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  • Healthcare personnel’s recognition of people with hydrocephalus affects their self-esteem

    Hydrocephalus is an illness characterised by abnormal circulation of the cerebrospinal fluid. The illness may be congenital or it may develop secondarily as a result of other conditions (1). The most common treatment is surgical implantation of a shunt that diverts the flow of cerebrospinal fluid from the brain to the abdominal cavity (1). 

    Many patients live their lives without limitations despite having been treated for hydrocephalus. In some patients, it may be difficult to achieve optimal drainage, and for them hydrocephalus means living with an invisible, chronic illness. Headaches, fatigue and cognitive impairments are common (1–3). There is always a risk that the shunt will fail, which can be life-threatening in some cases (1).

    For many people, living with hydrocephalus entails lifelong follow-up by the health services (4). Some patients require numerous operations. In addition to surgical treatment, many need follow-up nursing care to help them live with the illness. In spite of this, the patient perspective in the treatment of hydrocephalus appears to be under-researched.

    Norway does not have a national registry for hydrocephalus, and it is unknown how many people live with the diagnosis. In Norway, approximately 2200 hydrocephalus-related operations are performed each year across five neurosurgical departments (5). In addition, healthcare personnel in neurosurgical departments and in the primary health services encounter this patient group both pre- and post-operatively. Thus, the number of healthcare workers who deal with this patient group is quite large.

    Recognition of people with the diagnosis

    In the experience of the first and second authors, the diagnosis of hydrocephalus is not well known outside of the specialised hospital departments. Research indicates that adults with hydrocephalus do not always receive the follow-up they need, probably because the health services have not given the illness sufficient attention (4). Studies show that recognition of patients and their illness may be significant for how they perceive their own situation (6–10).

    Recognition was first postulated as a philosophical concept by Hegel. The Norwegian psychologist Schibbye writes about Hegel’s philosophy using practical, clinically oriented language (11). Experiences related to recognition may have profound importance because we as human beings need to be recognised in order to maintain our identity and self-esteem (12). The German philosopher Honneth also uses Hegel as his point of departure when he writes that disrespect is the opposite of recognition (12). Disrespect destroys identity and self-esteem (12).

    Recognition is one of the main principles of empowerment, as this term is understood in a health-promoting perspective (13, 14). Empowerment at individual level may be described as a process in which individuals gain greater control over their own lives and health (13–15). Helping patients to gain control is a crucial part of the professional practice of healthcare workers (14).

    Objective of the study

    The objective of this study is to investigate and describe the significance of experiences related to recognition for people with hydrocephalus.

    Although hydrocephalus can be compared to other chronic illnesses, it is different because it can become life-threatening at a moment’s notice. Improper treatment can cause irreparable harm. The patient’s subjective symptoms are important for assessing whether or not the patient requires emergency medical treatment (1). This, along with lack of attention to the illness, is the reason why we chose to study the significance of recognition for people with hydrocephalus.

    Method

    Design

    This is a descriptive, explorative study that employs a qualitative methodology. We used hermeneutical principles to analyse and interpret the data. This perspective was chosen because it accentuates the contextual basis of people’s interpretations and understandings (16). The informants as well as two of the authors had a connection to the topic under study, and it was therefore appropriate to take such a perspective. We recorded our preconceptions in writing before the study commenced so that we would be aware of them during the research process.

    The first and second authors conducted the study in cooperation with the third and fourth authors, who served as supervisors.

    Data collection

    We chose individual interviews and a focus group discussion as our method of data collection. By conducting individual interviews, we could investigate the informants’ thoughts and experiences, and through a focus group discussion we could explore the range of viewpoints. Interaction in focus groups generates different data than individual interviews (17).

    The sample was appropriate, meaning that the respondents had the competence to answer. The informants were recruited through the Norwegian Association for Spina Bifida and Hydrocephalus. The inclusion criteria were as follows: a member of the association, has hydrocephalus, over 18 years old, and speaks Norwegian. Those with spina bifida were excluded. The association’s general manager sent out invitations to all relevant members, and the members who wished to participate contacted us.

    We conducted 13 individual interviews divided between the first and second authors, and one focus group discussion in which the first and second authors were present. We collected the data in the autumn of 2014. Five of the individual interviews were held at the Oslo and Akershus University College (HiOA), now OsloMet – Oslo Metropolitan University, two at a different public location, one at the home of the informant and five on the telephone.

    We held the focus group discussion at HiOA after the individual interviews were completed. Four of the 13 informants were present. The interview guides were semi-structured and contained questions about the informants’ thoughts and experiences related to recognition when interacting with healthcare personnel (Table 1). We made an audio recording which was saved on a password-protected computer. The first and second authors transcribed the interviews. The individual interviews ran from 22 to 80 minutes, and the focus group discussion lasted 74 minutes.

    The group of informants consisted of 8 women and 5 men from 23 to 43 years old, with an average age of 35. Seven of them had congenital hydrocephalus and 6 had secondary hydrocephalus. The informants stated that they had been admitted to hospital 3 to 50 times, which is an average of 17 hospital admissions. The patient group is relatively small on a national basis. To ensure the anonymity of the informants, we do not provide any further demographic data.

    Table 1. Interview guide

    The transcribed material was analysed using qualitative content analysis inspired by Kvale and Brinkmann (17). Qualitative content analysis entails an analysis of the content and meaning of texts in the context in which they appear (17). First, we read the transcriptions of the individual interviews to form an overall impression. Then we identified meaningful words and sentences. Meaningful units were condensed into sub-categories, and the sub-categories were abstracted to main categories.

    The analysis revealed 15 sub-categories, which we abstracted to four main categories. The analysis of the focus group discussion uncovered no new information that had not already come to light in the individual interviews. The focus group discussion was used to validate the individual interviews. Hermeneutical principles of interpretation emphasise a continual process of shifting back and forth between the parts and the whole and between preconceptions and new understanding (17). As a result, the phases of the analytical process were not linear.

    Ethical considerations

    We conducted the study in accordance with the ethical guidelines set out for nursing research in the Nordic countries (18). The study was not encompassed by Section 2 of the Norwegian Health Research Act (19), and could be conducted without the approval of the Regional Committees for Medical and Health Research Ethics (REK). The study was approved by the Norwegian Centre for Research Data (reference no. 38995/3/AMS).

    The informants received verbal and written information about the study’s content and objective. They were guaranteed anonymity, informed that their participation was voluntary, and that they were free to withdraw whenever they wished. All of them signed informed consent forms in which they were asked to take part in an individual interview and a focus group discussion.

    The study’s first and second authors are nurses in a neurosurgical department. Five of the informants had met the authors before. We reflected on ethical dilemmas that could arise as the result of our dual role, which could cause informants to withhold information or provide more information than they wished to (17). This dual role required particular sensitivity, and is discussed in the section on the study’s limitations.

    Results

    The main categories and sub-categories are presented in Table 2. The first two main categories deal with the informants’ thought and experiences related to recognition. The final two address the significance of their experiences. We present the results in four paragraphs which are summarised with the associated main categories. The sub-categories are presented throughout and are exemplified with quoted material.

    Table 2. Main categories

    Recognition – to be believed and acknowledged as a person

    For the informants, recognition meant that their experiences were regarded as credible and valid. One patient stated the following: ‘The most important thing is to be believed; it’s more important than water’. They used words such as listening, understanding, acceptance and acknowledgement to describe recognition. Recognition also meant that their relationship with the healthcare personnel was equitable and friendly. Several used the word ‘compassionate’ about healthcare workers who gave them recognition.

    The most important thing is to be believed; it’s more important than water.
    Informant

    Care, time and involvement were significant for whether or not the patients felt recognised. One described recognition when interacting with nurses like this: ‘The ones who take the time to listen to you when you’re feeling down, even if it’s just two minutes, to have a chat and be acknowledged’.

    Lack of recognition – to be mistrusted and ignored

    A lack of recognition meant that their experiences were regarded as questionable or invalid. Several patients talked about situations in which healthcare personnel doubted their experiences, e.g. by making statements such as: ‘Are you sure you have a headache?’.

    Many patients felt that clinical findings were taken more seriously than their subjective experience. Several of them talked about similar experiences: ‘They believed me after an intracranial pressure measurement. Then I had proof for what I had been saying all along.’ Another said the following: ‘I wish I could have said: “You know what? It was no joke! Why didn’t you listen to me?”’.

    According to the informants, one reason they were not taken seriously was that their symptoms are invisible. Some emphasised that the competence level of the healthcare personnel was significant for whether they were taken seriously. A lack of recognition also entailed feelings of inferiority in their relationship with healthcare workers and that the healthcare personnel distanced themselves from them. Several had experienced condescending attitudes. One felt that she was treated like a ‘pawn in a game’. Another said the following about her interactions with healthcare workers: ‘I could have been a stone they kicked along the road’.

    The sub-categories suggest that recognition at its deepest level meant that the informants felt they were believed and acknowledged as a person, while a lack of recognition implied being mistrusted and ignored.

    Recognition promotes mental and emotional balance

    Recognition appeared to enhance the informants’ resilience and sense of security. One said the following: ‘It’s been most important for how I think about myself.’ Another said this: ‘Your self-confidence gets a boost when you are believed.’ Recognition had a positive impact on the patients’ disposition and helped to increase optimism and peace of mind. Recognition could establish trust in the health services and create a sense of security about living with the illness.

    To finally be taken seriously has helped me to accept my situation and set realistic goals.
    Informant

    One informant said the following: ‘The road to the hospital doesn’t feel so long, and this means that I need it less, because I know I will be taken seriously when I contact them’. Another described a sense of security like this: ‘No one can live your life for you, but if you use the health services like crutches to help you hold your balance, it gives you a sense of security.’

    Recognition could also contribute to a sense of control because patients were spared the stress of fighting to be believed, while at the same time recognition increased their acceptance and understanding of their own situation. One informant said: ‘To finally be taken seriously has helped me to accept my situation and set realistic goals’.

    Lack of recognition contributes to mental and emotional imbalance

    In contrast, it appeared that a lack of recognition led to vulnerability and worry. One informant said: ‘Your self-confidence plummets when you are not believed’. Another noted that recognition or a lack of recognition from neurosurgeons had the greatest impact on their feelings about themselves: ‘What is said by those who know something about your challenges has a huge impact. You feel very insignificant.’

    Lack of recognition created a sense of powerlessness, dejectedness and frustration, and could erode patients’ confidence in the health services and increase their fear of being ill. Lack of recognition from healthcare personnel could also cause them to keep quiet about their own situation. One informant said: ‘It was difficult to say that I had problems that were not recognised or that did not exist except in my head’. Lack of recognition increased stress and a focus on the illness because the patients had to spend their time and energy on being believed.

    Some found it difficult to contact the health services and struggled with their challenges by themselves. Some were more focused on their symptoms and searched for explanations on their own. One tried alternative treatment. One got sterilised in the hope that oral contraceptives were causing her symptoms. Others began to look at their close relationships as a possible cause of their challenges.

    The sub-categories suggest that recognition promoted mental and emotional balance in the situations that the informants were in, while a lack of recognition contributed to mental and emotional imbalance.

    Discussion

    In this section, we discuss the significance of experiences related to recognition for the informants.

    Small gestures – major consequences

    The informants described recognition using words such as listening, understanding, acceptance and acknowledgement. These qualities are embodied in an attitude of recognition (11). The informants emphasised the importance of equity in relationships. Equity is regarded as a precondition for recognition in a relationship (11).

    Informants said that a lack of recognition entailed a feeling of inferiority and invalidation of their experiences by healthcare personnel. Such experiences can be degrading and are a form disrespect. Degradation can have a negative impact on people’s self-esteem and identity because they feel that they are stripped of their own worth (12).

    The results indicate that recognition strengthened the informants by enhancing their resilience, sense of security and feeling of control. On the other hand, a lack of recognition led to vulnerability, worry, stress and a focus on the illness. Studies confirm that recognition has an enhancing effect because of its positive impact on self-confidence and self-esteem, and because recognition initiates a process of acceptance and self-understanding (6–10). In contrast, a lack of recognition can weaken self-confidence and self-esteem as well as increase isolation and loneliness (6–10).

    Perhaps recognition in encounters with healthcare personnel is particularly significant for people with hydrocephalus because the symptoms are invisible and the illness is not well known. This can make it difficult for patients to elicit understanding from most people. Studies suggest that recognition in encounters with healthcare personnel is especially crucial for patients with subjective symptoms (6–10).

    Recognition can validate patients’ experiences and spare them from having to fight for their credibility (8, 9). Some people with hydrocephalus live in fear that their illness will become life-threatening without proper treatment. We can assume that this fear increases their need for recognition.

    The informants felt that clinical findings were viewed as more valid than their subjective experiences. It can be comforting that healthcare personnel do not diagnose or treat without objective documentation indicating that it is appropriate. By the same token, listening to the patient is essential for proper diagnosis and treatment (20). Perhaps it is especially important in this context because optimal diagnosis and treatment options are still being developed (21). We can assume that current medical equipment does not always provide adequate answers.

    Several patients tried to find reasons for their symptoms when they were not believed. 

    There may be a basis for asserting that recognition of health symptoms can lead to greater focus on the illness. However, this and other studies suggest the opposite (6, 7, 22). The results indicate that a lack of recognition resulted in greater focus on the illness. Several patients tried to find reasons for their symptoms when they were not believed. It is common for patients to interpret their symptoms themselves when there is no dialogue with healthcare personnel (23). On one hand, this can be viewed as the patient taking active steps to address his or her own situation. On the other hand, it can result in more health problems if the patient tries out risky treatment.

    We wonder if the informants interpreted a lack of recognition more negatively than the healthcare personnel were aware of. Small gestures, such as speaking encouraging words and listening to the patient, were highly significant for whether or not they felt recognised.

    In general, people with a chronic illness can be sensitive and interpret comments in a negative way because chronic illness in itself can be detrimental to one’s self-confidence (24). The fact that we raise this question, however, should not be used to fail to hold healthcare personnel accountable, but rather to remind them of how important even the smallest of gestures may be to the patient.

    On the path to empowerment

    One way to understand the results is that recognition helped to put the informants on the path to empowerment because recognition gave them a sense of control. Studies indicate that recognition in encounters with healthcare personnel can lead to an empowerment process in the patient (8, 10, 25).

    In contrast, the results can be interpreted to mean that a lack of recognition led to powerlessness. When the informants were not acknowledged or believed, they felt powerless to take constructive action to address their situation. Powerlessness is regarded as the opposite of empowerment (26). Studies confirm that there is a correlation between a lack of recognition and a sense of powerlessness (6, 7, 10).

    The results suggest that recognition helped the informants to think differently about their own situation. Schibbye (11) confirms that recognition promotes self-reflection and heightened awareness. In their study, Aujoulat et al. assert that an expression of control is only a valid indicator of an empowerment process if the person also expresses some type of change in his or her values and priorities around living with a chronic illness (27).

    Feeling recognised can bring about change in a person’s values and priorities through self-reflection, and can therefore be linked to a person’s empowerment process (27).

    Significance for practice

    A hectic workday can make it difficult for healthcare workers to keep recognition in mind. However, the results indicate that even small gestures are meaningful. Even during busy moments it should be possible to have an attitude of recognition when interacting with patients. Perhaps the attitudes and skills of healthcare personnel constitute a greater threat to recognition than a lack of time. Studies confirm that the ability of healthcare personnel to instigate dialogue, show empathy and engage in ethical reflection can be significant for whether they take the patient seriously (28, 29).

    Even during busy moments it should be possible to have an attitude of recognition when interacting with patients.

    The results suggest that if patients feel more secure, they may seek out health services less frequently. As one informant said, the knowledge that one is taken seriously can provide a sense of security about living with the illness. It is conceivable that healthcare personnel can contribute to making savings in the health sector if their awareness is raised about interacting with this patient group with an attitude of recognition.

    Strengths and limitations of the study

    The authors’ dual role may have affected the study’s reliability. We attempted to use our background knowledge for the benefit of the informants and the data. We spoke with the informants about our dual role, were sensitive to how the interview impacted them emotionally and made adaptations based on their physical condition.

    When we interviewed the patients who had met us before, we emphasised that their comments would be anonymous and would not have an impact on the follow-up they received in the department so that, for example, they would not be afraid to express negative views.

    As a result of our dual role, we may have overlooked interesting perspectives in the analysis and interpretation. At the same time, this may have helped us to identify perspectives that others would not have noticed. We have strived for reliability in the study by being as transparent as possible in our account of the research process (17). The results correspond with similar studies, which may indicate that our study has transfer value to other patient groups.

    The focus group discussion did not generate new information. The reason may be the composition of the group, the researchers’ ability to lead the group or that people with hydrocephalus can have cognitive impairments that make it difficult for them to concentrate in a group (2, 17). However, the content of the focus group discussion corresponded with the individual interviews. It is unknown whether we would have obtained more information by holding another focus group discussion.

    The fact that several researchers analysed the data bolsters the study’s reliability. Reliability could have been strengthened even further if the informants had validated the results and interpretations. The relevance of the study could have been greater if people with hydrocephalus had participated in the research process, as recommended by the Ministry of Health and Care Services (30).

    Conclusion

    Being recognised can be significant for how people with hydrocephalus perceive themselves and their own situation. The results indicate that recognition can lead to empowerment, while a lack of recognition can contribute to powerlessness.

    Recognition from healthcare personnel may be especially crucial because the illness is invisible, not well known and potentially life threatening. To avoid negative ripple effects, healthcare personnel must have an attitude of recognition when interacting with this patient group. More research on the patient perspective in the treatment of people with hydrocephalus is needed.

    References

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    2. Paulsen H, Lundar T, Lindegaard KF. Twenty-year outcome in young adults with childhood hydrocephalus: assessment of surgical outcome, work participation, and health-related quality of life. J Neurourg Pediatrics. 2010;6(6):527–35.

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    21. Williams MA, McAllister JP, Walker ML, Kranz DA, Bergsneider M, Del Bigio MR et al. Priorities for hydrocephalus research: report from a National Institutes of Health-sponsored workshop. J Neurosurg. 2007;107(5):345–57.

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    25. Tveiten S, Knutsen IR. Empowering dialogues – the patients’ perspective. Scand J Caring Sci. 2011;25(2):333–40.

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    27. Aujoulat I, Marcolongo R, Bonadiman L, Deccache A. Reconsidering patient empowerment in chronic illness: A critique of models of self-efficacy and bodily control. Soc Sci Med. 2008;66(5):1228–39.

    28. Rundquist E, Lindström UÅ. Empowerment and authorization – who provides and who receives? A qualitative meta-study of empowerment in nursing research: a caring science perspective. International Journal for Human Caring. 2005;9(4):24–32.

    29. Pedersen R, Hofmann B, Mangset M. Pasientautonomi og informert samtykke i klinisk arbeid. Tidsskr Nor Lægeforen. 2007;127(12):1644–7.

    30. Helse- og omsorgsdepartementet. HelseOmsorg21. Et kunnskapssystem for bedre folkehelse. Nasjonal forsknings- og innovasjonsstrategi for helse og omsorg. 2014. Available at: https://www.regjeringen.no/contentassets/8ab2fd5c4c7746dfb51e3f64cd4d71aa/helseomsorg21_strategi_web.pdf?id=2266705(downloaded 02.05.2015).

    While the illness is potentially life-threatening, it is invisible and not well known. Consequently, patients may be mistrusted and ignored, and they may feel inferior, vulnerable and insecure.

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    English
    Sammendrag

    Background: Hydrocephalus is a chronic illness that often requires lifelong follow-up by healthcare personnel. However, the illness is not well known, and the symptoms are often invisible. This may make it difficult for patients to be taken seriously when interacting with healthcare personnel. The patient perspective in the treatment of hydrocephalus appears to be under-researched.

    Objective: The objective of the study was to investigate and describe experiences related to recognition from healthcare personnel for people with hydrocephalus.

    Method: This is a descriptive, explorative study that employs a qualitative methodology. We conducted 13 individual interviews and one focus group discussion with adults with hydrocephalus. Hermeneutical principles were used generally in the analysis and interpretation. The analysis was inspired by qualitative content analysis.

    Results: The analysis revealed four main categories:

    to be believed and acknowledged

    to be mistrusted and ignored

    to promote mental and emotional balance

    to contribute to mental and emotional imbalance

    Conclusion: The experience of being recognised when interacting with healthcare personnel can be highly significant for how people with hydrocephalus perceive themselves and their situation. The results indicate that recognition can lead to empowerment, while a lack of recognition can contribute to powerlessness. Empowerment at individual level can be described as having a sense of control over one’s own life and health.

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  • Fathers want to play a more active role in pregnancy and maternity care and at the child health centre

    Pregnancy and maternity care and the child health centre have undergone considerable changes in recent years. Instead of solely focusing on providing help to mother and child, the services now try to include the whole family. The gender perspective, men’s needs and service user participation must be key factors in the design of the healthcare services, and guidance must be aimed at both parents (1–3).

    The father’s role is being expanded, and the development keeps pace with the changing role of men, both in the family and in society. The pattern of family formation and cohabitation is in a process of change, and today encompasses several different forms of cohabitation. The family concept is broadening, and often includes more people and different combinations than the traditional nuclear family. Modern paternity also comprises a paternal role that is independent of sexual orientation and ethnic background (4, 5).

    Changed family pattern

    The family pattern has shifted from the nuclear family to the symmetrical family. The family’s function has changed from that of a production unit, via the industrial society and household society to the family of today, characterised by equality, parity and reciprocity between the sexes.  

    Kindergarten policies, women’s growing participation in working life and the introduction of the paternal quota has meant that gender roles have changed and become more flexible. Men who start a family today must shape their own role as a father, and must achieve a balance between employment, childcare, housework and professional and leisure interests in line with women (4, 6, 7).

    Becoming a parent is a major transition in life and entails a number of changes for both sexes (8), including psychological changes, a shift in life focus, new roles and an altered relationship with one’s partner (9–11). The purpose of pregnancy, maternity and post-natal care and the child health centre is to help the parents master and feel secure in the parental role (2).

    Despite increasing involvement from fathers in caring for their own child, it is still mainly mothers who accompany their children for consultations at the child health centre (5, 12). Succeeding in making fathers more active and engaged will be best for the children and the family as well as being in line with national and political aims (2, 3).

    Objective of the study

    The objective of the study is to describe how first-time fathers experience their encounter with the healthcare services throughout pregnancy, childbirth and the child’s first three months of life.

    The article focuses on the following research question: How do first-time fathers experience the encounter with the healthcare services (pregnancy and maternity care, the maternity ward and the child health centre) during pregnancy, during the birth and in the child’s first three months of life?

    Method

    The study has a qualitative design using interviews as a data collection method.

    Sample

    The informants constitute a strategic sample (13). Public health nurses recruited informants at four child health centres in a medium-sized municipality in Southeast Norway. The public health nurses presented the study to the fathers on home visits or at the six-week check-up. Altogether, 73 fathers with a new-born infant who met the inclusion criteria during the project period were invited in turn to participate in the study.

    The inclusion criteria were as follows: they had to be first-time fathers and have a satisfactory command of Norwegian. The child’s age had to be around three months at the time of the interview.

    We contacted the informants in turn after they had agreed to participate. We obtained informed consent and set a date for the interviews. We discontinued recruitment when no new factors emerged, i.e. when we reached data saturation (13) after conducting nine interviews.

    The informants had a mean age of 30.7 years. They were all ethnic Norwegians with married or cohabiting civil status. Upper secondary school was the highest level of education for three of the fathers, while six had a university or university college education. On average, they had had a relationship with the child’s mother for five years prior to the birth. The child’s age was 15 weeks on average at the time of the interview.

    All the informants had participated in one or more consultations with a midwife or public health nurse. Three of the fathers had participated in all types of consultation, i.e. home visits, six-week and three-month check-ups at the child health centre. All the fathers had been present at the birth.

    Data collection and implementation

    The first author conducted the interviews, which were based on a semi-structured interview guide consisting of altogether six open-ended main questions with more detailed follow-up questions (Table 1). All the main questions were based on the research question (14).

    Table 1. Main questions in the interview guide

    During the interviews, the informants spoke freely about the main questions. Consequently, we used few of the follow-up questions. All interviews included aspects relating to all the main questions.

    We carried out a pilot interview to test the interview guide and to gain experience of using the interview method. This did not result in any changes to the guide. The main objective of the pilot interview was to test the interview guide, method and technique. Since the focus was more on process and improvement than on content, the pilot interview was not included in the study itself.

    We carried out the interviews in the period from May to December 2016 and they lasted between 45 and 75 minutes. We conducted them in a neutral, private room: eight were carried out on the premises of the child health centre, and one at the informant’s workplace. The interviews were audiotaped.

    We transcribed the interviews on an ongoing basis. After transcription, we reviewed the audiotapes and compared them again with the transcribed text to ensure quality.

    Privacy protection and ethics

    The informants received oral and written information about the study and its objective. All participation was voluntary. The informants gave written consent and had the opportunity to withdraw during the process. We anonymised the data and processed them confidentially. The authors did not take part in the recruitment nor did they know the informants from earlier. The Norwegian Centre for Research (NSD) approved the study (project number 47652), which was conducted in accordance with research ethics guidelines (15).

    Analysis

    The analysis adheres to Graneheim and Lundman’s qualitative content analysis (16). The method is suited to analysing qualitative data with the purpose of describing informants’ perceptions. The analysis method encompasses the data material’s manifest and latent content, and employs an inductive approach. The manifest content consists of the informants’ direct statements. The latent content is what is said implicitly, allowing room for interpretation. The analysis is a five-step process. We first read all the interviews and identified meaning-bearing units, and then condensed and coded these. We sorted and assembled the codes in sub-categories and then categories (Table 2).

    Table 2. Example of qualitative content analysis – the ‘Being on the outside’ category

    Results

    Analysis of the interview data resulted in two main categories describing the fathers’ encounter with the healthcare services in pregnancy, during the birth and at the child health centre (here referred to as ‘meetings with professionals’): being on the outside and inclusion.

    Being on the outside

    The main category ‘being on the outside’ encompasses two sub-categories: ‘exclusion’ and ‘being overridden’.

    Exclusion

    In the encounter with all healthcare services, the fathers felt a sense of being on the outside, both in the mother–child relationship and in the mother–health personnel relationship. They often described themselves as only being physically present. They took part in consultations but did not feel that they were included:

    ‘It isn’t hostile to Dads, but the greatest focus is on mother and baby.’

    ‘They ask kind of in passing: “How’s Daddy doing?” They asked little ‘by the way’ questions but 80 to 90 per cent is devoted to the mother. We get a chair that’s placed behind her, and then we sit together.’

    Mother and child are the focus of attention. The father felt himself to be the least important person during meetings with professionals. The fathers described their vulnerability in this setting. They wanted to be included but had no expectation of this, however:

     ‘The times I was there, they didn’t address me. But maybe that’s quite natural?’

    It would be good if someone asked: “How are things?”
    Father (informant)

    The fathers described their role with words like ‘spectator’, ‘conversational helper’, ‘co-pilot’, ‘observer’, ‘helper’ and ‘supporter’. All of them expressed a wish and a need to be seen as having an independent role vis-à-vis the child:

    ‘It would be good if someone asked: “How are things?”

    Nevertheless, the fathers felt that they had the opportunity to ask questions at health check-ups, and they were asked for their opinions. Their involvement in pregnancy care mostly concerned how the mother felt, and the child health centre’s attention was primarily addressed to the child. Few fathers experienced being asked about their own situation and feelings.

    The fathers felt unprepared if they were asked direct questions and found it difficult both to answer and to ask questions in return. They also described feeling that they did not really believe that their opinions were important.

    ‘I was given the opportunity to ask questions but this was so sudden that I was almost unable to think of anything …’

    The fathers found that the child health centre was not adapted for them and they felt it was unnatural to take the initiative to visit the centre on their own. They would attend consultations on their own if this was part of the established programme. Attending consultations was just as much about giving the mother support as for their own sake. They described the child health centre as a female-dominated society:

    ‘I’m there mostly as a support for Mum when she needs it. She asks me if I can come along when there are injections.’

    The healthcare services are not a natural place to seek information. The internet was the main source of knowledge, then the mother and finally friends and family. All these came before the health services:

    ‘I feel that I can check this out later, find out myself.’

    The feeling of being excluded was also reinforced by the services being poorly adapted to working fathers. Several fathers wanted more convenient opening hours, for example in the evening. The fathers wanted to be invited to participate in consultations and believed it was important that health personnel communicated that the father was welcome to participate.

    The fathers were uncertain of their own role during home visits. Several experienced that the public health nurse was unclear about whether the father should participate or not. A couple of fathers chose to carry out other tasks in the house because they were unsure whether they should take part in the conversation or not. 

    Being overridden

    Another factor in relation to being on the outside was the feeling of being overridden by the health personnel. Several fathers described having a bad conscience about not doing enough to help and support the women in the everyday situation. One father felt that he had been designated a ‘scapegoat’ in relation to the woman’s pregnancy problems.

    The fathers described a certain degree of monitoring as to whether they did a good enough job. They described their vulnerability to remarks that they perceived as criticism. One father called this the health personnel’s ‘finger pointing mentality’, when someone from outside the family criticised his way of dealing with family members. This criticism created distance to the support system. Trust in the healthcare service was in general more dependent on relationships with individuals than with the system:

    ‘It doesn’t matter if they are highly skilled if they don’t have the personal qualities to build relationships.’

    The fathers felt a sense of security if they had good chemistry with the health personnel and if the health personnel exhibited solid professional competence. They felt secure when they perceived that health personnel took their concerns seriously, and when their own understanding of the situation corresponded with that of the health personnel.

    Inclusion

    The main category ‘inclusion’ encompasses two sub-categories ‘participation’ and ‘adaptation’.

    Participation

    The fathers felt that specific, practical tasks, particularly in connection with childbirth, gave them a sense of involvement and security. Having responsibility for things such as cold compresses, food, drink, folding sheets and the like resulted in security in an unknown situation:

    ‘They saw us both the whole time during the birth. Were attentive and gave me tasks: “Now you can do that.” I felt that now I could do something. Finally!’

    The fathers described some midwives as looking after them during the birth. They made provision for the father to play a practical role, and also stood out as clear and distinct.

    ‘I became midwife number two in a way.’

    It was important that the fathers received information underway in the delivery process, particularly when unexpected incidents arose. The fathers described that they felt more included during the delivery itself than in the period before and after. Having the opportunity to be together with mother and child in the maternity ward, preferably in a family room, gave a feeling of inclusion: 

    ‘It’s important that I’m not just a third person sitting there, but that they ask a bit about what we think. Otherwise I feel that there’s no point in being present.’

    The degree to which fathers felt involved and were invited to participate in the conversations determined whether they participated in further consultations.

    Adaptation

    All the fathers described the meetings with professionals as generally positive despite experiencing being on the outside.

    The fathers thought it was positive that check-ups had a good structure and a set programme. They wanted specific, clear information and direct answers. They specifically wished to be included more during pregnancy with a focus on their own role, independent of the mother’s role.

    The fathers wanted their own role to be a subject of discussion. Several suggested separate consultations for fathers because they felt there was a need for such consultations, both during pregnancy and in the post-natal period. These consultations would deal with the father’s role, mental health and how best to support mother and child. Several fathers felt that some topics, such as mental health and daily challenges were difficult to talk about when their partner was present, and they thought they would get better support through individual conversations.

     ‘Call it a father-child session if you like, to get some tips and advice, or simply to ‘get it off your chest.’

    The fathers wanted their own role to be a subject of discussion.

    Few of the fathers had experienced being asked directly about their own mental health. When the mother faced challenges, the fathers found it difficult to talk when the mother was present:

    ‘It’s challenging and difficult to broach topics related to this … what you feel.’

    The fathers also wanted more Dad-friendly information on the internet, preferably under the auspices of the child health centre. Several of them described mothers’ networks on Facebook, for example, and wanted to see similar forums for fathers as well. However, no one would take the initiative to start such a group but described it as a ‘useful place to take a look’.

    Several had been invited to take part in fathers’ groups at the child health centre and had considered this, but they were uncertain what it entailed, and therefore they had all declined the offer.

    The fathers emphasised that inclusion in relation to healthcare personnel also requires the fathers themselves to take the initiative themselves:

    ‘We must maybe become better at making room for ourselves.’

    An active father’s role means involving oneself as a father in the existing range of healthcare services.

    Discussion

    Father as a participant

    The secondary role fathers described in their encounter with the healthcare services made it difficult for them to find their role in consultations, and led to uncertainty about the relevance of their own participation. In a study of first-time fathers, Premberg found that good, well-adapted information can reduce this kind of uncertainty. Participating in forums where one meets other fathers-to-be and can discuss the father’s role can lead to a sense of inclusion and empowerment. She also found that a lack of inclusion may maintain and strengthen the secondary role to some degree, create greater distance and complicate the transition to the father’s role (6).

    The fathers felt most included in the maternity ward.

    The fathers had few expectations regarding the content of the consultations but later described their disappointment that their role had not been acknowledged. This disappointment is also described in other studies (6, 17, 18).

    The fathers felt most included in the maternity ward. Here they received practical, specific and clear tasks, and the health personnel indicated that their presence was vital. Other research also describes similar findings (19). A positive experience of childbirth is crucial for a good start in the father’s role (6). There must therefore be some correlation between expectation and experience.

    Preparations for childbirth mainly focus on the normal delivery process, and studies show that the fathers are not well prepared for any complications. Such incidents create more uncertainty and distance than if complications had been discussed in advance. This applies to Caesarean section deliveries in particular. The father is then often aware of the anticipated procedure regarding the mother but has little knowledge about his own role after the C-section (18).

    The fathers were uncertain how often they were to participate in check-ups at the child health centre. They more often took part more to satisfy the mother’s need for support than to meet their own needs. The purpose of the home visit, for example, appeared unclear. Consequently, they often held back from participating. Public health nurses should therefore be clear about the purpose of the child health centres as early as the first contact with the family. The literature supports this finding, and consultations should involve both parents, who must be invited along as equal status service users (12).

    New national professional guidelines also emphasise user participation, whereby service users’ experiences shall be used to improve and plan the activity (2). Fathers as a service user group can therefore constitute a relevant reference group in developing the range of services.

    Changing and adapting practice

    In the encounter with the healthcare services the fathers wanted there to be a change in focus, with greater emphasis on the father as a carer. National guidelines and political signals support the desire for more focus on the family, even though the amount of attention they call to the father’s role as an independent function varies (1–3). Few child health centres are practically adapted for working fathers. When fathers are involved to a greater degree, it will strengthen the opportunity to develop the father’s role, increase awareness of their independent function as carers and provide security in their role as fathers (7).

    Fathers want to play a more active role in pregnancy and maternity care and at the child health centre.

    Many child health centres have attempted to boost fathers’ participation by means of fathers’ groups, family relations groups and theme days, for example. There is little documentation on participation and there has been no systematic evaluation of this type of measure (2, 7). Clear signals as to how to increase the father’s participation and involvement are also absent in national guidelines (2, 3). Some international studies stress that having dedicated discussion groups for men with male group leaders is positive (6, 20).

    The fathers in this study were offered the opportunity to participate in a fathers’ group. They stressed uncertainty about the content as one of the reasons for their failure to participate. In this connection, the fathers themselves suggested that offering individual sessions, in the evening if possible, would be attractive. Groups might be of interest but their purpose would need clarification.

    Service user studies from Bergen municipality show, however, that fathers prefer individual consultations (12). The fathers in this study described the healthcare services as a female-dominated society where they often felt like outsiders, and they were uncertain what the child health centres could offer them as a group. Here too, the healthcare services appear to be have been unclear in communicating their goals.  

    Previously, a political proposal was put forward on inviting fathers in particular to the eight-month check-up at the child health centre (21). The proposal has not been implemented, and inviting fathers to all check-ups should be a natural part of the child health centre’s programme.

    It is a stated political goal to maintain the paternity quota. The aim is to pave the way for greater involvement of fathers during infancy and early childhood. Individual studies show that the paternity quota is a factor that increases the father’s involvement generally, not just in early childhood but also as the child grows older (22).

    The role of health personnel

    The fathers had difficulty distinguishing between the various professions and were often uncertain about the professional groups with which they had been in contact. Personal suitability and the ability to create good relationships with service users were more important for how fathers felt they were looked after than professional affiliation. A lack of clarity related to the role of health personnel and their competence may lead to uncertainty about what is expected of fathers in the various meetings with professionals. Clarification of this would help to create realistic expectations.

    Fägerskiöl stresses that satisfaction with the health service is reflected in professionals’ ability to include the service users (20). How satisfied fathers are depends more on the individual health worker’s suitability than on the support system as a whole (24). Studies show that fathers have greater trust in the health personnel who take their concerns seriously. In general they have greater trust in female personnel, preferably with children of their own, than male personnel (20). These descriptions also concur with the descriptions given by the fathers in our study.

    Despite the fathers’ descriptions of being on the outside, they were satisfied with the healthcare services for the most part. They felt that mother and child were well cared for, which meant that they were also satisfied. Here we can observe a certain degree of ambivalence between what they would like to see offered and how satisfied they were with the actual range of services. The fathers also said that they had to make more room for themselves, and be more proactive in order to ensure greater inclusion by the services.

    Strengths and limitations of the study

    The study has its limitations. The findings are based on a small number of informants, all with relatively similar backgrounds. The results are valid for this group and thus cannot be generalised. Nonetheless, the results will give a picture of the perceptions of a service user group and knowledge that may be transferrable to the healthcare services generally.

    First-time fathers were specifically chosen as informants because they have no knowledge of the service beforehand and are therefore not influenced by earlier experiences. This gives them a more similar point of departure.

    The use of an interview guide ensures an identical approach. Open-ended questions put emphasis on the informants’ own stories, and the findings are strengthened by the participants having first-hand knowledge of the subject. The interviewer was a public health nurse, which entails a degree of preconception (13) that may affect the interviews even though neutrality was sought.

    The study is limited to first-time fathers and their perceptions of the encounter with the healthcare services in connection with pregnancy, childbirth and the child’s first months of life. We know that fathers’ attendance at the child health centre increases when paternity leave starts, and it may be a weakness that the study does not also cover this period.

    Conclusion

    The study describes a healthcare service related to pregnancy, childbirth and infancy that still focuses on mother and child, even though the objective is to have a family perspective. The fathers found that their inclusion in the healthcare services varied. They wanted to play a more active role and to be included during pregnancy, childbirth and follow-up at the child health centre. This requires a change of focus in the healthcare services, where greater emphasis is placed on fathers as independent and equal carers. Moreover, provision should be made for fathers to participate to a greater degree.

    There is a need for further research on fathers’ participation in the encounter with the healthcare services. Different approaches to boost fathers’ participation should be assessed and evaluated, and national guidelines can include fathers to a greater degree. Research in this area should include fathers in different types of families, with a variety of orientations and cultural backgrounds in order to acquire an overall picture of the father’s role today in the encounter with the healthcare services.  

    References

    1.       St.meld. nr. 12 (2008–2009). En gledelig begivenhet. Om en sammenhengende svangerskaps-, fødsels- og barselomsorg. Oslo: Helse- og omsorgsdepartementet.

    2.       Helsedirektoratet. Nasjonal faglig retningslinje for det helsefremmende og forebyggende arbeidet i helsestasjon, skolehelsetjeneste og helsestasjon for ungdom. IS-2582. Oslo; 2017.

    3.       Helsedirektoratet. Nasjonal faglig retningslinje for barselomsorgen. Nytt liv og trygg barseltid for familien. Oslo; 2014.

    4.       St.meld. nr. 29 (2002–2003). Om familien – forpliktende samliv og foreldreskap. Oslo: Barne-, likestillings- og inkluderingsdepartementet.

    5.       Reform – ressurssenter for menn. Far gjør – perspektiver på menn og omsorg i Norge. Oslo: Reform; 2008. Available at: https://reform.no/wp-content/uploads/2017/04/2008-Far-gjoer.pdf(downloaded 20.08.2018).

    6.       Premberg Å. Förstagångsfäders upplevelser av föräldrautbildning, förlossning och första året som far. Gothenburg: Sahlgrenska akademin, institutionen för vårdvetenskap och hälsa, Universitetet i Göteborg; 2011.

    7.       Skjøthaug T. Fedres rolle i barnets tidlige utvikling. In: Holme H, Olavesen ES, Valla L, Hansen MB, eds. Helsestasjonstjenesten. Oslo: Gyldendal Akademisk; 2016. s. 35–97.

    8.       Brudal LF. Psykiske reaksjoner ved svangerskap, fødsel og barseltid. Bergen: Fagbokforlaget; 2000.

    9.       Condon JT, Boyce P, Corkindale CJ. The first-time fathers study: a prospective study of the mental health and wellbeing of men during the transition to parenthood. Australian and New Zealand Journal of Psychiatry. 2004;(38):56–64.

    10.     Moe V, Slinning K, Hansen MB. Håndbok i sped- og småbarns psykiske helse. Oslo: Gyldendal Akademisk; 2010.

    11.     Misvær N, Lagerløv P, ed. Håndbok for helsestasjoner 0–5 år. Oslo: Kommuneforlaget; 2013.

    12.     Bergen kommune. Rapport fra prosjektet: «Helsestasjon for hele familien». Bergen; 2009.

    13.     Malterud K. Kvalitative metoder i medisinsk forskning. 3.ed. Oslo: Universitetsforlaget; 2011.

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

    15.     NESH. Forskningsetiske retningslinjer for samfunnsvitenskap, humaniora, juss og teknologi. Oslo: De nasjonale forskningsetiske komiteer; 2016.

    16.     Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today. 2004;24:105–12.

    17.     Raphael-Leff J. Psychological processes of childbearing. 4. ed. London: Chapman and Hall; 2005.

    18.     Erlandsson K, Häiggström-Nordin E. Prenatal parental education from the perspective of fathers with experience as caregiver immediately following birth; a phenomenographic study. Journal of Perinatal Education. 2010;19(1):19–28.

    19.     Chin R, Daiches A, Hall P. A qualitative exploration of first-time fathers' experiences of becoming a father. Community Practitioner. 2011;84(7):19–23.

    20.     Fägerskiöld A. Support of fathers of infants by the child health nurse. Scandinavian Journal of Caring Sciences. 2006(20):79–85.

    21.     St.meld. nr. 8 (2008–2009): Om menn, mannsroller og likestilling. Oslo: Barne- og likestillingsdepartementet.

    22.     Rege M, Solli I. The impact of paternity leave on long-term father invovement. CESifo Working Paper Series nr. 3130; 2010.

    23.     Lindberg A, Hvatum I. Møtet med helsestasjonen – foreldre som aktive deltakere. In: Holme H, Valla L, Hansen MB, Olavesen ES, eds. Helsestasjonstjenesten. Oslo: Gyldendal Akademisk; 2016.

    24.     Carlson J, Edleson J, Kimball E. First-time fathers’ experiences of and desires for formal support: A multiple lens perspective. Fathering. 2014;12(3):242–61.

    The father’s role has changed, and fathers have become more active as regards childcare. Nevertheless, they may feel excluded during pregnancy, childbirth and follow-up at the child health centre.  

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    Sammendrag

    Background: In recent years, pregnancy and maternity care and the child health centre have changed. Instead of only focusing on mother and child, they now try to include the whole family. Meanwhile the father’s role has changed, and fathers play a more active role in childcare. Despite this, mothers remain the main users of the healthcare services. Little research has been conducted on how fathers feel the healthcare services cater for their interests, and what can be done to increase fathers’ participation.

    Objective: The purpose of the study was to describe first-time fathers’ perceptions of the encounter with pregnancy, maternity and post-natal care and the child health centre throughout the pregnancy and birth, and in the child’s first three months of life.    

    Method: The study has a qualitative design and consists of nine individual interviews with first-time fathers. We carried out a qualitative content analysis of the data material.

    Results: We identified two categories that describe the fathers’ encounter with the healthcare services: being on the outside and inclusion. Being on the outside is described through two sub-categories – exclusion and being overridden. Inclusion deals with the fathers’ perceptions of adaptation and participation in the healthcare services.

    Conclusion: The study describes healthcare services where fathers experience a varying degree of inclusion. The services focus mainly on mother and child, even though the family perspective should apply. The fathers want to play a more active role and be more included during pregnancy, childbirth and follow-up at the child health centre. In order to attain this degree of inclusion, the healthcare services must acknowledge fathers as independent and equal carers. They must also make better provision for the participation of fathers.

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  • Rescue workers had greater confidence in their own mastery after the terror attacks of 22 July 2011

    On 22 July 2011, Norway was hit by its biggest terror attack since World War II. Eight people were killed and ten were hospitalised after the bombing of the government buildings in Oslo. About 325 people were in the immediate vicinity of the bomb. At Utøya, 69 people were killed. Of the 564 people attending a summer camp on the island, around half were injured (1).

    Under the chaotic conditions, many of the rescue workers felt that they were also in danger, due to fire, unsafe buildings and fear of more bombs. At Utøya, the rescue workers also found that they were under attack.

    Earlier surveys of rescue workers have shown a correlation between serious accidents, disasters and the incidence of post-traumatic stress disorder (PTSD) or post-traumatic stress syndrome (PTSS) (2–5). The incidence of PTSD varies from 2 to 21 per cent.

    After the terror attacks in Norway, a low incidence (0.3 per cent) of possible PTSD was found among the professional rescue workers (6). The proportion taking sick leave of more than two weeks or requiring psychotherapy was also low (7).

    Earlier research

    Research has been conducted into personal growth as a result of solving complex new challenges and tasks in connection with a traumatic event (8, 9). This growth is often called post-traumatic growth (8). Studies of psychosocial professionals who help people in crises also show personal growth (10). The same is found among firefighters after major fires (11), and among the police in relation to serious violent crime (12).

    In a study on rescue workers in the aftermath of the tsunami in Southeast Asia in 2004, Thoresen (13) found that training, experience and preparedness prior to the rescue work, as well as organisational support, were linked to a heightened perception of mastery. Similar findings have been shown for emergency service personnel, such as police, firefighters and ambulance workers, as well as nurses in intensive care units in hospitals (14).

    Studies of growth cover very different events and have varying objectives. The work in connection with the terror attacks in Norway was exceptional in that the rescue workers were faced with a particularly destructive and confused situation.

    Objective of the study

    Terror attacks are a growing phenomenon in the Western world, and the associated rescue work is challenging and unpredictable. However, such work can also provide learning opportunities that rescue workers cannot gain from simulation exercises.

    We have previously found that the degree of preparation – such as training, experience and simulation exercises – was associated with role clarity (15). In this part of the study, we looked at the extent to which earlier experiences impacted on the rescue workers’ levels of functioning and mastery during the rescue effort. In this article, we examine whether the rescue workers feel that their efforts led to development and growth.

    Such work can also provide learning opportunities that rescue workers cannot gain from simulation exercises.

    We therefore posed the following research questions:

    • To what extent are rescue workers equipped to master similar situations in the future?
    • What factors are associated with a heightened perception of mastery?

    Method

    We conducted a quantitative cross-sectional study about ten months after the event. In addition to questions with response options, we included a section for open text with the heading ‘Comments’. We wanted to analyse potential explanations of future mastery that were not captured in the quantitative data. The comments from healthcare personnel were collected by theme. We did not conduct a systematic qualitative analysis, but selected some of the recurring comments that illustrate the quantitative findings.

    The inclusion criterion was participation in the rescue and follow-up work of 22 July and the subsequent two weeks. The managers of personnel who took part in the rescue and follow-up work were responsible for identifying the relevant members of staff as well as distributing and collecting the questionnaires. Completed forms were returned in a locked container or a sealed envelope.

    Potential respondents received a reminder after one month. We were unaware of which individuals did not respond, as it was the managers who distributed the questionnaire and the responses were anonymous. We did not perform a strength calculation since we invited everyone who participated in the work.

    This survey is part of a bigger study. The method is described in more detail in a previously published article (6).

    Questionnaire

    The questionnaire was partly based on a survey conducted on rescue workers in the aftermath of the tsunami in Southeast Asia in 2004 (13). In addition, we added some questions about the events of 22 July 2011.

    Participants

    The participants were divided into groups according to their age: < 30 years, 30–49 years and > 50 years. We wanted to know where the respondents carried out the majority of their rescue effort. The response options therefore consisted of the sites of attack – the government buildings and Utøya – and other workplaces, such as hospitals, support centres for survivors and their families, accident and emergency departments, offices and street patrols. We also wanted to know when they joined the rescue effort, and this was dichotomised to a) 23 July and later, and b) 22 July.

    Participants from the public health service consisted of: a) medical professionals (doctors, nurses, other healthcare personnel, ambulance workers, Emergency Medical Communication Centre personnel); b) psychosocial personnel (doctors, nurses, psychologists, other healthcare personnel, clergymen and spiritual advisers, social workers). Operational personnel and office staff from the police took part, and the fire and rescue service was represented by firefighters and rescue personnel as well as divers.

    In addition, we included different voluntary groups and the defence sector (the Norwegian Civil Defence, the Norwegian Home Guard, Norwegian People’s Aid and Norwegian Rescue Dogs). We asked if they had experience from events with > 5 deaths, with the response options ‘No/Yes’.

    Casual volunteers at Utøya also participated in the rescue work, but these were not included in this article because the target group was professional rescue workers.

    Exposure

    Perceived fear of explosion or shooting was measured using the following response options: a) ‘No, I didn’t feel that’, b) ‘Yes, was not stressful/hardly stressful at all’, c) ‘Yes, was moderately stressful’, and d) ‘Yes, was very stressful’.

    Answers b, c, and d were merged since few participants reported moderate or high levels of stress, and it was therefore more appropriate to use a dichotomous variable in the analysis.

    Exposure to impressions was measured by the number of witnessing experiences. Participants initially answered seven questions about possible witnessing experiences. A factor analysis yielded two factors: seeing distressed people and seeing or being in the physical presence of seriously injured or dead people. This result is shown in another article (6).

    In this article, the variable ‘witnessing experiences’ is used. Here the total stress and result of the seven questions are merged and dichotomised based on the median value 1 to the value ‘0 = not experienced/a few times’ and ‘1 = experienced several’. Questions about verbal abuse or harassment were similarly summarised and dichotomised (‘0 = not experienced’, ‘1 = experienced’. Few reported verbal abuse or harassment as being moderately or highly stressful.

    Organisational conditions

    Role clarity was measured through the question ‘Did you know your area of responsibility?’, with the response options from ‘1 = not at all’ to ‘5 = to a very high degree’.

    We categorised employer support measures under the following alternatives: defusing/debriefing meetings, meetings to mark change, specialists such as a psychologist etc., dinners or other social gatherings, etc. These were merged and dichotomised to ‘No/Yes’. We wanted to examine the total number of support measures implemented.

    The outcome variable ‘mastery’ was measured through the following question:

    To what extent are you better equipped to master similar situations since 22 July 2011?

    We used response options in a five-digit Likert scale, where ‘1 = not at all’ and ‘5 = to a very high degree’.

    Statistics

    Descriptive data are presented as mean values with a 95 per cent confidence interval (CI) or as absolute numbers and percentages. There were generally few cases of missing data in the question responses (0.4–1.7 per cent). We used chi-square and Kruskal-Wallis tests to compare categorical variables, and ANOVA to compare the mean in normally distributed variables.

    In order to counteract the problem of too many comparisons, we used the Bonferroni correction method. In order to identify independent correlations with the outcome metric ‘mastery’, variables with a bivariate p-value < 0.10 were entered in a multivariate logistic regression. We used unadjusted and adjusted odds ratios (OR) and a 95 per cent CI from logistic regression analysis and associated significance value. The software used was SPSS version 21.0. The significance level was set to p < 0.05.

    Ethics

    All data were collected anonymously. The reminder was therefore sent to everyone who had initially received the questionnaire. The survey was approved by the Data Protection Officer at Oslo University Hospital, who indicated that approval from the Regional Committee for Medical and Health Research Ethics was not required. We stored the data on the research server at Oslo University Hospital.

    Results

    We sent out a total of 2801 questionnaires, of which 1734 were returned (62 per cent). The response rate ranged from 82 per cent for the fire and rescue service to 51 per cent for volunteer groups (Figure 1).

    Figure 1. Rescue workers who were invited to participate in the study (n = 2801)

    Sixteen per cent of the medical personnel worked at the sites of the attacks. In comparison, none of the psychosocial personnel worked there, compared to 97 per cent from the fire and rescue service. Most of the medical personnel, the police and the fire and rescue service joined the rescue effort on 22 July. About 25 per cent of the personnel in all groups, except for the volunteer groups (9 per cent), reported having previous experience of accidents involving more than five fatalities (Table 1).

    Table 1. Background factors for gender, age, type of work and experience
    Table 2. Exposure to potential external stress factors

    Role clarity, measured with a mean value (Table 3), was strongly in evidence for the most part in all groups, but psychosocial personnel (score = 3.6, CI = 3.5–3.7) and police (score = 3.9, CI = 3.8–4.0) reported a somewhat lower mean value compared to the other groups (score = 4.2, p < 0.001).

    There was no significant difference between medical personnel, psychosocial personnel and police in terms of participation in support services, while the proportion for the fire service was significantly higher (95 per cent). Voluntary groups had a significantly lower proportion (65 per cent) than the three non-significant groups.

    Table 3. Work-related variables

    In the analysis of comments from the healthcare personnel, there were three recurring themes:

    • management support
    • cooperation
    • a sense of pride in own efforts and those of others

    Management support

    One respondent made the following observation: ‘Our unit manager spent almost an entire day with us. It was great!’ Another commented that ‘We were offered debriefing straight away. Our manager asked us every day (almost a bit too much).’ However, not everyone found the follow-up to be like this, especially those who took holiday leave or were at the end of a temporary position, and who were not offered any follow-up.

    Cooperation

    Many highlighted the cooperation on the relevant days: ‘The 22nd of July was the worst and at the same time the best shift I’ve ever had. The worst speaks for itself. The best was the way everything worked, where people pulled together, both in my group and across the different professions. No nonsense or dramas.’ One of the pre-hospital service personnel described the situation: ‘Accident and emergency staff at Ullevål put chocolate and fizzy drinks on stretchers for the rescue workers to take with them...’

    The best was the way everything worked, where people pulled together, both in my group and across the different professions.
    Participant

    One respondent from the psychosocial personnel wrote the following: ‘The cooperation with somatic healthcare personnel was good, and those of us who came from psychiatry were valued.’ However, there was also one area of frustration among somatic personnel in relation to the lack of psychosocial follow-up of traumatised or critically ill patients and their families in their daily lives. In relation to 22 July, the respondent commented that ‘All support functions were eager to help, unlike normally, when everyone is battling to get resources.’

    A sense of pride in own efforts and those of others

    One respondent wrote the following: ‘It was nice to see that the system worked and that everyone involved put in so much effort’. Another commented: ‘Ringerike Hospital made an enormous contribution on the 22nd of July... All patients survived.’

    A third highlighted the following: ‘I am proud that we managed to deal with this kind of situation in such a professional manner... [It was] a privilege as a healthcare worker to be allowed to contribute ... [I] will remember the work with gratitude.’ The respondents’ comments also reflected some of the challenges.

    One respondent described how there was ‘A sense of powerlessness among those who didn’t get the chance to contribute, who had the expertise, but who ‘weren’t needed’.

    One respondent concluded by saying, ‘Of course I would like to think that I would cope well in a similar situation after 22/7, but you just never know. I think I’m better prepared for my own reactions since the attacks’.

    All groups reported that they were now better equipped to deal with similar situations, and there were no significant differences between the groups (score = 3.5–3.7).

    Factors linked to perception of mastering similar situations in the future

    Fourteen variables were subjected to an unadjusted analysis of the perception of mastering a similar situation in the future. In the multivariate adjusted analysis, some variables were significantly associated with mastering similar situations in the future. Compared with the under 30s, the perception of mastery was lower for the 30–49 age group (OR 0.7, CI 0.5-0.9, p = 0.05) and the age group 50 years or older (OR 0.5, CI 0.3–0.7, p < 0.001).

    We found a heightened perception of mastery among those whose response effort began on 22 July, compared to those who started later (OR 1.5, CI 1.2–1.9, p = 0.002). This was also the case for personnel who had one or more witnessing experiences (OR 1.5, CI 1.2–1.9, p = 0.002) and those who experienced a greater degree of role clarity (OR 1.5, CI 1.2–1.9, p = 0.002).

    Compared with medical personnel, the perception of mastery was higher among psychosocial personnel (OR 1.9, CI 1.3–2.7, p < 0.001), police (OR 1.4, CI 1.0–2.0, p = 0.024) and volunteer rescue workers (OR 1.7, CI 1.2–2.3, p = 0.001), but lower for firefighters (OR 0.6, CI 0.4–1.0, p = 0.052). There was no significant gender disparity.

    Discussion

    All groups reported that they were better equipped to master similar situations after the terror attacks. The explanatory variables ‘joined the rescue effort on 22 July’, ‘several witnessing experiences’, ‘greater degree of perceived role clarity’ and ‘young age’ were associated with greater confidence in future mastery.

    STAMI Report no. 3 (14) emphasises that mastering challenges can improve resilience. This assumption was linked to findings from a study of firefighters, whose confidence in their own mastery had a protective effect against depression and PTSD. In the same report, Skogstad et al. argue that rescue workers, such as police and firefighters, tend to be selected for the role and trained in tasks that are performed under demanding conditions.

    All groups reported that they were better equipped to master similar situations after the terror attacks.

    The respondents in our study were selected in terms of education and training for tasks performed under demanding conditions, which may support our findings. We found that young age was associated with confidence in mastering situations. Janacsek et al. (16) found a gradual reduction in reaction time and capacity for observation with increasing age (4–85 years).

    No such reduction was observed in young adults or the middle-aged. However, there is reason to believe that because younger rescue workers have less experience, participating in disaster efforts could have a greater learning effect. It is conceivable that they developed new mastery strategies in connection with the work, something that was also highlighted in a study of the police in the STAMI report (14).

    Since the level of post-traumatic symptoms in our study was generally low (6), there is reason to assume that the perception of mastery was high and that this has impacted on the learning experience.

    Correlation between start day and confidence in future mastery

    A correlation was found between greater confidence in future mastery and the variable ‘joined the rescue effort on 22 July’. The work on this day also presented more challenges. Threats and witnessing experiences are likely to exceed the threshold for mastery and lead to more post-traumatic symptoms and less learning, particularly where prolonged exposure has hampered the work.

    The rescue effort on 22 July was carried out in a relatively short timeframe, and most reported a large degree of role clarity and support from their employer. In addition, respondents from the health service described good cooperation and a sense of pride in their efforts. The foregoing may indicate that there is a ‘window’ in which the degree of challenges can lead to the best learning experience: if the threshold for mastery is exceeded, the situation may be perceived as traumatic, and if the challenges are not sufficiently taxing, there will be little to learn.

    The low scores on post-traumatic stress reactions indicate that this event has not exceeded the mastery threshold. Although most of the fire and rescue service personnel reported witnessing experiences, they did not differ significantly from the other groups. This may be linked to the fact that most of them had experience from similar work.

    We do not have data to explain why the police seemed to be slightly more affected. However, the challenges were undoubtedly less familiar to them, and they also received more criticism afterwards (1).

    Role clarity linked to mastery

    Greater role clarity was associated with a heightened perception of mastery in our study. A study of police showed that work-related organisational conditions, including lack of role clarity and poor social interaction with colleagues, were linked to PTSD (14). Particularly in cases where something goes wrong, there can be a sense of inadequacy and inability to master a situation.

    The access to resources in the aftermath of the terror attacks in Norway was never challenged, and those involved could work on familiar job tasks. Many described a team spirit and an eagerness for inter-professional cooperation.

    The challenges faced by psychosocial personnel, police and voluntary groups, were likely to be tougher than those in their daily work. Being able to master these challenges may have given them greater confidence in future mastery. Many of the hospital workers reported that their tasks in the rescue effort were largely what they are used to, but that the influx of patients was higher.

    In the unadjusted regression analysis, gender (female) was associated with greater confidence in future mastery, but this correlation disappeared in the adjusted analysis. Circumstances related to the actual event and role clarity thus appear to be more closely linked to confidence in future mastery than to gender.

    We cannot provide a definitive explanation for the gender disparities, partly because of the skewed gender distribution among personnel, and because it was the occupations with a high proportion of men that were exposed to the greatest risks.

    Perceived level of support from employers had no significant correlation to confidence in future mastery. There are several possible explanations for this. We combined various measures, such as debriefing, meetings to mark change and social gatherings. The form and content of these meetings will vary, and they are not all aimed at processing experiences and perceptions.

    Social support, not least from employers, is crucial after extremely stressful situations. The criticism of the police has no doubt been an additional burden for many officers. Research has shown that support after serious events can reduce the incidence of post-traumatic stress (14). The outcome metric in the article was confidence in future mastery, not PTSD.

    Strengths of the study

    We examined perceptions after an actual event and compared different professional groups who were involved. The response rate was moderate to high, which represents a strength in comparison to similar surveys.

    The results from the fire and rescue service can be generalised because the response rate was high for this group. They probably represent a more homogeneous group in terms of work tasks, as they were hands-on at the sites of the attacks. The rescue workers in the other groups probably had a larger variety of tasks (operational, treatment, office, etc.).

    We need to take a more cautious approach to generalising the results for the groups with a lower response rate. The participants in these groups also represented a variety of professions and therefore had a wider range of tasks. Using the respondents’ comments to underpin their impressions of mastery is one of the strengths of the study.

    Weaknesses of the study

    Results are based on the subjective experience of the event in question – as assessed by those involved about ten months after it took place. A cross-sectional study only gives a snapshot of the situation. Terror attacks, and other major events, occur without warning. It is also conceivable that groups who were particularly exposed were less likely to answer the questionnaire.

    The survey is based on self-reporting, and interviews could have provided more information. It is a weakness of the study that we do not have a better metric for a heightened perception of mastery after the event. This is because we were not prepared for finding such a positive correlation when we designed the study. However, we believe that our metric is sufficient to cover our main point, which is that the challenging work of the rescue workers has led to personal growth.

    We also believe that we can demonstrate some factors that are associated with a heightened perception of mastery. It would have been preferable to decide which variables to include in the adjusted analysis before we performed it. However, since we did not foresee see the potential that emerged from the study, we had to choose the analyses later. Nevertheless, we believe that the variables used are relevant.

    Clinical implications

    Even though simulation exercises are important, real events provide a learning opportunity that cannot be gained through studying theory or from the exercises. A natural part of management’s work will be to ensure the follow-up and support of rescue workers after serious events. This can enhance the perception of mastery and cooperation.

    Even though simulation exercises are important, real events provide a learning opportunity that cannot be gained through studying theory or from the exercises.

    Conclusion

    All groups of rescue workers reported that they had greater confidence in their own mastery in similar situations after the terror attacks of 22 July 2011. Several factors, such as joining the rescue effort on the same day it happened, exposure to several potentially stressful witnessing experiences, perceptions of role clarity and young age, were associated with greater confidence in future mastery.

    Future research is needed to investigate the impact of supportive management, cooperation perceptions and pride in own efforts and those of others.

    References

    1.       NOU 2012: 14. Rapport fra 22. juli-kommisjonen. Oslo: Departementenes servicesenter, Informasjonsforvaltning; 2012.

    2.       Hartley TA, Violanti JM, Sarkisian K, Andrew ME, Burchfiel CM. PTSD symptoms among police officers: Associations with frequency, recency, and types of traumatic events. International Journal of Emergency Mental Health and Human Resilience. 2013;15(4):241–54.

    3.       Skogstad M, Skorstad M, Lie A, Conradi HS, Heir T, Weisæth L. Work-related post-traumatic stress disorder. Occupational Medicine. 2013;63(3):175–82. DOI: 10.1093/occmed/kqt003.

    4.       Perrin MA, DiGrande L, Wheeler K, Thorpe L, Farfel M, Brackbill R. Differences in PTSD prevalence and associated risk factors among World Trade Center disaster rescue and recovery workers. American Journal of Psychiatry. 2007;164(9):1385–94.

    5.       Whalley MG, Brewin CR. Mental health following terrorist attacks. British Journal of Psychiatry. 2007;190:94–6. DOI:​​​​​​ 10.1192/bjp.bp.106.026427.

    6.       Skogstad L, Heir T, Hauff E, Ekeberg Ø. Post-traumatic stress among rescue workers after terror attacks in Norway. Occupational Medicine. 2016;66(7):528–35. DOI: 10.1093/occmed/kqw063.

    7.       Gjerland A, Pedersen MJB, Ekeberg Ø, Skogstad L. Sick-leave and help seeking among rescue workers after the terror attacks in Norway, 2011. International Journal of Emergency Medicine. August. 2015;8:31. 

    8.       Blix I, Hansen MB, Birkeland MS, Nissen A, Heir T. Posttraumatic growth, posttraumatic stress and psychological adjustment in the aftermath of the 2011 Oslo bombing attack. Health and Quality of Life Outcomes, 2013;11:160. DOI: 10.1186/1477-7525-11-160.

    9.       Dyregrov A, Dyregrov K. Positiv vekst etter livskriser – implikasjoner for praksis. Tidsskrift for Norsk Psykologforening. 2011;48(9):873–7.

    10.     Brockhouse R, Msetfi RM, Cohen K, Joseph S. Vicarious exposure to trauma and growth in therapists: The moderation effects of sense of coherence, organizational support, and empathy. Journal of Traumatic Stress. 2011;24(6):735–42. DOI: 10.1002/jts.20704.

    11.     Leykin D, Lahad M, Bonneh N. Posttraumatic symptoms and posttraumatic growth of Israeli firefighters at one month following the Carmel fire disaster. Psychiatry Journal. 2013; article ID 274121. DOI: 10.1155/2013/274121.

    12.     Chopko BA. Posttraumatic distress and growth: an empirical study of police officers American Journal of Psychotherapy. 2010;64(1):55–72.

    13.     Thoresen S. Mestring og stress hos innsatspersonell og journalister mobilisert til Tsunamikatastrofen. Oslo: Nasjonalt kunnskapssenter om vold og traumatisk stress; 2007. Rapport nr. 2/2007.

    14.     Skogstad M, Skorstad M, Lie A, Conradi HS, Lau B, Heir T, et al. Posttraumatisk stresslidelse (PTSD) og arbeidslivet. Oslo. Nasjonalt kunnskapssenter om vold og traumatisk stress og Statens arbeidsmiljøinstitutt; 2011. STAMI- rapport; årgang 12, nr. 3.

    15.     Pedersen MJB, Gjerland A, Rund BR, Ekeberg Ø, Skogstad L. Emergency preparedness and role clarity among rescue workers during the terror attacks in Norway July 22, 2011. PLoS One. 2016;11(6). DOI: 10.1371/journal.pone.0156536.

    16.     Janacsek K, Fiser J, Nemeth D. The best time to acquire new skills: age-related differences in implicit sequence learning across the human lifespan. Developmental science. 2012;15(4):496–505. DOI: 10.1111/j.1467-7687.2012.01150.x.

    Healthcare personnel, the police and the fire and rescue service, as well as voluntary groups, felt that they were supported by management, worked well together and shared a sense of pride in their efforts.

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    English
    Sammendrag

    Background: Participation in the rescue effort after the terror attacks of 22 July 2011 was challenging, unprecedented and unpredictable. Work related to major events can be stressful, but can also lead to a sense of personal growth. However, there are few studies that elucidate the experience of gaining confidence in carrying out your own role.

    Objective: To investigate the extent to which rescue workers are better equipped to master similar situations in the future. We also wanted to identify what factors are associated with a heightened perception of mastery.

    Method: Ten months after the terror attacks on 22 July 2011, healthcare personnel, the police and the fire and rescue service, as well as voluntary groups, participated in a cross-sectional study on professional challenges, perceived support and personal reactions after the events. Qualitative data from healthcare personnel enabled a more in-depth analysis of the findings.

