimed that the management fails to provide follow-up skills training, and that there is no skills checkout for children. According to Bjerkelund et al. (4), each individual member of staff is responsible for maintaining their competence and undertaking in-practice skills training. The informants intimated that they wanted an instructor with specialist expertise and were looking for organised training and practice sessions.

    Simulations are desirable

    Some currently make use of checklists for completed practical training, but it is up to the individual whether the need for further practice and knowledge is followed up. Simulation as an educational method is an alternative to in-practice learning, according to Aggarwal et al. (24). Simulation is appropriate in this context because there are few opportunities to learn by experience, and the level of stress is high.

    Smith and Roberts (17) maintain that simulations prevent stress, which is a valuable factor in this line of work. Simulations can help healthcare personnel raise their awareness of their own expertise, strengthen their qualifications and create good, controlled learning scenarios that provide realistic practice.

    Simulations can replace real-life situations under guidance and enable reconstructions of recent events. Simulations will therefore be useful for practising and evaluating learnt skills. Healthcare personnel can sit down together to reflect on the treatment provided (19, 25, 27). Simulations are all about becoming competent and ready to implement procedures that are special to a particular profession (26).

    Good collaboration depended on personalities

    Good clinical competence is essential to be able to work independently and to maintain the patient’s safety (28). The informants felt that they worked well with air ambulance and hospital personnel, and that the cross-professional interaction was good. According to Aggarwal et al. (24), good cross-professional collaboration and management can lead to better independent working.

    Several informants expressed the opinion that the standard of collaboration depended on who was on duty. Personal qualities should not be a key factor in emergency interaction. Systematic, shared routines can help prevent patients from receiving different treatment depending on whose shift it is. The pattern of actions in emergency situations must be predictable (9).

    Personal qualities should not be a key factor in emergency interaction.

    The informants found that internal procedures provided a good reference, and that they were easily accessible, updated at all times and useful in the treatment of patients. Jewkes (29) supports the use of written internal procedures and maintains that in the face of limited access to sophisticated equipment and varying competence levels among staff, standards can be improved by good procedures.

    Inadequate competence enhancement

    The informants were concerned that they often worked independently, but clearly signalled that they needed to be flexible in order to be able to work well with their partner, the doctor, the emergency call service and the hospital. The study also showed that ambulance personnel should boost their professional and interactive competencies, particularly considering the fact that several local authorities have entered into inter-municipal partnerships with respect to their accident and emergency services and that timing conflicts may arise that require them to work without assistance from, for example, the air ambulance service.

    It may be necessary to introduce competence-enhancing measures into the education programme. The informants demonstrated clear frustration over the paramedic foundation course, which does not include the testing of skills in paediatric airway management. This suggests that the responsibility for skills training in paediatric airway management may rest with the practice field.

    Because specialty training and a postgraduate degree is not a requirement for joining the service, there will be individual differences with respect to professional background. One of the reasons for this discrepancy among ambulance personnel is that vacancies are often advertised without citing specialty or postgraduate education as a minimum requirement. It may be useful to introduce mandatory postgraduate education in this field. The ambulance service often employs nurses, as seen from the sample.

    Reflections on methodology

    The first author works in the prehospital service and is therefore familiar with the field and the topic of our study. The second and third authors are less familiar with the field. A range of different backgrounds may be a strength for the study because we were able to identify different nuances within the data material. A small sample taken from a single region does not demonstrate breadth of knowledge, so we cannot know with any degree of certainty how prehospital staff in other areas perceive paediatric airway management. Nevertheless, the informants showed engagement and an interest in the questions we asked, which enabled us to collect nuanced data.

    The focus group interviews constituted a strength because they facilitated discussion and reflection on the topics, and we felt that the material was sufficiently broad, varied and rich. It may nevertheless have been a weakness that there was a doctor included in only one of the three focus groups, because doctors train to a higher standard and may have acquired better knowledge of the study area. It may have been a strength that the analysis was conducted by two of the authors because the data was examined by more than one person.

    Conclusion

    The study shows that the informants were apprehensive about the prehospital treatment of children with acute and critical respiratory problems. They were unsure how to use medical equipment, had few opportunities to practise in order to maintain their competence, and their training was inadequate. Children who present with respiratory problems can therefore be a challenge for the prehospital service.

    Several informants intimated that professional and interactive competencies were not consistently optimal throughout the emergency medicine chain. They wanted the required training so they would be able to provide health services of a high professional standard and maintain patient safety in emergencies and critical situations. The informants were looking for more high-volume training, internships and simulations in order to maintain their skills and competencies.

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    10.        Helsedirektoratet. Kompetansebehov i ambulansefag. Rapport fra arbeidsgruppe. IS-0425. Oslo; 2014. Available at: https://helsedirektoratet.no/Lists/Publikasjoner/Attachments/134/Kompetansebehov-i-ambulansefag-rapport-fra-arbeidsgruppe-IS-0425.pdf(downloaded 12.10.2018).

    11.        Rehn M, Hyldmo PK, Magnusson V, Kurola J, Kongstad P, Rognås L, et al. Scandinavian SSAI clinical practice guideline on prehospital airway management. Acta Anaesthesiologica Scandinavia. 2016;60(7):852–64.

    12.        Goldmann, K, Ferson DZ. Education and training in airway management. Best Practice & Research Clinical Anaesthesiology. 2005;19(4):717–32.

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    22.        Månsson ME. Förberedelser av barn och föräldrar inför undersøkelse eller åtgärd. In: Hallström I, Lindberg T, eds. Pediatrisk omvårdnad. 2. ed. Stockholm: Liber; 2015. p. 123–7.

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    29.        Jewkes F. Prehospital emergency care for children. Arch Dis Child. 2001;84(2):103–105.

    The study’s informants were particularly apprehensive about critical emergencies and unsure how to use medical equipment such as bag valve masks.

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    English
    Sammendrag

    Background: Research on prehospital work indicates that paediatric airway management is neither straightforward nor simple. The prehospital expertise available in the field is inconsistent, and there is no standardisation of prehospital healthcare competence across the Nordic region.

    Objective: To enhance our knowledge about prehospital healthcare personnel’s perceptions of professional and interactive competencies within the service with respect to paediatric airway management.

    Method: We employed a qualitative design and conducted three focus group interviews with five, seven and eight informants respectively. They represented eight different ambulance stations and medical centres in Central Norway. Our analysis was based on an inductive approach.

    Results: The study demonstrates general apprehension with respect to paediatric airway management, particularly in critical emergencies. The informants also lacked confidence in using medical equipment such as bag valve masks. The informants felt they had received insufficient top-up training and were inadequately prepared for following procedures and for collaborating with other personnel.

    Conclusion: The study suggests that there may be a need to enhance competencies in order to optimise the prehospital treatment of children with acute and critical respiratory problems. The informants were looking for high-volume training, internships and simulations in order to maintain their professional and interactive competencies.

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  • Pain teams can provide good support to healthcare personnel in the pain relief of opioid-dependent patients

    Substance dependency is a major global health problem. Substance-related illnesses and injuries frequently lead to hospitalisation, and pain is one of the most common reasons that those with a substance dependency go to a hospital (1).

    Substance dependency is characterised by several behavioural, cognitive and physiological phenomena following repeated substance use. Taking drugs is given a higher priority than activities and obligations, which can lead to an increased tolerance for medicines and thus reduce their efficacy, as well as a physical withdrawal state (2).

    Obstacles to providing appropriate treatment

    Healthcare personnel’s lack of knowledge on tolerance development, hyperalgesia (increased sensitivity to pain), substitution medication and withdrawal symptoms can result in inadequate treatment and pain relief being provided (1, 3–5). The danger is that patients discharge themselves at their own risk. Lack of expertise on opioid dependency that stimulates neuropsychological, behavioural and social responses can also hamper the provision of appropriate pain relief (6, 7).

    Norwegian and international studies show that a relationship of trust between patients with a substance dependency and healthcare personnel is essential to forming an honest and good dialogue that will ensure the quality of further pain relief (1, 6–10). Several studies show that uncertainty in the approach to such patients is due to a lack of expertise, an inability to establish a relationship of trust, distrust of the patient and attitudes that substance dependency is self-inflicted (6, 7, 10).

    Pain teams

    Patients with a substance dependency are entitled to the same quality of treatment as other patients (5). International studies show that hospitals lack organised pain teams despite evidence showing that pain teams are important, useful and effective tools for ensuring that those with a substance dependency receive the necessary pain relief (6, 8).

    There appear to be no official statistics on the number of pain teams in Norway, but several hospitals have established pain teams for pain conditions that are difficult to treat in hospital patients (11). According to one conference paper, only 6 out of the 21 hospitals in South-Eastern Norway Regional Health Authority have pain teams (12).

    Objective of the study

    There are no published studies on Norwegian pain teams’ experiences with patients with a substance dependency. It is important to shed light on the pain teams’ knowledge. Their experiences can help increase health personnel’s knowledge and enable them to better serve the needs of this patient group. The objective of this study is to highlight the experiences of specialist nurses in pain teams with the pain relief of such patients.

    Method

    The study has a qualitative design with six individual, semi-structured in-depth interviews (13).

    Informants

    We contacted pain clinics at five hospitals in Southern Norway by email. Four hospitals had pain teams and experiences with pain relief for patients with a substance dependency. The pain teams consisted of one or more specialist nurses and an anaesthetist, and were affiliated with a pain clinic or anaesthesiology department. Two pain teams ran outreach activities, but all treated patients based on referrals.

    We gained access to research fields by applying the hospitals’ procedures. A contact person at each of the hospitals invited informants to participate. The inclusion criteria stipulated that informants had to be specialist nurses with at least two years of experience from working in a pain team and treating the target group of patients. After the informants had confirmed that they wanted to participate, we sent information to them by email.

    Interviews

    We conducted the interviews in November and December 2015, and they lasted 45 to 60 minutes. The first and second authors were present during all the interviews and had the main responsibility for three interviews each. We used a semi-structured interview guide with open-ended questions related to positive and challenging experiences with pain relief for the target group. Upon completion of each interview, we transcribed the audio recording.

    We used qualitative content analysis (14) and read the transcripts several times in order to form a general overall impression. The interview text was broken down into meaning units, which were then condensed, abstracted and coded. The first and second authors formed meaning units and codes jointly for four interviews and separately for two interviews.

    All the authors discussed and reflected on ambiguities that arose during the analysis process, which led to a new and deeper common understanding. The reflections were influenced by the authors’ preconceptions, experiences with the patient group from emergency departments and intensive care units, as well as their varying experiences with analysing research results. Using the codes, similarities and differences in the text content were identified and sorted into three categories (Table 1).

    Table 1. Presentation of categories and sub-categories

    According to the Norwegian Centre for Research Data (NSD), the study is not subject to notification (project number 44942). The study was carried out in accordance with the Declaration of Helsinki’s ethical guidelines (15). The transcripts were anonymised, securely locked away during the research process, and destroyed after completion of the content analysis. After receiving oral and written information about the study, the informants signed a consent form.

    Results

    A strategic sample consisting of six specialist nurses from pain teams at four Norwegian hospitals participated in the study. Two hospitals were represented by two informants, and the other two hospitals had one informant each. Five informants were nurse anaesthetists or intensive care nurses, and one had specialist expertise in pain management. All were women over the age of 30 and had worked in pain teams for more than three years.

    Trust

    All the informants found that the patients felt a sense of security when the pain team set aside time, took their pain seriously and treated them with respect:

    ‘Making the patient feel safe is everything.’ (ID-A1)

    There was broad agreement that a good meeting required honest and direct communication in which the pain team spent time and dared to ask challenging and direct questions, even when the questions could be awkward. The informants also described how some patients were articulate, sometimes told lies and were demanding and manipulative. Many of the patients came from environments where they were not accustomed to trusting anyone. One informant said she made the patients take responsibility:

    ‘Establishing trust is a two-way street.’ (ID-A2)

    The informants stated that they took the same approach to patients with a substance dependency as to other patients with pain issues, and that they did not stigmatise the patient, but did set boundaries. One informant pointed out how important it is to ‘reset yourself’ before meeting patients and taking a sincere interest. Everyone said that their experience gave them confidence, enabling them to deal with demanding situations:

    ‘Building an alliance with and trusting the patient is a difficult balancing act. If you are too sceptical, you can’t build an alliance. It’s important that they feel they are treated the same as other patients.’ (ID-A2)

    Expertise

    All respondents felt privileged to have time for individual pain management and pointed out that pain mapping and substance use analysis had to be carried out at an early stage:

    ‘Our priorities and mapping activities can differ from those of ward nurses. We can set aside time, pull up a chair and listen.’ (ID-B1)

    All the informants found that the patients’ racing thoughts, sleep deficit, anxiety and depression created challenges in the pain relief. The full facts had to be ascertained before pain regimes could be adapted and work for each patient:

    ‘We have become much better at communicating: talking about ‘the craving for drugs’, racing thoughts and seeing the patients’ perspective. This helps us achieve our objectives.’ (ID-A2)

    ‘So, I just want to stress that in relation to substance use analysis and pain mapping – recognise the context and give the patients what they need. Take them seriously.’ (ID-B2)

    It was agreed that patient involvement within defined limits was crucial. Close follow-up throughout the entire course of the patient’s treatment pathway aided continuity:

    ‘Patients with a substance dependency become demanding when there are no treatment arrangements in place and everything is random.’ (ID-B2)

    ‘Being present, close follow-up and evaluation are all important.’ (ID-B1)

    Patients with a substance dependency become demanding when there are no treatment arrangements in place and everything is random.
    Informant

    The informants had extensive knowledge of pain relief, which they considered to be a criterion for the successful pain relief of those with a substance dependency:

    ‘I don't necessarily give out more medication, but change the doses a bit. This can make things easier for the patient.’ (ID-D)

    ‘Sometimes, patients need medication other than opioids. We need to give them the right medication for them to feel well. The hospital therefore needs the pain team’s expertise.’ (ID-D)

    The informants found that pain management was occasionally poor and knowledge was lacking in some ward nurses and doctors. They also said that the nurses learned more when the pain team undertook assessments with them:

    ‘It’s safe for the nurses […] and easier for them to expand their knowledge.’ (ID-A1)

    All pain teams arranged workshops. One pain team taught newly-employed nurses about pain relief for those with a substance dependency. Three hospitals had nurses who acted as a pain contact in the wards. The pain contacts served as a link between the pain team and the ward.

    Cooperation

    Hospital departments sent referrals to the pain team, while some pain teams ran outreach activities in addition. If the patient was undergoing opioid replacement therapy (ORT), the pain team contacted the patient prior to and/or after surgery in order to check the instructions with the pain management guidelines.

    The informants said they carried out independent inspections and follow-ups. The anaesthetist prescribed medication, but treatment plans were drawn up jointly:

    ‘Much of what I do concerns the follow-up, and I give the anaesthetists updates and feedback.’ (ID-C)

    All the informants said that local guidelines for pain relief for the target group have been available for several years, and that the guidelines were important in the cooperation between the pain teams and the wards. Some said that patients with a substance dependency were more likely to discharge themselves at their own risk before the guidelines were applied:

    ‘The most important part of my work in relation to the quality assurance of pain teams is probably to devise guidelines.’ (ID-C)

    All informants believed it was important to be available and maintain good contact with ‘life at the coal face’. One informant said it was encouraging to see that the ward nurses got ‘a real boost’ when they mastered pain relief for the patients they perceived as challenging:

    ‘No ward nurse dares to titrate [gradually increase the dose until achieving the desired effect] up to 100 mg of morphine intravenously if they have never done it before.’ (ID-A1)

    The informants found that the cooperation with the ward doctors varied. They shared their experience and knowledge with the interns and junior registrars, and found their role as a contributor and sparring partner to be rewarding. Three informants, however, felt that their expertise was not used if the ward doctors wanted to draw up their own pain regimes. In these cases, the patients did not get the necessary pain relief, which caused frustration among the ward nurses:

    ‘I dare to speak up and stand by what I say. Just let the doctors get angry with me. As a nurse in a pain team, I can take it.’ (ID-D)

    All the informants contacted the ORT consultant as quickly as possible if the patient was receiving such treatment. The cooperation here was particularly useful when the pain team did not receive sufficient information from the patient:

    ‘I was called to a patient who was receiving a massive dose of methadone, 240 mg! When I contacted the ORT team, they were surprised. It turned out that the patient had been discharged from a hospital with the large dose, without a de-escalation plan.’ (ID-B1)

    All informants pointed out how important it was for the pain team, ORT team and GP to work together to form a de-escalation plan. They all had positive experiences with drawing up de-escalation plans, which the hospital doctors sent to the GPs.

    Discussion

    Trust

    All of the informants found that they had to establish a relationship of trust during their first encounter with a patient, that it takes time and is essential for ensuring appropriate pain management. These experiences are consistent with research showing that taking time to listen to the patient’s feelings and hardships helps build good relations (16), and that healthcare personnel rely on the patient’s trust in them to carry out their nursing work (17).

    The informants also said that patients with a substance dependency are used to people not trusting them and are often from environments where they were not accustomed to trusting anyone. This statement is in line with research showing that substance users are afraid of not being taken seriously (1, 8). Skau (17) claims that trust can be easily be broken by behaviour that is perceived as offensive. International studies also show that nurses can stigmatise and misinterpret the behaviour of those with a substance dependency, and that negative attitudes to those with an opioid dependency do exist (8–10, 18).

    It is particularly challenging for healthcare personnel to establish a relationship of trust with such patients.

    Among Norwegian healthcare personnel, there is also a general perception that patients with a substance dependency are dishonest about their substance use and about the effect of medication (7, 19). It is particularly challenging for healthcare personnel to establish a relationship of trust with such patients due to the scepticism of many of these patients to the public health service and healthcare personnel.

    However, it is important to make the patients take responsibility in the treatment programme, since ‘trust is a two-way street’, according to one informant. If the healthcare personnel fail to earn the patient’s trust, the patient may not receive the appropriate pain relief and choose to discontinue the treatment and discharge themselves from the hospital at their own risk. Healthcare personnel’s attitudes and moral caution are important for good nursing practices and successful pain management (9, 20, 21).

    According to Nielsen (16), a good attitude can reduce the patient’s fear and scepticism that the treatment will not help them. This is supported by earlier research, which shows that good attitudes are an important tool for healthcare personnel establishing trust and reducing the patient’s fear that treatment will not work (7, 9, 16). This research is consistent with the results of our study and shows that trust is a success criterion in the pain management of those with a substance dependency.

    Expertise

    The informants had positive experiences with allocating time to carry out substance use analysis and pain mapping, creating individual treatment plans, asking open-ended and direct questions, making the patients take responsibility, making agreements and setting boundaries. These experiences are consistent with a Danish study (16), which shows that the pain team motivates the patient and makes the treatment a joint undertaking.

    Skau (17) and Eide et al. (22) also emphasise that values such as compassion, care and respect for basic human rights are reflected in active listening, conversation, counselling and good interviewing skills.

    Research also shows that ward nurses have different experiences, expertise and time to take care of patients with a substance dependency (10). Communication skills and knowledge of what to map are not sufficient; healthcare personnel also need to understand the patient’s unique psychosocial context (10, 22).

    Mapping and further treatment programmes may fail if the healthcare personnel’s communication is not sincere and truthful. Furthermore, repeated meetings between pain teams and patients can help ensure that appropriate pain relief is provided if the patient is involved and made to take responsibility.

    Three informants expressed frustration when some doctors did not use the pain team’s expertise, which sometimes led to inadequate pain relief. All of the informants described how they had experienced inadequate pain management and lack of knowledge in some ward nurses and doctors. Several studies confirm that pain relief is not always offered, that little is known about the complexity involved, and that substance use mapping is inadequate (7, 8, 18).

    The informants in the study recommended workshops and pain contacts as a way of increasing staff expertise. Nurses and doctors, however, have an independent responsibility for keeping themselves professionally up-to-date, taking an evidence-based approach to their practices and working with other qualified personnel if the patient’s needs so dictate (23).

    It must also be a managerial responsibility to facilitate the establishment of procedures and systems for pain mapping, collaboration with pain teams where these exist, training and a sufficient number of personnel with the necessary qualifications to provide appropriate pain relief (23, 24).

    When the informants used their specialist expertise on medication combinations and doses, the patients experienced pain relief.

    According to one informant, patients with a substance dependency can easily act out and create uneasiness in a ward when they are not taken seriously or do not receive the necessary pain relief. These patients often find that the prescribed medication fails to have an effect (1). Consequently, the informants conducted individual pain management, which was continued and evaluated throughout the patient’s clinical pathway.

    When the informants used their specialist expertise on medication combinations and doses, the patients experienced pain relief. The experiences of the study’s informants show that the expertise on wards in relation to medication combinations and doses is insufficient, and that help is needed from the pain team.

    According to Duelund et al. (6), nurses were better equipped to treat patients with complex pain issues after discussions with pain teams. The pain team may be able to aid appropriate pain relief by helping to increase the level of expertise of healthcare personnel on the wards, but this is dependent on management facilitating the exploitation of the expertise in the organisation.

    Cooperation

    The pain team was readily available for the ward staff. The pain teams provide a low-threshold service, and are flexible, proactive and purveyors of new knowledge, which is important since doctors and nurses used the pain team to safeguard pain management throughout the patient’s treatment pathway. The informants pointed out that, in order for pain teams to serve as a resource for the hospital, it is essential that management has a positive attitude to them.

    If hospitals do not have pain teams, it could be questioned whether they are able to meet the requirements for specialist expertise in complex pain management. The needs of the patient should determine which occupational groups are involved (24). The development points to a practice in which the patient is involved in inter-professional interaction processes (8, 24). Patient involvement is a statutory right and must be taken into account (20).

    Continuity in the treatment programme can be compromised by ever-increasing professionalisation and specialisation (24) and can both impair the quality of treatment and lead to inadequate treatment. Pain teams seem to be a success criterion for quality and help ensure a good treatment programme by steering the patient through the support system, whereby specialist expertise benefits the patient (24).

    Pain teams seem to be a success criterion for quality and help ensure a good treatment programme.

    The hospitals in the study had pain relief guidelines for patients with a substance dependency. Prior to implementation of the guidelines, there had been some cases of such patients discharging themselves at their own risk, which posed challenges to the interdisciplinary cooperation. The informants stated that the guidelines helped create a better common understanding among the nurses and doctors of the principles of pain management and prevented the treatment from being person-dependent.

    The results from an Australian and a British study (1, 4) showed that patients with a substance dependency were treated with greater dignity and respect after the hospitals in the studies had implemented guidelines, and were less aggressive and manipulative. These findings are in line with our study and show that pain management guidelines are a success criterion for appropriate pain relief for the target group of patients.

    All informants had a good working relationship with the ORT staff in relation to the collection of information about medication and identifying use of any additional substances by hospital patients. When the patients are hospitalised, the contact with the ORT staff is important for maintaining and continuing the right substitution dose (3, 5).

    The Coordination Reform stipulates that the primary and specialist health services should coordinate their efforts when transferring patients between hospitals and municipalities (25). This emphasises the importance of the cooperation with GPs and ORT staff, who can ensure that de-escalation is organised as the final step in a comprehensive treatment programme.

    Methodological considerations

    The interviewers have experience as nurses in accident and emergency departments and are familiar with the patient’s challenges with pain relief in hospitals, but have no experience with pain teams. Prior understanding provides a good basis for recognising the challenges faced by the nurses in pain teams, and for asking illuminating questions during the interviews. However, preconceptions can also lead to certain matters being overlooked or underestimated.

    We sought to reduce this risk by mapping preconceptions throughout the research process, and by including all the authors in the analysis process (13, 14). The last author is a specialist nurse with experience from an intensive care unit. However, there is always the possibility that analyses and interpretations by others will produce different results.

    We chose these particular informants because they had many years of experience working in pain teams and were therefore able to highlight and elaborate on the specialist nurses’ experiences with relieving pain in patients with a substance dependency. Everyone was informed that we wanted to learn about both their positive experiences and their challenges. Nevertheless, most of the descriptions were positive, which suggests that the informants’ experiences from working in pain teams were predominantly positive.

    Conversely, the interviewers could have asked more questions about the challenges. There is a known tendency for informants to give positive answers to questions in research interviews (13). We do not know if this tendency has affected the findings of our study, but it is nevertheless something to be aware of. We found that the dynamic between the informants and the interviewers was good, and that the informants shared their experiences willingly.

    It is a strength that no similar studies have been published in Norway, and there is a need for knowledge based on experiences from specialist nurses in pain teams.

    Conclusion

    The experiences of specialist nurses in pain teams show that pain relief for patients with a substance dependency requires trust, expertise and cooperation in order for the patient to be safely guided through their stay in hospital. Having time for the patient is a success factor and a privilege afforded to specialist nurses in the pain team.

    In order to meet the patient’s need for pain relief, ward staff need to increase their level of expertise. Healthcare personnel find support in the pain team when they have pharmacological questions and when preparing individual treatment plans. They also receive support in relation to establishing relationships of trust and communicating openly with the patient.

    Good cooperation between healthcare personnel and pain teams is necessary during a patient’s stay in hospital in order to provide appropriate pain relief and comprehensive patient care. The pain team also has a unique role in facilitating follow-up plans after discharge from the hospital.

    It may be interesting to investigate the target patients’ experiences with pain teams in future studies. Studies of whether healthcare personnel gain more knowledge about pain relief for patients with a substance dependency by working with pain teams may also be beneficial.

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    18.     Liberto LA, Fornili KS. Managing pain in opioid-dependent patients in general hospital settings. Medsurg Nurs. 2013;22(1):33.

    19.     Krokmyrdal KA, Andenæs R. Nurses' competence in pain management in patients with opioid addiction: A cross-sectional survey study. Nurse Educ Today. 2015;35(6):789–94.

    20.     Ruyter KW, Førde R, Solbakk JH. Medisinsk og helsefaglig etikk. 3. ed. Oslo: Gyldendal Akademisk; 2014.

    21.     Stubberud D-G, Eikeland A, Søjbjerg IL. Psykososiale behov ved akutt og kritisk sykdom. Oslo: Gyldendal Akademisk; 2013.

    22.     Eide H, Eide T, Keeping D, Eide E. Kommunikasjon i relasjoner: personorientering, samhandling, etikk. 3. ed. Oslo: Gyldendal Akademisk; 2017.

    23.     Lov 2. juli 1999 nr. 64 om helsepersonell m.v. (helsepersonelloven). Available at: https://lovdata.no/dokument/NL/lov/1999-07-02-64(downloaded 15.02.2019).

    24.     Orvik A. Organisatorisk kompetanse: innføring i profesjonskunnskap og klinisk ledelse. 2. ed. Oslo: Cappelen Damm Akademisk; 2015.

    25.     St.meld. nr. 47 (2008–2009). Samhandlingsreformen: Rett behandling – på rett sted – til rett tid. Oslo: Helse- og omsorgsdepartementet; 2008. Available at: https://www.regjeringen.no/contentassets/d4f0e16ad32e4bbd8d8ab5c21445a5dc/no/pdfs/stm200820090047000dddpdfs.pdf(downloaded 14.12.2017).

    Helath personnel can learn from the pain team when they have pharmacology-related questions and are drawing up treatment plans, and when they are establishing open and trusting relations with the patient.

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    Background: International research shows that hospital patients with a substance dependency do not receive the pain relief they are entitled to. This may be due to a lack of knowledge about medication, use of pain mapping tools, how to approach such patients, or healthcare personnel’s attitudes. There are no studies on whether Norwegian pain teams have an impact on the pain relief of patients with a substance dependency.

    Objective: To highlight the experiences of specialist nurses in pain teams with the pain relief of patients with a substance dependency.

    Method: The study has a qualitative design. We conducted individual interviews with six specialist nurses in pain teams at four Norwegian hospitals, and used qualitative content.

    Results: Pain teams have time for direct patient contact. Where the pain team identifies a lack of expertise among healthcare personnel, they provide support and training in how to dose and combine different medications in order to relieve pain in patients with a substance dependency. Furthermore, pain teams contribute with knowledge of substance use analysis and pain mapping, how to establish trust and a sense of security and how to communicate with this group of patients. Cooperation with healthcare personnel both inside and outside hospitals is emphasised.

    Conclusion: The pain team is able to prioritise time for patients with a substance dependency and serve as a resource for patients, doctors and nurses. The results suggest that pain teams are a useful investment for meeting the need for optimum pain relief among patients with a substance dependency. The patients receive pain relief and are followed up in a treatment plan both at the hospital and after discharge.

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  • How nursing research has developed

    Nursing is historically regarded as a practical occupation: action-oriented and patient-oriented. Following the universities’ inclusion of nursing science in the 1980s, there have been discussions on the advantages and disadvantages of theorising nursing. The implementation of a scientific approach has led to an increase in nursing research and requirements for research competence in employees in education and the health service.

    The arguments for the implementation of a scientific approach are, inter alia, that nurses must base their actions on research in order to counteract the random treatment of patients (1). Objections have been raised to the academic ambitions that many claim divert nurses from practice (2). It is asserted that nursing expertise that is intended to be useful and practical is gradually losing its practice orientation (5).

    The nursing knowledge base has been the subject of criticism and debate. The key question has been what knowledge a nurse needs to perform good nursing (3). The answer is not clear. The academisation of practical professional subjects is constantly a topic of debate – more specifically, whether these subjects require more scientific knowledge (4–6). Is such criticism justified or does it conform to the views of those who perceive nursing as a profession in which practice is the most important aspect (7)?

    Previous research

    Empirical studies have been conducted in Sweden and Denmark on how nursing science has developed (8, 9). Heyman’s (8) doctoral thesis from 1995 is a comprehensive, scientific investigation of the growth of nursing research in Sweden between 1974 and 1991. Heyman found different types of theses where two scientific traditions in particular were clear: medicine and social sciences.

    The majority of the theses were written from the point of view of medical logic, and were based on articles and had an experimental-like design with intervention groups and control groups. Other theses had a social science approach with a more limited dataset where a qualitative analysis was performed. The topics were related to social phenomena or the interpretation of concepts. Most theses were monographs.

    Petersen’s (9) study of doctoral theses written by nurses in Denmark has a theoretical and empirical approach that is similar to that of Heyman. The results of both studies show heterogeneity in the theoretical assumptions, the methodological reasoning and the structure of the theses analysed. Various types of scientific logic were operative.

    In addition to medical and social science approaches, Petersen’s study highlights philosophical theses based on humanist scientific ideals. Empirical studies of the nurses’ theses thus show heterogeneity in their philosophy of science approach. Positivist, interpretative and critical approaches were represented.

    Lundgren et al.’s study (10), in which the authors examined Nordic doctoral theses in nursing and caring sciences in 2003, shows that knowledge about the patients dominates. Eighteen out of 26 theses targeted knowledge about the patient, two targeted interaction between nurses and patients and two focused on the patient’s environment.

    The patient was the primary focus in the research

    Heyman (8), Petersen (9) and Lundgren et al. (10) refer to nursing science as complex. For the most part, differing views of science, methodology and theoretical framework come to light. Research on the patient was the dominant topic. Although the studies indicate that nursing is a subject in which there is a clear medical logic, it can also be seen as interdisciplinary with elements of psychology, pedagogics and sociology, for example.

    Nursing research in the Nordic region appears to have a clinical, patient-oriented perspective.

    Most of the theses had an individualistic approach, which indicates that nursing research is devoted to the individual rather than to society in general. We can therefore conclude that nursing research in the Nordic region appears to have a clinical, patient-oriented perspective.

    Master’s degrees on the clinical context of nursing

    Various scholars have analysed nursing research at a lower level of education, including Hellesø and Fagermoen (11). They analysed master’s degree theses in nursing science from the University of Oslo submitted in the years from 1987 until 2015. In the analyses, they were inspired by Kim’s (13) conceptual domains. The main topics of the master’s degree theses centred on clinical practice studies and patient studies, i.e. the clinical context of nursing.

    There was less thematic focus on nursing education, and administration and leadership. The practice studies mainly included studies of nurses’ deliberations on their own practice. The patient studies were related to patients’ perceptions of the challenges that being ill or receiving care entailed.

    In order to understand the implementation of a scientific approach to nursing, PhD theses in our neighbouring countries have been studied. We lack this type of empirical study in Norway.

    The objective of the study

    The objective of the study was to examine whether the development of knowledge in nursing research has been patient-centred and practice-oriented, or if it has been practice-distant and solely focused on scientific interests. Our study examines Norwegian PhD theses in nursing science submitted to the University of Oslo (UiO) in the period from 1996 up to and including 2016. We examined theoretical and methodological approaches in addition to thematic perspectives.

    We also wished to elucidate how nursing science has developed in the Norwegian context in order to establish whether the trend is the same as in Sweden and Denmark or whether nursing research in Norway differs.

    Our research questions in this study are as follows:

    • What theoretical approaches do nursing researchers apply?
    • What thematic areas does the research cover, and what scientific methods do nursing researchers employ?
    • Does nursing research elucidate practice-relevant issues?

    Method

    The research questions can be studied in different ways. In our study, we chose to study them by means of PhD theses in nursing science submitted to UiO. We analysed a total of 50 PhD theses. The study has a qualitative design based on text analysis. The coding of the texts is inspired by Braun and Clarke’s (12) thematic analysis.

    We have analysed the theses using deductive analysis. First, we read the summary and then parts of the thesis. At the second stage, we applied Heyman’s (8, p. 62) classification of theoretical perspectives: the humanities, organisational theory, social sciences, psychology, pedagogics and medicine. In our study, we analysed PhD theses in nursing science. Nevertheless, we construct nursing science as a separate category because some theses apply nursing theory.

    Kim’s four domains

    Kim (13) describes four domains into which nursing science can be divided: the client (patient) domain, the client–nurse domain (interaction domain), the practice domain and the environment domain. The client–nurse domain refers to the interaction related to contact and communication between the patient and the nurse.

    The practice domain is related to what nurses do in procedures, actions and treatment. The environment domain refers to the patient’s surroundings, and structures the context in which nursing takes place. At the fourth stage, we went over the dataset a number of times and together discussed how to classify the theses according to different theoretical approaches and thematic areas.

    The domains are not mutually exclusive categories and the theses may encompass several categories. For example, communication can be understood as interaction between the patient and the nurse, but can also be classified as treatment and so belongs to the practice domain. When the thesis examined relationships, we placed it in the interaction domain. When communication is an intervention, we placed the thesis in the practice domain.

    Classification of the theses

    Some theses could be classified according to several theoretical perspectives; for the most part this applied to theses with a humanist perspective that at the same time utilised, for example, Kim’s theoretical approach. We placed these in the nursing science category.

    Theses dealing with quality of life could have been classified as nursing science because it is a key concept in nursing. However, when the theses dealt with quality of life instruments and measurements, we chose to place them in the medical approach category.

    Data sources were derived from open internet access and library loans. We classified the various theoretical approaches in line with Larsen and Adamsen’s (14) breakdown of nursing research. The theoretical perspective is explicit in most of the theses, although several perspectives are employed in some.

    The last type of thesis has a clinical approach without any clear theoretical perspective. However, such theses have a methodological approach closely linked to medical research ideals. We classified these theses according to the medical perspective.

    The form of the theses and co-authorship

    In addition, we examined co-authorship and the form of the theses. Moreover, we classified the use of methods into three categories: qualitative, quantitative and mixed methods. We included two theses employing mixed methods where the literature review is categorised as a qualitative method. The reason for this is that the reviews are not meta-analyses but explanations of concepts used in the measuring instruments.

    The study has been approved by the Norwegian Centre for Research Data (NSD) (project number 43577).

    Results

    In order to answer the research questions, we have divided the findings into the theoretical approach, research area and method of the thesis.

    Theoretical approach

    The study shows a tendency towards a medical and organisational theory approach and a move away from the humanities (Table 1). In the period 1996–2005, the humanities accounted for six out of 16 submitted PhD theses, while in the period from 2006 to 2016, only three out of 34 theses were humanist based.

    Table 1. Theoretical  approach in PhD theses

    Ødbehr’s (15) thesis, which applies theories related to spirituality and religiousness, is an example of a humanist approach in the second period. If we consider the medical approach, none of the theses in the first period adopted such an approach, while five out of 24 theses had this approach in the second period. Fagernes’ (16) thesis on infection risk in connection with the use of finger rings is an example of a medical approach.

    Since 2011, there has been an increase in the use of organisational theory approaches. This approach includes interprofessional collaboration (17), and documentation in organisations (18).

    Since 2011, there has been an increase in the use of organisational theory approaches.

    Although the application of the social science approach has been on a small scale, it has remained stable. If we extend this approach to include organisation, psychology and pedagogics, we see the same stability. Knutsen (19), who has studied the use of power vis-à-vis morbidly obese patients in light of Foucault’s theory, provides an example of this.

    In the nursing science category, we have placed only theses that utilise nursing theory, for example Haanes’ (20) thesis that applies Dorothea Orem’s self-care theory, and Kvignes’ (21) thesis that applies the theories of Kari Martinsen and Patricia Benner. In the period from 2006–2010, most theses have a nursing theory approach when examined in relation to the number of theses written in the same period (five out of 10).

    The theses’ research areas

    The majority of PhD theses focus on topics in the practice domain (Table 2), accounting for a total of 23 theses. The practice domain includes studies of nurses’ performance and interprofessional cooperation as well as documentation and ethical issues linked to the practice of nursing.

    One example is Wøien’s (23) study on pain relief and sedation practices at 54 intensive care units in Norway. Doctors and nurses characterised the practice as disorganised. There was no routine assessment of pain, discomfort or confusion.

    Fifteen of the theses fall within the client domain. The patient group studied is particularly centred on the elderly, mother and child in the post-natal period, patients suffering from a stroke and those with long-term illness.

    One example is Martinsen’s (22) study of patients of working age suffering from a stroke and their psychosocial challenges. The patients struggled to gain access to relevant health and care services. Follow-up was described as random and little suited to the needs of this younger group of stroke patients.

    Table 2. The development of PhD theses from 1996 up to and including 2016

    Nine theses fall within the environment domain, which includes the competence of health personnel, risk of infection, quality and quality development in the health service. One example is Hauge’s (25) study of the nursing home as a home, in which she investigates how common rooms for residents are used and organised. The study revealed unclear boundaries between the private and public spheres of the nursing home.

    Only three of the theses are classified within the interaction domain, which includes email communication between patients and health personnel as well as cooperation related to service user participation and influence.

    Fegran (24) sheds light on the domain by examining responsibilities and relationships between parents and nurses in a post-natal ward. She also studied how cooperation between parents and nurses developed during the period of the child’s hospitalisation. The study indicated that the nurses’ relationships with the father play a significant role for mother, father and child.

    The development of thematic areas in the theses indicates a trend towards increased focus on the practice domain, for example topics linked to the actions of the nurse.

    Form, method and co-authorship

    Up until 2004, the monograph was the dominant form of thesis, but since then it has been in the minority since article-based theses with a comparative discussion (Nor. Kappe) have been predominant. In the last five years, only two theses have been written as monographs (Table 2).

    We see a corresponding trend in methodology where the qualitative method prevailed as a research method up to 2010. After that time, a number of theses employed mixed methods. Few doctoral theses were based purely on quantitative methods.

    There has been a growth in the contributions of other professions, particularly doctors, both as co-supervisors and co-authors, in the course of the twenty years that UiO has educated doctoral degree candidates in nursing science. During the first five-year period, only three theses were submitted, one of which was article-based. In this thesis, no doctors were included as co-authors.

    In comparison, doctors and people from other professions were co-authors in approximately half of the theses submitted in the second period from 2011 to 2016. When we consider the type of studies that doctors have either co-authored or supervised, we find that these are largely based on mixed methods or quantitative methods.

    The research often takes place in hospitals, and issues in focus include medical diagnosis, follow-up treatment or interprofessional collaboration involving doctors. One example is Lie’s (29) thesis about patients following a heart operation, their symptoms and how these are managed. This was an intervention study. The thesis comprised, inter alia, four articles, and both the main supervisor, who is a nursing scientist, and the co-supervisor, who is a doctor, were co-authors.

    In comparison, staff of UiO’s Department of Nursing Science have co-authored all article-based theses by virtue of their position as main supervisor. All seven theses included in our study that apply the quantitative method are article-based. Doctors co-authored several of them. 

    Discussion

    In the period from 1996 to 2016, we see a development in PhD theses in nursing science at the University of Oslo. They have moved from a theoretical humanist approach to an organisational theory and medical approach. Likewise, we see a shift from the monograph form to article-based theses. From having a main emphasis on the qualitative method, the methodology changes to increasing use of mixed methods.

    The topics of the theses mainly concern nursing practice and patients’ perceptions and experiences.

    We also see a growing tendency for people from other professions, doctors in particular, to be co-authors. The topics of the theses mainly concern nursing practice and patients’ perceptions and experiences. Nursing researchers mostly perform clinical empirical research in collaboration with other professions.

    Nursing research is clinically based rather than theoretically based

    Our study shows that nursing researchers are interested in the large patient groups, such as elderly people and those with long-term illness. They are focused on the field of practice, such as the home care services, nursing homes and hospitals. If we consider the patient groups and the service areas studied, there appears to be little documentation that nursing research is practice-distant.

    Our study indicates that nursing research is practice-oriented. The question that arises is whether it is remote from theory. Larsen and Adamsen (14) demonstrated in their study that Nordic nursing research can be understood in light of three positions: a clinical and applied oriented position, a profession and knowledge oriented position, and a theoretical and concept oriented position.

    The PhD theses in our study refer to the theoretical and concept oriented position to a limited degree. Nevertheless, there appears to be a correlation between studies undertaken in Denmark (9), Sweden (8, 10) and Norway regardless of the period of time. The theses we studied seemingly show that nursing research has developed in the direction of clinical research and medical research ideals.

    Malterud (30, p. 185) claims that in the professional culture of medicine, theory is perceived as an accumulated mass of knowledge. We interpret this as meaning that nursing research is influenced by the medical understanding of theory. There is also a tendency towards a growth in organisational theory approaches. This can be interpreted as a clinical trend, since medical and organisational perspectives appear to be highly prevalent in the field of practice.

    The question arises as to whether knowledge development aims at understanding and explaining practice and the patients rather than developing new theories and concepts unique to nursing science. Our study shows the same variation in theoretical approaches and methods as the studies of Heyman (8) and Pettersen (9).

    Since nurses conduct research in a team together with medical professionals, we can assume that the earlier mentioned distance to medicine is in the process of change. We can therefore also ask whether nursing science as such is no longer in ‘opposition’ to medicine. In contrast to previous years when nursing research tended towards humanism, and philosophy in particular, we now observe clearer elements of medical research ideals and organisational theory.

    It is interesting to note that the opposition to medicine, which we have seen throughout the history of nursing, appears to be declining. Kari Martinsen (2) radically confronted reductionism and society’s treatment of patients in terms of the neglect of the weakest patients. Our study indicates that nursing researchers rarely engage in this critical debate. The individual perspective still predominates, while the social perspective is seldom invoked.

    Medical research ideals?

    Our study shows that both the form and method of PhD theses have changed from the use of qualitative methods and monographs to mixed methods and article-based theses. This change appears to apply to many subjects. Moreover, the theses are often written together with people from other professions. In the period up to 2004, the PhD programme in nursing was linked to UiO’s Faculty of Social Sciences.

