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  • Nursing competence in the municipal health service: can professional development be accommodated?

    Municipal health and care services have been the subject of comprehensive structural changes in recent years (1, 2). The Coordination Reform (1) has brought changes to the work responsibilities of nurses employed by the municipal health service, and the nurses report that more and increasingly complex patient-focused tasks have been assigned to them.

    It is the intention that specific patient groups should have a greater share of their health care provided outside the specialist health service, among them patients with chronic obstructive pulmonary disease, diabetes, dementia, cancer, certain forms of mental health issues, and substance abuse. Consequently, nurses need to increase their competence levels with respect to the observation and examination of these patient groups to ensure that changing clinical presentations can be discovered at an early stage. Additionally, the reform introduces greater demands on the nurses’ interaction skills (1, 3–8).

    Despite these challenges, our informants felt that their new nursing tasks were exciting, challenging and rewarding (3, 9, 10), yet there is uncertainty as to whether their professional competence levels have been sufficiently strengthened to enable them to handle the varied needs of patients.

    An inquiry conducted by the Office of the Auditor General shows that following the introduction of the Coordination Reform, local authorities have failed to sufficiently boost the competence levels of their staff. Consequently, their recommendation is for the Ministry of Health and Care Services to ensure that planned initiatives adequately contribute to a strengthening of professional competencies (11). One such initiative is SkillsPromotion 2020, which is intended to ensure that service providers have adequate numbers of appropriately skilled staff to provide a professionally robust service (12). Other Scandinavian countries have also witnessed growing demands for professional competence and changes to the work responsibilities of nurses in the municipal health service (13, 14).

    The concept of competence

    Competence is a complex concept that is open to interpretation. It is generally considered to refer to skills required to carry out duties or tasks in a workplace setting (15–17). Such professional skills can be developed, are non-permanent and will depend on the context in which they are put into practice (16–18). There is a multi-faceted discussion surrounding the exact scope of competence, but professionals tend to express clear views when it comes to what or who they consider to be incompetent (16, 19, 20).

    In order to assess the competence levels of nurses, we need to agree on what criteria to use, and how to verify their fulfilment (15). Nurses have a personal statutory obligation to carry out their work in a professional, ethical and lawful manner, irrespective of their workplace; the local authorities, as their employer, has an obligation to facilitate this (2, 21, 22).

    Professional development on an individual level may involve the acquisition of knowledge, skills, attitudes and understanding, as well as the ability to tap into the competence of others, with a view to present and future duties as well as the organisation’s community of practice (23). Benner’s model of skills acquisition takes a relational view on learning and points out that nurses can develop from novice to expert by gaining knowledge that is formed not only within the individual, but in dialogue with other people in the practice community.

    However, not everyone will reach the level of expert (24). For the individual’s skills acquisition to succeed, a number of factors must be present. The individual’s motivation, determination and personal qualities are important factors (17, 25–28), but additionally, the working environment must accommodate interaction between social and material contexts in order to enable staff to develop their own professional competence levels (26, 28–30).

    The study objective

    This article discusses a study that forms part of a larger work, Nursing Competence in Municipal Health Care Services – the NursComp Study 2014–2018. This examines the nursing competence available within the municipal health services of Sogn og Fjordane county.

    The sub-study follows up a survey that was conducted in three of the county’s municipalities in 2013, utilising the Nurse Competence Scale (NCS) instrument (31). In the autumn of 2014, we conducted focus group interviews in two of the three municipalities involved, in order to deepen our understanding of the issues.

    The study’s objective is to describe how nurses employed by the municipal health service are working to develop their professional skills and competence, and what challenges these nurses encounter in the process.

    The study seeks answers to the following questions:

    • How do the individual nurses feel about their daily work responsibilities?
    • What factors are conducive or obstructive to the nurses’ efforts to develop their own professional skills and competence?

    Methodology

    The study was conducted in two municipalities on the west coast of Norway, each with a population in excess of 10 000. We adopted an explorative qualitative research design, which involved focus group interviews. A qualitative research method was chosen to allow us to describe and explore human experiences, perceptions and qualities. The qualitative methodology accommodates our desire to present the variety and nuances in the material (32, 33).

    The inclusion criteria for nurses to take part in the study were employment by one of the local authorities that took part in the NCS survey, and that their workplace was either a nursing home or the community nursing service. We conducted one pilot interview prior to the focus group interviews. Testing the interview guide in this way is conducive to obtaining feedback on the questions included.

    By summarising their conversation together with the participants at the end of the interview, the researchers are able to clarify any ambiguous details in the questioning, establish whether the questions are topical, and check that they fit in with the natural flow of the conversation (34). We revised five of our seven interview guide questions following the pilot interview. Data obtained through the pilot interview have not been included in the study because the participants did not fulfil the inclusion criteria.

    The informants

    We contacted the chief municipal executives and the relevant heads of department for the two local authorities involved, and obtained their permission to conduct the study. Informants were recruited by local ward managers employed by the municipality.

    We recruited 14 nurses – one male and 13 female. There were six nurses allocated to Focus Group 1 and eight nurses to Focus Group 2. Nine of the nurses were working for the community health service, while five were working in nursing homes. The average age of the informants was 45.3 years, with a median of 45.5 years.

    The length of their respective employment histories ranged from 5 to 35 years, with an average of 23 years and a median of 14 years. Eight nurses had specialty training. Table 1 provides an overview of the informants with details of their age, employment history and specialty training.

    Table 1. The informants

    Data collection

    We conducted the focus group interviews in meeting rooms at the nursing homes where some of the informants worked. The interviews lasted for a maximum of 1.5 hours. The first author acted as moderator, while the second author took the role of assistant. The moderator’s job was to introduce the interview topics and to facilitate a good exchange that would allow everyone to voice their opinions (32–34).

    It is important for the moderator to believe that the informants hold interesting information and to be a sensitive listener who tries to understand the informants’ perspective (34). The assistant was tasked with recording the interviews on a digital sound recorder, noting down keywords and asking clarifying questions (33, 34).

    We made use of an interview guide with seven open-ended questions based on the categories in the NCS questionnaire. The questions referred to the helping role, teaching/coaching, diagnostic functions, managing situations, therapeutic interventions, ensuring quality and the work role (31).

    The informants received the interview guide prior to the focus group interview, to enable them to prepare. The informants were offered an opportunity to read the interview transcripts but declined the offer.

    Analysis

    We subjected our material to a qualitative content analysis. This method focuses on identifying similarities and differences in the studied text. The text’s manifest content is its specific narrative, often presented in categories. The themes that emerge from the content analysis are seen as expressions of the latent content, i.e. the implicit meaning of the text (35).

    The analysis process started at the interview stage. Following the interviews, the moderator and assistant discussed potential conversation outcomes and made notes of these discussions. The first author proceeded to transcribe the material. After transcription, we read the transcripts multiple times and compared them with the sound recording to make sure that the content had been fully understood.

    The moderator and the assistant reviewed the transcripts and wrote up summaries of the two interviews to facilitate the identification of any coinciding patterns. We also extracted quotes and studied these in depth in order to identify the meaning units. At the next stage of the process we condensed the meaning units without changing their content (35).

    We proceeded to subject the meaning units to analysis and abstraction, but all the while it was important to maintain their original sense. On this basis, we allocated codes to the various units. These had not been predefined, but were generated in the course of our work with the data (32).

    We then divided our material into categories before we eventually formulated its latent content which was split into three different themes. Table 2 shows an example of how we conducted the qualitative content analysis.

    Table 2. Example of qualitative content analysis

    Ethical considerations

    The study was approved by the Data Protection Official at the Norwegian Centre for Research Data (NSD) as a sub-study under the NursComp project (project number 47191). The study was conducted and the data stored in compliance with research ethics guidelines and the Declaration of Helsinki (36).

    Well ahead of the interviews, the nurses were informed in writing of the study, its themes and objectives, methodology, data anonymisation and voluntary participation. This information was repeated verbally at the start of each focus group interview. The informants took part in the study on a voluntary basis, and they all signed a declaration of informed consent. The informants are anonymised throughout the text and cannot be identified in the material presented.

    The results

    Changes to work responsibilities require competence upgrading

    The nurses consider their own role to be that of a common thread running through the service provision offered to patients. They carry out what they refer to as ‘standard nursing tasks’, which involves the planning and provision of nursing care, participation in cross-disciplinary work and cooperation and interaction with the patients’ families.

    The nurses consider their own role to be that of a common thread running through the service provision offered to patients.

    The informants have found that their work responsibilities have changed over time, particularly after the introduction of the Coordination Reform: ‘These days we deal with much more substance abuse and psychiatry, and our patients are much sicker. They are discharged from hospital at an earlier stage than was previously the case. And of course, that puts great demands on us’, said one of the informants.

    The nurses describe an increased need to develop their own clinical competencies and to avail themselves of good mapping tools, to enable them to discover changes in the patients’ condition at an early stage. They find that such professional development is essential to enable them to report correctly to the duty doctor, who at times may be based miles away from the patient in question.

    In nursing homes, the nurses also note differences with respect to more comprehensive patient rehabilitation initiatives, and they observe that individuals who suffer from dementia are hospitalised at a more acute phase of their disease. In this context they are looking to increase their knowledge and skills with respect to these specific patient groups. In relation to these changes, the informants report that they miss having time for reflection with their colleagues on professional issues and events: ‘I often miss having time to reflect. Just to sit ourselves down and think things through’.

    Plans are rarely made for systematic professional development

    The informants describe a complex and challenging working day, and they find it difficult to fit in any professional development. If professional challenges arise and they do not have the necessary knowledge to address them, they still need to resolve the matter on the spot. In this scenario, the informants access literature on the Internet, they discuss the matter with nursing colleagues and other health professionals, or they contact the specialist health service or a pharmacy for advice.

    The nurses make use of the master–apprentice learning method on a daily basis in that experienced and knowledgeable nurses involve less experienced colleagues in learning situations. They feel that his practice works well, but they have to facilitate it themselves, except when they are involved with the induction training of new employees, which is part of a standard routine.

    They need to read nursing journals in their spare time, for there is neither time nor space for it in the workplace.

    They need to read nursing journals in their spare time, for there is neither time nor space for it in the workplace. Staff who are meant to plan and implement training for their colleagues find that their supervisor fails to make the necessary arrangements: ‘Of course, we have made plans for first-aid training. And it’s been in the diary for a long time. You just come to a halt, and then you can’t afford the time because everyone else has such a lot to deal with – or there is such a lot of other things we all need to do.’

    Most of the informants knew nothing of the municipal authorities’ professional development plan for their workplace. They talked about this lack of knowledge as a factor in their uncertainty about whether they might receive support for attending courses or signing up for specialty training, and this in turn led to lower motivation. One of the informants says: ‘Well, we receive all sorts of offers of courses and that sort of thing, but finding someone to cover for you would create a problem. So it is never sufficiently prioritised, no.’

    Factors that are conducive or obstructive to professional development

    The community of practice was highlighted as an important channel for acquiring new knowledge. According to the nurses, learning from one another is the most important source of professional development – whether this involves theoretical knowledge acquired through specialty training, courses and in-service training days, or whether it involves practical skills such as procedures or the use of technical medical equipment. One of the nurses says: ‘We make use of one another for what it’s worth.’

    Self-motivation and a personal interest in the profession were also listed as factors conducive to professional development, as well as the need to be committed to the profession. Some informants talked about attending a weekly departmental staff meeting while on their lunch break, with the topic up for discussion frequently being of a professional nature. These staff meetings worked well, were planned for and were incorporated into staff routines. The doctors’ ward rounds and cross-disciplinary meetings were also listed as arenas conducive to professional development.

    The nurses reported that staffing levels were low at times, and that their shifts were so busy that they have more than enough to do just tending to their daily duties. In this scenario, professional development is not a priority. Meanwhile, the informants also report that professional development efforts are largely up to themselves. Arrangements are rarely put in place in order to allow for professional updating or specialty training, and the management do not set any requirements for updating skills.

    They also felt that there was no clear departmental plan for professional development that would give staff an insight into what competencies their employer wanted them to have. Furthermore, they pointed out that they miss a cross-disciplinary working environment where the topping up of professional competencies forms a part of the working day.

    One of the factors that influence the professional development of nurses is a lack of finances in the local authorities.

    One of the factors that influence the professional development of nurses is a lack of finances in the local authorities: ‘When it comes to courses, there’s just no budget for it. I came from a sector that was a priority investment area – and the budget for attending courses was really generous; I was extremely shocked to discover this municipal poverty.’

    Discussion

    The purpose of this study was to explore how nurses employed by the municipal health service are working to develop their professional skills and competencies, and how they tackle the challenges they encounter in the process.

    It is well known that the municipal health service is in great need of competent staff. In order to meet this need, the nurses have to work on their professional development (21, 22). The individual’s motivation and personal qualities are important prerequisites for personal professional development (17, 25–28).

    Learning from one another

    The study’s informants clearly stated that the community of practice provided by their colleagues was important to their efforts of keeping professionally updated, for instance by learning practical procedures from one another and by providing an opportunity for reflection. A community of practice can serve as an arena for individuals to exchange opinions about work responsibilities and professional issues.

    This interaction brings learning with respect to how the nurses may develop and improve their skills. According to social learning theory, a community of practice will bring about learning, even if to external eyes it may look like an ad hoc solution designed to make the working day run smoothly (37). It is warranted to question whether this theoretical stance on passing on knowledge is sufficient in the face of demands for new competencies in the workplace (17).

    Easier to identify incompetence than competence

    Evidence-based learning through interaction with patients and their families plays an important role in the nurses’ efforts to raise their level of competence (38), but inadequate specification of what skills are needed makes it difficult to decide what training paths to choose (15).

    The informants pointed out that when they find themselves in new and unfamiliar situations, they are quick to look for information from their colleagues, literature, the specialist health service or by contacting experts in the field. The same has been demonstrated by earlier studies (8, 38, 39). Consequently, it appears that incompetence is easier to identify than competence, and that this raises the nurses’ awareness in terms of professional development.

    This way of driving the work may serve to conceal the raised competence levels to managers, so that nurses individually respond to the needs that arise from changing tasks and responsibilities (39). This development will not be conducive to learning on an organisational level (40).

    Insufficient time and inadequate strategies

    Time constraints at work, and challenges associated with the municipal resource situation and staffing levels, are familiar problems (5, 41). In a pressurised work situation, the nurses find it difficult to set aside time for professional development, even if the organisational framework is safe and provisions are appropriately made (8, 41).

    Time constraints at work, and challenges associated with the municipal resource situation and staffing levels, are familiar problems.

    The informants feel that there is no overall strategy for professional development. Earlier studies have shown the same (8, 39, 41). Nurses with specialty training or other forms of expertise consider their own competencies to be relevant and important for their personal professional development and for their workplace community, but find that their skills are not always put to use.

    Employers may not be aware of the skills of their nurses, and staff representatives are never present when the matter of professional development is up for discussion. The officer who heads the municipal health service is responsible for ensuring that the appropriate competencies are available and for facilitating opportunities for employees to acquire these competencies (2).

    Nevertheless, it is important to point out that the nurses generally report to have found the changes to their work responsibilities to be interesting and challenging; this has been similarly demonstrated by a number of studies in recent years (3, 8–10). Mid-career changes may make working for the municipal health service a more attractive proposition, and this will be an important factor in the future when more staff and skills will be required to care for patients (8, 11).

    The nurses feel that in many areas they have the required competencies, but that due to the way the service is organised, their skills are not put to use where they are needed (5, 8). The results show that competencies relating to substance abuse, mental health and complex disorders are in demand among nurses. Nurses have only limited earlier experience of these areas of practice because they have never been prioritised by the municipal health service.

    The study’s weaknesses

    Only a limited number of informants took part in the study, and they were all recruited from a restricted geographic area. Population numbers are relatively low in both municipalities represented in the study. It is not possible to generalise on the basis of this qualitative study, and the results may well have been different if the study had been carried out in different municipalities.

    Nevertheless, it is our opinion that the findings are consistent with the findings of earlier studies, and that a repeat of the study in different municipalities would probably generate similar results. 

    Conclusion

    Nurses have a duty to keep professionally updated in order to meet the demands of the health service, but nurses cannot achieve this on their own. Our findings show that nurses frequently acquire new knowledge by turning to unplanned activities such as learning within the community of practice, looking up nursing issues on the Internet and contacting specialists in the field to discuss a patient’s case. They need the assistance of their management if they are to plan their work and organise their services so that professional development becomes a natural part of their working day. It appears that this is not the case today.

    Furthermore, local authorities need to put in place a strategy for the professional mapping and development of their nurses. Despite the problems, the nurses consider their working day to be challenging and exciting, and they enjoy their new responsibilities. Enjoyment may well lead to greater job satisfaction and enhanced motivation to stay in their jobs.

    This study’s findings suggest it would be pertinent to conduct further research into what measures are conducive to professional development in the municipal health service. Professional development will constitute a challenge for our educational institutions in the years ahead, both in terms of safeguarding basic nursing competencies and in terms of customising postgraduate courses and master’s degree programmes so that they meet the challenges of the municipal health service.

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    Following the introduction of the Coordination Reform, nurses employed by the municipal health service have had to deal with a growing number of complex, patient-focused tasks. The need for professional development is considerable, but there is no overall strategy in place.

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    Sammendrag

    Background: The Coordination Reform has brought changes to the work responsibilities of nurses employed by the municipal health service, and the demands on their professional skills have grown accordingly. The volume of complex, patient-focused work has increased, and the working day of nurses has become busier; their need for professional development is thus considerable. This study forms part of a major quantitative study (NursComp) which entailed a survey by research team of the nursing competence available to the municipal health services in the county of Sogn og Fjordane.

    Objective: The study seeks to describe how nurses employed by the municipal health service are working to develop their professional skills and competence, and what challenges these nurses encounter in the process.

    Method: We took a qualitative approach and conducted two focus group interviews in two municipalities in the county of Sogn og Fjordane. The sample consisted of six nurses from Municipality 1 and eight from Municipality 2.

    Results: The nurses refer to many influencing factors when they describe their efforts to keep professionally updated – including the community of practice with fellow nurses, pause for reflection, time constraints, financial factors and insufficient managerial input in terms of planning and facilitation.

    Conclusion: Nurses have a duty to keep professionally updated in order to meet the requirements of the health service. They need to plan their working day with their supervisors in order to ensure that such professional development is easily accommodated. The supervisors have an important role to play in facilitating professional development.

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  • People with dementia may benefit from adapted cognitive behavioural therapy

    In 2012, around 77 000 people were living with dementia in Norway, most of whom were over the age of 70 (1). The number of people affected is increasing and represents a global challenge. Estimates show that the number of people with dementia worldwide will reach 65.7 million by 2030, and the figure is expected to double every 20 years (2).

    The most common symptom is memory loss, particularly in respect of recent information. Daily activities like shopping and paying bills are gradually affected (3). There is currently no curative medicinal treatment, and the anti-dementia medicines that are available only have symptomatic and temporary effects (4).

    Results from a review article show that non-medicinal therapies can be realistic and viable treatment options for people with Alzheimer’s disease (5). Cognitive training and stimulation, practising daily tasks and carrying out meaningful activities improved the quality of life of the people with dementia as well as their families. By providing support for the families and increasing their knowledge it was possible to postpone the institutionalisation of the person with dementia (5).

    Objectives of the study

    A German multicentre study, CORDIAL (cognitive rehabilitation and cognitive-behavioral treatment for early dementia in Alzheimer disease), showed promising results for people with Alzheimer’s disease (6). The results showed that the interventions had an impact on depression, insight and quality of life.

    The German CORDIAL study forms the basis for the Norwegian KORDIAL study; a manual-based, randomised controlled intervention study that includes 200 people living at home with early stage dementia and their families.

    In connection with the KORDIAL study, we conducted a qualitative sub-study with two subjects and their families. The objective was to evaluate the impact of the manual-based intervention on the subjects’ everyday lives and quality of life. A further objective was to describe the interaction between the person with dementia, their family and the therapist.

    Research questions in the study

    Based on the objectives of our sub-study, we aimed to establish the following:

    • How did the intervention impact on the subjects’ everyday lives and quality of life, and how was the interaction between them and the therapist?

    Method

    In line with the objectives and research questions of the study, we used a hermeneutical approach that is rooted in a qualitative research tradition aimed at gaining an understanding, and where the goal is to describe (7). We therefore chose the case study method, which is relevant where there is a desire to explain, describe and thoroughly examine a phenomenon (8).

    Case studies can be descriptive, interpretive or evaluative, or they may include all three elements at the same time, as in our study. In the descriptive part, the subject’s perspective is prominent. The interpretive element is intended to illustrate, support, challenge and develop existing theory. The main focus in the evaluative part is the researcher’s evaluations, with theories as the starting point (9).

    We supplemented the study by using two quantitative measuring instruments as part of the main study: the Montgomery and Åsberg Depression Rating Scale (MADRS) (10), which maps depressive symptoms, and the Quality of Life in Alzheimer’s Disease Scale (QOL-AD) (11), which evaluates quality of life. The measuring instruments were used both before and after the intervention in order to identify any changes.

    Inclusion and exclusion criteria

    One of the criteria for inclusion in the study was an Alzheimer’s diagnosis within the last twelve months. Subjects also had to score at least 20–30 points on the cognitive test Mini Mental Status Examination (MMSE) (12) and be living at home with a minimum of weekly contact with their family. Exclusion criteria were ongoing psychotherapy and serious somatic or mental illness as an additional diagnosis (Table 1).

    Recruitment took place at a memory clinic at a university hospital in 2013. The memory clinic referred the subjects to a psychiatric clinic for the elderly in order for the intervention to be carried out there.

    Table 1. Biographic data

    Description of the intervention

    In the intervention, the therapist used a manual (13) containing topics for 11 weekly meetings (Table 2). The starting point was to find a relevant goal for the therapy based on the subject’s circumstances and everyday challenges. The manual also contained worksheets for use in meetings and at home. The therapist adapted the therapy to the subject’s level of functioning and needs.

    The objective of the intervention was to maintain the subject’s coping skills in everyday life and reduce depressive symptoms.

    A specialist mental health nurse with experience in cognitive therapy carried out the intervention. The objective of the intervention was to maintain the subject’s coping skills in everyday life and reduce depressive symptoms. The person with dementia recorded how daily activities affected their mood in a diary. This increased their awareness and enabled them to choose meaningful activities that had a positive impact on their mood.

    One of the worksheets that was used as an aid was a list of enjoyable activities. In addition, the intervention involved the therapist using memory aids, such as a weekly planner, biography work and photo albums. Family members attended every second meeting in order to gain knowledge of and support the therapy. When the subject attended the meeting alone, he/she received a letter for their family outlining the topics they had covered.

    Table 2. Overview of the topics in the intervention based on the manual in the KORDIAL study

    Data collection

    The therapist wrote journal notes and log notes after each meeting. The log notes constitute the bulk of the data in the study and indicate the topic of the meeting. They also provide a description of the interaction between the person with dementia, their family and the therapist. They also contain reactions and statements from the subjects and their families, as well as the therapist’s own observations and reflections. The log notes are made up of 31 typed pages.

    Analysis

    We analysed the log notes in accordance with Graneheim and Lundman’s content analysis method (14). The method consists of reading the text several times and identifying and condensing meaning units. It also includes an abstracting process in which subcategories, categories and topics are created. The analysis was conducted by the first author, who was also the therapist.

    Ethics

    The study was approved by the Regional Committee for Medical and Health Research Ethics (REC) for the South-Eastern Norway Regional Health Authority as part of the KORDIAL study. Subjects gave informed consent to participating and also consented to the material being used in the article. They received information about the right to withdraw during the study. Study subjects were anonymised.

    Results

    Case 1

    Knut noticed that he had memory loss four to five years before the intervention. His short-term memory and learning and organisational abilities were very poor. He also needed help in areas such as getting dressed and cutting up his food.

    Knut thought that he was managing well, but according to his wife, he was passive and preferred to sit in the chair and sleep.

    Knut thought that he was managing well, but according to his wife, he was passive and preferred to sit in the chair and sleep. He was aware that his memory was impaired, but did not consider it a problem. Knut did not feel depressed and thought life was fine. His wife told me they had a daily programme; they went for walks, attended the senior citizens’ centre and went to the shops.

    Table 3. Knut: Understanding of the situation, interaction in the intervention, impact on everyday life and quality of life

    Impact on everyday life and quality of life

    For Knut, the intervention did not lead to changes, and this is reflected in MADRS (10) and QOL-AD (11) (Table 3). His wife felt it was helpful to hear that she was already doing a lot of good for her husband and to find out that it was natural to get annoyed and feel fed up sometimes.

    The interaction

    Because Knut did not think that his memory loss was a problem, it was difficult to follow the manual on which the intervention was based. The therapist found it appropriate for Knut’s wife to participate in all of the meetings. The goal ‘to maintain the current level of functioning’ was something they formulated together.

    Knut did not manage to record tasks in the diary aimed at raising his awareness of what he thought was meaningful. When the therapist talked about genealogy and drawing, which his wife said he had been interested in before, he showed neither interest in them nor wistfulness over the fact that they no longer gave him any pleasure. He said he was finished with these activities: ‘There’s a time for everything’. He also showed no interest in the worksheets. When the therapist asked if he would rather have no more meetings, he said, ‘On the contrary, this is really nice’.

    Knut could not see the point of using a joint weekly planner, even though his wife thought it would be a good idea because he kept asking the same questions. He did not think he needed to use a planner because his wife ‘is so good at remembering’. When the therapist suggested making the planner an experiment and a joint project, he wanted to give it a try. By the end of the intervention, they had had some positive experiences with using the joint planner, but no new routine had been established.

    They brought photo albums from Knut’s childhood to the meeting about good personal memories. They also frequently looked through albums at home, which evoked good memories and interest on Knut’s part.

    Case 2   

    Åse’s memory started to deteriorate five to six years ago. She managed her everyday life well, was fond of housework and still cooked meals, but could easily lose track of time. She sometimes felt depressed, according to both herself and her husband, but was sociable and happy when with family and friends.

    Table 4. Åse: Understanding of the situation, interaction in the intervention, impact on everyday life and quality of life

    Impact on everyday life and quality of life

    Åse believed that the intervention had a positive impact on her dark moods, as shown in MADRS (10), where her score descended from 18/60 to 4/60 during the intervention (Table 4). Quality of life, QOL-AD (11), went up slightly, which may indicate that the intervention had a positive impact.

    Åse’s use of a joint weekly planner benefitted her considerably. Her communication with her husband improved, which led her to feeling more relaxed and not so afraid of making mistakes. Her husband said that the meetings were meaningful, and what they had learned was helping to make everyday life easier for them both.

    The interaction

    Åse was looking forward to getting started. She said at the beginning that her problem was memory loss and repeatedly asking the same questions. She formulated the following goal: ‘to have fewer mood swings and stop feeling down’. Her husband found it difficult when his wife did not remember anything from important conversations they had had recently.

    Åse said that she felt stupid when she noticed that her husband became impatient or irritated. This was hurtful to both of them. She said that she sometimes needed more time and some trigger words from conversations from her husband. They explored this strategy together and found a better way of communicating.

    Åse noticed that meaningful activities, such as light housework, had a positive impact on her mood. The home tasks that were part of the intervention made her aware of what she could do to improve her mood. She and her husband found a way to use a joint weekly planner. She was often a little depressed in the morning because she did not know how she was going to spend the day.

    When they started writing in the weekly planner that she would do some laundry, ironing or watch a TV programme, she experienced predictability and thus security because, as she said, ‘I know what I’m going to do’. It was also important for her to write down what time her husband would come home and when she was to cook dinner.

    They introduced routines for placing her keys, watch and handbag in designated places, which also made everyday life more predictable and made her calmer. Åse was able to remember a lot from the photographs they had used in the biography work, which made both her and her husband happy.

    Discussion

    The objective of our study was to evaluate the impact of manual-based intervention on the subjects’ everyday lives and quality of life. We also wanted to describe the interaction between the person with dementia, their family and the therapist.

    Impact on everyday life and quality of life

    The goal for Knut was ‘to maintain the current level of functioning’. The intervention had little impact on Knut’s everyday life and quality of life, which is consistent with the score in the MADRS and QOL-AD measuring instruments, where we saw little change. According to Knut, he felt that by being included in the study he was able to contribute.

    Flexibility and adaptation of the manual with a view to meeting individual needs is crucial, and is in accordance with the descriptions by Tonga et al. (15). Knut’s wife felt that the letters to families contained useful information, and through participation in the intervention she learned that her efforts were helping Knut considerably. 

    Åse’s goal was ‘to have fewer mood swings and stop feeling down’. The goal led to a change in the way she communicated with her husband, which made her less afraid of making mistakes. She felt that he had begun to see her differently. In light of Antonovsky’s theory, this can be interpreted as Åse gaining a sense of understanding and management of the situation (16).

    Understanding can lead to mastery, health and well-being, and hence a better quality of life, which is also indicated in Åse’s QOL-AD score. Her everyday life became more predictable through the introduction of a joint weekly planner. As a result, she was less depressed. This was reflected in her MADRS score, which showed a reduction in depressive symptoms.

    According to the findings of an international study, established psychological models such as cognitive behavioural therapy can reduce depressive symptoms in people with dementia (17). The study concludes that psychological interventions have the potential to increase the subject’s sense of well-being. The pleasure of looking through photo albums was a new experience for Åse and her husband, and they wanted to do more of it.

    The interaction

    From the therapist’s perspective, the interaction with Knut was a challenge because he did not think that he had memory problems. Knut and his wife had very different perceptions of their everyday lives. Among other things, Knut claimed that he participated in housework and wrote down appointments, which was not true according to his wife.

    Knut showed no interest in trying any of the measures suggested in the manual.

    Knut showed no interest in trying any of the measures suggested in the manual. He seemed passive and lacking initiative, which is a behavioural change that occurs frequently in early stage dementia (18). His behaviour can be understood as denial of the disease (19) as a way of concealing his fear of not mastering everyday life (20).

    His behaviour may also be due to lack of insight into the disease, which often occurs in early stage dementia (3). In Knut’s case, a different type of treatment may have been more suitable, such as cognitive stimulation, which can reduce apathy in people with dementia (21).

    The compensation phase

    The positive picture that Knut presented of his situation could be an expression of what Engedal calls the compensation phase (3). The phase is partly characterised by memory loss and problems relating to events in the right time perspective, such as when Knut claimed that he still wrote appointments in the desk calendar.

    The findings of an international study show that living with the disease is often presented as a positive story, with the people with dementia emphasising what they mastered and expressing that they were satisfied with life (22). We recognise this phenomenon in Knut, who, in addition to emphasising how well he was doing, spoke about things that he apparently still did; reading books, doing small jobs around the house and going for walks on his own. According to his wife, this was not the case.

    Knut had what Næss (23) describes as a fundamental mood of enjoyment in that he was content with life. This joy was also reflected in his MADRS and QOL-AD scores.

    Memory work evoked interest

    Knut got annoyed with his wife when she tried to motivate him because he did not understand the purpose of either the worksheets or the attempts to introduce a joint weekly planner. His wife found the situation challenging until the therapist suggested calling these home tasks an experiment and a joint project. This also appealed to Knut, who was then willing to try.

    The memory work evoked an interest in Knut whilst also giving the therapist an impression of the person Knut had been, the values he had held and how is life had unfolded. The memory work seemed to build Knut’s self-understanding and identity, and gave him positive experiences.

    Looking through photo albums can help recall happy feelings from times gone by. It can also enhance self-esteem, which is described as recognising oneself again (24), and is consistent with Tranvåg et al. (25), who argue that highlighting the life stories and life projects of people with dementia also helps to promote their sense of dignity in everyday life. Families also play a role in the continuity of their sick relative’s life (26).

    Feeling upset

    The therapist thought the interaction with Åse was fruitful and believed that the intervention was right for her. She was eager and interested in learning how she could increase her independence and improve everyday life, including in relation to her husband. Åse was aware of her memory failure, which in some situations made her feel upset.

    People with dementia are sensitive to signs of lack of acceptance and inadequacy (27). The need to be seen and respected is therefore important (28, 29). Åse devalued herself because her memory was poor. Such thoughts can increase the risk of depression (30).

    Feeling useful

    Both Knut and Åse experienced happiness in everyday life and had good relationships with their spouses, in line with Næss (23). Næss argues that quality of life is about love, commitment, self-respect and happiness. Both expressed that they felt useful: Knut by supporting his wife with his arm and carrying shopping bags, and Åse by ironing and doing housework.

    [Åse] thought the intervention was meaningful and was motivated to make an active contribution.

    Åse thought the meetings were exciting. She liked getting home tasks and thought it was satisfying to talk about what she had learned when she came to the next meeting. She thought the intervention was meaningful and was motivated to make an active contribution, which is at the core of Antonovsky’s sense of coherence theory (16).

    Antonovsky argues that our power of resistance depends on how understandable, manageable and meaningful we consider life to be. This includes a motivational component, which motivates change (16).

    Strengths and weaknesses of the study

    It is important that validity and credibility are an integral part of the research process, which entails all stages being transparent, open and carried out with conviction (7). A weakness of the study may be the dual role of therapist and researcher, since the study might be characterised by subjective observation. The subjectivity was moderated by the co-authors being involved in the reflections in the analysis process.

    The fact that the researcher was also the therapist meant that she could observe the subjects’ body language, which gave an indication of how they experienced the meeting. The observations were subjective and may therefore be inaccurate. If the dialogue in the meetings had been recorded digitally and then transcribed, this may have enhanced the credibility of the study by giving different researchers access to everything that was said.

    The study has just two subjects, with different degrees of cognitive impairment. This necessitated different approaches to the intervention and resulted in different levels of efficacy. Qualitative studies do not aim to generalise findings, rather they are intended to go into depth and describe what happened, which can be useful in terms of further developing the experiences from this study.

    One strength of the study was that the qualitative method was supplemented with quantitative measuring instruments to evaluate whether the intervention impacted on the subjects’ everyday lives and quality of life. The findings cannot be generalised, but further research can be carried out to examine quality of life and signs of depressive symptoms following a similar intervention with a larger dataset.

    In addition, future research can explore how the situation of family members is affected by participating in the intervention, and whether a positive change could help people with dementia to remain living at home for longer.

    Conclusion

    Findings from this study show that the intervention affected the everyday lives of subjects and their quality of life in different ways and to different degrees. The interaction between the subjects and the therapist varied considerably depending on the subject’s insight into the disease and their motivation to participate.

    Knut’s life was not particularly affected by his lack of insight. Åse was motivated to learn and felt that everyday life became more predictable when she used aids. Discovering what had a positive effect on her mood and improving the communication with her husband made her feel less depressed. Both spouses felt that their efforts were appreciated and that they had gained a better understanding of how they could support their family member.

    There is reason to believe that a thorough study of people with dementia may make it possible to determine whether this intervention is suitable. Further research should study the person more thoroughly before including them and investigate the significance of the number of meetings on the benefit different people gain from the therapy. The intervention can also be tested in group meetings, or in combination with individual meetings.

    References

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    28.     Husband HJ. Diagnostic disclosure in dementia: An opportunity for intervention? International Journal of Geriatric Psychiatry 2000;15:544–7.

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    People with early stage dementia can have different insights into their disease, and their motivation to participate in conversations with therapists can vary. A manual-based intervention can help find a relevant goal for the therapy based on the person’s circumstances.

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    Sammendrag

    Background: Studies show that psychotherapy can help maintain the level of functioning and quality of life of people with dementia.

    Objectives: This case study is part of the KORDIAL study. The objective of this randomised controlled intervention study was to assess how an intervention impacted on subjects’ everyday lives and quality of life. Furthermore, we want to describe the interaction between the subjects and the therapist.

    Method: The intervention was based on cognitive behavioural therapy where the focus was on meaningful activities aimed at modifying depression, memory aids and reminiscence. The intervention consisted of eleven weekly meetings. We recorded log notes for each meeting. The log notes were analysed according to the principles formulated in Graneheim and Lundman’s qualitative content analysis.

    Results: One subject did not understand the purpose of the intervention and thus failed to benefit from the tools. The other was motivated to learn and found out what she could do to have a meaningful everyday life, which, among other things, made her feel less depressed.

    Conclusions: Disease insight and motivation are factors that must be considered when choosing a therapeutic approach to people with early stage dementia. One of the subjects might have benefitted more from a different approach. For the other subject, the intervention had a positive impact on their everyday life and quality of life. The participation of family members seemed to be beneficial and supportive for the person with dementia.

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  • Individual care plan at the palliative stage – helping relatives to cope

    Many patients at the end of life often want to stay at home, and how their relatives cope with the home situation can be crucial in fulfilling this wish (1–3). Policy and research documents emphasise that an individual care plan can ensure user involvement and interdisciplinary collaboration, and can highlight contact persons and the needs of patients and relatives (1, 4–6).

    It is vital for a patient pathway that services are coordinated and holistic, that they secure good quality treatment and include relatives (6–9). This article is based on a study examining whether an individual care plan at the palliative stage helped relatives to cope (10).

    An individual care plan is an overall plan and tool that sets out what care services are required, goals, resources, service providers responsible, the coordinator and close relatives.

    An individual care plan is an overall plan and tool that sets out what care services are required, goals, resources, service providers responsible, the coordinator and close relatives (4, 5, 11) (Table 1). When the patient requires the coordination of two or more services over time, this triggers a legal right to an individual care plan (4, 5, 11, 12). Legislation such as sections 2−5 of the Patients’ Rights Act and appurtenant regulations and guidelines (11, 12) sanction this right.

    The patient must consent to the establishment of an individual care plan, the group responsible and the involvement of relatives. He/she shall define who is next of kin, cf. Section 1 paragraph 3b of the Patients’ Rights Act (4, 8, 12, 13). An individual care plan is considered to be a relational contract in which the service content of care services is clarified in a collaboration between the patient, relatives and service providers (14).

    Table 1. Content of an individual care plan for patients at the palliative stage

    Palliative care consists of active treatment and holistic care for patients with an incurable disease and limited remaining lifetime. The aim is to achieve the best possible quality of life for patients and their relatives. Patients often present a complex clinical picture with frequent changes in their health situation that require coordinated follow-up by the health care services, and this triggers the right to an individual care plan. At the same time, individual care plans are infrequently used at the palliative stage (1, 15).

    Search words and earlier studies

    A literature search was undertaken in health care databases such as Oria, EBSCO-Cinahl, Ovid, Evidenced-Based Nursing, Cochrane, ProQuest, Norart, Idunn, Swemed. We carried out our search using the following MesH search terms: individual plan, individual care plan, patient care plan, caregivers, family, coping, palliative care, palliative care nursing and terminal care. Our last search was carried out on 16 May 2017.

    There are a number of studies on the individual care plan (16–19), but none of them deal with both palliative care and the perspective of relatives. Several Norwegian studies deal with relatives as part of palliative care (20–26). In summary, the studies show that relatives want information, advanced care planning, support, and interdisciplinary and accessible health care services in order to cope with the complexities of everyday care provision.

    Background for this study

    ‘Advanced care planning’ (ACP) consists of structured conversations aimed at clarifying wishes and needs (2, 6, 21). We have used the findings of the literature search to discuss the results of this study.

    In our study, the experiences of relatives are examined in light of Antonovsky’s theory of salutogenesis (27). Antonovsky’s coping-oriented approach stresses factors that promote health and contribute to an overall sense of coherence (SOC). This requires that the inner and outer environment of the individual is comprehensible, manageable and meaningful.

    This means having available resources and challenges that are worthy of involvement (27). Heggen depicts coping as the ability to tackle challenging, stressful situations and using one’s own resources to move on (28, p. 65). The question this raises is ‘How can an individual care plan at the palliative stage help relatives to cope?’

    Method

    We have conducted a qualitative study with a phenomenological hermeneutical approach (29). The phenomenological perspective consists of the subjective descriptions of the informants – the case itself. The hermeneutic perspective – the abstract meaning – emerges through analysis and interpretation of the transcribed conversations. We chose this approach in order to elicit the experiences of relatives with an individual care plan at the palliative stage.

    The research design used was two multi-stage focus groups (30). Wibeck (31) refers to Morgan (1996) who describes the focus group as a research technique whereby data are gathered through group interactions between the group members in order to elicit qualitative data about a research issue chosen by the researcher. Teamwork and dynamic interaction among the informants will facilitate new insights and knowledge (32).

    Multi-stage focus groups

    In multi-stage focus groups, informants discuss topics and experiences in the course of several meetings. The dialogues create enhanced understanding by considering phenomena in detail and in depth, elevating the informants’ experiences to a higher level of abstraction (30).

    The role of the moderator is to guide the informants’ conversation, maintain a balance between empathy and distance, listen and identify the meaning of what is expressed, ask key questions and ensure structure in the group conversations (31, 32).

    The multi-stage focus groups, which had five and seven female participants respectively, met three times, with six group meetings altogether. Table 2 provides an overview of the informants.

    The informants were adult surviving relatives who had helped to design an individual care plan at the palliative stage. Their participation in the study took place between four and eighteen months after the death of an adult family member. The relatives were spouses, daughters and daughters-in-law recruited by health care personnel who were in contact with them during the palliative stage.

    The sample represented five individual care plans that had been established late in the palliative stage – from four months to one week before the death. The informants were unknown to the researcher before they consented to participate. The researcher was the moderator of the groups. An interview guide with open-ended topics based on the research questions was used in order to promote dialogue and the exchange of experiences.

    Topics that emerged from analysis of the data from the previous group meeting were introduced at the next meeting. This led to further elaboration of the topic. The Norwegian Centre for Research Data (NSD), formerly the Norwegian Social Science Data Services, approved the study, which was carried out in accordance with research ethics’ legislation and guidelines for medical and health care research (10).

    Table 2. Overview of informants in the focus groups

    Phenomenological hermeneutical analysis

    We chose Lindseth and Norberg’s (2004) method of phenomenological hermeneutical analysis (29). The phenomenological perspective, the lived experience, was described by the informants in the interviews. The hermeneutical perspective – meaning in a wider sense – emerged through the interpretation of the interview texts. The interpretation of the texts builds on Ricoeur’s hermeneutic circle, which moves between understanding and explanation (29).

    The steps in the analysis are 1) naive understanding, 2) structural analysis and 3) deeper understanding. Naive understanding is an initial read-through of the text in order to elicit a deeper understanding whereby the text ‘speaks to us’. Then we carried out a structural thematic analysis with interpretation of the transcribed text.

    We divided the text into meaning units that were condensed and abstracted in order to elicit topics in light of naive understanding. Finally, we read and reflected on the text in order to elicit an overall understanding and to quality assure the correlation between naive understanding and the structural thematic analysis (29). Table 3 presents an example of structural thematic analysis in the study.

    Table 3. Example of the process of abstraction in the analysis of the topic ‘Relieve the burden – share the responsibility’

    Results

    The informants described a demanding and complex everyday life with serious illness and constant alertness with little sleep or relief. Several informants found it supportive to have a formal, individualised plan in which the coordinator, contact persons and therapists were named.

    Several informants found it supportive to have a formal, individualised plan in which the coordinator, contact persons and therapists were named.

    The article is based on a study with several findings: trusting relationships, holistic care and treatment, bringing hope and dignity, the struggle of relatives, support for relatives and the final hours together (10).

    The further analysis and literature search highlight the perspective of relatives, and findings are reformulated. ‘Person-centred care’ summarises overall understanding, and in the article we present topics such as ‘Relieve the burden – share responsibility’, and ‘Knowing that someone cares’.

    Relieve the burden – share responsibility

    Receiving an individual care plan was like ‘bringing order to chaos’ according to one informant and gave a sense of security in an uncertain situation.

    Informant 6 said: ‘[…] you get a real sense of security as when everything else is up in the air […].’

    Being met in a good way was important for establishing trust in the health care services. The content of the individual care plan clarified what professional resources could be contacted at different levels of the health care services. The informants found that there was better planning and more holistic care when a care group supported the family. Participating in the planning prepared the informants even though the patient pathway differed from what had been planned.

    At the end of life when there was a great need for symptomatic relief, a coherent, interdisciplinary 24-hour service gave the informants a sense of security because they perceived that the health care services collaborated and were better informed, in contrast to the time prior to the establishment of an individual care plan.

    One of them said: ‘[…] we knew them, we felt safe […] it was positive even though it was sad […].’ 

    The informants stressed that the GP is of central importance and must be involved at an early stage. In a more peaceful pathway, where there are good relations with the health care services, an individual care plan was not so important.

    Several informants perceived being part of the decision to terminate life-prolonging treatment as a burden that affected their grief afterwards. When such a decision had to be made, the patient was too ill to make this choice. An interdisciplinary meeting in connection with the individual care plan at which the treating physician made the final decision was nevertheless a good support. The informants were of the opinion that the question of life-prolonging treatment should have been clarified with the patient and should then have been embedded in the individual care plan.

    The informants emphasised that information must be given and an individual care plan established early in the course of the disease. At that time, the patient is strong enough to understand what an individual care plan is, and can be involved in the planning.

    Knowing that someone cares

    The process surrounding the individual care plan was more important than the document. The coordinator was described as a mentor for the patient – a professional who prioritised time, inspired confidence and established a dialogue that gave strength and support. The informants reported meeting professionals who were familiar with the patient’s situation and they knew that someone in the health care services ‘cared’. ‘That someone cares, and that there are plans for a life – a plan for a dignified life,’ explained informant 12.

    Patients and relatives took part in the planning. Individual care plans often included the goal of being at home. Activities were planned so that life was not merely ‘waiting for death’. This goal gave patients and relatives a hope – not of recovery, but something to strive for in order to regain a zest for life.

    Informant 9 said: ‘[…] what I hoped – we can’t demand that he recovers. But that he can walk around or be at home as much as possible.’

    The support the informants experienced in the planning process was particularly important.

    ‘I found it was a huge support. And I think the work on the individual care plan – that it was recorded in writing that he should have plans, that someone had overall responsibility, that there was an overview […]. So when we received this plan – I felt that a terrible responsibility was kind of shared.’ Informant 2

    Discussion

    Our findings show that an individual care plan was vital in creating meaning and coherence. In order to shed light on how the individual care plan can help relatives to cope, we will discuss ‘Relatives need support to be a care resource’ and ‘Person-centred collaboration’.

    Relatives need support to be a care resource

    Studies show that relatives need care and support in order to be resource persons for the patient (1, 7, 8, 13, 20, 22, and 33). Milberg writes that relatives experience uncertainty and anxiety when no family-based and professional health care support is available at the palliative stage (3).

    Sørhus, Landmark and Grov’s study (22) confirms that relatives need information and support from the health care services, while at the same time they feel responsibility, a sense of coping and meaning in the care tasks they perform. In Fjose et al.’s study (20), relatives confirm how valuable the meaningful and yet challenging end of life stage is.

    For the informants in our study, it was challenging to have a family member who was seriously ill and at the same time find themselves in a situation characterised by uncertainty and helplessness. They felt that having an individual care plan and being part of a team surrounding the patient lessened their responsibility. Moreover, they found that having a coordinator and an individual care plan created order, and gave them an overview of relevant professional resources and a plan for the time ahead.

    This reduced their uncertainty and made everyday life more comprehensible and manageable. According to Antonovsky, receiving support in challenging situations can help people to understand, perceive meaning and cope with the situation (27).

    Relatives in a dilemma

    Milberg points out that relatives can experience conflict between the patient’s wish to die at home and their own uncertainty as to whether they will be able to cope with this (3). Stensheim, Hjermstad and Loge reveal that relatives experience great responsibility and strain, and must be seen and looked after (34). Collaboration between the relatives, the collaborating care services and the coordinator then becomes crucial. According to Breimo, Normann, Sandvin and Thommesen’s study, work on an individual care plan gave a feeling of security and of being taken seriously, and the coordinator was perceived as being more important than the plan itself (4).

    In contrast, substance users in Humerfelt’s study (16) found that an individual care plan did not lead to coordinated, holistic and individually-adapted services. They experienced a lack of participation, disappointing follow-up and disrespectful behaviour. This shows the importance of the coordinator’s attitude and dedication towards securing user involvement in the planning process. Holum and Nilssen’s studies show that a good process in relation to the individual care plan strengthens user involvement and empowerment (14, 18).

    The informants in our study felt that the coordinator alleviated relatives’ burden by acting as a support and a mediator between patients and relatives. In retrospect, they saw this time as a strength during the grieving process. The study shows that the process of putting in place an individual care plan – with a better information flow, distribution of responsibility and overview – created meaning and coherence. 

    Person-centred collaboration

    When working on the individual care plan, informants met professionals who had knowledge of the patient’s situation, and they knew that someone in the health care services cared. This created hope and meaning. The planning work ensured greater commitment, and provided goals to strive for and a perception of being seen as a person, as Alves’ study confirms (17).

    The planning work ensured greater commitment, and provided goals to strive for and a perception of being seen as a person.

    Alidina and Tettero (35) refer to Dufault and Martocchio’s definition of hope (1985), whereby hope can highlight strategies and motivation for reaching goals. The study showed that patients at the palliative stage needed hope in order to maintain their dignity, cope with stress and achieve a better quality of life. Hope is therefore an important resource in coping with life-threatening illness. The work on the individual care plan backs up this hope while our study also shows that relatives felt that they did not have to cope with the responsibility alone. 

    Must look after the relatives

    The relatives Grøthe interviewed said it was important to encounter professionals with dedication and expertise who kept them informed and attended to their needs (23). Relatives in Michael’s study wanted a plan for the future, even though the discussions were confrontational. This could secure patient involvement, information, joint decisions and support for relatives (36).

    The informants in our study said that the question of life-prolonging treatment and of where the patient wanted to be cared for at the end of life stage should have been clarified with him/her earlier, and this should have been included in the individual care plan. Such clarification would alleviate the situation of relatives. Bollig, Gjengedal and Rosland’s study (21) supports this since relatives in their study found that having to take important choices at the end of life stage was a burden because they were uncertain of the patient’s wishes.

    At the same time, patients in the study who lived in nursing homes had faith in leaving these decisions to relatives and health care personnel. The study concludes by stressing the need to systemise advanced care planning in order to clarify future wishes and thereby reduce relatives’ burden. Likewise, Gawande (37) points out that patients and relatives find that they are not in a position to make decisions about care in connection with life-shortening disease. 

    Adapted information

    Laws, who interviewed the caregivers of late-stage cancer patients, confirms the need for early, regular information and planning for the future by means of advanced care planning. This reduced the anxiety and uncertainty of caregivers and strengthened their coping strategies (38). Relatives interviewed by Hunstad wanted health care personnel to take the initiative in discussing and planning in order to reach specific goals, clarify the role of the caregiver and ensure 24-hour health care services and holistic care (24).

    Bøckmann emphasises that early involvement and targeted advanced care planning can create trust and clarify the needs of relatives (13). According to Brenne and Estenstad, access to palliative home care services, social support and the expertise of health care personnel are key factors in making provision for dying at home (2). Heath care personnel should therefore provide relevant information and take the initiative to carry out advanced care planning as early as possible so that patients and their relatives can make qualified decisions that can be embedded in an individual care plan.

    The dialogue the patient and relatives has with the coordinator, treating physician and the health care service is of fundamental importance for teamwork. Palliative care requires interdisciplinary collaboration (1, 15). In a study on an individual care plan in a course of rehabilitation, teamwork in the planning process was a tool for flexible collaboration (17).

    Good interdisciplinary teamwork in connection with an individual care plan can ensure the transfer of information and coordinated, targeted services, as confirmed by Nordsveen and Andershed’s study (39). An individual care plan can promote the involvement of relatives, create structure and highlight resources, so that relatives have an action tool in an uncertain future. According to Antonovsky, this reinforces their coping ability (27).

    An individual care plan reinforces the ability to cope

    The Norwegian Directorate of Health stresses that an individual care plan is vital for user involvement in a patient pathway (1). Involving patients and their relatives in decisions about their own future can help them to cope better with the situation. Wilson confirms how important relationships are in securing user involvement and independence of choice (autonomy) in a person-centred palliative practice (40).

    Involving patients and their relatives in decisions about their own future can help them to cope better with the situation.

    Breimo et al. write that the individual care plan requires an approach characterised by reciprocal enthusiasm (4). Mutual respect, dialogue and joint decisions were of fundamental importance in strengthening user involvement in Rise’s study (36). A study of people who were chronically ill in the Netherlands revealed that the individual care plan contributed to a more person-centred, planned and inclusive collaboration than if no such plan existed (41).

    Person-centred care is central to McCormack and McCance’s nursing model (42). The model emphasises individually adapted services, therapeutic relationships and user involvement, and is based on values such as respect and autonomy. ‘What is important to you?’ is a vital question in person-centred care. A person-centred relationship underpins the work on the individual care plan in which the nurse often plays a key role as a facilitator and coordinator.

    Discussion of method

    Although the study was conducted in 2011 prior to the entry into force of the new Act and regulations, the findings are still relevant and have been examined in light of new legislation and research. The objective of the study was to gain insight and knowledge about a topic on which there is little research. The multi-stage focus group design functioned as planned because new topics promoted fresh reflections and a deeper understanding. An example is the strain relatives experience when they are involved in the decision to terminate life-prolonging treatment.

    The sample was representative although one weakness was that only women were recruited. The sampling criterion was that relatives had been involved in the individual care plan process at the palliative stage. One man and one woman withdrew from the study before the first focus group interview.

    Another weakness was that one of the individual plans was only established one week before the patient’s death. According to Hummelvoll (30), groups of 5–8 participants are preferable in multi-stage focus groups, and one group is sufficient.

    The strength of the study is that the two focus groups have described shared experiences, for example the importance of hope and dignity, independently of each other. Although the sample is small, the findings of the study can be transferred to similar contexts. In retrospective studies, informants may recall experiences differently. The study has put emphasis throughout the process on answering the research questions. 

    Conclusion

    Our study shows that the individual care plan process at the palliative stage can help relatives to cope better. The informants experienced hope, being seen, less responsibility, involvement and support in a challenging everyday life. The planning process activated resources, established structure, created meaning and coherence.

    The coordinator and the individual care plan ensured user involvement by identifying the goals, roles and choices of patients and relatives at the end of life. The health care services emerged as a holistic, coordinated and coherent service in which the flow of information was strengthened.

    Nevertheless, our study shows that individual procedures must be quality assured. In order to strengthen user involvement and collaboration with relatives, individual care plans must be established at an early stage of palliative care. Clarifying important questions about treatment and the future can relieve the burden of relatives.

    The health care services should initiate advanced care planning so that important decisions can be embedded in the individual care plan. By strengthening relatives’ coping abilities, the health care services make provision for a better end of life at the palliative phase.

    There is a need for further research on factors contributing to the work on an individual care plan at the palliative stage and the collaboration of relatives.

    In order to achieve individually adapted, coordinated services and the use of an individual care plan in a patient pathway, a person-centred approach is fundamental. A person-centred, balanced approach and the use of an individual care plan requires a change of attitudes in the health care services. 

    Many thanks to the informants who shared their life experiences and to the health care personnel who helped to find informants. I would also like to thank Kristin Ådnøy Eriksen, Gerd Bjørke and Geir Sverre Braut for critical and constructive feedback on the text in the ongoing process.

    References

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    12. Lov av 2. juli 1999 om pasient- og brukerrettigheter (pasient- og brukerrettighetsloven). Available at: https://lovdata.no/dokument/NL/lov/1999-07-02-63(downloaded 26.09.2017).

    13. Bøckmann K, Kjellevold A. Pårørende i helse- og omsorgstjenesten – en klinisk og juridisk innføring (2. ed.). Bergen: Fagbokforlaget; 2015.

    14. Nilssen E. Kommunal iverksetting av retten til individuell plan. Tidsskrift for velferdsforskning 2011;14(2):79–94.

    15. Kaasa S, Loge JH. Palliativ medisin – en innledning. I: Kaasa S, Loge JH (eds.). Palliasjon – nordisk lærebok (2. ed.). Oslo: Gyldendal Akademisk; 2016 (p. 34–50).

    16. Humerfelt K. Brukermedvirkning i arbeid med individuell plan. (Doktoravhandling). Trondheim: Norges teknisk-naturvitenskapelige universitet, Fakultet for samfunnsvitenskap og teknologiledelse, Institutt for sosialt arbeid og helsevitenskap; 2012.

    17. Alve G, Madsen VH, Slettebø Å, Hellem E, Bruusgaard KA, Langhammer B. Individual plan in rehabilitation processes: a tool for flexible collaboration? Scandinavian Journal of Disability Research 2012;15(2):156–69.

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    20. Fjose M, Eilertsen G, Kirkevold M, Grov EK. A Valuable but Demanding Time Family Life During Advanced Cancer in an Elderly Family Member. ANS 2016 Oct;39(4):358–73.

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    23. Grøthe Å, Biong S, Grov EK. Acting with dedication and expertise: Relatives’ experience of nurses’ provision of care in a palliative unit. Palliative Supportive Care 2015 12;13(6):1547–58.

    24. Hunstad I, Svindseth MF. Challenges in home-based palliative care in Norway: a qualitative study of spouses’ experiences. International Journal of Palliative Nursing 2011;17(8):398–405.

    25. Stenberg U, Ruland CM, Miaskowski C. Review of the literature on the effects of caring for a patient with cancer. Psychooncology 2010;19(10):1013–25.

    26. Hanssen S. Lindring av lidelse mot livets slutt – et pårørendeperspektiv. (Master's thesis). Göteborg: Nordiska högskolan för folkhälsovetenskap; 2006.

    27. Antonovsky A. Helbredets mysterium. København: Hans Reitzel Forlag; 2000.

    28. Heggen K. Rammer for meistring. I: Ekeland TJ, Heggen K (eds.). Meistring og myndiggjering Oslo: Gyldendal Akademisk; 2007 (p. 64–82).

    29. Lindseth A, Norberg A. A phenomenological hermeneutical method for researching lived experience. Scand J Caring Sci 2004;18(2):145–53.

    30. Hummelvoll JK. Multi-stage focus group interview: a central method in participatory and action-oriented research designs. Klinisk sygepleje 2010 07;24(3):4–13.

    31. Wibeck V. Fokusgrupper – om fokuserade gruppintervjuer som undersökningsmetod. Lund: Studentlitteratur; 2010.

    32. Malterud K. Fokusgrupper som forskningsmetode for medisin og helsefag. Oslo: Universitetsforlaget; 2012.

    33. Wold KB, Rosvold E, Tønnesen S. «Jeg må bare holde ut...» Pårørendes opplevelse av å være omsorgsgiver for hjemmeboende kronisk syke pasienter – en litteraturstudie. In: Tønnesen S, Kassah B (eds.). Pårørende i kommunale helse- og omsorgstjenester – forpliktelser og ansvar i et utydelig landskap Oslo: Gyldendal Akademisk; 2017 (p. 52–78).

    34. Stensheim H, Hjermstad MJ, Loge JH. Ivaretakelse av pårørende. In: Kaasa S, Loge JH (eds.). Palliasjon: Nordisk lærebok (2. ed.). Oslo: Gyldendal Akademisk; 2016 (p. 274–86).

    35. Alidina K, Tettero I. Exploring the therapeutic value of hope in palliative nursing. Palliative & Supportive Care 2010;8(3):353–8.

    36. Michael N, O’Callaghan C, Baird A, Hiscock N, Clayton J. Cancer Caregivers Advocate a Patient- and Family-Centered Approach to Advance Care Planning. Journal of Pain and Symptom Management 2014;47(6):1064–77.

    37. Gawande A. Quantity and Quality of Life – Duties of care in Life-Limiting Illness. American Medical Association 2016;315(3):267–9.

    38. Laws RF. Evaluating the perceptions of quality of life in informal caregivers caring for hospice patients. (Ph.d. thesis). Hattiesburg: University of Southern Mississippi; 2014.

    39. Nordsveen H, Andershed B. Pasienter med kreft i palliativ fase på vei hjem – sykepleieres erfaringer med samhandling. Nordisk sygeplejeforskning 2015;5(3):239–52.

    40. Wilson F, Ingleton C, Gott M, Gardiner C. Autonomy and choice in palliative care: time for a new model? J Adv Nurs 2014 05;70(5):1020–9.

    41. Jansen DL, Heijmans M, Rijken M. Individual care plans for chronically ill patients within primary care in the Netherlands: Dissemination and associations with patient characteristics and patient-perceived quality of care. Scandinavian Journal of Primary Health Care 2015;33:100–6.

    42. McCormack B, McCance T. Underpinning principles of person-centred practice. In: McCormack B, McCance T (red). Person-Centred Practice in Nursing and Health Care: Theory and Practice Chichester, West Sussex, United Kingdom: WILEY Blackwell; 2017 (s. 13–35).

    Establishing an individual care plan at an early stage of palliative care gives relatives hope and support. They also feel seen and their burden of responsibility is lessened. 

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    Sammendrag

    Background: Patients at the end of life often want to stay at home, and how their relatives cope with the home situation can be crucial. In a patient pathway, an individual care plan can ensure interdisciplinary interaction with the patient and his or her relatives.

    Objective: The objective of the study was to examine how an individual care plan at the palliative stage helped relatives to cope.

    Method: A qualitative study was carried out. We collected data from two multi-stage focus groups consisting of 12 adult surviving relatives, and used a phenomenological hermeneutical approach to examine their experiences. The Norwegian Centre for Research Data (NSD) approved the study.

    Results: The informants described a challenging everyday life in a state of constant alertness. They perceived the individual care plan as a support. The content and process elicited resources and structure as well as creating meaning and coherence. The plan inspired the informants to feel hope, to feel that they were a resource and were part of a team surrounding the patient. ‘Person-centred’ care summarises the holistic understanding. The topics ‘Relieve the burden – share responsibility’ and ‘Knowing that someone cares’ are presented in the results section, and the focus areas ‘Relatives need support in order to be a care resource’ and ‘Person-centred collaboration’ are discussed in the article.

    Conclusion: Having an individual plan for palliative care can help relatives to cope. Early establishment of an individual care plan, person-centred relationships and collaboration can strengthen user involvement and collaboration with relatives. The relatives’ burden can be lessened by clarifying important questions about treatment and the future. Strengthening relatives’ ability to cope paves the way for a better end of life at the palliative stage. Further research is needed on the factors affecting work on the individual care plan at the palliative stage and on collaboration with relatives. 

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  • The contribution of a master’s degree to clinical practice

    Most educational institutions in Norway are converting their specialist training in advanced practice nursing to master’s degree programmes. This process is rife with opposing views and concerns about the consequences of this change, at both the societal level and the local level.

    Background

    Until a few years ago, specialist training in anaesthesia and intensive care nursing did not result in an academic degree. For the first time in spring 2014, advanced practice nurses at two of Norway’s 15 educational institutions in anaesthesia and intensive care nursing graduated with a master’s degree comprised of 120 credits. Eight of the 15 educational institutions in Norway offer master’s studies in anaesthesia and intensive care nursing (1). The design, structure and models vary somewhat, but the programmes largely meet the requirements of the framework plans and are function oriented (1–4).

    A national study showed a distinction in the learning outcome descriptions for the subjects ‘philosophy of science’, ‘methodology’ and ‘innovation’ between specialist training and a master’s degree in intensive care nursing (1). For specialist training, the learning outcomes for these subjects were designated as cycle 1-level (bachelor) (1, 5). The learning outcome descriptions in subjects such as ‘intensive care nursing’, ‘physiology/pathophysiology’, ‘pharmacology’ and ‘intensive care medicine’ were designated as cycle 2-level (master). It is reasonable to assume that the same holds true for anaesthesiology nursing, as these two fields have developed parallel to each other.

    There are several reasons for switching from specialist training to a master’s degree programme. The Bologna Accord has been especially significant in this regard, as it set the goal of developing comparable educational programmes in Europe for the three tiers of degrees: bachelor’s, master’s and Ph.D. (6). The Bologna Process is referred to as a ‘quiet revolution’ in the three levels of nursing education, and is characterised by slow progress and few scientific studies to refer to (7, 8).