    Results: The response rate was 62 per cent (1734/2801). All groups reported that they were now better equipped to master similar situations in the future (average value 3.5–3.7; scale 1–5). Early response (OR 1.5, CI 1.2–1.9), several witnessing experiences (OR 1.5, CI 1.2–1.9) and a greater degree of role clarity (OR 1.5, CI 1.2–1.9) were associated with a heightened perception of mastery. Compared with the under 30s, the perception of mastery was lower in the 30–49 age group (OR 0.7, CI 0.5–0.9 (p = 0.05) and the group aged 50 years and over (OR 0.5, CI 0.3–0.7, p < 0.001). 

    Conclusion: Real events provide a learning opportunity that cannot be gained from studying theory or through simulation exercises. High stress levels were associated with a heightened perception of mastery. Supportive management, the perception of cooperation and pride in their efforts may also have contributed to the healthcare personnel’s heightened perception of mastery.

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  • Few patients receiving multimodal antiemetic treatment experience postoperative nausea after ambulatory surgery

    Fakta
    Correction 26.02.2019

    Please note we have corrected the following numbers in table 3:

    • Whole sample n = 2794 (was n = 3022)
    • Open gastric surgery n = 154 (was n = 201)
    • Anorectal surgery n = 373 (was n = 390)
    • Major breast cancer surgery n = 533 (was n = 542)
    • Minor breast cancer surgery n = 471 (was n = 626)

    Ambulatory surgery, where the patient is operated on and discharged the same day, currently accounts for about 60 per cent of all elective surgery in Norway. By using short acting anaesthetic agents and local anaesthesia, for example, to reduce pain, the patient is soon awake, mobile and ready to go home. This method is effective and saves costs by reducing the need for the hospitalisation of patients (1).

    The clinical discharge criteria for a patient being able to go home after ambulatory surgery are that their circulatory and respiratory systems are stable, sufficient pain relief has been administered, they are not experiencing nausea and are mobile, and that they have had something to eat and drink and passed water (2).

    Postoperative nausea

    The exact pathophysiology of nausea and vomiting is complex, and many aspects remain unclear (3). The term ‘postoperative nausea and vomiting’ (PONV) is a generic term that includes nausea and/or vomiting following surgery (4, 5). In connection with ambulatory surgery, postoperative nausea can lead to prolonged stays in the department, hospitalisation (6) and a delay in the return to normal activity and work (7), which results in increased costs (8).

    Nausea can cause problems with eating, drinking and taking medication.

    Nausea can also reduce patient satisfaction (8, 9). For ambulatory surgery patients, postoperative nausea may be particularly problematic since they do not have immediate access to specialised health care and intravenous antiemetic treatment after discharge (4). Nausea can cause problems with eating, drinking and taking medication. Vomiting can, at worst, lead to ruptures of the surgical wound, bleeding, aspiration of gastric contents and dehydration (6).

    Postoperative nausea and vomiting after ambulatory surgery that occurs after discharge is known as postdischarge nausea and vomiting (PDNV), and even patients who did not initially experience nausea can suffer from this (7). Recent research has shown that patients experiencing postoperative nausea during their stay in the department are three times as likely to develop PDNV (4) and that the incidence of PDNV may be as high as 37–57 per cent after ambulatory surgery (4, 10, 11). In order to illustrate the extent of the number of patients exposed to PDNV, we refer to the USA, where approximately 35 million ambulatory surgery operations are performed every year (4).

    Predisposing risk factors and prevention of postoperative nausea

    Research has shown that being a woman (4, 5, 12) or a non-smoker (4, 5, 12), having a previous history of severe motion sickness or PONV (4, 5, 12) and postoperative use of opioids (4, 5, 12) are all predisposing risk factors to developing PONV.

    Based on these factors, Apfel et al. devised the so-called Apfel score (12), which is an instrument used to measure the risk of PONV. The more risk factors that are present, the higher the risk of PONV. Patients with all four risk factors have an 80 per cent risk of developing PONV without preventive treatment (12). Use of inhalational anaesthesia or nitrous oxide and long-acting anaesthesia has also been shown to increase the risk of PONV (5).

    In order to reduce the risk of PONV, Gan et al. recommend that the dosage of antiemetics is determined on a case-by-case basis according to estimated risk, in addition to providing adequate fluid therapy, minimising the use of postoperative opioids by administering other types of pain relief, as well as using regional anaesthesia or total intravenous anaesthesia (TIVA) instead of inhalational anaesthesia (13).

    There has been discussion on whether special surgical procedures are associated with an increased risk of PONV (5, 13). The Consensus Guidelines for the Management of Postoperative Nausea and Vomiting (the SAMBA Guidelines) (13) describe an increased risk associated with laparoscopic procedures, gallbladder surgery and gynaecological surgery.

    However, Apfel et al. (5) believe that it is the laparoscopic approach that is the determining factor, and not the type of procedure. Adequate pain relief appears to prevent postoperative nausea (14, 15), and a correlation has been shown between postoperative pain, opioid use and PDNV (10, 15). 

    In 2012, Apfel et al. presented a PDNV risk score (4) to calculate patients’ risk of developing PDNV with the following risk factors: PONV whilst in the postanaesthesia care unit (4, 10), female gender (4, 10), age < 50 years (4, 10), history of PONV (4, 10) and opioid administration in the postanaesthesia care unit (4, 10). Here too, the risk of PDNV increases with the number of risk factors. The Society for Ambulatory Anesthesia (SAMBA) recommends both of the risk-scoring tools devised by Apfel et al. (4, 12) in the SAMBA Guidelines (13).

    Objective of the study

    The objective of our study was to investigate what percentage of patients experienced PDNV following ambulatory surgery. We also wanted to investigate whether there were any disparities based on gender and type of surgery.

    After the department implemented new guidelines for targeted, systematic, nausea prophylaxis internally, we wanted to investigate the incidence, severity and distribution of PDNV after discharge in a large and wide-ranging patient data set. The knowledge gained from the study may be important for further work on preventing and treating postoperative nausea after ambulatory surgery.

    Method

    The study was a cross-sectional study in which we collected data at the Oslo University Hospital between September 2011 and August 2015. The data were collected during a follow-up telephone call the day after surgery. We used a structured questionnaire (see the appendix), which we obtained from another ambulatory surgery department. The ambulatory surgery department at the Oslo University Hospital, where we conducted the study, introduced the questionnaire in 2011 as a quality improvement measure.

    The questionnaire covers pain, nausea, bleeding, mobilisation, sleep, information and satisfaction. It consists of ten questions with set response options. In addition, it provides data on when the operation was performed, the type of surgery, the form of anaesthesia and the patient’s gender. We only used the data relating to nausea in this study. The question about postoperative nausea was as follows: ‘Have you felt nauseous since returning home?’ The patient assessed their own nausea based on the response options ‘No’, ‘A little’ or ‘A lot’.

    Inclusion criteria for telephone follow-up

    The inclusion criteria for following up a patient by telephone were that they were aged 18 or older and were discharged as planned after surgery or stayed overnight at a regular patient hotel that was not staffed with medical personnel. In addition, the patient had to be able to conduct the telephone conversation in Norwegian, Swedish, Danish or English.

    Data collection

    In this study, we chose only to consider patients who had received a general anaesthetic in the form of TIVA, since there were few patients who had received a different type of anaesthetic as the main form of sedation. Patients who met the inclusion criteria were given the questionnaire upon discharge from the ambulatory surgery department. They were informed that we would call them the next day to collect their responses. Where surgery had been performed on a Friday or the day before a public holiday, we called the patient the next working day.

    During the telephone follow-up, a nurse marked the patient’s response on a hard copy of the questionnaire. An external specialist nurse then entered the data in a statistical program. Responses or data that were missing were coded as ‘missing’.

    Seven dedicated postanaesthesia care nurses undertook the telephone follow-up. In order to safeguard the comparability of the data, all recorded data relate to the patient’s condition on the day after returning home from ambulatory surgery. The procedure required the nurses to follow the same questionnaire and ask the questions in the same way.

    Primary nursing care was practised at the department. In order to ensure that the patients felt free to express their opinion, they were called by a different nurse to the one who was responsible for them on the day of surgery.

    Anaesthesia, nausea prophylaxis and preventive pain relief

    All patients in the study received propofol-based TIVA, which is known to result in rapid awakening. TIVA also reduces the risk of PONV during the first few hours after surgery, and is less likely to cause nausea than inhalational anaesthesia (16–19). Remifentanil was used as an opioid. The patients were ventilated with oxygen and air. Perioperatively, the opioid fentanyl was also administrated intravenously, in addition to local anaesthetic wound infiltration in order to prevent pain.

    The patients were subject to perioperative antiemetic prophylaxis according to an internal standardised regime (Table 1) devised by the specialist responsible for ambulatory surgery in line with relevant knowledge and experience. The nausea prophylaxis consisted of three different drug combinations based on expected risk of nausea according to the type of surgical procedure. Some patient groups were also given a prescription for an oral opioid (codeine, tramadol), while others received tablets to take with them. If needed, patients were also given a potent opioid (oxycodone) to take home after surgery, which was to be taken for 1–3 days.

    The patients were subject to perioperative antiemetic prophylaxis according to an internal standardised regime.

    Premedication in the form of a combination of paracetamol and a non-steroidal anti-inflammatory drug (NSAID) or a COX-2 inhibitor was given as pain prophylaxis where there were no contraindications.

    Postoperative pain was further treated with fentanyl intravenously, paracetamol and NSAID or COX-2 inhibitors as well as oral opioids if needed. The patients were given a prescription for paracetamol and NSAID or COX-2 inhibitors upon discharge.

    Table 1. Nausea prophylaxis regime devised by the specialist responsible for ambulatory surgery

    Ethical considerations

    A nurse informed the patients that answering the questionnaire was voluntary, that the responses were anonymous and that the objective of the survey was internal quality improvement. By answering the questionnaire, the patient was regarded as consenting to participation in the survey. In order to comply with the duty of confidentiality, the patient was contacted on their own mobile phone.

    The Data Protection Officer at Oslo University Hospital defined the survey as a quality improvement initiative and, since all data were anonymous, did not consider it to be subject to the obligation to give notification. The head of the ambulatory surgery department granted permission to publish the data. The study did not entail any kind of additional interventions.

    Statistical analysis

    We divided the patient categories into subgroups by type of surgery, magnitude of the operation and expected risk of PONV (Table 2). The breakdown was carried out in consultation with the specialist responsible for ambulatory surgery at the hospital. In the bivariate analysis, we chose to dichotomise the response options ‘No’, ‘A little’ and ‘A lot’ to ‘Not nauseous’ and ‘Nauseous’ (slightly and very) as we considered the occurrence or absence of nausea to be most clinically relevant to this study.

    We performed statistical analyses using IBM SPSS Statistics, version 22.0 (SPSS Inc., Chicago, IL, USA). We performed frequency analyses to describe the sample, and bivariate analyses with chi-square tests to describe the incidence of PDNV within the various explanatory variables. In the analysis of the results shown in Table 3, we used McNemar’s test to indicate significance. The significance level was set at p < 0.05.

    Table 2. Surgical method, type of operation included in the patient group and gender (n = 2930)

    Results

    Out of the 3204 patients who were followed up in a phone call, 2952 were included in the study. The response rate was 99 per cent, and the data set contained < 5.5 per cent missing data. Women accounted for 79 per cent of the patients included, 40 per cent underwent gastric surgery, 24 per cent had a gynaecological procedure and 36 per cent had breast cancer surgery (diagnostic and therapeutic).

    Laparoscopic abdominal procedures accounted for a total of 46 per cent of all surgical procedures. The surgical method, type of operation and gender distribution are shown in Table 2. The anaesthesia may have been converted to inhalational anaesthesia in a few cases without this being recorded since inhalational anaesthesia was not a response option in the questionnaire.

    Nausea after returning home and surgical procedures

    In total, 16 per cent of the ambulatory surgery patients experienced PDNV after returning home. Of these, 14 per cent reported that they were slightly nauseous after returning home, and 2 per cent were very nauseous. In terms of the gender breakdown, 17 per cent of the women and 12 per cent of the men reported experiencing PDNV (p < 0.05).

    In total, 16 per cent of the ambulatory surgery patients experienced PDNV after returning home.

    Patients undergoing a gynaecological laparoscopy were most prone to PDNV (20–27 per cent) (p < 0.01), followed by upper laparoscopic gastric surgery (19 per cent) (p < 0.01) and anorectal surgery (19 per cent) (p < 0.01). The lowest incidence of PDNV was reported by those who had undergone major breast cancer surgery (10 per cent) (p < 0.01) (Table 3).

    Table 3. Incidence and distribution of nausea after discharge following the various surgical procedures

    Discussion

    Comparing the incidence of PDNV across studies is a challenge due to differences in patient samples, methods of anaesthesia, operation techniques, types of operation and in when the PDNV was measured. Comparisons have also become more complicated due to the major advancements in the fields of anaesthesia and surgery over the past decade.

    This study showed a total incidence of PDNV of 16 per cent the day after surgery. The sample had an increased risk of PDNV given that it was made up of almost 80 per cent women and nearly half of the operations consisted of laparoscopic abdominal procedures, which are associated with a greater risk of postoperative nausea.

    Apfel et al. (4) reported a 37 per cent incidence of PDNV in the first 48 hours after surgery in a multi-centre study of 2170 ambulatory surgery patients. The patients underwent various surgical procedures. The majority received prophylactic antiemetics, and women accounted for a lower percentage than in our study.

    In the study by Apfel et al. (4), inhalational anaesthetics were administered to all of the patients, which may have contributed to the higher incidence of PDNV. In our study, all patients received TIVA.

    Kappen et al. (11) examined 11 613 patients, all of whom received adequate nausea prophylaxis. The gender distribution was 50/50, and about half of the patients received inhalational anaesthesia. According to Kappen et al. (11), the sample was not a distinctly high-risk population, and consisted only of elective patients, some of whom underwent ambulatory surgery. Nevertheless, 41–43 per cent of the patients experienced nausea within the first 24 hours after surgery, which was considered to be an unexpectedly high incidence of PDNV.

    The relatively low incidence of PDNV in our study may be the result of all patients receiving multimodal antiemetic prophylactic treatment with both propofol-based TIVA and antiemetics according to a standardised regime, with medications that are recommended in the SAMBA Guidelines (13). Individual risk scoring was not practised in the department, so some patients probably received more antiemetics than they should have based on the number of risk factors, while some high-risk patients probably did not receive enough.

    Gynaecological patients had highest incidence of PDNV

    As expected, the women in our study reported a higher incidence of PDNV than the men, which concurs with earlier research (4, 5, 10, 12). In terms of procedures on the women, the gynaecological patients reported the highest incidence of PDNV (20–27 per cent) according to the data, while the breast cancer patients had the lowest incidence of PDNV (10–14 per cent). Chen et al. (20) report a 14 per cent incidence of PDNV after breast surgery performed using TIVA, which is in line with our findings.

    A contributing factor to the high incidence of PDNV among the gynaecological patients in our study may be the surgical method (5, 13). Paech et al. (21) presented a similar result. They reported a 25 per cent incidence of nausea following a gynaecological laparoscopy using TIVA combined with analgetic and antiemetic prophylaxis.

    Use of a multimodal antiemetic prophylaxis was also demonstrated by Scruderi et al. (22). Using a multimodal antiemetic approach similar to ours, 12 per cent of the patients reported PDNV after a gynaecological laparoscopy. In the same study, 32 per cent of the patients who received inhalational anaesthesia without antiemetics experienced PDNV. The patients who received multimodal treatment could also be discharged sooner than the other patients in the study (22).

    The patients who underwent upper laparoscopic gastric surgery reported the second highest incidence of nausea in our study, with 19 per cent experiencing PDNV. The majority were women, and cholecystectomies accounted for 98 per cent of the procedures, which is a predictor of an increased risk of postoperative nausea.

    In another study (23) where a multimodal approach including TIVA was used and most of the patients were women, the incidence of PDNV after a laparoscopic cholecystectomy was 20 per cent, which is in accordance with our findings.

    Less nausea following lower laparoscopic gastric surgery

    The two gastric surgery patient groups undergoing a lower laparoscopy and open surgery showed a lower incidence of nausea than the other gastric surgery patients in the study. Despite a laparoscopic operating method being used, the patients who underwent a lower laparoscopy reported a lower incidence of nausea than those who had undergone minor breast operations.

    One explanation may be that 99 per cent of the lower laparoscopic procedures consisted of surgery for inguinal hernia, where the latest technique entails operating outside the peritoneum using the so-called total extraperitoneal (TEP) approach. TEP has been shown to be a gentler surgical technique (24) that may reduce the risk of nausea in comparison with the other laparoscopic procedures in the study in which surgery takes place within the peritoneum. In the group with open gastric surgery, minor operations were generally performed.

    High incidence of PDNV after anorectal surgery

    The high incidence of PDNV after anorectal surgery was unexpected, as these operations are considered to be relatively simple and uncomplicated. In addition, the majority of the patients were men. We had expected to see a higher incidence of PDNV among the breast cancer patients – who were women that had undergone relatively major operations – than among those who had had anorectal surgery.

    The high incidence of PDNV after anorectal surgery was unexpected.

    Although the anorectal group received dexamethasone as an antiemetic prophylactic, which has proven to be effective (25), the incidence of PDNV was the same as for the group who underwent upper laparoscopic gastric surgery. It is difficult to know the reason for the high incidence of PDNV, but postoperative pain is a known problem after anorectal surgery (26), which can cause nausea (15). Many of the patients also received a prescription for an oral opioid, which may also have contributed to nausea.

    By comparison, Coloma et al. (25) found a PDNV incidence of 8 per cent after anorectal surgery, where dexamethasone was given as an antiemetic prophylactic and the surgery was performed under local anaesthesia and sedation. In our study, all patients received a general anaesthetic in the form of TIVA. This may indicate more extensive surgery in our patients and a need to increase nausea prophylaxis for this patient group.

    PDNV and postoperative pain

    The incidence of PDNV seems to remain relatively stable despite new knowledge. One of the reasons may be that advancements in the fields of surgery and anaesthesia have made it possible to carry out more extensive and more complicated ambulatory surgery operations. This in turn may affect both the incidence of pain and the need for postoperative opioids (27).

    Thagaard et al. (14) point out that non-opioid pain relief is important in preventing postoperative nausea. Using ketorolac perioperatively, they showed a reduction in postoperative pain, a reduced need for opioids and a lower incidence of postoperative nausea.

    Odom-Forren et al. (10) examined the incidence of PDNV during the first week after surgery in 248 ambulatory surgery patients. They found a total PDNV incidence of 57 per cent, which was considerably higher than expected. Six per cent of the patients were still experiencing PDNV seven days after the operation (10). Odom-Forren et al. found a correlation between PDNV and postoperative pain, with patients with a high pain score reporting a higher incidence of PDNV (10, 15), and the likely cause being a higher opioid consumption (10).

    Strengths and limitations of the study

    The study’s strength is the large sample within three patient groups and the high response rate. In addition, all patients had been subject to the same type of anaesthesia as well as pain and nausea prophylaxis under a standardised regime.

    A limitation of the study is that the questionnaire we used contained little background information on the patients. In future studies it will be important to include more information about the patients, such as age and known risk factors for developing PONV or PDNV. The data for postoperative pain were incomplete, which prevented us from investigating the link between nausea and pain, and therefore reduced the basis of interpretation. Furthermore, the incidence of vomiting should be recorded in connection with information about PONV or PDNV, as the terms include both nausea and vomiting.

    Conclusion

    In this study, the majority of the sample had an increased risk of developing PDNV. Nevertheless, a relatively low percentage experienced PDNV compared to other recent studies. These findings may imply that a systematic, multimodal approach to antiemetic prophylaxis can contribute to a low incidence of postoperative nausea after ambulatory surgery.

    The women in the study reported a higher incidence of nausea than the men. A breakdown by type of procedure showed that patients undergoing laparoscopic surgery experienced the most nausea, particularly after a gynaecological laparoscopy, while those who had undergone major breast cancer surgery were least nauseous. Anorectal surgery patients reported an unexpectedly high incidence of nausea, which is something that should be followed up further.

    In order to prevent and reduce the incidence of both PONV and PDNV, the incidence should be documented according to risk factors and prophylaxis throughout the entire course of the patient’s clinical pathway.

    References

    1.  Ræder J, Nordentoft J. Dagkirurgi og anestesi. Tidsskrift for Den norske legeforening. 2010;130(7):742–6.

    2.  Norsk anestesiologisk forening. Norsk standard for anestesi [Internet]. Oslo: Norsk anestesiologisk forening, ALNSF; 2010 [cited 06.05.2016]. Available at: https://www.alnsf.no/alnsf/norsk-standard-for-anestesi.

    3.  Blackburn J, Spencer R. Postoperative nausea and vomiting. Anaesthesia & Intensive Care Medicine. 2015;16(9):452–6.

    4.  Apfel CC, Philip BK, Cakmakkaya OS, Shilling A, Shi Y-Y, Leslie JB, et al. Who is at risk for postdischarge nausea and vomiting after ambulatory surgery? Survey of Anesthesiology. 2013;57(1):1.

    5.  Apfel CC, Heidrich FM, Jukar-Rao S, Jalota L, Hornuss C, Whelan RP, et al. Evidence-based analysis of risk factors for postoperative nausea and vomiting. Br J Anaesth. 2012b;109(5):742–53.

    6.  Keyes M. Management of postoperative nausea and vomiting in ambulatory surgery: The big little problem. Clin Plast Surg. 2013;40(3):447–52.

    7.  Carroll NV, Miederhoff P, Cox FM, Hirsch JD. Postoperative nausea and vomiting after discharge from outpatient surgery centers. Anesth Analg. 1995;80(5):903–9.

    8.  Parra-Sanchez I, Abdallah R, You J, Fu AZ, Grady M, Cummings K 3rd, et al. A time-motion economic analysis of postoperative nausea and vomiting in ambulatory surgery. Can J Anaesth. 2012;59(4):366–75.

    9.  Odom-Forren J, Hooper V, Moser DK, Hall LA, Lennie TA, Holtman J, et al. Postdischarge nausea and vomiting: management strategies and outcomes over 7 days. J Perianesth Nurs. 2014;29(4):275–84.

    10. Odom-Forren J, Jalota L, Moser DK, Lennie TA, Hall LA, Holtman J, et al. Incidence and predictors of postdischarge nausea and vomiting in a 7-day population. J Clin Anesth. 2013;25(7):551–9.

    11. Kappen HT, Moons GMK, Van Wolfswinkel JL, Kalkman AC, Vergouwe AY, Van Klei AW. Impact of risk assessments on prophylactic antiemetic prescription and the incidence of postoperative nausea and vomiting: A cluster-randomized trial. Anesthesiology. 2014;120(2):343–54.

    12. Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology. 1999;91(3):693.

    13. Gan TJ, Diemunsch P, Habib AS, Kovac A, Kranke P, Meyer TA, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2014;118(1):85–113.

    14. Thagaard KS, Jensen HH, Raeder J. Analgesic and antiemetic effect of ketorolac vs. betamethasone or dexamethasone after ambulatory surgery. Acta Anaesthesiol Scand. 2007;51(3):271–7.

    15. Odom-Forren J, Rayens MK, Gokun Y, Jalota LM, Radke O, Hooper V, et al. The relationship of pain and nausea in postoperative patients for 1 week after ambulatory surgery. Clin J Pain. 2015;31(10):845–51.

    16. Apfel CC, Korttila K, Abdalla M, Kerger H, Turan A, Vedder I, et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. The New England Journal of Medicine. 2004;350 (24):2441–51.

    17. Yoo YC, Bai SJ, Lee KY, Shin S, Choi EK, Lee JW. Total intravenous anesthesia with propofol reduces postoperative nausea and vomiting in patients undergoing robot-assisted laparoscopic radical prostatectomy: a prospective randomized trial. Yonsei Med J. 2012;53(6):1197–202.

    18. Eikaas H, Raeder J. Total intravenous anaesthesia techniques for ambulatory surgery. Curr Opin Anaesthesiol. 2009;22(6):725–9.

    19. Kumar G, Stendall C, Mistry R, Gurusamy K, Walker D. A comparison of total intravenous anaesthesia using propofol with sevoflurane or desflurane in ambulatory surgery: systematic review and meta-analysis. Anaesthesia. 2014;69(10):1138–50.

    20. Chen HP, Hsu YH, Hua KC, Lin CC, Lo YF, Yu HP. Comparison of sevoflurane versus propofol under auditory evoked potential monitoring in female patients undergoing breast surgery. Biomedical Journal. 2013;36(3):125–31.

    21. Paech MJ, Rucklidge MWM, Lain J, Dodd PH, Bennett E-J, Doherty DA. Ondansetron and dexamethasone dose combinations for prophylaxis against postoperative nausea and vomiting. Anesth Analg. 2007;104(4):808–14.

    22. Scuderi PE, James RL, Harris L, Mims GR 3rd. Multimodal antiemetic management prevents early postoperative vomiting after outpatient laparoscopy. Anesth Analg. 2000;91(6):1408–14.

    23. Habib AS, White WD, Eubanks S, Pappas TN, Gan TJ. A randomized comparison of a multimodal management strategy versus combination antiemetics for the prevention of postoperative nausea and vomiting. Anesth Analg. 2004;99(1):77–81.

    24. Nawaz T, Ayub MW, Murad F, Ali Q, Khan A, Anwar I. Comparison of laparoscopic total extra peritoneal (TEP) techniques versus transabdominal preperitoneal (TAPP) technique for inguinal hernia repair. Journal of Rawalpindi Medical College (JRMC). 2015;19(3):220–2.

    25. Coloma M, Duffy LL, White PF, Kendall Tongier W, Huber PJ Jr. Dexamethasone facilitates discharge after outpatient anorectal surgery. Anesth Analg. 2001;92(1):85–8.

    26. Vinson-Bonnet B, Higuero T, Faucheron JL, Senejoux A, Pigot F, Siproudhis L. Ambulatory haemorrhoidal surgery: systematic literature review and qualitative analysis. Int J Colorectal Dis. 2015;30(4):437–45.

    27. Rawal N. Postoperative pain treatment for ambulatory surgery. Best Practice & Research Clinical Anaesthesiology. 2007;21(1):129–48.

    Patients undergoing gynaecological laparoscopies and anorectal procedures suffered the most nausea, while those who underwent major breast cancer surgery experienced the least nausea.

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    Sammendrag

    Background: Ambulatory surgery, where the patient is operated on and discharged the same day, accounts for about 60 per cent of all elective surgery in Norway. Postoperative nausea is a known problem after anaesthesia and surgery, and one that can cause discomfort and, at worst, complications for the patient. In an ambulatory surgery setting, postoperative nausea can also lead to a prolonged stay in the postanaesthesia care unit or a need for unplanned hospital admission, which results in increased costs. International studies show that 37–57 per cent of patients report postoperative nausea after arriving home from ambulatory surgery. 

    Objective: To investigate what percentage of our ambulatory surgery patients experience postoperative nausea after discharge. We also wanted to investigate whether any patient groups are particularly vulnerable.

    Method: The study is a cross-sectional study. Telephone follow-up the day after surgery was used to collect data using a structured questionnaire with set response options.

    Results: A total of 2952 patients were included in the study and the response rate was 99 per cent. A general anaesthetic was administered to all patients in the form of total intravenous anaesthesia. Based on known risk factors, the majority of the sample had an increased risk of developing postoperative nausea. The study showed an incidence of postoperative nausea the day after the operation of 16 per cent, of which 14 per cent were slightly nauseous and only 2 per cent were very nauseous.

    Conclusion: The study shows that the incidence of postoperative nausea after ambulatory surgery can probably be reduced through systematic, multimodal antiemetic prophylactic treatment.

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  • Intranasal dexmedetomidine is of benefit as paediatric premedication – from the perspective of anaestetic nurses

    Bildet viser ei jente som får deksmedetomidin i form av nesespray før operasjon

    The drug dexmedetomidine is increasingly used for sedation and premedication in children (1). Dexmedetomidine enables a saving on analgesic and anaesthetic agents, has a minimal effect on respiration and can be administered by different routes (1–3). The intranasal route is minimally traumatic, and dexmedetomidine is taste-free, odour-free and painless when used on the nasal mucous membrane, and the drug is therefore well tolerated by children (4, 5).

    The benzodiazepine derivate midazolam provides good sedation and thus reduces anxiety, and is the most frequently used drug for paediatric premedication (2, 6, 7). The adverse effects of midazolam, such as foul taste, stinging pain when used intranasally, respiratory depression and in some cases increased agitation, nevertheless makes it a suboptimal choice (1, 3, 8). There is a need for an alternative paediatric premedication to improve treatment at the pre-, per- and post-operative stage (9).

    Surgery invokes anxiety

    Research has estimated that 40–70 per cent of all children of pre-school age experience anxiety in connection with a surgical procedure (1, 3, 8). Anxiety may complicate the induction of anaesthesia, which is stressful for the child, the parents and the anaesthetics team. The parents’ experience at this stage has a significant effect on their satisfaction with the treatment programme (7, 9).

    Reducing the children’s anxiety preoperatively helps prevent complications.

    Reducing the children’s anxiety preoperatively helps prevent complications. A high level of anxiety and difficult induction of anaesthetics are a risk factor for post-operative complications such as agitation, more pain and long-term, negative behavioural change such as bedwetting, reduced appetite and temper tantrums. Such complications may delay the departure from hospital and rehabilitation (7, 10, 11).

    Teamwork

    The anaesthetic nurse and the anaesthesiologist constitute an anaesthetics team that collaborates closely in a complex and dynamic environment, with overlapping job tasks. The doctor holds medical responsibility in the team (12).

    The anaesthetic nurse has an independent function and an expanded nursing competence that requires specific technical and non-technical skills. This competence is required to be able to observe, identify and assess different situations and take action to meet the complex needs of the patient who is about to undergo surgery and anaesthesia. The objective is to ensure patient safety and appropriate professional practice (12, 13).

    Objective of the study

    Literature searches revealed a number of quantitative studies describing the use of dexmedetomidine as paediatric premedication. Various academic articles indicate that dexmedetomidine is well suited as premedication and sedation for children down to the age of one year. Research also shows that the use of dexmedetomidine has positive effects at the post-operative stage, including calmer and less painful awakenings (1, 3, 8).

    However, we found no studies that had taken a qualitative approach to this question. Demands for appropriate professional procedures must be grounded in evidence-based practices, meaning that professionals make use of a variety of knowledge sources in the practice of their profession (14–16). For procedures to be changed, they need to be perceived as more suitable than those that are established.

    Based on the above considerations, the objective of our study was to explore the experiences of anaesthetic nurses, in order to contribute new knowledge about the properties and suitability of dexmedetomidine as paediatric premedication. These aspects form the backdrop to the following research question:

    • What experiences do anaesthetic nurses have with the use of intranasal dexmedetomidine as premedication at the pre-, per- and post-operative stage in children who will be placed under general anaesthesia?

    Method

    Design

    We used a qualitative, exploratory design that involved semi-structured interviews with anaesthetic nurses. This method is appropriate to capture the participants’ personal experiences by taking an open view (17, 18). The study is based on a phenomenological-hermeneutic tradition, in which reality is described as diverse and subjective, and findings are created in interactive processes. On the other hand, findings must be interpreted in light of relevant studies and the researchers’ preconceptions to obtain a more comprehensive understanding (17).

    Sample

    The goal of qualitative research is to include participants that can provide the richest possible descriptions in order to elucidate the research question (17). Contact persons in the hospitals recruited the participants based on the following inclusion criteria:

    • must be an anaesthetic nurse with at least one year of experience
    • works with children on a routine basis
    • possesses clinical experience with intranasal administration of dexmedetomidine
    • includes both genders

    Based on the inclusion criteria, six anaesthetic nurses were asked to participate in the study, all of whom assented. They made up the strategic sample on which the data collection was based. Average clinical experience as an anaesthetic nurse, from work with children and the use of dexmedetomidine as premedication amounted to 14.8 years (3–21 years), 16.3 years (3–21 years) and 2.2 years (0.5–4 years) respectively.

    The anaesthetic nurses were recruited from day surgery units in two Norwegian hospitals. The units had been established three and seven years ago respectively, and consisted of five to six operating theatres with appurtenant pre- and post-operative units. In general, the personnel was permanently linked to the departments, and surgical interventions included otorhinolaryngology, gynaecology, thoracic and endocrine surgery, orthopaedics and general surgery. Both departments operated on more than 800 children annually, mainly related to ear, nose and throat conditions.

    Ethical considerations

    The project is approved by the Norwegian Centre for Research Data (NSD) (project no. 50198) and by the heads of research in the hospitals. Prior to the interviews all participants received written information about the project accompanied by an invitation to participate in the study. They were informed about their right to withdraw at any time with no repercussions. They accepted to participate by coming for an interview.

    All information about the participants was treated as confidential, in line with the NSD guidelines and principles of research ethics. The participants were coded with random numbers ranging from one to six, and all data were anonymised.

    Data collection and analysis

    We collected the data in the autumn of 2016 with the aid of personal in-depth interviews conducted in the participants’ workplace. A semi-structured interview guide (Appendix 1) was used to focus the interview and encourage the participants to speak as freely as possible (17). The interviews lasted from 30 to 60 minutes. We used a digital audio device to record the interviews, which were subsequently transcribed.

    We analysed the data in light of Graneheim and Lundman’s (19) qualitative content analysis through a six-step abstraction process (Table 1). The text was divided into four natural domains in accordance with the three stages of the anaesthesia process plus the induction stage, and these constitute the units of meaning in the text.

    Through this abstraction process two main topics emerged: 1) dexmedetomidine as premedication has favourable properties throughout the anaesthetic process, and 2) Necessary precautions need to be taken throughout the anaesthetic process to ensure that no complications arise when dexmedetomidine is used as premedication (Table 2).

    Table 1. Steps of the analytical process
    Table 2. Examples of qualitative content analysis from sub-categories to categories and topics

    Results

    Pre-operative experience

    The anaesthetic nurses in both units described how dexmedetomidine was introduced after an intra-departmental pilot project. Participant 4 emphasised the importance of preparation: ‘It was well accepted by everybody, both in terms of the training and the ‘internal research’, where we compared children who had received dexmedetomidine, midazolam and nothing.’

    Some challenges were encountered initially, as described by Participant 2: ‘Of course there was a breaking-in period concerning the dosage and timing, but it was well received. The favourable effects manifested themselves early.’

    The anaesthetic nurses believed that the successful introduction of the new drug was largely due to the fact that the process was clinically endorsed by the unit’s anaesthesiologist. Participant 3 noted: ‘It’s essential to have an authority in the professional group when starting something new.’

    The anaesthetic nurses had observed that dexmedetomidine induces sleep. Participant 2 gave an account of the following experience: ‘The children receive it, and when it takes effect they fall asleep ... You can insert a cannula, take them to the operating theatre and initiate anaesthesia without them noticing. But little time must elapse once they have fallen asleep.’

    All participants found that the children could be woken up and had to be exposed to as little stimulation as possible. Participant 3 described it thus: ‘It’s an art to ensure that they do not wake up ... Having permanent staff who know how this works is an advantage ... It works really well now.’

    Positive effects for patient flow

    Experience indicated that the onset time for dexmedetomidine varied from 20 minutes up to one hour. This long onset time might delay patient flow in the morning hours. Participant 6 said: ‘The first child in the morning is a challenge. You must take the time needed and wait for the effect. For this you need a well-functioning system ... I nevertheless feel that I have a better daily situation with the children now.’

    Participant 5 had the following experience: ‘The optimal time to administer dexmedetomidine is one hour before the surgical procedure.’

    The anaesthetic nurses felt that interdisciplinary collaboration was crucial to achieve an efficient patient flow. Participant 2 described it thus: ‘The intensive-care nurses in the post-operative ward administer dexmedetomidine to the children when they arrive in the morning. They call us once the child has passed ‘the hand test’. Then, they are in a deep enough sleep to have an injection.’

    Participant 5 gave this description: ‘We have a very good plan for solving this ... Everybody is involved. Collaboration is easy here, compared to in a large department.’

    Despite the long onset time, the anaesthetic nurses found that using dexmedetomidine had a positive effect on patient flow. Participant 3 had the following experience: ‘The gain lies in the shorter induction time.’

    Negative experiences  

    Negative experiences gathered by the anaesthetic nurses were associated with some cases of unsatisfactory effect. Participant 3 said that: ‘It would be those who wake up and are agitated. It’s crucial to bring them into the operating theatre within the time window.’

    No experiences of serious adverse effects were described. Participant 4 had observed the following: ‘Once they have received the dexmedetomidine, the children turn pale around the mouth. They have a brief drop in oxygen saturation, although it never falls below 95 per cent.’

    It was clear that the anaesthetic nurses saw dexmedetomidine as a better alternative than midazolam as a paediatric premedication. This was confirmed by Participant 4: ‘The nurses in the post-operative ward do not want to revert to midazolam.’

    Experiences during induction

    The anaesthetic nurses perceived the inductions as gentle and safer than with awake and frightened children. Participant 3 described it thus: ‘The induction is perceived as very positive. A calm, sleeping child provides for a much better overview compared to previously, when this often involved quite a struggle. Safety is good ... Compared to previously, it’s a new era.’

    A general experience was that most children went from ‘sleep to sleep’, but this was contingent on minimal stimulation. Participant 5 explained: ‘The induction goes very gently. Only a pulse oximeter to begin with. We hold the mask lightly over the face so as not to wake them up. Once they are under full anaesthesia we move them to the operating table.’

    Safety is good ... Compared to previously, it’s a new era.
    Participant 3

    The participants felt that most parents were satisfied. Participant 1 said: ‘Fewer parents leave the operating theatre in tears, because they feel that we are in control. They see a child who sleeps his or her way into anaesthesia ... I believe they see us as more professional than before ... We provide a system that makes me proud.’

    Perioperative experiences

    All participants noted that dexmedetomidine can induce circulatory fluctuations, and bradycardia in particular. Participant 2 described it thus: ‘There’s been talk about bradycardia, and we administer Robinul prophylactically during the induction, but I don’t feel that this is a major problem.’

    All participants noted the potentiating properties of dexmedetomidine, meaning that this drug amplifies the effect of other drugs, which in turn means that less of these can be used. Participant 6 nevertheless found: ‘It reduces the use of opioids, but I can’t say that I notice anything during the surgery. We use approximately the same TIVA (total intravenous anaesthesia) settings for all patients. It works well.’

    Post-operative experiences

    The participants described a close, interdisciplinary collaboration in the day surgery units where the children stayed in the pre-, peri-, and post-operative stages. All participants shared the experience that the recoveries were characterised by less crying, agitation and pain. Participant 1 gave the following account: ‘It’s just wonderful. It’s so different. The children are sleeping and are OK ... The goal is for them to sleep through the distressing phase of recovery.’

    In the experience of Participant 5, certain precautions nevertheless needed to be taken. ‘Not too much time should elapse from the administration of dexmedetomidine until the child goes into surgery and comes to the recovery unit. And the children must have the opportunity to wake up quietly.’

    The anaesthetic nurses had observed that the children slept longer post-operatively after having been given dexmedetomidine as premedication. They did not believe, however, that this entailed any significant consequences for patient turnover. Participant 4 said: ‘The disadvantage is that there may be a backlog in the post-operative ward, but it’s not a major problem.’

    Discussion

    The objective of this study was to investigate the experiences of anaesthetic nurses at the pre-, peri‑, and post-operative stage with the use of intranasal dexmedetomidine as premedication for children who will be placed under general anaesthesia. In the discussion we will mainly focus on the pre-operative stage, because this stage is considered critical and the most comprehensive findings are also related to this stage.

    Pre-operative experiences and experiences during induction

    The pre-operative stage is challenging and encompasses the time from when the patient is admitted, premedication is administered and anaesthesia is induced (20). The anaesthetic nurse focuses on observing, identifying and assessing the child’s needs and on implementing measures to ensure that the treatment programme is individually adapted to the greatest possible extent. The objective of these measures includes ensuring patient safety and appropriate execution of tasks, thus to avoid adverse events (12, 13).

    The anaesthetic nurses included in this study had observed that dexmedetomidine induced good sleep preoperatively when sufficient time was allotted to let the drug take effect. When it worked as intended, the children slept through the insertion of a venous cannula and the induction of anaesthesia. The informants did not describe any adverse effects in the form of respiratory depression or circulatory disturbances that required treatment.

    The anaesthetic nurses reported positive experiences when dexmedetomidine ‘worked as intended’. They nevertheless described a number of challenges associated with dexmedetomidine used as premedication. Issues included absent and variable effects and onset times with identical dosages, especially at the breaking-in stage when the drug was unfamiliar to them. The literature indicates that in order to be effective, premedication should have a rapid and reliable onset (1).

    The participants’ experience of varying effects and onset times can be related to the fact that the drug is administered via the intranasal route, which gives a more unreliable onset than intravenous administration, for example. Knowledge about pharmacokinetics and pharmacodynamic properties is therefore essential when anaesthetic nurses administer drugs, including with a view to patient safety (21, 22). Provision of individually adapted dosages and prevention of adverse events should be a goal (21).

    Easy to wake up

    All of the anaesthetic nurses described how the children could easily be woken up from sedation with dexmedetomidine. For example, they needed to find the optimal time and the best procedure for inserting a venous cannula and starting the induction of anaesthesia without the child waking up. According to the participants, this timing was ‘an art’.

    All of the anaesthetic nurses described how the children could easily be woken up from sedation with dexmedetomidine.

    According to Yuen (23), sleep induced by dexmedetomidine resembles regular sleep, and the level of sedation is dose-dependent. Lower plasma concentrations result in lighter sedation. The experience of our participants could also be related to the fact that stimulation ought to happen at maximum plasma concentration of dexmedetomidine (22).

    Correct dosages for different children

    The anaesthetic nurses had found positive experiences with doses of 2 µg/kg to the youngest children, aged one to four years. They reported that in the beginning they faced some challenges in finding an appropriate dosage for children over the age of four. When the effect was unsatisfactory, they repeated the initial dosage. Some of them also reported that for children weighing more than 12 kg, they adjusted the dosage upwards to 2.5 µg/kg. The time of onset was reported as lasting from 20 minutes to one hour.

    These findings are largely consistent with the findings in the study conducted by Yuen and collaborators (24). The latter study indicates a time of onset varying from 25–30 minutes after a dosage of 1 µg/kg. The findings in our study corroborate those of Yuen and collaborators (25), which describe how children from five to eight years had a significantly poorer effect of a dose of 1 µg/kg when compared to children aged 1–4 years. They conclude that a dosage of 2 µg/kg results in a satisfactory sedation of children (25).

    Our findings show, however, that such premedication for the oldest children more often must be assessed individually. A recent study by Tug and collaborators (26) indicates that dexmedetomidine in doses of 4 µg/kg could be administered to sedate children from one to 10 years for MRI scanning without detection of respiratory depression or circulatory disturbances that required treatment.

    The findings in our study corroborate previous research on the challenges involved in finding the correct dosage of intranasal dexmedetomidine (25, 26). These studies nevertheless describe dexmedetomidine as a safe drug, even when used at high dosage.

    Collaboration is essential

    The anaesthetic nurses believed that the long onset time of the drug might cause problems for patient flow, especially at the start of work in the morning. They said that for the children to benefit from dexmedetomidine as premedication, the drug needed to take effect before they started working with the children. The anaesthetic nurses described interdisciplinary collaboration in the department as crucial to solving logistical challenges.

    This practice illustrates Bjørk and Solhaug’s (27) description of how innovations are introduced. This is not a solo task, it depends on collaboration among all members of the ward community to succeed. Some participants emphasised how collaboration across professional groups gave rise to shared ‘ownership’ of the project. This sentiment promoted a proactive approach and a positive commitment in the units, and a focus on the best interests of the child.

    Many participants described how efficiency improved when dexmedetomidine worked as intended and planning succeeded. Our findings elucidate the high level of motivation among the staff to succeed with the use of dexmedetomidine, despite the challenges involved. It became clear that the anaesthetic nurses have felt the need for a suitable alternative drug for premedication of children.

    The anaesthetic nurses described how the successful introduction of dexmedetomidine depended on collaboration with the department’s anaesthesiologist. The anaesthesiologist’s knowledge about the drug and belief in its suitability as a paediatric premedication meant that the introduction process enjoyed strong support.

    Flynn and collaborators (12) emphasise the importance of good teamwork between the anaesthesiologist and the anaesthetic nurse as a factor that ensures provision of appropriate health-promoting measures to patients and improves patient safety. Good teamwork is characterised by mutual trust and respect for the expertise of the other (12). The anaesthetic nurses in our study highlighted exactly this kind of collaboration with the anaesthesiologist.

    Bjørk and Solhaug (27) describe that in order to succeed, it is extremely important for professional development projects to be endorsed by the department management or other people in authority. Findings in our study clearly show the complexity involved in introducing new medical routines. Concerns for efficient and safe running of the unit must be prioritised, although the most important factor is the way in which the children and their parents perceive the treatment programme. Developing such projects requires information flow and collaboration between the professional groups in the institution (27).

    The drug was not anxiety-inducing

    The participants perceived the induction of anaesthesia with the sleeping children as safer than with children who are awake and resist. According to Scully (7), children’s anxiety with regard to the unknown increases at this stage, and the induction of anaesthesia may thus be a negative experience. The risk of anaesthesia-related complications is generally higher at the induction stage. Crying and resistance may increase this risk even further (7, 28). The findings in our study indicate that dexmedetomidine as paediatric premedication has favourable effects at the induction stage of anaesthesia and causes a minimum of complications when the necessary precautions are taken.

    Peri- and post-operative experiences

    The participants described the perioperative stage as calm and stable. Previous studies indicate that dexmedetomidine may reduce the need for anaesthetic drugs perioperatively and prolong the effect of opioids, which may entail a reduced need for analgesics postoperatively. The studies also indicate that dexmedetomidine as premedication protects better against postoperative agitation than midazolam (3, 8, 29).

    The anaesthetic nurses described recoveries that were characterised by less crying, agitation and pain. The participants clearly emphasised that the specialist nurses who monitored the children postoperatively preferred dexmedetomidine over midazolam as premedication. These findings corroborate studies that describe the sedative and analgesic properties of dexmedetomidine (1, 8, 21).

    The anaesthetic nurses described recoveries that were characterised by less crying, agitation and pain.

    The half-life of two to three hours explains why the children may benefit from the drug at the early postoperative stage after short interventions (3, 8, 21). Our findings corroborate that the premedication has a beneficial effect on the entire course of the anaesthesia process (8).

    Methodological considerations

    By using a phenomenological-hermeneutic approach we have gained a deeper understanding of the participants’ experiences. These experiences have in turn helped provide an important basis for interpretation and new knowledge about this topic. The intra-sample variation in age, gender, department culture, professional experience and experience with the use of dexmedetomidine produced largely identical data, which is evidence of a high degree of consistency in the data material, which in turn is corroborated by recent research.

    We also believe that such intra-sample variation has reduced the risk of biased elucidations of the research question. In our opinion, the study’s sample and informational strength are satisfactory in light of the objective, composition of the sample, theoretical basis, data quality and analysis (30).

    None of the authors had any affiliation with the hospitals from which the participants were recruited. This may have helped provide distance and an ‘outsider’s’ view of the data. In addition, the first author, who also conducted the interviews, had prior experience with dexmedetomidine through a pilot project undertaken at her own workplace involving children who were to undergo an MRI scan while under anaesthesia.

    The preconceptions that the first author brought with her into the study may have had an effect on our choice of research questions, how the interviews and analyses were conducted and the findings that we present. The authors’ long-standing experience of this research field as professional anaesthetic nurses may have helped provide unique insights that enabled the identification of patterns and complexities that would have been less obvious to outsiders (18).

    To ensure credibility we included the voices of the participants, described the analytical steps and made the abstraction process transparent. The first and third authors have primarily undertaken the data analysis, first individually and then jointly to achieve consensus on the categories chosen and the design of the topics, and to prevent biased interpretations of the data material (17).

    Our findings may be transferable to other departments where anaesthesia personnel are working with children, if the department culture and context are taken into consideration. Data collection methods and analyses may also be transferable. The findings must nevertheless be interpreted in light of their basis in the experiences of a small sample of anaesthetic nurses with a permanent workplace.

    Implications for practice

    The findings show that the anaesthetic nurses administer a drug which is well suited as premedication, provided that the given precautions are taken. Dexmedetomidine has helped provide better treatment options for children and is evidently safe in use. The sleep-inducing properties of this drug can be made use of to undertake simple and less painful procedures on children. The findings indicate that such systematic change processes should be introduced by way of internal pilot projects.

    Implications for further research

    We suggest that further research ought to focus on ways in which the potentiating effects of dexmedetomidine with regard to analgesics and anaesthetic drugs could be exploited in multimodal treatment and be included in general anaesthesia for an individually adapted treatment programme.

    We also recommend that further research be undertaken on how these sleep-inducing properties can be exploited to enable various procedures and examinations. Finding the correct dosage of dexmedetomidine has proven to be a challenge, and we recommend further research related to age, weight and dosage.

    Conclusion

    The study provides new knowledge from the anaesthetic nurse’s perspective on the properties and suitability of dexmedetomidine as paediatric premedication. The anaesthetic nurses’ experiences are generally of a positive nature, and dexmedetomidine has a beneficial effect on the pre-, peri- and post-operative anaesthesia process in children.

    Successful use of dexmedetomidine requires that special and individual precautions be taken at all stages of the anaesthesia process. We nevertheless regard the disadvantages as minor when compared to all the advantages that we have shown.

    References

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    4.       Ghai B, Jain K, Saxema AK, Bhatia N, Sodhi KS. Comparison of oral midazolam with intranasal dexmedetomidine premedication for children undergoing CT imaging: a randomized, double-blind, and controlled study. Pediatric Anesthesia. 2017;27(1):37–44. DOI: 10.1111/pan.13010.

    5.       Neville DNW, Hayes KR, Ivan Y, McDowell ER, Pitetti RD. Double-blind randomized controlled trial of intranasal dexmedetomidine versus intranasal midazolam as anxiolysis prior to pediatric laceration repair in the emergency department. Academic Emergency Medicine. 2016;3(8):910–7.

    6.       Mountain BW, Smithson L, Cramolini M, Wyatt TH, Newmann M. Dexmedetomidine as a pediatric anesthetic premedication to reduce anxiety and to deter emergence delirium. AANA Journal. 2011;79(3):219–24.

    7.       Scully SM. Parental presence during pediatric anesthesia induction. AORN Journal. 2007;96(1):26–33. DOI: 10.1016/j.aorn.2011.07.020.

    8.       Peng K, Wu S, Ji F, Li J. Premedication with dexmedetomidine in pediatric patients: a systematic review and meta-analysis. Clinics. 2014;69(11):777–86. DOI: 10.6061/clinics/2014(11)12.

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    13.     Jeon Y, Lahtinen P, Meretoja R, Leino-Kilpi H. Anaesthesia nursing education in Nordic countries: Literature review. Nurse Education Today. 2015;35(5):680–8.

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    26.     Tug A, Hanci A, Turk HS, Aybey F, Isil CT, Sayin P, et al. Comparison of two different intranasal doses of dexmedetomidine in children for magnetic resonance imaging sedation. Pediatric Drugs. 2015;17(6):479–85. DOI: 10.1007/s40272-015-0145-1.

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    Publication type
    Publication Year
    2018
    Edition Year
    13
    Publication Number
    71340
    Page Number
    e-71340

    Anaesthetic nurses found that the children were easier to wake preoperatively and that their awakenings were calmer and less painful.

    Article is Peer Reviewed
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    Research
    English
    Sammendrag

    Background: Nasal administration of the drug dexmedetomidine is increasingly used for children who need sedation and premedication before anaesthesia and surgery. Midazolam, which currently is most widely used, is associated with a number of adverse effects. There is thus a need for alternative paediatric premedication to improve treatment provision.

    Objective: To provide new knowledge on the properties of dexmedetomidine and how this drug is suited as premedication for children who will be given general anaesthesia, seen from the perspective of the anaesthetic nurse.

    Method: We conducted semi-structured interviews. The sample consisted of six anaesthetic nurses from two day surgery units in two different hospitals. We analysed the data with the aid of qualitative content analysis.

    Results: We identified two main topics: 1) Dexmedetomidine as premedication has favourable properties throughout the anaesthetic process. 2) Necessary precautions need to be taken throughout the anaesthetic process to ensure that no complications arise when dexmedetomidine is used as premedication. In general, the findings show that dexmedetomidine provides satisfactory sedation in the form of sleep preoperatively. It is found that the children are easy to wake up from their sedation. This means that the children need minimum exposure to stimulation before and during the induction of anaesthesia. However, the long onset time of dexmedetomidine necessitates interdisciplinary collaboration to achieve an efficient patient flow. The anaesthetic nurses did not describe any serious adverse effects of the drug.

    Conclusion: New knowledge from the perspective of the anaesthetic nurses shows that dexmedetomidine is perceived as a suitable alternative to premedication for children. The disadvantages were described as minor when compared to the advantages provided by dexmedetomidine used as premedication, with favourable effects prior to, during and after surgery. The anaesthetic nurses faced some challenges in the use of dexmedetomidine at the start of the introduction process, but experience with the drug’s properties showed that to use it successfully and safely, necessary precautions must be taken throughout the anaesthetic process. The findings show that new procedures should be introduced by way of internal pilot projects.

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  • Public health nurses make active use of a parental guidance programme in their practice

    The relationship between children and their caregivers early in life is important for children’s development, quality of life and health throughout their lifetime (1–3). Public health nurses have contact with the youngest children and their families through child health centres. It is essential that the health-promoting work of public health nurses encourages positive interaction between parents and children. National guidelines for child health centres and the school health services (4) identify parental guidance as a development-promoting and preventive psychosocial service that encourages positive interaction.

    There is solid evidence that parental support programmes have a positive impact (5–7). In Norway, the International Child Development Programme (ICDP) is one of the frequently used parental guidance programmes. Since 2010, about 120 public health nurses have been certified in ICDP as a part of their continuing education.

    The parental guidance programme ICDP

    The ICDP is a relatively simple preventive programme for improving social interaction. The ICDP is used in many countries (8, 9), and the Norwegian Directorate for Children, Youth and Family Affairs uses the programme frequently. The ICDP was developed by professors Karsten Hundeide and Henning Rye of the University of Oslo in the 1980s and 1990s as a way of translating research into practice.

    They based their work in part on knowledge about children as active participants in social interaction (10, 11) and on the findings that parents’ own ideas and feelings affect how they act towards their children (12, 13). The main focus of the programme is to help children by enhancing the parents’ competence in caregiving. This is done by acknowledging what parents are doing well, activating their sensitivity and increasing their understanding of their child.

    The ICDP is a relatively simple preventive programme for improving social interaction.

    The ICDP consists of principles for sensitising parents and three dialogues: the emotional, the meaning-creating and the regulatory. The dialogues are divided into eight guidelines for good quality interaction:

    • Show positive feelings – show that you love your child.
    • Adjust yourself to your child and follow your child’s lead.
    • Talk to your child about his/her interests.
    • Praise and acknowledge your child for what he/she is able to do.
    • Draw attention to shared experiences.
    • Create meaning by describing experiences with emotion and enthusiasm.
    • Elaborate on and explain shared experiences.
    • Make plans together and set boundaries in a positive manner.

    The programme is carried out under the direction of a certified ICDP facilitator with eight weekly group meetings of 1.5 to 2 hours involving parents or other caregivers. Emphasis is placed on sensitising the parents through individual activity, participation and reflection (8).

    An evaluation of the ICDP showed a positive impact on the interaction between parents and their children (14). The basic components of the ICDP were used together with a trauma approach in a randomised, controlled study during the war in Bosnia in the 1990s (15). The results indicated that the children of mothers who took part in the group intervention had better physical, cognitive and emotional health than the control group after six months.

    The effect of the entire programme with eight group meetings has previously been evaluated based on the experiences of parents (14, 16). We found only one peer-reviewed study that investigated the experiences of ICDP facilitators (17). This study concludes that there are challenges entailed in implementing the programme in its entirety. This finding corresponds with the feedback we received from public health nurses in the field of practice who are certified ICDP facilitators. They explain that they are seldom able to hold eight parent group meetings as part of the ICDP programme, but that they use the methodology in their interactions with parents at the child health centres. We found no peer-reviewed studies in our literature search that provided any information about how the ICDP was used when the nurses did not conduct eight weekly group meetings.

    Objective of the study

    The objective of our study was to gain knowledge of the public health nurses’ experiences with how they applied and benefited from their ICDP parental guidance expertise in their interaction with parents and children in their ordinary consultations at the child health centres.

    Method

    Design

    To try to understand the public health nurses’ experiences with how they applied and benefited from their ICDP facilitator expertise in their interaction with parents and children at the child health centres, we chose to use a qualitative method and conducted seven semi-structured interviews.

    We asked the following research questions:

    • What are the public health nurses’ experiences with using their ICDP facilitator expertise?
    • According to the nurses, how can they promote positive interaction between parents and their children?

    Participants

    The study participants were seven public health nurses certified in the ICDP parental guidance programme who worked at child health centres. To recruit participants, the lead author sent an email with information about the study to randomly selected public health nurses from three previous classes of nursing students in three different counties. The first eight nurses who gave a positive response to the inquiry and worked at a child health centre, but who did not apply the entire ICDP programme, were invited to participate. Only one of those asked to participate declined to take part.

    Conducting the interviews

    The lead author conducted all the interviews in the period from May to June 2016. The interviews lasted about one hour and were held at the workplaces of the individual nurses. The following is an example of the questions we asked: ‘What are your main concerns in consultations with regard to parent-child interaction?’ Follow-up questions were, for instance: ‘How do you do that?’ and ‘How do the parents respond to that?’

    The interviews were recorded on a dictaphone and transcribed in their entirety. The interviews took the form of a dialogue using an appreciative approach, while at the same time we interpreted the informant’s statements during the dialogue.

    Analysis

    The lead author analysed the text in a four-step procedure using systematic text condensation with an interpretive approach (18) (Table 1). In the first step, the lead author read the material numerous times and took notes on her reflections before writing down her overall impression and identifying preliminary themes.

    On the basis of these themes, she reviewed the text again in step 2 by coding the content with different colours as she noticed a new theme in the text. She identified seven themes. The text segments that made the individual themes meaningful were removed from the original context and sorted under each individual theme (decontextualisation).

    In step 3, the text under the seven preliminary themes was condensed by shortening each statement, while simultaneously ensuring that the meaning and content of the text was preserved. In addition, the lead author reviewed all the condensed text and sorted the seven themes into five categories with sub-categories.

    In step 4, the lead author reviewed the condensed text in light of the research questions. The categories and sub-categories were reorganised into three main categories that comprised the essence of the condensed material. The lead author then prepared an analytical text that described and gave meaning to these three categories, which are described as findings.

    The second author reviewed the transcribed interviews again. She looked for other possible themes and interpretations. In the final step, all the authors reviewed the material one more time and discussed it to see whether the findings from step 4 corresponded with the original content of the interview material.

    Table 1. Example of analysis from meaning-bearing unit to finding

    Ethical considerations

    The participants signed an information and consent form prior to the interviews. The audio recordings of the interviews were stored in a secure location and deleted after they were transcribed. The recordings did not contain personal information, the informants could not be identified, and the project was not required to submit reports to the Norwegian Data Protection Authority. We made sure to use an appreciative approach during the interviews, and the participants said that they had a positive experience.

    Results

    We present findings from the study using three main categories that describe how the ICDP facilitator expertise is applied and beneficial in consultations at the child health centres with a view to promoting positive interaction between parents and their children:

    • The ICDP has provided the public health nurses with a useful conceptual framework
    • The public health nurses put emphasis on enhancing parents’ perception of their own competence.
    • The public health nurses focus on the parents’ ability to see and understand their child.

    The ICDP has provided the public health nurses with a useful conceptual framework

    The public health nurses said that the guidance they provide to parents in consultations at child health centre is usually situational and short term in nature. They explained that the ICDP has given them a conceptual framework and tools for their daily work and that they use these in their observations, communication, guidance and documentation. Several of them said that they have integrated the ICDP components into their professional practice:

    ‘I use the principles as a basis for the perspective I have.’

    ‘I’m pleased to have the ICDP because it gives me a way of talking about the interaction.’

    Although they used all the ICDP guidelines in their professional and personal approach to parents and when advising them, the nurses highlighted two factors in particular: 1) praise and acknowledgement, and 2) how to understand the child. The nurses stressed the importance of praising and acknowledging the parents for what they did well in order to develop a good relationship with them.

    The public health nurses believed that acknowledgement has significance for their ability to step into the role of parental adviser and for being able to address difficult topics during the conversation: ‘I’m very focused on what they do well, and what I see is positive. They are then more open to discussing the difficult things and are more receptive to my guidance.’

    The public health nurses said that they use the ICDP when they teach and advise on what children need at various stages of their development. They also use the ICDP to make parents aware that their child is a separate individual who needs love and acknowledgement.

    I’m pleased to have the ICDP because it gives me a way of talking about the interaction.
    Informant

    The public health nurses emphasised that the eighth guideline in the ICDP on positive boundary setting and regulation was useful for providing concrete alternatives to child-rearing violence. They believed that positive boundary setting can also reduce tiresome daily conflicts. ‘There can often be a lot of scolding about small things in a busy daily life. They find that there is less arguing when you praise the things that are good, which makes you want to do more of it.’

    The public health nurses put emphasis on enhancing the parents’ perception of their own competence

    A general finding was that giving acknowledgement to parents helps to enhance their perception of their own competence in interacting with their child. The public health nurses said that they advise the parents so that the parents themselves can find solutions that work for them. Several nurses emphasised that this guidance must be delivered in a ‘non-didactic manner’, and that instead they must ‘ponder it together with them’, while giving the parents advice and information at the same time.

    The public health nurses explained that they focus on voicing what is good about the interaction and that it is important the parents feel that they are good parents: ‘I think it’s essential that parents feel competent so that they can be confident parents and not ambivalent in their child-rearing role. If they feel insecure, the children will be insecure. When we focus on the things they do well and praise them for it, I find that they do more of that.’

    The public health nurses believed that the acknowledgement and guidance they give parents can help to bolster their confidence in their role as a parent:

    ‘Having competence is not enough. They must believe that they can use it properly, have faith in themselves.’

    ‘I hope in each consultation that they leave with a better feeling, a little more confident about what they are doing.’

    The public health nurses focus on the parents’ ability to see and understand their child

    The public health nurses explained how in the home visit one week after the birth they start sensitising the parents by raising their awareness of the importance of seeing things from the child’s perspective, getting them to describe and praise the child, and giving the child positive attention. One example of this is the importance of becoming familiar with the child’s temperament and personality from early on by following the child’s lead and interpreting the child’s signals.

    The nurses said that they ‘make positive comments’ and describe how they see the parents expressing love to their child. All the participants were concerned about getting the parents to see the child, understand the child and his or her signals, and respond adequately to them.

    The participants in the study believed that one way to promote positive interaction was for the parents to imagine what it is like to be the child and understand his or her behaviour in relation to the context the child is in. It was said that children need to become familiar with their feelings, and the nurses encourage the parents to describe those feelings for the child when the child is angry or sad, for example.

    By doing this, the child can feel seen and understood, and consequently can settle down more quickly: ‘Some parents have a need for the child to stop crying immediately after getting a vaccine, for example. They have a smoothie, milk and dummy at the ready. I say in advance that it’s alright to let the child cry a little and get some confirmation that it actually did hurt a little before they give the child a dummy.’

    The participants said that the ICDP guidelines helped the parents to understand what is behind the child’s behaviour, especially when the parents speak of the behaviour in negative terms: ‘When they say that their children are obstinate, I try to change the focus by pointing out that they are independent. After all, that’s what they should learn to become.’

    The informants said that parents’ perception of the child is critical for the care they give. Seeing and acknowledging the child just as he or she is form the basis for interaction that promotes development. Some informants said that when parents express a negative view of their child, they can also sometimes see a negative pattern of interaction that may have unfortunate consequences for the child:

    ‘My main goal is to get them to understand what is happening inside the child. The perceptions you have of your child is the basis for how you interact with him or her. If you mainly see your child in a negative light, then your child has lost.’

    Discussion

    The main findings of this study are that the public health nurses give a rich description of the many ways that they can promote positive interaction between parents and children and that the ICDP methodology and guidelines are reflected in their general description of how they can promote positive interaction. In their experience, the ICDP is valuable and useful in their daily work, even when they do not use structured group meetings based on the eight guidelines.

    In their experience, the ICDP is valuable and useful in their daily work, even when they do not use structured group meetings based on the eight guidelines.

    The public health nurses said that they apply the knowledge and guidelines on interaction from the ICDP and that they have acquired a conceptual framework and a professional approach to the parents that is useful in consultations at the child health centre. The participants’ choice of words in the interviews also reflects concepts from the interaction guidelines and sensitising principles in the ICDP programme.

    Systematic follow-up requires regular group meetings

    The ICDP prioritises the parents’ own activity and reflection over instruction (8). In the conversations about consultations, the public health nurses show special interest in how the parents perceive their interaction with their child in daily life, and they encourage the parents to reflect on what they talk about. Both the parents’ perception of the child and acknowledgement of the parents’ competence in caregiving are key aspects of the nurses’ conversations with the parents.

    These principles are fundamental in the ICDP and are implemented in the consultations. However, without regular group meetings, as the ICDP calls for, there is no systematic follow-up of the parents’ reflections on the eight guidelines for good quality interaction.

    Although the goal of the study was not to compare the ICDP components used by the public health nurses in consultations with the full ICDP programme, it is interesting to consider the advantages and disadvantages of various work methods. There is less opportunity for individual activity and sharing of thoughts and experiences in consultations than in the eight weekly ICDP group meetings.

    The public health nurses are in a position where they can begin a process of sensitising, raising awareness and providing guidance as early as the child’s first week of life. As such, they have a golden opportunity to help the parents develop a positive, secure pattern of interaction from the very start of the child’s life. They also have the opportunity to follow up in the twelve ordinary consultations at the child health centre in the child’s first two years of life.

    The public health nurses can reach out to more parents by integrating their ICDP knowledge into ordinary consultations at the child health centres.

    In the national guidelines for child health centres and the school health services, the Norwegian Directorate of Health recommends that six of the ordinary consultations at the child health centre take place in groups (4), which also offers the opportunity for sensitising as parents share their experiences.

    The public health nurses can reach out to more parents by integrating their ICDP knowledge into ordinary consultations at the child health centres. At the same time, they can probably not expect to see changes in the parents similar to that which occurs in a group intervention spread over several weeks. In group interventions, they test out and share experiences in practice, which has been shown to be important for achieving lasting change (14, 19).

    The cognitive aspect is downplayed

    The findings illustrate a characteristic of the ICDP, namely, ‘its focus on the caregiver’s perception (definition) of the child as crucial for the quality of the interaction that will follow’ (8, p. 21), which is also supported by experience internationally (13, 20). The ICDP appears to encourage the public health nurses to focus on exploring parents’ thoughts and feelings. The programme is a practical tool, too, as it may help to reduce advice and attempts to change behaviour that are not based on what the parents already think and do.

    When the public health nurses reflect on which components of the ICDP they apply, they highlight the emotional and regulating components of the programme. They focus less on the pedagogical and cognitive components, such as putting experiences into words (8). It is possible that the nurses do not give priority to the cognitive aspect.

    However, it is also possible that they actually use the cognitive aspect, but that they take it for granted, or that they thought the interviewer was interested primarily in the emotional and regulating aspects. The cognitive aspect has previously been shown to be essential for children’s development (21) and this would be interesting to study further, possibly following up with observational studies.

    Reliability and limitations of the study

    The findings of this study do not apply to public health nurses in general. The study is based on the participants’ reflections, not on observation, and gives no indication of what the public health nurses actually do or how the parents perceive their interaction with the nurses.

    The lead author is a public health nurse and teaches in the ICDP. This may have helped to ensure that the questions were relevant and that there was an atmosphere of trust during the interviews, but may also have contributed to some components being overlooked or participants viewing the ICDP in an overly positive light. We tried to minimise the lead author’s impact by documenting her prior understanding throughout the entire research process.