    The institute was incorporated into the Faculty of Medicine from 2004. This change may explain the increasing medical influence on the form and method of the thesis. In terms of external medical factors of importance to nursing research, we can mention the Research Council of Norway’s evaluation of medical and health-related research. The evaluation concludes by stating that ‘the Norwegian society […] has a great need for evidence-based practices in the nursing area’ (31, p. 15).

    The question that arises is whether these factors are of significance for nursing as a discipline, education and profession. Does the nursing discipline emerge more clearly, or does it become part of a wider health profession in which medical knowledge and research ideals take precedence? Traditionally, the nursing discipline has two roots – one humanist and one medical (32).

    Little emphasis seems to be placed on the relational aspects.

    If the trend in nursing is a departure from the humanist perspective, a considerable body of the knowledge base may become unclear. Little emphasis seems to be placed on the relational aspects. Only in three theses has the interaction between patients and nurses been the main thematic area.

    The monograph has been the preferred form of thesis in the humanities. Some of the arguments in favour of this form have been that the candidate must show independence, depth and thoroughness in the analyses performed. The candidate is the sole author of the monograph. On the other hand, the article-based thesis has a short format that is better suited to the rapid dissemination of knowledge. The candidate is often one of multiple authors.

    Limitations of the study

    This study has only examined theses submitted to an institute at the University of Oslo, and therefore does not incorporate the total number of theses submitted by nurses. There are few theses in the first period, and the database for understanding the development as far back as 1996 is limited. Kim’s (13) theoretical categories are employed, and the use of standardised categories may have reduced the differences and variations in the dataset.

    Conclusion

    Nursing research at UiO’s Department of Nursing Science appears to represent heterogeneity in theoretical approach and method. In the second period examined, we see a trend towards organisational theory and medical perspectives.

    As regards thematic areas, nursing researchers are more interested in patients’ perceptions and the organisation of the execution of nursing but less interested in the interaction between patients and nurses. In this respect, criticism of the distance of nursing research from practice is not well justified. The patient groups that received most attention were the elderly and those who had long-term illnesses, which aligns with the needs of society.

    Seen in a twenty-year perspective, it is interesting to note that the theses in nursing science submitted to the University of Oslo have shifted from monographs, humanist approaches and the use of purely humanist approaches and qualitative methods. For the most part, the form of the theses has changed to article-based theses with multi-disciplinary authorship.

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    In the last twenty years, PhD theses in nursing science at the University of Oslo (UiO) have changed in terms of methodology, authorship and theoretical approach. Has the research become less patient-centred and patient-oriented?  

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    Sammendrag

    Background: Nursing science is complex and draws inspiration from various traditions. The application of a scientific approach to nursing has entailed a growth in nursing research and research competence in the case of employees in education and the health service. The discussion focuses on whether this has changed nursing in a theoretical direction at the expense of being practice-oriented.         

    Objective: The objective of the study was to examine whether the development of knowledge in nursing research is patient-centred and practice-oriented, or if it is practice-distant.

    Method: The study has a qualitative design based on text analysis. We examine 50 PhD theses submitted to the University of Oslo in the period from 1996 up to and including 2016. The study covers the theoretical and methodological approaches of the theses and their  thematic perspectives.

    Results: The study reveals a trend towards a medical and organisational theory approach, and a move away from the humanities. The bulk of the PhD theses’ research area is related to the patient or the field of practice. Up until 2004, the monograph was more or less the dominant form of thesis – since then it has represented a significant minority because article-based theses have been predominant. The qualitative method prevailed up to 2010. Subsequently, theses more frequently employed mixed methods.

    Conclusion: PhD theses in nursing science from the University of Oslo appear to represent diversity in respect of theoretical approach and method. Nursing research has moved away from monographs, humanist approaches and qualitative methods. The trend is now towards organisational theory, medical perspectives, article-based theses and mixed methods. Our study shows that researchers in nursing are particularly interested in patient perceptions and the field of practice, which indicates that nursing research is practice-oriented.

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  • Doctor’s visits to nursing homes: Are out-of-hours doctors given sufficient patient information?

    The out-of-hours primary healthcare service is called when nursing home residents experience acute illness, injury or death, and the nursing home doctor is not available. In Oslo, this service is responsible for arranging doctor’s visits, which are coordinated by an experienced nurse at the emergency medical communication centre. The nursing coordinator at the centre decides whether the condition is acute or whether it can wait until the next work day when the nursing home doctor is present.

    The handbook for doctor’s services at nursing homes states that a nursing home doctor must conduct an intake interview with the patient and/or the patient’s family and write comments in an intake journal (1–2). The intake journal should include items such as information about the patient’s diagnoses, medications the patient is taking, and a description of the patient’s physical and mental capacity.

    Many nursing home patients are in the final phase of life, and the disadvantages of active medical treatment and hospitalisation may outweigh the benefits. Nursing home doctors are therefore recommended to document any assessments and decisions about treatment intensity in the patient’s medical record in the event of acute deterioration of the patient’s condition or illness in the future (3).

    Must clarify advance care plans

    To ensure good, individualised treatment, it is the nursing home doctor’s responsibility to ensure that the patient’s values and wishes regarding life-prolonging treatment are clarified. The doctor must also ensure that the information about such values and wishes is easily accessible if the patient is examined and treated by doctors who do not know him/her, and when hospitalisation might be necessary (4).

    Advance care plans provide especially useful information for out-of-hours doctors who are called in to treat acutely ill nursing home residents.

    Thorough advance care planning entails discussing with the patient and/or the patient’s family whether it is best to refrain from intravenous fluid or antibiotic therapy and hospitalisation if acute illness occurs, or from an attempt at cardiopulmonary resuscitation (CPR) in the event of heart failure.

    Advance care plans provide especially useful information for out-of-hours doctors who are called in to treat acutely ill nursing home residents: This is because, firstly, the doctor has not met the patient before; secondly, a large percentage of nursing home patients are cognitively impaired and have a limited ability to speak for themselves; and thirdly, nursing home patients usually have a short life expectancy.

    Families may have unrealistic expectations

    The family’s wishes probably have an influence on the out-of-hours doctor’s decision regarding treatment intensity and hospitalisation (5). Previous studies show that the family’s views and participation in discussions about treatment intensity may supersede the patient’s wishes and what is clinically regarded as appropriate life-prolonging treatment (6, 7).

    Families that have not had the chance to discuss the level of intervention in the event of acute illness while the patient is still stable are often unprepared for a sudden deterioration of the patient’s condition. Even though the acute deterioration signals that the patient is actually about to die, unprepared family members may have unrealistic expectations about medical treatment and therefore insist that the patient is admitted to hospital.

    Out-of-hours doctors need correct patient information

    The decision of the out-of-hours doctor regarding hospitalisation and commencement or cessation of treatment is taken on the basis of the available medical information about the patient and the doctor’s clinical assessment. An out-of-hours doctor who is called in to treat an acutely ill nursing home patient may have difficulties assessing the appropriate level of intervention for any treatment.

    A lack of medical information about the patient’s normal condition and wishes, as well as any information from the family, may make it difficult to choose good treatment options and increases the likelihood of overtreatment and unwelcome hospital stays (5, 8). Hospitalisation may be useful for diagnostic clarification and treatment that may result in a better chance of survival or functioning (9).

    Nursing home staff feel unsure about palliation

    However, emergency hospitalisation for physically frail patients with serious dementia and a short life expectancy will often be inappropriate, especially if good, palliative treatment can be provided at the nursing home (10). In the experience of the Oslo out-of-hours primary healthcare service, nursing home staff are often unskilled and feel unsure about administering palliative treatment.

    A lack of qualified nursing home staff most commonly occurs outside of normal working hours and at weekends, when the percentage of unskilled staff is highest (11). During weekend and night shifts, on-duty nurses are often responsible for multiple wards where the nurses do not know all the residents.

    In the experience of the Oslo out-of-hours primary healthcare service, nursing home staff are often unskilled and feel unsure about administering palliative treatment.

    When acute deterioration of a chronic condition occurs, having prior clarification on the treatment intensity and interventions and easily accessible documentation in the patient’s medical record will be beneficial and save resources. Staff that must provide palliative care feel a greater sense of security when advance care plans are already in place should the patient’s condition rapidly deteriorate (12).

    Two-thirds of Norwegian nursing homes reported in a recent survey that they ‘always’ or ‘frequently’ had conversations with patients about preparing for such a scenario (7). This is far more than a similar study from 2007 in which few nursing homes reported having had such conversations (13). However, we know very little about how the content of these conversations is documented.

    Objective of the study

    Doctors at the Oslo out-of-hours primary healthcare service have reported that the patient information they are given at the nursing homes they are called to varies widely. The objective of our study was to compile an overview of the medical information that Oslo municipality’s out-of-hours doctors are given when they call on nursing home patients in the municipality. We also asked the out-of-hours doctors about the potential consequences that insufficient patient information could have for their diagnosis and treatment of patients.

    Methods

    Survey

    Doctors permanently employed at the Oslo out-of-hours primary healthcare service make visits during the daytime (n = 48), while GPs with on-call shifts make visits in the evening and at night (n = 311). The out-of-hours doctors completed a questionnaire in connection with visits to nursing homes in the period from 21 May–20 August 2013. The survey asked questions regarding visits for both short-term and long-term residents, regardless of whether the patient lived in a sheltered unit or an open ward. Visits for the purpose of completing a death certificate were not included in the study.

    Part I of the survey provides a general description of the patient (gender, age, cognitive functioning, actual diagnosis and type of unit). Part II documents the patient information that was made available during the visit (intake journal and annual examination) and whether advance care plans (hospital admission or antibiotics in case of acute illness, or CPR in the event of heart failure) were made available.

    In Part III, the visiting doctors listed the interventions that were carried out (active treatment, hospital admission or no intervention). They also gave their assessment of the treatment indications (clear or unclear) and of relevant information in the patient’s medical record, as well as the care staff’s familiarity with the patient.

    Information for the participants

    The lead author held informational meetings for permanently employed doctors and nurses at the Oslo out-of-hours primary healthcare service prior to the survey period. Coordinators at the emergency medical communication centre distributed registration forms and provided the doctors with information about the study when they arrived at work, before their shifts began. Information about the study and registration forms were also given to the doctors’ permanent drivers, who were encouraged to make the forms easily accessible for the doctors when they visited nursing homes. We only included the data in our study when the registration form was filled out.

    Analysis

    We chose to analyse the doctor’s visits as independent, individual events, and did not take into account the potentially uneven distribution of the number of visits at the various nursing homes. We used binary logical regression to identify potential explanatory variables associated with various factors, e.g. the patient’s medical record was made available, information about advance care plans was provided, or active treatment was commenced.

    The logical regression was performed in three stages and based on unadjusted analyses. This was followed by the full model (Model 1) with all variables included. From the full model we made two new models, one of them (Model 2) for variables with p < 0.20 in the full model. The other one (Model 3) only included variables from the full model when the significance level was <0.05.

    We used the Akaike Information Criterion (AIC) (14) for each stage in the model adjustment (Models 1–3) in the logical regression to check whether including one or more variables improved adjustment of the model. The model with the lower AIC value was regarded as the most suitable one. We therefore use this one as the basis for our presentation of results. We performed all the analyses using Stata/SE 13, and set the significance level at 5 per cent.

    Approvals

    The project was submitted to the Regional Committees for Medical and Health Research Ethics (REC), which responded that this quality study did not require its approval. We deemed it unnecessary to obtain approval from the Norwegian Centre for Research Data, as we did not record any personally identifiable information, either for patients or for doctors.

    Results

    During the 92-day survey period, Oslo municipality’s out-of-hours doctors made 610 visits to nursing home patients in the region. Fifty visits concerned deaths, and in the case of the remaining 560 visits, we received registration forms from the doctors in 362 (64.6 per cent) of the cases. Some forms were not completely filled out so that the denominator for some of the variables was less than 362.

    The characteristics of the 362 nursing home residents visited by Oslo municipality’s out-of-hours doctors are shown in Table 1. The majority of the patients (60.2 per cent) were women with an average age of 86. The doctors observed that 68.5 per cent of the residents had cognitive impairment or dementia. Most of them (56.1 per cent) had been living at the nursing home for more than three months (Table 1).

    Table 1. Characteristics of patients and institutions

    At least half of the patients were diagnosed with infections or symptoms in the urinary or respiratory tract (26.8 and 25.7 per cent, respectively) (Figure 1).

    Figure 1. Distribution (in percent) of reasons for 362 doctor’s visits to nursing homes in Oslo

    Altogether 18.5 percent of the patients were hospitalised. The out-of-hours doctors were not given written patient information at the nursing home in 52.5 per cent of the visits (Table 2). Factors positively associated with the doctor being given access to the patient’s medical record was a patient’s age less than 80 years [odds ratio (OR) 1.68 (1.07–2.81), p = 0.05].

    Factors negatively associated with access to the patient’s medical record were that the visit took place during the daytime on a weekday [OR 0.49 (0.25–0.97), p = 0.04] or that the doctor perceived that the care staff did not know the patient well [OR 0.23 (0.11–0.48), p < 0.01].

    The out-of-hours doctors were only informed of decisions relating to reduced therapeutic intensity for a small number of patients: hospital admission (21.3 per cent), intravenous treatment (17.1 per cent), attempt at cardiopulmonary resuscitation (19.6 per cent) (Table 2).

    Explanatory variables positively associated with such information were that the patient had little or no ability to communicate [OR 2.13 (1.31–3.46), p < 0.01] or that the visit took place during the daytime [OR 1.97 (1.3–3.76), p = 0.04].

    Table 2. Information received by doctors and interventions commenced by doctors

    Doctors commenced active treatment, such as intravenous fluids and/or antibiotics, at the nursing home less frequently for patients in sheltered units versus open wards [OR 0.46 (0.23–0.95), p = 0.04].

    Although less than half of the out-of-hours doctors had seen written, up-to-date patient information, the majority of those doctors (81.2 per cent) believed that they had been given sufficient information to be able to reach a diagnosis and begin treatment.

    Discussion

    Formal patient information was not given to out-of-hours doctors in at least half of the nursing home visits. Information about advance care plans was provided in only one-fifth of the visits. However, most of the out-of-hours doctors believed that they had sufficient information to be able to make a sound diagnosis and commence treatment.

    Formal patient information was not given to out-of-hours doctors in at least half of the nursing home visits.

    When the health condition of a nursing home patient rapidly deteriorates, it is often a sign that the patient is about to die a natural death. A doctor unfamiliar with the patient may find it difficult to make a medical assessment in this situation. It is therefore crucial that clinical background information and decisions about therapeutic intensity are given to the out-of-hours doctors as a matter of course.

    Formal patient information was not provided to the out-of-hours doctors in at least half of the nursing home visits. This represents a quality-related problem since it can make reaching a diagnosis and choosing treatment options more difficult. Thus, our study suggests that the quality of the cooperation between the nursing home and the out-of-hours doctor may need to be improved.

    Insufficient information about refraining from CPR

    In almost eight of ten nursing home visits, the doctor reported that there was no information about whether to refrain from cardiopulmonary resuscitation (CPR) in the event of acute heart failure or that intravenous treatment or hospitalisation was not desired. In most cases, CPR performed on multimorbid residents with cognitive impairment and a short life expectancy represents futile overtreatment, which in itself raises ethical questions.

    Nursing home residents usually have dementia or cognitive impairment. They often lack the ability to state whether or not they want active treatment. It is therefore reassuring that information about advance care plans was available more often in those cases where the patient was unable to communicate with the doctor.

    Short life expectancy and the diminishing benefit of active treatment underscores the general need to have information about treatment intensity and emergency hospitalisation easily available. This can prevent potentially harmful overtreatment and unnecessary, difficult hospitalisation.

    Pressure to admit patients to hospital

    Regarding the issue of hospitalisation, a Norwegian focus group study on cooperation between nursing home doctors and hospital doctors revealed that the nursing home doctors put great emphasis on avoiding unnecessary admissions (15). The nursing home doctors said that they write in the patient’s medical record in advance if a patient should not be hospitalised, but that out-of-hours doctors often admitted the patient anyway. The nursing home doctors also pointed out that they often feel pressure, from both family and staff, to hospitalise acutely ill nursing home patients (15).

    Family members take part more often in conversations about treatment intensity than the nursing home patients themselves (7). This emphasises the need for knowledge among healthcare personnel about ethical considerations and current statutory provisions on patient and service user rights (6, 16). A minority of Norwegian nursing homes have guidelines for such conversations, and the content of the conversations varies (7).

    Many unskilled and substitute workers

    Unskilled personnel and substitutes continue to comprise a large share of the staffing in Norwegian nursing homes (11). It is alarming that out-of-hours doctors had less access to patients’ medical records during visits in which they perceived that the care staff had little familiarity with the patient in question. Care staff who are unfamiliar with the patient are probably more uncertain in treatment situations, and it is therefore likely they will more often want the patient to be hospitalised.

    Oslo municipality’s out-of-hours doctors are most often called in on evenings, nights and weekends, when the nursing home doctor is not available and the proportion of unskilled employees is greatest (11). In such cases, it is particularly important that information about limitations on possible therapeutic interventions in the event of acute illness is easily available to the out-of-hours doctor (1).

    A few nursing homes in Norway have introduced on-call schemes for their own nursing home doctors to ensure that the patients can receive adequate emergency treatment at the nursing home and to avoid unnecessary transport to the out-of-hours clinic or admission to hospital (17).

    Difference for those over and under 80?

    It is also thought-provoking that the care staff in nursing homes more often give doctors the patient’s medical record for nursing home residents under 80 years of age than for those over 80. However, it should be mentioned that patients under 80 comprised only 24 per cent of the nursing home residents visited by an out-of-hours doctor.

    Information about therapeutic intensity was provided more often during daytime visits, which corresponds well with the fact that there are more staff working at that time of day who know the patient well. On the other hand, the finding of less access to medical records during daytime visits on weekdays can be explained because permanent employees who are familiar with the patient in question are usually at work then.

    Information about therapeutic intensity was provided more often during daytime visits.

    Difficult access to medical records

    Two-thirds of Norwegian nursing homes carry out conversations about advance care plans (7), but little is known about how decisions taken during such conversations are documented. Our study may suggest that the availability of such patient information does not conform with current guidelines (1, 16). In addition, many doctors find that Gerica, the medical records system used at nursing homes in Oslo, is generally very cumbersome and time-consuming to navigate. This may have made access to medical records difficult, but we did not explore this aspect in our study.

    When the preliminary results from this study were presented to Oslo municipality’s out-of-hours doctors, they told us that they managed fine without access to more detailed patient information in certain situations, e.g. changing a catheter or prescribing peroral antibiotic treatments for infections of the urinary or respiratory tract. Furthermore, they had become used to not expecting patient information to be available about limitations on therapeutic intensity, although it would clearly have been beneficial.

    The out-of-hours doctors described the ‘on-call doctor’s nature’ as the ability to make a diagnosis and assess interventions without much background information about the patient. They believed that factors such as satisfaction with one’s own effort vis-à-vis the patient and the opportunity to discuss the problem with on-duty care personnel probably had affected their evaluation of the patient information they had received during their nursing home visit.

    Limitations of the study

    A limitation of our study is that we did not chart whether the out-of-hours doctors requested the patient information when such information was not provided to them by the care staff as a matter of course. Is it the doctor’s responsibility to ask for this information or does the responsibility rest primarily with the nursing home staff? Or is it a joint responsibility? Regardless of how responsibility is assigned, our study indicates that establishing clearer routines in this area may be necessary.

    It is important to mention that there are geographical differences in how out-of-hours doctor services and nursing home services are organised. We have described the challenges related to patient documentation during doctor visits at nursing homes in Oslo, but it is natural to assume that out-of-hours doctors outside of Oslo are also familiar with this problem. However, a factor that distinguishes Oslo from most other municipalities in Norway is that the Oslo out-of-hours primary healthcare service has permanently employed doctors that make home visits during the daytime. Outside of daytime hours and at weekends, however, it is the GPs with on-call shifts who perform this task.

    Changes at the conclusion of the study

    Since the conclusion of this study in 2013, many municipalities have established better routines for documenting patient and/or family conversations about treatment intensity. Oslo municipality has launched a palliation project (18) which aims to formulate the most appropriate level of medical treatment for patients with a short life expectancy. More emphasis is now being placed on conversations between the patient, family members and healthcare personnel about issues related to end-of-life, as well as planning and documentation of the final phase of life.       

    Since 2010, a separate module for advance care plans has been available in the Gerica medical records system. While in 2013 this module was only used for 0.5 per cent of the patients in Oslo with a permanent nursing home place, this number increased to 42 per cent in 2014 and 86 per cent in 2017, according to the nursing home agency in Oslo municipality (figures from Gerica on 15 May 2018 given verbally). The availability of such documentation will probably facilitate the on-duty nurse’s communication with the out-of-hours doctors and the doctor’s decisions during nursing home visits.

    Conclusion

    If out-of-hours doctors are not given access to relevant clinical background information about acutely ill nursing home patients, this represents a quality-related problem for diagnostics and treatment, which may result in inappropriate treatment and unnecessary hospitalisation.

    The study has received a grant from the General Medical Research Committee of the Norwegian Medical Association. We wish to thank all the participating doctors for filling out the registration form.

    References

    1.       Helsedirektoratet. Veileder IS-1436. Legetjenester i sykehjem – en veileder for kommunene. Oslo; 2007.

    2.       Høie J. Sykehjemmenes oppgaver og legens rolle. Tidsskr Nor Legeforen. 2005;125(8):1009–10.

    3.       Engtrø E, Nore SP, Kittang BR, Krüger K. Metodebok for sykehjemsleger. Bergen: Bergen kommune; 2015.

    4.       Helsedirektoratet. Beslutningsprosesser ved begrensning av livsforlengende behandling. Revidert 2013. Oslo; 2009.

    5.       Ouslander JG, Naharci I, Enstrom G, Shutes J, Wolf DG, Alpert G, et al. Root cause analyses of transfers of skilled nursing facility patients to acute hospitals: Lessons learned for reducing unnecessary hospitalizations. JAMDA. 2016;17(3):256–62.

    6.       Romøren M, Pedersesn R, Førde R. How do nursing home doctors involve patients and next of kin in end-of-life decisions? A qualitative study from Norway. BMC Med Ethics. 2016;17:5. DOI: 10.1186/s12910-016-0088-2.

    7.       Gjerberg E, Lillemoen L, Weaver K, Pedersen R, Førde R. Forberedende samtaler i norske sykehjem. Tidsskr Nor Legeforen. 2017;137(6):447–50.

    8.       von Hofacker S, Naalsund S, Iversen GS, Rosland JH. Akutte innleggelser fra sykehjem til sykehus i livets sluttfase. Tidsskr Nor Legeforen. 2010;130(17):1721–4.

    9.       Ranhoff AH, Linnsund JM. Når skal sykehjemspasienter innlegges i sykehus? Tidsskr Nor Legeforen. 2005;125(13):1844–7.

    10.     Björck M, Wijk H. Is hospitalization necessary? A survey of frail older persons with cognitive impairment transferred from nursing homes to the emergency department. Scand J Caring Sci. 2018;32(3):1138–47. DOI: 10.1111/scs12559.

    11.     Dolonen KA. Ikke etter planen. Sykepleien 12.08.2009. Available at: https://sykepleien.no/2009/08/ikke-etter-planen(downloaded 20.05.2017).

    12.     O’Neill B, Parkinson L, Dwyer T. Nursing home nurses’ perceptions of emergency transfers from nursing homes to hospital: A review of qualitative studies using systematic methods. Geriatric Nursing. 2015;36(6):423–30.

    13.     Gjerberg E, Førde R, Bjørndal A. Staff and family relationships in end-of-life nursing home care. Nurs Ethics. 2011;18:42–53.

    14.     Akaike H. A new look at the statistical model identification. IEEE Trans Automat Contr. 1974;356:716–23. DOI: 10.1109/TAC.1974.1100705.

    15.     Romøren M, Pedersen R, Førde R. Én pasient, to verdener – samhandling mellom sykehjemsleger og sykehusleger. Tidsskr Nor Legeforen. 2017;137(3):193–7.

    16.     Lov 2. juli 1999 nr. 63 om pasient- og brukerrettigheter (pasient- og brukerrettighetsloven). Available at: https://lovdata.no/dokument/NL/lov/1999-07-02-63 (downloaded 19.05.2017).

    17.     Bollig G, Husebø BS, Husebø S. Vakttjeneste for leger i sykehjem. Tidsskr Nor Legeforen. 2008;128(23):2722–4.

    18.     Sluttrapport palliasjonsprosjektet 2016–2017. Kompetanseheving i lindrende behandling, pleie og omsorg for alvorlig syke og døende. Sykehjemsetaten.

    The out-of-hours doctor did not receive formal patient information in at least half of the doctor’s visits to nursing homes in Oslo. This may subject the patients to inappropriate treatment and unnecessary hospitalisation.

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    Sammendrag

    Background: The Oslo out-of-hours primary healthcare service is responsible for making doctor’s visits when the nursing home doctor is unavailable. Out-of-hours doctors report that the patient information they are given varies widely.

    Objective: To chart the patient information provided to out-of-hours doctors during nursing home visits. We also sought to identify factors associated with the availability of patients’ medical records, information about advance care plans, and the active treatment commenced.

    Method: Out-of-hours doctors filled out a survey for each nursing home visit in Oslo during a three-month period in 2013. We analysed the data as a cross-sectional study with binary logical regression.

    Results: We registered a total of 362 doctor’s visits. Altogether 60.2 per cent of the patients visited were women, 76.0 per cent were > 80 years old, and 68.5 per cent were assessed as being cognitively impaired or having dementia. The most frequent reasons for the visits were infections and symptoms in the urinary tract (26.8 per cent) and respiratory tract (25.7 per cent). Of the total number of patients, 18.5 per cent were hospitalised. Parenteral treatment was administered to 14.1 per cent of the patients.

    The out-of-hours doctor was not given access to the patient’s medical record in 52.5 per cent of the visits. Patient age under 80 years old was positively associated with access to the patient’s medical record [odds ratio, OR 1.68 (1.07–2.81), p = 0.05]. Factors negatively associated with access to the patient’s medical record were visits during the daytime on weekdays [OR 0.49 (0.25–0.97), p = 0.04] or when the doctor perceived that the care staff were unfamiliar with the patient [OR 0.23 (0.11–0.48), p < 0.01]. Out-of-hours doctors were informed about decisions relating to reduced therapeutic intensity for a small number of patients: hospital admission (21.3 per cent), intravenous treatment (17.1 per cent), attempt at cardiopulmonary resuscitation (19.6 per cent).

    Explanatory variables positively associated with receiving such information were that the patient had a limited ability to communicate [OR 2.13 (1.31–3.46), p < 0.01] or that the doctor’s visits took place during the daytime [OR 1.97 (1.3–3.76), p = 0.04]. Doctors commenced active treatment at the nursing home less often for patients in sheltered units than for those in open wards [OR 0.46 (0.23–0.95), p = 0.04].

    Conclusion: The finding that out-of-hours doctors regularly were not given or did not acquire clinical background information about acutely ill nursing home patients represents a quality-related problem for diagnosis and treatment. Inappropriate treatment and unnecessary hospitalisation are potential consequences.

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  • Small organisational adjustments can lead to better supervision of clinical practice in intensive care units

    The education of intensive care nurses in Norway is undergoing continuous change. It has developed from in-house training via further education at university college level to specialisation as an intensive care nurse at master’s degree level. It is in the process of becoming more academic whilst the requirement for a high proportion of clinical placements is maintained (1).

    As the education becomes more advanced, this also increases the demands placed on practice supervisors. If the quality of clinical placements is to keep pace with developments, we must apply new ways of thinking to the organisation of practice supervision.

    Previous research

    International studies point out that supervision is challenging and that the framework factors are often unsatisfactory. An Australian study showed that the lack of a formal supervision programme resulted in supervisors experiencing high work pressure, a lack of training, little cooperation with other supervisors, and limited time for planning (2).

    A Swedish study revealed that training in supervision, feedback about the supervision, preparation time, and support from management were precisely the factors that facilitated supervision (3). Supervisors at a Norwegian intensive care unit reported that sufficient time and involvement on the part of management were key framework factors (4).

    Supervisors of Swedish bachelor’s degree students evaluated a supervision model devised for the purpose of remedying deficiencies and facilitating a good academic learning environment. They were of the opinion that the supervision model was useful. A risk factor in clinical placements was that the practice supervisors did not have sufficient academic or pedagogical skills (5). A review of the literature concluded that structured supervision programmes are important in respect of the training, recruitment and satisfaction of nurses (6).

    The didactical relationship model

    The didactical relationship model is a pedagogical model that can assist in planning, conducting and evaluating teaching and supervision. The model was developed by Bjørndal and Lieberg (7) and elaborated further by Hiim and Hippe (8). The model describes the following six key factors of importance for learning: learning conditions, setting framework, goals, content, learning process and assessment.

    The factors are interdependent and comprise a holistic system in which none of the factors actually predominate (8). In this article, we have decided to highlight the organisational framework factors, and to show how these factors affect the participants in the project and therefore play a decisive role in the overall picture.

    The objective of the study

    This project was a collaborative project between an intensive care unit at Oslo University Hospital and Lovisenberg Diaconal University College (LDUC). We wished to explore new ways of organising practice supervision of intensive care nursing students in the unit. Our motivation was to create parameters for supervision that would offer both supervisors and students a better solution. We therefore formulated the following research question:

    How can practice supervision be organised to enhance its quality?

    Method

    Research design

    We considered action research to be a good design for this project since its core idea is that problems in practice can be studied scientifically together with those who are actually familiar with the problems (9). The method entails that solutions come from the lowest level in the organisation, i.e. a bottom-up-perspective (10).

    Practitioners participate actively in order to perform a critical assessment of current practice and find opportunities for improvement. Action research is a dynamic process, and practice can be changed throughout the data collection, and new measures implemented (11). The research and changes in practice took place in parallel, and we collected and analysed the data on an ongoing basis.

    The research group

    Two intensive care nurses from the intensive care unit, both with a master’s degree, took part. One of them was project manager. In addition, the head of unit participated as well as an assistant professor from the university college and the head of studies and the head of research. The two intensive care nurses also held part-time positions at the university college during the project period. The group held regular meetings from the time we started planning the project in May 2016 until we published the results.

    Ethical considerations

    We obtained approval for the project from the data protection officer at the hospital, and informed nurses in the unit about the project via circular letters and oral communication.

    We informed them that participation was voluntary, and that they could withdraw at any point in the process. Intensive care nurses who were particularly interested in supervision were encouraged to participate. The participants gave written, informed consent prior to the start of the project.

    Sample

    Six intensive care nurses took part in the project. They had from 2–16 years of experience as intensive care nurses and a range of supervisory experience as well as a common interest and involvement in student supervision.

    Project activities

    The project participants were offered a study programme in clinical supervision at the university college. The course was worth 10 credits and was organised in three modules. At the beginning of each period of practice, an information meeting was held for students, supervisors, the project manager and the teacher. These meetings functioned as an arena for participants to get to know each other and exchange experiences, and for expectations to be clarified. The assistant professor from the university college presented the syllabus and plan for the clinical practice period.

    Prior to the second and third clinical practice period, the supervisors, project manager, teacher and unit management held planning meetings to discuss experiences from the previous period of practice, and make plans for the ensuing period. During all practice periods, we arranged supervision group meetings for the supervisors, at which they had the opportunity to raise issues from practice and receive advice on these.

    We also arranged two reflection group meetings for supervisors and students together, allowing time for them to reflect on patient situations and supervision methods.

    Data collection

    We chose focus group interviews as the principal method of data collection. In addition, we wrote field notes during the supervision and reflection groups and the planning meetings. A focus group interview is a research interview in which the participants discuss a pre-determined topic as freely as possible (12).

    The challenge consists of creating dynamics in the group that help to elicit different perspectives that provide diversity and breadth, and that can answer the research questions. The aim is that no one dominates the group and that the group is not too homogenous (13, 14).

    We conducted five focus group interviews with the supervisors in the period from September 2016 to October 2017, with the first taking place prior to the start of the project and the last after the end of the project. All the focus group interviews began with a presentation of the research question. Then we posed open-ended questions about the supervisors’ experiences of student supervision and the organisation of the supervision. We expanded and concretised the open-ended questions by asking how the supervisors collaborated, and how interaction with management helped to facilitate student supervision.

    The supervisors could discuss and share their experiences of new supervision methods in the focus groups, and suggest changes in the project. We discussed the results of each individual interview in the research group. The results formed the starting point for new questions if relevant and the need for further elaboration in the next focus group.

    Analysis

    We transcribed the audio tapes from the focus group interviews and analysed them together with the field notes from the group meetings. In order to ensure reflexivity, relevance and validity (15), the entire research group was involved in the analysis process. We carried out Brinkmann and Kvale’s (16) five-step method for qualitative content analysis. We extracted and condensed the meaning-bearing units from the text, and preliminary topics were then formulated.

    In the next phase, we condensed the meaning units further, with some degree of interpretation. Subsequently, the topic was formulated with an overarching, abstract content. We discussed the results in the research group before further processing of the dataset. After analysing the interviews, we summarised the results and applied them in the ongoing evaluation of changes implemented in the project.

    Results

    Before the project started, the supervisors described deficiencies in the organisation of the practice supervision. For example, they believed that much was governed by sheer chance: ‘There probably hasn’t been all that much follow-up and so on. It’s been left to us supervisors to find our way.’

    The unit received many students, and because of different working time arrangements, the responsibility for the students often fell on the same nurses. The supervisors called for greater understanding from management and colleagues regarding the considerable demands of supervisory responsibility: ‘It is essential that management takes on board that having a student entails planning and a lot of extra work during the course of the day. They say they understand, but that doesn’t quite tally with what they do in practice.’

    The supervisors called for greater understanding from management and colleagues regarding the considerable demands of supervisory responsibility.

    The supervisors acknowledged that they themselves had a responsibility to communicate their needs to management: ‘I also think we’re not good enough at speaking up. We must make it clearer what having students demands.’

    On the basis of the prior situation and experiences we gained during the project period, we identified three main topics that were of significance for how practice supervision at the unit was organised. These topics were supervisors’ sense of community, adaptation of the operation of the unit,and building a supervisory culture.

    Supervisors’ sense of community

    The project participants felt positive about being included in a group in which they could share responsibility for the students, exchange experiences, and give each other feedback: ‘We’re a fixed group of supervisors who will work together. We’ll have the same teaching and we can discuss things, cooperate and ask each other for advice.’

    Several people had experienced challenging situations where they had been able to utilise their colleagues’ expertise to improve student performance. The supervisors said that having their own forums for discussing and exchanging experiences allowed them to cooperate and exploit each other’s competence.

    We held the group meetings on days when the staffing situation made it possible for the supervisors to leave the unit at the time scheduled. Those who attended in their free time were given extra time off. The supervisors said as follows: ‘The group discussions with and without students have been fine. You are away from the unit and you have the opportunity to talk and discuss things.’

    Even though the supervisors talked together about supervisory tasks in the course of the working day, the supervision groups gave them more leeway to look at issues in depth. They agreed that it would be wise to continue the supervisor groups even after the end of the project period.

    Adaptation of the operation of the unit

    The project participants emphasised the importance of good cooperation between the supervisors and unit management to permit the adaptation of the operation of the unit to the supervision. The supervisors hoped that the project would be positive in that respect: ‘I feel that supervision is given a higher priority now, and that the students are more in focus.’

    One of the main challenges the supervisors highlighted was caring for the interests of both the student and the intensive care patient simultaneously. It was preferable to work with complex cases to allow students to achieve their learning outcomes, but performing all the tasks and finding time for supervision and reflection at the same time was a challenge:

    ‘I find I’m often a bit short of time. Because it’s not a ward patient who’ll be going home soon. It’s a patient with complicated multi-organ dysfunction, and any change you make will impact on something else. So you’re supervising, and something happens, and you have to provide care, and then there’s the doctor’s round and then the day’s over.’

    In a busy everyday situation, it was difficult for the supervisors to take the student aside to reflect on learning situations.

    In order to strengthen the cooperation between management and supervisors, we held planning meetings for supervisors and management prior to the practice periods. We agreed on several measures to meet the wishes of the supervisors. To ensure good learning situations for the students, the supervisors themselves would take greater responsibility for communicating specific wishes regarding patient allocation and learning situations.

    To allow the supervisor and the student time to get to know each other and plan their cooperation, they were to have a ‘float nurse’ function for their first shift together, i.e. have no specific patient responsibility but help where needed if required.

    We set aside time for an extra follow-up conversation between the supervisor and student one week after the conversation about expectations in order to evaluate at an early stage whether the plans developed at that time were appropriate. The supervisors greatly appreciated these measures: ‘I think it’s good that we’ve been allowed to have a ‘floating’ role on the first day. And that has become the standard. That we’re together the first day, that we go around and look at things, and as long as it doesn’t affect the functioning of the unit, it’s really good to do this. Get to know each other and show the student round. That means that there’s a better flow of communication later.’

    Having time to lay a good foundation for the clinical practice period proved to be valuable for both student and supervisor, and they benefitted from this later on: ‘I think I’ve become more conscious of the importance of informing administration that “my student needs this and that”, and in fact we’ve had very good cooperation with administration, so we’ve really achieved what we wanted to.’

    During the project period, the supervisors became more aware of their own responsibility for facilitating good learning situations for the students. They found that management paid attention when they expressed their wishes and needs related to practice supervision.

    Building a supervisory culture

    The supervisors were concerned that the students should be made to feel welcome. At the start of the project period, a ‘getting-to-know-you’ day for students, the teacher and the supervisor group was held on the first day of clinical practice. The assistant professor presented the learning outcomes of the study, and the students and supervisors exchanged thoughts about their expectations.

    The ‘getting-to-know-you day’ received positive evaluations and created a common understanding of the objectives of the clinical practice period. Moreover, this measure functioned as an arena for exchanging information about students’ learning in practice.

    The ‘getting-to-know-you’ day received positive evaluations and created a common understanding of the objectives of the clinical practice period.

    The supervisors felt that the ICU staff did not really understand that having a student could be an arduous task. They wanted their colleagues to demonstrate greater recognition of these supervisory tasks.

    One of the supervisors expressed this as follows: ‘It’s not easy for the rest of the staff, like today with eight patients and the nurses running around […] It’s not as if we can just go and say “good luck”. And when you also get comments along the lines of “When will you be back?” it doesn’t feel good at all.’

    In order to create a common understanding and culture for student supervision in the group of personnel, the supervisors took the initiative to hold internal tutorials about supervision. The project participants wanted to give something back in connection with the study. They also saw it as an advantage that their colleagues learned more about supervision. In addition, the project participants invited colleagues to participate in a discussion about the challenges and opportunities arising from having students in the unit.

    The supervisors found that it was vital that the entire group of staff assumed collective responsibility for the students, including colleagues who had no specific supervisory responsibility. They emphasised that they themselves could help to build a supervisory culture by sharing their knowledge and experience, and by including colleagues in their work with students.

    Discussion

    The idea for the project stemmed from a desire to make practice supervision more attractive for intensive care nurses at the unit. There is evidence that supervisors need good support from management, and that good supervision can best be carried out if the supervision situation is well organised (3, 17).

    The didactical relationship model stresses that all factors affect each other, i.e. the supervisory framework will influence how the supervisor and the student are able to work, etc. The framework will also affect the content that the supervisor manages to include in the supervision, in other words the areas in which supervision is possible (8). Framework factors are therefore crucial for the scope offered to both students and supervisors.

    The changes implemented were partly introduced at the start of the project and partly during the project (Table 1). The first changes were a result of our assumptions about what would enhance the quality of supervision. We based these assumptions on research and experience from the unit. During the project, we assessed both established practice and the recently introduced activities, and made further changes on this basis.

    Table 1. Changes implemented in the project

    Easy to implement the ‘float nurse’ function at an early stage

    The relevant framework factors for good supervision of students in an intensive care unit encompass supervisory competence, daily work tasks and available resources in the form of time and organisation (17). The parameters in the project did not permit an increase in staffing or other resource-intensive measures to free up time for supervision.

    However, we identified several minor adjustments that were feasible within the applicable financial and staffing parameters. The ‘float nurse’ function early in the practice period gave the supervisor and the student time to get to know each other and to put in place parameters for the cooperation between them. Although the ‘float nurse’ function was a simple change, it required planning and cooperation between the supervisors and management.

    Active and cooperative management was of key importance in implementing the measures.

    The change was made because the supervisors had been made responsible and had been challenged to suggest improvements themselves, while managers saw opportunities to make changes within the existing framework. Active and cooperative management was of key importance in implementing the measures. In earlier studies, the supervisors sought support from management and clear parameters (4).

    Barriers to good supervision

    The students’ learning process was a motivating factor for the supervisors, whilst framework factors that disturbed the learning process were demotivating. Factors such as time pressure, uncertainty about own competence and a feeling of being alone with responsibilities for students were highlighted as barriers to taking on supervisory tasks. These findings are supported by other research, which shows that ad hoc solutions in the organisation of supervision give poor results (2, 17).

    The supervisors found that neither management nor colleagues understood how resource-intensive having supervisory responsibility was, a finding which is supported by several international studies (18, 19). Having supervisory responsibility together with responsibility for patients with complex needs was described as a challenging combination.

    Impacts of changed framework factors

    Even before any changes were implemented, the supervisors asserted that they felt positive about the efforts now being made to put in place a better framework for clinical practice supervision. During the project, the supervisors became more aware of their role. They took more responsibility, suggested improvements and participated actively in testing out changes. In line with the presentation in the didactical relationship model, we saw that when the framework factors changed, this had ripple effects on other factors of importance for supervision (8).

    Even though the operational framework did not always permit the implementation of the supervisors’ suggestions for improvement, we found that the close dialogue between management and the supervisor group made it easier to find good solutions. Several studies show that uncertainty about the parameters and the content of the supervisory role represents a barrier to good supervision that makes the supervisors’ position more difficult (17, 20).

    In our project, we highlight the responsibility embedded in the supervisory role, and clarify the opportunities supervisors have to influence their role. When supervisors took on more responsibility themselves, we found that they had more influence on their own work situation.

    Supervisory responsibility became less lonely

    The sense of community in the supervisor group also made supervision less lonely. It became a forum for learning in that supervisors shared their experiences and gave each other feedback on practical issues. Several studies have pointed out that supervisors feel lonely when they have sole responsibility for a student. They sought opportunities for greater cooperation and shared responsibility (4, 18).

    The sense of community in the supervisor group made supervision less lonely.

    Towards the end of the project period, the supervisors also emphasised the value of including other colleagues in student supervision through internal training and by utilising colleagues’ expertise. The supervisors themselves thus assumed responsibility for building a supervisory culture at the unit that could form a better framework for the practice supervision.

    In the didactical relationship model, the framework is composed of given conditions that limit or facilitate learning (21). The changes that we have made in the framework factors (Table 1) are adjustments that we have good experiences of, and that promote a good learning process in line with the didactical relationship model.

    Conclusion

    There will always be a gap between what is desirable and what is feasible at a workplace with high activity, constant changes and limited financial and staffing resources. In this project, it has been important for us to adhere to measures that are feasible within the ordinary operating framework.

    The sense of community and organisation have been the success factors for improving conditions for student supervision at the unit. Strengthening training and follow-up have increased the supervisors’ competence and commitment to student supervision. Closer cooperation between the supervisors and management has enabled us to see new opportunities to adapt the operation of the unit to supervision.

    Through this project, we have found that small adjustments can provide substantial benefits that entail a higher quality of supervision in intensive care units.