    Discourse characterised by ‘master’s obsession’

    In general, there is a positive attitude towards the master’s degree throughout Norway, but some also express objections and concerns which come to light in discourse at the general and local levels. In this context, discourse is defined as a meaning system that plays a role in constituting practice and is reflected in language as social practice (9). Discourse has been characterised by linguistic representations such as ‘function-oriented master’s’, ‘master’s obsession’, ‘avoiding a dead end’, ‘over-qualification’ and ‘a master’s degree is not a master’s degree’ (2, 10–12).

    There are many arguments in favour of a master’s level education, often related to increased recruitment and the need for changes in competence.

    There are many arguments in favour of a master’s level education, often related to increased recruitment and the need for changes in competence. This is due to changes in demographic factors in society, changes in the population’s disease profile, developments in medical technology and requirements related to evidence-based practice (EBP) (13–18). There are also arguments for the need to change the autonomy of the health professions by a blurring of roles and developing new functions in the form of advanced clinical nursing (19–22).

    In 2012, a Swedish report described a lack of adaptations for meaningful academic learning in the educational and practice field of specialised educational programmes (23). The report concluded that teachers must stand together on a pedagogical platform, and the field of practice must support and utilise the academic competence of recent graduates (23). Another Swedish study emphasised that methodology must be adapted to the professional field (24).

    Academisation is a natural part of development

    In a study from 2015, 18 practice supervisors in anaesthesiology, intensive care, surgery and cancer nursing viewed academisation as a natural part of development in society: All higher education should be at the bachelor’s, master’s or Ph.D. level, and a master’s degree is a prerequisite for ensuring future recruitment to advanced practice nursing (25). The informants said they had expectations that a master’s level education in the field should contribute something different than, for example, a master’s degree in administration, sociology and the like.

    In a 2016 report from the Norwegian Association of Higher Education Institutions, a systematic search of international literature was conducted on the added value of a master’s degree in nursing (26). The conclusion was that nurses with a master’s degree made a positive contribution to the quality of services and patient safety. However, the report found no systematic evaluations of the contributions of advanced practice nurses with a master’s degree compared to nurses with specialist training. The report recommends further research that evaluates the added value of a master’s degree versus specialist training in a Norwegian context (26).

    The fields of practice have little or no experience with what advanced practice nurses with a master’s degree represent. Therefore, the purpose of this study is to describe the opinions and expectations of the field of practice regarding the ways in which advanced practice nurses with a master’s level education working in anaesthesiology departments and on intensive care wards can contribute to clinical practice.

    Method

    This study is a collaboration between Oslo and Akershus University College (HiOA) and the University College of Southeast Norway (HSN). Both educational institutions have programme models with a design and structure that make the programmes comparable. They offer nursing students the opportunity to conclude their studies as advanced practice nurses after three semesters or continue on to carry out a master’s thesis for one semester at HSN and two semesters at HiOA. The university colleges also offer supplementary studies for previously educated anaesthesiology and intensive care nurses.

    We conducted the study at the hospital health trusts in Buskerud, Vestfold and Telemark counties. The study has a qualitative, explorative and descriptive design. We chose to carry out focus group interviews with three groups comprised of anaesthesiology and intensive care nurses. Focus group interviews encourage a discussion among informants, and thus provide insight into the meaning systems that represent the professional environment in daily practice (27–29).

    Sample

    The sample consisted of advanced practice nurses with a variety of experiences, expectations and positions on the ward. They were managers, advanced practice nurse mentors, experienced nurses and recent nursing graduates (Table I). About one-third of the informants have an educational background from the time of in-house specialist training. The informants were selected by the managers to ensure that different opinions about a master’s level education and voluntariness were represented.

    Of the 24 informants, four managers or advanced practice nurse mentors were pursuing master’s studies at the time (a cross-disciplinary master’s and a master’s in administration and management). This study was approved by the Data Protection Official for Research. The informants have given their written, informed consent to participate.

    Table 1. Transcription markers and coding of informants

    Data collection

    The lead author conducted the interviews and the second author took notes during the interviews. Initially we wanted the informants to be candid and different opinions to be voiced. We conducted a partially structured interview on three topics to bring out the informants’ ‘understanding and expectations related to master’s level competence’, ‘reflections on the consequences of switching to master’s studies’ and ‘the attitudes they experienced within the professional environment regarding master’s degree programmes’.

    We conducted all of the focus group interviews with seven of eight invited participants. The duration was approximately 80 minutes. Illness, a lack of staffing, and a misunderstanding about the number of people to be selected for the focus group interviews were reasons that the groups were not full. One group lacked a manager from the anaesthesiology department. This manager wrote a brief statement based on the three topics from the focus group interviews. The other two groups did not have any intensive care nurses with more than five years of practice.

    We recorded the interviews, transcribed them and anonymised them. Table 1 shows a selection of markers that are intended to capture explicit statements of opinion and in part how emotional expressions, body language and phonetics can represent implicit, ambiguous statements (30–32). We chose to use transcription markers that were not too detailed so that the text would flow without too many codes that would limit the ability to gain an overview of interactions, topics and the process.

    Analysis

    To analyse and interpret the meaning systems, we chose to use thematic content analysis, which is a methodological analysis tool to focus and process the material thematically (33). We chose to use an inductive, rich description of the data across the focus group interviews, paying particular attention to explicit statements.

    We condensed the meaning-related data by searching for meaning patterns around positive and negative expectations of master’s level competence. The patterns were analysed and structured in topics and sub-topics.

    We used the concept of ‘expectation horizon’ as an analytical perspective when we analysed the statements of opinion (34). When we use the term ‘expectation horizon’ as a metaphor, we give extra attention in the analysis to what the informants believe are future scenarios and consequences of switching to a master’s degree programme.

    Results

    Table 2 shows three multifaceted sub-topics based on how the conversations revolved around positive and negative statements regarding master’s level competence.

    • Scientific competence
    • Competence in teamwork and development
    • Skill level and theoretical knowledge

    In the presentation of the results, we attempted to provide insight into the interview process and the distribution of statements of opinion among the informant categories and groups. We have selected quotes to show thematic representativeness, diversity, objections and opportunities. To limit the number of quotes, we have selected a sample that illustrates the overall content of opinion. 

    Table 2. Topic: Condensed data on statement of opinion and sub-topics

    Scientific competence

    In the first part of the interviews, the informants made somewhat different statements about their understanding of the special competence of master’s degree holders. As they talked, they came to a more limited and common understanding of this. Especially in Group 3, but also in Groups 1 and 2, the informants had little knowledge of the master’s degree programme:

    ‘I think we have good advanced practice nurses now […] What more should we expect?’ 2/I4

    An informant had reflected on how most people understood what a master’s level education entails:

    ‘Everyone knows what a master’s degree is – it’s something everyone is familiar with, but when I say I have specialist training, people ask: ‘What is that?’ So a master’s degree certainly has more meaning!’ [Others around the table nodded in agreement]. 1/I1

    After we had completed the introductory interviews, most of the informants said they expected that advanced practice nurses with a master’s degree would have more knowledge about EBP than those with specialist training. They expected that identifying and using new research would come more naturally to those with a master’s degree:

    ‘No doubt you’ll have this more at your fingertips just as in the practical work.’ 1/I1

    Some also had the opposite view:

    ‘Doesn’t EBP have something to do with your interests as an advanced practice nurse? Using research articles – searching? Do you need to get a master’s degree for that?’ 2/A2

    Many said that they expected advanced practice nurses with a master’s degree to be more analytical and critical, and therefore to ask more questions about current practice: ‘The positive aspect, I think, is that there might be a more critical view of what we are doing – that we offer the best and most careful treatment there is.’ 2/I3

    ‘By conducting research ourselves in our own field, we will in the long term gain insight from research from our own perspective instead of acquiring information through others’ research.’ 3/A2

    ‘A master’s degree will enrich the field. They think a little differently in their daily work than those without a master’s degree, because you learn to base your thinking on research. They learn to look things up and rely on research instead of saying “We have always done it that way”.’ 1/A3

    Competence in teamwork and development

    This sub-topic is developed based on how the informants view the switch from specialist training to a master’s degree programme as a kind of secondary benefit. Both professional groups felt that their fields were changing all the time, which requires practitioners with critical thinking skills, teamwork and renewal. Many assumed that more nurses with a master’s degree on their ward would enrich practice because it would be easier to enact change when a number of people think along the same lines. Some reflected on how this could perhaps lead to cultural change:

    ‘As a manager, I expect that those who have this type of education [master’s degree] will make a significant contribution to the ward! Bring the other employees along with them – participate and shape practice.’ 1/I4

    ‘Perhaps this can be a small stepping stone so that we can change some of the culture.’ 3/I4

    Many also said they had expectations that a master’s level education develops a person’s thinking and language and that this would raise the level of dialogue with cooperating partners and possibly increase recognition:

    ‘[…] the language you use – that you carry more weight when know the subject – and can demands things in a way.’ 1/I3

    ‘We need to get better at speaking up. Be very specific, because we sit in the nurses’ station, and we have so many thoughts and opinions about this and that – and nothing comes of it!’ 2/A4

    ‘The nurse will get more recognition when you steer things more towards research and appeal to that rather than to opinion – you will get much more recognition and your voice will be heard.’ 1/A3

    Skill level and theoretical knowledge

    On the whole, the informants viewed the fields as practice-oriented professions. Concern was expressed as to whether the wards had enough to offer advanced practice nurses with a master’s degree. In all three groups, there were many who more or less shared this concern. Group 2 stated:

    ‘Our profession is very practical! That is the crucial element, and in fact we must hold fast to it.’ 2/A3

    ‘I’m very concerned about how this will be applied afterwards [when the degree is completed]. How satisfied will they be working at the anaesthesia table or hospital bed, and what adaptations must be made afterwards?’ 2/I4

    Several regarded clinical studies in specialist training as comparable to the master’s level:

    ‘With regard to practice and the typical specialist training, I can’t see any great difference!’ 1/I1

    Many were concerned that master’s studies might not produce functionally skilled advanced practice nurses on par with specialist training.

    Many were concerned that master’s studies might not produce functionally skilled advance practice nurses on par with specialist training.

    ‘Could we end up with less qualified advanced practice nurses, I mean, with regard to the practical part of the job? They had more than enough to do for one and a half years before they were good enough at the patients’ bedside. This might not be because they have had so much formal education in methodology and such. And it will take a much longer time on the job before they really can do everything – so that we are sure they have the experience we really need them to have.’ 2/I4

    ‘Maybe there has been a fear that nurses with a master’s degree may be more removed from the practical aspects of the job – this is one assertion. We have spoken with advanced practice nurse mentors and midwife mentors who have worked with three year groups of master’s graduates. Those who have taken a master’s degree versus those without a master’s are not more removed from the field of practice, but are rather on an equal footing.’ 1/I3

    Other informants said that practical skills would not be a problem, but that there is a huge amount of material that master’s students must learn in the programme, and it is impossible to acquire all of it, especially in the beginning. They questioned whether nurses with a master’s degree would manage to have adequate theoretical knowledge:

    ‘Can you absorb what you are supposed to learn about anaesthesiology and intensive care – in addition to taking a master’s degree? […] Do they have sufficient academic knowledge? […] Do they know their theory? […] Is there enough time to become a good anaesthesiology nurse? […] You must have both the theory behind a master’s degree and you must know the anaesthesiology field. And you are going to manage that in two years? I am less concerned about skills. You can spend time on those when you are finished [some around the table nod in agreement], as long as you have the theory under your belt.’ 1/A3

    Discussion

    The analysis gives insight into the opinions and expectations of a sample of anaesthesiology and intensive care nurses regarding master’s level competence. Some ask: ‘What are we supposed to do with a master’s degree?’, while others expressed expectations of a positive difference between specialist training and a master’s degree programme.

    Performance of evidence-based practice

    In this section we will discuss the question ‘Will nurses with a master’s degree be more competent in the performance of evidence-based practice?’ There is a general view among the informants that anaesthesiology and intensive care nursing are essentially practice-oriented professions, but that the development of the health care services requires a high level of competence to work according to EBP to take the best possible care of the patient.

    They point out that the professional fields are changing all the time. This means that nurses must develop their ability to think analytically and critically, which will be strengthened in a master’s degree programme. This view corresponds with a previous study showing that a master’s degree is expected to provide more training in critical and analytical thinking compared with specialist training (23).

    The informants anticipate that advanced practice nurses who take a master’s degree in the future will have more competence in evidence-based practice (EBP), argumentation and documentation, and that they will contribute to a culture that promotes EBP. Not everyone in the initial focus groups expressed this view explicitly, but this is an understanding that developed during the course of the interviews.

    Early in the group interviews, representatives of all the informant categories say that they are uncertain or do not understand what a master’s level education is supposed to be used for. They are satisfied with the advanced practice nurses with specialist training and believe that a search for knowledge and EBP have mainly to do with interest. Among the informants, only those at the management level – two managers and one advanced practice nurse mentor – have or were pursuing a master’s degree at the time, and they say they know what a master’s level education entails.

    Nobody has experience with the added value that master’s level competence can provide to nursing services and the working environment.

    Nobody has experience with the added value that master’s level competence can provide to nursing services and the working environment. One of the managers says that master’s level competence is needed only for certain positions, such as a nurse mentor. Otherwise it is managers and advanced practice nurse mentors in particular who support and justify the need the most. They do so based on their expectations that advanced practice nurses with a master’s degree will be a driving force for developing better services for patients and a culture for EBP on the wards. It is reasonable to assume, as the informants argue, that advanced practice nurses with a master’s degree will have more training in literature searches, have the ability to read research articles more critically and take an academic approach to knowledge.

    EBP is part of a common thread in the educational pathway towards the two master’s degree programmes. This topic has been strengthened in the new programmes. However, there is a limited amount of time and attention that EBP can be given in the 30 credits that have been added in the changeover from specialist training to master’s studies.

    In a study of a cross-disciplinary master’s degree programme in EBP at the University of Bergen, Hole et al. describe findings showing that those with a master’s degree are regarded as change agents in EBP at their workplaces (35). The study has 120 credits to develop competence in EBP and emphasises the development of competence in performance. Cycle 2, the master’s level, includes a requirement to advance new ways of thinking and innovation. Competence in performance is included as a part of competence in innovation. There are few parameters for developing such competence in the master’s programme for anaesthesiology and intensive care nurses. 

    Level of knowledge

    Here we discuss the question ‘Will nurses with a master’s degree have a lower level of skill than recent graduates?’ The informants are concerned whether the skill level of clinical practice will be reduced following a switch to master’s level education. Many are familiar with the educational programmes from the time when they took part in in-house specialist training lasting 18 to 24 months. They have followed the development from the transition to university colleges, updating of framework plans and a reduction of 18 months in specialist training.

    Many make statements suggesting they believe that specialist training and a master’s degree programme should in principle have the same level of skill in clinical practice.

    Many make statements suggesting they believe that specialist training and a master’s degree programme should in principle have the same level of skill in clinical practice. This view is reflected in a previous study which found that learning outcome descriptions for specialist training and a master’s degree programme in clinical studies are formulated in much the same way and at an advanced level (1).

    It is mainly theoretical courses that represent academic competence, such as the philosophy of science and methodology, in which the level is described as being comparable to the bachelor’s level. In a new report, the Norwegian Association of Higher Education Institutions also describes the level of specialist training as high and to some extent beyond the requirements of the framework plans and that the step up to the master’s level is short (26).

    In a master’s degree programme, the courses on the philosophy of science and methodology have become more extensive and demanding. These courses are intended to be completed over three semesters, comparable to specialist training without a master’s thesis. The informants’ concerns revolve around how the master’s students will manage to complete new courses, acquire functional skills and at the same time have an equally high level of theoretical knowledge, as after completion of specialist training.

    Theoretical knowledge is valued so high that one of the advanced practice nurse mentors prioritised it over acquisition of a full range of functional skills within the timeframe of the educational programme. She believed that advanced practice nurses can develop the practical skills after completing their education if they have good theoretical knowledge. The framework plans require advanced care nurses to possess functional skills and competence in taking appropriate action (3, 4).

    It is quite challenging from a teaching perspective to ensure that students acquire advanced clinical competence and at the same time satisfy the academic requirements set for a master’s degree programme. Many of the informants regarded these requirements as almost impossible to fulfil, and thus they should be evaluated on an ongoing basis.

    The field’s reputation and competence in teamwork

    In this section we discuss the question ‘Will a master’s level education help to enhance the field’s reputation and increase competence in teamwork?’ The philosophy of science and methodology are positive for the field in that students learn to elucidate research from their own vantage point. As nurses acquire a higher level of scientific language and strengthen their ability to think critically, the informants expect that cooperation between advanced practice nurses and doctors and other professional groups will be on a more equal footing, that their opinions will more likely be taken into account and that they will experience greater respect for their own views.

    The importance of language for creating a better common understanding and appropriate cooperation across professional groups is undeniable (32). It is a huge leap to go from linguistic representations such as an ‘in-depth subject paper’, which is a school assignmentin specialist training, to a ‘master’s thesis’, which is an academic project. This is not only a linguistic representation that sounds impressive, but it is also a step up in quality that is expected to be reflected in practice and which most people understand and recognise. Advanced practice nurses who have taken specialist training are recognised for their high skill level (35). Further recognition assumes that a master’s level education maintains a high theoretical level and skill level.

    Critique of methodology

    Both authors of this article, who also conducted the interviews, have many years of professional affiliation with the fields of intensive care and anaesthesiology nursing. As facilitators with deep insight into the culture and use of language, and great openness with regard to differing opinions, it is reasonable to assume that their competence has contributed to a rich, diverse data collection. In particular, the second author, who has not had knowledge of or contact with the professional environments in the study, has brought an outside view to the data.

    We have asked ourselves whether the lack of one informant in each group may have affected the interviews. In cases when an experienced advanced practice nurse was not present, the advanced practice nurse mentors have mostly represented the perspective of those with experience in the field. The dynamics of the group without a manager from the anaesthesiology department would perhaps have been different if the manager had been present.

    Conclusion

    It is natural to expect that an extensive, national restructuring of specialist training to a master’s level education will be characterised by ambivalence, approval and opposition. This study describes the reflections of highly competent informants on expectations of a master’s degree programme versus specialist training. The study also shows that clinicians and managers need more knowledge about what a master’s level education entails.

    At the master’s degree level, informants expect that nurses’ scientific language and critical thinking ability will be further developed, be integrated into professional knowledge and professional practice, and be reflected in the way nurses present themselves and interact. Informants’ linguistic representations regarding master’s level competence indicate an expectation about the future in which advanced practice nurses with a master’s degree will be better prepared to help to establish EBP due to their academic competence as role models and catalysts in practice. The master’s level education puts an overall emphasis on EBP, but the expectation of strengthening competence in performance among the students creates challenges within the current parameters of the master’s degree programme.

    As a result of the Bologna Accord, master’s degree programmes are here to stay. We strongly recommend that health trusts and educational institutions work closely together to develop educational models and adapt pedagogical approaches so that there is an appropriate balance between academic competence, theoretical knowledge and skill level.

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    35.  Hole G O, Brenna SJ, Graverholt B, Ciliska D, Nortvedt MW. Educating change agents: a qualitative descriptive study of graduates of a Master’s program in evidence-based practice. BMC Medical Education 2016;16:71.

    Anaesthesiology and intensive care nursing are regarded as practice-oriented professions. Can a master’s degree provide an equally high level of skill and theoretical knowledge as specialist training?

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    English
    Sammendrag

    Background: Educational programmes in advanced practice nursing are switching from specialist training to a master’s level education. In general, there is a positive attitude towards master’s degrees, but some have objections regarding ‘‘academisation’’ and ‘over-qualification’.

    Objective: To investigate the expectations that the anaesthesiology and intensive care professions have of master’s level competence.

    Method: We conducted three focus group interviews with anaesthesiology and intensive care nurses in three health trusts. They were managers, advanced practice nurse mentors, experienced nurses and recent nursing graduates. We used thematic content analysis to analyse and interpret meaning systems. The expectations of informants regarding master’s level competence were gleaned from the positive and negative statements made during the interviews.

    Results: At the master’s degree level, informants expect that nurses’ scientific language and critical thinking ability will be further developed, be integrated into professional knowledge and professional practice, and be reflected in the way nurses present themselves and interact. Many expect nurses with master’s degrees to have a higher level of competence and greater potential for satisfying the requirement of evidence-based practice (EBP). Anaesthesiology and intensive care nursing are regarded as practice-oriented professions, and there are concerns as to whether master’s degree programmes provide an equally high skill level and theoretical knowledge as specialist training.

    Conclusion: The added value of a master’s degree programme is found in the scientific language and critical thinking skills, as well as in the application of evidence-based practice. Health trusts and educational institutions should cooperate closely on developing educational models, study programmes and pedagogical approaches so that the skill level is maintained in a master’s degree programme.

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  • Dying patients in nursing homes: nurses provide “more of everything” and are “left to deal with everything on their own”

    In recent years, we have seen a rise in the number of patient deaths in Norway’s 1,000 nursing homes, and the trend continues with approximately 48 per cent of all deaths per year (1–3). The high mortality figures put considerable demands on the nursing home as an arena for the provision of end-of-life treatment and care, and on the healthcare staff who are providing services for the dying and their relatives (2, 4). According to national guidelines (5), all nursing home wards must provide a service which meets the patients’ needs for basic alleviating treatment and care, referred to as palliation.

    On average, long-stay in-patients have received 6.5 diagnoses (7), and approximately 80 per cent of patients suffer from cognitive impairment (8). According to Statistics Norway, 76 per cent of patients in nursing homes are over the age of 80 (6). Many elderly people have serious chronic afflictions. There is a need for palliative treatment and care of a high professional standard due to the inherent complexities of geriatrics (5).

    It is hard to obtain reliable research data from nursing homes about the end of life. One of the reasons may be a high turnover of staff, which means that study drop-out rates are high (9). Other reasons may include an insufficiently systematic approach and confusion over how to record documentation (10, 11). There is a need for more knowledge on how the needs of dying patients are looked after in nursing homes, from the patients’ perspective as well as from the perspectives of relatives and healthcare personnel (2).

    Nurses play a special part in the care of dying patients and their relatives because they provide round-the-clock monitoring of patients and handle complex problems associated with disease and the consequences of disease (12, 13). Consequently, we need to know more about the nurses’ experiences. This study’s objective is to explore the nurses’ experience of dying patients in nursing homes in order to identify what is required to provide optimal treatment and care at the end of life.

    Methodology

    The study had a qualitative, exploratory and descriptive design. We employed focus group interviews as our data collection method. The aim was to generate group dynamics by encouraging participants to share experiences and elicit different perspectives on the subject (14). Diverse experiences emerge in focus group interviews. In turn, this helps each participant see the situation in a new perspective, thus generating new understanding (15, 16).

    Recruitment and sample

    The first author distributed written information about the study to the health and care sector managers of three municipalities in East Norway. The invited managers from all three municipalities wished to take part. The first author was given a contact person in each local authority area; these contacts forwarded the information to the heads of their respective institutions, who in turn recruited participants. All participants signed a consent form, which was returned to the first author accompanied by contact details.

    It proved challenging to recruit sufficient numbers of informants based on the selection criterion of extensive experience of end-of-life care. We excluded nurses from special units in nursing homes such as palliative units and dementia care units because staffing ratios are higher in such units than on ordinary nursing home wards (5). In the end, the sample consisted of twelve nurses from three different local authority areas (table 1). They had an average of twelve years’ nursing experience, the variation ranging from two to 31 years. Six of the nurses had specialty training.

    Table 1: Sample

    Data collection

    The three focus groups were made up of three, four and five nurses. The interviews were conducted at their respective places of work. The first author (moderator) conducted the interviews. The assistant moderator took notes and observed the group dynamics. The interviews were recorded on tape and then transcribed verbatim. Interview duration was between 55 and 70 minutes.

    We made use of an indicative interview guide to provide a structure for our conversation. The interview guide was based on the question of how dying patients are looked after in nursing homes, as described by nurses. The guide focused on topics that had emerged from literature reviews and experiential knowledge. All three authors draw on extensive clinical experience of palliation.

    Analysis

    Having conducted the focus group interviews, we transferred the sound recordings to computer files and transcribed them. The transcription work can be considered part of the analysis process because the researcher establishes an overall impression of the material and its structure (17). This suggested a thematic, cross-sectional and data-led content analysis which involved all three authors.

    Our analysis is inspired by Gadamer’s philosophical hermeneutics, in which understanding is a key theme. By attempting to understand the text, we give validity to its factual content. A hermeneutic perspective inspired by Gadamer (18) argues that the “wonder” of understanding emerges as a result of the participants’ shared meaning. This approach dictated an interpretive process which involved returning iteratively to the whole body of data from its constituent parts and vice versa.

    The first author identified the meaning units. These units were condensed and labelled with codes in a table, one table per focus group interview. We proceeded to conduct our analysis across the interviews. We compared the codes in order to identify similarities and differences before we grouped them in sub-categories and categories (17). In order to ensure consensus and a common understanding, the meaning units were presented to each of the authors for independent coding and categorisation. We then met to discuss our way to consensus with respect to the points on which we disagreed (table 2). Our discussions facilitated interpretations on a higher level of abstraction. The results of the analysis support the synthesis as presented in figure 1. 

    Table 2: The analytic process exemplified

    Ethical considerations

    The study has been approved by the Norwegian Centre for Research Data (NSD) under reference number 38087. The nurses received both verbal and written information. They gave their consent to take part in the study in writing. We informed them that they were at liberty to withdraw from the study at any time without giving a reason for doing so. They were also informed that all personal details would be kept securely locked away, and that all computer files would be password protected. We emphasised that none of their statements would affect the informants’ working conditions.

    In order to instil a sense of confidence and trust within the focus group, all parties involved entered into a mutual confidentiality agreement. We have complied with the ethical principles for research as set out in the Declaration of Helsinki (19).

    Results

    The results showed that the complexities involved with providing care and treatment for dying patients in nursing homes call for “more of everything”, which requires considerable knowledge as well as special skills and attitudes. Moreover, the findings show that nurses are frequently “left to deal with everything on their own”, because the nursing home has a low staffing ratio and personnel are inadequately qualified. We will present the summary results in two categories with their associated sub-categories (table 3).

    Table 3. Presentation of sub-categories and categories

    Looking after dying patients in a nursing home

    The results showed that looking after dying patients in nursing homes involves patients, their relatives and nurses. The nurses focused on being present for the dying patient, which they saw as a prerequisite for providing holistic care and treatment. End-of-life care also involves the clarifications and plans that need to be made before the patient is dying. The relatives play a natural part in this process. The results showed that it can be emotionally engaging and challenging to look after dying patients. At the same time, the findings showed that the nurses considered it a privilege to be tending to the patient at the very end of life, and that that they had to contend with their own emotions and conscience in doing so.

    The nurses considered it a privilege to be tending to the patient at the very end of life, and that that they had to contend with their own emotions and conscience in doing so.

    Being present: observe, assess and act

    The nurses referred to being present as a prerequisite for looking after the patient by making clinical observations and assessments, and by taking action as required:

    “It takes more than looking in on them every now and then if you are to monitor the patients’ pain, fear and symptoms.”

    The results showed that it is not always simple to assess when a patient is dying, and that nurses do not always agree:

    “At times I receive reports that a patient is dying, and when I go to see them, I think ʻhmm, is he really?ʼ I think we have a slightly different understanding of when the end of life commences.”

    End-of-life care means providing more of everything.
    Focus group member

    A dying patient in a nursing home has complex needs that require close attention by a nurse, who can observe, assess and implement various alleviating measures. One nurse put it very succinctly:

    “End-of-life care means providing more of everything.”

    Looking after and involving relatives

    The nurses often referred to the patient and their relatives as one, which highlights the fact that nurses see how important it is to include the relatives when clarifying things and making plans before the patient is dying. According to the nurses, such involvement requires targeted information, and the information often needs to be repeated. They explained that many relatives wanted to be of assistance and to do more than just sit by the bedside:

    “I believe it creates a great deal of trust if they are allowed to join in. For example, I can show them how to provide mouth care, so they are able to do something when the patient is no longer taking food or drink. I think it helps them a lot, to be able to take part in what is happening.”

    However, several nurses also pointed to the value of reassuring relatives that simply being with the dying is important. The nurses agreed that it was important to validate relatives for who they are and what they do. Relatives often have different needs; some require close attention and extended presence by nursing staff, while others are happy to be left on their own with only occasional visits. The nurses found that their own availability influenced the relatives’ confidence with the patient, but it was necessary to make it clear that the responsibility was with the nursing staff:

    “If you see that the patient is unsettled, and if you need to administer medication, you can’t just administer and leave, you need to follow it up. It doesn’t matter if a relative is sitting there or not, it’s your job.”

    A privilege – contending with own emotions

    It can be emotionally engaging to look after dying patients, and one’s own conscience and emotions may be affected. Several said they felt it was a privilege to be allowed to tend to patients at the very end of their lives. They also reported that it can feel overwhelming to be given that much responsibility for an individual in the very last hours and days of their lives:

    “I feel something extra for them, for they are very helpless. I keep thinking that they no longer have a voice or energy to do anything at all, they are very much at our mercy. So it is a privilege, and it is a special situation; in a way, you inhabit a slightly different part of the nursing role.”

    The nurses reported that it can be a strain to be personally engaged when tending to the dying.

    The nurses reported that it can be a strain to be personally engaged when tending to the dying. They described a shared wish that the dying patient should receive the very highest standard of care:

    “You give all you have when you are caring for someone who is about to die. I keep going over it afterwards, in bed, and I evaluate my own performance: ʻDid I say the right things? Did I do all I could to make sure their bed was comfortable? Did my hands feel good?ʼ I take it very seriously.”

    The nurses have different views on becoming emotionally engaged:

    “I feel empathy, but when my work is done, I’m no longer involved. I have said my goodbye to the patient and the relatives. I don’t think about that particular patient any longer, even if I attend their funeral afterwards, to show my respect for the patient and the family, but it doesn’t affect me.”

    Roller og ansvar i arbeidet med døende pasienter i sykehjem

    Sykepleierne fremhevet kompetanse som en forutsetning for å føle seg trygge i egen rolle, både når det gjaldt å håndtere pasientens behov, ivareta den koordinerende funksjonen og samhandle med andre yrkesgrupper. Sykepleierne reflekterte over sin egen rolle i systemet og hva de kan påvirke. De reflekterte også over hva som administreres på et høyere nivå utenfor deres kontroll.

    The competence to meet the patient’s complex needs

    The data showed that competence involves professional confidence and the ability to make assessments and convey information. According to our results, the nurses have highly individual perceptions of what generates confidence, for example when it comes to the administration of drugs. Some doctors prescribe “until pain relief”, some write “mg up to x 6, may be increased if necessary …”, while others write “mg x 4” on the medication chart. Several nurses reported that they feel more confident when a maximum dose has been prescribed.

    Other nurses felt more confident if they were at liberty to administer whatever dose was required to alleviate the patient’s pain, so that there was no need to spend time on repeatedly contacting a doctor to increase the dose. They all agreed that clear procedures and drug prescriptions for the alleviation of troublesome symptoms are prerequisites for providing palliative care.

    The nurses highlighted a number of episodes when they had been forced to negotiate to obtain a prescription for the necessary drugs:

    “Some are very restrictive, almost to the point of you having to negotiate really hard to be believed regarding status. I find that really tiresome.”

    External factors

    The nurses highlighted organisational factors beyond their control, such as staffing ratios and professional cover:

    “In hospitals there are four–five nursing colleagues and four–five doctors you can confer with. If you’re unable to insert a venous cannula, an anaesthetic nurse will come and do it for you. In this place, they don’t. Here you need to make the decisions and choices on your own. You need to consult a doctor, and perhaps he’ll arrive in a couple of hours.”

    Here you need to make the decisions and choices on your own. You need to consult a doctor, and perhaps he’ll arrive in a couple of hours.
    Focus group member

    They expressed frustration at being pulled in different directions when there are multiple tasks, roles and responsibilities that need their attention:

    “I have been the only nurse covering 100 patients … And two or three of them are dying … There may be four or five relatives involved with each patient, and you need to attend to it all.”

    Providing more of everything, and being left to deal with everything on your own – a synthesis of the study’s results

    The nurses described their work with dying patients as professionally, personally and organisationally complex, as providing “more of everything “; meanwhile, they also say they are often “left to deal with everything on their own”. This means that the nurses give more focused attention to the patient’s complex needs and demonstrate greater emotional engagement; the relatives are also more involved. This complexity calls for knowledge and experience on an individual level as well as on a system level.

    Figure 1 illustrates the categories that emerged from our analysis of the study’s empirical material. The findings show that the various elements illustrated in the figure mutually affect one another. For example, it is hard to provide an appropriate, holistic service (system level) without involving the individual patients and their relatives (personal level), as in accordance with the definition of palliation (21). Our analysis revealed that the nurses’ experiences with dying patients in nursing homes involve multiple processes that have mutual reciprocal effects on one another, working in dynamic interaction. These processes involve individual nurses (individual level), the interaction among colleagues, and external factors (system level). 

    Figure 1. A synthesis of the study’s results

    Discussion

    The study’s objective was to establish what nurses consider to be required for the provision of optimal end-of-life treatment and care. The results show that nurses need to fulfil a number of functions and roles, on an individual level as well as on system level. On an individual level, the nurses feel it is essential to be able to be present for the dying, to make observations and assessments, and to take action to ease the patient’s pain.

    The findings show that the nurses are keen to involve and look after the patient’s relatives. They also describe their care for the dying as a privilege which involves contending with their own emotions, all of which need to be processed and managed. Earlier research demonstrates that there are challenges associated with caring for dying patients in nursing homes. Gjerberg et al. (21) found, among other things, that the lack of resources and competence can give rise to ethical challenges, while Flo et al. (10) uncover an insufficiently systematic approach to caring for the dying, as well as incomplete documentation.

    A privilege to tend to the dying and their relatives

    The findings of our study show that it is challenging to be present when a patient is dying. The patient has complex needs that require focused attention. The nurses report that they sometimes perceive the same situation in different ways. Meanwhile, they also describe their wish for the care provided for the dying to be of the highest standard. Other studies have documented that healthcare personnel have a genuine desire to ensure that dying patients have a good death, and that nurses go out of their way to fulfil the wishes of patients and their relatives (22–24).

    It is challenging to be present when a patient is dying.

    The nurses stress the significance of looking after and involving relatives, which is supported by the study conducted by Davies and Steele (25). Their study demonstrates that it may feel overwhelming, if rewarding, to attend the death-bed of a loved one. Furthermore, the study conducted by Dreyer (26) makes it clear that relatives need to be looked after. Thoresen et al. (27) also highlight the importance of being present through joint conversations in order to promote good palliation.

    In our study, the job of tending to patients and their relatives is referred to as “a privilege”. The nurses describe this work as emotionally engaging. They also report that the magnitude of the responsibility can feel overwhelming. Other studies have also documented that nurses worry they are not doing enough for the dying (21, 22).

    Low doctor-per-patient ratios shift more responsibility on to nurses

    The results of our study show that nurses find it problematic whenever it is difficult to get hold of a doctor, and there are few doctors to call on, and when the distribution of responsibilities between doctors and nurses is blurred. The doctor-per-patient ratio in Norwegian nursing home is too low (28). There is currently one full-time equivalent doctor per 130 nursing home patients. In comparison, there is one doctor per 1.3 hospital patients (28). Knowing when to contact a doctor requires a level of competence as well as an understanding of symptomatic relief.

    Our findings are supported by Marshall et al. (29), who show that healthcare personnel often find that no doctor is available, and that nurses have to make important decisions without being able to confer with competent personnel. According to Hov et al. (22), some nurses feel that their knowledge of caring for seriously ill and dying patients is ignored in their discussions with the doctor. Hov et al. reported situations that involved nurses having to negotiate to obtain prescriptions that would ease the patient’s symptoms. This highlights the need to continually confer with the doctor, which can be challenging to achieve in a nursing home.

    Challenging for nurses to take the overall responsibility

    The study’s findings showed that the nurses’ coordination of work carried out by other healthcare personnel, whether skilled or unskilled, forms a part of their working day. In nursing homes, 30 per cent of staff have no formal training (30). This means that nurses have a particularly challenging function because they carry overall responsibility for the nursing service, professionally (on the individual level) and organisationally (system level). Tasks obviously need to be delegated, but according to Orvik (31) not all tasks lend themselves to delegation.

    The NOVA report entitled “Underbemanning er selvforsterkende” [Understaffing is self-reinforcing] (4) points out that the low ratio of nurses to patients in nursing homes adversely affects the quality of services provided and the working environment. There is a need for competence on an individual level: tending to dying patients in a nursing home, and on a system level: roles and responsibilities in the care for dying patients in nursing homes. Our study shows that the nurses’ experiences of having to provide “more of everything”, and being “left to deal with everything on their own”, must be taken seriously, organisationally and policywise. National surveys of nurses and their experiences, and the consequences with respect to nursing education, are important areas for future research. Moreover, the nursing home as an arena for research should be prioritised.

    The study’s strengths and weaknesses

    One of the study’s strengths is that the informants are nurses with many years’ experience of palliation in nursing homes, and a number of the nurses have specialty training. The focus group interviews revealed a dynamic relationship among informants, which helped to bring forth multiple perspectives on the topic.

    One of the study’s weaknesses is the fact that only two male nurses took part, but this gender distribution is representative of Norwegian nursing homes. The body of data is relatively small, but the richness of the data provided by the three focus group interviews was considerable. We have tried to secure the reliability of our findings by following the analytic steps. We have included quotes to demonstrate the credibility of the results (20).

    Conclusion

    The nurses report that caring for dying patients in nursing homes requires “more of everything”. Meanwhile, they also find themselves to be “left to deal with everything on their own”. Nurses are expected to be proficient clinicians and show leadership, and to give advice and guidance to relatives and co-workers. They are also meant to reflect on their own practice in the light of attitudes and values. The study demonstrates how external factors such as staffing and competence levels affect the nurses’ functions and responsibilities.

    The nurses’ clear objective is to carry out their profession to ensure that patients receive optimal symptomatic relief. This objective is achieved by nurses being proficient in providing clinical assessments and having an ability to implement relevant interventions. They also look after the needs of relatives. Interdisciplinary collaboration and training of co-workers may seem to be demanding since access to the services of a doctor is limited in nursing homes and the ratio of nurses to patients is low.

    References

    1.       Statistisk sentralbyrå. Tabell: 09929: Helse- og omsorgsinstitusjonar, etter eigarforhold. 2015. Available at: https://www.ssb.no/statistikkbanken/SelectVarVal/Define.asp?MainTable=HelsOmsInst&KortNavnWeb=pleie&PLanguage=0&checked=true (downloaded 31.10.2016).           

    2.       Meld. St. 29 (2012–2013). Morgendagens omsorg. Oslo: Helse- og omsorgsdepartementet; 2013.

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    4.       Gautun H, Øien H, Bratt C. Underbemanning er selvforsterkende. Konsekvenser av mangel på sykepleiere i hjemmesykepleien og sykehjem. NOVA-rapport; 6/2016.

    5.       Helsedirektoratet. Nasjonalt handlingsprogram med retningslinjer for palliasjon i kreftomsorgen. Oslo: Helsedirektoratet; 2015.

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    9.       Tilden VP, Thompson SA, Gajewski BJ, Buescher CM, Bott MJ. Sampling challenges in nursing home research. Journal of the American Directors Association. 2013;14(1):25–8.

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    11.     Haugen DF, Iversen GS, Huurnink A. Hvordan kan behandlingsplaner være til nytte den siste tiden av pasientens liv? Omsorg. 2015;2:29–33.

    12.     Haugan G. The relationship between nurse-patient interaction and meaning-in-life in cognitively intact nursing home patients. J Adv Nurs. 2014;70(1):107–20. DOI: 10.1111/jan.12173.

    13.     Johnson S, Bott MJ. Communication with residents and families in nursing homes at the end of life. J Hosp Palliat Nurs. 2016;18(2):124–30. DOI: 10.1097/njh.0000000000000222.

    14.     Malterud K. Fokusgrupper som forskningsmetode for medisin og helsefag. Oslo: Universitetsforlaget; 2012.

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    16.     Krueger RA. Focus groups. A practical guide for applied research. Thousand Oaks, California: Sage Publications; 1994.

    17.     Kvale S, Brinkmann S. Det kvalitative forskningsintervju. 2. ed. Oslo: Gyldendal Akademisk; 2009.

    18.     Gadamer HG. Forståelsens filosofi. Utvalgte hermeneutiske skrifter. Oslo: J.W. Cappelens Forlag; 2003.

    19. World Medical Association. WMA Declaration of Helsinki – Ethical principles for medical research involving human subjects. Available at: https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/(downloaded 31.10.2016).

    20.     Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today. 2004;24:105–12. DOI: 10.1016/j.nedt.2003.10.001.

    21.     Gjerberg E, Førde R, Pettersen R, Bolling G. Ethical challenges in the provision of end-of-life care in Norwegian nursing homes. Social Science & Medicine. 2010;71(4):677–84.

    22.     Hov R, Athlin E, Hedelin B. Being a nurse in nursing home for patients on the edge of life. Scandinavian Journal of Caring Sciences. 2009;23(4):651–9.

    23.     Percival J, Johnson M. End-of-life care in nursing and care homes. Nursing Times. 2013;108(1/2):20–3.

    24.     Wallerstedt B, Andershed B. Caring for dying patients outside special palliative care settings: experiences from a nursing perspective. Scandinavian Journal of Caring Sciences. 2007;21(1):32–40.

    25.     Davies B, Steele R. Supporting families in palliative care. I: Ferrel BR, Coyle N (eds.). Oxford Textbook of Palliative Nursing. New York: Oxford University Press; 2010 (p. 613–28).

    26.     Dreyer A. End-of-life decision-making in nursing homes. A qualitative study. Upublisert manuskript. Medisinsk fakultet, Universitetet i Oslo; 2012. Available at: https://www.duo.uio.no/bitstream/handle/10852/28029/dravhandling-dreyer.pdf?sequence=3(downloaded 31.10.2016).

    27.     Thoresen L, Ahlzén R, Solbrække KN. Advance care planning in Norwegian nursing homes – Who is it for? J Aging Stud. 2016;Aug(38):16–26. DOI: 10.1016/j.jaging.2016.04.003.

    28.     Flo E, Husebø BS. Kvalitet og kompetanse på sykehjem – behov for en standard for behandling og omsorg. Omsorg – Nordisk tidsskrift for palliativ medisin. 2015;(1):5–9.

    29.     Marshall B, Clark J, Sheward K, Allan S. Staff perceptions of end-of-life care in aged residential care: A New Zealand perspective. Journal of Palliative Medicine. 2011;14(6):688–95.

    30.     Meld. St. 10 (2012–2013). God kvalitet – trygge tjenester. Oslo: Helse- og omsorgsdepartementet; 2013.

    31.     Orvik A. Organisatorisk kompetanse – i sykepleie og helsefaglig samarbeid. Oslo: Cappelen Damm Akademisk; 2004.

    Nurses report that the end-of-life nursing care provided in nursing homes calls on staff to provide “more of everything”, and that nurses feel they are “left to deal with everything on their own”. This situation must be taken seriously, organisationally and policywise.

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    Sammendrag

    Background: An increasing number of deaths take place in nursing homes. This puts a heavy burden of service delivery on nursing homes as an arena for the provision of end-of-life care and on the healthcare personnel who provide the service. We therefore need to increase our knowledge of how nurses perceive the care provided for dying patients in nursing homes.

    Objective: The study’s objective is to describe the nurses’ experience of dying patients in nursing homes. The research questions explore what is required to provide optimal treatment and care at the end of life. 

    Method: Data were generated by conducting three focus group interviews with a total of twelve nurses. Qualitative content analysis was our chosen methodology.

    Results: The nurses aim to carry out their profession to ensure that patients receive optimal symptomatic relief. They also need to look after the patients’ relatives. The nurses find that the complexity of the care and treatment provided for dying patients in nursing homes calls for more of everything. In order to meet the dying patients’ need for alleviating treatment and care, considerable knowledge is required, as well as special skills and attitudes. The findings show that nurses are often “left to deal with everything on their own” because the nursing home has a low staffing ratio and the personnel have inadequate nursing skills. Nurses are expected to be proficient clinicians, to show leadership and provide advice and guidance for relatives and co-workers.

    Conclusion: According to the nurses, end-of life care in nursing homes requires “more of everything”; meanwhile, they feel they are “left to deal with everything on their own”. The training of co-workers needs to take priority because the number of nursing staff is low.

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  • Translation and psychometric testing of the Family Collaboration Scale

    Most admissions of elderly patients in general hospitals are acute (1). Healthcare personnel have an obligation to involve the patient in their treatment and care, and the patient role entails statutory rights, such as the right to information and involvement (2). User involvement requires active and involved patients (3), but many older people are unprepared for taking part in such processes (4).

    Research shows that some patients do not get involved in their treatment and care due to a lack of resources during their hospital stay (5). Among other things, illness and impairment can make it difficult to comprehend and process the content of the information provided (6). The results of a study on the discharge procedures for elderly patients show that patients wanted to participate, but this wish was largely ignored by the healthcare personnel. More than half of the participants had little or no opportunity to explain what they considered to be important for managing on their own after being discharged (5, 7). More than a third wanted to receive information together with their family, and almost half stated that they had not been offered such information (5). 

    Relatives as a resource or challenger

    In the report to the Storting ‘Good quality – safe services – Quality and patient safety in the health and care services’ (3), patients’ relatives are characterised as an invaluable resource. They often have valuable knowledge about the patient’s background, medical history, resources and experiences from earlier treatment. They can take on the role of the patient’s spokesperson, contribute to the coordination between the various health services and help the patient to deal with information where the patient consents to this (3).

    The relative’s role during hospitalisation is also the subject of research. The relatives consider themselves to be a support for the patient, and want to ensure that the patient’s interests and needs are safeguarded. If they have been involved in assisting and caring for the patient before admission to hospital, they can still feel responsible after this role is taken over by the healthcare personnel (8, 9).

    Despite the theoretical and political ideals, studies show that the collaboration between nurses and patients’ relatives is marked by challenges.

    Interacting and collaborating with relatives is regarded as good nursing practice (10-12), and can safeguard the patient’s right to user involvement (3). Despite the theoretical and political ideals, studies show that the collaboration between nurses and patients’ relatives is marked by challenges (12-14). Initially, nurses are positive to collaboration, but this can prove to be both challenging and time consuming (12, 13). Collaboration can be hampered by inadequate communication (13) or conflicts if relatives get involved in the patient’s care, thereby representing a challenge for the nurses (8, 12).

    Charting the relatives’ perspective    

    Research shows significant correlations between relatives’ opportunities to participate in collaborative processes and their assessment of the quality of care in nursing homes (15). Correlations have also been found between the relatives’ degree of satisfaction with the hospital stay and the collaboration with nurses (16). It is therefore reasonable to assume that the relatives’ experiences with collaboration can be linked to their satisfaction and assessment of quality (17).

    Based on a review of earlier research and contact with international research communities, Lindhardt et al. (17) found that there were no instruments available that charted the relatives’ perspective of the collaboration with healthcare personnel after frail elderly patients were admitted to general hospitals. They therefore developed the Family Collaboration Scale (FCS) instrument through a process of selecting relevant variables, developing questions and response options as well as designing a logical structure. This work is partly based on two qualitative studies where patients’ relatives and nurses were interviewed (11, 12). The FCS contains five dimensions, each of which measures different aspects of collaboration:

    • Influence on decisions
    • Quality of contact with healthcare personnel
    • Trust and its prerequisites
    • Achieved information level
    • Influence on discharge

    Lindhardt and her colleagues tested the instrument on a Danish sample and considered the psychometric properties to be satisfactory (17). 

    The purpose of translating the FCS to Norwegian is to make the instrument available in clinical practice and research. The instrument identifies barriers to collaboration and results of the collaboration in the form of relatives’ satisfaction, information level and quality of the hospital stay. It also identifies whether collaboration exists between patients’ relatives and healthcare personnel (16, 17).

    Using the instrument can help to increase awareness of collaboration with relatives and their inclusion when desired by patients, which in turn can foster user involvement and improve the quality of care and treatment of elderly hospital patients.

    Objective of the study

    The objective of this study was to translate the FCS from Danish to Norwegian and to test the psychometric properties of the translated version in a sample of relatives of frail elderly patients following admission to an acute hospital ward for medical treatment.

    Method

    Translation and pre-testing of the FCS

    We translated and adapted the Norwegian version of the FCS in accordance with a sequential translation procedure (18-20) (Figure 1). Two separate translators translated the instrument from Danish to Norwegian. The first translator was bilingual and a government-authorised translator, and the other translator was a nurse with extensive experience from clinical practice and a high level of proficiency in Danish. The differing backgrounds were in accordance with theoretical recommendations, which require one translator to be a linguistic expert and the other to have specialist competence in the subject to be studied (20-22).

    Figure 1: Flowchart showing the various phases of the process to translate the FCS from Danish to Norwegian.

    We performed a synthesis of the translated versions. This synthesis was reviewed by a consensus group consisting of a Danish senior consultant and two nurses with research expertise and clinical competence from the field of geriatrics. The group’s mandate was to discuss similarities and differences between the original and the translated version, as well as propose suggestions for adaptations.

    Furthermore, we presented the Norwegian version to a panel of experts consisting of four nurses with extensive clinical experience from care of the elderly. They were asked to evaluate the wording, the relevance of the questions and the form as a whole. We then pre-tested the instrument on five relatives of sick, elderly patients who had recently been admitted to a general hospital with an acute illness. We conducted a personal interview after completion of the questionnaire, and asked the relatives whether they considered the questions to be comprehensible and meaningful. We also asked them to propose suggestions for changes.

    In the original version, the Danish term ‘ sygeplejepersonale’ (nursing staff) was used in several of the questions. According to the Danish author, the term referred to all occupational groups that are involved in patient care in the hospital. We discussed the term with both the panel of experts and the patients’ relatives, and most related the term to staff who were qualified nurses. Several of the relatives thought it was difficult to distinguish between nurses and other nursing staff when reporting their experiences, and therefore preferred the term ‘ pleiepersonalet’ (healthcare personnel) in the Norwegian version of the instrument.

    During the translation process, we made minor changes and adaptations to terms in order to make them more compatible with general Norwegian language usage. A different, independent, professional bilingual translator back-translated the edited version from Norwegian to Danish. We submitted the different versions as well as documentation from the translation procedure to the author of the questionnaire. The Danish author has worked in Norway for several years and has a good level of proficiency in Norwegian and terminology usage. She recommended only minor changes to individual words in order to ensure equivalence between the Norwegian and the original version.

    Testing the FCS

    The psychometric properties of an instrument refer to testing performed on a specific target group under given circumstances. It is therefore important to test psychometric properties when using the instrument in a different culture or in another target group (18, 20, 22). We tested the Norwegian version of the FCS using a cross-sectional survey.

    Sample and data collection

    We conducted the study at eight medical wards in a university hospital. A close collaboration was needed with healthcare personnel in order to recruit participants. Approved student assistants had responsibility for recruitment in three of the wards.

    The inclusion criteria for the patients were that they were over the age of 65 and admitted with an acute illness or due to the worsening of a chronic illness. They had to have been staying at home before admission to hospital, have impaired health related to one or more conditions, and be in need of assistance and support in everyday life. They had to be competent to give consent, i.e. speak Norwegian sufficiently and not have a conjunctive impairment. The patients received written and oral information. Those who wanted to participate gave written informed consent so that we could contact the relative who, according to the patient, were most involved in providing assistance and support and who had been present during their hospital stay.

    Fourteen days after the patient was discharged from hospital, the relative was sent an information letter with a request to participate, along with a questionnaire ( Appendix 1) and a stamped addressed envelope for returning the questionnaire. We conducted a selective reminder procedure by telephone three weeks after the first communication. Returning the questionnaire was regarded as consent to participate.

    The FCS questionnaire

    The FCS is composed of 27 questions, which contain a total of 45 Likert scales and make up the various dimensions of the instrument. In addition, nine categorical variables are included in the instrument ( Appendix 1, questions 20-56). The response options on the Likert scales are rated from 1-4 or from 1-6, where a low score indicates a high degree of collaboration.

    The questionnaire also contains nine socio-demographic questions about patients’ relative (questions 1-9) and five categorical variables that chart the scope of help that the relative provided (questions 10-14). Five questions about relatives’ experiences (questions 15-19) and the open-ended question at the end of the form were not part of the FCS instrument, and were not therefore analysed in this study.

    We added three questions for this study, which can be found in the questionnaire ( Appendix 1). These questions identify which department the elderly patient was admitted to as well as the reason for the admission. In addition, one question asks whether the relative of the patient wanted to fill out the questionnaire again after two to three weeks in order to test the instrument’s stability by repeat monitoring.

    Analyses

    We scanned data from completed questionnaires into a database. We then encoded, scored and summarised the data in dimensions based on the score description devised by the author of the questionnaire (17). We summarised and transformed questions in each dimension to values from 0-100, where higher scores indicated that relatives were less satisfied or experienced less collaboration with healthcare personnel. In questions with more than one possible answer, the number of answers was summarised.

    We performed the analyses using the statistics program SPSS version 21.0. Descriptive statistics were used to analyse socio-demographic variables and the type of assistance that relatives provided, and to obtain an overview of the dimensions of the form. We assessed reliability through internal consistency analyses (Cronbach’s alpha and the correlation of individual questions with each sub-scale) and stability (test-retest reliability).

    Stability was analysed using the intraclass correlation coefficient (ICC) through the variance measurement of average scores and repeated average scores from the participants who responded to the FCS twice. The panel of experts and pre-test participants evaluated the content validity of the instrument in the translation process and assessed the form as a whole, the suitability of the individual questions, and whether they were adequate to measure the collaboration with the healthcare personnel. We analysed construct validity using exploratory factor analysis (EFA), with Principal Component Analyses (PCA) as an extraction method and Varimax rotation.

    We focused on performing the analyses in the same way as the author of the questionnaire described in the test of the Danish version (17) in order to compare the results. A total of 44 questions were included in the EFA. The Kaiser-Meyer-Olkin (KMO) test of 0.81 indicated that the sample size was sufficient (23). Bartlett’s test for all correlations was significant (p <0.001), and the analysis was therefore justified (23).

    Spearman’s rank order correlation (Spearman’s rho) was used to analyse the correlation between the questions in each dimension and between the different dimensions. Significance level was set to p ≤0.05.

    Ethical aspects

    The study was approved by clinic managers, and in addition we informed ward administrators, charge nurses and healthcare personnel in writing and orally before recruitment started. According to the Regional Committees for Medical and Health Research Ethics (REC), the study did not require approval. The university hospital’s own Data Protection Official (DPO) approved the study and provided directives for anonymising and storing the data. A list of names and corresponding ID numbers were kept locked away and unavailable to unauthorised parties during the recruitment period, and we deleted the list at the end of the study.

    Results

    We contacted a total of 243 patients, and of these, 230 consented to us contacting their relative. A total of seven participants were excluded owing to death of the patient after consent was given (n = 3), a lack of contact details for the relative (n = 2), age (n = 1) or exercising of the patient’s right to withdraw consent (n = 1). We sent out 223 questionnaires, and a total of 147 relatives returned a completed form (66 per cent). All relatives were asked if they were willing to fill out the questionnaire again after three weeks in order to perform a stability analysis, and 22 relatives did this.

    We present an overview of the socio-demographic variables in Table 1. The typical participant was a married or cohabiting woman aged 58.5 with a higher education and in employment. She was the daughter of the elderly patient, and they did not live together.

    Table 1. Socio-demographic variables (n = 147)

    Table 2 presents a frequency overview of the variables that characterise the assistance provided by the relative to the elderly in need for support. In addition, analyses showed that relatives were mainly involved in assistance such as psychological support and encouragement (58 per cent), practical help in the home (57 per cent), accompanying the patient on outings (57 per cent) and shopping (57 per cent). Fewer provided personal assistance such as help with personal hygiene, toilet visits, washing hair and help to eat (22 per cent) or physical training (3 per cent).

    Table 2. Assistance before admittance to hospital (n = 147)

    In Table 3 we present the results for the summary measurements for the five original dimensions of the FCS. The dimension ‘influence on decisions’ had the highest average score of 62.6. The dimension ‘trust and its prerequisites’ had the lowest average score. The significant left-skewed distribution of the results, i.e. a prominence of low scores, indicates that relatives experienced a high level of trust. ‘Influence on discharge’ had the highest non-response rate. This may be due to the fact that one question should have been answered by respondents who had answered ‘no’ to a preceding question, which resulted in a 29 per cent non-response rate for the follow-up question.

    Table 3. Summary measurements for the dimensions in the Norwegian version of the FCS

    Reliability analyses

    Internal consistency, analysed by Cronbach’s alpha, showed a score in excess of 0.7 for all five original dimensions. The correlations between individual questions and each scale showed varying correlations as an expression of varying overlap between individual questions and the corresponding scale (Table 3). Test-retest reliability was analysed using the intraclass correlation coefficient (ICC), and all five dimensions held values in excess of 0.7.

    Validity

    Experts and the patients’ relatives assessed content validity in the pre-test of the questionnaire. Both groups considered the form to have good direct validity, and the first impression was that the content referred to various aspects of the collaboration between families and health personnel. All relatives pointed out that the content was easy to understand, relevant and recognisable. Several relatives thought that the questionnaire was useful as they had had varying experiences in the collaboration with healthcare personnel.

    Question 32 (Appendix 1) referred to whether the problem that led to the hospital admission had been resolved. This question was the only one that was removed from the factor analysis due to the low correlation with the other questions.

    A total of 44 questions were included in the factor analysis. According to Kaiser’s criterion (eigenvalue > 1) and interpretation of the scree plot, eight factors could be included, and these accounted for 61.5 per cent of the total variance. Two of the five original dimensions were split, and three new factors emerged. Table 4 presents an overview of factors and includes the questions’ factor loading (≥ 0.3).

     Table 4. Factor solutions of the Norwegian version of the Family Collaboration Scale (n = 147)
     Table 4. Factor solutions of the Norwegian version of the Family Collaboration Scale (n = 147)

    The first factor reflected the dimension ‘influence on decisions’, and a total of eight out of ten questions had the strongest loading here. The second factor in the analysis was in accordance with the ‘influence on discharge’ dimension. The factor contained five of the original seven questions, but one question (question 51) had a low loading. Factor three formed part of the dimension ‘trust and its prerequisites’, but four of the original questions formed a new factor (factor six). Factor four is compatible with the dimension ‘achieved information level’, but question 43 fell under factor eight. Factor five to some extent corresponds to the dimension ‘quality of contact with healthcare personnel’ and contains five of the original nine questions. Two of the questions fell under factor seven (questions 47 a and b), and two had the highest loading in factor eight (questions 49 a and b).

    The values for correlation between the five original dimensions of the FCS ranged from 0.18 to 0.61. Correlation between the questions in each dimension confirmed that the questions with a low loading in the factor analysis or that had fallen outside the original dimensions had a low correlation with the other questions in the respective dimensions.

    Discussion

    The response rate after the reminder procedure (66 per cent) is considered to be acceptable for a questionnaire survey (18). We did not carry out a non-response analysis, but frequency analyses indicated that some groups were underrepresented. Only 17 per cent of the participants were over the age of 70, and just under 25 per cent reported primary/lower secondary school as the highest completed level of education. These are groups that historically have high non-response rates in questionnaire surveys (24, 25).

    Descriptions and testing of the original Danish version of the FCS showed a good correlation between theory and practice, and the instrument was considered to be reliable and valid within the test population (17). The Norwegian version of the FCS is considered to have satisfactory internal consistency (18, 21) for the five original dimensions. High scores for ICC indicate that the Norwegian version of the FCS has stable properties, which is important for overall reliability (26).

    Different cultures can come into play

    The hypothetical correlations of a construct should be tested using a confirmatory factor analysis (CFA) (18). In our study, this method was not justified since the sample size did not meet the criteria for the analysis (27). We therefore assessed the construct validity of the instrument by analysing its structure using EFA, which is suited to assessing differences between the original and translated instrument (21).

    Although it is assumed that there are few cultural differences between Denmark and Norway, disparities may be attributed to the organisation of nursing and care.

    Where questions did not load into their original factors after translation, this may be an indication that they are not perceived in the same way in the different cultures (21). Although it is assumed that there are few cultural differences between Denmark and Norway, disparities may be attributed to the organisation of nursing and care. It may also be that relatives have different expectations of collaboration and user involvement, but this is not certain. 

    Questions should have factor loading ≥0.4 within the corresponding dimension (23, 25). A total of 13 of the questions have a low loading and cannot therefore be related to the original dimensions (Table 4). In this study, this means that they cannot be linked to the properties they were originally set to measure. In addition, the analysis shows that four individual questions have a high factor load of >0.4 in several dimensions, which complicates the interpretation of which factor they belong to (21).

    Different result when using other populations

    The first of the new factors (factor six) consists of four questions that relate to the physical conditions of the ward (Table 4, questions 54a-d), and originally belonged to the dimension ‘trust and its prerequisites’. Theoretically, the questions are related to the fact that contextual relationships in a hospital environment can be barriers to collaboration, which in turn may affect the relatives’ experience of trust (16, 17). In this study, the analyses showed that the questions had a low correlation to other questions about trust, and thus they do not reflect the same property (21). Differences in the results can be attributed to the composition of the samples, but it cannot be ruled out that Danish and Norwegian relatives had different perceptions of the impact of the physical environment in relation to the experience of trust and collaboration.

    Factors seven and eight emanate from the dimension ‘quality of contact with healthcare personnel’, and interpretation suggests that the new factors measure ‘healthcare personnel’s acceptance and understanding of the relatives’ situation’ and ‘healthcare personnel’s availability and satisfaction with contact’. Theoretically, they are linked to collaboration, since being available and accommodating are prerequisites for contact and communication (17). The analyses showed that several of the questions in these dimensions had low average scores. Such a floor effect arises when the response options are not adequate for what is being measured or when the instrument is used in a population that is different to the one for which it was developed (21).

    In structural analyses, such skewed distributions tend to have a lower correlation with other questions and to stand out (28). These factors must therefore be interpreted with caution, and this analysis cannot confirm whether they reflect separate dimensions of the concept of collaboration, or whether the dimensions are the result of highly correlated questions that measure other properties. A factor should also consist of at least three questions (21), and factor seven does not meet this criterion. 

    Norwegian relatives had lower scores

    On average, Norwegian relatives scored lower than the Danish relatives in all dimensions (17), indicating that they collaborated more with the healthcare personnel. The disparities can also be attributed to differences in the way interaction and collaboration with relatives is organised, but we do not know this for certain.

    On average, Norwegian relatives scored lower than the Danish relatives in all dimensions, indicating that they collaborated more with the healthcare personnel.

    Disparities in results between an original and a translated instrument can be attributed to the translation procedure, where terms and definitions used can change the meaning of the questions. Disparities can also emerge due to cultural differences (21). We took these factors into account in the translation process, and the objective was that the instrument should be equivalent to the original version. Similarity in expression and meaning means semantic equivalence (18, 20), and comparison of the original and the back-translated version of the form showed a satisfactory degree of such equivalence. The original factor solution that constitutes the five dimensions of the instrument was partly reflected in the subsequent results.

    The sample size of 147 participants may affect the results of the instrument’s construct validity. According to Field (23), a stable factor solution is found in samples with more than 300 participants, and factors with a low factor loading should be interpreted with caution in small samples (23). Other recommendations indicate that there should be at least three participants per variable, where ten respondents per variable is considered to be a good basis for analysis (18).

    In our study, the ratio was 3.3 participants per variable, which is within the lowest recommended limit. In addition, the KMO test showed that the sample had an above average degree of sufficiency, and the analysis was therefore justified (23). The size of the sample should nevertheless be taken into consideration when assessing the factor structure and stability thereof. Lindhardt et al. conducted the factor analysis of the original version in a sample of 158 participants (17), and we cannot therefore rule out that the disparities in the factor solutions may be attributed to the sample size in both studies.