    The lead author provided information about her role as a researcher before the interview and examined statements that were not related to the ICDP. None of the comments suggested that the lead author was perceived as being an exponent of the ICDP. The effect could also have been the opposite if the participants thought that the interviewer wanted the ICDP to be used in keeping with the intention.

    The reliability and interpretation may also have been affected by the lead author’s in-depth knowledge of the guidelines so that we overestimate the significance of the ICDP components in the data. The study’s reliability is enhanced, however, because we paid systematic attention to the lead author’s prior understanding and because the second author read all the interviews and looked for alternative interpretations and perspectives. Secondary analysis is a controversial practice, but is nonetheless used extensively and has resulted in greater transparency (22, 23).

    The study’s contribution to the ICDP knowledge base

    Despite the study’s limitations, it increases knowledge about the programme. The ICDP principles were used previously in an intervention study without applying the entire methodology (15, 24), and the findings are comparable in the sense that the informants thought that the guidelines were relevant and appeared to have positive results.

    Our study cannot speak to whether public health nurses with an ICDP certification are better or less prepared than public health nurses without this training. Recent studies show that it can be beneficial to use established programmes rather than create news ones that are adapted to the context in question (25).

    One of the strengths of the ICDP is cultural adaptation, since the programme is based on fundamental needs and universal activities. Another key aspect is the importance of activating existing patterns of caregiving.

    Internationally there is a dire need for better measures that promote the development of the youngest children, especially measures that prevent violence. The World Bank (29) documents that such support should include the parents’ perceptions of their child and focus on emotional development, cognitive development and positive regulation. The ICDP is one of the programmes that addresses this challenge, and this study helps to expand its knowledge base.

    Conclusion

    The public health nurses who took part in this study said that the ICDP has been an integral part of their way of approaching parents and children in consultations at child health centres. The ICDP influences what they choose to focus on and how they provide guidance so that parents and their children interact in a positive manner.

    The nurses said that the ICDP has given them confidence, which they believe is useful in their role as adviser even when they are unable to hold eight weekly group meetings at the child health centres as part of the programme. From this perspective, it appears that the ICDP facilitator training is valuable, even when it is not used as intended.

    We wish to thank the public health nurses who took the time to share their experiences with us.

    References

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    2.       Hart S, Schwartz R. Fra interaksjon til relasjon: Tilknytning hos Winnicott, Bowlby, Stern, Schore og Fonagy. Oslo: Gyldendal Akademisk; 2009.

    3.       Black MM, Walker SP, Fernald LCH, Andersen CT, DiGirolamo AM, Lu C, et al. Advancing early childhood development: from science to scale. Early childhood development coming of age: science through the life course. The Lancet. 2017;389(10064):77–90.

    4.       Helsedirektoratet. Helsestasjons- og skolehelsetjenesten. Nasjonal faglig retningslinje for det helsefremmende og forebyggende arbeidet i helsestasjon, skolehelsetjeneste og helsestasjon for ungdom. Oslo: Helsedirektoratet; 2017. Available at: https://helsedirektoratet.no/retningslinjer/helsestasjons-og-skolehelsetjenesten(downloaded 29.03.2017).

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    6.       Helle J, Boonstra JO, Broch KR, Rød BY, Vøllestad J. En god sirkel. Tidsskrift for Norsk psykologforening. 2017;54(6):546–57.

    7.       Britto PR, Ponguta LA, Reyes C, Karnati R. A systematic review of parenting programs for young children. New York: UNICEF; 2015.

    8.       Hundeide K. ICDP Programmet – et relasjonsorientert og empatibasert program rettet imot barns omsorgsgivere. Skolepsykologi. 2005;7:9–25.

    9.       Christie HJ, Doehlie E. Enhancing quality interaction between caregivers and children at risk: The International Child Development Programme (ICDP). Today's children are tomorrow’s parents. Journal of the National Network for Professionals in Preventing Child Abuse and Neglect. 2011;30:74–84.

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    13.     Super C, Harkness S. The developmental niche: A conceptualization at the interface of child and culture. International Journal of Behavioral Development. 1986;9(4).

    14.     Skar A-MS, von Tetzchner S, Clucas C, Sherr L. The long-term effectiveness of the International Child Development Programme (ICDP) implemented as a community-wide parenting programme. European Journal of Developmental Psychology. 2015;12(1):54–68.

    15.     Dybdahl R. Children and mothers in war: an outcome study of a psychosocial intervention program. Child Development. 2001;72(4):1214–30.

    16.     Sherr L, Skar A-MS, Clucas C, von Tetzchner S, Hundeide K. Evaluation of the International Child Development Programme (ICDP) as a community-wide parenting programme. European Journal of Developmental Psychology. 2014;11(1):1–17.

    17.     Westerlund A, Garvare R, Nyström ME, Eurenius E, Lindkvist M, Ivarsson A. Managing the initiation and early implementation of health promotion interventions: a study of a parental support programme in primary care. Scandinavian Journal of Caring Sciences. 2017;31(1):128–38.

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    23.     Bishop L, Kuula-Luumi A. Revisiting qualitative data reuse: A decade on. SAGE Open. 2017;7(1):1–15.

    24.     Dybdahl R. A psychosocial support programme for children and mothers in war. Clinical Child Psychology and Psychiatry. 2001;6(3):425–36.

    25.     Gardner F. Parenting interventions: How well do they transport from one country to another? Firenze: Innocenti UNICEF. 2017.

    Public health nurses make active use of the International Child Development Programme (ICDP) in their work to improve the interaction between parents and children.

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    Sammendrag

    Background: Positive interaction between children and their caregivers is essential for children’s development. Norwegian health policies emphasise the role of child health centres in improving such interaction. It is therefore crucial that public health nurses have expertise in promoting positive interaction.

    Objective: To investigate public health nurses’ experiences with using the skills they gained from their training in the parental guidance programme known as the International Child Development Programme (ICDP) during their continuing education in nursing.

    Method: The study is qualitative and based on seven semi-structured, individual interviews with public health nurses who have been trained in the programme, but who only apply parts of the programme in their work at the child health centres. We analysed the data using content analysis inspired by hermeneutic interpretation and text condensation.

    Results: The participants appear to use the ICDP in consultations, both as a conceptual framework for interaction and as a tool in their observation, communication, guidance and documentation.

    The experiences of the public health nurses can be summarised in three main categories:

    The ICDP has provided the public health nurses with a useful conceptual framework.

    The public health nurses put emphasis on enhancing the parents’ perception of their own competence.

    The public health nurses focus on the parents’ ability to see and understand their child.

    Conclusion: When the public health nurses do not implement the ICDP in the form of structured group meetings over an eight-week period, they still apply the knowledge and way of thinking from the programme in their communication and guidance when observing children and parents.

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  • Measures to improve nurses’ working environment often target individuals

    Psychosocial phenomena such as conflicting roles, poor leadership, high emotional demands, stress and exhaustion together with the problem of integrity represent major challenges for the working environment in the health and care professions (1, 2). A number of people claim that both research and practical measures aimed at the psychosocial working environment pay undue attention to approaches targeting the individual (1, 3). Consequently, it is argued that psychosocial working environment challenges must increasingly be examined in light of the physical, social and organisational aspects of the working environment and dealt with accordingly (3, 4).

    The practical implementation of efforts to improve the working environment mainly takes place in the field of health, safety and the environment (HSE) and human relations (HR) – or personnel management. Clinical incident reporting, quantitative assessments of the working environment and performance reviews are key instruments in mapping the working environment and introducing new measures.

    In the health service, the clinical incident reporting system is part of the overall quality system in which clinical incidents involving patients, HSE incidents and other adverse events are reported electronically. In general, clinical incidents in the health service are defined as adverse events or breaches of quality requirements, procedures, guidelines and laws that are intended to safeguard patients and staff and ensure a good living and working environment (5, p. 32).

    HSE incidents

    However, in this article we discuss HSE incidents rather than incidents involving patients. HSE incidents are adverse events that relate to the working environment, and are underpinned by the internal control requirement of the regulations concerning management and quality enhancement in the health and care services (6). This is an important distinction because HSE incidents and incidents involving patients are often confused in practice.

    In principle, clinical incident reports concern individual events with potentially negative consequences for the employee. This is also how we refer to a clinical incident in this article.

    Assessments of the working environment

    Quantitative assessments are often conducted as measurements of employee satisfaction and are frequently based on the assessment requirement in the Regulations relating to Systematic Health, Environmental and Safety Activities in Enterprises (Internal Control Regulations) or the regulations concerning management and quality enhancement in the health and care services.

    However, such assessments often have a more HR-based motivation that entails acquiring knowledge about management, organisation and development potential. With regard to performance reviews, these are carried out systematically in the form of discussions about personal and professional development between the staff member and manager, and are both an HSE and an HR initiative (7).

    The questionnaire as a method individualises, since the prime focus is on individual experiences.

    A number of people have pointed out that these systems do not sufficiently capture the complexity of the psychosocial working environment, and that working environment problems tend to be individualised through these systems (8–10). Clinical incident reporting is, by definition, about individual events – and has thus a tendency to trigger measures targeting the individual who reported the incident.

    The questionnaire is criticised as a method because it individualises, since the prime focus is on individual experiences. The knowledge generated by the questionnaire is easily transferrable and applicable in terms of individual measures. Performance reviews with a line manager are often aimed at solving the particular challenges of the employee in question, and do not contribute to the development of the working environment as a whole.

    The objective of the study

    In this article we wish to examine the challenges posed by the nurses’ psychosocial working environment, and to critically reflect on systems related to this such as working environment measures, as opposed to a ‘settings perspective’. The latter concept entails developing the working environment and health at the workplace by changing systemic and organisational factors.

    In a settings perspective, assessment and a solution-oriented approach to working environment issues should primarily take into account the framework conditions at the workplace (3, 4). We wish to answer the following research questions:

    • How do the nurses experience the hospital’s efforts to deal with psychosocial working environment challenges?
    • What opportunities do the nurses have to make their opinions heard about working environment challenges at the hospital?

    Method

    The study builds on a qualitative design using focus group interviews. We chose focus groups because we wanted to find out more about informants’ in-depth experiences of psychosocial working environment systems. It is reasonable to assume that such experiences will best be expressed through staff discussions, which foster the voicing of viewpoints and opinions.

    The focus group interviews generate a different kind of data than individual interviews, for example (11). Focus group participants have the opportunity to ask each other and the researcher questions, thereby developing reasoning and new insights that they would not have gained from individual interviews (12).

    The empirical data were collected and analysed in part in connection with the first author’s master’s degree thesis in health promotion (13). In this article, we analyse more specifically the empirical data that deal with the working environment, i.e. the staff’s experiences of the incident reporting system, assessments and performance reviews.

    Sample

    The informants consisted of nurses from a medical ward and two surgical wards at a university hospital in Norway. A clinical nurse educator or a clinical nurse manager selected the informants at random. The sample consisted of twelve nurses, with both sexes represented. Both recently qualified and experienced nurses were included in the study. Each group included a safety delegate or a clinical nurse educator.

    Interview guide

    We devised an interview guide with five overarching questions. This functioned as a template for the focus group interviews. The focus group interviews adopted a funnel approach whereby the questions were open-ended at the start and became more rigidly structured towards the end (11). We conducted a pilot test of the interview guide in one focus group to test the questions and time required as well as to gain experience with the researcher role.

    Data collection

    The first author conducted three focus group interviews in autumn 2014. The conversations began with an introduction of the topic, and lasted for 90 minutes. We used a dictation machine in all focus groups, and noted key words during and immediately after each focus group interview. Afterwards we played back the conversation.

    Data analysis

    We analysed the data using a critical hermeneutic approach, applying a stepwise deductive-inductive analysis (14). This entailed first roughly coding the empirical data and then developing some general categories from the individual focus groups. Next, we wrote a so-called ‘ethnographic summary’ for each focus group (1, 12). An ethnographic summary is a summary of the key topics (categories) developed in the focus groups.

    The summary was written in a coherent form that was as understandable as possible for the participants. We then submitted it to the participants to read through. After they had given their feedback, the summary was used in the further hermeneutic analysis process.

    An important part of this process concerns clarification of one’s own preconceptions. We attributed great importance to such clarification since the first author is a nurse. This entailed a general risk of bias when we interpreted the empirical material. We attempted to solve this challenge by working systematically with self-reflection in connection with the analysis. Specifically this meant interpreting the data in accordance with the double hermeneutic (15).

    Ethical considerations

    We reported the study to the Norwegian Centre for Research Data and the data protection officer at the hospital. The nurses received an information letter about the project and signed a declaration giving consent to participation. No names are given in our material and we deleted the audio files at the end of the project. Confidentiality requirements have thus been complied with.

    Results

    The results are synthesised under three topics:

    • Clinical incident reporting
    • Quantitative assessment and HSE measures
    • Personal follow-up

    Incident reporting

    The nurses said that they did not write many clinical incident reports, and that HSE incidents were seldom reported: ‘I feel that submitting incident reports doesn’t help. We send one after the other but nothing happens. We don’t see any results from the incident report. We don’t know what has been done.’

    The lack of feedback was the most important reason for the informants writing few clinical incident reports. They found that there was little point in doing so: ‘Often you don’t have the time (to write an incident report). As a result, you probably have to work overtime to write the report. When you feel you don’t get any response anyway, it means that people don’t take the time.’

    I feel that submitting incident reports doesn’t help. We send one after the other but nothing happens. We don’t see any results from the incident report.
    Focus group participant

    The nurses said that they had little faith in the clinical incident reporting system. They did not believe that submitting reports promoted learning and better handling of the challenges the reports might have pinpointed: ‘I feel when we don’t report, this is used against us … Then management say: “You haven’t written any incident reports so everything must be fine.” But when we do, nothing happens anyway.’

    ‘When you talk to people about it, especially those who’ve worked in the field for a while, they say they can’t be bothered writing incident reports because nothing happens as a result. It’s such a shame that the system doesn’t work.’

    Even though the nurses had little belief that writing incident reports helped, they nevertheless expressed a kind of bad conscience about not being ‘good enough’ at submitting incident reports: ‘Things are not done because we’re understaffed. We need more resources … even though it doesn’t help, you should submit them.’

    Quantitative assessment and HSE measures

    The nurses had different experiences in relation to the annual employee survey at the hospital. The survey is a statistical mapping that includes the psychosocial working environment and assesses areas such as well-being, motivation and health.

    In the focus groups, the nurses discussed whether the employee survey is a suitable tool for pinpointing working environment challenges. The informants thought that, in principle, such a survey had the potential to elicit important knowledge about the working environment. However, the nurses also claimed that no one had experienced improvements in the working environment as a result of the survey.

    The groups had divergent experiences with regard to different kinds of health, safety and environment measures (HSE measures). The informants said that HSE measures were often directed at individuals. One example was how a specific working environment problem in one of the wards was handled. This was related to slander. The nurses wanted external help to solve the problem, which resulted in them receiving help from the occupational health service and the Norwegian Labour and Welfare Administration (NAV).

    The measure implemented was mandatory discussion groups for the staff of the ward in question. The nurses in the focus group explained that the slander occurred because of a heavy workload over time: ‘I think that the work pressure in the ward is so great sometimes that there’s a tendency to complain about each other … there can be a focus on what everyone else hasn’t done.’

    They also explained: ‘People become uncertain, so that you start to feel unhappy at work … You were frightened someone would complain about you, yes, frightened of being slandered.

    The nurses said that the occupational health service and NAV focused, however, on how the nurses should change their own behaviour. The nurses should become more aware of how they came across, and how that affected the ward’s psychosocial working environment.

    After participating in the discussion groups, one of the nurses remarked: ‘You have to look inside yourself first: “What could I have done to improve things?” … That seems to have helped … Then maybe you fall back into old ways now and then when there’s a lot of pressure and people are tired …. In a stressful everyday situation, I think it’s important to think about how you come across.’

    Personal follow-up

    The nurses described the various opportunities they had to express their opinions about the working environment. According to the nurses, the clinical nurse manager, who is their line manager, actually represents one of the most important channels when it comes to discussing issues related to the working environment.

    It is the clinical nurse manager that they are in daily contact with and that they perceive as having practical responsibility for the working environment. For the most part, therefore, this is the person to whom they communicate their input, their concerns and suggestions. Some people stated that information and feedback often stop at this level: ‘I feel that many people’s attitude is that it’s not worth saying anything, because nothing happens anyway. But it is important to speak up.’

    Others felt that the line manager had limited room for action: ‘She [the clinical nurse manager] can’t always do much about it, but we know that she works on our behalf.’

    Above all, the nurses felt the lack of a good dialogue with management and information about cases that concern them.

    The nurses said that management should be more adept at communicating their work processes and what action they have taken regarding the input from the nursing staff. The informants experienced that information was not always reported to the next level of the system after they had informed the clinical nurse manager.

    In general, the nurses felt that they had few opportunities to express their opinions about their work situation, whether it concerned the imbalance between tasks and resources or reorganisations that have major impacts on the working environment. In the case of top-down changes, they said: ‘You must feel valued as an employee. That you do things the proper way … and don’t make decisions over people’s heads and use people like pawns.’

    Above all, the nurses felt the lack of a good dialogue with management and information about matters that concern them: ‘We can try to convey this, but we have no proper communication channels.’

    Discussion

    Broadly speaking, a general picture emerges showing that working environment challenges are seldom handled as organisational issues through the tools we have examined here: clinical incident reporting, quantitative assessments and HSE measures in addition to personal follow-up.

    Clinical incident reporting

    The nurses were of the opinion that the lack of feedback and the absence of perceived improvement after submitting clinical incident reports were the most important reasons for the underreporting of deviations. They appeared to have lost faith in the clinical incident reporting system. This finding agrees with research showing that nurses generally experience a lack of feedback after reporting adverse events, and that the feedback is not always in accordance with the nurses’ view of the event (16–20).

    The nurses found that the incident reports had little impact on future practice, nor did they contribute to constructive organisational learning processes (17, 18). When the Norwegian Journal of Clinical Nursing asked its readers about their clinical incident reporting, over half of the nurses replied that there was no point in writing incident reports because management remained silent (5).

    Both Norwegian and international studies point to an underreporting of clinical incidents among nurses in hospitals (16, 17). Inspections following the God vakt (Good shift) action ascertained that there is an underreporting of HSE incidents in Norwegian hospitals. In particular, they emphasise that the imbalance between tasks and resources in the case of health personnel constitutes an area in which more deviation reports should be submitted (21, 22).

    Lundberg et al. (23) also claim that the models used as analysis tools for incidents do not adequately capture the complexity underlying adverse events. The result is that the incidents are not sufficiently scrutinised in relation to systemic, underlying conditions, i.e. the real reasons behind many of the incidents.

    The unintended consequences of treating incidents as individual events can lead to an individualisation of the challenges nurses meet in their everyday work. The general challenge in respect of adverse events is therefore not only that they are underreported. The handling of incidents should be analysed to a greater extent in an organisational and systemic perspective, thus enabling organisational learning (24).

    We hold the view that it is vital to involve the staff following the reporting of clinical incidents so that they can take part in the necessary analyses of the deviations; partly because it is essential that they help to interpret the incidents (what do they ‘really’ mean?) and partly because it is important to establish a communication channel between staff and management in respect of clinical incidents.

    In order to facilitate learning in the wake of adverse events, Aase and Wiig (24) recommend involving the staff, for example by face-to-face follow-up, and providing speedy feedback after incidents are reported. By being involved in this work, staff will be more inclined to feel that reporting incidents is worthwhile (16, 20, 24).

    Quantitative assessment and HSE measures

    The informants did not find that they had experienced improvements in the working environment as a result of the annual employee survey. On a more general level, the results of the employee survey from 2012 to 2015 showed that psychosocial aspects such as opportunities to participate, perceived control and workload received the lowest scores when all employees at the university hospital evaluated their own working environment.

    The results of the survey are intended to form a platform for improvement. The absence of improvements in connection with the three challenge areas at the hospital may have many explanations. Nevertheless, we are of the opinion that there are good reasons for scrutinising the assessment system itself. Hasle and Hvenegaard, who studied the psychosocial working environment in the big Danish research project on enterprises’ efforts to improve the psychological working environment (the VIPS project), found that managers and staff did not perceive there to be any correlation between questionnaires and visible results and initiatives (25).

    The employee survey at the university hospital is based on QPS Nordic (26), which according to Nordrik (8) is the most usual method of identifying working environment challenges in Norwegian companies. She claims that this type of quantitative measurement of the working environment is little suited to capturing the complexity of psychosocial working environment challenges (8).

    We believe that the low scores on opportunities to participate, perceived control and workload are primarily dependent on organisational factors.

    The reasons for this are that the questionnaires do not provide sufficient information about the underlying causes of the problems. Therefore, it is challenging to use them to accomplish specific improvement efforts. We believe that the low scores on opportunities to participate, perceived control and workload are primarily dependent on organisational factors.

    In our opinion, in order to work with this kind of working environment challenge we need knowledge that tells us more about underlying reasons and that can thus identify some organisational solutions to the problems. The employee survey can serve as an aid in the working environment assessment because it provides an overview of the working environment in the various units and of the line manager

    However, we lack methods that properly capture the experiences of staff and that have a strong focus on understanding how the organisation affects their working environment. Alternatively, we can use more democratic methods of pinpointing, understanding and working with psychosocial working environment issues (25, 27). The current design of the working environment assessment does not capture the complexity of psychosocial working environment challenges, which means that it is difficult to solve them. The nurses therefore face these challenges alone. 

    Measures initiated by the occupational health service and NAV in connection with slander problems are clearly characterised by an approach that targets individuals. One of the nurses said that the conversation groups had helped to some extent but that it was easy to backslide in periods of considerable stress. Measures that solely focus on individuals have limited impact if other factors are not also considered, for example framework conditions for the work (3, 4). 

    The Norwegian Labour Inspection Authority’s (22) audits of six Norwegian hospitals in 2014 showed that the occupational health service has a much stronger focus on the individual level than on organisational factors. This thematic area can be viewed in light of a trend in contemporary working life to solve psychosocial working environment challenges by looking at the characteristics of individuals rather than solving these challenges at the executive level of the organisation (1, 8, 25). In our view, measures targeting the working environment that focus exclusively on changing behaviour also contribute to individualising nurses’ working environment challenges.

    Personal follow-up

    In their hectic working day, it is obvious that nurses direct many of their working environment challenges towards the clinical nurse manager. Therefore, in many ways the line manager appears to be the nurses’ key spokesperson vis-a-vis the organisation.

    Pettersen and Solstad (28), who carried out a study in five Norwegian hospitals, believe that clinical middle managers have to deal with different types of management logics which partly entail a large responsibility for budgets as well as for professionally responsible conduct. The researchers believe that it may be difficult for a middle manager to reconcile these two kinds of logic.

    The Swedish working life researcher Rydén (29) has the view that it is essential that employees’ views on their work situation should be heard. By this, she means that employees’ input must be discussed and not simply brushed aside as of lesser importance when discussing financial considerations, for example. She believes that the perception of not being taken seriously in these work situations reinforces the staff’s feeling of powerlessness in the encounter with the organisation (29).

    The informants’ perceptions of being heard by their line manager are twofold: some feel that there is a lack of information from management about what has happened as a result of the nursing staff’s input, and they express powerlessness when it comes to having their views about their own working situation heard. Others are certain that the clinical nurse manager takes their descriptions of the working environment further up the management chain, while at the same time they are aware that decision-making powers rest with another service level in many cases.

    The line manager can promote working environment-oriented efforts locally in the different hospital wards. However, strategic management must also be involved in order to change organisational factors (30). Continuing the research of Pettersen and Solstad (28), and Rydén (29), we can say that when staff are unable to express their opinions about their own working environment problems and the information is blocked in the system, this represents a serious failure.

    Conclusion

    Through examining the clinical incident reporting, quantitative assessments and HSE measures as well as personal follow-up, we have seen that the working environment challenges facing nurses are inadequately handled at the organisational level. Health personnel have an independent responsibility to report such challenges.

    Meanwhile it is important to keep in mind that clinical incident reports represent information that shall and should be used to develop the organisation of the work. Neither HSE or HR are meant to individualise working environment challenges. We believe it is opportune to point out that there is a danger of the systems we have described, which are of central importance to the psychosocial working environment, losing their support and legitimacy. When they do not actually pinpoint and deal with causes and problems, it is clear that staff will not make use of them.

    There is a need for further research to elucidate nurses’ psychosocial working environment challenges in a settings perspective. The specific areas we have dealt with do not appear to be able to tackle psychosocial working environment challenges as organisational issues.

    At a time when nurses and other professional groups in hospitals are already subject to an unfortunate deluge of responsibility, it is regrettable if the responsibility for solving working environment challenges is also shifted to individuals. 

    References

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    2.       NOA. Psykososialt arbeidsmiljø: delrapport. Oslo: Stami; 2008. Report 11/09. Available at: https://brage.bibsys.no/xmlui/bitstream/handle/11250/288520/stamirapporter_78.pdf?sequence=1&isAllowed=y(downloaded 05.06.18).

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    4.       Scriven A, Hodgins M. Health promotion settings. Principle & Practice. London: SAGE Publications; 2011.

    5.       Hofstad E. Avvik stoppet og avvises. Sykepleien. 2015;3:30–9.

    6.       Forskrift 28. oktober 2016 nr. 1250 om ledelse og kvalitetsforbedring i helse-og omsorgstjenesten. Available at: https://lovdata.no/dokument/LTI/forskrift/2016-10-28-1250(downloaded 05.06.18).

    7.       Kuvås B, Dysvik A. Lønnsomhet gjennom menneskelige ressurser – Evidensbasert HRM. 2. ed. Bergen: Fagbokforlaget; 2012.

    8.       Nordrik B. Psykososial arbeidsmiljøkartlegging: en trojansk hest?. 2. ed. Oslo: Gyldendal Arbeidsliv; 2012.

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    10.     Thomassen OJ, Larsen K. Arbejdsmiljø og sygeplejen i det magtpolitiske felt. København: Dansk Sygeplejeråd; 2016

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    16.     Kingston MJ, Evans SM, Smith BJ, Berry JG. Attitudes of doctors and nurses towards incident reporting: a qualitative analysis. MJA. 2004;181(1):36–9. Available at: https://www.mja.com.au/journal/2004/181/1/attitudes-doctors-and-nurses-towards-incident-reporting-qualitative-analysis(downloaded 05.06.2018).

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    Nurses’ psychosocial challenges are transformed into something private and personal instead of being solved at an overarching level in the organisation.

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    English
    Sammendrag

    Background: Earlier research calls for an increased focus on organisational factors that affect nurses’ psychosocial working environment. The disciplinary tradition of health promotion is based on the notion that individuals and their surroundings impact on each other and that working environment measures must be appropriate for the setting and not just target individuals.

    Objective: To examine nurses’ experiences of their psychosocial working environment, and to discuss obstacles and opportunities for a more coherent, settings-based approach.

    Method: The study has a qualitative design using focus groups. We interviewed the nurses in three wards at a university hospital in Norway. We analysed the data using critical hermeneutic meaning analysis.

    Results: The findings show that a number of central mechanisms related to psychosocial working environment challenges largely individualise nurses’ challenges in this area. This is revealed through the informants’ experiences of clinical incident reporting, quantitative assessment, HSE measures and managers’ follow-up of personnel. Both individually and in combination, these experiences have the effect of turning the psychosocial working environment into something private and personal as opposed to an organisational challenge that can be resolved as part of a collective effort.

    Conclusion: When working environment challenges are individualised, nurses must face them alone and must find their own solutions. Consequently, we need ways of working that focus more on the setting. This entails using working methods that take into consideration how the hospital’s organisation affects the psychosocial environment of the nurses.

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  • Down’s syndrome: Good communication by healthcare personnel reduces parents’ stress

    International research has suggested that children with Down’s syndrome and other disabilities have a higher risk of developing an insecure attachment and experiencing abuse and neglect than other children (1, 2). This risk is linked to the child’s greater care needs and the parents’ emotional resources and ability to accept and respond to the child’s needs (1). Contrary to this research, a NOVA report from 2011 shows that children with disabilities are not overrepresented in the Child Welfare Service in Norway (3).

    However, Lewis (4) suggests that the moment when parents are told that their child has a disability is a critical time in the long-term development of the parent-child interaction. When receiving the news, parents can find it a major emotional strain. Parents’ experience of shock, grief and anger can be linked to concern for the child’s future and health challenges, and the stigma attached to the child’s ‘otherness’ (5–9).

    The moment when parents are told that their child has a disability is a critical time in the long-term development of the parent-child interaction.

    Few studies, either nationally or internationally, have explored parents’ experiences of interacting with hospital healthcare personnel during the critical period after giving birth to a child with Down’s syndrome. The study presented in this article explores parents’ specific lived experiences of communication with healthcare personnel. The parents’ narratives highlight the role and potential of healthcare personnel in relation to the parents’ emotional needs and their interaction with the child in this early stage of parenthood.

    Method

    The study has a qualitative design with a phenomenological and narrative approach. Phenomenology can be understood as the study of experience as it appears to the subject, in other words, ‘what it’s like’ to experience something (10–12). Phenomenological approaches to embodiment, for instance, emphasise ‘lived experience’, and that which is felt and sensed in the body and in material space. (11, 12).

    The term ‘narrative’ can be interpreted as ‘story’ (13). A phenomenologically based narrative approach may be particularly useful for providing rich details about specific, lived experiences of a phenomenon. This approach enables participants to construct a story in which different experiences are given meaning and put in context.

    Participants

    We interviewed eight biological parents of children with Down’s syndrome aged between two and ten years. Six interviews were conducted with mothers, one with a father, and both the mother and father were present in one interview. We conducted the interviews in 2014. The children were born at various hospitals, and none of the parents knew that the child had Down’s syndrome before the birth. At the hospital, the point at which the parents were given the news varied from less than six hours (four children), between six and thirteen hours (one child), to more than thirteen hours (two children) after the birth.

    In order to recruit participants, we prepared and sent a written information letter to the Norwegian Network for Down's Syndrome and the Ups & Downs associations in Norway, who distributed the letter via e-mail and Facebook. Those who were interested in participating in the study contacted the researcher (first author) by phone or e-mail.

    Narrative interviews

    We devised an interview guide for the purpose of the study based on the existing literature. By using the guide, the researcher (first author) was able to encourage the parents to explore their own concrete and specific lived experiences, as opposed to asking them to talk about having a child with Down’s syndrome in more general terms (12).

    The parents were given the opportunity to explore their thoughts and perceptions of their experiences, and were better able to recall and reflect on their feelings and sensations during specific events in the encounter with healthcare personnel (‘what the experience was like’) (11, 12). Furthermore, they were able to merge the different experiences into a longer narrative. The duration of the interviews ranged from 1.5 to 2 hours.

    Narrative analysis method

    The interviews were transcribed verbatim and analysed using a narrative analysis method. The analysis process consisted of six overlapping analytical steps developed by Del Busso (13), based on Langdridge’s recommendations for critical narrative analysis (14). In the first step of the analysis, we undertook a close reading of all the interviews. We reflected critically on impressions, immediate interpretations, ideas and thoughts about the material as a whole, and the basis for these (14).

    In the next step, we identified descriptions of specific lived experiences. These descriptions were analysed according to the details of the description, for example which elements were emphasised by the participant, and the meaning that the participant afforded a particular experience (13). In the third step of the analysis, we coded each of the transcribed interviews for meaning-bearing units. The units were then synthesised into themes. We then identified recurring themes across the participants’ accounts.

    Using the themes as a starting point, the next step was to identify narratives in each of the interview transcripts. The narratives that recurred across the different participants’ accounts were then identified, and resulted in two main narratives being identified. The next step in the analysis entailed identifying how the participants ‘construed themselves’ in the narratives. We then explored these narratives in light of the existing research on disability.

    Ethics

    The study was reported to and approved by the Norwegian Social Science Data Services in 2013 (approval number 36355). We obtained informed written consent and notified participants of their right to withdraw from the study at any time during the process without having to give a reason. All identifying data was anonymised, and we gave each participant a pseudonym, which will be used in the publication of the findings of the study.

    We used researcher reflexivity as a methodological tool in all stages of the research in order to ensure an ethical, fair and reliable research process (15). Reflexivity included critically evaluating the aspects of the researcher and the research process that contributed to the data produced, and the interpretation of this data material.

    Results

    The two fathers and six mothers who participated in the study formulated two contrasting main narratives or main stories in relation to their specific experiences of interacting with hospital healthcare personnel in the post-natal period:

    • ‘not being seen as a whole person’, and
    • ‘being a fellow human being’.

    Not being seen as a ‘whole person’

    Most of the participants in the study had had several difficult experiences in their encounters with various healthcare staff when their child was born and in the period that immediately followed. Many had experiences in which they felt a sense of exclusion and abandonment. For example, they found that their opinions were not sought or listened to and that the healthcare personnel were unprepared for the situation. The parents described how during these experiences they did not feel they were being seen as a whole person by the healthcare personnel they met.

    Kari, mother to a little girl, told of a situation where she felt she was abandoned by the midwife immediately after the birth:

    ‘The midwife just disappeared, she just left, then I remember her sending a message through someone else: “Contact me if you need to.” When I now look at pictures of my daughter when she was first born, I think she must have seen it, but she didn’t say anything’.

    In hindsight, Kari thought it was likely that the midwife suspected that the child had Down’s syndrome and that she avoided telling them. If the midwife had seen that Kari’s baby had Down’s syndrome, the midwife’s ‘disappearance’ and delivery of a message through a third party could be interpreted by Kari as the midwife disclaiming responsibility. It may also be interpreted to mean that Kari, who had just given birth to a disabled child, was given the responsibility of asking for help and support.

    Ignored

    Lise, mother to a boy, also told of an experience where she felt that the nurses in the maternity ward were talking to each other about the child, but were avoiding talking to her:

    ‘It was like they were unprepared and didn’t know what to say or how to deal with the situation. They were uncertain, and were whispering to each other.’

    Lise recounted how she felt that the nurses in the maternity ward were uncertain, and that they spoke in hushed tones, whispering to each other instead of talking to her. Lise described how this made her insecure. She felt she was being ignored and that the nurses did not recognise her need to be included and involved in discussions. Both Kari and Lise described experiences where they felt they were not treated as people who deserved and were entitled to care and supportive communication.

    Patronising attitudes

    Unlike Kari and Lise, who found that the healthcare personnel did not communicate with them, Ina, mother to a boy, found that the communication with the healthcare personnel was diminishing or patronising. Ina described the experience of being hurt by the healthcare personnel’s way of communicating, and said that following the birth she was kept separate from her son:

    ‘… I wasn’t given the opportunity to look after him or get involved in anything, because they felt sorry for me. Because this was my first child, poor me, and it made me feel so angry. All the others were told, ‘he’s beautiful’, or ‘she’s so cute’, while all I heard was ‘is that your child? Poor you.’

    Ina told how the maternity staff’s attitudes towards her and her son hurt and provoked her. She described the feeling of the maternity staff not seeing her son as a new-born baby, whom it is normal to talk about in a positive way; ‘he’s so cute’, but as something that deviated from the norm. In addition to her sense of being diminished into someone to be pitied, she felt that the child was not treated like a ‘regular’ baby, but as a burden.

    All the others were told, ‘he’s beautiful’, or ‘she’s so cute’, while all I heard was ‘is that your child? Poor you.’
    Ina, participant

    Ina told how her son’s Down’s syndrome was not a great source of sorrow for her. She explained that when she gave birth to a child with Down’s syndrome it forced her to make changes in her life that she had previously wanted but failed to carry out. It was therefore meaningful and positive for Ina that she in particular was now a mother to a child with Down’s syndrome. Ina described how she felt that her child was valuable and helped strengthen her potential to carry things through. This was in contrast to experiencing that both she and her child were perceived as ‘poor things’ and ‘deviant’ by the staff in the maternity ward.

    Lack of empathy from the doctor

    Many of the participants had found that information was conveyed in a way that lacked sensitivity and empathy. They had also felt that they were not given sufficient information and that the information they did receive was inadequate or outdated. The participants described these experiences as frustrating and burdensome.

    Kari recounted an experience when she received information from a doctor:

    ‘A doctor arrived, a bit of a strange doctor, he used a lot of medical jargon: “Yes, it has to do with the oxygen uptake …”, but he didn’t make proper eye contact, and he stood like this [the participant demonstrates by partially turning her head away and looking at the ceiling], speaking into the air. “It has to do with the oxygen, so we’ve put her in an incubator.” I remember thinking, “I’m going mad, this is what it’s like going mad [laughs]’”.

    In the quote above, Kari said that she found the encounter with the doctor difficult. He was only concerned with imparting medical information, and not with recognising the parents’ situation and meeting their needs. In this context, the doctor had an exclusively medical approach to interacting with the parents and providing them with information. His focus was on identifying the child’s symptoms (insufficient oxygen uptake) and how the child could get better (treatment needs/incubation). The way he communicated (using medical jargon and speaking into the air) and his demeanour (did not make eye contact with the parents when he spoke) gave Kari a feeling of ‘going mad’.

    Based on Karis’ description, this situation can be interpreted as meaning that the doctor’s demeanour prevented Kari from being a ‘whole’ person during her interaction with him. The doctor’s demeanour entailed him failing to make eye contact or to address Karis’ need for supportive communication.

    She also reacted strongly to how the doctor referred to her child as belonging to ‘a group of people’, as opposed to being an equal and a person of worth.

    Similar to Kari’s experience, Åse also described the situation when the doctor told her that her son had Down’s syndrome:

    ‘... so, he said [the doctor]: “I’ve heard rumours that you suspect he has Down’s syndrome, and we’re not in doubt about it.” “Whaaat?” There we sat, you could’ve knocked my husband down with a feather ..., and then the doctor turns to my husband and asks if he has any knowledge about this group of people. “Ehhhh”, my husband said …. Then the doctor said there were actually opportunities for them, and that was it, end of conversation. Being as good as shoved out of the doctor’s office after getting that news, it was such a slap in the face.’

    Åse described how the experience of the doctor giving her the news that her son had Down’s syndrome was characterised by the doctor’s lack of understanding of their emotional and communication needs. She told how the news was not conveyed in a particularly empathic manner and that she and the baby’s father were shocked, both by the news and the way in which it was communicated to them.

    Åse clearly described a sense of not being seen as ‘a person with feelings’ in terms of the need for the news to be delivered in a careful and sensitive manner. She described her and her husband’s reaction (‘slap in the face’, ‘shoved out of the doctor’s office’). She also reacted strongly to how the doctor referred to her child as belonging to ‘a group of people’, as opposed to being an equal and a person of worth.

    Being a fellow human being

    In stark contrast to the parents’ description of feeling ‘less than a whole person’, several of the participants in the study felt they were given the opportunity to be a fellow human being in the encounter with healthcare personnel. They found that both they and their child were treated as fellow human beings, and that the healthcare personnel had a positive disposition, which made them feel like equals. In this main narrative, the participants described experiences where they were met with empathy and humility. They said that the healthcare personnel had time for them and that they received emotional care and support.

    Discrete and friendly nurses

    As already mentioned, Kari described how she felt abandoned by the midwife in the delivery room and that the doctor in the maternity ward did not recognise her needs. However, Kari also had a positive experience in the encounter with the nurses in the intensive care unit:

    ‘They asked, “Does she resemble anyone in your family?” “No”, we said ... They were so sweet and friendly – they were very specific, but very discrete and friendly. And then they said, “We think she has Down’s syndrome, and we think that because ...” and then they showed us: because of the ears, because of the toes. “Also because some lines are missing on her hands”, because of this and that.’

    The nurse also gave Åse’s husband time and space to express himself and to talk about the situation with her on his own.

    Kari described an interaction in which the nurses communicated in a careful and supportive manner, ‘discrete and friendly’. When the nurses gave them the news that they suspected their daughter had Down’s syndrome, they specifically explained the reasons for this by showing the parents the baby’s ears and toes. Here the nurses communicated that the child was a fellow human being and probably resembled her parents, like all other children. This was in stark contrast to the doctor who asked Åse’s husband if he had any knowledge about ‘this group of people’.

    Åse described how she felt she was treated well by a nurse in the maternity ward. This was in contrast to the description of Åse and her husband’s experience when a doctor told them that their child had Down’s syndrome:

    ‘She [the nurse] said she needed to talk to him, and they had a long conversation, without me being present.’

    Åse said that her husband had a strong reaction and that the nurse recognised his need for care and supportive communication. The nurse also gave Åse’s husband time and space to express himself and to talk about the situation with her on his own.

    In this interaction, both Åse and her husband felt that the nurse was a fellow human being. The nurse also made the husband feel like he was a fellow human being with a natural and understandable reaction to receiving the news that his baby had Down’s syndrome.

    Discussion

    International research shows that parents of children with Down’s syndrome receive little follow-up of their emotional needs and, at different times during their son’s or daughter’s childhood, find that healthcare personnel communicate in a manner they experience as burdensome (7–9, 16, 17). These findings are in line with how the parents in our study described their experiences of the birth and the period immediately after at the hospital.

    The parents had several specific experiences in their encounters with healthcare personnel where they felt that they and their child were less than ‘a whole person’. The ‘whole person’ can be understood initially as someone whose new-born child has a health challenge that needs to be taken care of, but who subsequently also needs support for their own worries and feelings. These can be seen as aspects of a holistic approach to the parents’ health, which is co-constructed in the encounter with healthcare personnel (18).

    Important to feel accepted

    When parents have been anticipating and looking forward to having a healthy baby, their emotional response may be characterised by strong feelings of shock, grief and anger. Dealing with their own emotions whilst also communicating with and responding emotionally to their child can be a challenge (5). It is therefore reasonable to assume that when parents’ need to be seen as a ‘whole person’ or as ‘a person with feelings’ is met by healthcare personnel, it can have a positive impact on the family’s future dynamic and quality of life.

    For example, when parents have specific experiences of acceptance and validation in their relations with healthcare personnel, it can foster good parent-child interaction. It can also provide a good starting point for the relationship that will be created over time between the main caregivers and the child (4). In this way, supportive communication with healthcare personnel can help parents to construct and communicate positive narratives about the child’s birth and the hospital.

    Such stories can be of major emotional importance and can counteract the social stigma they may face in their daily lives after returning home from the hospital (16). In line with this, some parents had experiences where healthcare personnel referred to their child in a way that equated them with fellow human beings, and they themselves felt validated, which was of crucial importance to the parents in this study.

    In relation to interacting with others in the manner described here, Anderson (19) argues that ‘withness’ is a way of communicating with other human beings that makes it possible for the person to feel accepted. She describes the healthcare personnel’s approach as ‘talking with’, ‘acting with’ and ‘responding with’ the person in need of assistance (19).

    Social stigma

    Research shows that parents of children with a disability experience ‘otherness’ and stigma in the social context (16, 17, 20, 21). It may therefore be particularly important in the early stage of parenthood for the healthcare personnel to be ‘together with’ the parents when they have their first reaction and initial experience.

    Healthcare personnel’s communication at the very moment parents learn that their child has Down’s syndrome, and in the period immediately afterwards, is crucial to the parents being able to cope with the emotional stress they feel there and then. In addition, feeling that they and their child are validated and supported can form a positive basis for the future attachment and interaction that will be created between the parents and the child over time (4).

    Weaknesses of the study

    We recruited the sample from Ups & Downs associations, and it is possible that the parents who volunteered had had particularly difficult experiences. The study could thus be strengthened by a larger sample and more descriptions of parents’ specific experiences, but time constraints did not allow for this. In the context of a narrative approach, it could also be preferable to interview participants several times, particularly with a view to exploring the importance of the initial encounter and communication with healthcare personnel for the family and the child over time.

    Conclusion

    In this study, we wanted to disseminate knowledge about the specific lived experiences of parents who had a child with Down’s syndrome, both at the time of the birth and the period immediately afterward. By doing so, the study shows the healthcare personnel’s key role and potential in relation to parents’ emotional needs and interaction with their child in this early stage of parenthood.

    The study indicates that facilitating communication that makes parents feel they and their child are ‘fellow human beings’ can be an important resource for dealing with parents’ emotional responses at the hospital during the post-birth period.

    It is also reasonable to assume that by taking a validating and supportive approach to communication, healthcare personnel can help lay the foundation for the relationship and interaction that will be created between the parents and the child over time.

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    9.       Lundeby H, Tøssebro J. Exploring the experiences of «not being listened to» from the perspective of parents with disabled children. Scandinavian Journal of Disability Research. 2008;10:258–74.

    10.     Cromby J, Harper D, Reavey P. Psychology, mental health and distress. Hampshire: Palgrave Macmillan; 2013.

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

    12.     Del Busso L, Reavey P. Moving beyond the surface: poststructuralist phenomenological research on young women's embodied experiences in everyday life. Psychology & Sexuality. 2013;4:46–61.

    13.     Del Busso L. Being-in-motion: movement, femininity and space in young women's narratives of their embodied experiences in everyday life. (Doktoravhandling.) London: London South Bank University; 2009.

    14.     Langdridge D. Phenomenological psychology: theory, research and method. UK: Pearson Education Limited; 2007.

    15.     Ramazanoglu C, Holland J. Feminist methodology: challenges and choices. London: Sage; 2002.

    16.     Berg B, Strøm A. Foreldregrupper når barnet har store funksjonsnedsettelser. Sykepleien Forskning. 2012;7:350–5. DOI: 10.4220/sykepleienf.2012.0153.

    17..    Berg B, Strøm A. Et annerledes og ensomt foreldreskap: en kvalitativ studie av foreldre til barn som har funksjonsnedsettelser og deres utfordringer i møte med sine uformelle sosiale nettverk. Fontene forskning. 2012;1:56–68.

    18.     Leonardsen AL, Del Busso L, Grøndahl VA, Jelsness-Jørgensen L. «It’s a whole human being»: A qualitative study of care experiences among patients treated in decentralised healthcare services. European Journal for Person Centered Healthcare. 2017;5:82–7.

    19.     Anderson H. Collaborative Practice: A way of being «with». Psychotherapy and Politics International. 2012;10(2):130–45.

    20.     Green SE. «What do you mean ‘what’s wrong with her?’»: stigma and the lives of families of children with disabilities. Social Science & Medicine. 2003;57:1361–74.

    21.     Borg E. Holdninger til funksjonshemmede i Norge 1999–2005. Oslo: Norsk institutt for forskning om oppvekst, velferd og aldring; 2008.

    Parents who unexpectedly have a child with Down’s syndrome can interact with the child in a more constructive way when healthcare personnel talk to them in a positive manner immediately following the birth.

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    Background: Being told that their child has Down’s syndrome in the hospital after giving birth can be a profound and stressful life experience for parents. Parents’ experiences of the communication with healthcare personnel can therefore be crucial to how they deal with their emotional responses in the post-natal period and can impact on the parent-child interaction.

    Objective: The purpose of the article is to disseminate knowledge about the experiences of parents of children with Down’s syndrome in terms of the communication with hospital healthcare personnel in the post-natal period. Furthermore, we want to show how such communication impacts on how parents deal with their own emotional responses.

    Method: The study has a qualitative design with a phenomenological and narrative approach. We conducted narrative in-depth interviews with eight biological parents of children with Down’s syndrome aged between two and ten years. None of the parents knew that the child had Down’s syndrome before giving birth. The collected data was analysed using a narrative analysis method.

    Results: Through the main narrative of ‘not being seen as a whole person’, the parents spoke about their sense of abandonment, feeling excluded from communications, being referred to a computer to find information about the diagnosis of their child, and being talked to by the healthcare personnel in a way they found burdensome. In contrast, the parents recounted through the narrative of ‘being a fellow human being’ specific situations where the healthcare personnel’s attitude helped them to feel that both they and their child were treated as fellow human beings.

    Conclusion: The study indicates that the communication with healthcare personnel in the post-natal period has a strong emotional impact on parents. The study also suggests that parents need a style of communication that makes them feel that their child and their own responses are validated and supported.

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  • Sexual coercion in marriage or cohabitating relationships is linked to other types of intimate partner violence

    International human rights standards stipulate that legal sexual contact becomes a criminal act when consent is absent. Breaching the law on sexual conduct is a serious violation of an individual’s integrity and right to free choice. Sexuality belongs to the private sphere of intimacy, and a person’s private sexual life is traditionally not something that is openly discussed (1).

    Sexual coercion by an intimate partner or spouse is an issue that is even more hidden than violence in close relationships and rape (2). Knowledge about sexual violence in marriage and cohabiting relationships is crucial in order for nurses to be able to address the topic and help vulnerable women talk about violations, enabling them to get help to break free of violent relationships (1, 2).

    Sexual coercion by an intimate partner or spouse is an issue that is even more hidden than violence in close relationships and rape.

    Under Section 291 (3) of the Norwegian General Civil Penal Code, sexual coercion is defined as rape if a person is forced into sexual activity through violence or threatening conduct, or is incapable of opposing the act.

    Strengthening knowledge on violence

    Violence in close relationships is described in the Public Health Report 2015 as one of the new focus areas in public health policy in Norway (4). In a Norwegian survey from 2005, 8.2 per cent of women reported that they had been subjected to serious violence by a partner. About 4 per cent of all pregnant women reported that they had experienced physical violence during the pregnancy (5).

    National action plans have clarified that knowledge about violence in close relationships needs to be strengthened within the health and social care sectors (6). Intimate partner violence includes physical, psychological, sexual, material, economic and latent abuse (7). A pattern of repeated psychological and physical violence increases the risk of various health problems (8–10).

    Women who are exposed to intimate partner violence also visit their GP or primary care doctor significantly more often than other women. Their health problems are often unspecified and chronic, and are rarely viewed in the context of past or ongoing violence (10). Minor physical injuries such as swelling, bruising and grazes can be due to partner violence.

    Significant markers for partner violence are acute injuries to the head, neck and face among women who seek medical assistance at accident and emergency departments and claim that no one saw how the injury occurred (11). Examples of sexual violence in marriage or cohabiting relationships that were revealed among women exposed to partner violence include being forced into vaginal or anal intercourse, being beaten or burned during intercourse, having objects forced into their vagina and anus, or in rare cases being forced to have sex with others, including animals (12).

    Sexual violence

    In Norway, one in ten women experience rape at some point in their life (13), and the global figure is one in four (7). This also includes rape carried out by someone other than a spouse or cohabitant. Men are also subjected to sexual assaults. In the Norwegian survey from 2014, 4.7 per cent of the women and 0.9 per cent of the men reported that they had been raped. ‘Other sexual assault’ was reported by12.3 per cent of the women and 5 per cent of the men (13).

    The incidence of sexual assault is generally high, although different definitions and varying samples lead to major discrepancies in study figures. Associations have been found between sexual violence and partner murder at an international level (12). Correlations between sexual violence and serious violence such as violent acts on pregnant women have also been found in Norway (14). Correlations between different types of intimate partner violence against women and health problems are now well documented, both in Norway and internationally (4, 7–11, 15).

    Knowledge about correlations between sexual violence and controlling behaviour by a partner is limited (2). Psychological violence, especially acts of dominance and isolation, is associated with sexual violence among women seeking assistance at refuge shelters in Norway (16). Earlier research found that acts of dominance and isolation against women who seek help because of partner violence are also associated with actions by the partner that make it difficult for the woman to stay in paid employment (16, 17). However, there is little knowledge about the different types of violence also associated with sexual coercion by a partner among women in general in Norway.

    The purpose of this study was to investigate the correlation between sexual coercion, physical and psychological violence and actions that make it difficult for women to stay in paid employment in Norway.

    Method

    Sample

    A random sample of 1500 women aged 18–70 living in the county of Hordaland received our questionnaire via Statistics Norway. Everyone was sent one reminder and the data collection took place in 2010 and 2011. Of the 527 women who answered the questionnaire, 480 women who were currently living with or had previously lived with a partner were included in the study.

    Questionnaire

    The questionnaire contained questions about age, education, employment, nationality, number of children and experience with different types of violence by their partner. The questions about different types of acts of physical violence and sexual coercion are the same as those used in several Norwegian population studies (5, 13, 16). We mapped sexual coercion using two questions:

    Has your partner tried to force you to have sex

    • during the last year? (yes/no), or
    • at some point in your life before then? (yes/no)?

    Participants answering in the affirmative to one of the questions were categorised as being subjected to sexual coercion by a partner. The term ‘partner’ is not gender specific.

    We mapped physical violence through three questions about threats of violence and eight questions about physical acts of violence (Table 1). The questions required a ‘yes’ or ‘no’ answer, both for the period ‘during the last year’ and ‘at some point in your life before then’. Those who answered in the affirmative for one of the periods were categorised as being subjected to violence.

    Table 1. Percentage of women who have experienced physical violence in total and broken down into those who have been subjected to sexual coercion (n = 480*)

    In order to map psychological violence, we used the Psychological Maltreatment of Women Inventory (PMWI), an instrument developed and validated by Tolman (18) and translated and used in an earlier Norwegian survey (19). The questions are divided into two categories: ‘acts of dominance and isolation’ (Table 2) and ‘emotional and verbal abuse’ (Table 3). Each question has five response options: ‘never’, ‘seldom’, ‘occasionally’, ‘often’ and ‘very often’. In our study, the response options ‘often’ and ‘very often’ were merged.

    Table 2. Percentage of women who have experienced psychological violence in the form of dominance and isolation in total and broken down into those who have been subjected to sexual coercion (n = 480*)
    Table 3. Percentage of women who have experienced sexual violence in total and broken down into those who have been subjected to various degrees of emotional or verbal psychological violence (n = 480*)

    The questions about actions by a partner that make it difficult to stay in gainful employment (Table 4) are based on earlier studies of how violence in close relationships impacts on the working lives of women who are subjected to intimate partner violence (16, 17). Each of the questions could be answered with ‘never’, ‘sometimes’, ‘often’ or ‘very often’. Here too, ‘often’ and ‘very often’ were merged in the analyses.

    Table 4. Percentage of women who have experienced sexual coercion broken down into those who have been subjected to various degrees of actions that make it difficult to stay in paid employment (n = 480*)

    We sent out the questionnaire both in Norwegian and English in order to be able to include non-Norwegian speakers.

    Analysis

    The incidence of sexual coercion in the different categories of violence is shown as absolute numbers and percentages. Possible associations between sexual coercion and other types of partner violence were tested using the chi-square method. For groups with small sample sizes, we used the Fisher or Fisher-Freeman-Halton exact test. To test whether an increased level of violence is associated with a higher incidence of sexual coercion, we used the Mantel-Haenszel trend test.

    T-tests and chi-square tests were used to establish whether background variables were evenly distributed among the women who had and had not been subjected to sexual coercion. Significance levels were set at p <0.05, and all of the analyses were performed in IBM SPSS Statistics 22.

    Ethical considerations

    Participation was voluntary and anonymised, and was in line with the Declaration of Helsinki. Participants’ safety was paramount, and in line with the ethical guidelines of the World Health Organization (WHO).

    The study is approved by the Regional Committees for Medical and Health Research Ethics (REC) (ref. no. 2009/2591). REC granted permission for us to only include women, since a population sample that also included men would have required a significantly larger sample and thus incurred very high costs.

    Special challenges

    The first page of the questionnaire contained the telephone number of the researcher (first author) so that participants could call if they wanted to talk to the researcher. This opportunity to talk to the researcher was given in an attempt to increase the response rate, which is generally low in such surveys. The letter of information stated that participation was voluntary.

    Results

    In the random sample of 1500 women between the ages of 18 and 70, 527 answered the questionnaire. Of these, 480 were living with or had lived with a partner and were included in the study. The mean age was 44.8 years. A total of 5.8 per cent of the women in the population sample reported having been subjected to sexual coercion by a partner.

    There were no significant differences in age, education, labour force participation, nationality or number of children among the women who had or who had not been subjected to sexual coercion.

    All actions in the ‘physical violence’ category were significantly associated with sexual coercion (p <0.001). Among those who had received death threats from a partner or had been threatened with a knife or other weapon by a partner, 50 per cent had also experienced sexual coercion. One-third of those who had been stalked (33.3 per cent), or whose partner had tried to strangle them (38.1 per cent) or had been subjected to other violent behaviour (31.5 per cent) by a partner had also experienced sexual coercion. Among those who had been subjected to life-threatening violence by a partner, such as their head being banged against the floor, 46.2 per cent reported sexual coercion by a partner (Table 1).

    All actions in the ‘psychological violence’ category were significantly associated with sexual coercion (p <0.001). There was also a significant trend showing the more often women had experienced various acts of dominance and isolation or emotional and verbal abuse, the more likely they were to be subjected to sexual coercion (Tables 2 and 3). Among those whose partner had often or very often tried to make them believe they were insane, 53.8 per cent had experienced sexual coercion. All of the women who had been subjected to sexual violence had experienced one or more acts of psychological or physical violence.

    Six of the twelve questions about actions by a partner that make it difficult to stay in paid employment were significantly associated with sexual coercion. Among those who were often or very often late for work or had to leave work early, 25 per cent reported sexual coercion, while this was the case for 75 per cent of those who often or very often were unable to participate in social activities in connection with work (Table 4).

    Discussion

    This study shows that sexual coercion does not happen in isolation, but within a pattern of violence in marriage or cohabiting relationships. At the same time, it is important to point out that most people exposed to psychological and physical violence by a partner do not report sexual coercion. However, we see that when sexual violence occurs, half of the women receive death threats from their partner and one-third report serious physical violence, such as strangulation.

    All acts involving psychological violence, such as dominance or control and emotional or verbal abuse are associated with sexual coercion. Thus, sexual coercion in marriage or cohabitating relationships represents a type of violence that is difficult to define as episodic violence (20). Episodic violence refers to situational anger in equal relationships.

    Sexual coercion, as reported in this study, is classified as what Johnsen (20) terms ‘intimate terrorism’. Intimate terrorism occurs where one party is systematically violent and controlling. Systematic violence means that many different types of violence occur in parallel and that actions are repeated. Insecurity is therefore a major feature in the lives of victims of violence. Violent acts that are part of a recurring pattern over time have a major impact on the health of the victims. Documentation of various types of acts of violence is vital in the context of criminal justice (21).

    Sexual coercion makes it difficult to hold down a job

    Our study shows that sexual coercion is associated with actions that make it difficult to stay in paid employment. For example, the partner prevents the woman from getting to work on time or repeatedly fails to collect their children from nursery. They do not let the woman participate in social activities at work and become more and more jealous and critical. Sexual coercion is also associated with fear that the partner will pay a visit to the woman at work. Actions that make it difficult for women to stay in paid employment are a type of psychological violence that is also termed ‘economic violence’.

    Our study shows that sexual coercion is associated with actions that make it difficult to stay in paid employment.

    The correlation between intimate partner violence and difficulties staying in paid employment is not well documented in previous studies, and the findings of this study are therefore important. Being unemployed can have far-reaching consequences for women’s opportunities for an independent life (22). Income throughout working life impacts on pensions, credit rating and activities in society as well as the experience of being recognised as an independent subject (16).

    Isolation from friends as well as control of money and appearance are also associated with sexual violence by a husband or cohabitant in the study by Basile (24). The study suggests that sexual violence in marriage and cohabiting relationships is linked to the partner’s need for power and control. 

    Physical violence is associated with sexual coercion

    In our study, all physical acts of violence are associated with sexual coercion. Very serious violence, such as threats using a knife or other weapon, was reported by half of those who had experienced sexual coercion. Sexual coercion is therefore often associated with other violence in marriage or cohabiting relationships, which implies a more serious pattern of violence. Such patterns of violence can have consequences in terms of health and criminal justice.

    In a study of women at Norwegian refuge shelters (14), sexual coercion by a partner was associated with other serious physical and psychological violence, such as violence against pregnant women, dominance and isolation, as well as biting, hair pulling and twisting of the arm (14). Sexual coercion occurs in conjunction with many other types of violence and very serious violence, including in our population sample.

    Our study is a cross-sectional study that does not examine causality or whether other violence occurs before or after sexual violence. However, other studies show that sexual coercion can take place after other forms of psychological or physical violence (23, 24). Women describe how the man wants sex after an episode of violence, as a comfort when he regrets his actions and wants reconciliation, and as an escape from the disturbing fact that he has subjected his spouse or cohabitant to serious acts of violence.

    In our study, all physical acts of violence are associated with sexual coercion.

    Women who experience violence also report that they believe the men enjoy this kind of sex, despite the women being coerced into it (23). Whether the sexual acts can be defined as coercion, i.e. they did not take place voluntarily, is also a key issue in the legal treatment of rape cases. In such cases, it is often the credibility of the victim versus that of the defendant that becomes the determining factor. Healthcare personnel’s records and mapping, as well as forensic medicine documentation of psychological and physical violence will increase the victim’s credibility (21).

    Our study shows that none of those who have experienced sexual coercion have evaded other forms of dominance and isolation, emotional and verbal abuse or physical violence. This fact emphasises the importance of health professionals’ mapping of different types of violence when dealing with women exposed to such behaviour.

    Sexual violence is kept hidden

    Sexual coercion in marriage or cohabiting relationships is often hidden, and the woman will seldom use the word ‘rape’ or ‘violence’, or even ‘coercion’. According to WHO, there are norms that support violence against women, such as that a man has a right to assert power over a woman, and that sexual activity (including rape) is a marker of masculinity (27).

    When sexual coercion occurs within marriage or cohabiting relationships, the acts are often not defined as rape or abuse, either by the victim or society in general, even though the law is clear on this point. This may be due to the fact that, historically, women are often conditioned to think that a husband or cohabitant is entitled to have sex whenever they wish (23, 24).

    Strengths and weaknesses of the study

    The response rate in our study is too low for the incidence of 5.8 per cent of sexual coercion among women to be generalised as applying to the population of women in Norway as a whole. However, Norwegian population surveys, which pose the same questions about sexual coercion, report a similar occurrence (5, 13). A low response rate is less significant in studies examining associations between different variables.

    Low response rates are not uncommon in studies of taboo subjects. Women exposed to the most serious violence rarely respond to surveys as they are afraid of reprisals by their partner. Violence in close relationships is usually hidden in our society and is associated with shame. The victims are often told that no one must know what is happening behind the four walls of their home.

    The private sphere is also traditionally regarded as something that should not be revealed if it puts the family in a bad light. If the victim speaks out about the violence, the perpetrator also loses some of their control. The experience of losing control increases the risk of violence. One study shows that the more serious the violence that women had been exposed to, the less often they would respond to questionnaires, even when the man was in a separate room, but nearby (25). The low response rate means that the study results must be interpreted with caution.

    The strengths of the study are that the questions have previously been asked and validated and that the sample is random.

    Implications for practice

    Knowledge that sexual coercion occurs in conjunction with other intimate partner violence will have implications for nursing approaches to the victims of violence and in the work of detection or mapping, risk assessment, safety planning and forensic medicine documentation. If a woman says that her husband refuses to let her study or work, it is important to ask if there are other ways he controls and asserts his power over her.

    Minor injuries like bruising, swelling and grazes can also be due to intimate partner violence. It is therefore important that nurses know the best way to identify partner violence. Knowledge of the correlation between psychological and physical violence and actions that make it difficult to stay in paid employment means that nurses must ask questions that include all forms of partner violence. Likewise, identifying sexual coercion will trigger questions about other partner violence.

    In order for the women to feel taken care of, the way that healthcare personnel ask questions and the surrounding framework are essential elements (26, 27). Safety planning and risk assessment, as well as secure and accurate record keeping, are also vital in the context of forensic medicine (27, 28).

    Minor injuries like bruising, swelling and grazes can also be due to intimate partner violence.

    In forensic medicine documentation and in connection with applications for victim compensation, records and other documentation in the form of photos and evidence are of great importance. Although the forensic medicine declarations are mainly written by doctors in Norway, nurses can help to identify violence in close relationships and to ensure that it is communicated to the doctor and referral centre where relevant, which have good expertise in forensic medicine documentation (29).

    Nurses’ knowledge of their own duties, such as the duty to notify versus confidentiality, and knowledge of relevant support agencies, such as refuge shelters and Alternative to Violence, is important in reducing the health risk to the victim. Most victims of sexual and other violence by a partner need medical care and help to establish a life free from violence.

    Conclusion

    Sexual coercion by husbands or cohabitants against women occurs together with psychological and physical violence. Sexual coercion also occurs in conjunction with actions that make it difficult for the women to stay in paid employment.

    References

    1.          NOU 2008:4. Fra ord til handling. Bekjempelse av voldtekt krever handling. Oslo: Justis- og politidepartementet; 2008. Available at: https://www.regjeringen.no/no/dokumenter/nou-2008-4/id497659/(downloaded 16.08.2017).

    2.       Logan TK, Walker R, Cole J. Silenced suffering: The need for a better understanding of partner sexual violence. Trauma Violence & Abuse. 2015;16:111–35.

    3.     Lov 1. oktober 2015 om straff (straffeloven). Available at: https://lovdata.no/dokument/NL/lov/2005-05-20-28(downloaded 16.08.2017).

    4.       Folkehelseinstituttet. Folkehelserapporten 2014. Helsetilstanden i Norge. Oslo: rapport 2014:4. Available at: https://www.fhi.no/globalassets/dokumenterfiler/rapporter/folkehelserapporten-2014-pdf.pdf(downloaded 09.04.2018).

    5.       Schei B, Haaland T, Clausen S-E. Vold mot kvinner i Norge. In: Haaland T, Clausen S-E, Schei B, eds. Vold i parforhold. NIBR-rapport 2005:3. Oslo: Norsk institutt for by- og regionforskning; 2005.

    6. Meld. St. nr. 15 (2012–2013). Forebygging og bekjempelse av vold i nære relasjoner. Available at: https://www.regjeringen.no/no/dokumenter/meld-st-15-20122013/id716442/sec1(downloaded 16.08.2017).

    7.       Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, eds. World report on violence and health. Genève: WHO; 2002.

    8.       Campbell JC. Health consequences of intimate partner violence. Lancet. 2002;359:1331–6.

    9.       Bonomi AE, Thompson RS, Anderson M, Reid RJ, Carrell D, Dimer JA, et al. Intimate partner violence and women's physical, mental, and social functioning. Am J Prev Med. 2006;30:458–66.

    10.     Eberhard-Gran M, Schei B, Eskild A. Somatic symptoms and diseases are more common in women exposed to violence. J Gen Intern Med. 2007;22:1668–73.

    11.     Spedding R, McWilliams M, McNicholl B, Dearden C. Markers for domestic violence in women. J Accid Emerg Med. 1999;16:400–2.

    12.     Campbell JC, Alford P. The dark consequences of marital rape. Am J Nurs. 1989;89:946–9.

    13.     Thoresen S, Hjemdal OK. Vold og voldtekt i Norge. En nasjonal forekomststudie av vold i et livsløpsperspektiv. Oslo: Nasjonalt kunnskapssenter om vold og traumatisk stress; 2014.

    14.     Alsaker K, Morken T, Baste V, Campos-Serna J, Moen BE. Sexual assault and other types of violence in intimate partner relationships. Acta Obstet Gynecol Scand. 2012;91:301–7.

    15.     Howard L, Feder G, Agnew-Davies R. Domestic violence and mental health. London: Royal College of Psychiatrists; 2013.

    16.     Alsaker K, Moe BE, Baste V, Morken T. Vold i parforhold kan gjøre lønnsarbeid vanskelig. Tidsskrift for kjønnsforskning. 2014;38:270–86.

    17.     Alsaker K, Moen B, Baste V, Morken T. How has living with intimate partner violence affected the work situation? A qualitative study among abused women in Norway. Journal of Family Violence. 2016;31:479–87.

    18.     Tolman R. The validation of the psychological maltreatment of women inventory. Violence Vict. 1999;14:25–37.

    19.     Alsaker K. Quality of life among women who have experienced intimate partner violence: a one year follow-up study among women at Norwegian women's shelter. (Doktoravhandling.) Bergen: Universitetet i Bergen; 2008.

    20.     Johnson MP. Patriarchal terrorism and common couple violence; Two forms of violence against women. J Marriage Fam. 1995;57:283–94.

    21.     Aas G. Politi- og påtalemyndighetens praktisering av familievoldsbestemmelsen (jf. straffelovens §219). Tidsskrift for strafferett. 2013;13:236–45.

