| 1. |
- Abrahamsen Grøndahl, Vigdis, 1964-
(författare)
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Patients’ perceptions of actual care conditions and patient satisfaction with care quality in hospital
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- There are theoretical and methodological difficulties in measuring the concepts of quality of care and patient satisfaction, and the conditions associated with these concepts. A theoretical framework of patient satisfaction and a theoretical model of quality of care have been used as the theoretical basis in this thesis. Aim. The overall aim was to describe and explore relationships between person-related conditions, external objective care conditions, patients’ perceptions of quality of care, and patient satisfaction with care in hospital. Methods. Quantitative and qualitative methods were used. In the quantitative study (I-III), 528 patients (83.7%) from eight medical, three surgical and one mixed medical/surgical ward in five hospitals in Norway agreed to participate (10% of total discharges). Data collection was conducted using a questionnaire comprising four instruments: Quality from Patients’ Perspective (QPP); Sense of Coherence scale (SOC); Big Five personality traits – the Single-Item Measures of Personality (SIMP); and Emotional Stress Reaction Questionnaire (ESRQ). In addition, questions regarding socio-demographic data and health conditions were asked, and data from ward statistics were included. Multivariate statistical analysis was carried out (I-III). In the qualitative study 22 informants were interviewed (IV). The interviews were analysed by conventional content analysis. Main findings. Patients’ perceptions of quality of care and patient satisfaction ranged from lower to higher depending on whether all patients or groups of patients were studied. The combination of person-related and external objective care conditions explained 55% of patients’ perceptions of quality of care (I). 54.7% of the variance in patient satisfaction was explained, and the person-related conditions had the strongest impact, explaining 51.7% (II). Three clusters of patients were identified regarding their scores on patient satisfaction and patients’ perceptions of quality of care (III). One group consisted of patients who were most satisfied and had the best perceptions of quality of care, a second group of patients who were less satisfied and had better perceptions, and a third group of patients who were less satisfied and had the worst perceptions. The qualitative study revealed four categories of importance for patients’ satisfaction: desire to regain health, need to be met in a professional way as a unique person, perspective on life, and need to have balance between privacy and companionship (IV). Conclusions. Patients’ perceptions of quality of care and patient satisfaction are two different concepts. The person-related conditions seem to be the strongest predictors of patients’ perceptions of quality of care and patient satisfaction. Registered nurses need to be aware of this when planning and conducting nursing care. There is a need of guidelines for handling over‑occupancy, and of procedures for emergency admissions on the wards. The number of registered nurses on the wards needs to be considered. Healthcare personnel must do their utmost to provide the patients with person‑centred care.
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| 2. |
- Arvidsson, Susann
(författare)
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Health promoting factors in people with chronic musculoskeletal pain or with rheumatic diseases: a descriptive and interventional study
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Aim: The overall aim of this thesis with a salutogenic approach was to describe health promoting factors in people with chronic musculoskeletal pain and in people with rheumatic diseases, and to evaluate the effects of an intervention study with a self-care promoting PBL-program for people with rheumatic diseases having chronic musculoskeletal pain, sleep disturbances and/or fatigue. Methods: This thesis is comprised of four samples: a randomly selected sample from a Swedish general population (study I) and three different samples containing people with rheumatic diseases registered at a hospital for rheumatic diseases in the southwest of Sweden (studies II, III and IV). Study I had a longitudinal cohort design with an eight-year follow-up in a general population. There were 1109 participants without chronic pain and 700 participants with chronic musculoskeletal pain. Study II had a longitudinal cohort design with participants with rheumatic diseases (n=185) 12 months after rehabilitation at a hospital for rheumatic diseases. Study III had a descriptive qualitative design with a phenomenological approach based on a reflective life-world perspective. Twelve participants were interviewed about their experiences about health-promoting self-care. Study IV had a randomised controlled design with post-test six months after the one-year self-care promoting problem-based learning (PBL) program for people with rheumatic diseases. The participants were randomly assigned to the experimental group, 54 participants, or to the control group, 148 participants. Data in studies I, II and IV were analysed with statistics. In study III a Husserlian phenomenological approach based on a reflective life-world perspective was used in the data collection and analysis. Results: Study I: Although participants without chronic musculoskeletal pain reported better health-related quality of life (HRQL) than participants with chronic musculoskeletal pain, similar health factors were found to promote a better HRQL in the eight-year follow-up. The most important factors were feeling rested after sleep and having good sleep structure. Study II: The most important factors promoting better outcome in HRQL 12 months after rehabilitation in participants with rheumatic diseases were having a strong sense of coherence (SOC), feeling rested after sleep, having work capacity, and having good sleep structure. Study III: The meaning of health-promoting self-care as experienced by people with rheumatic diseases was that self-care takes place against a background of continual hope and belief to be able to influence health in positive ways. Self-care was a way of life and implied being ready to understand and respond to signals from the body. Three interrelated constituents elucidated the experiences: dialogue, power struggle and choice. Study IV: At the six month follow-up the participants in the experimental group had stronger empowerment after participation in the self-care promoting PBL-program compared with the control group which only got standard care for people with rheumatic diseases. There were no differences in HRQL, self-care ability, SOC, pain, quality of sleep or fatigue between the experimental group and the control group. The participants in the experimental group also stated that they had implemented lifestyle changes which they had not done without the PBL-program. Conclusion: The results of this thesis provide a valuable and useful insight in health promoting factors in people with chronic musculoskeletal pain and in people with rheumatic diseases, but also in that people with rheumatic diseases have benefit from taking part in patient education with a self-care promoting PBL-program. These results contribute to evidence supporting the introduction of a more salutogenic approach in rheumatology care and research.
