| 1. |
- Andersson, Ann-Christine
(författare)
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Quality Improvement in Healthcare : Experiences from a Swedish County Council Initiative
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Quality improvement (QI) has become an important issue in healthcare settings. A central question for many healthcare systems is how to manage improvement initiatives adequately. All county councils and regions managing healthcare in Sweden have started to work with QI at an organizational system level, to varied extents. The Kalmar county council improvement initiative constitutes the empirical basis of this thesis. The aim of the thesis is to provide knowledge about different aspects of a county-wide improvement initiative, and a broader understanding of factors and strategies that affect participation, management and outcomes. The overall study design is based on a case study.The first two studies illuminate the practice-based (micro level), bottom-up perspective. Inductively five different areas (categories) were identified. Factors influencing participation in improvement initiatives provided the basis for the next study. The result showed that different staff categories were attracted by different initiatives. The next two studies illuminate the top-down (macro/meso) management perspective. Managers’ views of how patients can participate were investigated and a content analysis of the written answers was made. Four main areas (categories) were identified. A survey study investigated all of the county council managers’ experiences of the whole improvement initiative. Overall the managers thought that the improvement work was worth the effort. To evaluate the Breakthrough Collaborative program, a survey was developed and tested. This survey was used to investigate process and outcome of the BC program. The majority of the respondents were satisfied with their work, but wanted more time for teams to meet and work. To find out if an improvement program can affect outcome and contribute to sustainable changes, interviews were made with project applicants (n=202). Almost half (48%) of the projects were funded, and of those 51% were sustained. Of the rejected (not funded) projects, 28% were accomplished and sustained anyway. The results in this thesis cannot show that the “golden mean” exists, or that a single best way to manage changes and improvements in a healthcare organization has been found, but the way QI initiatives are organized does affect participation and outcomes. The intention, from the management topdown system level, encouraging staff and units and letting practice-based ideas develop at all system levels, can stimulate and facilitate improvement work.
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| 2. |
- Bölenius, Karin, 1973-
(författare)
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Improving venous blood specimen collection practices : method development and evaluation of an educational intervention program
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: About 60%–80% of decisions regarding diagnosis and treatment are based on laboratory test results. Low adherence to venous blood specimen collection (VBSC) guidelines may lead to erroneous or delayed test results, causing patient harm and high healthcare costs. Educational intervention programs (EIPs) to update, improve and sustain VBSC practices are seldom evaluated. After testing a self-reported venous blood sampling questionnaire, the overall aim of this thesis was to evaluate the impact of a large-scale EIP on healthcare personnel’s VBSC practices.Methods: The study settings were primary healthcare centres (PHCs) in northern Sweden. Participants were VBSC personnel. Data consisted of a VBSC questionnaire of self-reported practices, records of low-level haemolysis index in serum samples (specimen quality indicator), and interviews reflecting VBSC practices. First, experts on questionnaires and VBSC were consulted, and test-retest statistics were used when testing the VBSC questionnaire for validity and reliability. Thereafter, we evaluated the impact of a short, large-scale EIP with a before-after approach comparing self-reported VBSC questionnaire of two county councils. The personnel of the county councils (n = 61 PHCs) were divided into an intervention group (n = 84) and a corresponding control group (n = 79). In order to test changes in blood specimen quality we monitored haemolysis in serum samples (2008, n = 6652 samples and 2010, n = 6121 samples) from 11 PHCs. Finally, 30 VBSC personnel from 10 PHCs reported their experiences. The interview questions were open-ended with reflective elements and the interviews were analysed by qualitative content analysis.Results: The VBSC questionnaire was found to be valid and could be used to identify risk of errors (near misses) and evaluate the impact of an EIP emphasising VBSC guideline adherence. The intervention group demonstrated several significant improvements in self-reported practices after the EIP, such as information search, patient rest, test request management, patient identification, release of venous stasis, and test tube labelling. The control group showed no significant improvements. In total, PHCs showed minor differences in blood specimen quality. Interviews summarized VBSC personnel experiences in the overall theme: education opened up opportunities for reflection about safety. Conclusion: