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1.  Primary healthcare in transition – a qualitative study of how managers perceived a system change 
Background
Primary healthcare in Sweden has undergone widespread reforms in recent years, including freedom of choice regarding provider, freedom of establishment and increased privatisation. The key aims of the reforms were to strengthen the role of the patient and improve performance in terms of access and responsiveness. The aim of this study was to explore how managers at publicly owned primary healthcare centres perceived the transition of the primary healthcare system and the impact it has had on their work.
Methods
In this qualitative study, 24 managers of publicly owned primary healthcare centres in the metropolitan region of Gothenburg were recruited. Semi-structured interviews were conducted and data were analysed using content analysis inspired by Silverman.
Results
The analysis revealed two core themes: The transition is perceived as a rapid change, enforced mainly through financial incentives and Prioritisation conflicts arise between patient groups with different needs, demands and levels of empowerment. The transition has produced powerful and rapid effects that were considered to be both positive and negative. While the new financial incentives were seen as a driving force and a tool for change, they also became a stress factor due to uncertainty, competition with other primary healthcare centres and negative feelings associated with staff cutbacks. The shift in power towards the patient improved access and service but also led to more patients with unreasonable demands. Managers found it difficult to prioritise correctly between patient groups with different needs, demands and levels of empowerment and they were concerned about potentially negative effects on less empowered patients, e.g. multi-morbid patients. Managers also experienced shortcomings in their change management skills.
Conclusions
This qualitative study shows the complexity of the system change and describes the different effects and perceptions of the transition from a manager’s perspective. This suggests a need for improved follow-up and control in order to monitor and govern system changes and ensure development towards a more effective and sustainable primary healthcare system.
doi:10.1186/1472-6963-13-382
PMCID: PMC3854127  PMID: 24090138
Qualitative research; Leadership; Practice management; Health care reform
2.  The application of evidence-based measures to reduce surgical site infections during orthopedic surgery - report of a single-center experience in Sweden 
Background
Current knowledge suggests that, by applying evidence-based measures relating to the correct use of prophylactic antibiotics, perioperative normothermia, urinary tract catheterization and hand hygiene, important contributions can be made to reducing the risk of postoperative infections and device-related infections. The aim of this study was to explore and describe the application of intraoperative evidence-based measures, designed to reduce the risk of infection. In addition, we aimed to investigate whether the type of surgery, i.e. total joint arthroplasty compared with tibia and femur/hip fracture surgery, affected the use of protective measures.
Method
Data on the clinical application of evidence-based measures were collected structurally on site during 69 consecutively included operations involving fracture surgery (n = 35) and total joint arthroplasties (n = 34) using a pre-tested observation form. For observations in relation to hand disinfection, a modified version of the World Health Organization hand hygiene observation method was used.
Results
In all, only 29 patients (49%) of 59 received prophylaxis within the recommended time span. The differences in the timing of prophylactic antibiotics between total joint arthroplasty and fracture surgery were significant, i.e. a more accurate timing was implemented in patients undergoing total joint arthroplasty (p = 0.02). Eighteen (53%) of the patients undergoing total joint arthroplasty were actively treated with a forced-air warming system. The corresponding number for fracture surgery was 12 (34%) (p = 0.04).
Observations of 254 opportunities for hand hygiene revealed an overall adherence rate of 10.3% to hand disinfection guidelines.
Conclusions
The results showed that the utilization of evidence-based measures to reduce infections in clinical practice is not sufficient and there are unjustifiable differences in care depending on the type of surgery. The poor adherence to hand hygiene precautions in the operating room is a serious problem for patient safety and further studies should focus on resolving this problem. The WHO Safe Surgery checklist “time out” worked as an important reminder, but is not per se a guarantee of safety; it is the way we act in response to mistakes or lapses that finally matters.
doi:10.1186/1754-9493-6-11
PMCID: PMC3495663  PMID: 22697808
3.  Information Retrieval – Swedish Specialist Student Nurses` Strategies for Finding Clinical Evidence 
The Open Nursing Journal  2012;6:47-52.
The care that intra-operative nurses perform has to be based on scientific knowledge. It is therefore vitally important that they have access to different databases and the Internet, as well as knowledge of the search procedure to find evidence for best practice. This means that specialist nurses should be proficient in the search procedure, interpretation of data, and implementation of available knowledge.
The aim of this study was therefore to highlight the search strategies of specialist student nurses for finding scientific knowledge with regard to specific clinical issues. An additional aim was to assess their ability to critically evaluate scientific articles.
Methods:
The participants, n 16, all students enrolled in a university programme for specialist nursing in anaesthesia care, were required to find support for six questions, by using scientific knowledge databases. The tasks that required support are related to their future profession and were divided into three main areas: pre-, intra-, and post-operative care. Two distinct questions for each main area had to be answered. The data was analysed quantitatively using manifest content analysis as a basis.