    References

    1.       Utdannings- og forskningsdepartementet. Rammeplan for videreutdanning i intensivsykepleie. Oslo; 2005. Available at: https://www.regjeringen.no/globalassets/upload/kilde/kd/pla/2006/0002/ddd/pdfv/269388-rammeplan_for_intensivsykepleie_05.pdf(downloaded 20.04.2018).

    2.       Trede F, Sutton K, Bernoth M. Conceptualisations and perceptions of the nurse preceptor's role: A scoping review. Nurse Education Today. 2016;36:268–74.

    3.       Martensson G, Engstrom M, Mamhidir AG, Kristofferzon ML. What are the structural conditions of importance to preceptors' performance? Nurse education today. 2013;33(5):444–9.

    4.       Hansen BS, Gundersen EM, Bjorna GB. Improving student supervision in a Norwegian intensive care unit: a qualitative study. Nursing & Health Sciences. 2011;13(3):255–61.

    5.       Hall-Lord ML, Theander K, Athlin E. A clinical supervision model in bachelor nursing education – purpose, content and evaluation. Nurse education in practice. 2013;13(6):506–11.

    6.       Nash DD, Flowers M. Key elements to developing a preceptor program. Journal of Continuing Education in Nursing. 2017;48(11):508–11.

    7.       Bjørndal B, Lieberg S. Nye veier i didaktikken? En innføring i didaktiske emner og begreper. Oslo: Aschehoug; 1978.

    8.       Hiim H, Keeping D, Hippe E. Undervisningsplanlegging for yrkesfaglærere. 3. ed. Oslo: Gyldendal Akademisk; 2009.

    9.       Hummelvoll JK. Kunnskapsdannelse i praksis : handlingsorientert forskningssamarbeid i akuttpsykiatrien. Oslo: Universitetsforlaget; 2003.

    10.     Sjøvoll N. Aksjonsforskning i sykepleie : en kommunikativ utfordring : en litteraturstudie av utviklingen i aksjonsforskning i sykepleien etter 1994. Bodø: Høgskolen i Bodø; 2002.

    11.     McNiff J. Action research : principles and practice. 3. ed. London: Routledge; 2013.

    12.     Wibeck V. Fokusgrupper : om fokuserade gruppintervjuer som undersökningsmetod. Lund: Studentlitteratur; 2000.

    13.     Kvale S, Brinkmann S, Anderssen TM, Rygge J. Det kvalitative forskningsintervju. 2. ed. Oslo: Gyldendal Akademisk; 2009.

    14.     Malterud K. Fokusgrupper som forskningsmetode for medisin og helsefag. Oslo: Universitetsforlaget; 2012.

    15.     Malterud K. Kvalitative metoder i medisinsk forskning : en innføring. 3. ed. Oslo: Universitetsforlaget; 2011.

    16.     Brinkmann S, Kvale S. InterViews : learning the craft of qualitative research interviewing. 3. ed. Thousand Oaks, California: Sage; 2015.

    17.     Williams L, Irvine F. How can the clinical supervisor role be facilitated in nursing: a phenomenological exploration. Journal of Nursing Management. 2009;17(4):474–83.

    18.     Valizadeh S, Borimnejad L, Rahmani A, Gholizadeh L, Shahbazi S. Challenges of the preceptors working with new nurses: A phenomenological research study. Nurse Education Today. 2016;44:92–7.

    19.     McCarthy B, Murphy S. Preceptors' experiences of clinically educating and assessing undergraduate nursing students: an Irish context. J Nurs Manag. 2010;18(2):234–44.

    20.     Omansky GL. Staff nurses' experiences as preceptors and mentors: an integrative review. J Nurs Manag. 2010;18(6):697–703.

    21.     Hiim H, Hippe E. Læring gjennom opplevelse, forståelse og handling : en studiebok i didaktikk. Oslo: Universitetsforlaget; 1993.

    Measures such as the ‘getting-to-know-you’ day, the ‘float nurse’ function at an early stage, group meetings and internal training greatly benefitted supervisors and students at Oslo University Hospital.

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    Sammendrag

    Background: The education of intensive care nurses in Norway is undergoing continuous change – it is in the process of becoming more academic whilst the requirement for a high proportion of clinical placements is maintained. This change entails challenges for the organisation of practice supervision.

    Objective: The objective of the project was to enhance the quality of practice supervision by means of organisational adjustments.

    Method: This action research project was a collaboration between an intensive care unit at Oslo University Hospital and Lovisenberg Diaconal University College (LDUC). Six intensive care nurses acting as supervisors for intensive care students in practice participated in the project and supervised a cohort of master’s degree students at LDUC throughout three clinical placements. During the same period, they carried out a training and monitoring programme consisting of a clinical supervision course worth 10 credits, and took part in supervision groups and reflection groups as well as planning and evaluation meetings. We studied the supervisors’ experiences by means of focus group interviews before, during and after the project period.

    Results: The supervisors found that the project had positive impacts on the quality of student supervision. The sense of community with other supervisors, competence development and the opportunity to discuss and get advice on issues they encountered in practice were of value in developing the supervisory role. The supervisors were given the opportunity to participate in the development of practice through continuous evaluation of practice and the testing of new measures. We implemented some organisational adjustments to adapt the functioning of the unit to the supervision through close cooperation between management and supervisors.

    Conclusion: There will always be a gap between what is desirable and what is possible to achieve at a workplace with high activity, constant changes and limited financial and staffing resources. This project had the goal of implementing measures that were feasible within the ordinary operational framework. We discovered that small adjustments could result in substantial benefits.

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  • The ISBAR tool leads to conscious, structured communication by healthcare personnel

    Teamwork and communication between healthcare personnel are vital to quality of care and patient safety (1, 2). Patient safety is defined as protection against unnecessary harm resulting from the health service’s efforts or lack of efforts (3).

    Communication failures in treatment teams are one of the most common causes of adverse events in the specialist health service, and about 70 per cent are due to human errors in non-technical skills such as communication, management and decision-making (1, 4, 5). A lack of structure and standardisation is sometimes to blame for communication failures (6).

    The communication structure Identify, Situation, Background, Assessment and Recommendation (ISBAR) was created to standardise the effective transfer of information in the US armed forces. ISBAR was adopted by the public health service in the 2000s (1, 7) (Table 1).

    Table 1. ISBAR – structured communication

    What is ISBAR?

    ISBAR is one of several frameworks for communication between healthcare personnel in relation to patient situations. Use of the instrument is considered to improve patient safety through more structured, focussed and concise communication among healthcare personnel (1, 8, 9). The US healthcare system implemented ISBAR around 2003, and its overarching goal in patient safety work is to improve communication (1).

    Norway introduced a national programme for patient safety in 2014 (10), but communication between healthcare personnel was not a focus area until 2017 (11). The further education programmes in paediatric and intensive care nursing recommend giving more attention to teamwork and patient safety, as well as communication and interaction with patients and their families, but team communication is not covered (12, 13).

    Earlier research and the objective of the study

    International studies show a reduction in unexpected deaths from 0.99 to 0.34 per thousand, as well as significant and personally experienced improvements in communication, teamwork and safety since the implementation of ISBAR (1, 14–16). Nurses found that they were better able to prioritise tasks appropriately, better prepared in general (16, 17) and better able to convey patient issues. The communication flow improved, as did the communication and interaction with the treatment team, and they felt more confident in their role (9, 14–16).

    International communication training programmes and ISBAR show an improvement in observational and assessment abilities (16–19). Studies that include training in teamwork and communication using full-scale simulation show only small significant improvements compared to other teaching methods. Nevertheless, simulation is recommended for training in communication and teamwork (16, 17, 20, 21).

    There is little research to confirm that theoretical skills are transferred to practice (9). Wang et al. (19) show that students want to use ISBAR in clinical practice after training. Bowling (20) calls for education strategies that ensure that students exercise patient safety in their nursing care.

    No research has been found on master’s students’ experiences of using a communication structure in actual patient situations in a Norwegian context. The objective of the study is therefore to elucidate specialist nursing students’ experiences of using ISBAR as a communication structure in clinical practice on a master’s degree programme in specialist nursing.

    Method

    Design

    The study has a qualitative descriptive design, and comprises focus group interviews.

    Sample

    All master’s students (n = 18) in the fourth semester of the further education programmes in paediatric and intensive care nursing were invited to participate by the management at a relevant educational institution in southern Norway. One student declined, and another was off sick on the data collection day. The total number of students who participated was therefore 16. All were women aged 27–49 with nursing experience of between 4 and 16 years.

    Context

    The master’s degree programme in specialist nursing included both the teaching of theory and full-scale simulation of non-technical skills (6). There was no separate training programme for the ISBAR structure, but the teaching was inspired by a training programme on communication and teamwork (22).

    The first semester consisted of a two-hour resource lecture on teamwork and communication in a patient safety perspective, with ISBAR as the chosen communication structure. The students performed role plays in ISBAR communication as part of the lesson.

    Between the 2nd and the 4th semester, the students completed about twelve full-scale simulations over the course of five days. ISBAR and teamwork were one of the learning outcomes. The students were encouraged to use ISBAR in clinical practice at the hospital.

    Data collection

    We conducted three focus group interviews in January 2016, immediately after the last simulation in the fourth semester. One focus group consisted of four paediatric nursing students, and two focus groups consisted of five and seven intensive care nursing students respectively. The first author conducted two interviews, and the third author conducted one. The second author observed the focus group interviews and acted as secretary (23).

    We used an interview guide with two open-ended questions about positive experiences and challenges when using ISBAR in clinical practice. Audio recordings were made of the interviews, which were then transcribed verbatim by two of the authors. The interviews lasted between 57 and 70 minutes and were held in a meeting room at the educational institution.

    Analysis

    We undertook a qualitative content analysis with an inductive approach to the dataset (24). Raw data (68 pages) was read in its entirety and divided into meaning units using NVivo 11 Pro (25). Statements were condensed and systematised by content, then described and partly interpreted into subcategories and further abstracted into three main categories (24) (Tables 2 and 3). Interpretation is influenced by the researchers’ preconceptions (24).

    All the authors are teachers, and three are intensive care nurses with experience from ISBAR and simulation. The results are supported by quotes from all the focus group interviews, where different voices are heard.

    Table 2. From condensed meaning units to the main category

    Ethical considerations

    The study has been reported to the Norwegian Centre for Research Data (NSD) (project number 45068) and carried out in accordance with the Declaration of Helsinki’s ethical guidelines (26) on voluntary participation and anonymisation. Participants received oral and written information about the study, and all provided written consent.

    Results

    Table 3. Main categories and sub-categories

    More awareness and structure in own communication

    Many students had experienced that the nurse and doctor used different terminology in communication. Using ISBAR made the students more aware of the importance of uniform communication in content and language.

    The students found that the patient problem was communicated more clearly and more specifically when they used ISBAR. The communication with the doctor improved, and the students found that their language had become more uniform. The students therefore felt that the teamwork had improved, and that this teamwork served as a quality assurance measure in patient treatment: ‘If we don’t have a common language between ourselves and the doctor, then the problem doesn’t get communicated… We actually communicate at a completely different level with quite a few doctors.’ (ID1-7)

    Some students found the ISBAR structure to be useful, effective and time-efficient, and felt that the patient problem was communicated more swiftly: ‘Being structured certainly saves a bit of time...’ (ID1-4)

    The structure and systematics of ISBAR made communication clearer and more predictable.

    After the ISBAR training and simulation, all students agreed that structured communication was necessary. The structure and systematics of ISBAR made communication clearer and more predictable.

    The students did not forget important information, and this made them feel more secure. They also conveyed patient problems in a more objective manner. When the students provided information, they focused on specific observations and changes instead of unfounded opinions: ‘ISBAR helped to make things more concrete. You describe what the problems are as opposed to what you yourself feel. The observations that emerge are more objective.’ (ID1-1)

    The students agreed that ISBAR had made it easier for them to propose their own solutions for patient treatment. They all said that ISBAR had also made them aware of how important it was to ask for advice and clear feedback and to confirm agreements and instructions that had been drawn up. ISBAR thus became a tool that could be used to prevent misunderstandings and as a way of quality assuring the necessary information about the patients:

    ‘When I’m communicating with doctors, I try to confirm messages. Just yesterday, I wanted to wait to give a patient a tablet. ‘We’ll wait to give the patient the tablet,’ I suggested. ‘That’s right,’ said the doctor. I’ve never suggested interventions very consciously [to the doctor] before.’ (ID2-3)

    Increased awareness of own expertise

    Most students agreed that ISBAR had made them more confident in their own assessments in the communication with the doctor. Having confidence in their own assessments made them more aware of their own expertise: ‘Its structure shows that you’ve understood and have a lot of expertise. It helps make you more analytical.’ (ID1-7)

    ISBAR was particularly useful for use in acute care situations because the students quickly gained an overview of the patient situation. This made them feel better prepared and able to be a step ahead if complications arose: ‘I think ahead more, think worst case scenario. ISBAR helps to develop that way of thinking.’ (ID1-7)

    Several students found that when they used ISBAR, they received feedback from the doctor that their observations, assessments and solution proposals were relevant. This gave them a good sense of mastery, and made them feel that they had gained the respect of the doctors. They discovered through this that their own expertise was useful input to patient treatment.

    Using ISBAR provided more scope for professional discussions, which led to agreement on treatment and further plans for the patient. The students found that using ISBAR resulted in good teamwork and improved patient safety: ‘I think the doctor appreciates recommendations. When we have an opinion and have assessed the situation, it’s no longer a top-down approach. We can discuss things.’ (ID3-2)

    It was widely agreed that the ISBAR structure was important for all nurses, but particularly for newly qualified nurses. Some students believed that experienced nurses were able to convey the necessary information without using a fixed communication structure.

    However, the students were uncertain whether it was ISBAR that had made them feel more secure in their own assessments, or if it was because their expertise had improved: ‘You learn more if you study for two years, and that impacts on the content of my assessments in ISBAR.’ (ID3-3)

    Several students also had positive experiences with using ISBAR in oral reporting and written documentation. This applied to communication between nurses, during patient transfers and doctor’s rounds, and in the communication with patients’ families: ‘I also use ISBAR when I report to other departments, when we have a patient who is to be moved, or for reporting in general.’ (ID3-1)

    Challenges of using ISBAR in clinical practice

    Although most students thought that the ISBAR structure was useful in acute care situations, some found it difficult to follow the structure ‘automatically’ because ‘it takes many years to master it’ (ID3-2). Another challenge was that the students focused more on the sequential order in ISBAR than on the content to be conveyed, which slowed them down.

    The students felt it was important to focus on ISBAR at an early stage in health studies in order to receive enough training. The importance of high-volume simulation training was emphasised: ‘It’s great that we have ISBAR in every simulation. I felt after perhaps the fourth or fifth time, yes, this is working.’ (ID2-4)

    The students found that the doctors could be impatient and that they interrupted them when the students were conveying information about patient situations in accordance with the ISBAR structure: ‘[It’s a] drawback if the doctor is not familiar with ISBAR and is wondering if the nurse will get to the point soon.’ (ID2-1)

    Some students said that it was sometimes difficult to suggest their own solutions and elicit a response to them, particularly from new doctors: ‘This can be a problem with new doctors if they feel undermined by the nurses’ assessments and suggestions.’ (ID3-1)

    The students found it a drawback that the ISBAR structure had not been implemented and was not known throughout the hospital.

    Most of the students found that they often used ISBAR during the doctor’s rounds, during telephone contact with the doctor and in nursing reports. Some students said that they used ISBAR subconsciously, while others had hardly used ISBAR at all, but wanted to do so. The students found it a drawback that the ISBAR structure had not been implemented and was not known throughout the hospital. Some students received comments such as: ‘I’ve never heard of that before...’ (ID1-2).

    They feared, however, that it would be difficult to implement a fixed communication structure for experienced nurses who believed that their communication was already structured and protected patient safety: ‘Those who have been working for a long time are a huge challenge. They want to do what they’ve always done, it’s what they know.’ (ID1-7)

    Since ISBAR was not implemented at the hospital in question, the students talked about different ways of implementing ISBAR. They all agreed that ‘ISBAR is here to stay’ (ID3-2).

    Several suggested holding a workshop with a focus on ISBAR as a communication structure. They all believed that simulation was a suitable method for learning and using the ISBAR structure. Simulation can provide training and direct feedback on the language, content and structure of the communication: ‘Using ISBAR at a workshop. You practice [and can] use it in simulation situations, so all colleagues take part in communication training. I think that’s the way to learn it.’ (ID1-7)

    Discussion

    More awareness and structure in own communication

    All the students found that the communication was better structured and the content was more specific when they used ISBAR. They were more conscious about conveying key, objective information about patients, and there were no linguistic misunderstandings. Uniform terminology can play a role in preventing misunderstandings and communication failures (1, 5).

    The findings correspond to studies showing that the ISBAR structure improves both content and clarity in communication – it distinguishes between essential and insignificant information (14, 16). Nurses are also better prepared and can prioritise more easily (16, 17).

    The students pointed out that the ISBAR structure was predictable; they did not forget important information, thereby saving time in acute care situations. This predictability is confirmed in research on ISBAR, and predictability and effectiveness are two of the objectives of implementing the structure (1, 8).

    The students believed that the effectiveness of the tool was dependent on whether they had integrated ISBAR into their own professional practice. We interpret this to mean that the importance of repeated simulations is crucial to learning, a view that is supported by Husebø and Rystedt (6).

    The students emphasised that getting advice was one of the most important elements of the ISBAR structure in terms of preventing misunderstandings and ensuring patient safety. Being more aware of the importance of asking for clear feedback and confirming agreements meant that the necessary information about the patient was quality assured. It is interesting to note that earlier research does not pinpoint receiving advice as one of the most important features of the ISBAR structure, but discusses clarity in general terms in all the factors of the structure (20).

    Increased awareness of own expertise

    Greater confidence in their own assessments and analyses, and an increased sense of mastery were prominent findings. The students found it easier to obtain an overview of the patient situation and were ready to deal with potential problems. Other studies confirm that using ISBAR improves observational and assessment abilities and self-confidence, and facilitates decision-making (9, 17).

    Greater confidence in their own assessments and analyses, and an increased sense of mastery were prominent findings.

    The students felt that they received more respect from doctors when they used ISBAR. This led to more professional discussions, which resulted in agreement on treatment strategies. Professional discussions and respect from doctors supported and strengthened their expertise and sense of security in their practices. The students also found that ISBAR encouraged good teamwork and ensured patient safety in the nursing. These findings are in keeping with other studies (18).

    The students reported that the ISBAR structure, together with increased expertise through the training, made them more analytical and inspired them to voice their own suggestions and reflections. The ISBAR structure also seems to represent a tool for developing clinical assessment and reasoning.

    The students further found that ISBAR was useful in various reporting contexts and in communication with patients’ families. This may indicate that the students have subconsciously integrated ISBAR into their professional practice, and that they use ISBAR in various situations. Research shows that ISBAR is also used in the context of reporting and doctors’ rounds (14, 15), and supports the students’ experiences of being able to use ISBAR in such situations.

    Challenges of using ISBAR in clinical practice

    The students found that using ISBAR was time-consuming because the communication structure was not integrated into the work routine in the hospital. It also emerged that it was difficult to follow the structure automatically, despite them finding it easier after several ISBAR simulations. These findings show that high-volume simulation training is necessary.

    Various studies show that classroom teaching alone leads to little change in communication, while a significant improvement in the nursing students’ communication can be seen through both the teaching of theory and simulation (21, 27). A meta-analysis showed that simulation had a significant impact compared to other learning strategies (21).

    These findings and other research support recommendations for the closer integration of theoretical and clinical components in nursing education programmes, and for a greater focus on clinical reasoning than on critical thinking in the study programme (17).

    The students were often interrupted by doctors who were not familiar with ISBAR. Some found that certain doctors did not allow a dialogue in which the students could convey their own assessments. A systematic literature review shows that different modes of communication, offensive behaviour and culture are barriers to effective nurse-doctor communication (28), and confirms the experiences of the students.

    The students were often interrupted by doctors who were not familiar with ISBAR.

    An important leadership skill in teamwork is listening to input, and obtaining and disseminating information (2, 29). Using ISBAR alone is not enough to foster good teamwork. Human factors, management and a patient safety culture are important prerequisites for teamwork and patient safety. Attention to improving non-technical skills, interprofessional collaboration and team performance where everyone can have their say are also crucial factors (29).

    The students found it difficult to apply the ISBAR structure in a field of practice that had not implemented ISBAR. The Norwegian Patient Safety Programme lacks a clear focus on safe communication and has therefore not been prioritised at a number of hospitals. It was not until 2017 that ISBAR was mentioned in the care bundle for hospitals concerning early detection of deterioration in a patient’s condition (11).

    Whether it is appropriate for the students to apply ISBAR in clinical practice when the field of practice has not implemented the communication structure is debatable. However, one positive aspect is that the students gain experience in introducing new knowledge on patient safety to the field of practice. It will raise students’ awareness and make them more knowledgeable about relevant quality measures. Patient safety will also improve through the use of knowledge-based practices and students will represent a useful resource in future implementation processes (12, 13, 30).

    Students feared it might be a challenge to implement ISBAR with experienced nurses who showed little interest or willingness to change their own communication structure. However, the students used ISBAR to varying degrees, and some used the structure subconsciously. These findings seem to have similarities with the challenges of implementing knowledge-based practices (30) and support the fact that theoretical skills are not always transferred to practice (9).

    The students suggested workshops where doctors and nurses were taught theory and carried out interdisciplinary simulations. In simulations, healthcare personnel can receive specific feedback on what they are actually saying, and not just on what they think they are saying. Communication and team training are key factors for creating and maintaining a safety culture (22, 29).

    Methodological considerations

    The study is important as no corresponding studies have been conducted in Norway. The authors expected the sample population to be well-informed and to have a large potential to shed light on the subject of the study (23). The study has between four and seven female respondents in each focus group, which is in line with recommendations (23, 24).

    Homogeneity can strengthen the group dynamics through recognition of associative effects and past common experiences. The absence of male participants may be a weakness of the study. There were numerous congruent findings in the data collected, which may be an indication of saturation.

    The first and third authors participated in all the simulations and followed the students throughout the master’s degree programme. The first author gave the ISBAR resource lecture. The authors’ existing knowledge provided a good basis for understanding how ISBAR is applied in a hospital context.

    As the interviewer was also a teacher on the master’s programme, the students may have refrained from relating their negative experiences, and answered in a way that they thought the interviewer wanted to hear. In order to reduce this risk, the second author was present in all the focus group interviews. The interviewers did not supervise the students in clinical practice, and the students were informed about the authors’ dual role as both researchers and teachers before the interviews.

    Preconceptions can influence the questions and the analysis, such that certain elements might be overlooked or underestimated (24). We tried to identify the preconceptions throughout the research process by involving three of the authors in the analysis process. Others may, however, analyse and interpret the findings differently.

    Conclusion

    The findings of the study showed that the students became more aware of their own communication structure when using ISBAR in clinical practice. They also felt more confident about their own expertise and communication, and were able to obtain a quicker overview of patient situations. These elements led to improved patient safety.

    However, the students found it a challenge to use the ISBAR structure in practice as it had not been implemented in the hospital. The findings throw light on the importance of systematic training and simulations with the ISBAR structure in order to improve patient safety, both in the training of specialist nurses and in the specialist health service.

    We have not investigated the long-term effects of using ISBAR in the students’ training. It is therefore important to conduct a follow-up study of students and other healthcare personnel who have received training in ISBAR.

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    Students who used this framework for communication conveyed more specific observations, gave fewer unfounded opinions, and experienced improvements in teamwork and patient safety.

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    Sammendrag

    Background: ISBAR is a patient safety communication structure that aids simplified, effective, structured and anticipated communication between healthcare personnel. No research has previously been conducted on master’s students’ experiences of using ISBAR in Norway. In the past, there have been calls for education strategies that ensure students receive training in patient safety communication.

    Objective: To elucidate specialist nursing students’ experiences of using ISBAR as a communication structure in clinical practice on a master’s degree programme in specialist nursing.

    Method: The study has a qualitative descriptive design, and comprises three focus group interviews. A qualitative content analysis was carried out.

    Results: Using the tool made the students’ communication more conscious, structured, clear and predictable. They conveyed objective, unambiguous and specific observations and changes instead of giving unfounded opinions. The students more readily proposed solutions of their own and clarified medical regulations. Using ISBAR made them feel more confident about their own communication and expertise, and improved their teamwork and patient safety. However, the ISBAR tool presented some challenges for the students since the communication structure had not been implemented at the hospital.

    Conclusion: Using ISBAR increases the awareness of users’ own structured communication and expertise and allows them to obtain a quicker overview of patient situations. The findings highlight the importance of systematic training and simulation with the ISBAR structure in order to improve patient safety, both in the training of specialist nurses and in the specialist health service.

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  • Palliative patients get greater relief from early screening of symptoms and implementation of measures

    Palliative or supportive care is a new area of expertise in both the Norwegian and the international context. Cecily Saunders (1918–2005), who worked at St. Christopher’s Hospice in London (1), established modern palliation in the 1960s. Throughout the 1990s, palliation received more attention in Norway, partly as a result of the establishment of the Norwegian Association for Palliative Medicine (2).

    In 2007, the Norwegian Directorate for Health and Social Affairs issued for the first time a national action programme with guidelines for palliation in cancer care (3). A new Official Norwegian Report on palliative care was issued in 2017: På liv og død (A matter of life or death) (1), which reviewed and revised existing palliative care programmes and set out parameters for future programmes.

    Many patients in the palliative phase have both physical and mental problems, and often present a complex picture that can vary over time. Good knowledge of the symptoms of this patient group is a prerequisite for optimal care of the patient.

    Earlier research

    International research has shown that there is little correlation between nurses’ impressions of the patient’s symptoms and the patient’s actual clinical picture (4). Nurses’ knowledge of the patient’s clinical picture can be improved by using systematic screening tools, particularly if the information acquired from using such tools is included in nursing documentation (5).

    Nurses’ knowledge of the patient’s clinical picture can be improved by using systematic screening tools.

    There is a clear correlation between a high symptom score on the Edmonton Symptom Assessment System (ESAS) and the implementation of clinical actions (6). A number of international studies have presented statistical data from ESAS (6–9). One of the main goals of palliative care is to give higher quality of life through better control of symptoms.

    Myhra (2010) points to a need to conduct further research on ESAS in which respondents are included, at all of Norway’s palliative care units (10). Earlier research has described different clinical pictures, depending on gender, for various forms of cancer at different stages. On the other hand, there is a lack of information on gender-specific differences in respect of palliative cancer patients (11, 12).

    The national action programme for palliative cancer care (13) provides guidelines for treatment, competence and the organisation of palliative services in Norway. These guidelines formed the framework used when the palliative care unit at the University Hospital North Norway, Harstad (UNN Harstad) was established in 2008.

    Objective of the study

    The objective of the study was to identify:

    • how palliative cancer patients report their symptoms on initial admission to the palliative care unit at UNN Harstad;
    • whether male and female cancer patients report a different clinical picture; and
    • how patients’ experience of symptoms changes during their initial stay at a palliative care unit.

    Method

    Palliative Care Unit - UNN Harstad

    When the palliative care unit at UNN Harstad was established in 2008, it was the first palliative ward in the Northern Norway Regional Health Authority. The unit is open five days a week from Monday to Friday as a palliative centre with three to four beds and an outpatient clinic. It offers supervision and guidance to the primary health service as well as home visits. Over 90 per cent of the unit’s patients have a cancer diagnosis.

    Design

    The study is designed as a retrospective, quantitative study using anonymised data from the quality database at the Palliative Care Unit, UNN Harstad. The theoretical perspective is palliative nursing.

    ESAS

    The Edmonton Symptom Assessment System (ESAS) is a validated (8, 9, 14) and internationally recognised self-reporting tool for systematic registration of symptoms by patients receiving palliative care (15). The screening tool was devised in Canada (15) and is used both nationally and internationally.

    Systematic use of ESAS is one of the quality measurements in palliative care (1, 2). The tool exists in several versions and has been translated to a number of languages. The Norwegian version uses a numerical scale from 0–10, where 0 represents ‘no symptoms’ and 10 represents ‘worst possible symptoms’.

    ESAS is used to chart pain when resting, pain when active, fatigue, nausea, shortness of breath, dry mouth, appetite, feeling anxious or nervous, and sadness or depression. In addition, it includes a more general question: ‘Overall, how do you feel today?’ The ESAS form used in this study also charts constipation, in line with recommendations from earlier research (10, 15–17).

    The patients’ symptoms are charted on a daily basis using ESAS. On first admission to the unit, the patient completes the form together with a nurse to avoid misunderstandings. Afterwards, if the patient so wishes, he/she can complete it on their own. The conversation between the patient and the nurse or doctor in this process is important and valuable, but is not discussed further in this article.

    In 2010, a revised version of the form was launched: ESAS-R (18). In this study, we have used a traditional ESAS form.

    Diagnosis

    The International Statistical Classification of Diseases and Related Health Problems, ICD-10, was used to classify cancer diagnoses (19).

    Inclusion

    We employed the following inclusion criteria: 1) The patient must have a cancer diagnosis on initial admission, and 2) symptoms must be charted using ESAS.

    Figure 1. Inclusion and exclusion procedure

    Statistical analyses

    Patient data are directly registered in IBM SPSS (Statistical Package for the Social Sciences). We used IBM SPSS version 22–23 and Microsoft Excel Version 2010 for the statistical analyses. Excel was used to select the week’s first and last symptom score as well as to prepare statistical figures. We used descriptive statistics to present the dataset. The Shapiro-Wilk and Kolmogorov-Smirnov tests demonstrated a skewed distribution.

    Based on earlier research (6, 20, 21), we categorised the ESAS symptoms into four categories: ‘No symptoms’, ‘Mild symptoms’, ‘Moderate symptoms’, and ‘Pronounced symptoms’ (Figure 2). The Mann-Whitney U test was used to test differences between genders (Figure 3). We omitted gender-specific diagnoses such as breast cancer, gynaecological cancers and prostate cancer.

    We used McNemar’s test to examine whether there were significant differences in the clinical picture between the first and last charting of symptoms (Figure 4). Only patients screened using ESAS both on admission and discharge were included in this specific analysis. Data were dichotomised, and the scores 0, 1 and 2 were compared against the scores 3–10. The goal is that the patient will score the symptom as 0–2.

    In the case of pain when resting, the goal is defined as NRS (Numeric Rating Scale) ≤3 in the Standard for Palliative Care (2). We used the same categorisation as for the other symptoms. This corresponds with the goal that daily clinical practice attempts to achieve. The significance level was set at 0.05. We carried out a Bonferroni correction to reduce the risk of Type 1 errors.

    Ethics

    The material we used in this project consists of anonymised data from the quality database at the Palliative Care Unit, UNN Harstad. The study was subject to administrative processing by the Norwegian Social Science Data Services (NSD), now the Norwegian Centre for Research Data, via the data protection officer at UNN.

    The Regional Committee for Medical and Health Research Ethics (REC North) has determined that the database is not subject to the Health Research Act and therefore does not require further approval (reference number 2015/1661/REC North). We collected all data as a routine part of patient treatment and the study has therefore not entailed any kind of extra strain on the informants.

    To ensure full anonymity, we omitted the patients’ ID numbers when extracting data from the quality database. The sequence of observation units was randomised and the different diagnoses were combined in ten large groups, none of which had less than five patients (Table 1).

    Results

    The study presented symptom data from 274 cancer patients, of whom 135 were women and 139 were men. The average age was 69.5 years with a distribution from 38 to 90 years. Average survival after first admission was 24 weeks. Data collection took place in the period from 2008 to 2016. The number of patients who charted the various symptoms is shown in Figures 2, 3 and 4.

    Table 1. Patient characteristics and distribution of diagnoses, by prevalence

    Clinical picture on admission

    In Figure 2, we present the symptoms dichotomised into the following categories: ‘None’ (score 0), ‘Mild’ (score 1–3), ‘Moderate’ (score 4–6) and ‘Pronounced’ (score 7–10). Fatigue, dry mouth, loss of appetite and sense of well-being (‘Overall, how do you feel today?’) are symptoms which more than 50 per cent of the patients rated as between 4 and 10. We find the largest number of ‘pronounced symptoms’ for loss of appetite (score 7–10).

    Figure 2. Clinical picture on admission

    Clinical picture for women and men

    Figure 3 presents the mean symptom burden stratified for men and women. We have omitted patients with breast cancer, gynaecological cancers and prostate cancer.

    With the exception of shortness of breath, women report higher values than men for the symptoms charted. However, the differences are only statistically significant for the symptoms fatigue (p = 0.009) and dry mouth (p = 0.005).

    Figure 3. Clinical picture for women and men on admission

    Status on admission and discharge

    The average length of stay at the unit was 3.3 days (SD 0.93), with 4 days constituting a whole week. Figure 4 shows a reduction in all symptoms after a stay at the palliative care unit. McNemar’s test shows that the change is statistically significant for all the symptoms screened.

    Figure 4. Mean values for ESAS on admission and discharge

    Discussion

    The health and care services are being evaluated and assessed in respect of waiting time, use of resources and time taken to receive the discharge report. There are few quality indicators that provide information about the quality of palliative care and follow-up received by our most seriously ill patients in palliative care (1). Recommendations were made as early as 2004 on identifying the proportion of patients screened by ESAS as well as the proportion who achieved satisfactory symptom relief (2).

    The 2018 Official Norwegian Report on palliation also highlighted ESAS as an effective screening tool (1). National studies show that a systematic approach to the patient using ESAS to provide targeted charting of symptoms provides better information about patients’ problems and enhances nursing quality (16). Rhondali et al. have shown that there is little correlation between the patient’s symptoms and nurses’ impressions of these symptoms (4).

    Symptoms

    Research that identifies correlations between various symptoms shows that pain is often associated with fatigue, nausea, tiredness and loss of appetite (11). The findings in our study are of interest because the secondary effects of pain seem to be more pronounced than the pain itself. In contrast to pain, these symptoms can be difficult to pinpoint, treat and evaluate without repeated and systematic use of a validated screening tool.

    The findings in our study are of interest because the secondary effects of pain seem to be more pronounced than the pain itself.

    Charting symptoms is of central importance in a palliative disease course in order to give the patient optimal and effective relief for the troublesome symptoms. The aim of charting symptoms, follow-up treatment and evaluation is to achieve the best possible quality of life. Symptoms that patients describe as moderate to pronounced (4–10 on ESAS) should be prioritised in patient treatment.

    Loss of appetite

    Loss of appetite and cachexia constitute a common problem for palliative patients (22). In our study, 72 per cent of patients have a symptom score of >3 on this question on admission (Figure 2). There may be many causes such as oral fungal infections, changes in sense of taste, difficulties swallowing, obstructions in the GI tract, side effects of radiation therapy or cytostatic treatment, accumulation of fluid in the abdominal cavity (ascites), pain etc. (22).

    Cachexia is a negative prognostic factor that is often associated with a shorter life expectancy (22). Loss of appetite alone or together with other symptoms increases the nutritional risk for the patients. In everyday clinical practice, it may be difficult for nurses to identify whether a patient is facing a nutritional risk before significant weight loss is observable (22).

    National recommendations stipulate that inpatients in the specialist health service must be nutritionally screened on admission using a validated tool, and should then be monitored on a weekly basis. Measures must be implemented, documented, evaluated and reported to the next treatment level (23).

    Poor nutrition increases the symptom burden and reduces quality of life. Early intervention in the form of dietary recommendations and nutritional supplements is therefore crucial, particularly for this patient group (22).

    Fatigue

    In our study, 69 per cent of patients rate fatigue at an intensity of >3 on admission (Figure 2). Cancer-related fatigue is estimated to affect 90 per cent of the patients (21). The intensity increases during the cancer trajectory (21).

    Fatigue is a considerable challenge in cancer care and is often overlooked and therefore inadequately treated (21). The causes of fatigue are complex, and nutrition, pain, side effects of tumour-related treatment and anxiety are important contributory factors. It is therefore vital that nurses have knowledge of the phenomenon.

    Dry mouth

    A dry mouth (xerostomia) is indicated as a problem for over half of the patients with advanced cancer (24). In our study, 53 per cent rate dry mouth at an intensity of >3 on ESAS. A dry mouth is often due to a combination of different medications, chemotherapy and radiotherapy, and results more readily in infections in the oral cavity. In addition, seriously ill patients experience a decline of the immune system, making them more vulnerable to oral infections (25).

    It is vital that nurses pay attention to oral health. Focus on this issue and early implementation of recommended measures may prevent and relieve symptoms. There is a range of measures that can ease a dry mouth, such as good oral hygiene, the use of lozenges or a spray to stimulate saliva secretion, and avoiding sweet foods in addition to frequently drinking copious amounts of water. Medication can also relieve a dry mouth (24, 25).

    Constipation

    Constipation is reported as a considerable problem for palliative patients (10, 15–17). Nevertheless, only 26 per cent of patients in this study score this at >3. Other studies have revealed that constipation occurs in 50–60 per cent of patients with advanced cancer, and in up to 90 per cent of patients who use opioids (13).

    Constipation is often accompanied by a distended abdomen, pain, loss of appetite, nausea, vomiting, headache, restlessness and obstipation diarrhoea (13), and can thus have a considerable negative effect on quality of life. Several publications have emphasised that constipation should be included in ESAS (10, 15, 16), which may have been a contributing factor in its inclusion in ESAS-R.

    The low prevalence of constipation problems in the study can partly be explained by good prevention measures at the referral wards. Early referral to the palliative care unit during the disease course may also be a contributory cause.

    Well-being

    In answer to the question ‘Overall, how do you feel today?’ 53 per cent of the patients give a score of >3 on ESAS. Successful palliative care demands the capacity to interpret the patient’s clinical picture as well as the ability and willingness to alter palliative measures as the disease changes (24).

    Clinical experience of using ESAS has shown that the question of well-being can be difficult to answer because the question is seen as fairly vague. Many patients answer this question by saying ‘not too good and not too bad’. Bergh et al. found the same in a 2010 study (26).

    The degree of accuracy in answers to this question depends on the nurse taking the time to have a conversation about how the patient feels. It is in conversations about everyday topics that important issues can emerge.

    Such a conversation is exemplified by a nurse’s dialogue with a patient with advanced cancer who was in the middle of a house renovation. During the conversation, the patient produced a colour chart and asked the nurse: ‘Do you think I would be happy with this colour in my kitchen?’

    The question related of course to the choice of colour but it was equally a desire for confirmation that the patient would live to see the newly painted kitchen. Use of ESAS is often a starting point for good conversations about existential questions, questions that go far beyond the charting of symptoms.

    Gender differences

    The study shows that women, with the exception of those experiencing shortness of breath, present a greater symptom burden on average than men. The differences are statistically significant in the case of fatigue and dry mouth. In a 2011 study, Culleton et al. found no significant differences in the clinical picture for men and women when gender-specific diagnosis groups were excluded (27).

    The study shows that women, with the exception of those experiencing shortness of breath, present a greater symptom burden on average than men.

    Earlier research has shown that women experience more opioid-based side effects than men (28). Nevertheless, it is uncertain if the differences in our dataset can be explained by gender-based differences in the metabolisation of opioids. Several studies have discussed fatigue or tiredness in cancer patients in relation to gender-based differences (12, 27, 29).

    Our study does not provide an explanation of gender differences in respect of cancer symptoms. Nevertheless, it highlights the importance of focussing on and maintaining an awareness of how patients may experience different symptoms depending on gender.

    The effect of a stay at the Palliative Care Unit - UNN Harstad

    The study shows a significant decline in all symptoms in both men and women on discharge from our palliative care unit. This is the case regardless of the short duration of hospitalisation and despite the fact that the unit is a five-day ward with an average hospitalisation period of 3.34 days (a whole week = 4 days).

    Systematic, repeated measurements of symptoms are crucial to safeguarding accurate and targeted treatment measures.

    The factors that may explain the improvement in symptoms are that the patients come for planned hospitalisation and assessment. Treatment measures have often been decided prior to admission and these can be implemented immediately after charting the symptoms upon admission. Systematic, repeated measurements of symptoms are crucial to safeguarding accurate and targeted treatment measures.

    The use of a validated assessment tool such as ESAS gives nurses and doctors precise measurements of the patient’s symptom burden. Repeated measurements using ESAS are effective because the patients themselves become the key to healthcare personnel accurately evaluating symptoms.

    The study’s limitations and sources of error

    The study presents the symptom burden of palliative cancer patients at UNN Harstad on their initial admission to the palliative care unit. Our study only monitored patients for a few days and contains no information about the impact of symptom relief on prognosis, life expectancy and quality of life. In order to answer the research questions, we used only ESAS as a screening tool, which naturally constituted a limitation.

    Although spiritual and existential needs in addition to the perspectives of the patient’s family are a natural part of holistic, palliative care, our study does not discuss these. The patients in the study included both men and women with different cancer diagnoses and of different ages. Any generalisation of the findings must therefore be made with caution since the patient data are limited.

    Many patients said it was difficult to rate a symptom. Some symptoms, such as ‘dry mouth’ and ‘Overall, how do you feel today?’ were described as particularly difficult to define on a numerical scale.

    Norwegian research from 2011 revealed a risk that patients may misunderstand ESAS and wrongly interpret the questions. It is therefore necessary to go over the form together with the patient (26), as we did systematically in our study. Eight to ten different nurses, all of whom had received prior training in the use of ESAS, collected the data.

    The fact that different nurses helped patients to complete ESAS may have led to variations in the values submitted. The most seriously ill patients were not included.

    It is easy to give an inverse response for the ‘appetite’ symptom (good appetite should be ‘0’, no appetite ‘10’). A number of publications have pointed out this phenomenon (26, 30). The personnel at the unit were aware of this potential source of error and avoided erroneous registration.

    Conclusion

    Proficient nursing entails attention to and knowledge of patients’ symptoms. The study shows that systematic registration of symptom data together with swift implementation of palliative measures to relieve symptoms leads to a diminished symptom burden. Systematic use of ESAS increases the likelihood of discovering symptoms that might otherwise be overlooked.

    Loss of appetite, dry mouth and fatigue are the dominant challenges for cancer patients on initial admission to the Palliative Care Unit - UNN Harstad. In a palliative disease course, systematic charting of symptoms, swift start-up of interdisciplinary treatment measures and evaluation of these measures are prerequisites for effective treatment.

    The study shows that systematic use of ESAS with rapid implementation of treatment measures gives a reduction in all symptoms charted despite short hospitalisation. Finally, we would emphasise that ESAS cannot replace a proper conversation but is a useful tool for more targeted treatment of symptoms.

    Recommendations for further research

    One of the main goals of a stay at a palliative care unit is to relieve the patient’s symptoms. This study presents a picture of how palliative patients report their symptoms. The study can be used in future qualitative and quantitative research to underpin how cancer patients in the palliative stage rank their symptoms.

    The study also confirms the need for treatment programmes offering expertise in palliation in Norway. It is important to direct focus to cancer patients’ symptoms. Cancer symptoms are complex and challenging for patients, their families, and health personnel.

    The results of this study can have clinical implications for the nursing of palliative patients. For example, further research could focus on the impact of specific nursing measures in respect of symptom relief and improved quality of life.

    The study has not received external funding, and the authors report no conflicts of interest.