    22.     Gilroy H, Symes L, McFarlane J. Economic solvency in the context of violence against women: a concept analysis. Health & Social care in the community. 2014;23:97–106.

    23.     Råkil M, ed. Menns vold mot kvinner. Behandlingserfaringer og kunnskapsstatus. Oslo: Universitetsforlaget; 2002.

    24.     Basile KC. Histories of violent victimization among women who reported unwanted sex in marriages and intimate relationships findings from a qualitative study. Violence Against Women. 2008;14:29–52.

    25.     Waltermaurer EM, Ortega CA, McNutt LA. Issues in estimating the prevalence of intimate partner violence. J Interpers Violence. 2003;18:959–74.

    26.     WHO. Responding to intimate partner violence and sexual violence against women. WHO clinical and policy guidelines. Genève: WHO; 2013.

    27.     WHO. Understanding and addressing violence against women: Intimate partner violence. Genève: WHO; 2012.

    28.     McFarlane J, Malecha A, Gist J, Watson K, Batten E, Hall I, et al. An intervention to increase safety behaviors of abused women: results of a randomized clinical trial. Nurs Res. 2002;51:347–54.

    29.     Johnsen GE, Hunskår S, Zachariassen S, Alsaker K, Nesvold H. Overgrepsmottak 2017. Status etter spesialisthelsetjenestens ansvarsovertakelse. Bergen: Nasjonalt kompetansesenter for legevaktmedisin – Uni Research Helse; 2017.

    Women who have experienced sexual coercion have normally been subjected to other forms of violence, such as acts of dominance and isolation, or emotional, verbal or physical abuse.

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    Background: Intimate partner violence in the form of sexual coercion is largely a hidden issue. In this study we have investigated whether the sexual coercion of women occurs in isolation or in conjunction with other forms of violence within marriage or cohabiting relationships in Norway.

    Objective: To disseminate knowledge on a taboo subject that impacts on women’s health. Knowledge about sexual coercion is crucial when planning interventions in the nursing profession.

    Method: We sent a questionnaire about sexual coercion, psychological and physical violence in relationships to a random sample of women in Norway. The incidence of sexual coercion in the various categories of violence is shown as absolute numbers and percentages, and associations between the variables were tested using the chi-square method.

    Results: Of the 1500 questionnaires sent out, 527 responses were received. A total of 480 had lived with the partner and were included in the study, and 5.8 per cent of these reported sexual coercion by the partner. Sexual coercion is associated with both physical and psychological violence as well as actions by the partner that make it difficult for the woman to stay in paid employment. There is a clear correlation between increasing psychological violence and sexual coercion. The more often a woman is subjected to various acts of dominance and isolation, or emotional and verbal abuse, the more sexual coercion she will experience.

    Conclusion: The sexual coercion of women by a spouse or cohabitant is associated with acts of psychological and physical violence. Sexual coercion also occurs in combination with actions that make it difficult for women to stay in paid employment.

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  • The e-multidose is better for patients’ safety than dosette boxes and faxes

    Using the correct medication to prevent and treat illness is a vital element of the health services today. When the patient has several chronic illnesses, the complexity of medication often increases, and consequently the possibilities of drug interactions and adverse side effects. The handling of medication affects whether patients receive the correct medication at the correct time. This article sheds light on the impacts of new ways of handling patient medication.

    From dosette box to multidose – purpose and experiences

    A dosette box containing the drugs the patient is to take is a device that makes it easier for him/her to take the correct medication at the correct time. The use of the dosette box requires qualified personnel to distribute the drugs correctly in the box. However, this procedure is not only time-consuming but entails the danger of erroneous placement in the dosette box (1).

    The multidose has been developed to reduce these disadvantages through medications being machine packed into dose unit bags. Discarding of medication is also expected to decline (2). While the dosette box was packed by a nurse, machine packaging takes place at the pharmacy after the doctor has sent the pharmacy a prescription card. The multidoses are usually packed for a two-week period, and the bags are marked with the patient’s ID, drug product information and the time of intake (3).

    The use of the multidose has increased. In 2002, altogether 3000 patients received multidoses while in October 2015 the total was approximately 77 300 patients. Of these, 60 000 were attended to by the community nursing service, and 3200 received multidoses directly from the pharmacy at their own request (2).

    However, studies find both advantages and new challenges in relation to the multidose (2, 4, 5). The multidose appears to make the handling of medication simpler and safer by reducing errors in the dispensing process (1, 4, 6). The challenges include the manual recording and updating of patients’ medication lists in three different systems: at the GP surgery, by the community nursing service and at the pharmacy. This entails the risk of inconsistency and errors.

    Ordering multidose drugs is based on paper prescriptions in the form of a prescription card, while ordering drugs for patients without multidose is based on electronic prescriptions, so called e-prescriptions. Two parallel routines– both prescription cards and e-prescriptions – can result in unintended duplicate orders and duplicate delivery of medication. Such duplication constitutes a weakness in the system that requires attention (1).

    The health authorities have pointed out that the multidose is unsuitable for dealing with frequent changes in medication dosage, but that it is a scheme that is suitable for distributing drugs for regular use to home-dwelling patients with a stable dosage (7).

    Fakta
    Definitions and abbreviations

    Electronic prescription (e-prescription): E-prescriptions are replacing paper prescriptions and have been introduced throughout Norway.

    E-multidose: Requisitioning of multidoses in an e-prescription solution. This means that multidoses are ordered by means of a general procedure for e-prescriptions, whereby doctors and pharmacies communicate via a national database for electronic prescriptions called Reseptformidleren (prescription mediator).

    LIB: Legemidler i bruk (current medication list) – list of patient’s medication, dietary supplements, critical information on drugs and drugs that have been recently discontinued.

    Patient safety: This refers to whether the patient receives the correct medication at the correct time.

    Prescription card: When the multidose is to be used for the first time, the pharmacist prepares an overview showing the entire medication regime of the service user. The overview is used in a prescription card that is valid as a one-year prescription for all medication listed on the card when it has been signed by the doctor.

    From multidose to e-multidose

    At the time the multidose came into use, fax was the most important medium for information transfer and communication between the main actors – the GP, home care services and the pharmacist – when they dealt with medication lists. This handling procedure has many undefined manual checks, and there are many chances of making errors when dispensing drugs to patients. As a result, there was a need to communicate medication data between actors electronically.

    A multidose solution via e-prescription, termed e-multidose, was implemented and tested in five Norwegian municipalities. The e-multidose is intended to support efficient work processes and ensure that the patient receives the correct medication at the correct time. Testing commenced in 2014 (2).

    While the introduction of the multidose primarily concerned a change from manual to automised dosage of medications, the transfer to the e-multidose entailed a change in the data and communication systems. The e-multidose is linked to the introduction of the e-prescription in the primary healthcare service in 2013, and in hospitals from 2016.

    The e-multidose is intended to support efficient work processes and ensure that the patient receives the correct medication at the correct time.

    In the paper-based multidose solution, the doctor faxes a prescription card to the pharmacy with a list of all the drugs prescribed for a patient, and the pharmacy uses machine-packaging for the multidoses. With the use of the e-multidose, the doctor no longer has to prescribe drugs by faxing a prescription card to the pharmacy, but must send the order electronically as an e-prescription. This means that multidoses are prescribed under a general procedure for e-prescriptions via the national database for electronic prescriptions.

    Instead of the prescription card, a notification termed LIB (current medication list) is now employed. The LIB list does not replace the prescription card since it does not function as a prescription, but simply shows the drugs and dietary supplements listed for the patient. In addition, it contains critical information regarding drugs as well as those recently discontinued. Thus in order to pack multidoses, a LIB list and an e-prescription are required (2, 5).

    Studies from other countries found that the multidose scheme gave a higher risk of medication error than ordinary prescriptions without the multidose, and also reported that the multidose medication lists had lower quality (4, 8–11). These findings have not been examined more closely but researchers are reflecting on whether this may be because the multidose scheme is more automised and entails less frequent contact with the GP and thus fewer reviews of medication than for patients without the multidose (8, 12). We would stress that studies with empirical material from other countries often deal with the multidose in the context of e-procedures that differ from those in the Norwegian pilot project (5).

    Research question

    Our article focuses on how the transfer to the e-multidose may affect patient safety. By patient safety, we mean whether the patient receives the correct medication at the correct time. The correct use of medication is conditional on many aspects of the process from time of diagnosis until the drugs are dispensed and ingested.

    The article addresses the following research question:

    How does the e-multidose scheme that is being tested affect information and communication between the pharmacy, the community nursing service and the regular GP, and what consequences may this have for patient safety?

    Method

    Recruitment of informants

    The Norwegian Directorate of eHealth commissioned the study. The Directorate informed us about what group practices were taking part in the pilot project and helped us to find contact persons at multidose pharmacies and the community nursing service in the pilot municipalities. We invited all the participants in the pilot project to participate in the study and sent a letter by email to the pharmacies that functioned as multidose pharmacies, the management of community nursing services and group practices in the relevant municipalities.

    The letter gave a brief description of the project with the name of the client and the main theme of the interviews. All service users who wished to participate were included as informants. In respect of the community nursing service, three out of five managers helped us to arrange interviews.

    Obtaining interview material

    One of the authors of the article and another project member, Doctor Nils Kolstrup, conducted the interviews at the beginning of November 2016. The interviews took place at the workplaces of the GPs and the pharmacy staff, and in common rooms for community nurses. We carried out six interviews with altogether 24 service users. We interviewed a group of three participants at the multidose pharmacy. Four GPs were interviewed, three of them as a group.

    In the community nursing service, we interviewed 17 nurses in three groups. In one of the three groups, patients had returned to the paper multidose system because ‘their’ doctors had changed from patient records supporting e-multidose to a system that did not do so. We believe that the informant groups represented the experiences we sought, but are unsure whether different views and experiences would have emerged if more doctors had participated.

    The interviews lasted approximately 45 minutes and were face-to-face. They were audiotaped and transcribed by a professional agency. We used group interviews because we felt that they would give the in-depth information we wished to obtain, and because we wanted the informants to be able to inspire each other to put forward their views and experiences. Differences in these were just as interesting as uniform perceptions.

    The interviews were semi-structured and accommodated open-ended questions and follow-up questions. The interviews raised questions about how the actors’ work processes were affected by the e-multidose, the accompanying challenges and improvement measures. In this article, we have focused on topics and sub-topics of relevance to patient safety.

    Processing and analysing the interview material

    We employed a topic-centred approach (13, 14) in order to obtain, code and analyse data. At least two co-authors read each interview, while three shared the task of coding the interviews.

    The analysis mainly utilises a retroductive research strategy (14, 15); we looked for underlying reasons that might explain the experiences and situations communicated by the empirical material. This strategy has proved useful since the community nurses and other health personnel must act in accordance with a number of formal requirements – such as procedures, circulars, regulations and laws – related to how information and communication tasks shall be performed. Such parameters and guidelines affect behaviour; they can both solve problems and create new, and they can trigger reflections and proposals for change.

    Ethics

    Written informed consent was given before the start of the interviews. We anonymised the data material in the transcription, and stored audiotapes and identification data separately from the material.

    Results

    Better conditions for information and communication

    The pharmacy and the GPs considered that the e-multidose increases patient safety compared with multidose paper prescriptions. They found that the inclusion of the current medication list in the national database for e-prescriptions gave a better overview of what medications are listed for patients, and what medication lists are correct. Pharmacy staff stressed that e-multidose procedures detect any change in the medication list, and that the inclusion of the current medication list in the national database for e-prescriptions is under pharmaceutical control. This control also includes changes made by doctors other than the regular GP.

    Pharmacy staff were more confident that the medication list, in the form of the LIB list in the national database, is up to date when the multidose is packed. Moreover, with the e-solution the pharmacist can simply send an e-message to the doctor and ask about valid prescriptions and renewal of prescriptions, something that both the pharmacy and the doctor see as an advantage:

    ‘All changes in the LIB list will reach us somehow. So you must make up your mind […]. Renewing prescriptions – of course that also requires the pharmacist to check […]. The e-multidose has vastly improved safety […]. You can spot things that may have been dispensed. Or an interaction.’ (Pharmacist)

    ‘I’m convinced that patients with the e-multidose get more correct medication […], and I think they benefit from an entirely different level of review than was the case ten years ago.’ (GP)

    The regular GPs talked about the positive response of the community nursing service because they got faster answers to their questions about medications. They also praised the e-multidose scheme because it made it easier to give the hospital physician the correct medication list, and generally keep the patient’s LIB list updated by copying the medication lists in the national database for e-prescriptions. Some doctors routinely copied the LIB list in their referrals to hospitals.

    I’m convinced that patients with the e-multidose get more correct medication.
    GP

    Community nurses had differing views about the e-multidose as opposed to the paper-based multidose. One group felt there was no difference. Another group emphasised that paper routines gave them a better overview of what medications were listed for the patients via the prescription card that serves as a valid prescription for one year. The third group believed that the e-multidose was more efficient with fewer errors and less need to chase up the doctors. They also felt that the updating of the patients’ medication lists had improved because the prescription is altered when the patient has seen a doctor:

    ‘[Electronically] it’s much simpler, because then we know it will arrive quite quickly. [But without] electronic communication, it may be that they haven’t sent the fax, or the fax hasn’t arrived, and then they have to send it in the post. So the process takes a lot more time.’ (Nurse)

    New challenges: Reminders and questions about prescriptions

    However, all three instances experienced challenges in respect of the e-multidose. The pharmacy had to contact doctors more frequently because of questions about valid prescriptions as well as reminders to renew the prescriptions. Some doctors did not answer written requests within the pharmacy’s deadline for packing, and the pharmacy had to ring the GP’s surgery:

    ‘We have many well-organised doctors, and then it functions perfectly, and then we have doctors who do not answer these questions, and we have to send the same questions two or three times. And in the end, we have to call them.’ (Pharmacy)

    The prescription card for the paper-based multidose has an expiry date, with medications that are normally prescribed for one year’s consumption. With e-routines, each listing in the current medication list has its own prescription, but this is not always issued for a whole year’s consumption, and the pharmacies found this particularly challenging for medications in prescription groups A and B:

    ‘It is not particularly helpful when you take a sleeping tablet every evening as a multidose, and the doctor writes a prescription for 30 tablets […] instead of writing it for a whole year at a time.’ (Pharmacist)

    With the e-multidose, the community nursing service would need to call the pharmacy more frequently to ask about valid prescriptions, and according to the pharmacist, about attempts to order medications without a valid prescription:

    ‘I have to pester the pharmacy more often about the renewal of e-prescriptions. I have no access to the module, and we have a very limited overview really, [of] what medications the patient uses. We call the pharmacy and ask what prescriptions they have there, and we also have to call the GPs to check what they’ve entered.’ (Nurse)

    ‘We get an awful lot of phone calls: "I just want to check", "Is there a prescription for so-and-so?’ (Pharmacy)

    Regular GPs also found that they were hassled at times by the community nursing service. This might occur when the GP had not yet received the case history from the hospital. At other times, the fault seemed to lie with the community nursing service itself:

    ‘[The community nursing service] requisitions the medication, and a few days go by, and then they requisition it again even though the prescription has been written out.’ (Doctor)

    Uncertainty and lack of clarity: Who sees what and who has responsibility for what?

    Some doctors were uncertain whether the community nursing service see the LIB list in the database for e-prescriptions, and some wondered ‘why the hospitals cannot see the LIB list when they are not in e-multidoses.’ Others felt they would like more specific and accurate information about ‘the difference between the e-prescription and the multidose e-prescription’.

    They mentioned differing views among doctors, including GPs, as to whether others than the GP can discontinue medications on the LIB list. Such disagreements led to uncertainty among GPs about the status of the LIB list in their prescription module:

    ‘A hospital doctor wrote in the case history that one medication had been exchanged for another and that the former had been discontinued, but both prescriptions were found in the prescription module.’ (Doctor)

    The doctors wanted everyone to enter drug prescriptions in the same system in real time. Then the reader would always know what drugs had been prescribed for the patient.

    The nurses described a need to clarify for everyone involved who had responsibility for updating the LIB lists. Some felt that the doctors should inform them of changes straightaway and not wait until the end of the working day. They felt they had to be vigilant and pester the doctors and the pharmacy, and that part of the quality assurance rested on them.

    Prerequisites, weaknesses and wishes

    The GPs believed that devising good routines at the GP surgery in cooperation with the pharmacy and community nursing service is a prerequisite for optimising the advantages of the e-multidose:

    ‘The dialogue box must be checked every day if the 24-hour response time agreed with the community nursing service is to be fulfilled.’ (Doctor)

    One weakness of the health service pathway is that after discharge from hospital, some time passes before the GP receives the case history and notification about changes in medication if this is relevant. By that time, the community nursing service may already have sent a reminder based on the discharge summary they have received, and the pharmacy perhaps receives notification of the change in the multidose too late.

    Another weakness is linked to the electronic patient record (EPR) used by the doctors. They describe EPRs where it is easy to lose the full picture when they switch between modules. Some had partly given up trying to learn how to use their e-tools, which may result in a failure to answer questions from pharmacies and the community nursing service. One doctor believed that the dialogue box was generally intended for dispensing messages of no relevance to his/her own work:

    ‘When I receive a case history, I can paste in the text and compare the lists. But often I actually think it’s quicker to do it manually. […] Now both the manufacturer’s name and the generic name were included, and then one of the lists ended up being twice as long. And then everything’s a mess. So I still miss some kind of sort key in the e-prescription module. And I also miss an option for printing out not only medication lists but also […] the history and that kind of thing.’ (Doctor)

    ‘The coordination module for drugs, I haven’t quite understood it. So I haven’t used it […] So if I happen to access it when the patient is at the surgery, I suddenly see that ‘Oops, there’s a request for information there, and it may have been there for quite a while.’ (Doctor)

    The pharmacy, the doctor and the community nurses all wanted the nurses who administer the patient’s medications to have read-access to updated medication lists in real time. The nurses felt it would be an advantage for all three instances if they also had access to their patients’ e-prescriptions, and that it would be of great help in efforts to establish a shared hub where all the actors involved could see the patients’ medication lists:

    ‘Then it would probably be better if the e-multidose [had] a base that all instances had access to. That you have a cloud, or whatever it’s called, where everyone can access information […]. If the hospital makes any changes, they end up in that cloud.’ (Nurse)

    ‘[Being able to] see the e-prescriptions […] would simplify the work tremendously and would create less hassle for the doctors and the pharmacies as well. So that would be a win-win situation.’ (Nurse) 

    Discussion

    New e-procedures – More accurate prescribing of medication 

    Our interviews show that the pharmacies and doctors had confidence in the LIB scheme in the national database for e-prescriptions, and good experiences with it. Community nurses found that there were fewer errors, and that e-procedures are faster than paper-based procedures when multidoses need to be altered, which also helps to ensure that the patient receives the correct medication at the correct time.

    E-prescription routines enable a more secure transfer of information about drug-based treatment between the doctor and the pharmacy than the use of fax.

    We consider that several elements in the e-multidose scheme promote greater patient safety. The GP and the pharmacy use the same source for prescription data – the LIB list in the national database for e-prescriptions – and a uniform requisition practice via e-prescription replaces parallel routines. E-prescription routines enable a more secure transfer of information about drug-based treatment between the doctor and pharmacy than the use of fax, and the risk of error is reduced when the manual transfer of drugs information from paper to electronic systems is a thing of the past. Another study (16) from the pilot project provides a similar picture.

    A lack of information about what medications the patient uses may also be a problem in the case of hospitalisation (17). The LIB lists in the national database for electronic prescriptions constitute an important medication coordination aid for doctors in regional health trusts as well as for doctors in out-of-hours emergency care and specialists. 

    Weaknesses of the present scheme

    With the e-multidose, however, community nurses lose access to the patient’s medication lists via the prescription card, and they must administer drugs without access to the service user’s prescriptions. All three groups of informants expressed a wish that community nurses should have access to the LIB lists. Such access would probably lead to a decline in reminders and chasing up prescriptions, eliminate time wasting and delays, and make provision for community nurses to continue helping to quality assure medication handling.

    The problem of lack of access applies to all health and care services in the municipality. The Norwegian Directorate of Health has recommended that national criteria and professional guidance describing the distribution of responsibility for both the current paper-based scheme and the e-solutions should be drawn up for procedures and tasks related to the multidose. Such criteria and guidance would promote correct and satisfactory medication handling. Furthermore, the Directorate has proposed the provision of a regulatory platform that would give nurses and social educators with professional needs access to updated medication lists (18).

    The problem of renewing prescriptions – other proposals

    The pharmacy staff wanted the doctors to prescribe larger quantities so that the prescriptions did not need to be renewed so often. One proposal was the automatic calculation of one year’s consumption each time the doctors prescribed medications. Another proposal that would make it easier for doctors to requisition larger amounts of medications in the A and B prescription groups was to limit prescriptions to multidose packages only.

    The desire to make provision for prescribing large quantities of these medications conflicts with the regulations relating to the dispensing of drugs by pharmacies (19). Moreover, the health authorities have explicitly stated that habit-forming medications intended for use as required, should not be prescribed in multidose packaging (7). The doctors we interviewed did not support this proposal either.

    Another suggestion from the pharmacy staff regarding ‘the problem of renewing’ was that every time the doctor altered a patient’s current medication list, all the patient’s prescriptions had to be renewed. It is relevant to view the suggestion in light of the probability that multidose patients receive poorer follow-up by their primary doctors and regular GPs, as mentioned in the introduction.

    Need for information, training and reorganisation

    The interviews revealed uncertainty and ignorance among the doctors regarding who can see the patient’s LIB list in the national database for electronic prescriptions. We presume that information from the health authorities and perhaps the Norwegian Medical Association can clarify this.

    Uncertainty and lack of clarity regarding the responsibility for updating the patient’s current medication list represents another major problem in terms of information. It should be easy for all prescribing doctors to establish who can and shall alter the patient’s LIB list. Regulations relating to regular GPs (20) require GPs to coordinate the medication-based treatment of their registered patients and update these patients’ medication lists when they alter the medication or receive information that this has been altered. In order to maintain an updated LIB list, the GP needs speedy and adequate information from the specialist health services when they change a medication-based treatment.

    The current discharge summary from the hospital to the home care services is prepared for the nursing function, not for the work of the doctor. The time gap from discharge until the regular GP receives the case history leaves room for urgent requests, hassle and uncertainty when the doctor and the community nurse do not know what medication has now been prescribed for the patient. Having to wait for the case history is a familiar problem for the primary doctor (22).

    If doctors find it difficult to use their own IT systems…this undermines the optimal functioning of the e-multidose solution.

    On the basis of current opportunities for speedy e-communication, we set focus on the organisation of work in the hospital. We assume that it may be helpful to investigate or assess how the hospital can reorganise its work in order to solve or alleviate this problem.

    Wishes were expressed for a shared hub where every instance with professional needs could read the patient’s medication list in real time. In connection with this, the most urgent need that manifests itself in our material is for community nurses to be given access to patients’ current medication list. Regarding the further development of the service systems, it would be interesting to investigate how one could organise and adopt a shared hub where a patient’s medications were continuously updated and prescribed by the different instances.

    The doctors perceived the EPR solutions as cumbersome, and found it challenging to use them. If doctors find it difficult to use their own IT systems and consequently do not answer requests from pharmacies and community nursing services, this undermines the optimal functioning of the e-multidose solution. The problems described show the necessity of both training in and development of better EPRs.

    The National Action Plan for e-Health 2017–2022 specifies plans for including municipal institutions and the home care services in the digital medication chain (18). In the course of 2018, electronic prescribing of multidoses will be introduced for several regular GPs and pharmacists. A summary care record has been introduced and will be further developed in the Norwegian health service. Here in the course of time, health personnel will find a continuously updated list of the patient’s medications (23, 24).

    Conclusion

    The study supports and supplements earlier research. The multidose in the form of an e-prescription improves the quality of medication handling. Sources of error linked to paper-based solutions will disappear. Further quality assurance will result from the pharmacy systematically checking all changes in medication.

    Lessons learned from the study point to three measures that can support the good effects of the e-multidose:

    • The distribution of responsibilities among some of the actors must be clarified.
    • Doctors’ EPR systems must be made more transparent and easier to use.
    • Everyone who handles the e-multidose, including community nurses, must have access to the current medication list (LIB).

    From our perspective, the home care services have a key function in quality assuring the handling of medication for patients. Access to the LIB will facilitate this function. Such access will also benefit the work situation of the community nurses, pharmacies and regular GPs.

    Many thanks to Doctor Nils Kolstrup for his valuable contribution to the multidose project.

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    With the use of multidose electronic prescriptions, sources of error linked to paper-based solutions have been eradicated. However, it is still challenging to achieve optimal handling of medication.

    Article is Peer Reviewed
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    English
    Sammendrag

    Background: The quality of drug-based treatment may be affected by how drugs are handled. This is why the multidose has been introduced as a replacement for the dosette box. Moreover, this is the background for a pilot project in a number of Norwegian municipalities where multidoses are dispensed via an e-prescription scheme.

    Objective: The objective of the article is to shed light on experiences gleaned from the pilot project on whether patients receive the correct medication at the correct time.

    Method: The empirical material consists of interviews with the key actors in the administration of drugs: pharmacies, regular GPs and community nurses. Findings are discussed in light of other research and formal regulations in the field.

    Results: Pharmacies and doctors have good experiences with the scheme. Community nurses find that there are fewer errors and that e-procedures are faster than paper-based procedures when multidoses need to be altered. The actors describe how sources of error linked to paper-based solutions have disappeared. The fact that all changes in drug prescriptions are checked routinely by the pharmacy represents a further quality assurance. A weakness of the scheme is that community nurses no longer have access to their patients’ medication list.

    Conclusion: Multidoses in e-prescriptions give improvements in quality in the handling of drugs. A number of measures will support the beneficial impacts of the e-multidose:

    The distribution of responsibilities among some of the actors must be clarified.

    Doctors’ EPR systems must be made more transparent and easier to use.

    Everyone who handles the e-multidose, including community nurses, must have access to the current medication list (LIB).

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  • Being in contact with nature activates memories and offers elderly people in nursing homes beneficial experiences

    Elderly people living permanently in nursing homes have little contact with nature. This often entails a significant difference from what they were accustomed to in their earlier years (1). Nature and the outdoor environment have important qualities in promoting well-being, reducing stress, improving cognitive functions and activating good memories. Nevertheless, little use is made of nature, the outdoors, and outdoor activities in the therapeutic use of environments (2, 3), despite the fact that this may significantly affect elderly people’s quality of life (4).

    The opportunity to get out of the nursing home ward and take part in meaningful activities is of key importance for thriving (5), happiness, well-being and quality of life (6). Likewise, the ability to concentrate has been reported to be improved in elderly people who regularly spend time outdoors compared with those who primarily remain indoors (7).

    A systematic review addressing the benefits of sensory gardens for dementia disorders reports increased well-being, improved sleep, a reduction in serious falls and less use of psychotropic medications (8). A well organised outdoor environment or a sensory garden helps the elderly to get outside and facilitates meaningful conversations (9).

    Reminiscence

    Nature and gardens provide a multisensory and symbolic environment that can help to recall episodes from a person’s past (10), since different sensory stimuli have the potential to activate memories (11), both referred to as reminiscence. Reminiscence is defined as the process of thinking about or telling others about one’s own past experiences (12).

    The process of reminiscence helps to activate memories that promote identity, self-worth and self-perception, which in turn reinforces the feeling of wholeness, coherence (11) and meaning (13). The outdoor surroundings are also important in terms of exposure to daylight (14), participation in enjoyable activities (15) and experiences involving change and freedom (16). In addition, the garden and outdoor surroundings pave the way for social interaction and meaningful conversations (9).

    When people are outdoors, both an emotional and an aesthetic response are triggered (17). The emotional response affects perception and cognition, activating a complex interaction of thoughts, feelings, meaningful experiences and memories (17). The aesthetic response is characterised by joy and positive feelings, and may have a stress-reducing effect by blocking worries and negative thoughts (17, 18).

    The outdoor surroundings are also important in terms of exposure to daylight and participation in enjoyable activities.

    According to the Attention Restoration Theory (ART) developed by Kaplan and Kaplan (19), exposure to and experience with nature can also help to restore attentional functions and reduce mental tiredness. Four qualities of the natural environment are of key importance for the occurrence of these processes:

    • The natural environment entails a real change and distance (being away) from one’s ordinary environment.
    • The natural environment has the potential to fascinate (fascination).
    • The natural environment is extensive enough to be explored and retain engagement over time (extent).
    • The natural environment’s qualities must be in accordance with the individual’s interest in nature (compatibility).

    A change in the environment from indoors to outdoors thus entails a change in stimuli that permits multisensory perceptions, emotional and aesthetic responses, cognitive engagement, fascination and stress reduction. 

    The objective of the study

    The objective of the study was to explore in a Norwegian context what characterises experiences and memories linked to nature for nursing home residents, underpinned by the theoretical perspectives presented and earlier research.

    Method

    Design

    The study had a qualitative exploratory and descriptive design where individual semi-structured interviews were used to collect data. We selected three nursing homes situated in rural surroundings as the research context.

    Sample

    The informants in the study were residents staying permanently in a nursing home. The inclusion criteria were the ability to narrate stories from their own lives and the absence of serious sight or hearing impairment. The informants were recruited by the nursing home director passing on the request to the ward managers who then asked suitable residents if they would like to participate.

    Eight residents between the ages of 62 and 90 agreed to take part in the study. Three of these were women. The residents had an average residence time of 3.7 years, with a variation of from one to twelve years.

    Collection and analysis of the data

    We interviewed all eight residents twice using the same interview guide – once outdoors in the natural environment and once indoors in the patient’s own room. In the outdoor interviews, we focused on the residents’ experiences of the surroundings in a here and now perspective. In the interviews that took place in the resident’s room, we addressed the recalling of memories and the life history of the individual related to nature experiences. In the latter interviews, we used photographs of four different natural environments as a supportive tool since this has proved to be useful in interviews with frail elderly people (20, 21). We conducted altogether 16 research interviews with the eight nursing home residents. The interviews lasted 45 minutes on average, with a total interview time of 7.5 hours. All the interviews were audiotaped.

    The activation of the residents’ memories was triggered by the interviewer’s questions, by what the interviewer added, by the photographs accompanied by the interviewer’s questions, and in some cases by the photograph itself. The findings of the interviews outdoors were consistent with the interviews indoors using photographs.

    We transcribed the audiotaped recordings and analysed the transcribed material in accordance with Malterud’s method of systematic text condensation (22). This method entails the condensation of meaning units with the ensuing development of categories and subcategories. Our text material coded into categories and subcategories provided the basis for preparing analytical texts that in turn resulted in meaningful descriptions of the different categories in the material.

    Ethical issues

    We obtained written consent from the residents who participated in the study. The project was approved by the then Norwegian Social Science Data Services, now NSD – Norwegian Centre for Research Data (project no. 38162).

    Results

    We present the findings in accordance with the structure used in Table 1. The findings are presented as a summary informed by illustrative statements.

    Table 1: Overview of categories and subcategories for nursing home residents’ experiences and recollections of nature

    Being engaged

    The category ‘being engaged’ was related to a need for change, acquiring good sensory impressions and being fascinated. The wish for change was linked to a longing for engagement since staying indoors was associated with being passive: ‘I find it easy just to put my feet up in my room and not move, and that’s not good.’

    ‘If I spot a roe deer in a field outside, I feel like going outdoors, but I just can’t manage it.’

    The residents appreciated good sensory impressions both indoors and outdoors: ‘That birch tree over there – the tall one – I think it’s so beautiful. Now it’s come into leaf, but the first thing you see are the small green shoots, they’re so pretty.’

    ‘I like to sit and gaze at the trees from the window, I need to have a glimpse of that.’

    Being engaged was related to the experience of fascination and joy inspired by nature: ‘Oh look! There’s Pussy and just look. It’s caught something!’

    ‘When the birds are in the trees, it’s such fun [voice expresses emotion].’

    Thriving

    This category accommodates perceptions of well-being, activity and being outdoors together with others. The residents said, ‘I feel more alive in springtime’, and that being able to go outside gave a feeling of freedom: 'It represents freedom, I think it’s wonderful to be outdoors as much as possible.’

    Some residents also associated being outdoors with their enjoyment of the sunshine: ‘I think you need all the sunshine you can get, because after all, it’s medicine.’

    It represents freedom, I think it’s wonderful to be outdoors as much as possible.
    Informant

    Several residents emphasised that being outdoors also entailed being active and in the company of others: ‘Outdoors I’m kind of more active and talk more and so on.’

    ‘Now that I’m at the nursing home, the thing is to get out and get some fresh air and meet other people.’

    Recalling contact with one’s roots and identity

    This theme was related to how identity and stories set against the natural surroundings of childhood and adolescence were linked to being rooted in the landscape, remembering your life history and being the person you are. The longing for the landscape of childhood was central: ‘If I could only go back and see the ocean now and again. I miss that here.’

    ‘Seeing the ocean is like experiencing tranquillity and finding your place.’

    Some of the residents also related how their memories of nature helped them to remember their own life history: ‘I bought climbing boots and climbed all the way up Galdhøpiggen. Climbed to the very top, then I had a view of several countries.’

    The residents might also say things that for them described sources of meaning: ‘That was kind of what life was all about, sitting outdoors picking [berries].’

    Nature was also closely linked to the residents’ identity: ‘If you were born by the ocean, then you feel it’s something that lies in your blood.’

    The photographs helped to bring back memories of natural landscapes and experiences of nature. ‘When we talk about it, I remember fishing trips, and I haven’t thought about fishing for several years.’

    Experiencing old age in contact with nature

    Experiencing old age in contact with nature was characterised by using nature differently than before, that the perception of nature was different, and that one’s relationship with nature had become different during the life course. They talked about functional impairment and tiredness, using expressions such as: ‘Then I was in good health and I went walking and things.’

    ‘I don’t miss the mountains now, I have a lot of difficulty walking. Hiking in the mountains was something I did earlier, when I was younger.’

    The residents’ statements made it clear that when you can no longer move around on foot in the natural environment, your attitude to nature changes. Some of the utterances also showed signs of reconciliation with their own functional impairment and their determination to make the best of the situation: ‘Yes, now I don’t get out and about, so I simply have to sit here. Well, I have to face it with a smile.’

    Several residents also found that their impaired senses meant that they could not hear the sounds of nature and birdsong. The course of nature and the changing seasons were also associated with their own life course: ‘It was green and lush with flowers, but when autumn comes, they wither one by one [said in a sad tone of voice].’

    Discussion

    The interviews gave the overall impression that the residents had made active use of the natural environment where they had lived earlier, and that contact with nature offered them joy, meaningful experiences and activities, and fellowship with others. The findings suggest that their relationship with nature had become somewhat different in old age, and indicated that their roots, identity and good memories were closely linked to experiences and a life lived in nature and the outdoor environment.

    The findings referring to involvement and activity are interesting in light of the findings of other studies that have reported that elderly people stress the importance of having days filled with meaning at the nursing home (23). Moreover, good sensory experiences and variation in everyday life are reported to be essential (16), and the outdoor environment and nature may significantly influence the quality of life of elderly people (4).

    Passivity led to discontent

    Studies that report that the outdoor surroundings promote physical and mental well-being (16, 24, 25) also confirm our findings, in particular that passivity is reported as being a major problem for nursing home residents (26). The residents mostly appreciated being outdoors. They expressed their discontent with a passive and sedentary life indoors.

    These findings further underline the importance of nursing homes actively utilising the outdoor environment, since inactivity rather than the ageing process has most impact on functional impairment and the ability to take care of oneself (27). The residents’ voices in this study contrast with reported findings that nursing home staff have low expectations of residents’ ability and willingness to take part in activities (28). Our findings are more in line with Day et al. (29) who reported contact with nature and the outdoor environment can strengthen the feeling of having good health, and help to mitigate the sense of functional impairment.

    They expressed their discontent with a passive and sedentary life indoors.

    We consider that both the categories and individual statements in the study suggest that the elderly expressed the view that being outdoors and experiencing a change of environment led to both fascination with the surroundings (19) and relief from stress, worries and negative thoughts (30). This concurs with ART and research reporting that environments that provide relief from stress and tiredness are important in the care of the elderly (7).

    Important social arenas

    Nature and the outdoor environment were also important social arenas. This finding is in accordance with Kearney and Winterbottom (24), who reported that meeting others is one of several reasons why nursing home residents want to be outdoors. Furthermore, Bengtsson and Carlsson (16) wrote that outdoor areas facilitate a variety of ways of being together with other people.

    Research reporting that the natural environment helps to promote social interaction as a source of restitution (30), and that staff find that sensory gardens encourage communication and strengthen social interaction (9), also supports these findings. Interestingly, both the findings of our study and the studies mentioned stand in contrast to those of studies reporting that the staff spend the minimum amount of time facilitating social interaction among the nursing home residents (31, 32).

    Our findings indicate that the residents had a sense of loss in relation to the place where they had their roots, their affiliation and their identity. Giuliani’s findings (33) that involuntary separation from places to which you are attached can lead to pain and despair, and entail an interruption in the continuity of the life course, also support our findings.

    Fellowship and social interaction were more associated with being outdoors than previously.

    We found that using photographs strengthened recollections of good memories, stories and the feeling of identity, which is of considerable importance in geriatric care (34). Drageset, Normann and Elstad (35) emphasise that nursing home residents with dementia disorders also ‘appear strengthened’ when they relate recollections linked to nature experiences.

    In various ways, the residents indicated that their relationship to nature and outdoor activities had become different in old age, and that fellowship and social interaction were more associated with being outdoors than previously. If this is interpreted as part of the process of adaptation in later years, the findings are in line with Bergland’s study (5), in which it is reported that elderly people adjust their expectations in line with the reality of their situation.

    The findings can also be understood as a desire for more social activity and outdoor life than what they experience in their everyday lives in the nursing home. These are significant factors in enabling them to regard the nursing home as a real home (36). In addition, next of kin value these factors as important qualities in the nursing home (37).

    Experiences linked to the connection between the life course and the course of nature can help to create meaning and support a sense of coherence and wholeness, as Takkinen and Ruoppila (38) have reported. These existential reflections can contribute to the important work of reflecting on peace and reconciliation when facing death, as Andersson, Halberg and Edberg (39) have described.

    The study’s strengths and limitations

    It is considered a strength of the study that we have conducted two interviews with eight residents in two different contexts, and that we have used photographs to elicit the residents’ memories. The outdoor interviews helped us to acquire good and spontaneous descriptions of here and now experiences. The use of photographs also allowed for activating reflections and memories of residents’ earlier lives in connection with nature, and they constituted a helpful tool as described by Chao et al. (20). The interviewer himself had a strong commitment and a close relationship with nature as well as considerable clinical experience with nursing home residents, which was also considered to strengthen the study.

    Limitations of the study are that the interviewer was inexperienced, and that all the interviews were conducted prior to transcription and analysis (22). 

    Conclusion

    When asking nursing home residents about their experiences and memories related to contact with nature, this study shows that they acquired a change of environment, beneficial sensory experiences, meaningful activities, social interaction and good memories. They also got in touch with feelings such as sadness at impaired functional ability and the loss of childhood landscapes and geographical affiliation. Conversations inspired by photographs of different kinds of landscape activated memories and stories linked to their roots and identity. The findings are in line with research and relevant theories.

    Based on the findings, we recommend a practice that makes it easy for elderly people to spend time outdoors regularly. Moreover, we recommend that being outdoors is established as a regular and natural component of the therapeutic environment at nursing homes, based on the individual resident’s preferences and resources (40).

    Research communities in this field are challenged to explore and describe further relations between ageing and experiences of the natural environment. In addition, research should address how experiencing nature on a regular basis can promote well-being, quality of life, improved functioning and greater satisfaction of the basic needs of elderly people. We also encourage researchers to identify similarities and differences between residents’ needs and wishes for good days at the nursing home and the staff’s expectations and priorities in the everyday life of the nursing home.

    References

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    2. Kearney A, Winterbottom D. Nearby nature and long-term care facility residents: Benefits and design recommendations. Journal of Housing For the Elderly. 2006;19(3–4):7–28.

    3. Cutler LJ, Kane RA. As great as all outdoors: A study of outdoor spaces as a neglected resource for nursing home residents. Journal of Housing For the Elderly. 2006;19(3–4):29–48.

    4. Sugiyama T, Thompson CW. Environmental support for outdoor activities and older people's quality of life. Journal of Housing For the Elderly. 2006;19(3–4):167–85.

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    6. Orr N, Wagstaffe A, Briscoe S, Garside R. How do older people describe their sensory experiences of the natural world? A systematic review of the qualitative evidence. BMC Geriatrics. 2016;16(1). DOI: 10.1186/s12877-016-0288-0.

    7. Ottosson J, Grahn P. Measures of restoration in geriatric care residences: The influence of nature on elderly people's power of concentration, blood pressure and pulse rate. Journal of Housing for the Elderly. 2006;19(3–4):227–56.

    8. Gonzalez MT, Kirkevold M. Benefits of sensory garden and horticultural activities in dementia care: A modified scoping review. Journal of Clinical Nursing. 2014;23(19–20): 2698–715.

    9. Gonzalez MT, Kirkevold M. Clinical use of sensory gardens and outdoor environments in Norwegian nursing homes: A cross-sectional e-mail survey. Issues in Mental Health Nursing. 2015;36(1):35–43.

    10.      Webster JD, Haight BK. Memory lane milestones: Progress in reminiscence definition and classification. In: Webster JD, Haight BK, eds. The art and science of reminiscing: Theory, research, methods, and applications. London: Taylor & Francis, 1995;273–86.

    11.      Webster JD, Bohlmeijer ET, Westerhof GJ. Mapping the future of reminiscence: A conceptual guide for research and practice. Research on Aging. 2010;32(4):527–64.

    12.      Cappeliez P, O’Rourke N, Chaudhury H. Functions of reminiscence and mental health in later life. Aging & Mental Health. 2005;9(4):295–301.

    13.      Chao JS-Y, Liu JH-Y, Wu JC-Y, Jin JS-F, Chu JT-L, Huang JT-S, et al. The effects of group reminiscence therapy on depression, self esteem, and life satisfaction of elderly nursing home residents. Journal of Nursing Research. 2006;14(1):36–45.

    14.      Burns A, Byrne J, Ballard C, Holmes C. Sensory stimulation in dementia. BMJ: British Medical Journal. 2002;325(7376):1312–13.

    15.      MacDonald C. Back to the real sensory world our «care» has taken away. Research into the effects of multisensory stimulation. Journal of Dementia Care. 2002;10(1):33–6.

    16.      Bengtsson A, Carlsson G. Outdoor environments at three nursing homes – Qualitative interviews with residents and next of kin. Urban Forestry & Urban Greening. 2013;12(3):393–400.

    17.      Ulrich RS. Aesthetic and affective response to natural environment. In: Altman I, Wohlwill JF, eds. Human behavior and the environment. New York: Plenum; 1983; 88–125.

    18.      Ulrich RS. Visual landscapes and psychological well-being. Landscape Research. 1979;4(1):17–23.

    19.      Kaplan R, Kaplan S. The experience of nature: a psychological perspective. Cambridge: Cambridge University Press; 1989.

    20.      Chao SY, Chen CR, Liu HY, Clark MJ. Meet the real elders: Reminiscence links past and present. Journal of Clinical Nursing. 2008;17(19):2647–53.

    21.      Kirkevold M, Bergland D. The quality of qualitative data: Issues to consider when interviewing participants who have difficulties providing detailed accounts of their experiences. International Journal of Qualitative Studies on Health and Well-Being. 2007; 2(2):68–75.

    22.      Malterud K. Systematic text condensation: A strategy for qualitative analysis. Scandinavian Journal of Public Health. 2012;40(8):795–805.

    23.      Dybvik TK, Gjengedal E, Lykkeslet E. At the mercy of others – For better or worse. Scandinavian Journal of Caring Sciences. 2014;28(3):537–43.

    24.      Kearney AR, Winterbottom D. Nearby nature and long-term care facility residents. The role of the outdoors in residential environments for aging. New York: Routledge; 2005;7–28.

    25.      Reynolds L. A valued relationship with nature and its influence on the use of gardens by older adults living in residential care. Journal of Housing for the Elderly. 2016;30(3):295–311.

    26.      Matthews CE, Chen KY, Freedson PS, Buchowski MS, Beech BM, Pate RR, et al. Amount of time spent in sedentary behaviors in the United States, 2003–2004. American Journal of Epidemiology. 2008;167(7):875–81.

    27.      Bergland A. Fysisk aktivitet og trening gir størst gevinst for de eldste. In: Bondevik M, Nygaard HA, eds. Tverrfaglig geriatri. En innføring. 3. utg. Bergen: Fagbokforlaget. 2012. s. 221–38.

    28.      Haugland BØ. Meningsfulle aktiviteter på sykehjemmet. Sykepleien Forskning. 2012;7(1):16–21. DOI: 10.4220/sykepleienf.2012.0030.

    29.      Day AM, Theurer JA, Dykstra AD, Doyle PC. Nature and the natural environment as health facilitators: The need to reconceptualize the ICF Environmental Factors. Disability and Rehabilitation. 2012;34(26):2281–90.

    30.      Ulrich RS. Effects of gardens on health outcomes: theory and research. In: Marcus CC, Barnes M, eds. Healing gardens therapeutic benefits and design recommendations. New York: Wiley; 1999. s. 27–86.

    31.      Mallidou AA, Cummings GG, Schalm C, Estabrooks CA. Health care aides use of time in a residential long-term care unit: A time and motion study. International Journal of Nursing Studies. 2013;50(9):1229–39.

    32.      Slettebø Å. Safe, but lonely: Living in a nursing home. Nordic Journal of Nursing Research. 2008;28(1):22–5.

    33.      Giuliani MV. Theory of attachment and place attachment. Psychological theories for environmental issues. Burlington: Ashgate Publishing Company; 2003. s. 137–70.

    34.      Calnan M, Badcott D, Woolhead G. Dignity under threat? A study of the experiences of older people in the United Kingdom. International Journal of Health Services. 2006;36(2): 355–75.

    35.      Drageset I, Normann K, Elstad I. Personer med demenssykdom i sykehjem: Refleksjon over livet. Nordisk tidsskrift for helseforskning. 2013;9(1):50–66.

    36.      Rijnaard M, van Hoof J, Janssen B, Verbeek H, Pocornie W, Eijkelenboom A, et al. The factors influencing the sense of home in nursing homes: A Systematic review from the perspective of residents. Journal of Aging Research. 2016; Article ID 6143645.

    37.      Isola A, Backman K, Voutilainen P, Rautsiala T. Family members’ experiences of the quality of geriatric care. Scandinavian Journal of Caring Sciences. 2003;17(4):399–408.

    38.      Takkinen S, Ruoppila I. Meaning in life in three samples of elderly persons with high cognitive functioning. The International Journal of Aging and Human Development. 2001;53(1):51–73.

    39.      Andersson M, Hallberg IR, Edberg A-K. Old people receiving municipal care, their experiences of what constitutes a good life in the last phase of life: A qualitative study. International Journal of Nursing Studies. 2008;45(6):818–28.

    40.      Gonzalez MT, Kirkevold M. Design characteristics of sensory gardens in Norwegian nursing homes: A cross-sectional e-mail survey. Journal of Housing for the Elderly. 2016;30(2):141–55.

    Nursing home residents are dissatisfied with a sedentary life indoors and reach out more to others socially when they are outdoors. Nevertheless, they have little contact with nature and the outdoor environment. 

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    Sammendrag

    Background: Earlier research shows that contact with nature can promote well-being in nursing home residents. However, little use is made of nature and the outdoors as therapeutic environments in nursing homes.  

    Objective: The objective of this study was to explore and describe what characterises experiences and memories linked to nature and the outdoor environment in a Norwegian context for residents staying permanently in a nursing home.

    Method: The study had a qualitative exploratory and descriptive design. We collected data using semi-structured interviews. Eight participants aged between 62 and 90 were interviewed twice. We carried out one interview outdoors and one indoors in the resident’s room with the aid of photographs of natural environments, with each participant. The audiotaped interviews were transcribed and analysed using systematic text condensation.

    Results: We identified four main themes with sub-groups:

    Being engaged: wanting change, receiving beneficial sensory impressions, experiencing fascination

    Thriving: experiencing well-being, being more active, being together with others

    Recalling contact with one’s roots and identity: being rooted in the landscape, recalling one’s life history, being the person I am, being helped to remember

    Experiencing old age in contact with nature: using nature differently than before, difference in nature experiences, relationship with nature is different, nature and the human life course

    Conclusion: Residents’ perceptions of nature and the outdoor surroundings are characterised by good experiences and a reactivation of their own life history. Nature and the outdoor surroundings should have a key position as therapeutic environments in nursing homes. The findings are in line with established theories and are supported by reported research in the field.

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  • Nurses are better equipped for evidence-based practice following postgraduate study

    The authorities expect the health service to base decisions concerning treatment, prevention and care on reliable knowledge about the outcome of interventions (1). In the Health&Care21 strategy (2) and the follow-up action plan (3), evidence-based practice (EBP) is described as an instrument for promoting quality, greater patient safety and effectiveness in health and social services.

    EBP entails basing decisions on the patient’s wishes and needs in the given situation as well as recommendations from the best research-based and experience-based knowledge available. EBP is presented as a six-step process:

    Step one is about reflecting on own practice and step two concerns the framing of a good clinical question. Step three relates to finding research-based knowledge and step four entails the critical appraisal of research literature. Step five is about integrating valid and applicable research-based knowledge with experience-based knowledge and the user’s preferences. Step six involves evaluating own practice (4).

    EBP in practice

    Melnyk et al. (5) point out that nurses’ EBP-related knowledge, skills and attitudes impact on how research is applied in practice. Despite the increasing focus on evidence-based health services, many Norwegian nurses report that they seldom read research findings or apply them to their own practice (5–7).

    Many Norwegian nurses report that they seldom read research findings or apply them to their own practice.

    One reason for this may be that not all nurses have the knowledge or skills to search for, read, critically understand or apply research (7, 8). In order to achieve the goal of an evidence-based health service, Sandvik, Stokke and Nortvedt (7) suggest that nurses need to be trained in EBP.

    EBP in education

    Systematic reviews (9, 10) suggest that training in EBP is most effective when it is based on principles for how adults learn. Good information, clear learning goals and specific work tasks with the opportunity to exercise practical skills are indicated as having a positive effect. This also applies to variation in the use of lectures and interactive methods, as well as interaction between participants in the form of small group discussions and group work.

    In addition, Khan and Coomarasamy (9) and Young et al. (10) emphasise that the EBP training is most effective when it is based on real issues from practice. This is also the case when students receive training in critical assessment and when they are given regular feedback.

    Several studies have shown that EBP training makes nurses more positive towards EBP (7, 11, 12). However, we do not know of any Norwegian surveys that chart nurses’ EBP-related attitudes and behaviour at the start and end of postgraduate study in EBP. The purpose of this study was to map whether postgraduate study in EBP helped change nurses’ attitudes and behaviour with regard to EBP.

    Method

    Sample and data collection

    We conducted a survey of nurses from the specialist health service and primary health service who had completed a postgraduate study programme in EBP at Molde University College in the period 2009–2012 (n = 62, distributed in three cohorts). At the start (pretest) and end (posttest) of the postgraduate study, academic administrators distributed two questionnaires that respondents answered anonymously within 15 minutes.

    Postgraduate study

    The postgraduate study programme consists of seven seminars over two semesters. The content and teaching methods are based on the recommendations in the book Jobb kunnskapsbasert(4) about evidence-based practice, and the recommendations by Khan and Coomarasamy (9) and Young et al. (10). The systematic reviews indicate that training in EBP is most effective when the participants find it useful for their own practice.

    The students therefore use a problem from their own practice as a basis for acquiring knowledge and skills about the first four steps in EBP. At the seminars, the teaching methods alternate between lectures, small group discussions, skills training and the use of interactive methods such as the online course at kunnskapsbasertpraksis.no. devised by Western Norway University of Applied Sciences and the Norwegian Knowledge Centre for the Health Services. The purpose is to teach healthcare personnel to search for, critically appraise and use research-based knowledge in practice.

    Between the seminars, the students work on specific course requirements linked to the steps. These requirements are solved in groups of three to five students and are assessed by the teacher. At the final seminar, each group presents a summary of completed course requirements. The groups receive feedback from fellow students and teachers. They then bring together the course requirements in a written assignment, which is the home exam.

    Fifteen ECTS credits are awarded to students who pass the exam. Students are encouraged to present the exam assignment at their workplace. The postgraduate study programme does not have a stated goal of training students to implement EBP, but the intention is that student-based methods contribute to the knowledge and skills that are considered to be transferable to practice after completion of the programme. 

    Measuring instruments

    We used the Norwegian translations of the Evidence-Based Practice Beliefs Scale (13) and Evidence-Based Practice Implementation Scale (13) to measure self-reported changes in attitudes and behaviour with regard to EBP. The scales were translated to Norwegian in 2008 by a research group at the Centre for Evidence-Based Practice, Western Norway University of Applied Sciences in collaboration with the original US authors.

    The translation was in line with the World Health Organization’s (14) principle for forward and back translations. In the Norwegian translation, the Evidence-Based Practice Beliefs Scale was called KBP holdningsskalaand the Evidence-Based Practice Implementation Scale became KPB implementeringsskala. We were given permission to use the scales by Nina Rydland Olsen at the Centre for Evidence-Based Practice. 

    The EBP Beliefs Scale consists of 16 items that measure self-reported attitudes and confidence in the respondents’ own knowledge and skills in connection with EBP (Table 1). The responses were scored on a five-point Likert scale, ranging from 1 (strongly disagree), 2 (disagree), 3 (neither agree nor disagree), 4 (agree) to 5 (strongly agree). The total score for the scale varies from 16 to 80. A high total score indicates positive attitudes towards EBP.

    The EBP Implementation Scale consists of 18 items that measure self-reported activity related to EBP (Table 2). The response alternatives are 0 = 0 times, 1 = 1–3 times, 2 = 4–5 times, 3 = 6–8 times and 4 = > 8 times. The total score for the survey varies from 0 to 72. A high total score indicates increased self-reported practice of EBP. National and international reliability analyses show that the scales have good internal consistency (12, 15, 16).

    Research ethics considerations

    The Dean of the Faculty of Health Sciences and Social Care granted permission to conduct the survey. At start-up, the nurses received written and oral information about the survey. Participation was voluntary, and those who agreed to participate signed a letter of consent. In order to ensure the confidentiality and anonymity of participants, we did not collect any demographic data.  

    Statistical analyses

    In line with recommendations by Melnyk et al. (15), the values for the two negatively formulated items in the EBP Beliefs Scale were recoded into reversed content (items 11 and 13 in Table 1) before we conducted the statistical analyses.

    The element of missing data for the entire sample was < 3 per cent for all questions. Questions that a participant had omitted to score were given a value that corresponded to the participant’s mean score on the other questions. Mean scores were used as a measure of central tendency in each section of the EBP Beliefs Scale.

    In the EBP Implementation Scale, median values were used as a measure of the mean value in each section, since all the score steps above 0 (= 0 times) had more than one specific value (1 = 1–3 times, 2 = 4–5 times, 3 = 6–8 times and 4 = > 8 times). The one-sample Kolmogorov-Smirnov test (17) was used to establish whether the distribution of the scores in the EBP Beliefs Scale and the EBP Implementation Scale were approximately normal.

    Since none of the score distributions were normal, we used non-parametric tests in further analyses. Anonymisation prevented us from making a direct (matched) comparison of the individual participant’s scores at pretesting and posttesting. These comparisons were therefore done with statistical tests for dependent samples.

    We used the Wilcoxon signed-rank test (17) to test differences between pretesting and posttesting for each section of both scales, and to test differences in the sample’s total scores at pretesting and posttesting. We measured the internal consistency reliability in the EBP Beliefs Scale and the EBP Implementation Scale using Cronbach’s alpha. The study was based on a conventional significance level of p < 0.05.

    Since repeated tests in the same sample can give measurement errors, whereby differences that are not real are shown to be statistically significant (type 2 errors), we used the Bonferroni procedure. The Bonferroni procedure involves the use of a more stringent criterion: p < 0.001, for significant findings. We analysed the data using the Statistical Package for Social Sciences (SPSS) version 22.

    Results

    At pretesting, 56 of 62 nurses (90.3 per cent) completed both scales. At posttesting, 55 of 62 nurses (88.7 per cent) completed both scales. Gender was the only demographic variable available, but since there was only one man in the sample, it was not possible to analyse any gender disparities. The internal consistency of the distribution of responses we measured using Cronbach’s alpha was 0.80 in the EBP Beliefs Scale and 0.89 in the EBP Implementation Scale.

    Attitudes towards evidence-based practice

    Table 1 shows that the average total score in the EBP Beliefs Scale at pretesting was 52.84, standard deviation (SD) = 5.75 with a range from 41 to 65. At posttesting, the mean total score was 60.80, standard deviation (SD) = 5.41 with a range from 51 to 73. The change in mean total score from pretesting to posttesting for the EBP Beliefs Scale was statistically significant, p < 0.001.

    Table 1. Differences in mean scores1 in the EBP Beliefs Scale at pretesting and posttesting

    The results in Table 1 show that the change between pretesting and posttesting for items 2, 3, 10, 14 and 15 in the EBP Beliefs Scale was statistically significant (p < 0.001). The pretest results show that nurses were unsure about their own EBP-related knowledge and skills at the start of the postgraduate study (items 2, 10, 14 and 15 in Table 1). A higher mean score at posttesting may indicate increased confidence in their own EBP-related knowledge and skills at the end of the postgraduate study.

    At pretesting, the nurses reported that they did not know the steps in EBP (item 2 in Table 1), while at posttesting they reported that they were familiar with these. The nurses also reported that they were sure they could implement EBP both at the start and the end of their postgraduate studies (item 3, Table 1). In connection with knowledge about how they could measure the effect of clinical practice (item 10, Table 1), the results show that they did not know this at pretesting and were unsure about it at posttesting.

    [At pretesting] the nurses were not confident in their own ability to implement EBP or how EBP could be used to bring about changes in practice.

    With regard to their skills in using EBP, it was found at pretesting that the nurses were not confident in their own ability to implement EBP (item 15 in Table 1) or how EBP could be used to bring about changes in practice (item 14). A higher mean score at posttesting may indicate that a change has taken place. 

    A high mean score for items 1, 5, and 9 (Table 1) shows that nurses were confident that EBP could improve their work when they started their postgraduate studies. The posttest results suggest that their studies reinforced their positive attitudes. It was also found that the nurses were confident that critical appraisal of research-based knowledge is an important step in EBP (item 4 in Table 1) at both measurement times.

    With regard to items concerning whether their practice is evidence-based (item 16, Table 1), the nurses report that they were unsure about this at both measurement times. 

    Behaviour in relation to EBP

    At pretesting, median values < 1 indicate that the response alternative ‘0 times’ is the response that the nurses give when answering how many times they have performed various activities related to EBP during the last eight weeks (Table 2). Only for the item about whether they have collected clinical information about a patient problem in the last eight weeks (item 5, Table 2) does the median value indicate that they have done so one to three times (median value > 1).

    Table 2. Median values for the EBP Implementation Scale at pretesting and posttesting

    Table 2 shows that the mean total score in the EBP Implementation Scale at pretesting was 4 (SD = 5.79), with a range from 0 to 25. At posttesting, the mean total score was 20 (SD = 8.92), with a range from 6 to 43. The change in mean scores in the EBP Implementation Scale from pretesting to posttesting is statistically significant, at < 0.001. 

    The results show that the nurses report increased activity from pretesting to posttesting for all items except item 7. In addition, the change is statistically significant in 10 out of 18 items, at p < 0.001 (Table 2).

    This relates to items about increased activity due to, within the last eight weeks, applying knowledge from different sources, critically appraising a research study, framing a clinical question in a standardised manner and discussing a research study informally with a colleague, presenting research-based knowledge in a report or to a colleague, telling a colleague about clinical guidelines based on research, disseminating knowledge from a research study to an interdisciplinary group, reading and critically appraising a clinical research study, using the Cochrane database and promoting the use of EBP among colleagues.

    Discussion

    To the best of our knowledge, this study is the first to evaluate whether Norwegian nurses’ EBP-related attitudes and behaviour change between the start and end of postgraduate study in EBP. The main findings in the study show that the nurses gained more confidence in their knowledge of the steps in EBP and in the importance of EBP in the health service. The study also showed that the nurses reported undertaking evidence-based activities to a greater extent after they had completed their postgraduate studies.

    A high mean total score on the EBP Beliefs Scale at both pretesting and posttesting may indicate that the nurses have a positive attitude towards EBP and agree that clinical practice based on research improves the quality of the health service. The change in total scores from pretesting to posttesting is significant. Variations in education programmes, differing measurement times and analytical methods make it difficult to draw direct comparisons with results in previous Norwegian studies, but overall the studies reinforce the belief that EBP produces the best treatment outcome for patients (5, 7, 11, 12, 18). 

    Attitudes, abilities and knowledge changed 

    A review article (19) examining how individual factors impact the use of research in clinical practice suggests that a positive attitude is crucial to whether nurses read and use research in their practice. In our study, we observed that the nurses’ attitudes and assessments of their own ability to use an evidence-based approach in their work were more positive at the end of their postgraduate studies than at the start.

    The biggest change was in item 2 (Table 2), where the nurses went from disagreeing that they had knowledge of the steps in EBP, to reporting that they were familiar with the steps at posttesting. The result suggests that the nurses learned more about the steps in EBP in their postgraduate studies. This result concurs with a Norwegian (12) and an international study (19). These studies reinforce the assumption that training in EBP is crucial to meeting the health authorities’ expectations for an evidence-based health service (20).

    A low mean total score at pretesting of the EBP Implementation Scale shows that the nurses reported low EBP-related activity before starting their postgraduate studies, which may suggest that they had little focus on evidence-based activities in practice.

    Barriers to implementing EBP

    The increase in mean total scores from 4 at pretesting to 20 at posttesting indicates that the nurses reported more EBP-related activity after they had completed their postgraduate studies. The result is still low, but is somewhat higher than that found in, for example, the study by Snibsøer et al. (12). According to Snibsøer et al. (12), a low mean total score on the EBP Implementation Scale may be associated with barriers such as lack of allocated time, resources, knowledge and authority to change practice.

    In order to successfully implement EBP, it is therefore important to map barriers in the specific context (21). Dahlheim et al. (22) indicate that skills and knowledge in EBP can help reduce such barriers. They found that nurses with evidence-based skills more often read research than those who do not have such skills (22). Increasing research-related activity can lead to better patient safety and job satisfaction (23).

    Evidence-based activities in practice

    In post-testing, the results showed a statistically significant change in the nurses’ EBP-related activity level in 10 out of 18 items after the Bonferroni correction. The nurses reported that they had used knowledge from different sources, critically appraised a research study and framed clinical questions in a standardised manner to a greater extent at posttesting than at pretesting. They had also discussed research with colleagues and disseminated and presented it to them, used Cochrane Library’s database and promoted the use of EBP among colleagues.

    Although the plan was for the nurses to work with the steps in EBP based on a clinical problem from their own practice (9), it may be that the education only had an ‘academic’ effect. The nurses’ uncertainty about whether their practice was evidence-based both at the start and end of their postgraduate studies may indeed indicate this.

    Comparable studies (11, 12, 18) show that nurses report limited evidence-based activity in practice despite their EBP training. Further research on what is needed to ensure greater implementation of EBP in practice is therefore necessary.

    The understanding of research needs to improve

    A surprising result in the study was statistically significant changes in items about EBP that were not thematised in the postgraduate study, e.g. items 6, 8 and 10 (Table 2), which deal with presenting research to colleagues. Greater understanding and discussion of research results in practice can help more nurses to recognise the value of using research-based knowledge in practice.

    According to a literature review by Sandvik et al. (7), healthcare personnel’s ability to read and understand research is crucial to being able to implement research in practice. Researchers must therefore take responsibility for presenting research results in a way that healthcare personnel understand. Another surprising result showed that, during their postgraduate studies, the nurses indicated that they had become more sure about how to measure the impact of clinical practice. The postgraduate study programme did not focus on impact assessment, but emphasised learning activities aimed at increasing the nurses’ critical appraisal abilities.

    Reading and critically appraising more research

    At both measurement times, the nurses agreed that critically appraising research-based knowledge (item 4, table 1) is an important step in EBP. The change between pretesting and posttesting showed a significantly greater emphasis on this (p < 0.005). Because repeated significance tests within the same sample can give unreliable findings, we used Bonferroni-corrected p-values. In order to identify a significant difference, the p-value would have to be at least 0.001.

    The postgraduate study [contributed] to the greater emphasis on critically appraising research.

    Despite this, the finding suggests that there was a statistical tendency for the postgraduate study to contribute to the greater emphasis on critically appraising research. The change between pretesting and posttesting in items 2 and 11 in the EBP Implementation Scale (Table 2) shows that reading and critically appraising research were two of the activities that had increased most. This partly explains the growth in support for EBP.

    Other Norwegian studies (6, 24) show that Norwegian nurses think that critically appraising research is a challenge. It is therefore positive that the nurses in our study report obtaining more knowledge and skills in this area. The ability to think critically is found to be crucial to being able to use research in practice (24, 25).

    Everyone should have competence in EBP

    Whether nurses should learn EBP in undergraduate or postgraduate studies is open to discussion. Today’s nursing students learn about the steps in EBP in their undergraduate education, but not all nurses who graduated in past years received such training. Nurses with many years of experience often have an informal authority to set the standard in practice.

    Efforts to ensure that everyone has competence in EBP are therefore necessary to safeguard the quality in the future health service. Health policy makers are therefore proposing the mandatory training of healthcare personnel in EBP as one of several instruments for improving the quality in the health service (2). Nurses are the largest healthcare profession in the health service, and their ability to apply EBP therefore impacts on the quality of the entire health service.

    More knowledge about the steps in EBP can make nurses more likely to search for and discuss research with colleagues and nursing students. We believe that establishing a culture in which it is natural to read and discuss research can make a positive contribution to implementing EBP in practice.

    Some of the items in the study also showed no significant change between pretesting and posttesting. These results can reflect themes where the postgraduate study programme has potential for improvement. Results from the EBP Beliefs Scale suggest that more emphasis should be placed on the positive effects of EBP on clinical practice.

    Results from the EBP Implementation Scale indicate that postgraduate study should have a greater focus on measures that can reduce barriers to implementing EBP in practice. Postgraduate study programmes should also focus on the patient’s right to research-based information. According to Snibsøer et al. (12), the results of training in evidence-based practice can differ depending on whether it takes place in an academic institution or in a clinical nursing context.  

    Strengths and limitations of the study

    Although the results are in keeping with national and international studies, the sample size in the study limits our ability to generalise the results. On the other hand, generalisation is aided by the high response rates at both measurement times and the participation of respondents from different parts of the specialist health service and the primary health service.

    The reliability of the survey is also strengthened since the internal consistency reliability was good for both scales. A high internal consistency in the scores of a tool means that the respondents have understood the different elements of the tool in the same way and that the difference between the participants’ scores is not due to systematic measurement errors. With a conventional p-value of 0.05, there would have been 8 significant differences in the EBP Beliefs Scale and 14 in the EBP Implementation Scale.

    Using a more stringent significance level (p < 0.001) gave fewer significant differences, but increased the probability of the differences found between pretesting and posttesting being real. We believe that the increased reliability in the study’s result strengthens the study’s internal validity. 

    A methodical limitation of the study was that the academic administrator for the postgraduate study programme carried out the study. Since the scales are based on self-reporting, this may have contributed to systematic errors in scores if the respondents adapted the answers to what they thought the researchers expected to find. That participants’ responses do not necessarily reflect reality will always be a weakness in such surveys (26). However, the fact that the questionnaires were answered anonymously may reduce this source of error.

    Ideally, the students should have been randomised into a group that had studied EBP and a control group that received the corresponding amount of teaching in other thematic content. However, such a randomised design was not feasible given the eight-month survey period. The choice of a naturalistic pre- and post-design means we can steadfastly assert that only postgraduate study in EBP contributed to the result.