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| 3. |
- Bergsten, Ulrika, 1966-
(författare)
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Patients' and healthcare providers' experiences of the cause, management and interaction in the care of rheumatoid arthritis
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Aim: The overall aim of this thesis was to explore and describe patients’ and healthcare providers’ experiences of the causes, management and interaction in the care of rheumatoid arthritis (RA). Method: The thesis is based on four studies. Studies I and II contain data from an epidemiologic project involving patients who were recently diagnosed with RA. The patients answered an open-ended question about their conception of the cause of their RA (Study I). Qualitative data from 38 patients were analysed using the phenomenographic approach in order to identify variation in conceptions. The results of Study I formed the basis for categorizing the conceptions of 785 patients in the search for patterns of background factors (Study II). Study III aimed to explore how patients experienced their management of RA in everyday life. Data were collected by interviews with 16 patients and analysed according to Grounded Theory (GT). In study IV, the aim was to explore healthcare providers’ experiences of their interaction with patients’ management of RA. Data were collected by interviews with 18 providers representing different professions and analysed using GT. Findings: Patients’ conceptions of the cause of their RA revealed new aspects from the patient perspective that can complement pathogenetic models. Two descriptive categories emerged: consequences beyond personal control and overloaded circumstances, which included six categories of conceptions (Study I). The most common conceptions of the cause of RA were unexpected effects of events followed by work and family-related stress (Study II). Background factors that influenced the conceptions of the cause were age, sex and educational level. Patient management of RA involved using personal resources together with grasping for support from others in their striving for a good life. When linking these aspects together, four ways of management emerged: mastering, struggling, relying and being resigned (Study III). Healthcare providers’ experiences of their interaction with patients’ management shed light upon the important issue of delivering knowledge and advice. The providers’ attitudes constituted one cornerstone and patients’ responses the other. The providers reported that the interaction led to different outcomes: completed delivery, adjusted delivery and failed delivery. Conclusions: The findings contribute new knowledge from both patients’ and healthcare providers’ perspectives, which could be used to develop a more person-centred approach in rheumatology care. Person-centred care involves taking patients’ beliefs and values into account in addition to creating a trusting relationship between patient and provider. A successful person-centred approach requires an organisation that supports the person-centred framework.
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| 4. |
- Elmqvist, Carina, 1964-
(författare)
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Akut omhändertagande : i mötet mellan patienter, närstående och olika professioner på skadeplats och på akutmottagning
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Aim: To describe and develop understanding of the patient’s first encounter with the involved persons at the scene of an accident and at the emergency department; with a special focus on describing the meaning of emergency care of patients in these caring contexts. Method: The thesis uses a reflective lifeworld research (RLR) approach founded on phenomenological philosophy. The purpose with this approach is to describe the essential meaning and the variations of a phenomenon. Interviews with a lifeworld perspective were used for data collection and analyzed according to the RLR approach for searching for the essence of the phenomenon. The four essences in the studies (I-IV) establish a general structure for the phenomenon.Findings: Emergency care is characterized by an organisation, whose goal and resources are focused on life-saving, and that encounters a human being with needs of emergency care as well as existential support. The responsibility in emergency care means an intertwining of doing and being. The one who is in charge takes responsibility for performing or “doing” medical actions, and by “being” close and present in the situation the patient can at the same time feel an existential support. The responsibility for the injured or ill body is handed over to a chain of persons with more and more specialized competence and resources. This hand-over entails a relief for all involved but fails in one link in the chain, namely to explicitly hand back the responsibility to the patient. When the patient’s condition allows the distance to be larger the responsibility pales and the existential support decreases. A gap between doing and being arises where the patient is left to regain control and independence. The intertwining of doing and being, which appears as soon as the one in charge is close and present to the patient, facilitates the hand-over to the patient who in a natural way is able to receive the responsibility with possibilities to be able to conclude the encounter.Conclusions: A new understanding of emergency care appears which entails more than just life support measures. Emergency care includes different ways of communication in order to hand over the responsibility and complete the care chain back to the patient in a safe way. The results highlight the importance of empowering patients with a confirming, communicative contact throughout the whole caring process in order for them to retain their identity. There are also implications for educating students and personnel in inter-professional communication and work. In order to assist the intertwining between doing and being there are needs for the development of supportive structures for inter-professional reflection, which in turn would improve the interaction between patients and professionals in their encounter.