    We wish to thank all the nurses at the Palliative Care Unit - UNN Harstad, who have contributed with great enthusiasm and dedication to the charting of symptoms in ESAS. Our thanks also go to senior consultant and former head of department Per Christian Valle, who has been a key driver in the establishment and development of the unit. Last but not least, we wish to thank our patients. 

    References

    1.       NOU 2017: 16. På liv og død. Palliasjon til alvorlig syke og døende. Oslo: Departementenes sikkerhets- og serviceorganiasasjon, Informasjonsforvaltning; 2017. Available at: https://www.regjeringen.no/contentassets/ed91baf5d25945b1a0b096c0ce376930/no/pdfs/nou201720170016000dddpdfs.pdf(downloaded 07.12.2018).

    2.       Engstrand P, Haugen DF, Hessling SE, Jordhøy M, Kaasa S, Kristiansen B, et al. Standard for palliasjon: Norsk forening for palliativ medisin; 2004. Available at: https://legeforeningen.no/Emner/Andre-emner/Publikasjoner/Standard/Standard-for-palliasjon/(downloaded 20.12.2018).

    3.       Loge JH, Haugen DF, Aass N, Huurnink A, Skarholt K, Nandrup E, et al. Nasjonalt handlingsprogram med retningslinjer for palliasjon i kreftomsorgen. Oslo: Helsedirektoratet; 2007. Available at: http://helsedirektoratet.no/publikasjoner/nasjonalt-handlingsprogram-med-retningslinjer-for-palliasjon-i-kreftomsorgen-/Sider/default.aspx(downloaded 20.12.2018).

    4.       Rhondali W, Hui D, Kim SH, Kilgore K, Kang JH, Nguyen L, et al. Association between patient-reported symptoms and nurses' clinical impressions in cancer patients admitted to an acute palliative care unit. J Palliat Med. 2012;15(3):301–7.

    5.       Stromgren AS, Groenvold M, Sorensen A, Andersen L. Symptom recognition in advanced cancer. A comparison of nursing records against patient self-rating. Acta Anaesthesiol Scand. 2001;45(9):1080–5.

    6.       Seow H, Sussman J, Martelli-Reid L, Pond G, Bainbridge D. Do high symptom scores trigger clinical actions? An audit after implementing electronic symptom screening. J Oncol Pract. 2012;8(6):e142–e8.

    7.       Guner CK, Akin S, Durna Z. Comparison of the symptoms reported by post-operative patients with cancer and nurses’ perception of patient symptoms. European Journal of Cancer Care. 2014;23(4):523–30.

    8.       Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care. 1991;7(2):6–9.

    9.       Chang VT, Hwang SS, Feuerman M. Validation of the Edmonton Symptom Assessment Scale. Cancer. 2000;88(9):2164–71.

    10.     Myhra CB, Grov EK. Sykepleieres bruk av Edmonton Symptom Assessment Scale (ESAS). Sykepleien Forskning. 2010;5(3):210–8. DOI: 10.4220/sykepleienf.2010.0113.

    11.     Cheung WY, Le LW, Gagliese L, Zimmermann C. Age and gender differences in symptom intensity and symptom clusters among patients with metastatic cancer. Support Care Cancer. 2011;19(3):417–23.

    12.     Miaskowski C. Gender differences in pain, fatigue, and depression in patients with cancer. J Natl Cancer Inst Monogr. 2004(32):139–43.

    13.     Helsedirektoratet. Nasjonalt handlingsprogram for palliasjon i kreftomsorgen. Oslo: Helsedirektoratet; 2015.

    14.     Watanabe SM, Nekolaichuk CL, Beaumont C. The Edmonton Symptom Assessment System, a proposed tool for distress screening in cancer patients: development and refinement. Psychooncology. 2012;21(9):977–85.

    15.     Strand E, Ellingsen E. Hvordan har du det i dag? Sykepleien. 2007;95(17):60–64. 2009. DOI: 10.4220/sykepleiens.2007.0050.

    16.     Slåtten K, Fagerström L, Hatlevik OE. Clinical competence in palliative nursing in Norway: the importance of good care routines. Int J Palliat Nurs. 2010;16(2):80–6.

    17.     Watanabe S, Nekolaichuk C, Beaumont C, Mawani A. The Edmonton Symptom Assessment System –what do patients think? Support Care Cancer. 2009;17(6):675–83.

    18.     Watanabe SM, Nekolaichuk C, Beaumont C, Johnson L, Myers J, Strasser F. A multicenter study comparing two numerical versions of the Edmonton Symptom Assessment System in palliative care patients. J Pain Symptom Manage. 2011;41(2):456–68.

    19.     Helsedirektoratet. ICD-10. Den internasjonale statistiske klassifikasjonen av sykdommer og beslektede helseproblemer [Internet]. Oslo: Helsedirektoratet [updated 01.01.2018, cited 20.12.2018]. Available at: https://finnkode.helsedirektoratet.no.

    20.     Selby D, Cascella A, Gardiner K, Do R, Moravan V, Myers J, et al. A single set of numerical cutpoints to define moderate and severe symptoms for the Edmonton Symptom Assessment System. J Pain Symptom Manage. 2010;39(2):241–9.

    21.     Lynch MT. Palliative care at the end of life. Semin Oncol Nurs. 2014;30(4):268–79.

    22.     Nordøy T, Thorsen L, Kvikstad A, Svendsen R. Ernæring og væskebehandling til pasienter med ikke-kurabel kreftsykdom. Tidsskrift for Den norske legeforening. 2006;126(5):624–7.

    23.     Guttormsen AB, Hensrud A, Irtun Ø, Mowé M, Sørbye LW, Thoresen L, et al. Nasjonale faglige retningslinjer for forebygging og behandling av underernæring. Oslo: Helsedirektoratet; 2009.

    24.     Nordøy T, Svendsen R, Johansen MJ, Buitink M, Ervik B, Aasebøe U, et al. Håndbok i lindrende behandling: Universitetssykehuset i Nord-Norge – Lindring i Nord; 2012.

    25.     Trier EL, Jørstad C. Munnstell av alvorlig syke. Sykepleien. 2014;102(9):58–61. DOI: 10.4220/sykepleiens.2014.0108.

    26.     Bergh I, Kvalem IL, Aass N, Hjermstad MJ. What does the answer mean? A qualitative study of how palliative cancer patients interpret and respond to the Edmonton Symptom Assessment System. Palliat Med. 2011;25(7):716–24.

    27.     Culleton S, Dennis K, Koo K, Zhang L, Zeng L, Nguyen J, et al. Gender difference in symptom presentations among patients with bone metastases in gender-specific and gender-neutral primary cancers. World J Oncol. 2011;2(3):102–12.

    28.     Fillingim RB, Ness TJ, Glover TL, Campbell CM, Hastie BA, Price DD, et al. Morphine responses and experimental pain: sex differences in side effects and cardiovascular responses but not analgesia. J Pain. 2005;6(2):116–24.

    29.     Sigurdardottir KR, Haugen DF. Prevalence of distressing symptoms in hospitalised patients on medical wards: A cross-sectional study. BMC Palliat Care. 2008;7:16.

    30.     Watanabe SM, Nekolaichuk CL, Beaumont C. Palliative care providers' opinions of the Edmonton Symptom Assessment System Revised (ESAS-r) in clinical practice. J Pain Symptom Manage. 2012;44(5):e2–e3.

    Fatigue, dry mouth and loss of appetite are the most distressing symptoms, according to a screening with the ESAS tool.

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    Sammendrag

    Background: Palliative cancer patients experience a complex clinical picture. Research shows little correlation between nurses’ impressions of the patient’s symptoms and the patient’s experience of their own symptoms. National guidelines recommend the use of screening tools to chart and evaluate the patient’s symptoms systematically.

    Objective: The objective of the study is to elucidate palliative cancer patients’ self-reporting of symptoms on admission to and discharge from a palliative care unit.

    Method: The study was conducted at the Palliative Care Unit, University Hospital North Norway, Harstad, in the period 2008–2016. The study uses data from the Edmonton Symptom Assessment System (ESAS). The dataset is presented using descriptive statistics.  

    Results: The study comprised 274 patients, of whom 135 were women and 139 men. Fatigue, dry mouth and loss of appetite emerge as the most distressing symptoms. Women exhibited a greater symptom burden than men, with the exception of shortness of breath. There was a significant reduction in all symptoms on discharge.

    Conclusion: Good palliative care entails that nurses are attentive to and have knowledge of the patients’ symptoms. Systematic registration of symptom data facilitates the detection of symptoms that might otherwise have been overlooked. Early screening and treatment may reduce the risk of major, problematic symptoms over a lengthy period, and therefore give improved quality of life.

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  • The organisation of community nursing services may impact negatively on safety and the quality of care

    Norway’s community nursing service is the country’s largest primary care provider, and user numbers are increasing (1, 2). In Norway, it is the local authorities that are responsible for organising the municipal community nursing services. Organisational choices are made locally by elected local councillors in partnership with the municipal administration.

    Decisions may be made on the basis of an instrumental rationality in which the best solution is chosen based on clear objectives and available information about all conceivable ways of achieving these objectives. Decisions may also be made on the basis of a communicative rationality, in which the actors involved in the decision-making process have different objectives and values, and decisions are based on a negotiated consensus (3).

    Municipal organisation

    The way that Norway’s municipalities organise their community nursing services affects the quality of service as well as patient safety. In this article, high-quality services are conceptualised as effective, safe and co-ordinated services that ensure user influence through user involvement, and provide continuity (4). The choice of organisational model for the community nursing service is made by decision-makers like local councillors and the municipal administration. Their choices influence three different factors:

    • The number of staff that any one patient will need to relate to,
    • the professional expertise and competence available among staff, and
    • (external) administrative requirements and expectations that may interact with or follow from decisions made.

    According to the Norwegian Government, patients are often required to relate to many unfamiliar members of staff within their own personal space. This can affect the patients’ continuity of care, dignity, sense of security and level of safety (5). The requirements imposed by decision-makers with respect to the professional expertise and competence of those who provide the care, can also considerably affect quality and safety levels (6).

    One example is competence levels in rehabilitation, where the attention is directed towards what is important for the patient (7). It is also important that community nurses are given scope to use their professional discretion. The provision of nursing care is contingent on room for negotiation and the opportunity to accommodate genuine service user involvement (8).

    New Public Management

    Decision-makers also influence the administrative requirements imposed on the community nursing service, as well as the nature and extent of reporting to the management by staff. Many Norwegian municipalities introduced instruments based on New Public Management approaches such as management by objectives and a purchaser–provider model (9).

    Decision-makers also influence the administrative requirements imposed on the community nursing service.

    A purchaser–provider model defines the need for care through a decision made by parties (the purchaser) other than those who provide the patient care. Studies suggest that the model may lead to increased bureaucracy through standardisation, regulatory control and paperwork (10), which in effect can reduce the opportunity to provide service user involvement (11). Figure 1 shows how the three above factors influence the quality of the care provided as well as patient safety.

    Figure 1. Model of how the local authorities’ organisational decisions may influence quality and safety

    Objective

    There is limited knowledge available about the decision-makers’ reasons for choosing particular organisational models and what factors they take into consideration in this connection. Our study set out to gain more knowledge about how local authority decision-makers justify their decisions and how the factors of quality, patient safety and health promotion are described and accentuated with respect to the organisation of community nursing services. The study deals with the following research question:

    • How do local councillors and the heads of municipal healthcare services describe good quality and patient safety in relation to community nursing, and how does this impact on the current organisation of these services?

    Method

    The study was based on a comparative case study (12) of two municipalities (‘municipality 1 and 2’) carried out in the period 2015–2016. A case study may be defined as empirical research that uses various data collection methods to investigate a contemporary phenomenon (the case) in its real-life context, particularly when the boundaries between context and phenomenon are not clearly evident (12).

    The two municipalities were selected on the basis of their co-location within the same region and due to the fact that their models of local government are the same, although they differ in terms of size and organisational model. Both municipalities are governed by an executive council according to the alderman model. Municipality 1 is roughly five times larger than municipality 2 in terms of population. Furthermore, both municipalities have implemented a purchaser–provider model in the community nursing service.

    In each of the municipalities we collected data from a focus group interview with five and four local councillors respectively, each with at least 3 ½ years of experience of sitting on a ‘healthcare committee’. We also collected data from individual interviews with the heads of municipal healthcare services, and from our analysis of municipal documents obtained for the period 2000–2015.

    Document searches

    The respective municipal documentation systems were accessed through the local authority websites and we searched for political documents that concerned community nursing and home-based care services since the year 2000, using ‘hjemme*’ [“home”] as our search term.

    For both municipalities our search produced action plans, financial plans and municipal plans, as well as minutes of meetings: a total of 27 documents in municipality 1 and 29 documents in municipality 2. Our study involved eleven informants and we conducted our interviews between April and July 2015.

    Interviews

    All interviews were conducted according to the same interview guide. The topics covered by the guide included the organisation of the community nursing service in general, as well as the specific grounds for choosing this organisational model, and the concepts of quality and patient safety in the community nursing service.

    During the interview, informants received a written list of six possible factors: ‘research’, ‘earlier experience’, ‘patient safety’, ‘quality’, ‘finance’ and ‘formal recommendations made by the municipal administration’. The factors were discussed in an effort to bring out a range of perspectives.

    We recorded all interviews on tape and produced verbatim transcriptions. The data were subjected to an inductive content analysis (13) and the two municipalities were compared. As far as the documents were concerned, this analysis covered only relevant paragraphs from 2015 onwards. Earlier documents gave more of an insight into the history of each municipality in terms of how their community nursing services were organised.

    The study was reported to and approved by the Norwegian Centre for Research Data (NSD) (project number 42252).

    Results

    Before we go on to describe the results of the data analysis, table 1 illustrates the characteristics of each municipality.

    Table 1. The municipalities’ general characteristics (2015)

    The reasons given by each municipality for choosing the organisational model of their community nursing service

    The documents show that municipality 1 introduced a number of organisational changes in the period 2000–2015. Municipality 1 introduced a ‘profit model’ in 2000, involving a two-tier structure (chief administrative officer and municipal enterprise units) as well as the purchaser–provider model. In 2003, municipality 1 reduced its number of municipal enterprise units from fourteen to eight on ‘discretionary grounds’.

    In 2010 the number of municipal enterprise units was reduced from eight to seven, and in 2012 this was further reduced to six in an effort to make each unit more ‘robust’. According to the local councillors in the smallest municipality (2) the team serving area 2 was split for the following reason:

    ‘It was something they realised was necessary … to enable them to provide a better service …, probably relative to the number of employees, that there were many staff …. And to achieve a better operational structure, they decided to split in two’ (local councillors in municipality 2).

    The local councillors in municipality 2 reported that they had not been involved in the decision. Our results show that neither research evidence nor health promotion were factors that impacted on the way that the community nursing service was organised in any of the municipalities, but the formal recommendations made by the administration did have an impact. The local councillors stated that they were completely dependent on these recommendations.

    Dominated by financial affairs

    The local councillors in municipality 1 said that ‘the plans often looked great’, but that they were required to ‘read between the lines’ because there was insufficient knowledge about whether the plans would work. The local councillors in municipality 1 agreed that financial concerns are at the heart of any reorganisation aimed at saving money. While this factor dominates, the local councillors doubted whether reorganisation does in fact generate savings, since changes are also a drain on resources.

    According to the head of healthcare services in municipality 1 the introduction of the purchaser–provider model was an organisational trend, and this individual was uncertain whether the current organisation was founded on concerns for quality or finances. The municipal documents from the period 2003–2015 in this municipality showed that financial concerns were more prominent than concerns for quality.

    For example, based on service user surveys conducted in 2005, 2008 and 2010, the municipality concluded that the quality had deteriorated when the purchaser–provider model was introduced due to reduced user involvement, accessibility, reliability and information. Also, patients were required to relate to a greater number of staff.

    The documents gave considerably more prominence to finances than patient experiences.

    These user experiences appeared not to have influenced the organisation of the service. The documents gave considerably more prominence to finances than patient experiences, which is why the municipality wished to invest even further in the purchaser–provider model. Our analysis of the data shows that neither earlier experience nor patient safety had been included in the rationale for organisational decision-making in municipality 1, but that in municipality 2 these factors may have had some impact.

    Quality was highlighted as an important factor in municipality 2, and all informants from this local authority said that quality had been a prime concern when deciding how the community nursing service should be organised. According to them, this was the reason why one of the teams had been split in two. An overall assessment of findings in both municipalities shows that health promotion (cf. the Norwegian Public Health Act) has had no impact on the current organisation of the community nursing service.

    The importance of quality and patient safety

    In terms of defining quality and patient safety in the community nursing service, our analysis of the data brings out similarities as well as differences among the informants and in the documents obtained from both municipalities (see table 2).

    There was agreement across the municipalities that patients should have to relate to as few staff as possible.

    The head of healthcare services in municipality 2 was the only person who believed that the needs of the population should be mapped with regard to quality improvement initiatives and that the public must be involved with the planning, since ‘they know best’. The informants and documents also mentioned ‘the right help, from the right person, at the right time, in the right place’, qualified professionals, good dialogue with relatives and awareness of psychosocial factors when talking about the nature of quality and patient safety in the community nursing service.

    There was agreement across the municipalities that patients should have to relate to as few staff as possible. The local councillors in municipality 1 felt that quality of life was important, and spending more time with patients was key. They argued however that expectations with respect to the standard of service had to be lowered, and that satisfaction among all patients would be impossible. This is reflected in the documents from municipality 1, which show that expectations for an increased standard of services must be lowered due to reduced municipal revenues.

    Table 2. Descriptions of the concepts of ‘quality’ and ‘patient safety’ within the community nursing service

    Assessment of how the community nursing service is organised

    With respect to the current organisation of the community nursing service, all sources from both municipalities were in agreement that ‘patients currently have to relate to far too many members of staff’. The documents from municipality 1 included multiple references to how team mergers can make the community nursing service more robust and yield financial savings. The head of municipal healthcare services supported this line of thinking:

    ‘There is a need for the municipality to be subdivided on geographic grounds, but four enterprise units will be more sustainable than six, which will produce a larger pool of employees for making up small teams if that’s desirable’ (head of healthcare services in municipality 1).

    Nevertheless, this individual also stated that it is possible to lose control and the overview if the units are too big. The local councillors appeared to be more skeptical towards team mergers out of consideration for staff, who would need to adapt:

    ‘Then there’s something about the need for constant reorganisation in the health service and other services. As healthcare professionals it’s enough to drive you up the wall… All of these councillors who are constantly thinking of something new in order to make their mark … It’s never-ending. So I’m not saying that we shouldn’t reorganise, but give the professionals a bit of peace and quiet to do their job’ (local councillor in municipality 1).

    Different views on the purchaser–provider model

    In accordance with the documents, the head of healthcare services in municipality 1 highlighted the purchaser–provider model. The model was described as sensible in light of the requirements for legal protection, but it was made clear that simplification was needed. However, the local councillors in municipality 1 rarely referred to this model and appeared to take a neutral view on it, or they wished to have it abolished for the following reason:

    ‘The level of bureaucracy is immense [and even] the Norwegian Nurses Organisation considers it to be nonsense … First you need to place an order and then you need to wait for someone else to deliver. Why can’t the same person do both jobs?’ (local councillor in municipality 1)

    Among the local councillors it appeared that legal protection and documentation requirements were more important: ‘If you haven’t documented it, just forget it.’

    In municipality 2, no mention was made of the purchaser–provider model or of the reporting requirements. All sources were positive to a future merger and co-location of all teams. A merger could not, according to the document, be ‘disadvantageous for the patients’. The head of municipal healthcare services used the word ‘synergy’, but said that the argument against mergers involved a potential that there would be too many members of staff to relate to.

    Although the local councillors in this municipality were positive to co-location, multiple teams would provide a better service: ‘… fewer members of staff to relate to.’ The results show that in both municipalities it was only the local councillors who reflected on what the staff felt about the current organisation, and they were concerned about pressures of time and stress, insufficient time spent with patients, dialogue, the exercise of discretion, and excessive financial control.

    Discussion

    Table 3 provides an overview of all factors and their impact on the municipalities’ organisation of the community nursing service.

    Table 3. The significance of various factors to the organisation of the municipalities’ community nursing services

    Despite the fact that the White Paper about the primary health service of the future (1) expects the organisation of community nursing services to be evidence-based, with a clear emphasis on health promotion (14), our results show that the opposite is the case. The lack of an evidence-based approach may be explained by the fact that research is not an overarching concern when decisions are made (15).

    However, the results show that formal recommendations made by the municipal administration are a determining factor in the way that the community nursing service is organised. This may reflect a growing trend ‘that important decisions are transferred away from the local council and over to bodies that are made up of non-elected representatives’, i.e. so-called fragmentation (16, p. 129).

    Other studies also describe a development that sees the local council becoming more of a decision-making body (17), with increasingly detailed control being exerted by central government, thereby influencing the decision-making processes considerably (18). The government’s growing reporting requirements are highlighted as an important factor in the decision-making process, but our results showed differences among the informants in this respect.

    The head of municipal healthcare services pointed to the purchaser–provider model as an answer to the reporting requirements, while the local councillors queried the model because it led to more bureaucracy; some considered abolishing the model. In a decision-making perspective (3), the results show that different actors have different values and objectives (cf. communicative rationality), while they suggest that the recommendation made by the municipal administration is often the chosen alternative (instrumental rationality) although the local councillors may not necessarily feel that the various options have been sufficiently researched with respect to quality and patient safety.

    Criticism of the purchaser–provider model

    Earlier research shows that a so-called ‘profit model’ does not bring about better financial control and efficiency, but instead breeds bureaucracy and higher administrative costs (19). An organisation based on New Public Management may lead to higher costs and more complaints (20). Specifically with reference to the community nursing service, the purchaser–provider model has been described in earlier studies as a threat to service user involvement (11) and sound professional practice (21).

    Despite this criticism, the head of healthcare services in municipality 1 argued in favour of this model on grounds of legal protection, in line with the documents. This decision may suggest that in municipality 1 the model has benefited from a so-called ‘protective immune resistance’ (22).

    In addition to voicing strong criticisms against the purchaser–provider model, earlier research suggests that mergers of community nursing teams may make staff anxious and insecure and may lead to overly complex systems (23). The larger teams formed by team mergers mean that patients will need to relate to a greater number of staff members, and may thereby suffer a risk of experiencing poorer quality and a lower level of patient safety (4).

    Studies have shown that autonomous teams consisting of fewer staff may provide a better quality of care and generate a reduced need for care (24), as well as lower costs and more satisfied employees (25, 26). In this light, the findings of our study suggest a number of paradoxes. Several decisions that appear to be rational, do not necessarily have the intended effects (3).

    Contradicting arguments in favour of mergers

    The arguments in favour of mergers do not coincide with earlier research. In municipality 2, a team was split in two in order to improve quality and reduce the number of staff members that each patient would need to relate to. It is therefore a paradox that this local authority later decided to merge all three teams. The paradox appears to be reinforced by the fact that our sources in both municipalities pointed out that patients already have to relate to too many people.

    This paradox may appear to be even greater when we examine the numerical consequences of a team merger. Although table 1 must be interpreted with caution, it is theoretically possible that a patient in municipality 1 is attended to by 110 different members of staff in the course of a single year. Additionally, some patients encounter staff members from the Night Patrol and the rehabilitation service, student nurses and others.

    Our study suggests the existence of a management paradox in that the local authorities are more concerned with the continuity of day-to-day operations than with the patients’ need for continuity of care.

    We may ask what this means for the most vulnerable patients whose need for continuity of care is considerable (27). Our study suggests the existence of a management paradox (28) in that the local authorities are more concerned with the continuity of day-to-day operations than with the patients’ need for continuity of care.

    Quality and safety at risk

    Earlier research suggests that there are different interpretations of the concept of ‘quality’ among front-line staff and decision-makers (29). Our study shows that decision-makers have a broad understanding of what quality and patient safety entail within the context of the community nursing service. They highlight the importance of involving as few members of staff as possible with the care for any single individual (4) as well as the need to employ qualified personnel (6), focus on quality of life (30) and encourage service user involvement (8).

    According to the Norwegian government it may seem as if the municipal freedom of choice does not work as intended because the chosen organisational model sometimes fails to meet the legal requirements pertaining to good practice and quality of care (1). In terms of assessing the current organisation of services, the statements made by the local councillors may give the impression that quality and safety are at risk.

    We may ask to what extent the legal requirements for sound professional practice can be fulfilled within an organisational structure described as complex and fragmented, where there is a wide gap between decision-makers and patients, and where patients, according to all data sources, are forced to relate to too many staff.

    The study has several limitations. Data were collected from only two municipalities, and neither staff nor patients were included in the sample. The first author has been working in the community nursing service since 2003. Both authors contributed to the analysis in order to strengthen its merit and credibility, and to avoid bias.

    Conclusion

    It was the case in both municipalities that the administration’s formal recommendations had significantly impacted on the way that the community nursing service was organised, while evidence-based knowledge and public health promotion were of limited importance. It seems that the role played by local councillors is marginalised in that they appear on the scene only at the decision-making stage, and the gap between decision-makers and patients is wide.

    We identified several differences between the two municipalities. In municipality 1, the purchaser–provider model, reporting and regulatory requirements, and particularly finances, had a significant impact on the way that the community nursing service was organised. These factors were of limited importance in the smaller municipality.

    Despite a reasonably broad understanding among decision-makers of the importance of quality and patient safety, these factors were in practice only considered to be of moderate importance in the smaller municipality and of little importance in the larger municipality.

    One common denominator was that both municipalities expected the merger of community nursing teams and enterprise units to be beneficial. The fact that they advocated mergers, appears paradoxical since all informants highlighted that patients need to relate to as few members of staff as possible.

    In line with more recent White Papers (1, 5), we therefore recommend that municipal decision-makers:

    • focus on the quality of services and health promotion in the local community from the citizens’ perspective,
    • map the community’s (healthcare) needs, networks and resources, and
    • use the two points above as a basis for their organisation and funding of the community nursing service, and the municipality’s organisational structure.

    Research suggests that this approach and organisational model may not only improve the health of the local community, but can also generate better satisfaction rates among patients, citizens and staff, in addition to financial savings.

    References

    1. Meld. St. nr. 26 (2014–2015). Fremtidens primærhelsetjeneste – nærhet og helhet. Oslo: Helse- og omsorgsdepartementet; 2015. Available at: https://www.regjeringen.no/contentassets/d30685b2829b41bf99edf3e3a7e95d97/no/pdfs/stm201420150026000dddpdfs.pdf(downloaded 04.04.2016).

    2. Mørk E, Sundby B, Otnes B, Wahlgren M. Pleie- og omsorgstjenesten 2013. Statistikk om tjenester og tjenestemottakere. Oslo, Kongsvinger: Statistisk sentralbyrå; 2014. Available at: http://www.ssb.no/helse/artikler-og-publikasjoner/_attachment/201126?_ts=1499f2338b0(downloaded 20.09.2015).

    3. Engen OAH, Kruke BI, Lindøe PH, Olsen KH, Olsen OE, Pettersen KA. Perspektiver på samfunnssikkerhet. Oslo: Cappelen Damm Akademisk; 2016.

    4. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: National Academy Press; 2001.

    5. Meld. St. nr. 29 (2012–2013). Morgendagens omsorg Oslo: Helse- og omsorgsdepartementet; 2013. Available at: https://www.regjeringen.no/no/dokumenter/meld-st-29-20122013/id723252/ (downloaded 31.10.2014).

    6. Hughes RG, red. Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality (US); 2008. Available at: https://www.ncbi.nlm.nih.gov/books/NBK2651/(downloaded 30.10.2016).

    7. Bredland E, Linge OA, Vik K. Det handler om verdighet og deltakelse: verdigrunnlag og praksis i rehabiliteringsarbeid. 3. ed. Oslo: Gyldendal Akademisk; 2011.

    8. Hanssen H, ed. Faglig skjønn og brukermedvirkning i helse- og omsorgstjenestene. 2. ed. Bergen: Fagbokforlaget; 2015.

    9. Vabo SI, Stigen IM. Moteslaveri, interesser og behov. En analyse av utbredelsen av «moderne» organisasjonsløsninger i norske kommuner. Nord Organ. 2004;6(1):48–88.

    10. Vabø M. Norwegian home care in transition – heading for accountability, off-loading responsibilities. Health Soc Care Community. 2012;20(3):283–91.

    11. Vik K, Eide A. Older adults who receive home-based services, on the verge of passivity: the perspective of service providers. Int J Older People Nurs. 2013;8(2):123–30.

    12. Yin RK. Case study research: design and methods. 5. ed. Los Angeles: SAGE; 2014.

    13. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–12.

    14. Plochg T, Klazinga NS. Community-based integrated care: myth or must? Int J Qual Health Care. 2002;14(2):91–101.

    15. Culyer AJ, Lomas J. Deliberative processes and evidence-informed decision making in healthcare: Do they work and how might we know? Evid Policy J Res Debate Pract. 2006;2(3):357–71.

    16. St.meld. nr. 33 (2007–2008). Eit sterkt lokaldemokrati. Oslo: Kommunal- og regionaldepartementet; 2008. Available at: http://www.regjeringen.no/nb/dep/kmd/dok/regpubl/stmeld/2007-2008/stmeld-nr-33-2007-2008-.html?regj_oss=1&id=517539(downloaded 12.12.2014).

    17. Ringkjøb H-E, Folkestad B, Offerdal A, Aars J. Demokrati heile vegen – Gode styringsgrep og metodar for folkevalte. Bergen: Stein Rokkand Senter; 2007. Available at: https://www.researchgate.net/publication/242781377_Gode_styringsgrep_og_metodar_for_folkevalte(downloaded 4.12.2018).

    18. Baldersheim H, Smith E. Lokalt demokrati uten kommunalt selvstyre?: En publikasjon fra Demokratiprogrammet ved Universitetet i Oslo. Oslo: Abstrakt forlag; 2011.

    19. Berge DM. Økonomistyring i resultatkommunen. I: Torsteinsen H, red. Resultatkommunen: reformer og resultater. Oslo: Universitetsforlaget; 2012.

    20. Hood C, Dixon R. A government that worked better and cost less?: evaluating three decades of reform and change in UK central government. 1. utg. Oxford: New York, NY: Oxford University Press; 2015.

    21. Tønnessen S, Nortvedt P. Hva er faglig forsvarlig hjemmesykepleie? Sykepleien Forskning. 2012;7(3):280–5. Available at: https://sykepleien.no/forskning/2012/10/hva-er-faglig-forsvarlig-hjemmesykepleie(downloaded 14.12.2014).

    22. Vabø M. Reformtrender og endringsparadokser. In: Vabø Mia, Vabo SI, ed. Velferdens organisering. Oslo: Universitetsforlaget; 2014.

    23. Andersen GR, Westgaard RH. Discrepancies in assessing home care workers’ working conditions in a Norwegian home care service: differing views of stakeholders at three organizational levels. BMC Health Serv Res. 2015;15(1):286. Available at: http://www.biomedcentral.com/1472-6963/15/286(downloaded 21.10.2014).

    24. Hussey PS, Schneider EC, Rudin RS, Fox DS, Lai J, Pollack CE. Continuity and the costs of care for chronic disease. JAMA Intern Med. 2014;174(5):742–8.

    25. Nandram SS. Organizational innovation by integrating simplification. New York, NY: Springer; 2014.

    26. Laloux F. Reinventing organizations: a guide to creating organizations inspired by the next stage of human consciousness. Brussel: Nelson Parker; 2014.

    27. Woodward CA, Abelson J, Hutchison B. My home is not my home anymore: Improving continuity of care in homecare. Ontario: Canadian Health Services Research Foundation; 2001.

    28. Gjevjon ER, Romøren TI, Kjøs BØ, Hellesø R. Continuity of care in home health-care practice: two management paradoxes. J Nurs Manag. 2013;21(1):182–90.

    29. Wiig S, Aase K, von Plessen C, Burnett S, Nunes F, Weggelaar A, et al. Talking about quality: exploring how ‘quality’ is conceptualized in European hospitals and healthcare systems. BMC Health Serv Res. 2014;14(1):478.

    30. Nies H. Communities as co-producers in integrated care. Int J Integr Care. 2014;14(2):1–4.

    Some municipalities gave considerably more prominence to finances and day-to-day operations than safe and secure patient experiences.

     

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    Sammendrag

    Background: Norway’s community nursing service is the country’s largest primary care provider, and user numbers are increasing. The way that the community nursing service is organised may contribute to improving or reducing safety and the quality of care. The Government favours an evidence-based organisational model.

    Objective: This study was conducted in order to increase our knowledge of how municipal decision-makers justify their choices, and how they describe and accentuate quality, patient safety and health promotion with respect to the organisation of the community nursing service.

    Method: The study is based on a comparative case study of two Norwegian municipalities. We gathered data by conducting focus group interviews with local councillors in each of the municipalities and individual interviews with the respective heads of municipal healthcare services. We also retrieved a number of municipal documents. We subjected the material to an inductive content analysis and compared the data obtained from the two municipalities.

    Results: Formal recommendations put forward by the municipal administration have a significant impact on how the community nursing service is organised in each municipality, while evidence-based knowledge and health promotion are of limited importance. Concerns for quality and safety have a moderate impact in one of the municipalities, while they have little impact in the other. There appears to be considerable distance between the levels of decision-maker and patient.

    Conclusion: The study shows that the organisation of community nursing services is complex and fragmented, and there is reason to ask whether the organisation of services allows for fulfilment of legal requirements pertaining to quality and safety.

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  • New form is suitable for assessing clinical nursing education

    In clinical nursing education, it is a common challenge internationally to ensure that the learning outcome is achieved, and several methods of assessing this have been tested (1–3). The Bologna declaration is a process that began in 1999, and the Qualifications Framework for Higher Education was introduced in Norway in 2005.

    Preparation of a qualifications framework (EQF, European Qualifications Framework) for all levels of the educational system began in 2006, and in 2009 Norway decided to endorse this instrument (5). The introduction of the framework affected both education and learning in clinical nursing education, as well as assessment and tools used for assessment.

    There has been an ongoing discussion within bachelor-level nursing education about where students should learn, how learning can best take place, and how the learning outcome should be assessed (2, 6, 7). Universities Norway (UHR) recommends focusing on research on education in health and social care subjects at university level, with special emphasis on work methods and learning outcomes in clinical education (8).

    This article focuses on students and preceptors in clinical practice and their experience with and views on a recently developed assessment tool for clinical education.

    Previous research

    International research shows that it is challenging to assess students in all health-related professions that include clinical education as a core component (1, 9). In addition, research shows that preceptors in clinical education are seeking comprehensible standards to use in their assessments and that a lack of standards and ambiguously formulated learning outcomes make it difficult to give students a failing mark (10, 11).

    It is challenging to assess students in all health-related professions that include clinical education as a core component.

    It is a well-known problem that educational institutions’ documents may be difficult to understand for those who are required to use them (2, 12). Research shows that far fewer students pass theoretical examinations than clinical education programmes. There is a call for processes that further develop assessment criteria that are relevant, manageable and robust enough to distinguish between the competence level of the various students in clinical education (10, 11).

    Some of the problem lies in ambiguously formulated learning outcomes in the assessment document (11). Research shows that a lack of clear criteria for satisfactory completion of clinical education is an international problem, and more studies have described the problems associated with assessing clinical nursing competence than have proposed solutions (3, 13).

    Assessments

    Assessment entails a normative or value-related judgment based on expectations, requirements and criteria (14). It could be argued that assessing students in clinical education has a great deal in common with assessing the achievement of goals. In fact, the learning outcomes in the student’s educational plan are the goals that the student is expected to achieve and that he or she is assessed in relation to. Assessing achievement of goals requires clear criteria regarding what is needed in order to reach the goals (15).

    The aim of a summative assessment is to compare the student’s knowledge, skills and general competence with standards that the student is expected to achieve. The assessment may also be formative and put greater emphasis on the student’s progress during and throughout the clinical education programme (16).

    A formative assessment must also clarify how the student can achieve the expected learning outcome, thus promoting more in-depth learning and motivation and fostering self-regulated learning. Feedback is a key aspect of formative assessment (14, 16, 17).

    Form for assessing learning outcomes

    The Assessment for Clinical Education (AssCE) was developed in Sweden as a result of the Bologna declaration (1, 18). After 2000, it was further developed into an assessment form that is used in countries such as Norway, Sweden and Finland. The form was developed to ensure that students are assessed on the basis of their learning outcomes in the clinical education portion of the bachelor’s degree in nursing.

    The AssCE form contains 21 different factors or questions divided among five areas in which the student is assessed. The five areas are ‘Communication and teaching’, ‘The nursing care process’, ‘Examinations and treatments’, ‘Management and cooperation’ and ‘Professional approach’.

    Examples of factors are ‘Participates by carrying out examinations and treatments’ and ‘Administers medications’, which are factors under the area ‘Examinations and treatments’. Each factor is assessed on a three-level scale: ‘Inadequate achievement of goals’, ‘Good achievement of goals’ and ‘Very good achievement of goals’.

    The assessment is conducted in accordance with the description of learning outcomes in the student’s educational plan. From the middle to the end of the clinical education programme, the teacher places a check next to each factor, which highlights the student’s progress within the various factors. The content and design of the AssCE form are the same for all clinical education (1, 19).

    Use of the form

    When the students use the AssCE form, they must complete a self-assessment and place themselves on the assessment scale in preparation for the performance review. A major study describes experiences of using the AssCE form after the researchers analysed the questionnaire given to preceptors and nursing students at two Swedish universities.

    The study concludes that each factor which clarifies achievement of goals should have a better description (1). Clear criteria for achievement of goals makes it possible to distinguish and discuss the students’ progress within the various areas of clinical education. The study also shows that information about use of the form is essential for being able to use it (1).

    Alternative assessment form

    In the spring of 2015, a university college in Norway created an alternative assessment form based on the AssCE form (1). Unlike the AssCE form, this form contains clearly defined learning activities to clarify what is expected of the student. The aim is to achieve consensus and validity in the assessment (3, 11).

    The learning outcomes in the educational plan have been formulated to encompass what the student is expected to do. These learning outcomes in the plan show the progression throughout the course of study so that clarification of the learning outcomes of required learning activities will ensure progression.

    For example, the learning outcome under ‘Skills’ in the educational plan is described as follows: the student ‘can apply knowledge about crises and crisis response, and demonstrate insight into the experiences and reactions of patients and their families in the event of acute and critical illness’. Table I shows an example of what achievement of goals implies for the learning outcome for ‘Skills’, as well as the scale for the assessed level of competence.

    Table 1. Levels of competence for ‘Skills’

    This form is different from the AssCE form (1) in that it has different content for the various periods of clinical education. The form’s assessment scale uses a five-level Likert scale from ‘Unsatisfactory’ to ‘Highly satisfactory’ for each criterion related to achievement of goals.

    The students prepare for their performance review in the same manner as when the AssCE form is used (1). The form provides space for more extensive comments about special circumstances or relevant tasks that the student should work with to satisfy the criteria for achievement of goals.

    Critique of methods

    The literature describes various methods that have been developed and tested for assessing students’ clinical competence, but these methods have been criticised for giving too much latitude to the preceptor’s subjective interpretation of competence and assessment of students (7, 20, 21). Research shows that it is difficult to find clear assessment criteria that are interpreted in the same way by students, preceptors and teachers (7, 21).

    Research shows that it is difficult to find clear assessment criteria that are interpreted in the same way by students, preceptors and teachers.

    Consequently, there is a need for an assessment form for clinical nursing education that uses clear, unambiguous descriptions of learning outcomes and criteria for achievement of goals to ensure that the learning outcome is achieved (22).

    Objective of the study

    The objective of our study is to evaluate students’ and preceptors’ views on a new assessment form for clinical nursing education that is based on the principles of the AssCE form.

    The research questions in this study are as follows:

    • Does the assessment form clearly show the student’s progression in the clinical education programme?
    • Does the new assessment form satisfy the requirement for clear criteria for how the students can achieve the learning outcome goals?
    • Does use of a scale with descriptions of level facilitate discussion in the performance review?
    • Is enough information given on the assessment form to enable its use?

    Method

    Questionnaire

    This study has a descriptive design based on a questionnaire which was developed by Löfmark and Thorell-Ekstrand to assess the AssCE form (1), and which has been adapted to the assessment form in our study. To ensure face validity, three teaching colleagues read and assessed the questionnaire, and found it to be relevant.

    The same version of the questionnaire was used for students and preceptors so that we could compare their responses in the survey. The preceptors were asked additional questions about how long they had worked as nurses, the number of times they had served as a preceptor, and any preceptor training they had undergone (1).

    A total of eight Likert scale responses from 1 = ‘Strongly disagree’ to 5 = ‘Strongly agree’ are shown in Table 2.

    Table 2. Reponses of students and preceptors

    In addition to the eight statements, the questionnaire consisted of four questions. These questions were adapted to students and preceptors, respectively, and one of the questions asked if the student had completed a self-assessment on a separate form prior to the performance review. The response options were ‘Yes’ and ‘No’.

    One question was whether the student or preceptor had incorporated views from various preceptors in the assessment, and another asked whether the assessment form could affect the quality of the health services. These two questions had four response options: ‘Always’, ‘Almost always’, ‘Seldom’ and ‘Never’. The final question asked whether anything in the form should be developed – with the opportunity to write a free response.

    Sample

    In the autumn of 2016, we invited all the students (n = 158) in their first hospital training period in their second year of studies, as well as their preceptors in clinical education (n = 18), to take part in the survey after they had used the assessment form. The clinical education spaces were divided amongst four hospitals in Norway – both medical and surgical departments.

    The students took part in clinical education in two subsequent groups. Some of the clinical education spaces had head preceptors, which means that they were responsible for supervising and assessing all the students (2 –14) in the relevant department. Other students had contact nurses with supervisory responsibility for one student.

    Data analysis

    We used Microsoft Excel to analyse the data. The data were analysed using descriptive statistics which reveal the frequency-related and summative features of the students’ and preceptors’ assessments of the assessment form that was used (23). We reported data from students and preceptors in both percentages and numbers to facilitate comparison (Table 2).

    Not all the respondents answered all the questions, but there was no systematic drop-out. The responses to the open-ended questions consisted of individual statements that we did not believe constituted material sufficient for a content analysis, but we read through the statements and used them to support our findings.

    Ethical considerations

    The study falls outside the mandate of the Regional Committees for Medical and Health Research Ethics (REK), as it does not involve information related to the participants’ own or others’ health. The Norwegian Centre for Research Data (NSD) found the study to be ‘not subject to notification’ with the explanation that all the information is anonymous and individuals cannot be identified.

    All the participants signed a declaration of consent in which they agreed to take part in the survey. In addition, they agreed to the use and publication of the information that they provided, and they could withdraw from participation without giving a reason. The survey was carried out after the final assessment to prevent the uneven power relationship between students and teachers from affecting the students’ responses.

    Students who did not pass the clinical education programme were excluded from the survey, as they were in a situation that could influence their responses. The participants’ responses were anonymous and confidentially was ensured by placing the completed questionnaires in an envelope that was collected by teachers at the university college.

    Results

    We invited a total of 158 students to participate in the survey. Seven students were not asked to take part because they did not pass the clinical education programme. Thus, we have based our results on the fact that 129 of 151 students responded and that all 18 preceptors responded. Not all the students responded to all the statements and questions, resulting in fewer than 129 responses to the four questions. There was only one question that not all the preceptors answered (Table 2).