    Conclusion

    We translated the Family Collaboration Scale (FCS) instrument from Danish to Norwegian according to international criteria. The Norwegian version is considered to have satisfactory reliability, and experts and pre-test participants judged its content validity to be good. Our analyses of construct validity showed that the factor structure partly corresponds to the five original dimensions.

    Certain questions differed by not being included in their original dimension, by creating new factors or by emanating from the analysis. The instrument should therefore be tested in a larger heterogeneous sample, and a confirmatory factor analysis should be performed in order to test the hypothetical relationships between the questionnaire’s original dimensions before further use.

    According to the recommendation from the author of the questionnaire, a short version should be devised for the oldest family members (17). In order to expand the area of application of the instrument, consideration should be given to adapting and testing the FCS on different relative groups to those included in this study, such as relatives of patients who have been admitted to hospital for surgical treatment or intensive treatment.

    References

    1.          Meld. St. 47 (2008–2009). Samhandlingsreformen: Rett behandling – på rett sted – til rett tid. Oslo: Helse- og omsorgsdepartementet; 2009.

    2.          Lov 2. juli 1999 nr. 63 om pasient- og brukerrettigheter (pasient og brukerrettighetsloven). Available at: https://lovdata.no/dokument/NL/lov/1999-07-02-63(downloaded 25.08.2017).

    3.          Meld. St. 10 (2012–2013). God kvalitet – trygge tjenester: Kvalitet og pasientsikkerhet i helse- og omsorgstjenesten. Oslo: Helse- og omsorgsdepartementet; 2012.

    4.          Bentley J. Older people as health service consumers 4: disempowered or disinterested? British Journal of Community Nursing. 2003;8(4):181–7.

    5.          Foss C, Hofoss D, Romøren TI, Bragstad LK, Kirkevold M. Eldres erfaringer med utskrivning fra sykehus. Sykepleien Forskning. 2012(4):324–33. Available at: https://sykepleien.no/forskning/2012/11/eldres-erfaringer-med-utskrivning-fra-sykehus(downloaded 25.08.2017).

    6.          Hellesø R, Eines J, Fagermoen MS. The significance of informal caregivers in information management from the perspective of heart failure patients. Journal of clinical nursing. 2012;21(3–4):495–503.

    7.          Foss C, Hofoss D. Elderly persons’ experiences of participation in hospital discharge process. Patient Education and Counseling. 2011;85(1):68–73.

    8.          Allen D. Negotiating the role of expert carers on an adult hospital ward. Sociology of Health & Illness. 2000;22(2):149–71.

    9.          Li H, Stewart BJ, Imle MA, Archbold PG, Felver L. Families and hospitalized elders: A typology of family care actions. Research in Nursing & Health. 2000;23(1):3–16.

    10.        Norsk Sykepleierforbund. Yrkesetiske retningslinjer for sykepleiere. Available at: https://www.nsf.no/vis-artikkel/2193841/17102/Yrkesetiske-retningslinjer(downloaded 04.11.2016).

    11.        Lindhardt T, Bolmsjö IA, Hallberg IR. Standing guard – being a relative to a hospitalised, elderly person. Journal of Aging Studies. 2006;20(2):133–49.

    12.        Lindhardt T, Hallberg IR, Poulsen I. Nurses’ experience of collaboration with relatives of frail elderly patients in acute hospital wards: A qualitative study. International Journal of Nursing Studies. 2008;45(5):668–81.

    13.        Hertzberg A, Ekman SL, Axelsson K. ʻRelatives are a resource, but…ʼ: Registered Nurses' views and experiences of relatives of residents in nursing homes. Journal of Clinical Nursing. 2003;12(3):431–41.

    14.        Ward-Griffin C, McKeever P. Relationships between nurses and family caregivers: Partners in care? Advances in Nursing Science. 2000;22(3):89–103.

    15.        Voutilainen P, Backman K, Isola A, Laukkala H. Family members' perceptions of the quality of long-term care. Clinical Nursing Research. 2006;15(2):135–49.

    16.        Lindhardt T, Nyberg P, Hallberg IR. Collaboration between relatives of elderly patients and nurses and its relation to satisfaction with the hospital care trajectory. Scandinavian Journal of Caring Sciences. 2008;22(4):507–19.

    17.        Lindhardt T, Nyberg P, Hallberg IR. Relatives’ view on collaboration with nurses in acute wards: Development and testing of a new measure. International Journal of Nursing Studies. 2008;45(9):1329–43.

    18.        Polit DF, Beck CT. Nursing research: Generating and assessing evidence for nursing practice (9th edition). Philadelphia: Wolters Kluwer Health; 2012.

    19.        Beyer N, Magnusson P, Thorborg K. Målemetoder i forebyggelse, behandling og rehabilitering: Teori og anvendelse. (2nd edition). København: Munksgaard; 2012.

    20.        Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000;25(24):3186–91.

    21.        de Vet HCW, Terwee CB, Mokkink LB, Knol DL. Measurement in medicine : A practical guide. Cambridge: Cambridge University Press; 2011.

    22.        Wahl AK, Hanestad BR. Måling av livskvalitet i klinisk praksis: En innføring. Bergen: Fagbokforlaget; 2004.

    23.        Field A. Discovering statistics using IBM SPSS statistics (4th edition). Los Angeles: SAGE; 2013.

    24.        Crow R, Gage H, Hampson S, Hart J, Kimber A, Storey L et al. The measurement of satisfaction with healthcare: Implications for practice from a systematic review of the literature. Health Technology Assessment. 2002;6(32):1–244.

    25.        Eikemo TA, Clausen TH. Kvantitativ analyse med SPSS : En praktisk innføring i kvantitative analyseteknikker (2nd edition). Trondheim: Tapir akademisk forlag; 2012.

    26.        Walters SJ. Quality of life outcomes in clinical trials and health-care evaluation: A practical guide to analysis and interpretation. Hoboken: Wiley; 2009.

    27.        Schreiber JB, Nora A, Stage FK, Barlow EA, King J. Reporting structural equation modeling and confirmatory factor analysis results: A review. The Journal of Educational Research. 2006;99(6):323–38.

    28.        Clark LA, Watson D, Butcher JN. Constructing validity: Basic issues in objective scale development. Psychological Assessment. 1995;7(3):309–19.

    The instrument measures the collaboration between healthcare personnel and the relatives of frail elderly patients in acute hospital wards. Having a Norwegian version of the instrument will mean it can be used in our clinical practice and research.

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    Sammendrag

    Background: The Family Collaboration Scale (FCS) instrument has been developed to assess relatives’ experiences of the collaboration with healthcare personnel when a frail elderly person is admitted to an acute hospital ward.

    Objective: The purpose of the study was to translate the FCS from Danish to Norwegian. We also wanted to test the psychometric properties of the translated version on a sample of the relatives of frail elderly patients who had been admitted to an acute hospital ward for medical treatment.

    Method: The instrument was translated according to international criteria. The Norwegian version has been tested in a cross-sectional study with 147 relatives of patients over the age of 65. Reliability is tested through analyses of internal consistency and test-retest reliability. Validity is assessed through the evaluation of content and construct validity.

    Results: Reliability analysed using Cronbach’s alpha and intraclass correlation coefficient (ICC) showed values above 0.7 for the five original dimensions. A panel of experts and relatives of patients rated the content validity as satisfactory. Evaluating construct validity using exploratory factor analysis showed that the original dimension structure was recreated to some extent, but three new factors emerged.

    Conclusion: The Norwegian version of the FCS is essentially a reliable and valid instrument for measuring relatives’ experiences of the collaboration with healthcare personnel after a frail elderly person is admitted to an acute hospital ward. Before using the instrument in research and practice, we recommend further testing on a larger sample for further assessment of construct validity. 

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  • High-energy smoothies for patients in nursing homes

    Undernutrition arises when the intake of energy and nutrients does not satisfy nutritional needs, which may affect the person’s state of health (1). According to the World Health Organization, good health is not only the absence of sickness and injury but also the perception of physical, mental and social wellbeing (2). The incidence of undernutrition in elderly patients in nursing homes varies from between 10 and 60 per cent (1, 3, 4).

    Undernutrition occurs for a variety of reasons. One reason may be the ageing process, which is often accompanied by poor appetite and reduced food intake (4, 5). The overnight fast is the time between the last meal of the evening and the first meal of the morning (6). Earlier studies show that an overnight fast exceeding eleven hours increases the risk of undernutrition and reduced body weight (7). In addition, various illness processes may result in an increased energy need and low food intake, which in turns leads to undernutrition. The patient may then be caught in a vicious circle of illness and consequent low food intake, resulting in more illness, lower food intake and undernutrition (3, 5, 8).

    Overestimating food intake

    It has been shown that health personnel and the patients themselves overestimate food intake and thereby assume that the intake of nutrients is satisfactory (9). Earlier research shows that it is easier to prevent undernutrition than to treat those who are already undernourished (10). Normally, nurses have the main responsibility for ensuring that the diet of elderly patients in nursing homes is adapted to their nutritional needs, but close cooperation with other health personnel such as health workers, doctors and nutritionists is essential in securing an individually adapted diet (6, 9, 11, 12).

    Routine use of energy-boosting smoothies may be an alternative way of satisfying nutritional needs.

    Frequent meals and energy-boosting and nutritious food are ways of ensuring a customised diet (5, 13, 14). Routine use of high-energy smoothies may be an alternative way of satisfying nutritional needs (9, 15, 16). Smoothies are a nutritional drink consisting of, for example, fresh berries, fruit, vegetables, juice, sugar, yoghurt or ice cream puréed in a blender (17, 18).

    In 2012, a white paper called attention to the importance of safeguarding the diet of elderly patients in nursing homes (19). Furthermore, the Norwegian Directorate of Health prepared guidelines for preventing and treating undernutrition among the elderly in nursing homes that recommended high-energy food in combination with nutritional drinks such as smoothies for those at risk of developing undernutrition (1). The Norwegian Directorate of Health has also provided grant funding to encourage Norwegian municipalities to comply with the requirements in the guidelines (1).

    In this connection, the pilot project ‘Reduced overnight fasting for residents in nursing homes’ was tested at two nursing homes in Rogaland in 2014. The aim of the pilot project was to reduce the length of overnight fasting and to prevent and treat undernutrition in elderly patients in the nursing home. In connection with the project, all the patients were offered a high-energy smoothie in the evening and when they woke up during the night. The smoothie was based on dairy products that were rich in protein, fat and carbohydrates, and sugar, fruit and berries were added to boost the intake of energy, vitamins and minerals (18). The objective of this study was to explore the experiences of health personnel in relation to high-energy smoothies for elderly patients in nursing homes.

    Method

    The study adopts a qualitative, exploratory approach, and we conducted three focus group interviews (20).

    Sample

    We recruited participants to the study from two nursing homes in Rogaland, where the pilot project ‘Reduced overnight fasting for residents in nursing homes’ had been tested. The coordinator at the nursing homes carried out a strategic selection (20) of participants based on the following inclusion criteria: health personnel who had participated in the implementation of the pilot project and who were ≥18 years of age.

    We included 16 health personnel altogether. Four of these failed to attend. The sample in the study therefore included 12 health personnel (75 per cent). Table 1 presents a description of the participants.

    Table 1. Characteristics of informants who took part in the study (n = 12)

    Data collection

    We collected data from three focus group interviews. We conducted one of these interviews at one nursing home, and the other two at the other one. The interviews lasted from between 1.5 and 2 hours, and the first author was the moderator. An audio recording was made of all the interviews. The subject of the group discussions was high-energy smoothies for elderly patients in nursing homes. The moderator attempted to explore the informants’ experiences with high-energy smoothies, and asked follow-up questions when it was natural to do so. We also made provision for everyone to have their say in the discussions, and for everyone to be heard (20).

    Ethical considerations

    Prior to conducting the study, all participants received written and oral information. We also informed participants that we would treat all information anonymously and confidentially, that participation was voluntary and that they could withdraw from the study at any point without having to give a reason. We also obtained their consent to tape the conversations. Before the study began, the heads of department at the nursing homes gave their consent to our conducting the study. The Norwegian Centre for Research Data (NSD) approved the study.

    Analysis

    We analysed the transcribed interviews in line with Graneheim and Lundman’s qualitative content analysis method (21). We carried out the analysis in five stages. At stage 1, we read the transcribed material several times to acquire an overall impression. At stage 2, we identified units of meaning that dealt with the experiences health personnel had with high-energy smoothies for elderly patients in nursing homes. At stage 3, we abbreviated the units of meaning but retained the essence of the text content. At stage 4, we codified the condensed units of meaning, basing the comparison on similarities and differences.

    Then we categorised them according to different topics. At stage 5, we read the text relating to each topic carefully. The text was then critically analysed, compared and abstracted. Finally, we formulated five topics and six sub-topics (21). In order to ensure the credibility of the process of analysis, we discussed text content and how this could be understood and interpreted (21).

    Results

    The findings of the analysis of the focus group interviews can be summarised under five topics, two of which have sub-topics:

    • Individual reactions
      • Digestive problems
      • Nausea
    • Individual adaptation
      • Addition of nutrients
      • Individual food and drink lists
      • Some patients get fed up of smoothies
      • Some patients like smoothies
    • More fruit with smoothies
    • Those who were undernourished did not gain weight
    • Smoothies give energy

    Individual reactions

    Digestive problems

    The analysis revealed that some patients became obstipated while others experienced heartburn. This is illustrated by the following statements:

    ‘There was a long article in the paper when we started with this, and it said that the fibres are destroyed in smoothies, whereas if you eat a pear whole, for example, your gut functions much better, so you think a bit about that, and they get fruit during the day.’

    ‘One patient had heartburn, she didn’t tolerate them.’

    Nausea

    Smoothies made some patients nauseous, but it was uncertain whether this was due to the sugar, the cream or the oil that had been added. Two informants described this as follows:

    ‘Some people felt a bit sick.’

    Too much sugar, oil and cream – a lot of people found that sickening.
    Informant

    ‘It wasn’t always a success. Too much sugar, oil and cream, a lot of people found that sickening.’

    Individual adaptation

    Addition of nutrients

    Several informants pointed out that the smoothies were gradually adapted to the individual patient:

    ‘At the start, it seemed very rigid, and you were meant to comply with all of this. You had your own experiences, and of course not everyone liked this [the smoothie], there should have been more flexibility.’

    ‘Because there were many smoothie recipes, and I think it’s important to get enough vitamins. We all need them.’

    According to several informants, different nutrients were added to the smoothie:

    ‘If the bananas are going off, we chuck in a few of them or some other kind of fruit, and also if we find fruit we’ve forgotten about.’

    ‘ … a lot of yoghurt, milk and cream, juice and frozen fruit, and a lot of sugar and a little ice cream.’

    ‘Some people wanted to add egg yolks as well.’

    Individual food and drink lists

    Two of the informants pointed out the need for individual food and drink lists in order to document what nutrients the individual patient ingested and the number of calories:

    ‘What I find a bit difficult about this is that we don’t actually know what they were consuming. How many calories, how much energy and how many nutrients are there in fact in what we’re going to give them; we didn’t know that. It would be a different story if someone had noted that today the patient received so and so many millilitres of that type.’

    ‘Nothing was written down when you followed a recipe, but that’s what would have been interesting because then you could have seen the result. If you noted down what you had given the patient, so much sugar, that means that he would be rearranging the furniture afterwards. If you had only a little, it would be absolutely fine.’

    Some patients get fed up of smoothies

    Several statements indicated that the patients got fed up of smoothies. Reducing this from every evening to two days a week would give room for variation. Two of the informants regarded it in this way:

    ‘And we also find that some people say, “Oh, are you coming already with that again?”, so then I thought, we can’t have this too often, we need to have a break.’

    ‘I think they got fed up of it, and maybe it would be best to have it twice a week so they don’t have to taste the same thing all the time.’

    Some patients like smoothies

    Some informants said that individual patients really liked smoothies. Two statements exemplify this:

    ‘Some nutritious drinks were so good. We have a patient who’s 103, she wiped the glass with her finger and then licked it.’

    Some nutritious drinks were so good. We have a patient who’s 103, she wiped the glass with her finger and then licked it.
    Informant

    ‘There was one patient in particular, she praised it to the skies. Preferably every evening, the best thing she’d tasted. Then we offered her a little more, if there was anything left, and she would say, “Yes, please, yes”.

    More fruit with smoothies

    The informants were not sure whether patients consumed more fruit with the smoothie. Three informants described this as follows:

    ‘Whether it's in the smoothie or in other fruit, the total amount is the same, because we’ve always had a strong focus on fruit and vegetables.’

    ‘… but at the same time I think there’s more fruit in the smoothie compared with the fruit they would get in the evening anyway.’

    ‘I’m sure they consume more, because of course not everyone can eat fruit.’

    Patients who were undernourished did not gain weight

    Several informants had experienced that patients who were undernourished did not gain weight. The following examples illustrate this:

    ‘[It was] exciting to observe whether undernourished patients gained weight on account of the smoothie, but they didn’t. It’s the nature of their illness.’

    ‘I can’t remember that there was a change in weight.’

    ‘The lady who’s 103–104, she’s more poorly, but that’s because of age and a reduced appetite.’

    Smoothies give energy

    Several of the informants believed that smoothies gave the patients extra energy:

    ‘Some really got going after getting smoothies, some had a real burst of energy.’

    ‘It must have been him who started to rearrange the furniture after 20 minutes. It’s quite amazing, I think. Without fail, after 20 minutes he began to get restless, and after a while he got other things and we saw that he calmed down, and we found out the reason. This was very typical after 20 minutes.’

    ‘[They should] get smoothies during the daytime instead [of in the evening and at night]. It’s simply an energy bomb, they become more active because they get so much energy.’

    Discussion

    The objective of this study was to explore the experiences of health personnel in relation to high-energy smoothies for elderly patients in nursing homes. The analysis revealed that not everyone tolerated the smoothie. Some had heartburn, some became obstipated while yet others felt nauseous. It was anticipated that some would have heartburn, since juice was added to the smoothie and this can give hyperacidity and a burning sensation in the lower part of the oesophagus (5, 22). An interesting finding was that some patients became obstipated. When fruit and berries are puréed in the blender, they are cut into small pieces, and the fibres are destroyed (23), increasing the risk of obstipation (13).

    According to earlier research, it is important that elderly people get sufficient fibre to prevent them from becoming obstipated (24, 25). Some informants resolved this by providing fruit during the day. Another way of preventing obstipation is to add vegetables to the smoothie. Vegetables contain more fibre that is not destroyed in the blender, thereby promoting increased bowel movement and nourishing the good gut bacteria (26, 27).

    Additives can cause nausea

    According to the informants, on some occasions sugar, cream and oil were added to the smoothie, and some of our informants were of the opinion that this could make the patients feel nauseous. This assumption is in accordance with an earlier study of patients with diabetes. The study reports that those who had elevated blood sugar levels became nauseous (28). The nausea experienced may also be due to elderly people having a reduced production of bile, lipase and digestive enzymes (29), which results in lowered fat tolerance and nausea (30).

    The analyses showed that those who were undernourished did not gain weight. According to the informants, this might be due to age, underlying illness or diminished appetite. For those with underlying illness or diminished appetite, it may be wise to add nutrients to the smoothies in line with individual needs (9, 31, 32). Based on the findings of our study and earlier studies (9, 31, 32), individual adaptation of the smoothie is important, so that individual needs for energy and nutrients are satisfied.

    Difficult to document nutrient intake

    Some informants felt that the smoothie gave the patients energy, and that some of them became active as a result. It was anticipated that a few patients would become active, since the smoothie that they received had added sugar (10). Due to the addition of sugar, some of the informants were of the opinion that it would be better to give the patients smoothies during the day.

    Some informants felt that the smoothie gave the patients energy, and that some of them became active as a result.

    Moreover, the informants also pointed out that they found it difficult to know what nutrients and fluids patients consumed when everything was mixed together in the blender and recipes were not always followed. The informants therefore wanted the content and amount of smoothies to be recorded and documented in each case so that they had control of how much energy, nutrition and fluids the individual patient received. Documentation of food and drink is in accordance with national guidelines intended to ensure that nursing homes have systems to document patients’ nutritional status and risk of undernutrition (1, 5).

    Can increase fruit intake

    There were differing views among the informants about whether the patients consumed as much or more fruit and berries during the pilot project as they did before it started. Some believed that the patients consumed more fruit with smoothies, while others thought that they consumed as much fruit as before the start of the pilot project. An earlier study (33) shows that 4 per cent of children who ate breakfast also ate fruit, but when the school offered smoothies, the intake of fruit increased to 45 per cent. Although the study (33) was conducted on schoolchildren, its findings may possibly have transfer value to elderly patients in nursing homes.

    Another study also shows that those who have regular access to smoothies are more able to consume enough fruit in comparison to those who do not have regular access to smoothies (15). Based on earlier studies and the findings in this study, there is reason to believe that the patients had an increased intake of fruit in connection with the pilot project.

    Strengths and weaknesses of the study

    A strength of our study is that we chose focus group interviews. Experiences and opinions that the participants shared in the group discussions can thus promote new reflections and thoughts that they can apply in their own practice (20).

    The interviewer has a first degree in nursing education and further education in nutrition. This competence is a source of knowledge and understanding when asking follow-up questions (34). A limitation may be that this prior knowledge may have resulted in biased attitudes, and curbed the interviewer’s curiosity regarding the participants’ perceptions when the questions were asked (34). The interviewer was aware of this problem and endeavoured to ensure that her own knowledge, experiences and perceptions did not influence the interview situation, so that informants could relate their experiences freely.

    A weakness of the study may be that only health personnel who worked during the day and in the evening were included in the study. The reason was that it proved difficult to recruit participants who worked during the night. Two of the focus groups were homogenous, and consisted of health workers, while one was less homogenous and consisted of nurses, social educators and health workers.

    Some scholars recommend that focus groups should be homogeneous, since heterogeneous groups where participants have different educational backgrounds and work experience can lead to ranking of the participants, which may hamper discussion in the group (20, 35). According to Malterud (20) on the other hand, the aim of homogeneity must be balanced against variation in the participants, both within each group and among all the participants, since diversity of experience may create nuances in the empirical data. In one of the groups, which consisted of nurses, social educators and health workers, two people withdrew. The perception of ranking may have been the reason for this.

    Conclusion

    The objective of this study was to explore the experiences of health personnel with high-energy smoothies for elderly patients in nursing homes. The findings show that some patients had problems with heartburn, nausea and constipation. Moreover, it was revealed that those who were undernourished did not gain weight because of smoothies, and that smoothies gave the patients energy and led to some of them becoming overactive. Individual adaptation of smoothies for elderly patients in nursing homes is necessary, so that the wishes and needs of the individual patient can be safeguarded. In order to control the individual patient’s intake of fluids, nutrients and energy, individual nutrition and drink lists are required.

    References

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    4.          Mowé M, Bøhmer T. Reduced appetite. A predictor for undernutrition in aged people. J Nutr Health Aging 2002;6:81–3.

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    9.          Sortland K, Skjegstad G, Jansen L, Berglund A. Eldre personers ernæring og matinntak ved et sykehjem – en pilotstudie. Vård i Norden 2009;29:25–9.

    10.        Aagaard H. Mat og måltider i sykehjem. En nasjonal kartleggingsundersøkelse. Sykepleien Forskning 2010;4:36–43. Available at: https://sykepleien.no/forskning/2010/03/mat-og-maltider-i-sykehjem-en-nasjonal-kartleggingsundersokelse(downloaded 17.08.2017).

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    13.        Bondevik M, Nygaard H. Tverrfaglig geriatri. Bergen: Fagbokforlaget; 2012.

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    17.        Crocker P. Juicing and smoothies for Dummies. Toronto: John Wiley and Sons; 2013.

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    20.        Malterud K. Fokusgrupper som forskningsmetode for medisin og helsefag. Oslo: Universitetsforlaget; 2012.

    21.        Graneheim U, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurs Educ Today 2004;24:105–12.

    22.        Drevon C, Blomhoff R. Mat og medisin. Kristiansand: Høyskoleforlaget; 2012.

    23.        Parada J, Aguilera J. Food microstructure affects the bioavailability of several nutrients. J Food Sci Nutr 2007;72:R21–32.

    24.        Cruz-Jentoft A, Calvo J, Duran J, Ordonez J, DeCastellar R. Compliance with an oral hyperproteic supplement with fibre in nursing home residents. J Nutr Health and Aging 2008;12:669–73.

    25.        Slavin J, Lloyd B. Health benefits of fruits and vegetables. Adv Nutr 2012;3:506–16.

    26.        Myskja A. Sannheten om mat. Oslo: J.M. Stenersens Forlag; 2012.

    27.        Svihus B. Spiselig – en fortelling om maten og mennesket. Oslo: Aschehoug; 2016.

    28.        Malik V, Popkin B, Bray G. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes. Diabetes care 2010;33:2477–83.

    29.        Sortland K. Ernæring mer enn mat og drikke. Bergen: Fagbokforlaget; 2012.

    30.        Nes M, Müller H, Pedersen J. Ernæringslære. Oslo: Gyldendal Akademisk; 2006.

    31.        Manders M, de Groot C, Blauw Y, Dhonukshe-Rutten R, van Hoeckel-Prust L, Bindels J et al. Effect of a nutrient-enriched drink on dietary intake and nutritional status in institutionalised elderly. Eur J Clin Nutr 2009;63:1241–50.

    32.        Allen V, Methven L, Gosney M. The influence of nutritional supplement drinks on providing adequate calorie and protein intake in older adults with dementia. J Nutr Health and Aging 2013;17:752–5.

    33.        Bates D, Price J. Impact of fruit smoothies on adolescent fruit consumption at school. Health Educ Behav 2015;42:487–92.

    34.        Malterud K. Kvalitative metoder i medisinsk forskning. Oslo: Universitetsforlaget; 2011.

    35.        Lerdal A, Karlson B. Bruk av fokusgruppeintervju. Sykepleien Forskning 2008;03:172–5. Available at: https://sykepleien.no/forskning/2009/02/bruk-av-fokusgruppeintervju(downloaded 17.08.2017).

    Health personnel find that high-energy smoothies do not always have the intended effect. Some patients become obstipated or nauseous, and undernourished patients do not gain weight.

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    Sammendrag

    Background: Elderly patients in nursing homes are at risk of becoming undernourished, and it has been found that high-energy smoothies can serve as a supplement to high-energy and nutritious foods in order to prevent and treat undernutrition.

    Objective: To explore the experiences of health personnel in relation to high-energy smoothies for elderly patients in nursing homes.

    Method: The study includes three qualitative focus group interviews of health personnel from two different nursing homes.

    Results: Some patients experienced heartburn, obstipation and nausea after drinking smoothies. Patients who were undernourished did not gain weight, and it is uncertain whether the patients consumed more fruit during the period they were given smoothies. The informants agreed that smoothies gave the patients energy, which could lead to some individuals becoming over-active. To control the intake of energy, nutrition and fluids, it is necessary to have individual nutrition and drink lists.

    Conclusion: Smoothies can cause heartburn, nausea and constipation, and those who were undernourished did not gain weight. Preparing individually adapted smoothies will help to ensure that wishes and needs for fluids and nutrients are safeguarded.

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  • Self-evaluation of competence by nurses working offshore

    Nurses who work in the Norwegian offshore industry are responsible for examining, diagnosing and treating ill and injured patients (1). On most offshore installations, nurses are the only medical staff. Formerly, Norwegian authorities required this group of personnel to have specialised in anaesthetic nursing or intensive care nursing (2). The authorities dropped this requirement in the 1980s after the introduction of stricter health and safety rules, which led to a sharp reduction in the number of accidents involving personal injuries (3).

    Norwegian authorities have not investigated whether the changes they introduced to the professional requirements have brought about any changes to the medical emergency response capability on the Norwegian continental shelf, but the Framework Regulations require all offshore health services to be of a high standard (4). This study examines how nurses who work in the offshore industry evaluate their own competence and capability to undertake the activities requested of them on an offshore installation.

    We found a number of articles that provided data from patient evacuations in the Norwegian and British sectors (5–7), but we were unable to find studies that looked into the offshore nurses’ autonomous assessments, their treatment results or patient satisfaction. The literature searches were carried out in Norwegian as well as English texts. They included words such as “nurse offshore”, “medic offshore”, “HSE coordinator”, “medevac”, “medical evacuation”, “offshore health”, “offshore competence” and “nursing competence”. 

    Dissimilar competence requirements

    To ensure that the medical emergency response capability holds a consistently high standard, nurses are required to attend mandatory courses in emergency medicine. Courses in medical examination techniques and the follow-up of other diseases and conditions are however not covered by a similar ruling. There has been an increase in the rate of acute medical conditions caused by age and lifestyle related health problems (8) and this is now the most common reason for requisitioning a helicopter to take patients ashore. Some oil companies still prefer specialist nurses who have been trained to provide anaesthetic or intensive care (9). Other oil companies employ nurses without any advanced specialist training and whose experience of clinical and emergency medicine is limited, despite the fact that the petroleum industry’s collective wage agreements (10) ensure that all nurses receive the same rate of pay as the specialist nurses.

    Some oil companies still prefer specialist nurses who have been trained to provide anaesthetic or intensive care.

    “Competence” is this study’s key concept. Cowan et al. (11) investigated how competence has been defined in the nursing sector. They emphasised that a holistic definition, covering knowledge, performance, practical skills and attitudes, was required in order to embrace the full complexity of nursing. Nurses need to be able to transfer knowledge, make thorough assessments and adjust their skills to unexpected and unfamiliar situations (11).

    Eraut (12) describes the development of competence as a gradual process: Knowledge and theories are put into a system of standards for each discipline. They are then further developed into general principles, which in turn form the basis for knowledge about procedures and guidelines. He describes the last step as a cognitive process that involves planning, problem solving, analysis, evaluation and decision-making. This last step cannot be achieved by simply following procedures because it requires a robust knowledge base, retrieval of information, recognition of patterns and quick interpretation of data (12). Eraut maintains that experts make decisions intuitively rather than analytically, and that this requires considerable experience. It is generally accepted that competence, as a concept, means to be qualified to do a job, for instance after completing professional training. Expertise, however, is required to deal with the unexpected. (12).

    In order to examine how nurses working in the offshore industry evaluate their own capability to examine, diagnose and treat patients, we drew up the following research questions:

    • Do specialist anaesthetic and intensive care nurses assess their competence to be different to the competence of nurses with another specialty or with no advanced specialist training?
    • What is the correlation between self-reported competence and past work experience?
    • What type of competence do the nurses report that they need most in order to carry out their work?

    Method

    Design

    In order to reach the greatest possible number of nurses we decided on a sample survey design (13). The method is based on information obtained through standardised questions and can be used to gather quantitative data from large groups of people. A self-administered questionnaire with predefined response alternatives is well suited to collect data without the researcher exerting an influence on participants (14). The challenge is to formulate questions that are unambiguous, and response alternatives that reflect the area being investigated (15).

    Competence can be investigated in several different ways. According to a systematic literature study that charts instruments used to measure competence, all such instruments include a form of self-evaluation, some of them in combination with other methods such as practice observation, interviews or manager evaluation (15). For reasons of distance and cost we decided to use an online questionnaire.

    Drawing up the questionnaire

    We drew up a two-part questionnaire. Part 1 was based on a questionnaire developed by Valeberg, Grønseth and Fagermoen (16). Their questionnaire was made for the purpose of studying the perceived competence of specialist nurses on completion of their specialist training. This questionnaire included questions relating to seven different areas of competence: nursing care, medical skills, technical skills, teamworking, teaching skills and professional development, decision-making and improvisation, and liaison with relatives. We adjusted our questions to the most commonplace offshore patient scenarios, excluding liaison with relatives, as this responsibility lies with the oil companies’ onshore management.

    Medical competence was split into two skills areas: “Medical treatment” included questions about medication and the ability to make autonomous decisions about initiating treatment, while “medical assessment” included questions concerning anamnesis and examination as a basis for the nurses’ diagnoses. The other areas of competence were adjusted to the nurses’ role as the only health care staff aboard the installation and therefore the leader of the medical emergency response.

    The competence part of the questionnaire included 44 questions. The nurses were asked to evaluate themselves on a Likert scale (13) from 1–10 (1 = considerable gap between own competence and the competence required to do the job, 10 = meets the competence requirements for the relevant area in a fully satisfactory way).

    Part 2 of the questionnaire consisted of questions concerning age, gender, specialist training, past work experience, and the duration of employment at up to three different places of work. The alternative responses with respect to advanced specialist training were anaesthetic nursing, intensive care nursing, theatre nursing, emergency care nursing, other advanced specialist training and paramedic training (for ambulance crews) (17). The nurses were also asked to indicate what type of clinical experience they felt was the most relevant when they started working offshore. The greater the number of relevant explanatory variables, the stronger a study that investigates correlations is considered to be (13).

    Three nurses with different offshore histories took part in a pilot study in order to strengthen the validity of the questionnaire’s content. They were each asked to submit comments in writing on the design of the questionnaire, the phrasing of the questions and their relevance with respect to the areas of competence. Based on their feedback, we added further questions under “medical treatment” associated with acutely ill and seriously injured patients. This was done to reflect the fact that an ability to provide emergency medical care is a requirement relating to the nurses’ emergency medical response provision offshore (4, 18). We also added further questions concerning common offshore health problems, such as skin rashes, eye injuries, ear, nose and throat problems, respiratory problems, musculoskeletal complaints (19).

    Under the heading of “Medical assessment” we included questions about infectious diseases, ECG interpretation, neurological examination and the ability to carry out the examinations referred to in the Norwegian Electronic Medical Handbook(NEL) (20). The three nurses completed the questionnaire again, after which some of the questions were rephrased. The nurses felt that the website login procedure and the questionnaire format were satisfactory.

    Data collection

    We tried to recruit all nurses working in the Norwegian petroleum industry. Twenty oil companies and crewing agents that provide nurses for offshore work, were contacted by email or telephone. The sixteen companies that agreed to assist with the recruitment employed a total of 261 nurses offshore. For this study, we used an online form that had been developed at the University of Oslo. This required the questionnaire and the login and password details to be sent electronically to the informants’ email addresses. The various oil companies operated with different internal standards with respect to handing out the email addresses of employees. Some made their email lists available, while others chose to have their HSE manager, company doctor or coordinator forward the information letter and invitation to the nurses. Those who wished to take part subsequently contacted us direct by email and gave their consent, after which they were sent the form and login details electronically.

    We collected data in the period between November 2013 and March 2014. We issued two reminders – after four weeks and then again after eight weeks. The responses were recorded in a closed database. Data were electronically transferred to SPSS following closed inclusion. The study has been approved by the Data Protection Official at the Norwegian Centre for Research Data (NSD). The participants’ email addresses have since been deleted, and the data have been anonymised.

    Analysis

    All data were transferred electronically to IBM SPSS Statistics 22, which was the software used for our analyses. All education and past work experience data were summarised in groups and analysed by means of descriptive statistics: frequencies, percentages, mean scores and standard deviations. When an analysis involves several independent variables, we need to carry out multiple comparisons. We conducted an analysis of variance (one-way ANOVA) to establish whether there were significant differences between the distribution of responses within each group and between groups. We also used one-way ANOVA to study the effect of several factors at the same time.

    Levene’s test is included in the SPSS analysis and is used to test the null hypothesis that there is homogeneity of variance, so that the groups are statistically comparable. The significance testing was corrected using the Bonferroni and T2 methods in order to avoid any type 1 errors that would lead to incorrect rejection of the null hypothesis. The significance value was set to p <0.05.

    We recoded the respondents into three educational groups: The first two groups consisted of anaesthetic nurses and intensive care nurses. Anaesthetic nurses who had also specialised in intensive care nursing, were nevertheless categorised as anaesthetic nurses because prehospital acute medical services are defined as the remit of anaesthetic nurses (21). The remaining educational groups were too small to warrant separate analyses; they were therefore combined into a single educational group.

    We recoded age and experience into three groups of near-equal size. We recoded clinical experience into little experience (≤8 years), moderate experience (9–14 years) and long experience (≥15 years). Offshore experience was recoded into little experience (≤4 years), moderate (5–14 years) and long experience (≥15 years). Age was recoded into youngest (≤44 years), middling (45–53 years) and oldest (≥54 years).

    Results

    A total of 89 nurses reported that they wanted to take part, but only 66 completed the questionnaire, which gave a take-up rate of 25.3 per cent of the 261 nurses working offshore. Table 1 presents the sample’s demographic data.

    Table 1: Sample composition and background

    The sample consisted of 34 (51.5 per cent) men and 32 (48.5 per cent) women. Men and women had the same number of specialties, but men had significantly less clinical experience than women (p = 0.002). Table 1 shows that the group with either no specialty or with a different specialty had less clinical experience, and included fewer nurses with multiple specialties, than the groups with anaesthetic or intensive care training.

    A few of the nurses had advanced specialist training in theatre nursing, acute care nursing or paramedic training, but many of them had specialist training in anaesthetic nursing or intensive care nursing as well. Twenty-three nurses reported that they had a different specialty, which may have referred to other healthcare disciplines, a master’s degree or possibly healthcare management. The responses for clinical experience indicated that 59.1 per cent had worked in an Accident & Emergency department in the past, 48.5 per cent in anaesthetic departments, 47 per cent in an intensive care unit and 27.3 per cent in the ambulance service.

    The first variance analysis showed that no age group, educational group or past work experience group was significantly different from the others. To facilitate further analyses, we recoded all of the competence-related questions into seven variables, each corresponding to one of the seven areas of competence referred to in the questionnaire. Table 2 shows each of the educational groups’ results in all seven areas of competence.

    Table 2: Variance analysis with mean scores for self-reported competence

    Our analysis of the variance showed no significant differences between educational groups (p values between 0.498 and 1.0). In all educational groups, the standard deviation was greatest for medical assessment, which suggests that this was the skills area with the greatest distribution of responses. The respondents considered their own competence to be somewhat lower in this area than within the other areas.

    Figure 1 clarifies the difference in distribution by showing the responses as percentages.

    Figure 1: Distribution of self-reported competence, all respondents (n = 66)

    We also investigated whether the reported types of past work experience, or the length of clinical experience, the length of offshore experience, or multiple specialties influenced the self-reported competence levels. The variance analysis showed that nurses with less than four years’ clinical experience considered themselves to be just as competent in all seven areas as the specialist nurses with more than 20 years’ clinical experience. Responses to each of the 44 competence-related questions in the three educational groups were compared. Only one of ten questions under the Medical treatment heading showed a significant difference: The intensive care nurses considered that they were less capable of implementing emergency medical procedures than what anaesthetic nurses did (p = 0.037).

    When asked what clinical experience was most relevant to their work offshore, the highest scorers were out-of-hours primary care (92.3 per cent), Accident & Emergency departments (87.2 per cent) and surgical wards (83.3 per cent).

    The respondents were asked to indicate up to three areas of healthcare competence which they felt were required for their work. The highest scorer was the ambulance service (17.6 per cent), followed by Accident & Emergency departments (15.6 per cent) as second choice and out-patient clinics (12.6 per cent) as third choice. Past work experience did not influence the respondents’ ratings.

    Discussion

    The offshore nurses in this sample rated their respective competencies to be at the same level, irrespective of their past work experience and nursing specialties. No correlation was found between the nature and duration of past work experience and self-reported competence levels within any of the areas we looked at. We had expected to find greater variance among the groups of nurses in terms of how they evaluated their own competence, with a lower score achieved by those whose experience was less varied and of short duration. One explanation may be that offshore nurses have to attend the same mandatory type of course, irrespective of their past experience, and they have to attend regular onshore practice sessions. Also, limited practice in emergency care offshore is compensated for by frequent training in standardised emergency medical protocols.

    The offshore nurses rated their respective competencies to be at the same level, irrespective of their work experience and nursing specialties.

    Protocols and manuals work well in practical training situations for people with little experience (12), and the less experienced nurses may thus have rated their own competence highly because they mastered every part of the protocol. It is likely that the sample’s high scores in all areas better reflect the competence levels of experienced nurses. The scores suggest a competence level that requires a unique combination of theoretical knowledge, situation awareness and professional assessment (11, 12).

    The only significant finding, then, was the fact that the intensive care nurses’ rating of their own ability to implement emergency medical procedures was lower than the rating reported by the anaesthetic nurses. Emergency medical procedures form a part of both groups’ specialist training and job descriptions (21, 22). One possible explanation may be the fact that anaesthetic nurses are trained to establish a secure airway and intravenous access within and outside their own place of work, while intensive care nurses often treat patients who have already been intubated and have cannulas and a central venous catheter. Moreover, different criteria for competence attainment are clearly defined in the framework plans for both nursing specialties (21, 22).

    Intensive care nurses are not normally part of trauma teams, which is why we expected to see differences between the anaesthetic and intensive care nurses and the other nurses in terms of their own perceived ability to treat seriously injured patients. The fact that there was no difference may be due to the fact that all nurses who work offshore train to provide the same trauma care. Research has shown that it is more difficult to evaluate knowledge than practical skills, and findings have suggested that respondents evaluate their own potential performance rather than their true performance, or they put an emphasis on their own effort rather than their own results (15).

    Medical assessment

    The results relating to “medical assessment” were slightly different to the results relating to other areas of competence in that there was greater distribution of responses and a lower mean score, although none of the results were significant. The questions focused on the ability to examine patients and make assessments in various fields of medicine. These tasks are included among the core competencies of doctors, for example the ability to carry out an eye examination or a neurological examination according to the guidelines provided by the Norwegian Electronic Medical Handbook. Awareness that such examinations or assessments come within the remit of doctors, may have meant that the nurses evaluated their own competence to be lower. Several researchers have suggested that when respondents measure their own competence against a given standard, in this case the competence of doctors, they give themselves a lower score (23, 24).

    Research has shown that it is difficult for the least competent individuals to evaluate what constitutes a high level of competence within a discipline. Individuals with less education and experience of a certain discipline cannot fully appreciate the level of their own abilities within a wider context (24). At the same time, more competent individuals have a tendency to believe that a task that they find easy, will also be easy for others. Furthermore, they may have experienced a number of situations where they found their own competence to be lacking. Such situations may have led them to underestimate their own competence compared to that of colleagues with less education and experience (23, 25).

    All respondents rated their own emergency medical competence as being very good.

    The respondents reported that the need for past experience of work in out-of-hours primary care and Accident & Emergency departments was greater than the need for experience of work in specialist emergency medical wards, such as anaesthetic and intensive care units. One of the reasons may be that the majority of offshore patients are people that need treatment for less serious conditions (5, 19). However, the respondents’ wish for more experience of work in emergency medicine does not match up with the fact that all respondents rated their own emergency medical competence as being very good. The offshore companies expect the nurses they employ to be fully skilled in emergency medicine, and offshore jobs are highly desirable. We can only speculate as to the reasons for the discrepancy, as we have found no research that fully elucidates the matter. Some literature has however established that there is a gap between assumed and real learner needs among health care personnel (23). 

    The study’s limitations

    Some of the advantages of a questionnaire survey of perceived competence are the possibility of recruiting more respondents, generating large volumes of first-hand data and receiving standardised response alternatives that are easy to analyse (13, 15). The disadvantage is low reliability, particularly in the case of respondents whose level of competence is low. There is also a greater likelihood that those who feel the least competent, refrain from taking part, or that they award themselves a higher score because the results may affect their opportunity of future employment (15). Our questionnaire was based on a validated template, but we have made a few adjustments to the instrument that have yet to be validated.

    The recruitment procedure via companies in the petroleum sector is the study’s weakest factor, and the low response rate may have affected the results. Sending out the questionnaire during the nurses’ off-duty periods, the login procedure and the use of an online questionnaire are other factors that may have had an adverse effect on the rate of participation. 

    Conclusion

    This survey found no differences among the overall self-reported competence levels of offshore nurses despite there being great differences among the respondents with respect to their educational background and past work experience. Nor was it established whether past experience impacted on the self-reported competence levels. Due to the low response rate, the survey findings cannot be generalised, but they may nevertheless be of interest since there is no previous research in this field.

    References

    1.          Tronsmoen S. Helsetjenesten offshore. Sykepleien 1992;80(3):20–1.

    2.          Sosialdepartementet. Norm for midlertidig instruks for sykepleier ansatt på anlegg for produksjon m.v. i petroleumsvirksomheten på kontinentalsokkelen [fastsatt av Sosialdepartementet 11. mai 1978]. 1979.

    3.          Ulven J. Medical and psychological challenges in the offshore petroleum industry. Int Marit Health 2009;60:40–2.

    4.          Forskrift av 12. februar 2010 nr. 158 om helse, miljø og sikkerhet i petroleumsvirksomheten og på enkelte landanlegg (rammeforskriften). Available at: https://lovdata.no/dokument/SF/forskrift/2010-02-12-158(downloaded 21.01.2016).

    5.          Evensen AMC, Brattebø G. The use of integrated operations in order to improve quality of health care and medical evacuations from offshore installations. [presentation] SPE Intelligent Energy Conference and Exhibition, Amsterdam; 2008.

    6.          Duffy B. Dental problems in the offshore oil and gas industry: A review. Occup Med 1996;46:79–83.

    7.          Ponsonby W, Mika F, Irons G. Offshore industry: medical emergency response in the offshore oil and gas industry. Occup Med 2009;59:298–303.

    8.          Gilja A. For syke til å jobbe offshore. Available at: https://sysla.no/offshore/for_syke_til_229_jobbe_offshore/(downloaded 07.08.2017).

    9.          Statoil.com. HMS-koordinator/leder (sykepleier) (7725). Available at: https://jobb.tu.no/jobb/hms-koordinatorleder-offshore-sykepleier-7725/20519(downloaded 07.08.2017).

    10.        Industri Energi. Lønns og arbeidsvilkår. Tariffavtaler. Flyteriggavtalen NR. Available at: http://www.industrienergi.no/lonns-og-arbeidsvilkar/tariffavtaler/flyterigg-norsk-samleversjon-sokie-2014/(downloaded 18.05.2015).

    11.        Cowan DT, Norman I, Coopamah VP. Competence in nursing practice: a controversial concept – A focused review of literature. Accid Emerg Nurs 2006;15:20–6.

    12.        Eraut M. Developing professional knowledge and competence. London: Routledge; 1994.

    13.        Polit DF, Beck CT. Nursing research (int. ed., 9. ed.) Philadelphia: Lippincott Williams & Wilkins; 2012

    14.        Lund T, Haugen R. Forskningsprosessen. Oslo: Unipub forlag; 2006.

    15.        Bing-Jonsson P, Bjørk IT, Hofoss D, Kirkevold M, Foss K. Instruments measuring nursing staff competence in community health care: a systematic literature review. Home Health Care Management Practice 2013;25:282–94.

    16.        Valeberg BT, Grønseth R, Fagermoen MS. Spesialsykepleieres opplevde kompetanse etter endt utdanning. Sykepleien Forskning 2009;4:206-213. Available at: https://sykepleien.no/forskning/2009/10/spesialsykepleieres-opplevde-kompetanse-etter-endt-utdanning(downloaded 01.08.2017).

    17.        Høgskolen Betanien. Studietilbud, paramedic. Available at: http://www.studiesok.no/paramedic-hogskolen-betanien/(downloaded 08.08.2017).

    18.        Forskrift av 29. april 2010 nr. 613 om utføring av aktiviteter i petroleumsvirksomheten (aktivitetsforskriften). Available at: https://lovdata.no/dokument/SF/forskrift/2010-04-29-613(downloaded 21.01.2016).

    19.        Parkinson G. Working as a medic on an offshore oil rig. Intervju av Clare Lomas. Nursing Times 2005;101:76–7.

    20.        Norsk Helseinformatikk. Norsk Elektronisk Legehåndbok. Available at: https://legehandboka.no/(downloaded 18.08.2017).

    21.        Kunnskapsdepartementet. Forskrift til rammeplan for videreutdanning i anestesisykepleie. 2005. Available at: https://lovdata.no/dokument/SF/forskrift/2005-12-01-1388 (downloaded 01.08.20.17).

    22.        Kunnskapsdepartementet. Forskrift til rammeplan for videreutdanning i intensivsykepleie.2005. Available at: https://lovdata.no/dokument/SF/forskrift/2005-12-01-1389 (downloaded 01.08.20.17).

    23.        Colthart I, Bagnall G, Evans A, Allbutt H, Haig A, Illing J, McKinstry B. The effectiveness of self-assessment on the identification of learner needs, learner activity, and impact on clinical practice: BEME Guide no. 10. Med Teach 2008;30:124–45.

    24.        Jensen, R. Clinical reasoning during simulation: comparison of student and faculty ratings. Nurs Educ Pract 2013;3:23–8.

    25.        Schlosser T, Dunning D, Johnson Kl, Kruger J. How unaware are the unskilled? Empirical tests of the «signal extraction» counterexplanation for the Dunning-Kruger effect in self-evaluation of performance. J Econ Psych 2013;39:85–100.

    Today, nurses working in the offshore industry include staff who have specialised in intensive care or anaesthetic nursing as well as staff with no particular specialty. Are there differences between their own perceived competence levels?

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    Sammendrag

    Background: Nurses who work in the offshore oil and gas industry are usually the only medical staff aboard an installation, which means they are responsible for the medical emergency response. Following a sharp reduction in the number of offshore accidents in the 1980s, the authorities decided to drop the requirement for offshore nurses to have specialised in anaesthetic or intensive care.

    Objective: The objective was to investigate how offshore nurses from different backgrounds in terms of education and past work experience evaluate their own competencies in examining, assessing and treating patients.

    Method: We drew up a questionnaire designed to establish how offshore nurses evaluate their own level of competence with respect to nursing care, medical assessment and treatment, technical skills, teamworking, decision-making and improvisation, teaching skills and professional development.

    Results: A total of 66 offshore nurses took part in the survey. No significant difference was found between specialist anaesthetic nurses, intensive care nurses and nurses with no nursing specialty.

    Conclusion: Despite substantial differences in the respondents’ educational backgrounds and work histories, the study found no differences between their self-reported overall competence levels.

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  • Deficient reporting of falls in nursing homes

    Prevention has long been a key target area for Norwegian health authorities; the Coordination Reform has further emphasised the need for prevention and better coordination between the different parts of the health service. Prevention is intended to help avoid unnecessary discomfort for patients and reduce the number of unnecessary hospital admissions (1).

    The Norwegian Patient Safety Programme entitled In Safe Hands 24–7has highlighted fall prevention as a particularly important target area. This programme aims to reduce the incidence of patient injuries and increase patient safety in Norway (2). It is a continuation of a comprehensive national patient safety campaign that was run by the Norwegian specialist and primary healthcare services in the period 2011–2013. The campaign was commissioned by the Norwegian Ministry of Health and Care Services, and the primary healthcare services was invited to participate on a voluntary basis. There were three main objectives: to reduce the number of patient injuries, to establish lasting systems and structures for patient safety, and to improve the patient safety culture in the health service. The Patient Safety Programme covers 12 main target areas, two of which include the prevention of falls in nursing homes and the correct use of medication in nursing homes (medication review).

    The health and social care services’ quality requirements and improvement strategies are well known, yet it has repeatedly been demonstrated that there is a gap between desired and real practices (3). Nursing documentation requirements are disregarded, or the documentation may be inadequate or of a poor standard (4). The implementation of secondary prevention measures can therefore be deficient. There is a need for more knowledge as to whether the secondary prevention strategies are in fact put in place in connection with fall incidents, and more knowledge about factors that may affect the work involved with implementing fall prevention strategies.

    Falls – a serious health problem for the elderly

    Falls and fall injuries can be defined in various different ways. One definition used by Norwegian authorities describes a fall as an incident which results in a person coming to rest inadvertently on the ground or floor or other low level, irrespective of the reason and irrespective of whether an injury arises as a consequence of the fall (2). A fall injury is defined as a cut that needs suturing, a graze or abrasion that requires treatment, sprains, suspected fractures, fractures and all head injuries (2).

    This article is based on a wider analysis of data collected in connection with a clinical review at three Norwegian nursing homes (5). The study examined the medication assessments associated with falls, which showed that 32 per cent of the 652 residents had experienced at least one fall. Of the 208 residents who had experienced a fall, 46 per cent had fallen once, while 25 and 29 per cent respectively had fallen two times or more. The study further showed substantial deficiencies with respect to the reporting of falls. This was established by identifying considerable under-reporting of falls on injury report forms (non-conformance reports) compared to the number of falls reported in the patient records. This article does not examine and discuss this matter in depth and thus invites further consideration and questioning with regard to whether the documentation practice requirements for fall incidents are being fulfilled.

    Falls represent a serious health problem among the elderly, whether they live in a nursing home or in their own home.

    Our focus on fall prevention is also based on our current knowledge of the considerable negative consequences that falls may have for the elderly. Falls represent a serious health problem among the elderly, whether they live in a nursing home (6, 7) or in their own home (8). Studies show that more than a third of the elderly population experience a fall every year, that the risk of falling increases after the age of 75, and that 50 per cent of elderly individuals over the age of 80 has at least one fall per year (7, 9). A systematic review article showed that 10 to 20 per cent of falls in the elderly population gave rise to serious injuries such as head traumas or fractures (7).

    Our focus on falls is also based on the fact that there is considerable documented potential for improvement if preventive interventions are implemented in healthcare institutions (2). Norway has seen the introduction of a special intervention package for fall prevention (2). Risk assessments of falls and medication reviews make up two of the most important fall prevention interventions.

    Prevention and risk factors

    Secondary prevention strategies have now been proposed in order to reach the goal of reducing the incidence of falls and falls that cause injury in healthcare institutions (10). Secondary fall prevention involves, among other things, the identification of individuals with an increased risk of falling. Documenting the risk of falling is needed to ensure that individuals who have had a fall will have their medical prescriptions re-assessed (5), that all people with an increased risk of falling are identified, and that other interventions can be implemented in order to prevent further falls.

    Today we have a great deal of knowledge about factors that influence the risk of falling (7, 11, 12). A previous fall is a key risk factor for further falls (2), combined with internal risk factors such as health and level of functionality (13), and external environmental factors (11). This means that the patients’ risk of falling must be assessed if they have already had a fall (2).

    It is recommended that this type of risk assessment is carried out as a secondary prevention intervention for all patients over the age of 65 and other adults with neurological or cognitive disorders or considerable visual impairments. This should take place no later than 24 hours after admission to hospital, or after the first meeting with the patient. The assessment must be conducted by a nurse or healthcare worker. The risk of falling must be re-assessed if the patient’s general level of fitness should change or if the patient has a fall, and at least once a year for any long-stay patients. The risk of falling must be documented in the patient records (2).

    This study’s objective was therefore to describe documentation practices in connection with falls in nursing homes and discuss the degree to which these coincided with the nursing homes’ internal documentation requirements. We also wanted to investigate whether the age and gender of residents, the location of the nursing home, the type of fall and whether or not the resident was admitted to hospital were factors associated with the completion of injury report forms.

    Method

    This quality improvement project was conducted as a retrospective descriptive study of patient records and injury report forms in the period 1 August 2010 to 31 July 2011 at three nursing homes in a large Norwegian municipality. According to the nursing homes’ written procedures and explicit documentation requirements for fall incidents at the time of data collection, all falls had to be documented in accordance with the institution’s current documentation procedures. This means that falls had to be documented as an undesirable incident, in the patient records as well as on an injury report form. All staff were made aware of this requirement during their training. The injury report form that was used by all the nursing homes takes the form of an electronic document in which all data about the fall should be recorded, such as the date of the incident and a description of it, the consequences of the fall and any further follow-up measures.

    During the survey period a total of 652 individuals over the age of 65 were admitted to the three nursing homes included in the survey, and all falls that were documented in patient records, on injury report forms or both, were registered. The nursing homes all used the same IT system for documentation purposes and to follow up each individual resident.

    Data collection and variables

    Data were collected by gathering information about falls from anonymised patient records and injury report forms; free text searches of patient records were carried out for the words ‘fell’ and ‘tripped’. The patient records and injury report forms were carefully reviewed and checked against each other. This registration exercise resulted in an overview of all the falls suffered per person, and this enabled us to establish whether falls appeared in both sets of records or in only one of them.

    Each fall incident was listed and recorded as having been documented in the patient records only, on the injury report form only, or in both places. The date of the fall was registered, as well as the age and gender of the patient. The consequences of the falls were listed against the following variables: ‘injury’ and ‘hospitalisation’. The following values were assigned to the ‘injury’ variable: ‘fall without injury’, ‘fall with non-fracture injury (pain and cuts)’ and ‘fall with fracture’. The ‘hospitalisation’ variable was assigned the values ‘admitted to hospital’ or ‘not admitted to hospital’.

    Analysis

    Categorical variables are expressed as absolute numbers and percentages, while continuous variables are expressed as the mean and standard deviation. Multiple logistic regression was used to establish whether age, gender, practice location (the nursing homes), fall with injury and hospital admission were factors associated with non-completion of an injury report form following a fall. Odds ratio (OR) > 1 indicates an increased risk of not completing an injury report form. A two-sided P-value < 0.05 suggests statistical significance. SPSS version 20 was used for the statistical analyses.

    Ethical considerations

    The Regional Committees for Medical and Health Research Ethics (REC) considered the project to be exempt from any obligation to seek their approval under the Norwegian Health Research Act, but because this was an internal quality improvement project conducted by an external person, the project was submitted to the Norwegian Data Protection Authority for clarification of the legal aspects. The Data Protection Authority recommended that the matter be submitted to the Norwegian Directorate of Health, which granted approval for the project, provided that all health information was anonymised. This condition was met by collecting all data from an anonymised version of the nursing homes’ databases.

    Results

    Of the 652 individuals in the sample, 208 (32 per cent) had experienced a fall; a total of 556 fall incidents had been reported (Table 1). This shows that many residents had fallen more than once. The average age of individuals who had experienced a fall was 85.5 years. The majority of falls were reported to involve women (60.8 per cent).

    Table 1. Description of fall incidents with background variables

    Falls without injury accounted for 74.1 per cent of the falls. Falls with non-fracture injuries (pain and cuts) accounted for 19.6 per cent, while 6.3 per cent of the falls resulted in a fracture. Twenty-six of the fall incidents resulted in the patient being admitted to hospital (4.7 per cent).

    The average age of individuals who had experienced a fall was 85.5 years.

    We found that 91.4 per cent of the fall incidents were described in patient records, while 19.2 per cent of the falls were documented on injury report forms. In total, 10.6 per cent of the falls were documented in both the patient records and on an injury report form.

    Factors associated with injury reporting

    The logistic regression analysis showed that there were statistically significant differences between the nursing homes in terms of how frequently an injury report form was completed after a fall (P = 0.008) (table 2).

    Table 2. Logistic regression with non-completion of injury report form as dependent variable (N = 556)

    Moreover, there was a clear correlation between the severity of the injury caused by the fall and whether an injury report form was completed (P = 0.026). The relative probability of non-completion of an injury report form was lower when the fall resulted in a fracture than when the fall did not cause an injury (OR = 0.21; P = 0.007).

    Whether or not the fall caused the individual to be hospitalised did not produce a significant difference with respect to the relative probability of non-completion of an injury report form (OR = 0.45; P = 0.242).

    Discussion

    This study’s objective was to examine the extent to which the nursing homes’ practices comply with their own internal requirements with respect to falls, and to identify any associated factors.

    We found that most falls involve women. This must be seen in the light of the large percentage of female residents in nursing homes. The risk of falling increases after the age of 75, and 50 per cent of those over the age of 80 fall at least once a year (9). Similar figures are brought out by this study. Average age at the time of the fall incidents was 85.5, which suggests that this may be a high-risk group and therefore that there is a need for follow-up measures.

    Only 10.6 per cent of the falls were documented in both the patient records and on an injury report form.

    The results of this study show that the nursing homes in practice do not comply with their own documentation requirements in connection with falls. Only 10.6 per cent of the falls were documented in both the patient records and on an injury report form, even though the nursing homes’ own requirements expressly state that that these forms must be completed when a fall occurs. However, the study also shows that nursing homes vary in their compliance with fall documentation requirements, and that more serious falls are associated with better compliance.

    Deficient reporting of falls

    There are several reasons why the current rule is to report any fall by an elderly person, and why a risk assessment must be carried out after an elderly person has experienced a fall. First and foremost, this practice provides an opportunity to implement preventive interventions. A risk assessment involves a systematic review of various factors, both external and internal, that increase the risk of falling, including the prescription of medication for the elderly person (5). Deficient reporting may mean that no such risk assessment is conducted, so that necessary preventive measures cannot be implemented. Deficient reporting of falls also means that we cannot gain more knowledge about the extent of the problem and the consequences to society.

    There may be several reasons why falls are not documented in compliance with the nursing homes’ requirements. Research on risk factors gives us knowledge about preventive interventions. One reason may be that this knowledge is not passed on to staff. The personnel may have insufficient knowledge about the fall documentation requirements and about the potentially serious negative consequences of a fall for the elderly person (14). Consequently, they will not appreciate the need for documentation, which is why they fail to comply faithfully with the reporting requirements.

    This study has investigated whether falls are documented in compliance with the guidelines established by the nursing homes themselves. We cannot therefore rule out the possibility that risk assessments and necessary changes are introduced without this being documented. If so, the documentation will be deficient due to insufficient knowledge about quality-enhancing efforts and documentation, not insufficient knowledge about the risk of falling and fall prevention. We have little knowledge of how nursing home staff might assess and consider the need to report non-conformances. It may well be that non-conformance reporting is felt to constitute extra work or to be onerous in other ways, if no positive culture has been established around doing so.

    Reasons for deficient documentation

    The correlation between the severity of the fall and whether an injury report form was completed may indicate that nursing home staff are insufficiently acquainted with their institution’s internal documentation requirements when it comes to reporting incidents (non-conformances). However, we have also found that it was not until the fall caused an injury that it was satisfactorily documented. This may suggest that one contributory explanation is insufficient understanding of the importance of prevention and the link between non-conformance reporting and quality improvement (15).

    It was not until the fall caused an injury that it was satisfactorily documented.

    The significant difference between the nursing homes with respect to the probability of completing an injury report form may be caused by cultural differences. The Patient Safety Programme is also conscious that patient safety is affected by various employment issues, and patient safety culture is therefore one of its three main objectives (2). Different knowledge levels may also be a reason associated with, for example, the difficulty of recruiting staff with relevant skills and expertise, or associated with the management’s focus on fall prevention, as this differs between institutions. All of the nursing homes included in the study were located within the same municipality, which suggests that they all have the same opportunity to recruit qualified staff. It is therefore reasonable to assume that the differences between them were caused by cultural differences and by their respective managements’ different focus on fall prevention.

    Another potential reason why the reporting is deficient is that inadequate attention is paid to the overall implementation process. When it comes to fall prevention practice, documentation requirements and risk assessments are innovations that may represent new ways of working. Implementing new practice is never easy. Research on fall incidents has given us knowledge about risk factors and fall prevention, but this research provides no knowledge about how to implement the interventions. A transfer of knowledge may, on its own, not necessarily be enough to change practice (16-18). When introducing fall prevention interventions the organisation will need to focus on the overall implementation process (19).

    A change of practice may require the introduction of a competence development regime adjusted to the specific context, including provision of follow-up and guidance, and involving and supporting the people who will be implementing the intervention (16, 17, 20). Adjusting the implementation to the specific practical context (21) will be important. The management of the institutions will play a key role throughout this process. Insufficient attention from management to the overall implementation process may be a contributing factor to deficient documentation (22). Time pressure, large workloads and insufficient knowledge about nursing documentation will of course play a part (23, 24). Further obstacles to good nursing documentation include frequent interruptions while writing the report and insufficient guidance (25). It is important to be aware of these barriers so that the initiatives put forward as part of quality improvement strategies can be targeted towards them (26).