This thesis is, to our knowledge, the first to evaluate the impacts of a large-scale EIP on VBSC practices. The VBSC questionnaire and monitoring for low-level haemolysis reflected VBSC practices. The frequently occurring near-miss markers made it possible to compare and benchmark VBSC practices down to the healthcare unit and hospital ward. The short, general EIP opened up opportunities for reflection about safety and improved VBSC practices in PHCs with larger deviations from guidelines. EIPs that provide time for reflection and discussion could improve VBSC further. Directed EIPs focused on specific VBSC flaws might be more effective for some near misses in VBSC practices, while some near misses must be changed at a different level in the system.Clinical relevance: Our results indicate that monitoring and counteracting the near misses in VBSC practices is a well-functioning preventive action. We propose that the VBSC monitoring instruments (VBSC questionnaire & haemolysis index) we used and the EIP strategy proposed should be tested in additional countries with different healthcare settings. It is suggested that a national program intended to identify near misses and prevent VBSC errors be developed in the healthcare system. General e-learning programs may be cheaper than, and as effective as, the EIP program and may be performed everywhere and any time. Systematic planning, useful for reflection and with focus on the specific elements in a skill, together with VBSC guidelines, could probably increase improvements. Our studies have led to deeper and extended knowledge of the impact of an EIP on VBSC practices. Our results can be used when considering future VBSC practice interventions. Using a model for practical skills in nursing to describe VBSC in a more holistic and less technical way might highlight VBSC as a practical nursing skill.
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| 3. |
- Näsström, Lena, 1967-
(författare)
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Participation in heart failure home-care : Patients’ and partners’ perspectives
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: Patient participation is important for improving outcomes and respecting selfdetermination and legal aspects in care. Heart failure is a chronic condition that puts high demands on self-care and patient participation. Patients often need advanced care due to deterioration of their heart failure symptoms, and one option is to provide care as home-care. There is limited knowledge of how patients with heart failure and their partners view participation in home-care.Aim: The overall aim of this thesis was to describe different perspectives of participation in structured heart failure home-care among patients with heart failure and their partners.Methods: All patients in this thesis received structured heart failure home-care, according to a model aiming to facilitate care, where safety, participation, and gaining knowledge about the illness and treatment, are in focus. Study I had a prospective pre-post longitudinal design including 100 patients with heart failure receiving home-care. Data was collected by selfadministered questionnaires. Study II had a descriptive design. Nineteen patients receiving home-care were interviewed, and data was analysed using qualitative content analysis. Study III had a descriptive and explorative design. Data was collected by video-recorded observations of 19 home visits and analysed by qualitative content analysis. Study IV had a parallel convergent mixed-method design including 15 partners of patients receiving structured home-care. Data was collected by interviews and self-administered questionnaires. Datasets were first analysed separately and then together.Results: Better self-care behaviour was significantly associated with all measured aspects of participation. Participation by received information increased significantly during the 12-month follow-up (I). Patients’ descriptions of participation included communication between patients and health care professionals, access to care, active involvement in care, a trustful relation with health care professionals, and options for decision-making(II). Observed care encounters revealed that participation was made possible by; (i) interaction, including exchange of care-related information, care-related reasoning, and collaboration, (ii) an enabling approach, including the patient expresses own wishes and shows an active interest, and the nurse is committed and invites to a dialogue (III). Partners scored fairly positive for their participation in care and they performed different levels of caregiving tasks. Descriptions of participation included; adapting to the caring needs and illness trajectory, mastering caregiving demands, interacting with care providers, and gaining knowledge to comprehend the health situation. The mixed-method results showed both convergent results and expanded knowledge (IV).Conclusions: Structured heart failure home-care facilitated participation both for patients and their partners. Patient participation with regard to received information improved significantly after receiving home-care. Aspects of patient participation were consistently associated with better self-care behaviour. Patients’ and partners’ descriptions revealed many aspects of participation, and observed home visits revealed how interaction and an enabling approach underpinned participation.