Result:
This study reveals that the student nurses mostly used the CINAHL and PubMed databases to search for answers related to the areas in focus. The keywords the participants used differed between the individuals and were applied more frequently than MESH terms. In addition, the critical evaluation of articles of scientific value that were found was not optimal. The study demonstrated that most of the participants were unable to complete all the required tasks. With regard to the initial questions, all 16 participants provided answers, while only eight student nurses completed the final questions.
Conclusions:
The specialist student nurses in this study used the databases Chinal and PubMed to find scientific knowledge with the help of MESH-terms and keywords. Further research is needed to understand how education of the specialist student nurses should be carried out, in order to optimise their search strategies and critical evaluation of scientific articles.
doi:10.2174/1874434601206010047
PMCID: PMC3349943  PMID: 22582108
Information retrieval; search strategies; nurses.
4.  Nursing Students’ Self-Graded Motivation to Complete their Programme of Study 
The Open Nursing Journal  2010;4:42-47.
The aim of this study was to explore variation in nursing students’ motivation to complete their programme of study, as well as factors relating to low versus high motivation and students’ opinions of what would increase their motivation to complete their programme of study.
A study was carried out between April 2006 and December 2007. A total of 872 students registered in a 3-year nursing programme randomly participated in self-rating their motivation score once each semester. Descriptive statistics, statistical calculations and content analysis regarding open-ended questions were performed. Most of the students, 73%, rated their motivation as ≥6 on a 0-10 Likert scale; and 16% gave a rating of ≤4.
The desire to become a registered nurse (RN) and having a positive attitude towards the studies were the main factors influencing high motivation to complete the programme of study. Having a negative attitude towards the studies was an explanation of decreased motivation. There was a significant decrease (p=0.001) in the motivation score with respect to number of semesters, and motivation increased with the student’s age (p=0.0119). Suggestions for increasing motivation given by those who rated their motivation as ≤4 mainly focused on improvements in didactics and study organisation.
doi:10.2174/1874434601004010042
PMCID: PMC3043268  PMID: 21347211
Nurse education; motivation.
5.  Night nursing – staff's working experiences 
BMC Nursing  2008;7:13.
Background
Although the duties and working conditions of registered, and enrolled nurses have previously been described from different perspectives, they have not been examined from the night nursing aspect. The aim of the study was to describe the night nursing staff's working experiences.
Methods
The design of the study is qualitative and descriptive. Interviews were conducted with 10 registered and 10 enrolled nurses working as night staff at a Swedish University Hospital. The interview guide was thematic and concerned the content of their tasks, as well as the working conditions that constitute night nursing. In addition, the interviews were transcribed verbatim and analyzed using content analysis.
Results
The night duties have to be performed under difficult conditions that include working silently in dimmed lighting, and making decisions when fatigue threatens. According to the night staff, its main goals are to provide the patients with rest and simultaneously ensure qualified care. Furthermore, the night nursing staff must prepare the ward for the daytime activities.
Conclusion
The most important point is the team work, which developed between the registered and enrolled nurses and how necessary this team work is when working at night. In order for nurses working at night to be fully appreciated, the communication between day and night staff in health care organizations needs to be developed. Furthermore, it is important to give the night staff opportunities to use its whole field of competence.
doi:10.1186/1472-6955-7-13
PMCID: PMC2606673  PMID: 18976475
6.  The ESEP study: Salpingostomy versus salpingectomy for tubal ectopic pregnancy; The impact on future fertility: A randomised controlled trial 
BMC Women's Health  2008;8:11.
Background
For most tubal ectopic pregnancies (EP) surgery is the treatment of first choice. Whether surgical treatment should be performed conservatively (salpingostomy) or radically (salpingectomy) in women wishing to preserve their reproductive capacity, is subject to debate. Salpingostomy preserves the tube, but bears the risks of both persistent trophoblast and repeat ipsilateral tubal EP. Salpingectomy, avoids these risks, but leaves only one tube for reproductive capacity. This study aims to reveal the trade-off between both surgical options: whether the potential advantage of salpingostomy, i.e. a better fertility prognosis as compared to salpingectomy, outweighs the potential disadvantages, i.e. persistent trophoblast and an increased risk for a repeat EP.
Methods/Design
International multi centre randomised controlled trial comparing salpingostomy versus salpingectomy in women with a tubal EP without contra lateral tubal pathology. Hemodynamically stable women with a presumptive diagnosis of tubal EP, scheduled for surgery, are eligible for inclusion. Patients pregnant after in vitro fertilisation (IVF) and/or known documented tubal pathology are excluded. At surgery, a tubal EP must be confirmed. Only women with a tubal EP amenable to both interventions and a healthy contra lateral tube are included. Salpingostomy and salpingectomy are performed according to standard procedures of participating hospitals. Up to 36 months after surgery, women will be contacted to assess their fertility status at six months intervals starting form the day of the operation.