    The study’s limitations and weaknesses

    The results from this study describe the current practice at three Norwegian nursing homes over a specific period of time. This suggests that we need to be careful not to generalise the results and assume they also apply to other nursing homes. Furthermore, it is reasonable to believe that the results may have been different had the study been conducted after the implementation of the Patient Safety Programme. The IT system used by the nursing homes is very well suited for retrieving data, and many data were imported directly from the database and into the analysis tool. Reporting errors that might have been caused by manual input of data were therefore avoided.

    This article is based on information obtained from patient records. There may have been reporting errors, or reports may have been based on an incorrect definition of a fall. Some may have defined a fall as a fall resulting in an injury, and falls may have been described by using words other than ‘fell’ or ‘tripped’. These are possible sources of error that may account for under-reporting of fall incidents. Furthermore, the non-significant association between hospitalisation and completion of an injury report form (OR = 0.45) (Table 2) may be a type II error caused by low statistical power.

    The road ahead

    The results of this study show that there is great potential for improvement in nursing homes when it comes to their documentation of fall incidents. There is reason to believe that training in how to follow documentation procedures may help to improve the documentation practice, since several systematic overviews show that training interventions can improve the quality of nursing documentation (4, 27). Furthermore, feedback may form part of the training intervention, thereby ensuring that the results of research into current practice are communicated to staff to boost their motivation to try to close the gap between current practice and what research has shown to constitute high-quality nursing documentation (28, 29).

    Research has highlighted that reviews and feedback can serve as effective tools for improving current practices if there is a significant gap between real and recommended practice (30), which is the case in this study. In addition, it will be important that further fall prevention initiatives focus on the overall implementation process, so as to create a culture of patient safety within the health service. We need more research on the actual implementation practices in nursing homes, both in terms of fall prevention and other interventions, and we need research on the characteristics of successful implementation processes.

    Conclusion

    By measuring the quality provided at three nursing homes in Norway, this study has demonstrated that there is a large gap between requirements and actual practice. Only 10.6 per cent of reported falls had been documented in accordance with the nursing homes’ internal requirements. Some improvements may already have been introduced as a consequence of the Patient Safety Programme, but this nevertheless suggests that there is a need for training, for a revision of requirements and procedures, and for feedback on the level of compliance in addition to a cohesive implementation process.

    This study is based on a master’s thesis on evidence-based practice within the health and social sciences at Bergen University College, Centre for Evidence-based Practice. The author wishes to thank Monica W. Nortvedt, Birgitte Espehaug and Katrine Aasekjær, the thesis supervisors, for their assistance with project implementation. The author also wishes to thank the software developer and IT administrator for the nursing homes, Magne Rekdal of Emetra AS, for providing training in the use of the software and for his assistance with data retrieval.

    References

    1.       Helse- og omsorgsdepartementet. Samhandlingsreformen. Helse- og omsorgsdepartementet, Oslo. 2008.

    2.       Helsedirektoratet. Forebygging av fall i helseinstitusjoner 2015. Available at: http://www.pasientsikkerhetsprogrammet.no/no/I+trygge+hender/Innsatsomr%C3%A5der/forebygging-av-fall-i-helseinstitusjoner;jsessionid=72C5D43A140951BDD3263E6C10BCE32A. (downloaded 21.12.2015.)

    3.       Sosial- og helsedirektoratet. ... OG BEDRE SKAL DET BLI!: nasjonal strategi for kvalitetsforbedring i Sosial- og helsetjenesten (2005–2015). Sosial- og helsedirektoratet, Oslo. 2005.

    4.       Saranto K, Kinnunen UM. Evaluating nursing documentation – research designs and methods: systematic review. J Adv Nurs. 2009;65(3):464–76.

    5.       Øygard SH, Nortvedt MW, Espehaug B, Aasekjær K. Samsvar mellom praksis og retningslinje for førebygging av fall og vurdering av medikamentordinasjon på sjukeheim. Sykepleien Forskning. 2013;8(3):242–8.

    6.       Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and non-fatal falls among older adults. Inj Prev. 2006;12(5):290–5.

    7.       Sterke CS, Verhagen AP, van Beeck EF, van der Cammen TJ. The influence of drug use on fall incidents among nursing home residents: a systematic review. Int Psychogeriatr. 2008;20(5):890–910.

    8.       Boyé ND, Van Lieshout EM, Van Beeck EF, Hartholt KA, Van der Cammen TJ, Patka P. The impact of falls in the elderly. Trauma. 2013;15(1):29–35.

    9.       Helsedirektoratet. Fallforebygging i kommunen. Kunnskap og anbefalinger. Helsedirektoratet, Oslo. 2013. Available at: https://helsedirektoratet.no/Lists/Publikasjoner/Attachments/98/Fallforebygging-i-kommunen-kunnskap-og-anbefalinger-IS-2114.pdf. (downloaded 25.06.2017).

    10.     Cameron ID, Gillespie LD, Robertson MC, Murray GR, Hill KD, Cumming RG et al. Interventions for preventing falls in older people in care facilities and hospitals. The Cochrane Library. 2012. Available at: http://www.cochrane.org/CD005465/MUSKINJ_interventions-for-preventing-falls-in-older-people-in-care-facilities-and-hospitals. (downloaded 26.06.2017).

    11.     Kenny RA. Mobility and falls. The Cambridge handbook of age and ageing. Cambridge University Press, Cambridge. 2005. (s. 131–40).

    12.     Woolcott JC, Richardson KJ, Wiens MO, Patel B, Marin J, Khan KM et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Archives of Internal Medicine. 2009;169(21):1952–60.

    13.     Bergland A. Fall risk factors in community-dwelling elderly people. Norsk epidemiologi. 2012;22(2):151–64.

    14.     Phillips VL, Roberts DY, Hunsaker AE. Certified nursing aides’ and care assistants’ views on falls: Insight for creation and implementation of fall prevention programs. Journal of the American Medical Directors Association. 2008;9(3):168–72.

    15.     Wagner LM, Capezuti E, Taylor JA, Sattin RW, Ouslander JG. Impact of a falls menu-driven incident-reporting system on documentation and quality improvement in nursing homes. The Gerontologist. 2005;45(6):835–42.

    16.     Fixsen D, Scott V, Blase K, Naoom S, Wagar L. When evidence is not enough: The challenge of implementing fall prevention strategies. Journal of Safety Research. 2011;42(6):419–22.

    17.     Etheridge F, Couturier Y, Denis J-L, Tremblay L, Tannenbaum C. Explaining the success or failure of quality improvement initiatives in long-term care organizations from a dynamic perspective. Journal of Applied Gerontology. 2014;33(6):672–89.

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    20.     Szczerbinska K, Zak M, Ziomkiewicz A. Role of method of implementing multi-factorial falls prevention in nursing homes for elderly persons. The EUNESE Project. Aging Clinical and Experimental Research. 2010;22(3):261–9.

    21.     Neyens JC, van Haastregt JC, Dijcks BP, Martens M, van den Heuvel WJ, de Witte LP et al. Effectiveness and implementation aspects of interventions for preventing falls in elderly people in long-term care facilities: a systematic review of RCTs. Journal of the American Medical Directors Association. 2011;12(6):410–25.

    22.     Rask K, Parmelee PA, Taylor JA, Green D, Brown H, Hawley J et al. Implementation and evaluation of a nursing home fall management program. Journal of the American Geriatrics Society. 2007;55(3):342–9.

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    25.     Paans W, Sermeus W, Nieweg RM, van der Schans CP. Prevalence of accurate nursing documentation in patient records. J Adv Nurs. 2010;66(11):2481–9.

    26.     Burgess R. New principles of best practice in clinical audit. 2. edition. Radcliffe Publishing, Oxford. 2011.

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    29.     Flottorp S, Jamtvedt G, Gibis B, McKee M. Using audit and feedback to health professionals to improve the quality and safety of health care. World Health Organization, København. 2010. Available at: http://www.euro.who.int/__data/assets/pdf_file/0003/124419/e94296.pdf?ua=1. (downloaded 20.12.2015.)

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    Deficient documentation of falls may stop the implementation of necessary preventive interventions. The nursing homes in the study are nevertheless failing to comply with their own documentation requirements.

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    Sammendrag

    Background: Fall prevention in nursing homes is one of the main target areas set out in the Norwegian Patient Safety Programme, and the documentation of fall hazards is a requirement.

    Objective: The objective of this study was to investigate whether the nursing homes’ documentation practices with respect to fall incidents comply with their internal documentation requirements and to identify any factors associated with compliance.

    Method: This quality improvement project involves a retrospective descriptive study which reviewed the fall documentation practices at three different nursing homes and examined whether these practices were compliant with the nursing homes’ internal documentation requirements.

    Results: The total sample included 652 people. Of these, 208 (32 per cent) had experienced a fall. A total of 556 fall incidents were reported for these people. Falls involving injuries (pain, cuts, fractures) accounted for 26 per cent of the reported incidents. Only 10.6 per cent of the falls were reported in accordance with the nursing homes’ internal requirements. There was significant variation between nursing homes with respect to their documentation practices, but fractures were generally associated with correct completion of an injury report form.

    Conclusion: The results show that nursing homes fail to comply with their own documentation requirements in connection with falls in general, but that falls involving fractures were associated with correct documentation practices. 

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  • Inadequate medication reconciliation in hospitals

    Treatment by drugs involves multiple professional groups and service levels, and this makes it particularly challenging to gain an overview of a patient’s medication regime. There is extensive documentation showing that an incomplete overview of the medications a patient is taking during transition between levels of care presents a potential risk to patient safety (1–7).

    The Norwegian Patient Safety Programme

    In recent years many countries and organisations have developed their own guidelines on medication reconciliation as a means of enhancing patient safety (8–11). The Norwegian Patient Safety Programme has identified reconciliation of medication lists as one of its target areas. In medication reconciliation, health professionals work together with the patient to draw up a precise, complete list of all the medications that the patient is actually taking (12).

    The programme describes which tasks must be carried out and what the measurable indicators are, but it does not provide guidance on how medication reconciliation should be performed, how the process should be organised or what knowledge the health professionals should have to carry out these tasks. The healthcare institution itself must decide how to address these issues and how to implement solutions through, for example, procedures, leadership, and training of employees. Medication reconciliation in hospitals has proven to be both complicated and challenging to implement (13).

    Research on medication reconciliation

    In 2010, a group of US experts prepared a list of 10 areas that required attention in order to succeed with medication reconciliation (13). The Norwegian Knowledge Centre for the Health Services has published a systematic overview of medication reconciliation. The report concludes that medication reconciliation likely reduces the number of unintended discrepancies. At the same time, the report draws no conclusion about how reconciliation can be carried out in an effective manner (14).

    In most of the studies that investigate the effect of medication reconciliation, clinical pharmacists have played a key role in the process (15). Up to now this group of health professionals has had a very limited presence in Norwegian hospitals, and it is therefore necessary to look at what contribution doctors and nurses can make. In focus group interviews with doctors, nurses and pharmacists, Vogelmeier et al. found that the term “medication reconciliation” was understood differently depending on one’s profession. It was also unclear who was responsible for the process (16).

    Experts have emphasised that clarifying both the term and roles is important for successful medication reconciliation (13). Other barriers to implementing medication reconciliation are unreliable information sources, the fact that health professionals give the task low priority, and poor communication and cooperation between professional groups and between hospitals and the primary healthcare services. 

    Complex process

    A process can be described as a complex organisational phenomenon, and process orientation indicates that attention is directed towards how employees from various units work together on shared tasks (20). Medication reconciliation is a complex process involving multiple professional groups and hospital wards. As a general rule, the process begins by asking the patient what medications he or she is taking (medication history). In addition, there are other relevant sources of information about medications, depending on the level of care the patient is receiving.

    Medication reconciliation is a complex process involving multiple professional groups and hospital wards.

    Ålesund Hospital has conducted a number of projects over a period of years to define the process of medication reconciliation and establish procedures for it. In 2011, a descriptive study documented the quality of medication information after a procedure for obtaining patients’ medication histories and training doctors and nurses on the emergency ward was introduced (3). The study showed the medication lists in the patients’ charts and the actual medications the patients were taking did not correspond in two-thirds of the cases. This discrepancy was clinically relevant for one of four patients. These results differed from expectations held when the procedure was introduced.

    Involving staff on the medical ward

    On the basis of these results, a new measure was introduced in 2012 which involved medical ward staff in the medication reconciliation process. A key element in the process was a patient transfer form that would serve as a documentation and communication tool for the various personnel who took part in medication reconciliation. A survey from the medical ward in the period up to seven months after the procedure was introduced showed that medication reconciliation had been verifiably conducted for only eight per cent of the patients (21).

    In the surgical clinic it was decided to introduce the procedure on three different wards simultaneously, and a prospective controlled study was conducted. The share of patients whose medication lists in their charts did not correspond with their actual medication use was reduced from 53 to 25 per cent following the “implementation project” (22). To summarise, the study showed that it is possible to reduce the number of errors on the medication lists of patients when they are admitted to hospital if the staff works systematically to obtain and document information about their medications. This was achieved by giving nurses on the wards training in and responsibility for medication reconciliation.

    Purpose of the study

    The purpose of this study was to gain insight into doctors’ and nurses’ experiences with medication reconciliation upon admission to hospital. As far as we know, no such study has been conducted at Norwegian hospitals before. Since medication reconciliation is dependent on cross-professional cooperation and organisation, it is not possible to simply transfer results from international studies to Norwegian conditions. At the time the study was conducted, the hospital procedures distinguished between the terms “medication history interview on the emergency ward” and “medication reconciliation on medical wards”. Thus the emergency ward staff described their part of the job as obtaining patients’ medication history. Today these processes are compiled into a single procedure. We have therefore chosen to refer to the entire process as medication reconciliation. The research question formulated was:

    “What are the experiences of doctors and nurses related to medication reconciliation upon admission to hospital?”

    Knowledge about this will be valuable in the effort to develop effective routines and learning concepts for medication reconciliation, and may have a positive impact on patient safety in hospitals.

    Method

    Design

    The study has a qualitative design (23). We conducted interviews with doctors and nurses because we wanted to obtain data about their experiences with medication reconciliation. We chose to conduct one-on-one interviews because we wanted to understand the experiences of the individual (24).     

    Sample

    We selected a strategic sample of doctors and nurses at Ålesund Hospital (23). The informants were recruited by the ward manager. We chose to include both professional groups since both doctors and nurses have duties related to the medication reconciliation process. The sample was comprised of nurses and various groups of doctors, such as house officers, speciality trainees and senior consultants, because they have different roles in the process. The sample included staff from the emergency ward as well as medical wards because we wanted to see how the various wards cooperated on the process.

    Data collection and analysis

    One-on-one interviews were conducted with five doctors and four nurses (24). The interviews took place during a two-week period in January 2013 in Ålesund. The lead author (TK) conducted the interviews, which lasted 30–60 minutes. On the basis of previous research (3, 22) we developed a semi-structured interview guide with questions about the medication reconciliation process. We used a digital sound recorder, and the interviews were held in a meeting room in the hospital pharmacy. We concluded the interviews when we felt we had obtained as much data as possible (25), and the interviews were transcribed to standard Nynorsk with no dialectal variations.

    We performed an analysis of the data using systematic text condensing (24). The method has four analytical steps. First the transcriptions were read so we could gain an overall impression of the material and identify preliminary themes. Then the data that shed light on the research question were organised into meaning units and sorted into code groups (decontextualising). In the third step of the analysis, the knowledge obtained from coding the meaning units were extracted into three condensates. Finally, we compiled the essence of each of the condensed groups into one analytical text (recontextualisation) that describes the kind of experiences the health professionals had with the medication reconciliation process (24).

    Both the lead author and the last author analysed the data and discussed the material until they arrived at themes and codes in the various steps of the analysis. The last author was knowledgeable about the process from work with procedures and training of health personnel, while the lead author became familiar with the process during the study.

    Ethics

    Informed consent was obtained prior to the start of the interviews. The project was pre-approved by the Norwegian Centre for Research Data. The data was anonymised, and sound recordings and name lists were destroyed when the study was concluded.

    Results

    The findings from the interviews with five doctors and four nurses are presented under three main themes: 1) different and unreliable sources of medication information, 2) the need to clarify responsibilities, and 3) inadequate communication and standardisation.

    We have chosen to present the results from the various professional groups and units together because medication reconciliation is a task that involves a cooperative effort.

    Different and unreliable sources of medication information

    The doctors and nurses reported that they use a number of different sources when compiling information on the patient’s medication use upon admission to hospital. These sources included the general practitioners’ list, hospital admission papers from the general practitioner or on-call doctor, previous patient records, case summaries, lists from home-based care services or nursing homes, multidose lists and the patient’s own list. The informants said they had more faith in the lists from home-based care services and nursing homes than from general practitioners’ lists and hospital admission papers. One of the doctors stated, “The lists from nursing homes and home-based care services have updated information on what medications the patient is actually taking, so this is often regarded as the gold standard.”

    The lists from nursing homes and home-based care services have updated information on what medications the patient is actually taking, so this is often regarded as the gold standard.
    Doctor

    Another doctor emphasised that it is important to assess which sources can be trusted in each case. He was concerned about the fact that the general practitioner should in theory have a complete list of all the medications a patient is taking, but his experience suggested otherwise. One of the hospital house officers had a patient who was taking completely different medications than those listed on the admission papers: “On my last shift a patient came directly from her general practitioner. It was my understanding that she had been to many medical check-ups, but the patient had her own list of medications on a piece of paper that did not correspond with her doctor’s list.” The experienced doctors said they had high expectations for ICT solutions, such as the Kjernejournal(Summary Care Record), and thought that this would solve the problem of different lists.

    The informants emphasised that the patient is an important source of information, but in their experience, the patients do not always have a complete overview of the medications they are taking. One doctor stated, “When the average age is high and numerous drugs are involved, as is often the case, the patients have limited information about their own medications.” A recurring theme in the interviews was that there is not a common standard for how health professionals speak with patients about their use of medications. It appeared to be random and up to each individual as to how to do this. The informants emphasised that everyone should do a better job of specifically asking the patients if they actually take the medications on the list and whether they take other drugs – such as over-the-counter medicines.

    Need to clarify responsibilities

    Both the doctors and nurses stated that the doctors are responsible for all treatment by drugs in the hospital, but that it is a joint responsibility to ensure that the information about the patient’s medication use is correct. They emphasised that medication reconciliation is important, but many of the informants could not say who had responsibility for what in the medication reconciliation process – this was especially true for the medical ward. One of the doctors said that he did not think that one particular professional group had responsibility for medication reconciliation. One of the nurses put it this way: “I would say that we are a team. While some things are our responsibility, other things are the doctor’s responsibility”.

    The allocation of responsibilities on the emergency ward appeared to be clear. The nurses stated that they obtained the patient transfer form and retrieved the list of medications, while the house officers said that they spoke with the patient and prepared the patient’s chart. The house officers explained that the patient interview was a prioritised task on the emergency ward, but that the patients were often stressed and that the health professionals felt pressured for time. This made it difficult to gain a complete overview of the medications a patient was taking. In their experience, the health professionals often needed more time to complete this task thoroughly than they had available on the emergency ward.

    The doctors on the emergency ward thought this was handled on the ward in calmer surroundings, but they said they were unsure whether this was actually done. One of the house officers said there is a need to quality assure the ward patients’ medication information and to clarify whose responsibility it is to do so: “We must look at ways to ensure that the medication information is followed up on the medical wards. I think this is important. It may be defined whose task it is to check the information when a patient arrives on the ward, but it must be clearer whose responsibility it is”.

    The interviews revealed that it was unclear who is supposed to do what on the medical ward.

    The interviews revealed that it was unclear who is supposed to do what on the medical ward. It did not appear that tasks such as interviewing the patients and obtaining lists were allocated to specific professional groups. The nurses said that they received patients when they came from the emergency ward, and explained that they often used this occasion to talk with the patients about their medications. They also reported that they were involved in contacting general practitioner offices and home-care nurses to obtain medication lists. Although the nurses said that they were concerned about medications, they also stated that medication reconciliation was dependent on time and resources. The task was not prioritised in busy situations. Several of the informants, both doctors and nurses, noted that clinical pharmacists could play a supportive role in medication reconciliation, but it was also mentioned that this group should not be given the responsibility for the process because pharmacists are not always present on the medical ward.

    Inadequate communication and standardisation

    The informants knew that the purpose of the patient transfer form was to communicate to hospital personnel about a patient’s medications. The emergency ward staff said that they made notes about missing lists or dubious information on the form. At the same time, they said poor communication pervaded the medication reconciliation process and that hospital staff thought but did not know for sure what others did. It was emphasised that the doctors used the form to convey their uncertainty if the situation on the emergency ward did not allow them to totally clarify a patient’s medication situation, but it also came to light that they did not know for certain whether their notes were followed up on the ward.

    One specialty trainee put it this way: “I remember that it felt safe and secure to have the transfer form on the emergency ward. If I was unsure of something, there was actually someone who would check on it. Well, someone was supposed to check, in any case.” The interviews with medical ward personnel revealed that the notes written on the transfer form were not always dealt with on the medical ward. The nurses said that if the transfer form was placed on top in the patient’s folder and it was not too busy, the nurse might read the notes while admitting the patient to the ward. If not, the next checkpoint was the pre-visit on the following day during which doctors and nurses allocate tasks between them, but neither the doctors nor the nurses said that they paid much attention to the transfer form.

    One of the doctors thought that the notes were not always heeded on the medical wards. “I think there is often a glitch. If the notes say that someone should check on something, it may not get done if there are no routines for looking for the patient transfer form.” The interviews revealed that information about a patient’s medication use was communicated by means other than the form – for example, through yellow post-it notes or the admission records. It was stated that during the pre-visit, doctors make decisions based on the information on the patient’s chart, and one of the doctors thought that the information should be linked to this: “I think the best method is to put it in the chart if something needs to be checked, because you cannot complete a pre-visit without having looked at it.”

    Discussion

    The findings in this study show that both doctors and nurses felt that the process of medication reconciliation was inadequate. They stated that they used many different sources of information about the medications a patient was taking upon admission to hospital and that they were often unsure whether the information reflected the patient’s actual medication use. They described a process of reconciling medication information that entailed an unclear allocation of responsibilities and inadequate communication and standardisation of tasks. This corresponds with relevant literature on this topic (13, 16-19).

    Both national and international research shows that there is good reason to be critical as to which sources should be consulted to gain an overview of the medications a patient is taking (1–7, 26). Despite the uncertainty among the health professionals and their knowledge of gaps in the system, we did not find that they were critical in a systematic way. Neither the house officers nor the nurses on the medical wards gave any indication that there was a common standard for how to speak with patients about their use of medications. The summary from the Norwegian Knowledge Centre for the Health Services shows that medication reconciliation likely reduces unwanted discrepancies when the process is carried out in a standardised way (14).

    Can the Kjernejournal(Summary Care Record) help?

    The informants in this study expressed a lack of confidence in the information sources, and several of the doctors had great hope for the Kjernejournal(27) which has now been introduced in Norway. The Kjernejournalhas become an important source of information about the medications a patient is taking upon admission to hospital. The medication information found in a patient’s Kjernejournalis taken from Reseptformidlaren, the central database for electronic prescriptions in Norway. Thus the quality of the information is dependent on the doctors’ updating the prescription information in the central database. Consequently, the health personnel who reconcile the medication lists must be critical about the information found in the Kjernejournal. Not least, it will still be crucial that the health professionals speak with patients to find out which medications they are actually taking, how they take them, and whether they take over-the-counter medicines or dietary supplements as well. Our results suggested that there was room for improvement in 2013. In interviews with doctors and pharmacists, Boockvar et al. found that when electronic sources were used, health professionals spoke less with the patients because they put too much trust in IT tools (18).

    Situation on the emergency ward

    The study showed that the emergency ward staff were well organised and had a clear allocation of tasks related to gathering medication information. It could be asked, however, whether the situation and competency in the emergency ward are suited for this task. The nurses said that they helped to obtain medication lists from general practitioners, home-care nurses and nursing homes, but of course they are dependent on access to sources, e.g. open hours. The situation on the emergency ward can be chaotic at times, and assessments must often be done quickly. In addition, the house officers, who see the patient first, are the least experienced doctors in the hospital.

    Information about medications was communicated in multiple ways – for example, through patient charts, patient transfer forms, admission records and yellow post-it notes.

    We found that the doctors on the emergency ward conveyed their uncertainty about a patient’s medication use on the patient transfer form, but neither the doctors nor the nurses on the medical wards said that they paid much attention to the form. This may indicate that at the time of the study a truth about the patient’s prescribed medication was postulated by emergency ward staff upon admission and that this was never systematically queried on the ward. Our results showed that information about medications was communicated in multiple ways – for example, through patient charts, patient transfer forms, admission records and yellow post-it notes. Such a lack of standardisation makes the process of medication reconciliation even more complex. We believe it will be critical to develop uniform solutions for communication about medications and internal prescribing when developing ICT solutions for hospitals in the future.

    Prioritising tasks

    Qualitative research from other countries has shown that a lack of awareness and knowledge among health professionals about what medication reconciliation entails may be a barrier to implementing the process (17). In our study both doctors and nurses agreed that medication reconciliation is important, and there was no question as to whether or not it should be done. We did find, however, that medication reconciliation was given lower priority during busy periods. Prioritising other tasks that are viewed as more important is another barrier to carrying out the process (18). Medication reconciliation is required under the regulations, and the Møre og Romsdal Hospital Trust has described the procedures in its quality assurance system as well.

    Section 5 of the Norwegian Regulations on Medication Management states: “An updated, reconciled list of medications in use shall, with the patient’s knowledge, always accompany the patient during transitions in levels of care” (28). The general level 1 procedures for medication reconciliation at the Møre og Romsdal Hospital Trust applies to all health professionals involved in the process. At the time of the study, the tasks of the ward staff had been defined, but not who should do what in the process. Our findings confirmed that the tasks related to medication reconciliation on the medical ward were not assigned to particular professional groups, nor were they standardised in any way. At the same time, the findings showed that the nurses were prepared to help with obtaining written sources as well as interviewing patients.

    Clarifying roles and responsibilities

    In a study conducted on the surgical ward of the same hospital, the accuracy of the medication lists improved when the nurses on the ward gathered the medication information (22). Prior to the project, the nurses received training from a pharmacist who also was present on the ward throughout the project period. They were not given additional nursing resources to carry out the task (22). When involved in a process, a person will take action on a case based on his or her level of competency, responsibility and authority (20). As such, we believe that systematising the process of medication reconciliation largely entails defining roles, assigning responsibility and ensuring that the health professionals are well trained on medication reconciliation. However, this is probably not sufficient to achieve long-term improvement.

    In addition to clarifying roles and responsibilities, Greenwald et al. identify nine other areas that require attention in order to successfully carry out medication reconciliation (13). Medication reconciliation may increase the need for greater changes in traditional roles (29) – e.g. giving nurses responsibility in medication reconciliation. This should be given consideration, and we think it is crucial to develop good learning concepts. We believe that emphasis should be placed on critically assessing the sources of medication information, in addition to training health professionals how to communicate with patients in order to gain an overview of the medications they are actually taking.

    A patient admitted to hospital unexpectedly comes in contact with many wards and many employees, and good information flow and communication about medication use is critical. Our study shows that this can be improved. Medication reconciliation is dependent on good communication between the employee who gathers the medication information and the doctor who assesses and decides what medications the patient will take. Medication reconciliation upon admission to hospital has not been completed until the medication information obtained has been assessed by the doctor and transferred into the patient’s chart or records (12). It is therefore crucial that the messages between the nurses and doctors, and between the emergency ward and the medical wards, are sent and understood. The patient transfer form was intended to serve as a “baton” for transferring such messages, but our results show that this system was not working to its full potential.

    Strengths and weaknesses

    The study was based on the experiences of both doctors and nurses from the emergency and medical wards with medication reconciliation. We chose one-on-one interviews as our method because we wanted to understand the experiences of the individual informants. This method gives only indirect information about what actually occurs in the process (24). If we had used observation or focus group interviews as our method, we could possibly have obtained more data on the actual cooperation that takes place in the medication reconciliation process. This would have been interesting as well.

    The informants were interviewed in a quiet meeting room in the hospital pharmacy. We believe this was a strength because the informants were away from their daily activities. The author group represented a cross-section of professions, and none of them has personally participated in the medication reconciliation process. This was a strength when formulating the research question, performing the analysis and interpreting the data. Although the study was conducted at Ålesund Hospital, it is likely that the findings have transfer value to other hospitals because the medication process is largely organised in the same way at the various hospitals. It is therefore reasonable to believe that other hospitals will also benefit from the knowledge produced in this study.

    Implications for practice

    The medical ward at Ålesund Hospital has focused attention on the proper use of medications for many years, and it has had clinical pharmacists working on the ward since 2010. The results from this study, through improvement projects in the clinic, have contributed to further development of the routines for medication reconciliation. This has been significant for practice and is in keeping with the guidelines from the Norwegian Knowledge Centre for the Health Services (14). In addition, this area has received more attention from the hospital management through the Norwegian Patient Safety Programme (12). When they began to demand results, the percentage of patients whose medication lists had been reconciled increased (30).

    According to Iden’s work model, which has three main elements (management, resources, and work and information flow), it is just as important to specify who (which roles) are included in the process and the relationship between them as it is to define the activities of the process (20). Incorporating new routines is a complex task that is dependent on many factors relating to the organisation, the employees and the managers, in addition to the process itself (31). There is ongoing work with motivation and training of health professionals. The training includes production of a video on the topic (32) and an e-training course. In the future it will be interesting to look more closely at the management aspect of Iden’s work model, which points out that in order to administer and further develop a process, someone must be responsible for the process as a whole (20).

    Conclusion

    The doctors and nurses agreed that medication reconciliation is important for patients. However, they experienced numerous challenges. Many different and unreliable sources of medication information combined with a lack of routines made the process inadequate. The results from this study have been important in the effort to establish good routines for medication reconciliation. Important aspects that came to light in the study included the need to standardise the tasks, improve communication and assign responsibility. More research is needed to investigate whether such measures will help to increase patient safety in hospitals.

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    9.       Institute for Healthcare Improvement (IHI). Medication Reconciliation to Prevent Adverse Drug Events. Available at: http://www.ihi.org/topics/ADEsMedicationReconciliation/Pages/default.aspx(downloaded 30.06.2016).

    10.     National Institute for Health and Clinical Excellence (NICE). Technical patient safety solutions for medicines reconciliation on admission of adults to hospital 2007. Available at: https://www.nice.org.uk/sharedlearning/medicines-reconciliation(downloaded 30.06.2016).

    11.     The Joint Commission. Sentinel Event Alert, Issue 35: Using medication reconciliation to prevent errors 2006. Available at: http://www.jointcommission.org/sentinel_event_alert_issue_35_using_medication_reconciliation_to_prevent_errors/(downloaded 30.06.2016).

    12.     Pasientsikkerhetsprogrammet. Samstemming av legemiddellister 2016. Available at: http://www.pasientsikkerhetsprogrammet.no/no/I+trygge+hender/Innsatsomr%C3%A5der/Samstemming+av+legemiddellister.16.cms(downloaded 30.06.2016).

    13.     Greenwald JL, Halasyamani L, Greene J, LaCivita C, Stucky E, Benjamin B et al. Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps. J Hosp Med 2010;5(8):477–85.

    14.     Holte H. Oppsummering av systematiske oversikter om effekt av samstemming av legemiddellister. Rapport fra Kunnskapssenteret nr. 7/2015, Systematisk oversikt. 2015.

    15.     Lo L, Kwan J, Fernandes OA, Shojania KG. Medication Reconciliation Supported by Clinical Pharmacists. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices: Agency for Healthcare Research and Quality; 2013.

    16.     Vogelsmeier A, Pepper GA, Oderda L, Weir C. Medication reconciliation: A qualitative analysis of clinicians' perceptions. Res Social Adm Pharm 2013;9(4):419–30.

    17.     van Sluisveld N, Zegers M, Natsch S, Wollersheim H. Medication reconciliation at hospital admission and discharge: insufficient knowledge, unclear task reallocation and lack of collaboration as major barriers to medication safety. BMC Health Serv Res 2012;12.

    18.     Boockvar KS, Santos SL, Kushniruk A, Johnson C, Nebeker JR. Medication reconciliation: barriers and facilitators from the perspectives of resident physicians and pharmacists. J Hosp Med 2011;6(6):329–37.

    19.     Lee KP, Hartridge C, Corbett K, Vittinghoff E, Auerbach AD. «Whose job is it, really?» Physicians’, nurses’, and pharmacists’ perspectives on completing inpatient medication reconciliation. J Hosp Med 2015;10(3):184–6.

    20.     Iden J. Prosessledelse: Fagbokforlaget; 2013.

    21.     Kleppe T. Legemiddelanamnese og legemiddelsamstemming ved Ålesund sjukehus. 2013.

    22.     Holler JG, Helgesen KS, Aarset M, Major A-L. Legemiddelsamstemming – et tiltak som virker. Sykepleien Forskning. 2015;1. Available at: https://sykepleien.no/forskning/2015/02/et-tiltak-som-virker(downloaded 15.06.2017).

    23.     Pollit D, Beck C. Nursing Research: Generating and Assessing Evidence for Nursing Practice: Lippincott, Williams, & Wilkins; 2008.

    24.     Malterud K. Kvalitative metoder i medisinsk forskning. En innføring. 3. utgave, Oslo: Universitetsforlaget; 2013.

    25.     Malterud K, Siersma VD, Guassora AD. Sample Size in Qualitative Interview Studies: Guided by Information Power. Qual Health Res. 2016, 26 (13), 1753–1760.

    26.     Wekre LJ, Spigset O, Sletvold O, Sund JK, Grimsmo A. Multidose drug dispensing and discrepancies between medication records. Qual Saf Health Care 2010;19(5):e42.

    27. Direktoratet for e-helse. Kjernejournal. Available at: https://helsenorge.no/kjernejournal(downloaded 28.12.2016).

    28.     Lovdata. Forskrift om endring i forskrift om legemiddelhåndtering for virksomheter og helsepersonell som yter helsehjelp. 23. november 2014 nr. 1455. Tilgjengeleg frå: https://lovdata.no/dokument/LTI/forskrift/2014-11-23-1455(lasta ned 30.06.2016).

    29.     Sanchez SH, Sethi SS, Santos SL, Boockvar K. Implementing medication reconciliation from the planner's perspective: a qualitative study. BMC Health Serv Res 2014;14:290.

    30.     Nilsen L. Gikk fra 7–80 % samstemte legemiddellister. Dagens Medisin. 24.02.2015.

    31.     Konsmo T. Hvordan skape vedvarende forbedringer? Helsebiblioteket 2015. Tilgjengeleg frå: http://www.helsebiblioteket.no/kvalitetsforbedring/slik-kommer-du-i-gang/verkt%C3%B8y/verkt%C3%B8y-for-vedvarende-forbedringer-sustainability(lasta ned 06.01.2016).

    32.     Hegle H. Legemiddelsamstemming ved Ålesund sjukehus. Tilgjengeleg frå: https://vimeo.com/153702879(lasta ned 28.12.2016).

    Although there are procedures for medication reconciliation, the process is challenging to implement and the allocation of responsibility is unclear.

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    Background: Inadequate information about what medications a patient is taking may jeopardise patient safety upon admission to hospital. Medication reconciliation is a method that can mitigate this problem. Ålesund Hospital has conducted a number of projects over a period of years to describe the process of medication reconciliation, but the process has proven to be challenging to implement.

    Purpose: The purpose of this study is to gain insight into doctors’ and nurses’ experiences with medication reconciliation. Knowledge about this will be valuable in the effort to develop good routines for medication reconciliation, and thus may have a positive impact on patient safety in hospitals.

    Method: Semi-structured interviews were conducted with five doctors and four nurses who had experience with reconciling medication information. The sample included personnel from both the emergency ward and medical wards.

    Results: In the informants’ experience, the process of medication reconciliation was inadequate. They stated that they used many different sources of information about the medications a patient was taking and that they were often unsure whether the information reflected the patient’s actual medication use. They described a process of reconciling medication information that entailed an unclear allocation of responsibilities and a lack of communication and standardisation of tasks.

    Conclusion: Doctors and nurses agreed that medication reconciliation is important for patients. However, they experienced numerous challenges related to unreliable information sources and inadequate routines. They said there is a need to clarify responsibilities.

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  • A daughter’s experience when her mother is struck by dementia

    The purpose of this essay is to examine family members’ experiences when a loved one is affected by dementia. The starting point is a daughter’s experience with her mother’s dementia journey. The theme is explored by analysing Marie Peterson’s documentary novel Du tror du vet alt (You think you know it all) (1). The essay is a reflection of a daughter’s experiences, and is based on the question: ‘How does it feel to be a daughter when your mother is affected by dementia?’

    A desire to understand

    Marie experiences a series of events with her mother that trigger a desire to understand. One such event is when her mother wants to go to the bank and Marie accompanies her. The mother’s problems with language mean that it is not always easy to understand what she is saying.

    ‘I need to have for my hands…’

    ‘Do you mean gloves? … This one goes on your right hand, and this one on your left.’ 

    This simplistic explanation irritates the mother: ‘You think you know it all’, she hisses (1, p. 7).

    The book opens with this exchange. We see frustration and underlying irritation, and a clash of strong wills and fiery tempers. Marie’s mother is a retired school librarian. She has always been and still is a strong and independent woman. She has had a tough life, but has always thought it important to manage on her own. She is now becoming increasingly forgetful.

    As a child of divorced parents, Marie has not grown up with her mother. Her mother left home when Marie was two and her sister was just a baby: ‘She’s my mother, and I’m her daughter, but we've never been part of each other’s everyday life’ (1, p. 124). Now the daughter is putting considerable effort into understanding and helping her ailing mother, whose need for help is becoming greater as time passes. The mother herself insists on managing on her own, and objects to the intervention.

    When life is turned on its head

    Marie’s life is turned upside down when her mother becomes sick. Her sister calls: ‘Mum can’t tell the time’. The information seems completely surreal. ‘She can so’, replies Marie (1, p. 19). It transpires that her mother’s cognitive grip on life, including telling the time, is slipping away. Her memory is failing and her behaviour is changing. The changes make Marie feel uncertain and confused.

    It hurts Marie to see her mother searching for words. She never gets to the point, which makes her feel embarrassed. Marie tries to identify a system in the linguistic deterioration. Understanding abstract concepts is becoming difficult for her mother. ‘It’s logical’, Marie thinks, ‘but why are the verbs disappearing before the nouns?’ The language is noticeably stripped down.

    In an effort to understand her mother, Marie goes through old letters she has received from her. She compares letters from before her mother became ill with letters she has received since. Marie looks at the handwriting, looking for the ‘tone’ in the letters. The early ones are impersonal. When she was 12, she received a matter-of-fact letter, as if her mother was writing to a friend her own age. In the last letters, her mother shows affection: ‘Big hug, hope you come soon, kiss, kiss, kiss’ (1, p. 17). Now that Marie is an adult, her mother calls her ‘her little nestling’ (1, p. 97). Mother and daughter have always been out of step.

    Trying to understand her mother by understanding herself

    In the beginning, the visits to the mother are dictated by specific needs. Marie listens to her in an attempt to understand a mysterious and brutal disease. She wants to try to preserve her mother’s memories. Marie gradually notices that she herself changes tack. It becomes more and more about her own life rather than her mother’s life. It is striking that the first part of the book documents Marie’s struggle to understand her mother, while the last part is about Marie trying to understand herself. Meanwhile, her mother is falling apart... (1, p. 51).

    Her mother’s illness triggers a need in Marie to understand what her mother is going through and how the disease is changing her behaviour and language.

    Her mother’s illness triggers a need in Marie to understand what her mother is going through and how the disease is changing her behaviour and language. The visits to her mother also awaken a longing to understand who her mother was, and by extension, a desire to understand her own childhood. The conversations, the time spent looking through photo albums and reading old letters become discoveries and insights that give Marie a new understanding of her childhood years, and that fill in some of the blanks about the past and her mother’s role in it.

    Alzheimer’s disease does not only put the spotlight on the mother and who she was; Marie is also confronted with herself and her previous and current relationship with her mother. In the end, Marie comes to terms with the situation – that she was not exactly successful in reconciling with her mother, ‘but the most important thing was that we tried’ (1, p. 157). Marie’s story shows the universality of facing a frightening disease where death is an inevitable outcome. The need to understand what is happening and to take stock of one’s own life when parents are close to death is something that all patients’ families can experience.

    Different levels of understanding

    The deadly Alzheimer’s disease throws Marie into turmoil. ‘Leads to death, leads to death’, Marie repeats, still not fully comprehending: ‘How can you die of it? Do you forget to live?’ (1, p. 21). Losing the ability to use language and to think is alarming, both for the person struck by the disease and for their family.

    The clock-drawing test is simple, but demonstrates severe cognitive failure. The circle that the mother draws is not connected. After much doubt, she places the clock hands at 11 when she wants to show that it is 3 o’clock. The test situation is very embarrassing for the language enthusiast. For Marie, it is shocking. The test becomes a mark of the disease, as well as a symbolic declaration: Now the countdown begins. The mother’s days are numbered. The thoughts become intrusive. Marie makes coffee and thinks: ‘dementia’. When doing the washing up her nagging thought is: ‘Alzheimer’s is fatal ... the doctor said 15 years ...’ (1, p. 21).

    Psychiatrist Lars Sjöstrand (2) writes that people understand at different levels – concrete as well as existentially. Explanations of cellular changes that kill brain cells represent one level, but this does not touch on questions related to death and existence. Sjöstrand calls it ‘the phenomenology of death’. Marie is confronted with her mother’s looming death. Her mother’s existence is coming to an end.

    Existence characterises the conscious person and involves ‘standing up or exceeding oneself’ (2, p. 22). That is exactly what Marie does. For her, the idea of ​her ​mother’s death entails an existential challenge. Marie has a genuine desire to reach out to her mother, but time is now short. Marie tries out the word ‘mum’. Her mother is not ‘mum’, and never has been. When Marie thinks about her mother, she thinks of ‘Siv’. Sometimes she just thinks about her laughter. She thinks of someone who did not care about protecting her when she needed it the most – and who rejected her daughter’s questions by starting to cry.

    Seeking shared experiences

    Marie often visits her mother now that she is sick. Hours are spent looking at old pictures. Shared experiences that neither of them remember clearly. Her mother dancing in front of a mirror, ready to go out. Her hands are always busy, strong and rough. Marie does not remember a single caressing touch. Looking at pictures serves at least two purposes; it is something that mother and daughter can do together, and it evokes memories.

    Time is always an integral part of our experiences. As such, we do not just live in the here and now, but seek to link the past with the present with a view to the future (2). At the same time, looking at the pictures makes Marie realise just what a small part she played in her mother’s reality. Symptomatically, Marie finds a photo from their trip to Telemark, where she is barely visible – only half of her boot can be seen at the edge of the picture, and the rest of her is not in the shot (1, p. 108).

    Her mother’s disease makes it clearer to Marie that life has its limitations, and triggers a need to take stock.

    Her mother’s disease makes it clearer to Marie that life has its limitations, and triggers a need to take stock. The deterioration in her mother’s body and her impending death make it clear that this is a last chance to reach out to her. Or rather – a last chance for Marie to have the experience of her mother wanting to reach out to her eldest daughter. ‘That was a ridiculous wish’, she admits (1, p. 147). Nevertheless, she gives it a go. Photos and old letters serve as aids to Marie’s stock-taking. The outcome is bad for Marie; her mother is the same as she has always been: self-absorbed and self-centred.

    Death sums up life

    In the end, Marie has to force her mother into a nursing home. Her mother is suffering from a lack of care following a long period of living alone in her flat. Heart-wrenching scenes ensue. Both mother and daughter are temperamental. They stand screaming at each other. The mother is steadfast and angry, and Marie is in despair. There is little to suggest here that the mother-daughter relationship is getting any closer. Or is that exactly what is happening? Marie’s mother fumes and screams. Marie gives as good as she gets (1, p. 78).

    Marie’s struggle to understand takes place at several levels; on the concrete level – in terms of the progression of the disease, and her mother’s behaviour and needs. Efforts to understand also take place at the abstract level – in relation to the life that was, which is soon over, and to death. Both for her mother and herself. Death is life’s final destination, and becomes an end point that helps to delimit and define life (2). The conceptualisation of the ​​mother’s imminent passing sums up life in its entirety, not just the mother’s life, but also Marie’s. The need to understand is all-encompassing for Marie.

    Letting go

    There is a pained undertone to Marie’s quest in the book. She desperately wants to reach out to her mother, and has a deep need for her mother to be willing to reciprocate: ‘That’s why I visited her so often. I hoped she would want to get to know me. I hoped she would be, not a mum, because it was too late for that, but someone who was a bit more normal’ (1, p. 147).

    She desperately wants to reach out to her mother, and has a deep need for her mother to be willing to reciprocate.

    Marie then has a revelation. She suddenly sees the barriers that she herself has erected in her relationship with her mother. She surrenders them now. It happens in a single defining moment: ‘... and it took no longer than changing hands on a shopping bag ... That barrier had remained in place for many years, with myself as the strictest border guard’ (1, p. 146). Marie suddenly realises that she has been on the defence. She now sees her mother in a different light: ‘She's so small, so thin, just an old lady really, totally harmless’ (1, p. 152). Marie can now even accept compliments: ‘“I like you a lot,” her mother says. My mother has never said that before’ (1, p. 159).

    Marie’s mother is slowly disappearing. Her movements are becoming stiffer. Her gaze is becoming empty. She cannot follow what is going on. ‘How do you let go’, Marie wonders (1, p. 153). She understands that she needs to loosen her grip and let go, ‘but I don’t know if I can’ (1, p. 153). The grief comes first. Suddenly and directly, and in images: ‘... as if I’m filling up with water. When it reaches the heart, it suddenly transforms into a stone that forces its way into the bloodstream ... and circulates ... and every time it passes the heart the pain returns’ (1, p. 155). An all-consuming grief, felt in every breath: ‘... at its worst when I breathe in. No, when I breathe out’ (1, p. 155).

    The grief seems to help Marie let go. It signifies that the time has come. Marie ‘lets go’ by imagining her mother sitting in a boat, half turned away and looking out at the water. The bow of the boat is in the sand. Marie squats down and holds the railings on the boat with both hands. She does not want to let go, but she has to. ‘Mother looks so lonely! And it’s as though my hands know what to do. They let go of the boat. And as she glides out, I realise that I made it. ... Strictly speaking, our attempt to reconcile was completely unsuccessful, but the most important thing is that we tried’ (1, p. 157).

    Coming to terms with her childhood

    A childhood can be a long ‘sentence’ to serve. Now well into adulthood, Marie still feels a sense of longing for her mum. The mother of her childhood was rarely there for her. Marie feels aggrieved by her mother’s choices and actions. Actions always involve a risk of causing hurt, claims Hannah Arendt (3). The very nature of actions means that they can have detrimental effects for others, often without the person carrying out the action being aware of it (3, p. 236).

    One way to understand Marie is through how she comes to terms with the neglect of her childhood years in adulthood. The photos that she and her mother look at show that she was not part of her mother’s life. The letters signify her mother’s impersonal and scant involvement when Marie was a child. According to an ‘Arendtian’ interpretation, the daughter may have been hurt without the mother knowing or realising that she had caused offence. Readers of the book are left to speculate how it is possible for a mother to let her child down so badly, without ‘realising what she is doing’.

    By their very nature, actions are irrevocable (3, p. 236). Even if her mother had regrets, her past actions could not be undone. Marie has to live with the consequences of her mother’s actions. Must people live the rest of their life with the burden of others’ past mistakes? ‘No’, Arendt says, ‘The possible redemption from the predicament of irreversibility – of being unable to undo what one has done though one did not, and could not, have known what he was doing – is the faculty of forgiving.’ (3, p. 237). What’s done cannot be undone.

    Forgiveness can release a person from the consequences of hurtful actions, and give them a fresh start. It is not the action that is forgiven, but the person. The aggrieved party says ‘you hurt me’ (3, p. 237). The question of forgiveness primarily applies to actions that are not intended to be hurtful, in Arendt’s opinion. Actions with malicious intent are another matter. ‘The reason for the insistence on a duty to forgive (…) does not apply to the extremity of crime and willed evil…’ (3, p. 239).

    The importance of forgiveness

    Forgiveness entails a form of relationship, claims Arendt, indicating that it is an interhuman experience (3, p. 241). Some of the most powerful descriptions in the book are when Marie writes about the new relationship that arises from the defining moment she experiences. Broken relationships are resumed. The ability to forgive has a bearing on mental health (4, 5).

    ‘To reconcile’ means to bring together. This is precisely what Marie writes about. Mother and daughter are brought together again, but not in such a way that there is harmony in the relationship. Marie discovers the barriers she herself has put up, and lets them go. Her mother did not play much part in her daughter’s life, but in spite of this, Marie breaks down the self-constructed barriers to reconcile with her mother. While Marie tries to understand and hold onto what is happening, her mother’s life is nearing its end, and Marie has to let go. For Marie, it is about letting go of her own defence mechanisms, and also letting go of the mother she became close to as her life was drawing to a close.

    Relevance for nurses

    How is Marie’s story relevant to nursing? Can nurses do anything in the reconciliation process between a mother and daughter? It is highly likely that a nurse will encounter mothers and daughters in, for example, nursing homes, as relatives and patients. Being given a life-threatening diagnosis is painful on various levels for patients and relatives. Painful situations can open up opportunities for good conversations about relationships and forgiveness. The time can therefore be important both for the ailing patients and their relatives (6). Being aware of this can make a difference to how nurses deal with a patient’s relatives.

    The accusatory title of the book – You think you know it all – can also affect nurses who already think they know what a patient’s relatives are going through.

    A lack of knowledge about other people’s existential experiences makes it easy to resort to clichés in conversations (7). The accusatory title of the book – You think you know it all – can also affect nurses who already think they know what a patient’s relatives are going through. Conversely, knowledge about other people’s turmoil and life challenges can be a good starting point for good conversations, if a patient’s relatives so wish. When nurses actively listen and respond to input, relatives can gain strength from the interaction.

    An open and caring attitude is the best starting point for understanding the other person’s perspective. Patients’ relatives may not want to talk to nurses about existential issues. Nevertheless, they need to be treated with respect and an understanding that life can be painful. It is essential that nurses are aware of the pain of others. In Marie’s situation, the mother and daughter are feeling their own personal pain in different ways.

    Reflections on method

    The essay is used as a critical exploratory method (9, 10). Ontologically, this method involves using human experiences as a basis for developing knowledge. In epistemology, critical questions are posed about the experience (the text) in order to garner reflections and discover the inherent meaning of the experiences (9). The method becomes critical and exploratory when the questions result in personal preconceptions being challenged, enabling new insights to emerge (10). It is Marie’s experiences with being the daughter of a seriously ill mother that are examined.

    Michel de Montaigne is known for developing the essay as a literary genre. According to him, ‘essay’ meant to try or test (11). Literary texts can be fertile sources for testing out our personal understandings, both from a moral and professional perspective, thereby developing insights into human diversity. In this article, arguments are explored by essayistic reflections on Marie’s experiences.

    Fundamental element of the method: asking questions

    Gadamer (12) argues that asking questions plays an important role in learning from experience. The essence of the question is to generate possibilities and test them out (12). My purpose of asking critical questions about the book’s text is to shed light on the daughter’s experiences when her mother ‘falls apart’. In the essay, I have tried to understand the experiences in ways that may be relevant to nursing. Marie’s story is unique in the sense that it is based on her personal experiences. Yet her experience can be representative of what many people go through in similar situations. Collecting knowledge and understanding from an experience represents an analogic form of reasoning that can be transferrable, and thereby constitute a significant contribution to learning (13).

    Analysis

    The systematic examination of the book’s text has taken place in three stages (9). In the first stage, I read the entire book in order to get an overview. I then asked questions about the text, paragraph by paragraph, page by page, chapter by chapter. During this phase, units of meaning were identified that are relevant to the experience of being a daughter when the mother’s cognitive ability becomes impaired. I distributed the units of meaning into categories and themes, which showed three main themes in the efforts to understand Marie’s experiences:

    1. A need to understand arises.
    2. The understanding takes place at various levels.
    3. Managing to let go when the inevitable death takes place.

    In the third stage, I examine the phenomena through theoretical reflection (9). Here the themes are illuminated using theory. Arendt’s (3) descriptions of ‘action’ and ‘forgiveness’ are particularly useful for gaining an insight into Marie’s struggles during the process of letting go and saying goodbye to her mother.

    Validity

    The reflections are intended to capture the inferences from Marie’s experiences, and how these can prompt research questions (10) that are relevant to the development of knowledge in nursing. The determining factors in terms of validity of the new insights are whether readers recognise the phenomena described and whether they are considered to be relevant to nursing practice. 

    Role of the researcher

    Writing about other people’s experiences can be challenging because these experiences will always be understood in the context of the author’s own preconceptions. Hermeneutics and interpretation relate to the binding of people to a tradition that will always influence new realisations (12). The challenge in all interpretation work is therefore to be conscious of one’s own standpoint. The reader will determine whether the reflections here create recognition that can serve as a guide for nurses and healthcare personnel in their work.

    Closing reflections and conclusion

    When a family member becomes ill, a need arises to understand what is happening. A multitude of questions are thrown up as the disease progresses, and even more when death is approaching. It may seem paradoxical that Marie tries to ‘reach out to her mother’ without ever managing to do so. However, she finds peace and a sense of reconciliation in the knowledge that they tried.

    Understanding takes place at various levels. While actively trying to understand what is happening, death is approaching. Paradoxically, Marie needs to let go whilst also trying to understand. What help can be given to a loved one who struggles to understand and hold on, whilst simultaneously needing to let go?

    The book shows the relational interplay between a sick mother and her daughter up to the point of the mother’s death. The daughter’s empathy with the mother’s suffering, and her struggle to regain her footing are enlightening, and help the reader understand what is at stake between the two of them. Thus, the book is a unique source for understanding both mother and daughter. It inspires conversations about relationships, life and death – and the need for support from the nursing profession.  

    I would like to thank Professor Ingela Josefson for reading the script, and for the valuable conversations whilst I was working on the article. Thank you also to the Centre for Practical Knowledge, Nord University, for the inspirational and informative discussions.

    References

    1.    Peterson M. Du tror du vet alt. Ganesa, Oslo. 2007.  

    2.    Sjöstrand L. Den fragmenterade tiden. Dialoger 85–86. Dialoger, Sverige. 2008.

    3.    Arendt H. Vita activa. Pax Forlag, Oslo. 1996.

    4.    Quenstedt-Moe GW. Forgiveness and health in Christian women. (Doktoravhandling). University of Kansas. 2007.

    5.    Knowles A. Resilience among Japanese atomic bomb survivors. Int Nurs Rev. 2011;58(1):54–60.

    6.    Prince-Paul M, Exline JJ. Personal relationships and communication messages at the end of life. Nurs Clin North Am. 2010;45(3):449–63.

    7.    Kautz D. Inspiring hope in our rehabilitation patients, their families, and ourselves. Rehabil Nurs. 2008;33(4):148–77.

    8.    Mickley JR, Cowles K. Ameliorating the tension: use of forgiveness for healing. Oncol Nurs Forum. 2001;28(1):31–7.

    9.    Lindseth A, Norberg A. A phenomenological hermeneutical method for researching lived experience. Scand J Caring Sci. 2004;18:145–53.

    10.  McGuirk J, Methi JS. Praktisk kunnskap som fag og forskningsfelt. In: McGuirk J, Methi JS (eds). Praktisk kunnskap som profesjonsforskning. Fagbokforlaget, Bergen. 2015. p. 9–30.  

    11.  Melberg A. Essayet. Universitetsforlaget, Oslo. 2013.

    12.  Gadamer HG. Sannhet og metode. Pax Forlag, Oslo. 1960.

    13.  Flyvbjerg B. Case study. In: Norman KD, Lincoln YS (eds). The SAGE Handbook of Qualitative Research. Sage Publications, Los Angeles. 2011.

    Healthcare personnel who interact with patients and their families can learn from the families’ experiences when a loved one is affected by dementia.

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    Background: Dementia affects not only the person who is sick, but also their close family. Knowledge about their experiences can be helpful for healthcare personnel who interact with patients and their families.

    Objective: To examine families’ experiences when a loved one is affected by illness and does not have long to live. The experiences are taken from Marie Peterson’s documentary novel Du tror du vet alt (You think you know it all). The following question is the starting point: ‘How does it feel to be a daughter when your mother is affected by dementia?’

    Method: The essay is used as a critical exploratory method. 

    Results: The story provides insight into what it is like to be a family member when a loved one becomes sick, in need of help and nearing the end of their life. When a family member becomes ill, there is a desire to understand what is happening. A multitude of questions are thrown up as the disease progresses, and even more when death is approaching. It may seem paradoxical that Marie tries to ‘reach out to her mother’ without ever managing to do so. Marie’s need to understand is also at odds with the realisation that she needs to ‘let go’. What help can be given to a family member who is struggling to comprehend what is happening whilst simultaneously trying to let go? 

    Conclusion: The book shows the relational interplay between a sick mother and her daughter up to the point of the mother’s death. The daughter’s empathy with the mother’s suffering, and her struggle to regain her footing are enlightening, and help the reader understand what is at stake between the two of them. Thus, the book is a unique source for understanding both mother and daughter. It inspires conversations about relationships, life and death – and the need for support from the nursing profession.

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  • Experiences with mobile intensive care nurses (MICNs)

    Several countries use dedicated teams that are called out to hospital wards when a patient’s condition shows signs of deterioration. The most common names of such teams are Medical Emergency Team (MET), Rapid Response Team (RRT), Rapid Response System (RRS) and Critical Care Outreach (CCO) (1–4). Internationally, the function and composition of such teams vary somewhat, but normally consist of a doctor and a nurse, known as a mobile intensive care nurse (MICN) or a mobile intensive care group (MICG) (5, 6).

    The purpose is to identify high-risk patients in hospitals at an early stage in order to prevent deterioration in their condition and potentially improve their outcome.

    Although some hospitals in Norway and Sweden have introduced such teams either as a project in individual wards or as an additional resource, little is known about the scope of these arrangements. The purpose is to identify high-risk patients in hospitals at an early stage in order to prevent deterioration in their condition and potentially improve their outcome. (7). Two previous meta-analyses concluded that the introduction of such teams is associated with a reduction in cardiac arrest rates, and some studies have found a decrease in mortality (8, 9). 

    MICNs established at OUH

    MICNs were established at the Division of Medicine, Oslo University Hospital (OUH), Ullevål, in the summer of 2015. The hospital also has a resuscitation team that can be called out to any ward in the event of cardiopulmonary arrest.

    The Division of Medicine at Ullevål consists of ten wards, with a capacity of 193 beds. The wards cover the following specialities: infectious diseases, geriatrics, heart disease, lung disease, stroke treatment, kidney disease, gastromedicine and general internal medicine. There is also a ward that is used as an observation unit specifically for the treatment and observation of poisoning.

    If a nurse observes signs of deterioration in the condition of a patient in one of these wards, or if the nurse needs advice and/or guidance on specific nursing procedures, they can call an MICN. A dedicated mobile number is in use for this purpose. The MICN post is staffed between 15:00 and 08:00 on weekdays, and around the clock at weekends.

    Although patients are moved to observation units or intensive care units prior to the manifestation of respiratory or cardiac arrest, ward patients whose condition is showing signs of deterioration have initially been taken care of by ward nurses and the duty doctor.

    However, experience has shown that doctors are not always available when they are called out, because they may, for example, be attending to new and critically ill patients in the accident and emergency department. Time conflicts sometimes occur. The purpose of establishing the MICNs was to provide an extra resource that could relieve the doctor, provide professional guidance to ward nurses, participate actively in assessing the health status of patients and initiate adequate measures. MICNs have extensive experience in dealing with complex medical patients.

    The aim of the study

    Some studies have shown that deterioration in the condition of hospital patients is mainly caused by hypotension or respiratory failure (10, 11). The studies also show that a number of measures are initiated to stabilise such patients, such as intravenous fluids and medicinal treatment (1, 11). In a number of European countries and countries such as the USA and Australia, it is the METs and RRTs that handle such patients. When nurses identify symptoms of deterioration at an early stage, such as sepsis symptoms, earlier studies have shown an increase in the 30-day survival rate (12). A previous study by OUH, Rikshospitalet found that the nurses were satisfied with the MICN service, but did not provide reasons for use or descriptions of measures taken by the MICNs (5). 

    The aim of this study was therefore to map the number of requests for MICNs within a six-month period. We also wanted to assess the reasons for such requests, the measures initiated by MICNs and the number of admissions to an intensive care unit.

    Method

    Design, sample and setting

    In this observation study, which has a descriptive design, we included all patients aged ≥18 who had been admitted to wards in the Division of Medicine at OUH, Ullevål during the period 1 July to 31 December 2015. For practical reasons, the inclusion period was limited to six months, as the first author wanted to use the data in his master’s thesis.

    Two groups: consultations and interventions

    Based on different levels of use of MICNs, we classified patients during the inclusion period in two different groups: 1) consultations and 2) interventions. Patients in group 1 represent cases where ward nurses call on an MICN for professional advice or assistance, and professional guidance on specific nursing procedures. Group 2 is made up of patients whose condition deteriorated, as identified using the National Early Warning Score (NEWS).

    The nurses used NEWS to score the patient based on their vital signs, such as respiratory rate, blood pressure, heart rate and temperature. In addition, a score was given for whether or not the patient received O2 and for the level of oxygen in the blood. Consciousness was also given a score. All values outside the normal window will trigger a score (table 1). In group 2, we recorded which interventions the MICNs performed on patients in this group, and how many patients had to be transferred to an intensive care unit.

    Table 1: NEWS – early identification of patients at risk

    Data collection

    A registration form developed by the Division of Medicine for use with MICN call-outs was used to retrieve all of the relevant data (Appendix 1). Socio-demographic variables included the patient’s gender and age. Clinical data included the reason for call-out, NEWS score, which nursing procedures and other measures were performed on the patient, and whether the patient was admitted to an intensive care unit. In addition, we collected data on the patient’s status in relation to cardiopulmonary resuscitation and what time of day the MICN was called out.

    We also collected information about the call-out time, described as the time from when the MICN was contacted to when they were in the physical presence of the patient. Where the data in the registration form were incomplete, we used the electronic patient record system DIPS to fill the gaps. In cases where the NEWS score was not calculated in the form, the project manager entered this based on other data given in the form.

    Analysis

    In order to describe the population, we used descriptive analyses, frequency analyses and exploratory analyses. We used normally distributed data curves to control whether collected data were normal or skewed. Abnormally distributed data were examined with non-parametric tests such as the chi-square test, Spearman’s correlation coefficient (rho) and the Mann-Whitney U test. Continuous data that were not normally distributed were expressed as the median and interquartile range (IQR). Statistical significance was set to p values below 0.05. We analysed the data using the Statistical Package for the Social Sciences (SPSS), version 22.0.

    Ethics

    This study was submitted to and approved by the Data Protection Official at OUH as a quality assurance study. Clinical management at the Division of Medicine, OUH also approved the study and the use of registered data. All collected data was de-identified.

    Results

    During the six-month study period, the MICNs were contacted a total of 163 times. There were no statistically significant disparities between the two groups (figure 1).

    Figure 1: Overview of all call-outs

    Of the 163 call-outs by MICNs, there were 91 cases (group 1) where an MICN provided guidance to a ward nurse on nursing procedures, or gave other advice. In this group, information about age and gender was available for 59 patients. In the group (group 2) where MICNs physically attended to a patient in a ward due to a clinical change in the patient and a change in the NEWS score, a total of 72 patients were registered.

    Figure 2 shows the number of call-outs broken down per month during the study period for both group 1 (consultations) and group 2 (interventions). Table 2 shows a complete overview of age and gender within the groups and between the groups. 