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| 4. |
- Wåhlin, Ingrid, 1955-
(författare)
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The circle of strength and power : Experiences of empowerment in intensive care
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Patients and next of kin in intensive care often experience powerlessness, anxiety and distress and intensive care staff are repeatedly exposed to traumatic situations and demanding events. Empowerment has been described as a process of overcoming a sense of powerlessness and a model through which people may develop a sense of inner strength through connections with others. The aim of this thesis was to describe empowerment as experienced by patients, next of kin and staff in intensive care and to compare patient's experiences with staff and next of kin beliefs. Empowerment is reflected in this thesis as experiences of inner strength and power and of participation/self-determination.The study was based on open-ended interviews with 11 patients, 12 next of kin and 12 staff members from two intensive care units in southern Sweden. A phenomenological perspective was applied in three studies, while a qualitative content analysis was used in the forth study.Findings showed that nourishing relationships were of crucial importance, and contributed to every participant's experiences of empowerment regardless of whether he/she was an intensive care patient, a next of kin or a staff member. Patients were found to be strengthened and empowered by a positive environment where their own inherent joy of life and will to fight was stimulated, where they felt safe and a sense of value and motivation were encouraged and where they were taken seriously and listened to. Next of kin were extremely important to patients' experiences of safety, value, human warmth and motivation, and patients were strengthened when their next of kin were acknowledge and welcomed by staff.Next of kin in intensive care were strengthened and empowered by a caring atmosphere in which they received continuous, straightforward and honest information that left room for some hope and in which closeness to the patient was facilitated and medical care was experienced as the best possible. Some informants were also empowered by family support and/or participation in caring for the patient. Intensive care staff were empowered by both internal processes such as feelings of doing good, increased self-esteem/self-confidence and increased knowledge and skills, and by external processes such as nourishing meetings, excitement and challenge, well functioning teamwork and good atmosphere.When comparing patient experiences with staff and next of kin beliefs, there was agreement regarding joy of life and will to fight being essential to patients' experiences of inner strength and power, but staff and next of kin seemed to see this as a more constant individual viewpoint or characteristic than the patient did. Next of kin, and especially staff, seemed to regard the patient as more unconscious and unable to participate in the communication and interaction process than the patient him/herself experienced. A mutual and friendly relationship was experienced by the patients as highly empowering, while a more professional relationship was emphasized by the staff. These findings could serve as a basis for reflection about patient, next of kin and staff experiences of strength and power and if empowerment is seen as a dimension in quality of care, the findings from this thesis ought to be taken into consideration to increase the quality of care in intensive care.
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| 5. |
- Åkerman, Eva, 1961-
(författare)
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Assessment and tools for follow-up of patients' recovery after Intensive Care
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Aim: The overall aim of this thesis was to describe and explore the use and content of ICU-diaries and to develop and psychometrically test a questionnaire to detect physical and psychosocial problems for ICU patients in their recovery process. Methods: This thesis is based on four studies. Study I had an explorative descriptive design with a quantitative and qualitative approach. Data were collected by telephone interviews with staff at Swedish ICUs (n = 65) which kept ICU-diaries. One question “what was the purpose of keeping ICU-diaries” was analysed with latent content analysis, and the other data were analysed with descriptive and comparative statistics. Study II had an explorative descriptive cohort design with a concurrent mixed method approach. The sample in study II was a part of the sample in study IV in which 421 former ICU patients responded to a new developed questionnaire 3-set 4P two months after discharge from ICU. Patients from this sample who have had an ICU-diary (n = 115) responded to a questionnaire six months after discharge from ICU. Fifteen patients were interviewed about the content and usefulness of the ICU-diary. Data were analysed with descriptive statistics, descriptively by content and interviews with manifest content analysis and then combined at the interpretive level to seek convergence, as enable by the mixed method approach. Study III had a methodological design. In this study, the questionnaire 3-set 4P was developed and psychometrically tested in a pilot setting. In study IV, the questionnaire was further developed and tested based on psychometric evaluation of the 3-set 4P. In study III the