    Another limitation is that the anonymous nature of the study meant we were unable to collect demographic information about the respondents and analyse the possible impact of such factors. However, the results from two systematic literature reviews (27, 28) showed no significant correlation between socio-demographic variables and attitudes and behaviour in connection with EBP among nurses.

    The danger of using the same scale at pretesting and posttesting is that the respondents learn something from the first measurement that affects the result of the subsequent measurement. Since pretesting and posttesting were more than eight months apart, it is unlikely that the respondents remembered exactly how they responded in the pretest. Another limitation may be that some respondents answered the EBP Implementation Scale at pretesting based on learning activities in the postgraduate study programme and not on their own practice.

    Since the scales were developed in and for a US context, the applicability of the scales needs to be studied in the Norwegian health service context. Furthermore, that our study could have given different results if it had been carried out today cannot be ruled out.

    Implications for further research

    There is a great need for studies that use methods other than self-reporting of attitudes, knowledge and skills in order to evaluate training in EBP. Future research should instead focus on process outcome metrics that measure whether practices change as a result of training in EBP.

    Conclusion

    Postgraduate study strengthened the nurses’ positive attitudes towards EBP and their belief in the value of using evidence-based knowledge in practice. In addition, the nurses reported an increase in evidence-based activities. Since we lack empirical evidence on whether nurses actually changed their own practices, we cannot conclude that postgraduate study leads to greater implementation of EBP in practice.

    Postgraduate study strengthened the nurses’ positive attitudes towards EBP and their belief in the value of using evidence-based knowledge in practice.

    Self-reporting of attitudes and practices is important, but it is the actual implementation of EBP and the impact this has on patients that is most crucial for the quality in the nursing profession. 

    References

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    7.       Sandvik GK, Stokke K, Nortvedt MW. Hvilke strategier er effektive ved implementering av kunnskapsbasert praksis i sykehus? Sykepleien Forskning. 2011;6(2):160–7. Available at: https://sykepleien.no/forskning/2011/05/hvilke-strategier-er-effektive-ved-implementering-av-kunnskapsbaser-praksis-i(downloaded 27.04.2017).

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    24.     Wangensteen S, Johansson IS, Bjørkstrøm ME, Nordstrøm G. Critical thinking dispositions among newly graduated nurses. Journal of Advanced Nursing 2010;66(10):2170–81.

    25.     Horsley T, Hyde C, Santesso N, Parkes J, Milne R, Stewart R. Teaching critical appraisal skills in healthcare settings. Cochrane Database of Systematic Reviews. 2011;(11):1–35.

    26.     Polit DF, Beck CT. Nursing research: generating and assessing evidence for nursing practice. Philadelphia: Wolters Kluwer Health; 2012.

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    Nurses are better at using their professional knowledge and applying research in their work following postgraduate study in evidence-based practice (EBP). Their belief in the value of such work also increases.

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    Sammendrag

    Background: Norwegian health authorities expect the health service to be evidence-based. In order to meet this expectation, Molde University College established a postgraduate study programme in EBP in 2009.

    Objective: To examine whether postgraduate study in EBP helped nurses to change their attitudes and behaviour in relation to EBP. 

    Method: A cross-sectional study with a pretest-posttest design. Nurses (n = 62) answered the Norwegian versions of the Evidence-Based Practice Beliefs Scale and Evidence-Based Practice Implementation Scale at the start (n = 56) and end (n = 55) of a postgraduate study programme in EBP. 

    Results: The response rate was 90.3 at pretesting and 88.7 at posttesting. The distribution of responses to both scales showed good internal consistency. That is, the nurses did not use the scales in a random or unreliable way. The change between pretest and posttest was statistically significant for 5 of 16 items in the EBP Beliefs Scale and for 10 of 18 items in the EBP Implementation Scale.

    Conclusion: The results indicate that postgraduate study strengthened nurses’ positive attitude towards EBP. In conclusion, the nurses reported increased activity in connection with the first four steps in EBP. However, it was beyond the scope of this investigation to assess whether this change actually resulted in more and improved evidence-based practice.

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  • Surgical nurses lack the time and competence to work in an evidence-based manner

    Continual advancements in medical equipment and treatment are resulting in more and better treatment services and methods. This creates a special obligation on the part of healthcare professionals whose work is evidence based to update their professional knowledge and heighten their awareness.

    In 2014, the specialist health service reported 414 adverse and/or serious incidents to the Norwegian Board of Health Supervision. Of these, 38 were classified as incidents related to surgical intervention (1). Some of the incidents were related to surgical complications that arose during or after the surgery. However, some complications arose from an injury caused by incorrect surgical positioning of the patient.

    Incidents of sudden death due to a heart attack, blood clot or difficulties relating to the administration of anaesthesia were reported as well (1). We can therefore state that such incidents occur relatively often. Surgery-related injuries or death are often cited as examples when adverse incidents in the health service are discussed in general (1, 5, 6).

    Evidence-based practice

    Within the sphere of ‘evidence-based practice’ (EBP), it is important to base clinical decisions on up-to-date, research-based knowledge when it is available. Furthermore, the concept of EBP includes experience-based knowledge, i.e. clinical expertise and judgment, reflection and tacit knowledge. Acquisition of knowledge from health service users is also a crucial dimension of EBP (7).

    Multiple studies have identified various barriers that impede evidence-based practice (3, 7–10). These barriers are related to, for example, a lack of knowledge that nursing research is available and can be used to change practice, as well as to limited experience with acquiring relevant, up-to-date knowledge from research. Another barrier is that research is perceived as unclear and difficult to read (8, 9, 11, 12).

    Other noteworthy findings are a shortage of time during working hours, professional and research literature that is not compiled in a single location, a lack of rooms with access to PCs, and difficulties in implementing new measures due to resistance from managers and doctors (3, 7–9, 12). Recent research shows a positive attitude towards EBP. However, there are challenges relating to a time shortage and lack of support from managers in the effort to assess and implement new measures (10, 13–15).

    Purpose of the study

    This article describes the results from a qualitative study based on focus group interviews of surgical nurses from different parts of Norway. The purpose of this study was to gain insight into surgical nurses’ understanding of the concept of ‘evidence-based practice’ (EBP), as well as their experiences with evidence-based practice. On this basis, we formulated two research questions:

    • What is surgical nurses’ understanding of the concept of evidence-based practice?
    • To what degree and in what way do surgical nurses work in an evidence-based manner?

    Method

    The study has a qualitative design, and we assembled four focus groups. We chose to use focus groups because the dynamic that arises from this method makes it well-suited to revealing the participants’ knowledge about, experiences with and attitudes towards the application of EBP (16). The focus group interviews were conducted between October and November 2012 and each group consisted of four to six surgical nurses.

    We took a strategic decision to include three hospitals from different parts of the country. By including various hospitals, we were able to uncover a variety of practices based on different educational backgrounds or educational institutions, or systemic differences within the hospitals, e.g. time allocated to professional development.

    We phoned the administrative managers of the various surgical departments. The managers were informed of the study’s purpose and method, and they were asked to help with recruitment. We recruited participants with 2 to 40 years of work experience in a surgical department. Most of them worked in full-time positions, and none of them worked in a position of less than 70 per cent. The sample consisted of women because there were no male surgical nurses in the respective departments.

    Data collection

    The surgical departments provided a venue for the interviews, and all the focus group discussions were therefore held in the respective hospitals. We conducted one of the interviews during working hours and three at the end of the work day. The focus group discussions lasted from 60 to 80 minutes. Based on our research questions, we created an interview guide. The main questions in the interview guide were as follows:

    • What is your understanding of the concept of evidence-based practice?
    • In what way and how often do you acquire new knowledge?

    The first author served as the moderator for the interviews. In addition to broad, open-ended questions related to EBP and professional development, we asked questions about procedures and structures in the department. It can be beneficial for the moderator to have adequate background knowledge of the topic being discussed, as that individual may have different perspectives on the topic being discussed and can follow up on important aspects of the topic (16).

    In our view, the moderator’s background in surgical nursing laid a good foundation for the interviews. However, because the moderator was knowledgeable about the field, what is regarded as ‘common knowledge’ among surgical nurses may not have been integrated into the discussion.

    Ethical considerations

    It was not necessary to apply for permission from the Regional Committees for Medical and Health Research Ethics to conduct this study. The application to the Norwegian Social Sciences Data Service, now called the Norwegian Centre for Research Data, was approved prior to project start-up. The managers of the respective departments informed all the participants about the study, both verbally and in writing.

    Prior to the interview, the moderator reiterated information about the study and the participants’ right to withdraw. Ethical guidelines on confidentiality and anonymisation of data were complied with (17). The data were encrypted and stored on a password-protected PC.

    Analysis

    We analysed the findings using Malterud’s (18) modified version of Giorgi’s phenomenological analysis. The objective of the analysis was to illuminate the surgical nurses’ own perceptions and experiences, and we focused on both the group and each individual surgical nurse. In the analysis process, we sought to identify the surgical nurses’ understanding of the concept of EBP, and to what degree and in what way they work in an evidence-based manner. Consequently, we had to gather information about their work, or lack of work, with EBP in the surgical departments, as well as identify connections and contradictions in the information conveyed.

    In the first phase of the analysis, we thoroughly read the transcribed texts several times. In so doing, we gained an overall impression of the opinions and patterns that predominated. In the next phase, we conducted a systematic review of the interviews. We focused on identifying meaning units of phenomena that the focus groups revealed and that resulted in knowledge about the research problem.

    The main points of the interview guide were used to create codes, i.e. labels to gather extracts of text that had commonalities. Such extracts were systematised and placed in the following columns:

    • What is surgical nurses’ understanding of the concept of evidence-based practice?
    • In what way and how often is new knowledge acquired?

    Then we compared and assessed the meaning units from the same column from each focus group interview to gain a deeper understanding of the important patterns and nuances that came to light. We formulated the following categories:

    • professional development versus EBP
    • promotes professional development
    • impedes professional development
    • departmental culture

    In this phase of the analysis, the concept of EBP was put in the context of ‘professional development’, as very few nurses used or had a clear understanding of EBP, which in itself represented a finding. In the third phase, we critically assessed the codes that represented the basis for the categories. Potential topics were developed, and connections between meaning units, codes, categories and topics were brought to light. In the fourth phase, we critically assessed the meaning connections within the topics in relation to the data as a whole. We identified three main topics:

    • structural factors
    • attitudes and responsibility for one’s own profession
    • competence and knowledge related to evidence-based practice

    Results

    The findings show some lack of knowledge about, understanding of and use of the concept or term ‘EBP’. By the same token, the findings show that the participants are already working with aspects of the concept of EBP. Experiential knowledge such as reflection and sharing clinical experience with others stand out as key strategies that are used to enhance competence and increase patient safety. A focus group participant stated the following:

    ‘We learn from each other’s experiences. We can have different experiences with different things, and if you’re unsure about something, then you go and find the person who dealt with it last and you ask, “How did you do that exactly?”.’

    A shortage of time is one of the main barriers to searching for, reading and assessing professional and research articles.

    However, most of the participants have little awareness of and experience with research-based knowledge as a part of the concept of EBP, which proved to be one of the main findings in this study. The findings also show that a shortage of time is one of the main barriers to searching for, reading and assessing professional and research articles.

    All the surgical nurses talked about the increasing demand for production and efficiency. A busy work situation and scare resources on the job were emphasised as important barriers. At the same time, the findings show that time allocated to working in an evidence-based manner is not always used as intended and that spare time is regarded as ‘sacrosanct’.

    Structural factors and responsibility for one’s own profession

    In order for surgical nurses to be able to improve patient safety, they must plan and prioritise time to work with professional development and updating their knowledge. The participants emphasised this challenge in all the focus groups. Many said that they have a scheduled time to work on certification and/or procedural tasks of one to four days per year in rotation.

    Beyond this, no time or resources are allocated to updating their professional knowledge, e.g. reading professional and research articles. A focus group participant alludes to this: ‘If we had more staff, so that you had time to sit down and work with professional development every now and then, make it part of a rotation, because our daily work is so hectic that there’s little time for it.’

    Extreme time pressure

    Another participant in the same group adds the following: ‘There are so many aspects to this job that you really need time to get familiar with it all, and that’s something you don’t have during the day.’ Many emphasised that a lack of knowledge could lead to uncertainty when carrying out their duties. In addition, several participants noted that the pace of work is very fast. As a result, many appeared to be somewhat resigned to their inability to take responsibility for their own professional development.

    One experienced participant described how her work situation puts patient safety at risk: ‘It goes so fast that it’s not possible to work any faster. It would be wrong, quite simply. We have worked ourselves up to an extremely fast pace, and I think we become so “effective” in the end that you almost don’t think, your head’s not in it, you just act on impulse, and I don’t think that’s a good thing.’

    All the participants tended to regard external factors such as time pressure as the reason that they were not sufficiently up-to-date or prepared for a surgery, which in turn affected patient safety. Multiple participants in several of the groups noted, however, that there is time between work duties, but that they do not use this time to update their knowledge. One participant described it as follows: ‘Yes, we have time, but you don’t always prioritise that 15 minutes for that. At least I don’t.’

    Must use their spare time for professional updating

    In the discussion of responsibility for increasing their own competence, they talked about whether they could envisage using their spare time to update their professional knowledge. A basic attitude among the participants was that ‘spare time was sacrosanct’. Many argued that surgical nurses have an extremely demanding job and that they therefore do not have the energy to search for, read and assess professional and research articles in their spare time.

    One participant expressed her opinion on this by stating: ‘Time is not allocated for me to go online and gather knowledge or to do a search, so I have to do it in my spare time, and I’m not going there, I’m not!’.

    Several participants from the focus groups said that their department has one or more rooms with a PC that can be used to search for and read professional and research articles. It came to light that the rooms were mainly used for conversation and eating – as well as a place where they talked about private matters.

    One participant described the situation as follows in one of the focus groups: ‘We have four PCs really. We can sit in the staff room and go in and check if we want something, where we eat, and we can go in the corner where the doctors often sit, or we can go into the small room, or we can go into the room next door…’.

    Another participant from another focus group gave a similar description: ‘We’ve got a study room where we’re supposed to be able to sit at the end of the day and study professional material and such, but the room is used to discuss everything from train schedules to recipes, and it’s difficult to sit there and work.’

    In all the focus groups, the participants agreed that there was a genuine opportunity to search for professional and research material. However, it was clear from the discussions that this time and the rooms were used primarily to rest or to talk with colleagues.

    Competence and knowledge related to evidence-based practice

    The focus group discussions show that searching for relevant research literature does not represent a natural part of the working day, nor is it regarded as a normal work duty. The participants think the search process is difficult, that they do not have the expertise to conduct a literature search properly or thoroughly enough. This lack of competence is seen, for example, in the fact that many of the participants do not know which databases they can search in.

    Moreover, many prefer to read the literature in Norwegian. One participants said the following: ‘I don’t know where I can find articles on surgical nursing and treatment, and I prefer to read in Norwegian. English is too difficult.’

    Challenges with PCs and the internet

    Some participants point out that they are generally not good at using PCs: ‘You don’t have much time to sit down at the computer, and besides, my computing skills are really bad.’ Furthermore, it came to light that it is more common to surf the internet for various diseases and topics they are most interested in, rather than actively search for peer-reviewed research. Some said they preferred to use Google instead of the medical databases. ‘If there are things I’m wondering about, diagnoses for example, I quickly pick up my phone, and I find out a lot just by googling on the internet.’

    Some said they preferred to use Google instead of the medical databases.

    Several participants responded to such comments by pointing out that information found on the internet is not necessarily of good quality. It also came to light in the discussions that the participants thought it was difficult to assess the quality of and difference in professional and research articles. In addition, they found it difficult to know where on the internet they can find professionally sound material that they can apply in their work.

    Difficult to apply research results

    Another aspect mentioned in one of the focus groups was resistance from the management to attempts to implement new measures based on recent research, often through feedback like this: ‘We don’t do that here.’

    In the other focus groups, participants generally did not know how they could initiate the use of research results to improve practice, while at the same time they thought there was little relevant research on nursing.

    The participants had completed their surgical nursing education in Norway and abroad, and the findings show no obvious tendencies in differences based on the participants’ background or workplace with regard to working in an evidence-based manner.

    Discussion

    Many of the participants pointed out various barriers to working in an evidence-based way. In our study, these barriers involve the inclusion of research-based knowledge along with experience-based and user-based knowledge. The barriers are related to a scarcity of time and resources, as well as to a lack of organisational facilitation, insufficient commitment on the part of management and a lack of personal commitment.

    It is uncertain how many patients die in hospital due to patient injury, but enough is known to state that the number of patient injuries is considerable (6, 19). To reduce this number, we must increase knowledge about the causes of patient injuries and death (19). To avoid adverse incidents from occurring, healthcare personnel’s professional knowledge and competence should be enhanced.

    The Norwegian Medical Association (19) notes that, in addition to identifying the causes of errors, it is important to study the factors that prevent transparency related to these errors. Patient safety is created in the organisation, and by ensuring a high level of transparency and safety through reporting deviations, follow-up and learning can also take place. Patient injuries and adverse incidents are a socioeconomic burden, and as such, the line of governance in the health trusts should continually focus on quality and ensure that those who deliver health services have sufficient competence (1, 6, 19).

    Time not allocated for professional development

    The findings in this study show that some departments have set aside time for certification and procedures on a rotating basis, but beyond this, time is not set aside for individual professional development. By the same token, healthcare personnel can actively take advantage of the opportunities available to ensure they possess such competence, and thus help to promote the implementation of up-to-date knowledge in clinical settings (19, 21–23).

    It is both the responsibility of the department and of each individual surgical nurse to create a framework in which healthcare professionals can work in an evidence-based manner (5, 24). However, it could be envisaged that nurses would more fully step into their responsibility for applying EBP if organisational measures that ensure time for professional updating were given priority and emphasised in the rotation plans.

    It is both the responsibility of the department and of each individual surgical nurse to create a framework in which healthcare professionals can work in an evidence-based manner.

    Moreover, findings from a literature review (25) indicate that it is important for educational institutions to draw up programme plans with learning activities related to EBP (25). By adopting a systematic training programme in close cooperation with practitioners, knowledge about EBP will increase among the surgical nurses in the field of practice and among the students (25).

    EBP must be integrated into educational programmes

    We have read through the programme plans of various university colleges on their websites and have had verbal contact with various representatives from different university colleges. It seems that there are still some university colleges in Norway that do not include EBP as a course in their programme plan, even though the Ministry of Health and Care Services has required EBP to be implemented among teachers and healthcare professionals by 2015 (26). The educational institutions can therefore assume a greater responsibility for integrating and implementing EBP as a course in their programme plans.

    By emphasising specific learning activities such as searching for, reading, understanding and assessing research articles and different research designs, nurses and those obtaining a specialisation can learn how to work in an evidence-based manner during their studies. Contact nurses, supervisors and teachers, together with the students, can help to formulate research problems that are clinical and patient centred. As a result, employees will be involved and able to recognise the value of research in practice.

    This, in turn, can lead to a positive attitude towards using research to change practice (10, 12, 13, 28). In addition, they can complete courses and training programmes in EBP. Resource persons at the departmental level, such as specialist nurses, can be used to train other employees (12, 29). More knowledge will increase safety, and greater safety will result in positive attitudes towards the ongoing work with evidence-based practice (12, 28).

    Surgical nurses must take more responsibility

    The findings show that the surgical nurses work at a very fast pace, and they believe they are at risk of not performing their nursing duties in a safe, professionally sound manner. However, the findings also suggest that surgical nurses take little responsibility for working in an evidence-based way, i.e. that they show relatively little commitment to ensuring that they are up-to-date on relevant knowledge so they can carry out their nursing duties in a sound manner. Their reasoning seems to involve acceptance of the notion that evidence-based practice must give way to demands for production and efficiency.

    The findings also suggest that surgical nurses take little responsibility for working in an evidence-based way.

    The 1990s saw the introduction of ‘New Public Management’, which is expressed in the health trust reform, the coordination reform and the hospital mergers (15). According to Wyller et al. (15), one of the features of this management strategy is the demand for loyalty to the management. As a result of this demand, the personal responsibility that the professional practitioner has for looking after the patient is replaced with a demand for loyalty to the managers, who in turn must be loyal to their managers.

    Professional practitioners are turned into disciplined employees whereby, among other things, each individual assessment, and thus professional accountability, is suppressed by decisions made at a higher level (15). One could therefore ask whether derogation of responsibility and demands for sound professional practice lie with the individual or whether they are a result of the organisations’ management structure (4, 10, 19, 30). The findings in this study indicate that there is a derogation of responsibility at multiple levels in the field of practice. 

    Conclusion

    This study reveals a lack of competence among the surgical nurses and an organisational structure and culture that fail to underpin and support EBP, both in the surgical departments and in the educational institutions. The findings suggest that this may be viewed in connection with a lack of facilitation, as well as an insufficient commitment at both an individual and an organisational level.

    There is a need for systematic training and follow-up to increase knowledge about EBP, both in the surgical departments and in the educational institutions. By focusing on the departmental level as well as relevant educational institutions, we can achieve a synergy effect that can bring about an attitudinal change that more effectively addresses all the aspects of evidence-based practice.

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    30.     Opheim AE. Fagutvikling må prioriteres. Sykepleien Forskning. 2010;5(4): 293. Available at: https://sykepleien.no/2011/01/fagutvikling-ma-prioriteres(downloaded 27.02.2018).

    Surgical departments and educational institutions lack an organisational structure and culture that supports evidence-based practice. This may affect patient safety.

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    English
    Sammendrag

    Background: Advancements in medical equipment and treatment are continually being made. This results in more and better treatment services and methods, which in turn creates a special obligation on the part of healthcare professionals whose practice is evidence based to update their professional knowledge and heighten their awareness.

    Purpose: The purpose of this study was to gain insight into surgical nurses’ understanding of the concept of ‘evidence-based practice’ (EBP), as well as their experiences with evidence-based practice. By including various hospitals, we sought to investigate a variety of practices or systemic differences, such as attitudes and time allocated to evidence-based practice.

    Method: We assembled four focus groups in three different parts of Norway. The focus group interviews were conducted between October and November 2012 and consisted of four to six surgical nurses.

    Results: The nurses emphasised that an increasing demand for production and efficiency impeded their ability to work in an evidence-based manner. They said that a lack of knowledge could create uncertainty in the performance of their duties. However, the findings show that they did not always take advantage of the opportunities or take the time to work with EBP in the way it was intended, and they made little use of available rooms and PCs in the surgical departments to search for, read and assess professional and research articles.

    Conclusion: This study reveals a lack of competence among the surgical nurses and an organisational structure and culture that fail to underpin and support EBP, both in the surgical departments and in the educational institutions. The findings suggest that this may be viewed in connection with a lack of facilitation, as well as insufficient commitment at both an individual and an organisational level.

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  • How nurses and service users deal with malodour in the home

    Community nurses must often deal with unpleasant ambient odours as well as malodour caused by illness. Smelling bad, or surrounding yourself with odours that are offensive to other people is generally regarded as socially unacceptable. This often leads to patients suffering because they are afraid of others’ disgust (1–8).

    Meanwhile nurses find it challenging to be in patient-centred situations that involve malodour. This creates physical reactions such as grimaces, nausea, and a desire to withdraw from the situation (6, 9, 10). Malodour is also a difficult topic to raise with service users (11).

    The studies we refer to here were conducted at a hospital or other institution. Research on how nurses perceive and deal with malodour challenges in relation to service users in their own home is limited. Moreover, there are few descriptions of how service users experience and view how nurses deal with smell in this context, and how service users want to be treated (12).

    The objective of this article is to explore the problem of smell in the home, based on the following questions:

    • What smells do nurses encounter in the home?
    • How do nurses perceive and deal with unpleasant odours in the home when they engage with the service users?
    • How do service users experience and view the nurse’s choice of action?

    The article presents a sub-study that is part of a larger study, where the objective was to develop knowledge of how the community nursing service deals with the problem of smell vis-à-vis service users, and how the problem is dealt with as a job-related issue at workplaces (12).

    Method and analysis strategy

    We used an ethnographic design where the key concern is to describe what people say and do in situations that are not completely structured by the researcher (13). In the empirical survey, the fields incorporated three community-nursing districts and a private service-provider delivering home-based palliative care in a large Norwegian town.

    We chose informants strategically, and 30 nurses and 11 service users participated. We recruited nurses following information meetings in the chosen fields. The inclusion criteria were at least two years’ professional experience where the problem of smell arose. Moreover, the informants had to be proficient in oral and written Norwegian. The nurses recruited the service users.

    The inclusion criteria for service users were that they were over 20 years old and had had an illness for at least a year that entailed the problem of smell. They were required to understand oral and written Norwegian and to have the capacity to give informed consent.

    We used participant observation and semi-structured interviews as methods. The observations and interviews took place in the period from autumn 2009 until spring 2011. The first author had the main responsibility for the data collection and analysis, in close dialogue with the co-authors.

    Observation

    The observation material included nine observations in nursing situations in the service users’ homes. We designed the observation guide with the aim of eliciting how nurses dealt with the challenges of smell in interaction with the users. The first author made field notes that included accurate situation descriptions as well as reflections on own reactions and methodological and ethical questions.

    The interview material involving the nurses incorporated six focus group interviews and six individual interviews following observation of the nurses’ interaction with service users in their homes. 

    Interviews

    The focus group interviews lasted between 45 and 75 minutes while the interviews following observation lasted between 15 and 25 minutes. All the interviews took place in community nursing facilities. We designed the nurse interview guide with the aim of eliciting their perceptions of smell in the home, their choice of action and their reasons.

    The service user interviews were individual and incorporated seven women and four men aged 35–85 years with long-term malodour problems relating to wounds, infections and stomas. Cancer was the underlying diagnosis in the case of four of the informants. The interviews took place in the users’ homes and lasted between 15 and 55 minutes. We designed the service user interview guide with the aim of eliciting their experiences and wishes related to the nurses’ handling of the problem of smell. 

    Analysis

    All the interviews were recorded and transcribed. In the analysis, we used an actor-oriented approach based on the informants’ statements and the researcher’s observations. Ideally, experiential concepts should be developed that reflect the informants’ perspectives (13) (Table 1). In line with the recommendations of studies that include different informant groups, we first undertook separate analyses of groups before the results were collated (14).

    Table 1. Example of the development of experiential concepts based on the question: ‘How do nurses deal with unpleasant odours in the encounter with service users?’

    We commenced with a cross-cutting analysis of the field notes and interviews with nurses about what smells they encountered in the homes and how they perceived these. Then we examined how the nurses dealt with their perceptions in interaction with service users, and how they justified their choice of action. The informants’ answers reflected both their current and earlier experiences. We condensed the answers into text summaries with a focus on key points, differences, similarities and influential factors.

    We then carried out a cross-cutting analysis of service user interviews about how they perceived the handling of the problem of smell, and what changes they would like to see. We condensed the responses into text summaries with a focus on key points, differences and similarities. In addition, we compared the service users’ experiences, reflections and wishes to the strategies employed by the nurses.

    We discussed the findings in the light of sociocultural and nursing perspectives on how taboo and shame-related issues are handled in the Western cultural tradition. 

    Approval and consent

    The project was reported to the Norwegian Centre for Research Data and approved by the Regional Committees for Medical and Health Research Ethics (REC) (application number S-09148d, 2009/1953).

    We obtained informed consent in writing from the informants – both nurses and service users. Smelling bad is taboo and poses ethical requirements in relation to maintaining the informants’ integrity. Those who were asked to participate in the study received an information letter that clarified where nurses and service users could ask for help if they found that participation was burdensome. We received no such requests.

    Results

    Nurses’ perceptions and choice of action

    Malodour in the home

    A single, pervading disease-related odour could cause malodour in the home, for example putrid smells in the case of infections or cancerous wounds. It filled the entire home and camouflaged everything else. Complex constellations of odours were more common, in that odours connected with disease, the body and a lack of cleanliness in the home formed an indefinable combination:

    ‘And sometimes when you open the door of an apartment, a hotchpotch of smells hits you – from wounds, urine, faeces, cooking, rubbish lying around, and stale air.’

    The nurses felt that unpleasant odours in the home were shame-related regardless of the reason. They also believed that service users who had these problems were doubly vulnerable because the smells not only affected them as individuals but also pervaded their space. Both the person and the home risked exposure to the disgust of others. At the same time, the unpleasant odours evoked physical reactions in the nurses in the form of grimaces, gagging and disgust.

    The nurses felt that unpleasant odours in the home were shame-related regardless of the reason.

    The nurses lacked knowledge about the physiology of smell, and interpreted their own reactions in line with general cultural understanding as expressing abhorrence vis-a-vis the service users and their home. Such reactions on the part of the nurses conflicted strongly with their professional ethical commitment to safeguard vulnerable service users. This conflict created considerable moral anguish and a feeling of being unprofessional:

    ‘Sometime when you open a colostomy pouch, there’s an intense smell… And there was a cat darting between my legs. Then the cat vomited a hairball it had swallowed … And that’s the only time I’ve had to turn away and throw up. The patient was terribly upset, and I was terribly upset. Because I think it must be awful for that person to see that I am uncomfortable caring for him. And I think that I wasn’t being professional when I had to throw up.’

    Strategies for dealing with smell

    The nurses justified their choice of action by their wish to give the service user proper help and to protect them and their home against others’ abhorrence. For the most part, they employed three strategies:

    One strategy was to reduce or remove the odours by means of practical actions addressing illness-related causes, for example through wound and stoma care, or assistance with personal hygiene. It was less common to remove whatever was causing the ambient smell because they viewed this as an inappropriate intervention in the service user’s home.

    Facemasks were seldom used because of fears that service users would be offended.

    Another strategy was to minimise the olfactory impression so as not to react physically. The nurses used different techniques such as working quickly, creating physical distance in the care situation, holding their breath or breathing through the mouth. Facemasks were seldom used because of fears that service users would be offended. It was also usual to keep a mental distance by thinking of other things.

    These techniques helped the nurses to avoid reacting physically, for example by grimacing gagging or showing disgust. However, the observations in the home showed that this strong focus on disciplining oneself physically resulted in several cases in impaired observation powers and reduced presence of mind.

    A third strategy was silence and explaining away things, for example by saying, ‘I don’t notice anything, don’t think about it,’ if service users commented on the smell. The nurses believed that it would be offensive to initiate a conversation about smell. The fact that they were in other people’s homes reinforced this view:

    ‘I’ve never spoken to service users about smell … It offends patients if we talk a lot about it. Then I feel that the patients believe that we don’t want to do the job we do. So I don’t usually bring up the subject of smell.’

    ‘And then for our part, we’re going hometo people. We’re guests in other people’s houses. We can’t just blurt out this thing about smell.’

    The nurses stressed that a lack of knowledge about smell perception and the absence of adequate language related to malodour were important reasons for their silence. One of them expressed this as follows:

    ‘You can say to someone else, “You look poorly today,” but you can’t say to anyone, “You smell bad,” with empathy.’ 

    Service users’ assessment of the nurses’ choice of action

    The service users’ experiences of and views on the nurses’ approaches varied. Practical action in terms of confidently performed procedures and the use of dressings and stoma equipment that reduce odour gave the service users a feeling of confidence. They greatly feared smells from the stoma, urine leakages and wounds. When the appliances were comfortable and well fitted, this reduced anxiety and resulted in people daring to participate in social situations to a greater degree.

    However, several people expressed a deep-seated fear that their house might smell bad, not just them personally. The service users had rarely experienced that the nurses removed possible sources of offensive ambient odours.

    Became insecure because of the nurses’ silence

    The service users had little experience of or views on the nurses’ techniques to minimise smell. However, they reflected on situations where they had seen nurses react physically. One service user had seen that the nurse grimaced and turned away when dressing a wound. The nurse neither explained nor commented on these reactions. This created uncertainty in the actual situation and fear afterwards:

    ‘Because I’m now fearful – oh! For example, someone sat down beside me on the tram. And then he just got up and sat somewhere else. I just felt completely [face expresses consternation]: “What is it? Is it smell? Am I starting to smell again?”’

    The physical reactions in themselves did not create the problem; it was the fact that they were not explained. The strategy the service users most objected to was silence on the part of the nurses. They wanted more openness generally. No one could recall that nurses had taken the initiative to talk to them in a professional manner about the problem of smell, or asked about their needs and wishes. Several of the service users said that they were aware of the odours themselves. They found the nurses’ attempts to gloss over the problem as lacking in respect.

    ‘No, but you know, almost all the nurses say that they don’t notice anything. … If I say when they’re changing the dressing: “Oh, ugh, that smell again”, they say that they don’t notice it so much. I don’t know if that’s meant to comfort me, or what? [Laughs a little.]. What about what I experience, then? Is what I experience plain wrong?’

    The service users also use strong images to describe their own perceptions of smell: ‘When I notice the smell, I see myself as something hideous’; ‘The smell from the wound reminds me of a morgue’; or ‘Me and my home smell like rotten fish’. Everyone used swear words when talking about the problem of smell. 

    Discussion

    The objective of this study was to explore how nurses perceived and dealt with unpleasant odours when engaging with service users in their homes. We also wanted to examine how the service users regarded the nurses’ choice of action.

    The findings show that the smells in a home were diverse. They might be caused by illness or a combination of illness, body odours and unhygienic conditions in the home. A combination of smells was reported as most common. There are few contextual descriptions of smell, whether in relation to home-based nursing or in institutions. Therefore, it is difficult to relate the findings to other research. 

    The home should be clean and smell appealing and fresh.

    The descriptions are not pretty, and clearly infringe social and cultural norms for how a home should smell and appear. The home should be clean and smell appealing and fresh. Sociocultural studies of smell show that offensive smells emanating from a person and home are associated with moral judgements. Pleasant smells are associated with the good and the beautiful – unpleasant smells with the bad, repulsive and immoral (15, 16). Waskul and Vannini’s study describes offensive smells in the home and emanating from people as low status and related to social exclusion (17).  

    Silence as protection against shame

    The nurses saw service users living in foul-smelling homes as doubly vulnerable because both the person and the home were exposed to others’ disgust, which aligns with general cultural assessments. The nursing researcher Liaschenko terms vulnerability that affects both the person and their home as ‘spatial vulnerability’ (18). This expression conveys well the perceptions of the nurses and service users presented in this study.

    The guiding principle in the nurses’ choice of action was acting in such a manner as to protect service users and the home from others’ disgust. They removed the smells through silently taking practical action without letting this affect them physically. These are general and conventional ways of dealing with shame-related and taboo matters (19). 

    They are also embodied in professional nursing literature that provides recommendations on how health personnel should exercise their professional and moral responsibility in care situations involving shame-related and taboo issues (20, 21). Practical action in combination with physical discipline and verbal reticence in the encounter with shame-related bodily issues has a long tradition in nursing. Having an inner sense of what the other needs without the service user having to say anything has been described as expressing respect, empathy and care (20–22). In this respect, the nurses acted in line with professional recommendations. 

    The service users wanted openness

    Service users’ experiences showed that the nurses’ strategies functioned differently in respect of protecting the service users and the home from others’ disgust. Practical action in the shape of good wound and stoma care and assistance with personal hygiene were of basic importance in ensuring that service users felt confident when meeting others. Several studies refer to similar results (3–5, 23–25).

    Unhygienic conditions and stale air in the home also caused malodour. The service users wanted nurses to speak more about this and put forward suggestions as to how to deal with it. The nurses were more reserved. They justified their choice by referring to the users’ autonomy and the fact that they were guests in someone else’s home.

    The right to autonomy in the home is enshrined in Western culture (26–28) and is reflected in legislation (29) and the ethical principles of nursing (30). Emphasis on the service user’s autonomy in legislation and the professional nursing tradition can help to explain the reticence of nurses, but there is cause to ask whether their morally based choice of action reinforced the service users’ vulnerability in the home with respect to causing revulsion in others.

    Strategies may have the opposite effect

    The strategy of minimising olfactory impressions led to nurses avoiding visible reactions to odours, but it also entailed decreased powers of observation and reduced presence of mind. Accurate observations are fundamental to appropriate treatment, and presence of mind is crucial in creating good relationships. Disciplining the body in order to protect the service user from experiencing shame and disgust might therefore reduce the possibility of treatment and developing well-functioning relationships. 

    The service users called for greater openness in general.

    Nurses kept quiet and explained things away so as not to offend the users and their homes. However, the experiences of service users showed that this strategy had the opposite result. Silence reinforced their sense of shame and loneliness, undermined trust in their own perceptions and reduced the possibility of help. The service users called for greater openness in general.

    The perceptions of service users and their wishes for openness about the problem of smell have not been systematically discussed in other studies. Therefore, it is difficult to assess how our findings relate to the problem of smell in other contexts. Silence can reinforce the sense of shame and loneliness and reduce the possibility of getting help. This has been documented in the case of other issues related to shame and taboos, for example mental disorders, AIDS and abuse. (31, 32).

    Language taboos

    A fundamental challenge linked to openness about malodour is language, as findings in our study also demonstrate. There are several reasons. The growth of a modern society with public sanitation projects helped to remove the smell of rubbish, decay, urine and faeces from public spaces and relegated these odours to the private sphere. Privatisation of these kinds of odours means that they are not part of a collective vocabulary to any extent, and the words used to describe them are negatively charged. Nor is there any publicly accepted discourse about how one talks about what is repulsive and unpleasant (2, 33). 

    This taboo makes it challenging for those who come from outside, in this case the nurse, to raise the problem of smell. There is a considerable risk of using words that might be perceived as disrespectful and stigmatising. In such situations, the service users’ own descriptions of smells are extremely important. They give an insight into how to verbalise culturally silent shame-related and taboo issues in a meaningful way. However, this requires the nurses to break their silence and enquire about the service users’ experiences.

    Language is also related to knowledge. The nurses lacked fundamental knowledge about perception of smell, which explains reactions to unpleasant odours as autonomous, physiological reactions rather than as an expression of abhorrence of the person (34, 35). Knowledge of physiological causal explanations is important. It can help to reduce the nurse’s sense of shame when reacting and the disgust perceived by the person who is the object of such reactions. This may enable a more open and genuine interaction.

    Limitations of the study

    The sample of fields and informants is too small to be able to draw any general conclusions. Moreover, the fields have a limited geographical dispersion. The nurses’ assessments of vulnerability and choices of action might have been different if we had conducted the study in rural or heavily industrialised areas where unpleasant odours form a greater part of the public olfactory context than in this study.

    Conclusion and implications for practice

    The study provides an insight into the complexity of dealing with smell in the home. The findings indicate that malodour in the home makes the service users doubly vulnerable because both the individual and the home are exposed to others’ disgust. Established professional choices of action for nurses such as practical action, disciplining the body and silence functioned differently in terms of providing service users with adequate help. They perceived practical action as important, but questioned the silence and wanted more openness.

    A lack of knowledge about smell perception and the absence of an appropriate language were key reasons for the nurses’ silence. The study indicates that strengthening nurses’ knowledge base regarding smell perception, asking about service users’ experiences and discussing smell perception in professional bodies is crucial for the ability to develop satisfactory help options for services users with problems related to smell. We need further research in this field. 

    We wish to thank Lovisenberg Diaconal University College and the Faculty of Medicine, University of Oslo, for having funded and facilitated this study. 

    References

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    2.          Isaksen LW. Om lukten og skammen. En historie om kroppens uorden. In: Gressgård R, Meyer S, ed. Fanden går i kloster: Elleve tekster om det andre. Oslo: Spartacus Forlag; 2002.

    3.          Lund-Nielsen B, Muller K, Adamsen L. Qualitative and quantitative evaluation of a new regimen for malignant wounds in women with advanced breast cancer. J Wound Care. 2005a;14(2):69–73.

    4.          Lund-Nielsen B, Muller K, Adamsen L. Malignant wounds in women with breast cancer: feminine and sexual perspectives. J Clin Nurs. 2005b;14(1):56–64.

    5.          Lindahl E. Striving for purity. Interviews with people with malodorous exuding ulcers and their nurses. Umeå: Umeå universitet; 2008.

    6.          Alexander SJ. An intense and unforgettable experience: the lived experience of malignant wounds from the perspectives of patients, caregivers and nurses. Int Wound J. 2010;7(6):456–65.

    7.          Lindahl E, Norberg A, Soderberg A. The meaning of living with malodorous exuding ulcers. J Clin Nurs. 2007;16(3a):68–75.

    8.          Akhmetova A, Saliev T, Allan IU, Illsley MJ, Nurgozhin T, Mikhalovsky S. A comprehensive review of topical odor-controlling treatment options for chronic wounds. J Wound Ostomy Continence Nurs. 2016;43(6):598–609.

    9.          Wilkes LM, Boxer E, White K. The hidden side of nursing: why caring for patients with malignant malodorous wounds is so difficult. J Wound Care. 2003;12(2):76–80.

    10.        Lindahl E, Norberg A, Soderberg A. The meaning of caring for people with malodorous exuding ulcers. Journal of Advanced Nursing. 2008;62(2):163–71.

    11.        Aranda S. Silent voices, hidden practices: exploring undiscovered aspects of cancer nursing. Int J Palliat Nurs. 2001;7(4):178–85.

    12.        Breievne G. Lukt og lidelse: fortolkning og håndtering av ubehagelig lukt i hjemmesykepleie. Oslo: Institutt for helse og samfunn, Det medisinske fakultet, Universitetet i Oslo; 2014.

    13.        Fangen K. Deltagende observasjon. 2. ed. Bergen: Fagbokforlaget Vigmostad og Bjørke; 2010.

    14.        Malterud K. Kvalitative metoder i medisinsk forskning. En innføring. 3. ed. Oslo: Universitetsforlaget; 2011.

    15.        Corbin A. The foul and the fragrant. Odor and the French social imagination. Cambridge/Massachusetts: Harvard University Press; 1986.

    16.        Classen C, Howes D, Synnot A. Aroma. The cultural history of smell. London / New York: Routledge; 1997.

    17.        Waskul DD, Vannini P. Smell, odor, and somatic work: Sense-making and sensory management. Social Psychology Quarterly. 2008;8(No. 1):53–71.

    18.        Liaschenko J. Ethics and the geography of the nurse-patient relationship: Spatial vulnerabilities and gendered space. Sch Inq Nurs Pract. 1997;11(1):45–59.

    19.        Goffman E. Interaction ritual: Essays in face to face behavior: Chicago: Aldine Transaction; 2005.

    20.        Lawler J. Bak skjermbrettene. Sykepleie, somologi og kroppslige problemer. Oslo: Gyldendal Norsk Forlag; 1996.

    21.        Martinsen K. Løgstrup og sykepleien. Oslo: Akribe; 2012.

    22.        Nightingale F. Notater om sykepleie. Samlede utgaver. Oslo: Universitetsforlaget; 1997.

    23.        McKenzie F, White CA, Kendall S, Finlayson A, Urquhart M, Williams I. Psychological impact of colostomy pouch change and disposal. Br J Nurs. 2006;15(6):308–16.

    24.        Getliffe K, Fader M, Cottenden A, Jamieson K, Green N. Absorbent products for incontinence: ʻtreatment effectsʼ and impact on quality of life. J Clin Nurs. 2007;16(10):1936–45.

    25.        Kelechi TJ, Prentice M, Madisetti M, Brunette G, Mueller M. Palliative care in the management of pain, odor, and exudate in chronic wounds at the end of life: a cohort study. J Hosp Palliat Nurs. 2017;19(1):17–25.

    26.        Martinsen K. Huset og sangen, gråten og skammen. In: Wyller T, ed. Skam: Perspektiver på skam, ære og skamløshet i det moderne. Bergen: Fagbokforlaget Vigmostad og Bjørke; 2001.

    27.        Angus J, Kontos P, Dyck I, McKeever P, Poland B. The personal significance of home: habitus and the experience of receiving long‐term home care. Sociology of Health & Illness. 2005;27(2):161–87.

    28.        Molony SL. The Meaning of Home. A qualitative metasynthesis. Research in Gerontological Nursing. 2010;3(4):291–307.

    29.        Forskrift 27. juni 2003 nr. 792 om kvalitet i pleie- og omsorgstjenestene for tjenestetyting etter lov av 19. november 1982 nr. 66 om helsetjenesten i kommunene og etter lov av 13. desember 1991 nr. 81 om sosiale tjenester m. v. Tilgjengelig fra: https://lovdata.no/dokument/SF/forskrift/2003-06-27-792(nedlastet 21.02.2018).

    30.        Oresland S, Maatta S, Norberg A, Jorgensen MW, Lutzen K. Nurses as guests or professionals in home health care. Nurs Ethics. 2008;15(3):371–83.

    31.        Zerubavel E. The elephant in the room: Silence and denial in everyday life. Oxford: Oxford University Press; 2006.

    32.        Lauveng A. Unyttig som en rose. Oslo: Cappelen; 2006.

    33.        Skårderud F. Prestens løgn. Vårt Land; 2013.

    34.        Hawkes CH, Doty RL. The neurology of olfaction. Cambridge: Cambridge University Press; 2009.

    35.        Rouby C, Bensafi M. Is there a hedonic dimension to odors? In: Rouby C, Schaal B, Dubois D, Gervaris R, Holley A, eds. Olfaction, taste and cognition. Cambridge: Cambridge University press; 2005. s. 140–59.

    Some nurses say nothing about the problem of smell in order to protect the service user. However, the silence of the nurses reinforces shame and loneliness.

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    Sammendrag

    Background: Unpleasant odours in the home or emanating from a person are socially unacceptable and shame-related. Currently, little research has been conducted into how community nurses perceive and deal with unpleasant odours in their interactions with service users and how service users experience the nurse’s choice of action.

    Objective: The objective of the study is to examine how nurses perceive and deal with the problem of smell in the home, and how the service users experience and view the nurses’ choice of action.

    Methods: We carried out a qualitative study in which we observed and interviewed 30 nurses and 11 patients in three community nursing districts in a large Norwegian town.

    Results: Unpleasant odours in homes were most often caused by illness and service users’ inadequate hygiene. The nurses regarded smell in the home as shame-related. They felt that service users were doubly vulnerable because both the person and the home were exposed to others’ disgust. They wanted to protect service users from feeling shame. The most usual strategies were removing smell through practical action, avoiding discernible physical reactions to smell, and keeping quiet about the problem. The service users felt that removing smells through practical action was important for their feeling of social confidence. Silence reinforced their sense of shame and loneliness, and sometimes contributed to a poorer range of treatment options. Service users wanted there to be more openness.   

    Conclusion: There is a need for more openness and expertise about the problem of smell in the home. It is important to ask about service users’ experiences and wishes in order to develop appropriate nursing and treatment options.

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  • Preoperative warming with a forced-air warming blanket prevents hypothermia during surgery

    Hypothermia is a complication that often occurs in connection with surgery, and preventing it can be a challenge. Hypothermia is defined as a core temperature below 36.0°. The body temperature of patients about to undergo surgical procedures under general anaesthesia generally drops by 2–3° if preventive measures are not taken (1).

    Prognostic factors such as age, body mass index (BMI), morbidity rate (American Society of Anaesthesiologist (ASA) classification) and length of operation can all affect the extent to which the patient is exposed to hypothermia.

    Patients arriving at the operating theatre are immediately exposed to heat loss due to low temperatures in theatres, removal of clothes and disinfection of the surgical site with cold liquids.

    Infusing cold liquids and transferring the patient from the hospital bed to the operating table lead to further heat loss. During the induction of anaesthesia, the body reacts with vasodilation, and the natural thermoregulation does not function as normal. During surgery, the patient lies still on the operating table, and heat production is thus by means of basal metabolism. 

    Muscle blockade also prevents the body from compensating for heat loss by shivering. The body redistributes heat from central to peripheral parts of the body, causing the core temperature to fall. Surgical patients also lose heat through vaporisation from the skin, operation wounds and respiratory tracts (2, 3).

    Shared responsibility for preventing hypothermia

    The entire surgical team is concerned with preventing hypothermia, and it is a shared responsibility. This responsibility is given as a separate item in the checklist for safe surgery. The checklist aims to prevent unnecessary complications and injuries from occurring during surgery (4).

    Nurse anaesthetists have a special responsibility to observe and measure temperatures as well as initiate measures to prevent hypothermia.

    If the surgical patient becomes hypothermic, the risk of various anaesthetic-related complications increases. These include increased oxygen demand, bleeding risk, infection risk and unnecessary discomfort during and after surgery. Hypothermia may also prolong the effect of the anaesthetic agents (3). According to Bozimowski (2), hypothermia can also lead to undesired cardiovascular events.

    Nurse anaesthetists have a special responsibility to observe and measure temperatures as well as initiate measures to prevent hypothermia (5). The nurse anaesthetist’s responsibility for preventing complications and implementing pre-, intra- and post-anaesthetic measures is set out in the nurse anaesthetist’s job specification (6).

    Preoperative warming

    Preoperative warming is defined as the heating of patients’ peripheral tissue or skin surface using various warming methods prior to surgery. This contributes to a peripheral increase in temperature. The heat is redistributed from core to peripheral parts of the body, thereby reducing heat loss (7).

    The research literature shows that active warming with a forced-air warming blanket is the most effective warming method for preventing accidental hypothermia in surgical patients. When using a forced-air warming blanket, warm air is blown from a heat source into a thin disposable blanket placed over the patient (8).

    We conducted preliminary searches in relevant databases prior to our literature search and found a systematic review from 2012 and a review article from 2013. These articles indicate that active preoperative warming of surgical patients can prevent accidental hypothermia in such patients (9, 10).

    However, the quality of the methodology in the studies in these articles is considered to be variable, and the findings were inconclusive. These review articles also cover different types of preoperative warming methods, and anaesthesia methods vary across the studies.

    Objective of the study

    The purpose of the study was to generate new knowledge about the effect of using forced-air warming blankets as a means of preventing accidental hypothermia during surgery.

    We formed the following research question:

    ‘What effect can preoperative warming with a forced-air warming blanket have on preventing accidental hypothermia in elective surgery patients under general anaesthesia?’

    Method

    This article is a systematic literature review – a systematic summary of knowledge gleaned from relevant research articles that can help answer the research question. Systematic literature reviews are often regarded as the core of evidence-based practice and can lead to conclusions that may be useful in practice (11).

    Before we started the literature search and review, we drew up a methodological plan for how we would conduct our study. This plan is described in a separate protocol in the form of a project plan. The protocol can be obtained by contacting the first author. We used the PRISMA checklist throughout our work to quality assure the reporting of our systematic review (12).

    In 2012 and 2013, a systematic review article and a general review article were published with the aim of clarifying whether preoperative warming can prevent accidental hypothermia in surgical patients (9, 10). Following a critical review of the articles using the PRISMA checklist, we chose de Brito Poveda et al. (9) in preference to Roberson et al. (10).

    We chose this article because the study by de Brito Poveda et al. (9) is a systematic review based on randomised controlled trials (RCT). We believe it is necessary to update the work of de Brito Poveda et al. (9) since they use the Jadad quality tool and present inconclusive results.

    The Cochrane Collaboration advises against using the Jadad quality tool, as the scoring scale is not considered to be a reliable instrument for measuring validity, and no clear indication is given of the basis for assessment. In addition, the tool does not include any checks to establish whether the randomisation process is properly concealed (13).

    Literature search and search terms

    In the study by de Brito Poveda et al. (9), the systematic literature search was conducted in several databases, and different variations of subject terms and key words were used (see appendix). The search string is not specified. The inclusion criteria for this systematic review were as follows: RCT studies published between January 1990 and November 2011 that tested whether preoperative warming can prevent hypothermia in elective surgery patients over the age of 18.

    Language delimitation was English, Spanish and Portuguese, and in total, this included 14 articles. On the basis of the aforementioned considerations, we chose to perform an updated literature search based on the systematic review article by de Brito Poveda et al. (9).

    Prior to the literature search, we devised a search strategy based on the PICO model as well as search terms from the study by de Brito Poveda et al., which we chose to update (9). The PICO model is a good tool for creating the correct structure and combination of search terms (14). In a new, updated literature search, we used subject terms and key words in different combinations for population, intervention and outcome goals.

    We used the same search terms as de Brito Poveda et al. (9), but we also added new, relevant terms. The updated literature search in various databases took place between October 2015 and February 2016 (see appendix). As we were building on a literature search already conducted by other researchers, we searched for studies published from January 2011 to February 2016.

    Individual searches and citation searches

    In addition, we performed individual searches in the selected articles’ reference lists, as well as citation searches. The inclusion criteria for the systematic review were as follows: RCT studies published in English or a Scandinavian language that tested the effect of preoperative warming with a forced-air warming blanket as a means of preventing accidental hypothermia.

    The studies involved adult surgical patients between the ages of 18 and 85 who were to undergo elective surgery procedures under general anaesthesia. We excluded studies using regional anaesthesia or other warming methods. The outcome goals we were looking for were the patients’ core temperatures and cases of sustained normothermia, i.e. a core temperature of over 36°.

    Selection and assessment

    The two authors carried out the selection process independently of each other. Initially, we assessed the title and summary in relation to the inclusion and exclusion criteria. We then obtained full-text versions of all potentially relevant articles, and finally we considered whether to include or exclude them. The two authors also performed data extraction independently and concluded the process by collecting relevant data in two descriptive tables (Tables 1 and 2 under Results).

    First, we carried out a critical review of the studies selected using the checklist for RCT studies, which was prepared by the Norwegian Knowledge Centre for the Health Services (15). We then assessed the risk of systematic bias using the validation tool ‘Cochrane Collaboration’s tool for assessing risk of bias (RoB)’. Seven key points reflect different features of the study that could pose a risk of systematic bias (13).

    The two authors independently assessed the risk of systematic bias in the studies selected. The different points in the validity tool (RoB) were graded as low, high or indeterminate risk of systematic bias. Based on these assessments, we provided an overall evaluation of the entire study. The assessments were then entered into the RevMan computer programme, which presents tabular summaries showing the risk of systematic bias (13).

    As indicated in the project plan, we initially intended to perform a meta-analysis. However, after the literature search, we considered this method to be unsuitable since the degree of heterogeneity between the studies selected was too high. This was due to variations in intervention duration, heat strength, measuring instruments and outcome goals between the studies. We therefore performed a narrative analysis in order to provide an overarching description of the results.

    Both authors close read the selected articles and classified them into two categories with subthemes. This provided us with a structured description and comparison of the results of the studies.

    Results

    We identified a total of 624 references through our systematic literature search. Of these, we printed 14 for close reading. After assessing these articles in relation to our inclusion and exclusion criteria, we excluded ten of them (Figure 1). Four further studies were included from a new, updated literature search (16–19). We also assessed all of the articles by de Brito Poveda et al. (9) for inclusion and exclusion, and included six studies (20–25). In total, we were left with ten articles that were relevant for further analysis.

    Figure 1. Flowchart for selecting studies

    The number of participants in the studies ranged from 27–383, with an average age from 40–60 years, and an average BMI of 25 among participants. All participants underwent elective surgery under general anaesthesia, and the majority had an ASA classification of ≤ III. The ASA classification is an indication of a patient’s morbidity rate and reflects their physiological state prior to the induction of anaesthesia (2). Table 1 shows the distinctive features of the studies selected.

    Table 1. Distinctive features of RCT studies selected

    All studies selected tested the effect of preoperative warming with a forced-air warming blanket. We classified the studies in two categories: studies that tested preoperative warming, and studies that tested preoperative warming where active warming continued perioperatively. Table 2 describes the intervention in more detail.

    Table 2. Description of the intervention

    Preoperative warming with a forced-air warming blanket

    Three of the studies involve only preoperative warming with a forced-air warming blanket to prevent accidental hypothermia (20–22). In the article by Camus et al. (20), the results showed that one hour of preoperative warming before the induction of anaesthesia reduces accidental hypothermia in surgical patients. Fossum et al. (21) and Kim et al. (22), who reported on interventions of a short duration, demonstrate results that support the claim that preoperative warming reduces accidental hypothermia.

    The results are significant in all three of these studies (p <0.05), but we found that the two latter studies contained a high and indeterminate risk of bias respectively. This assessment is mainly based on the incomplete description of whether distribution of the groups was concealed and whether the outcome goals were blinded for the intervention.

    Nor is there any explanation of the participant drop-out rate in the study. Fossum et al. (21) also used an inaccurate measuring instrument, which was a determining factor in our assessment. We considered Camus et al. (20) to have a low risk of bias.

    Preoperative warming combined with perioperative warming with a forced-air warming blanket

    Seven of the studies involved preoperative warming combined with perioperative warming with a forced-air warming blanket (16–19, 23–25). In the study by Horn et al. (18), the results showed that preoperative warming for periods of 10, 20 and 30 minutes reduced the risk of perioperative hypothermia and postoperative shivering. The core temperature was significantly higher in the intervention groups compared to the control group (p < 0.05).

    Perl et al. (17) did not specify p-values, but nevertheless concluded that the core temperature was significantly higher in the intervention group compared to the control groups. De Witte et al. (24) found no significant differences in core temperature between the control group and the intervention group that received preoperative warming from a forced-air warming blanket. Nevertheless, the study concludes that active preoperative warming has a significant effect.

    In our opinion, these three studies have a low risk of bias. In the studies by Andrzejowski et al. (23) and Smith et al. (25), the results show that the average core temperature in the intervention group was significantly higher than in the control group. However, due to the large variation in intervention duration, we found that the study by Andrzejowski et al. (23) has a high risk of bias.

    In two of the studies, the results show that preoperative warming does not reduce cases of accidental hypothermia in surgical patients (16, 19). Neither of these studies show significant results, and the risk of systematic bias is high in both studies.

    This assessment is largely based on the high drop-out rate among participants. In addition, participants received different treatment prior to the measure being studied. Nicholson (19) used various measuring instruments, which could pose a high risk of bias. Figure 2 summarises the risk of bias in the studies.

    Figure 2. Summary of risk of systematic bias in the studies

    Discussion

    The purpose of the study was to generate new knowledge about the effect of using forced-air warming blankets as a means of preventing accidental hypothermia in elective surgery patients under general anaesthesia. The main findings in this systematic review indicate that preoperative warming with a forced-air warming blanket has a positive effect on the core temperature of surgical patients and can help maintain normothermia.

    This study shows that it is possible to reduce the rate of hypothermia by using a forced-air warming blanket. The different outcomes show the positive trends and suggest that complications of hypothermia can be prevented.

    The effect of preoperative warming

    Maintaining normothermia in surgical patients can be a challenge even where a forced-air warming blanket is used to warm the patient during surgery (7). According to Lange (1), patients consider hypothermia to be one of the most uncomfortable factors associated with surgery. Thus, it is also important to prevent hypothermia in order to ensure the well-being of the patient.

    Under general anaesthesia, patients are in a particularly vulnerable situation and are not in a position to express their needs (26). During surgery under anaesthesia, the patient’s body temperature can fall by 2–3° if preventive measures are not taken (1). Therefore, it is crucial that the nurse anaesthetist has knowledge about the consequences of hypothermia and is able to prevent its occurrence, and by so doing, protect patient safety.

    The responsibility for implementing preventive measures where complications are expected is explained in the nurse anaesthetist’s job specification (6). As hypothermia can lead to unnecessary complications in surgical patients, we believe that prevention is a natural requirement for professionally responsible conduct (27).

    It is also important to prevent hypothermia in order to ensure the well-being of the patient.

    Sessler (28) indicates that active warming aids the body’s ability to maintain its core temperature when subjected to heat loss. It can therefore be envisaged that surgical patients would benefit from preoperative warming with a forced-air warming blanket. Of the ten studies we included, eight show that preoperative warming with a forced-air warming blanket has a positive effect and can prevent hypothermia in surgical patients (17, 18, 20–25).

    The majority of these studies show significant results and have a low risk of bias (17, 18, 20, 24, 25). The low risk of bias makes the results more credible, as they are more likely to reflect reality (11). The findings in the two remaining studies suggest that preoperative warming has no effect, but the results were not statistically significant (16, 19).

    These studies also have a high risk of bias, which may imply that their results do not match reality (13). Our analysis of the risk of bias across the studies showed that the risk is low in most of the seven main points. However, two main points stood out as having the highest risk of bias: ‘drop-out bias’ due to the drop-out of participants from the study, and ‘other bias’ due to different measuring instruments being used (Figure 2).

    Factors that may have affected the results

    In intervention studies, several factors can impact on the effect of a measure. Prognostic factors such as age, weight and illness can, in many cases, affect the outcome. Such factors among the participants should be equally distributed between the groups (13). The average population age in the studies selected may imply that there was a large variation in the age of participants.

    Some of the participants had a high BMI, which may have had a positive effect on the results since overweight patients are less exposed to heat loss than slim patients (3, 28).

    The intervention durations in the studies differ. A long intervention means a higher core temperature in surgical patients. Horn et al. (18), however, show that a short intervention duration of 10 minutes has a significant effect on preventing hypothermia. This finding is new in relation to the recommendations by de Brito Poveda et al. (9), and can be explained by the high heat strength used.

    The conflated findings show a clear correlation between high heat strength and positive effects of the measure. In light of this, we found that it was beneficial to use a high heat strength. However, the high heat strength must not cause discomfort to the patients. Short warming times can also be more practical and cost effective.

    We believe that the focus should not only be on efficacy, but on the prioritising of patient safety and quality. Healthcare personnel have a duty to ensure quality in the work performed, including focussing on the patient (29).

    The majority of the studies selected continued to actively warm patients with a forced-air warming blanket perioperatively. Based on the findings in the studies, we found that perioperative warming tended to have a positive effect on the results. Thus, it is natural to continue patient warming perioperatively as the patient is most exposed to heat loss during this period (2).

    The conflated findings show a clear correlation between high heat strength and positive effects of the measure.

    Another key element that may have affected the accuracy of the measurements is the measuring instruments that were used. The outcome goals of our study were mainly the patient’s core temperature, which is the best indicator of a patient’s temperature status (30). Which measuring instruments should be used is the topic of much debate in both the research literature and in practice.

    The ear thermometer (ear drum), oesophageal thermometer, nasopharyngeal thermometer and pulmonary artery thermometer are considered to be reliable instruments for measuring the core temperature (30, 31). The ear thermometer is used in several of the studies selected (18, 20, 21, 24). This measuring instrument is considered to be reliable when aural probes are used.

    Infrared thermometers, on the other hand, are regarded as inaccurate measuring instruments (31). Three of the studies used infrared thermometers (16, 21, 23). The various studies also had different measurement times. This may have affected the results, making it difficult to compare the studies.

    Methodological considerations

    This systematic literature review is based on RCT. Systematic literature reviews that include high-quality quantitative research are ranked highly in the evidence hierarchy (11). In order to generate new knowledge about the effect of preoperative warming, it was necessary to perform an updated literature search.

    We conducted an extensive systematic literature search in relevant databases according to the recommendations of the Norwegian Knowledge Centre for the Health Services, which reinforces the validity of the study (32). Even though we did not contact de Brito Poveda et al. (9) to obtain their detailed search strategy, we nevertheless undertook a broad-based literature search where we found many articles that were relevant to our research question.

    However, we recognise that the optimum approach would have been to also search for unpublished studies and reviews, known as grey literature, and are therefore aware that we may have missed relevant literature. The two authors carried out independent reviews and critical assessments of all the articles in terms of internal validity, with a view to safeguarding objectivity (11).

    Another factor that reinforces the validity of our study is our use of a reliable tool – one recommended by the Cochrane Collaboration – to evaluate the study’s risk of systematic bias (13). In our opinion, this validation tool provides a more solid basis for giving clear recommendations.

    In relation to further research, we recommend conducting studies of children, the over 85s and patients with an ASA classification of > 3. These patient groups are more susceptible to developing hypothermia and are seldom included in the studies we found. In order to assess the effect of preoperative warming more generally, studies with preoperative warming should be carried out for several types of surgical procedures.

    Patients receiving regional anaesthesia are also prone to hypothermia, and more studies should therefore be conducted where this type of anaesthesia is practised. It is crucial that future studies use measuring instruments with satisfactory psychometric properties and that the use of instruments is consistent.

    In practice, more emphasis is placed on carbon fibre technology as a warming method, but research on this is limited. The benefits of carbon fibre technology as a warming method therefore need further investigation.

    Clinical implications

    Our systematic literature review only identifies the benefits of offering surgical patients preoperative warming with a forced-air warming blanket. Besides time spent and costs, we did not find any disadvantages or adverse side effects associated with this measure. Earlier reviews of other types of warming methods support this finding (9, 10).

    Besides time spent and costs, we did not find any disadvantages or adverse side effects associated with this measure.

    Based on the results, we recommend in the strongest terms that nurse anaesthetists use preoperative warming with a forced-air warming blanket as a preventive measure. We recommend using forced-air warming blankets with a high heat strength – above 40° – and with an intervention duration of 10 to 30 minutes. We particularly recommend this measure for adult patients undergoing elective surgery under general anaesthesia, where surgery time is more than 30 minutes.

    Conclusion

    Maintaining normothermia in surgical patients is crucial to preventing anaesthetic-related complications and to safeguarding the quality of the work performed. Our findings clearly show that several factors can lead to a drop in a patient’s core temperature. Nevertheless, the results in this systematic review indicate that preoperative warming with a forced-air warming blanket has a significant effect on preventing accidental hypothermia in adult elective surgery patients under general anaesthesia.

    The results also suggest that it may be beneficial to warm the patient perioperatively. We believe that this systematic literature review can provide a balanced picture of research findings on preoperative warming with a forced-air warming blanket and prevention of hypothermia. In addition, we believe that the study is a good source of knowledge for healthcare personnel making decisions in practice in connection with preoperative warming.

    Thanks go to the librarians Elisabeth Hundstad Molland at Stavanger University Hospital and Grete Mortensen at the University of Stavanger for their assistance with our systematic literature search. We would also like to thank Lillebeth Larun at the Norwegian Knowledge Centre for the Health Services for her helpful advice during the process.

    References

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    2.       Bozimowski G. Clinical monitoring II: Respiratory and metabolic systems. In: Nagelhout JJ, Plaus KL, eds. Nurse Anesthesia. St. Louis, Missouri: Saunders/Elsevier; 2014. p. 313–24.

    3.       Berg T, Hagen O. Forebygging og behandling av anestesirelaterte komplikasjoner. In: Hovind IL, ed. Anestesisykepleie. Oslo: Akribe; 2011. p. 280–307.

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    7.       Hooper VD, Chard R, Clifford T, Fetzer S, Fossum S, Godden B, et al. ASPAN's evidence-based clinical practice guideline for the promotion of perioperative normothermia. Journal of PeriAnesthesia Nursing. 2009;24(5):271–87. DOI: 10.1016/j.jopan.2010.10.006.

    8.       Galvao CM, Liang Y, Clark AM. Effictiveness of cutaneous warming systems on temperature control: meta-analysis. Journal of Advanced Nursing. 2010;66(6):1196–206. DOI: 10.1111/j.1365-2648.2010.05312.x.

    9.       de Brito Poveda V, Clark AM, Galvao CM. A systematic review of the effectiveness of prewarming to prevent perioperative hypothermia. Journal of Clinical Nursing. 2012;22:906–18. DOI: 10.1111/j.1365-2702.2012.04287.x.

    10.     Roberson MC, Dieckmann LS, Rodriguez RE, Austin PN. A review of the evidence for active preoperative warming of adults undergoing general anesthesia. AANA Journal. 2013;81(5):351–6.

    11.      Polit D, Beck CT. Nursing research: Generating and assessing evidence for nursing practice. Philadelphia: Lippincott Williams & Wilkins; 2012.

    12.     Liberati A, Altman D, Tetzlaff J, Mulrow C, Gøtzsche P, Ioannidis J, et al. The  PRISMA statement for reporting systematic review and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration. PLoS Medicine. 2009;6(7):1–28. DOI: 10.1371/journal.pmed.1000100.

    13.       Higgins JPT, Altman DG. Assessing risk of bias in included studies. In: Higgins JPT, Green S, eds. Cochrane handbook for systematic reviews of interventions England: The Cochrane Collaboration; 2008. p. 187–241.