     Figure 2. Number of call-outs in group 1 (consultations) and group 2 (interventions), distributed by time series (July–December)

    Reasons for contact

    In the registration form, the reason for calling out an MICN was either specified as a diagnosis (such as pneumonia, sepsis or hypotension), or as free text describing the problem. We redefined these reasons according to actual patient problems as well as clinical findings noted on the form, and identified the following reasons for contact:

    • respiration (including: dyspnoea, hypoxaemia, rapid respiratory rate, secretion stagnation)
    • circulation (including: hypotension and/or fast heart rate. Such conditions are revealed in isolation using NEWS (table 1)).
    • infection
    • neurology
    • other

    Where an MICN was called out to a patient with hypoxaemia and a rapid respiratory rate, which in turn triggered a high NEWS score, the reason for contact was registered as respiratory. Some patients had few deviations in their NEWS scores. These patients could, however, have isolated scores on ‘consciousness’, where the reason for contact was classified as neurological. Other conditions noted on the form, such as hyperglycaemia, anaphylaxis, hypothermia and urinary retention, only occurred rarely. We collated these conditions into the group ‘other’. More than half of the MICN call-outs were due to respiratory problems (n = 41; 56.9 per cent) followed by circulatory problems (n = 13; 18.1 per cent). Figure 3 shows the distribution for other categories.

    Figure 3. Reasons for contact in group 2 (n = 72)

    National Early Warning Score

    Of the 72 call-outs in group 2, five patients did not have a NEWS score. In the data that were available for 67 patients, the NEWS scores ranged from 1–18 with a median of 8 (IQR 4). Of the patients with available NEWS data, 15 were admitted to an intensive care unit with a median NEWS score of 10 (IQR 3). Table 1 shows which parameters are included in the assessment of the patient, and the NEWS score threshold that triggers the need to call out an MICN and further follow-up.

    Measures initiated by MICNs

    In group 1, MICNs assisted with certain nursing procedures, such as the insertion of a peripheral intravenous cannula or dealing with a blocked intrapleural drain. Blocked intrapleural drains were dealt with either by performing the procedure directly or by guiding the ward nurse. Other types of tasks related to advising ward nurses on medication and its administration (e.g. Atrovent/Ventoline, Furix and Seloken), and providing general advice.

    In group 2, MICNs assisted with specific measures related to the stabilisation and treatment of patients. The most common measure was administering O2, but advice was often recorded on the form, for example, when an MICN advised a ward nurse on further follow-up and what observations the nurse should continue. Table 3 shows a complete overview of measures.

    Table 3. Measures initiated by MICNs during all call-outs (n = 163)

    Number of admissions to intensive care units

    Of the 72 patients in group 2 who received interventions from an MICN, 22.1 per cent (n = 16) were transferred to a higher treatment level in an intensive care unit. Of these, 12 were admitted due to respiratory problems. Two had circulatory problems, and two belonged to the neurology group. Of those who were admitted to an intensive care unit, half (n = 8) had been given a status for cardiopulmonary resuscitation. Five of these patients had the status ‘do not resuscitate’.

    Time of day and time spent on call-out

    In 153 of a total of 163 call-outs, the time of day that the MICN was contacted was registered. In total, for groups 1 and 2, 92 (60.1 per cent) of the call-outs took place between 15:00 and 22:00, and 61 (39.9 per cent) between 22:00 and 08:00. In group 2, the time spent by the MICN from the first contact up to the point of meeting the patient was registered in 65 cases. This time ranged from 1 to 20 minutes, with a median of 5 (IQR 2).

    Discussion  

    The intention of this study was to map the use of MICNs over a period of six months. Respiratory and circulatory deterioration were the main triggers of MICN call-outs. In order to detect deterioration in a patient’s condition, NEWS scores were used, and a number of measures were initiated with a view to stabilising the patient. Few patients were transferred to a higher level of treatment at an intensive care unit.

    Respiratory and circulatory deterioration were the main triggers of MICN call-outs.

    MICNs were frequently called out in the start-up period July–August in group 2, but the number of call-outs for this group tended to decline during the period of the study (figure 2). Some previous studies have also observed a decline in the use of such teams after the initial start-up period. Calzavacca et al. (13) concluded that implementation of such teams is a process that takes several years to complete. In this study, we have not mapped the process prior to the implementation of the MICNs, but it is known that MICNs actively contacted all wards during the start-up period. This may have helped to bring the service to the attention of nurses, and served as a reminder of its existence.

    In group 1, the use of MICNs was evenly spread throughout the study period, but with a spike in October. One potential explanation for this may be that the patient base was higher than in other months, that patients had more complex issues, or that they were generally more unstable. However, we have not obtained internal reports on the number of patient beds filled, which could provide valuable information in this context.

    Reasons for MICN call-outs

    Deterioration in cardiopulmonary status was by far the dominant reason for calling out an MICN. A number of studies from other countries have reported that METs or RRTs are called out due to cardiopulmonary issues (10, 11, 14). Silva et al. (1) demonstrated that METs were mainly contacted due to respiratory problems, which corresponds to the findings in our study. In an MET call-out, both a doctor and a nurse attend to the patient (1, 3, 15). The inclusion of a doctor in the team means that more advanced treatment can be given to the patient on the spot. This composition of professionals can therefore strengthen the team (15-17).

    Maharaj et al. (9) concluded in a meta-analysis, however, that the presence of a doctor was not significantly associated with a reduction in mortality. In our study, MICNs were called out to unstable patients. Patients with serious and life-threatening conditions would have been dealt with by the resuscitation team. Silva et al. (1) found that staff concerns about a patient (‘staff worried’) was the second most common criterion for activating an MET. This may be due to the fact that the criteria for calling out an MET are stricter (18) than in our study. Bellomo et al. (19) recommended that the ‘staff worried’ criterion be used for patients who did not fit the other criteria for MET call-outs.

    Silva et al. (1) identified a need for greater competence among the staff in assessing vital signs and awareness that calling out an MET should be based on actual clinical findings. ‘Staff worried’ is a broad term that does not identify the actual problem. However, this should not be excluded as a criterion for MICN call-outs as studies have shown that the threshold for calling out such teams is sometimes set too high. Where this is the case, the use of MICNs may be reduced or delay call-outs (19-21), which in turn can lead to increased mortality (22).

    Jackson et al. (23) asked nurses if they would call out an RRT if they were concerned about a patient even though their vital signs were normal. A total of 29.2 per cent of those asked said they would feel uncertain about what to do. The point is that the MICNs should represent a low-threshold service where only an intensive care nurse is called out, not a whole team. In our study, ‘staff worried’ was not a criterion on the registration form, and we therefore do not know whether this criterion would have been in frequent use at OUH, Ullevål.

    More frequent use of MICNs in the summer

    After the MICN service was started, an overarching NEWS procedure was established at OUH, which was to be implemented in all medical divisions. The Division of Medicine implemented the procedure upon start-up of the MICNs, while all nurses received training in the assessment and treatment of patients. Improving nursing knowledge about patients and practical skills in assessing and treating patients during the training period was likely to have contributed to a reduced need for active use of MICNs in the months that followed.

    It is also possible that many of the nursing staff were replaced in the summer by temporary personnel and new employees with less experience, and that this employee group needed more assistance and guidance from the MICNs. This may explain the increased use of MICNs in July (figure 2). At the same time, our analyses show that the patients that the MICNs were called out to had a median NEWS score of 8. According to both internal recommendations (table 1) and international recommendations, this score triggers the need for a doctor to be called out and measures started to stabilise the patient (13). MICNs were also called out to patients with a low score, which may be an indication that MICNs were also considered to represent a low-threshold service.

    The high number of cases where ward nurses requested advice from MICNs may be an indication that it was easy and safe to contact MICNs for this reason.

    In group 1, we observed that MICNs were contacted to give advice to ward nurses, which was also noted in group 2. The high number of cases where ward nurses requested advice from MICNs may be an indication that it was easy and safe to contact MICNs for this reason. Providing support and training in different procedures was also covered in the definition of advice. This is in line with the purpose of establishing MICNs, and corresponds with the recommendations in other studies (15).

    In group 2, supplying 02 in cases of hypoxaemia, intravenous fluid for hypotension and medication were the most widely used measures. These measures are easy to carry out, as described in other studies (19, 24). The ‘bedrest’ measure was also used frequently, but we have not found descriptions of this measure in international studies. This measure may be considered to be of little importance in an emergency situation, despite being described as a basic nursing measure in nursing literature (25).

    Reduced mortality?

    It is known that patients who suffer a severe deterioration in their condition, including patients in cardiac arrest, show signs of deterioration several hours earlier. In order to prevent catastrophic outcomes, these warning signs must be treated at an early stage (26–28). In a meta-analysis from 2010, it was not possible to conclude that RRTs reduced mortality (29). However, in the latest meta-analyses, Solomon et al. (8) and Maharaj et al. (9) concluded that RRTs/METs reduced mortality and the occurrence of cardiac arrest.

    Our study was not designed to capture these peripheral points. On the other hand, the findings show that only 16 of the patients who MICNS were called out to were transferred to an intensive care unit. Since this study has only used the registration form that was used by MICNs and has not mapped long-term data, we cannot rule out the transfer of patients to an intensive care unit at a later date. Hillman et al. (16) found that METs did not contribute to any significant reduction in the number of admissions in intensive care units, while a Dutch study found a downward trend in the number of intensive care admissions (3).

    We also found that most (75 per cent) of the patients admitted to an intensive care unit had respiratory problems. We assume that the majority of these needed respiratory support using, for example, Continuous Positive Airway Pressure (CPAP) or Bilevel Positive Airway Pressure (BiPAP). Future studies aimed at mapping efficacy are needed in order to examine the clinical effect of MICNs, including early transfer to an intensive care unit, or reduced transfers due to early intervention.

    Where call-out times and the time taken to initiate measures exceed 15 minutes, a poorer prognosis may be expected (22). Our survey showed that MICNs had a median call-out time of 5 minutes. Silva et al. (1) reported a call-out time of less than 2 minutes for METs. The fact that the MICNs’ call-out time in our study was more than twice that of the other study may be because our hospital covers a large area and some departments are located a considerable distance from the MICNs’ base. Other studies reported call-out times of 4.5 and 12.3 minutes respectively (17, 19).

    Weaknesses of the study

    In addition to the obvious weaknesses of a cross-sectional study, this study also has a short period of inclusion. It also only covers a small number of call-outs and patients. The finding that patients mainly had respiratory problems may also be due to seasonal variations. Despite these weaknesses, we believe that the study provides valuable clinical information that can be used in the further development of these types of services.

    Conclusion

    Mobile intensive care nurses are usually called out to medical patients whose condition has deteriorated due to respiratory problems. Future studies should assess whether it is possible to identify symptoms of deterioration at an earlier stage, so that targeted treatment can be initiated sooner and transfer to a higher level of treatment can potentially be avoided.

    The measures initiated for the patients are, in principle, simple measures that nurses with broad knowledge and good clinical knowledge can deal with. Future studies should therefore examine whether such a role can also be filled by advanced clinical nurses and not exclusively intensive care nurses. Mobile specialist nurse models can also potentially be tested in the primary health service.

    References

    1.       Silva M, Saraiva M, Cardoso T, Aragao, IC. Medical Emergency Team: How do we play when we stay? Characterization of MET actions at the scene. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2016 Mar 22;24:33.

    2.       Jones D, Rubulotta F, Welch J. Rapid response teams improve outcomes: yes. Intensive Care Med 2016 42:593–595.

    3.       Ludikhuize J, Brunsveld-Reinders AH, Dijkgraaf M, Smorenburg S, de Rooij S et al. Outcomes associated with the nationwide introduction of Rapid Response Systems in the Nederlands. Critical care Medicine Dec 2015;2544–51.

    4.       Priestley G, Watson W, Rashidian A, Mozley C, Russell D, Wilson J et al. Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a general Hospital. Intensive Care Med 2004;30:1398–1404.

    5.       Stafseth SK, Grønbeck S, Lien T, Randen I, Lerdal A. The experiences of nurses implementing the Modified Early Warning Score and a 24-hour on-call Mobile Intensive Care Nurse: An exploratory study. Intensive Critical Care Nursing 2016 Jun;34:25–33.

    6.       Nordlund K, Joelsson-Alm E. Mobil intensivvårdsgrupp ger bättre patientövervakning och trygg personal. Läkartidningen 2009;42:2690–3.

    7.       Marquet K, Claes N, De Troy E, Kox G, Droogmans M, Schrooten W et al. One fourth of unplanned transfers to a higher level of care are associated with a highly preventable adverse event: A patient record review in six Belgian hospitals. Critical Care Medicine 2015 May;43(5):1053–61.

    8.       Solomon RS, Corwin GS, Barclay DC, Quddusi SF, Dannenberg MD. Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: A systematic review and meta-analysis. Journal of Hospital Medicine 2016 Jun;11(6):438–45.

    9.       Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Critical Care 2015 Jun 12;19:254.

    10.     Choi S, Lee J, Shin Y, Jung J, Han M, Son J et al. Effects of a medical emergency team follow-up programme on patients discharged from the medical intensive care unit to the general ward: a single-centre experience. Journal of Eval Clinical Practice 2016 Jun;22(3):356–62.

    11.     Topple M, Ryan B, Baldwin I, McKay R, Blythe D, Rogan J et al. Tasks completed by nursing members of a teaching hospital Medical Emergency Team. Intensive Critical Care Nurse 2016 Feb;32:12–9.

    12.     Torsvik M, Gustad LT, Mehl A, Bangstad IL, Vinje LJ et al. Early identification of sepsis in hospital inpatients by ward nurses increases 30-day survival. Crit Care 2016;20:244.

    13.     Calzavacca P, Licari E, Tee A, Egi M, Downey A et al. The impact of Rapid Response System on delayed emergency team activation patient characteristics and outcomes—A follow-up study. Resuscitation 2010 Jan;81(1):31–5.

    14.     Mullins CF, Psirides A. Activities of a Medical Emergency Team: a prospective observational study of 795 calls. Anaesth Intensive Care 2016 Jan;44(1):34–43.

    15.     Jung B, Daurat A, De Jong A, Chanques G, Mahul M, Monnin M, Molinari N, Jaber S. Rapid response team and hospital mortality in hospitalized patients. Intensive Care Medicine 2016 Apr;42(4):494–504.

    16.     Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet 2005;365:2091–7.

    17.     Konrad D, Jaderling G, Bell M, Granath F, EkbomA, Martling CR. Reducing in-hospital cardiac arrests and hospital mortality by introducing a medical emergency team. Intensive Care Med 2010;36:100–6.

    18.     Aneman A, Frost SA, Parr MJ, Hillman KM. Charasteristics and outcomes of patients admitted to ICU following activation of the Medical Emergency Team: Impact of introducing a Two-Tier Response System. Critical Care Medicine 2015 Apr;43(4):765–73.

    19.     Bellomo R, Goldsmith D, Uchino S, Buckmaster J, Hart GP, Opdam H et al. A prospective before-and-after trial of a medical emergency team. Med J Aust 2004 Mar 15;180(6):308.

    20.     Chen J, Bellomo R, Flabouris A, Hillman K, Finfer S. The relationship between early emergency team calls and serious adverse events. Crit Care Med 2009 Jan;37(1):148–53.

    21.     Cretikos M, Chen J, Hillman K, Bellomo R, Finfer S, Falbouris A et al. The objective medical emergency team activation criteria: a case-control study. Resuscitation 2007 Apr;73(1):62–72.

    22.     Chen J, Bellomo R, Flabouris A, Hillman K, Assareh H. Delayed emergency team calls and associated hospital mortality: A multicenter study. Critical Care Medicine 2015 Oct;43(10):2059–65.

    23.     Jackson S, Penprase B. Factors influencing registered nurses' decision to activate an Adult Rapid Response Team in a community hospital. Dimens Crit Care Nurs 2016;35(2):99–107.

    24.     Lobo R, Lynch K, Casserly LF. Cross-sectional audit on the prevalence of Elevated National Early Warning Score in medical patients at a Model 2 hospital in Ireland. Ir J Med Sci 2015 Dec;184(4):893–8.

    25.     Eikeland A, Gimnes M, Holm HM. Sirkulasjonssvikt. I: Gulbrandsen T, Stubberud DG (red). Intensivsykepleie. Akribe AS, Oslo. 2010.

    26.     Goldhill DR, White SA, Sumner A Physiological values and procedures in the 24 h before ICU admission from the ward. Anaesth 1999;54:529–34.

    27.     Smith AF, Wood J. Can some inhospital cardio-respiratory arrests be prevented? A prospective survey. Resuscitation 1998;37:133–7.

    28.     McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, Nielsen M, Barrett D, Smith G. Confidential inquiry into quality of care before admission to intensive care. Br Med J 1998;316:1853–8.

    29.     Chan P, Jain R, Nallmonthu BK, Berg RA, Sasson C. Rapid Response Team: A systematic review and meta-analysis. Arch Intern Med 2010 Jan 11;170(1):18–26.

    Mobile intensive care nurses are called out to hospital wards when a patient’s condition is showing signs of deterioration. When are they called out, and what measures do they initiate?

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    Sammendrag

    Background: Mobile intensive care nurses (MICNs) have been established at Oslo University Hospital, Ullevål, but there is little knowledge about how these resources are used or what their work entails.

    Objective: To map the number of requests for MICNs during a six-month period, and to assess the reasons for the requests, measures initiated by MICNs and the number of admissions to an intensive care unit.

    Method: We recorded the requests for MICNs over the period June–December 2015. The MICNs recorded socio-demographic and clinical variables on a registration form for each call-out. When the data on the registration form were inadequate, we retrieved information from DIPS, the electronic patient record system. 

    Results: The MICNs received a total of 163 requests during the registration period. Of these, 91 were either for advice to ward nurses or assistance in dealing with various nursing procedures (group 1), while 72 were mainly associated with respiratory (56.9 per cent) and circulatory (18.1 per cent) deterioration in a patient (group 2). The most common measures taken in group 2 were the following: supplying O2, intravenous fluid, medication, correct positioning for bedrest and consulting with an MICN. Of the patients in group 2, 22.1 per cent were transferred to an intensive care unit for treatment.

    Conclusion: In most cases, MICNs were called out due to deterioration in a patient as a result of respiratory distress. Future studies should map whether MICNs can prevent admissions to intensive care.

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  • Encountering parents of a sick newborn child

    Having a newborn baby admitted to a neonatal intensive care unit (NICU) is a frightening experience for most parents. All parents react differently, but many experience anxiety, powerlessness, loss of control, guilt and shame (1). Parents’ reactions do not necessarily correspond to the degree of severity of the child’s diagnosis (2). Stress, anxiety and suppressed grief can be obstacles to forming a parental attachment to the child and to a natural parent-child interaction (3).

    In order to prevent parents’ emotional strain from becoming a protracted burden, and to foster an attachment between the parent and child, it is essential that nurses have relational competence, as well as good communication skills and effective methods for conveying information. Relational competence is the set of skills, abilities, knowledge and attitudes needed to establish, develop and repair relationships between people (4).

    Communication tools

    There is much to suggest that communication tools based on empathy, such as the Empathetic Communication principle, boost nurses’ skills and confidence in conversations with parents (5, 6). Empathetic Communication was devised by Lisbeth Holter Brudal and entails the gradual building of dialogue. The method is a process in which the nurse becomes attuned to the parents and tries to understand their inner lives. The core elements of the method are the parents’ narrative and their mental reality as well as their need for existential validation.

    Empathetic Communication as a tool has an overarching goal to promote health, and it is partly based on Aaron Antonovsky’s sense of coherence theory. The goal is for the parents to achieve a sense of coherence that is characterized by three dimensions: comprehensibility, manageability and meaningfulness (6). 

    Open communication in family-centred care

    Communication is also an essential aspect of family-centred care. Family-centred care is recognized as a fundamental approach to care for families with sick children. The core elements are the family’s right of access to care, and the parents’ abilities and emotional well-being. Parents’ perceptions of the efficacy of the care and of themselves as the child’s most important care person are also important elements of family-centred care (7, 8).

    Communication between nurses and parents in an NICU poses special challenges due to the stressful situation in which the parents find themselves. Another element that represents a challenge is the complexity of the high-tech environment of the unit (9). Open communication is a fundamental principle for successful family-centred care. Achieving open communication is a challenge (10), and research shows that there is a need to foster the communication between nurses and parents (9, 11, 12).

    Communication between nurses and parents in an NICU poses special challenges due to the stressful situation in which the parents find themselves.

    Qualitative research has been conducted both in Norway and internationally on mothers’ and fathers’ experiences with and perceptions of their stay in an NICU (13, 14). There are studies of nurses’ and parents’ experiences of the relationship in the cooperation (15, 16) and the importance of a supportive relationship (17). However, we have not found any phenomenological studies that focus on nurses’ descriptions of what is important in the encounters and conversations with parents of a sick newborn baby who is admitted to an NICU.

    A phenomenological approach is appropriate when trying to gain an understanding of individual experiences of people that cannot be measured or understood through causal relationships. The aim is to develop knowledge about people’s experiences within a particular field (18). The purpose of our study was to describe a group of nurses’ experiences of what is important in the encounters and conversations with parents of a sick newborn child. The research question presented in the study was as follows:

    ‘What do nurses consider to be important in the encounters and conversations with parents of a sick newborn child?’

    Method

    Design

    The study has a qualitative design with a phenomenological approach, and data were obtained through individual interviews. According to phenomenological philosophy, our consciousness is always directed towards something. This means that we experience different phenomena based on how they present themselves to us. The descriptive phenomenological research method aims to gather accurate descriptions of how a person experiences a phenomenon. Here, the phenomenological reduction is an important prerequisite. Prior knowledge of the phenomenon being studied must therefore be set aside in order to produce an unbiased description. This requires the researcher to describe the experiences of the informants without interpreting them based on his or her own experiences (18).

    Sample

    The criteria for inclusion in the study were that informants had to be a paediatric nurse or a nurse with at least two years’ experience from an NICU. Recruitment took place from September to November 2013 at an NICU in Southeast Norway. Five female nurses between the ages of 30 and 50 reported an interest in participating, and all were included. Four of these nurses had further education in paediatric nursing.

    Data collection

    We conducted individual interviews in the autumn of 2013 at the informants’ workplace. The informants were asked two open-ended questions:

    • Can you give as detailed a description as possible of an encounter in which you felt you had a good conversation with parents of a sick newborn child?
    • Can you describe an encounter where you did not have such a successful conversation?

    In order to obtain as rich descriptions as possible, we asked questions like ‘Would you like to tell me more about it?’, ‘Can you give a reason for it?’ and ‘What did you think then?’. The interviews lasted up to 47 minutes. We made audio recordings of the interviews and transcribed the data verbatim shortly after each interview.

    Analysis

    We carried out the analysis process according to the four steps in Giorgi’s (18) descriptive phenomenological research method. The interview text was read several times with a phenomenological reduction in order to gain an overall impression. In order to make the data more manageable for further analysis, we identified units of meaning in which there was a natural division in content. The everyday language in the units of meaning was transformed into scientific nursing language. We transformed the text using imaginary variations, where the aim was to establish as exact a description of the units of meaning as possible, with correct scientific language.

    According to Giorgi (18), imaginary variations entail a given phenomenon being varied freely in its possible forms. The constant in the different variations is the essence of the phenomenon. We also rewrote the text from first to third person in order to create greater distance to the data material. Finally, we summarized transformed units of meaning that addressed the problem, and related them to each other, i.e. we identified common features of the interviews. These common features formed the general structure of the phenomenon. Table 1 shows a practical example of the analysis process.

    Table 1. Practical example of the analysis process

    Research ethics

    The Norwegian Centre for Research Data (NSD) was notified of the study. We were given permission to carry out the study by the R&D unit at the hospital in question. The informants received oral and written information about the study, and were informed about voluntary participation and the option to withdraw. We also obtained written informed consent.

    Results

    General structure

    In the informants’ encounters with parents, the informants considered it essential to establish a relationship based on empathy, where the parents were treated as individuals, where the mutual exchange of information was facilitated, and where the parents’ sense of coping was fostered. When these aspects were present, the informants perceived the encounters and conversations as good. Where these aspects were absent, the encounters and conversations were described as less successful.

    Establishing a relationship based on empathy

    The informants emphasized that the relationship aspect was a core element of the encounter with the parents. They believed that the parents appreciated the empathy they were shown, and that it gave the parents the courage to confide in them. In order to establish an empathetic relationship, the informants pointed out that nurses must be attentive to the parents and not have the attitude that nurses know best. They must also take care not to talk over the parents’ heads. They must show understanding for the parents being in a difficult situation.

    The nurses must also take care not to talk over the parents’ heads.

    Furthermore, they must know that crisis and stress reactions can manifest themselves in different ways, and that being separated from the child is often extremely challenging. These factors were particularly applicable when the parents felt they were in a crisis under circumstances that the informants considered to be straightforward and which they knew would have a good outcome. The informants also emphasized that adopting an empathetic approach would stop the nurses from having unrealistic expectations of the parents and regarding the parents as difficult. Where there was no such comprehension, the relationship could be adversely affected. Accepting and being open to and tolerant of the different reactions of the parents were considered important for establishing a relationship based on empathy.

    Treating the parents as individuals

    Another important aspect of the encounters and conversations with the parents was to make them feel that they were ‘seen’, for example by showing them that they cared about their child and the particular situation of that child. The informants considered it essential to act according to the individual situation and reactions of the parent, since all parents differ and have different needs that change during the hospital stay. The opportunity to focus fully on the parents is a prerequisite for being able to treat the parents as individuals. When the nurses also had to concentrate on other work at the same time, giving their full attention to the parents often presented a challenge. For example, other tasks sometimes had to be prioritized over the sick child or other acute events.

    The informants considered it essential to act according to the individual situation and reactions of the parent.

    Other challenges to the nurses’ time included where the nurses were responsible for several children and parents or where they had different procedures or documentation to adhere to. In order to be able to give their full attention to the parent, there was occasionally a need to move the setting from the incubator or the child’s bedside in the unit. The informants said it was important to take the parents out of the unit to a suitable room with comfortable chairs, for example, in order to allow them to focus on the parents as individuals.

    Facilitating the mutual exchange of information

    The informants felt that it was crucial to facilitate the mutual exchange of information in order to adapt the information to the individual’s aptitudes and needs, and to show understanding for the child’s situation in the conversations with the parents. The informants wanted to keep the parents informed of the child’s situation and development from their first meeting right up until the child was discharged.

    They told of the child’s need to have the parents with them at the hospital, and what they thought was best for the child. The informants often found that the parents did not take on board all of the information they were given. They therefore recognized the importance of identifying how they could best provide the individual parent with explanations that he or she could understand. In order to identify what was important to the individual, it was crucial to listen actively and make sure they understood the parents. The informants wanted to find a balance so that they could facilitate the best possible overall situation for the whole family.

    Helping parents to cope

    The informants described how when the child was admitted to the NICU, the parents entered an unknown world that could feel confusing and unmanageable. They felt it was important to facilitate conversations about the parents’ experiences and perceptions. They could, for example, encourage the parents to share their stories and versions of what had happened, and then ask follow-up questions about how they felt or what they thought about this. The informants felt that this could help the parents to express their emotions and thoughts.

    In the conversation with the parents, the nurses discussed how the parents could take part in the care, and provided information and guidance. Everyone agreed that involving the parents in the care of their child helped parents to feel that they were coping and helped them to form an attachment to their child. They pointed out that it had to be on the parents’ terms. When the informants were unable to meet the parents’ needs and do what was right for them, it sometimes led to insecurity, stress and a negative experience for both the parents and the informants.

    Discussion

    All of the informants described how it was crucial to establish a relationship based on empathy in the encounter with parents. Earlier research confirms this, and highlights the importance of nurses showing empathy towards the parents (19, 20). The experience of being met with empathy fosters and strengthens the individual’s mental resources in a difficult situation (21). Empathy gives parents the resolve to continue and a zest for life (6). New knowledge about mirror neurons and the mirror neuron system has introduced new aspects to the concept of empathy. Evidence suggests that empathy is an innate ability to recognize the emotions and intentions of other people (22).

    Only when the nurse recognizes the parents’ inner world does he or she have the opportunity to understand the parents.

    Empathy has both a cognitive and emotional aspect. Based on the principle of Empathetic Communication, it may be said that through a process characterized by mutual reflection and dialogue, the nurse can start to comprehend what the parents are going through by recognizing their feelings and intentions. Only when the nurse recognizes the parents’ inner world does he or she have the opportunity to understand the parents. This recognition adds a distinctive quality to the relationship and dialogue between nurses and parents, which gives a sense of cohesion and equality. Both have the same experience simultaneously (6).

    The informants describe how they met the parents with an open, empathetic and receptive attitude. The parents are the key figures in the relationship, and as such will sense the intention to help, which is implicit in such behaviour. Empathy can arise as a result of such a process because, in practice, it is about the nurse attuning to the parents and taking part in their reality (6).

    Failing to recognize that the parents are having a crisis

    The informants’ descriptions of the significance of the relationship concur well with other studies (15-17). Several studies have, for instance, shown that parents of sick newborn babies have a crisis reaction to childbirth and the post-natal period (1, 23). Hillgaard et al. (2) examine whether some crises are not discovered because health professionals consider the behaviour to be normal for that particular person. They interpret the situation as having to do with difficult parents, and fail to recognize that the parents are having a crisis. In order to be able to provide effective help for the parents, the nurse must have knowledge of the parents’ reactions in connection with having a sick newborn baby (24). The nurse must also use a communication tool, such as Empathic Communication (5, 6).

    All of the informants emphasized the importance of making parents feel that they are seen. Being seen gives an immediate sense of being understood and validated (25). When the nurse starts to comprehend the parents’ understanding, the parents can feel valued. This strengthens their resolve and self-esteem (6). Earlier research suggests that nurses who are sensitive and supportive to parents’ needs can foster parents’ self-confidence and strengthen their response to the child’s needs (26). This is because when parents have self-confidence and are able to cope they can more quickly adapt their response to the child’s signals (27).

    The informants also emphasized that giving their full attention to the parents was a prerequisite for identifying the individual’s needs. Such attention to the parents requires the ability and capacity to be present and mindful (6). When the nurse focuses on the parents’ thoughts and perceptions, they are signalling that the parents are important. The role the parents have as a caregiver for the child is asserted (28).

    Information both ways

    Enabling the mutual exchange of information between parents and nurses was emphasized as a key aspect of the conversations. Through the mutual exchange of information, the nurse gains a better understanding of the parents’ reality and what is important for the individual (6). Such understanding of the parents’ problems, resources and needs thus makes it possible for the nurse to adapt the amount and type of information that is preferred by the parents (29, 30). In this way, an empathetic dialogue is created (6). Duncan (31) refers to this as client-directed and outcome-informed practice. Attention is directed to the information shared by the parent, and to giving professional feedback based on the fact that the parents are the key figures in the dialogue.

    In order to foster the parents’ sense of coping, it was important for the informants to encourage the parents to share their stories and ask follow-up questions about what the parents felt and thought. This is also in line with the communication tool Empathetic Communication. Parents are given the opportunity to express and convey their own feelings and thoughts in an empathetic relationship that can foster a sense of coping. By mirroring what the parent says, the nurse can create a valuable process in which tension and stress are dampened, and mental strength is further developed (6).

    The parents need to express their perceptions and be heard in order to be able to process impressions and reactions in relation to what has happened.

    Parents need to express their perceptions and be heard in order to be able to process impressions and reactions in relation to what has happened (32). They can receive information and concentrate on caring for the child more effectively once they have processed their own perceptions. Such processing may affect how they bond and interact with the child (33, 34).

    All the informants felt that involving the parents in the care of the child helped give the parents a sense of coping and helped them bond with the child. Informants described how they talked to and guided the parents in what was best for the child and how they could take part in the care. Research shows that early intervention aimed at learning parental interaction and sensitivity to the child’s signals can foster good mental development in the sick newborn child and a sense of coping in the parents (3, 23, 34-36).

    Methodological considerations

    One weakness of the study is that we only have five informants. The ideal would have been to include more informants from more NICUs. According to Giorgi (18), however, three in-depth interviews can be sufficient for a phenomenological study. Thus, five informants in the study can be a sufficient basis for illuminating the phenomenon.

    A researcher will always have a certain influence on the data material, and it may, therefore, be unrealistic to assume that all prior knowledge will be set aside. The first author has an understanding of the phenomenon as she has the same professional background as the informants. She also works in the same type of unit, and has opinions about the phenomenon being investigated. It is thus important for the authors to have a reflective relationship to their own preconceptions and to try to use solely the informants’ experiences.

    The convergence of findings from the various interviews helps to enhance the reliability of the study. The findings also concur with other research in the field. The reliability of the study is further enhanced by the fact that all of the authors have been involved in the analysis. The first author conducted the analysis in close collaboration with the co-authors. We followed the analytical steps carefully, which is essential for obtaining valid findings, according to Giorgi (18).

    Conclusion

    This study has thrown light on a group of nurses’ experiences in terms of what is important in the encounters and conversations with parents of sick newborn children in an NICU. The results emphasize that the nurses are responsible for establishing an empathetic relationship with the parents and treating each parent according to their own situation in order to help them cope with the vulnerable situation in which they find themselves.

    The informants’ descriptions indicate that nurses at NICUs can benefit from adopting the communication tool Empathetic Communication. The method is in many ways consistent with the findings of the study: information must be adapted to the parents, the parents are the real experts on themselves, there is no such thing as ‘difficult parents’, and coping gives parents a sense of security.

    Further research is needed to investigate whether training in the communication tool Empathetic Communication can help develop nurses’ relational competence and communication skills, thereby facilitating good encounters and conversations with parents of a sick newborn child. 

    References

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    When nurses encounter parents with a sick newborn child, it is vital that they see them as individuals and establish a relationship based on empathy.

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    Sammendrag

    Background: Parents often experience stress when their newborn child is admitted to a neonatal intensive care unit (NICU)ward. Nurses who meet parents must have knowledge about communication and relational competence to provide support based on the parents’ experiences and needs.

    Objectives: To describe a group of nurses’ experiences of what is important in the encounters and conversations with parents of a sick newborn child.

    Method: The study has a qualitative design with a phenomenological approach, where the aim is to obtain an accurate description of the informants’ experience of a phenomenon. Individual interviews were conducted with five nurses at an NICU. The interviews were analysed according to a descriptive phenomenological research method.

    Results: When meeting the parents, the informants described it as crucial to establish a relationship based on empathy, to see the individual parent, to facilitate the mutual exchange of information and to foster parents’ sense of coping. When these aspects were present, the informants experienced a good encounter and conversation with the parents, but if these aspects not were present, the encounters and conversations were described as less successful.

    Conclusion: The results emphasize that when encountering parents of a sick newborn child, nurses have a responsibility to establish a relationship based on empathy and to treat each parent according to their own situation in order to help them cope with their vulnerable situation.

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  • The organization of 22 care pathways in the Western Norway Regional Health Authority

    The Norwegian health service faces various challenges related to coordination, the transfer of information and undesired variation (1). Poor quality and undesired events can lead to injury or early death (2). The challenges posed by the organization of the care trajectory in the health system (3) mean that more knowledge is needed on quality and safety.

    The introduction of 28 care pathways within cancer treatment (4) has once again put a spotlight on the standardization of care pathways as a means of improving the quality of the health service. Internationally, standardized care pathways are increasingly being used as a tool for improving the quality of diagnostics, treatment and follow-up of hospital patients (5).

    Confusing terminology

    The diverse terminology used in standardized care processes is confusing. ‘ Behandlingsline’ and ‘ strukturert/standardisert pasientforløp’ are used in Norwegian, while English synonyms include ‘care pathways’, ‘clinical pathways’ and ‘critical pathways’ (6-8). In principle, it is important to make a distinction between when a ‘care pathway’ is used as an intervention, i.e. ‘standardization’, aimed at improving the quality of work processes, and when referring to the care trajectory from measure to measure, unit to unit, or between levels in the health service. The aim of standardizing care processes is to improve the quality of treatment processes (8–11).

    The European Pathway Association (E-P-A) defines the standardization of care processes into ‘care pathways’ as ‘a methodology for the mutual decision making and organization of care for a well-defined group of patients during a well-defined period’ (12). This method is used to define goals and make decisions on what measures to include in the treatment. The measures included in the treatment should reflect evidence, best practice and the expectations of the patient. Health care personnel must facilitate and coordinate the communication, roles and order of work in the interdisciplinary team. In addition, it is important to document and follow up the improvement work systematically. The perspectives of the user and their family play a key role in the E-P-A’s definition of a standardized care pathway.

    Towards a standardized care pathway

    A good first step in the standardization of a treatment process is to develop a written procedure or written guidelines (10). However, improving the service requires the personnel working with the relevant patient group to adhere to such written specifications. In the efforts to standardize care processes, the interdisciplinary team (13) takes a targeted and systematic approach to methodology from the field of quality (10, 11, 14, 15). It is shown that this way of improving the organization of processes leads to a better patient outcome, a lower risk of undesired events, better documentation (11, 16-19), a better working environment and a lower risk of burnout (20, 21).

    However, the methodology has also been criticized for not having measurable effects for all patient groups, and whether the cost of developing standardized care pathways justifies their use is a matter of debate (19, 22). In Norway, there is still a need for research on the standardization of care processes. Earlier studies in this country have shown that staff find that such interventions change practices, that the cooperation between contributors improves (23), treatment time is reduced (24), the number of operations performed increases (25), and the outcome for patients is better (26, 27).

    Objectives of the study

    Using the Care Process Self-Evaluation Tool (CPSET), we asked interdisciplinary teams in the specialist health service about their experiences with the organization of the treatment for specific patient groups. The aim of this sub-study was to map the staff’s perceptions of the degree to which the organization was patient focused, how well the treatment for the patient groups was coordinated, how well the communication with patient and family worked, how well the collaboration with primary care worked, and whether the standardization of care processes was followed up. A further goal was to examine whether the staff considered the organization to be better in the care processes that were standardized using a written clinical procedure compared to pathways without such procedures.

    Method

    Design and participants

    In this study, staff took part from a total of six somatic hospitals and six psychiatric units in three of the four health enterprises in Western Norway Regional Health Authority: Førde Hospital Trust, Bergen Hospital Trust and Fonna Hospital Trust. The units included varied considerably in size, and both urban and more rural institutions participated. Participants were recruited at the care process, team and individual level. The goal was to include care processes within a wide range of conditions. Care processes were selected after asking senior managers in the health enterprises if units in their organization could provide data from specific care processes. In consultation with researchers and professionals, the managers selected relevant care processes and designated a contact person for each.

    The goal was to include care processes within a wide range of conditions.

    Care processes were defined according to the patient group, and were based on diagnosis or clinical images. Each individual care process should be typical of and represent a large share of the patients in the units, such as a ‘tonsillectomy’ patient in an ear, nose and throat unit. The contact persons knew both the patient group and the staff who were involved in their treatment. These contact persons provided a list of staff who made up the interdisciplinary team responsible for the treatment of patients in the selected care process. The following inclusion criteria were applied to the members of the team:

    • All occupation groups that were involved in the treatment of the patient group.
    • The respondents should have daily contact with the relevant patient group.

    We then sent information about the project and a link to the questionnaire in Corporater Surveyor v.3.3 (Corporater Inc.) in an e-mail to 503 selected health personnel in 27 teams in 2012 and 2013.

    At the start of the questionnaire, the patients were instructed on which patient group they should relate their answers to. For example, the respondents in the units where the care process for COPD was to be evaluated were instructed to answer the CPSET questions based on their experiences with the organization of treatment for patients with COPD in their units. A reminder was sent out to those who were invited to take part. The responses received were deidentified. In order to protect the anonymity of respondents, the ‘key’ that linked their identity to the analysis file was stored by Western Norway Regional Health Authority’s ICT service provider, Helse Vest IKT, in line with the regulations. The project was approved by the Norwegian Social Science Data Services, now known as the Norwegian Centre for Research Data (NSD). Table 1 shows the participating care processes:

    Table 1: Overview of care processes included, response rates, valid answers and percentage of respondents with valid answers who report that written clinical procedures are in daily use in the pathway (N = 503)

    The CPSET questionnaire

    The CPSET is a questionnaire developed by researchers at the Catholic University of Leuven (KU Leuven) in Belgium, and is validated in the Belgian-Dutch Clinical Pathway Network in collaboration with the E-P-A (28-30). Patients, health care managers and a variety of professionals helped to develop the instrument (29). The questionnaire can be useful both for mapping the organization of specific work processes in a team perspective and for evaluating work aimed at improving the quality of processes in hospitals and research.

    The form is used in several European countries (30, 31), and is currently being tested in France, Italy, Ireland and Germany. The CPSET measures how well work processes performed by interdisciplinary teams for specific patient groups in hospitals are organized, and asks respondents to give their opinions on 29 statements covering five conceptual areas (29, 30). The areas are represented by the following sub-scales:

    • Patient-focused organization (P01–PO6)
    • Coordination of the care process (COR1–COR7)
    • Communication with patient and family (COM1–COM4)
    • Collaboration with primary care (SE1–SE3)
    • Monitoring and follow-up of the care process (OP1–OP9)

    The health care worker gives a score for each statement using an ordinal scale from 1 to 10, where 1 means ‘totally disagree’ and 10 means ‘totally agree’.

    An authorized translation agency translated the CPSET from the original Flemish to Norwegian. As a pilot, we first tested the translated version using ten professionals in the specialist health service (32). These came from various disciplines at a medium-size hospital in Western Norway Regional Health Authority. The feedback from the professionals suggested that the understanding of key terms, such ‘ behandlingsprosess’, ‘ behandlingsline’, ‘ behandlingsforløp’ and ‘ pasientforløp’, which are translations of ‘care process’, ‘care pathway’, and ‘clinical pathway’, varied a lot, while the understanding of ‘written clinical procedure for the care process’ was mostly good.

    We therefore chose to translate ‘care pathways’ that referred to interventions aimed at standardizing the treatment process as ‘written clinical procedure for the care process’. In the study, we asked the respondents to answer the following questions: ‘Is there a written clinical procedure for the care process in the daily treatment of patients?’, and ‘If the procedure description/care pathway is being developed or currently in use, how many months has this been the case?’

    Statistical approach

    Because we had data from a variety of care processes, we chose to show the CPSET scores within each care process descriptively by giving an average, with upper and lower limits for a 95 per cent confidence interval (CI). This enabled us to see the pattern in the CPSET scores without having to conduct statistical tests with many comparisons. We wanted to test the disparities in the CPSET sub-scales and overarching scales between the groups who responded ‘yes’, ‘being developed’ or ‘no’ to the question of whether a written clinical procedure was used in the relevant care process. For this we used the Kruskal-Wallis test, with follow-up tests between sets of two groups. The tests were done in SPSS version 20 and were two-tailed with p-level 0.05.

    Results

    Response rate and valid care processes

    Of the 503 team members who were asked to complete the CPSET form, 293 (58 per cent) responded. This corresponds to 27 care processes for 17 different conditions, representing nine clinical areas (Table 1). Nineteen care processes/teams worked within somatics and eight were in mental health care. We excluded questionnaires that lacked answers to more than three of the 29 statements. For respondents who had answered 27 or more statements, we replaced the missing answers with the average of the scores for the remaining answers.

    We excluded five care processes that had fewer than five respondents with valid answers and/or a response rate below 40 per cent. The final analysis file (N = 239) thus consisted of 22 care processes. Of these, 17 related to somatics and five to mental health care. The average valid response rate in the care processes included was 56 per cent. Descriptive statistics for background variables in the valid sample are shown in Table 2.

    Table 2: Age of the respondents, gender, occupation and information on the use of written clinical procedures in care processes (N = 239)

    Health personnel’s perceptions of the organization in the selected care processes

    Figure 1 shows the average score with a 95 per cent CI for the 29 CPSET statements, in addition to the five sub-scales and the total scale in the valid sample (N = 239).

    Figure 2 shows the average score with a 95 per cent CI for CPSET total scores per valid care process in the field of surgery, medicine and psychiatry. Of all the 22 care processes included, health care personnel in the care pathway ‘In vitro fertilization (IVF)’ gave the highest CPSET total score (9.0). Further examination of the average score with a 95 per cent CI in Figure 2 shows that health care personnel in the three lung-patient care processes gave a significantly poorer total score on the CPSET than most other care processes.

    Staff in the care processes for stroke patients gave a significantly higher CPSET total score than those in the other processes. In the field of surgery, none of the processes stood out with a particularly high or low score. In mental health care, two care processes for patients with psychosis had significantly higher CPSET total scores than two of the other pathways in mental health care.

    _________________________________________________________________ Figure 1: Descriptive statistics of the CPSET total scale, sub-scales and sub-statements (N=239)
    Figure 2: Descriptive statistics of the CPSET total scale for each relevant care process (22 care processes, N = 239)

    CPSET scores per organizational area

    Examination of the 95 per cent CI limits on the five CPSET sub-scales (Figure 1) shows that the staff gave significantly higher scores on the sub-scales ‘Patient-focused organisation’ (PO) and ‘Coordination of the care process’ (COR) than on ‘Collaboration with primary care’ (SE) and ‘Monitoring and follow-up of the care process’ (OP).

    Improved organization with written clinical procedures?

    Table 2 shows the number of employees in the valid care processes who reported having a written clinical procedure in daily use in the care process. The total scores and sub-scores in the CPSET for employees in a care processes with a written clinical procedure in daily use were significantly higher than in the other two groups without a written clinical procedure in daily use (Table 3).

    Figure 3 shows that the CPSET sub-scores range from the lowest scores in the care processes with no written clinical procedure in daily use, to the highest scores in the care pathways with a written clinical procedure in daily use.

    Table 3: CPSET dimensions broken down according to whether a written clinical procedure was used in the care process (N=229)
    _________________________________________________________________ Figure 3: CPSET total score shown based on whether a written clinical procedure for the care process was used (N = 229)

    Discussion

    We found that the health care personnel’s perceptions of the organization of care processes in Western Norway Regional Health Authority vary, but on average they reported the quality of the organization as one point higher on the CPSET total scale than that reported by Belgian and Dutch health care staff in 2013 (30). However, among the Norwegian health care workers, the sub-scales ‘Monitoring and follow-up of the care process’ and ‘Collaboration with primary care’ were below average in relation to the Belgian and Dutch figures (30).

    Health care personnel’s perceptions of the organization of care processes in Western Norway Regional Health Authority vary.

    This finding, and the fact that the study sample considered the sub-scales ‘Monitoring and follow-up of the care process’ and ‘Collaboration with primary care’ to be poorer than ‘Patient-focused organization’ and ‘Coordination of the care process’ indicates that there is a need to improve the systematic follow-up of care pathways and the collaboration between primary care and specialist care in Norway.

    Clinical procedures are associated with higher scores

    Many studies have shown that standardizing care processes has a positive effect on teamwork and process outcomes in the health service (11, 16-21). In line with Vanhaecht et al. (2009) (17), we found that health care personnel considered the organization of care pathways with a written clinical procedure to be better than care processes that did not have such a procedure. In our study, care pathways with a written clinical procedure had the highest average CPSET scores. The staff in the highest scoring care pathways had been working systematically to improve the quality of treatment and follow-up of patients in recent years. The care processes with the lowest scores had either not adopted a written clinical procedure or the respondents were unsure whether such written procedures existed.

    Health care personnel considered the organization of care pathways with a written clinical procedure to be better than care processes that did not have such a procedure.

    Quality, efficiency and the safeguarding of comprehensive and coordinated care pathways are key elements of the regional health authorities’ mandate and of the new national research strategy Health&Care21 (33). A wide range of initiatives have been implemented over the last 20 years aimed at improving the quality of health services in Norway. These initiatives include various ‘Breakthrough’ projects such as the Norwegian Patient Safety Programme: In Safe Hands using Global Trigger Tool (34), and the introduction of checklists (35).

    This strong focus on quality and coordination in the Norwegian health service in recent years may be an alternative explanation as to why health care personnel in some care processes give the care process a lower score. Perhaps those who work with these care processes gave lower scores precisely because they set the bar high for themselves and their units when it comes to the organization of the care process.

    Varying perceptions of the ‘care pathway’ concept

    During the pilot study of CPSET, it emerged that professionals in the specialist health service interpreted the concepts of ‘care process’ and ‘care pathway’ in quite a few different ways. A written document describing necessary treatment measures in a sequential order is essential in most methods for standardizing care processes. However, we do not know of any Norwegian term for a comprehensive written document that corresponds to the English term ‘pathway document’ (10).

    In order to make it easier for the respondents to understand what we were looking for, we therefore used the term ‘written clinical procedure in the care process’ in the questionnaire. We do not know whether respondents considered this term to be ambiguous, and using ‘written clinical procedure in the care process’ instead of ‘standardized care process’ or ‘care pathway’ may have made the findings less valid.

    Some care processes, where health care personnel and managers had a strong focus on quality improvement, may have been more frequently included than other care processes, since the managers were asked to select care processes. However, the opposite is also conceivable, where managers who saw the need for improving the coordination of the treatment of patient groups in a unit wanted the staff who were responsible for this patient group to answer the CPSET statements.

    One other potential source of error is that the parties involved may have had different understandings of the ‘care process’ concept, and if the term was less relevant, it may have made the findings less accurate. On the other hand, it could be argued that the results have a strong ecological validity because the units themselves defined ‘care process’ based on how this term was understood by staff in the Norwegian specialist health service today.

    Not all disciplines were included

    We believe that because so many different disciplines, occupation groups and units were represented, the findings can be generalized to a greater extent than if only a few occupations, disciplines and care processes had been included. However, some important occupation groups did not respond to the CPSET. For example, radiologists and radiographers, who are key personnel in the processes for stroke patients, were not represented, and doctors were also generally underrepresented. Doctors often initiate treatment measures, and may therefore perceive the organization as better than other occupation groups.

    In the deep vein thrombosis (DVT) care pathway, only nurses were asked to participate, despite the fact that the CPSET was developed to measure the organization in an interdisciplinary team perspective. In general, nurses have close contact with the patient, and they can play a central role in the coordination between different occupation groups and units, but in this care pathway as well as others, overrepresentation or underrepresentation of occupation groups can lead to a somewhat skewed result.

    We have recently shown that the Norwegian version of the CPSET has acceptable psychometric attributes (convergent validity, reliability) (32). Other translated instruments that measure coordination and communication are the Relational Coordination Survey (RCS) (36, 37) and the Nijmegen Continuity Questionnaire (38).

    An important snapshot

    Despite the weaknesses of the study mentioned above, we believe that our results provide an important snapshot of care processes in the Norwegian context. Although care processes have been mapped and researched in Norway (23–27, 39–45), we do not know of any other large-scale studies that have used validated measuring instruments and extensive sampling from a wide range of units in the Norwegian health service. We therefore believe that the knowledge this study provides about the organization of care processes is useful for health care personnel and managers who have a strong focus on quality improvement and patient safety.

    Future research should link systematic quality work aimed at improving work processes to relevant outcome goals at the system and patient level. These may be related to complications, recovery and resource use. It will be particularly important to include the user perspective in future studies. This will throw light on whether and how the standardization of care processes impacts on the service user’s experiences of how they are approached and treated and whether they think they are given the opportunity to make important decisions about their own treatment and health care within the framework of standardization (46).

    Conclusion

    The average CPSET total score was higher than the equivalent international measurements. Staff in the specialist health service who were associated with care pathways that had a written clinical procedure reported better coordination of the treatment process than personnel in care processes where there was no such procedure.

    The specialist health service should improve the systematic and targeted quality work by standardizing and following up care processes.

    The specialist health service should improve the systematic and targeted quality work by standardizing and following up care processes, and the collaboration with primary care should be strengthened. In this work, we believe it is particularly important to protect the user’s perspective, both in relation to treatment experiences and outcomes.

    I would like to extend thanks to all staff in Western Norway Regional Health Authority who participated in the survey. Thanks also to Sissel Hauge at Stord Hospital for her linguistic assistance. The project was funded by the liaison committee in Western Norway Regional Health Authority through the Research Network on Integrated Health Care in Western Norway at Fonna Hospital Trust.

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    Norwegian health care personnel find the systematic follow-up of care pathways and the collaboration with the primary health service to be poorer than other organizational areas.

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    English
    Sammendrag

    Background: The organization of health care in Norway poses a number of challenges in terms of assessment, treatment and follow-up. The introduction of care pathways in oncology has increased the focus on systematic improvement of care processes as a means of quality improvement. However, it is unclear how well the existing care processes are currently organized.

    Objective: To assess health care personnel’s perceptions of the organization of care processes in the specialist health service in Norway.

    Method: The Care Process Self-Evaluation Tool (CPSET) assesses five dimensions of the organization of care processes: Patient-focused organization, Coordination of the care process, Communication with patients and family, Collaboration with primary care, and Monitoring and follow-up of the care process. Employees (N = 503) in 27 selected care processes in the Western Norway Regional Health Authority (Helse Vest) were asked to complete the CPSET. Analyses were based on responses from 239 employees in 22 valid care processes (48 per cent response rate).

    Results: The CPSET average score of 6.9 (standard deviation 1.80) in the sample was higher than comparable international figures. However, Norwegian employees considered the follow-up of the care process and the collaboration with primary care to be poorer than other dimensions of care organization. Care processes with a written clinical procedure were better organized than processes without such standardization.

    Conclusion: The specialist health service should improve the systematic follow-up of care pathways as well as the collaboration with primary care. 

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  • How parents react when their child is overweight

    The child health clinic and school health services have a long tradition of carrying out height and weight measurements during health check-ups of children and adolescents. Such check-ups have provided vital information and an overview of Norwegian children’s weight development. In 1998 however, the number of routine measurements of height and weight was reduced, and replaced by measurements undertaken when the public health nurse or doctor felt this was required on medical grounds (1). The reasons for the change in practice include a lack of documentation on the effect and usefulness of screening for height and weight, as well as concern that a focus on weight might trigger eating disorders (2).

    More children and adolescents are overweight

    The prevalence of overweight and obesity among children and adolescents has increased in recent decades and is described today as one of the greatest challenges in public health work (2–4). In Norway, 15 per cent of boys and 18 per cent of girls aged 4–16 are either overweight or obese (2). This increase places prevalence in Norway on a par with Great Britain and the other Nordic countries. 

    The prevalence of overweight and obesity among children and adolescents has increased in recent decades.

    Overweight and obesity constitute a complex challenge (5) that can partly be explained by more sedentary lifestyles combined with changed eating habits (6). The increase in weight is found in all social classes but overweight is more prevalent in the lower socioeconomic groups (7). Such groups are associated with less physical activity and a lower intake of fruit and vegetables (8, 9). Based on the weight increase, the Norwegian health authorities have decided to reintroduce systematic measurements of weight and height. They also recommend measures to prevent and treat overweight and obesity (2, 6).

    New guidelines

    In 2010, the Norwegian Directorate of Health issued national clinical guidelines for the primary health service on the prevention, assessment and treatment of overweight and obesity among children and adolescents (6). The guidelines describe the responsibility of health professionals for health-promoting and preventive measures, assessment and treatment. The measures are categorized based on iso-BMI. BMI stands for Body Mass Index, which is calculated on the basis of weight in kilograms divided by height in metres squared. Iso-BMI is BMI adjusted for age and gender (10). The World Health Organization (WHO) has classified weight in four iso-BMI levels (6, p. 31), as presented in table 1.

    Table 1. Classification, initiatives and responsibility at different iso-BMI levels

    An iso-BMI of 25 to 30 is defined as overweight (6), and the national clinical guidelines recommend individual assessment and counselling by the public health nurse for this group. Research shows that it is beneficial to initiate measures as early as possible since this can result in the child ‘outgrowing its overweight’ (6). In 2011, the Norwegian Directorate of Health also issued national clinical guidelines on measuring weight and height at the child health clinic and school health services designating the points in time recommended for measurement (2).

    Project to motivate lifestyle changes

    A project group from the child health clinic and school health services in a municipality in south-east Norway conducted a project in the 2011/2012 school year. The aim was to encourage overweight children and their parents to change their lifestyle. Based on the point of time recommended for height and weight measurements in the national clinical guidelines (2), the project group focused on children aged 4 and 8-9 (Year 3 of primary school).

    One cohort of Year 3 pupils from two schools, and four-year-olds from one cohort linked to a public health nurse at the child health clinic were given the opportunity to participate in the project. The project group made a strategic choice of two primary schools in order to include children from different social classes. The public health nurse at the health centre or at the child’s school informed the parents if weight and height measurements showed an iso-BMI of 25 or above. The children and their parents were invited to participate in one of the two following initiatives:

    1. Three counselling sessions with a public health nurse and a physiotherapist at 0, 1 and 6 months after the measurement.
    2. Three counselling sessions with a public health nurse and a physiotherapist at 0, 1 and 6 months after the measurement. In addition, the offer of participation in an activity group in the evening, once a week for eight weeks.

    The aim of the first counselling session was to map the eating and physical activity habits of the child and the family in order to motivate them to start a change process and help them to set goals (11). The public health nurse and the physiotherapist carried out two more sessions with the aim of providing further counselling as required.

    If the family agreed to participate in the second initiative, both the child and the parents were expected to take part in the activity groups, which consisted of different games and physical activity. A physiotherapist was responsible for the groups and conducted them in cooperation with physiotherapy students. As part of the activities offered, there were also two group sessions on the topic of diet. The parents of nine Year 3 pupils agreed to take part in either the counselling sessions (initiative 1) or the counselling sessions plus the activity group (initiative 2), while none of the parents of the four-year-olds wished to take part. 

    The study and its purpose

    In this study, we examine parents’ experiences with the project described above. In order to elicit parents’ perceptions, thoughts and experiences, we carried out a qualitative study with individual interviews (12). We wanted to acquire knowledge about how parents reacted to being told that their child was overweight, and how they felt about participating in counselling sessions and the activities offered. We applied to the Norwegian Centre for Research Data for permission and received approval to carry out our study.

    Method

    All nine parents who had participated in the project under the auspices of the child health clinic and school health services were asked to participate in the interview study. Six mothers agreed. Of the six who were interviewed, two participated in initiative 1 and four in initiative 2. Those who did not wish to participate said this was due to time constraints. We carried out the interviews in autumn 2012.

    The first author of the article headed the child health clinic during the project period, but had not met the parents prior to the project. She was also project manager and carried out the semi-structured interviews. In order to be able to ask follow-up questions aimed at acquiring a deeper understanding, the interview format was flexible (12). We transcribed the interviews verbatim and analysed them with a view to eliciting the parents’ perceptions. Both authors read the interview texts in their entirety and we collaborated in the further analysis process to elicit further nuances in meaning. We used Giorgi’s method of text condensation and identified key topics in the results (13).

    Results

    A key finding in this study is that parents who were contacted by the public health nurse on account of the child’s overweight had conflicting emotions. They were concerned about protecting the child from the feeling that he/she was not good enough, whilst also recognizing the need for change in order to counter the further development of overweight. The findings shared common features that are summarized in four main topics: 1) Perception of criticism of the child and oneself, 2) A wish to protect the child, 3) Concern about the child’s experiences, and 4) Raising awareness and support for lifestyle changes.

    Feeling that the child and the parents are being criticized

    The public health nurse called the parents and informed them that their son or daughter had shown a considerable weight increase since the last measurement performed by the school health services. In our study, all the telephone calls were answered by mothers, and their reactions varied from surprise and anger to gratitude that someone cared. Some of the mothers were single parents, but when the parents lived together, the mother had discussed this communication with the father. Several said that they were unprepared when the public health nurse called, and that they felt ashamed and had a need to defend themselves. They stated that a letter in advance of the telephone call would have prepared them better.

    Several felt that the child’s weight gain was not only a criticism of the child but also an indication that they had failed as parents:

    ‘But it’s like receiving a blow just where you’re most sensitive. And when it’s your child, it always hurts. And we kind of know that we haven’t done our job as parents. And there’s also an element of shame. You try to be positive and all that, but actually these feelings are still smouldering under the surface.’

    Several of the parents in the study said that they too struggled with their weight, and that it was difficult to help the child with something they could not deal with themselves:

    ‘It was actually difficult thinking – now I have to go there (to the public health nurse), and I’m a bit heavy myself, and they might think that I’m not capable of eating sensibly.’

    A wish to protect the child

    All the parents felt that it was negative to direct too much attention to weight. They were worried that their child might acquire negative feelings about his/her own body, and at worst develop an eating disorder. Therefore, they did not want the child to be present during the sessions with the public health nurse, or that the nurse spoke to him/her alone about the weight development. There were variations in to what extent the parents told the child about their own participation in counselling sessions with the school health services, or why they were participating.

    All the parents felt that it was negative to direct too much attention to weight.

    When both the child and the parents took part in the activities offered, several parents wanted to protect the child by saying that the activities were offered to all children. Other parents declined to take part because they were afraid that the child would be associated with ‘those who are overweight’.

    ‘And throughout the entire process he has never understood what he’s been part of. I don’t want him to go around thinking he’s fat, I don’t like the thought. I think he should have a good self-image, and that he should feel fine just as he is. The last thing I want is for him to find out in any way whatsoever that he’s chubby, or that he’s fat or that there’s something wrong with him, because there isn’t.’

    Concern about the child’s experiences

    Several parents said that the children perceived themselves as fat, and that they had said they were upset about this. Some of the children were very preoccupied with their weight, and weighed themselves every day. Several had received comments from their peers, and some had been teased by their fellow-pupils:

    ‘So he said himself that his tummy had grown big, and that he’d received comments in the shower at school that …, and he didn’t like that, so he was very upset about it. And this autumn he started Year 4, and they’ll have swimming so he’s dreading that, because of the girls.’

    ‘But he notices that when he has physical training, he soon starts sweating. And he thinks that’s uncomfortable. And he gets tired more quickly and lags a bit behind the others – they are faster.’

    The mothers were frightened that the child would take it as a criticism if they limited their food intake. This was particularly challenging if the child was the only one in the family who needed such restrictions. Several mothers wanted more attention paid to healthy food in teaching at school – as a topic for all the children regardless of weight. It was difficult, for example, if other children took food to school that their child had been told was ‘off limits’. 

    Raising awareness and support for lifestyle changes

    Despite feelings of shame and guilt, the mothers said that they wanted information about the child’s weight gain. Some had not been aware that the child had gained so much weight, and the counselling sessions with the school health services had raised their awareness sufficiently to deal with the situation. Others wanted closer follow-up and were very satisfied with both the activity groups and the counselling sessions. 

    Despite feelings of shame and guilt, the mothers said that they wanted information about the child’s weight gain.

    Taking part in physical activity without pressure to excel was a new and positive experience for the child. The mothers got ideas for different activities they could do together as a family, and that led to happy and satisfied children and positive parents. They received crucial support in their attempts to change the family’s routines, and felt it was positive that people other than the parents provided information about physical activity and a healthy diet. The mothers were aware that the child’s diet was their responsibility, but found it a challenge.

    ‘It feels good to sit around a table and talk about it, but how will we manage to do this at home, and how can we ensure that the children are happy with what we’re doing, without putting pressure on them in any way?’

    Discussion

    The interviews reveal that the child’s overweight is a sensitive issue for the parents. Several parents were also unprepared for being told that their child was in the overweight category, as other studies have also demonstrated. Parents are more frequently unprepared in the case of boys, and the younger the child, the more unprepared they are (14–16). Our study shows that it was difficult to involve the parents of four-year-olds; none of them wanted to be followed up by the child health clinic. Perhaps this is related to the fact that many do not think about overweight in connection with a small child (14), and public health nurses are often met with resistance when they point out the increase in a child’s weight.

    The child’s overweight is a sensitive issue for the parents.

    A new study, however, shows that overweight can be predicted from an early age, and when a small child’s iso-BMI increases, this should be noted (17). Parents feel that their parenting skills are being questioned when health personnel call attention to overweight. This perception is heightened when the parents themselves are overweight (10), as our study also found. Moreover, they feel that criticism is being aimed at a vulnerable and innocent child (18). Several of the parents in our study had unsuccessfully tried to lose weight, and they did not want their child to have the same experience. We see similar findings in another study (14).