    The 18 preceptors had nursing experience ranging from a few months to 45 years, and 15 preceptors had more than ten years of experience. Ten of them had undergone preceptor training. The number of times they had served as a preceptor varied from one to 40.

    Can use the form as a model

    An overview of responses from the students and preceptors about use of the assessment form with an emphasis on progression, learning outcome and criteria for establishing the level of competence is shown in Table 2. Altogether 73 per cent of the students said they agree (score 4 or 5) with the statement that the assessment form can be used as a model in various clinical education programmes in nursing education. About the same percentage said that the scale makes it possible to show the student’s progress.

    Slightly more than 60 per cent of the students agreed with the statements about learning outcome and the assessment form. About the same percentage of students agreed with the statements about criteria for establishing the level of competence, and 64 per cent of the students said that the information about the assessment form was sufficient.

    When we analysed the preceptors’ responses to the questions about progression, more than 90 per cent generally agreed that the assessment form can be used as a model in various clinical education programmes in nursing education and that the scale makes it possible to show the student’s progress.

    Roughly 80 per cent of the preceptors generally agreed with the statements about learning outcome and the assessment form, and about 90 per cent gave a score of 4 or 5 on the statement about criteria for establishing the level of competence. Almost all the preceptors regarded the information about the assessment form as sufficient.

    Preceptors gave higher scores

    The average score on all statements was slightly higher for the preceptors than for the students. Almost all the students and preceptors responded ‘yes’ to the question about whether the students had prepared for the assessment. Half of the preceptors said that the views of other preceptors had influenced their assessment of the students, which may indicate that many believe that student assessment is a joint responsibility.

    Some open-ended questions at the end of survey were included to capture new thoughts and ideas. The responses from the students and preceptors dealt with difficulties in understanding some of the phrases used in the questionnaire. Examples of such phrases were ‘the overall description’ and ‘achievement of goals of the assessed level of competence’.

    Other comments indicated that it was important for the university college teachers to have a common understanding of how they should use the assessment form. Some students would have liked to receive comments with positive feedback.

    Discussion

    The difference between the AssCE form and the assessment form in this study lies in the clarity of the criteria for achievement of goals, i.e. the specific actions that students are expected to perform and that form the basis for the assessment.

    Both students and preceptors found that it was helpful to make learning outcomes more specific, which is consistent with Benner’s proposed changes for improving nursing education (6). Benner also stresses the importance of making knowledge more concrete and referring to clinical examples (6).

    Both students and preceptors found that it was helpful to make learning outcomes more specific.

    The high average scores on the responses regarding progression may indicate that both students and their preceptors believe that progression was clearly defined in the assessment form (Table 2) and show a concurrent positive response. The response to the statement about progression is slightly higher in this survey than in the response to the statement about progression in the study conducted by Löfmark and Thorell-Ekstrand (1).

    Distribution of responses to statements

    The responses to the statements about learning outcome and the assessment form have a wider distribution than those in the other groups of statements. In Löfmark and Thorell-Ekstrand’s study, about 50 per cent of both the students and preceptors agreed that it worked well to combine achievement of goals for the various assessed levels of competence in the assessment form with the learning outcome for the period (1).

    In this study, two-thirds of the students and almost 90 per cent of the preceptors agreed with this statement, which shows a more positive response than in Löfmark and Thorell-Ekstrand’s study (2). A possible explanation for this difference may be that the AssCE form requires the teacher to clarify what is expected of the student, while the assessment form used in this study provides a more specific description of what is expected.

    Likes to use the scale for assessing the level of competence

    Regarding the criteria for assessing the level of competence, the responses show that the participants generally agree that the descriptions of the levels clarify and enable a discussion of the levels of knowledge, skills and general competence. The responses also show that when the scale is used, the discussion regarding assessment can be improved.

    We regard the responses about assessment of the level of competence as an indication that a scale with levels is viewed as a useful tool in the assessment process. A strength of the assessment form is that the students can actively participate in their own assessment, something which is desirable and can promote learning (17). This finding is consistent with findings in the study of the AssCE form (1).

    A strength of the assessment form is that the students can actively participate in their own assessment, something which is desirable and can promote learning.

    It could be argued that use of the scale for assessing the level of competence aligns with principles for a formative assessment in that the student’s progress is emphasised and highlighted and that it clarifies what is expected in order for the students to achieve the learning outcome (14).

    Received enough information to be able to use the form

    The assessment form also contains a summative assessment, as the final assessment is an assessment of whether the students’ knowledge, skills and general competence meet expectations (14).

    The information in the assessment form was sufficient, as more than 80 per cent of the participants agreed that enough information was provided to be able to use the form. In Löfmark and Thorell-Ekstrand’s study, about half of the preceptors agreed that they had received enough information, and therefore the researchers concluded that more information was needed about how both students and preceptors should use the AssCE form (1).

    The finding that the assessment form in this study provided sufficient information indicates that the form is successful, as research shows that forms should as far as possible be self-explanatory (10, 11).

    Discussion of method

    We clearly defined the inclusion criteria in the study by having all the students in their first hospital training period and their preceptors take part in the trial. Only students who did not pass the clinical education programme were excluded from the study. The students who participated were a strategic sample in the sense that they were the ones who had this period of clinical education in autumn 2016 in their course of study (n = 158). Thus, they can be regarded as a representative sample of nursing students in their first hospital training period. All the preceptors were nurses whose task was to assess students in autumn 2016 (n = 18).

    A systematic bias in this study may be the differences within the group of preceptors, as some had undergone preceptor training and others had not. This may have affected their responses since those with preceptor training are more knowledgeable about what is important in the preceptor role. In addition, the preceptors had different lengths of preceptor experience (1–40 times), which gave breadth to the sample. Gender and age in the sample were not taken into account, as these variables were not deemed to have an effect on the responses.

    Conclusion and implications for clinical practice

    The main finding of this study was that nursing students and their preceptors in clinical education appear to have a concurrent, positive view that the new assessment form can be used as a model for assessing students in clinical education. Our study shows that an assessment form with operationalised learning outcomes and assessed levels of competence is regarded as a good tool to use in the assessment process for students and preceptors and that the information about use of the assessment form was instructive.

    The form can be said to contain a description of relevant, clinical learning situations, and can thus be an important contribution to quality assuring the work involved in identifying students who have not achieved the expected learning outcome. This can be illustrated by the statement of a newly hired assistant professor: ‘The student’s weaknesses showed up very clearly’.

    References

    1.          Löfmark A, Thorell-Ekstrand I. Nursing students' and preceptors' perceptions of using a revised assessment form in clinical nursing education. Nurse Education in Practice. 2014;14(3):275–81.

    2.          Bjerknes MS, Christiansen B. Praksisveiledning med sykepleierstudenter. Oslo: Gyldendal Akademisk; 2015.

    3.          Yanhua C, Watson R. A review of clinical competence assessment in nursing. Nurse Education Today. 2011;31(8):832–6.

    4.          NOU 2000:14. Frihet med ansvar – Om høgre utdanning og forskning i Norge. Oslo: Statens forvaltningstjeneste, Informasjonsforvaltning; 2000. Available at: https://www.regjeringen.no/contentassets/b27a1ef056e64f9d85e3a93460710ac4/no/pdfa/nou200020000014000dddpdfa.pdf(downloaded 05.12.2018).

    5.          Kunnskapsdepartementet. Nasjonalt kvalifikasjonsrammeverk for livslang læring (NKR). Oslo; 2011. Available at: https://www.regjeringen.no/globalassets/upload/kd/vedlegg/kompetanse/nkr2011mvedlegg.pdf(downloaded 05.12.2018).

    6.          Benner P, Heggen K. Å utdanne sykepleiere: behov for radikale endringer. Oslo: Akribe; 2010.

    7.          Boud D, Garrick J. Understanding learning at work. London og New York: Routledge; 2012.

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    10.        Hunt LA, McGee P, Gutteridge R, Hughes M. Assessment of student nurses in practice: A comparison of theoretical and practical assessment results in England. Nurse Education Today. 2012;32(4):351–5.

    11.        Hauge KW. Veilederes beveggrunner for å unnlate å gi ikke-bestått i praksisstudier til tross for at læringsutbyttene ikke er nådd. Nordic Journal of Nursing Research. 2015;35(1):20–8.

    12.        Alvsvåg H, Førland O. Sykepleierutdanningen i lys av nyutdannedes yrkeserfaringer. Vård i Norden. 2006;26(3):34–8.

    13.        Wangen MG, Torjuul K, Sorlie V. Hva praksisveiledere vektlegger i vurderingen av sykepleierstudentenes kliniske kompetanse-en kvalitativ intervjuundersøkelse. Nursing Science & Research in the Nordic Countries. 2010;30(4):43.

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    16.        Taras M. Assement-summative and formative – some theoretical reflections. British Journal of Educational Studies. 2005;53(4):466–78.

    17.        Raaheim A. Læring og undervisning. Bergen: Fagbokforlaget; 2011.

    18.        Löfmark A, Thorell‐Ekstrand I. An assessment form for clinical nursing education: a Delphi study. Journal of Advanced Nursing. 2004;48(3):291–8.

    19.       Engstrøm M, Löfmark, Ugland Vae KJ, Mårtensson G. Nursing student's perceptions og using Clinical Education Assessment tool AssCE and their overall perceptions of the clinical learning environment. A cross-sectional correlational study. Nurse Education Today. 2017;51(1):63–7.

    20.        Haddeland K, Söderhamn U. Sykepleierstudenters opplevelse av veiledningssituasjoner med sykepleiere i sykehuspraksis – En fenomenologisk studie. Nordisk sygeplejeforskning. 2013;3(01):18–32.

    21.        Taras M. Student self-assessment: processes and consequences. Teaching in Higher Education. 2010;15(2):199–209.

    22.        Hauge KW, Brask OD, Bachmann L, Bergum IE, Heggdal WM, Inderhaug H, Grønvik CKU, Julnes SG. Kvalitet i praksisstudier i sykepleier- og vernepleierutdanning. Nordisk tidsskrift for helseforskning. 2016;12(1):19–33.

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    Both students in clinical nursing education and their preceptors think that the assessment form, which is based on the principles of the AssCE form, can be used as a model to assess the students.

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    Sammendrag

    Background: Research shows that it is a difficult task both nationally and internationally to assess students’ learning in clinical nursing education. The Bologna declaration has had major consequences for learning, teaching and the assessment of students’ learning. Numerous studies have examined the problems related to assessment in clinical education, but there is a call for processes that further develop assessment criteria that are relevant, manageable and robust enough to distinguish between the students’ levels of competence.

    Objective: The objective of this study is to evaluate students’ and preceptors’ views on a new assessment form for clinical nursing education, based on the principles of the AssCE form (Assessment for Clinical Education).

    Method: The study has a descriptive survey design based on data from a questionnaire given to 158 students and 18 preceptors at four Norwegian hospitals. The questionnaire consisted of eight Likert scale statements and four questions, and took its point of departure in the survey used by Löfmark and Thorell-Ekstrand when they evaluated the AssCE form (1).

    Results: The results are based on responses from 129 students and 18 preceptors. We found a positive response in the form of high average scores on all the Likert scale statements, both from the students (lowest average score 3.6, highest average score 4.3, maximum score 5.0) and from the preceptors (lowest average score 4.0, highest average score 4.7, maximum score 5.0). The results show a positive response from the students and their preceptors to the statements regarding descriptions of learning outcomes, the assessment form, progression, and the instructiveness and thoroughness of the information provided on the form.

    Conclusion: The main findings of the study are that students and their preceptors in clinical education have a concurrent, positive view of the new assessment form and that it is perceived as a useful tool in the assessment process. The new assessment form can thus be an important contribution to quality assuring the work involved in assessing students in clinical nursing education by clarifying the criteria for achievement of goals. Clear criteria for what the student is expected to achieve in order to successfully complete the clinical education programme can help to identify when students have not achieved the expected learning outcome, which is a problem area in clinical education assessment.

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  • How to ensure safe and appropriate medication management

    Medication management is an important part of the health care provided to users of municipal nursing and care services. It is a sub-process in the overall treatment of patients and is subject to requirements for professional accountability (1). Medication management is a challenging task. The form, strength and efficacy of medications vary, and they are often prescribed for patients with more than one illness, known as comorbidity (2).

    Medication management

    Medication management involves any medicine-related task performed from the point the medicine is prescribed or requisitioned until it is dispensed to the patient or discarded (3). Medication management is a complex process that includes preparation, checks, administering to patients, observation and documenting reactions and side effects, as well as reporting any deviations (4).

    The current regulations on medication management do not provide detailed instructions on how to address various practical challenges (3). A circular to the Norwegian regulations on medication management (1) gives advice and practical examples intended to maintain good routines and safeguard quality in medication management. However, there is evidence that healthcare personnel still have different understandings of what constitutes safe and appropriate medication management (5), and this can lead to medication management errors from the requisitioning of the medication until it is dispensed to the patient (6).

    Medication management errors

    Bielecki (4) categorises medication management errors as a breach of one of the ‘7 Rights’. The ‘7 Rights’ entail the right patient receiving the right medication at the right time, in the right form, and in the right way with the right strength or dose.

    More than 80 per cent of the errors are linked to assembling, preparing and dispensing medications to patients.

    Medication management errors are defined by Shawahna et al. (6) as deviations from that prescribed in the patient’s medical records, deviations from the manufacturer’s recommendations for storage, expiry date, preparation and administration or deviations from relevant institutional policies. More than 80 per cent of the errors are linked to assembling, preparing and dispensing medications to patients (7).

    Medication management errors can be caused by outdated practices, poor routines, the absence of procedures or skills, carelessness or lack of knowledge (8). Simonsen et al. (7) refer to surprising weaknesses in basic knowledge on medication management among nurses in the specialist health service and primary health care. These weaknesses represent a significant potential for error.

    Responsibilities in medication management

    Healthcare service managers are responsible for development, implementation and compliance in relation to procedures and instructions for medication management. They must also ensure that healthcare personnel have the necessary knowledge and skills within medication management (1). Nevertheless, many studies, both national and international, identify a major need to improve medication management routines (9, 10) and internal controls (11).

    Safety procedures are not always possible to carry out in practice, and there is a mismatch between medication competence, work tasks and staffing (11). Healthcare personnel are often interrupted when preparing and administering medication and when monitoring patients’ reactions. The employer’s expectations within medication management are also unclear sometimes (9). Improving competence and dealing with deviations are vital to reducing the risk of errors (7, 11–14).

    Pharmaceutical advice and medication audits can reduce the risk of errors in medication management, but Circular IS-7/2015 does not clarify how the advisory aspect should work in practice (10). Role clarification or clarifying responsibilities, establishing interdisciplinary teams and increased knowledge of medication management are among the measures covered.

    According to the report on appropriate medication use for elderly patients/residents in nursing homes and in the community nursing service (15), the measures can contribute to optimum use of medicines in primary health care. However, the report has a limited focus on the practicalities entailed in the actual handling of medications in the nursing and care service.

    An updated and harmonised list of medications used should always accompany patients when the level of care is changed (3). The literature shows that the manual exchange of information on medications can represent a threat to patient safety (16). An electronic list of medications is a recognised way of safeguarding the quality of information on medications and increasing patient safety (17), but there is still scope for improvement in terms of the electronic exchange of information in Norway (18).

    Objective of the study

    The objective of the study was to present the practical challenges of medication management in the nursing and care service, and to establish a consensus on how to address these challenges.

    Method

    The Delphi method involves a consensus processes and associated questionnaire development. This method is a group communication process aimed at conducting detailed surveys and discussions on a particular topic with a view to reaching a consensus (19). The method has been used in a number of surveys, both nationally and internationally (6, 20).

    Typical surveys seek to examine ‘what is’, while the Delphi method tries to establish ‘what should or may be’. The Delphi method entails several rounds of questionnaires (19). Researchers collect and analyse data from a questionnaire, and then create a new questionnaire, which is sent to the same respondent group, normally accompanied by the results from the previous round.

    The questionnaires are answered anonymously and the respondents do not meet each other, thus preventing group influence during the process. Selecting questions and which indicators should be considered can be a challenge for researchers.

    Consensus achieved through this method entails agreement or concurrence in opinions and attitudes between qualified experts within a defined field. Clear criteria should therefore be drawn up for selecting respondents, often referred to as the group or panel of experts (21).

    Sample

    First, we retrieved the e-mail addresses of chief executives and heads of department from the websites of 26 local authorities in one county. They were all sent an information letter about the study and permission was requested to conduct the survey. Those we contacted were also asked to provide the names and e-mail addresses of charge nurses or healthcare service managers at all relevant municipal services, such as nursing homes, sheltered housing and the community nursing service.

    We received 17 positive replies, and subsequently sent letters to the healthcare service managers and charge nurses in the 17 local authorities. The letter asked the recipients to convey information about the study to all nurses and social educators at their institution.

    We requested permission to conduct the study among staff at a pharmacy with a regulatory role within pharmaceutics in the nursing and care sector. We collected 183 e-mail addresses of nurses, social educators, pharmacists and department heads.

    Ethical considerations

    The study was approved by the Norwegian Centre for Research Data, project number 34428. Participation in the study was voluntary. The respondents were informed that they could reserve the right not to receive the questionnaires and withdraw from the study at any time. The data were stored in accordance with research ethics guidelines and the Declaration of Helsinki (22).

    Preparing the questionnaire and data collection

    The starting point for the questionnaire was a list of the 161 most common medication management problems in nursing homes and in the community nursing service. The list was based on regulatory reports covering more than half of the municipalities in one county in the period 2008–2012. We further refined this list and discussed it with the reference group, which consisted of a researcher and a manager from the municipal nursing and care service.

    We formulated 65 statements relating to medication management, which we used to create the questionnaire. Twenty-seven of these statements were used in round one, 21 in round two and 17 in round three. In addition to the initial statements, we devised new statements as a result of the analysis of comments received in rounds one (28 statements) and two (15 statements). 

    The respondents gave responses to 27, 49 and 32 statements in rounds one, two and three respectively. In the statements, we chose to use both ‘should’ and ‘must’, which is in line with the wording of the regulations on medication management and the associated circular. The respondents were asked to indicate the extent to which they agreed with the statements using a five-point Likert scale with the following values: ‘Completely agree’, ‘Partly agree’, ‘Neither agree nor disagree (neutral)’, ‘Partly disagree’ and ‘Completely disagree’. Alternatively, they could select ‘Don’t know’.

    In the first questionnaire round, respondents could comment on each statement, while in the second and third rounds we asked for comments on statements to be assembled thematically. The questionnaire also included questions about work experience, education and function in the organisation. We used the Questback program to design and distribute the questionnaire.

    We first conducted a pilot test of the questionnaire in one of the municipalities. The questionnaire was sent to six nurses, and four responded. The respondents were asked to assess whether the statements were understandable and whether potential difficulties could arise when answering the questionnaire.

    No relevant issues were identified in the pilot test, and only small, linguistic adjustments were made after consulting the reference group. We conducted the survey in three rounds in the period November 2013 to May 2014. In all three rounds, we sent reminders after one week of sending the first e-mail, and another after two weeks.

    Data analysis

    Quantitative analysis

    We produced descriptive statistics using the analysis tool IBM SPSS Statistics 22.

    Since the data were not normally distributed, we used the Mann-Whitney U test (non-parametric test) (23) to compare the responses from different respondent groups. P-value <0.05 was considered to be statistically significant.

    Different definitions of consensus have been used in various Delphi studies (24). In our study, we used the interquartile range (IQR) to describe consensus:

    • A consensus was considered to be reached in statements with IQR = 0.00.
    • No consensus was considered to be reached in statements with IQR > 1.00.

    Using the IQR criterion does not allow for distinctions between the different degrees of consensus for statements with IQR = 1.00. The frequency distribution of responses to a statement can be bimodal, meaning that the IQR is greater than 1.00, despite 60 per cent of respondents generally agreeing with the statement. We therefore developed an additional criterion:

    • A consensus was considered to be reached in statements with IQR = 1.00 which received generally positive responses (‘completely agree’ and ‘partly agree’) from more than 60 per cent of respondents.

    We excluded non-responses and ‘Don’t know’ responses from the analysis.

    Qualitative analysis

    Respondents’ comments on statements in the questionnaire formed the basis for the qualitative analysis. The comments were entered in Excel and analysed using the framework approach (25, 26). This method enables the researcher to perform a systematic qualitative data analysis and frame the ongoing data collection (25, 26).

    The volume of data in our study was relatively small. We therefore used a simplified framework analysis (27). We interpreted the comments after sorting them into categories. The aim of this analysis was also to identify where statements needed to be clarified or reformulated in the next round.

    As a result, we changed some statements and added more follow-up statements. Special attention was paid to statements with IQR = 1.00. Here we searched for findings that could undermine the consensus or non-consensus.

    Results

    We invited a total of 183 nurses, social educators and pharmacists to participate in the study. Eighty-one of these were department heads in municipal nursing and care services. In the first round (n = 183) we received 54 responses (30 per cent). Some of the respondents exercised their right not to receive questionnaires. The number of questionnaires sent out in the second round was therefore 169, and 164 in the third round.

    In the second round, we received 46 responses (27 per cent) and in the third round the figure was 43 (26 per cent). In total, 23 respondents answered in all three rounds. Table 1 shows the composition of the respondent group in all rounds. A consensus was reached in the study for 77 standards in medication management (Table 2).

    Tabell 1. Kjennetegn ved respondentene

    Link to Table 2. Consensus-based standards for best practice in medication management

    The response rate in the study was low, with 26–30 per cent, and somewhat lower among respondents without managerial responsibility. A total of 57 per cent of respondents in all three rounds had managerial responsibility. The results did not show significant differences across occupational backgrounds.

    Statistically significant differences were found in the study between nurses and pharmacists for nine consensus statements (p-value = 0.001-0.0034). These differences were particularly linked to statements regarding agreements with pharmacies, expiry dates and cross-checks. Nurses and social educators responded differently to four consensus statements concerning loans of emergency supplies, cross-checks and medication storage procedures (p-value = 0.015-0.037).

    Statistically significant differences were also found between healthcare personnel with and without managerial responsibility for two statements (p-value = 0.01). The differences between the two groups were linked to statements concerning loans of emergency supplies and cross-checks.

    Many statements for which a consensus was not reached also related to cross-checks. Storage of the patient’s private medications in medical supply rooms was another area of non-consensus. Many of the non-consensus statements were reworded or refined, which led to a consensus being reached in the subsequent data collection round.

    Discussion

    As far as we are aware, this is the first Norwegian Delphi study aimed at developing universal interdisciplinary medication management standards based on Norway’s regulations on medication management. Many studies show that there is a need to improve medication management practices (7, 11–13).

    The study identified a consensus for cross-checking medications in pre-prepared dosette boxes.

    Consensus on medication management standards, which we achieved in this study, may represent an important tool in establishing uniform procedures and serve as a supplement to the medication management regulations for healthcare personnel devising local procedures and routine descriptions.

    We achieved a consensus on 77 standards relating to all stages of medication management. We call particular attention to four areas for further discussion: competence, cross-checks, pharmaceutical advice and the exchange of information.

    Competence

    More than 80 per cent of medication management errors are linked to assembling, preparing and dispensing medications to patients, and can be prevented through increased knowledge and good practices (7). There is often a mismatch between medication management competence, work tasks and staffing (11).

    The study does not provide an answer to how safety procedures should be carried out, but specifies that the organisation should devise a training plan that enables permanent employees and agency workers to develop and maintain pharmaceutical competence. We also suggest the content of such a training plan.

    Our experiences show that nurses and social educators are rarely given the opportunity to participate in medication management courses, unlike healthcare workers. In many organisations, staff with limited authority in medication management attend refresher courses on this subject every two or three years.

    It could be argued that staff groups who have a bachelor’s degree in health and social care studies also need regular updates in medication management. Errors are often caused by actions based on old habits, poor routines or the absence of procedures (8). Participation in the study may therefore have prompted respondents to reflect on current practices.

    Healthcare service managers are responsible for ensuring that healthcare personnel possess the necessary knowledge and skills within medication management (1). Dilles et al. (9) emphasise the importance of managers explaining the expectations they have of employees. Healthcare service managers are also responsible for ensuring that routines are developed and monitored. This includes procedures for risk assessment, evaluation, controls and dealing with deviations. Staff throughout the organisation should be familiar with the procedures (3).

    In the study, 57 per cent of respondents had managerial responsibility, which could be a crucial factor in implementing the study results in daily practice. The somewhat higher response rates among managers may be due to the fact that it is the manager of a service that is responsible for quality assurance and for updating local guidelines (3).

    The list of consensus-based standards in medication management can serve as an aid in defining what should be treated as a deviation, and can be used by healthcare personnel to update guidelines (Table 2). These standards can also help clarify the employer’s expectations in terms of medication management.

    Cross-checks

    Study respondents put forward recommendations on what is best practice for adhering to the ‘7 Rights’ (4). Medication management errors also include deviations from that prescribed in the patient’s medical records, the manufacturer’s preparation, recommendations and administrative instructions and deviations from relevant institutional procedures (6).

    Many studies show that there is a need to improve medication management practices.

    The study has focused on all aspects of the medication management chain, including those taking place in the medical supply room before the medication is administered to the patient. An important measure for preventing errors is cross-checks. The statutory framework does not clarify the use of this measure and views it as a part of healthcare service managers’ risk assessments.

    The study identified a consensus for cross-checking medications in pre-prepared dosette boxes, which entails a check by a healthcare professional other than the one who prepared the dosette box. This cross-check should also be a defined task for nurses and social educators.

    Statements concerning self-cross-checks did not achieve a consensus, and nurses and pharmacists gave different responses to some of the statements about cross-checks. This can be interpreted to mean that the respondents believe it is important for another qualified employee to perform a quality assurance check.

    Pharmaceutical advice

    The findings in the study correspond to the measures suggested in the report on appropriate medication use for elderly patients/residents in nursing homes and in the community nursing service (15). Clear responsibilities and role clarification, interdisciplinary teams and a focus on increased competence are all areas that are highlighted in the study.

    Employees in the municipal nursing and care service face a variety of barriers to appropriate medication management in relation to organisation, interdisciplinary cooperation and the interaction with patients and their families (9). Research shows that pharmaceutical advice and medication audits can reduce the risk of errors in administering medication (10).

    The findings from our study can improve the understanding of the role that pharmaceutical advisors or pharmacists can play in the nursing and care service. Action plans drawn up on the basis of regulatory reports should be made known to staff throughout the organisation, including doctors and pharmacists, and used actively to improve routines. This point achieved a consensus in the study.

    Medication reviews are now governed by regulation (3), but even in this study – which was carried out before the regulation was introduced – we achieved a consensus for medication review routines to be established as part of the quality assurance process.

    Exchange of information

    The literature shows that the manual exchange of information on medications can represent a threat to patient safety (16). Electronic medication lists are recommended for safeguarding quality in the information transferred between service levels (17).

    Our findings suggest a need to improve routines surrounding the transfer of responsibility and information on medications between service levels (18), something that the regulations on medication management do not cover in detail. These routines can be added at the system level through electronic exchanges of medication information, but can also be applied in the day-to-day service at an individual level between the patient (and their family) and the professional practitioner.

    Our findings suggest a need to improve routines surrounding the transfer of responsibility and information on medications between service levels.

    The service must have routines to ensure that the patient receives the right dose of medicine at the right time and in the right way. This information must be documented in the patient’s medical records (1). The regulations do not specify requirements for documentation in medication management.

    We achieved a consensus in the study in relation to who should document medication-related data and what practices should be adopted. Further studies could elaborate on and examine this work in more detail.

    Strengths and weaknesses of the study

    A strength of the study is the complex use of the Delphi consensus process. Combining qualitative and quantitative analyses, using initial statements and respondents’ comments, enabled us to portray interprofessional ownership of developed standards.

    The fact that the respondent group was not exactly the same in each round was a weakness of the study. In addition, the response rate of 26–30 per cent was low. It may be that those who participated are particularly interested in the topic of the study. Their answers may therefore reflect their interest and insight.

    The questionnaires were quite extensive, which may have deterred participants from responding to rounds two and three. The total number of respondents was 66, but only 23 participated in all three rounds. However, the majority of earlier Delphi studies have had between 15 and 20 respondents (19). The scope of the dataset can therefore be considered satisfactory.

    Although the data were collected in 2013–2014, current medication management practices remain largely unchanged, and we therefore consider our findings to still be pertinent. Further research in other municipalities is necessary to verify the consensus standards that emerged in the study. The barriers to and challenges of implementing standards also need to be clarified.

    Conclusion

    The study highlights selected risk areas for medication management and the need for a more uniform understanding of safe and appropriate medication management. Consensus-based standards for best practice in medication management, as developed in the study, can play an important role in safeguarding quality in this area.

    The list of 77 consensus-based standards from the study can be used to update local guidelines. 

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    21.     Saunes IS, Deilkås E, Kristoffersen M, Lyngstad M, Nyen B. Formaliserte konsensusprosesser, veiledning ved vanskelige valg? Oslo: Kunnskapssenteret. 2009.

    22.     Helsinkideklarasjonen. WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects. 2013. Tilgjengelig fra: http://legeforeningen.no/PageFiles/175539/Declaration%20of%20Helsinki-English.pdf (downloaded 13.12.2017).

    23.     Aalen OO, Veierød MB, Frigessi A, Moger TA, Scheel I, Skovlund E. Statistiske metoder i medisin og helsefag. Oslo: Gyldendal Akademisk; 2006.

    24.     Rayens MK, Hahn EJ. Building consensus using the policy Delphi method. Policy, Politics, & Nursing Practice. 2000;1(4):308–15.

    25.     Gale KN, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology. 2013;13:117.

    26.     Ritchie J, Spencer L, O'Connor W. Carrying out qualitative analysis. I: Ritchie J, Lewis J, red. Qualitative research practice: A guide for social science students and researchers. London: Sage Publications; 2003.

    27.     Pope C, Ziebland S, Mays N. Analysing qualitative data. Qualitative research in health care. BMJ. 2000;320:114–6.

    Nurses, social educators and pharmacists have reached a consensus on 77 standards for best practice in medication management in the nursing and care service.

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    Background: Healthcare personnel can have different understandings of what constitutes a safe and appropriate medication management process, from requisition of the medication until it is dispensed to the patient. This can lead to medication management errors. Best practice standards therefore need to be developed for medication management.

    Objective: The objective of the study was to illuminate various practical challenges and risk areas in medication management in nursing homes and the community nursing service. We also wanted to build a consensus for detailed solutions to address these challenges and risk areas.

    Method: We used the Delphi method and carried out three rounds of Questback questionnaires to collect data. Respondents were asked about the extent to which they agreed with statements relating to medication management using a five-point Likert scale. IBM SPSS was used to analyse the quantitative data. In order to calculate the degree of consensus, we used descriptive statistics with an interquartile range (IQR) <1 as a threshold for consensus. We also collected qualitative data from open-ended questions in the questionnaires. These data were analysed using the Framework method.

    Results: The study encompassed 54, 46 and 43 participants in the three rounds respectively, made up of nurses and social educators from 17 municipalities and regulatory pharmacists from a pharmacy in the region. We established a consensus for 77 standards for best practice in medication management.

    Conclusion: The consensus-based standards for best practice in medication management in the nursing and care service that were developed in this study may represent an important contribution to safeguarding quality in medication management.

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  • The traditional doctor–patient roles may be disempowering the patient

    The hospital ward round has historically been described as a ‘procession’ of doctors, house officers, medical students and consultants, accompanied by nurses, who demonstrated more or less complete power over their patients (1, 2). These days, patient engagement is a concept enshrined in law that affords patients greater control and influence over the implementation of treatments and their follow-up (3).

    ‘Empowerment’ is a more general concept based on the actors’ inherent resources, skills and competencies. These resources must be put to use to allow the health service to offer relevant and appropriate services (4, 5).

    Service user engagement and empowerment can thus be said to carry an inherent value as well as a therapeutic value. They can also be tools used to improve and assure the quality of services to patients (6). Nevertheless, there is reason to ask whether the hospital ward round, which is key to the communication between the patient and the hospital, has implemented measures that promote greater parity between the patient and the healthcare personnel.

    Research suggests that the ward round may even expose the patient to a loss of autonomy, i.e. loss of independence, and is based on an inherently paternalistic tradition (7–9). In order to facilitate a ward round that seeks to adjust the power imbalance, we should explore ways in which the health service can implement changes at system level in order to create a more person-centred service that facilitates patient engagement (10).

    Objective of the article

    This article discusses how established roles influence the patient’s opportunities for user engagement. We want to establish how the traditional roles of doctor and patient influence the empowerment processes, and how the ward round can be conducted in ways that promote patient empowerment. The theory is based on the concept of role in sociology (11).

    In this context, patients, doctors and nurses are the role players. By studying ethnographic data acquired through participatory observation, (12) we investigated the interaction between doctors, nurses and patients during the ward round.

    Method

    Design

    A qualitative study involving participatory observation is a relevant method for obtaining empirical data about role enactment and role conceptualisation. The method distinguishes itself from other research methods in that the researcher personally is the most important instrument for collecting data – together with the participants (12, 13).

    The fieldwork was facilitated by the first author being a qualified nurse practitioner. She took on the role of nurse and accompanied the doctors on their ward rounds. All information and all impressions were filtered through the first author.

    Sample

    We conducted the fieldwork on three different inpatient wards. Patients and staff were required to be fluent Norwegian speakers, and staff were required to have experience of the ward round. We excluded patients who were seriously ill, whether physically or mentally, who suffered from dementia, or who were incapable of giving their consent for any other reason.

    The results included field observations covering a total of six different ward rounds on three different wards. A total of 26 patients, 7 doctors and 10 nurses took part in these rounds, thereby contributing to the rich data on which the study is based. 

    Ethical reflections

    When studying your own culture, it is necessary to reflect on your own preconceptions and experiences. During the fieldwork and analysis phases it was essential to engage in self-reflection according to hermeneutic principles (14) and active exploration of personal prejudices.

    There were advantages as well as disadvantages associated with the fact that the first author is a nurse practitioner. One disadvantage was the risk of her failing to ask necessary follow-up questions. Critical analysis of the data might also be more difficult to achieve. However, the role enabled understanding of details that might have escaped the attention of others, thereby ensuring that additional information was obtained and appreciated (15).

    We asked Vestfold Hospital Trust’s (SiV) Clinical Ethics Committee (CEC) for permission to conduct field observations at the hospital’s inpatient wards. They had no objections.

    We reported the project to the Data Protection Officer and requested the consideration of the Regional Committees for Medical and Health Research Ethics (REC. We were apprised that the project was not subject to notification. Doctors and nurses were informed and gave their consent to taking part in the study. Patients gave their consent by signing an information form on the day of the observations.

    Data collection

    We combined our field observations with informal conversations (13), which enabled us to listen, observe and ask questions. We conducted informal and ad hoc conversations with seven patients, some of only brief duration, others for longer. The result was 40 pages of field notes and a field diary containing reflections on methodology and ethical issues.

    Data analysis

    We analysed the data material by employing Tjora’s (15) incremental deductive-inductive methodology. The analysis process was not linear, but provided a basis for structured, step-by-step research.

    The field notes provided the empirical basis for further observations and were recorded in the style referred to as ‘naïve notes’ by Tjora. These are brief descriptions of things that happened during the fieldwork. They were later used as a basis for analysis and theorising. These naïve notes enabled us to find unifying categories, which in turn could be linked to theoretical concepts.

    Results

    The findings were systematised according to the data analysis. Their presentation includes excerpts from the field notes combined with extracts from statements made by anonymised patients, provided as verbatim quotes. The findings show the interaction between doctors and patients, how their respective roles influence the ward round, and how alternative ward round arrangements may have an empowering effect.

    Lying in bed

    ‘Odd’ is walking around the room, but when we enter, he lies down on the bed. The doctor takes up position by the bedside and bends down over him. I ask Odd if he has reflected on taking to his bed. He answers as follows: ‘It’s a bit like at work, you know, when the director enters the room. You do what they tell you to do, that’s how it has to be. They know their job, after all.’

    Several of the patients who were not bedbound, popped themselves down on the bed as soon as the ward round started. Even if they were fully dressed and wearing shoes, they would lie down on top of the bed or under the blanket.

    Several of the patients who were not bedbound, popped themselves down on the bed as soon as the ward round started.

    ‘Åse’ is a patient with frequent hospital admissions. During the pre-ward round session the doctor comments that ‘there is really nothing specific that’s wrong with her’, that Åse tends to exaggerate her own illness. Åse says that she feels the hospital staff do not believe her. She says the same thing happens with the community nursing staff. However, it feels more serious not to be believed by the doctors in the hospital: ‘Here in the hospital I lie in bed, and I feel so inferior when the doctors don’t believe me.’

    To some extent the patients themselves refer to their apparent subordinate role vis-à-vis the doctors and nurses. ‘Mona’ says that she received her cancer diagnosis while the doctor was standing casually over by the door, with herself lying in bed. She explains: ‘When you’re lying in bed, it’s no use being strong and tough in the day-to-day. For the doctors have all the power; they influence things purely because of who they are.’

    Roles play a part

    During one of the observations, ‘Åse’ hardly greets the doctor when he enters. She launches into telling the doctor and the nurses that she cannot be sent home because she is in pain. The doctor takes a step back and starts leafing through the pages of the patient file without looking up. He gives her no direct answer, but instead pronounces: ‘Yet again, nothing wrong showed up in the tests.’ He smiles at her before he turns around and smiles at the nurse.

    One of the doctors chose to undertake the ward round from the consulting room. The patients attended dressed in their own clothes, accompanied by a nurse, and sat down in the chair opposite the doctor. After these consultations, the doctor said he felt this was a more time-consuming way of conducting the ward round.

    On the other hand, he felt that he was able to establish a fuller picture of the patients’ situation because the patients were put at ease and would provide more information about their own lives. The doctor said: ‘I believe that I’m saving time in the long term, but of course it’s difficult to gauge that sort of thing.’

    ‘Anna’ attends this type of ward round. Doctor and patient are looking each other in the eyes, and the doctor’s hands and feet are facing the patient. They review Anna’s medications. She knows when she is supposed to take her drugs, but not why.

    She says that she often feels dizzy, and they agree to try a lower dose of heart medication ‘because dizziness is a common side effect of this drug’, according to the doctor. Later on, Anna says: ‘The way the doctor conducted the ward round made me feel closer to the doctor. Closer than when a whole bunch of them stand around my bed, while I’m lying there in it. It was like visiting my GP.’

    One of the patients, ‘Tove’, would like to go home, but the doctor would prefer the pinkness surrounding her wound to subside before she is discharged. Nevertheless, Tove insists on leaving. The doctor suggests that she calls in to see her GP in a few days, and the patient is happy with this solution.

    Discussion

    We wanted to establish how the traditional doctor and patient roles affect the empowerment processes during the ward round, and how the ward round may be conducted in a way that promotes patient empowerment.

    The first part of our discussion deals with the ways that internalised role behaviours, in patients as well as in doctors, may appear to jeopardise service user engagement and patient empowerment during the ward round. We then go on to discuss some principles and practical measures designed to facilitate a more empowering ward round.

    The doctor as an expert and the patient as a compliant recipient of care

    The roles enacted between doctors and nurses on the one hand, and patients on the other, lend themselves to analysis in light of the concept of role complementarity (16), which suggests that the role of exclusive expert (doctor and nurse) complements the role of being passive and dependent (the patient).

    Furthermore, these roles can be understood as being created and sustained by a set of diverse factors. These factors are associated with historic and sociological circumstances that affect the role conceptualisation and the various ‘entitlements’ associated with each of these roles.

    From a role perspective we can therefore say that the doctor is assigned the role of exclusive expert on the patient’s health.

    When examining how the doctor role is enacted during the ward round, it is evident that this reflects the doctor’s indisputable authority in terms of understanding the patient’s health and taking appropriate action. Based on the empirical data, we find it is the doctor who ‘knows and understands’ what is important with respect to the patient’s health, thereby holding the power of definition.

    From a role perspective we can therefore say that the doctor is assigned the role of exclusive expert on the patient’s health. The fact that the doctor plays the role of expert, will be considered natural and obvious from a medical as well as a historical perspective. Doctors hold and are given the most senior positions in the hospital hierarchy and may be said to exercise their role supported by centuries of medicratic hospital management traditions (17, 18). In the medical tradition, doctors are expected to be treatment providers, the people who explain and find solutions to illness (19).

    Passive versus active

    Looking at how patients enact their role, it is clearly influenced and shaped by the doctors’ ‘natural’ and indisputable authority in terms of understanding health in general and the individual patient in particular. The fact that patients lie down on the bed as soon as the doctor and nurses enter the room is the most expressive manifestation of this internalised role behaviour.

    From this perspective, the role of patient can be described as primarily passive and dependent. In the same way as for doctors, the patient role is shaped by a long, historical tradition in which patients primarily are the recipients of the medical treatment ordained by doctors. People who fall seriously ill therefore naturally assume the role of compliant recipient of care provided by the expert.

    The passive and dependent role can also be seen in light of an essential meaning-making process. One day you live a normal life, the next day you have lost control of your body or what is happening to it. When people lose control, they will subconsciously try to create order and structure in their new situation (20).

    From this perspective it is also reasonable to see that some aspects of the role of being passive and dependent are beneficial to patients: Lying down on the bed when the doctor and nurses enter may be interpreted as demonstrating that ‘I am ill’. For instance, the patient will therefore be entitled to continued hospitalisation and a close follow-up.

    Playing the role of being passive and dependent may thus serve to ensure that patients receive treatment because they meet the ‘requirements’. Living the role of being ill and dependent can also, in a wider social context, involve the benefit of not having to face some of society’s expectations of healthy people, such as being in paid employment.

    Playing the role of being passive and dependent may thus serve to ensure that patients receive treatment because they meet the ‘requirements’.

    A Dutch study concluded that patients with obvious physical complaints received more attention from the doctor than those whose symptoms were of a vaguer character (21). The so-called ‘machine fault model’ is a concept that implies easy detection of decease (22). Similarly, an American study shows that patients who complain, weep, suffer from vague symptoms or fail to conform with the norm feel that they receive less attention from the doctor (23).

    Healthcare personnel expect patients to be ill and motivated to receive treatment. This perspective on illness held by healthcare personnel and society at large may serve to reinforce expectations that patients should be passive and dependent (20, 22).

    Towards an active-active role?

    One of the doctors expected patients to get dressed and sit up during the ward round if they were able to do so. The doctor worked to the ‘Ask Me 3’ method, a tool designed to elicit greater patient engagement. The method requires the doctor to ask the patient three questions during the consultation, or in this case, the ward round (24). The questions had been modified to suit the hospital scenario. One of the doctor’s questions concerned the patients’ understanding of why they had been admitted to hospital, the continued follow-up after being discharged, and what drugs they used.

    The patients on this ward reported that they felt they were taken seriously and that the doctor engaged with them – more so than they had experienced on earlier occasions. They also described a better understanding of the reasons why they had been admitted to hospital and the treatment they were receiving. The doctor pointed out that the method was more time-consuming but argued that it provided a better overview and raised the patients’ awareness of their own responsibility for their treatment.

    The doctor’s physical position has an impact

    From a role perspective we can say that this way of conducting the ward round to some extent challenges the roles of exclusive expert versus passive and dependent patient. During the traditional ward round, patients can be said to be made more passive by the very nature of their own physical position within the room relative to the doctor. Whether the doctor is sitting or standing may affect the quality of their communication.