    14.       Boland A, Cherry MG, Dickson R. Doing a systematic review : A student's guide. Thousands Oaks, California: Sage; 2014.

    15.      Nasjonalt kunnskapssenter for helsetjenesten. Sjekklister for vurdering av forskningsartikler [Internet]. Oslo: Nasjonalt kunnskapssenter for helsetjenesten; 2014 [cited 01.05.2016]. Available at: http://www.kunnskapssenteret.no/verktoy/sjekklister-for-vurdering-av-forskningsartikler. New, updated version available at: https://www.fhi.no/globalassets/kss/filer/filer/verktoy/sjekkliste-rct-2014.pdf.

    16.     Fettes S, Mulvaine M, Van Doren E. Effect of preoperative forced-air warming on postoperative temperature and postanesthesia care unit length of stay. AORN Journal. 2013;97(3):323–9. DOI: 10.1016/j.aorn.2012.12.011.

    17.     Perl T, Peichl LH, Reyntjens K, Deblaere I, Zaballos JM, Brauer A. Efficacy of a novel prewarming system in the prevention of perioperative hypothermia. A prospective, randomized, multicenter study. Minerva Anestesiologica. 2014;80(4):436–43.

    18.     Horn EP, Bein B, Bohm R, Steinfath M, Sahili N, Hocker J. The effect of short time periods of pre-operative warming in the prevention of peri-operative hypothermia. Anaesthesia. 2012;67(6):612–7. DOI: 10.1111/j.1365-2044.2012.07073.x.

    19.     Nicholson MA. Comparison of warming interventions on the temperatures of inpatients undergoing colorectal surgery. AORN Journal. 2013;97(3):310–22. DOI: 10.1016/j.aorn.2012.12.018.

    20.     Camus Y, Delva E, Sessler DI, Lienhart A. Pre-induction skin-surface warming minimizes intraoperative core hypothermia. Journal of Clinical Anesthesia. 1995;7:384–8. DOI: 10.1016/0952-8180(95)00051-I.

    21.     Fossum S, Hays J, Henson MM. A comparison study on the effects of prewarming patients in the outpatient surgery setting. Journal of PeriAnesthesia Nursing. 2001;16(3):187–94. DOI: 10.1053/jpan.2001.24039.

    22.     Kim JY, Shinn H, Oh YJ, Hong YW, Kwak HJ, Kwak YL. The effect of skin surface warming during anesthesia preparation on preventing redistribution hypothermia in the early operative period of off-pump coronary artery bypass surgery. European Journal of Cardio-thoracic Surgery. 2006;29:343–7. DOI: 10.1016/j.ejcts.2005.12.020.

    23.     Andrzejowski J, Hoyle J, Eapen G, Turnbull D. Effect of prewarming on post-induction core temperature and the incidence of inadvertent perioperative hypothermia in patients undergoing general anesthesia. British Journal of Anesthesia. 2008;101(5):627–31. DOI: 10.1093/bja/aen272.

    24.     De Witte JL, Demeyer C, Vandemaele E. Resistive-heating or forced-air warming for the prevention of redistribution hypothermia. Anaesthesia Analgesia. 2010;110(3):829–33. DOI: 10.1213/ANE.0b013e3181cb3ebf.

    25.     Smith C, Sidhu R, Lucas L, Mehta D, Pinchak A. Should patients undergoing ambulatory surgery with general anesthesia be actively warmed? The Internet Journal of Anesthesiology. 2006;12(1):1–10. Available at: http://print.ispub.com/api/0/ispub-article/10591(downloaded 01.05.2016).

    26.     Nortvedt P. Etiske utfordringer. In: Hovind IL, ed. Anestesisykepleie. Oslo: Akribe; 2011. s. 51–61.

    27.     Lov 2. juli 1999 nr. 64 om helsepersonell m.v. (helsepersonelloven). Available at: https://lovdata.no/dokument/NL/lov/1999-07-02-64?q=helsepersonelloven(downloaded 01.05.2016).

    28.     Sessler DI. Perioperative heat balance. Anesthesiology [Internet]. 2000; 92(2):578–96 [cited 01.05.2016]. Available at: http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1946305.

    29.      Meld. St. nr. 10 (2012–2013). God kvalitet – trygge tjenester – Kvalitet og pasientsikkerhet i helse- og omsorgstjenesten. Oslo: Helse- og omsorgsdepartementet; 2012. Available at: https://www.regjeringen.no/no/dokumenter/meld-st-10-20122013/id709025/?ch=1&q=(downloaded 01.05.2016).

    30.   Sessler DI. Temperature monitoring and perioperative thermoregulation. Anesthesiology. 2008;109(2):318–38. DOI: 10.1097/ALN.0b013e31817f6d76.

    31.    Lenhardt R. Monitoring and thermal management best practices & research. Clinical Anaesthesiology. 2003;17(4):569–80. DOI: 10.1016/S1521-6896(03)00048-X.

    32.     Nasjonalt kunnskapssenter for helsetjenesten. Handbok for Nasjonalt kunnskapssenter for helsetjenesten: Slik oppsummerer vi forskning. Oslo: 2013. Available at: http://www.kunnskapssenteret.no/verktoy/slik-oppsummerer-vi-forskning(downloaded 01.05.2016). New, updated version available at: https://www.fhi.no/globalassets/kss/filer/filer/verktoy/2015_handbok_slik_oppsummerer_vi_forskning.pdf.

    Surgical patients are exposed to heat loss, which can lead to complications such as increased oxygen demand, higher infection risk and cardiovascular problems.

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    English
    Sammendrag

    Background: Surgical patients are exposed to heat loss. It is important to prevent accidental hypothermia in surgical patients in order to avoid unnecessary complications such as increased oxygen demand, higher infection risk and cardiovascular problems.

    Objective: To generate new knowledge about the effect of using forced-air warming blankets as a means of preventing accidental hypothermia in elective surgery patients under general anaesthesia.

    Method: We conducted an updated systematic literature search in the databases CINAHL (EBSCO), Embase (Ovid), Cochrane Register of Controlled Trials (Wiley), MEDLINE (Ovid) and ScienceDirect for material published between January 2011 and February 2016 in order to complement existing systematic reviews. Randomised controlled studies published in English and Scandinavian languages were included. We made a critical assessment of the studies with regard to the risk of systematic bias and presented aggregate findings in a narrative analysis.

    Results: We identified 624 references and included a total of 10 articles in the analysis. Eight of the ten studies show a positive effect from preoperative warming with a forced-air warming blanket. The majority of these studies show statistically significant results and have a low bias risk.

    Conclusion: The results indicate that preoperative warming with a forced-air warming blanket has a significant effect on preventing accidental hypothermia in adult elective surgery patients under general anaesthesia. Continuing to warm patients perioperatively can also be beneficial.

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  • Lack of clear framework impedes work with children of sick parents

    A clear link has been demonstrated between mental illness or substance abuse in a parent and impaired mental health in children (1–5). There is a risk that the parents’ mental or substance abuse problems affect how they function as a parent, thereby having a negative impact on the environment in which the children grow up (1, 3, 6).

    According to the Norwegian Institute of Public Health (1), children of parents with a mental illness or substance abuse problem have almost a 100 per cent greater risk of experiencing adverse events in their childhood home than children who do not grow up with such parents.

    The increased risk of the children experiencing adverse events depends on the severity of the problem, the severity of the parents’ psychopathology and the age of the children when the problems first arose. It also depends on whether both parents are sick (1, 4, 6). Depression has been shown to impair parents’ ability to understand the children’s signals, their need for safety and their parents’ presence (1, 2, 6).

    Approximately 290 000 children in Norway have at least one parent with a moderate mental disorder or substance abuse problem.

    Other mood disorders and substance abuse problems can create unpredictable parental behaviour that scares the children (4, 5). A negative emotional climate of frequent conflicts can develop in the home (7). Such factors create sustained stressors, which in turn have a negative impact on brain development and increase the chance of developing learning difficulties, behavioural problems and impaired physical and mental health later in life (8).

    Calculations from the Norwegian Institute of Public Health (1) show that approximately   290 000 children in Norway have at least one parent with a moderate mental disorder or substance abuse problem. Being able to provide preventative and support measures for families where the parents have substance abuse problems and mental disorders is therefore a high priority (9, 10). 

    Government focus and new legislation

    We have gradually gained more knowledge about the extent of atypical development and the increased risk of this in children of parents with a mental illness or substance abuse problem. The Ministry of Children and Equality initiated an investigation into the follow-up of these children. This resulted in three reports (11–13), which all concluded that despite the knowledge about risk factors, the healthcare provision for these children was haphazard, unpredictable and disjointed.

    The reports resulted in the government’s focus on funding in the period from 2007 to 2010. The focus was aimed at initiatives in competence development and administration, in addition to long-term support through measures and early-stage intervention to help the children (14). Towards the end of the focus period, new legislative acts were passed, which entered into force on 1 January 2010: in general, section 10a (15) of the Health Personnel Act and section 3-7a (16) of the Specialist Health Services Act.

    These laws define the patients’ children as children of sick parents and impose a requirement for all departments in the specialist health service to have dedicated healthcare personnel with a child welfare role who have responsibility for fostering and coordinating healthcare personnel’s follow-up of minors. The laws are intended to complement each other, and aim to ensure that these children are identified at an early stage. Their purpose is also to ensure that processes are initiated to give the children and parents the tools they need to better master their situation (10, 14).

    Shortcomings in work with children of sick parents

    After the end of the focus period and when the new legislation was implemented, recent surveys indicate that the work with children of sick parents is still subject to shortcomings. In a review from 2012 (14), the Norwegian Directorate of Health points out that only a limited number of children and young people have used the measures that were introduced after the focus period.

    Inadequate registration of the patients’ children shows that implementing the new legislation in clinical practice is taking longer than intended (17, 18). Earlier studies highlight barriers in the work with children of sick parents and failings in the interaction between different agencies (19–22).

    A Norwegian multicentre study indicates lack of cooperation and coordination as an existing problem (22). One of the main findings in this study is that the specialist health service only partly adheres to the legislation on children of sick parents.

    The purpose of our study is to gain more knowledge about the perceptions of healthcare personnel who have a responsibility for children of sick parents in relation to the process of identifying families’ needs and initiating support.

    Method

    Design and sample

    The study has a qualitative research design. We used an exploratory method (23) in order to understand and describe how those who work with patients and their children perceive and understand their work. By attempting to set aside their own existing knowledge of the subject, the authors sought to study the informants’ experiences, and hence generate knowledge about the field (23).

    We searched for informants with experience in working with children of sick parents. The inclusion criteria were as follows: holding a position of responsibility and personal experience in working with children of parents with a mental illness or substance abuse problem. A total of seven informants formed the knowledge base. Five of the informants were personnel with a child welfare role in accordance with the new legislation from 2010, while two of the informants had previous experience of working with children of sick parents.

    Part of the sample was assembled using the ‘snowball method’ (24). By asking each informant about other potential informants with experience from such work, the first author learned of other professionals within county 1. For county 2, we received contact details from the health trust’s research department about relevant informants in line with the inclusion criteria.

    We invited the informants personally via an information e-mail and a subsequent telephone call. Of those invited, one declined the invitation to take part. The sample consisted of four women and three men aged 38–65, made up of qualified specialist nurses, nurses, social educators and special needs teachers.

    Informants from adult psychiatric wards and outpatient clinics were included. Four informants had over five years of experience working with children of sick parents, while one had two years of experience.

    Data collection

    We conducted the data collection through individual in-depth interviews of personnel from four different workplaces in Central Norway. A semi-structured interview guide with a phenomenological approach provided a framework for the interviews (24).

    The interview guide had four main themes: 1) how is the daily work, 2) experiences with child and parent contact, 3) experiences with and perceptions of arranging support, and 4) perceptions of support reaching where needed. The interview form was flexible and allowed for follow-up questions with a view to gaining a more in-depth understanding.

    The interviews were conducted by the first author at the informants’ workplace during their working hours. The first author interviewed the informants in a suitable meeting room or in their office. She used a tape recorder, and all the interviews were transcribed immediately afterwards. The interviews lasted from 45 to 85 minutes.

    Analysis

    We used Malterud’s (25) systematic text condensation method to analyse the text. The form of analysis is a descriptive, cross-sectional analysis through four stages of decontextualisation and recontextualisation. The first two steps have a phenomenological foundation. The latter two also use interpretation and the hermeneutical circle through an analytical journey between the whole and its parts until a new understanding is developed.

    In the first step, we read through all the transcribed interviews in their entirety, focusing on listening to the narrative. In step two, we used a computer program for qualitative analysis, MAXQDA 11. Most of the text was categorised into meaning units with different codes based on how the statements answer the problem.

    In the third stage, we condensed the meaning units within each theme into shorter sentences with the same meaning content. Similarities and differences in the informants’ perceptions were then identified. In the final step, we summarised the condensed text in parallel with returning to the raw material and examining the whole from which the text sequence was extracted.

    Ethics and data protection

    The study was approved by the Norwegian Centre for Research Data (NSD) and the research and development departments at Nord-Trøndelag Regional Health Authority and St. Olavs Hospital. We invited the informants personally, so that no one other than those conducting the study would know the identity of the participants. In order to ensure confidentiality, we deleted the audio recordings after the informants approved the transcribed text.

    We endeavoured to anonymise place names or other specific factors that might be recognisable. The consent form and encryption key were kept separately from the data material and stored in accordance with applicable guidelines.

    Results

    Lack of information on time use

    The informants lacked a clear specification of how much time they should dedicate to their work with children and their families. The personnel with a child welfare role who were nurses and social educators reported that their new ‘post of responsibility’ was prioritised above their normal work as a nurse or social educator: ‘There’s no specific time set aside. It’s just something that needs to be done in addition.’

    The personnel with a child welfare role had no reduction in ordinary duties. Nor had they received any guidance on how long they were expected to spend on duties in their child welfare role: ‘It’s hard to say how much time is spent on the child welfare part of the job. Management has given no indication of how long we should spend on it.’

    In addition to the practical challenges of finding enough time, the informants stated that they were uncertain about the expectations in terms of the depth and scope of the work. For example, they were unsure how hard they should try or how long they should endeavour to motivate the parents.

    The personnel with a child welfare role who were nurses and social educators said that they were already busy in their positions as nurses and social educators, and that the added responsibility presented major challenges in terms of prioritisation: ‘Actually, it’s quite a lot of extra work, you have several patients and therefore numerous tasks. So, there can sometimes be a bit too much, and then I think the children get less attention. Or not less attention, but there just isn’t enough time.’

    The ward personnel in particular felt the time constraints. Staff at the outpatient clinic were more inclined to feel that they had time to talk to their own patients about their children. However, they pointed out that only having an overview of their own patients was a challenge, and that it was difficult to arrange meetings with other personnel with a child welfare role: ‘It’s actually a bit of an isolated position.’

    The parents shied away from seeking help

    All of the informants in the study found that the parents were often hesitant to talk about the situation at home, the children and their role as parents. One reason could be that many parents do not have knowledge about and an understanding of how their own disorder affects their children: ‘They often believe that the children don’t understand or don’t know. But children know more than we think.’

    One informant told of an example where a mother claimed to be a better mother when she was high than when she was sober. The informants also said that many parents believe that the children do not notice if they cry or have a moderate drug habit.

    Some informants described how the work was ‘difficult to progress’, and that it could therefore stagnate: ‘I try to arrange meetings at the family centre or some such thing. Sometimes they don’t turn up. As if they don’t have a need.’

    The fear of child welfare services was another reason why the parents were hesitant to talk about their children. Consequently, patients often quickly brushed aside questions by saying that everything was fine: ‘Some parents say that the children are doing well, and that’s the end of it. But then it turns out that they may have been through quite a lot.’

    It’s usually those who aren’t worried about their children who are the most difficult to have contact with.
    Informant

    The parents’ fear and hesitation were a major challenge for all of the informants. Some also found that the parents’ reticence to talk prevented them from procuring further support for the family. Additionally, it was often difficult to assess which cases were serious enough to warrant reporting their concern to the child welfare services.

    Several of the informants said that it was not the patients who worried most about their children who caused them the most concern. Those who were most worried were open to seeking help and changing the situation. One informant described it as follows: ‘It’s usually those who aren’t worried about their children who are the most difficult to have contact with. And then it’s a case of if they’re aware of it, they’re terrified of revealing something.’

    Some informants described the situation as follows: ‘Those kinds of concerns play on my mind after I get home from work.’ Others described how they had to spend a long time reassuring the parent and gaining their understanding before the parent opened up and wanted to discuss the situation surrounding the children and possible support.

    Challenges in the interaction with other support agencies

    The informants who had a child welfare role in addition to their position as an occupational therapist and outpatient clinician had minimal cooperation with other agencies in the support work for children of sick parents: ‘We can provide brochures about the primary health service measures, but it’s only giving out a brochure, not direct contact with the local authority. So, it’s really left up to the parents to make contact.’

    At the information meeting where families can ask questions, parents are given good guidance on how to chat with their children and how to seek further support. However, it is primarily the parents who need to take the initiative to contact other support agencies.

    Several informants reported that there is seldom more than one information meeting, and that they lose track of whether the family is receiving further follow-up. It transpired that when they have direct contact with another agency, it is mainly in the form of a report of concern to the child welfare services.

    Several informants said that despite having positive experiences working with parents and children of sick parents, they feel that they have little insight into how the support functions operate outside their own department.

    One informant felt that the support work lacked a holistic approach: ‘I feel in a way that we’re at the core of things at the hospital, and then there’s this large apparatus scattered about externally. I don’t even know what they all do. It’s like a bit here and a bit there, where is the big picture?’

    Another informant said the following: ‘It's like we’re sitting on our own islands, without really knowing what’s going on on the other ones.’ Only one of the informants reported a close dialogue with support agencies outside the department, where these agencies were actively used. The informant said the following: ‘It depends on how you ask and how well you explain about the parent. It takes time.’

    The informant further explained how achieving a good cooperation requires a close dialogue with local support agencies. The person also explained how time-consuming it is to establish good contact and how close cooperation will be almost impossible for someone who is also working on a ward or has set patient hours during the day.

    Discussion

    In this study, all healthcare personnel with a child welfare role performed their statutory duty to report whether the sick patient has children, but the healthcare personnel face a number of challenges in their work.

    According to the Norwegian Directorate of Health (10), the purpose of the new legislation is to ensure that the children are identified at an early stage and that processes are initiated to give the children and parents the tools they need to better master the situation when a parent becomes seriously ill. Identifying children of sick parents requires extensive efforts that not only involve registering the number of children with sick parents, but also mapping the child’s life situation and need for support (9, 10, 14).

    No clear timeframe

    The informants reported that it is often healthcare personnel with a child welfare role who conduct the information meeting with parents and children. In addition, they are responsible for guiding and following up other healthcare personnel, keeping their knowledge up to date and maintaining an overview of relevant support services (10). Although supervisors and guidelines encourage personnel to allow time and space to become familiar with their role, informants said that this was not feasible in practice.

    The reason is that the child welfare role is in addition to other regular tasks they have. This additional responsibility corresponds to the findings in another study (26) and partly explains the informants’ feelings of uncertainty about the time they are expected to spend on the work. When the child welfare role does not have a defined timeframe, the workload in the department will impact on how much time the employee has available for her work with the children.

    Earlier studies show that the level of healthcare personnel’s involvement in the focus on children is determined by random factors. Variations occurred due to, for example, the age, gender and level of education of healthcare personnel (18, 19). The variations in focus on the child perspective in combination with undefined timeframes for the work had a detrimental effect. These factors create a synergy and result in a child receiving haphazard support.

    Insufficient guidance

    The implementation of the child and family perspective in adult psychiatry requires moving the spotlight from being individual-oriented to being family-oriented (20). The informants expressed a desire to succeed in the work, and when they felt they had not done enough for a family it played on their mind at home. In order to succeed, good communication from management is important when new tasks are to be included in the daily work (27).

    Either the work tasks must be understandable and clear in practice, or the employee must know how much time is to be given to the new task. The informants reported a lack of guidance. For example, how much time was it sensible to spend on the work and how could they ensure they had enough time.

    This lack of guidance corresponds to findings from the multicentre study (22) and may indicate a shortcoming in the implementation at management level. Uncertainty about time use will also create uncertainty about the scope and depth of the work.

    Unclear home situation complicates the work

    The informants talked about the challenges they face with regard to parents who deny that they need help, and the feeling that these are actually the ones who are most likely to need help. The healthcare personnel were concerned about these challenges. Children can sometimes help to hide how much a parent is struggling out of loyalty (28). Both children and parents may feel a sense of shame and that they are being stigmatised for being different, and this will exacerbate their unwillingness to talk about their home situation (29, 30).

    It is therefore not possible to tell by looking at a child whether they have a good or difficult home situation, and time needs to be spent talking with the family to find out if there is a need for further support. Healthcare personnel must be given the opportunity to map risk factors and protection factors in order to assess whether further follow-up is needed. Several informants talked about how the support grinds to a halt when parents do not recognise a need for help.

    Their uncertainty about how much time they are to spend on the tasks also makes them unsure of the extent to which they should map the children’s situation.

    These findings correspond to findings from other studies (20, 21). According to Maybery and Reupert (21), the fact that the patients themselves do not acknowledge that a problem exists represents a barrier in the work with children of sick parents. Their uncertainty about how much time they are to spend on the tasks also makes them unsure of the extent to which they should map the children’s situation. For example, has the situation been sufficiently mapped when the parent answers that the children are doing well, or should the healthcare personnel continue to ask questions?

    They are also unsure as to whether they provide adequate information to parents and children. Can anyone get enough information in one hour? By no means least, uncertainty about time use also causes uncertainty in the healthcare personnel as to whether they should continue to motivate the parent to participate in support measures even when they declined the initial offer of help. Such uncertainty can make the parents’ reticence to talk about the home situation a real obstacle to providing support for the children.

    Not everyone uses the measures

    We know from the countless and serious potential harmful effects we see in children who have lived with parents who are mentally ill or have a substance abuse problem (1) that it is vital to get more of these children to participate in preventive interventions (14, 30–32). In recent years, a number of support programmes and services aimed at children of parents with a mental illness or substance abuse problem have been established.

    According to Kallander et al. (14), there are nevertheless only a limited number of children and young people who have used the measures that were introduced after the focus period. Possible reasons may be too much faith in child welfare services as a primary measure, limited user involvement and lack of interaction with children of sick parents (14).

    These three factors correspond to the challenges described by the informants. The informants have a certain overview of the primary healthcare services, but have no contact or any cooperation with these support measures. When the healthcare personnel with a child welfare role initially refer the parents to another municipal authority, it is mainly the child welfare services that are contacted, which is of concern to many parents.

    Personnel lack a clear framework

    Healthcare personnel who are responsible for ensuring the children’s need for information is met and for providing the necessary follow-up report time constraints in their daily work and are uncertain how much time they can devote to these important tasks. This uncertainty indicates that they lack a framework for the work. If the desire for user involvement is to be fulfilled, it will be necessary to spend time talking with the parents in order to establish the appropriate level for further support.

    The healthcare personnel will also need more time to stay abreast of developments in the field and familiarise themselves with local support programmes (10). They will need to consult with other professionals in relevant situations that raise concerns. The informants felt isolated in their role of responsibility, which is a further indication that the framework for the work is not clear enough.

    Time is also a crucial framework factor for achieving a sense of security and understanding, and a good alliance that entails direct contact with the patient.

    A coordinated effort requires having time to take telephone calls and participate in meetings with other parties involved in the support work. Time is also a crucial framework factor for achieving a sense of security and understanding, and a good alliance that entails direct contact with the patient. This can be vital to whether the parents let their children or family participate in a preventive intervention (33).

    The lack of defined timeframes for this work can be one reason why the informants felt there was little chance of providing further support outside the specialist health service. Time constraints can also be the reason why relatively few families are transferred to other support measures outside the specialist health service (14). Studies have shown that support services are used to a greater extent when personnel are able to allocate time to working with families (22, 34).

    Methodological considerations and limitations

    The sample represents a limited number of informants, and we cannot therefore draw general conclusions. The in-depth interviews gave us a deeper understanding of the informants’ challenges in the workplace. The study shows that informants from different workplaces have a variety of similar experiences. What the informants have described can therefore be transferred to the same practices in other places where work is carried out with children of sick parents.

    Conclusion

    The results of our study reveal the challenges that healthcare personnel face in their work with parents who are mentally ill or have substance abuse problems. The informants appear to be genuinely interested in helping families who need support in caring for their children, but they encounter obstacles when parents are reticent to talk about the children and their parenting role.

    In their efforts to hold informative talks with the children or provide other support, informants describe a challenging situation that often involves guiding parents to understand their own disorder and how they can affect the children. Staff in wards and at outpatient clinics already have a busy working day. Several informants reported that when they have no clear guidelines on how much time they can or should spend on their work with children it creates uncertainty.

    While some informants managed to gain parents’ confidence and understanding to the extent that they accepted further follow-up of the family, others felt that their efforts were not successful, even though they had identified a need for further follow-up. The sum of these conditions indicates that the work aimed at children lacks a clear framework and that the support given to children of sick parents is haphazard.

    We would like to thank the acute psychiatric ward at Namsos Hospital, which has helped enable us to complete our study. Thanks also go to Professor Ottar Ness at NTNU and Nord University and research fellow Anne Kristine Bergem at Nord University for their input to the manuscript.

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    33.     Van Doesum K, Riebschleger J, Carrol J, Grové C, Lauritzen C, Mordoch E et al. Successful recruitment strategies for prevention programs targeting children of parents with mental health challenges: An international study. Child & Youth Services. 2016;37:156–74.

    34.     Selbekk AS. Utvidet oppfølging av barn og pårørende i spesialisert rusbehandling: evaluering av prosjektstillingen barne- og pårørendekontakt. Vol. 1/2011. Stavanger: Kompetansesenter rus – region vest Stavanger, Rogaland A-senter; 2011.

    Healthcare personnel who work with parents who are mentally ill or have substance abuse problems are uncertain about their role. The support that the children receive can therefore be haphazard.

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    Sammendrag

    Background: According to the Norwegian Institute of Public Health, 290 000 children are living in families where at least one of the parents has a moderate alcohol abuse problem or mental illness. Research conducted over several decades has shown clear links between mental illness or substance abuse in a parent and impaired mental health in children. Several reports and studies also demonstrate shortcomings and difficulties in the work aimed at children of sick parents. In 2010, new legislation was introduced to ensure that children of sick parents in the specialist health service are better taken care of.

    Objective: To investigate the perceptions and experiences of healthcare personnel who have a special responsibility for the work with children of sick parents.

    Method: Through in-depth interviews, the study investigated healthcare personnel’s perceptions of working with children of sick parents. The data were analysed using systematic text condensation.

    Results: The informants identified a number of practical challenges in their daily work, including difficulty in getting parents to understand how their mental condition affects their children. The healthcare personnel also reported that they have trouble motivating parents to receive help with the parenting role. They face major challenges in the work with children of sick parents, where lack of time to perform statutory tasks is highlighted as a key factor.

    Conclusion: The study indicates that healthcare personnel who work with children of sick parents need a clearer framework for their work and more time to carry out the work. 

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  • The home care services carry out extensive laboratory activity

    The home care services are a statutory primary healthcare service which seeks to ensure that residents have access to the necessary health and care services (1). The users of home care services comprise part of the GP’s patient list and must be given the same priority as other listed patients (2). About 145 000 users of home care services received home-based nursing care in 2015 (3).

    Employees of the home care services also perform certain laboratory services, but there is little systematic knowledge about the extent and content of these types of services. For example, it is not known which point-of-care tests (POCT) are analysed in the user’s home. There is also reason to believe that the Coordination Reform (4), which calls for more patients to receive treatment in their homes, will increase the amount of laboratory activity carried out by the home care services.

    There is relatively sound knowledge about what analyses are performed in the laboratory activity at GP surgeries and in nursing homes. For example, data from 2014 show that 95 per cent of nursing homes perform analyses of C-reactive protein (CRP) and urine strips, 98 per cent analyse glucose, 79 per cent analyse haemoglobin, and 40 per cent analyse prothrombin time/international normalised ratio (PT/INR) (5).

    Laboratory services performed by the home care services

    Alternatives to the home care services performing laboratory services are 1) that healthcare personnel (mobile laboratory personnel from hospitals or private laboratories or employees of GP surgeries) travel to the users, or 2) that the users are transported to the closest testing point (6).

    The distance a user must travel to the closest testing point and the distance from the home care services to laboratories in nursing homes or GP surgeries can be significant for how the home care services units are organised and for which services are performed. For example, home care services co-located with nursing homes can improve cooperation on laboratory activity.

    If the home care services offer laboratory services, the potential advantages are that the users can avoid tiring journeys and get their test results more quickly.

    If the home care services offer laboratory services, the potential advantages are that the users avoid tiring journeys and get their test results more quickly. A potential disadvantage is that the quality of the laboratory services performed is not satisfactory due to inadequate expertise of the personnel.

    Laboratory services, like other health services, have consequences for treatment and require resources. Thus, it is critical that these services are carried out properly and at the correct level. A survey of the extent and structure of the laboratory activity in the home care services is therefore important in order to assess how the organisation and quality assurance of such services can be optimised in the future.

    Study of laboratory activity

    In this article, we present the results of a study of laboratory activity in three Norwegian counties. The study was part of a pilot project in 2014–2015 conducted under the auspices of the organisation known as Norwegian Quality Improvement of Laboratory Examinations (Noklus). The study is included in the Care Plan 2015 (7) and is intended to comprise part of the basis for future recommendations on how laboratory activity in the home care services should be organised (8).

    Noklus is a national, not-for-profit organisation that works to ensure that laboratory analyses are ordered, carried out and interpreted correctly in accordance with the patient’s need for examination, treatment and follow-up. Almost all GP surgeries and nursing homes in Norway are affiliated with Noklus. To the best of our knowledge, no other studies, national or international, have surveyed laboratory activity in the home care services.

    However, some studies have investigated the competence of employees in the home care services. In a study of 1016 employees in nursing homes and the home care services, Bing-Jonsson et al. (9) found inadequate expertise in certain areas, such as nursing measures, advanced procedures and documentation. They also found a lower level of competence in the home care services than in nursing homes.

    In a study of 209 employees in the home care services in six Norwegian municipalities, Bing-Jonsson and Tønnessen (10) found a need to increase competence in identifying symptoms of urinary tract infections and the use of urine strips.

    Materials and method

    We conducted the survey by sending out a web-based questionnaire to all home care services units in Nordland, Sogn og Fjordane and Østfold counties. We contacted a total of 165 units, of which 79 were located in Nordland, 46 in Sogn og Fjordane and 40 in Østfold.

    The home care services units were identified from a list created by Statistics Norway. Then we quality assured the list by contacting the development centres for nursing homes and home care services (11) and by gathering information from the websites of the individual municipalities.

    Various terms such as zones, main facilities and wards are used about the units in the various municipalities. We therefore decided in the questionnaire to define a ‘home care services unit’ as the physical space where the employees are co-located. Thereafter we use the term ‘unit’.

    Preparation of the questionnaire

    We prepared the questionnaire in consultation with employees of Noklus and Noklus’ advisory group for the home care services. A revised version was circulated for review to two or three different units in each of the three counties.

    In spring 2014, we sent out a final version of the questionnaire with a three-week response deadline. We attached a letter from the Norwegian Director of Health encouraging the units to respond to the questionnaire. A reminder was emailed two weeks after the questionnaire was sent out initially, and in the final week we phoned those who had not responded.

    We asked about organisation of the services, the analytical repertoire and cooperation with GP surgeries and nursing homes. To assess the appropriateness of a given form of organisation, we asked about 1) the users’ travel time to the closest GP surgery and 2) the travel time from the units to the closest GP surgery and nursing home.

    Response to the questionnaire

    Altogether, 146 of a total of 165 units (89 per cent response rate) responded to the questionnaire, of which 70 were from Nordland, 40 from Sogn og Fjordane and 36 from Østfold. We registered responses from units in all municipalities in the three counties.

    The alternative travel times in the questionnaire were as follows: 0 (co-located), 1–5, 6–15, 16–30, 30–60, 60–120 and more than 120. Few respondents reported a travel time of more than 30 minutes, and three of the categories were therefore consolidated into the category ‘> 30 minutes’.

    Some of the respondents failed to answer all the questions, and therefore the response rates vary. We used chi-square tests to test differences between the counties. We used Microsoft Excel for the analyses.

    At the same time as we sent out the questionnaire to the home care services, we sent out the questionnaire to all GP surgeries in the counties. We asked about the type and degree of cooperation with the home care services on laboratory activity. GPs in the three counties reviewed the questionnaire in advance. Then we sent it to 220 GP surgeries. This resulted in a response rate of 83.6 per cent.

    To avoid having too many tables in the results section, we decided to report some of our results in written form only. We also chose not to present the percentages with decimals due to the relatively low number of observations.

    Results

    Table 1, characteristics of the units in the counties, shows that Sogn og Fjordane county has far fewer users who receive home-based nursing care than Nordland and Østfold counties. Each unit in Østfold county has almost three times as many users as the units in Sogn og Fjordane county and nearly twice as many as the units in Nordland county.

    Sogn og Fjordane county has far fewer users who receive home-based nursing care than Nordland and Østfold counties.

    Eighty-two per cent of the units stated that the travel time to the nearest GP surgery was less than 30 minutes for most of their users. This percentage is highest for Østfold county (100 per cent).

    Table 1. Characteristics of the units in the counties

    Table 2 shows the travel time from the units to the nearest nursing home and the nearest GP surgery, measured in minutes. Altogether, 47 per cent of the home care services units were co-located with a nursing home, while 19 per cent were co-located with a GP surgery (Table 2).

    The percentage of units co-located with a nursing home was rather evenly distributed among the counties, while Østfold county had the lowest percentage of units co-located with a GP surgery. However, Table 2 shows that Østfold county has the shortest travel time, both to the nearest nursing home and to the nearest GP surgery.

    Table 2. Travel time from the units to the nearest nursing home or GP surgery

    The units were asked to respond ‘yes’ or ‘no’ to the question of whether they perform sampling and/or analysis of blood or urine. Henceforth, those units that responded ‘yes’ to this question are considered to conduct laboratory activity, and the subsequent tables contain data from this group only.

    A total of 139 of these units responded ‘yes’ (95 per cent) to this question – 96 per cent in Nordland, 98 per cent in Sogn og Fjordane and 92 per cent in Østfold. The units were also asked to state whether they perform venous sampling. The percentage of units that performed venous sampling was high for Nordland (97 per cent) and Sogn og Fjordane (92 per cent) and significantly lower (p-value < 0.05) for Østfold (69 per cent).

    Table 3 shows that almost all the units take capillary samples and analyse urine strips and/or transport urine samples. Glucose is analysed most frequently (96 per cent); about half of the units analyse CRP (56 per cent) and haemoglobin (46 per cent), while one-third analyse PT/INR (32 per cent). No units stated that they conducted other analyses than those mentioned above.

    Table 3. Percentage of units that perform various types of analyses

    All types of employees perform glucose measurements and urine strip tests, and transport urine samples, while nurses are by far the most important group regarding venous sampling. In our study, 99 per cent of the units state that nurses perform venous sampling, while the corresponding figure for auxiliary nurses (health workers), social educators and unskilled personnel is 14 per cent, 11 per cent and 4 per cent, respectively.

    Twenty-eight per cent of the units also performed analyses at night. In this regard, there was a relatively large variation between the counties: Nordland 22 per cent, Sogn og Fjordane 15 per cent and Østfold 55 per cent.

    Table 4 shows that half the units in all the counties perform venous sampling more than once a week, while the percentages are much lower and vary for the remaining three types of analysis; between 6 and 21 per cent. The percentage that analysed CRP differs significantly between the counties.

    All types of employees perform glucose measurements and urine strip tests, and transport urine samples, while nurses are by far the most important group regarding venous sampling.

    In addition, Table 4 shows that the percentage of units that analysed CRP more than once a week is highest for Østfold county. The percentage that performed PT/INR more than once a week is significantly lower in Sogn og Fjordane county.

    The units were also asked which types of analyses they performed. Almost 46 per cent of the units conducted at least four of the five analyses we asked about: glucose, CRP, haemoglobin, PT/INR and urine strip testing. One-quarter of the units performed all five.

    The respondents stated that glucose, PT/INR and haemoglobin were usually analysed in the home of the user. CRP was analysed both in the user’s home and at the unit’s main facility. Urine strip testing was performed most often in the patient’s home, then at the unit’s main facility and then at the GP surgery.

    Table 4. Units that perform various laboratory services more than once a week

    Table 5 shows that GP surgeries are the units’ most important partners. Sogn og Fjordane county, and Nordland county to some extent, cooperated for the most part solely with GP surgeries or with GP surgeries and nursing homes. Østfold county had the highest percentage of units which stated that they cooperate with both GP surgeries and A&E departments.

    The units stated that they often chose to order specific services based solely on their own experience: 44 per cent said that they almost always order urine samples on this basis, and 31 per cent said that they often order urine samples for CRP. This occurred far less often for venous sampling, haemoglobin and PT/INR. Except for urine samples, in which Nordland county has a higher percentage than the other counties, there were no significant variations among the counties.

    When we compared our findings for the units and GP surgeries regarding requisitions, we found that the GP surgeries thought that they ordered a higher percentage of all CRP tests than was actually the case. We also found that 54 per cent of the units almost always, based on the test results, assessed whether it was necessary to contact a doctor, while only 23 per cent of the GP surgeries believed that the units did this.

    Altogether, 117 of 135 units stated that they ‘almost always’ entered the test results in a journal, while 7 units stated that they ‘did this in more than half the cases’. Only 7 per cent of the GP surgeries reported having signed a written agreement with the home care services on the type and extent of cooperation.

    Table 5. Unit’s description of partners regarding sampling and/or analysis of blood or urine tests

    Table 6 shows that 63 per cent of the units used their own urine strips, while the percentage of units that owned their own equipment for measuring glucose, CRP, haemoglobin and PT/INR was lower – between 10 and 30 per cent. Moreover, the table shows that the units in Østfold county generally owned more equipment than the units in Nordland and Sogn og Fjordane counties.

    Table 6. Units that own laboratory equipment

    Discussion

    It is surprising that more than 95 per cent of the home care services units in Nordland, Sogn og Fjordane and Østfold counties conduct laboratory activity and that a large percentage of them perform many different types of laboratory services. All the units perform capillary sampling and analysis in the user’s home, while 90 per cent of the units in Nordland and Sogn og Fjordane counties perform venous sampling. The percentage is somewhat lower in Østfold county. A disadvantage of performing analyses in a location other than the patient’s home is that the test results are received at a later time.

    Analytical repertoire

    There are no significant differences between the counties regarding analysis repertoire. This finding is rather surprising in light of the variation between counties in terms of travel distance.

    When we processed the results, we did not account for the variation in the units’ size and travel distances (Tables 1 and 2). Since the users in Østfold county have the shortest travel distance to alternative laboratories where samples are taken, such as the A&E department, we anticipated a narrower analysis repertoire for this county. One possible explanation is that Østfold county has larger units with more users and employee full-time equivalents, and therefore has a greater need for easily accessible laboratory equipment.

    Another interesting observation was that the units’ analysis repertoire corresponded somewhat with the repertoire of Norwegian nursing homes (5). The percentage of nursing homes and units that performed urine strip tests, glucose and PT/INR was relatively equal, while it varied for haemoglobin and CRP: 79 and 95 per cent for nursing homes, and 45 and 56 per cent for the units respectively.

    Cooperation with GP surgeries and A&E departments

    We also found that the units in Østfold county cooperated more with A&E departments and less with GP surgeries than the two other counties. This is probably because the users in Østfold county have a shorter travel distance to alternative laboratories. When we compared the lists of the analysis repertoire and the percentage of equipment owned by the home care services, we found that 42 per cent of the units that perform CRP analysis own the instruments themselves.

    The percentage was highest for Østfold county, which could be because Østfold county has larger units and therefore a greater need for easily accessible laboratory equipment. A previous study found that increased accessibility of an analysis instrument at the GP surgery resulted in more frequent use of the relevant analysis (13). This finding confirms that accessibility of the analysis equipment alone affects the frequency of analysis.

    The units in Østfold county cooperated more with A&E departments and less with GP surgeries than the two other counties.

    The units carry out more laboratory activity than the GP surgeries are aware of, which may be because not all the test results are reported to GP surgeries.

    The failure of units to report test results and record information in patient journals may be due to an absence of written agreements that clarify the tasks of the home care services. In addition, Bing-Jonsson et al. have confirmed that there is a lack of documentation activity in the home care services (9).

    Representative sample for the three counties

    With a response rate of 89 and 84 per cent from the home care services units and the GP surgeries respectively, there is reason to believe that the respondents are representative of the three sample counties. It is likely that our findings also provide relevant information about the situation in other counties. However, this study does not include any of Norway’s five largest cities, which means that we must be cautious when generalising.

    In densely populated areas, for example, it is much easier to dispatch healthcare personnel to the users in order to perform planned analyses, while at the same time the user’s travel time and distance to the closest GP surgery is shorter. Any future expansions of our project should include more counties and larger cities. Studies may be carried out both to include more counties and to choose other units of observation, e.g. to distinguish between large and small units.

    There is also some difference between the units as to who responded to the questionnaire. In Sogn og Fjordane county, 82 per cent of the respondents were heads of units, while this percentage was somewhat lower in the other two counties. Such differences could have impacted on our findings.

    In our study, we do not know the number of samples that were analysed in the individual units and by the individual employees. We decided not to ask about such conditions since we thought it was unlikely to find respondents who had such an overview. Instead we asked about the number of tests the units had available and whether the units analyse the samples more than once a week.

    It is likely that the individual employee in the home care services carries out laboratory activity less often than employees in GP surgeries, and just as seldom as employees in nursing homes. Therefore, it is especially important to have good training and quality assurance systems.

    Conclusion

    Our study shows that most of the units conduct laboratory activity and that this activity is relatively extensive and more extensive than the GP surgeries are aware of. This means that there are many employees in the home care services who, in one way or another, are involved in laboratory activity.

    The units have multiple partners that they must engage with. It is therefore crucial that those involved in laboratory activity have adequate professional expertise, while at the same time they develop tailored quality assurance systems to ensure that cooperation between the GP surgery, nursing home and home care services is satisfactory.

    Nurses carry out a considerable amount of laboratory activity. Therefore, an important measure to ensure that nurses have adequate expertise could be to include laboratory activity in their basic nursing education.

    We wish to thank the laboratory advisor and project coordinator Marit Steinsund in Noklus for data collection and helpful suggestions during the preparation of this article.

    References

    1.       Lov 24. juni 2011 nr. 30 om kommunale helse- og omsorgstjenester m.m. (helse- og omsorgstjenesteloven) § 3.1–3.2. Available at: https://lovdata.no/dokument/NL/lov/2011-06-24-30(downloaded 08.01.2018).

    2.       Forskrift 28. august 2012 nr. 842 om fastlegeordning i kommunene. Available at: https://lovdata.no/dokument/SF/forskrift/2012-08-29-842?q=Forskrift om fastlegeordning i kommunene(downloaded 08.01.2018).

    3.       Statistisk sentralbyrå. Omsorgstenester. 2017. Available at: https://www.ssb.no/helse/statistikker/pleie(downloaded 13.02.2017).

    4.       St.meld. nr. 47 (2008–2009). Samhandlingsreformen. Rett behandling– på rett sted – til rett tid. Oslo: Helse- og omsorgsdepartementet; 2009.

    5.       Laboratorietilbud i sykehjem; Veileder for utvidelse og vurdering av laboratorietilbud i sykehjem. Available at: http://www.noklus.no/Portals/2/Kurs%20og%20veiledning/R%E5d%20om%20analyserepertoar/2014-10-21%20Laboratorietilbud%20i%20sykehjem%20med%20dato%20-%20Veileder%20fra%20Noklus.pdf(downloaded 19.10.2016).

    6.       Helserådet. Skal hjemmesykepleien ta blodprøver. 2013;2:6–7. Helsebiblioteket.no. Available at: http://www.helsebiblioteket.no/samfunnsmedisin-og-folkehelse/helseradet/?index=100(downloaded 19.10.2016).

    7.       Omsorg 2020. Regjeringens plan for omsorgsfeltet 2015–2020. Oslo: Helse- og omsorgsdepartementet. Available at: https://www.regjeringen.no/contentassets/af2a24858c8340edaf78a77e2fbe9cb7/omsorg_2020.pdf(downloaded 15.02.2017).

    8.       Fauli S. Hvilken laboratorievirksomhet bør hjemmetjenesten ha? Tidsskr Nor Legeforen 2014;134:487.

    9.        Bing-Jonsson PC, Hofoss D, Kirkevold M, Bjørk IT, Foss C. Sufficient competence in community elderly care? Results from a competence measurement of nursing staff. BMC Nursing 2016;15:5.

    10.     Bing-Jonsson PC, Tønnessen S. Urinveisinfeksjon blant eldre i hjemmesykepleien. Sykepleien Forskning. Available at: https://sykepleien.no/forskning/2016/11/urinveisinfeksjon-blant-eldre-pasienter-i-hjemmesykepleien(downloaded 08.01.2018).

    11.     Senter for fagutvikling og forskning, Utviklingssenter for sykehjem og hjemmetjenester i Oslo. Available at: http://www.utviklingssenter.no/index.php?cat=176135(downloaded 17.01.2018).

    12.     Statistisk sentralbyrå. Folkemengde og areal, etter fylke og kommune. Available at: http://www.ssb.no/a/aarbok/tab/tab-057.html(downloaded 17.01.2018).

    13.     Fauli S, Thue G. Decision making in general practice: the availability and use of a specific laboratory analysis. International Journal of Technology Assessment in Health Care. 2005;21(3):386–92.

    A study shows that most home care services in Nordland, Sogn og Fjordane and Østfold counties perform a wide range of laboratory services.

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    English
    Sammendrag

    Background: Little is known within the health service about the types of laboratory services that are performed for the roughly 145 000 Norwegian users of the home care services who receive home-based nursing care.

    Purpose: To compile an overview of the laboratory activity carried out in the home care services in Nordland, Sogn og Fjordane and Østfold counties.

    Method: Data was collected on laboratory activity in the home care services by sending out a web-based survey to 165 home care services units and 220 GP surgeries in the three counties in 2014. The response rate was 89 per cent and 84 per cent, respectively.

    Results: A total of 95 per cent of the units perform laboratory services. Of these, 99 per cent analyse capillary samples, 96 per cent perform urine strip tests, and 89 per cent perform venous sampling. Of those units that take capillary samples, 99 per cent analyse glucose, 56 per cent C-reactive protein (CRP), 46 per cent haemoglobin, and 32 per cent analyse prothrombin time/international normalised ratio (PT/INR). It is the GPs who usually order venous sampling and capillary INR, glucose and haemoglobin, while the home care services often order urine strip tests and CRP tests. The GP surgeries think that they order a higher percentage of CRP tests than they actually do.

    Conclusion: The home care services units conduct extensive laboratory activity with an analysis repertoire rather similar to that of nursing homes. Given the wide range of laboratory services performed by the home care services and the large number of employees involved in these activities, it is crucial to have quality assurance systems in combination with adequate professional expertise.

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  • Daily life after a kidney-pancreas transplantation

    A successful kidney-pancreas transplantation (KPT) is the most effective treatment for patients with unstable diabetes who develop late-stage chronic renal failure (nephropathy). A transplantation can prevent further development of late-stage complications from diabetes, and to some extent reverse already existing complications (1–3).

    Oslo University Hospital (OUH), Rikshospitalet is home to Norway’s only organ transplantation centre, and performs between 15 and 20 KPTs every year (4). Studies show that 87 per cent of KPT recipients are insulin-free one year after the transplantation, 78 per cent five years later and 64 per cent ten years later. Meanwhile, 95 per cent have a functioning transplanted kidney one year after a KPT, 79 per cent five years later and 59 per cent after ten years (1).

    After the transplantation

    Patients who have undergone a KPT often report an improvement in their quality of life (2, 5–7). Nevertheless, KPTs present new challenges in their daily lives. Following transplantation, immunosuppressive drugs are essential for preventing organ rejection (3). These drugs have a number of side effects that the recipient has to make allowances for.

    In order to reduce the extent of side effects such as infections, cardiovascular disease, osteoporosis and skin cancer, transplant recipients must be mindful of their health, including good hygiene, a healthy diet, physical activity and prudent exposure to the sun (3). Following a KPT, recipients must, therefore, be vigilant for signs of infection and side effects of drugs. Organ rejection will always be a source of uncertainty (3).

    In addition to changes in patients’ health situation, an organ transplantation brings about changes in roles, abilities and expectations.

    In addition to changes in patients’ health situation, an organ transplantation brings about changes in roles, abilities and expectations. This requires new knowledge, new skills and, for some, new coping strategies (8, 9). Amerena and Wallace (9) showed that kidney transplant recipients had conflicting experiences in the post-transplant period. Everyday life could feel like a roller coaster, changing between good health and illness. Society viewed them as healthy even though they felt physically vulnerable and feared infections and organ rejection.

    Objective of the study

    Earlier studies examining the post-transplant lives of KPT patients have mainly used quantitative mapping of self-perceived quality of life (2, 5–7, 10). Few studies have investigated patients’ experiences in the transition from life with diabetes and renal failure to daily life after a KPT. The purpose of this study was therefore to identify the important aspects of the transition from the KPT patients’ perspective. We posed the following question:

    ‘How do people who have undergone a kidney-pancreas transplantation describe the transition from life with diabetes and chronic renal failure to daily life in the first year after the transplantation?’

    The study may serve as a useful contribution to the follow-up provided both before and after a KPT.

    Method

    Design and sample

    The study has a qualitative, exploratory design (11). We recruited informants in connection with the one-year KPT follow-up. In order to meet the inclusion criteria, participants had to be competent to give consent, speak Norwegian, have good functioning in the transplanted organs at the time of interview and not suffer from other serious medical conditions. In the period October 2013 to May 2014, eight people – seven men and one woman – were called in to the one-year follow-up. Six men agreed to participate in the study.

    The informants were from different parts of Norway, aged between 38 and 46 years and had been diagnosed with diabetes type 1 25-34 years before the KPT. They had all developed nephropathy as a late-stage complication of diabetes. In addition, the majority had retinopathy with impaired vision and neuropathies with pain and reduced function in their legs prior to the KPT. None of the informants underwent dialysis.

    Data collection

    Data were collected through interviews with a view to obtaining rich descriptions of participants’ daily lives prior to the KPT and in the first year after the transplantation. We developed an interview guide in order to ensure we covered the same main themes with all participants. These themes were the transition from life with a chronic illness to life after the transplantation, social relationships and follow-up after the transplantation. We chose these themes based on findings from studies of quality of life following a KPT (2, 5–7, 10), transplant recipients’ experiences (8, 9, 12) and clinical experiences from transplant surgical wards.

    The term ‘daily life’ was not predefined since the purpose of the study was to collect subjective descriptions of daily life. The interviews were conducted by the first author in an office near the medical outpatient clinic, and lasted for 45–80 minutes. The audio recordings were transcribed after each interview.

    Data analysis

    We used Tjoras’ (13) stepwise deductive-inductive (SDI) method in the analysis. This method was chosen because it is textual and because we wanted the results to reflect the participants’ descriptions as accurately as possible. We applied a deductive coding approach to the data analysis based on the words and expressions used by the informants. In order to make it easier to identify the transitions, we then categorised the codes according to pre and post-transplanttimeframes. The codes were subsequently categorised by themes and transitions, which in turn provided the basis for the main themes presented in this article (see Figure 1).

    The deductive part of the SDI method entailed verifying the codes, categories, main themes and results by constantly returning to the transcribed text from the interviews. The co-author participated in the analysis. Figure 1 shows an analysis example.

    Figure 1. Example of textual coding and thematisation of the interview material

    Ethics

    Before conducting the study, we obtained the necessary permission from the Data Protection Official, the head of research and departmental heads in the Department of Transplantation Medicine at Oslo University Hospital (OUH), Rikshospitalet. The Data Protection Official did not consider it necessary to seek approval from the Regional Committees for Medical and Health Research Ethics (REC) since the main focus of the study was on quality assurance in connection with KPTs.

    Potential informants received information about the study together with their one-year follow-up letter. The information was repeated during their appointment at the medical outpatient clinic, and written informed consent was obtained from those who wanted to participate. The nurses at the medical outpatient clinic recruited the informants. The first author of the article is a nurse at the Section for Clinical Transplantation Surgery, but was on leave when the informants were admitted for transplantation. Therefore, the author did not meet the informants before the interviews.

    Results

    The analysis identified four main findings that dominated the transition from life with a chronic illness to life after the KPT: greater autonomy, independence, coping and motivation, in addition to some new elements of uncertainty.

    Greater autonomy

    The biggest change following the KPT was the informants’ stable blood sugar levels. One major area of transition was that it was no longer necessary to regularly measure blood sugar or to plan meals and activities. Before the transplantation, unpredictable blood sugar levels and the risk of hypoglycaemia and loss of consciousness were a source of worry and anxiety, especially before bedtime. One informant explained it as follows:

    ‘I was terrified to go to bed because I never knew if I would wake up ... Now I can go to bed in the knowledge that I will wake up in the morning!’ (Informant 6).

    Several informants said that before the KPT, the planning that was necessary for physical activities was tiresome. One informant expressed this as follows:

    ‘You couldn’t be bothered going for a walk because you knew you would become unwell anyway, you would get hypoglycaemia. So I stopped doing it, and didn’t need to think about it any longer.’ (Informant 2).

    I can walk for four to five hours without eating, it's a dream.
    Informant 5

    Normal levels of blood sugar gave the informants more freedom, and they were able to choose food and activities according to their own wishes as opposed to the need to stabilise their blood sugar:

    ‘I can walk for four to five hours without eating, it's a dream.’ (Informant 5).

    The informants felt they had greater autonomy and more stability in their daily lives.

    All of the informants had been affected by their renal failure to some degree, experiencing tiredness and fatigue before the transplantation. They said that they felt exhausted at the end of the working day, and that they had little energy left to engage in family life or other social activities:

    ‘I didn’t realise just how ill I had become, daily life had become a real struggle.’ (Informant 3).

    One year after the transplantation, all of the informants described how they had considerably more energy in their daily lives and at work, which played a large role in their experience of freedom and autonomy.

    Greater independence

    Four of the six informants had very unstable blood sugar levels before the transplantation, and two had ‘unawareness’ symptoms where they did not feel any sign of hypoglycaemia. These informants in particular were therefore dependent on family, friends and colleagues knowing what to do in the event of a hypoglycaemic episode. One informant told how he had to explain to new colleagues what to do if he had such an episode. Another described how colleagues had to contact his parents if he did not show up at work in the morning.

    One year after the transplantation, the informants expressed their sense of relief at being less dependent on others. They also found that relatives were no longer worried and anxious, and they also felt relief. One informant described this as follows:

    ‘My mum has lost a huge weight from her shoulders ... she sleeps well at night now.’ (Informant 2).

    The informants also said they felt a sense of relief as they no longer had to feel guilty about passing the responsibility to others when they had a hypoglycaemic episode. Their new daily life after the transplantation therefore meant greater independence and a less guilty conscience towards others.

    Greater coping and motivation

    Several informants described how challenging it was to monitor their own health in a satisfactory manner before the transplantation. They suffered from a guilty conscience if they did not monitor their blood sugar levels well enough, and felt that the late-stage complications of diabetes were their own fault:

    ‘Ideally, you were supposed to measure your blood sugar, and when you didn’t, you had a constant guilty conscience.’ (Informant 1).

    ‘I don’t need to have a guilty conscience all the time, because whatever you do, you never feel that you’ve done enough (talking about the time prior to KPT).’ (Informant 3).

    The informants further explained how risky it was to follow the doctor’s recommendation for a low long-term blood sugar level, because the risk of hypoglycaemia increased. Although they knew that hyperglycaemia could have adverse effects on their body, several of the informants said they preferred a high blood sugar level, especially before they went to bed or before driving:

    ‘I was anxious about having a hypoglycaemic episode so I took very little insulin.’ (Informant 4).

    After the transplantation, it was easier to exercise and have an active life. The informants were no longer reliant on sugary foods and drinks to prevent hypoglycaemic episodes. It was easier to choose a healthy lifestyle, and many coped better and felt more motivated to take care of their own health. 

    New elements of uncertainty

    A significant source of uncertainty for the informants after the transplantation was the risk of organ rejection. One informant described it as a sense of uneasiness that occurred immediately after the transplantation, and that stayed with him. The informants dealt with this uncertainty in different ways. Some collected stories about transplant recipients whose transplantation had been performed a long time ago. Others relied on medical developments, while some avoided thinking about it and wanted to focus on the present. However, several expressed concern about potential rejection. One informant said he went from having a constant guilty conscience about not monitoring his blood sugar level properly to feeling uncertain and concerned about the lifetime of the organs:

    ‘It creates uncertainty, and makes you hesitant about feeling too happy.’ (Informant 1).

    The fear of organ rejection was not a topic that healthcare personnel discussed very much.

    Another informant found it difficult to apply for a new job because he was afraid of becoming an unreliable employee. Several of the informants also mentioned that the fear of organ rejection was not a topic that healthcare personnel discussed very much with them. It was difficult for some of the informants to talk to those closest to them about this uncertainty, largely because they did not want to worry them:

    ‘I try to avoid saying things that can frighten her [his wife].’ (Informant 3).

    The uncertainty surrounding potential organ rejection led to the informants frequently measuring their blood sugar levels for a long time after the transplantation. A blood sugar reading served as effective confirmation that the pancreatic transplant was working well. The informants described a combination of positive curiosity and fear associated with measuring blood sugar levels:

    ‘After six to seven months, the doctor told me to stop, but it’s intriguing to keep monitoring it ... you become curious and then you become afraid.’ (Informant 5).

    ‘I didn’t really believe in this, so I measured my blood sugar much more after the transplantation than before.’ (Informant 6).

    Three out of six informants reported that they had symptoms of abnormal blood sugar even though the measurements were within the reference range. They described symptoms of hypoglycaemia, such as tremors and ‘a sensation in the stomach’ (informant 6), or symptoms of hyperglycaemia, such as dry mouth or ‘a strange feeling in the body’ (informant 4). An abnormal blood sugar reading could increase their fear of organ rejection and cause them to measure their blood sugar more often.

    Another important element of uncertainty for the informants was the side effects from immunosuppressive drugs. Five of the informants reported periods of diarrhoea and/or obstipation. Some reported having a poor appetite, constantly feeling hungry, tremors, rashes, excessive sweating and a reduced libido, thin and dry skin, and cuts taking longer to heal. Several had had a urinary, respiratory or wound infection, or a cytomegalovirus (CMV) infection. Infections had led to either short or long hospital stays and sick leave from work.

    None of the informants had considered themselves to be sick before the transplantation because their diabetes was part of their normal life, and the renal failure happened so gradually that it was difficult to see the changes in health. An impaired immunity system and the long-lasting infections represented a new way of being sick, and for some of the informants this was both unexpected and tiresome. The informants who had suffered from frequent hypoglycaemic episodes before the transplantation nevertheless described daily life as more stable and generally better despite these new elements of uncertainty.

    Discussion

    Daily life after the KPT was mainly described as positive one year after the transplantation, particularly because the stable blood sugar level gave a stronger sense of autonomy, independence and coping. Nevertheless, the informants described challenges in the change from a state of uncertainty as a diabetic to a new state of uncertainty as a transplant recipient. Fear of organ rejection was the main element of uncertainty. Organ rejection can lead to elevated blood sugar levels, abdominal pains where the organ is situated, fever, flu-like symptoms, weight gain and reduced urine production (3). However, not all transplant recipients suffer such symptoms. It is therefore essential to monitor the kidney -and pancreas function with regular blood tests, as well as a biopsy of the transplanted organs (3, 14).

    Three of the informants described a sensation of abnormal blood sugar fluctuations, even though the glucose level was within the reference range. This could make it difficult to interpret the definition of ‘normal’, and what could be signs of rejection. However, Redmon et al. (15) show that symptoms of hypoglycaemia can occur in 30 to 50 per cent of pancreas transplant recipients, even when the blood sugar is within the reference range.

    The fear of organ rejection is still apparent one year after the KPT.

    In order to alleviate concerns, it is important that transplant recipients who experience the sensation of abnormal blood sugar – but who are within the normal range – are told that the symptoms are normal. Nilsson et al. (14) show that many transplant recipients fear organ rejection, and that this fear does not diminish with time. Our study also shows that the fear of organ rejection is still present one year after the KPT.

    Studies of kidney transplant recipients show that it can be difficult to assess and differentiate between symptoms (12, 16). For example, both fever and flu-like symptoms can be a sign of organ rejection and infection. The challenges faced when interpreting symptoms underlines the importance of close contact with the health service, and that the threshold for making contact should be low. The new elements of uncertainty require follow-up in the form of good information and psychosocial support. Our study showed that the six informants coped with the uncertainty surrounding organ rejection in different ways, whilst also reporting that it was a topic that is seldom discussed.

    Patient education should be customised

    The patient education provided by healthcare personnel on organ rejection is usually general and not well adapted to the individual’s thoughts about what a rejection entails or their personal coping strategies (14). Nilsson et al. (14) are concerned that healthcare personnel should acknowledge the recipient’s own thoughts about what rejection entails in order to help them form a realistic perspective of the risk and consequences. Avoidance can also be a coping technique, but this can be risky if the recipient does not want to know details that can be vital to self-monitoring and preventing organ rejection (14).

    A Norwegian study of patient educational intervention after kidney transplantation showed how customised teaching for seven weeks gave good results. Providing relevant information about medication, rejection and lifestyle, as well as competence building and interactive support from nurses, led to an increase in recipients’ level of knowledge and improved self-monitoring of medication within six months. Coping expectations and perceived quality of life were also higher (16). Changes to the patient education given to recipients in the clinic have recently been implemented based on findings in Urstad’s (16) study. Since these changes were implemented after the transplantation of the informants in our study, everyday life after the KPT should also be examined in order to identify possible effects.

    Side effects of immunosuppressive drugs

    Five out of six informants reported various side effects from immunosuppressive drugs, including infections that had led to long-term absences from work. Such fluctuations between good health and illness can affect the recipient’s perception of autonomy, independence, coping and motivation. It is challenging and perhaps paradoxical that a recipient’s life following a KPT may still entail long periods of impaired health (9).

    The role of a healthy transplant recipient can create expectations that may be challenged by a fluctuating health condition.

    Some informants said that it could be difficult to share their concerns about side effects or other symptoms after the transplantation, which is consistent with other studies of kidney transplant recipients (8, 9). The role of a healthy transplant recipient can create expectations that may be challenged by a fluctuating health condition. Such expectations can prevent recipients from sharing their concerns about organ rejection, infections and side effects of medication. They can also lead to concerns not being taken seriously (8, 9).

    The findings of this study indicate that there is a need for healthcare personnel to customise their conversations with transplant recipients and their families both before and after the transplantation. Conversations prior to a KPT may be useful for managing the expectations of recipients and their families, and for providing helpful information about what their new daily life after a KPT may entail. Meanwhile, conversations after the transplantation will be crucial to addressing the individual’s personal challenges and helping to establish relevant coping strategies.

    Limitations of the study

    The theme of the study is complex, diverse and largely unexplored. It was therefore necessary to retrieve data that could capture many aspects of daily life one year after transplantation. The interview guide could have had fewer themes to make the study more in-depth. Six out of eight potential informants were included in the study, and only men agreed to participate. The sample may be one limitation because some studies show that women, more so than men, report lower quality of life, more side effects of immunosuppressive drugs and more concern following a transplantation (6, 7, 17).

    Although the majority of patients undergoing a KPT are probably men, more studies are needed on female kidney-pancreas transplant recipients. The informants had not received dialysis, and there is reason to believe that those who have undergone dialysis before a transplantation have a different experience of the post-transplantation transition. The findings in the study, however, point to important aspects of the transition to a new daily life after a KPT.

    Conclusion

    The findings in the study showed that the daily lives of informants were characterised by greater autonomy and independence. They expressed a greater sense of coping and improved motivation, but also new elements of uncertainty one year after the KPT. Important implications are therefore that healthcare personnel should place more emphasis on individually tailored conversations with recipients and their families before a KPT in order to manage expectations and prepare for the new set of challenges that patients may face following the transplantation. Meanwhile, it can also be crucial for the transplant recipient to receive more customised patient education and psychosocial support over time with a view to managing the challenges of daily life after a KPT. 

    References

    1.       Lindahl JP, Jenssen T, Hartmann A. Long-term outcomes after organ transplantation in diabetic end-stage renal disease. Diabetes Research and Clinical Practice 2014;105:14–21.

    2.       Sollinger HW, Odorico JS, Becker YTD, Alessandro AM, Pirsch JD. One thousand simultaneous pancreas-kidney transplants at a single center with 22-year follow-up. Annals of Surgery 2009;250:618–30.

    3.       McPhee IAM, Fronek J. Handbook of renal and pancreatic transplantation. Chichester, Great Britain: Wiley-Blackwell; 2012.

    4. Bakken, PA. Organdonasjon og transplnatasjon. Oslo universitetssykehus, Rikshospitalet. Available at: https://organdonasjon.no/content/uploads/2017/01/organdonasjon-transplantasjon-4-kvartal-2016.pdf(downloaded 14.08.2017).

    5.       Sureshkumara KK, Patel BM, Markatos A, Nghien DD, Marcus RJ. Quality of life after organ transplantation in type 1 diabetics with end-stage renal disease. Clinical transplantation 2006;20:19–25.

    6.       Pera PI, Vasallo JM, Rabasa AT, Salinas FO, Laureano LFC, Brulles MJR. Quality of life in simultaneous pancreas-kidney transplant recipients. Clinical transplantation 2009;23:600–5.

    7.       Kwiatkowski A, Michalak G, Czerwinski J, Wszola M, Nosek R, Ostrowski K, Chmura A, Danielewicz R, Lisik W, Adadynski L. Quality of life after simultaneous pancreas-kidney transplantation. Transplantation Proceedings 2005;37:3558–9.

    8.       Nickles MW. Common psychiatric problems in the well transplant patient. Graft 2001;4:290–8.

    9.       Amerena P, Wallace P. Psychological experiences of renal transplant patients: A qualitative analysis. Counseling and Psychotherapy Research 2009;9:273–9.

    10.     Smith GC, Trauer T, Kerr PG, Chadban SJ. Prospective quality-of-life monitoring of simultaneous pancreas and kidney transplant recipients using the 36-itm short form health survey. American Journal of Kidney Disease 2010;55:698–707.

    11.     Polit DF, Beck CT. Nursing research: Generating and assessing evidence for nursing practice. Philadelphia, USA: Lippincott Williams & Wilkins; 2008.

    12.     Kamran F. Living with a kidney transplant: Perceptions and experiences. American Journal of Applied Psychology 2014;2:5–12.

    13.     Tjora A. Kvalitative forskningsmetoder i praksis. Oslo: Gyldendal Akademisk; 2012.

    14.     Nilsson M, Persson L-O, Forsberg A. Perceptions of experiences of graft rejection among organ transplant recipients striving to control the uncontrollable. Journal of Clinical Nursing 2008;17:2408–17.

    15.     Redmon BJ, Teucher AU, Robertson RP. Hypoglycemia after pancreas transplantation. Diabetes Care 1998;21:1944–50.

    16.     Urstad KH, Øyen O, Andersen MH, Moum T, Wahl AK. The effect of an educational intervention for renal recipients: a randomized controlled trial. Clinical Transplantation 2012;26:246–53.

    17.     Kugler C, Geyer S, Gottlieb J, Simon A, Haverich A, Dracup K. Symptom experience after solid organ transplantation. Journal of Psychosomatic Research 2009;66:101–10.

    A successful kidney-pancreas transplantation improves and stabilises patients’ daily lives. It also brings with it new elements of uncertainty that are important to convey to the patient.