    Uninformed, judgmental and disrespectful approaches to problems of overweight may lead to reluctance to seek help from health professionals (14, 19). Our study confirms that overweight is stigmatized and reflects norms in contemporary society. This confirms that the public health nurse’s professional attention to the child’s weight development demands both sensitivity and professionalism in the encounter with parents. The public health nurse must speak to the parents about the child’s weight and development, and find out what kind of help and guidance they want. It is vital to take the parents’ feelings of shame and guilt seriously when planning preventive measures (20).

    Parents have ambivalent feelings

    In our study, as in others (16, 18, 21), parents are afraid that a child will form a negative perception of its own body if attention is drawn to weight. Being the parents of a child with a big body can be perceived as an ambivalent process. On the one hand, the parents will do everything they can to ensure that the child is in good health and does not suffer from overweight. On the other hand, they have an even stronger desire for their child to have a good self-image (18). A longitudinal study of Canadian children aged 10–11 shows the correlation between overweight and the risk of developing low self-esteem and poor mental health later in life (21, 22). Children as young as four–five are preoccupied with their own bodies and what they look like (23), and several of the children in the study themselves thought that they were too fat, and had received comments from their fellow pupils and been teased. 

    It is vital that health professionals are concerned about the child’s self-esteem and mental health as well as the overweight.

    The public health nurse plays a dual role in that he/she ‘warns’ the parents that the child is too heavy, while also counselling the child and the parents on how to achieve a good self-image. This poses a dilemma. It is vital that health professionals are concerned about the child’s self-esteem and mental health as well as the overweight (16, 19). The session with the parents should focus on the opportunity to safeguard the child’s self-esteem while initiating the necessary measures to stop the overweight. We know that it is better if the child outgrows its overweight as opposed to waiting for the child to put on even more weight, when it is more difficult to treat (17, 24).

    Participated in activities

    Parents of overweight children have different reasons for declining to take part in interventions against overweight. For example, some people are frightened that the child will be viewed as overweight (16), as was found in our study. It is important to take this challenge seriously so as not to do more harm than good.

    Some mothers, nevertheless, chose to participate in the activity groups and found that being together with others with the same challenges was a help. They described how being physically active together with their own children and other parents and their children was a new and positive experience. Children’s sports activities often consist of various kinds of competitions instead of fun and games. Overweight children often feel a sense of defeat when they are not picked for the team, or when they realise that they cannot keep up (21). It is vital that there are alternative arenas where everyone can enjoy being physically active without being pressurized by a performance culture.

    In our study, it was the mothers who participated in conversations and the activities offered. They explained that the fathers had no opportunity to participate. A systematic study of the literature shows that the mother often plays a more active role than the father in terms of the family’s diet (25), but in our study it emerged that the mothers may need support in this respect. The fathers can provide such support but research indicates that fathers often do not regard themselves as a target group for the work of the child health clinic (26). This gives pause for thought in terms of efforts to promote health.

    The mothers in our study found the activities offered helpful, and they felt that they themselves were an important driver for activity and happy children. These perceptions are backed up by knowledge of the positive correlation between physical activity and self-image (21). Other studies also show that interventions focusing on physical activity and diet can have a positive effect on both weight and physical health (27, 28).

    Although our study was small, and the findings cannot be generalized, it nevertheless provides important knowledge about parents’ experience with initiatives at the child health clinic and school health services.

    Conclusion

    Our study provides fresh knowledge about how parents perceive the encounter with the child health clinic and school health services regarding efforts to prevent overweight and obesity. Parents feel that the child’s weight gain is not only equated with criticism of the child but also criticism that they have failed as parents. Having an overweight child can entail a sense of shame. In order to protect their children, parents do not want to include them in dialogue with the school health services. Public health nurses play an important role in disseminating new information that overweight children can become overweight adults, and that the earlier attempts are made to reverse this adverse development, the better.

    Lifestyle interventions can have a positive effect on the child’s weight development and health, and the public health nurse must support the parents in efforts to safeguard the child’s self-esteem in parallel with making changes to the level of activity and the diet. The study reveals that mothers feel that counselling sessions with the school health services are helpful, as is participation in the activities offered where they meet others in the same situation.

    A positive feature was that the intervention involved both parents and children, and that the competitive element was replaced by fun and games. However, it is vital to focus more on including the fathers. The parents who did not wish to participate in the activities offered found it problematic that the child might be associated with being overweight. More research is needed on how lifestyle interventions can prevent overweight and safeguard the child’s self-image.

    References

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    When staff in the child health clinic and school health services tell parents that their child is overweight, many feel both a sense of shame and guilt.

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    Sammendrag

    Background: National clinical guidelines recommend individual assessment and counselling of overweight children and adolescents by the child health clinic and school health services.

    Purpose: The purpose of the study was to acquire knowledge of how the parents of children aged 4 and 8−9 felt about being told that their child was overweight, and their experiences of participating in counselling sessions and activity groups.

    Method: A qualitative study with individual interviews of six mothers. We analysed the interviews using text condensation inspired by Giorgi’s method.

    Results: We found common features in parents’ experiences, which are summarized in four key topics: (1) Perception of criticism of the child and oneself, (2) A wish to protect the child, (3) Concern about the child’s experiences, and (4) Raising awareness and support for lifestyle changes.

    Conclusion: Parents not only feel that the child’s weight gain is criticism of the child, but also a criticism that they have failed as parents. Having an overweight child may be perceived as shameful. Counselling sessions organized by the school health services provided good support but parents do not want their child to take part in order to protect him/her. The parents who did not wish to participate in the activities offered found it problematic that the child might be associated with being overweight. Those who participated in the activities offered felt it was very helpful to be with others in the same situation. They emphasized the positive aspects of children and parents taking part in fun activities together. 

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  • Nutritional status assessment – a professional responsibility in community nursing

    Elderly home dwelling patients who suffer from multiple diseases, oral or dental problems, or who take multiple drugs may have reduced awareness of hunger and thirst. These problems may be underlying causes of malnutrition (1–3). Social isolation, depression and cognitive failure may also represent underlying risk factors of malnutrition (4–6). Norwegian and international studies have shown that the home-dwelling elderly are at risk of malnutrition (7–13). A number of studies point out that health care personnel have inadequate routines for, and insufficient knowledge of, the systematic recording of patients at risk of malnutrition (8, 14–16).

    As early as in 2003, the European Society for Clinical Nutrition (ESPEN) recommended the use of standardised screening tools for assessing nutritional risk (17). In 2009, the Norwegian Directorate of Health recommended the use of such tools in the Norwegian Professional Guidelines for Prevention and Treatment of Malnutrition (18). The guidelines imposed a duty on the primary health service to carry out an assessment of nutritional risk on admission or registration with the service, and monthly thereafter unless there are medical factors that indicate otherwise (18). 

    Guidelines may serve as a catalyst

    It is often a long and complicated incremental process to implement guidelines based on research-based knowledge in the healthcare services (19, 20). Nurses and managers in the primary health service must be given an opportunity to familiarise themselves with the knowledge base, how the guidelines may be interpreted and how they may benefit patients. They also need to reach agreement on how to incorporate the professional guidelines in the organisation’s local routines. At the same time, it is important that nurses become aware of and can account for their own understanding of what is important and reasonable nutritional practice. They must also have the opportunity to discuss different points of view with patients and their relatives (21).

    In other words, this is not a linear or technical process through which synthesised knowledge from research is transferred to practical actions. The guidelines may nevertheless serve as a catalyst that promotes knowledge-based clinical decisions in practice (20). McCormack and McCance (22) therefore maintain that the sharing of experiences is a basic requirement for practice development. Reflective group discussions on a focused theme may also form the starting point for participant and action oriented research collaborations (23–25). This type of research approach lends itself to involving several groups that follow their own discussion process, and then subject the resultant material to an analysis of the same theme (26).

    The purpose of this study was to investigate the ways in which community nurses interpret and uphold professionally sound nutritional practice in accordance with the requirements set out in the Norwegian Guidelines for Prevention and Treatment of Malnutrition (18).

    Method

    The study is based on and analyses qualitative data gathered through two practice development projects in which community nurses were asked to explore their own practices in relation to nutritional care. The study was carried out in two Norwegian municipalities, studies A and B, each with a population of approximately 20 000 (27, 28). The focus theme was the nutritional care provided by the community nurses and their respective interpretations of the requirements set out in the national guidelines for the profession. In study A the exploration of the community nurses’ nutritional practice was particularly focused on their use of a specific screening tool: the Nutrition Journal (Ernæringsjournalen). Data were analysed across the two projects in order to provide new insights, if possible, and involve new concepts (26).

    Sample

    We asked the managers of the community nursing services in the two municipalities to recruit nurses for participation in the practice development projects. They assisted with recruitment by issuing an information letter to their nurses. The inclusion criterion for study A was a full time work equivalent of 75 per cent. Five nurses gave their consent to participating in study A, while 14 nurses gave their consent to participating in study B. Two of the participants in study B were nursing supervisors. In total, 19 nurses agreed to take part, all of whom worked a full time equivalent of 75 per cent or more.

    Data collection

    The data collection method in both projects was cyclical, involving experience exchanges, critical reflection and practical problem solving (29). Participants attended a number of meetings to explore a focus theme (26). The researchers in studies A and B made use of thematic interview guides with open-ended questions adapted to the focus theme. Participants were given an opportunity to voice their experiences and to give practical examples of their nutritional work.

    The researchers conducting studies A and B encouraged participants to talk and reflect between themselves without exerting control (30). If anything was unclear or required further elaboration, the researchers would ask follow-up questions along the way. By utilizing multiple meetings and an explorative reflective approach, a number of different views, basic values and practice improvement proposals were put forward (25, 26). The third author was the research supervisor for both projects and a participant moderator in study B.

    We collected data over a six-month period from three groups of participants: one group of five nurses under study A and two groups under study B – one with nine (B1) and one with five (B2) participant nurses. Each group met on four occasions. The body of data consists of the researchers’ transcribed recordings of twelve group discussions, four from each group. The study A group of participants retained the same members throughout. In study B, the groups were open and new participants joined along the way, challenging the group consensus with questions and alternative views. The researchers drafted a summary note of each meeting. The note was approved by the participants at the start of the next meeting. Themes for further exploration were carried forward to the next theme guide. This procedure strengthens the participants’ involvement with the knowledge process and the studies’ communicative validity (31).

    Analysis

    This study provides an analysis of the content of the twelve group discussions as well as the researchers’ reflections in retrospect on the possibilities and challenges encountered by the community nurses as they carry out their nutritional work. All authors studied the results of the two earlier projects. The qualitative content analysis was incremental, inspired by Graneheim and Lundman (32). As we identified meaning units, sub-themes and themes, we looked for patterns and categories across the material (table 1). When encoding the material we put emphasis on accommodating the community nurses’ different views (30). Our result chapter includes a number of quotes that highlight the participants’ different experiences.

    Table 1. Examples of analysis of meaning units, cross-cutting themes in the material

    The last analytic step involved an overall interpretation of the data material seen in the light of the study’s purpose as well as earlier research. This process saw the emergence of new dimensions and understandings of the community nurses’ nutritional work. These factors are presented in our discussion chapter, and they are also illustrated in figure 1 (see below). The discussion chapter further includes a critical assessment of the validity of the analyses.

    Ethical considerations

    The Data Protection Official for Research (NSD) considered studies A and B separately and gave their approval of both. All participants have given their informed consent in writing. Participation was voluntary and took place during working hours. According to the NSD, this study did not require further consideration and approval.

    Results

    The results are presented under four themes that were identified through our analyses of all the data: 1) support, 2) familiarity with the patients and their nutritional needs, 3) patient autonomy and the requirements relating to systematic nutritional assessment, and 4) practical challenges in providing nutritional care.

    Support

    The nurses were agreed that for systematic nutritional screening to be implemented, the support of the local authorities was required, as well as that of the management of the community nursing service. The managers must have an interest in and awareness of the theme: “The management needs to focus on it.” Nutritional screening must be integral to the organisation and routines must be implemented, both for staff who make decisions about the provision of care services in the home, and for the providers of such care, or in the words of the nurses: “It’s easy to let things slide; we need to have routine put in place.”

    In study A, the local authority had decided on the Nutrition Journal as their chosen screening tool. In study B, the local authority had yet to choose a specific nutritional screening tool. Participants in this study found it problematic that this indecision prevented them from implementing a nutritional screening tool.

    Familiarity with the patients and their nutritional needs

    The community nurses described the practical facilitation of meals in various patient situations as being significant. Several of them reported that they talked to their patients about what they had eaten on a daily basis, and about what they had in their fridge. The nurses emphasised that they were well acquainted with the patients and that they intervened as and when required: “We know them so well that we intervene straight away when the home becomes chaotic.” The nurses felt it was most important to prioritise the assessment of nutritional risk in the sickest patients, and in those who had lost considerable weight.

    The nurses discussed the definition of “malnutrition”. They said as follows: “We talk to them about not eating very much; we never say that they are malnourished.” A joint read-through of the national professional guidelines gave the nurses new understanding that malnourishment is the mismatch between the patient’s needs and their actual intake: “We knew that nutrition was important, but now we think more broadly.”

    The nurses strengthened their professional involvement with nutrition and local knowledge through group discussions. The nurses passed on this local knowledge through reports, in staff meetings and by providing guidance: “When the assistants say: ʻHe’s so skinny’, I explain that this means we need to keep records, you see.”

    Patient autonomy and the requirements for systematic nutritional assessment

    The nurses stressed their own respect for the home-dwellers’ autonomy. They put particular emphasis on the domestic arena as a private space and on behaving in ways they assumed to be appropriate in the patient’s own home. Some of the nurses felt it was inappropriate to weigh the patient, because this might affect the patient’s dignity and autonomy.

    Some of the nurses felt it was inappropriate to weigh the patient, because this might affect the patient’s dignity and autonomy.

    During group reflection sessions it emerged that the patients themselves were reluctant to step onto the scales, and this could influence the nurses so that they skipped the weighing. Others were worried about offending the elderly women’s “pride as a housewife”: “You can’t tell an old housewife that she is unable to look after her own food intake.” During the professional reflective sessions the nurses asked questions such as: “Is it natural for them not to want to eat that much any longer?” and “Should they be allowed to choose for themselves?” 

    The nurses felt it was challenging to keep track of the home-dwellers’ actual intake of food and drink. They were particularly concerned about dementia sufferers who forget to eat or drink, and felt it could be difficult to follow up with systematic recording: “We never make use of drink lists, as they might be drinking when we’re not around. They live at home, after all, so there is no point.”

    Practical challenges associated with providing nutritional care

    The nurses discussed how they could best prepare the patients for the nutritional screening. They felt it was best to provide information about the weighing and screening for nutritional status beforehand, for instance the evening before: “A bit of planning is required. You need to bring a set of scales, forms, measuring tape and such like.” Nurses who agreed a suitable time for the weighing with the patient, were positively received: “He’s been waiting for me with those scales, you know.”

    Nurses who suggested and carried out the weight check were surprised by the patients’ positive response: “I think the service users felt it was a positive thing; that it was a sign that we cared.” This motivated the nurses to raise questions about weighing with more patients. They found that systematic nutritional screening could be carried out in connection with other jobs. Relatives expressed that they were grateful for the screening. They were also grateful that professional attention was given to insufficient food intake and weight loss.

    The nurses felt that it was challenging to meet the requirement for systematic screening of the patient’s nutritional status.

    Because the nurses found that many had no scales in their own home, the community nursing service purchased several simple sets of scales. If the patient was unable to stand, there were practical challenges involved with conducting the weight check in the home. The nurses would then propose to delay the weighing until the patient was scheduled for a short stay in a nursing home. The nurses found that it could be difficult to measure height: “She is unable to stand upright.” They discussed other ways of measuring height, for example by taking under-arm measurements, but this method was never tested in practice.

    Study A made use of the Nutrition Journal screening form. This tool strengthened the nurses’ observations and their interaction with the patients: “We are able to make lots of observations while we are preoccupied with this.” New nutrition-related initiatives were implemented, and they evaluated the effect relative to the patient’s situation. In their evaluation summaries, the nurses pointed out that the nutritional screening did not take up much extra time: “It’s not as time-consuming as you think.”

    If the nurses were working under great pressure, some chose to postpone the nutritional screening to another day. A number of nurses in study B pointed to the staffing situation as a constraint that could prevent them from undertaking the nutritional screening. They were also critical of the local authorities’ practice of drawing up time schedules to the minute, which they felt was a professional constraint: “If the job is shower x 1, we will never ask about food before we see it is a problem.”

    When the nurses were planning meals for people with a poor appetite, they accentuated the social significance of meals: “Eating together creates a sense of wellbeing.” The nurses felt that for home-dwellers who live alone and whose food intake is low, eating in the company of others would be an important initiative to improve their wellbeing. They considered that co-eating was not feasible within the time constraints imposed on community nurses. They were also critical of the practice of re-heating dinners: “Three minutes of a faint aroma emanating from the microwave will never sharpen anyone’s appetite.”

    Discussion

    The community nurses considered that the provision of patient-centred, practical nutritional care was important. They felt that it was challenging to meet the requirement for systematic screening of the patient’s nutritional status. In institutions they are able to observe and screen the intake of foods and liquids, but in a domestic setting it can be difficult to undertake such observations and screenings if the home-dwelling patients forget what they eat and drink. They also pointed out that it may be inappropriate to make use of such recording practices in the home.

    In an effort to explain the complexity of the nutritional practice in community nursing, this is illustrated through four mutually dependent dimensions (figure 1).

    Figure 1. The four levels of nutritional care in community nursing

    The individual

    The first dimension includes the nurses’ knowledge and understanding of the home-dweller’s experience of their own life situation and personal challenges. This is the very core of the nurses’ practice. This person-centred perspective goes beyond the traditional perception of individualized care (33). Person-centred care means that the nurse is familiar with the individual’s values and life story, demonstrates responsiveness and attention and involves the individual in decisions about their own physical and mental care (33). This dimension involves an understanding that the patients’ assessment of their own functional abilities may differ from that of the health care personnel (34). Decisions made by the nurse are therefore the results of negotiations between nurse and patient (35).

    In nursing, nutritional person-centred care revolves around making practical arrangements for meals in cooperation with the home-dweller. Furthermore, the studies’ findings showed that the nurses were concerned about the food intake of dementia sufferers who live alone. The challenge for their nutritional practice was to support the home-dwellers autonomy while at the same time identifying the health-related challenges of reduced appetite and weight loss (6, 36).

    Some nurses assumed that the patients did not wish to be weighed and were surprised that the home-dwellers and their relatives took a positive attitude to the weight check. Relatives were grateful for the screening and for professional attention being paid to insufficient food intake and weight loss. These findings coincide with earlier research which has shown that relatives are often very concerned when the patient suffers involuntary weight loss (10, 37, 38). The discrepancy between the nurses’ assumptions and the home-dwellers’ experience of being weighed, highlights the importance of ensuring that community nurses are aware of the patient’s values and preferences in their nutritional work.

    The home

    The next dimension includes the importance of the domestic arena to the provision of nutritional care. The home may be described in positive terms such as security, intimacy, private life and control (39). The findings of our study showed that the nurses attached importance to the home-dwellers’ independence and dignity when referring to the home. This finding matches the traditional values of the community nursing service whose hallmarks include the preservation of domesticity, and ensuring that the home remains the individual patient’s arena (40).

    On the other hand, it was a challenge that the home visits were of short duration and gave little opportunity for systematic nursing observations around the clock. When seeking to develop the nutritional care work further, it will therefore be important to ask how the community nurses may strike a balance between what is appropriate in the private space, and the requirement for systematic observations.

    Practical arrangements

    The third dimension includes practical arrangements, which are often based on the nurses’ local knowledge relating to available time slots and their opportunity to prioritise tasks. The solution-oriented attitude of nurses with respect to practical nutritional interventions coincides with earlier studies of service-provision in the home (41). Within their own scope of action the nurses prioritised the sickest patients with a need for intake of nutrition. This matches reasonable expectations of the right course of action in a medical context (42).

    The screening and follow-up of a large number of people would result in greater workloads, and this requires a level of prioritisation beyond what is available to individual nurses within the confines of their shift. The assessment of nutritional risk should therefore be included in decision-making procedures, and screening tools should be included in the documentation system and daily schedules. A number of case studies have shown that the discussion about screening tools may end up with no screening tool being chosen because no agreement is reached about which is the most useful (43). The choice of a screening tool is therefore a necessary first step (43).

    The nutritional screening is intended to help ensure that malnutrition is not ignored.

    Our study showed that in one municipality, the managers were involved with the choice of a screening tool, while no such decision had been made in the other municipality. Inadequately resolute support was considered to be an obstacle to a change of practice. This finding coincides with other studies which point out that managers must be active participants and drivers in the quality development effort (25). The nutritional screening is intended to help ensure that malnutrition is not ignored. According to Juul and Frich (44), “bottom-up” and “top-down” processes are all useful and important for achieving change of practice. A lack of clarity with respect to areas of responsibility may therefore prevent the development of knowledge-based practice (44).

    Professional guidelines

    The fourth dimension includes the need for general knowledge about nutrition and the need to understand how the professional guidelines may be applied. It is also necessary to understand how malnutrition arises, and what actions must be followed up in order to draw up long-term strategies for change (43).

    In their reflective discussions the nurses discussed the requirements set out in the national professional guidelines with respect to assessments of nutritional risk. They voiced their professional appreciation of the need to record food intake and check the patients’ weight when assessing their nutritional risk (18). However, they also questioned whether it was possible to meet the nutritional risk assessment requirements with respect to all patients on registration with the community nursing service, and monthly thereafter.

    Furthermore, the wording of the guidelines was considered to be academic and far removed from the every-day language used in clinical practice. The nurses also had no experience of using standard tools for assessing nutritional risk. These findings were not unexpected. Earlier research has demonstrated negative attitudes among nursing staff to systematic screening and nutritional assessment (41, 45). The Norwegian Board of Health Supervision have found in their system audits that 80 per cent of all local authorities undertook no systematic risk assessment with respect to nutrition (46). This demonstrates that there is a need for greater knowledge and more systematic nutritional care in community nursing.

    The study’s strengths and weaknesses

    The focus theme of this study concerned the nutritional care provided by community nurses and the requirements set out in the national professional guidelines. It is a strength that the study is based on and analyses data from three different groups of nurses who had explored their own practice over time. At the same time, it is a challenge that data from these groups stem from two independent projects in which the nurses in study A were more action-oriented than those who took part in study B.

    The purpose of this study has therefore been to look for commonalities between the two earlier studies while ensuring that the nurses’ different views were voiced across all groups. While conducting our analyses we have however been aware that a pressure for consensus may be a possible source of error, causing participants to express a shared understanding while they in fact hold different views (26).

    In both projects the researchers made use of open-ended questions and invited the nurses to share their experience of providing nutritional care in compliance with the requirements of the professional guidelines. The methodology involving reflective discussions was used in both projects since the third author acted as research supervisor for study A and as participant moderator for study B.

    The objective is not to generalise from the results of the qualitative analyses (30). The study shows the nurses’ experiences while the researchers add theoretical knowledge and research methodology beyond their experience-based knowledge. Because there is little research-based knowledge available about the implementation of the Norwegian Guidelines for Prevention and Treatment of Malnutrition (18) in the community nursing service, the results of the study will have validity if they can contribute to continued discussion and inspire further studies.

    Conclusion

    The nutritional nursing care provided by the community nursing service is characterised by person-centred and practical approaches suitable for the domestic arena. Implementing standardised screening for nutritional risk, which is one of the requirements set out in the national professional guidelines, may therefore be seen as a challenge (18). On the other hand, the national professional guidelines create a shared knowledge base for managers and nurses. The findings of this study show that it is important to ask critical questions about whether the national professional guidelines take sufficient account of the domestic context. The community nurses have limited opportunities to accurately record the intake of food and drink around the clock.

    In order to strengthen the nutritional work carried out by community nurses, it is important to continue sharing experiences and to contribute to critical reflection on ways that standardised mapping tools may serve to provide quality assurance of practice. To implement systematic assessments of nutritional risk within the existing framework of resources, it is essential that management and staff within the community nursing service work in closer partnership with patients and their relatives. 

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    It is challenging for community nurses to screen their patients’ nutritional risk because the guidelines fail to take sufficient account of the domestic arena. 

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    Sammendrag

    Background: According to the recommendations set out in the Norwegian Guidelines for Prevention and Treatment of Malnutrition, community nurses must assess their patients’ nutritional risk at the time of admission or registration with the health service, and regularly every month thereafter.

    Purpose: To investigate how community nurses interpret and uphold sound professional practice with respect to the requirements set out in the Norwegian Guidelines for Prevention and Treatment of Malnutrition.

    Method: A qualitative study involving analysis of data from two practice development projects. The incremental analysis identified meaning units, sub-themes and themes (32). Four themes were identified and categorised from across the body of material. The data include twelve group interviews with nineteen nurses employed by two different local authorities.

    Results: Management support is important for the implementation of systematic nutritional screening. The nurses suggested that their familiarity with the patients and their nutritional needs is an important factor with respect to organising the practical arrangements in the home. The nurses felt it was challenging to assess the patient’s intake of food and drink around the clock. They found themselves in the field of tension between preserving the home dweller’s autonomy, complying with the recommendations for systematic nutritional screening and coping with pressures of time.

    Conclusion: Nutritional care is a person-centred, practical approach adjusted to the domestic arena. The community nurses ask whether the requirements of the professional guidelines take sufficient account of the home-based context. Close cooperation between managers and staff is required for systematic assessment of nutritional risk to be achieved within the constraints imposed by existing resources.

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  • Ethical reflection and awareness in supervision

    Clinical supervision is a complex activity that can be difficult to measure in terms of effect, and there are few randomised studies on the benefit of supervision. The studies that do exist show that supervision can be most effective when the focus is aimed at relevant and contextual themes. Due to the complexity of supervision, qualitative studies are best suited to exploring the impact of supervision and its potential transfer value in practice (1).

    If supervision is to be successful, it must be anchored locally. The supervisor must recognise the contextually complex challenges experienced by professional practitioners in their work (1). Many decisions in nursing practice are taken intuitively. Nursing supervision can provide an opportunity to reflect on ethical challenges. The supervision can also strengthen the nurses’ awareness when faced with difficult ethical choices (2).

    Obligations and ethical considerations

    A study on nursing in primary mental health and substance abuse work (3) shows that nurses working within this field are well qualified, with relevant further education and extensive clinical experience in working with pertinent target groups. The study also reveals that nurses possess qualities such as flexibility and pragmatism, and that they give priority to a relational cooperation with the patient.

    The binding relational cooperation with patients in different life crises at district psychiatric centres (DPC) entails a variety of ethical and professional requirements. Nurses may be affected by meetings with patients experiencing such life crises (4). The context in which the relational cooperation and the ethical requirement occurs can sometimes prevent nurses from doing what they feel is right for the patient. One such example may be when a nurse is instructed to discontinue an ongoing and unfinished collaboration process with a patient. An ethical awareness of what the nurse considers necessary, but is not allowed to carry through, may be a challenge, but it may also prevent moral stress in the long term (5).

    Responsibility versus authority

    It is important for professional practitioners to have collaborative relationships in which individuals’ ideas are challenged and safeguarded, and can develop jointly (6). Under the provisions of the Coordination Reform (7), professional practitioners at DPCs are required to collaborate with many different actors and agencies. The purpose of interprofessional, interdisciplinary and interagency collaboration in mental health work is to build a common value basis for the collaboration. Professional practitioners may, however, consider this challenging and complex (8, 9). Feeling a sense of personal responsibility when dealing with patients can sometimes represent an ethical dilemma and create problems (8). Nurses are responsible for their decisions, but they do not always have the authority to act in situations where other collaboration partners are involved. Responsibility and authority can be linked to both individuals and systems (2).

    The purpose of the study is to examine how ethical reflection in supervision can help raise awareness and prevent moral stress.

    We will elucidate two research questions:

    • What can be the theme of a supervision group that specifically raises questions about ethical challenges and collaboration?
    • How can supervision contribute to ethical awareness and reflection in interprofessional and interagency collaborations?

    Method

    Design, data collection and the focus of the supervision

    The study has a qualitative approach and a descriptive and exploratory design. We collected data from two 90-minute focus group interviews. The first of these was held in June 2013 prior to holding eight 90-minute supervision group meetings. The second focus group interview was held in August 2014 after the supervision group meetings. Focus group interviews are a suitable interview method for eliciting views and opinions about a specific topic. The group conversation can trigger various reflections and associations that can shed light on practices, thus providing a richer body of data than individual interviews (10). The second author led the focus group interviews. A digital audio recorder was used to record the interviews. The first author, who was also a group supervisor, transcribed the recordings verbatim.

    After describing a practice situation and reflections on this, the supervisor asked two specific reflective questions:

    • What do you think was the core ethical challenge in the situation that was presented?
    • What do you think were the main challenges in the collaboration in this situation?

    The keywords noted in a journal by the supervisor following the supervision group meetings also form part of the data source, and are included in the discussion.

    Sample

    We invited all of the nine psychiatric nurses at a DPC to take part in the study, and they all accepted. The participants were employed at the same workplace and therefore faced many of the same challenges in their daily work. Having a common starting point can be a benefit in the supervision (1). Seven of the participants were affiliated with the centre’s general psychiatric outpatient clinic, and two were affiliated with the substance abuse outpatient clinic. The participants had worked as psychiatric nurses at the centre for more than ten years.

    Ethical aspects

    The invitation to participate in supervision and a focus group interview was cleared with the participants’ manager. Because the supervision was part of a research project at our college, it was provided free of charge by the first author. All of the participants received written and oral information about the project and gave written consent to participation. We have not recorded personal data relating to the participants, their collaboration partners and/or patients and their families. Only the professional and ethical content of the collaborative situations has been described and analysed. The Norwegian Centre for Research Data (NSD) did not impose a notification requirement on the study.

    Analysis

    We have used a hermeneutic-phenomenological method to analyse the text with a view to understanding and describing the nurses’ subjective experiences of their working day. As researchers, we have searched for meaning and understanding through an interpretative process: we first read the text whilst remaining as open-minded and non-judgemental as possible. Then we conducted a structural analysis before formulating an overall understanding (11).

    On first reading, we endeavoured to maintain an open mind, and were empathic to the content of the text. Repeated readings led us to a structural analysis. The structural analysis was conducted by identifying statements that link the participants’ experiences in four meaningful themes. The overall understanding emanates from the participants’ descriptions of different collaborative situations.

    The first and second author carried out the main analysis. The third author was a participant in the focus group interview and the supervision group. She subsequently participated in the research process by reading the texts and giving comments.

    Results

    Here we present first the researchers’ overall understanding of the ethical challenges described by the study participants. We have summarised the overall understanding in a statement used by several interviewees. The statement is: ‘I feel frustrated on the patient’s behalf’. Then we describe the study results from the structural analysis through four meaningful themes.

    The statement reflecting the overall understanding of the study was used by the participants to describe situations where they considered the treatment offered to the patients to be inadequate. They expressed concern that patients did not receive the necessary health care within a reasonable period of time. The statement was also linked to the participants’ perception that the assistance offered to the patients was not good enough. One participant said the following in relation to how it feels when management lacks understanding in such situations:

    ‘We feel a bit useless sometimes. Patients are suffering. Treatment doesn’t help. When I raise the issue with management, they say, “What do you want me to tell you? Just end the treatment!” All I ask is that we discuss what is beneficial.’

    Theme 1: The tension between professional and ethical dilemmas

    ‘Patient assessment means moving away from ethics – there are an increasing number of assessments and diagnoses.’

    This is a quote from a participant who described the sense of tension between professional and moral dilemmas when dealing with patients. On the one hand, participants felt a professional obligation to follow the existing guidelines. On the other hand, they felt a sense of loyalty to protect the patient ethically. One participant made the following comment:

    ‘Prioritising means rejecting the patient – it leads to a feeling of shame and touches on existential issues.’

    The participants spoke about meetings with patients that touched them personally. At the same time, they felt an obligation to take into account the requirements of the treatment system, which they were also part of. One such statement was as follows:

    ‘I am often touched by a situation, and when I am, I have a good tool to draw on. When I'm not affected; those are the ones I spend the most time on in supervision.’

    Emotional experiences such as sadness, loss of confidence, feelings of inadequacy, shame, and being unable to adapt the nursing care to the individual patient were topics discussed. Participants expressed the feeling of being unable to show compassion and having insufficient time to get more involved as ethical and professional dilemmas.

    I despair about the things I don’t have time to do and that I am not allowed to do. Sometimes I do it in secret.
    Focus group participant

    The participants felt they had a solid professional basis for considering what they thought was necessary for the patients they were responsible for. This self-assuredness could present a challenge when they were expected to follow management’s wishes and requirements. The following two statements exemplify this:

    ‘A bad conscience for not doing what you should.’

    ‘I despair about the things I don’t have time to do and that I am not allowed to do. Sometimes I do it in secret.’

    According to the participants, ethical questions were neither adequately discussed nor prioritised in their daily work. The participants often felt alone when dealing with ethical issues, with one making the following observation:

    ‘Ethics and ethical issues sound good – like decorations on a cake. But any time I have raised the subject, I haven’t got anywhere.’

    Theme 2: The dilemma between patient needs and the treatment system

    The participants described how the framework for the help they should give has become narrower. They meet patients with major challenges, but find that the systems in the specialist health service and the first line do not have a holistic approach and are limited in terms of time. One participant described the experience of not being able to accommodate the patient due to a constricted framework as follows:

    ‘The patient is falling by the wayside. The framework is not fit for purpose.’

    The participants put a large emphasis on situations where they had to refer a patient for treatment at a different level when they knew that treatment did not work or did not exist. Expressions like ‘to witness’, ‘end the treatment and then what?’ and ‘to feel shame’ were used in relation to such experiences.

    They experienced several ethical dilemmas. One example was the treatment system’s guidelines, which were not adapted to individual patients’ needs for time and pace. Another example was that the treatment should be quick and effective:

    ‘Challenge the patient at a suitable pace – don’t just thrust her into exposure therapy! That would be unethical.’

    The participants used the relationship between professional practitioners and systems to describe ethical reflection in the team collaboration. The participants had varying experiences here; some expressed that there was no ethical reflection in the collaboration, while others commented that ethical reflection was an integral part of the daily collaboration in the team.

    Theme 3: The challenges of the collaboration

    The participants described ethical challenges related to collaborative situations, where, as nurses, they felt the gap between treatment needs and treatment options was too great. They also told of collaborative situations where they felt that the dignity and autonomy of patients were not adequately protected. They described situations where the duty of confidentiality obstructed therapeutic openness. They discussed the need for fast and seamless interventions instead of slow systems bound by rules. One participant described how rules that are too stringent can mean less flexibility:

    ‘Being tied down by rules gives fewer opportunities to act.’

    The participants described ethically challenging situations where the duty of confidentiality obstructed the necessary therapeutic openness.

    Several of the professional groups in the team they belonged to shared this opinion. Ethical issues in different collaborative situations were in evidence irrespective of the profession according to the participants, as reflected in the following statement:

    ‘The systems are after all made up of people... Rigidity exists in all disciplines.’

    The participants described ethically challenging situations when the duty of confidentiality obstructed the necessary therapeutic openness. One such example was a patient who did not want his GP to know that he was receiving treatment for substance abuse at a DPC.

    Theme 4: The impact of supervision on ethical awareness and exercising resolve

    The participants said that the supervision had positive effects, such as strengthening their resolve and making them more aware of their values. Other examples were that they became more reflective and articulate, particularly when there was a disagreement in the collaboration:

    ‘Explaining ethical dilemmas can have an effect on the system – the system world. The supervision has strengthened my courage.’

    The participants felt that the systematic and specific ethical reflection in the supervision was practical and relevant. It also helped to clarify the values of their professional role and the moral responsibility they had for the patients. Some participants felt a sense of shame when they were unable to act, in terms of their own values, the patients’ needs and the requirements of the treatment system.

    Awareness of own values in a collaborative situation is probably also more important than finding clear answers, with one participant making the following observation:

    ‘A dilemma is by its very nature unsolvable – which makes it hard to come up with good answers! The question that has been asked: What is the core challenge here? I think that’s good. It makes us think. And finding an answer isn’t easy.’

    Another theme was that raising issues ‘behind someone’s back’, such as in a supervision group where the other party is not present, could in itself be an area of vulnerability and be perceived as an ethical dilemma.

    Discussion

    The overall understanding of the study ‘I feel frustrated on the patient’s behalf’ can be interpreted as an expression that the nurses recognise and care about the patients’ unfortunate experiences in their dealings with treatment systems. The participants’ descriptions of their practice confirm that they are expert nurses (12), and as such their work with the patient is based on intuitive clinical judgment and a large degree of flexibility (3). They also describe how these characteristics clash with the restrictive frameworks and guidelines.

    The phrase ‘on the patient’s behalf’ can be understood as an expression of values ​​that relate to the nurses’ personal and professional responsibilities and obligations in their dealings with individual patients. General basic values ​​in nursing are linked to the individual’s life and inherent dignity (13). The participants describe how individual adaptation of measures is often ignored in favour of more general measures. One example of individual adaptation was an appropriate timeframe and pace for a young person who needs a certain amount of time to build a relationship of trust with the nurse.

    Ethical dilemmas could arise because clinical judgment and desired treatment for the patient are at odds with systems that prevent the nurses from fulfilling the individual patient’s needs. Such individual adaptation can be described as ‘tailored’, while the term ‘ready-made’ could be applied to measures that are appropriate for a group of patients with the same diagnosis (14).

    Experiencing moral stress and shame

    The nurses in this study reported experiencing moral stress when working in systems that made it difficult for them to act in accordance with their responsibilities and obligations (15). Moral stress differs from other forms of stress, and is manifested when professional obligations and professional integrity are compromised, thus creating a barrier to acting in an ethically appropriate manner (15).

    Loyalty to what is necessary for the patient appears to play a significant role in the participants’ professional and ethical considerations.

    The study participants reported that they were prevented from performing the nursing care they considered necessary and in line with basic care values. This made them feel a sense of shame. Shame is linked to the self or to the person we want to be (16). We may feel shame when we are party to actions that are contrary to the ideals we formed during our education, and which we wish to live by (17). The participants associate shame and existential issues with priorities that led them to reject patients. Loyalty to what is necessary for the patient appears to play a significant role in the participants’ professional and ethical considerations.

    One participant claimed that ‘ethical reflection helps prevent the lifeworld from being colonised by the system world’. The statement can be understood as a perceived conflict of values when the practitioner’s values are compromised in interaction situations in which they act on the patient’s behalf. Work on ethical awareness in supervision may have served as a counterweight to structural power that empowers professional practitioners (18). If nurses are to clearly identify problems and find good alternatives for action, both the lifeworld and the system world must be discussed and differentiated in the supervision (19). Although framework conditions may be at odds with a person’s conscience and the professional code of ethics, being aware of the moral responsibility in every situation will make the nurses more attentive and vigilant (20).

    Ethical challenges

    When the scope to act was too constricted, the participants sometimes dealt with their ethical challenges, or the dilemma they were facing, by keeping actions secret from collaboration partners. This may be a way of taking back power in a context where power structures define the content of a patient’s treatment. Dealing with the ethical challenges in this way can accommodate the patient’s needs and reduce the nurse’s dilemma.

    Based on a more comprehensive and societal argument, using this method to deal with ethically challenging situations may undermine important professional and ethical grounds for what patients need. If conversations about ethical challenges, choices and decisions are part of the professional practitioner’s working day, they can become an interdisciplinary and interprofessional collaboration. In the long term, this may benefit more patients (21).

    Bad conscience when they are unable to meet their obligation

    The phenomena ‘responsibility’ and ‘duty’ appear to represent important care values for the nurses in this study. The way in which they describe their sense of responsibility can be understood as a combination of professional responsibility as enshrined in the legislation (22) and work ethics guidelines (13), and a personally perceived responsibility that can be understood as an individual and existentially substantiated responsibility (20).

    When the participants find that they are unable to meet their obligation, they feel a sense of despair and have a bad conscience. They describe it as being witness to something they consider inadequate or wrong for the individual patient. The perceived dilemma can be understood as a gap between what they think is appropriate and correct for a patient and what is actually offered. For the nurses, witnessing something can entail watching something happen without being able to exercise their responsibility and carry out their duty. This can partly explain the bad conscience that participants expressed in several of the supervision group meetings and the focus group interviews.

    Collaboration challenges

    The study’s other research question asks how supervision can contribute to ethical awareness and reflection in interprofessional and interagency collaborations. The participants consider the opportunity that the supervision provides for focused reflection on ethics and collaboration to be more important than finding clear answers. This concurs with other descriptions of expert nurses’ experiences and needs in supervision (8).

    The results from the focus group interviews are consistent with the themes in the supervision group, which are, for the most part, descriptions of challenges related to systems and frameworks as opposed to the participants’ day-to-day collaboration partners. The participants described it as an ethical dilemma ‘to go behind someone’s back’, and did not therefore want to discuss collaborative situations from the interprofessional team they worked with on a daily basis. Supervision teams, made up of various professions working together on treating patients, could generate a wider variety of perspectives (23) than supervision groups composed of just one profession.

    Reflection in the supervision

    In this study, we sought to delimit our focus on the supervision by using two specific reflective questions for the narratives about practice. One question was aimed at the core of the ethical challenge in situations from practice. This delimitation can make the supervision more targeted and more measurable (1). The opportunity to think about defined themes and in a focused manner was appreciated by the participants.

    One participant describes how reflections in supervision related to ethics and collaboration have given them the resolve to influence the systems.

    One participant describes how reflections in supervision related to ethics and collaboration have given them the courage to influence the systems. Courage can be attributed to qualities such as strength, resolve and boldness (24). As such, we suggest that supervision that focuses on reflection on ethical challenges and collaboration can help create a greater scope to act.

    Supervision can be described as the ‘space for reflection’, where we consider practice with the benefit of hindsight, and where professional practitioners have the time and opportunity to think slowly (8). Clinical practice, where meetings with patients and collaboration take place, is on the other hand characterised by rapid, instinctive and emotional assessments and decisions (25). We can use the term ‘slow thinking’ about the form of ethical awareness that took place in the supervision in this study (25). The term entails a slower and more reflective process than when in the middle of complex and challenging practice situations. In a supervision group, the supervisor can ensure that professional practitioners review ethically challenging situations from practice at a slow pace. The slow review enables plenty of time for reflection, and can help the practitioner to make more integrated, conscious and moral choices (2), which in turn strengthen courage.

    Limitations of the study

    This study focuses on describing how nurses can reflect on ethical challenges in the collaboration with the patient and treatment system. Such reflection can lead to greater awareness of ethical values. The results of the study may have been influenced by the fact that the participants were all from the same workplace and the supervisor had a dual role as a researcher and professional. Proximity with the field of research is useful, but may also be a weakness, and requires conscious reflection on preconceptions (26). If the results are to be useful to others, the interpretations in the study must provide recognition and meaning in the reader’s lifeworld. In addition, the results must be used to improve practice.

    Conclusion

    Collaboration can be described as an interaction in which individuals’ values are under threat from different systems. The system world can be at odds with and affect individual values and norms for good practice, and can represent a source of anguish for professional practitioners. When supervision specifically focuses on reflection on ethical dilemmas in interprofessional and interagency collaborations, it appears that the choice of values faced by professionals becomes clearer. Raising awareness in supervision can help the individual professional practitioner to find the courage to articulate and clarify important ethical care values in practice. The fact that courage can be the result of ethical awareness in supervision is a new and interesting phenomenon to pursue in further research.

    References

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    2.      Berggren I, Barbosa da Silva A, Severinsson E. Core ethical issues of nursing supervision. Nursing and Health Sciences 2005;(7):21–8.

    3.      Karlsson B, Kim SH. Sykepleie i kommunalt helse- og rusarbeid. Forskningsrapport nr. 16/2015. Senter for psykisk helse og rus: Høgskolen i Buskerud og Vestfold. Available at: https://brage.bibsys.no/xmlui/bitstream/handle/11250/298288/Forskningsrapport%20IFPR%2016-2015.pdf?sequence=1&isAllowed=y(downloaded 30.03.2017).

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    6.      Aasland DG, Eide SB. Samarbeid og etikk: Jeg, vi og den andre. I: Aasland DG, Eide SB, Grelland HH, Kristiansen A, Sævareid HI og Aasland DG. Fordi vi er mennesker; en bok om samarbeidets etikk. Fagbokforlaget, Bergen. 2011.

    7.      Samhandlingsreformen. Helse- og omsorgsdepartementet. 2012. Available at: https://www.regjeringen.no/no/tema/helse-og-omsorg/helse--og-omsorgstjenester-i-kommunene/samhandlingsreformen/id680424/(downloaded 19.04.2017).

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    10.    Lerdal A, Karlsson B. Bruk av fokusgruppeintervju. Sykepleien Forskning 2008; 3(3):172–5. Available at: https://sykepleien.no/forskning/2009/02/bruk-av-fokusgruppeintervju(downloaded 30.03.2017).

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    14.    Kinn LG, Ekeland T-J, Byrkjeflot H. Psykisk helsearbeid: konfeksjon eller skreddersøm? Tidsskrift for velferdsforskning 2012;15:23–6.

    15.    Lamiani G, Borghi L, Argentero P. When healthcare professionals cannot do the right thing: A systematic review of moral distress and its correlates. Journal of Health Psychology 2015; July28:1–17.

    16.    Mesel T. Når noe går galt. Fortellinger om skam, skyld og ansvar i helsetjenesten. Cappelen Damm, Oslo. 2014.

    17.    Martinsen K. Evidens – begrensende eller opplysende? I: Martinsen K, Eriksson K. Å se og å innse. Om ulike former for evidens. Akribe, Oslo. 2009.

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    25.    Kahneman D. Thinking, fast and slow. Farrar, Straus and Giroux, New York. 2011.

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    Nurses can experience moral stress and feel a sense of shame when they are torn between a patient’s needs and the requirements of the treatment system. Ethical reflection in supervision can help.

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    English
    Sammendrag

    Background: Perceived personal responsibility in the interprofessional collaboration with patients can represent an ethical dilemma. We wanted to explore whether ethical reflection in supervision could stimulate reflection and raise awareness in relation to interaction in practice.

    Objective: To examine how ethical reflection in supervision can help to raise awareness and prevent moral stress.

    Method: The study was exploratory and descriptive. We collected data from two focus group interviews before and after eight supervision group meetings with nine psychiatric nurses. The supervision focused on two main questions: What was the core ethical challenge in the situation, and what was the main challenge in the collaboration related to this situation? A hermeneutic-phenomenological approach was used to analyse the data.

    Results: The overall understanding is summarised in the statement: ‘I feel frustrated on the patient’s behalf’ – a statement that was used by several participants. We identified four themes: the tension between professional and ethical dilemmas, the dilemma between patient needs and the treatment system, the challenges of the collaboration and the impact of supervision on ethical awareness.

    Conclusion: Collaboration can be described as an interaction in which a person’s values are under threat from different systems. Supervision can help to raise ethical awareness of what is at stake in the collaboration between the patient and the treatment system. Ethical awareness can help the professional practitioner to work up the courage to articulate and clarify important ethical care values in practice.

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  • Co-ordinated collaborative meetings as patients transition from the psychogeriatric health service

    In recent years, co-ordination issues have received increased attention in Norwegian health policy (1) and research (2, 3). The national health and care plan for 2011–2015 revealed that many patients still experience discontinuity of treatment. Inadequate continuity of care may give rise to insecurity, provision of incorrect treatment and care, inefficient services and a reduced quality of life for patients and their relatives (4).

    In 2013 the Norwegian Directorate of Health issued a circular concerning national objectives and priorities within the health and care services (5). It was pointed out that discontinuity of care and disrupted service provision, as well as inadequate communication, often occurs at the point of transition between hospital and nursing home. Regional health trusts were asked to follow up collaboration agreements and to “facilitate co-operation and dialogue meetings involving the primary health service, the specialised health service and other service providers” (author’s italics) (5, p. 21).

    Health care personnel across all disciplines and service sectors must give due attention to information transfer in order to ensure that good and health-promoting relationships are sustained between patients and health professionals throughout the course of the patient’s treatment (4). The exchange of knowledge, information and experiences in connection with the hospital discharge process is of great importance to the continued development of services, the continuity of care and a medically acceptable patient progression.

    Co-ordinated collaboration in the mental health services

    Serious mental disorders in the elderly are often complex in nature (6). When patients are in the vulnerable phase of being transferred from a psychogeriatric hospital ward to a nursing home, the challenge is to ensure that health care personnel work in partnership in order to avoid discontinuity of interventions, relationships, objectives and treatments (5). Earlier research shows that successful interaction between the different parts of the mental health service can be brought about by influences from the system level, organisational level and interpersonal level (3).

    Individual service providers can deliver collaborative interaction if the premise for interdisciplinary collaboration has been established at the organisational level. There are reciprocal influences at work between the education system, the organisation of the healthcare system, government policies, ideologies, structures, resources, shared objectives, and the willingness to co-operate and communicate (7–10).

    Co-ordinated collaboration involves more specific commitment than co-operation.

    Co-ordinated collaboration involves more specific commitment than co-operation. The concept involves a commitment to do something together in order to ensure that the work processes are streamlined and that services and measures are co-ordinated (11–13). This requires colleagues to make mutual adjustments to their respective jobs. Collaboration amongst individuals requires “trust, reciprocity and equality” and a shared understanding of the situation (11, p. 257).

    Description of the study

    This is a qualitative study which forms part of a larger participation-based research project entitled PASSUS (patient-oriented collaboration at the point of discharge into nursing homes) (14), set up to study quality development and actions. The objective of PASSUS is to develop and test a new collaborative model that might improve the discharge process, the continuity of care and the exchange of information between psychogeriatric hospital departments and sheltered or long-stay nursing home units at personal and system levels (14, 15).

    One of the improvement measures put forward in the collaborative model was to conduct collaborative meeting across disciplines and service sectors at the nursing home two weeks after discharge (14). The purpose of this sub-study was to examine the experiences of the health care professionals who attended these collaborative meetings. The sub-study was restricted to descriptions submitted by participating health care personnel of their own role and professional contribution to an interactive process. 

    Method

    The study has a descriptive qualitative design and is based on written notes from twelve collaborative meetings. The meetings were held at the nursing homes approximately two weeks after the patient had been discharged from the psychogeriatric hospital ward. Every collaborative meeting was attended by at least one specialist nurse and one psychiatrist from the hospital, as well as at least one nursing home doctor, primary contact or manager.

    The collaborative meetings accommodated a mutual exchange of information concerning the patients’ symptoms and functioning in their new surroundings. The forum was used to discuss how the transfer of information had worked, and whether the measures proposed by the psychogeriatric service had proved effective. After each meeting, all participants would complete a self-reporting form by answering the following open-ended questions:

    • What were your contributions to the collaborative meeting?
    • What are your thoughts about the collaborative meeting?
    • What have you learnt?

    The questions had been drawn up in liaison with representatives of the nursing homes involved and the work group that had been set up at the psychogeriatric department as part of the preparations for PASSUS (14).

    Sample

    We recruited the responsible doctor or psychiatrist from the psychogeriatric department as well as a specialist nurse who was familiar with the relevant patient, and who had been involved with discharging the patient into the nursing home. We further recruited a nursing home doctor, primary contact or manager who had come to know the patient after the transfer to the nursing home. All participants were required to be proficient in writing in Norwegian.

    We included 10 participants from the psychogeriatric hospital department and 26 participants from nursing homes. There were 27 females and 9 males, all of them health professionals from a wide range of backgrounds (table 1).

    Table 1. Overview of participants

    Data collection

    We set aside a full hour for each of the collaborative meetings. Data were collected through self-reporting forms that were handed in immediately after each meeting. The full body of data consists of 80 such forms. The participants responded in handwriting on paper, formulating short sentences and keywords. These handwritten responses were transcribed verbatim and transferred to electronic media. The resulting electronic text makes up the study’s 36 pages of data.

    Ethical considerations

    The study was approved by the health trust’s data protection officer and by senior management at the nursing homes. We obtained written consent from all participants prior to the collaborative meeting. They were informed that participation was voluntary. No-one dropped out before completion. All information that emerged was securely treated in accordance with Norwegian Personal Data Act and the Data Protection Authority’s guidelines (18, 19). This meant that all self-reporting forms containing names were de-identified. There is no code list of names and contact details.

    Analysis

    We conducted a qualitative content analysis of our material, inspired by Graneheim and Lundman (16, 17). The hallmark of a qualitative content analysis is a process that moves back and forth between the whole material and its parts. The text may be interpreted at a variety of levels; we chose the manifest level of analysis (16). This means that our interpretations were closely linked to that which is explicitly expressed in the material. Each self-reporting form was therefore identified as a unit of analysis.

    We conducted the analysis in multiple stages, the first involving a read-through of the electronic data generated by each participant. We also read the whole material for each of the self-reporting questions in order to gain an understanding of the complete body of data. At the next stage we condensed the text. Examples of this process are set out in Table 2. Similar meanings were grouped in sub-categories before being allocated to four main categories. We conducted the analysis several times in order to ensure a uniform process. The sub-categories represent different aspects of a category (16, 17).

      Table 2: Sample analysis process

    Results

    From our analysis of the material four categories emerged that summarised the participants’ descriptions: 1) information about individualised care and treatment, 2) knowledge exchange, 3) mutual recognition and affirmation, and 4) improvement measures.

    Information about individualised care and treatment

    The psychogeriatric nurses reported that they chaired the collaborative meetings and that they provided patient information that complemented the written transfer report: “I have provided more specific details about interventions that had been inadequately described in the nursing summary – such as the administration of medication, the patient’s behaviour and moods.”

    Health care personnel from the specialised health service highlighted the exchange of information concerning their experience of working with the patient’s relatives, and activity programmes that had been implemented to good effect. Nurses and occupational therapists alike reported that complex needs made it difficult to summarise the care provided in writing: “This is a patient with many needs which are difficult to describe” (psychogeriatric nurse).

    The nursing home staff on the other hand, reported that the transfer information provided by the psychogeriatric department at the time of discharge was good and comprehensive: “I have received good descriptive information about the patient’s condition as well as an action plan that was ready for immediate implementation when the patient arrived here” (nursing home nurse). The health care personnel at the nursing homes also reported that they had followed up on the proposed measures: “I have followed up with specific measures at meal times and when providing personal care, and by creating a sense of calm around the patient. This has worked very well” (auxiliary nurse at nursing home).

    The nursing home doctors reported that during the collaborative meetings they had a different focus than other professional groups. They sought supplementary information from the psychiatrist about the background to the diagnosis, the assessment, case history and medical treatment: “I raised questions concerning the medication.” The psychiatrist from the psychogeriatric department reported having provided in-depth information and having given her reasons for her choice of medical treatment: “I have explained the history, the medication and MR findings.” The nursing home doctors described the information provided in the medical discharge summary as good. A number of nursing home doctors reported that they contributed with supplementary information concerning the patient’s case history prior to hospitalisation at the psychogeriatric ward, and that they planned the continued treatment in partnership with the doctor or psychiatrist from the psychogeriatric department.

    Knowledge exchange

    A number of participants described receiving useful information about the patient through the interdisciplinary knowledge exchange at the collaborative meetings, and that they gained new insight into how it might be possible to interact with the patient in a good way. Particularly the nursing home doctors reported that they acquired more knowledge about psychogeriatric assessment methods and treatments: “I learnt more about the assessment methods.” Another nursing home doctor reported: “I have acquired insight into the treatment of Lewy body dementia: advice about what should be at the back of my mind in special cases. Have received an update.” The psychiatrist from the psychogeriatric department reported that she had acquired new knowledge about available support of significance to the transition into sheltered nursing home accommodation. This individual had also gained greater respect for the working practices at the nursing home.

    Recognition and affirmation

    The participants described their discussions during the collaborative meetings as frank exchanges conducted on equal terms: “I felt that the discussion was good and frank. Nursing staff were given a good opportunity to describe their observations of the patient. Everyone listens to one another” (nursing home doctor). Both the nurses and the nursing auxiliaries felt it was very useful to review the measures that work, and to give each other credit. They reported as follows: “it feels good to receive recognition for what is being done the right way [in the nursing home], and whether this coincides with your views [in the psychogeriatric department]”.

    Everyone listens to one another.
    Nursing home doctor

    The psychogeriatric nurses reported that openness surrounding challenges was seen as particularly important. This was confirmed by the nursing homes. One person reported that: “I felt we received affirmation that what we are doing is not wrong, and that our frustrations were met with understanding” (nursing home nurse). A number of participants from both the psychogeriatric department and the nursing homes reported a good atmosphere at the collaborative meetings, and a sense that the participants were engaged. One participant gave a different account of one particular meeting where few people had been in attendance: “I felt it was not particularly motivating because few people contributed to the discussion and we appeared to run out of things to say” (psychogeriatric nurse).

    Some described the discussions about challenging situations as being useful and informative, and based on a wish to do their very best for the patient: “The meeting was clarifying and very positive in that this was a patient with great challenges. I felt that the meeting was factual and I am impressed with all the good initiatives that were gradually forthcoming” (psychogeriatric nurse).

    Health care personnel from the psychogeriatric department reported that it was good to receive feedback and confirmation that the patient’s needs were being met, and that the measures suggested by their department were being followed up. A number of doctors from the specialised health service reported that they had gained an insight into the work of nursing homes: “[G]ood to learn how the nursing home doctors are thinking with respect to medication and the patient’s condition. Am now better informed with regard to the programmes offered at the nursing home.” Health care personnel working for either service provider reported that they received mutual acknowledgement, irrespective of their occupation.

    Improvement measures

    The supplementary descriptions of the patient’s situation and the dialogue with health professionals with different experiences, helped to solve problems: “I started getting ideas about how to improve the things we do . It was a real boost for me” (nursing home nurse). It was emphasised that interdisciplinary dialogue can contribute to raising the participants’ competence levels, which might influence the patient’s future care: “[T]his kind of meeting will raise our level of competence, so that we jointly can come up with initiatives designed to maintain the patient’s identity and dignity” (student nurse at nursing home).

    Several participants reported that the collaborative meetings constituted an important improvement measure in terms of ensuring the continuity and quality of care for elderly people suffering from mental disorders, and they wanted the practice to continue. Health care personnel from the psychogeriatric department reported that the collaborative meetings had brought to their attention that some of the nursing homes were struggling for too long before patients were admitted to hospital for assessment. They asked whether this could possibly be changed: “In the future I feel it would be wise for nursing home doctors to have an open line of communication to the specialised health service” (psychiatrist at the psychogeriatric department).

    Discussion

    This study looks at a group of health professionals who attend co-ordinated collaborative meetings. The meetings involved a level of commitment and focused on an exchange of knowledge that may contribute to better continuity of care between psychogeriatric hospital departments and nursing homes. Co-ordinated collaboration between health care personnel in the specialised health service and the primary health service is often taken for granted, and the responsibility for ensuring continuity of care has received growing attention after the introduction of the Coordination Reform (1, 3). A number of studies have also pointed to the need for new approaches (2, 3).

    Previously, elderly patients suffering from complex mental disorders and dementia used to be assessed and treated during lengthy periods of hospitalisation in psychogeriatric departments. These days, the requirement is for outpatient services, nursing home adaptations and as few inpatient nights as possible. In compliance with the Coordination Reform, the psychogeriatric hospital services have become more specialised and focused on assessment. This is why there are complex interactions and decision-making processes involved with the transfer of patients from psychogeriatric hospital departments to nursing homes. Furthermore, there is a risk of discontinuity of care (3). Demands for knowledge-based practice ensure that care and treatment are provided on the basis of research-based knowledge and adjusted to the individual patient’s resources and wishes (1).

    All professions were able to contribute to the exchange and put forward suggestions from their own viewpoint, and it was useful to exchange knowledge.

    The study shows that interdisciplinary health care personnel at nursing homes felt they were receiving useful information from the medical discharge summaries and nursing summaries when patients were transferred from the psychogeriatric service. The nursing home doctors nevertheless often asked for assessment details and the reasoning that formed the basis for drug treatment choices. The attention of the nursing staff was to a greater extent directed towards the patient’s basic needs. All professions were able to contribute to the exchange and put forward suggestions from their own viewpoint, and it was useful to exchange knowledge.

    Recognition and affirmation are important

    Health care personnel from both service sectors reported that the collaborative meetings provided affirmation of their own work. Affirmation arises in the moment and is all about the way we listen, our attitude to other people and how an individual’s overall behaviour appears as they encounter other people. Affirmation relates to our appreciation of another person as an individual and the acceptance and validation of this other person’s experiences (22, 26).

    An earlier psychogeriatric study conducted by Brattrud and Granerud (10) shows that it may be challenging for personnel within the primary health service and the specialised health service to see each other as equal partners (10). In our study, the health professionals from the specialised hospital department were described as “experts” by the nursing home staff, which may suggest that there is an informal hierarchy in place. Nevertheless, it appears that the health care personnel saw each other as equal participants. We interpret this to mean that each participant attending the collaborative meetings felt confident about their own background, which matches the findings of earlier research on individual factors that are essential to good co-operation (12, 26).

    Another interpretation may be that those who attended the collaborative meetings focused their attention on the patient’s health and treatment. In other words, equality is linked to equality of experience, as all participants had some knowledge of the patient. They felt it was really useful to listen to each other and to meet up face-to-face as interdisciplinary partners. Earlier studies have also shown that meetings are conducive to co-operation and to ensuring a good flow of information (2, 25). It is therefore useful to highlight various aspects of the interactions that may serve to enhance the level of continuity and collaboration, and encourage learning from the experiences.

    Exchanging experiences

    The interdisciplinary nature of the interaction between health care personnel was an important factor. The collaborative meetings in our study were characterised by exchanges of relevant medical information and in-depth descriptions of the care provided for the individual patients. Our findings show that the exchange of experiences gave participants new knowledge about the patient and an insight into each other’s service areas. Other studies point out that the specialised health service and the primary health service represent different approaches in terms of ideology, culture, resources and competence, and that this may prove to be an obstacle to collaboration (3). Nevertheless, our study showed that the participants included each other on equal terms.

    Earlier studies have demonstrated that collaboration is greatly enhanced by regarding each other as “we” rather than “us and them” (9). In their study from the Swedish mental health service, Magnusson and Lützén (9) found that different views and focus in the approach to people with mental health problems may be obstructive to co-operation and interaction. The same applies if the health care personnel involved make use of different concepts, expressions and terminology within the field (9).

    The health care personnel who took part in the study reported that one particular collaborative meeting was not considered useful. This may have been caused by disrupted dialogue and misunderstandings (22). Dialogue disruptions may be attributed to attitudes or insufficient engagement, or a poor sense of belonging or community (22). According to Goffman (21) the emotional response among participants is a third significant factor in focused social meetings. Meeting each other in person allows the participants access to a number of social clues in the form of words, facial expressions, gestures and actions. In the light of Goffman (21), our findings may suggest that the participants tried to “build bridges” to one another in the interest of doing their utmost for the patient.

    Different resources and different requirements

    Earlier studies have pointed out that specialised health services and nursing homes have different resources and different competencies available to them (24). Within the context of a hectic working day at a nursing home, it may be challenging to follow up the residents’ developing needs to ensure that the appropriate measures are put in place (24). Participating health care personnel from either service sector described it as challenging to identify suitable measures for individual patients. During the meetings they exchanged knowledge and provided mutual affirmation of each other as resource persons.

    The detailed descriptions provided by participants through the questionnaires, told us that the participants became better acquainted with the physical circumstances, resources and competencies provided at the various nursing homes and in the specialised health service. This type of mutual knowledge exchange helps the health professionals realise when there is reason to seek or provide advice and guidance (10).