The primary outcome measure is the occurrence of spontaneous viable intra uterine pregnancy. Secondary outcome measures are persistent trophoblast, repeat EP, all pregnancies including those resulting from IVF and financial costs. The analysis will be performed according to the intention to treat principle. A cost-effectiveness analysis will be performed within a decision analysis framework, based on costs per live birth, including IVF treatment whenever a spontaneous pregnancy does not occur. Patients' preferences will be assessed using a discrete choice experiment.
Discussion
This trial will provide evidence on the trade off between salpingostomy and salpingectomy for tubal EP in view of the pros and cons of both interventions and will offer guidance to clinicians in making the right treatment choice.
Trial registration
Current Controlled Trials ISRCTN37002267
doi:10.1186/1472-6874-8-11
PMCID: PMC2464580  PMID: 18582372
7.  Nursing students motivation toward their studies – a survey study 
BMC Nursing  2008;7:6.
Background
This study focuses on Swedish nursing students' motivation toward their studies during their three year academic studies. Earlier studies show the importance of motivation for study commitment and result. The aim was to analyze nursing students' estimation of their degree of motivation during different semester during their education and to identify reasons for the degree of motivation.
Methods
A questionnaire asking for scoring motivation and what influenced the degree of motivation was distributed to students enrolled in a nursing programme. 315 students who studied at different semesters participated. Analyzes were made by statistical calculation and content analysis.
Results
The mean motivation score over all semesters was 6.3 (ranked between 0–10) and differed significantly during the semesters with a tendency to lower score during the 5th semester. Students (73/315) with motivation score <4 reported explanations such as negative opinion about the organisation of the programme, attitude towards the studies, life situation and degree of difficulty/demand on studies. Students (234/315) with motivation score >6 reported positive opinions to becoming a nurse (125/234), organization of the programme and attitude to the studies. The mean score value for the motivation ranking differed significantly between male (5.8) and female (6.8) students.
Conclusion
Conclusions to be drawn are that nursing students mainly grade their motivation positive distributed different throughout their entire education. The main motivation factor was becoming a nurse. This study result highlights the need of understanding the students' situation and their need of tutorial support.
doi:10.1186/1472-6955-7-6
PMCID: PMC2386463  PMID: 18439276
8.  Swedish social insurance officers' experiences of difficulties in assessing applications for disability pensions – an interview study 
BMC Public Health  2007;7:128.
Background
In this study the focus is on social insurance officers judging applications for disability pensions. The number of applications for disability pension increased during the late 1990s, which has resulted in an increasing number of disability pensions in Sweden. A more restrictive attitude towards the clients has however evolved, as societal costs have increased and governmental guidelines now focus on reducing costs. As a consequence, the quantitative and qualitative demands on social insurance officers when handling applications for disability pensions may have increased. The aim of this study was therefore to describe the social insurance officers' experiences of assessing applications for disability pensions after the government's introduction of stricter regulations.
Methods
Qualitative methodology was employed and a total of ten social insurance officers representing different experiences and ages were chosen. Open-ended interviews were performed with the ten social insurance officers. Data was analysed with inductive content analysis.
Results
Three themes could be identified as problematic in the social insurance officers' descriptions of dealing with the applications in order to reach a decision on whether the issue qualified applicants for a disability pension or not: 1. Clients are heterogeneous. 2. Ineffective and time consuming waiting for medical certificates impede the decision process. 3. Perspectives on the issue of work capacity differed among different stakeholders. The backgrounds of the clients differ considerably, leading to variation in the quality and content of applications. Social insurance officers had to make rapid decisions within a limited time frame, based on limited information, mainly on the basis of medical certificates that were often insufficient to judge work capacity. The role as coordinating actor with other stakeholders in the welfare system was perceived as frustrating, since different stakeholders have different goals and demands. The social insurance officers experience lack of control over the decision process, as regulations and other stakeholders restrict their work.
Conclusion
A picture emerges of difficulties due to disharmonized systems, stakeholder-bound goals causing some clients to fall between two stools, or leading to unnecessary waiting times, which may limit the clients' ability to take an active part in a constructive process. Increased communication with physicians about how to elaborate the medical certificates might improve the quality of certificates and thereby reduce the clients waiting time.
doi:10.1186/1471-2458-7-128
PMCID: PMC1913505  PMID: 17597536
9.  Captured voices in cancer: experiences from networking between individuals with experiential and professional knowledge 
Background
Patients needs and experiences attract increasing attention within health care. In order to generate knowledge about the voices that emerge from collaborative experiences between members of patient associations for cancer patients (PACP) and health care professionals (HCPs), we studied a permanent network aimed at improving cancer care through increased attention to the cancer patients' view and experiences.