questionnaire was responded by 39 patients and in study IV by 421 patients. Data in study III and IV were analysed with descriptive statistics and psychometrical tests. Results: The main purpose for keeping ICU-diaries was to provide a tool in the recovery by helping the patient remember and give time back. Keeping ICU-diaries was common although there was a difference in practice and patient recruitment among different hospitals (study I). An ICU-diary with content and photos in a chronological order describing the whole picture of critical illness and ICU stay could be a tool for the patient to construct a coherent individual story. The ICU-diary could be one piece to give a deeper understanding and meaning in the personal story and to give a realistic expectation of the recovery process. Absence of guidelines for keeping ICU-diaries could affect the possibility for the ICU-diary to be a helpful tool during the recovery process (study II). In study III, the 3-set 4P was developed to be used for identifying and evaluating former ICU patients’ physical, psychosocial problems and outcome during follow-up. The psychometrical tests showed acceptable validity and internal consistency reliability. The stability reliability was acceptable in two of three sets. The psychometrical tests of the further modified version of 3-set 4P in study IV showed good construct validity and internal consistency but it needs some modification before it can be used in clinical practice (study IV). Conclusion: Recovery can be a difficult process where different tools can be useful. Today there is no evidence about tools to use during follow-up. To promote high quality of the follow-up there is a need for evidence-based guidelines. The ICU-diary is one tool but this thesis shows that guidelines for keeping ICU-diaries have to be developed to meet the patients’ wishes in order for the ICU-diary to become a useful tool during the process to recovery. The 3-set 4P can after some modification be used at the follow-up clinic to identify the individual patient’s problems and create an individual program for recovery.
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| 6. |
- Allvin, Renée, 1956-
(författare)
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Postoperative recovery : development of a multi-dimensional questionnaire for assessment of Recovery
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This thesis aims to present a multi-dimensional instrument for self-assessment of progress in postoperative recovery. The author employs different research paradigms and methodologies to achieve this aim. Walker and Avant’s approach to concept analysis was used to examine the basic elements of postoperative recovery (Study I). The analysis identified different recovery dimensions and developed a theoretical definition showing postoperative recovery to be an energy-requiring process of returning to normality and wholeness, defined by comparative standards. Fourteen patients and 28 staff members participated in individual and focus group interviews aimed at describing patient and staff experiences of patient recovery (Study II). The essence of the postoperative recovery process was described as a desire to decrease unpleasant physical symptoms, reach a level of emotional wellbeing, regain functions, and re-establish activities. In Study III, 5 dimensions and 19 items were identified as a part of the operationalization process of the concept postoperative recovery. Fifteen staff members and 16 patients participated in the evaluation of content validity. On average, 85% of the participants considered the items as essential to the recovery process. In a test run of the questionnaire, 14 of 15 patients considered the questionnaire to be easy to understand and easy to complete. Twenty-five patients participated in the evaluation of intra-patient reliability. Percentage agreement (PA), systematic disagreement (RP, RC), and individual variability (RV) between the two assessments were calculated. PA measures ranged from 72% to 100%. The observed disagreement could be explained mainly by systematic disagreement. In total, 158 patients participated in the evaluation of construct validity, the ability to discriminate between groups, and the investigation of important item variables (Study IV). A rank-based statistical method for evaluation of paired, ordered categorical data from rating scales was used to evaluate consistency between the assessments of the Postoperative Recovery Profile (PRP) questionnaire and a global recovery scale. The number of months needed by participants to be regarded as fully recovered was studied by means of recovery profiles displayed by the cumulative proportion of recovered participants over time. A ranking list based on the participant’s appraisal of the five most important item variables in the PRP questionnaire was compiled to illustrate the rank ordering of the items. In comparing the assessments from the PRP questionnaire and the global recovery scale, 7.6% of all possible pairs were disordered. Twelve months after discharge 73% in the orthopaedic group were regarded as fully recovered, compared to 51% of the participants in the abdominal group (95% CI: 6% to 40%). The pain variable appeared among the top five most important items on eight measurement occasions, of eight possible, in both study groups. In conclusion, the PRP questionnaire was developed and support was given for validity and reliability. The questionnaire enables one to evaluate progress in postoperative recovery.