    In order to be able to provide health care which is medically sound, health care personnel must be able to interact with members of other health care professions (11). Equally, knowing each other’s competence and services will enable mutual understanding and recognition of one another’s differences. Willumsen (12) points out that recognition of differences is a factor that may encourage dynamic collaboration. This requires health care personnel to be flexible and capable of taking advantage of each other’s contributions. Willumsen (12) argues that good interdisciplinary co-operation requires members of different professions to work in partnership on a joint task, with everyone contributing on equal terms. Our study demonstrated that a shared understanding of the patient’s situation helped the health professionals jointly draw up detailed interventions for the patient’s future nursing care.

    The study’s limitations and strengths

    There are some limitations to the study. It was based on a limited number of written feedback reports from a specific geographic area. The body of data consists of written responses to three questions and the participants’ ability to express themselves clearly in writing differs. The researchers have not had the opportunity to follow up with further questions.

    The timing and location of the collaborative meetings may have influenced the results. They were all held after the patient’s discharge from hospital to ensure that both parties would be familiar with the patient and had made their own observations. The meetings were held at the nursing homes in order to boost participation levels. We presumed that it would be difficult for nursing home staff to travel to the hospital, as few staff are assigned to a shift.

    It is one of the study’s strengths that six different healthcare professions are represented, and that the questions were drafted in liaison with the target group. The study raises important points, corroborates the need for co-ordinated collaborative meetings and highlights themes of universal significance. A relatively low number of participants, and the data collection method, represent limitations to the study’s transfer value.

    Our study does not discuss co-ordinated organisational collaboration, but we have communicated our sub-project findings to the main PASSUS project. This resulted in written guidelines being issued with respect to the collaboration between nursing homes and the psychogeriatric service. Neither patients nor their relatives were included as study participants. In future research, it will be important to include interaction with these key groups.

    Conclusion

    This study involved meetings between health care personnel who had been responsible for the care of patients in the psychogeriatric department, and those who took over responsibility for the patient in the nursing home. Our analysis of the participants’ self-reported experiences showed that the collaborative meetings contributed to interdisciplinary knowledge exchange, as well as increased understanding and insight into the patient’s situation. It was important for health care personnel at the nursing homes to receive detailed information about the psychogeriatric assessment and the reasoning behind treatment choices, while also receiving affirmation of their work.

    The collaborative meetings contributed to mutual respect and exchange of detailed patient-oriented knowledge.

    The health care personnel in the psychogeriatric department reported that the feedback received from health care personnel at the nursing homes was significant to their practice. The collaborative meetings contributed to mutual respect and the exchange of detailed, patient-oriented knowledge. They are examples of how systematic collaboration can improve the individual’s competence and ensure continuity of care between service sectors.

    References

    1.       Helse- og omsorgsdepartementet. St.meld.nr. 47 (2008–2009). Samhandlingsreformen. Rett behandling – på rett sted – til rett tid. Oslo.

    2.       Elstad TA, Steen TK, Larsen GE. Samhandling mellom et distriktspsykiatrisk senter og kommunalt psykisk helsearbeid: Ansattes erfaringer. Tidsskrift for psykisk helsearbeid 2013;10(4):296–305.

    3.       Olsen BM, Vatne S, Buus N. Kontinuitet og samhandlingsutfordringer i psykiske helsetjenester – en fokusgruppestudie. Klinisk Sygepleje 2015;29(4):55–68.

    4.       Helse- og omsorgsdepartementet. Nasjonal helse- og omsorgsplan for 2011–2015. Oslo. 2011. 

    5.       Helsedirektoratet. Nasjonale mål og prioriterte områder for 2013. Rundskriv til kommunene, fylkeskommunene, de regionale helseforetak og fylkesmennene fra Helsedirektoratet, Oslo. 2013.

    6.       Engedal K, Haugen PK et al. Demens: Fakta og utfordringer. Forlaget Aldring og helse, Tønsberg. 2009.

    7.       San Martin-Rodriguez L, Beaulieu M-D, D'Amour D, Ferrada-Videla M. The determinants of successful collaboration: A review of theoretical and empirical studies. Journal of Interprofessional Care 2005;1:132–47.

    8.       Bramesfeld A, Ungewitter C, Bottger D, El Jurdi J, Losert C, Killian R. What promotes and inhibits cooperation in mental health care across disciplines, services and service sectors? A qualitative study. Epidemiology and Psychiatric Sciences 2012;21:63–72.

    9.       Magnusson A, Lützén K. Factors that influence collaboration between psychiatric care and CSSs: experiences of working together in the interest of persons with long-term mental illness living in the community. Scand J Caring Sci 2009;23:140–5.

    10.     Brattrud TL, Granerud A. Sammen om gode overganger. Samarbeid mellom kommunene og spesialisthelsetjenesten i psykisk helsevern. Tidsskrift for psykisk helsearbeid 2011;3:206–16.

    11.     Orvik A. Organisatorisk kompetanse i sykepleie og helsefaglig samarbeid. Cappelen Akademisk Oslo. 2004.

    12.     Willumsen E (ed.). Tverrprofesjonelt samarbeid i praksis og utdanning. Universitetsforlaget, Oslo. 2009.

    13.     Hagen R, Johnsen E. Styring gjennom samhandling: Samhandlingsreformen som kasus. I A Tjora og L Melby (red.). Samhandling for helse. Kunnskap, kommunikasjon og teknologi i helsetjenesten. Gyldendal Akademisk, Oslo. 2013 (p. 32–53).

    14.     Jensen LH, Rekve KH (red.). PASSUS: Pasientorientert samhandling ved utskrivning til sykehjem. Skriftserie nr. 5 / Høgskolen i Buskerud og Vestfold. Drammen. 2014.

    15.     Kristoffersen K. Helsepersonells erfaringer fra samarbeid med pårørende til personer med demens i utskrivelsesprosessen fra alderspsykiatris avdeling til sykehjem: En kvalitativ studie. [Master's thesis]. Fakultet for helsevitenskap, Høgskolen i Buskerud, Drammen. 2013.

    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.     Graneheim UH, Lundman B. Kvalitativ innhållsanalys. In: MG Granskär og B Höglund-Nielsen (eds.). Tillämpad kvalitativ forskning inom hälso- och sjukvård. Studentlitteratur, Lund. 2008 (p. 187–201).

    18.     Lovdata. Lov om behandling av personopplysninger. 14. april 2001; nr. 31 [personopplysningsloven]. Available at: https://lovdata.no/dokument/NL/lov/2000-04-14-31. (Downloaded 03.03.2017).

    19.     NEM, Den nasjonale forskningsetiske komité for medisin og helsefag. Veiledning for forskningsetisk og vitenskapelig vurdering av kvalitative forskningsprosjekt innen medisin og helsefag. Oslo. 2010.

    20.     Røkenes OH, Hanssen P-H. Bære eller briste. Kommunikasjon og relasjon i arbeid med mennesker. Fagbokforlaget, Oslo. 2002.

    21.     Goffman E. Interaction ritual: essays in face-to-face behavior. Aldine Transaction, New Brunswick. 1967/2005.

    22.     Schibbye, A-LL. Relasjoner: Et dialektisk perspektiv på eksistensiell og psykodynamisk psykoterapi. Universitetsforlaget, Oslo. 2009.

    23.     Repstad P. Sosiologiske perspektiver for helse- og sosialarbeidere. 3. ed. Universitetsforlaget, Oslo. 2014.

    24.     Gautun H, Bratt C. Bemanning og kompetanse i hjemmesykepleien og sykehjem. NOVA-rapport 14/14. Velferdsforskningsinstituttet NOVA, Oslo. 2014.

    25.     Danbolt LJ, Kjønsberg K, Lien L. Hjelp når du trenger det. En kvalitativ studie av samhandling og gjensidighetskunnskap i den psykiske helsetjenesten. Tidsskrift for psykisk helsearbeid 2010;3:238–45.

    26.     Molyneux J. Interprofessional teamworking: What makes teams work well? Journal of interprofessional care 2001;15:29–35.

    Collaborative interdisciplinary meetings may increase the mutual respect between health professionals and provide more knowledge about the patient.

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    Sammendrag

    Background: For many years, co-ordinated collaboration has been a challenging issue for the health and social services, nationally and internationally. In the mental health sector it has been particularly difficult to identify initiatives that might ensure continuity of care as patients transition from the specialised health service and into the primary health service.

    Purpose: The purpose of this study was to examine the experiences of health care professionals across the disciplines when attending collaborative interdisciplinary meetings held two weeks after the patient had been discharged from the specialised psychogeriatric health service and into nursing homes.

    Method: This sub-study forms part of a larger participation-based research project, PASSUS, which looks into quality development and actions. This project focuses on patient-oriented interaction at the point of discharge into nursing home care and involves one psychogeriatric hospital department and four nursing homes. It looks specifically at one of the improvement measures: co-ordinated collaborative meetings. The study has a descriptive qualitative design and is based on written notes from twelve such collaborative meetings.

    Results: Our analysis of the material suggests that the participants’ descriptions can be grouped in four summary categories: 1) information about individualised care and treatment, 2) knowledge exchange, 3) mutual recognition and affirmation, and 4) improvement measures.

    Conclusion: The study involved meetings between the health care personnel who had been responsible for the follow-up of patients in the psychogeriatric department, and those who took over this responsibility for the patient in the nursing home. Our analysis showed that the collaborative meetings contributed to interdisciplinary knowledge exchange, as well as increased understanding and insight into the patient’s situation. The collaborative meetings show how co-ordinated systematic interaction can boost competence levels and ensure continuity of care between service sectors. 

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  • Routines in the community nursing services for assessing nutritional status

    In 2009, the Norwegian Directorate of Health issued national professional guidelines for the prevention and treatment of undernutrition. The guidelines stressed that all patients admitted to institutions or registered for community nursing services are to be assessed for nutritional risk (1).

    The purpose of the assessment is to detect patients at nutritional risk as early as possible in order to initiate targeted measures. Around 78 000 people in Norway receive help from the community nursing services. Even though figures from Statistics Norway show that the group of younger people who need assistance is increasing, a large number are over the age of 67 (2).

    Groups at risk of undernutrition

    Elderly people who receive assistance from the community nursing services are either susceptible to undernutrition, at risk of undernutrition or are undernourished (3–9). Patients suffering from a serious or long-term illness are particularly susceptible to undernutrition (10). For example, some types of cancer can lead to metabolic alterations in the body. The patient may develop different levels of stress metabolism and cachexia resulting in weight loss etc. (10). Patients with cognitive failure who live at home are also susceptible to undernutrition (11).

    The causes of undernutrition may be multifactorial. A meta-analysis from the Netherlands identified 37 factors that could affect nutritional intake in older people (12. These factors were partly associated with the person in question, the food that was served and the eating environment.

    Definition of undernutrition

    Undernutrition, or PEM (protein–energy malnutrition) as it is often called, may be defined as a nutritional situation in which a lack of energy, protein and/or other nutrients causes measurable adverse effects on body composition and function, together with a clinical result (1, p. 14).

    Undernutrition may affect both physical and mental function.

    Undernutrition may affect both physical and mental function. It leads to loss of protein-rich muscle mass (13). Likewise, older people are susceptible to sarcopenia due to changes in body composition with further loss of muscle mass leading to decreased muscle strength and muscle function (14). Poor nutrition and protein deficiency in particular have proved to be one of the main underlying causes of sarcopenia (14).

    Undernutrition is associated with a greater risk of falling, impaired immunity and increased mortality (15–17), and may result in longer periods of hospitalisation and increased costs (18–20). Following acute illness, the elderly patient may take longer to recover, and consequently it is better to prevent undernutrition than to treat it (21). Undernutrition may result in concentration difficulties, apathy and depression, which may affect the person’s quality of life (21).

    How to measure undernutrition

    A number of screening instruments have been developed to measure PEM. The incidence of undernutrition has proved to vary according to which instrument is used (22–23). In one study, elderly people aged from 65 to 96 living at home were asked to map their nutritional status using two different screening instruments: MNA-SF (Mini Nutritional Assessment – Short Form) and NUFFE-NO (Nutritional Form for the Elderly) (22).

    The incidence of patients in danger of becoming undernourished varied from 13.5 per cent in one form (MNA-SF) to 22.5 per cent in the other (NUFFE-NO) (22). In its national guidelines, the Norwegian Directorate of Health has recommended the screening instruments that should be used. Its recommendations are linked to whether the person is ill and has been admitted to a hospital or a nursing home, or whether the person is registered with the community nursing services. Some instruments, for example the MNA, are especially adapted to elderly people (1).

    Insufficient knowledge

    In 2010, the Norwegian Board of Health Supervision carried out supervision of nutritional routines in 21 municipalities in seven counties in Norway (24). The results revealed that the current statutory requirements had been violated in two out of three municipalities. The Board’s conclusion was that many municipalities paid little attention to the nutritional needs of the elderly and had insufficient knowledge about this (24).

    Managers are responsible for preparing written procedures and for ensuring that the basic needs of service users are satisfied, including their nutritional needs. Health care personnel are responsible for adhering to the written procedures. There is little research on the assessment of nutritional status in the community nursing services, and we need more studies that present the views of both managers and health care personnel on nutritional routines.

    The purpose of this study was to describe and compare what routines managers and health care personnel follow in order to quality assure nutrition efforts. 

    Method

    The study had a descriptive, cross-sectional design, and consisted of two sub-studies: one among managers in the community nursing services and one among the health care personnel. We gathered data using a questionnaire dealing with nutrition efforts in the community nursing services.

    Sample

    Sub-study 1: Managers in the community nursing services in all municipalities in Norway were invited to take part in the study, and to answer on behalf of their own municipality.

    Sub-study 2: We asked health care personnel working in the community nursing services in 13 municipalities distributed across five health regions to participate in the survey. In each region we chose random municipalities linked to the Centre for Development of Institutional and Home Care Services. We also selected municipalities without such links. In order to calculate the number of respondents that were to participate in each municipality, we gathered information about the number of FTEs for health care personnel from the respective municipalities. Then we selected a proportional stratified random sample of health care personnel from each municipality. The aim was to control the number of respondents per municipality in order to minimise sample error.

    Data collection

    We collected data using a structured questionnaire. The questions were based on the results of an earlier survey on food and meals in nursing homes (25). We adapted the questions to apply to the community nursing services. In addition, two nutritionists gave feedback on the questionnaire. In order to enhance its validity, we also conducted a pilot study with four respondents chosen from the same population as the sample. The responses from the pilot study are not included in the results. The pilot study did not lead to any changes in the questionnaire.

    The questionnaire in sub-study 1 consisted of altogether 61 questions, and there were 67 questions in sub-study 2. The form was structured on the basis of the following main areas: background variables (education and work experience), assessment of food and the routines for nutritional status. Several questions were formulated as questions with the response categories ‘Yes’, ‘No’ or ‘Don’t know’, for example ‘Are there written procedures for assessing nutritional status?’

    The form also contained statements with which the respondents could agree or disagree, with response categories ‘Disagree’, ‘Somewhat disagree’, ‘Somewhat agree’ or ‘Completely agree’. The following is an example of such a statement: ‘The food is appetising and tasty.’ Other questions were formulated about the frequency of measures with response categories such as ‘Never’, ‘Almost never’, ‘Almost always’, ‘Always’ or ‘Don’t know’. The following is an example: ‘How often are there service users with a poor nutritional status in the community nursing services where you work?’ In this article, we have focused on questions relating to the assessment of the patients’ nutritional status.

    Implementation

    We conducted the study in the period from May to June 2011.

    Sub-study 1: The target group for sub-study 2 was managers. TNS Gallup was responsible for sending the information letter and the questionnaire to the municipalities. The information letter and invitation were emailed to the municipalities’ postal address. The questionnaires were web-based and were filled in online via a link. The municipalities that had not responded by the deadline were reminded once electronically and once by a telephone call from TNS Gallup.

    Sub-study 2: The target group for sub-study 2 was health care personnel. The project manager contacted managers in the community nursing services and managers of the development centres in the municipalities selected. They were given information and were asked if health care personnel in their municipality could participate in the study. The managers appointed a contact person at the place of work. We informed the contact persons in writing that respondents should be selected at random. The contact persons then distributed the questionnaire to those who had been selected to participate in the survey. All municipalities answered by the deadline.

    We distributed a total of 758 questionnaires – 460 in sub-study 1 and 298 in sub-study 2.

    Analysis of data

    We conducted the analyses using SPSS version 23. Descriptive statistics of frequency and percentage were used to describe the sample. We used the same method to describe how the samples assessed nutritional status. In order to test whether there were significant differences between the responses of managers and health care personnel, we used Pearson’s Chi-Square test. The significance level was set at 0.05.

    Ethical considerations

    Sub-study 1: TNS Gallup, which had responsibility for the practical implementation of sub-study 1, complies with current acts and regulations at all times. The questionnaire contained no personal information, and confidentiality and voluntary participation were safeguarded. Only TNS Gallup had access to the list of municipalities that participated in the survey and answered the questions. The list was only available in connection with reminders, and the researchers received anonymous SPSS files from TNS Gallup.

    Sub-study 2: After conferring with the Norwegian Social Science Data Services, we did not submit a notification form for sub-study 2. The reason was that the survey did not include personal information. Moreover, the questionnaire was anonymous. 

    Results

    Altogether 485 respondents answered the questionnaire on nutrition efforts in the community nursing services. A total of 273 were managers, giving a response rate of 59, and 212 were health care personnel, equivalent to a response rate of 74 (Table 1).

    Table 1: Description of sample

    Most of the managers were nurses, while approximately half of the health care personnel were nurses. Four per cent of the health care personnel had no health care training. Fifty-five per cent of the health care personnel were employed in a municipality that was linked to the Centre for Development of Institutional and Home Care Services. Sixty-seven per cent of the managers and 76 per cent of the health care personnel answered that there were always or often service users in a poor nutritional condition at their workplace.

    Table 2 shows how health care personnel and managers assess patients’ nutritional status, how this is documented and how they rate their knowledge of nutrition. The results show that there is a difference between how the managers and the health care personnel answer. 

    Table 2: A comparison of the routines of health care personnel and managers when assessing patients’ nutritional status

    Eighty-eight per cent of the managers and 80 per cent of the health care personnel in the community nursing services wanted to improve their knowledge of nutrition efforts. The managers mainly wanted more knowledge of how to assess service users’ nutritional condition and calculate their energy needs in addition to knowledge about how to give service users nutritional guidance. The health care personnel mainly wanted knowledge about the different nutrients.

    In response to the question of how managers felt that the staff assessed the importance of screening and assessing service users’ nutritional condition, altogether 14 per cent answered ‘Very well’. Sixty-six per cent answered ‘Well’, while 18 per cent answered ‘Badly’. Less than one per cent answered ‘Very badly’. Similarly, health care personnel were asked how they thought management assessed the importance of screening and assessing service users’ nutritional status. Fifteen per cent answered ‘Very well’, 58 per cent answered ‘Well’, 26 per cent answered ‘Badly’, and less than one per cent answered ‘Very badly’.

    In the case of follow-up of service users’ nutritional condition, 14 per cent of the managers and 8 per cent of the health care personnel answered that this was ‘Very good’. Some 75 per cent and 69 per cent respectively answered ‘Good’, and 17 per cent of the managers and 27 per cent of the health care personnel answered ‘Poor’. Less than one per cent of both the managers and the health care personnel answered ‘Very poor’.

    The managers rated knowledge, time and then resources as the three greatest obstacles to the assessment and follow-up of nutritional status. This answer largely correlates with the health care personnel’s answers, but the latter assessed time as the greatest obstacle followed by knowledge and resources. 

    Discussion

    Nutritional status

    This survey showed that service users in poor nutritional condition are common in the community nursing services. Other national and international surveys show that undernutrition may be a problem among users of community nursing services (3–9). Therefore, it is vital that there are good routines for assessing service users’ nutritional condition.

    The Norwegian Directorate of Health recommends that a standardised set of diagnostic criteria should be applied in order to identify and document undernutrition in clinical practice (1). Weight, changes in weight over time and body mass index (BMI) are highlighted as the simplest measurements of nutritional status (1).

    Weighing patients is one of the most important measures to reveal and assess the person’s nutritional condition.

    In this survey, one out of five managers and one out of five health care personnel stated that it was usual to weigh the service user on registration with the community nursing services. Furthermore, 12.5 per cent of the health care personnel answered that they did not know whether it was usual to weigh the service user on registration. If it is not known whether weighing is a routine procedure, this may indicate that the service user is not weighed despite the fact that weighing is one of the most important measurements in revealing and assessing a person’s nutritional condition (1).

    The results are poorer than in two Swedish studies in which 31 per cent (26) and 84 per cent (7) respectively of the primary health service staff replied that all service users were weighed on registration. Surveys tend to indicate that the situation could be better at Norwegian nursing homes (25, 27). In order to follow weight alterations over time, the service user must be weighed at fixed intervals. Our study shows that a greater number of health care personnel weighed service users at fixed intervals compared with weighing them at the time of registration. Nevertheless, the results show that weighing the service user is still a challenge in the community nursing services of several municipalities.

    In addition to weight, BMI can be used as a measurement of nutritional status. The study showed that calculating service users’ BMI value was not usual either. Weight and height are the two values used to calculate BMI value. The lack of weighing routines may thus be instrumental in the failure to calculate the BMI value.

    Our survey showed that just under half of the municipalities have routines for screening and evaluating the nutritional condition of users of the community nursing services. Even fewer have documented this in written procedures. The failure to use written procedures indicates that screening instruments are not used either. In a Scandinavian study on whether evaluating nutritional status was standard procedure in hospitals, Norway had the poorest result (28), even though several different screening instruments are available (1, 3, 22).

    Documentation

    The results of the survey showed that there is no standard procedure in all municipalities for noting service users’ food habits on registration. Fewer health care personnel than managers answered this question in the affirmative. Such documentation is required by law and the health care personnel are responsible for ensuring that the data are recorded (29).

    In order to implement correct nutrition-related measures, it is vital that health care personnel are aware of the individual service user’s food habits. A Swedish study showed that it was usual to include questions related to nutrition in the admission interview for hospitals, separate housing for the elderly, and the community nursing services (26). A Norwegian study on community nurses’ documentation showed that 70 per cent of the reports contained data associated with the nurses’ subjective perceptions rather than the patient’s perceptions (30).

    One study showed that one out of four patients discharged from hospital in Norway was at nutritional risk (31). These patients will therefore need further nutritional treatment following discharge. Feldblum et al. (32) showed in a survey that patients who received individual nutritional treatment during and after acute hospitalisation had lower mortality and a moderate improvement in nutritional status. A Swedish survey of community nursing services showed that half of the service users need nutrition-related support (33), and that documentation is thus important. It is therefore alarming that only half of the respondents in our survey answer that nutrition is included as an item in the nursing plan they receive for patients when they are discharged from hospital.

    As of 1 January 2016, the authorities require all municipalities in Norway to document service users’ nutritional status in the IPLOS register (34). IPLOS is a statutory health register for municipal health and care services. Nutrition efforts and screening for nutritional status should be highlighted as a key area in nursing, both in respect of data collection during registration with the community nursing services and in further documentation going forward. 

    Knowledge

    Both health care personnel and managers in our survey were of the opinion that more knowledge about nutrition was needed. The majority wanted to know more about this topic in connection with ‘how to assess service users’ nutritional condition’. The results of the survey correlate with results from Norwegian nursing homes (25, 27) and from an Australian study (35). These showed that there was a need for more knowledge about nutrition. Both managers and health care personnel described a lack of knowledge as the main barrier that had to be removed to enable health care personnel to assess and follow up service users’ nutritional status.

    Both health care personnel and managers in our survey were of the opinion that there was a need for greater knowledge of nutrition.

    A Scandinavian study among hospital doctors and nurses showed that the lack of knowledge about nutrition was the most common cause of inadequate nutritional practice (36). In our study, a greater number of managers than health care personnel were familiar with the national professional guidelines for the prevention and treatment of undernutrition (1). These guidelines include information about how to screen for nutritional status. Drawing up guidelines and procedures is not sufficient. Staff must also be trained in how to apply the guidelines. Furthermore, the community nursing services must have good routines to ensure that procedures are followed.

    In a qualitative survey at a Norwegian hospital, the nurses answered that they lacked adequate knowledge and skills to identify and treat undernourished elderly patients. Moreover, several of the respondents were not aware of the above-mentioned guidelines (37). The health care personnel in our survey mentioned time as being the key obstacle to achieving good routines for assessing nutrition. A qualitative survey showed that nurses in the community nursing services considered that their expertise was not being utilised correctly (38).

    One out of five managers in our study answered that they believed that health care personnel did not understand the importance of screening for nutritional status while one out of four health care personnel felt that the managers did not understand the importance of assessing nutritional status. Even though most answered that the nutritional status of community nursing service users was safeguarded, it is alarming that 17 per cent of the managers and 27 per cent of the health care personnel answered that the follow-up of nutritional status was poorly safeguarded. 

    Limitations of the study

    We collected the data in 2011. However, the literature review indicates that there have been no major changes in routines linked to nutrition in recent years (3–9, 11), even though a qualitative study among community nurses showed that the patients they received from hospitals were ‘sicker’ than was the case prior to the introduction of the Coordination Reform (38). Nevertheless, the results must be interpreted with caution. A total of 59 per cent of the managers in the community nursing services answered the questionnaire. Although this may appear to be a low figure, it includes managers from municipalities throughout Norway. The response rate among the health care personnel included in the survey was 74. The health care personnel were randomly selected and represented all five health regions, thus reinforcing the ability to generalise the results. However, the results must be interpreted with caution because the sample itself is limited.

    Conclusion

    This study showed that weighing service users in the community nursing services poses a challenge. Awareness of the importance of weighing is vital to ensure that the guidelines are followed. Perhaps systemising weight measurement might help. Such an initiative could be realised by putting in place standardised guidelines and procedures regarding how and when service users should be weighed. Weighing can be introduced, for example, at the same time as providing assistance for showers or baths.

    Guidelines exist; more managers than health care personnel are aware of the national professional guidelines for the prevention and treatment of undernutrition. It is still important to publicise the guidelines and ensure that health care personnel are trained in applying them. It is essential that all municipalities put procedures in place to screen and assess service users’ nutritional status. 

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    19.     Freijer K, Tan SS, Koopmanscha MA, Meijers JMM, Ruud JG, Halfens M, JC Nuijten JC. The economic costs of disease related malnutrition. Clin Nutr 2013; 32:136–41.

    20.     Baumeister SE, Fischer B, Döring A, Koenig W, Zierer A, John J, Heier M, Meisinger C. The Geriatric Nutritional Risk Index predicts increased healthcare costs and hospitalization in a cohort of community-dwelling older adults: results from the MONICA/KORA Augsburg cohort study, 1994–2005. Nutrition 2011;27:534–42.

    21.     Flanagan D, Fisher T, Murray M, Visvanathan R, Charlton K, Thesing C, Quigley G, Walther K. Managing undernutrition in the elderly: Prevention is better than cure. Aust Fam Physician 2012;41:695–9.

    22.     Söderhamn U, Dale B, Sundsli K, Söderhamn O. Nutritional screening of older home-dwelling Norwegians: a comparison between two instruments. Clin Interv Aging 2012;7:383–91.

    23.     Poulia KA, Yannakoulia M, Karageorgou D, Gamaletsou M, Panagiotakos DB, Sipsas NV, Zampelas A. Evaluation of the efficacy of six nutritional screening tools to predict malnutrition in the elderly. Clin Nutr 2012;31:378–85.

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    27.     Aagaard H, Grøndahl V. Mat og måltid i sykehjem 2, Høgskolen i Østfold. Rapport 2015:1.

    28.     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. Clin Nutr 2006;25:524–32.

    29.     Lovdata. Lov om helsepersonell. 2. juli 1999; nr. 64. [Helsepersonelloven]. Available at: https://lovdata.no/dokument/NL/lov/1999-07-02-64. (Downloaded 20.01.2016).

    30.     Andrés E, Bekker G. Sygeplejepersonalets oplevelse af ernæringsscreening og kostregistrering. Klinisk Sygepleje 2013;27:52–9.

    31.     Tangvik RJ, Tell GS, Guttormsen AB, Eisman JA, Henriksen A, Nilsen RM, Ranhoff AH. Nutritional risk profile in a university hospital population. Clin nutr 2014;34:705–11.

    32.     Feldblum I, German L, Castel H, Harman-Boehm I, Shahar DR. Individualized nutritional intervention during and after hospitalization: the nutrition intervention study clinical trial. J Am Geriatr Soc 2011;59:10–17.

    33.     Akner G, Engelheart S. Vanligt att kommunalt bistånd till äldre rör nutrition. Läkartidningen 2013;110:1987–9.

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    35.     Beattie E, O’Reilly M, Strange E, Franklin S, Isenring E. How much do residential aged care staff members know about the nutritional needs of residents? Int J Older People Nurs 2014;9:54–64.

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    37.     Eide HD, Halvorsen K, Almendingen K. Barriers to nutritional care for undernourished hospitalised older people. J Clin Nurs 2014;24:696–706.

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    Weight is one of the simplest measurements of nutritional status. Nevertheless, a number of personnel in the community nursing services lack knowledge about nutrition and good routines for weighing patients. 

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    Background: Studies show that patients who receive assistance from the community nursing services may be susceptible to undernutrition. In order to map nutritional status, in 2009 the Norwegian Directorate of Health issued national professional guidelines for the prevention and treatment of undernutrition, which stressed that all patients admitted to institutions or persons registered with the community nursing services are to be assessed for nutritional risk.

    Purpose: The purpose of this study was to describe the routines that managers and health care personnel in the community nursing services follow when assessing patients’ nutritional status.

    Method: The study was a quantitative cross-sectional study, comprising two sub-studies: one among managers in the community nursing services and one among health care personnel. Data were collected by means of a questionnaire. A total of 273 managers (response rate 59%) and 212 health care personnel (response rate 74%) answered the questionnaire.

    Results: 67% of the managers and 37% of the health care personnel were familiar with the Directorate of Health's national guidelines. One out of three respondents replied that the community nursing services have written procedures for assessing nutritional status. 80% of the managers and 69% of the health care personnel stated that it was not usual to weigh service users when registering them for community nursing services.

    Conclusion: Written procedures should be prepared for assessing nutritional status in the municipalities. Guidelines are available, but they should be better publicised, and the training of health care personnel should be a priority area. 

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  • Simulation-based team training in paediatric units

    Medically justifiable practice of health care requires collaboration between the health professionals involved. They must have sound professional knowledge and practice in coordination (1, 2). In recent decades, healthcare providers have undergone simulation training in realistic patient situations demanding complex decision making and teamwork. The training was based on experiences with ‘Crew Resource Management’ (CRM) (3-7), as used in civil aviation.

    Simulation-based training is described as a measure to improve teamwork, reduce adverse events and improve patient safety (3, 7, 8). Establishing simulation-based team training requires resources for training facilitators (instructors), as well as available room capacity and equipment. The task of facilitators is to facilitate learning (7, 9).

    Ziv and collaborators define simulation as ‘any educational activity that utilizes simulation aids to replicate clinical scenarios’ (10), and it is divided into three phases:

    • the briefing phase, in which the participants are informed of what will happen, the learning objectives, the patient simulator, the room and available equipment
    • the implementation phase, in which the participants implement the scenario and behave as though it were a real patient situation
    • the debriefing phase, in which the participants have the opportunity to reflect on their participation in the simulation as compared with the predetermined learning objectives.

    Simulation has been shown to enhance knowledge and skills. However, only a small number of studies support its transfer value to clinical practice (11, 12). The educational principles that lead to effective learning are discussed. According to Motola and collaborators, feedback, awareness of practice and integration of theory are key elements (13).

    The purpose of the study was to describe how clinical nurse specialists experience their participation in simulation-based team training. We also wished to describe the impact that this training may have on patient care in an emergency situation.

    We formulated the following research questions:

    • ‘How do you find that simulation-based team training is organised and implemented in your unit?’
    • ‘How do you find that participation in simulation-based team training affects your competence in emergency situations?’
    • ‘In your opinion, what impact does simulation-based team training have on patient care in an emergency situation?’

    Method

    The study has a qualitative, inductive and descriptive design based on ten individual, semistructured interviews.

    Sample

    We invited senior charge nurse at seven hospitals in one selected regional health authority to participate. We included nurse specialists in intensive, paediatric and neonatal care (clinical nurse specialists with between two and ten years of experience from the paediatric units at three hospitals. The participants needed to have undergone simulation-based team training in the previous year, and been involved in a minimum of one emergency situation since then. The sample consisted of nine women and one man, employed in 70–100 per cent positions.

    Ethical considerations

    We obtained informed consent from the participants, and the study followed guidelines for research ethics (14). The Norwegian Centre for Research Data (NSD) considered that the study was exempted from the obligation to give notification and to obtain a licence. None of the informants withdrew from the study.

    Data collection

    The interviews were conducted at the informants’ workplace and were undertaken over a period of three months. In the interviews, we needed to strike a balance between seeking answers to the research questions and allowing the informants to speak freely. An interview guide based on the research questions gave structure to the interview, while the follow-up questions encouraged more detailed information. We recorded the interviews on a dictaphone, having obtained the informed consent of the participants.

    Analysis

    In order to identify meaning units in the text, we analysed the interviews based on Graneheim and Lundman’s qualitative content analysis method (15). We listened continuously and repeatedly to the audio files to ensure verbatim transcription. Meaning units were identified and converted to condensed text, then arranged according to subject matter. A systematic and continuous process of analysis resulted in nine subcategories, three descriptive categories and one latent content.

    Methodological considerations

    Two of the authors had extensive work experience from paediatric units and had participated in simulation-based team training in their own unit. The third author had experience with simulation used in nurse education. In order to reduce sample-related errors, we excluded our own workplace and took no part in the recruitment of informants.

    Results

    The results were synthesised into one latent content that expresses the underlying opinion communicated by all the clinical nurse specialists: ‘Realistic training provides quality and confidence in one’s own skills.’ The content includes three descriptive categories (Table 1):

    • scheduled, realistic training
    • learning and mastery through simulation
    • impact on emergency situations

    Table 1: Categories and topic based on inductive content analysis

    Scheduled, realistic training

    The clinical nurse specialists described the various ways in which simulation is planned, organised and implemented. They reflected on role distribution and interdisciplinary collaboration, and described their perception of realism, time pressure and stress during the simulation.

    The majority of the clinical nurse specialists had experience of simulation-based team training that was held weekly in the unit. They were uncertain whether they could be freed from their work with patients, as it was only decided on the same morning who would participate. The training was perceived as a non-scheduled activity, and the clinical nurse specialists explained that the simulation training needed to be more systematic.

    Three clinical nurse specialists had participated in simulation-based team training at a simulation centre up to three times per year. The unit management’s objective was that all employees should attend, and participation was therefore included in scheduling of rosters. The clinical nurse specialists reported having obtained a good learning outcome from regular training. 

    The clinical nurse specialists immersed themselves in the scenario, felt the time pressure and could feel their pulses racing.

    The clinical nurse specialists described the simulation of real patient situations in an interdisciplinary context together with doctors and nurses as very instructive and realistic. They immersed themselves in the scenario, felt the time pressure and could feel their pulses racing. When they were challenged on recognisable elements from practice, such as the role of next of kin, the entire scenario became more realistic. The clinical nurse specialists perceived the scenario and the simulation training as an authentic emergency situation.

    Through the training in roles and role distribution, the clinical nurse specialists became more aware of the content of their own role, and also that of other roles in the team. Training in leadership was especially important. One clinical nurse specialist stated the following:

    ‘I think I got a lot of benefit from it, especially regarding roles. They are very conscious of roles when we are taking part in the simulation.’ 

    Learning and mastery through simulation

    The clinical nurse specialists described the feeling of mastery they acquired from training in communication, procedures and use of medical equipment. They also described how they learned through reflection.

    The clinical nurse specialists found it to be advantageous that the simulation-based team training was undertaken in the same location where emergency situations arise. In a familiar environment, they were able to concentrate on the scenario and find and hook up emergency medical equipment such as a ventilator. Regular training with medical equipment and relevant procedures resulted in better coping For example, simulation training could focus on advanced cardiopulmonary resuscitation. Theoretical teaching often formed part of the preparations and could be linked to cardiopulmonary resuscitation, like the algorithm for resuscitation. In their opinion, having both a theoretical and practical element enhanced their competence. One clinical nurse specialist described the participation as follows:

    ‘If you manage to forget that it is a training situation, and try to focus on learning, you learn a great deal.’

    They highlighted the importance of good communication in the team. The clinical nurse specialists explained that emergency situations could be chaotic, and might give rise to harsh words and aggressive behaviour. They believed that training in communication is necessary and that simulation-based training gives the whole team a unique opportunity to practise crisp and clear communication. This gives them more confidence in themselves and their role in the team.

    Regular training in equipment and relevant procedures increased mastery.

    The interviews revealed that clinical nurse specialists took a positive view of reflecting on what they had participated in, and what they had done well and less well. They indicated that this was important for learning. A facilitator was present in the simulation centre and led the debriefing. The weekly simulation could be conducted with or without a facilitator. Simulation without a facilitator was perceived as unstructured, and the participants did not feel that they were given a systematic review of what had occurred.

    For example, they wanted the following type of feedback:

    ‘You might think about that next time, remember to give a clearer message, and to have it confirmed.’

    Impact on emergency situations

    The clinical nurse specialists described how they transferred their thought process from simulation to emergency situations. They also spoke of the impact that simulation had on patient care, and the aspects of simulation that affect their actions in an emergency situation.

    In emergency situations, they automatically began to allocate roles and responsibilities in the way that they had been trained. They claimed that the time that had elapsed between the simulation and the occurrence of an emergency situation had an impact on how quickly they accessed their knowledge. One clinical nurse specialist described her experience of performing chest compressions on a baby in an emergency situation:

    ‘The feeling that with a baby, it was enough to use my fingers; I felt I was doing it correctly, in the way that I had been trained.’

    The level of stress was reduced when they mastered the tasks and felt confident in emergency situations. All the clinical nurse specialists stated that simulation-based team training has an impact on patient care in emergency situations, and thereby also on patient safety. One clinical nurse specialist illustrated the impact on patient care as follows:

    ‘When you practise it, you know what to do, and you act more quickly. And this benefits the patient […] yes, you quite simply become more skilled.’

    Interdisciplinary participation in simulation increases team members’ understanding of each other.

    The clinical nurse specialists underlined the need to maintain and ensure necessary skills. In simulation-based team training, the clinical nurse specialists were drilled in realistic patient situations without entailing risk for the patient. They felt that they were able to test themselves, but also that they obtained confirmation of their own competence. At the same time, they claimed that interdisciplinary participation in simulation gave the team members a better understanding of each other, enabling the entire team to function better.

    They had found that their managers and colleagues expected clinical nurse specialists to be competent and up-to-date, and to feel comfortable with mastering their tasks when an emergency arises. They were concerned about the lack of training in practice and found that they have little chance to build up experience-based expertise in pediatric units, where centralized patient management led to shorter hospital stays and less complexity.

    Discussion

    In this study, we wished to describe clinical nurse specialists’ experiences with participating in simulation-based team training in paediatric units. We also wished to examine the impact of this type of training on patient care in an emergency situation.

    The importance of good planning and realism in simulation

    The clinical nurse specialists claimed that simulation-based team training must be properly scheduled and organised to provide a learning outcome. In units that arranged weekly simulation training, the clinical nurse specialists found the training not to be well planned, with random opportunity for them to participate. However, if simulation-based team training was part of the ward’s objectives and was planned as part of the roster, they were able to participate regularly – up to twice yearly.

    There was common agreement that resources must be allocated, and that managers and network administrators must see the need for a scheduled and organised simulation. This view is supported by the literature, which states that effective results are achieved through a systematic approach to incorporating simulation (5, 16). Investment in simulation should be endorsed by the management and included in the unit’s quality management (13, 17).

    Realistic simulation important for learning

    In order to provide a learning outcome from simulation-based team training, training in realistic patient situations is highlighted. The clinical nurse specialists stated that to achieve this, it is essential for all those healthcare providers that are present in emergency situations to train together. The literature supports the clinical nurse specialists’ opinion that it is essential for learning that the participants feel that the simulation is realistic (18). Scenarios should be designed that are linked to the learning objectives (7, 13). The participants must be prepared for what they are to react to during the scenario, and they should be familiar with the environment, available equipment and patient history (7, 19). Rules and expectations should be clarified in a briefing session, and the environment should be made safe in order for the participants to feel secure (13).

    The literature also supports the clinical nurse specialists’ view that the entire team must train together. Østergaard and collaborators describe simulation that includes a complete, interdisciplinary team as a method which improves the quality of teamwork behaviours (9). In emergency situations, so-called ad hoc teams are formed, which may represent a challenge for team collaboration. They have little time to plan and may find it challenging that team members are unfamiliar with each other and each other’s competence (8, 20).

    The importance of a good leader

    Experience shows that team members also change continuously. Roberts and collaborators claim that even short simulation-based team-training sessions can improve teamwork and communication in ad hoc teams, as they enhance behavioural skills and critical thinking (20). According to Salas and collaborators (2008), ‘patient care is a team sport’ (21), and the composition of the teams who train together is therefore important.

    The clinical nurse specialists also communicate the need for a good team leader to improve the progress and quality of patient care in emergency situations. They believe simulation training in leadership is important. Failures of leadership and team collaboration have been shown to be points of vulnerability for adverse events (8, 9, 20). Leading a team includes coordination and planning of the course of events, for which clear communication is absolutely essential. 

    Leadership is crucial in emergency situations, which underpins the need to train for this role.

    Hunt and collaborators point out that a good leader must be capable of giving instructions and ensuring that messages are received, understood and acknowledged (8). Another important quality is to listen to the team members and collect and disseminate the information that emerges (7). Leadership is highly important in emergency situations, which underpins the need for training in this role to improve team collaboration in order to avoid adverse events.

    Experience of learning and mastery through simulation

    According to the clinical nurse specialists in this study, they both learned and coped by participating in stimulation-based team training. Three of them had participated in a simulation centre, which they found provided them with a considerable learning outcome. The majority of the clinical nurse specialists had experienced that the emergency room in the department was used as a practice area.

    They claimed that it was very advantageous that the simulation was conducted in a familiar environment. The clinical nurse specialists described how they introduce elements from the simulation into emergency situations. This may indicate that simulation-based team training is beneficial for clinical practice.

    The clinical nurse specialists’ perception that simulation-based training provides them with both learning and mastery may be explained by the fact that simulation as a learning activity builds on key principles of andragogy. The educator Malcolm Knowles claims that safe, familiar surroundings are important to enable adults to learn. He also says that adults learn best when learning provides immediate benefits (22, 23).

    Conducting the simulation in familiar surroundings was a significant advantage.

    In situ training sessions

    When healthcare providers train in the established simulation centres, they are given the opportunity to train in everything from simple skills at the individual level to advanced interactions and team-based decision-making (24). Using the emergency room in the department as a practice area, in an environment where emergency situations occur, is referred to in the literature as in situ training (25). The literature supports the need for in situ training in paediatric units, as this can enable healthcare providers to recognise signs of acute illness and therefore provide better treatment (26).

    The study by Sørensen and collaborators showed that the participants perceived the situation as more realistic when the training was conducted in situ. It made no difference whether the simulation was conducted in a simulation centre or in situ, in terms of attitude to patient safety, coping with stress or teamwork (27).

    The clinical nurse specialists had found that it could be challenging to achieve good communication and dialogue in emergency situations. Communication was set as a learning objective for the simulation training, underlining the importance for the entire team to train in communication. They described it as especially challenging to persuade team members to communicate (9). Good dialogue and communication within the team gives team members the courage to provide valuable input with regard to patient care (8). Based on the principles of CRM, the precise purpose of simulation is for the team members to communicate and cooperate (9). Training in communication skills should therefore be formulated as learning objectives in the simulation.

    New knowledge acquired

    Other learning objectives and attention with regard to the simulation-based team training were connected to advanced cardiopulmonary resuscitation and medical equipment. The clinical nurse specialists were supplied with new knowledge by participating in the simulation, while also obtaining confirmation of their own competence. They prepared themselves for the simulation by reading up on theory and described this as being useful to bring with them into emergency situations. The practical skills they acquired were also useful.

    The concept of the learning circle is used in connection with simulation training. It means that theoretical knowledge is put into practice through training in patient situations before this knowledge is translated into clinical practice and experience is augmented for new learning (28, 29). This may indicate that simulation is a suitable learning activity for experienced clinical nurse specialists, and that it provides learning that can be transferred to emergency situations.

    Importance of regularity and feedback

    There was variation in the frequency with which clinical nurse specialists had the opportunity to participate in simulation, but those who were able to participate regularly reported having obtained a significant learning outcome from it. This tallies with recommendations from the Norwegian Society of Paediatricians that training in basic and advanced cardiopulmonary resuscitation should be undertaken at least every six months (17). This is also in line with Motola and collaborators, who claim that simulation is most successful when it is an established, regular activity (13). In considering how frequently simulation should be conducted, it is important that it is seen as a learning process, and not as a one-time event (30).

    The clinical nurse specialists had positive experiences of debriefing and considered feedback from the facilitator and the participants to be important for learning. If simulation is to be used as an educational tool, reflection on one’s own efforts is essential (31). According to Eppich and Cheng, facilitated debriefing is necessary, as learning from simulation-based training begins after completion of the scenario (3, 32).

    Hunt and collaborators furthermore claim that simulation training without reflection and feedback does not lead to effective learning (8). The facilitator directs the debriefing in order to elicit systematic reflection in the participants. The learning effect of reflection is therefore dependent on the supervisory expertise of the facilitator (9, 32). This underlines the importance of facilitator’s role, which is described in the literature as a key component of simulation training (9).

    The importance for patient care in an emergency situation

    The clinical nurse specialists claimed that they acted more quickly and effectively in emergency situations after having participated in simulation training. They brought with them elements from the training situation, such as distribution of roles and tasks and thinking about dialogue and communication in the team.

    They argued that participation in simulation training provides an opportunity to enhance the clinical nurse specialists’ competence to act in emergency situations. All of them agreed that regular simulation-based team training in paediatric units is crucial for improving patient care in these situations. The literature supports the notion that training in communication, leadership and teamwork has an impact on patient safety (9). It also helps to enhance the technical skills of the individual participant as well as the team (33).

    Truijens and collaborators claim that the patient-reported quality of health assistance improves when the personnel are trained in the principles of CRM (34). According to Draycott and collaborators, this is the first time that a pedagogical intervention has yielded a clinically important and permanent improvement in perinatal outcomes (35). The clinical nurse specialists take responsibility in this regard when they communicate a need to participate in simulation-based team training, because they wish to maintain their competence and improve patient care in emergency situations.

    In order to substantiate the fact that simulation is a learning activity that actually improves patient safety, Schmidt and collaborators claim that there is also a need to identify clear patient safety objectives (33). Ziv and collaborators maintain that if simulation is not used as a learning activity, this constitutes not only a training issue, but also an ethical issue (10). Standardised training and certification through simulation-based team training makes it possible to reduce errors and adverse events, and thus improve patient safety. The establishment of this scheme will, in our opinion, enable the health services to appear more reliable and ethically sound. 

    Conclusion

    The clinical nurse specialists in this study found that participation in simulation-based team training contributes to quality of patient care and confidence in one’s own skills. They highlight the need to offer simulation-based team training as a well-planned learning activity in paediatric units, with realistic scenarios and including the entire team. The clinical nurse specialists feel that by participating in simulation training they obtain confirmation of their own competence and a basis for further learning, mastery and sense of security. In the interviews, they point to examples from practice, showing that simulation training has had a positive influence on their competence to act in emergency situations.

    This study revealed that the organisation and implementation of simulation in individual paediatric units is random and lacking in clear requirements and parameters. There may therefore be a need for a Norwegian standard for simulation-based team training for doctors and nurses in paediatric units to ensure patient safety in emergency situations. 

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    25.     Kobayashi L, Patterson MD, Overly FL, Shapiro MJ, Williams KA, Jay GD. Educational and research implications of portable human patient simulation in acute care medicine. Academic emergency medicine 2008;15(11):1166–74.

    26.     Theilen U, Leonard P, Jones P, Ardill R, Weitz J, Agrawal D et al. Regular in situ simulation training of paediatric medical emergency team improves hospital response to deteriorating patients. Resuscitation 2013;84(2):218–22.

    27.     Sørensen JL, van der Vleuten C, Rosthøj S, Østergaard D, LeBlanc V, Johansen M et al. Simulation-based multiprofessional obstetric anaesthesia training conducted in situ versus off-site leads to similar individual and team outcomes: a randomised educational trial. BMJ open 2015;5(10):e008344.

    28.     Lindamood KE, Weinstock P. Application of high-fidelity simulation training to the neonatal resuscitation and pediatric advanced life support programs. Newborn and Infant Nursing Reviews 2011;11(1):23–7.

    29.     Kolb AY. The Kolb learning style inventory–version 3.1 2005 technical specifications. Boston, MA: Hay Resource Direct; 2005.

    30.     Beaubien J, Baker D. The use of simulation for training teamwork skills in health care: how low can you go? Quality and Safety in Health Care 2004;13(suppl 1):i51–i6.

    31.     Cates LA, Wilson D. Acquisition and maintenance of competencies through simulation for neonatal nurse practitioners: Beyond the basics. Advances in Neonatal Care 2011;11(5):321–7.

    32.     Eppich W, Cheng A. Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simulation in Healthcare 2015;10(2):106–15.

    33.     Schmidt E, Goldhaber-Fiebert SN, Ho LA, McDonald KM. Simulation exercises as a patient safety strategy: a systematic review. Annals of Internal Medicine. 2013;158(5_Part_2):426–32.

    34.     Truijens SE, Banga FR, Fransen AF, Pop VJ, van Runnard Heimel PJ, Oei SG. The effect of multiprofessional simulation-based obstetric team training on patient-reported quality of care: A pilot study. Simulation in Healthcare 2015;10(4):210–6

    35.     Draycott T, Sibanda T, Owen L, Akande V, Winter C, Reading S et al. Does training in obstetric emergencies improve neonatal outcome? BJOG: An International Journal of Obstetrics & Gynaecology 2006;113(2):177–82.

    Simulation-based team training improves quality of patient care, but the training should be a planned activity.

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    Background: Medically justifiable practice of health care requires collaboration between the health professionals involved, who must have excellent professional knowledge and practical training in teamwork. In recent decades, healthcare providers have undergone simulation training in realistic patient situations demanding complex decision-making and teamwork. The training was based on experiences with “Crew Resource Management” (CRM) used in civil aviation.

    Objective: To describe the experiences of clinical nurse specialists working in paediatric units related to participation in simulation-based team training and the impact this may have on patient care in emergency situations.

    Method: The study has a qualitative, inductive and descriptive design. The sample consisted of ten clinical nurse specialists recruited from the paediatric units of three different hospitals. Data were collected through individual interviews and analysed according to Graneheim and Lundman’s (2004) content analysis.

    Results: Clinical nurse specialists in paediatric units described the importance of a scheduled and realistic simulation, how they learn and cope through simulation, and the importance of these simulations for their performance in emergency situations.

    Conclusion: Clinical nurse specialists in this study found that participation in simulation-based team training contributes to enhancing the quality of patient care and confidence in their own skills. They emphasise that simulation-based team training should be offered as a scheduled activity. The organisation and implementation of simulation in individual paediatric units is described as random and lacking in clear requirements and parameters. This study may indicate a need for a common Norwegian standard for simulation-based team training to ensure patient safety in emergency situations.

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  • From hospitals to nursing homes – the consequences of the Care Coordination Reform

    To better meet the health challenges of the future, many industrialised countries have implemented health reforms during the last decade (1). The challenges have been described as including insufficient coordination of the health services, little focus on prevention and an expected growth in the number of elderly people with chronic illness and need for assistance (1). This is reflected in the Care Coordination Reform, which was introduced in Norway in 2012, with the goal of improving public health and sustainably improving the health and care services (2).

    In line with the health reforms in the Nordic countries, the Norwegian coordination reform has been concerned with relocating the responsibility for treatment to places closer to the patient’s home (1). This implies that a larger proportion of the health services will be transferred to municipal health providers, thus to slow down the growth in the use of hospital services. According to Grimsmo and Magnussen (1), the Norwegian coordination reform is distinctive in having been implemented in the specialist and primary health services separately.

    One of the instruments in the Norwegian coordination reform has been to establish collaboration agreements between the municipalities and the health enterprises. According to the evaluation of the coordination reform undertaken by the Research Council of Norway (3), the reform has had a limited impact on the way in which the municipal health services perceive this collaboration. The collaboration is described as asymmetrical, since the hospital doctors are authorised to decide when a patient is ready for discharge without having to involve the medical competence in the municipality to any appreciable extent in this decision (3).

    Shorter hospitalisation periods after the reform

    The fee paid by the municipalities for patients who are deemed to be ready for discharge from hospital is a further key instrument in the Norwegian reform. During the first year after the reform, some hospitals reported a reduction of up to 96 per cent in the number of excess hospitalisation days of patients who were ready for discharge (4). According to the investigation made by the Office of the Auditor General of resource utilisation and quality in the health services after the introduction of the coordination reform (5), more than 80 per cent of the patients who were registered as ready for discharge nationwide in 2014 were received by the municipality on the day when the discharge was announced. Hospitalisation times for the oldest patients have also been reduced.

    At the geriatric emergency department of Diakonhjemmet Hospital, the reduction in hospitalisation time after the introduction of the coordination reform was associated with an increase in readmissions in the same period (7). According to the evaluation report for the coordination reform, this is not linked to an increase in readmissions, but an increase in admissions during the same period in which a reduction in hospitalisation periods had been observed (3). Coordination statistics from the Directorate of Health confirm that there is a correlation between shorter hospitalisation periods and readmissions (8). There is a greater risk of readmission among patients who are transferred to the municipality on the same day that the discharge is notified, when compared to patients who remain in hospital beyond this time (8). A large-scale Swedish study found a correlation between shorter hospitalisation periods and reduced survival after discharge among elderly patients with femoral neck fractures (9). 

    Flaws in patient transfer

    Because of the shorter hospitalisation periods for the oldest patients, we can see an increase in the number of patients being transferred to nursing homes (8). This increase has not resulted in a significant increase in nursing home beds (5). However, more widespread use of double rooms and corridor patients has been registered (10), as well as an increase in short-term stays at the cost of permanent places in nursing homes (11). The transfer of responsibility for treatment from the hospitals to the municipalities entails that the patients being transferred suffer from more serious, complex and treatment-intensive conditions, when compared to the situation before the introduction of the coordination reform (10, 11). Thus, the nursing homes have been charged with more specialised care and treatment, with a concurrent need for more competence. However, the municipalities have not upgraded their competencies to any great extent since the introduction of the coordination reform (5). The nursing homes report having unfulfilled needs for competence and increased time constraints after the coordination reform (9).

    Because of the shorter hospitalisation periods for the oldest patients, we can see an increase in the number of patients being transferred to nursing homes.

    When seriously ill patients needing treatment are to be transferred to health services at another level, collaboration between the service levels is essential. Measures including collaboration agreements between the municipalities and the health enterprises have been introduced to reinforce the coordination between the service levels. The municipalities nevertheless report that the collaboration associated with transfer of patients has been weakened since the introduction of the reform (10). This was confirmed by a nationwide inspection, which identified deficiencies in the flow of information when patients were transferred between hospitals and municipalities (5).

    We wished to obtain more knowledge about the consequences of the coordination reform for frail elderly patients who are transferred from hospitals to nursing homes. We therefore compared the incidence of deaths, age, sex, hospitalisation days and discharge destination before and after the reform.

    Material and method

    We undertook a retrospective study in one of the nursing homes in Bergen municipality by retrieving data for the periods from May 2009 to December 2011 and March 2012 to May 2014, i.e. before and after the introduction of the coordination reform respectively (2). The study was undertaken in a 35-bed short-term ward. This ward received patients who could not be discharged to their own homes after emergency hospitalisation. The objectives of their stay in the ward were:

    • to complete medical treatment and care that had been initiated in the hospital, and
    • to identify care needs and the possibilities for transfer to their own homes.

    Through this period (2009–2014), the ward has followed the same procedures, with unchanged staffing. When our study was initiated in 2013, all the patients included had either been discharged from the nursing home or were deceased.

    Patients

    We included all patients ≥ 70 years who were transferred from Haukeland University Hospital or Haraldsplass Diaconal Hospital to the short-term ward at the nursing home during the period in question. We collected patient characteristics, such as age, sex, hospitalisation days, discharge destination and death, from the municipal patient administration system.

    Statistics

    We analysed the data with the aid of descriptive statistics. The data were not normally distributed, and we used the Mann-Whitney U-test to compare continuous data and the chi-square test to compare categorical data between two groups. The data were analysed with the aid of the statistics package SPSS, version 20 for Windows.

    Ethics

    The study was approved by the Regional Committee for Medical and Health Research Ethics (REK Western Norway), which also granted exemption from the requirement for patient consent.

    Results

    We included a total of 363 patients with a median age of 86 years (range: 70 to 103 years), whereof 59 per cent were women. The patients who were admitted after the introduction of the coordination reform were significantly older (p < 0.001), and more than twice as many died in the nursing home (p = 0.002) (Table 1).

    The patients who were admitted after the introduction of the coordination reform were significantly older.

    Mortality increased after the introduction of the coordination reform, at six as well as twelve months (p = 0.04 and p = 0.01 respectively) (Table 2).

    Fewer patients were transferred to a long-term place in another nursing home (p = 0.001), while a higher proportion of patients were discharged to their homes (p = 0.04). There was no significant difference (p = 0.91) in the number of days the patients remained alive prior to and after the coordination reform (Table 1).

    Mortality increased after the introduction of the coordination reform, at six as well as twelve months (p = 0.04 and p = 0.01 respectively) (Table 2). Fewer patients were transferred to a long-term place in another nursing home (p = 0.001), while a higher
    Table 2. Mortality at 6 and 12-month follow-up before and after the introduction of the coordination reform

    Discussion

    This study shows that patients who were transferred from a hospital to a nursing home after the introduction of the coordination reform were older than those transferred before the reform. In addition, a larger proportion of the patients died in the nursing home (Tables 1 and 2). As far as we are aware, this study is the first to have retrieved information on age and death in this patient population.

    Unfortunately, we have no variables that may explain the increased mortality that we have found. Despite an increase in survival in hospitals from 2010 to 2014 (12), we have limited information on the correlation between changes in the frequencies of deaths in hospitals and nursing homes. The most likely explanation, which has also been emphasised in previous studies (10, 11), is that the patients who were transferred to nursing homes after the coordination reform suffered from more serious, complex and treatment-intensive conditions than those who were admitted before the reform. Moreover, the patients admitted after the reform were older. The number of diagnoses has been shown to contribute to increased mortality among residents in nursing homes (13, 14).

    Weakening of service levels

    We found that the number of patients who died in nursing homes doubled after the introduction of the coordination reform (from 13 per cent to 27 per cent; p = 0.002). Nursing, care and treatment of extremely ill and dying patients are especially challenging, in terms of both competence and resources. According to the National Action Plan’s guidelines for palliative cancer care (15), the palliative pathway is characterised by a complex clinical picture with acute conditions such as complications and organ failure, and an increasing need for care. Those who follow up this patient group emphasise close follow-up with appropriate information to the patients and their next of kin (15). Studies show that sufficient time and competence with regard to palliative care as well as communication with the patients and their next of kin are essential for the provision of good end-of-life care (16–19).

    We found that the number of patients who died in nursing homes doubled after the introduction of the coordination reform.

    To provide seriously ill and terminal patients with appropriate follow-up and care, planning of the transfer of treatment responsibility to another service level is essential. It is therefore a source of concern when nurses in the municipal health services report that the collaboration between the service levels has weakened when it comes to discharge planning in the specialist health services since the introduction of the coordination reform (10). Moreover, it is problematic that medical competence in the municipality is rarely involved in assessments and decisions regarding the transfer of treatment responsibility from the specialist health services.

    Weaknesses of the study

    One weakness of our study is that we have no data regarding any possible differences in terminal care between nursing homes and hospitals. Nor do we have any data on how the patients or their next of kin perceive the transfer to a nursing home at this stage of life. We are therefore unable to draw any conclusions as to where terminal care can best be provided to this group of patients. When departing from life or losing someone close, security, predictability and a perception of support and competence are essential factors. Whether this can be best ensured close to the patient’s home or where the specialist competence is highest, depends on several factors that are not elucidated in this study. Further research should focus on the treatment needs of patients admitted to nursing homes since the coordination reform. There is a need for knowledge on how patients and their next of kin perceive a transfer from a hospital to a nursing home at this stage of life. User experience is a key element in optimising service provision.

    Our results are generated by a small retrospective study undertaken in a single nursing home, and we have no information on morbidity. This is a weakness of this study. It would consequently be interesting to compare our figures with equivalent figures from other short-term wards from the same period and area. No such figures are available, however.

    A less favourable situation for the elderly and frail

    The results show that fewer patients were transferred to long-term places in other nursing homes, and that a higher proportion of the patients were discharged to their homes (Table 3). Other studies also conclude that a higher number of frail, elderly people are discharged from hospitals to nursing homes. This transfer entails an increase in short-term and rehabilitation places at the cost of permanent places in nursing homes (10).

    Table 3. Relocation pattern after short-term stays before and after the introduction of the coordination reform

    There is reason to assume that frail elderly patients who are discharged from nursing homes to their own homes constitute a group with a high risk of multiple readmissions. Our argument for this assertion is a general increase in readmissions after the introduction of the coordination reform (8), specifically in the patient population in acute geriatrics (7). Since the coordination reform, there has been a small increase in the number of readmissions from nursing homes to hospitals.

    It remains to be seen what role the establishment of municipal emergency day-care units (KAD units) may have for this patient population. The scheme was introduced in the period from 2012 to 2016. Bergen municipality established the scheme in 2016, after the completion of our study. So far, there are indications that very few patients are admitted from nursing homes, while close to 18 per cent of the patients who pass through these units are transferred to nursing homes within a few days (21).

    Conclusion

    Our results show that patients who have been transferred from hospitals to nursing homes since the coordination reform tend to be older and have shorter survival when compared to the situation before the introduction of the reform. The nursing homes may thus face a higher throughput of patients as well as challenges related to less clarified patient issues when it comes to active treatment versus terminal care.

    There is reason to assume that these factors entail consequences for the competence and staffing needs in nursing homes in order to achieve the coordination reform’s objective of sustainably improving public health and the health and care services. To cope with the new situation after the introduction of the coordination reform, the staffing in nursing homes ought to be reviewed in light of their tasks and competence needs. Further research should focus on the treatment needs of patients who have been admitted to nursing homes after the coordination reform.

    References

    1.       Grimsmo A, Magnussen J. Norsk samhandlingsreform i et internasjonalt perspektiv. 2015.

    2.       Helse- og omsorgsdepartementet. Samhandlingsreformen: Rett behandling – på rett sted – til rett tid. Oslo. 2009.

    3.       Norges forskningsråd. Evaluering av samhandlingsreformen. Sluttrapport fra styringsgruppen for forskningsbasert følgeevaluering av samhandlingsreformen (EVASAM). 2016.

    4.       Otterstad HK, Birkestrand T. Samhandlingsreformen. Færre overliggere i sykehus. Sykepleien 2014;102(2):49–51. Available at: https://sykepleien.no/forskning/2014/02/faerre-overliggere-i-sykehus. (Downloaded 06.02.2017).

    5.       Riksrevisjonen. Riksrevisjonens undersøkelse av ressursutnyttelse og kvalitet i helsetjenesten etter innføringen av samhandlingsreformen. Dokument 3:5 (2015–2016). Oslo: Helse- og omsorgsdepartementet. 2016.

    6.       Hermansen Å, Grødem AS. Reformeffekt: Redusert liggetid blant de eldste. Sykepleien Forskning 2015;10(1):24–32. Available at: https://sykepleien.no/forskning/2015/02/redusert-liggetid-blant-de-eldste. (Downloaded 06.02.2017). 