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    English
    Sammendrag

    Background: A successful kidney-pancreas transplantation (KPT) is the most effective treatment for patients with diabetes who develop late-stage chronic renal failure. Although studies show an improvement in self-reported quality of life following a KPT, daily life can nevertheless be challenging due to the risk of organ rejection and side effects from immunosuppressive drugs. Little is known about KPT recipients’ personal experiences of the transition from chronic disease to daily life after a KPT.

    Objective: To examine patients’ experiences in the transition from a life with diabetes and chronic renal failure to daily life in the first year after a KPT.

    Method: The study has an exploratory design, and data are collected through semi-structured interviews. Six men agreed to an interview at the one-year follow-up after their KPT, and we used a stepwise deductive-inductive method to analyse the interviews.

    Results: Transplant recipients’ new daily life was characterised by greater autonomy, independence, coping and motivation, but also by new elements of uncertainty. The main uncertainties related to fear of the new organs being rejected and side effects from immunosuppressive drugs.

    Conclusion: The study provides an insight into the everyday challenges faced by transplant recipients in the first year after a KPT. One key finding of the study was the need for a greater focus on good information before and after a KPT, both for patients and their families. More tailored patient education and psychosocial support over time can be crucial the first year after transplantation.

    Bildet viser en nyretransplantasjon ved Rikshospitalet. To kirurger står over pasientens operasjonssår.
  • Translation and cultural adaptation of the Attentional Function Index (AFI)

    Cancer incidence is rapidly increasing, and it is assumed that approximately 40 000 people will be affected by cancer by 2030. Two-thirds of these will be older than 60 years (1). Elderly patients may be at an elevated risk of changes to their cognitive function when undergoing treatment for cancer (2).

    Changes in cognitive function have been shown to constitute a significant problem for many cancer survivors (3). Cognitive changes after cancer treatment manifest themselves as reduced attention, reduced concentration and poorer short-term and long-term memory. In addition, problems may arise with regard to verbal or visual learning, as well as problems in executive and planning functions (4).

    Assessing cognitive function is especially important for cancer patients, prior to, during and after the treatment. The patients must go through a treatment sequence where they need to relate to a number of health service agencies (5). It can be argued that cancer treatment may have a negative effect on cognitive function in both the short and long term.

    Assessing cognitive function is especially important for cancer patients, prior to, during and after the treatment.

    Furthermore, the treatment may have a negative effect on social relationships, education and work, as well as on quality of life (4). A review article (6) revealed that clinicians need better knowledge to be able to recommend interventions to address the cognitive changes that cancer survivors experience. One way to obtain this information is to measure the patient’s own perception of his or her cognitive function.

    Attentional Function Index

    Attentional Function Index(AFI) is an instrument developed by professor Bernadine Cimprich in the USA for use on cancer patients. The objective of the instrument is to assess the patients’ self-reported ability to focus on activities of daily living that require fundamental cognitive processes (5, 7).

    The AFI measures the patient’s ability to stay focused, short-term memory and higher-level executive functions. Executive functions are cognitive processes that enable a person to generate ideas, initiate actions, adapt to new or unfamiliar situations, sort sensory impressions, concentrate, persevere, show cognitive flexibility, relate to multiple cognitive processes at the same time, and suppress undesired responses (8, 9).

    Originally, AFI included 16 questions (7, 10), later reduced to 13 based on the results of a factor analysis (5). The questionnaires are primarily used for patients with breast cancer (10–13), but also in samples of persons with other cancer diagnoses (14, 15). AFI is used for both genders and various age groups of adult cancer patients before, during and after the treatment. Cronbach’s alpha for both questionnaires is > 0.90 (10–15) with high test-retest reliability (16).

    COSMIN

    ‘COnsensus-based Standards for the Selection of Health Measurement Instruments’ (COSMIN) includes recommendations for terminology, taxonomy and methodology in studies concerning self-reporting questionnaires and their measurement properties. According to these recommendations, inter-cultural validity is described as a small element of the total validity of the instrument in question (17).

    Similarly, COSMIN makes few references to the translation procedure for an instrument (18). In our study, we emphasise the cultural adaptation in the translation of the instrument and have therefore not undertaken any testing of its psychometric properties.

    Objective of the study

    AFI assesses cancer patients’ own perception of their cognitive functioning in daily life and is thus relevant for studies that highlight this function. We therefore wished to apply a systematic and thorough approach to the translation process.

    We wished to include users in this process in order to ensure cultural adaptation to Norwegian conditions. Cimprich gave permission to translate the questionnaire. In consultation with Cimprich we chose to translate the 16-question version, in order to be able to test the factor structures of the two different versions of the questionnaire.

    This article thus has two objectives:

    • to provide an account of the translation of AFI into Norwegian
    • to present results from testing of AFI among people older than 60 years

    Method

    Translation procedure

    To translate and assess the content of the instrument we used the first three steps in the protocol from the World Health Organization (WHO) (19): translation, expert panel and back-translation.

    Five experts with a broad range of competence in cognitive processes and development of instruments were involved in the translation procedure and assessment of the validity of the content. The expert group included one user representative, three researchers with specialist competence in psychology, nursing and cancer, and a psychologist with specialist competence in cognitive instruments.

    These professionals possess wide-ranging research experience, including previous experience from Norwegian translations of instruments developed in the USA. They all possess level C English skills, advanced user (20), and many of them have sound understanding of American culture. In the translation procedure – back-translation into English – an authorised translator participated actively.

    The English-language version of the AFI (Appendix 1) was translated into Norwegian by the first author. The expert group discussed and commented on this version as well as a previous Norwegian version of the AFI (21). We assessed the extent to which the English and Norwegian texts were conceptually, technically and linguistically equivalent, consistent with the selected recommendations (19, 22).

    The expert group agreed on a preliminary translation. The questionnaire was then translated into English by the professional translator, who had no previous knowledge of the instrument (19) and sent to Cimprich, the author of the AFI, for a statement.

    The first author communicated the feedback from Cimprich to the translator. The first author and the translator thoroughly assessed the comments to the questions from Cimprich, in terms of language as well as culture. The comments were returned to the instrument developer, who assessed this input. Finally, we convened the expert panel to approve the Norwegian version.

    Pilot testing

    For purposes of quality assurance of the translation with potential users of AFI, we undertook a pilot test to examine whether the translated questionnaire functioned well for persons older than 60 years. Polit and Young (23) recommend undertaking such a pilot test before the instrument is trialled with the target group. In the period from December 2015 to March 2016 we recruited men and women using the ‘snowball sampling’ method (24, 25).

    These persons could then refer us to further informants. Five of the co-authors contacted a person older than 60 years in their network, who in turn recruited participants in their network. Snowball sampling can be used when informants cannot be easily identified.

    All these persons responded to the questionnaire, and the respondents noted their own gender and age. We requested twelve selected persons, three persons from two of the groups and two persons from three of the groups, to provide written feedback, noting whether some of the questions were hard to understand, hard to answer or unacceptable and intrusive.

    We deliberately chose not to test the translation on cancer patients, since this would have imposed an unnecessary burden on them. We wished to produce the best possible translation before testing the questionnaire on elderly cancer patients.

    The AFI instrument

    The AFI includes twelve questions on activities that require varying degrees of cognitive function associated with defining goals, planning and performing activities of daily living. The questionnaire also includes questions on goal attainment. In addition, the questionnaire includes four questions that measure subjective perception of attention deficit (5, 7).

    The answers are crossed off on a numerical rating scale (NRS) (0–10), on which higher scores indicate better functioning. Questions 13 to 16 are reversed, so that lower scores indicate better functioning. Total scores are calculated as an average of the points scored on each item, where higher scores indicate better functioning and less attention deficit (11).

    Data analysis

    We analysed the data with the aid of IBM SPSS Statistics, Version 24. We used descriptive statistics, analysing demographic data and each of the AFI questions using frequency analyses, averages and standard deviations.

    Ethics

    Participation in the study was voluntary, and all participants provided an indirect informed consent by submitting the completed questionnaire and any supplementary comments to the form. All respondents remained anonymous. The participants noted only their gender and age. The response forms have been shredded, but the computer file will be stored for five years as recommended by the Regional Committees for Medical and Health Research Ethics (REK).

    Results

    The expert group’s proposed translation

    The expert group met to discuss the two versions of AFI. The members of the expert group each provided their feedback based on their respective competencies. Each question was discussed with a view to its applicability. The input provided by the user representative was critical, especially in her pointing out the importance of using a simple and easily understandable language that would cause no offence to the target group.

    Each question was discussed with a view to its applicability.

    The translation of the scale in the English version is a case in point. In the English version, the end point of the scale is ‘extremely well’. In Norwegian, the equivalent is an uncommon phrase, especially when assessing cognitive function in a group that may perceive this as difficult. The user proposed to reformulate the end point to ‘svært godt’ (‘very well’), i.e. a deviation from a direct translation that would have been ‘ekstremt godt’ (‘extremely well’)

    The specific contribution from the psychologist to this process concerned the translation of the conceptual content of questions 7, ‘Keeping your mind on what you are doing’, and 11, ‘Keeping yourself from saying or doing things you did not want to say or do’. The expert panel reviewed all questions, identified ambiguities in the proposed translations and discussed them until a consensus was reached.

    Translation from Norwegian into English with the approval of the instrument developer

    All questions were subsequently translated back into English by the authorised translator and sent to Cimprich. They contained some deviations from the original English version, and the instrument developer gave comments to the back-translation. After a discussion between the first author and the translator, we responded to the instrument developer’s comments. This communication continued until Cimprich approved the questionnaire, as did the expert panel. Examples of the process are shown in Table 1.

    Table 1. Examples of the exchange of comments between the instrument developer and the translator, and the final Norwegian translation

    Pilot testing

    The sample included 114 persons; 42 men and 72 women. Their age varied from 60 to 90 years, with an average age of 71 years, standard deviation (SD) 7. Averages and SDs for each of the questions in AFI are shown in Table 2.

    The average scores varied from 6.2 (SD 2.2) for question 16 ‘Getting easily annoyed or irritated’ to 7.9 (SD 1.7) for question 5 ‘Making your mind up about things’. Questions 13, 15 and 16 had an SD of 2.4, 2.4 and 2.2 respectively. For questions 1, 3 and 12 there was one missing score, for question 6 there were two and for question 11 there were eight.

    Table 2. Mean and standard deviations for the items in the Attentional Function Index (n = 114) *

    The respondents’ feedback regarding their comprehension of the questions

    In addition to those twelve who were requested to provide supplementary comments to the instrument, another six people provided comments to the questionnaire on their own initiative. Fifteen of these eighteen respondents commented on question 11 ‘La være å si eller gjøre noe du ikke vil’ (‘Keeping yourself from saying or doing things you did not want to say or do’). The comments varied in content; some wrote that the question was hard to understand, and that it was ambiguous.

    Others noted that it was difficult to answer, because the question asks about two different things. Some simply entered one or more question marks on this item. Similar comments on asking about two things were also entered for questions 8 ‘Huske å gjøre alle de tingene du har begynt på’ (‘Remembering to do all the things you started out to do’) and 9 ‘Holde orden på hva du sier eller gjør’ (‘Keeping track of what you are saying or doing (keeping your train of thought’)).

    Many of those who were asked to comment also provided suggestions for changes to the questions. For question 8 ‘Huske å gjøre alle de tingene du har begynt på’ they suggested changing the two last words from ‘begynt på’ (started out to do’) to ‘tenkt å gjøre’ (‘thought of doing’). They also suggested changing question 7 ‘Være konsentrert om det du holder på med’ (‘Keeping your mind on what you are doing’) to ‘Lar du deg lett distrahere/forstyrre?’ (‘Do you let yourself be easily distracted/disturbed?’).

    Two respondents commented that the scoring of the last four questions was reversed. One noted that this scoring could confound someone who answered quickly, while another remarked: ‘Is this in itself a test of attention?’

    Discussion

    This study shows that it might be appropriate to make all steps in a translation procedure available to future users of an instrument. The work of the expert panel and the composition of the group highlight the fact that differences in background experience were crucial to clarify the choices that were made before a consensus was reached. A procedure of this type may be essential to ensure the validity of an instrument.

    It might be appropriate to make all steps in a translation procedure available to future users of an instrument.

    Without a complete presentation of each part, providing justification for all the choices made and the need for any changes called for, will be difficult. Many articles on validation describe the translation procedure only in terms of the type of procedure used (26–28). According to Johnson, it is difficult to assess the translation of questionnaires without having a description of the cultural adaptation available (29).

    A review of 13 articles on validation of the Edmonton Symptom Assessment System (ESAS) reports that only a single study was concerned with translation as a challenge in the validation process (30).

    Multiple versions are not uncommon

    It is not uncommon to find multiple Norwegian-language versions of the same questionnaire. For example, Bergh and collaborators show that a total of 40 different versions of ESAS are found in Norway (31). The researchers assessed their differences in terms of content, wording, end points and scale formats for this instrument.

    The review showed major variations in the heading, introduction, time frame for the assessment, the symptoms included, sequence and wording, adjectives on the numerical scale and the format of the response scales in the ESAS instrument. We do not know why as many as 40 different versions exist, and we have no knowledge as to whether they represent improvements on previous versions or have been produced because researchers have been unaware of the existing versions.

    In Denmark, Boel and collaborators have described what they see as problematic due to the availability of numerous versions of ESAS (32). They highlight the importance of describing the translation process and adapting the questionnaire to the culture within which it will be used. They discuss, for example, whether there is a difference between being ‘sløv’ (‘lethargic’) and ‘døsig’ (‘drowsy’, ‘dazed’). 

    Cultural adaptation of an instrument should be an ongoing process in order to ensure its validity.

    Our results corroborate this line of argument. Even though the validity of an instrument has been documented by a single study and published in one academic journal, there are no set standards for validation. Cultural adaptation of an instrument should be an ongoing process in order to ensure its validity. This view is supported by a review article that points out the necessity of continuing the validation process (30).

    Using a professional for the back-translation

    International translation procedures set as a standard that a professional translator be used when translating back to the original language (22). Some studies refer specifically to the back-translation and comment on linguistic challenges (33, 34). To our knowledge, the use of a professional translator as a language expert after completion of the first back-translation has not been described previously.

    By using an authorised translator in the process of argumentation in a Norwegian context, the researchers will be able to ensure validation of the language used and thus also the validity of the instrument’s content. If no authorised translator is used in the dialogue with the instrument developer, the expert panel risks accepting the instrument developer’s response to the translator’s version without question.

    In our study, the user representative emphasised that the word ‘ekstrem’ (‘extremely’), which was one of the end points of the scale, should not be used. In the quality-of-life instrument RAND-36, the end point of the scale in the Norwegian version is ‘ekstremt mye’, which is a direct translation of ‘extremely’.

    It is questionable whether responding that ‘... physical health or emotional problems have extremely affected daily activities with family, friends, neighbours or other groups of people’ (... ekstremt mye’) is as common in Norway as it is in the USA. Boel and collaborators point out that attention must be paid to the end points of the scale, giving a Danish version of ESAS as an example, in which ‘unconscious’ is one of the end points (32).

    Linguistic challenges in translation

    The pilot test of AFI that was undertaken once the expert panel and the instrument developer had reached agreement showed that the instrument was easy to complete. The vast majority answered all questions. There were, however, objections to one question in particular: ‘La være å si eller gjøre noe du ikke vil’ (‘Keeping yourself from saying or doing things you did not want to say or do’). The translator and the instrument developer had previously discussed this question, and the psychologist and other members of the expert panel had commented on it.

    The expression ‘keeping yourself from’ has no obvious Norwegian translation. The expert group assessed the input conceptually, culturally and in terms of language. In particular, we discussed whether ‘la være’ (‘refrain from’) is a negation or not. After thorough consideration the expert panel chose not to change the wording.

    The results from the pilot test showed that the question ‘La være å si eller gjøre noe du ikke vil’ had the most missing scores and most comments in the questionnaires. Eight persons did not answer the question, and 18 others had entered comments. Since this applied only to this question, one possible explanation could be that that the respondents simply failed to understand what was asked.

    This discussion illustrates that translating an American instrument into Norwegian, in terms of language as well as culture, may involve challenges. If the argumentation on which a translation is based is made available to those who want to use the instrument, this will increase the understanding of the choices made and the changes that can be made, if any are called for. 

    Reversed scores

    It is interesting to note that on the whole, the standard deviations for the four last questions in the AFI are higher than for the other questions. The same tendency is reported from a sample of young women with breast cancer, for whom the same instrument was used (5).

    We cannot know for certain whether this is due to the content of the questions or a larger variation in the responses. We may speculate, though, that this is a result of the reversal of the scales, when compared to the preceding questions.

    On the other hand, the use of reversed scoring may indicate the respondent’s level of attention, since this instrument also measures any attention deficit in the respondents (35). Results from the participants in our study are comparable to those in a study undertaken among women and men aged 65–87 who were living at home (36).

    However, they had better cognitive function than women aged 27–86 with breast cancer (5). Since the sample in our study included persons older than 60 years, without any known cancer diagnosis as an inclusion criterion, this may indicate that the instrument functioned well.

    One of the strengths of this study is its use of an expert panel with a user representative and a professional translator. Moreover, the participants in the pilot study had the opportunity to provide feedback on the design of the instrument. We might have wished for a representative sample of the general population, but this was impossible for practical, ethical and financial reasons.

    Use of snowball sampling may be another strength, since large parts of the country were included. On the other hand, this methodology may have a weakness in causing sampling bias, nor do we have any information about the participants’ condition of health.

    Conclusion

    Translation and cultural adaptation of an instrument is a comprehensive process. It is appropriate to make each step of the translation procedure available, thus to enable researchers to assess the choices that have been made. Including user representatives in an expert panel may help improve the validation of a questionnaire. In collaboration with the expert panel, the dialogue between the translator and the instrument developer may help ensure that the intention behind the instrument is maintained.

    The Norwegian version of the AFI which is now available must be tested on a larger sample of cancer patients aged 60 and above before we can draw any final conclusions regarding its intercultural validity. Accordingly, this study does not permit any conclusions regarding the reliability, validity and responsiveness of this instrument.

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    Involving a user and a professional translator may be appropriate when an instrument is translated and adapted to another culture.

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    Background: The incidence of cancer among older adults is rapidly increasing, and as a result of treatment cancer patients may be subject to cognitive changes. Many cancer survivors experience reduced attention and concentration, as well as poorer memory. The Attentional Function Index (AFI) is an instrument developed in the USA to assess cognitive processes.

    Purpose: To describe the translation and pilot testing of the Norwegian version of AFI.

    Method: Three researchers with knowledge of psychology, nursing and cancer, one psychologist with specialist knowledge of cognitive instruments, and a user representative, constituted the expert group in translation and cultural adaptation of the instrument. An accredited translator participated actively in the work. In the pilot testing of the Norwegian version persons ³ 60 years were recruited using “snowball sampling”. A total of 114 persons between 60–90 years were recruited for the testing, and twelve of these were specifically asked to comment on the instrument.

    Results: The expert group members provided feedback based on their competence. The user representative wanted a simple and understandable, non-offensive language, and the translator provided linguistic comments. Fifteen persons commented particularly on question 11 “Keeping yourself from saying or doing things you did not want to say or do”.  

    Conclusion: The inclusion of users and a translator in the translation process can improve the validation. We recommend that the process be made available for future users of translated instruments.

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  • Nutritional screening in home-based nursing care can be improved 

    Half of the elderly patients receiving home-based nursing care are undernourished or are in danger of becoming so, usually because of illness (1–6). National professional guidelines and the nutrition manual give advice on how the health and care services can prevent and treat undernutrition. By screening for nutritional status when the need for home-based nursing care arises, and subsequently at regular intervals, the nurse can detect nutritional problems at an earlier stage (7, 8).

    In the absence of good routines, unintended weight loss can be difficult to detect, with undernutrition as the result (1, 3). Symptoms of undernutrition may be confused with the symptoms of cognitive impairment or dementia, or may mask other illnesses that necessitate treatment (9).

    Using targeted nutritional interventions as part of good screening routines will make it easier to prevent patients from becoming undernourished and underweight. Screening forms the basis of future assessment and implementation of nutritional interventions to prevent the occurrence of undernutrition (7, 8).

    The nurse has clear responsibility for screening for nutritional status (7). Despite explicit national guidelines, the Norwegian Board of Health Supervision reports inadequate follow-up of nutrition in several municipalities (10).

    Therefore, we wonder why there is such a variation in practice. In this article, we discuss the challenges associated with screening for nutritional status in home-based nursing care. The objective is to shed light on good solutions that simplify and systemise the assessment of nutritional status.

    Inadequate screening

    There is no lack of evidence about the extent of undernutrition among elderly people in the healthcare services and about the considerable lack of knowledge, resources and staff with nutritional expertise (5, 11, 12). Many municipalities have routines for systematic screening for nutritional status (10). For example, nutritional follow-up of cognitively impaired elderly people living at home has proved to be fruitful (13).

    What explanation can there be for nurses failing to screen for nutritional status?

    In other municipalities, no such standardised practice exists. The Norwegian Board of Health Supervision also finds municipalities with written routines that call for the use of screening tools, but where no such practice has been established (10).

    What explanation can there be for nurses failing to screen for nutritional status? Home visits are shorter and less frequent than in an institution. Sometimes there is no opportunity to ask about or observe food intake, to measure weight or screen for nutritional status in the time allocated. In cases where screening is difficult and the patient is unable to answer, the patient may become undernourished and underweight before the nurse has a chance to react. 

    Unable to change practice

    Earlier screening can prevent such developments if there are targeted nutritional interventions. In one study, nurses talk about the lack of weight measurement scales. They describe patients who do not want to be weighed or to talk about their own diet. The familiarity of the nurses in the study with the content of the national professional guidelines varies. Many of them are not familiar with terms such as nutritional status, nutritional plans and undernutrition.

    Instead, the nurses talk about what the patient has eaten, and how to facilitate intake of food and meals. They have thoughts about deficiencies and about what is needed but they are unable to change their practice. The nurses expect managers to choose a screening tool and put nutritional screening on the agenda (14). In this respect, managers have a key responsibility for improving screening routines. 

    Seek clarification of the doctor’s role

    When a nurse discovers that a patient is in danger of becoming undernourished, the doctor must follow up by making a diagnosis and assessing nutritional interventions. The doctor is responsible for medical treatment and the nurse is responsible for screening for and assessing nutritional status. The nurse must prepare a nutrition plan and evaluate the intervention in conjunction with the doctor (7, 8). The nurses in the study seek clarification of the doctor’s role in nutritional efforts (14).

    The doctor is responsible for medical treatment and the nurse is responsible for screening for and assessing nutritional status.

    This may indicate that many patients present a complex clinical picture that makes assessment of nutritional status more difficult. When the clinical picture is complex, nutritional problems can be interpreted as something other than undernutrition (9). It may not be easy to detect gradual weight loss until the patient’s clothes become too loose. A simple solution is to measure the weight of the patient regularly.

    It is essential that the nurse observes the patient’s general condition on each home visit and assesses relevant interventions. Since the clinical picture may be complex, nurses need a professional community where they can discuss their assessments. Is there sufficient leeway for such discussions?

    The nurse holds the key to collaboration

    Nurses are responsible for consulting others with the relevant professional background in order to discuss their professional assessments (8). Thus, the key to collaboration lies with the nurse. For some of the nurses in the study, it was unclear who had responsibility for what (14). As a result, it was difficult to take the initiative in interdisciplinary collaborations.

    There are many different actors working in the field of nutrition in the healthcare services. The establishment of interdisciplinary resource groups consisting of, for example, a cook, care worker, nurse and doctor can strengthen collaboration (8). In order to ensure quality and continuity in nutritional efforts, it is crucial that everyone in the healthcare services knows who is responsible for what. When there is no allocation of responsibility, it is difficult to put in place good routines and a professionally sound collaboration. This concerns more than doctors’ failure to diagnose undernutrition (15), or nurses omitting to assess nutritional status.

    According to the Norwegian Board of Health Supervision, written documentation on the distribution of responsibility for nutritional efforts is lacking in several municipalities (10). National professional guidelines set out requirements for closer collaboration and a clearer distribution of responsibility (7, 8). Managers are in a key position to put screening on the agenda as part of interdisciplinary nutritional efforts. 

    Many screening tools

    The Board finds that there is a variation in the extent to which municipalities screen for nutritional status (10). Lack of knowledge may be an explanation when nutritional problems are not detected at a sufficiently early stage (2, 11, 14). Can lack of knowledge about screening tools also be a reason? The many screening tools differ as regards nutrition-related factors and the recommended target group. Does this make it difficult to choose the most suitable tool?

    The Ernæringsjournal(nutrition record chart) and the Mini Nutritional Assessment (MNA) are most often used in home-based nursing care and in projects under the auspices of the Centre for Development of Institutional and Home Care Services (16). National professional guidelines recommend the MNA and the Malnutrition Universal Screening Tool (MUST) in the primary health service, supported by well-designed, non-randomised studies.

    Other screening tools such as the nutrition record chart, screening for nutritional risk (NRS 2002) and the Subjective Global Assessment of Nutritional Status (SGA) are good alternatives, but the recommendations are not backed up by research studies (7).

    Effective screening tools

    Since the recommendations of the Norwegian Directorate of Health regarding the two screening tools carry different professional weight, it is interesting to examine the grounds for the recommendations more closely. It is crucial that the nutritional variables in the screening tool take diet, body measurement and bodily functions into account (17). Both of the tools do so.

    Moreover, they are both evaluated as being valid and reliable tools for nutritional screening but on different grounds (7). The nutrition record chart is used in Norway and only exists in Norwegian (2). The MNA is validated for use in different languages, including the Norwegian version (18, 19). The nutrition record chart has been developed in a joint student project between several Norwegian nursing colleges.

    Nursing students assessed the qualities of the screening tool in use, and this forms the basis of the evaluation of validity (20, 21). The MNA has been validated over a number of years in many different countries in projects with elderly patients living mainly in institutions (22–26). The MNA-SF has been evaluated as the best alternative when compared with other international tools (22, 27).

    The screening procedure is faster and reveals nutritional risk just as well as the full version (22–24). Choosing a tool that is efficient when the time allotted to each patient is short is a relevant factor.

    What should be done?

    What should be done to ensure that the screening tool is used? Health personnel must understand that body measurement is an important supplement to clinical assessment. Weight development is, for example, an early marker of unsatisfactory nutrition (17). Both the nutrition record chart and the MNA are based on body mass index (BMI), which is the ratio of height to weight (7, 8). BMI is controversial when screening for nutrition in elderly people (17, 18).

    Health personnel must understand that body measurement is an important supplement to clinical assessment.

    It can be difficult to measure height correctly when the vertebral column is compressed, or when the patient has a stooped body posture or is bedridden. If the patient is unable to stand on the scales, it is difficult to use body measurement. Without the weight measurement, it is impossible to calculate BMI. What can the nurse do in such cases to screen for nutritional status?

    In the MNA-SF, a measurement of the calf circumference can replace BMI when height or weight measurements are lacking (22). A tape measure can therefore simplify the screening. If only the height measurement is lacking, the nurse can estimate height by using forearm length, knee height or demi arm span in both the nutrition record chart and the MNA. Our impression is that many nurses are not familiar with these alternatives, even though the nutrition manual recommends them as appropriate solutions (8).

    Student project led to quality enhancement

    Many of the Centre for Development of Institutional and Home Care Services’ projects have had the aim of using screening tools in nutritional efforts (16). This was the objective of a student project in which nursing students on practice placements in the home-based nursing services screened for the nutritional status of elderly patients. Screening and instruction in the field of practice provided the students with valuable knowledge and experience. It also provided the field of practice with a golden opportunity for quality improvement (28).

    In one of the municipalities the project resulted in the appointment of nutrition contact persons in the home-based care services. A course on nutrition was also arranged for primary health service personnel with a clinical dietician from the specialist health service. Skills enhancement and collaboration between the Centre and nursing colleges can thus contribute to better quality in nutritional efforts in home-based nursing services. 

    Dieticians in the primary health service

    In addition to the interventions mentioned above, expertise is of vital importance in strengthening and quality assuring nutritional efforts in home-based nursing care. The Directorate of Health therefore wishes to incorporate dieticians into the primary health service (29). Clinical dieticians in the specialist health service have qualifications in nutritional therapy.

    Dieticians have formal qualifications in nutrition and want to have a clear mandate in interdisciplinary nutritional efforts in the primary health service (8). Greater knowledge of nutrition will strengthen the prerequisites for evidence-based practice. It would be easier for the nurses to provide the patient with evidence-based nutritional advice and interventions, and they would be able to consult someone other than doctors about issues related to nutritional assessment or screening for nutritional status.

    About time to react?

    In order to prevent undernutrition, we need to change our screening routines. It is a well-known fact that changing routines on the basis of national guidelines can be a challenge (30). How can we deal with challenges that seem impossible to solve? We need knowledge, determination and resources in order to implement quality improvements. 

    It is a well-known fact that changing routines on the basis of national guidelines can be a challenge. 

    Management has a specific responsibility for seeking nutritional assessments and ensuring good documentation routines. For example, management must pave the way for training in the use of screening tools. Good knowledge of screening tools will make it easier to introduce new routines.

    In addition, management must earmark sufficient time for screening and documentation. Screening for nutritional status need not supplant other work tasks when the MNA-SF only takes a few minutes (14, 22). Undertaking screening without following up with assessment and nutritional interventions, as is the case in a number of municipalities, is pointless (10, 29).

    Nutritional data in electronic patient records

    At the outset, screening tools are not part of the system for electronic patient records (EPR). Might this partly explain the failure to map nutritional status? A working group in the Directorate of Health concludes that the structure of the EPR in municipalities is not suited to standardising nutritional data. Nutritional data are primarily documented unsystematically in free text, and are not well suited to quality measurement (29).

    Our experience is that screening tools are used in paper format independently of electronic patient records (EPR). The working group wants to standardise documentation in the EPR based on nutritional variables from validated screening tools. When the same nutritional variables are incorporated into the Norwegian Information System for the Nursing and Care Sector, this may result in a wider use of nutritional screening.

    The working group also focuses on the problem of different electronic documentation systems between municipalities and between the municipalities and the specialist health service as an obstacle to interaction and standardised nutritional routines (29). The EPR is therefore of vital importance in reinforcing the prerequisites for nutritional screening. Many factors must be taken into consideration for nutritional efforts to be completely successful. 

    Conclusion

    We have highlighted some challenges that can explain the lack of nutritional screening in home-based nursing care. When time for each patient is short, nurses may perceive nutritional screening as unnecessary use of time (14). On the other hand, it would be a sensible use of the allocated resources if more patients can be helped at an earlier stage (29).

    Making nutritional screening a routine procedure would make it easier to detect nutritional problems before illness and weight loss arise (23). Many are unaccustomed to carrying out prevention work as opposed to treatment (24). High-quality nutritional efforts demand robust routines and good interdisciplinary collaboration in order to meet the challenges posed by undernutrition in elderly patients receiving home-based nursing care. The nutrition manual can be a useful document to use as a starting point (8).

    Until the necessary changes have been introduced in the EPR, a good solution may be to use the MNA-SF. In this way, we can improve targeted nutritional screening of more patients receiving home-based nursing care. 

    References

    1.       Sørbye LW. Ernæringsstatus hos eldre i hjemmetjenesten. In: Bergland Å, Moser I, eds. Kvalitetsarbeid i helsetjenester til eldre. Oslo: Cappelen Damm; 2013. p. 169–185.

    2.       Landmark BT, Gran SV, Grov EK. Ernæringsstatus blant pasienter i sykehjem og hjemmesykepleien kartlagt ved hjelp av Ernæringsjournalen. Klinisk Sygepleje. 2014;30(1):4–14.

    3.       Sørbye LW, Schroll M, Finne-Soveri H, Jonsson PV, Topinkova E, Ljunggren G, et al. Unintended weight loss in the elderly living at home: the aged in Home Care Project (AdHOC). J Nutr Health Aging. 2008;12(1):10–6.

    4.       Saletti A, Johansson L, Yifter-Lindgren E, Wissing U, Österberg K, Cederholm T. Nutritional status and a three-year follow-up in elderly receiving support at home. Gerontology 2005;51:192–8.

    5.       Soini H, Routasalo P, Lauri S. Nutrition in patients receiving home care in Finland: tackling the multifactoral problem. J Gerontol Nurs 2006;32(4):12–7.

    6.       Sørbye LW. Kunnskap om svikt i tjenester til skrøpelige eldre. Diakonhjemmets høgskole. Report 2009/5.

    7.       Helsedirektoratet. Nasjonale faglige retningslinjer for forebygging og behandling av underernæring. IS-1580. Oslo, 2009.

    8.       Helsedirektoratet. Kosthåndboken. Veileder i ernæringsarbeid i helse- og omsorgstjenesten. IS-1972. Oslo, 2012.

    9.       Reiakvam KK, Astor MC, Kittang RK. En kvinne i 70-årene med rask forverring av kognitiv funksjon. Tidsskrift for Den norske legeforening. 2016;136(12):1096–8.

    10.     Helsetilsynet. Tilsyn med kommunenes tiltak for å forebygge og behandle underernæring i sykehjem eller i hjemmetjenesten. Available at: https://www.helsetilsynet.no/no/Tilsyn/Landsomfattende-tilsyn/Landsomfattende-tilsyn-2011-kommunale-tjenester-til-eldre/(downloaded 25.05.2017).

    11.     Mowé M, Bosaeus I, Rasmussen, HH, Kondrup J, Unosson M, Irtun Ø. Nutritional routines and attitudes among doctors and nurses in Scandinavia: a questionnaire based survey. Clinical Nutrition 2006;25(3):524–32.

    12.     Munch C, Pedersen P, Færgeman K, Thulsrup AM. Plejepersonalets viden og holdning om ernæring til ældre plejehjembeboere, en spørgeskemaundersøgelse. Vård i Norden 2006;26(1):20–4.

    13.     Rognstad M-K, Brekke I, Holm E, Linberg C, Lühr N. Underernæring hos eldre hjemmeboende med demens. Sykepleien Forskning 2013;8(4):298–307. DOI: 10.4220/sykepleienf.2013.0137.

    14.     Meyer SE, Velken R, Jensen LH. Vurdering av ernæringsstatus – et sykepleiefaglig ansvar i hjemmesykepleien. Sykepleien Forskning 2017;12(61797/e-61767). DOI: 10.4220/sykepleienf.2017.61797.

    15.     Mowé M. Behandling av underernæring hos eldre pasienter. Tidsskrift for Den norske legeforening 2002;122(8):815–8.

    16.     Utviklingssenter for sykehjem og hjemmetjenester. Available at: http://www.utviklingssenter.no/(downloaded 25.05.2017).

    17.     Donini LM, Savina C, Rosano A, Cannella C. Systematic review of nutritional status evaluation and screening tools in the elderly. J Nutr Health Aging 2007;11(5):421–32.

    18.     Ranhoff AH, Gjøen AU, Movè M. Screening for malnutrition in elderly acute medical patients. The usefulness of MNA-SF. J Nutr Health Aging 2005; 9(4):221–5.

    19.     Fossum M, Terjesen S, Ehrenberg A, Ehnfors M, Söderhamn O. Evaluation of the Norwegian version of the Mini Nutrional Assessment (MNA) among older nursing home patients. Vård i Norden 2009;29(92):50–2.

    20.     Aagaard H, Roel S. Utvikling av ernæringsjournal: beskrivelse av ernæringsjournalen og dens praktiske gjennomføring foretatt av sykepleiestudenter. Høgskolen i Østfold, Arbeidsrapport 2004/8.

    21.     Aagaard H. Ernæring nedprioriteres ofte. Tidsskriftet Sykepleien 2005;93(17):68–9. Available at: https://sykepleien.no/forskning/2009/03/ernaering-nedprioriteres-ofte(downloaded 19.12.2017).

    22.     Skates JJ, Anthony PS. Identifying Geriatric Malnutrition in Nursing Practice. The Mini Nutritional Assessment (MNA) – An Evidence-Based Screening Tool. J Gerontol Nurs 2012;38(3)18–27.

    23.     Kaiser MJ, Bauer JM, Rämsch C, Uter W, Guigoz Y, Cederholm T, et al. Validation of the Mini Nutritional Assessment Short-Form (MNA-SF): A practical tool for identification of nutritional status. J Nutr Health Aging 2009; 13(9):782–8.

    24.     Phillips M, Foley AL, Barnard R, Isenring EA, Miller MC. Nutritional screening in community-dwelling older adults: a systematic literature review. Asia Pacific Journal of Clinical Nutrition 2010;19(3):440–9.

    25.     Guigoz Y, Lauque S, Vellas BJ. Identifying the elderly at risk for malnutrition The Mini Nutrional Assessment. Clin Geriatr Med 2002;18(4):737–57.

    26.     Guigoz Y. The Mini Nutritional Assessment (MNA) review of the literature. What does it tells us? J Nutr Health Aging 2006;10(6):466–87.

    27.     Gjerlaug AK, Harviken G, Uppsata S, Bye Aa. Verktøy for screening av risiko for underernæring hos eldre. Sykepleien Forskning 2016;11(2):148–56. DOI: 10.4220/Sykepleienf.2016.57692.

    28.     Melheim BG. Svolten som blir oversett. Ernæringskartlegging i heimetenesta. Poster, Forskingsdagane i Førde 2014.

    29.     Alhaug J, Bjørnstad E, Ore S, Rai R, Lind J. Forprosjekt innen kvalitetsindikatorer for ernæring og legemiddelgjennomgang. Helsedirektoratet. Avdeling for statistikk og kodeverk. IS-2336. Oslo, 2015.

    30.     Sandvoll AM, Kristoffersen K, Hauge S. New quality regulations versus established nursing home practice: a qualitative study. BMC Nursing 2012;11(7). DOI: 10.1186/1472-6955-11-7.

    In order to meet the challenges associated with undernutrition in elderly patients who receive home-based nursing care, it is necessary to screen for nutritional status.

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    Background: Half of the elderly patients receiving home-based nursing care are undernourished or are in danger of this. National professional guidelines and Kosthandboka (nutrition manual) provide advice on how healthcare services can prevent and treat undernutrition. Screening for nutritional status must be performed regularly for all patients. Without good screening routines, it may be difficult to detect undernutrition. Inspection shows that the screening process varies among municipalities, despite the fact that the nurse has a clear responsibility to screen for nutritional status.

    Objective: To elicit good solutions that simplify and systemise the assessment of nutritional status. 

    Results: Many elderly patients present a complex clinical picture that complicates the assessment of nutritional status. Short visits to patients make it difficult to prioritise screening for nutritional status. Moreover, the large selection of screening tools available makes it challenging to choose the best suited. The short form of the Mini Nutritional Assessment (MNA-SF) is evaluated as being best. The MNA is based on weight and height measurement (BMI). Standing on a set of scales may be a challenge for some elderly patients. Moreover, a changing body posture or being bedridden may make height measurements uncertain. In the MNA-SF, measurement of calf circumference can replace BMI.

    Managers are well positioned to put screening on the agenda as part of interdisciplinary nutritional efforts. Nurses want to have more nutritional expertise and a clearer allocation of responsibility. A variety of studies call for more knowledge about screening tools and a better standard of documentation of nutritional data in electronic patient records (EPR). Therefore, expertise is of key importance in strengthening and quality assuring nutritional efforts.

    Conclusion: Screening for nutritional status can make it easier to detect nutritional problems before undernutrition arises. A good solution is to screen for nutritional status using the Mini Nutritional Assessment short form (MNA-SF). The nutrition manual provides useful tips. 

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  • A survey of healthcare professionals’ experiences with the Paediatric Early Warning Score (PEWS)

    It is the responsibility of paediatric nurses to ‘evaluate acute situations, set priorities and implement measures that help to maintain or restore vital functions’ (1). This requires systematic monitoring of children who are hospitalised. To prevent acute situations, nurses must quality assure the monitoring of sick children so that any deterioration in the child’s clinical condition can be identified at an early stage.

    Paediatric Early Warning Score (PEWS)

    The Paediatric Early Warning Score (PEWS) is a scoring tool that quantifies the severity of children’s clinical condition, regardless of diagnosis. Monaghan’s version of PEWS, which was developed in the early 2000s in England, was translated into Norwegian, modified and validated in 2011 at Akershus University Hospital.

    A growing number of paediatric departments in Norway have implemented the tool, and a joint initiative to implement the tool nationally is currently underway. The tool is based on normal values on clinical parameters according to the child’s age (0–18 years) within three categories: respiration (AB), circulation (C) and behaviour (D). Increasing deviation from normal values for the child’s age raises the score. A total score indicates the patient’s risk of clinical deterioration (2).

    Several validation studies of PEWS have been carried out (3–10). Individual studies are summarised in review articles (11, 12), and reports discuss the implementation of PEWS and evaluate the tool (4, 13, 14). Research shows that PEWS improves, to varying degrees, the ability of healthcare professionals across professions to identify early clinical deterioration in sick children.

    PEWS gives nurses more self-confidence in their work with sick children.

    A survey of employees’ experiences following the implementation of PEWS (13) and a collection of nurses’ feedback on the use of PEWS show that PEWS gives nurses more self-confidence in their work with sick children. They are uncertain, however, whether their own assessment skills are more effective than the tool (14).

    Researchers are seeking more knowledge about users’ experiences of the tool’s applicability. If healthcare professionals are to prevent and identify clinical deterioration and improve the outcome of treatment by using PEWS, the healthcare professionals group must focus on continuing to use the tool (15).

    Purpose of the study

    It is important to evaluate the tool in order to find out whether PEWS identifies symptoms of clinical deterioration in the child’s condition and that it works as intended. One aspect of the evaluation will also be to elicit the experiences of healthcare professionals and to identify areas for potential improvement (16). However, we have not found studies that have investigated this topic in Norway.

    Thus, the purpose of this study is to describe healthcare professionals’ experiences with PEWS in three Norwegian hospitals.

    We formulated three main research questions:

    • Does PEWS promote a systematic approach to the monitoring of sick children?
    • Does PEWS help to improve communication?
    • How do users perceive the applicability of PEWS?
    • Is the tool used according to established guidelines?

    We also formulated the following secondary question:

    • Do the responses differ across hospitals or professional groups?

    Method

    Design

    We used a quantitative method with a descriptive design, and conducted a cross-sectional study of paediatric departments in three Norwegian hospitals.

    Questionnaire

    A validated questionnaire that surveys users’ experiences with PEWS was not available, so we developed our own. The questionnaire contains statements about PEWS that are divided into four main topics which we believed to be especially important for quality-assured monitoring of sick children: a systematic approach, communication, applicability and guidelines.

    The statements are based on research findings (3–5, 9, 10, 13, 14) and relevant professional literature. The questionnaire was adapted following a pilot study conducted in autumn 2015 in two hospital departments that had recently introduced PEWS. We also based it on feedback from the individuals who promoted the introduction of PEWS in Norway.

    The questionnaire begins with three demographic questions. These are followed by 37 different statements about PEWS, which are divided into the aforementioned topics. The response options are on a Likert Scale with the following options: ‘strongly disagree’, ‘slightly disagree’, ‘neither agree nor disagree’, ‘slightly agree’ and ‘strongly agree’. The respondents were asked to rank their perceptions of the statements according to their experience with PEWS.

    The sample

    We used a non-probability sample recruited according to predefined criteria (17, 18). Our intention was to recruit nurses, doctors, auxiliary nurses and paediatric nurse assistants who work in paediatric departments and use PEWS. To avoid recruiting in an implementation phase and to ensure that the respondents had clinical experience with children in hospital and PEWS, the inclusion criteria were as follows:

    • PEWS implemented at least two years ago
    • Healthcare professionals must have a minimum of three months’ clinical experience

    We contacted three hospitals in different counties, and they agreed to participate. One was a university hospital and two were regional hospitals. The three hospitals together have four medical and surgical wards for children, as well as one paediatric admission unit. We refer to the entire sample as healthcare professionals. For reasons of personal privacy, we combined nine paediatric nurse assistants and auxiliary nurses with the nursing group in the analysis.

    Data collection

    Data were collected in spring 2016 over a three-week period. We sent information to the management in advance, and we visited the various departments in person. We provided thorough information about the project and established a cooperative relationship with the contact persons, who assumed special responsibility for recruitment and data collection.

    The questionnaires were distributed in paper form to the nurses during their shift change and at joint meetings of the doctors. Everyone who satisfied the inclusion criteria at that point in time received an invitation to participate. The respondents gave their consent by answering the questionnaire. To ensure voluntary participation, everyone received a questionnaire together with an envelope so that they could also choose to return an unanswered form.

    Altogether 177 of 220 potential respondents returned completed questionnaires, which is a response rate of 80 per cent. The response rate at Hospital A is 86 per cent, at Hospital B 92 per cent and Hospital C 70 per cent. Five questionnaires were later withdrawn from the analysis because the respondents did not satisfy the inclusion criteria.

    Analysis

    We performed descriptive analyses of the data. We used non-parametric rank-sum tests (Kruskal-Wallis and Mann-Whitney-Wilcoxon) to compare the hospitals and professional groups.

    To simplify the data processing, we consolidated the values ‘slightly disagree / strongly disagree’ and ‘slightly agree / strongly agree’ into ‘disagree’ and ‘agree’, respectively. We used IBM SPSS, version 23 for the statistical analyses, and the significance level was set at 5 per cent, corresponding to a p-value of < 0.05.

    Missing data

    Under demographic data, three respondents (2 per cent) did not state their profession, seven (4 per cent) did not report their experience with children, and eleven (6 per cent) did not state their experience with PEWS. A maximum of 8 per cent did not answer the other statements on the questionnaire.

    Approvals

    The study has been approved by internal research coordinators at the hospitals and the data protection official for research, the Norwegian Centre for Research Data (NSD). The data have been treated confidentially. We did not find it relevant to seek approval from the Regional Committees for Medical and Health Research Ethics (REC) (19).

    Results

    The distribution of nurses and doctors is relatively the same at the three hospitals. In total, 75 per cent are nurses and the rest are doctors (Table 1). Over half of the sample have more than five years of experience with hospitalised children. At Hospitals A and B, over one-quarter of the respondents have more than 15 years of experience. Only 12 percent of the total sample have less than one year of experience with PEWS.

    Table 1. Description of the sample

    Systematic approach

    At all three hospitals, over 90 per cent generally agree with the statements that PEWS promotes a systematic approach to the monitoring of sick children (Table 2). A total of 91 per cent agree that PEWS results in earlier identification of clinical deterioration (Figure 1). The results show no significant differences between the hospitals or among the professional groups regarding a systematic approach.

    Table 2. Survey of statements related to a systematic approach to monitoring
    Figure 1. PEWS results in earlier identification of deterioration in critically ill children

    Communication

    Altogether 85–90 per cent of the sample agree that PEWS promotes more effective communication (Figure 2) and a more shared understanding among the healthcare professionals (Table 3). There is a significant difference between Hospitals A and B (p = 0.01) and Hospitals A and C (p = 0.047) regarding how much the respondents agree that PEWS reduces misunderstandings among healthcare professionals. Healthcare professionals at Hospital A agree more with this statement.

    Figure 2. PEWS promotes more effective communication among nurses and doctors about the child’s condition
    Table 3. Survey of statements related to communication

    Applicability

    Of all the respondents, 92 per cent agree that PEWS is useful (Figure 3). Altogether 80 per cent state that they have received training in PEWS, although fewer doctors than nurses report this at all the hospitals (A: p = 0.01, B: p = 0.04, C: p = 0.03) (Table 4). In addition, a total of 93 per cent state that they have confidence in the scoring.

    Fewer doctors than nurses state that they carry out PEWS scoring (p < 0.001). More of the respondents at Hospital A compared with Hospital B (p = 0.01) agree that PEWS measures whether there is a risk of clinical deterioration in the child’s condition.

    Figure 3. PEWS is useful in the monitoring of critically ill children
    Table 4. Survey of statements related to applicability

    Guidelines

    The responses are generally distributed among the response options (Table 5). At Hospital A, more of the respondents agree that the children are scored during the first hour than at Hospitals B and C (A and B: p = 0.01, A and C: p = 0.01). At Hospital A, they also agree that the PEWS form is signed by a doctor during rounds (A and B: p < 0.001. A and C: p < 0.001).

    Regarding the question of whether doctors are actively involved with PEWS for hospitalised patients and prescribe the frequency of scoring, more of the respondents at Hospital A than at Hospital C agree with this (p = 0.01).

    More respondents at Hospital A than at Hospital B agree that a PEWS score ≥ 3 results in increased monitoring (p = 0.01). In addition, more respondents at Hospital A than at Hospitals B and C agree that a worsening of PEWS by ≥ 2 or a score of 3 leads them to inform a doctor (A and B: p < 0.001, A and C: p = 0.01).

    Table 5. Survey of statements related to guidelines

    Discussion

    It is positive that almost all respondents state that PEWS results in earlier identification of clinical deterioration in sick children and that the tool is easy to use. These findings correspond with previous studies (3–5, 9, 10, 13). If using a systematic tool helps healthcare professionals to recognise symptoms in sick children at an earlier stage, it is an important means of improving the quality assurance of monitoring (20).

    Systematic approach

    Almost all the respondents agreed that PEWS results in a systematic monitoring of clinical parameters. They also agreed that PEWS leads to a standardisation of the parameters that are used and that the tool ensures continuity in monitoring. When PEWS is used, systematic observations help to identify changes in the patient’s clinical condition.

    A systematic approach to changes in the child’s vital signs is crucial for assessing how ill the child is (21). Experience shows that observations and assessments can often be unsystematic and dependent on the individual doctor’s or nurse’s experience and knowledge.

    When PEWS is used, systematic observations help to identify changes in the patient’s clinical condition.

    Studies have indicated that routine observations of hospitalised children were carried out in an unsystematic manner and were dependent on the nurse’s perceptions, the doctor’s preference and their clinical specialty. They conclude that the lack of consistency in observing and registering vital signs must be improved because it is critical that a thorough set of observations are recorded for sick children (22). It is therefore useful to have a tool that systematises the monitoring activity.

    Almost all respondents agreed that PEWS is a supplement to their daily work which ensures that a minimum of clinical observations are carried out, but that PEWS does not replace their own professional assessments. These findings show that PEWS does not replace either the professional knowledge or the experience that serves as a basis for how healthcare professionals observe the sick child, but that they regard PEWS as a useful aid (2). 

    Communication

    As in previous research (3, 4), healthcare professionals from the hospitals mostly agree that PEWS results in more effective communication and a shared understanding across professional groups, which is especially important when working with sick children, most notably in acute situations (23, 24). It is a strength that many of the respondents confirm that PEWS contributes to this, and other studies also mention improved collaboration and communication as positive reasons to use PEWS (2, 10).

    There are some divergent experiences as to whether PEWS reduces misunderstandings among healthcare professionals. A significantly higher percentage of healthcare professionals at Hospital A agree with this statement, compared with Hospitals B and C. More respondents from Hospitals B and C answered ‘neither agree nor disagree’, so we cannot assume that they disagree. It may be that the question is stated unclearly and does not distinguish between ‘whether they have experience with it’ or ‘whether they do not understand the question’.

    However, the fact that one-quarter of the entire sample agrees that PEWS reduces misunderstandings is especially important as it pertains to monitoring of the child. Other studies also suggest that misunderstandings related to the patient’s condition are reduced when PEWS is used (10).

    Applicability

    The respondents confirm that PEWS is easy to use. Many state that they received training in the use of PEWS, but one weakness of the implementation is that not everyone who uses PEWS has been trained in its use. Fewer doctors than nurses have received training, and significantly fewer doctors than nurses carry out the scoring themselves. The explanation for this may be that the scoring has been completed by the time the doctors come to check on the child, and as such it is unnecessary to do the scoring again.

    It is a strength that most respondents state that they have confidence in how they conduct the scoring. We assume that more doctors would also have done it themselves if it were necessary. By the same token, it is a weakness that few of the doctors have received PEWS training.

    Previous studies suggest that healthcare professionals were concerned that PEWS would be time-consuming and increase their paperwork (13). In our study, less than one-fifth of the respondents believe that PEWS takes a lot of extra time. However, we are surprised that so many still believe that it takes more time. In our view, the observations included in the tool are no different from the daily monitoring that should be recorded.

    One weakness of the implementation is that not everyone who uses PEWS has been trained in its use.

    The advantage of PEWS is that by systematising the monitoring, healthcare professionals are better able to follow the patient’s clinical development over time. In future improvement efforts, it will be important to consider what makes some professionals feel that PEWS is time consuming, even though it can simplify their daily work and is intended to quality assure the monitoring of sick children.

    Many of the respondents agree that PEWS is useful and that it increases their sense of security about their assessment of sick children, boosts their self-confidence and supports their own medical assessment. At the same time, relatively few agree that PEWS shows the degree of risk of clinical deterioration, and almost half agree that they would have recognised the risk just as early without PEWS.

    One explanation for these findings could be that the statements were not worded clearly, especially because many responded ‘neither agree nor disagree’. However, this may not be the entire explanation, as PEWS received varying feedback from healthcare professionals when the scoring tool was introduced in other countries.

    In addition, many believed that they were able to recognise the patient’s risk of clinical deterioration without the tool (14). Despite this, we see both in this study and in previous research that it is viewed as beneficial to use the tool and that the advantage of PEWS is that it gives healthcare professionals greater security, more self-confidence and better support when they assess sick children (2–4, 10, 13).

    Guidelines

    The findings show that the hospitals have different experiences with the established guidelines for the use of PEWS. Previous studies emphasise that it is important to have a culture that supports the use of PEWS if the tool is to serve its purpose (15). It is a weakness that there is not more agreement among healthcare professionals that the established guidelines must be followed.

    Regarding the issue of guidelines, there is a generally significantly higher percentage of agreement among the respondents at Hospital A than at the other hospitals. One possible explanation for the differences may be the length of time that they have been using PEWS in practice. However, this assumption does not correspond with the findings from our study in which Hospitals A and B have both been using PEWS for two and a half years, while Hospital C has been using PEWS for five years.

    There is a higher percentage of paediatric nurses and doctors at Hospital A than at the other hospitals, and the possibility that expertise has a bearing on how the guidelines are followed cannot be ruled out. Research also shows that up to 70 per cent of improvement efforts do not maintain the results over time if one does not maintain the focus and view the work as an ongoing process (16). Perhaps Hospital A has been more successful in sustaining motivation within the healthcare professionals group that supports the use of PEWS (15).

    The possibility that expertise has a bearing on how the guidelines are followed cannot be ruled out.

    The findings also show that over one-third of the respondents have seen a high PEWS score (> 4) be ignored. Altogether 19 per cent of these respondents agree that this resulted in an undesirable outcome for the child, although no further explanation was given.

    The respondents at Hospitals B and C agree the least that PEWS is used according to the tool’s established guidelines. At the same time, it is from these two hospitals that most respondents state they have seen a high PEWS score be ignored and that this resulted in an undesirable outcome for the child. The numbers are low, but the findings are serious. Research shows that when clinical deterioration of the child’s condition occurs, it is a major problem when healthcare professionals fail to react appropriately and correctly (25). 

    Strengths and limitations

    The response rate in our study is high, and the analysis shows that few of the responses to the questionnaire lacked data. We chose hospitals where the tool was well established, and we recruited from hospitals in different geographic locations. The participants in the study represent healthcare professionals who use PEWS in their clinical work. The aforementioned measures strengthen the study’s external validity and generalisability (17, 26, 27).

    A limitation of the study is that we did not have a validated questionnaire to survey healthcare professionals’ experiences with PEWS. There is a risk that the respondents may have misunderstood the questions, which constitutes a validity threat (17). Prior to this study, we launched measures to minimise this threat by conducting a pilot study, gathering feedback from the driving forces behind PEWS in Norway, and putting a great deal of effort into recruitment.

    The fact that the analysis mostly shows similar results among different hospitals is a strength, but a large percentage responded ‘neither agree nor disagree’ to certain statements. This may mean that those statements were not worded clearly, which poses a threat to concept validity. We take this into account when we discuss the results.

    None of the authors is affiliated with the hospitals, and thus there are no validity conflicts or bias in this regard (17).

    Conclusion

    The study shows that the respondents generally agreed that PEWS promotes a systematic approach to monitoring and better communication and that healthcare professionals find the tool to be applicable. The general experiences with the tool seem to be positive.

    It is worth noting that healthcare professionals have different experiences with the guidelines introduced for PEWS. The differences are greatest between Hospital A and the other hospitals. The respondents at Hospital A have a considerably higher, and in some cases a significantly higher, level of agreement about the use of the guidelines than the respondents at the other two hospitals.

    The findings provide important knowledge about healthcare professionals’ experiences with PEWS, and may thus be important for further quality efforts, with regard both to follow-up and to improvements. The findings indicate the importance of keeping the spotlight on PEWS in the healthcare professionals group and viewing the work with PEWS as an ongoing process in order for the tool to be applicable.

    The findings cannot be generalised as a matter of course, but they may nonetheless be useful for everyone who has used or will use the tool in clinical practice since the response rate is high and the sample is relatively large in terms of the number of professionals in Norway who have experience with PEWS. The findings may lead to better follow-up and utilisation of the tool at the hospitals that use PEWS and a better planning phase for implementation of the tool at other health trusts.

    Further research

    In order to compare the study and evaluate its results, more research is needed on users’ experiences with PEWS. Further research should investigate whether there are reasons that can explain the difference in the use of guidelines. Qualitative studies could help to increase our insight into these issues.

    References

    1. Høgskolen i Oslo og Akershus. Programplan for mastergradsstudium i barnesykepleie. 2015. Available at: http://www.hioa.no/Studies/HF/Master/Barnesykepleie/Programplan-for-Mastergradsstudium-i-barnesykepleie-2015(downloaded 26.02.2016). 

    2. Bjerke AT, Moen E, Bråthen A-DB, Schröder J, Solevåg AL, Nakstad B. PedSAFE. Et utdannings- og treningsprogram for helsepersonell som jobber med barn og ungdom. Tidsskrift for barnesykepleiere 2015;1:5–6.

    3. Akre M, Finkelstein M, Erickson M, Liu M, Vanderbilt L, Billman G. Sensitivity of the Pediatric Early Warning Score to identify patient deterioration. Pediatrics 2010;125(4):763–9. DOI: 10.1542/peds.2009-0338.

    4. Ennis L. Paediatric early warning scores on a children’s ward: a quality improvement initiative. Nurs Child Young People 2014;26(7):25–31. DOI: 10.7748/ncyp.26.7.25.e478.

    5. Fuijkschot J, Vernhout B, Lemson J, Draaisma JMT, Loeffen JLCM. Validation of a Paediatric Early Warning Score: first results and implications of usage. Eur J Pediatr 2015;174:15–21. DOI: 10.1007/s00431-014-2357-8.

    6. Parshuram C, Duncan H, Joffe A, Farrell C, Lacroix J, Middaugh K, et al. Multicentre validation of the bedside paediatric early warning system score: A severity of illness score to detect evolving critical illness in hospitalised children. Crit Care 2011;15:1–10.

    7. Parshuram C, Hutchison J, Middaugh K. Development and initial validation of the bedside paediatric early warning system score. Crit Care 2009;13R135. DOI: 10.1186/cc7998.

    8. Skaletzky S, Raszynski A, Totapally B. Validation of a modified pediatric early warning system score: A retrospective case-control study. Clin Pediatr (Phila) 2012;51(5):431–5. DOI: 10.1177/0009922811430342.

    9. Solevåg AL, Eggen EH, Schröder J, Nakstad B. Use of a Modified Pediatric Early Warning Score in a Department of Pediatric and Adolescent Medicine. PloS One 2013;8(8):1–6. DOI: 10.1371/journal.pone.0072534.

    10. Tucker K, Brewer T, Baker R, Demeritt B, Vossmeyer M. Prospective evaluation of a pediatric inpatient early warning scoring system. J Spec Pediatr Nurs 2009;14(2):79–85. DOI: 10.1111/j.1744-6155.2008.00178.x.

    11. Chapman SM, Grocott MP, Franck LS. Systematic review of paediatric alert criteria for identifying hospitalised children at risk of critical deterioration. Intensive Care Med 2010;36(4):600–11. DOI: 10.1007/s00134-009-1715-x.

    12. Murray JS, Williams LA, Pigantaro S, Volpe D. An integrative review of pediatric early warning system scores. Pediatr Nurs 2015;41(4):165–74.

    13. Monaghan A. Detecting and managing deterioration in children. Paediatr Nurs 2005;17(1):32–5. DOI: 10.7748/paed2005.02.17.1.32.c964.

    14. Watson A, Skipper C, Steury R, Walsh H, Levin A. Inpatient nursing care and early warning scores: a workflow mismatch. J Nurs Care Qual 2014;29(3):215–22. 

    15. Hogan J. Why don’t nurses monitor the respiratory rates of patients? Br J Nurs 2006;15(9):489–92.

    16. Modell for kvalitetsforbedring. Oslo: Kunnskapssenteret; 2015. Available at: http://www.helsebiblioteket.no/kvalitetsforbedring/slik-kommer-du-i-gang/modell-for-kvalitetsforbedring(downloaded 05.01.2016). 

    17. Polit DF, Beck CT. Nursing research. 9. ed. Philadelphia, PA: Wolters Kluwer Health; 2012.

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    20. Hazinski MF. Children are different. In: Hazinski MF., eds. Nursing care of the critically ill child. St. Louis, MO: Mosby; 2013. s. 1–18.

    21. Markestad T. Klinisk pediatri. 3. ed. Bergen: Fagbokforlaget; 2009.

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    PEWS promotes a systematic approach to monitoring and better communication in paediatric departments, but there is a need to follow up and improve guidelines and quality-assurance activities.

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    English
    Sammendrag

    Background: The Paediatric Early Warning Score (PEWS) is a scoring tool that was developed in the early 2000s in England and modified for Norwegian conditions in 2011. The tool quantifies the severity of children’s clinical condition, regardless of diagnosis, and identifies children between 0 and 18 years of age who are at risk of clinical deterioration. PEWS is regarded as a useful tool for recognising at-risk patients, but research on user experiences with PEWS is limited.

    Purpose: To describe the experiences of nurses and doctors with PEWS. We describe these experiences in terms of whether the tool contributes to a systematic approach to monitoring and better communication, as well as whether the tool is applicable to the user. In addition, we investigate whether PEWS is used according to established guidelines and whether different hospitals or professional groups have different experiences with the tool.

    Method: We used a quantitative method with a descriptive cross-sectional design. We developed our own questionnaire to survey the user experiences of 172 healthcare professionals at three Norwegian hospitals, and performed descriptive analyses with non-parametric rank-sum tests (Kruskal-Wallis and Mann-Whitney-Wilcoxon).

    Results: There is general agreement among the healthcare professionals that PEWS promotes a systematic approach to monitoring and better communication and that PEWS is a user-friendly tool. The healthcare professionals at one hospital agreed significantly more often that they use PEWS according to established guidelines, as compared with the other hospitals.

    Conclusion: The healthcare professionals report positive experiences with PEWS, but the study shows that they use the guidelines in very different ways.

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  • Interaction between nurses and doctors is important for the nutritional status of nursing home patients

    The provision of medically sound nutritional treatment requires competence and follow-up on all levels within the health and care service (1). In the primary health service, we are currently witnessing a major re-structuring process which focuses on multi-disciplinary initiatives and flexible job descriptions.

    While patient safety is accentuated, rationalisation and cost-cutting initiatives are intended to provide good health services for the benefit of the general population (2, 3). Local authorities invest in quality-improvement packages and evidence-based practices are prioritised in nursing homes. 

    Patients in nursing homes are elderly and their clinical situation is often complex. Most patients need help to have their basic needs fulfilled, including their nutritional needs (4, 5). The nutritional work carried out in nursing homes therefore constitutes health care that is both necessary and important.

    Most patients need help to have their basic needs fulfilled, including their nutritional needs.

    There is a link between functional capability and health, and people’s nutritional status is closely associated with their functional capability (6, 7). Research and monitoring have exposed shortcomings in routines for identifying and following up undernourished patients in hospitals as well as in nursing homes (1, 8).

    Nutritional work in nursing homes

    In many nursing homes, nutritional work is carried out in collaboration between several disciplinary groups and professionals (9). The nursing home doctor has the overall responsibility for the medical examination, diagnosis and treatment, while the nurses are responsible for implementing initiatives and ensuring that the patients’ intake of food and drink is sufficient (9). The nursing home doctor is responsible for the patients’ medical care but often has no supervisory function in relation to the nursing home (10).

    The nature of the interaction between the nursing staff and the doctor will therefore impact on patient safety. The Norwegian Directorate of Health points out that good interaction among the parties involved is required for nursing home patients to have their nutritional needs fulfilled (9). The exact group of people and disciplines involved at each nursing home may vary with the size of the home and the patient’s needs. 

    The study’s objective

    Having conducted searches in SveMed+, PubMed and CINAHL, we found no articles that discussed the cooperation between doctors and nurses with respect to nutritional work carried out in nursing homes.

    Consequently, this article highlights the role of the doctor in the nutritional work carried out in nursing homes. We approached our data material with the following question in mind: ‘How do nurses perceive the nursing home doctor’s role with respect to the nutritional work?’

    Method

    The study has a qualitative design and involves an analysis of focus group interviews. We chose focus groups because they allow the participants’ experiences to be shared and discussed. This type of interview encourages different views, attitudes and perspectives that shed light on how nurses perceive their day-to-day experiences in nursing homes (11).

    Sample and situation

    We recruited our informants by contacting the management of the nursing homes, who in turn selected appropriate candidates. The inclusion criteria were defined as nurses whose duties included hands-on patient care, and who had at least three years’ experience of nursing for residents with a dementia diagnosis.

    A total of 15 nurses from seven nursing homes in four different counties took part. The informants had between four and 25 years of nursing experience from nursing homes, and we conducted four focus group interviews. We chose to have three to four participants per group in order to encourage them to expand on their viewpoints.

    Data collection

    The interviews were conducted in the autumn of 2013. The main question was as follows:

    ‘Talk about episodes or experiences and ethical dilemmas you have encountered in your work with undernourished residents in nursing homes’.

    The interviewer was specifically tasked with presenting the purpose of the interview and promoting positive group dynamics and interactions among the participants during the interview (12).

    We took an open-ended approach because we wanted to explore the informants’ personal experiences and thoughts regarding the nutritional work carried out in nursing homes. We made use of follow-up questions and sentence repetition to clarify and verify statements. The duration of interviews was between 55 and 110 minutes. All interviews were recorded on tape and transcribed verbatim.

    Data analysis

    The analysis is based on Malterud’s (12) approach to analysing data material, which in turn is a modified version of Giorgi’s (13) phenomenological analysis. We started by individually reading the whole material to gain an overview, before we went on to look for meaning units that were later categorised by allocating codes. We worked together on the coding and the content abstraction before synthesising the significance of our findings (11).

    The interview focused on ethical dilemmas encountered in relation to nutritional work. In the course of this exercise, the doctor’s role in the collaboration with the nurses clearly emerged. Against this background, we conducted a secondary analysis of the material in order to gain a deeper understanding of the nurses’ perception of the role played by the doctor with respect to nutritional work.

    Ethical considerations

    All participants received written and verbal information about the study and its objective. We emphasised the fact that participation was voluntary, and that the participants could withdraw from the study at any time. All information in the transcribed material has been anonymised, and the informants were given fictitious names. The study has been approved by the Norwegian Centre for Research Data (NSD).

    Results

    Three of the findings that were key to our analysis could all be related to the role played by the nursing home doctor with respect to nutritional work: the doctor’s contact with the patients, with the nursing staff, and with the patient’s family. Translated quotes from the interviews have been put in quotation marks.

    Contact with patients

    The nurses described their nutritional work in nursing homes as demanding. It was particularly challenging when patients lost weight or refused to eat. The informants talked about patients who had lost their appetite, a shortage of staff at mealtimes, limited nutritional knowledge and inadequate documentation. Some of them also talked about insufficient follow-up of the patients’ nutritional needs, and they felt that the quality of the nutritional work was unsatisfactory.