Methods
Open-ended interviews were carried out with 16 individuals; 6 PACP members and 10 HCPs, and after transcription the texts were analysed by inductive content analysis.
Results
Four voices, which represent various experiences from networking, were identified; the hesitant voice, the enlightened voice, the liberated voice, and the representative voice. The hesitant voice reflects uncertainty experienced when the participants were exposed to different views and opinions within the network. The enlightened voice reflects new points of view and gain of knowledge. The liberated voice signifies trust, balance, and confidence related to individual experiences and responsibilities being viewed in a broader perspective. The representative voice is derived from the transformation of experiences and responsibilities through insight, understanding, and new perspectives.
Conclusion
Networking between representatives for PACPs and HCPs may help the participants manage uncertainty, strengthen the patient's perspective and provide new views on common issues. The different voices identified in this study demonstrate that both PACP members and HCPs distanced themselves from their individual experiences in order to be perceived as unselfish and knowledgeable within the network. Although the climate was characterized by trustfulness, the members' unique positions need to be defined in order to obtain an optimal balance between the groups and prevent members' patient experiences of losing their character by learning to much from the HCPs. Increased understanding of the hesitant, the enlightened, the liberated, and the representative voices, and awareness of experiential versus professional knowledge of cancer may facilitate and probably improve future networking efforts.
doi:10.1186/1472-6963-7-23
PMCID: PMC1808449  PMID: 17309806
10.  Pride and confidence at work: potential predictors of occupational health in a hospital setting 
BMC Public Health  2005;5:92.
Background
This study focuses on determinants of a healthy work environment in two departments in a Swedish university hospital. The study is based on previously conducted longitudinal studies at the hospital (1994–2001), concerning working conditions and health outcomes among health care personnel in conjunction with downsizing processes. Overall, there was a general negative trend in relation to mental health, as well as long-term sick leave during the study period. The two departments chosen for the current study differed from the general hospital trend in that they showed stable health development. The aim of the study was to identify and analyse experiential determinants of healthy working conditions.
Methods
Thematic open-ended interviews were carried out with seventeen managers and key informants, representing different groups of co-workers in the two departments. The interviews were transcribed verbatim and an inductive content analysis was made.
Results
In the two studied departments the respondents perceived that it was advantageous to belong to a small department, and to work in cooperation-oriented care. The management approaches described by both managers and co-workers could be interpreted as transformational, due to a strain of visionary, delegating, motivating, confirmative, supportive attitudes and a strongly expressed solution-oriented attitude. The daily work included integrated learning activities. The existing organisational conditions, approaches and attitudes promoted tendencies towards a work climate characterised by trust, team spirit and professionalism. In the description of the themes organisational conditions, approaches and climate, two core determinants, work-pride and confidence, for healthy working conditions were interpreted. Our core determinants augment the well-established concepts: manageability, comprehensiveness and meaningfulness. These favourable conditions seem to function as a buffer against the general negative effects of downsizing observed elsewhere in the hospital, and in the literature.
Conclusion
Research illuminating health-promoting aspects is rather unusual. This study could be seen as explorative. The themes and core dimensions we found could be used as a basis for further intervention studies in similar health-care settings. The result could also be used in future health promotion studies in larger populations. One of the first steps in such a strategy is to formulate relevant questions, and we consider that this study contributes to this.
doi:10.1186/1471-2458-5-92
PMCID: PMC1208911  PMID: 16137331
11.  Supporter or obstructer; experiences from contact person activities among Swedish women with breast cancer 
Background
Swedish patient associations for breast cancer patients (PABCPs) offer patients with breast cancer unlimited meetings with a breast cancer survivor, a contact person (CP). We applied the voluntary action perspective in this interview study with members of Swedish PABCPs in order to explore how women with breast cancer experienced their contact with a CP from a PABCP.
Methods
Audio-taped narratives from 8 women were analysed using Reissman's monitoring and Gee's analysis structure.
Results
Three themes appeared: 1. Shared experiences give new perspectives on having cancer, 2. Feelings of isolation are a part of the identity of the illness and 3. Relations with others enable self-help. However, the relationship with the CP is sensitive to timing, correct information and understanding.
Conclusions
CPs act as sounding boards and should optimally have capacity for listening, gives support and act as partner in this conversation. On the other hand, CPs should be aware that their presence and limited general medical knowledge could at times disturb the patient's psychological recovery and strengthen feelings of isolation. Thus, PABCPs must be careful in selecting CPs and offer relevant educational activities related to the themes identified herein.
doi:10.1186/1472-6963-5-9
PMCID: PMC548515  PMID: 15670335

Results 1-11 (11)