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| 7. |
- Berg, Katarina, 1959-
(författare)
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Postoperative recovery in daysurgery : Evaluation of psychometric properties and clinical usefulness of a questionnaire in day surgery
- 2010
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Day surgery has increased during recent decades in many countries and represents approximately 50% of surgical procedures performed in Sweden. Day surgery implies that the patient is admitted and operated on during the same day and discharged without an overnight stay at the surgery unit. Undergoing a day surgical procedure thereby means that the major part of the postoperative recovery takes place in the patient’s home, leaving the patient and his/her supportive network responsible for the postoperative care. Day surgery also implies that health care professionals have to adapt to outpatient care and find valid measurements for monitoring a patient’s recovery progress after discharge.Aims: The aim of Study I was to evaluate the psychometric properties of a translated version of the Post-discharge Surgical Recovery (PSR) scale in a Swedish day surgery sample in terms of data quality, internal consistency, dimensionality and responsiveness. The aim of Study II was to describe postoperative recovery on postoperative days 1, 7 and 14 after different orthopaedic day surgical procedures, as well as to identify possible predictors associated with postoperative recovery two weeks after surgery.Methods: Six-hundred and seven patients who had undergone an orthopaedic surgical procedure (n=358), general surgery (n=182) or gynaecological surgery (n=67) were included. To assess postoperative recovery, the PSR scale and the emotional state, physical comfort and physical independency dimensions of the Quality of Recovery-23 (QoR-23) were used. In addition, patients’ background data and self ratings of their ability to work or handle usual business and general health were obtained. Data were collected preoperatively and on postoperative days 1, 7 and 14. In Study I data quality and internal consistency were evaluated using descriptive statistics, correlation analyses and Cronbach’s alpha. The dimensionality was determined using an exploratory factor analysis, and the responsiveness was evaluated through the standardized response mean (SRM) and the area under the receiver operating characteristics curve (AUC). In Study II, patients’ postoperative recovery and general health were compared over time using Friedmann’s ANOVA and between surgical groups of patients using the Kruskal-Wallis test. To determine predictors of recovery, a multiple linear regression analysis was performed with the PSR score on postoperative day 14 as the dependent variable.Results: In Study I, two items were deleted from the Swedish version of the PSR scale. This was based on several low inter-item (<0.30) and item-total correlations (<0.40) and substantial ceiling effects (65%). After the deletion of two items, the Cronbach’s coefficient alpha was 0.90 and the average interitem correlation was 0.44. According to the factor analysis, a single dimension was found explaining the common variance to 44%. The SRM (1.14) indicated a robust ability to detect changes in recovery. The AUC was 0.60 for the entire scale, but varied (0.58-0.81) when the PSR score on postoperative day 1 was categorized into three intervals. In Study II, the shoulder patients experienced significantly lower postoperative recovery and general health one and two weeks after surgery (p<0.001). Significant predictors of recovery on postoperative day 14 were age, perceived health and emotional status on postoperative day 1 and type of surgery, and explained the dependent variable to 33%.Conclusions: The Swedish version of the PSR scale seems to be a consistent and valid instrument for the assessment of postoperative recovery at home in Sweden. The recovery process for orthopaedic day surgery patients differs, with shoulder surgery patients in particular showing poor recovery, which could be considered when day surgery patient education programmes are developed.