    When making their rounds, most of the doctors who took part in this study stood by their patient’s bedside or a short distance away from the patient. A few of them sat down on the bed or on a chair within the room, or squatted down next to the patient. This may have the effect of widening the power imbalance between doctor and patient. If the doctor and the patient look at each other from the same level, this can help reduce the power imbalance.

    Whether the doctor is sitting or standing may affect the quality of their communication.

    The doctor in the sample who chose to conduct the ward round from his consulting room with patients sitting in a chair enabled the adoption of an empowering body language, which in itself can help adjust the power balance. The criteria for conducting the round in this way was for patients to be cognitively alert, capable of leaving their room and getting dressed in their own clothes. This process naturally mobilises patients who will therefore recover more quickly from their illness. The fact that they are dressed in their own clothes rather than a hospital gown steers them out of the patient role (2).

    One study that looked at the effects of sitting versus standing by the patient’s bedside showed that if the doctor sits down, patients will feel they are given more of their time (25, 26). The patients also said they felt important when the doctor sat down. The real time spent on the patient remained the same whether the doctor was standing or sitting, but patients felt that doctors who sat down spent more time on them.

    To a certain extent this alternative ward round can be said to have altered some aspects of the traditional roles of doctor and patient. The patient’s passive and dependent role was challenged, and perhaps the doctor’s role of exclusive expert was somewhat moderated. This way of conducting a ward round potentially points to a new role complementarity. For doctors and nurses the role of non-exclusive expert emerges, while the patient role is more active and independent.

    Visitor chairs

    One practical measure adopted by some hospitals is the introduction of visitor chairs (27) during ward rounds. These chairs are brought on to the ward while doctors conduct their rounds, thereby obliging them to sit down when talking to patients. The visitor chairs tend to signal time and respect for the patient, and they facilitate good dialogues that may reduce the risk of errors and misunderstandings.

    Ward managers and senior hospital staff thus carry a great burden of responsibility to facilitate each individual doctor’s efforts to promote patient empowerment. The limited availability of rooms that lend themselves to sensitive conversations warrants criticism.

    The job of leading a culture-changing process is a demanding one. There is much evidence to suggest that managers fail to act as good role models. Moreover, staff frequently receive no training in how to use specific tools that may enable them to carry out their work in a more person-centred way. Moore et al. (28) concluded that the absence of clear leadership is one of the most conspicuous obstacles to patient empowerment. 

    Conclusion

    Based on our analysis and on the field data we have collected, this article has observed that internalised roles impact significantly on hospital ward rounds. Doctors and patients assume their roles subconsciously, with doctors playing the part of exclusive experts and patients playing the part of passive and dependent recipients of care.

    The findings suggest that these roles contribute to a form of patient disempowerment. The role assumed by and given to doctors is not necessarily overtly paternalistic, but the traditional role of doctor can divest patients of their autonomy.

    Patients on the other hand, often have no opportunity to take control of their own situation because their illness, and the expectations associated with the patient role, put them in a subordinate position. They lie down on the bed even if they think that being bed-bound makes them powerless.

    Accordingly, the traditional roles of doctor and patient, and the power and powerlessness vested in these roles, affect their communication and interaction. There is a potential to challenge the traditional roles and strive towards achieving a role complementarity made up of the roles ‘non-exclusive expert’ for doctors and nurses and ‘more independent’ for patients.

    It is tempting to point out that doctors, nurses and patients need to practice their ‘non-exclusive expert’ and ‘more independent’ roles. In particular, doctors and nurses should perhaps be encouraged to reflect on the power they hold and familiarise themselves with the power imbued in their professions. Better understanding of roles and power may be required if we are to see a change in the way they enact their roles.

    It is too simplistic to argue that it is down to the individuals concerned whether the ward round becomes a successful arena for service user engagement. The most important prerequisite for breaking away from the established roles is to change various organisational and physical practices associated with the ward round.

    This article has highlighted various ways of changing the physical and practical ward round arrangements. Clear leadership and training can facilitate a change from traditional to empowering practice.

    References

    1.       Swenne CL, Skytt B. The ward round--patient experiences and barriers to participation. Scand J Caring Sci. 2014;28(2):297–304.

    2.       O’Hare JA. Anatomy of the ward round. European Journal of Internal Medicine. 2007;19(5):309–13.

    3.       Lov 2. juli 1999 nr. 63 om pasient- og brukerrettigheter (pasient- og brukerrettighetsloven). Available at: https://lovdata.no/dokument/NL/lov/1999-07-02-63(downloaded 04.11.2018). 

    4.       Green J, Tones K. Health promotion: planning and strategies. Los Angeles: SAGE Publications; 2010.

    5.       Stang I. Makt og bemyndigelse: om å ta pasient- og brukermedvirkning på alvor. Oslo: Universitetsforlaget; 1998.

    6.       Verdens helseorganisasjon (WHO). Exploring patient participation in reducing health-care-related safety risks. Copenhagen: WHO; 2013. Available at: http://www.euro.who.int/en/publications/abstracts/exploring-patient-participation-in-reducing-health-care-related-safety-risks(downloaded 05.11.2018).

    7.       Grimen H. Power, trust and risk: some reflections on an absent issue. Medical Anthropology Quarterly 2009;23(1):16–33.

    8.       Zandbelt LC, Smets EM, Oort FJ, Godfried MH, de Haes HC. Patient participation in the medical specialist encounter: does physicians' patient-centred communication matter? Patient Educ Couns. 2007;65(3):396–406.

    9.       Redley B, McTier L, Botti M, Hutchinson A, Newnham H, Campbell D, et al. Patient participation in inpatient ward rounds on acute inpatient medical wards: a descriptive study. BMJ quality & safety. 23. February 2018. DOI: 10.1136/bmjqs-2017-007292.

    10.     McCormak B, Tanya M. Person-centered practice in nursing and health care theroy and practice. 2. ed. Chichester: Whiley Blackwell; 2017.

    11.     Goffman E. Vårt rollespill til daglig: en studie i hverdagslivets dramatikk. Oslo: Pax Forlag; 1992.

    12.     Fangen K. Deltagende observasjon. Bergen: Fagbokforlaget; 2010.

    13.     Wadel C. Feltarbeid i egen kultur: en innføring i kvalitativt orientert samfunnsforskning. Oslo: Cappelen Damm Akademisk; 2014.

    14.     Neumann C, Neumann I. Forskeren i forskningsprosessen: en metodebok om situering. Oslo: Cappelen Damm Akademisk; 2012.

    15.     Tjora AH. Kvalitative forskningsmetoder i praksis. Oslo: Gyldendal Akademisk; 2017.

    16.     Vilhelm A. Sosialt samspill. Oslo: Universitetsforlaget; 1981.

    17.     Berg O. Spesialisering og profesjonalisering. En beretning om den sivile norske helseforvaltnings utvikling fra 1809–2009. Oslo: Helsetilsynet; 2009. Report 8/2009.

    18.     Slagstad R. De nasjonale strategier. Oslo: Pax Forlag; 2001.

    19.     Norvoll R. Makt og avmakt. In: Brodtkorb E, Rugkåsa M, eds. Mellom mennesker og samfunn: Sosiologi og sosialantropologi for helse- og sosialprofesjonene. 2. ed. Oslo: Gyldendal Akademisk; 2009. p. 67–92.

    20.     Album D. Nære fremmede: pasientkulturen i sykehus. Oslo: Tano; 1996.

    21.     Zandbelt LC, Smets EM, Oort FJ, Godfried MH, de Haes HC. Determinants of physicians' patient-centred behaviour in the medical specialist encounter. Social science & medicine. 2006; 63(4):899-910.

    22.     Repstad P. Mellom nærhet og distanse: kvalitative metoder i samfunnsfag. Oslo: Universitetsforlaget; 2007.

    23.     Satterfield JM, Bereknyei S, Hilton JF, Bogetz AL, Blankenburg R, Buckelew SM, et al. The prevalence of social and behavioral topics and related educational opportunities during attending rounds. Academic Medicine: Journal of the Association of American Medical Colleges. 2014;89(11):1548–57.

    24.     Guglielmi CL, Stratton M, Healy GB, Shapiro D, Duffy WJ, Dean BL, et al. The growing role of patient engagement: Relationship-based care in a changing health care system. AORN Journal. 2014;99(4):517–28.

    25.     Johnson RL, Sadosty AT, Weaver AL, Goyal DG. To sit or not to sit? Ann Emerg Med. 2008;51(2):188–93.

    26.     Dunbar NE, Jensen ML, Bessarabova E, Burgoon JK, Bernard DR, Harrison KJ, et al. Empowered by persuasive deception: The effects of power and deception on dominance, credibility, and decision making. Communication Research. 2014;41(6):852–76.       

    27.     Visittstolen [internett]. I trygge hender 24/7. Pasientsikkerhetsprogrammet.no [sitert 20.05.2018]. Available at: http://www.pasientsikkerhetsprogrammet.no/brukermedvirkning/visittstolen.

    28.     Moore L, Britten N, Lydahl D, Naldemirci Ö, Elam M, Wolf A. Barriers and facilitators to the implementation of person-centred care in different healthcare contexts. Scandinavian Journal of Caring Sciences. 2017;31(4):662–73.

    Makten og avmakten som ligger i rollene der legen er ekspert og pasienten hjelpetrengende, påvirker kommunikasjonen og samhandlingen under legevisitten.

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    Background: Communication and social interaction during the hospital ward round significantly influence the distribution of power between health personnel and the service user or patient. We need knowledge about the ways in which the social roles of doctor and patient influence patient empowerment. Patient engagement with the healing process is not only an entitlement; it is potentially significant for the outcome of hospital treatments.

    Objective: The article focuses on how established social and cultural practices affect the roles of doctor and patient during hospital ward rounds. The objective is to point to the limitations and opportunities that exist in order to facilitate more empowering communication during the hospital ward round.

    Method: The article is based on our qualitative field study that involved participatory observations of ward rounds. We have analysed the gathered data using an incremental deductive-inductive method.

    Results: The results show that the role-specific behaviours of doctors and patients during ward rounds can contribute to disempowerment. The doctor’s role may not necessarily reflect an overtly paternalistic attitude, but it is nevertheless based on a view that doctors are ‘exclusive experts’ and patients should be their subordinates. Patients therefore tend to underestimate their own knowledge about their health and generally take on the traditional role of being ‘passive and dependent’.

    Conclusion: Assuming that the disempowerment is largely inflicted by internalised role behaviours in patients as well as doctors, we discuss the need for awareness-raising and specific measures capable of challenging these role conceptualisation. In particular, we point to ways of conducting the ward round that expressly challenge the doctor’s role as an ‘exclusive expert’, and the patient’s role of being ‘passive and dependent’.

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  • Nursing students develop cultural competence during student exchanges in Tanzania

    Globalisation has created a need for cultural competence in nursing (1). With a goal of providing patient-centred nursing irrespective of cultural background, the development of cultural competence has become a topical issue in nursing education, both nationally and internationally (2–4). Report no. 16 to the Storting (4) emphasises that nursing education must teach students to be active, sought-after and responsible participants in the international community.

    In order to ensure equality in services for all groups in society, the proposal in the National Regulations relating to a Common Curriculum for Health and Social Care Education states that students should develop cultural competence during the course of their education. Cultural competence can be defined as ‘the ongoing process in which the healthcare professional continuously strives to achieve the ability and availability to work effectively within the cultural context of the patient’ (2).

    Cultural competence requires cultural encounters with people, where the competence is developed through five components:

    • awareness of own cultural prejudices;
    • knowledge of cultural and ethnic groups;
    • skills in cultural assessments;
    • encounters with people from a different cultural background, and
    • a desire to develop cultural awareness (5).

    Nurses need more knowledge about culture and skills within cultural assessment. The nursing education needs to focus more on culture through strengthening the student’s ability to assess how culture impacts on the patient’s situation (2, 3, 6).

    Nurses need more knowledge about culture and skills within cultural assessment.

    A review article on the cultural competence of healthcare professionals shows that such competence increases significantly following interventions involving training in cultural competence, and that this increase is significantly associated with patient satisfaction (7).

    Extended student exchanges are the most effective

    Student exchanges that stretch over a significant period are one of the most effective ways of developing cultural competence because students are immersed in a different culture over time. They are ‘foreigners’, which gives them a clear perspective from which to see the differences between cultures (8–10). However, a meta-analysis of short-term student exchanges of two to four weeks indicates no improvement in cultural understanding (11).

    Analyses of 350 reflection notes written by 197 Norwegian nursing students during a three-month clinical placement in Africa revealed a low level of cultural understanding among the students (12, 13). Several studies indicate that students exhibit a paternalistic or ethnocentric attitude in their encounters with people from a different culture, and that the student exchange poses ethical challenges (10, 14, 15).

    Student exchanges in Tanzania

    Since 2008, Norwegian nursing students have had the opportunity to undertake part of their clinical studies in the bachelor’s degree in nursing at Tanga International Competence Centre (TICC) in Tanzania (16). TICC focuses on sustainable development of the local community, and has established twelve development programmes in health and education for vulnerable groups.

    In the exchange programmes, the students participate in clinical practice at health clinics, day centres, school health services and retirement homes, and in mental health services in home nursing and outpatient clinics.

    Objective of the study

    The objective of the study was to gain an insight into nursing students’ personal experiences with developing cultural competence during a three-month exchange in Tanzania. The research question was as follows:

    What are Norwegian nursing students’ experiences with developing their cultural competence during a three-month student exchange in Tanzania?

    Method

    In order to gain an insight into nursing students’ personal experiences with developing cultural competence, we chose an inductive, qualitative approach with focus group interviews. The focus group interviews are suitable when participants have a common background of experience (17). The experiences of students in their encounters with people from a different culture provided a good basis for the kind of discussion and conversation engendered by a focus group interview.

    Focus groups provide supplementary information through the informants’ dialogue with each other, and the discussion in the group can bring to light diversity and nuances (17). The group is headed by a moderator, and a facilitator helps to conduct the interview. The authors shared these roles.

    Sample and interview

    The sample in the study was strategic, and recruitment took place among 25 nursing students who were undertaking a student exchange at TICC in autumn 2015. TICC’s study section sent out the invitations to participate, and 21 students; 19 of whom were women, from three learning institutions agreed to take part. For practical reasons, the participants were divided into four groups.

    We conducted the focus group interviews at TICC, where the students lived, at a point when the students had completed 9 of their 12 weeks in a clinical placement. We devised the interview guide in line with the objective of the study, where the main questions were: (i) ‘What do you think of when you hear the term “cultural competence”?’ (ii) ‘What is your personal experience with developing cultural competence? Give examples.’

    The interviewers asked in-depth questions about the students’ experiences from the exchange in general and their clinical placement experiences in particular, with a view to understanding the students’ personal experiences with developing cultural competence. The interviews were audiotaped and lasted between 65 and 80 minutes.

    Analysis

    We analysed the data using thematic content analysis, where the first step involved a systematic reading of all the interviews in order to gain an overall impression. We then noted the meaning behind the sentences, paragraphs and verbal exchanges, and coded them accordingly. Coding often leads to a categorisation that entails the meaning being reduced to a few categories (18). The coding was carried out by both authors separately.

    We then discussed the resultant codes. During our discussion, we systematised the categorisation into overarching thematic categories and subcategories. This process summarised the meaning behind all of the codes within each category. We did not focus on which student said what, but on what was commonly expressed across the four focus groups. We used data from all four interviews.

    Ethical considerations

    The study was approved by the former Norwegian Social Science Data Services (reference number 44841), now called the Norwegian Centre for Research Data (19). Before the interview started, the students received oral and written information about the study and how they could withdraw. They then signed a declaration of consent.

    No names are given in the material, and we deleted the audio recordings after transcription in order to protect confidentiality. The study did not involve any Tanzanian people. We therefore decided that there was no need for ethical approval from the National Health Research Ethics Sub-Committee (NatHREC).

    Results

    The interviews with the students highlighted three main themes as central to their personal development of cultural competence (Figure 1).

    Figure 1. Results are presented in three main themes with four sub-themes

    Receiving an explanation

    In all the interviews, the students brought up the importance of knowledge as a means of developing cultural competence, and they emphasised the significance of explanation and understanding. One student expressed the following: ‘If you know something about the culture you are immersed in, it’s much easier to show understanding and respect, and to work together and generally carry out the clinical placement.’

    The students gave several examples of how explanations helped them gain more insight into the culture and to better understand situations. One student commented as follows: ‘Someone explains something to you, and it then makes sense.’

    Another student, who had experienced a situation in which she reacted negatively, said the following: ‘I’m given an explanation, or I realise that in this situation, that’s the best solution. And then I understand they are doing the best for the patient... Even if we would do it in a completely different way in Norway. But that’s because we have much more resources.’

    When situations were explained to the students, they changed their attitudes to people and situations. One student involved in a home visit to a psychiatric patient who was tied to the bed said: ‘You go in with the attitude that this is not acceptable. We don’t do this in Norway. Then suddenly the situation is explained to you, and you can see the other side, and then you think that maybe this is sort of acceptable after all.’

    Someone explains something to you, and it then makes sense.
    Nursing student

    The students experienced a variety of situations that were alien and incomprehensible to them, and their initial emotions and reactions sometimes changed after they were given an explanation and gained new insight. One student described the change as follows: ‘Once you know why they’re doing something differently, you stop going around being annoyed about it.’

    Clinical supervisors provided explanations in the clinical placement and in the compulsory daily reflection groups. The students emphasised the importance of reflection as a means of developing cultural competence. One student made the following observation: ‘Reflection makes us more aware of what we have seen, done and experienced in the clinical placement. Without it, it would be a case of: you don’t quite know why you reacted like this or why you did that, but when we talk about it, we become more aware, which is a good thing.’

    In the beginning, the students often reacted negatively to what they experienced. However, they understood more as time passed. It takes time to accept other attitudes, behaviour and methods, with one student commenting as follows: ‘At first there was a lot for me to think about, and that I spent energy being annoyed about, but now I have – I don’t know if it’s good or bad, but I’ve gradually accepted that that’s just how it is.’

    Maintaining an open attitude

    The students felt that it was important to have an open attitude and accept differences before travelling to a country with a different culture. One student described cultural competence as follows: ‘Accepting that it’s not like home, but that it’s different. Try not to turn it into a problem, just accept it. Ask ‘why?’ in order to get an understanding of their reasons for doing it that way.’

    The students nevertheless stressed that it was not always necessary to agree with what the locals did in order to show understanding. For example, they reacted to the healthcare professionals’ attitudes to the patients. However, with time and experience they accepted it for what it was. The students also spoke about gender disparities they reacted to, but which they accepted. They tried to show respect by not interfering in such situations.

    One student told of situations where children were physically punished: ‘That’s not permissible in Norway under any circumstances, but we can’t tell them that it’s wrong because we are outsiders in a way. We’re not part of their culture, we can’t just barge in, so we try to tread carefully.’

    The students were conscious of treading carefully and being humble in their cultural encounters with people who thought, lived and worked in other ways. One student expressed the following: ‘We must take a little care not to offend the healthcare professionals here. We need to be humble and think about things differently, and not assume that we are right.’

    It’s important to find new ways to think about situations and view things in a different perspective.
    Nursing student

    By proceeding with care, the students felt that they were showing respect: ‘We cover up when we go out in order to respect their culture and how they view women and the body.’ The students pointed out that they were simply visitors, and they linked the development of cultural competence to showing respect and being humble in their cultural encounters with others.

    One student made the following observation: ‘I think it's important to be humble. I’m a student on a clinical placement here. It’s important to find new ways to think about situations and view things in a different perspective. They have a different structure, economy and culture and ... I feel we have learned a lot and grown personally and gained cultural competence.’

    Outside the comfort zone

    The students said that it was no good being reserved if they wanted to get acquainted with and gain an insight into a different culture. They were challenged to go outside their comfort zone, and several said that they had changed considerably. Among other things, they described how they had participated in singing and dancing in health education campaigns at schools and in villages – something they would never have done in Norway.

    Many students said they had discovered new sides of themselves through the challenges they had faced in clinical placements and daily life, but that they would not see the consequences of this for a while. As examples, the students discussed how they demonstrated more courage and determination in the clinical placement situations than they would have done before. They were more independent, took charge more and suggested measures in patient situations: ‘I think I’ve toughened up a bit too – more likely to get stuck in.’

    Several students said they often had to improvise and be creative, especially given the lack of resources. One student described this as follows: ‘Seeing the possible in the impossible.’

    The students undertook a one-week course in Swahili at TICC before starting the clinical placement, but this was not enough to enable them to communicate in Swahili in daily life. They therefore had to be independent and creative when communicating with others. One student described this as follows: ‘Thinking for yourself, thinking outside the box and reading people.’

    Several students described how they tried to follow local customs, even though they were new to them. One student told of their experience in a patient situation: ‘... and not always to be so priggish about it and just give it a try. Eat the food they eat and drink what they drink! So I started to just dive in and do the same. It created such a good atmosphere. Then the other students began to get on board and follow suit.’

    Discussion

    The objective of the study was to gain an insight into nursing students’ experiences with how they developed cultural competence during a student exchange in Tanzania. The students linked this development to receiving explanations of situations that they found challenging or difficult to understand, and to maintaining an open attitude in their cultural encounters with people and situations. They also emphasised that their willingness to go outside their own comfort zone was essential for developing cultural competence.

    Time, knowledge and reflection foster awareness of personal values and contribute to increased cultural competence (7, 10, 20). In the supervision, aspects of clinical placement situations that the students reacted to or did not understand were explained or put into a cultural context.

    Such explanations included how the health service was organised, what factors impacted on the service, how the local healthcare professionals assessed and treated various conditions, such as mental disorders, and why they used coercion.

    The explanations could also be linked to the role patterns that existed in the family, where the father or the oldest male in the house made decisions on behalf of the household members. Through acknowledging the circumstances, the students increasingly tried to participate in patient situations instead of critically observing them from the sidelines.

    Developed a new understanding

    The students’ personal knowledge, skills and attitudes were constantly being challenged, and they had to negotiate with the people they encountered (2). Campinha-Bacote (2) presents the LEARN mnemonic (List, Explain, Acknowledge, Recommend, Negotiate), which describes the professional assessment nurses make when interacting with patients who have a different cultural background to their own.

    The students’ personal knowledge, skills and attitudes were constantly being challenged.

    The LEARN process is demonstrated in the students’ descriptions of their personal development up to the point of acknowledging persons with a different cultural background. Through their personal experiences, reflections and dialogues with people, they developed new understandings and attitudes, and an acknowledgement of the differences in the cultures.

    However, they did not develop competence that enabled them to make recommendations and negotiate with the people they met in the clinical situations. This was partly because the role of student was limited in terms of responsibility and opportunities for following up patients or service users. Another reason was that they did not have sufficient professional competence to ask critical questions in the dialogues they had with people in clinical situations.

    Linguistic challenges

    A third factor that restricted the students’ ability to be involved in the last two elements of LEARN was their lack of language skills in Swahili. Language has a large impact on human interaction, and the students described how they often used nonverbal communication or a supervisor and interpreter when there were language barriers.

    Nonverbal communication is not always sufficient when interacting with patients and assessing their situation in cases where making recommendations and negotiations are essential elements for achieving patient satisfaction, for example (7). Some interpreters were qualified healthcare workers and supervisors with extensive clinical experience, but they were not responsible for patient care.

    In cases where patients only spoke Swahili, the students were not proficient enough in the language to interact with the patients without an interpreter. In view of this and the role of student in a foreign culture, the students’ contribution to assessing patients was therefore limited. Developing cultural competence takes time (2). The students’ development of cultural competence and ability to carry out a professional assessment in a different culture must therefore be considered in light of the short time they participated in the culture.

    A desire to develop cultural awareness

    A desire to develop cultural awareness is a key factor in developing cultural competence (5, 21), and the students expressed this desire, partly through their open attitude in cultural encounters with people. This mindset contributed to personal development, and strengthened their confidence in their abilities. Personal development and a sense of mastery are essential learning outcomes of student exchanges (10, 22, 23).

    In her review article on how nursing students benefit from student exchanges, Kelleher (22) concludes that ‘participation in a study abroad experience is associated with many benefits for nursing students, including various forms of personal and professional growth, cultural sensitivity and competence, and cognitive development’ (p. 690).

    Several studies (10, 22, 23) do not describe what level or degree of competence the students have achieved after taking part in a student exchange. The students in our study did not mention this either, but several of them stated that they had a greater learning outcome from the exchange in Tanzania than from their clinical placements in Norway.

    Culture needs to be an integral part of the education

    In order for nursing students to develop cultural competence as part of their nursing education, the cultural aspect should be an integral part of the learning process and not something that is only brought up in some university classes. One measure that has proven to be effective is to conduct workshops for staff and students (24, 25). More research is also needed on what factors impact on the students’ learning outcomes from student exchanges (11, 22, 26).

    In addition to the importance of language skills and personal development, the development of cultural competence can be linked to the content of the partnership between the institutions, the organisation of the exchange programme, the student role, the duration of the exchange and the process that takes place when the students interact with people in the local community (27–29).

    Strengths and weaknesses of the study

    This study presents the development of cultural competence from the student’s perspective; something that has not been studied previously as far as we are aware. A further strength of the study is that the experiences we present in this article are from students from three different learning institutions in Norway. The students had a common understanding of the process of developing cultural competence, and the findings concur with earlier research.

    The focus group was an appropriate method because it created opportunities for dialogue, and several students said that sharing their experiences with fellow students gave them valuable feedback. It is open to debate whether we could have learned about other experiences by using a theory-driven interview guide with points from the theory of cultural competence.

    The study only covers the experiences of Norwegian students in one exchange country. Several of the studies we refer to were conducted in the USA, but we have not discussed differences in culture and education systems. The students in this study lived with up to 70–80 other Norwegian students in a centre founded and run by Norwegians.

    In addition, the centre is physically isolated from the local community. It would have been useful to explore the importance of exchanges between Tanzanian and Norwegian culture in more depth in the interviews. The exchange between two cultures and the degree of proximity to the local culture can impact on the benefits and level of cultural competence gained from the exchange.

    Conclusion

    The students strengthened their cultural competence during the exchange period. Communication and interaction with people who had a different cultural background to their own supported this process. Receiving explanations of aspects they found difficult to understand contributed to the development of their cultural competence. The students emphasised that the ability to maintain an open attitude and go outside their comfort zone was essential for developing cultural competence.

    It was crucial for them to have the opportunity for organised reflection on their personal experiences in order to strengthen their cultural competence. The student exchange did not, however, contribute to developing competence that enabled the students to make recommendations and negotiate with people they met in the clinical placements.

    It takes time to develop cultural competence, and language skills, the role of student as well as the length and content of the exchange programme are some of the factors that impact on the process. There is therefore a need for more research on teaching programmes that strengthen students’ cultural competence.

    References

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    The students gain an increased understanding of cultural differences by maintaining an open attitude and receiving explanations of cultural differences that they do not understand.

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    Sammendrag

    Background: Globalisation has led to increased migration, and nursing students need cultural competence in order to meet the health challenges that can arise in a multicultural society. Student exchanges are an effective learning method for developing cultural competence because the students encounter people in a different cultural context over time.

    Objective: To gain an insight into nursing students’ personal experiences with developing cultural competence during a student exchange in Tanzania.

    Method: We conducted focus group interviews with nursing students taking part in a three-month exchange in Tanzania.

    Results: Development of cultural competence was dependent on the students being given explanations of aspects they did not understand and having their attitudes challenged. They developed an increased understanding by participating in cultural encounters with people over time and by reflecting on their personal experiences. Maintaining an open attitude in their cultural encounters with people and situations combined with a willingness to go outside their comfort zone also helped the students to develop cultural competence.

    Conclusion: The students who took part in a three-month exchange developed cultural competence by maintaining an open attitude and obtaining explanations that gave them an increased understanding of cultural differences. More research is needed on teaching programmes that can help strengthen the students’ cultural competence.

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  • New practice model improved students’ leadership and organisational skills

    Changes in the health and care sector in recent years have led to requirements for better interaction, coordination and more effective services while also safeguarding patient safety and quality (1–3). These changes affect the education of health personnel, and nursing education must correspond to competence needs – particularly in the municipal health services (4).

    Nursing leadership

    Earlier research shows that increasing the focus on nursing leadership skills helps to ensure good quality care and patient treatment (5, 6).

    Nursing leadership involves tasks intended to secure professional content and flow in work processes related to the patient (7, 8). The main task is to assess the patient’s need for nursing, evaluate nursing measures, and coordinate interaction with other professions. This function also includes responsibility for delegating tasks, following up and collaborating with colleagues as well as interacting with other professions. In addition, nurses are responsible for professional updating and documentation (8).

    Nursing leadership is challenging and is characterised by working methods with clear goals, professional problems being solved jointly with others, while communication and interaction skills are paramount (9). Learning outcomes at the end of nursing education programmes include requirements for knowledge and skills in coordination, professional development and communication. It is also expected that the candidate is a change-oriented leader in their field (10).

    Earlier research

    Earlier studies show, however, that newly qualified nurses lack competence in nursing leadership and that they are not prepared for tasks linked to leadership and the organisation of patient care (11–14). Research also shows that newly qualified nurses do not acquire occupational competence in nursing leadership until three years after the end of their education (11, 13).

    Earlier studies show that newly qualified nurses lack competence in nursing leadership.

    Meanwhile employers expect nurses to possess such skills at the time of their appointment. A number of researchers point out that there is a need to strengthen nursing education in order to close the gap between education and the employer’s expectations, particularly in terms of leadership and organisation (5, 9, 12, 15).

    Explanation of concepts

    The National Framework Curriculum for the Bachelor Degree in Nursing uses the terms ‘occupational tools’ and ‘occupational competence’ (16). Occupational tools include areas in which nursing education helps to ensure that newly qualified nurses have knowledge of the field while lacking experience in acting independently (16).

    Occupational competence encompasses areas where nursing education is responsible for enabling newly qualified nurses to function independently (17). Competence is linked to the subject-related context, the individual mental process and the social context in which competence is developed and applied. Occupational competence is developed and realised through action.

    Students’ occupational competence

    At UiT – The Arctic University of Norway, Narvik campus, we wanted to strengthen nursing students’ occupational competence in nursing leadership. We devised a course plan in the sixth semester for a new practice model at nursing homes (18). The course plan focuses on students acquiring occupational competence in managing and organising nursing, and participating in interprofessional collaboration as well as supervising first year students, colleagues and patients.

    The students must complete coursework requirements during the clinical practice period. Coursework requirements focus on health-promoting and preventive nursing, which entails project management and interaction with several actors. Moreover, students must gain knowledge about and contribute to quality improvement measures, internal controls and clinical incident reporting.

    We devised the practice model in collaboration with managers and practice supervisors at nursing homes. Collaboration with the field of practice was necessary in order to gain a joint understanding of the subject-related content of the course and to understand the obligations of nursing education and the field of practice to implement the practice model.

    Objective of the study

    The objective of this study was to gain knowledge of how the students perceived their own development of occupational competence in nursing leadership following the introduction of the new practice model in the sixth semester. The students’ experiences provide key knowledge for developing the practice model in accordance with the requirements of the field of practice regarding newly qualified nurses.

    This study examines the following research question:

    What is the students’ personal experience with developing occupational competence in nursing leadership during clinical practice in the nursing home?

    Method

    In order to answer the research question, we used a qualitative approach with a descriptive, exploratory design. We used the focus group interview as a data collection method. The discussion between the participants led to ideas for potential improvements as well as further elaboration of the issue.

    Two important elements characterise focus group interviews. The first is that the group must be headed by a moderator who presents a well-defined topic and helps to keep the participants on track without influencing the group. The second is the aim of eliciting elicit participants’ perceptions of the topic presented, and their attitudes and feelings towards it (19). The method is therefore well suited to collecting data with a view to developing practice (20).

    Focus group interviews

    We conducted focus group interviews in the study at the end of the clinical practice period in spring 2016. The sample consisted of students who had had clinical practice at four different nursing homes. We undertook three focus group interviews chaired by a moderator. One of the authors carried out two focus group interviews while the other author conducted one. The third author transcribed the data material.

    The number of participants in the focus group interviews varied from two to seven, and altogether twelve students participated in the study. We had devised a study guide with six open-ended questions that centred on students’ experiences with managing and administering a ward, supervising first year students, and how the practice contributed to their knowledge of nursing leadership.

    The participants were active and the moderator’s role was to ensure that they discussed the stated topic. The moderator had good knowledge of the content of the practice model and could follow up important elements. The focus group interviews were recorded digitally and transcribed verbatim.

    Review of method

    The moderator was the teaching supervisor for the students when they carried out their practice, which may have affected what students chose to bring up in the focus group interviews. The students had completed their practice, therefore the discussions did not affect the final assessment.

    We distributed an information letter and an invitation to participate in the project to a strategic sample of altogether twenty students who had carried out practice at four nursing homes in the sixth semester. The non-participation of eight students may have been related to the fact that the interviews were conducted after the end of the clinical practice period, and that the students were engaged in other tasks. Due to these students withdrawing a short time before the interviews, two of the groups consisted of only two and three participants respectively in addition to the moderator.

    The fact that two of the groups had few participants resulted in a sub-optimal interaction among the participants, and the discussions were less nuanced. While having few participants may prevent the formation of groupings in focus group interviews, it can be difficult to elicit the range of opinions that emerge in larger groups (19).

    Despite the small number of participants, we chose, nevertheless, to carry out the focus group interviews out of consideration for the participants. Based on the resource situation, we conducted the interviews without an observer, which may have led to less focus on the interaction in the groups.

    We have been involved in the entire process, from supervising students in practice to conducting focus group interviews, and interpreting and analysing their content. The person who did not act as a moderator during the focus group interviews had an ‘outsider perspective’ on the material.

    Ethical considerations

    We obtained written, informed consent, and the participants were informed that they could withdraw from the survey at any time, although no one did so. The study was reported to the Norwegian Centre for Research Data. We anonymised directly identifiable personal data in the transcription and stored the data in accordance with UiT’s current guidelines.

    Analysis

    We employed qualitative content analysis inspired by Graneheim, Lindgren and Lundman (21, 22). Qualitative content analysis is characterised by a systematic analysis of the text in order to understand how the text gives meaning and content to a particular phenomenon (22).

    In the first part of the analysis, we read through all the text several times in order to gain an overview of the dataset. Then we split the text into meaning units that were condensed and coded. In order to elicit the manifest content of the material, we identified subcategories in our analysis. This resulted in four categories:

    • experience of nursing leadership
    • supervisory experience
    • participation in quality assurance work
    • challenges posed by a lack of interprofessional interaction.
    Table 1. Example of the analysis process

    Results

    Here we present the findings of the study divided into the four above-mentioned categories, underpinned by the participants’ statements in the focus group interviews.

    Experience of nursing leadership

    Our findings reveal that the students were satisfied that they had been challenged to function as nurse leaders in the ward. They found that the practice supervisors ‘took a back seat’ and delegated much of the responsibility for the daily organisation of patient care to the students. This meant that the students felt more secure about the challenges they faced.

    The students were satisfied that they had been challenged to function as nurse leaders in the ward.

    One participant remarked: ‘We have been challenged and have really experienced the responsibilities we will have when we graduate as nurses.’ Another said: ‘I think it’s important that as a student you get some experience of the leader role. We’re better equipped after such practice.’

    Many of the students felt greater confidence in their professional platform in relation to the personnel group. The students discussed the fact that their views and professional input were acknowledged and listened to in a different way from in earlier clinical practice periods. One participant expressed it as follows: ‘During this practice period I felt that I was listened to from day 1. My input regarding patients was taken into consideration. They were more open to listening to us because we would shortly be qualified nurses.’

    During the clinical practice, the students were expected to take over the work for two days. The personnel could hold meetings and carry out internal training, while the students were responsible for the patients and the first year students. The participants described this as good experience that also challenged them to organise their own work. One participant said: ‘Managing the ward was very educational, and I was challenged to delegate work tasks … that’s a little difficult.’

    Supervisory experience

    Nursing students supervise first year students as part of the coursework requirements in the sixth semester. Our findings indicate that all participants benefitted considerably from this task. They said that their own experience of different practice supervisors gave them greater insight into the supervisor role.

    One of the participants said: ‘I found supervising students to be a very positive experience. We are in the final phase of our studies and feel more secure about supervising others. It’s good to get some experience and to find out what we can do better.’ Another expressed this in the following way: ‘A lot of people don’t take being a supervisor seriously enough. It actually requires a lot of work, both before and after. What could we have done differently … in order to give feedback.’

    The students were to have responsibility for ward management for two days together with the first year students. As supervisors, they had to be aware that personal hygiene care takes time, and the first year students needed supervision in using the patients’ resources.

    One participant said: ‘They [first year students] worked too slowly because they lacked experience. I had one [student] who spent one and a half hours on a patient’s shower when the patient could manage most of it on their own. They are too careful at the start.’

    Participation in quality assurance work

    The students discussed their experiences of incident reporting from the clinical practice period. They gave many specific examples of situations in which incidents were recorded and documented. Our findings indicate that practice varies at the individual institutions, and that the students were unsure what they were supposed to write incident reports about.

    One of them said: ‘There was a very high threshold for writing incident reports. Quite a lot had to happen before they were written.’ Several of the students had no clear idea of what routines applied or how the incident reports were dealt with higher up in the system, as shown by the words of this participant: ‘We asked what happens to these incident reports, what’s done with them, and who looks at them. But even so, I was none the wiser.’

    As nurse leaders in the wards, the students gained experience of documenting nursing. The participants stated unequivocally that there was a lack of documentation and that the reports were mainly oral reports about the patient’s situation. One participant expressed this as follows: ‘The documentation is a challenge for the ward, there’s no common approach.’

    As nurse leaders in the wards, the students gained experience of documenting nursing.

    The participants expressed criticism of the fact that only nurses could provide documentation and a very small number of other employees or a few of the agency nurses. One participant said as follows: ‘Very brief notes and a lot of unusable information. When I read the documentation, I wondered what was the point of writing this. I wouldn’t accept it if I worked there.’

    Challenge posed by the lack of interprofessional interaction

    The study indicates that nursing home employees had little interprofessional interaction. The various services, physiotherapy and ergonomics for example, are requisitioned for the individual patient as required.

    The nurses interacted mainly with the doctor, and much of the contact with other professions took place via the telephone. The participants felt that they liaised well with the doctor, and that they were challenged to answer questions and discuss treatment and medication.

    However, some students talked about challenges related to dialogue with the doctors. One participant said: ‘At the start I had to kind of go along with what the doctor said. The nurses gave me tips about what I should say, so that improved over time.’ Another participant said: ‘You often have to stand your ground to get things approved regarding the patient. We know the patient best.’

    Discussion

    The study shows that the students gained greater insight into the nurse’s leader role at the nursing home following the introduction of the new practice model. Nursing leadership must be strengthened because nursing homes are characterised by a lack of nursing positions, understaffing and increased pressure on the nurses (23, 24). This puts a great personal responsibility on the individual nurse and requires a high level of proficiency in their work (7).

    The nursing leadership role was demonstrated by the students’ participation in both patient-related and organisational duties. Practice in which the main emphasis is on nursing leadership can help to challenge both the education and the field of practice in knowledge-based practice. The students are updated regarding new theory, and become more aware of the core values necessary for developing occupational competence (25).

    The practice supervisor’s approach strengthened the students’ commitment and allowed them to ask critical questions. Critical reflection and dialogue can increase the professional quality of nursing homes as a learning arena (9).

    Enhanced occupational competence

    The dataset shows that when the students took over the ward for a given period, this allowed them to ‘lift their gaze’ and recognise both the clinical and organisational challenges entailed in being a nurse leader. The students had to organise work with several patients and allocate work tasks to colleagues, which challenged their abilities to organise teamwork. Attention to individual care and the nurses’ core values were safeguarded (25).

    The students’ occupational competence increased when the nursing home management, the practice supervisor and the teaching supervisor showed trust in them and gave them responsibilities that they could master. The practice supervisors were accessible and ensured that the students safeguarded professional accountability. According to Blekken et al. (12), taking over the ward gives the students more realistic experience as nurse leaders.

    Student supervisors experienced mastery

    The course description includes the topic of communication and supervision, which constitutes one of the prerequisites for creating trust and good interaction with patients and their families, colleagues and students. Orvik (9) refers to the supervision of colleagues as an important part of nursing leadership. The students faced the challenge of supervising first year students in basic nursing.

    The findings show that the students found that they mastered the supervision of first year students, and this is supported by other studies (12). The participants’ occupational competence developed through their having enough time, and having to use their theoretical knowledge and practical experience in supervision.

    Developed awareness of quality assurance work

    The findings also show that provision was made for complying with quality development requirements in nursing homes to a varying degree. This may be associated with the nurses’ limited time, resources and knowledge of following up requirements imposed on nursing homes (23). Arntzen (26) maintains that the main instruments in quality assurance work are the personnel’s knowledge and competence as well as their satisfaction in being successful at their jobs.

    The students gradually developed awareness of quality assurance work and were critical to the lack of follow-up.

    The findings show that the students developed their occupational competence by participating actively in reporting deviations. However, they expressed uncertainty regarding how these were dealt with higher up in the organisation. Incident reporting is possibly not regarded as important knowledge for nurses in the municipal health services (12).

    The study shows that the students gradually developed awareness of quality assurance work and were critical to the lack of follow-up. This particularly applied to reporting and dealing with incidents, and documentation of nursing. The students also saw the necessity of basing changes in routines on a professional assessment. The nurses who supervised the students during the clinical practice period found that the students became important discussion partners and put forward specific suggestions for improvements (27). The practice model can thereby help to improve the quality of the practice.

    Interprofessional collaboration

    The findings show that the students had little experience of interprofessional approaches to patients in nursing homes. A prerequisite for providing a holistic range of services to patients is close interaction between nurses and other professional groups based on the patients’ individual needs (1). The lack of a variety of care professions in the municipal health services leads to a reduced range of services in nursing homes.

    The students’ limited experience of interprofessional collaboration may mean that they are not aware of the nurse’s role in respect of this. Nursing leadership is about ensuring collaboration and flow in patient work (9). Awareness of your own role and responsibility as a professional manager requires more focus on interprofessional approaches in order to address the complexity of patient treatment in nursing homes (28).

    The nurse leader role entails building relationships and developing the group as a team (9). When other professions are absent from the nursing home, this poses an even greater challenge to the nurses’ competence.

    As qualified nurses, the students must be relatively well prepared to meet the challenges faced by the health and care services in the future. The new course plan is intended to enhance the students’ nursing leadership by putting the spotlight not only on occupational tools but also on occupational competence. Nursing leadership competence will also be of key importance for nurses in the health and care services going forward (29, 30).

    Conclusion

    The objective of our study was to gain knowledge about students’ experiences of how the new practice model introduced in the sixth semester can help to strengthen nursing leadership. The study shows that a new practice model can help to enhance students’ leadership and organisational skills, thereby reducing the gap between nursing education and nursing homes’ expectations of newly qualified nurses.

    The students participated actively in nursing tasks and functions at the nursing home together with practice supervisors and other personnel. The study shows that a critical examination of, among other things, quality at the nursing home and the lack of interprofessional collaboration promotes discussion and boosts nurses’ awareness of their professional responsibility.

    The practice model will be further developed in cooperation with students, practice supervisors and teaching supervisors. We are conducting further studies of practice supervisors’ and unit heads’ experiences following the implementation of the new practice model. A follow-up study of students educated in line with the new practice model will also be of interest.