    7.       Ranhoff A, Alaburic S, Engstad T, Mensen L, Svendsen T. Readmissions after discharge from an acute geriatric unit; an analysis of probable causes. European Geriatric Medicine (EUGMS) September 2014; Rotterdam, Nederland, 2014. p. S207 – S8. Available at: http://www.em-consulte.com/en/article/927637. (Downloaded 12.02.2017).

    8.       Helsedirektoratet. Samhandlingsstatistikk 2013–14. Oslo. 2015.

    9.       Nordström P, Gustafson Y, Michaëlsson K, Nordström A. Length of hospital stay after hipp fracture and short term risk of death after discharge: a total cohort study in Sweden. BMJ 2015.

    10.     Gautun H, Syse A. Samhandlingsreformen. Hvordan tar de kommunale helse -og omsorgstjenestene i mot det økte antallet pasienter som skrives ut fra sykehusene? NOVA. 2013.

    11.     Abelsen B, Gaski M, Nødland SI, Stephansen A. Samhandlingsreformens konsekvenser for det kommunale pleie- og omsorgstilbudet. International Research Institute of Stavanger. 2014. Available at: http://www.ks.no/globalassets/vedlegg-til-hvert-fagomrader/helse-og-velferd/samhandlingsreformen/forskning-og-evaluering/iris-2014-382-samhandlingsreformens-konsekvenser.pdf. (Downloaded 12.02.2017).

    12.     Lindman AS, Kristoffersen DT, Hansen TM, Tomic O, Helgeland J. Kvalitetsindikatoren 30-dagers overlevelse etter innleggelse i norske sykehus – resultater for året 2014. Oslo: Kunnskapssenteret for helsetjenesten i Folkehelseinstituttet. 2015.

    13.     Drageset J, Eide GE, Ranhoff AH. Mortality in nursing home residents without cognitive impairment and its relation to self-reported health-related quality of life, sociodemographic factors, illness variables and cancer diagnosis: a 5-year follow-up study. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation. 2012.

    14.     Barca ML, Engedal K, Laks J, Selbaek G. A 12 months follow-up study of depression among nursing-home patients in Norway. Journal of Affective Disorders 2010;120(1–3):141–8.

    15.     Helsedirektoratet. Nasjonalt handlingsprogram med retningslinjer for palliasjon i kreftomsorgen. Oslo. 2010.

    16.     Dreyer A, Forde R, Nortvedt P. Autonomy at the end of life: life-prolonging treatment in nursing homes—relatives’ role in the decision-making process. Journal of Medical Ethics 2009;35(11):672–7.

    17.     Davies E, Higginson I. Better palliative care for older people. WHO. 2004.

    18.     Wille I-L, Nyrønning S. Omsorg og behandling ved livets slutt i sykehjem. Geriatrisk Sykepleie 2012;3.

    19.     Husebø B, Husebø S. Sykehjemmene som arena for terminal omsorg – hvordan gjør vi det i praksis? Tidsskr Nor Lægeforen 2005;125(1352):4.

    20.     Lovdata. Lov om kommunale helse- og omsorgstjenester m.m. 24.06.2011 [helse- og omsorgstjenesteloven]. Available at: https://lovdata.no/dokument/NL/lov/2011-06-24-30. (Downloaded 06.02.2017).

    21.     Skinner MS. Øyeblikkelig hjelp døgnopphold. Oppsummering av kunnskap og erfaringer fra de første fire årene med kommunalt øyeblikkelig hjelp døgnopphold. Rapportserie nr. 13. Gjøvik: Senter for Omsorgsforskning. 2015. Available at: https://brage.bibsys.no/xmlui/bitstream/id/398536/rapport_13_2015_web.pdf. (Downloaded 06.02.2017).

    Following the Care Coordination Reform, more frail elderly patients have died after discharge from hospitals to nursing homes and more have been discharged to return home.

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    Background: The coordination reform was introduced in January 2012 to ensure sustainability of health and care services. The transfer of responsibility for treatment from the specialist to the primary health service formed a central pillar of the reform. This study compares the situation before and after the introduction of the coordination reform for frail elderly patients being transferred from hospitals to nursing homes, related to: 1) deaths, and 2) age, sex, days of hospitalization and discharge destination.

    Objective: Investigate possible differences in the population of patients transferred from hospitals to nursing homes before and after the introduction of the Care Coordination Reform.

    Method: The data were retrieved from a 35-bed short-term ward at one nursing home, where the procedures and staffing were unchanged in the period before and after the reform. Information on the patients' age, sex, days in the nursing home, discharge destination and death in the nursing home was retrospectively collected for 186 patients aged ≥ 70 years for the period before the introduction of the coordination reform, and for 177 patients after the introduction of the coordination reform.

    Results: We found that the number of patients who died in the nursing home after hospitalization doubled (27% versus 13%, p <0.002) following the introduction of the coordination reform. Compared with the situation before the reform, patients admitted after the reform were older (median 88 years (range 73–103) versus 85 years (range 70–99), p <0.001). Fewer patients were transferred to a different nursing home (21% versus 45%, p < 0.001), and more were discharged to their own home (47% versus 36%, p = 0.04).

    Conclusion: Our results show that patients transferred from hospitals to nursing homes after the introduction of the coordination reform were older. Moreover, more patients died during short-term stays in nursing homes after being transferred from hospitals. There is reason to assume that these results have consequences for the needs for competence and staffing in nursing homes.

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  • Screening for symptoms of depression associated with heart disease

    The study described in this article is based on three key facts:

    • Heart disease gives increased risk of depression.
    • Depression has serious consequences for the sick person.
    • The health service is not sufficiently proficient at identifying and implementing measures to combat depression in connection with heart disease.

    Background

    The prevalence of depression associated with heart disease is estimated at between 15 and 40 per cent (1). There is considerable variation linked to the type of study and whether self-report questionnaires or structured diagnostic interviews are used. Nonetheless, depression is consistently found to occur far more often among those who are medically ill than in the healthy population, with a two to three times higher estimated prevalence (2). Studies at somatic hospitals indicate that 15 to 20 per cent of patients with myocardial infarction have a depressive disorder consistent with diagnostic criteria, but an even greater number have an increased level of symptoms of depression. The same prevalence is reported among patients hospitalised with other kinds of heart disease (3). Outpatients also exhibit a clearly higher prevalence than people who do not have cardiovascular disease. An American study of 30 000 adults found a prevalence of 9.3 per cent among patients with cardiovascular disease over a 12-month period, and 4.8 per cent for those with no concomitant medical disorders (4).

    Major negative consequences

    Depression can have a profound effect on the course and outcome of heart disease and is associated with non-compliance with treatment and rehabilitation programmes (3). When reviewing approximately 150 000 participants in 54 studies, Nicholson et al. found that depression predicted a cardiovascular event in people who had not previously had heart disease and new events for those who had. Moreover, the risk of major negative consequences was twice as great following a cardiovascular event (5).

    The report by Folkehelseinstituttet [Norwegian Institute of Public Health] on mental disorders in Norway from a public health perspective (6) states that depression is as strong a risk factor for death as smoking. This applies in particular to mortality resulting from cardiovascular disease and infectious diseases. The report refers to three correlations between depression and death resulting from cardiovascular disease. Firstly, depressed patients smoke more than the rest of the population. They drink more alcohol, train less and have a poorer diet. Secondly, depression may be a result of the burden of somatic illness. However, the risk of serious illness also increases with depression. Thus, the negative impact has a two-way effect. Thirdly, a negative interaction may arise that in itself leads to increased mortality due to depression and heart disease since depression weakens the body’s powers of resistance.

    Greatest impact on working capacity

    Patients with cardiovascular disease and concomitant depression demonstrate three times less compliance with recommended medical treatment than patients without depression (7). This entails reduced health and life quality, increased financial expenses and at worst a shorter life expectancy. For the health service, this means more consultations, longer periods of hospitalisation and more readmissions.

    Depression is a major cause of increased sickness absence in the case of somatic illness (8) and can be the determinant that excludes the person concerned from the labour market (9). An American study of 20 000 employees who were treated for depression showed that depression affected working capacity more negatively than all other illnesses (10). Depression may result in withdrawal from social life and increased irritability and pessimism, which in turn affects relationships with managers and colleagues. Some employees may become less productive due to a decline in energy, poorer concentration and a reduced ability to make decisions (11).

    Depression may have a profound effect on the course and outcome of heart disease.

    Depression is underdiagnosed and undertreated in patients with concomitant somatic illness. In line with the American Heart Association (3) and a number of European guidelines (12), Helsedirektoratet [Norwegian Directorate of Health] (13) recommends screening routines for depression. How can we make provision for this in a busy hospital everyday setting, and at what point during the treatment should we conduct such screening? The purpose of our study is to test and evaluate a method for systematic screening for depression in patients in cardiac medical wards. Early identification may enable mental health assistance to be provided at an earlier stage.

    Method

    We conducted the study in cooperation with the cardiac medical ward (professional nurses, head of the unit and senior consultant) and specialists in psychology at the Diakonhjemmet Hospital’s Unit for Mental Health Services in Somatic Care. The specialists in psychology lectured on depression as well as training health personnel on the ward in the use of the screening tools. The specialist nurses on the ward were of key importance in developing specific procedures for when, how and where screening should take place, and they administered the collection of data. A specialist in psychology and a specialist nurse carried out interviews with patients in the further screening of those assessed as possibly depressed (score on Beck’s depression inventory scale (BDI-II) was 14 or more). For practical reasons, we tested the screening over two six-week periods. 

    Inclusion and exclusion criteria

    We assessed all the patients admitted to the cardiac medical ward with a heart-related diagnosis with a view to their participation in the study. We excluded patients who had been admitted with a myocardial infarction, and who were already included in another research project. The exclusion criteria were language problems, reduced reading ability and inability to complete the questionnaire. In addition, we excluded patients who were too ill, or who were unable to participate for other practical reasons. We asked a total of 154 patients, 48 of whom declined to participate in the survey. Out of 106 participants, just over half were men (58 patients). The reasons for refusal to participate were complex. Some were too tired to complete the questionnaire mapping symptoms of depression (Patient Health Questionnaire-9 (PHQ-9)), some did not wish to participate, whilst others had been discharged before we offered screening. The most common diagnoses on admission were arrhythmia, heart failure and valvular heart disease. The Regional Committee for Medical and Health Research Ethics (REC) has approved the project.

    Screening instrument

    We asked the patients taking part to fill in PHQ-9 – a questionnaire with nine diagnostic criteria for depression (14) (table 1). Like other well-documented questionnaires, PHQ-9 has fairly high accuracy with a sensitivity of up to 80–90 per cent (15), while some studies have exhibited lower sensitivity (16). It takes 2–5 minutes to complete the form. Each question has four possible responses from 0 to 3 (0 = Not at all, 1 = Several days, 2 = More than half the days and 3 = Nearly every day). A score of 10 or more indicates possible depression and a need for further screening (16).

    Table 1. Questions about symptoms of depression (PHQ-9)

    Further screening

    A nurse carried out further screening of the patients with a score of 10 or more on the PHQ-9 questionnaire. The screening was based on Beck’s depression inventory scale (BDI-II), one of the most commonly used self-report scales for level of depression, i.e. degree of symptoms of depression (17). In addition, we asked patients about earlier depression, grief reactions and social support. Patients with symptoms of depression were given the opportunity to meet with a psychologist at the hospital, or were referred to the outpatient clinic for follow-up. We conducted a cluster analysis to explore possible patterns and profiles related to PHQ-9 scores in accordance with the k-means clustering method, whereby the values of a sample of variables are analysed to identify any sub-groups (18).

    Results

    Of the 106 patients who were screened for depression, 19 (18 per cent) had a PHQ-9 score of 10 or more, and underwent further screening for depression. Seven of these (7 per cent of the total number of screened patients and 37 per cent of the patients with a PHQ-9 score of 10 or more) had a BDI-II score of 14 or more, and had a feedback session with a psychologist. Six of these patients (6 per cent of the total number of screened patients and 32 per cent of the patients with a PHQ-9 score of 10 or more) were diagnosed with depression. The cluster analysis showed that a group of 33 participants had a relatively high mean score on questions about sleeping problems and tiredness. 

    Depression is just as strong a risk factor for death as smoking.

    Figure 1 shows the distribution of mean scores for women and men for each of the nine questions. All nine questions for both sexes gave 0 as the minimum value and 3 as the maximum value. Women tended to score higher than men on most of the questions but the disparities were not statistically significant for any of the questions. Nor were there any statistically significant gender disparities for the total score on PHQ-9.

    Figure 1. Distribution of mean scores for symptoms of depression in men and women on each of the nine questions in PHQ-9

    Discussion

    We were able to implement the screening method we tested in the study in a systematic manner. However, a large number of responses were lacking (48 patients), which may have been due to the fact that it is challenging to carry out screening during the short period of admission to the ward (two days on average). It may be difficult for many patients to answer the questionnaire and questions on their mental health during this acute medical phase. Moreover, since this is a research project, patients had to deal with a written consent form in addition to verbal information about the study.

    An alternative to using the questionnaire may be to ask the first two questions in PHQ-9, referred to as PHQ-2, orally, as recommended by Helsedirektoratet [Norwegian Directorate of Health] (13): ‘Over the past two weeks, have you been feeling down, depressed or hopeless?’ and ‘Over the past two weeks, have you often felt little interest or pleasure in doing things?’ If the patient responds affirmatively to these questions, further questions about symptoms of depression can be posed. This method can work just as well as using questionnaires (19). However, using PHQ-2 might have captured a larger number of those who reserved the right to refuse to participate.

    Should be examined at a later stage

    When we compared prevalence with previous studies, we found fewer patients who satisfied the criteria for depression and concomitant heart disease – only six out of 106. A weakness of our study is that patients with acute myocardial infarction are not included, since this group exhibits a high incidence of depression (20). Another weakness may be that the PHQ-9 screening instrument was not sufficiently sensitive, and we know of no validation studies among patients with heart disease in Norway. Another explanation for the identification of only a few patients with depression may be the time of the screening, since this was undertaken at an acute phase when the patients were tired and distressed with regard to having heart disease or aggravated symptoms, while they were also happy about having survived. The hospital’s self-management courses for patients with cardiovascular diseases and family members reveal that some people only report problems of depression after they have been at home for a period of time. It will be interesting to conduct follow-up Norwegian surveys of screening for symptoms of depression in hospitalised patients at some point after they have been discharged from hospital. We are now in the process of conducting such a study. 

    Some people only report problems of depression after they have been at home for a period of time.

    How did patients react to questions about depression? Patients who proved to be depressed expressed their gratitude that this had been detected and that they had been offered follow-up. Meanwhile, several did not wish to participate because they were tired. They said that they had more than enough to think about without also having to fill in a questionnaire on depression.

    A number of patients reported symptoms of depression, but did not meet the criteria for clinical depression. A total of 33 patients had considerable problems with sleep and exhaustion, and in some cases other mild symptoms of depression. It is important to also pay attention to mild symptoms because they undermine life quality, reduce functional level and can diminish compliance with recommended measures (15). Moreover, patients who experience considerable tiredness and sleeping problems may be at risk of developing depression at a later stage. Prevention is vital in this respect, for example by informing the patient, family members and GP about the increased risk, and informing them of the measures described in the guidelines of the Helsedirektoratet [Norwegian Directorate of Health] (13).

    Conclusion

    Screening for symptoms of depression in a cardiac medical ward requires methods that are straightforward and easy to implement because the period of hospitalisation is short and the hospital personnel have a hectic working day. The study shows that it is possible to carry out screening using the PHQ-9 questionnaire in line with the recommendations of professional guidelines. A possible alternative is to ask PHQ-9’s first two questions, also referred to as PHQ-2, orally. Many patients with heart disease report signs of depression after they have been at home for a period of time following discharge, when they are trying to get their lives back on track. It is vital to put in place screening procedures later in the course of the illness.

    We are in the process of initiating a new study in which we map symptoms of depression at the outpatient follow-up, using PHQ-2 and another scale for level of depression: the Hospital Anxiety and Depression Scale (HADS). The latter form replaces BDI-II, which we used in this study. HADS gives us the opportunity to establish whether an anxiety disorder is present. Heart disease combined with anxiety is associated with increased risk of aggravation of heart disease (21, 22).

    Referanser

    1.       Kop WJ, Plumhoff JE. Depression and coronary heart disease: Diagnosis, predictive value, biobehavioral mechanisms, and intervention. In: Allan R, Fisher J (ed.). Heart and mind. The practice of cardiac psychology. Washington DC: American Psychological Association 2012:143–68.

    2.       Creed F, Dickens C. Depression in the medically ill. I: Steptoe S (red.). Depression and physical illness. Cambridge University Press 2007:3–18.

    3.       Lichtman JH, Bigger JT, Blumenthal JA et al. Recommendations for screening, referral, and treatment: A science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: Endorsed by the American Psychiatric Association. Circulation 2008;118:1768–75.

    4.       Egede LE. Major depression in individuals with chronic medical disorders: prevalence, correlates and association with health resource utilization, lost productivity and functional disability. Gen Hosp Psych 2007;29:409–16.

    5.       Nicholson A, Kuper H, Hemingway H. Depression as an aetiologic prognostic factor in coronary heart disease: A meta-analysis of 6362 events among 146,538 participants in 54 observational studies. Eur Heart J 2006;27:2763–74.

    6.       Nasjonalt folkehelseinstitutt. Psykiske lidelser i Norge: Et folkehelseperspektiv. Rapport 8:2009. Oslo: Nasjonalt folkehelseinstitutt 2009.

    7.       DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: Meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 2000;160:2101–7.

    8.       Soderman E, Lisspers J, Sundin O. Depression as a predictor of return to work in patients with coronary artery disease. Soc Sci Med 2003;56:193–202.

    9.       Henderson M, Harvey SB, Øverland S, Mykletun A, Hotopf M. Work and common psychiatric disorders. J R Soc Med 2011;104:198–207.

    10.     Kessler R, White LA, Birnbaum H, Qiu Y, Kidolezi Y, Mallett D, Swindle R. Comparative and interactive effects of depression relative to other health problems on work performance in the workforce of a large employer. J Occup Environ Med 2008;50:809–16.

    11.     Berge T, Falkum E. Se mulighetene. Psykisk helse og arbeidsliv. Oslo: Gyldendal Akademisk 2013.

    12.     Graham I, Atar D, Borch-Johnsen K et al. European guidelines for cardiovascular disease prevention in clinical practice: executive summary. Eur Heart J 2007;28:2375–2414.

    13.     Nasjonale retningslinjer for diagnostisering og behandling av voksne med depresjon i primærhelsetjenesten og spesialisthelsetjenesten. Helsedirektoratet 2009.

    14.     Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16:606–13.

    15.     U.S. Preventive Services Task Force. Screening for depression: Recommendations and rationale. Ann Intern Med 2002;136:760–64.

    16.     McManus D, Pipkin SS, Whooley MA. Screening for depression in patients with coronary heart disease (data from the Heart and Soul Study). Am J Cardiol 2005;96:1076–81.

    17.     Beck AT, Steer RA, Brown GK. Beck Depression Inventory – Second Edition. Harcourt Assessment, Inc., USA. 1996.

    18.     SPSS Statistics 22.0.0. K-means Cluster Analysis. Available at: http://www-01.ibm.com/support/knowledgecenter/SSLVMB_22.0.0/com.ibm.spss.statistics.help/spss/base/idh_quic.htm (downloaded 23.03.2016).

    19.     Henkel V, Mergl R, Coyne JC, Kohnen R, Moller HJ, Hegerl U. Screening for depression in primary care: will one or two items suffice? Eur Arch Psychiatry Clin Neurosci 2004;254:215–23.

    20.     Lichtman JH, Froelicher, ES, Blumenthal JA et al. Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: Systematic review and recommendations. A scientific statement from the American Heart Association. Circulation 2014;129:1350–69.

    21.     Janszky I, Ahnve S, Lundberg I et al. Early-onset depression, anxiety and risk of subsequent coronary heart disease. 37-year follow-up of 49,321 young Swedish men. Am J Cardiol 2010;56:31–6.

    22.     Roest AM, Martens EJ, de Jone P et al. Anxiety and risk of incident coronary heart disease. A meta-analysis. Am J Cardiol 2010;56,38–46.

    Heart disease increases the risk of depression. How can we best identify depressed cardiac patients?

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    English
    Sammendrag

    Background: Depression is associated with an increased risk of death from heart disease and has major implications for quality of life, working capacity and ability to comply with medical treatment. Therefore, health authorities recommend routine screening for depression.

    Purpose: The purpose of the study was to test a method of mapping symptoms of depression in patients with heart disease.

    Method: We tested a method of screening for depression in 106 patients with cardiovascular disease in a cardiac medical ward, using the Patient Health Questionnaire (PHQ-9). The most common diagnoses on admission were arrhythmia, heart failure and valvular heart disease.

    Result: Compared with previous studies, we found far fewer patients who met the criteria for depression and concomitant heart disease. Only six out of 106 satisfied these criteria, while a significant subset of 33 patients had mild symptoms of depression.

    Conclusion: Patients with heart disease are at risk of developing depression, and the patients in question must be identified so that they can receive appropriate health assistance. The study showed that it was possible to implement a method of screening for symptoms of depression in a cardiac medical ward using PHQ-9. It may be the case that screening at an acute phase of heart disease is premature. We are now conducting a study of screening procedures during the outpatient follow-up after discharge. 

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  • Are group-based self-management programmes suitable for all patients with type 2 diabetes?

    Type 2 diabetes is an increasingly prevalent illness (1), and is placing significant demands on patient self-management. In Norway, as in the rest of Europe, the health authorities are investing in group-based self-management programmes to enhance coping skills and improve therapeutic compliance (2). Since 1997, approximately 60 Learning and Mastery Centres have been established in the specialist health services, and these arrange ‘Beginners’ courses’ for patients with type 2 diabetes (3). Since the introduction of the Coordination Reform in 2012, various generic self-management programmes have also been established by local authorities to support recommended health behaviour. In addition, the Norwegian Diabetes Association runs local motivation groups.

    Socioeconomic factors

    A summary from the Norwegian Knowledge Centre for the Health Services shows that group-based self-management programmes have a positive effect on mental health, coping, relationships and knowledge of one’s disease (4). Long-term studies also indicate improved blood sugar control in persons with type 2 diabetes after group-based programmes (4-6). However, it is uncertain whether group-based self-management programmes are equally attractive for all groups of patients. Studies from other countries show selection bias, and differences are related to socioeconomic factors. Participation in group-based self-management programmes declines with lower economic status and increasing age (7).

    A Canadian cross-sectional study of 46 553 patients with diabetes shows significant differences between participants and non-participants in group-based self-management programmes. Among non-participants, there is a preponderance of persons with a low educational level, advanced age, immigrant background, mental illness and comorbidity (8). One study also shows that patients recruited to the group programmes are those who initially exhibit the best health behaviour (9), which indicates that it is difficult to recruit persons who struggle to maintain appropriate health behaviour. Studies also indicate higher participation in group-based self-management programmes by women than by men (10, 11).

    Selection bias

    The association between patients’ socioeconomic status, gender, health behaviour and participation in group-based self-management programmes has not been investigated in Norway, but less use of health services in groups with a low socioeconomic status can generally be observed (12, 13). There are significant correlations between socioeconomic conditions and health (14-16), with a higher prevalence of obesity (17, 18) and smoking (19, 20), as well as little physical activity and low intake of fruit and vegetables (20, 21) in groups with a low socioeconomic status. With regard to type 2 diabetes, an increased prevalence can be observed in certain immigrant groups (22), in groups with a low educational level (23, 24) and among pensioners in receipt of disability benefit and persons who are not economically active (25).

    According to Report No. 20 to the Storting, ‘National strategy to reduce social inequalities in health’ (15), the health services shall contribute to reducing social inequality, and Learning and Mastery Centres are described as an important arena for this (p. 54). Experience from other countries showing that group-based self-management programmes do not attract men or persons with a lower level of education to the same extent as other groups suggests a need to investigate how the current service functions in Norway. The purpose of this study was to investigate a sample of Norwegian patients with type 2 diabetes. We wanted to discover how large a proportion of these had participated in group-based self-management programmes and what characterises participants and non-participants. Are there differences in socioeconomic factors, gender and health behaviour?

    Method

    Our study is based on Norwegian data from an EU study (EU-WISE) that involves six European countries and is funded under the 7th Framework Programme. The study focuses on social networks and self-management of type 2 diabetes in economically deprived groups (26). Although EU-WISE has the express objective of reaching those who struggle with diabetes, there was no capacity to focus on the particular challenges of immigrant groups. In conformity with the protocol of EU-WISE, each participant country recruited 300 patients with type 2 diabetes in urban and rural areas to a descriptive cross-sectional study (26). Criteria for inclusion were that the patient was diagnosed with type 2 diabetes, was older than 18 years and spoke Norwegian sufficiently well to be able to understand and complete a questionnaire.

    We excluded patients with double diabetes, gestational diabetes, severe cognitive impairment, severe psychiatric illness, terminal illness and patients who had recently undergone extensive surgical or medical treatment. We approached outpatient clinics in the specialist health service with the aim of reaching patients who had been referred there by their GP, as such patients very often struggle to cope with the disease and develop long-term complications. Via a total of eight outpatient clinics in health trusts in Eastern Norway, diabetes nurses invited patients who fulfilled the inclusion criteria to participate in the study in the period from August 2013 to February 2014. The study has been approved by the Regional Committees for Medical and Health Research Ethics (REC). Participation was voluntary and the participants signed an informed consent form.

    The questionnaire

    The questionnaire that was used in EU-WISE was composed of various validated instruments (26). The study participants provided sociodemographic data (gender, age, highest completed education, employment status, number of household members, income level and parents’ country of birth). They were also asked whether they had participated in a group-based self-management programme. Comorbidity was measured using self-reporting, and the participants were asked whether they had been diagnosed with

    • hypertension,
    • high cholesterol,
    • angina,
    • heart attack,
    • heart failure,
    • TIA/ transient ischaemic attack,
    • stroke,
    • atherosclerosis/intermittent claudication, or
    • depression.

    They were also asked if they had undergone heart surgery.

    The Summary of Diabetes Self-Care Activities (SDSCA) scale was used to measure health behaviour (27). The SDSCA scale asks respondents to indicate the number of days in the previous week that they have followed the recommended diet, been physically active, measured their blood sugar and checked their feet. Smoking is indicated in the yes/no category. SDSCA is internationally validated. In connection with the study, we have followed international principles for translation and adaptation to Norwegian conditions (28), but otherwise the instrument has not been validated in Norwegian. 

    Analysis and coding

    The dependent variable in the study is participation in group-based self-management programmes. We used sociodemographic data to describe the sample, and compared socioeconomic conditions, comorbidity and smoking in participants and non-participants in group-based self-management programmes. Somatic comorbidity was summarised (varying from zero to nine additional disorders) and categorised as ‘low comorbidity’ (zero to two disorders) or ‘high comorbidity’ (three or more disorders). Depression was analysed as a separate category as a mental health indicator.

    In relation to health behaviour in the previous seven days, we divided the continuous data into three strata: those who did not self-monitor their illness (zero days per week), constituted the reference group. Those who self-monitored to some extent, i.e. one to four days per week, constituted one stratum, while those who self-monitored regularly, i.e. five to seven days per week, represented another stratum. In addition, gender was cross-tabulated with socioeconomic variables to obtain an overview of variation and comparability between men and women in the sample. We investigated statistical disparities using the chi-square test and logistic regression analysis. P-value for significance was set at < 0.05. We performed the analyses using IBM SPSS Statistics version 23.

    Main result

    We asked 362 patients to take part in the study, and 298 gave their consent (response rate 82.4 per cent). The sample is presented in Table 1. The table shows that the average age of the sample was 60 years, with a slight preponderance of men. Somewhat less than half are in full-time or part-time work, while one-quarter are unemployed, disability pensioners or on sick leave. Almost half are only educated to primary/lower secondary level, and two-thirds have an annual income corresponding to, or less than, NOK 350 000. The vast majority have parents born in Norway or another European country.

    A higher proportion of women and those with a higher education among participants, and a lower proportion of smokers.

    To the question of participation in group-based self-management programmes, 112 (38 per cent) respond that they have participated, while the remainder have not. With regard to socioeconomic conditions, there are significant differences between participants and non-participants in group-based self-management programmes in terms of gender, educational level and smoking (p <0.05). The proportion of women and those with a higher education is higher, and that of smokers is lower. There is an indication of covariance between low participation in group-based self-management programmes and patients with high comorbidity, but this is uncertain as the difference is not significant (p = 0.055). 

    Table 1. Description of sample, socioeconomic factors, comorbidity and smoking

    Table 2 compares women and men in the sample with a view to socioeconomic conditions. We find two significant differences between the groups: the men in the study are older than the women, while the women have a lower income. Health behaviour is presented in Table 3, and the results demonstrate that physical activity clearly increases the odds of participating in patient education programmes, where daily physical activity shows an OR equal to 0.4, and physical activity one to four days per week shows an OR equal to 0.32. Foot care (one to four days per week), on the other hand, is associated with an OR equal to 2.6. The findings in Table 3 remain valid when we control for gender.

    Table 2. Comparison of women and men in the sample
    Table 3. Course participation related to health and lifestyle factors

    Discussion

    The findings generally indicate a selection bias for group-based self-management programmes, consistent with findings in other countries (7-9). Among those who have not participated in group-based training programmes, we see a tendency towards poorer health behaviour (smoking) and indications of poorer health (more comorbidity). We also see a greater probability that those who participate in training programmes perform some or a significant amount of physical activity. The findings thus support the notion that patients with less appropriate health behaviour participate less, despite the fact that these patients may be said to be those who need help to pursue more health-promoting coping strategies. More women had participated in group-based training, but the fact that the men in the sample are older than the women might partly explain their lower course participation. This accords with findings from other studies (6, 7).   

    There is reason to believe that the proportion who have participated in group-based self-management programmes in this study is somewhat high in relation to the entire population with type 2 diabetes. Recruitment to the study was undertaken at diabetes outpatient clinics and the personnel at the outpatient clinics are often co-organisers of self-management courses. It may therefore be assumed that personnel at the outpatient clinics actively recruit their patients to courses. 

    More women use the service

    Gender selection bias with a preponderance of women among the participants in group-based self-management programmes is consistent with findings from other studies, which show that women with type 2 diabetes have a greater tendency to use socially interactive training programmes than men (11, 29). We argue that this is because men are often less open about the diagnosis and prefer a more ‘private’ approach to the chronic disease, for example through written information and the internet (29). We have little knowledge as to the reason for these different preferences. However, one study shows that participants on group-based self-management programmes compare themselves to each other and find that some participants appear ‘diligent’ while those that struggle feel like the ‘losers’ of the group (30). A Norwegian study shows that position and affiliation to the group can influence participation in coping groups (31).

    Position and affiliation to the group can influence participation in self-management groups.

    Findings on group dynamics may explain why few smokers in the study had participated in group-based self-management programmes. Previous studies show that smokers feel that they are stigmatised and receive unwanted attention in group contexts (32, 33). The group setting around group-based self-management programmes may consequently be perceived to be challenging. Diabetes nurses, GPs and medical specialists will therefore fail to reach all patients, even though they have increased the focus on referring exposed patient groups to group-based self-management programmes. In a qualitative Danish study (34) related to patients who do not wish to participate in such programmes, the patients point to four challenges with the courses, which are associated with the following:

    • lack of flexibility in course programmes (too intense and a wish for fixed start times and breaks that are not too rigid)
    • teaching methods (a wish for easily understood, hands-on teaching, active participation and a clear focus without too many choices)
    • groups that are too large (a wish for small groups of six to seven persons)
    • lack of respect from health personnel

    The study indicates that low participation in group-based programmes is related to factors in the course design rather than in the patients’ personal traits. This again begs the question of whether investment in group-based self-management programmes has the potential to reach all patient groups. It also raises the question of whether the programme we have today is good enough.

    Health and social networks

    Poor health among economically deprived groups coincides with minimal social networks and few resources in the networks that they have (35). One alternative is therefore to develop interventions to strengthen these networks and the patients’ local community. Attention must shift from the individual and their ability to change and control themselves, to factors beyond the realm of the individual and the individual’s self-control (36). Lifestyle and health are shaped and play out in the social space surrounding the patient. With this understanding, it is possible to look at potential resources in the network and local community as an alternative approach to persons who struggle to cope with type 2 diabetes. Increased social activity beyond the sphere of the health service and the traditional ‘health arenas’ may represent health-promoting interventions for the patient with type 2 diabetes, without the person, the disease and lifestyle changes taking central stage.

    Investment in patient education in Norway is biased towards group-based self-management programmes.

    As health personnel, we have a responsibility to meet the interests of all groups in the population and test out several approaches in order for health information to reach more people, thereby reducing social inequality in health (37). Investment in patient education in Norway is biased towards group-based self-management programmes, and apparently few objections are raised with regard to the fact that these programmes are not equally suitable for all groups. (38). Our study indicates that there is a need for new and different thinking, and for a focus that extends beyond individual factors in the training programmes.

    Broader self-management programmes are suitable for reaching patients who are difficult to recruit to group-based programmes. Moreover, we need more knowledge regarding the wishes of non-participant patient groups. With the increasing prevalence of type 2 diabetes (1), the lack of self-management programmes constitutes a serious problem with regard to health, long-term complications and increased suffering. At a societal level, an inability to cope and inappropriate health behaviour push up treatment and follow-up costs. Awareness and attention to social health disparities is an important priority area for health policy (15), which unfortunately until now has received little attention in nursing science research. 

    Methodological assessments

    The purpose of the study’s recruitment strategy via outpatient clinics in the specialist health service was to obtain a sample that included patients with a complex disease, who struggle to cope with their type 2 diabetes. In line with the statistics, a poor ability to cope and a complex disease are more frequent in population groups with a low socioeconomic status (24). It is generally difficult to recruit persons with a low economic status to participate in research (39). The picture portrayed by the sample in this study (Table 1) shows that one-quarter are disability pensioners or on sick leave, one-third live alone and have a lower than average income, and one in three report high comorbidity. By way of contrast, the proportion of disability pensioners in the Norwegian population in the age group 18–67 years is 9 per cent (40).

    Altogether, 47.7 of study participants reported having a primary/lower secondary education, while the figure is slightly less than 30 per cent of the population among those who are 60 years and over (41). With this comparison, we believe that we can estimate to have obtained a sample that is in line with our intention. However, the representativity of the sample in relation to the total population with type 2 diabetes in Norway is somewhat uncertain. With regard to morbidity, data from the Norwegian Quality Improvement of Laboratory Examinations (NOKLUS) register show that 5.5 per cent have suffered a stroke (42), while the corresponding figure in this study is 5.3 per cent. The NOKLUS register is based on 16 223 Norwegian patients with type 2 diabetes. Other figures are difficult to compare. Although the percentage that has suffered a stroke is approximately the same as the percentage in the NOKLUS population, we cannot guarantee the representativity of the sample. Caution should therefore be exercised in making any generalisations.

    The health condition of the informants in the study is based on self-reporting, which may represent a weakness in the study. Holseter and colleagues, however, find that self-reporting yields valid data when presenting health disparities, also when different social groups are compared (43). There are few respondents with an immigrant background in the study, which is probably attributable to the fact that the questionnaire was in Norwegian. The diabetes nurses who did the recruitment for the study confirmed that informants with another cultural background did not manage to complete the questionnaire due to language difficulties. The decision not to translate the questionnaire to minority languages was a joint decision by EU-WISE and was related to finances. We have thereby not included participants with another cultural background, who represent an important and exposed group with regard to type 2 diabetes, socioeconomic status and health behaviour (22). This constitutes a weakness in our study.

    Conclusion

    The results show that more than half of the informants have not participated in group-based self-management programmes, and that there is a selection bias in patient education programmes among people with type 2 diabetes. Participation is higher among women and persons with a higher education, while smokers and persons with high comorbidity have a lower participation rate. There are also higher odds of participation among patients who are physically active and therefore have better health behaviour. These findings are consistent with those from international studies, which show that certain groups fail to benefit from group-based self-management programmes on which there is a considerable focus today. Our study highlights a need for more knowledge on which programmes may suit those groups of patients who do not find existing ones attractive. The study also indicates a need for more targeted recruitment to existing programmes. In order to help equalise social health disparities, it seems to be important to pursue approaches that go beyond programmes that are clearly oriented towards the individual, thereby reaching more groups in the population.

    References

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    2.          Blakeman T, Bower P, Reeves D, Chew-Graham C. Bringing self-management into clinical view: a qualitative study of long-term condition management in primary care consultation. Chronic Illness 2010;6:136–50.

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    22.       Jenum A, Diep L, Holmboe-Ottesen G, Holme I, Kumar B, Birkeland K. Diabetes susceptibility in ethnic minority groups from Turkey, Vietnam, Sri Lanka and Pakistan compared with Norwegians – the association with adiposity is strongest for ethnic minority women. BMC Public Health 2012;1(12):150.

    23.       Jenum A, Holme I, Graff-Iversen S, Birkeland K. Ethnicity and sex are strong determinants of diabetes in an urban western society. Diabetologia 2005;48:435–9.

    24.       Agardh E, Allebeck P, Hallqvist J, Moradi T, Sidorchuk A. Type 2 diabetes incidence and socio-economic position: a systematic review and meta-analysis. Int J Epidemiol 2011;40:804–18.

    25.       Hewitt S, Graff-Iversen S. Risk factors for cardiovascular diseases and diabetes in disability pensioners aged 40–42: A cross-sectional study in Norway. Scandinavian Journal of Public Health 2009;37:280–6.

    26.       Koetsenruijter J, van Lieshout J, Vassilev I, Portillo M, Serrano M, Knutsen I et al. Social support systems as determinants of self-management and quality of life of people with diabetes across Europe: study protocol for an observational study. Health and Quality of Life Outcomes 2014;12(29).

    27.       Toobert D, Hampson S, Glasgow R. The Summary of Diabetes Self-Care Activities Measure Results from 7 studies and a revised scale. Diabetes Care 2000;23:943–50.

    28.       Gjersing L, Caplehorn JR, Clausen T. Cross-cultural adaptation of research instruments: language, setting, time and statistical considerations. BMC Medical Research Methodology 2010;10(13).

    29.       Gucciardi E, Wang S, DeMelo M, Amaral L, Stewart D. Characteristics of men and women with diabetes: observations during patients’ initial visit to a diabetes education centre. Can Fam Physician 2008;Febr 54(2):219–27.

    30.       Rogers A, Gately C, Kennedy A, Sanders C. Are some more equal than others? Social comparison in self-management skills training for long-term conditions. Chronic Illness. 2009;5(4):305–17.

    31.       Sandaunet A-G. The challenge of fitting in: non-participation and withdrawal from online self-help group for breast cancer patients. Sociology of Health & Illness. 2008;30(1):131–44.

    32.       Stuber J, Galea S, Link B. Smoking and the emergence of a stigmatized social status. Soc Sci Med 2008;67(3):420–30.

    33.       Sæbø G. «Vi blir en sånn utstøtt gruppe til slutt ...» Røykeres syn på egen røyking og denormaliseringsstrategier i tobakkspolitikken. Oslo: SIRUS-rapport 3/2012.

    34.       Torenholt R, Varming A, Engelund G, Vestergaard S, Møller BL, Pals RA. Willaing I. Simplicity, flexibility, and respect: preferences related to patient education in hardly reached people with type 2 diabetes. Patient Prefer Adherence 2015;Nov 5(9):1581.

    35.       Gele A, Harsløf I. Types of social capital resources and self-rated health among the Norwegian adult population. International Journal of Equity in Health 2010;9(8).

    36.       Vassilev I, Rogers A, Sanders C, Kennedy A, Blickem C, Protheroe J et al. Social networks, social capital and chronic illness self-management: a realist review. Chronic Illness 2011;7(1):60–86.

    37.       Gopinathan U, Iversen J. Hva kan helsepersonell gjøre med sosiale helseforskjeller? Tidssk Nor Lægeforen 2011;131:1560–2.

    38.       Solberg H, Steinsbekk A, Solbjør M, Granbo R, Garåsen H. Characteristics of a self-management support programme applicable in primary health care: a qualitative study of users’ and health professionals’ perceptions. BMC Health Serv Res 2014;14:562.

    39.       Honningsvåg L, Linde M, Håberg A, Stovner L, Hagen K. Does health differ between participants and non-participants in the MRI-HUNT study, a population based neuroimaging study? The Nord-Trøndelag health studies 1984–2009. BMC Medical Imaging 2012;12(23).

    40.       Grebstad U, Hetland A. Uføretrygd og sosialhjelp - to ulike formål. Samfunnsspeilet. 2014;5:47–53.

    41.       Statistisk sentralbyrå. Befolkningens utdanningsnivå. Available at: www.ssb.no/utniv (Downloaded 29.06.2016). 2015.

    42.       Løvaas K, Madsen T, Cooper J, Thue G, Sandberg S. Norsk diabetesregister for voksne. Årsrapport for 2014 med plan for forbedringstiltak. Bergen: 2015. Available at: http://www.noklus.no/Portals/2/Diabetesregisteret/Arsrapport%20Norsk%20diabetesregister%20for%20voksne%202014.pdf

    43.       Holseter C, Dalen J, Krokstad S, Eikemo T. Selvrapportert helse og dødelighet i ulike yrkesklasser og inntektsgrupper i Nord-Trøndelag. Tidsskr Nor Lægeforen 2015;5(135):434–8.

    Group-based self-management programmes make it easier to cope with the disease. However, half of all patients decline to participate in such programmes. 

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    Background: Group-based self-management programmes are arranged for patients with type 2 diabetes to increase coping skills and prevent complications of type 2 diabetes. However, it is uncertain whether the programmes are attractive to all groups of patients. International studies show that patients who fail to comply with recommendations on lifestyle and have a low socioeconomic status are under-represented in group-based self-management programmes.

    Objective: The study examines a Norwegian sample of type 2 diabetes patients and aims to investigate the percentage who have attended group-based self-management programmes, and characteristics of participants and non-participants.

    Method: This is a descriptive cross-sectional study for which 298 patients with type 2 diabetes completed a questionnaire (84.2% response rate). Chi-square test and logistic regression analysis were used to compare participants and non-participants.

    Result: In the study, 61% of participants are men and 39% are women, and the mean age is 60 years. Altogether 38% of the respondents had participated in group-based self-management programmes. Significant differences emerged when comparing participants with non-participants. Among participants, the majority were women and persons with a higher education, while smokers were in the majority among non-participants. Physical activity was strongly correlated with participation.

    Conclusion: The findings reveal selection bias in group-based self-management programmes and indicate the need to develop and test alternative programmes to reach more groups of patients in the population.

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  • Do the scales at child health clinics show the correct weight?

    Weight measurement is one of the basic indicators of child and adolescent well-being, nutrition and health. Norwegian authorities follow the World Health Organization (WHO)’s recommendations for close follow-up of a child's weight. The authorities’ main goal with weighing and measuring by child health clinics and school health services is to help identify children and adolescents with weight deviations at an early point in time. Another goal is to reduce the negative consequences that deviant weight can have for the individual child (1).

    Measuring weight is an important part of the work of a public health nurse, whose duties are guided by a preventive and health promotion perspective. Measuring weight is a primary preventive action whereby all children are routinely weighed from birth to adolescence (2). In order to enable public health nurses to implement appropriate actions, it is essential that the scales that are used provide precise measurements. Earlier studies show that many scales used to measure body weight are imprecise (3, 4). Among other things, inaccurate scales can yield Body Mass Index values (BMIs) that can result in an incorrect assessment of a child's weight status (5, 6).

    Recommended tests

    To ensure accurate measurements, the national professional guidelines for weighing and measuring by the child health clinic and school health services recommend that scales be tested twice annually, and more often if they are moved around (1). No specifics are given for how the scales are to be tested, nor are there any requirements to use medically approved scales. According to Júlíusson et al. (7) it is important to test a scale with the weight the scale is meant to measure, i.e. baby scales should be tested with weights corresponding to the weight of children under the age of two. Flat scales at child health clinics should be tested with weights corresponding to the weight of children over the age of two.

    The tests should be performed with certified weights to ensure accurate measurements (4). Placement of the scale, the surface underneath and type of scale are also significant (3). Norway has a requirement to use medically approved scales for monitoring, diagnosing and medical treatment in medical practice (8). Public health nurses perform health monitoring by following the growth development of the child and adolescent population, which can provide a good basis for preparing targeted preventive measures and evaluating the local and national effect of the measures (1).

    Measuring weight is a primary preventive action whereby all children are routinely weighed from birth to adolescence.

    Evaluating the extent to which the child health clinics follow evidence-based recommendations necessitates a survey of actual practice compared with what is standard. In this way, any need for improvements can be discovered (9).  

    Survey current practice

    Clinical audits set criteria and standards for surveying practice. The purpose of this audit was to ascertain whether the scales used at child health clinics and during home visits to newborns measure correctly. We also wanted to map whether current practice is consistent with evidence-based recommendations (1). According to the National Strategy for Quality Improvement in Social and Health Services, a prerequisite for good quality is the probability of reducing errors to a minimum (11). The following questions were the starting point for undertaking a clinical audit:

    • Do the scales used at the child health clinics and during home visits measure the correct weight?
    • Are there differences in accuracy between medically approved and non-medically approved scales?
    • Do the child health clinics follow the recommendations for testing scales a minimum of twice a year with a weight the scale is meant to measure?

    Methodology

    In the period January to May 2015 we carried out a clinical audit of baby and flat scales used at child health clinics and during home visits.

    Criteria and standards

    Clinical auditing is a method for systematic evaluation and quality improvement consisting of five steps. First, the area of improvement must be identified, after which criteria and standards are set. Practice is surveyed before practice is compared with criteria and standards. Finally, measures are implemented, and new surveying can be carried out. Criteria are set based on best practice, and shall be predicated on evidence-based recommendations (10).

    A standard must be defined if criteria are to be useful. A standard describes the quality level of what one desires to achieve, and is presented as a percentage (12). The criteria set for our project prescribed that baby and flat scales used at child health clinics and during home visits must show the correct weight. They shall also be tested a minimum of twice a year with a weight the scale is meant to measure. To gain an overview of how many of the scales are accurate, we set an ideal standard of 100 per cent correct weight.

    Preparation and execution

    The reference standard that was used was certified weights loaned by the Outpatient Obesity Clinic at Haukeland University Hospital (HUS) and Teck-Ho Service. The weights were calibrated in advance at Kiwa Teknologisk Institutt. We tested stationary baby scales, portable baby scales for use during home visits, and stationary flat scales. The weights represented the weights the scales were meant to measure. Baby scales are used to weigh children from birth to age two, and these were tested with 2 kg, 5 kg, 7 kg, 10 kg and 15 kg weights. Flat scales used at child health clinics weigh children from age two until they start school. These scales were tested with 10 kg, 15 kg, 20 kg, 30 kg and 40 kg weights. In advance, we received an introduction to and briefing on the calibration of scales at Kiwa Teknologisk Institutt.

    The tests should be performed with certified weights to ensure accurate measurements. 

    We performed all of the tests at the child health clinics on a flat, hard and stable surface, such as a suitable table, or on the floor. In order to check that the scales measured correctly, we tested the scales’ accuracy, repeatability and stability. We measured accuracy by placing certified weights on the scale. We tested repeatability by repeating the procedure three times. Stability was checked by performing the corner test on the scales. This was done by placing a 10 kg weight on the various points (the middle and all four corners) of the scale. The scales were re-set to zero between each test. We recorded the results of the measurements, information about the scales and the control routines at the child health clinic.

    Collection of data

    Data were collected from March to May 2015. We included one large city municipality and four rural municipalities in the same hospital trust, with altogether 27 child health clinics. Because midwives from the “Midwife Home Visitor” service at the hospital visit the homes in the city municipality during the first week of a child’s life, we also tested five of their baby scales. The hospital requires the scales to be medically approved and has routines for testing them. In all, we tested 152 scales, of which 102 were baby scales and 50 were flat scales. Prior to collection of the data, we informed senior public health nurses at the various child health clinics about the study by e-mail, and we received approval to come to the clinics at agreed times. We asked the available public health nurse about the control routines at the child health clinic.

    Data analysis

    We analysed data with the aid of SPSS 22. Coding and entry of data were quality assured by a duplicating check. We used descriptive statistics and average deviation to evaluate the accuracy and average standard deviation per scale to assess repeatability. The chi-square test was performed to examine differences between accuracy on medically approved and non-medically approved scales. The level of significance was set at p <0.05 (13).

    Results

    Accuracy, repeatability and stability

    Of 152 scales, 16 showed 100 per cent correct weight during all control measurements; of these nine were baby scales (n = 102) and seven were flat scales (n = 50). The baby scales that were not correct had deviations ranging from 0.01 kg to 1.65 kg, while the deviations on the flat scales varied from 0.05 kg to 2.00 kg. Accuracy and repeatability declined with increasing weight (Table 1). Scales with stability deviations also had accuracy and repeatability deviations.

    Table 1. Measurement characteristics

    Medically approved and non-medically approved scales

    Eighty-two of the scales were medically approved, of which 50 were baby scales (n = 102) and 32 were flat scales (n = 50). All of the stationary baby scales were medically approved. Many of the portable baby scales used during home visits were non-medically approved. The medically approved scales were significantly more accurate during most measurements than the non-medically approved scales (Table 2 and Table 3). Half of the non-medically approved flat scales had a deviation of 0.5 kg or more, while only one of the medically approved flat scales had a deviation of 0.5 kg (Table 3). The medically approved scales also did better with regard to repeatability and stability.

    Table 2. Comparison between medically approved and non-medically approved baby scales that showed the correct weight
    Table 3. Comparison between medically approved and non-medically approved flat scales that showed the correct weight or had a deviation of <0.5 kg.

    Control routines

    Three of 27 child health clinics had good routines in accordance with the recommendations, where the baby scales were tested a minimum of twice a year with a 5 kg weight. The “Midwife Home Visitor” service also had good routines, where the scales were regularly checked when serviced. Five child health clinics had routines where they regularly tested the baby scales with weights under 5 kg. For instance, they used weights of 0.5 to 1 kg, toys, large liquid soap containers, loose-leaf binders and packages of butter. The other child health clinics had no regular control routines for baby scales, and none of the child health clinics had routines for testing flat scales. The child health clinics that had good routines and the “Midwife Home Visitor” service had more accurate scales than the child health clinics that had no routines, or had routines where they tested the scales with weights under 5 kg.

    Discussion

    Our results showed that even though many scales are highly accurate, a scale that is not tested can in principle show any reading. Only 16 of 152 scales showed 100 per cent correct weight. Schlegel-Pratt and Heizer (4) believe that established standards are important for accurate scales. It is conceivable that a standard of 100 per cent correct weight is somewhat strict, but it is difficult to judge acceptable deviations. Two different scales used at the same child health clinic can be imprecise in either direction, and can thus yield a wider discrepancy. This can result in weight loss at one visit and weight gain at another visit, and vice versa. Such weight variations can potentially affect decisions with respect to interventions. A deviation of only 20 grams on a baby scale can produce a discrepancy of 40 grams, and the larger the deviation, the greater the potential consequences.

    Consequences for practice

    It is very important to assess weight development during the neonatal period because weight reflects nutrition and well-being. Difficulty with breastfeeding is the main reason for large weight loss after birth (14). In newborns, a 10 per cent weight loss limit has been established for implementing interventions (1). We saw scales used for home visits that showed up to 590 grams too little at 5 kg (Table 1), a deviation of more than 10 per cent. It is conceivable that inaccurate scales can trigger interventions on a completely erroneous basis. Such instances require public health nurses to invest time and resources and can also have negative consequences for the family concerned. For example, already well-established breastfeeding may be disrupted if the mother loses confidence in her ability to breastfeed.

    A scale that is not tested can in principle show any reading.

    We also saw scales that showed up to 140 grams too much at 5 kg (Table 1). Such a deviation can cause serious consequences in cases where a mother is assured that her newborn has gained the normal amount of weight, when in reality this may not be the case. Collection of reliable weight measurements is usually not an isolated act, but must be viewed in the context of an overall assessment of the child (15). The clinical eye must therefore never be underestimated. Looking at clinical signs in conjunction with assessing the child's general condition provides valuable additional information (1). It can be the most important background for the decisions that are taken in cases where the scales do not measure correctly.

    After babyhood, the child will be weighed at ages two and four. The measuring point at age four is particularly important for being able to determine early development of child overweight/obesity (1). Public health nurses have a particular responsibility for tracking a child's weight and recognising risk factors for overweight/obesity and metabolic disorders (16). Earlier studies have shown that inaccurate scales can lead to miscalculations of a child's BMI (5, 6). It is essential that the scales measure correctly if public health nurses are to prevent overweight/obesity and implement individual interventions.

    Control routines and standards for use

    According to the weighing and measuring guidelines for the child health clinic and school health services, growth measurements are the surest method for assessing whether children are growing satisfactorily (1). In view of this we question why the same requirements are not made of the scales used in the public health nurse service, as are made at GP surgeries and hospitals (8). Today, it may appear that random circumstances and finances determine the type of scale that is used. While public health nurses do not diagnose and provide medical treatment, they perform health monitoring at the individual and population level by weighing (1).

    Since the results show significant differences in accuracy when medically approved and non-medically approved scales are compared, is it far from sufficient to perform health examinations with scales that are not subject to requirements. A standard should therefore also be introduced for the use of medically approved scales in the child health clinic and school health services. WHO recommends that bathroom scales should not be used in assessing a child's growth since they have often proven to be unreliable (17). This bolsters our recommendations to use medically approved scales.

    It is conceivable that inaccurate scales can trigger interventions on a completely erroneous basis.

    Control routines at child health clinics vary considerably. Few child health clinics tested the scales in accordance with the guidelines, and no child health clinics had routines for testing flat scales. Minor deviations were found while testing 2 kg, but at 5 kg and above the deviations were considerable. Our results showed reduced precision with increasing weight, particularly for non-medically approved scales. These findings are in line with Stein et al. (3), who also report that the scales show reduced precision with increasing weight, and that control routines are important for accuracy. Testing the scales with, for instance, 0.5 kg will give a false sense of security that the scales are accurate.

    Schlegel-Pratt and Heizer (4) recommend regular tests with certified weights. For this reason the child health clinics should at least have 5 and 10 kg weights. In this way, systematic tests of both baby and flat scales can be performed with 5, 10 and 15 kg, and more deviations can be discovered. While procurement of weights may be a question of finances, such an investment is a one-off expense that will contribute to greater quality assurance in the public health nurse service.

    Transferability to the school health services

    In this clinical audit we tested the scales at child health clinics, but we believe that the results can also be transferred to the school health services. The study conducted by Biehl et al. (5), which was performed on scales at various schools, points out that failure to test the scales will likely lead to miscalculations of overweight and obesity. This finding is supported by Gerner et al. (6), who state that inaccurate scales can lead to miscalculations of children’s BMI. In the school health services, children are weighed in the first, third and eighth grade (2). During 40 kg tests, the maximum weight we tested, there was a discrepancy of three and a half kilograms between the lowest and highest measured weight (Table 1). It is conceivable that the deviation will increase with higher weight. An eighth grader can weigh more than 40 kg. Scales in the school health services should therefore be tested with heavier weights, which can be a challenge in terms of procurement and storage. One possibility is to consider a service agreement with a calibration firm.

    Strengths and weaknesses

    One advantage of the audit was that all data were collected directly at the child health clinics, with no use of intermediaries. Accuracy was thoroughly tested by checking several weights. We also tested repeatability and stability. We recorded the type of scales that were used and could therefore compare results from medically approved and non-medically approved scales. We found few studies about the accuracy of scales through systematic searches for scientific articles and no studies concerning the accuracy of baby scales. Not recording the year in which the various scales were put into service may constitute a weakness, but it was difficult to obtain this information.

    Public health nurses have a particular responsibility for tracking a child's weight and recognising risk factors for overweight/obesity and metabolic disorders.

    According to Biehl et al. (5), newly procured scales usually measure the correct weight. However, heavy use, incorrect use, general wear and tear, and wear and tear due to frequent transport affect accuracy. A common misunderstanding is that when a scale has been installed and calibrated, instrument error is insignificant (4). The scales at child health clinics are frequently used and are moved in connection with home visits. Combined with the lack of control routines, these factors entail a risk that the scales used at child health clinics measure inaccurately. The study conducted by Stein et al. (3) showed a level of inaccuracy that was three times higher with worn scales than with scales in perfect condition. 

    Going forward

    The final step in a clinical audit process involves implementing measures in practice and conducting a new survey. Data collection per se has no impact unless it is followed up (18). All of the child health clinics received verbal or written feedback about the results of their scales. Conducting this clinical audit heightened awareness of the necessity of testing the scales at child health clinics. Routines must be improved before a new survey can be conducted. A good start would be for all child health clinics to begin following the weighing and measuring guidelines for the child health clinic and school health services by testing the scales a minimum of twice a year. Furthermore, the tests must be conducted with a weight the scale is meant to measure.

    Conclusion

    This audit, which was conducted on scales in use at child health clinics and during home visits, showed that only nine of 102 (8.8 per cent) baby scales and seven of 50 (14 per cent) flat scales were 100 per cent correct. There were also significant differences in accuracy between medically approved and non-medically approved scales. Only three of 27 (11.1 per cent) child health clinics had good control routines for their scales. Our results thus show that there is a discrepancy between practice and evidence-based recommendations.

    Measuring weight is a cost-effective and simple way of gathering data about the population, but the validity of the measurements must be critically assessed. Although the importance of weight measurements is well documented, it appears that there may be a lack of awareness about checking whether the scales actually measure accurately. Ensuring good control routines and introducing standards to use medically approved scales can help to quality assure a valid collection of data in the child health clinic and school health services.

    Many thanks to all who made it possible to conduct the study: Jörg Aßmus for helpful guidance in statistics, Evelyn Kvamme for briefing us on weight calibration, and Petur Júlíusson and Jan Larsen for lending certified weights.

    References

    1.         Helsedirektoratet. Nasjonale faglige retningslinjer for veiing og måling i helsestasjons- og skolehelsetjenesten. Oslo: Helsedirektoratet. 2011. Available at: https://helsedirektoratet.no/Lists/Publikasjoner/Attachments/236/Nasjonal-faglig-retningslinje-for-veiing-ogmaling-IS-1736.pdf (downloaded 20.04. 2016)

    2.       Sosial- og helsedirektoratet. Kommunens helsefremmende og forebyggende arbeid i helsestasjons- og skolehelsetjenesten. Oslo: Sosial- og helsedirektoratet. 2004. Available at: https://helsedirektoratet.no/Lists/Publikasjoner/Attachments/388/veileder-til-forskrift-kommunens-helsefremmende-og-forebyggende-arbeid-i-helsestasjons--og-skolehelsetj-.pdf (downloaded 20.04. 2016).

    3.       Stein RJ, Haddock CK, Poston WS, Catanese D, Spertus JA. Precision in weigting: a comparison of scales found in physician offices, fitness centers, and weight loss centers. Public Health Rep. 2005;120:266–70. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497726/pdf/16134566.pdf (downloaded 20.04.2016).

    4.         Schlegel-Pratt K, Heizer WD. The accuracy of scales used to weigh patients. Nutr Clin Pract. 1990 Des 5(6):254–7.

    5.       Biehl, A, Hovengen R, Meyer HE, Hjelmesæth J, Meisfjord J, Grøholt EK et al. Impact of instrument error on the estimated prevalence of overweight and obesity in population-based surveys. BMC Public Health 2013;13:146. Available at:  http://www.biomedcentral.com/1471-2458/13/146 (downloaded 20.04.2016). 

    6.       Gerner B, Maccallum Z, Sheehan J, Harris C, Wake M. Are general practitioners equipped to detect child overweight/obesity? Survey and audit. J Pediatr Child Health. 2006;42(4):206–11. 

    7.       Júlíusson PB, Vinsjansen S, Nilsen B, Sælensminde H, Vågset R, Eide GE et al. Måling av vekst og vekt: En oversikt over anbefalte teknikker. Pediatrisk Endokrinologi 2005;19:23–9.

    8.       Lovdata. Forskrift om krav til ikke-automatiske vekter. 21. desember 2007 nr. 1527. Available at: https://lovdata.no/dokument/SF/forskrift/2007-12-21-1735 (downloaded 20.04.2016).

    9.         Kunnskapsbasert praksis. Oslo: Nasjonalt kunnskapssenter for helsetjenesten. 2004. Available at: http://www.kunnskapssenteret.no/kunnskapsbasert-helsetjeneste/kunnskapsbasert-helsetjeneste (downloaded 19.05.2015). 

    10.     Nortvedt MW, Jamtvedt G, Graverholt B, Nordheim LV, Reinar LM. Jobb kunnskapsbasert! En arbeidsbok. 2 ed. Oslo: Akribe. 2012.

    11.     Helsedirektoratet. Nasjonal strategi for kvalitetsforbedring i sosial- og helsetjenesten … Og bedre skal det bli (2005–2015). Oslo: Helsedirektoratet. 2005. Available at: https://helsedirektoratet.no/Lists/Publikasjoner/Attachments/233/Og-bedre-skal-det-bli-nasjonal-strategi-for-kvalitetsforbedring-i-sosial-og-helsetjenesten-2005-2015-IS-1162-bokmal.pdf (downloaded 20.04. 2016).

    12.     Anderson DG. ABC of audit. Tees Valley: Vocational Training Scheme. 2012. Available at: http://www.gp-training.net/training/tutorials/management/audit/audabc.htm (downloaded 19.05.2015).

    13.     Polit DF, Beck CT. Nursing research: generating and assessing evidence for nursing practice. 8. ed. Philadelphia: Wolters Kluwer Health. 2014.

    14.     Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics 2003;112(3 Pt 1):607–19.

    15.     Royal college of nursing. Standards for the weighing of infants, children and young people in the acute health care setting. London: The Royal College of Nursing. 2013. Available at: https://www2.rcn.org.uk/__data/assets/pdf_file/0009/351972/003828.pdf (downloaded 20.04.2016).

    16.     Helsedirektoratet. Nasjonale faglige retningslinjer for forebygging, utredning og behandling av overvekt og fedme hos barn og unge. Oslo: Helsedirektoratet. 2010. Available at: https://helsedirektoratet.no/Lists/Publikasjoner/Attachments/389/nasjonal-faglig-retningslinje-for-forebygging-utredning-og-behandling-av-overvekt-og-fedme-hos-barn-og-unge.pdf (downloaded 20.04.2016). 

    17.     World Health Organization. Training Course on Child Growth Assessment. Geneve: WHO. 2008. Available at: http://www.who.int/childgrowth/training/en (downloaded 20.04.2016).

    18.     Benjamin A. Audit: how to do it in practice. BMJ 2008;336:1241–5.

    Weight measurement provides an indication of the well-being, nutrition and health of children and adolescents. It is therefore important that the scale that is used provides precise measurements.

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    Background: Weight measurement is a basic indicator of child and adolescent well-being, nutrition and health. For a public health nurse to take the appropriate action based on a child's weight, it is essential that the scales used are accurate.

    Objective: To find out whether the scales at child health clinics measure correct weight, if there are differences in accuracy between medically approved and non-medically approved scales, and if current control routines correspond with evidence-based recommendations.

    Method: Clinical auditing was used for mapping the scales and the routines at 27 child health clinics. In total 152 scales were tested: 102 baby scales and 50 flat scales.

    Results: 16 of 152 scales showed a 100 per cent correct weight in all tests. 82 of the scales were medically approved and these were significantly more accurate than those scales which were not medically approved. Three of 27 child health clinics had good procedures where the baby scales were tested according to set criteria. None of the child health clinics had procedures for testing flat scales.

    Conclusion: The audit shows that few scales are 100 per cent accurate and that there is a discrepancy between practice and evidence-based recommendations. Ensuring strict controls and introducing a standard to mandate the use of medically approved scales at all child health clinics will result in more accurate data collection in public health nursing services.

    Bildet viser en mor som er på helsestasjonen, der babyen veies av helsesøster.
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