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| 8. |
- Andersson, Ann-Christine
(författare)
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Practice-based Improvements in Healthcare
- 2010
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- A central problem for the healthcare sector today is how to manage change and improvements. In recent decades the county councils in Sweden have started various improvement initiatives and programs in order to improve their healthcare services. The improvement program of the Kalmar county council, which constitutes the empirical context for this thesis, is one of those initiatives.The purpose of this thesis is to contribute to a broader understanding of large-scale improvement program in a healthcare setting. This is done by analyzing practitioner’s improvement ideas, describing participants in the improvement projects, revising and testing a survey to measure the development of improvement ideas and describing the improvement program from a theoretical perspective. The theoretical change model used looks at change from two opposing directions in six dimensions; Goals, Leadership, Focus, Process, Reward system and Use of consultants.The aims of the county council improvement program are to become a learning organization, disseminate improvement methodologies and implement continuous quality improvements in the organization. All healthcare administrations and departments in the county council were invited to apply for funds to accomplish improvement projects. Another initiative invited staff teams to work with improvement ideas in a program with support from facilitators, using the breakthrough methodology. Now almost all ongoing developments, improvements, patient safety projects, manager and leader development initiatives are put together under the county council improvement program umbrella.In the appended papers both qualitative and quantitative research approach were used. The first study (paper I) analyzed which types of improvement projects practitioners are engaged in using qualitative content analysis. Five main categories were identified: Organizational Process; Evidence and Quality; Competence Development; Process Technology; and Proactive Patient Work. Most common was a focus on organizational changes and process, while least frequent was proactive patient work. Besides these areas of focus, almost all aimed to increase patient safety and increase effectiveness and availability.Paper II described the participants in two of the initiatives, the categorized improvement projects in paper I and the team members in the methodology guided improvement programs. Strong professions like physicians and nurses were well represented, but other staff groups were not as active. Managers were responsible for a majority of the projects. The gender perspective reflected the overall mix of employees in the county council.Paper III described a revision and test of a Minnesota Innovation Survey (MIS) that will be used to follow and measure how quality improvement ideas develop and improve over time. Descriptive statistics were presented. The respondents were satisfied with their work and what they had accomplished. The most common comment was about time, not having enough time to work with the improvement idea and the difficulty of finding time because of regular tasks. This was the first test of the revised survey and the high use of the answer alternative “Do not know” showed that the survey did not fit the context very well in its present version.Trying to connect the county council improvement program and the initiatives studied in papers I and II with the change model gave rise to some considerations. The county council improvement program has an effort to combine organizational changes and a culture that encourages continuous improvements. Top-down and bottom-up management approaches are used, through setting out strategies from above and at the same time encouraging practitioners to improve their day-to-day work. Whether this will be a successful way to implement and achieve a continuous improvement culture in the whole organization is one of the main issues remaining to find out in further studies.
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| 9. |
- Forsberg, Angelica
(författare)
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Patients' experiences of undergoing surgery : From vulnerability towards recovery -including a new, altered life
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim of this thesis was to explore patients’ experiences of undergoing surgery, including their perceptions of quality of care and recovery. A mixed methods design was used, and studies with qualitativemethods (I, II) and quantitative methods (III, IV, V) were performed. Data were collected through interviews with ten patients after gastric bypass surgery (I) and nine patients after lower limb fracture surgery (II) and weresubjected to qualitative content analysis. Data were also collected using two standardized questionnaires; The Quality from Patient’s Perspective (III) and Postoperative Recovery Profile (IV, V). A total of 170 orthopedicand general surgery patients participated in study III. In study IV and V, 180 patients participated. Accordingly, 170 of patients were the same in study III, IV and V. Data were analyzed by descriptive statistics (III, IV, V)and a manifest content analysis of the free-text answers (III) as well as with analytical statistics (IV, V). Prior to surgery, patients undergoing gastric bypass surgery (I) described a sense of inferiority related to their obesity. In the post-anesthesia care unit, patients felt both omitted and safe in the unknown environment and expressed needs to have the staff close by. Despite the information provided prior to surgery it was difficult toimagine one’s situation after homecoming, thus it was worth it so far and visions of a new life were described. Patients undergoing lower limb surgery (II) described feelings of helplessness when realizing the seriousness oftheir injury. The wait prior to surgery was strain, and patients needed orientation for the future. They remained awake during surgery and expressed feelings of vulnerability during this procedure. In the post-anesthesia careunit, patients expressed a need to have control and to feel safe in their new environment. Mobilizing and regaining their autonomy were