    References

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    6.       Dyess S, Sherman R. Developing the leadership skills of new graduates to influence practice environments: a novice nurse leadership program. Nursing Administration Quarterly. 2011;35(4):313–22.

    7.       Kristoffersen NJ. Sykepleierens ansvar og arbeidsområder i helsetjenesten. In: Kristoffersen NJ, Nortvedt F, Skaug E-A, Grimsbø GH, eds. Grunnleggende sykepleie. Sykepleie – fag og funksjon, bind 1. Oslo: Gyldendal Akademisk; 2016.

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    24.     Pedersen KR, Tingvoll W-A. Kompetanseutfordringer i sykehjem – en studie basert på sykepleieres erfaring fra hverdagssituasjoner. In: Kassah BL, Tingvoll W-A, Kassah AK, eds. Samhandlingsreformen under lupen : kvalitet, organisering og makt i helse- og omsorgstjenestene. Bergen: Fagbokforlaget; 2014.

    25.     Karoliussen M. Tilbake til kjerneverdiene. Sykepleien. 2015;103(2):62–4. Available at: https://sykepleien.no/forskning/2015/02/tilbake-til-kjerneverdiene(downloaded 18.10.2018).

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    27.     Pedersen K, Nymo R, Tingvoll W-A. De kommer som sykepleiere, ikke som studenter. Geriatrisk sykepleie. 2018;(1):28–35. Available at: https://sykepleien.no/meninger/innspill/2018/02/de-kommer-som-sykepleiere-ikke-som-studenter(downloaded 18.10.218).

    28.     Tingvoll W-A, Sæterstrand TM. Sykehjemmets rolle i fremtidens helsevesen. Tidsskrift for Den norske legeforening. 2007;127(17):2274–5.

    29.     Meld. St. nr. 26 (2014–2015). Fremtidens primærhelsetjeneste – nærhet og helhet. Oslo: Helse – og omsorgsdepartementet; 2015.

    30.     Tyrholm BV, Kvangarsnes M, Bergem R. Mellomlederes vurdering av kompetansebehov i sykepleie etter samhandlingsreformen. In: Kvangarsnes M, Håvold JI, Helgesen H, eds. Innovasjon og entreprenørskap. Oslo: Universitetsforlaget; 2016.

    At the University of Tromsø, first year students in nursing homes are supervised by final year students in order to strengthen their occupational competence in nursing leadership. 

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    Sammendrag

    Background: Nurses form the largest group of health personnel in the municipal health and care services. Even as newly qualified nurses, they are expected to have nursing leadership skills in order to be able to organise and manage patient care. Nursing education programmes together with the field of practice share joint responsibility for developing theoretical and practical knowledge to enable nurses to acquire occupational competence in nursing leadership.

    Objective: The objective of this study was to gain knowledge of how the students perceive their own development of occupational competence in nursing leadership following the introduction of a new practice model in the sixth semester. The students’ experiences provide key knowledge for developing the practice model in accordance with the requirements of the field of practice regarding newly qualified nurses.

    Method: We chose a qualitative approach using student focus groups at the conclusion of the clinical practice period in spring 2016, utilising qualitative content analysis.

    Results: The study shows that a new practice model can help to boost the students’ leadership and organisational skills, thereby helping to reduce the gap between nursing education and nursing homes’ expectations of newly qualified nurses.

    Conclusion: The students faced challenges linked to nursing leadership, student supervision, involvement in quality assurance work as well as interprofessional collaboration. The study shows that the balance between challenges and reflection is central for learning and critical thinking in nursing.

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  • No increase in in-patient detoxification completion rates following pre-hospital telephone intervention

    The drop-out rate in interdisciplinary substance abuse treatment is a major challenge. The proportion who do not complete such treatment varies from 10 to 60%, depending on the level of treatment and population surveyed (1). Treatment drop-out has been associated with, inter alia, a higher risk of relapse, multiple readmissions and poorer physical and mental health compared to those who complete their treatment (2).

    In addition to treatment drop-out, failure to present for treatment is also a problem. Auspicious measures aimed at reducing drop-out rates and increasing uptake are as follows: clarifying expectations at an early stage of the treatment phase, strengthening patient relations or treatment alliance, and helping patients to muster the desire to attend, for example by providing practical information about the treatment (1).

    In addition to treatment drop-out, failure to present for treatment is also a problem.

    Research in the field

    Numerous international studies examine out-patient attendance rates at mental health services. A systematic review from 2014 distinguishes between a ‘simple reminder’, such as a text message, and a ‘reminder plus’, which can take the form of a personal phone call (3).

    In summary, these studies showed promising results, and the simple reminder was recommended for use as a regular measure. The reminder plus was sometimes more effective than the simple reminder at reducing non-attendance, and was considered to be particularly useful for first appointments. Simple reminders were recommended for subsequent appointments.

    There are considerably fewer studies on uptake of institutional treatment. A PubMed search for research articles written in English within the field of substance abuse using the search string ‘(substance related disorders[MeSH Major Topic]) AND ((((detoxification[Title/Abstract]) AND telephone[Title/Abstract])) OR pre-hospital[Title/Abstract])’ gave 35 matches. A keyword search for ‘substance related disorders’ and ‘reminder systems’ gave 13 new matches.

    Only one was relevant: a pilot study that included 80 patients referred for admission to an in-patient unit. The findings showed that the admission rate was not significantly higher for the group who had been called in advance, and that the drop-out rate had not been reduced (4). More large-scale experimental studies are needed into pre-hospital reminder interventions.

    Objective of the study

    The objective of this study was two-fold. First, we wanted to investigate whether a pre-hospital telephone intervention could increase the admission and completion rates for in-patient detoxification treatment. In addition, we wanted to gain an insight into the experiences that those making the phone calls had with the intervention.

    Method

    We collected quantitative data in order to investigate the effect of a pre-hospital telephone intervention in addition to qualitative data with a view to gaining an insight into the experiences of those who performed the intervention. The study was conducted at the detoxification units in the Addiction Unit at Sørlandet Hospital Trust, located in Kristiansand and Arendal.

    The catchment area for the units is mainly the counties of Aust- and Vest-Agder. There are 24 beds equally distributed between the units. On average, there are approximately 10 planned admissions per week at each of the units. Both units offer medical detoxification and clarification of motivation for further treatment.

    Quantitative part of the study

    A quasi-experimental (off-on) design was used to compare a period without a telephone intervention to a period with a telephone intervention (5). In the first phase, none of the participants were called prior to the planned admission. This period lasted for twelve weeks. We recorded demographic data, such as age and gender, and noted whether the patient had presented for treatment or not, as well as reasons for non-attendance – whether they had notified the unit or not – and whether the treatment was completed.

    In the second phase, a pre-hospital telephone intervention was carried out. The duration of this phase was similar to the first phase. Attempts were made to call all patients referred for planned in-patient treatment at the detoxification unit during the week before the admission date. The same person in each unit made the calls on the same day every week.

    A total of three staff members were involved in calling the patients. The intervention was intended to serve as an appointment reminder, and to clarify whether the patients had received the appointment letter and were ready to be admitted. In addition, we believed that the telephone intervention may be a good starting point for relationship building.

    According to the informants, the biggest challenge was trying to establish contact with the patients. Some of the patients had new phone numbers that had not been recorded in the patient journals. Others did not answer their phone. The informants estimated that they managed to contact about half of the relevant patients. This was in line with the data in the quantitative part of the study.

    Prior to the telephone intervention, the staff prepared themselves by reading the referrals and assessment notes. If their initial attempt to contact a patient was unsuccessful, they tried again. If they failed to established contact on the second attempt, they sought information on how to reach the patient by contacting collaborating partners and/or family members with whom the patient was in contact according to their journal.

    The phone calls were logged. The staff recorded the outcome of the intervention: if they had established contact, if the patient had declined the offer of treatment, if the patient wanted up to a one-week deferral or if the patient had said that he/she would present for treatment. In the study, ‘failure to present for treatment/non-attendance’ was defined as when a patient did not meet up at the agreed time or by 2pm on the day of admission without giving advance notification.

    We defined treatment drop-out as discontinued treatment, i.e. where the patient left the unit or chose to terminate the treatment before the agreed end date, contrary to the unit’s recommendation. In the quantitative analysis, we compared data on admission rates in the first phase with the period when the telephone intervention was carried out. We used a cross-tabulation analysis and chi-square test. For the analysis, we used the statistics software IBM SPSS version 21.

    Qualitative part of the study

    In order to describe the staff’s experiences with the intervention, we asked those who conducted the phone calls to take part in an interview, and all three agreed. The first author conducted the interviews. We used a semi-structured interview guide devised for the purpose (6).

    The topics covered in the interviews were as follows: the content of the phone conversations, the patients’ responses, time spent on the intervention, the informants’ thoughts on the potential benefits of conducting such an intervention, the informants’ experiences with the calls, the challenges of the intervention and suggestions for possible improvements. Each interview lasted approximately one hour.

    The first author took notes during the interviews, which she then typed into the computer. We presented a print-out of the notes to the informants and asked them to read these and make corrections if necessary. We anonymised the informants to ensure that it was not possible to know who had said what.

    The interviews were analysed using the systemic text condensation method; they were read, coded and sorted, and reviewed again (7). Texts with the same content were conflated and condensed. We then reviewed the text to establish whether the themes and the condensed text under each theme gave a valid description of the context from which it was derived.

    Ethical considerations

    We sent the study for evaluation to the Regional Committees for Medical and Health Research Ethics (REC) (reference number 2014/1611). They considered the study to be a quality investigation, and as such was not subject to their approval. We did not, therefore, obtain individual consent from the patients. The staff who were interviewed signed a declaration of consent. The study was approved by the Norwegian Centre for Research Data (NSD) (reference number 40167).

    Results

    Quantitative findings

    In total, we included 414 patients in the study. Of these, 125 (30%) were women, and the mean age was 38 years (standard deviation (SD) = 13). We included 214 in the first phase without a telephone intervention, and 200 in the second phase with a telephone intervention (Figure 1). In the intervention phase, the informants managed to contact 48% of the patients (Table 1).

    A total of 13 (7%) patients declined the offer of treatment: ten because they did not want it, and three because they had received and accepted another offer or did not need detoxification. Five patients (3%) received a deferral. In total, 10% of the patients with an admission date provided the informants with information that formed the basis for logistical changes in the intake (Table 1).

    Figure 1.	Flow chart of admission rates for detoxification treatment
    Table 1. Results of pre-hospital telephone intervention (n = 200)

    When we compared the phases, 120 (56%) of patients presented for treatment at the unit in the phase without a telephone intervention, while the corresponding figure for the phase with a telephone intervention was 123 (62%) (Figure 1). Overall, 41% did not present for treatment. The higher figure by 6 percentage points in the intervention phase was not significant (χ2 = 1.3, p = 0.26).

    No data was available on the completion of treatment for three of the 243 patients who presented for treatment, and these were therefore excluded from further analysis. A total of 43 (18%) patients did not complete their treatment. The completion rate in the two phases was 84% and 80% (Figure 1) in phase 1 and phase 2 respectively (χ2 = 0.71, p = 0.40).

    Qualitative findings

    The informants reported that the phone calls lasted an average of five minutes, and the longest call was twelve minutes long. They were unsure whether the intervention helped increase the admission and completion rates for the detoxification treatment.

    Furthermore, the informants had the impression that most people they spoke to on the phone had already made a decision, and that the intervention did not alter this choice. Nevertheless, the informants believed that the patients found the conversations to be helpful.

    Relationship building

    The informants felt that the phone calls were useful as a starting point for building relations prior to admission. They qualified this by explaining that their experiences with conducting the intervention had been purely positive. Many of the patients also gave the impression that they appreciated the intervention.

    The informants felt that the phone calls were useful as a starting point for building relations prior to admission.

    When the patients who had spoken to the informants on the phone presented for treatment, the patients were able to remember the phone conversations:

    ‘When the patients I called arrived for treatment, I sometimes said hello and commented that we had spoken on the phone earlier. The patients then often remembered our conversation and I felt that contact had already been established.’

    Clarifications

    The informants believed that the intervention helped to clarify a number of points. The conversations established whether the patients had received the offer of detoxification and whether they planned to present for treatment. Most of the patients who said they would attend did in fact do so. Some of the patients that informants contacted were not aware that they had been offered detoxification treatment, partly because they had changed their address and had not received the letter.

    Other patients asked for the treatment to be deferred, and this was normally granted. The informants were notified several times that the patient they were trying to contact had either already been admitted to another department or had started detoxification with a different follow-up method or on their own. During the phone calls, several practical matters and expectations relating to the patient’s stay at the unit were also clarified.

    Some of the patients had negative ideas about the detoxification, and the informants then informed them that the conditions were better than the patients feared, for example, patients have their own rooms in the units.

    Other practical issues that could be clarified were how long they would remain at the unit and whether it was possible to arrive later in the day than the time specified. The informants also provided information about the unit’s routines and location, transport to the unit and the staff’s attitude to the use of drugs and medication during treatment.

    During the phone call, some patients expressed ambivalence towards the treatment. The informants then tried to adopt a supportive manner:

    ‘If the patient I’m calling has mixed feelings about the treatment, I make it clear that the offer still stands and that they are welcome if they decide to go ahead. I also tell them that the unit wishes to be informed about their choice the day before admission. Most people then call and let us know by the deadline.’

    The informants believed that providing clarification helped prepare the patients for their stay at the unit and strengthened the patients’ sense of coping:

    ‘Some of the younger patients in particular who are referred for detoxification for a drug use disorder feel afraid and insecure, and may therefore need confirmation and reassurance that they are expected. The information provided can make it easier for them to form a picture of their stay at the unit, and what awaits them.’

    Receiving information about the patients

    The informants reported that when preparing for the intervention and calling the patients they received some information about them that they would not otherwise have received. This information was useful for informants as well as the rest of the unit:

    ‘I’m often asked by the others, and especially the doctors in the unit, if I’ve had contact with the patients being admitted and if there was anything in particular that came to light during the conversation that could have a bearing on their stay at the unit.’

    The content of the calls was recorded in the patient journals, which provided the admission staff in the unit with clarification and information about whether the patients were available.

    The unit found the information a useful aid in the planning of admissions and bed availability. Where patients declined the offer, the units could offer the space to others who had been referred, or use the space for acute admissions. This led to greater predictability in terms of intake and improved the logistics in the units.

    Challenges

    In cases where the informants did not manage to establish contact with the patient or the collaborating partner that issued the referral, the informants were unsure whether it was appropriate to contact the patient’s family. They feared creating a dilemma if it transpired that the patient’s family was unaware of the referral. In addition, the informants wondered if they would undermine the good preparatory work carried out by the community-based services:

    ‘The system is extensive, and the patients come across a large number of people each with their own opinions.’

    This was especially true in cases where they had read before the intervention that the person they were calling was ambivalent to being treated at the unit. They resolved this by treading carefully and not trying to provoke a decision that the patient was not ready to make.

    Discussion

    Telephone contact with patients prior to treatment did not significantly increase the proportion who presented for detoxification, and nor did the treatment completion rate increase. The staff who conducted the intervention generally perceived the measure as positive: the phone call enabled them to establish a starting point for relationship building, and to provide and receive information and clarify various points.

    The informants reported several challenges, such as whether they would be breaching confidentiality by calling the family of patients they had not managed to contact, and whether their conversation with the patient could undermine the good preparatory work carried out by the community-based services.

    Many did not present for treatment

    Forty-one per cent of the patients did not present for treatment. The corresponding figures from two detoxification units at the University Hospital of North Norway show a non-attendance rate of 33 and 30% respectively (8). The high proportion of patients who failed to present for treatment shows that the topic of our study is highly relevant.

    Forty-one per cent of the patients did not present for treatment.

    Our study covered a larger number of respondents than an earlier pilot study, but the findings were similar: there was no clear evidence that a telephone intervention was an effective measure for ensuring that patients presented for treatment (4). The informants were of the opinion that the patients had largely made up their minds beforehand, and that the phone call did not change their position.

    Despite the fact that the intervention did not increase the admission rate, earlier studies have shown that patients missed out on some of the benefits that the informants believe the patients gained from the telephone intervention. For example, a national survey estimates that half of the in-patients undergoing interdisciplinary substance abuse treatment had not received satisfactory information about the treatment they were to receive (9).

    A survey conducted at the Addiction Unit also showed that there were challenges linked to patients not receiving adequate information (10). Receiving information on an ongoing basis was crucial to patients being able to have a say in their treatment and making optimal choices (11).

    The informants also found that the telephone intervention provided them with supplementary information about the patients, which was useful for optimum facilitation of the patient’s stay at the unit. Good knowledge of patients is essential to providing appropriate treatment that is adapted to the individual patient’s needs (12). The intervention can therefore help to ensure that patients and staff receive the necessary information.

    Contacting the patient is recommended

    Earlier studies recommend that a ‘reminder plus’ is given for first-time admissions to an in-patient unit, i.e. that the patient is contacted (3). In our study, the informants reported that even the patients who had been in hospital before had questions. The intervention also meant that intake planning could be more systematic and considered.

    The biggest challenge was getting hold of the patients; only half could be reached. In order to establish contact with more patients, efforts could be made to call them in the evening, and not just during the day as in this project. One suggestion that could have improved the relationship-building aspect of the intervention is for the person admitting the patient at the unit to also call the patient.

    The biggest challenge was getting hold of the patients; only half could be reached.

    Resource use for the intervention seemed to be reasonable: a rough estimate shows a full-time equivalent of 0.15 for each unit. After the study was completed, the staff wondered if they should continue the intervention as it had positive secondary consequences, but did not give the desired increase in admission or completion rates. A reminder by text could be an option.

    Such reminders are standard practice for out-patient consultations, but only for second and subsequent appointments after it has been clarified if the patient wants such reminders and their phone number has been verified. We therefore considered text reminders to be unsuitable for in-patients.

    One of the units in our study continued with a systematic telephone intervention. Each unit should conduct a cost-benefit analysis to assess whether it is worth using resources on such a measure. The benefits that were identified in the qualitative findings should also be included in this analysis.

    Strengths and weaknesses of the study

    The strength of the quantitative part of the study was that we systematically compared two periods with and without an intervention and had a relatively large sample of patients. In order to make the intervention manageable for the staff, we needed to use a quasi-experimental design instead of randomisation.

    There were few informants in the qualitative part of the study. We only selected the staff who had actually conducted the phone calls because they were in the best position to comment on the practice employed. In terms of further development of the intervention, it would have been useful to explore the patients’ own experiences and perceptions of the telephone contact: what they considered to be useful about the intervention and what can be improved.

    Conclusion

    A pre-hospital telephone intervention did not lead to any significant increase in the admission or completion rates for detoxification treatment, and these findings cannot therefore justify the use of resources.

    The staff nevertheless found that the intervention was useful and positive because it led to clarification, the exchange of information and established a starting point for relationship building. We can thus view the intervention as a way of meeting the health authorities’ requirement for patients to receive more information about the service and for the service to be better adapted to the individual patient. 

    References

    1.       Brorson HH, Ajo Arnevik E, Rand-Hendriksen K, Duckert F. Drop-out from addiction treatment: a systematic review of risk factors. Clin Psychol Rev. 2013;33(8):1010–24.

    2.       Stark MJ. Dropping out of substance abuse treatment: A clinically oriented review. Clin Psychol Rev. 1992;12(1):93–116.

    3.       McLean S, Gee M, Booth A, Salway S, Nancarrow S, Cobb M, et al. Targeting the Use of Reminders and Notifications for Uptake by Populations (TURNUP): a systematic review and evidence synthesis. Health Services and Delivery Research. 2014;2(34).

    4.       Gariti P, Alterman AI, Holub-Beyer E, Volpicelli JR, Prentice N, O'Brien CP. Effects of an appointment reminder call on patient show rates. J Subst Abuse Treat. 1995;12(3):207–12.

    5.       Shadish WR, Cook TD, Campbell DT. Experimental and quasi-experimental designs for generalized causal inference. Boston: Houghton Mifflin; 2002.

    6.       Kvale S, Brinkmann S. Det kvalitative forskningsintervju. 2. ed. Oslo: Gyldendal Akademisk; 2009.

    7.       Malterud K. Kvalitative metoder i medisinsk forskning : en innføring. 2. ed. Oslo: Universitetsforlaget; 2003.

    8.       Brox H, Eilertsen MK, Hårvik V, Jakobsen T. Kartlegging av pasienter som avbryter eller ikke møter til rusbehandling ved Psykisk helse- og rusklinikken, UNN HF. Delrapport 1 fra prosjekt «Hindre drop-out fra rusbehandling» ved Psykisk helse- og rusklinikken. Tromsø: Universitetssykehuset Nord-Norge; 2016.

    9.       Haugum M, Holmboe O, Iversen HH, Bjertnæs ØA. Pasienterfaringer med døgnopphold innen tverrfaglig spesialisert rusbehandling (TSB). Resultater etter en nasjonal undersøkelse i 2015. Oslo: Kunnskapssenteret; 2016.

    10.     Gallefoss L, Årseth AL. Drop-out prosjektet. Delrapport 2: Pasientforløp og drop- out i overgang fra Avd. for rus- og avhengighetsbehandling (ARA) Sørlandet Sykehus HF til videre behandling i private døgninstitusjoner. Kristiansand: ARAs forskningsserie; 2016.

    11.     Helsedirektoratet. Veileder om rehabilitering, habilitering, individuell plan og koordinator. Oslo: Helsedirektoratet; 2015. Available at: https://helsedirektoratet.no/retningslinjer/rehabilitering-habilitering-individuell-plan-og-koordinator(downloaded 09.05.2018).

    12.     Helse- og omsorgsdepartementet. Opptrappingsplanen for rusfeltet (2016–2020). Prop. 15 S (2015–2016). Oslo: Helse- og omsorgsdepartementet; 2015.

    Despite staff calling patients prior to the admission date, the proportion who presented for treatment did not increase. Nevertheless, it was a useful exercise for exchanging information and building relations.

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    Background: The number of patients who fail to present for planned substance abuse treatment or drop out of such treatment is a major challenge.

    Objective: The objective of our study was to investigate whether a pre-hospital telephone intervention could increase the admission and completion rates for in-patient detoxification treatment. We also wanted to gain an insight into the experiences that those making the phone calls had with the intervention.

    Method: We used a quantitative data collection method in order to compare a period without a telephone intervention to a period with a telephone intervention. The qualitative data we collected provided an insight into the experiences of the staff who made the phone calls. The study was conducted in the Addiction Unit at Sørlandet Hospital Trust.

    Results: The telephone intervention led to a modest and non-significant 6% increase in the admission rate. There was no increase in the treatment completion rate. The intervention was viewed in a positive light by the staff who conducted the phone calls because they led to clarification and the exchange of information, and served as a starting point for relationship building.

    Conclusion: Despite the fact that the intervention did not lead to significant changes in the admission and completion rates for detoxification treatment, it was nevertheless viewed as an aid for increasing the flow of information and for facilitating the service.

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  • Practice supervision of minority language nursing students requires more time and adaptation

    Nurses have a professional, ethical and personal responsibility for patients and their relatives (1) as well as responsibility for teaching and supervising nursing students (2). This can be particularly challenging when the students are minority language speakers, i.e. their mother tongue is not Norwegian. They often need additional support during work placements (3). With this in mind, our focus in this study is to direct attention to practice supervisors’ experiences of supervising minority language students in hospital work placements.

    Education is an important goal for integration.

    Nursing education is complex and the combination of theoretical knowledge and practical skills is particularly challenging for minority language students. They represent diversity but have in common that they speak two languages (3). It can take from five to eight years to acquire both linguistic and communicative competence, which constitutes a major challenge for many of them (3).

    Education is an important goal for integration and it is challenging for educational institutions to differentiate individual supervision needs through good pedagogical programmes that are perceived as inspiring (4). The prerequisite must be that students have an understanding of the language that enables them to derive benefit from supervision.

    We need minority language nurses

    Norway has become a pluralistic society (5). According to Magelsen (6), there is a growing need to provide health assistance to minority groups. It is therefore important and valuable to educate nurses with a minority language background who can meet health challenges in Norwegian society (7). Research also confirms that such knowledge is important in order to better safeguard the health needs of minority groups (8–10).

    Many minority language nursing students terminate their education before they graduate (11). According to Lauglo (12), social satisfaction and zest for life are lower among minority language nursing students than Norwegian students. In order to promote good integration processes, the programme of study must meet the needs of minority language students by adapting the study situation so that they complete their education and experience well-being and security (11, 13).

    Practice supervisors must have intercultural skills

    The national framework curriculum for the bachelor’s degree in nursing (14) states that practice supervisors should have pedagogical competence in order to assess the professional development of students. Supervisors who are to supervise minority language nursing students need to have special competence in intercultural knowledge (3). According to Boruff (11), both teachers and practice supervisors need to develop positive strategies and interventions that can conceivably influence minority language students to complete their education.

    Fillingsnes and Thylén’s study (15) reveals that practice supervisors often feel professionally inadequate in their interaction with nursing students. The authors assert that it is vital to cooperate with the educational institution (15). The teaching principles are the same for all students but Boruff (11) claims that minority language students have a greater need for supervision and follow-up due to their lack of language skills.

    Both national and international research has had little focus on practice supervisors’ experiences of supervising minority language nursing students. The objective of this study is to shed light on practice supervisors’ experiences of supervising minority language nursing students in a hospital context.

    Method

    Design

    The study has a qualitative design with individual interviews of nurses who have supervised minority language nursing students at a hospital trust under the South-Eastern Norway Regional Health Authority. We conducted the study in spring 2017.

    Sample

    The inclusion criteria for participating in the study were: being an employee of the regional health trust, having at least two years’ experience as a nurse and experience in supervising a minimum of one minority language nursing student. The nurse with responsibility for work placements at the relevant hospital recruited informants for the study.

    All relevant wards received the request. Ten practice supervisors with between 5 and 25 years experience were asked and agreed to take part in the study. Six of the practice supervisors had supervised one minority language student and four had supervised two students. All were women and they represented the surgical ward, medical ward, post-operative ward and paediatric ward, as well as the emergency ward and the medical and surgical outpatient clinic.

    Data collection

    The informants were contacted in order to schedule a time for the interview. We interviewed eight practice supervisors on the hospital’s premises and two at the nearby educational institution. The first author conducted individual, semi-structured interviews.

    The practice supervisors were asked about their experiences of supervising minority language students, what challenges they had encountered, what the practice institution could do to improve the study situation and what measures the educational institution could introduce. In order to obtain more detailed answers, we asked follow-up questions. The interviews lasted from 20 to 50 minutes, and we audiotaped them. An external transcriber transcribed the data material.

    Context

    The bachelor’s degree in nursing at the educational institution in question includes 18 weeks’ practice in a somatic hospital during the second or third year of study, with a focus on surgical and medical studies. According to the national framework curriculum for the bachelor’s degree in nursing (14), the practice supervisors are responsible for ensuring that the learning situation is in accordance with the learning outcomes. The practice teacher must inform the practice institution about the requirements and goals in the programme description, and facilitate cooperation with the practice supervisor.

    In situations in which the student has experienced challenges in connection with an earlier work placement, a conversation will take place prior to the start of the work placement between the student, the practice teacher and the practice supervisor. This is termed a transition conversation. The suitability of all students is assessed on an ongoing basis throughout the course of studies and this forms part of the overall evaluation of the student’s professional and personal aptitudes for working as a nurse (16).

    Analysis

    We analysed the data using manifest content analysis (17). The whole text was read several times and divided into meaning-bearing units. These units were condensed, abstracted and coded. Based on the codes, the condensed and abstracted meaning units were gathered in the following three categories:

    • Uncertain about language understanding
    • Need more time
    • Need for cooperation

    Table 1 shows examples of the process of analysis.

    Table 1. Analysis process

    Ethics

    We conducted the study based on research ethics guidelines in accordance with the Declaration of Helsinki (18). We applied for permission to carry out the study via the hospital’s research unit. The project was approved by the Norwegian Centre for Research Data (NSD) (project number 52027).

    The practice supervisors received oral and written information about the study, and gave written consent to participation. During the interview situation and in the analysis process, we took care to prevent identification of any informants by a third party.

    Results

    In the results section, we present the findings in relation to the three categories.

    Uncertain about language understanding

    The practice supervisors stated that they found it challenging to supervise minority language students because they were often uncertain about whether the students understood what was said. They found that the students worked hard to master the subject of nursing and they were often unsure whether the students had understood information and messages correctly: ‘I don’t know if they know what they don’t understand.’

    They described how busy their daily work was. The students struggled to keep up with what was going on at the nurses’ station and in the break room when instructions were given quickly. This could result in some students failing to understand what had been said, and backing away.

    When the students were unable to understand the communication, the practice supervisor believed that this could lead to the students feeling inadequate. The supervisor believed that this feeling could be reinforced when she had to monitor the student closely: ‘It’s not good to hang over the student all the time. It can make them feel even more inadequate.’

    Several supervisors brought up the point that students apparently got little language training: ‘They seemed to have little contact with Norwegians or any social life at university.’ When the supervisors were unsure about the students’ understanding, this affected the opportunity to delegate tasks. As a result, it could take time before the students were given the chance to work independently compared with Norwegian students: ‘I had to tag along with the student because I wasn’t sure if she had understood the instructions.’

    The supervisors felt that they showed the same respect for all the students, i.e. treating everyone equally, but they needed more time to feel secure about the minority language students. This need to spend more time on establishing trust led to a fear of being perceived as prejudiced.

    It also transpired that when students struggled to master the language, it affected their self-confidence. The practice supervisors believed that minority language students were more vulnerable than Norwegian students: ‘The students are vulnerable regardless of background, but minority students are much more vulnerable than I thought. Comments from others were very hurtful as they made her feel that she wasn’t good enough because she spoke differently. It shook her self-confidence.’ However, the supervisors clarified that there were weak and strong students among both minority language students and Norwegian students.

    Need more time

    The supervisors said that it was more time-consuming to supervise minority language students than other nursing students: ‘Minority language students need more supervision and you need more time to adapt things and make sure that they’ve understood the instructions.’ More detailed planning was needed as well as more time to evaluate the work afterwards: ‘It takes time, and I wish I had more time in the morning for planning, and more time in the afternoon for summing up to make sure that the student has understood.’

    Minority language students need more supervision.
    Informant

    The practice supervisors felt that spending more time on supervision meant that the students had better opportunities to achieve the learning outcomes in the work placement. However, it was challenging for the practice supervisors to set aside enough time for the students due to work pressure in connection with patients and their relatives: ‘It’s a challenge to set aside enough time in the hope that the student will achieve the goals.’

    This could result in some practice supervisors being over-lenient rather than strict because they saw that many of the students were in a difficult social situation. The supervisors could also find it challenging to set limits for what could be expected and the amount of supervision to which the students were entitled: ‘A lot of time is consumed by uncertainty as to where to set the standard.’

    Need for cooperation

    The practice supervisors felt that having open and frank cooperation with the educational institution was crucial for a good learning environment. Most supervisors were of the opinion that there was positive cooperation between the educational institution and the field of practice. They stressed that the practice teacher and the practice supervisor must jointly assume responsibility for supervising and following up the students during the work placement. The practice supervisor has daily responsibility for following up the students in the department and the practice teacher must maintain a close dialogue with the practice supervisor and the student: ‘We must be united as a learning institution and field of practice. That is absolutely essential.’ Similarly, ‘The university must provide close follow-up, and it must be easy to get in contact.’

    The practice supervisors found that there was more need for good cooperation when a student experienced challenges. They highlighted situations where the students had not gained a pass mark for an earlier work placement, but the educational institution had not informed them about this before the start of the current placement. The practice supervisors wanted more transparency in this situation about earlier challenges: ‘If you have problems with Norwegian, a transition conversation takes place almost automatically.’

    When such a conversation did not take place beforehand, this meant that the supervisors got off to a bad start with the student: ‘It’s challenging to be unable to meet the student at their current level.’ One practice supervisor expressed this as follows: ‘It took a long time for me to find out this student’s professional level.’

    The supervisors generally perceived there to be an inadequate exchange of information in between the various work placement periods as regards the professional level of weak students. They felt that students with major language problems should get help at an early stage of their education: ‘Extra resources should be allocated as early as the first year. It’s terrible that they get to the third year and their Norwegian is really bad and no one has told them properly.’

    They described situations where the supervisor and the teacher disagreed about the student’s professional level: ‘I felt that the teacher did not share my opinion of the student, and that meant cooperation was difficult.’ It was described as very unfortunate when disagreement led to the teacher correcting the supervisor while the student was present: ‘I don’t want to be corrected by the teacher when the student is listening.’

    Discussion

    The purpose of the study was to shed light on practice supervisors’ experiences of supervising minority language nursing students in a hospital context. The practice supervisors often felt uncertain about the students’ language understanding, and found this a major challenge.

    Daily life at the hospital is characterised by considerable work pressure and quick decisions. The supervisors became insecure when they were uncertain about whether the students had understood instructions. Hanssen and Helleland (3) assert that acquiring linguistic and communicative skills takes time because it is difficult to learn a foreign language. Minority language students must practice Norwegian and get a grounding in attitudes, values and customs in order to understand the society they live in and will work in (3).

    The supervisors became insecure when they were uncertain about whether the students had understood instructions.

    When the practice supervisors were uncertain about whether students understood what had been communicated, it was difficult for them to allow students to work independently. A lack of language understanding can give rise to risky situations for patients, and this gives the practice supervisor additional challenges. It is vital, therefore, to use simple language when conversing with the students in order to avoid misunderstandings (3).

    Important to be part of a community

    For students to develop their professional identity it is essential to interact with others in a professional context (7). This requires the practice supervisor to trust the students and delegate relevant work tasks that the students can master. When the students feel this sense of mastery, they will acquire greater self-confidence, more motivation and a feeling of responsibility. Furthermore, mastering work tasks will enable students to feel that they have control of the situation (19).

    The practice supervisors found that the students withdrew from social situations at the hospital when a lot of information was communicated in a short period of time. According to Sedgwick et al. (20) and Bekkeli (4), it is vital that students feel that they are part of a community in order to be able to develop their knowledge. In this process, the practice supervisors found it was important to spend more time during supervision helping students understand communication in the hospital context. This is in line with the findings of Bolderston et al. (21), who state that communication in context is a key learning arena.

    A lack of time can limit supervision

    Our findings showed that minority language students needed more time in respect of practice supervision. A hectic daily life in the ward and little time posed a strong challenge to the supervisory function. A lack of time was often identified as the reason for limited supervision (22, 23). The practice supervisors expressed a need to be informed about students who needed extra supervision before the start of the work placement.

    It is important to be well-informed in order to be able to employ pedagogical strategies that suit the individual student (13). The practice supervisors strove to have realistic expectations, and deciding where to set the standard was challenging. It was difficult to know how much time should be set aside for supervision when there were considerable language challenges. How supervision should be structured and how much time should be set aside are well-known challenges in the supervision of minority language students (22, 23).

    The supervisors wanted to have more time both in the morning to check that the student had understood what had been reported and at the end of the day to sum up. In the future, the population will change and become more multicultural. Consequently, nursing education must include a study programme that can educate students from all cultures. Implementing such a programme will take time (13).

    Practice supervisors must be given information about the students

    The practice supervisors emphasised that good cooperation between the educational institution and the field of practice was crucial. It was particularly challenging if they had not received information about the students before the placement started. To achieve good-quality supervision, it is essential that the educational institution and the practice institution cooperate well (2).

    The practice supervisors emphasised that good cooperation between the educational institution and the field of practice was crucial.

    If the practice supervisors are to give useful feedback to the students, they must have knowledge about the students and the study programme’s progression, requirements and learning outcomes (19). For this reason, the teacher, practice supervisor and student must take part in a conversation before the start of the work placement if the student has language difficulties or other challenges.

    The students must feel secure and experience a good atmosphere when they start in the department. If the practice supervisor has no information about the student’s professional and language-related level, a considerable part of the work placement will be spent on establishing the student’s professional level. 

    According to Boruff (11), minority language students spend considerable energy on creating good strategies to master the study situation (11). It is vital that students receive help in learning to interpret signals mediated through body language and behaviour. They gain such knowledge via social arenas where they speak Norwegian (24).

    The practice supervisors stated that they were reliant on mutual respect in difficult situations and found situations where the practice supervisor and the teacher had opposing views extremely taxing. Feeling responsible for a student who has not achieved the learning outcomes can be stressful.

    Sometimes practice supervisors felt that their responsibility for minority language students was very heavy, since the students work hard and often have obligations both in Norway and their country of origin. It is challenging when they fail to achieve their professional and personal goals for a hospital work placement, and the supervisors find that the students become disheartened (13). Students who are training to become nurses must have good language skills and the ability to expand their cultural understanding.

    Strengths and weaknesses

    The strength of our study was that it fills a knowledge gap where there is little research both nationally and internationally on practice supervisors’ experiences of supervising minority language nursing students. Moreover, the findings are in accordance with similar research and with the authors’ experiences as nursing education teachers.

    A weakness of the study is that the practice supervisors had only supervised one or two minority language students. None of them had experience of supervising many. Another weakness was that some interviews lasted only 20 minutes because the supervisors had little experience of supervising minority language students. Despite this, we gathered a rich data material.

    Conclusion

    It is challenging to supervise minority language students in hospital work placements because the practice supervisors often feel uncertain about the students’ language understanding. More time is needed for supervision and better cooperation between the educational institution and the field of practice.

    The education plan must be adapted to the individual in order to ensure that minority language students will be better able to complete their education. Practice supervisors should be offered courses in intercultural communication and cultural understanding.

    Research going forward should focus on minority language nursing students’ experiences of being a student as well as teachers’ experiences of supervising these students.

    References

    1.       Norsk Sykepleierforbund. Yrkesetiske retningslinjer for sykepleiere. Oslo; 2016. Available at: https://www.nsf.no/vis-artikkel/2193841/17036/Yrkesetiske-retningslinjer-for-sykepleiere(downloaded 08.10.2018).

    2.       Lov 2. juli 1999 nr. 64 om helsepersonell m.v. (helsepersonelloven). Available at: https://lovdata.no/dokument/NL/lov/1999-07-02-64(downloaded 28.09.2018).

    3.       Hanssen I, Helleland EH. Minoritetsspråklige studenter ved norske sykepleiehøgskoler – problemer og utfordringer. Vård i Norden. 2005;25(1):48−51.

    4.       Bekkeli LH. Å være minoritetsstudent i grunnutdanning i sykepleie. Elverum: Høgskolen i Hedmark; 2004. Rapport nr. 5 – 2004. Available at: http://www.nb.no/idtjeneste/URN:NBN:no-bibsys_brage_29404(downloaded 06.10.2018).

    5.       Statistisk sentralbyrå. Innvandrere i Norge, Befolkningsgruppe i stadig endring. Publisert 04.06.2017. Available at: http://www.ssb.no/befolkning/artikler-og-publikasjoner/befolkningsgruppe-i-stadig-endring(downloaded 06.10.2018).

    6.       Magelsen R. Kultursensitivitet. Om å finne likheter i forskjellene. Oslo: Akribe; 2008.

    7.       Greek M. Å være annerledes i sykepleierutdanningen. Sykepleien. 2004;92(11):34−7.

    8.       Dellenborg L, Skott C, Jacobsen E. Transcultural encounters in a medical ward i Sweden: Experience and health care practitioners. J Transcult Nurs. 2012;23(4):342−50. DOI: 10.1177/1043659612451258.

    9.       Goth US. Toleranse, kultursensitivitet og akkulturasjon: Interkulturelle utfordringer i for primærhelsetjenesten og nyankomne innvandrere i Norge. Scandinavian Journal of Intercultural Theory and Practice. 2014;1(1):1−19. DOI: 10.7577/fleks.843.

    10.     Goth US. Migrasjonshelse i U.S. In: Goth US, ed. Folkehelse i et norsk perspektiv. Oslo: Gyldendal Akademisk; 2014. p. 91−117.

    11.     Boruff SM. Experiences of success by minority students, attending a predominantly Caucasian nursing program. Electronic theses and dissertations. Paper 1484. Tennessee: East Tennessee State University; 2012. Available at: http://dc.etsu.edu/etd/1484/(downloaded 08.10.2018).

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    13.     Graham CL, Phillips SM, Newman SD, Atz TW. Baccalaureate minority nursing students perceived barriers and facilitators to clinical education practices – An integrative review. Nursing Education Perspectives. 2016;37:130−38. DOI: 10.1097/01.NEP.0000000000000003.

    14.     Kunnskapsdepartementet. Rammeplan for sykepleierutdanning. Oslo; 2015. Available at: https://www.regjeringen.no/globalassets/upload/kilde/kd/pla/2006/0002/ddd/pdfv/269376-rammeplan_for_sykepleierutdanning_05.pdf(downloaded 08.10.2018).

    15.     Fillingsnes A-B, Thylén I. Praksissykepleieres pedagogiske utfordringer i klinisk veiledning av sykepleierstudenter. Nordisk sygeplejeforskning. 2012;2(4):249−62.

    16.     Forskrift 30. juni 2006 nr. 859 om skikkethetsvurdering i høyere utdanning. Available at: https://lovdata.no/dokument/SF/forskrift/2006-06-30-859(downloaded 08.10.2018).

    17.     Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105−112. DOI: 10.1016/j.nedt.2003.10.001.

    18.     Helsinkideklarasjonen. Ethical principles for medical research involving human subjects. 64th WMA General Assembly. Brazil: Fortaleza; 2013. Available at: https://www.wma.net/wp-content/uploads/2016/11/DoH-Oct2013-JAMA.pdf (downloaded 12.10.2018).

    19.     Haddeland K, Söderhamn U. Sykepleierstudenters opplevelse av veiledningssituasjoner med sykepleiere i sykehuspraksis. Nordisk sygeplejeforskning. 2013;3(1):18−32.

    20.     Sedgwick M. Oosterbroek T, Ponomar V. «It all depends»: How minority nursing students experience belonging during clinical experiences. Nursing Education Perspectives. 2014;35(2):89−93. DOI: 10.5480/11-707.1.

    21.     Bolderston A, Palmar C, Fagan W, McPaland N. The experience of English as a second language radiation therapy student in undergraduate clinical program: perspectives of staff and students 2007. Radiography. 2008;14(3):216–55.

    22.     Löfmark A, Wikblad K. Facilitating and obstructing factors for development of learning clinical practice: a student perspective. J Adv Nurs. 2001;34(1):43−50.

    23.     Wilkes Z. The Student–mentor relationship: a review of the literature. Nursing Standard. 2006;20(37):42–7.

    24.     Småland Goth U, Løkhaug Jensen T, Skyrud R. Fra innvandrer til medstudent og ressurs i undervisningen ved helsefaglig høyskoleutdanning. Nordic Journal of Vocational Education and Training. 2015:5(1):1–25.

    Practice supervisors are of the opinion that the students need specially adapted arrangements for hospital work placements in order to complete their education.

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    Sammendrag

    Background: Research among minority language nursing students shows that they have a strong need for supervision and follow-up due to poor language understanding. Acquiring both linguistic and communicative competence takes time, and it is important that the students are offered specially adapted arrangements in order to complete their education.

    Objective: To shed light on practice supervisors’ experiences of supervising minority language nursing students in a hospital context.

    Method: The study has a qualitative design with individual interviews with ten practice supervisors from different departments in a hospital belonging to a regional hospital trust under the South-Eastern Norway Regional Health Authority. Data were analysed using manifest content analysis.