    The nursing home doctor’s knowledge of the individual patient was important. The informants stressed the significance of the nursing home doctor working in partnership with the ward by familiarising themselves with the patients’ situation and ascertaining and following up their nutritional status:

    ‘She [the doctor] doesn’t look at things merely from the medical perspective, it’s as if she is looking more to people’s overall situation.’

    This approach might appear to be obvious, but in order to interact with patients, doctors would have to familiarise themselves with and listen to patients individually. At two of the nursing homes, the nutritional situation was routinely discussed with the doctor during the admission interview with the patient.

    This made it easier to form a picture of the patients’ relationship with food and their wishes and needs at later stages. Sometimes the nurses found that the doctor was more interested in the patient’s medication list than in their nutritional status and overall situation.

    Patients listen more to the doctor

    Whenever the nursing home doctor discussed the nutritional situation with the patient, the informants felt that patients would listen more carefully to the doctor’s recommendations than to their own. The doctor’s say-so was perceived to be ‘more important’ than the nurses’ say-so. This meant it was essential for the doctor to know patients well and to be able to relate to them with ease.

    Several informants mentioned that the follow-up of patients was much better if there was a regular doctor who knew the individual patients. Moreover, it was important for the doctor to enjoy talking to elderly people. One of them said:

    ‘So it’s important that we have a doctor who is regular, who enjoys talking to the elderly, [who] sort of takes pleasure in it, and when that’s not the case, then things are difficult.’

    The difficulties often arose when the patients lost weight or stopped eating, or when their condition was noticeably deteriorating. Several informants described situations where hospitalisation could have been avoided if the doctor who had been called had been better acquainted with the patient.

    Familiarisation with the patients’ wishes and needs

    The informants gave examples suggesting that the annual medication review should involve more than merely reviewing and monitoring the patient’s medication list. Doctors should be willing to take the time to familiarise themselves with the patient’s wishes and needs. Doctors who asked to see patients to talk to them, were given a completely different insight into their life situation than doctors who restricted themselves to a medication review in the staff duty room:

    ‘We have introduced a medication review, and at that point we review the overall health situation. […] Both the nurse and the doctor talk to the patient and the family, and they [the patient and the family] talk about all sorts of things, and they bring up the question of how things will progress even at that stage.’

    Just over half the nurses found that doctors were well informed about patients. Doctors in small nursing homes did not necessarily know their patients better than doctors in large nursing homes; it was more a matter of personal interest and continuity than nursing home size.

    Collegial cooperation

    The nurses considered the nursing home doctor to be an important fellow contributor to the institution’s nutritional work. In several focus groups, the nursing home doctor was described as a good collaborative partner, both in terms of assessing the patient’s nutritional situation and in terms of implementing nutritional initiatives:

    ‘I think our doctor is really good, she is so nice, ascertains that sort of thing beforehand, and talks to the relatives and to us about what is going to happen, and then she writes it all down in the patient’s records.’

    The nurses saw it as their role to make sure that patients receive sufficient food and drink according to their own wishes and needs, and to discuss things with the doctor if they came across difficulties in the nutritional work.

    The doctor’s role was that of an important discussion partner. The doctor’s willingness to be present and to get to know the patients and the staff on the ward impacted significantly on the nature of the collaboration and the nutritional work.

    Close contact with the doctor means better nourishment

    The informants listed close contact with the doctor as a nutrition-improving factor, and the fact that ‘he [the doctor] drops by to check if there are any particular concerns whenever he calls in at the nursing home’. The fact that the nursing home doctor focused on the individual patient’s nutritional status when he visited the home, was important for the other staff on the ward to also focus on nutrition.

    Whatever receives the doctor’s attention when he visits, will also receive the nurses’ attention. If the nursing home doctor did not concern herself with nutrition, then the subject would sometimes be considered less important by the rest of the staff.

    Whatever receives the doctor’s attention when he visits, will also receive the nurses’ attention.

    If the nutritional collaboration with the doctor worked well, the informants felt that it was less demanding for them to face challenging nutritional situations because they dared to show their uncertainty and to raise issues they felt unsure about. One informant particularly mentioned how important the nursing home doctor had been to her when, as a newly trained nurse, she found herself in a dilemma with respect to a patient who no longer wanted to live and refused to eat:

    ‘The doctor gave us a little help in that process, and then he says [the doctor]: ʻAllow her to go through the process she has embarked on.’

    Her cooperation with the doctor gave the nurse the re-assurance she needed to accept the patient’s wish not to eat, and it also helped her to see the situation in a new light.

    Good communication has an impact

    Several nurses pointed out that their nutritional work was made easier by good communication, discussions about the nutritional situation on admission, and on-going nutrition-related record-keeping. The informants described a monitoring system that could involve a gap of several days between the doctor’s visits. Good cooperation was therefore essential to ensuring that the nurses were confident about expected developments and the path ahead:

    ‘We want a doctor who knows what’s what, who knows who I am talking about.’

    Good cooperation could also prevent hospitalisation if the patient deteriorated or stopped taking any sustenance, because the nurses knew the wishes of the patient and the doctor.

    We want a doctor who knows what’s what, who knows who I am talking about.
    Nurse

    Several nurses described their own reluctance to contact the out-of-hours emergency service because they were worried about exposing the patient to excessive treatment and hospitalisation by a doctor who did not know the patient:

    ‘And sometimes we ring the out-of-hours emergency service, and then the guys there are unable to access the doctor’s module, which means the attending doctor won’t be able to read what’s been described, and then it’s a matter of starting up with this, that and the other.’

    The informants found their contact with the out-of-hours emergency service to be challenging if the attending doctor was unable to access the patient’s medical records.

    Contact with relatives

    The nurses described conversations with the patients’ relatives as an important part of their nutritional work in nursing homes. They pointed out that family members are concerned about the nutritional situation for their loved ones, and could be anxious about patients eating too much or too little. Several nurses reported that the nursing home doctor was taken more seriously and commanded more authority than themselves during conversations with patients’ relatives about food and drink:

    ‘They take more note of what the doctor says, I believe, for we can say whatever we want, but then you’re only a nurse. But if a doctor says the same thing, then it’s sort-of right.’

    Family-centred medicine

    The informants described how important it was for the nursing home doctor to be willing to set aside time to talk to the patients’ relatives and to show an interest. If nutrition had been raised as a topic during the admission interview it was easier for the family to relate to the nursing home’s guidelines if the patient were to refuse food, or if the patient’s life was nearing the end. This prepared them for what was to come, and enabled them to play a part in the patient’s own process.

    Two nurses used the concept ‘family-centred medicine’ and felt this expression was commonly used at the nursing home:

    ‘We call it family-centred medicine, that they have been so fixated on their mother dying from thirst that we have inserted an intravenous line just to make things easier for the relatives.’

    Explaining the final stage

    If the doctor explained to the relatives what the patient’s last days would be like, as part of the nursing home’s routine, it was more likely that the relatives would accept the patient’s end-of-life process.

    Several informants talked about how many relatives worried that the nurses were killing their loved ones if they did not offer food and drink to patients who did not want to eat or who could not muster the energy. The reason was that they did not understand the patient’s process. One of the nurses compared the dying process to a wilted plant on the window ledge:

    ‘It’s no use watering the plant if it has shrivelled up, and that’s how it is with our bodies as well.’

    This was an image the relatives understood, but they often refused to accept the situation until they heard it from the doctor. Consequently, it was important for relatives to feel that the doctor and the nurses had a joint approach to the patient’s nutritional problem.

    Discussion

    This study shows that nurses believe a collaborative partnership with the nursing home doctor is important for the patients’ nutritional treatment and status. The nurses carry the day-to-day responsibility for the nutritional work, while the nursing home doctor has a key function as a dialogue partner for the nurses, the patients and their relatives.

    Furthermore, it is important that the doctor knows and takes an interest in the individual patients, their relatives and the nurses on the ward. If the patient’s nutritional status is discussed during the admission interview and when doctors do their round, all parties will be prepared and can focus on the patient’s path ahead.

    Assessing the nutritional need

    Good nutritional practices in nursing homes require nursing staff and doctors to work together to establish and continually assess whether the patients’ nutritional needs are met by the meals provided. They also need to follow up as required and document the patients’ nutritional status (8, 9).

    The nurses’ responsibilities include an assessment of the nutritional situation as well as appropriate follow-up initiatives. They are also tasked with obtaining assistance from other qualified personnel if required. The doctor, however, has overall responsibility for the medical examination, diagnosis and treatment (1, 9). This distribution of responsibilities requires constant interaction and a systematic review of the patient’s nutritional status.

    Inadequate nutritional expertise has been identified among health care personnel (9, 14) and among Norwegian nurses (15, 16). Mowe et al. show that doctors and nurses in Scandinavia have insufficient knowledge about nutrition, and that good nutritional practices are dependent on a good level of nutritional knowledge (17).

    The World Health Organization points to a shortage of targeted courses on nutrition for health care personnel, and emphasises that nutritional work must be integrated at local level (18).

    The need to keep professionally updated

    It is worrying that nurses fail to keep professionally updated within the area of nutrition. All nurses have an independent function which involves a professional, ethical and personal responsibility for their own actions and assessments (19). This includes a personal responsibility for keeping professionally updated on research, development and documented practices within the areas of nutrition and geriatrics.

    Furthermore, they should help ensure that new knowledge is applied in practice. It is also worrying if the World Health Organization is correct in pointing to an inability to integrate nutritional work at individual nursing homes and in the service provision to individual patients (18).

    If doctors and nurses enhance their nutritional expertise, they will find it easier to cooperate and focus on the nutritional work in nursing homes (18). Task distribution, patient base, nutritional competence, professional development, service user involvement and adaptation are also important factors that impact on their ability to cooperate with respect to the patient’s nutritional status (20).

    It is worrying that nurses fail to keep professionally updated within the area of nutrition.

    There is a need for roles and responsibilities to be clearly distributed between doctors and nursing staff on each ward, and a good collaborative climate is important. It may be worth noting that the nurses who contributed to our study consider the doctor’s rounds and the doctor’s discussions with the patients and their family to be important arenas for collaboration that provide opportunities to clarify expectations, roles and responsibilities.

    For patients, sound nutritional treatment of a high standard means the provision of individual assistance adjusted to the patient’s needs (1). If the nurses have inadequate nutritional expertise and there is no dialogue or interaction between nurses and doctors, then the required level of nutritional safety and quality will be difficult to achieve.

    Increased focus on nutritional work

    The informants report varying degrees of involvement from nursing home doctors with respect to the patients’ nutritional situation. It is however a matter for concern that the nurses afford less attention to the patients’ nutritional needs if this is not specifically raised during the doctor’s visit to the home.

    Leirvik et al. (21) show that nurses in nursing homes are not particularly focused on nutritional work because other nursing tasks take priority. Pressures of time and a multitude of tasks are the reality of today’s nursing homes. Nevertheless, we query how nurses can overlook the patient’s need for nourishment, as all nurses have a professional responsibility to fulfil the patient’s basic needs (7, 22).

    The patient’s nutritional status is an important part of the patient’s overall treatment, and the nurses in the study stressed this point. They also emphasised that good cooperation with the nursing home doctor could prevent hospitalisation and excessive treatment if the patient’s condition deteriorated or if they refused to eat.

    A survey of patients admitted to hospital from nursing homes in the area around Bergen concluded that the homes did not have satisfactory procedures for the medical assessment made by doctors prior to hospitalisation. It also appeared that the decision-making processes in relation to hospitalisation were inadequate (23), a point also made by the nurses in our study.

    Strengths and weaknesses of the study

    The study’s strength is its focus group interviews with nurses from different parts of the country. All informants have many years’ experience and represent nursing homes of different sizes. The data have been processed by both the first and second author, and there is consensus with respect to the analysis and the results.

    It may be a weakness that we never asked the focus groups specifically about the role of the nursing home doctor in relation to their nutritional work. Nevertheless, the interaction with the doctor is clearly raised during the interviews. We therefore feel it is important to highlight the need for good cooperation between nurses and doctors in order to achieve the best possible standard of nutritional care for nursing home patients.

    Conclusion

    This article explores the nurses’ perception of the role played by the nursing home doctor with respect to the nutritional work. The main finding is that the interaction between nursing staff and doctors impacts significantly on the nutritional status of nursing home patients.

    To be able to attend to their patient’s nutritional status in the best possible way, the nurses need a regular nursing home doctor who knows the patients’ individual nutritional wishes and needs, and who takes an interest in and checks up on the nutritional work carried out on the ward.

    Nurses, patients and relatives all feel more re-assured when the nursing home doctor interacts with the nursing staff and discusses the expected development with patients and their family. As life is nearing its end, it is particularly important that both nurses and doctors know the patient’s wishes and needs.

    References

    1.        Helsedirektoratet. Nasjonale faglige retningslinjer for forebygging og behandling av underernæring. 2009. Available at: https://helsedirektoratet.no/Lists/Publikasjoner/Attachments/916/Nasjonal-faglig-retningslinje-for-forebygging-og-behandling-av-underernering-IS-1580.pdf(downloaded 09.01.2017).

    2.        Busch T, Johnsen E, Klausen KK, Vanebo JO. Modernisering av offentlig sektor. Trender, ideer og praksiser. 3. ed. Oslo: Universitetsforlaget; 2011.

    3.        Meld. St. 11 (2015-2016). Nasjonal helse- og sykehusplan. Oslo: Helse- og omsorgsdepartementet; 2015. Available at: https://www.regjeringen.no/no/dokumenter/meld.-st.-11-20152016/id2462047/sec (downloaded 20.02.2017)

    4.        Mowe M, Bosaeus I, Rasmussen HH, Kondrup J, Unosson M, og Irtun Ö. Nutritional routines and attitudes among doctors and nurses in Scandinavia: A questionnaire based survey. Clinical Nutrition 2006;25(3):524–32.

    5.        Sortland K. Ernæring – mer enn mat og drikke. Bergen: Fagbokforlaget; 2015.

    6.       Baldwin C, Weekes CE. Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults. Cochrane Database Syst Rev. Sep 2011 7;(9):CD002008. DOI: 10.1002/14651858.

    7.       Sortland K, Gjerlaug AK, Harviken G. Vektdokumentasjon, kroppsmasseindeks, måltidsfrekvens og nattfaste blant eldre sykehjemsbeboere – en pilotstudie. Vård i Norden 2013;33(1):41–5.

    8.       Aagaard H. Mat og måltider i sykehjem: undersøkelse utført for Sosial- og helsedirektoratet. Halden: Høgskolen i Østfold; 2008.

    9.       Helsedirektoratet. Kosthåndboken : Veileder i ernæringsarbeid i helse- og omsorgstjenesten. 2012.

    10.      Hjort PF. Legens ansvar for kulturen i sykehjemmet. Tidsskr Nor legeforen 2002;122:1586–8.

    11.      Malterud K. Fokusgrupper som forskningsmetode for medisin og helsefag. Oslo: Universitetsforlaget; 2012.

    12.      Malterud K. Kvalitative metoder i medisinsk forskning: En innføring. Oslo: Universitetsforlaget; 2011.

    13.         Giorgi A. Sketch of a psychological phenomenological method. In: Giorgi A (ed.). Phenomenology and psychological research. Pittsburgh, PA: Duquesne University Press; 1985.

    14.        Persenius MW, Hall-Lord M, Baath C, Larsson BW. Assessment and documentation of patients’ nutritional status: Perception of registered nurses and their chief nurses. J Clin Nurs 2008;17:2125–36. DOI: 10.1111/j.1365-2702.2007.02202.x.

    15.        Sæland M. Sykepleiere trenger mer utdanning for å servere mat. Sykepleien. 2014. Available at: http://sykepleien.no/meninger/innspill/2014/11/servering-av-mat-er-sykepleierens-oppgave (downloaded 10.01.2017).

    16.        Juul H, Frich JC. Kartlegging av underernæring i sjukehus. Hva hemmer og fremmer sykepleieres bruk av screeningverktøy for identifisering av ernæringsmessig risiko? Nordisk Sygeplejeforskning 2013;3:77–89.

    17.        Mowe M, Bosaeus I, Rasmussen HH, Kondrup J, Unosson M, Rothenberg E, Irtun Ø, The Scandinavian Nutrition group. Insufficient nutritional knowledge among health care workers? Clinical Nutrition 2008;27:196–202.

    18.        Verdens helseorganisasjon (WHO). Evaluation of the Norwegian nutrition policy with a focus on the Action Plan on Nutrition (2007–2011). Available at: http://www.euro.who.int/__data/assets/pdf_file/0003/192882/Evaluation-of-the-Norwegian-nutrition-policy-with-a-focus-on-the-Action-Plan-on-Nutrition-20072011.pdf(downloaded 20.02.2017).

    19.        Norsk Sykepleierforbund. Yrkesetiske retningslinjer for sykepleiere. Available at: https://www.nsf.no/vis-artikkel/2193841/17102/Yrkesetiske-retningslinjer(downloaded 20.02.2017).

    20.        Helse- og omsorgsdepartementet. I-4/2007 Nasjonal standard for legetjenester i sykehjem. Available at: https://www.regjeringen.no/no/dokumenter/i-42007-nasjonal-standard-for-legetjenes/id458057/(downloaded 20.02.2017).

    21.        Leirvik ÅM, Høye S, Kvigne K. Mat, måltider og ernæring på sykehjem – erfaringer fra et aksjonsforskningsprosjekt. Nordisk Sygeplejeforskning 2016;02:179–97. DOI: 10.18261/issn.1892-2686-2016-02-07.

    22.        Söderhamn U, Söderhamn O. A successful way for performing nutritional nursing assessment in older patients. J Clin Nurs 2009;18(3):431–9. DOI: 10.1111/j.1365-2702.2008.02378.x.

    23.        von Hofacker S, Naalsund P, Iversen S, Rosland JH. Akutte innleggelser fra sykehjem til sykehus i livets sluttfase. Tidsskr Nor Legefor 2010;130:1721–4. DOI: 10.4045/tidsskr.09.1028.

    For nurses to be able to attend to their patients’ nutritional status in the best possible way, they need a regular nursing home doctor who knows the nutritional wishes and needs of individual patients.

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    English
    Sammendrag

    Background: The nutritional work carried out in nursing homes constitutes necessary and important health care. In many nursing homes, the nutritional work forms part of a collaborative procedure that involves a number of disciplinary groups and professionals. Research and monitoring have found that between 20 and 60 per cent of patients in nursing homes are undernourished.

    Objective: The study examines how nurses interact with the nursing home doctor. This topic has received little attention in research.

    Method: The study has a qualitative design and involves the analysis of focus group interviews with nurses whose duties include hands-on patient care. The analysis is based on Malterud’s approach to analysing data, involving the reading of the text as a whole, meaning units, categorisation and abstraction before the findings are summarised.

    Results: The level of cooperation between nurses and the nursing home doctor impacts significantly on the nutritional work carried out in nursing homes. Patients and their relatives are reassured when the nursing home doctor raises the subject of nutrition on admission, informs them of expected developments and is familiar with the patient’s wishes and needs. Similarly, nurses need a nursing home doctor who knows the nutritional wishes and needs of individual patients, and who checks up on the nutritional work on the ward.

    Conclusion: The experiences of the nursing home nurses suggest that collaboration with the nursing home doctor is an important factor for the institution’s nutritional work. Good cooperation promotes medically sound nutritional treatment of nursing home patients.

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  • Healthcare personnel’s assessment of their competence after a course in trauma nursing

    Trauma is the leading global cause of death and disability (1). In western countries, injuries are the main cause of death among people aged between 1 and 44 (2). An organised and formalised trauma system with dedicated trauma teams has been shown to optimise patients’ clinical outcomes after injury and lead to higher survival rates (3, 4).

    Based on recommendations in a report on the trauma system in Norway ( Traumesystem i Norge), Norwegian trauma hospitals must meet certain criteria for resources, and trauma team specialists must meet competence requirements (5).

    Competence can be defined as ‘the aggregate knowledge, skills, abilities and attitudes that make it possible to perform relevant functions and tasks in accordance with defined requirements and goals’ (6, p. 48). Self-perceived competence relates to how individuals view their own competence in different areas, and is not an objective measurement (7).

    Background

    Oslo University Hospital, Ullevål is Norway’s largest trauma hospital, with around 2000 trauma patients every year. Its trauma team consists of 15 specialists, each with their own specific duties (8).

    Oslo University Hospital, Ullevål is Norway’s largest trauma hospital, with around 2000 trauma patients every year.

    Trauma treatment at Oslo University Hospital, Ullevål began in 1984 with the activation of teams of trauma specialists and the implementation of guidelines for receiving and treating trauma patients in line with the hospital’s trauma manual (3, 8). The trauma manual is based on Advanced Trauma Life Support (ATLS), a course in life-saving treatment for doctors. The course aims to provide theoretical knowledge and practical skills in relation to trauma patients (9-11).

    Course in Trauma Nursing

    Advanced Trauma Care for Nurses (ATCN) is an international course for nurses in trauma teams. This course is based on ATLS. In Norway, the Course in Trauma Nursing is organised as a two-day basic course in trauma treatment. The course model is based on ATLS and ATCN, and provides an introduction to standardised principles for receiving and treating injured trauma patients.

    The Course in Trauma Nursing focuses on initial treatment upon arrival at a hospital qualified to deal with trauma patients. The course began in 2011 and has since expanded its reach to 40 Norwegian hospitals with a trauma function. The target group for the course is nurses who are involved in the reception of trauma patients, but it is also offered to other professions with an active role in trauma treatment. The course has been quality assured by the Department of Traumatology at Oslo University Hospital, Ullevål and the National Advisory Unit on Trauma.

    Several studies claim there is a need for more knowledge about the impact of trauma courses and trauma training on nurses (12-15). Evidence shows that the level of professional knowledge increases after participation in ATLS and ATCN (16-19). However, the literature identifies shortcomings in studies that have evaluated the impact of self-perceived competence in nurses after participating in trauma courses.

    Objective of the study

    The objective of our study was to investigate healthcare personnel’s (henceforth referred to as course participants) self-perceived change in competence in the reception and treatment of trauma patients before and after completing the Course in Trauma Nursing.

    We formed the following hypothesis: course participants’ competence in the reception and treatment of trauma patients will be improved two months after completing the Course in Trauma Nursing. The aim of the study was to answer two research questions:

    • To what extent does the Course in Trauma Nursing contribute to self-perceived change of competence in the reception and treatment of trauma patients?
    • What correlations are there between gender, age, number of years of further education, trauma team participation, participation in previous trauma courses and changed competence after the Course in Trauma Nursing?

    Method

    Design

    The study has a prospective survey design, where we have applied the pretest-posttest method to a single group. We collected data in an electronic questionnaire two weeks before the start of the course and two months after the end of the course.

    Sample

    Seven hospitals that arranged the Course in Trauma Nursing in November and December 2014 were invited to participate in the study. One of the seven hospitals did not provide consent to the study before the start of the course and was therefore excluded. The hospitals varied in geographical location and size.

    A coordinator for the course at each institution asked registered course participants if they wanted to participate in the study, and 94 participants were invited. Inclusion criteria were nurses, specialist nurses, radiographers and ambulance workers who signed up for the Course in Trauma Nursing. Exclusion criteria were course participants who did not complete the course or answered less than 50 per cent of the questions in the questionnaire.

    Questionnaire

    For this study, we further developed an existing, validated questionnaire (20). Figure 1 provides a summary of this.

    The original questionnaire consisted of four parts. Part 1 dealt with concordance between specialist nurses’ self-perceived competence and job requirements. Part 2 related to concordance between colleagues’ expectations for competence and self-perceived competence after completion of their education. In Part 3, we asked for suggestions for improvements to the education programme, and in Part 4 we recorded background data.

    We excluded Parts 2 and 3 because they were not relevant to our study. Part 1 contained 36 closed questions about self-perceived competence, divided into seven competence areas. Four of the seven areas were excluded because they were not relevant to the Course in Trauma Nursing.

    The three competence areas that we used in the questionnaire for this study were medical competence, teamwork competence and choice and improvisation competence.

    Figure 1. Further development of questionnaire

    We revised and adapted the questions in Part 1 to the course syllabus in order to survey the competence of the course participants. The resulting questionnaire was given the title ‘Evaluation of self-perceived competence in the reception and treatment of trauma patients before and after the Course in Trauma Nursing’ (EVAKITS1 for the pretest and EVAKITS2 for the posttest).

    The questionnaire consisted of 23 closed questions about practical and theoretical competence in the reception and treatment of trauma patients. Of these, 17 questions related to medical competence, three related to teamwork competence and three concerned choice and improvisation competence.

    The response alternatives were in the form of a seven-point Likert scale, where 1 = I do not feel very competent at all and 7 = I feel very competent. We asked the course participants to evaluate their self-perceived competence using the scale for each question within the three competence areas. The questionnaires were produced electronically using the Questback computing program.

    Panel of experts

    We created a panel of experts in order to reinforce the validity and reliability of the questionnaire. The remit of the panel was to use their experience to evaluate the questionnaire as a data collection method (21). Twelve nurses from different hospital departments were invited to join the panel.

    The panel was made up of nurses and specialist nurses, about half of whom had completed the Course in Trauma Nursing. They gave us feedback on the questionnaire content and question formulation (22). This feedback led us to reformulating some questions that seemed unclear, without changing the areas of competence and content.

    Data collection

    We collected the data in the period from November 2014 to February 2015. The Course in Trauma Nursing coordinator instigated the first contact with the course participants. We sent letters with information about the purpose of the study and informed consent to the respondents before EVAKITS1 was distributed. Return of the questionnaire was regarded as consent to taking part in the study.

    In order to investigate changes in competence, it was necessary to compare the course participants’ responses from EVAKITS1 and EVAKITS2 and then consider the group’s overall change. Respondents who did not answer EVAKITS1 were not therefore sent EVAKITS2.

    Analysis

    The data were transferred electronically from Questback to the Statistical Package for the Social Sciences (SPSS), version 22.0 for Mac. We used descriptive statistics with frequency and percentages for categorical variables to describe the demographics of the course participants.

    We also used mean and standard deviations for continuous variables. The response alternatives on the Likert scale were treated as continuous because the Likert scale was greater than 5 and summarised as a total score (23).

    Each question had a minimum score of 1 and a maximum score of 7. Medical competence gave a maximum score of 119. Teamwork competence and choice and improvisation competence each had a maximum score of 21. The majority of the answers to the questions had a normal distribution.

    In order to answer the first research question, we examined the change in competence with a paired sample t-test. For the second research question, we examined how the independent variables (number of years of further education, trauma team participation, age, trauma course participation and gender) impacted on the dependent variable (mean change examined for 23 questions in the questionnaire). The mean change was the differential between mean posttest and mean baseline.

    First, we tested the independent variables in univariate analyses. We then performed a multiple regression analysis where we examined the variables that were significantly related to change in competence (the dependent variable). Only variables that achieved significance in the univariate analyses for the same question were controlled in the latter analysis. P-value <0.05 was considered statistically significant.

    Ethics

    The study is approved by the Norwegian Centre for Research Data (NSD). The data we collected were stored separately from personal identification information and password-protected linked identifiers between course participants and the data material.

    Results

    Sample

    Of the 94 participants, 52 responded to the pretest (55.3 per cent). Forty-five of those who responded to the pretest returned the posttest questionnaire (86.5 per cent). A total of 16 men (31 per cent) and 35 women (69 per cent) took part.

    Seventy-seven per cent of the course participants were involved in a trauma team. The mean clinical experience for receiving and treating trauma patients was 8.5 years (SD 8.3). Table 1 gives an overview of the participants’ socio-demographic variables.

    Table 1. Demographic characteristics of course participants (n = 52)

    Competence after completed course

    Course participants reported a significantly greater increase in medical competence and choice and improvisation competence two months after the Course in Trauma Nursing compared to the pretest (see Table 2). Course participants also reported an increase in teamwork competence, but for the question relating to knowledge of own area of responsibility in the trauma team, the increase was not significant.

    Table 2. Mean score of course participants' competence from 1–7

    How individual variables impact on changed competence

    The individual variables that were controlled for change are shown in Table 3.

    Table 3. 	Independent variables’ impact on mean change (dependent variable) for each question (n = 52)

    Gender

    Regarding the questions ‘Receiving and treating pregnant trauma patients’ and ‘Assessing trauma patients according to the Glasgow Coma Scale (GCS)’, men found that their competence improved to a greater extent than women.

    Trauma team

    For the question ‘Having knowledge of your own area of responsibility in the trauma team’, course participants who were not part of a trauma team reported a significantly greater improvement in their competence compared to those who did work in a trauma team.

    Trauma course

    Trauma course was the variable that impacted on changes for most questions. Course participants who had not participated in trauma courses other than the Course reported an improvement in competence for four of the questions, compared to those who had attended other trauma courses.

    All of the questions related to medical competence: ‘Receiving trauma patients according to the ABCDE approach’, ‘Fitting and adjusting neck collars’, ‘Receiving and treating respiration and/or circulation in unstable trauma patients’ and ‘Receiving and treating trauma patients with unstable head injuries’.

    Age and number of years of further education

    Three questions showed a significantly negative change for age. When age increases by one year, the change is reduced by 0.04 for the question ‘Initiating measures to clear respiratory passages’. ‘Identifying different types of shock’ was reduced by 0.03 and ‘Rapid prioritising/re-prioritising of tasks when the situation so demands’ was reduced by 0.03.

    As Table 3 shows, the changes for the answers to the aforementioned three questions were also adversely affected by the number of years of further education. Because the two variables showed significant change for the same three questions, we performed a multiple linear regression analysis to investigate whether the combination of variables impacted on each other.

    The analyses showed that when the number of years of further education is constant and the age increased by one year, the course participants reported a reduction in competence for one of the questions: ‘Rapid prioritising/re-prioritising of tasks when the situation so demands’ (p = 0.044) (data not shown).

    The combination of age and further education was not significant for the other two questions. None of the remaining independent variables showed change for the same question, so a multiple regression analysis was only performed for the aforementioned two variables.

    Discussion

    The results show that all course participants largely reported a positive change in competence in all competence areas, from baseline to two months after the course.

    Questions showing the greatest change in competence

    As Table 2 shows, the course participants experienced the greatest change in competence in relation to the questions ‘Fitting and adjusting neck collars’, ‘Log rolling patients’ (see the fact box), ‘Receiving and treating pregnant trauma patients’ and ‘Initiating measures to stop blood loss in accordance with the massive haemorrhage protocol’.

    The practical exercise stations in the Course in Trauma Nursing focus on teaching course participants procedures that are highly relevant to the reception and treatment of trauma patients. Fitting a neck collar and log rolling are themes of two of the exercise stations. Course participants are taught the theory before practising the procedures under the supervision of an instructor.

    Fakta
    Log roll

    In cases of a suspected vertebral fracture, the log rolling technique is used when patients need to be moved onto their side. Log rolling is performed by four people rolling the patient onto their side without flexing the body in a way that could aggravate the fracture (37).

    The large differential in mean scores may indicate that the course participants find that the exercises help to improve competence. The findings are supported by the literature, which shows that training in technical simulation improves skills and increases the rate of retention (24-25).

    The reception and treatment of trauma patients in the period between the baseline and the posttest may be a factor that impacts on the change of competence as a result of course participants being able to put their knowledge from the course into practice. The Course in Trauma Nursing has a standardised, theoretical education programme. Lectures are given on, for example, injury mechanisms and special patient groups such as the elderly, children, burns patients and pregnant patients.

    Pregnant trauma patients 

    Pregnant trauma patients are a rare patient group (8, 26). It is therefore considered unlikely that a marked change in competence is correlated with two months of experience from practice. It is more likely that the lecture on pregnant trauma patients has contributed to their knowledge. The improvement in course participants’ competence is due to the fact that they have learned how to receive and treat this patient group.

    Massive haemorrhage is greatest challenge

    Haemorrhages account for 40 per cent of trauma-related deaths, and the most challenging surgical situations in trauma treatment are caused by massive haemorrhages (27, 28). Patients in haemorrhagic shock are critically ill and require immediate blood transfusion and surgical intervention (29).

    On the Course in Trauma Nursing, the guidelines on massive transfusion protocol are discussed in the lecture on shock treatment. The participants’ increase in self-perceived change in relation to the question ‘Initiating measures to stop blood loss in accordance with the massive haemorrhage protocol’ may be the result of newly acquired knowledge from the theoretical lecture.

    Positive change in competence

    The questions about medical competence focused specifically on the theoretical lectures in the Course in Trauma Nursing. Teamwork competence and choice and improvisation competence are not covered so specifically in theoretical lectures. Nevertheless, the results show a positive change of competence for both areas of competence.

    Teamwork competence entails the team members’ ability to perform their duties in a flexible manner, among other things. The reception and treatment of trauma patients can be challenging and resource-intensive because many parallel actions take place simultaneously.

    This requires every person in the trauma team to carry out their specific duties satisfactorily. At the same time, knowledge about their own duties and the duties of others is a contributing factor in functional teamwork (30).

    The reception and treatment of trauma patients can be challenging and resource-intensive because many parallel actions take place simultaneously.

    The positive self-perceived change in relation to the question ‘Having knowledge of other trauma team members’ areas of responsibility’ may be due to the fact that the Course in Trauma Nursing is offered to specialist nurses and other professions involved in trauma teams.

    Joint training for the different professions involved in a trauma team can generate interest across the groups. The Course in Trauma Nursing instructors are nurses with different specialities from trauma teams. This gives the course a broad scope in terms of areas of responsibility since the respective occupational groups can provide more detailed descriptions of their duties.

    Questions without significant change in competence

    Knowledge of own area of responsibility in the trauma team was the only question that showed no statistical significance after participants had completed the course. Mean baseline scores for this question had the highest output value. This value indicates that the course participants felt that their competence was already very good prior to taking the course. There was therefore less potential for improvement.

    Choice and improvisation competence also shows a positive change from baseline to posttest, and had the lowest mean change differential. In hindsight, the formulation of questions in this area of competence could be called into question since the questions are rather vague and are open to interpretation.

    The questions are not necessarily a good indicator of the effectiveness of the actual course. However, the overall positive change may be due to the fact that the Course in Trauma Nursing generally contributes to knowledge, which makes participants feel more confident and competent in making choices and improvising.

    Involvement in a trauma team as a contributing factor

    The results for two of the questions showed significantly greater competence for course participants who were not involved in a trauma team than for those who were part of a trauma team. These two questions were ‘Fitting and adjusting neck collars’ and ‘Having knowledge of your own area of responsibility in the trauma team’.

    All trauma patients received and treated by a trauma team must have a neck collar fitted prior to their arrival in hospital. Patients who arrive without a neck collar are fitted with one as a matter of urgency.

    The differential between the two groups can be explained by the fact that course participants who are not involved in a trauma team benefit more from the practical exercise station because they are less knowledgeable about the procedure in the first place. Even if a procedure has not been carried out in practice after the Course in Trauma Nursing, new knowledge can contribute to a self-perception of greater competence.

    Gender as a contributing factor

    The mean change in competence between the sexes showed a significant differential in just one question. For the question ‘Receiving and treating pregnant trauma patients’, men reported more of an improvement in competence than women.

    Trauma course as a contributing factor

    Compared with course participants who had been on a trauma course, participants who had not participated in a trauma course showed a significant positive change for four of the questions about medical competence.

    The changes shown for the relevant questions may indicate that the Course in Trauma Nursing learning curve is steeper for participants who have not taken a trauma course than for those who have participated in such a course. The reason may be that course participants who have been on a trauma course, such as ATCN, already have knowledge within the areas covered in the Course in Trauma Nursing. Thus, it is not quite so apparent whether this group’s competence has changed.

    Age and number of years of further education as a contributing factor

    The course participants’ age and number of years of further education showed a significantly negative change for the same three questions: ‘Initiating measures to clear respiratory passages’, ‘Identifying different types of shock’ and ‘Rapid prioritising/re-prioritising of tasks when the situation so demands’.

    It is conceivable that newly qualified course participants with less work experience have greater self-confidence, and therefore give themselves higher scores. At the same time, younger participants may have a steeper learning curve because they tend to learn faster than the older participants (31).

    It is conceivable that newly qualified course participants with less work experience have greater self-confidence, and therefore give themselves higher scores.

    Nevertheless, it is difficult to explain why age and number of years of further education only affected three of the 23 questions when combined in the regression analysis. However, for the question ‘Rapid prioritising/re-prioritising of tasks when the situation so demands’, age had a negative effect on the change when the number of years of further education was constant.

    This indicates that age is the variable in this question that had the greatest negative impact on the changes. Because both of the aforementioned variables relate to a small minority of the questions, we cannot conclude that age and further education were contributing factors for changes in competence after the course.

    Strengths and limitations

    The biggest challenge in this study is the small sample. The sample size makes it particularly difficult to examine sub-samples. We may not, therefore, be able to identify statistical changes that could have been shown in a larger sample. This particularly applies to the results shown in Table 3. It was also difficult to make a calculation of strength before the study started as we lacked input data.

    Course participants may be influenced by their expectations of the course, leading them to give their competence a higher score in the posttest (28). At the same time, renewed knowledge may make participants feel that they are more competent. There may also be a correlation between change in competence and motivation, prior knowledge and the field of practice’s interest in competence development (32).

    These factors are important and must be taken into consideration when the results are to be generalised vis-à-vis other samples or studies. In the linear regression analysis, we performed multiple analyses. This may be a weakness of the study since statistical significance can be achieved by chance (33).

    Good response rate

    The sample is taken from hospitals that vary in geographical location and size, something that strengthens the representativeness of the study. The original response rate of 55.4 per cent should ideally have been higher in order to be able to generalise (22, 34).

    The response rate for EVAKITS2 (85.6 per cent) strengthens the internal validity of the study. The purpose of the study is to measure the subjective competence of course participants. The internal validity of the study is impaired because of the study’s inability to measure the changes without a control group, and this is the greatest weakness of the study.

    Control group recommended

    The pretest-posttest design of the study, where the same group is used without a control group, makes it difficult to check for sources of error, bias and contributing factors (35). We call on researchers who wish to carry out future studies to use a control group.

    We further developed the validated questionnaire aimed at evaluating competence after further education in anaesthesia nursing, paediatric nursing, critical care nursing and theatre nursing ( Evaluering av kompetanse etter videreutdanning i anestesi-, barne-, intensiv- og operasjonssykepleie). As not all of the questions were relevant to our study, a panel of experts evaluated the relevant part of the questionnaire to ensure that it was clinically credible and valid (36).

    Some working groups in the sample population were too small to investigate the mean change in competence for different professions. Future studies with larger samples are, however, encouraged to investigate change across the Course in Trauma Nursing working groups.

    Conclusion

    The study shows that the Course in Trauma Nursing contributes to increased self-perceived competence for course participants who receive and treat trauma patients, from baseline to two months after the course. The changes after completion of the course are statistically significant for 22 of the 23 questions concerning medical competence, teamwork competence and choice and improvisation competence. Thus, we can conclude that the hypothesis that we put forward before the study is supported.

    There is essentially no differential in self-perceived change in competence in relation to gender, age, participation in a trauma team and number of years of further education.

    Course participants who have not previously participated in trauma courses report a greater improvement in competence for about a quarter of the medical competence questions than those who have attended a trauma course.

    There is essentially no differential in self-perceived change in competence in relation to gender, age, participation in a trauma team and number of years of further education.

    The Course in Trauma Nursing should continue to be a priority area for acute care hospitals with a trauma function, both for trauma team specialists and for other professions involved in the treatment of trauma patients.

    Given the study’s positive finding two months after the Course in Trauma Nursing, it would be interesting to investigate the long-term effect of the course. It would also be useful to investigate whether taking part in the course increases participants’ interest in traumatology. 

    References

    1.       Mock C, Lormand JD, Goosen J, Joshipura M, Peden M. Guidelines for essential trauma care. Geneve: World Health Organization; 2004.

    2.       Groven S. Performance assessment of a major Scandinavian trauma center during implementation of a dedicated trauma service. (Doktoravhandling). Oslo: Det medisinske fakultet, Universitetet i Oslo; 2014.

    3.       Groven S, Eken T, Skaga NO, Roise O, Naess PA, Gaarder T. Long-lasting performance improvement after formalization of a dedicated trauma service. J trauma 2011;70(3):569–74.

    4.       Lo CJ, Lee HY. Evaluation of an advanced trauma life support course in Taiwan. Formosan Journal of Surgery 2014;47:221–6.

    5.       Røise O. Traumesystem i Norge: forslag til organisering av behandling av alvorlig skadde pasienter. Hamar: Helse Øst; 2006.

    6.       Lai L. Strategisk kompetansestyring. Bergen: Fagbokforlaget; 2004.

    7.       Kleve R-AT. Motoriske vansker av selvopplevd kompetanse. (Master's thesis). Oslo: Psykologisk Institutt, Universitetet i Oslo; 2012.

    8.       Ullevål universitetssykehus. Traumemanualen – initialbehandling av den multitraumatiserte pasient ved Ullevål universitetssykehus. 6 utgave. Oslo: Fresenius Kabi; 2011.

    9.       Bell RM, Krantz BE, Weigelt JA. ATLS: A foundation for Trauma Training. Ann Emerg Med 1999;34(2):233–7.

    10.     Ali J, Adam R, Stedman M, Howard M, Williams JI. Advanced trauma life support (ATLS) program increases emergency room application of trauma resuscitative procedures in a developing country. J Trauma 1994;36:391–4.

    11.     Kennedy DWG, Gentleman D. The ATLS course, a survey of 228 ATLS providers. Emer Med J 2001;18:55–8.

    12.     Hadfield-Law L. Advanced trauma nursing course (ATNC). Care of Critically Ill 1994;10(1):18–21.

    13.     Tippet J. Nurses acquisition and retention of knowledge after trauma training. Accid Emerg Nurs 2004;12(1):39–46.

    14.     Hammond F, Saba M, Simes T, Cross R. Advanced life support: retention of registered nurses’ knowledge 18 months after initial training. Aust Crit Care 2000;13(3):99–104.

    15.     Armstrong B, Crouch R, Read C, Palfrey R. Training nurses in trauma management. Emerg nurse 2013;21(4):14–8.

    16.     Ali J, Adam R, Pierre I, Bedaysie H, Josa D, Winn J. Comparison of performance 2 years after the old and new (interactive) ATLS courses. J Surg Res 2001;97(1):71–5.

    17.  Mohammad A, Branicki F, Abu-Zidan FM. Educational and clinical impact of Advanced Trauma Life Support (ATLS) courses: A systematic review. World J Surg 2014;38:322–9.

    18.     Patient L. Trauma training: a literature review. Emer nurse 2007;15(7):28–37.

    19.     Canzian S, Nanni J, McFarlan A, Chalkin K, Sorvari A, Barratt L et al. Application and evaluation of knowledge retention related to Advanced Trauma Care for Nurses (ATCN) Course content: a preliminary study. J Trauma Nurs 2016;23(4):202–9.

    20.     Valeberg BT, Grønseth R, Fagermoen MS. Spesialsykepleieres opplevde kompetanse etter endt utdanning. Sykepleien Forskning 2009;4(3):206-213. Available at: https://sykepleien.no/forskning/2009/10/spesialsykepleieres-opplevde-kompetanse-etter-endt-utdanning(downloaded 16.11.2017).

    21.     Kirkevold Ø. Praktiske tips ved spørreundersøkelser, del 2. Sykepleien Forskning 2014;9(1):92–4. Available at: https://sykepleien.no/forskning/2014/04/praktiske-tips-ved-sporreskjemaundersokelser-del-2(downloaded 27.11.2017).

    22.     Gustavsen G. Spørreskjemametodikk etter kokebokmetoden. Oslo: Ad Notam Gyldendal. 1999.

    23.     Johannessen A. Introduksjon til SPSS. Versjon 17. Oslo: Abstrakt Forlag. 2008.

    24.     Park C. Simulation and quality improvement in anesthesiology. Anesthesiology Clin 2011;(29):13–28.

    25.     Green M, Tariq R, Green P. Improving patient safety through simulation training in anesthesiology: Where are we? Anesthesiol Res Pract 2016;2016:4237523.

    26.     Horstmann P, Larsen CF, Grønborg H. Adherence to protocol in pregnant trauma patients? A 12-year retrospective study. European J Trauma Emerg Surg 2014;40(5):561–6.

    27.     Nascimento B, Callum J, Rubenfeld G, Neto JBR, Lin Y, Rizoli S. Clinical review: Fresh frozen plasma in massive bleedings – more questions than answers. Critical Care 2010;14(1):202.

    28.     Gaarder C, Naess PA, Buanes T, Pillgram-Larsen J. Advanced surgical trauma care training with a live porcine model. Injury 2005;36:718–24.

    29.     Colwell C, Moreira M E, Grayzel J. Initial evaluation and management of shock n adult trauma. 2015. Available at: https://www.uptodate.com/contents/initial-evaluation-and-management-of-shock-in-adult-trauma?source=see_link(downloaded 02.02.2017).

    30.     Flovik AM, Normann L, Mølstad K. Sykepleie – et selvstendig og allsidig fag (Sykepleiehefte). 2008. Available at: https://www.nsf.no/Content/135904/Sykepleie%202008.pdf(downloaded 03.02.2015).

    31.     OECD. Statistics Canada. Learning a living: First results of the adult literacy and life skills survey. Ottawa/Paris: Statistics Canada: OECD; 2005. Available at: http://www.oecd.org/edu/innovation-education/34867438.pdf(downloaded 16.11.2017).

    32.     Ellis L, Nolan M. Illuminating continuing professional education: unpacking the black box. Int J Nurs Stud 2005;42(1):97–106.

    33.     Goldman M. Why is multiple testing a problem? 2008. Available at: http://www.stat.berkeley.edu/~mgoldman/Section0402.pdf(downloaded 10.04.2017).

    34.     Cozby P C. Methods in behavioral research. 10. ed. Boston, MA: McGraw-Hill Medical Publishing; 2007.

    35.     Campbell D T, Stanley A. Experimental and quasi-experimental designs for research. New Jersey, USA: Ravenio Books, 2015.

    36.     Malt U. Face validity. I: Store norske leksikon. Available at: https://snl.no/face_validity(downloaded 11.04.2017).

    37.     American College of Surgeons, Committee on Trauma. Advanced trauma life support (ATLS®). 9. utgave. Chicago, IL: American College of Surgeons; 2012. 

    Healthcare personnel find that they are better equipped to receive and treat trauma patients after taking the Course in Trauma Nursing.

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    Sammendrag

    Background: The Course in Trauma Nursing is a basic course in trauma nursing care that was introduced in South-Eastern Norway Regional Health Authority in 2011.

    Objective: The purpose of the study was to survey whether the course participants felt they were better equipped to receive and treat trauma patients after completing the course. There is little Nordic research on nurses’ own assessment of their competence following a trauma course.

    Method: The study has a prospective survey design, where the pretest-posttest method is applied to a single group. We collected data using an electronic questionnaire that contained 23 questions divided into three areas of competence: medical competence, teamwork competence and choice and improvisation competence.

    Results: The study shows that the course participants reported that the Course in Trauma Nursing leads to improvements in the three competence areas. Gender, age, participation in a trauma team and number of years of further education have no impact on the results. Course participants who had not previously participated in a trauma course reported an improvement in competence in about a quarter of the questions concerning medical competence, compared to those who had previously participated in a trauma course.

    Conclusion: The Course in Trauma Nursing should continue to be a priority area for healthcare personnel in acute care hospitals with a trauma function, both for trauma team specialists and for other professions involved in treating and rehabilitating trauma patients. 

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  • How public health nurses use sources of knowledge

    The general population’s access to research is ever-increasing. Public health nurses and other nurses must therefore be prepared to answer questions and to discuss findings from research. In line with the requirements for safety and high standards, the objective set out in the consultation draft of the new national professional guidelines for community and school health care centres is to offer health promotional and preventive services (1).

    Evidence-based practice involves making decisions in a professional capacity based on a combination of systematically obtained research-based knowledge, evidence-based knowledge and the patient’s wishes and needs in the given situation (2–4). It is an important principle in evidence-based practice to search for research summaries and evidence-based reference works and guidelines before looking for single studies (5), as shown by the 6S pyramid (see figure 1).

    Figure 1: The 6S pyramid

    Earlier studies

    A Norwegian study conducted among nurses in the municipal health service (6) showed that the most frequently used sources of knowledge were personal experience, the experience of colleagues, knowledge acquired while training as a nurse, the patient’s wishes, and health legislation. Research findings were rarely used.

    Some nurses read articles published in the Sykepleien Forskning nursing research journal, but this knowledge was never used as a basis for clinical decision-making. The nurses also reported limited understanding of the importance of updating their professional knowledge.

    A study conducted by Austvoll-Dahlgren and Helseth among public health nurses investigated barriers and facilitators to the use of research in consultations about childhood vaccinations. They also investigated what sources of knowledge are most frequently used (7). These were found to be national guidelines and other information issued by the Norwegian Institute of Public Health.

    The public health nurses commented that research formed an important basis for making good decisions in practice. Research also provided a good base from which to meet the demands of parents, and to develop professionally. Nevertheless, the public health nurses were reluctant to search for research articles. They did not see it as their role to seek out knowledge on their own initiative; rather, they saw their responsibility and role to be one of trusting the information and guidelines issued by public authorities.

    One review article showed that nurses working in the primary and specialist health services encountered known barriers such as a shortage of time, knowledge and skills to find and assess research articles (8). This review article included studies about the implementation of evidence-based practice from several countries.

    The study’s objective

    There are many international and several Norwegian studies that survey how nurses in the specialist health service utilise sources of knowledge (9–12). Fewer studies have been conducted among nurses in the primary health service, but there is a growing body of research in this field as well (6, 13, 14). No earlier studies have surveyed how Norwegian public health nurses use sources of knowledge in general.

    If we know how public health nurses use sources of knowledge, this may influence the way that evidence-based practice is taught at public health nursing courses. It may also give us knowledge about the demand for refresher courses within the field of practice. It is important that public health nurses work from evidence. There is a need to look closer into what sources of knowledge public health nurses use as a basis for their professional decision-making.

    The study’s objectives were to identify 1) the sources of knowledge that public health nurses use in practice, 2) what skills enable public health nurses to find and assess research and national guidelines, 3) what barriers public health nurses encounter as they endeavour to find and assess research and national guidelines, and 4) influences that impact on their skills in assessing research-based knowledge.

    Method

    Sample and data collection

    In this cross-sectional study, we wished to survey the population of professionally active public health nurses practising in Norway. According to Statistics Norway, a total of 4 368 public health nurses were in work in 2014 (15). This study’s sample was recruited among the members of the NNO Professional interest group of public health nurses (LaH) who had registered an email address.

    The LaH provided information about the survey in a newsletter distributed to 3 130 email addresses. The study was carried out in the period between 26 October 2015 and 5 December 2015. Two reminders were issued.

    Translation and adaptation of the questionnaire

    We wanted to investigate whether an instrument already existed that could be used for the purpose of this survey. Consequently, we searched for studies that utilised questionnaires associated with the appraisal of evidence-based practice (14, 16–18). To restrict our search further, we only considered questionnaires that had already been translated into Norwegian, and which had been used for studies carried out in Norway (9, 10, 17, 19–21).

    The ‘Developing Evidence-Based Practice Questionnaire’ (DEBP) (18) turned out to be the one best suited to our study. This had been translated into Norwegian in accordance with the World Health Organisation’s translation procedure (10, 19). Its Norwegian translator, Anne Dalheim, has granted us permission to use the Norwegian version of the questionnaire.

    We needed to adapt the questionnaire to suit the public health nurses’ work situation. Consequently, we left out all questions that were clearly aimed at nurses in hospitals. These questions referred to patient information, conferring with doctors, and new treatments and medication. 

    Furthermore, we changed certain questions to make them appropriate for public health nursing. For example, ‘my personal experience of nursing patients over time’ was changed to ‘my personal experience of public health nursing over time’. 

    We also added some questions for the purposes of our adapted version. These questions referred to sources of knowledge such as guidance, cross-disciplinary cooperation, placements and service user feedback. Moreover, we left out a section of the original questionnaire that dealt with the implementation of practice changes, because the study’s objective was not to look at changing practices.

    The questionnaire

    The adapted questionnaire was tested in a pilot study at a health care centre that employs ten public health nurses. We removed question no. 2 concerning ‘my intuitive sense of what appears to be the right thing to do for the service user or the family’ because the public health nurses interpreted this question in different ways.

    We also omitted question number 4 concerning ‘what has worked for me for a long time’. The public health nurses felt it was difficult to distinguish this question from number 3: ‘the way I have always been doing it’, which we retained. Reliability testing shows that the adapted instrument’s internal consistency is good (Cronbach’s α = 0.87) (22).   

    The questionnaire had one introductory question: ‘Are you currently working as a public health nurse?’ Those who replied no to this question were excluded from the survey. There were 40 compulsory questions that were graded on a five-point Likert scale. The last question was open-ended: ‘Do you have anything to add?’ This provided an opportunity to respond by way of free text comment. We stated that it would take approximately eight to ten minutes to complete the questionnaire.

    The questionnaire was divided into four sections. Section one asked what sources of knowledge the public health nurses were using in their work. Section two asked the public health nurses how they assessed their own skills in finding, assessing and using various sources of knowledge. Section three asked what barriers the public health nurses encountered when they endeavoured to find and assess research articles and national guidelines.

    Section three of the original DEBP questionnaire concerned the nurses’ skills in finding, assessing and using various sources of knowledge. This was moved forward and became part two. The last section of our questionnaire surveyed the demographic variables.

    Ethical considerations

    The study was reported to and approved by the Norwegian Centre for Research Data, formerly Norwegian Social Science Data Services We secured anonymity by distributing the questionnaire by email via Questback. Participation was voluntary, and we informed the participants that by completing the survey, they gave their consent to taking part in the study.

    Data analysis

    We used descriptive statistics to describe the sample and to get an indication of the frequency distribution of all categorical variables (see table 1). Logistic regression analysis was used to investigate the factors that might influence the public health nurses’ opinion of their own skills in assessing research-based knowledge.

    We had reason to believe that working conditions might differ with the municipalities’ population size, so this was controlled for in the logistic regression model (23). The significance level was set to 0.05 in all analyses. The statistics software SPSS for Mac, version 23 was used for the analysis of all responses except the free text comments. These were subjected to content analysis (24).

    Table 1. Descriptive statistics of the sample. n = 638

    Results

    Of the 3 130 registered public health nurses, 708 completed the questionnaire, which gives a response rate of 22.6 per cent. We excluded 70 of them from the study because they answered no to the introductory question of whether they were currently working as a public health nurse. Of the public health nurses who completed the full questionnaire, 638 were included.

    Two thirds of the included public health nurses were aged between 41 and 60, and over half of them had been working as public health nurses for between six and twenty years. Approximately one quarter indicated that they had a supervisory function, and almost six percent responded that they held a Master’s degree (see table 1). The content analysis led us to divide the free text responses into three main themes: time, competence and attitudes.

    The sources of knowledge used by public health nurses

    The public health nurses’ ranking of their sources of knowledge showed that the four most frequently used sources were national plans and guidelines, knowledge acquired while training as a public health nurse, personal experience, and guidelines and procedures issued by their local authorities. Other commonly used sources of knowledge included external courses and internal medical meetings, as well as knowledge shared among public health nursing colleagues.

    The Norwegian public health nursing journal was the most commonly read literature, while other journals were less popular.

    The Norwegian public health nursing journal was the most commonly read literature, while other journals were less popular. Articles published in English-language journals represented the least frequently used source of knowledge (see figure 2)..

    Figure 2. The different sources of knowledge used by public health nurses

    Skills and barriers 

    The public health nurses reported that they were generally proficient or expert at finding and assessing national guidelines. Fewer reported that they were proficient or expert at finding and assessing research-based knowledge.

    They indicated that the greatest barrier to finding research articles was a shortage of time (see figure 3). Similarly, it was also apparent from the questionnaire’s free text comments that insufficient time was a barrier to finding research. Another major barrier was the language used in articles published in English, which they found difficult to understand. Furthermore, the public health nurses did not feel confident in their ability to appraise the quality of research articles.

    Figure 3. Barriers to finding and assessing research and national guidelines

    Shortage of time was an insignificant problem with respect to seeking out national guidelines and recommendations. Less than five per cent of the public health nurses indicated that they were in complete agreement or in agreement with a statement that it was difficult to find national guidelines and recommendations. Only ten per cent indicated that they were in complete agreement or in agreement with a statement that it was difficult to assess the significance of guidelines for their own practice.

    Having controlled for age, work experience, full-time equivalent ratio, municipality population size, and supervisory function, we found that two factors significantly influenced the public health nurses’ opinion of their own skills in assessing research. Compared with the public health nurses without a Master’s degree, the odds were more than 3.5 times greater (OR 3.72, p = 0.033) that public health nurses who hold a Master’s degree will assess themselves as being fairly good, proficient or expert at assessing research.

    Compared with public health nurses in part-time employment, the odds were 1.5 times greater (OR 1.49, p = 0.045) that public health nurses in a full-time job will consider themselves to be fairly good, proficient or expert at assessing research (see table 2).

    Table 2. Logistic regression – factors that may influence the public health nurses’ self-reported skills in assessing research-based knowledge*

    Free text responses

    Time

    The public health nurses feel that their day-to-day work regime allows far too little time for them to read and look up research articles and other professional literature: ‘That’s something I have to do at home, to keep updated.’ They report that due to great work pressure, it is often down to chance whether they are able to keep updated.

    Competence

    The public health nurses feel they receive little management support for attending courses and completing specialty training programmes, and that such professional development is never rewarded in the form of increased pay or new tasks. In their view, holding a Master’s degree is important for being able to understand and apply evidence: ‘I have attended several refresher courses since I first trained as a public health nurse, so have kept professionally updated. It is sad that there is little local recognition of our professional competencies.’

    The public health nurses feel they receive little management support for attending courses and completing specialty training programmes.

    Attitudes

    The public health nurses believe that research-based knowledge should be given a greater focus in practice: ‘There are far too many personal views, and a prevailing attitude that ʻwe have always done thingsʼ [this way].’ They feel that professional development comes a long way down on the list of priorities, and that practices and attitudes differ with respect to keeping updated.

    Discussion

    This study shows that national guidelines constitute the most frequently used source of knowledge among public health nurses. The greatest barriers to finding and assessing research include shortage of time, difficulties in understanding articles published in English and a lack of confidence in appraising the quality of research. Holding a Master’s degree, and full-time employment, are factors that significantly impact on the public health nurses’ assessment of their own competence to appraise research.

    Sources of knowledge

    In recent years, numerous new guidelines have been issued for public health nurses to absorb and comply with. Such guidelines are therefore becoming an increasingly important source of knowledge for public health nurses (25–29). National guidelines are professionally normative; any non-compliance will have to be based on good reasons, even if health care personnel need to use their professional discretion in making the assessment (1).

    More than 90 per cent of the public health nurses in our study report that they frequently or always use national recommendations and guidelines as a source of knowledge in practice. This finding matches the findings of a study conducted in 2012 on how public health nurses use sources of knowledge in relation to paediatric vaccinations (7).

    Criticism against guidelines

    There are both positive and negative sides to having increasing numbers of national guidelines. There is little research and knowledge concerning the impact of ever more national guidelines on the professional practice of public health nurses. Many argue that the simplest way that public health nurses can base their practice on relevant and updated research, is to comply with national guidelines. On the other hand, the criticism levelled at the guidelines is often aimed at their tendency to oversimplify the treatment of patients.

    Criticism is also directed at their failure to accommodate the context and the patients’ multimorbidity since guidelines often deal with a single disease or an isolated condition (30, 31). There is no research that examines the degree to which this criticism affects public health nurses and their compliance with the guidelines.

    Similarly, our study tells us nothing about the public health nurses’ day-to-day practical compliance with the guidelines. It appears, however, that the guidelines are increasingly influencing the public health nurses’ working day since they report on their frequent use.

    The study that looked at facilitators and barriers to the use of research by public health nurses in consultations about paediatric vaccinations (7) may suggest that the public health nurses feel their responsibility is to comply with national guidelines rather than to seek out research on their own initiative.

    National guidelines are based on research summaries, which make them more reliable than single studies as a basis for professional decision-making. Public health nurses should nevertheless be able to explain their actions in a better way than by simply referring to the fact that ‘this is the recommendation of the national guidelines’. One particular problem is that several of the guidelines were issued a number of years ago and have never been updated to reflect more recent research.

    National guidelines are more important to public health nurses than to other nurses

    Approximately 50 per cent of the public health nurses who took part in our study reported that they often or always use the guidelines and procedures issued by their local authority as a source of knowledge. Studies conducted among nurses in the primary health service rate national guidelines as an infrequently used source of knowledge, while municipal or hospital procedures are frequently used (6, 10).

    Public health nurses are required to relate directly to recommendations provided by national guidelines more frequently than other nurses in the primary health service. The study’s finding that national guidelines constitute a more important source of knowledge for public health nurses than for other primary health nurses without a specialty, is therefore not unexpected.

    No utilisation of research findings

    In line with earlier research among nurses (6, 32, 33), our study shows that the public health nurses who completed the questionnaire rarely make direct use of research findings in their practice. This may be a cause for concern. It may be particularly challenging to transfer or ‘translate’ research findings into the context of preventive healthcare. For example, it is not unusual that programmes or initiatives whose effectiveness has been documented, fail to have the expected effect when implemented in a different context or population (34).

    The public health nurses who completed the questionnaire rarely make direct use of research findings in their practice.

    A method or intervention that has proved to be effective in one population will not necessarily have the same effect in a different context. In order to answer whether the intervention is effective, it is always necessary to assess not only the intervention, but also the relationship between the intervention and its context (35). There is therefore reason to assume that public health nurses need the skills to assess research. They also need to know how research can be implemented in different contexts.

    Barriers and skills

    Our study shows that the greatest barrier to the use of research is shortage of time. This result matches findings from earlier studies (8, 10, 14, 20, 36). The public health nurses expand on this shortage of time in their free text comments. Almost 40 per cent of them also report that they agree or fully agree with a statement that it is difficult to assess the significance of research findings for their own practice, which matches the findings of other studies (10, 13, 14).

    The greatest barrier to the use of research is shortage of time.

    The majority of the public health nurses found it difficult to understand articles published in English, a problem which has also been reported in other countries where English is not the native tongue (37). This language barrier restricts the public health nurses’ opportunity to obtain and assess new evidence. Their free text comments also explain that while they focus on professional development and research, time is a restricting factor.

    However, this finding does not coincide with the study that demonstrated limited understanding among other primary health care nurses of the importance of updating their professional knowledge (6). Our result may be explained by the fact that all public health nurses have specialty training, which may well influence their views on professional development.

    A Master’s degree is significant

    Compared with public health nurses without a Master’s degree, the odds were more than 3.5 times greater that public health nurses who hold a Master’s degree will consider themselves as being fairly good, proficient or expert at assessing research. There has been much debate about the general need for a Master’s degree programme. Arguments have been put forward both for and against the trend of introducing ever more postgraduate specialty training programmes for nurses (38–40).

    Nurses agree that evidence-based practice is useful to clinical work, but they lack the skills to implement such practices (41). Like other studies, our study supports the view that public health nurses with a Master’s degree will be better equipped to assess research findings (36, 42).

    The odds were 1.5 times greater that public health nurses in a full-time job will consider themselves to be fairly good, proficient or expert at assessing research-based knowledge. Other studies also show that the full-time equivalent ratio impacts on the implementation of evidence-based practice (43). It is reasonable to assume that fewer working hours result in correspondingly fewer opportunities to read up on research and other professional literature or to attend courses and medical meetings during working hours.

    Implications

    In order to implement evidence-based work practices, the public health nurses need to be adept at assessing multiple sources of knowledge rather than solely referring to national guidelines and local procedures. This study tells us nothing about the ways that public health nurses use the various sources of knowledge. Further research is therefore required in this area.

    The training

    The study’s findings should impact on the teaching of evidence-based practice at public health nursing courses in order to build confidence in newly qualified public health nurses that they are able to access different sources of knowledge. Local authorities and university colleges should also consider introducing refresher courses for public health nurses in evidence-based practice and sources of knowledge.

    The local authorities

    Public health nursing is a widely scoped profession, and public health nurses work independently, which may suggest that the training programme for public health nursing should be at postgraduate level. It is also important that local authorities utilise the competence of public health nurses with a Master’s degree to develop the area’s service provision.

    There is currently no body that holds an overarching responsibility for implementing national guidelines and safeguarding the quality of procedures issued by local authorities. Work has been on-going for some time to establish a national competence and development centre for services provided at community and school health centres (44–46). The Professional interest group of public health nurses (LaH) also recognises that there is a great demand for such a centre and has pushed for its establishment. This work should be intensified and may play an important role in achieving the objective of introducing evidence-based practice in the public health nursing service (47).

    Strengths and weaknesses

    A total of 3 130 public health nurses were invited to take part in the survey. Of these, 708 completed the questionnaire. This gives a response rate of 22.6 per cent, which matches that of other comparable studies (48). In 2014, a total of 4 368 public health nurses were working in Norway.

    This study was able to obtain responses from 16.2 per cent of the entire population (15). The fact that we chose to recruit via LaH, may have introduced a bias in the sample. However, we have no data that might verify whether public health nurses outside the LaH are significantly different to those who are members of the LaH. Consequently, it is difficult to assess whether the findings are representative of the public health nurses who did not take part in the survey. Nevertheless, we hold the opinion that the results of the study provide a general indication of conditions within the service.

    One of our study’s limitations, however, is that we have only established what the public health nurses report that they do, not what they are actually doing in practice. Neither can the study establish possible causes and effects; it can only describe associations between variables.

    The modifications made to the original UKBP questionnaire proved to be so comprehensive that the results of this study cannot readily be compared with the results of studies that have employed the original English or Norwegian version of the questionnaire.

    Conclusion

    This study shows that national guidelines constitute the source of knowledge most frequently used by public health nurses. Public health nurses who hold a Master’s degree, and public health nurses in full-time employment, feel that they are better at assessing research-based knowledge than public health nurses without a Master’s degree, or who are in less than full-time employment.

    The field of practice should consider how these resources may be better utilised. The educational institutions should also reflect on how they teach evidence-based practice and offer refresher courses for public health nurses. The establishment of a national competence and development centre for services provided at community and school health care centres will potentially have a considerable impact on the use of evidence-based practice and knowledge development in the public health nursing service.

    I would like to thank Anne Dalheim for allowing me to use the Norwegian translation of the questionnaire entitled ‘Developing Evidence-Based Practice Questionnaire’ (DEBP).

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    Public health nurses consider themselves to be adept at finding and assessing national guidelines, but feel less proficient at assessing research-based knowledge.

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    Sammendrag

    Background: Public health nursing is constantly evolving; the profession must adjust to new focus areas, new professional demands, new tasks and more responsibilities.

    Objectives: The study’s objectives were to identify 1) the sources of knowledge that public health nurses use in practice, 2) what skills enable public health nurses to find and assess research and national guidelines, 3) what barriers public health nurses encounter as they endeavour to find and assess research and national guidelines, and 4) influences that impact on their skills in assessing research-based knowledge.

    Method: This is a cross-sectional study which involved 708 public health nurses completing an online questionnaire. We used statistical analyses to investigate their use of sources of knowledge and the factors that may influence their skills in assessing research-based knowledge.

    Results: National guidelines, knowledge acquired while training as a public health nurse, personal experience and  guidelines issued by local authorities were the most commonly used sources of knowledge. The most significant barriers reported were a shortage of time to find research, and the challenge of understanding articles written in English. The public health nurses considered that they were generally adept at finding and assessing national guidelines, but that they were less proficient at assessing research-based knowledge. The odds were significantly greater that public health nurses with a Master’s degree, and public health nurses in full-time employment, would consider themselves adept at assessing research.

    Conclusion: National guidelines constitute the source of knowledge most frequently used by public health nurses. In order to implement evidence-based professional practice, public health nurses must be proficient at assessing the recommendations set out in national guidelines in combination with other sources of knowledge. A future national competence and development centre for services provided at community and school health care centres may come to play an important role in implementing national guidelines and safeguarding the quality of procedures issued by local authorities. 

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