struggles, and patients stated that their recovery was extended. The quality of theperioperative care was assessed as quite good (III). While undergoing a surgical procedure (III), the areas identified for improvement were information and participation. Patients preferred to hand over the decisionmakingto staff and indicated that having personalized information about their surgery was important. However, too detailed information before surgery could cause increased anxiety (III). After surgery, orthopedic patientswere substantially less recovered than general surgery patients (IV, V). Approximately two-thirds of orthopedic patients and half of general surgery patients perceived severe or moderate pain in the first occasion (day 1-4after surgery) (IV). Both the orthopedic and general surgery group showed a significant systematic change at a group level towards higher levels of recovery after one month compared with day 1-4 after surgery. The same patterns occurred regarding acute and elective surgery (V). Patients overall recovered better (IV, V) after a gastric bypass, than after other surgeries. Compared with the period prior to surgery; certain Gastric bypass patients felt after one month that they had improved (IV). The orthopedic groups assessed their psychologicalfunction as being impaired after one month compared with the first occasion (IV, V). The overall view of patients’ experiences of undergoing surgery (I-V) can be understood as a trajectory, from vulnerability towards recovery, including a new, altered life. Patients’ experiences and perceptions of the caregiven (I, II, III) are embedded within this trajectory. As a thread in this thesis, through all studies, patients expressed vulnerability in numerous ways. A progress towards recovery with regards to regaining preoperativelevels of dependence/independence could be concluded. Thus, for patients undergoing gastric bypass surgery, a view of a new, altered life after surgery was also discernible. While undergoing surgery, satisfaction with theprovision of information not necessarily include receiving as much and the most detailed information as possible; nevertheless, the need for information to a great extent is personal. The recovery-period for orthopedic patients is strain, and the support must be improved. In conclusion, the perioperative support may contain a standardized part, made-to-order to the general procedure commonly for all patients, such as information about the stay in the post anesthesia care unit. Moreover, the support should be person-centered, accounting for the patients’ expectations about the future but also tailored to the specific surgical procedure; with its limitations and possibilities. Then, patients in a realistic way would be strengthened towards recovery, including a new, altered life.
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| 10. |
- Idvall, Ewa, 1950-
(författare)
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Development of Strategic and Clinical Quality : Indicators in Postoperative Pain Management
- 2001
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of this thesis was to identify important aspects of surgical nursing care, designing strategic and clinical quality indicators in postoperative pain management, investigate content validity, develop and evaluate psychometric properties of an instrument to measure the indicators, test the applicability of the instrument and investigate patient and nurse assessment.To identify the important aspects of nursing care which might impact on quality of care in surgical wards, it was conducted 4 focus group interviews with clinical nurses (n=20). A tentative model with 15 categories in 2 dimensions, elements of performance and prerequisites, emerged from the data analysis. The categories were, e.g. detecting and acting on signs and symptoms, informing and educating, promoting relationships, responsibility and attitudes. The model was used as a foundation for developing indicators in postoperative pain management, one in each category, each supported by a literature review. To assess the content validity of the indicators, a questionnaire was compiled and sent to registered nurses with a special interest in pain (n=210) and to a random sample of clinical nurses working in surgical wards (n=321). The groups assessed the indicators as essential for achieving high quality, realistic to carry out and possible for nurses to influence management. The first group validated 14 of the 15 indicators and the second group validated 12 as “major” factors in terms of being essential to achieve high quality of care. The remaining factors were classified as “supportive”. No indicator was discarded.To measure the indicators, an instrument was developed and psychometric properties were evaluated. The indicators were converted to statements suitable for a patient questionnaire and were scored on a 5-point scale with higher values indicating higher quality of care. Patients (n=198) answered the questionnaire on their second postoperative day. The inter-item and item-total correlation coefficients were in a satisfactory range, and Cronbach’s coefficient alpha (0.84) supported internal consistency reliability. Four sub-scales, entitled communication, action, trust and environment emerged from the factor analysis with a total variance of 61.4%. The total scale correlated (rs=0.53) with the single item pain-relief-satisfaction question. The patients who reported more pain than expected scored lower on the total scale and the patients who received epidural analgesia reported higher scores on the total scale. A nurse questionnaire, similar to the patient questionnaire, was compiled. The responsible nurse at the time (n=63) answered 196 questionnaires paired with the individual patient. The new instrument appeared to be useful in identifying important areas for improvement both from the patients’ and nurses’ perspectives, based on the number of disagreements (1 and 2). Differences were found among departments. The patients’ assessments on the environment sub-scale and the overall satisfaction question were higher than the nurses’ assessments. The findings suggest initial support for the instrument as a means to measure the quality of nursing care in postoperative pain management. Key words: quality indicators; health care, pain; postoperative, focus groups, psychometrics, questionnaires, nursing care.