    Results: The practice supervisors found it challenging to supervise minority language students due to the students’ language skills. More time is needed for supervision and better cooperation between the educational institution and the field of practice.

    Conclusion: The study shows that minority language nursing students face language challenges, and therefore need more supervision. There must be cooperation between the field of practice in hospitals and educational institutions in order to create a good learning situation for minority language nursing students. Consequently, facilitating individual follow-up of minority language students in bachelor's degree programmes in nursing is highly recommended.

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  • Inadequate documentation of nutritional practice in the specialist health service

    Disease-related malnutrition is a major challenge for the health service, and has serious health and economic consequences (1–3). The prevalence of malnutrition varies from 18 to 45 per cent (2, 4–9), depending on the population measured and method used.

    At Haukeland University Hospital (HUS), 29 per cent of hospitalised adult patients are at nutritional risk (10). Patients 70 years or older and those with infectious diseases, cancer and lung diseases are particularly at risk (6, 10). The nutritional risk in these groups is 40–43, 51, 44 and 42 per cent, respectively.

    Identification of nutritional risk and early initiation of targeted nutritional treatment may increase energy intake (11), improve nutritional status, shorten recovery time following illness, prevent complications and death (12), and reduce the length of hospitalisation (13, 14).

    Adequate nutritional practice

    According to the national guidelines on prevention and treatment of malnutrition, adequate nutritional practice includes screening for nutritional risk, preparing a targeted nutrition plan for patients at risk and implementing interventions. It also involves documenting nutritional status and interventions in the patient’s medical record and discharge summary, and communicating this to the next phase of care (1).

    Establishing routines for adequate nutritional practice is a challenge (15–17). Barriers that prevent nurses from providing adequate nutritional care are a lack of time, insufficient knowledge and skills, a lack of cross-disciplinary goals, and little involvement from management (18). Results from Norwegian qualitative studies show that nurses perceive a lack of involvement on the part of doctors, that risk assessment is given low priority because patients do not appear to need nutritional intervention, and that nurses have too many other duties (19, 20).

    Establishing routines for adequate nutritional practice is a challenge.

    In 2006, HUS established a management-based nutrition strategy that included targeted efforts to implement good nutritional practice among nurses and doctors in order to introduce adequate nutritional care. The hospital established a cross-disciplinary, management-based nutrition network, introduced online courses and implemented mandatory registration of nutritional information to improve risk assessment skills and increase knowledge about prevention and treatment of nutritional risk.

    Registration of nutritional information was conducted four times a year in which nurses, and later on doctors as well, submitted reports on the results of risk assessment (21). During the first two years, the proportion of patients screened for nutritional risk increased from 54 to 77 per cent, but only half of those found to be at nutritional risk received interventions to improve their nutritional status.

    Geiker et al. compared the planned registration with a retrospective survey of medical records. They concluded that pre-planned, self-reported registration does not provide the best basis for assessing nutritional practice (22). Therefore, we wanted to study which information on nutritional status and nutritional practice is documented in medical records.

    Objective of the study

    The objective of the study was to survey medical record data to assess whether nutritional practice at HUS complied with recommendations in the national guidelines for prevention and treatment of malnutrition.

    Research questions

    The research questions were as follows:

    • Are data on nutrition documented in medical records?
    • Are the nutritional data documented in medical records at HUS in compliance with recommendations in the national guidelines for prevention and treatment of malnutrition?

    Method

    We conducted a retrospective data collection from medical records at HUS. Webport software generated a list of all hospitalised adult patients from eight different departments at 8 am on 4 November 2011.

    The eight departments were as follows: internal medicine (which also included cardiovascular specialisations), orthopaedics, rehabilitation, oncology, surgery, internal medicine/surgery, neurology/surgery, and other departments that included head/throat, rheumatology, dermatology, ophthalmology and gynaecology. We collected data from the entire duration of the relevant hospital stay. Data collection was carried out by the lead author from 4 November 2011 to 1 May 2012.

    Nutritional practice is routinely documented by doctors, nurses or clinical nutritional physiologists in the DIPS Electronic Patient Record using the following two assessment forms: 1) ‘Assessment of nutritional risk’, which is used to identify patients at nutritional risk, and 2) ‘Nutritional intervention/follow-up’, which is the nutrition plan and follow-up of the plan.

    ‘Assessment of nutritional risk’ consists of four introductory questions and one main survey, which is based on the NRS 2002 (Nutrition Risk Screening 2002) (1). The introductory questions are as follows:

    • Is Body Mass Index (BMI) < 20.5?
    • Has the patient lost weight in recent weeks?
    • Has the patient had reduced nutritional intake in recent weeks?
    • Is the patient seriously ill?

    A positive response to at least one of the questions triggers more thorough documentation of the patient’s nutritional condition and level of severity of the illness. Age is given special consideration. ‘Nutritional interventions/follow-up’ is used to prepare a targeted nutrition plan for patients at nutritional risk and to document whether the plan is followed up.

    We collected data on nutritional practice from the two assessment forms. We prepared a standardised registration form based on qualitative indicators from the national guidelines for prevention and treatment of malnutrition (1) and gathered the following information:

    • the patient’s weight
    • at nutritional risk or not
    • whether the risk assessment had been carried out within 24 hours of admission
    • whether the risk assessment had been conducted weekly for patients hospitalised for more than one week

    If the patient was at nutritional risk, we gathered information about the nutrition plan and calculated the nutritional needs and nutritional intake.

    Variables

    In addition, we registered the following background variables from the medical records: length of hospitalisation, age, gender, and department and ward affiliation. From discharge summaries we collected information about the following ICD-10-CM Diagnosis Codes: E46 (at nutritional risk), E44 (moderate malnutrition) and E43 (severe malnutrition).

    We used descriptive statistics to describe background variables and variables related to nutritional practice. Categorical variables were reported in absolute numbers and percentages. Numeric variables were reported as an average and standard deviation (SD). Length of hospitalisation was reported as the median with dispersion given as interquartile range (IQR 25–75 per cent).

    We used the Mann-Whitney U test to compare age and length of hospitalisation between men and women, and the Kruskal-Wallis test to compare the difference in length of hospitalisation between age groups and departments (23).

    We used a chi-squared test to examine the relationship between the proportion of patients found to be at nutritional risk, the proportion found to be at nutritional risk within 24 hours of admission, those for whom weight was recorded, and the background variables of gender, age groups and departments (23). We performed the analyses using SPSS version 24.0 (24).

    Two nurses piloted the registration form for 25 medical records. Both nurses recorded the same information for all the items on the form.

    Ethics

    The study is part of a quality-enhancement project at HUS, and was approved by the data protection official at HUS in August 2011 (reference number 2011/4146).

    Results

    Of 726 relevant medical records, we included 714 in the study. Twelve medical records were excluded because the patients were pregnant (n = 6), terminally ill (n = 1), did not show up for the planned hospitalisation (n = 2), were registered as a participant in a research project (n = 2) or the medical record was not available (n = 1).

    Patient characteristics

    The average age was 63 years (SD 19.4), and there were more men than women (56 vs. 44 per cent, p = 0.04) (Table 1). Median length of hospitalisation was 8 days (IQR 4–17). Men had longer hospital stays than women (9 vs. 7 days, p = 0.01). Length of hospitalisation varied among departments and age groups. The longest hospital stays were recorded for patients admitted to the rehabilitation department (median 49 days, p < 0.05).

    Patients in the age groups 40–59 years and older than 80 years had longer hospital stays than the youngest group of 18–39 years (median 9 days, IQR 4–24, median 9 days, IQR 5–15 and median 6 days, IQR 2–14, respectively).

    Table 1. Patient characteristics and documentation of risk assessment in the various departments (n = 714)

    Screening for nutritional risk

    We found documentation of nutritional risk in 107 medical records (15%). Of these, 64 medical records (60%) were assessed within 24 hours of admission (Table 1). Two patients were assessed weekly during their hospital stay. This practice varied among the departments.

    A larger proportion of patients were screened in the orthopaedic department (33%) than in the departments of internal medicine (4%, p ˂ 0.01), rehabilitation (9%, p = 0.026), oncology (30%, p = 0.191), surgery (4%, p ˂ 0.01) and neurology/neurosurgery (11 %, p < 0.01). Patients in the age group 60–79 years (16%) comprised the largest proportion screened compared to other age groups (p < 0.01). Weight was documented in 133 (19%) of the 714 medical records.

    Nutritional interventions when nutritional risk is present

    Of 107 patients screened for nutritional risk, 26 patients (24%) were found to be at nutritional risk – 16 men and 10 women. Eighteen of these patients (69%) received a nutrition plan – 13 men and 5 women. Nutritional needs and nutritional intake were calculated in two of the nutrition plans. In our data we found three nutrition plans for patients who were not assessed to be at nutritional risk.

    Diagnosis

    The diagnosis codes for malnutrition (the ICD-10-CM diagnosis codes E46, E44 and E43) were used in 26 discharge summaries. We found discrepancies between documentation of nutritional risk and the use of diagnosis codes for malnutrition. For example, 19 patients in the age group 60–79 years were given a diagnosis code for malnutrition in the discharge summary, but no information about nutritional risk was recorded in 7 of the medical records.

    We found discrepancies between documentation of nutritional risk and the use of diagnosis codes for malnutrition.

    Discussion

    We collected medical record data to obtain information about nutritional care at HUS. The survey of 714 medical records showed that information about nutritional practice in the medical records was inadequate and not in compliance with national guidelines.

    We found no information about screening for nutritional risk in 85 per cent of the medical records. Almost 70 per cent of the patients at nutritional risk were given a nutrition plan, but the plans were not adequately followed up.

    Previous documentation of nutritional practice

    Our results differ significantly from the hospital’s quarterly registration which indicated that 70 per cent of the patients were screened and over half received a nutrition plan (21). Nutritional registration provides critical information about the prevalence of nutritional risk in the various patient populations, but does not adequately reflect the daily routines.

    Similar differences between findings from medical records and planned registration of nutritional information were seen in a previous study at Rigshospitalet in Denmark (22). Geiker et al. found that 2393 medical records were examined in the period 2009–2010, and screening for nutritional risk was documented for only 8 per cent of the patients (22). In contrast, the planned registration showed that 70–80 per cent of the patients had been screened as required.

    Our findings are consistent with previous studies that have looked at documentation of nutritional practice in medical records (7, 22, 25). A total of 590 medical records were examined at another Danish hospital (7). Screening for nutritional risk was documented in less than 8 per cent of the records, and few patients were followed up with a nutrition plan and interventions.

    If the inadequate documentation we found actually reflects the hospital’s nutritional practice, this is a serious concern for patient safety.

    Results from a survey of medical record data at a Belgian hospital showed that important nutritional parameters for nutritional risk screening, such as body weight and height, were documented in only 22 per cent of 506 nursing records in the first three days following admission (25).

    If the inadequate documentation we found actually reflects the hospital’s nutritional practice, this is a serious concern for patient safety. A previous survey at the hospital shows that one of three patients is at nutritional risk, which is associated with an almost five-fold higher mortality rate and 70 per cent more days in hospital than the subsequent year (3).

    Such practice may have consequences for the hospital’s financial situation since preventive interventions for patients at nutritional risk are shown to reduce illness and length of hospitalisation (2). Documentation of nutritional status and nutritional practice is crucial information that should be communicated to the next phase of care upon discharge. When this documentation is missing, the next phase of care must conduct another screening and examination in order to prepare a nutrition plan.

    Barriers to nutritional care

    Previous studies have documented barriers to nutritional care (18–20, 26, 27). A main barrier to adequate nutritional treatment is a busy clinical day with many competing tasks (18, 20, 26, 27). Porter et al. reported that tasks such as clinical observations, attending to patient hygiene, administration of medication and documentation were prioritised over screening, prevention and treatment of nutritional risk (28).

    Nurses state that they conduct their own clinical observations rather than use survey instruments (18, 20). Sufficient time and resources must be set aside to overcome common barriers that lead to inadequate nutritional practice (27, 29).

    National guidelines emphasise that nutrition-related work is a joint responsibility shared by nurses, doctors and clinical nutritional physiologists (1, 30). However, nurses feel that they are alone in these efforts. They report that doctors show little involvement and interest and that clinical nutritional physiologists are not present (19, 20, 27). A clearer cross-disciplinary distribution of responsibility is necessary.

    In addition, barriers to adequate nutritional practice arise during encounters with patients. Many patients are unable to provide information about their food intake or weight gain/loss (18). Poor appetite, nausea, constipation, and problems with chewing and swallowing are daily challenges in the health service.

    It is the responsibility of management to ensure there is sufficient expertise on nutrition within the organisation.

    Nurses feel that they must protect patient autonomy by accepting the patient’s reluctance to eat (27), and expressed concern that standardisation of nutritional treatment does not meet individual needs and wishes. More knowledge about nutrition is essential for addressing such challenges. It is also important to have ongoing training related to screening, prevention and treatment of nutritional risk in order to advance knowledge and skills (18). It is the responsibility of management to ensure sufficient expertise on nutrition within the organisation.

    Inadequate documentation of nutritional practice may also be due to the current documentation system, which is not well suited for documenting nutritional status and the patient’s food intake in a systematic, effective and user-friendly manner.

    Our findings are confirmed by O’Connell, who concludes that standardised documentation on separate assessment forms in the medical record (27), as is the case at HUS, makes information less accessible than an updated electronic graph in the record. Therefore, we believe that developing appropriate documentation systems that can structure, simplify and improve documentation of nutrition is a pre-condition of adequate nutritional practice and important for integrating nutrition into clinical practice.

    National initiative on nutrition

    Our findings show that nutrition has a legitimate place in the Norwegian Patient Safety Programme: In Safe Hands. Such a large-scale, national initiative with implementation of the national guidelines for prevention and treatment of malnutrition is crucial for patient treatment and hospital budgets.

    Intervention packages have been prepared, tested and found to be feasible for use in clinical practice, and they are ready to be introduced nationwide in 2018. Local barriers should be identified to ensure successful implementation of the intervention packages (29).

    Strengths and weaknesses of the study

    A strength of the study is that data were collected from a large number of medical records from a university hospital where the management has been concerned about nutrition for many years.

    A weakness of the study is that we cannot rule out that different documentation practices were used, e.g. that information about weight, nutritional status and nutritional intervention may have been documented in places other than in the dedicated assessment forms in the medical records that we surveyed. To our knowledge, our study is the first of its kind in Norway that documents nutritional care by using medical record data.

    Conclusion

    A survey of medical record data showed that documentation of the nutritional care provided at Haukeland University Hospital was inadequate and not in compliance with the guidelines. The large-scale initiative on nutrition under the Norwegian Patient Safety Programme is a unique opportunity to incorporate adequate, systematic nutritional practice. Sufficient knowledge, skills, clear distribution of responsibility, routines and systems are a precondition for success.

    References

    1.          Helsedirektoratet. Nasjonale faglige retningslinjer for forebygging og behandling av underernæring. IS-1580. Oslo: Helsedirektoratet; 2013.

    2.          Sørensen J, Kondrup J, Prokopowicz J, Schiesser M, Krahenbuhl L, Meier R, et al. EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome. Clin Nutr. 2008;27(3):340–9.

    3.          Tangvik RJ, Tell GS, Eisman JA, Guttormsen AB, Henriksen A, Nilsen RM, et al. The nutritional strategy: four questions predict morbidity, mortality and health care costs. Clin Nutr. 2014;33(4):634–41.

    4.          Imoberdorf R, Meier R, Krebs P, Hangartner PJ, Hess B, Staubli M, et al. Prevalence of undernutrition on admission to Swiss hospitals. Clin Nutr. 2010;29(1):38–41.

    5.          Lamb CA, Parr J, Lamb EI, Warren MD. Adult malnutrition screening, prevalence and management in a United Kingdom hospital: cross-sectional study. Br J Nutr. 2009;102(4):571–5.

    6.          Pirlich M, Schutz T, Norman K, Gastell S, Lubke HJ, Bischoff SC, et al. The German hospital malnutrition study. Clin Nutr. 2006;25(4):563–72.

    7.          Rasmussen HH, Kondrup J, Staun M, Ladefoged K, Kristensen H, Wengler A. Prevalence of patients at nutritional risk in Danish hospitals. Clin Nutr. 2004;23(5):1009–15.

    8.          Allard JP, Keller H, Jeejeebhoy KN, Laporte M, Duerksen DR, Gramlich L, et al. Malnutrition at hospital admission-contributors and effect on length of stay: A prospective cohort study from the Canadian Malnutrition Task Force. JPEN J Parenter Enteral Nutr. 2016;40(4):487–97.

    9.          Banks M, Ash S, Bauer J, Gaskill D. Prevalence of malnutrition in adults in Queensland public hospitals and residential aged care facilities. Nutrition & Dietetics. 2007;64(3):172–8.

    10.        Tangvik RJ, Tell GS, Guttormsen AB, Eisman JA, Henriksen A, Nilsen RM, et al. Nutritional risk profile in a university hospital population. Clin Nutr. 2015;34(4):705–11.

    11.        Jie B, Jiang ZM, Nolan MT, Efron DT, Zhu SN, Yu K, et al. Impact of nutritional support on clinical outcome in patients at nutritional risk: a multicenter, prospective cohort study in Baltimore and Beijing teaching hospitals. Nutrition. 2010;26(11–12):1088–93.

    12.        Stratton RJ, Elia M. Who benefits from nutritional support: what is the evidence? Eur J Gastroenterol Hepatol. 2007;19(5):353–8.

    13.        Johansen N, Kondrup J, Plum LM, Bak L, Norregaard P, Bunch E, et al. Effect of nutritional support on clinical outcome in patients at nutritional risk. Clin Nutr. 2004;23(4):539–50.

    14.        Kruizenga HM, Van Tulder MW, Seidell JC, Thijs A, Ader HJ, Van Bokhorst-de van der Schueren MA. Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients. Am J Clin Nutr. 2005;82(5):1082–9.

    15.        Johansson U, Rasmussen HH, Mowe M, Staun M, Scandinavian Nutrition Group. Clinical nutrition in medical gastroenterology: room for improvement. Clin Nutr. 2009;28(2):129–33.

    16.        Mowe M, Bosaeus I, Rasmussen HH, Kondrup J, Unosson M, Irtun O. Nutritional routines and attitudes among doctors and nurses in Scandinavia: a questionnaire based survey. Clin Nutr. 2006;25(3):524–32.

    17.        Meijers JM, Halfens RJ, van Bokhorst-de van der Schueren MA, Dassen T, Schols JM. Malnutrition in Dutch health care: prevalence, prevention, treatment, and quality indicators. Nutrition. 2009;25(5):512–9.

    18.        Green SM, James EP. Barriers and facilitators to undertaking nutritional screening of patients: a systematic review. J Hum Nutr Diet. 2013;26(3):211–21.

    19.        Juul HJF, Jan C. Kartlegging av underernæring i sykehus. Nordisk Sygeplejeforskning. 2013;3(2):77–89.

    20.        Eide HD, Halvorsen K, Almendingen K. Barriers to nutritional care for the undernourished hospitalised elderly: perspectives of nurses. J Clin Nurs. 2015;24(5-6):696–706.

    21.        Tangvik RJ, Guttormsen AB, Tell GS, Ranhoff AH. Implementation of nutritional guidelines in a university hospital monitored by repeated point prevalence surveys. Clin Nutr. 2012;66(3):388–93.

    22.        Geiker NR, Horup Larsen SM, Stender S, Astrup A. Poor performance of mandatory nutritional screening of in-hospital patients. Clin Nutr. 2012;31(6):862–7.

    23.        Field A. Discovering statistics using IBM SPSS Statistics. 4. utg. London: SAGE Publications; 2013.

    24.        IBM Corp. Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp; 2016.

    25.        Geurden B, Wouters C, Franck E, Weyler J, Ysebaert D. Does documentation in nursing records of nutritional screening on admission to hospital reflect the use of evidence-based practice guidelines for malnutrition? Int J Nurs Knowl. 2014;25(1):43–8.

    26.        Ross LJ, Mudge AM, Young AM, Banks M. Everyone's problem but nobody's job: Staff perceptions and explanations for poor nutritional intake in older medical patients. Nutrition & Dietetics. 2011(68):41–6.

    27.        O’Connell MB, Jensen PS, Andersen SL, Fernbrant C, Norholm V, Petersen HV. Stuck in tradition. A qualitative study on barriers for implementation of evidence-based nutritional care perceived by nursing staff. J Clin Nurs. 2017;27(3–4):705–14.

    28.        Porter J, Raja R, Cant R, Aroni R. Exploring issues influencing the use of the Malnutrition Universal Screening Tool by nurses in two Australian hospitals. J Hum Nutr Diet. 2009;22(3):203–9.

    29.        Fischer F, Lange K, Klose K, Greiner W, Kraemer A. Barriers and strategies in guideline implementation. A scoping review. Healthcare (Basel). 2016;4(3):36.

    30.        Kondrup J, Allison SP, Elia M, Vellas B, Plauth M. ESPEN guidelines for nutrition screening 2002. Clin Nutr. 2003;22(4):415–21.

    Many medical records lacked information about nutritional risk, and few patients at nutritional risk were followed up.

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    English
    Sammendrag

    Background: With few exceptions, all adult patients admitted to somatic departments must be screened for nutritional risk. Nutritional risk is associated with a reduced nutritional status resulting from increased nutritional needs, as well as from reduced nutritional intake or uptake, due to illness or treatment. Patients at nutritional risk should receive individual interventions to prevent or treat malnutrition, and these interventions should be documented in the patient’s medical record.

    Objective: The objective of this study was to assess whether the nutritional care provided at Haukeland University Hospital complied with the recommendations in the national guidelines on prevention and treatment of malnutrition.

    Method: We performed a retrospective survey of nutritional data from medical records.

    Results: We reviewed 714 medical records from eight somatic departments. Screening of the patient’s nutritional risk was documented in 107 medical records (15%). Altogether 64 patients were assessed within 24 hours of admission, and 26 patients were identified to be at nutritional risk. A nutrition plan was recorded for 18 of the patients, and energy needs were calculated and energy intake was documented for two of these patients. Twenty-six discharge summaries included malnutrition diagnostic codes, but they did not correspond to the documentation of nutritional risk.

    Conclusion: Documentation of nutritional care in the medical records at Haukeland University Hospital was inadequate and did not comply with national guidelines. A national initiative under the Norwegian Patient Safety Programme provides a unique opportunity to improve nutritional practice at the hospital.

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  • Almost half of patients experience full remission after treatment at a psychiatric clinic

    The white paper concerning the Escalation Plan for Mental Health (1) led to a large increase in personnel and financial resources at the district psychiatric centres. According to the guide for district psychiatric centres (2), the centres are responsible for performing specialised evaluations and providing outpatient, inpatient, ambulant and day-care treatment.

    Furthermore, the health services provided at the district psychiatric centres must be safe and effective, and include systems for evaluation and quality assurance. The guide for the centres states that this development and resource allocation should be reflected in the research activity at the centres.

    The Norwegian Directorate of Health’s report on district psychiatric services from 2015 (3) states the following: ‘Adjusted for population growth, outpatient activity increased by 167 per cent during the period 1998–2015. The entire growth stems from the district psychiatric centres. The share of consultations at the centres has thus increased from 53 to 86 per cent of all consultations.’

    Central health authorities have not calculated basic preferred figures for staffing at district psychiatric centres, but they stress the importance of an interdisciplinary group of personnel in which the representation of specialists is strong enough to maintain a well-functioning specialist health service (2). On a national basis, graduates with additional qualifications make up 28 per cent of the clinicians employed at the district psychiatric clinics (3).

    Other research in the field

    In a societal and health-economics perspective, it is important to obtain information on the effects of outpatient treatment provided at the district psychiatric centres. It is important to secure systematic knowledge of the changes that patients experience over time, which patients experience change, as well as to map the factors that influence these changes, including the profession of the therapists.

    In a literature search in PubMed and CINAHL, we did not find any relevant Norwegian studies from the district psychiatric centres relating to these factors. International research on mental health care concerns the understanding of the nurse’s role in general terms (4), mainly described in the context of the primary health service (5, 6).

    In connection with outpatient specialist health services, literature was found on the nurses’ function in defined roles, such as stimulating physical activity (7), and their coordinating role in improving psychiatric patients’ access to general practitioners and psychiatrists (8), or to ensure continuity between different treatment levels (9). Some studies compare psychiatric nurses and psychiatrists, but only in a limited clinical context, such as a risk assessment (10, 11).

    We did not find any international research describing patients’ perceptions of their degree of improvement or reductions in symptoms where nurses work on a more independent basis in the specialist health service with both evaluations and treatment, as is the case in the district psychiatric centres in Norway. This finding is in line with a report by the Norwegian Directorate of Health (12), which describes the international literature on the subject as follows:

    ‘Such consultation-based services are organised in different ways in different countries, and the type of healthcare personnel involved can vary, including psychiatric nurses, psychologists, psychiatrists or other authorised healthcare personnel. The comparative data on access and use of consultation-based services is limited.’

    Objective of the study

    The objective of our naturalistic pilot study was to investigate the extent to which patients experienced full remission after treatment at a general psychiatric clinic. We also wanted to map the factors that affected such remission, including the significance of the therapist’s profession.

    The research questions in the study were as follows:

    Are there significant changes in the symptom severity and the incidence of psychiatric diagnoses in patients treated at district psychiatric centres in Norway when they are followed up six years later on average? If so, what characterises those patients who improve, and is the profession of the therapist significant?

    Method

    The study included patients treated at Elverum-Hamar district psychiatric centre, a general psychiatric clinic. The baseline survey covered 156 patients who were evaluated and treated between 1 February 2009 and 15 May 2010. Exclusion criteria in the baseline survey were age below 20 years, clinically perceptible cognitive reduction, psychosis, severe risk of suicide, severe somatic illness or linguistic problems. Patients who abused alcohol or other substances were treated at a different unit in the district psychiatric centres.

    In the baseline survey, the therapists asked patients who met the criteria if they were willing to take part. Since the original study had aimed at obtaining a sample in which 50 per cent of participants had a personality disorder, we did not ask all patients. However, it has been documented that the incidence of personality disorders upon referral to the specialist health service is about 50 per cent (13). Additional information about the inclusion process is described in a separate article (14).

    In the follow-up survey, we received responses from 65 of the patients (42 per cent). One patient had died and 13 had an unknown address (the correspondence was returned). Thus, 142 patients received a written invitation to participate in the period 22 April 2015–30 March 2016. One reminder was sent, and responses were received from 97 of those invited (68 per cent), of whom 26 (18 per cent) did not want to take part and 4 (3 per cent) did not meet at the agreed time. A total of 67 (47 per cent) therefore participated (Figure 1).

    Figure 1. Flowchart for study sample

    Of the 67 participants, 59 (88 per cent) attended the interview and submitted a satisfactorily completed questionnaire. Six patients only returned a completed questionnaire, and two only attended an interview. Our analyses are based on the 65 patients who responded to the symptom instrument (SCL-90-R, see the section below), and on the 59 patients who took part in a diagnostic interview both as part of the baseline survey and the follow-up.

    Demographics

    Demographic data was dichotomised as follows: marital status in ‘married/cohabiting’ and ‘single’, education in ‘12 years of education or less (low)’ and ‘more than 12 years of education (high)’, employment situation in ‘paid employment’ and ‘non-paid employment’.

    Full-time and part-time employees and self-employed patients represented the first group, while the unemployed, those on sick leave, benefit recipients and work assessment allowance claimants belonged to the other. Self-reported health related to the question ‘How is your health at the moment?’, with four response options (‘Poor’, ‘Not so good’, ‘Good’ or ‘Very good’), dichotomised as ‘Good health’ and ‘Poor health’, with two alternatives in each category (15).

    Checklist for symptom severity 

    The Symptom Checklist 90 Revised (SCL-90-R) (16, 17) is an instrument for measuring patients’ psychiatric symptom severity in the last week. SCL-90-R consists of 90 questions scored on a five-point scale (0–4) from ‘Not at all’ to ‘Extremely’.

    The Global Severity Index (GSI) measures the general psychopathology in SCL-90-R, and is calculated by adding the scores of the nine sub-scales and dividing this number by the total number of questions. All 65 patients provided complete SCL-90-R responses at both measurement times.

    Interviews

    The Mini International Neuropsychiatric Interview (MINI) is a structured interview for axis I diagnoses in the DSM-IV classification. The Norwegian 5.0.0 version from 2007 was used at both measurement times (18).

    In the baseline survey, the therapists conducted the MINI interviews, and the distribution of their main diagnoses was 71 per cent for affective disorders, 24 per cent for anxiety disorders and 5 per cent for other disorders. During the follow-up, the first author conducted the MINI interviews.

    The SCID-II interview was used to map personality disorders. The interview covers ten specified personality disorders plus the category ‘personality disorder not otherwise specified’ (19). We used the official Norwegian version of SCID-II, which was last revised in 2004.

    The therapists conducted the interviews in the baseline survey, where everyone had already participated in a two-day SCID-II course held by the Norwegian National Advisory Unit on Personality Psychiatry. The therapists found that 41 per cent of the patients had one or more personality disorders. The first author conducted the SCID-II interviews in the follow-up.

    The use of psychopharmaceuticals (antipsychotics, antidepressants, anxiolytics) was only registered at the follow-up interviews.

    Therapists

    The profession of the therapists was divided into nurses with further education in psychiatry and a continuing education qualification in therapeutics (cognitive/group analytical therapy) in one group, and psychiatrists, speciality registrars, consultant clinical psychologists and psychologists in the other.

    From the electronic journal, we recorded the sum of all treatment contact, i.e. conversations and telephone calls, and further treatment series in addition to the index treatment patients received at Innlandet Hospital’s Psychiatric Health Services Division from the start of the baseline survey up to the follow-up survey.

    The contact included individual outpatient conversations, group conversations and conversations with therapists as part of inpatient treatment, as well as telephone consultations of at least 15 minutes. Contact with patients by letter or e-mail was not included.

    The baseline and follow-up surveys were recommended by the Regional Committee for Medical and Health Research Ethics, South-East Norway (reference number 2014/95). All patients provided written informed consent prior to participation.

    Analyses

    We analysed continuous variables using t-tests, and Wilcoxon signed-rank tests were used for skewed distribution, as indicated by an asterisk (*) in the tables. We used Fisher’s exact test to analyse categorical variables. Change over time for continuous variables was analysed using a paired t-test. We measured the effect size of the changes in the GSI score using Cohen’s d method (20).

    Clinically significant improvement was set to a reduction of ≥0.34 on the GSI score from the baseline to the follow-up survey since that value corresponded to a standard deviation (SD) of 0.5 of the mean score in the GSI at the baseline survey (21, 22). Statistical significance was set to p<0.05, and all tests were two-tailed. All analyses were conducted with SPSS version 23 (IBM, Armonk, NY).

    Results

    We conducted a drop-out analysis that compared the profession of the therapists, the patients’ demographic data and psychopathology in the baseline survey between the 65 patients who participated in the follow-up survey and the 91 who did not.

    The analysis showed only one significant difference – those who did not participate were significantly older: 39.4 years (SD = 11.5) compared to 35.4 years (SD = 11.9). There was no significant difference in the response rate between patients who had seen a specialist nurse and those who had been treated by a doctor/psychologist.

    The average time span between the baseline survey and the follow-up survey was 6.1 years (SD = 0.4). The 65 patients who participated had a mean age of 45.5 years (SD = 11.4) in the follow-up survey. Sixty per cent were married or cohabiting, 52 per cent had a higher education, and 45 per cent were in paid employment. None of these percentages had changed significantly from the baseline survey (Table 1).

    Table 1. Description of the sample (n = 65) in baseline and follow-up surveys

    The percentage who reported good health had increased from 29 per cent to 48 per cent, which was almost significant (p = 0.05). The median treatment contact in this time period was 53, with a spread of 4 to 328.

    Twenty-seven out of 59 patients (46 per cent) did not have a psychiatric diagnosis in the follow-up survey. These cases particularly concerned a reduction in the incidence of affective disorders (71 per cent at baseline and 29 per cent in the follow-up, p<0.001). The changes were not significant for the other two diagnostic groups. The reduction of patients with comorbid axis I + personality disorders was almost significant (p = 0.05) (Table 1).

    The GSI showed a significant improvement in the mean scores in the follow-up compared with the baseline survey, and the effect size was 0.43 measured as Cohen’s d.

    The criteria for a clinically significant improvement in the GSI was met by 28 patients (43 per cent). The mean age of these patients was higher than the group of patients who did not show a significant improvement (p = 0.03, effect size 0.54), but otherwise we found no significant differences between the groups in the baseline survey in terms of socio-demographic data, health or diagnostic occurrence (Table 2).

    Table 2. Comparison of patients with and without clinical improvements in the six-year follow-up

    There was no significant difference in the median number of recorded treatment conversations between those who showed a clinical improvement (53, with a 7–184 spread) and those who did not (56, with a 4–328 spread).

    The share that had received two or three treatment series was 19 per cent among those who showed an improvement, and 37 per cent among those who did not show any improvement (p = 0.11). The share using psychopharmaceuticals at the follow-up was 14 per cent among those who showed an improvement, and 32 per cent among those who did not (p = 0.07).

    There were no significant differences in improvement between patients treated by specialist nurses and those treated by psychologists/psychiatrists (Table 3).

    Table 3. Description of patient sample (n = 65) at the follow-up survey based on the profession of the therapist

    Discussion

    In the follow-up, 28 patients (43 per cent) showed a clinically significant remission and 27 out of 59 patients (46 per cent) no longer had any mental disorder. This was particularly due to an improvement in affective disorders.

    Apart from a higher mean age, we found no significant differences between the patients who showed a clinical improvement and those who did not show any improvement. There were no significant differences in remission between patients treated by psychiatric nurses and those treated by psychologists/psychiatrists.

    Therapeutic efforts and treatment contact

    Viewed in the context of the median treatment contact of 53, it is reasonable to describe the share of 43 per cent with a full remission as modest. Finding research-based comparison data for such a heterogeneous patient group has, however, proven to be difficult. We consider 53 instances of treatment contact to be high. By comparison, cognitive therapies of 10–15 hours and dynamic short-term psychotherapy of 12–20 hours are often recommended for axis I disorders, such as anxiety and depression.

    We consider 53 instances of treatment contact to be high.

    However, the clinical reality in the specialist health service often entails patients with complex disorders, and it has therefore been necessary in countries such as Denmark to extend the dimensions of care pathways for psychiatric disorders, which originally indicated 15 and 18 hours respectively for these disorders.

    In the Norwegian Directorate of Health’s consultation paper (23) on care pathways for treatment in mental health services, no specific number of hours has been given. Although the symptom level was not checked at the start of the treatment, it is interesting to note that the incidence of treatment contact overlaps between the group that showed an improvement and the one that did not.

    This finding can be interpreted in several ways that can be of major importance to the treatment at district psychiatric centres, if we dare to generalise. One interpretation is that much of the treatment contact is of a general nature, and does not entail evaluations being done of whether the patient is actually improving along the way. Another point of view is that evaluations are done, but that the therapists choose to continue with patients who, realistically, have little potential for change or who are not particularly motivated.

    A third interpretation is that finalising treatment with a patient and taking on new patients requires a lot of work and documentation. This requirement may lead to therapists retaining patients out of convenience, whereby the contact increases without any well-founded professional basis.

    Associated factors for improvement

    Symptom improvement is not significantly associated with being employed or having good self-reported health, but this finding may correlate to possible type II errors. Of the 65 patients who participated, the share in paid work and with self-reported good health increased by 10 and 19 percentage points respectively (Table 1).

    Our findings imply that both the socio-economic and personal gain over time is moderate, while other factors that were not mapped in the study may also play a role. For example, a reduced incidence of affective disorders at the follow-up may be due to spontaneous remission (24). Another example is the use of antidepressants. Unfortunately, we do not have data on how many patients were taking antidepressants at the time of referral or were prescribed them during the course of the baseline survey.

    Our therapists are well acquainted with the national guidelines for treating anxiety disorders and affective disorders. However, we have not specifically mapped the extent to which the guidelines were followed. The Norwegian Directorate of Health assumes that the treatment given in the psychiatric specialist health service complies with these guidelines.

    Since the treatment outcome in the study is moderate in relation to the extent of treatment given, we believe that treatment guideline compliance would be a useful area of research in new studies of treatment outcomes at district psychiatric centres.

    Profession

    The therapists at district psychiatric centres have different occupations and professional experience, and their theoretical fields of interest and level of further education also differ. By virtue of their expertise, psychiatric nurses with a continuing education qualification in therapeutics have attained a high level of independence as therapists.

    An interesting question is whether specialist nurses achieve treatment outcomes that do not differ materially from those achieved by psychiatrists and psychologists. A profession-based analysis showed no significant differences in the treatment outcome. Nor did ‘sicker’ patients with higher GSI scores in the baseline survey show a skewed distribution between the two groups of professions. The finding supports the claim that specialist nurses have an equal value as therapists in interdisciplinary collaborations vis-à-vis patients referred to general psychiatric clinics at the district psychiatric centres.

    A profession-based analysis showed no significant differences in the treatment outcome.

    Patients whose therapist was a specialist nurse in the baseline survey may have been treated by a doctor or psychologist in subsequent treatment series, and vice versa. Due to the throughput of therapists, professions or therapists may also have changed during the baseline survey itself. We do not have data on such changes, but our impression is that they did not occur often enough to affect the result.

    Several professions with three-year undergraduate programmes today offer the opportunity to study for a master’s degree in mental health work. The Norwegian Nurses Organisation’s professional interest group for nurses within mental health and substance abuse is working to introduce a master’s degree based on a purely nursing specialisation (25), while others believe that nurses need a master’s degree in psychiatric treatment (26).

    We believe that our findings may be of significance to the ongoing discussion concerning professions and staffing policy at district psychiatric centres. There is no doubt a difference between the professions in terms of pay, however this study found that the profession of the therapist had no impact on the patients’ degree of improvement.

    Earlier studies

    We did not find any research on specialist nurses’ results with conversational therapy at a specialist level, but the nurse’s role and function in municipal health and substance abuse work is well documented in a report (27). The report shows that the majority of nurses working in mental health and substance abuse have further education and more than five years of clinical experience. It also shows that those who work in a clinical setting have the highest levels of education, but does not mention treatment outcomes.

    The Norwegian Directorate of Health’s report (12) states that there is little international research that satisfactorily compares the outcomes achieved between the various professions employed in psychiatric clinics in the specialist health service.         

    Strengths and limitations of the study

    In principle, we believe that our patient dataset on affective disorders (mostly depression), anxiety disorders and comorbid personality disorders is fairly representative of what is generally treated at general psychiatric clinics at district psychiatric centres in Norway with a similar organisation. The drop-out analysis showed minimal differences in the baseline survey between those who participated in the follow-up survey and those who did not, which reinforces the representativeness of the material.

    In the follow-up, 17 per cent (n = 26) of invited patients declined to participate, and this may be due to the experiences with the district psychiatric centres, the treatment outcome or a need to put this particular period of their life behind them. This may also be the case for the 45 patients (29 per cent) who did not respond.

    It is difficult to know whether the 46 per cent who did not take part in the follow-up would have had a positive or negative effect on the share who experienced full remission. There was no significant difference in the response rate between patients who saw a specialist nurse and those who were treated by a doctor/psychologist.

    Based on our experience, almost half of former outpatients at district psychiatric centres will participate in a follow-up survey six years after starting treatment. This finding may be of importance when planning new follow-up studies at general psychiatric clinics at district psychiatric centres.

    We believe that the participation rate may increase if patients are referred by their previous therapists rather than a senior consultant that the patient is not familiar with, or if the patients are given an incentive to participate. The fact that the follow-up was conducted after six years is a strength in that it enables patients to take a retrospective view of the treatment and weigh up its importance in relation to other life events.

    The drop-out rate in the study and lack of information on the extent to which the therapies were terminated by agreement represent a weakness in our findings, with a probable selection bias towards patients who were either satisfied with the treatment and/or were satisfied with their current life situation. The drop-out rate also means that the groups we examined were small and had an increased risk of statistical type II errors. This means that several differences could have been significant if our group had been larger, which in itself is a weakness of the study.

    A third weakness is the lack of consideration that our design gave to possible intermediate variables in the six-year follow-up period. Intermediate variables can include negative life events during the follow-up period, such as the death of a close relative, the breakdown of a relationship or unemployment. Over a six-year period, we must also consider that spontaneous remission may occur. Despite these weaknesses, we cannot preclude treatment as an explanatory factor for the registered improvement.

    The final weakness relates to the diagnostics being carried out by several therapists in the baseline survey, but only the first author in the follow-up, despite the same diagnostic tools being used in both surveys. We therefore decided to change the self-reported symptom severity (GSI) as our primary outcome measurement.

    Implications of the study

    A few years ago, one of Norway’s leading psychiatrists, Trond F. Aarre (28), wrote that psychiatry should not require more resources, but should rather assess the way in which the employees work. Our findings seem to support Aarre’s conclusion. It is positive that resources are added, but it is worrying that, despite the requirement in the regulations, little research is done on the impact of the treatment at the district psychiatric centres on patients’ function and symptom level.

    Central health authorities and regional health authorities should therefore jointly map possible obstacles and initiate measures to stimulate treatment research at the district psychiatric centres. The production requirement at the centres is high, and planning and conducting research that increases the workload of the therapists is a challenge.

    Conclusion

    Central health authorities require mental health care to be beneficial and cost effective. Our study shows that despite a high instance of treatment contact at district psychiatric centres, only a moderate share of patients experience full remission. The profession of the therapist appears to have no bearing on this finding.

    Our results indicate that there is a need to review patient selection and working methods at the general psychiatric clinics at district psychiatric centres. There is also a need to investigate whether patient selection and working methods are in line with current national guidelines for the most common diagnoses.

    Thanks go to specialist nurse Hildur Rosenlund Engen, who assisted with the data collection and proofread the manuscript.

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    Whether the therapist at the district psychiatric centre was a psychologist, psychiatrist or psychiatric nurse seemed to have little bearing on the outcome.

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    Sammendrag

    Background: The share of consultations at district psychiatric centres is increasing. In a health-economics perspective, it is important to describe the effects of the outpatient treatment provided at such centres.

    Objective: The aim of the study was to map changes in symptom severity and the incidence of mental disorders in patients following treatment at a district psychiatric centre. We also wanted to assess whether the therapist’s profession had an impact on these variables.

    Method: At Elverum-Hamar district psychiatric centre, we mapped 156 patients before therapy, and 65 patients (42 per cent) participated in a follow-up six years later. Participants reported their own symptom severity and took part in diagnostic interviews before therapy and as part of the follow-up. In separate analyses, treatment outcomes were compared for patients of psychiatric nurses (n = 31) and psychologists/psychiatrists (n = 34).

    Results: In the follow-up, 28 out of 65 patients (43 per cent) showed a clinically significant improvement, and 27 of the 59 patients (46 per cent) who were interviewed no longer exhibited a mental disorder. These results were due to a particular improvement in affective disorders. The median number of consultations during the time period was 53 (with a 4–328 spread). There was no significant difference between patients treated by psychiatric nurses and psychologists/psychiatrists. Apart from a higher mean age, we found no significant difference between the patients who showed a clinical improvement and those who did not show any improvement.

    Conclusion: Despite numerous consultations at district psychiatric centres, only a moderate share of the patients experienced a significant reduction in symptoms. The profession of the therapists does not seem to impact the effects in the long term.

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