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| 11. |
- Nilsson, Ulrica, 1960-, et al.
(författare)
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Psychometric evaluation of the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery and postoperative behavior and recovery inchildren undergoing tonsil surgery
- 2019
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Ingår i: Journal of Perioperative Practice. - : Harrogate : Association for Perioperative Practice. - 1750-4589 .- 2515-7949. ; 29:4, s. 94-101
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Tidskriftsartikel (refereegranskat)abstract
- The study comprised a prospective, comparative cross-sectional survey in 143 (of 390) children undergoing tonsil surgery. Parents answered the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery (PHBQ-AS), and children answered the questionnaire Postoperative Recovery in Children (PRiC). The PHBQ-AS had positive correlation with the PRiC and with general health. On day 10 after surgery, up to one-third of the children still reported physical symptoms (PRiC). No gender or age differences concerning the items of behavior (PHBQ-AS) were found. The quality of postoperative recovery (PRiC) in girls was lower, with higher levels of nausea, dizziness, coldness, and headache compared to the boys. Children <6 years of age reported higher levels of dizziness and lower sleep quality and lower general health.
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| 12. |
- Söderberg, Johan, 1980-
(författare)
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Sources of preanalytical error in primary health care : implications for patient safety
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background Venous blood tests constitute an important part in the diagnosis and treatment of patients. However, test results are often viewed as objective values rather than the end result of a complex process. This has clinical importance since most errors arise before the sample reaches the laboratory. Such preanalytical errors affect patient safety and are often due to human mistakes in the collection and handling of the sample. The preanalytical performance of venous blood testing in primary health care, where the majority of the patients contact with care occurs, has not previously been reported.Aims To investigate venous blood sampling practices and the prevalence of haemolysed blood samples in primary health care.Methods A questionnaire investigated the collection and handling of venous blood samples in primary health care centres in two county councils and in two hospital clinical laboratories. Haemolysis index was used to evaluate the prevalence of haemolysed blood samples sent from primary health care centres, nursing homes and a hospital emergency department.Results and discussion The results indicate that recommended preanalytical procedures were not always followed in the surveyed primary health care centres. For example, only 54% reported to always use name and Swedish identification number, and 5% to use photo-ID, the two recommended means for patient identification. Only 12% reported to always label the test tubes prior to blood collection. This increases the possibility of sample mix-up. As few as 6% reported to always allow the patient to rest at least 15 minutes before blood collection, desirable for a correct test result. Only 31% reported to have filed an incident report regarding venous blood sampling, indicating underreporting of incidents in the preanalytical phase.Major differences in the prevalence of haemolysed blood samples were found. For example, samples collected in the primary health care centre with the highest prevalence of haemolysed samples were six times (95% CI 4.0 to 9.2) more often haemolysed compared to the centre with the lowest prevalence. The significant variation in haemolysed samples is likely to reflect varying preanalytical conditions.Conclusions This thesis indicates that the preanalytical procedure in primary health care is associated with an increased risk of errors with consequences for patient safety and care. Monitoring of haemolysis index could be a valuable tool for estimating preanalytical sample quality. Further studies and interventions aimed at the preanalytical phase in primary health care are clearly needed.
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