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| 5. |
- Isaksson, Rose-Marie, 1964-
(författare)
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Symptoms, prehospital delay and long-term survival in men vs. women with myocardial infarction : a combined register and qualitative study
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The general aim of this thesis was to study symptoms, prehospital delay and time trends in long-term survival in men and women with myocardial infarction (MI). The study was based on quantitative and qualitative data collections. Study I was based on The Northern Sweden MONICA Myocardial Infarction Registry, 1989-2003, including 5072 men and 1470 women with a confirmed MI. Symptoms and prehospital delay were described and trends over time according to sex and age were studied. Typical pain was present in 86% of the men and 81% of the women and typical symptoms were more common among younger persons than older persons. Up to the age of 65 no gender differences were seen in the prehospital delay. In the oldest age group (65–74 years) time to hospital was longer than among the younger group, especially among women. Study II was based on individual interviews with 20 men with a first confirmed MI, representing the age range 65-80 years, about their experiences during the prehospital phase. The interviews were analyzed using qualitative content analysis. The interviewed older men described how the symptoms developed from diffuse ill-being, to a cluster of severe symptoms. The men had difficulties to relate to the experienced symptoms, which did not correspond to their expectations about an MI, and about whether they should seek medical care. By using different strategies the participants initially tried to understand, reduce, or treat the symptoms by themselves, with a desire to maintain an ordinary life. As the symptoms evolved to a persistent and alarming chest pain, the men realized the seriousness in the perceived symptoms, that all strategies were inefficacious and they came to the decision to seek medical care. Study III was based on individual interviews with 20 women with a first confirmed MI, representing the age range 65-80 years, about their experiences during the prehospital phase. The interviews were analyzed using qualitative content analysis. The interviewed older women described how the symptoms were perceived as a stepwise evolvement from intangible and bodily sensations to a more distinct, persistent and finally overwhelming chest pain. The women struggled against the symptoms and used different strategies, by downplaying and neglecting the symptoms in order to maintain control over their ordinary lives and maintain the social responsibilities. As the symptoms evolved to a persistent and overwhelming chest pain the women realized the seriousness in the perceived symptoms, they were not able to struggle against them anymore and they came to the decision to seek medical care. Study IV was based on The Northern Sweden MONICA Myocardial Infarction Registry which was linked to The Swedish National Cause of Death Registry for 6762 men and 1868 women, 25 to 64 years of age, with a first MI during 1985-2006. Also deaths before admission to hospital were included. Follow-up ended on August 30, 2008. Between 1985 and 2006 long-term survival after a first MI increased in both men and women. Over the whole 23-year period women showed a 9 percent higher survival then men. This slight difference was due to lower risk for women to die before reaching hospital, and during the last period similar rates of long time survival were noted in men and women. In conclusion there were no major differences between men and women in symptoms, prehospital delay or long-term survival. However, older patients had fewer typical symptoms and longer prehospital delay, especially among women. The prehospital phase was found to be multifaceted with experiences difficult to interpret in both men and women, with a dynamic development of symptoms, conceptions and expectations while the participants strove to maintain the ordinary and familiar life. The symptoms experienced presented a more heterogeneous and complex picture in both men and women than is usually described in the literature. Women under the age of 65 have a slightly higher age-adjusted long-term survival than men. Over a 23-year period long-term survival has improved similarly in both men and women.
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| 6. |
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| 7. |
- Wieslander, Inger
(författare)
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Women’s recovery after a first myocardial infarction from an organisational, a relational and an individual perspective
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim of this thesis was to explore and describe women’s recovery after a first myocardial infarction (MI) from an organisational, a relational and an individual perspective. In this thesis a longitudinal, explorative and descriptive design combining both quantitative (papers I-II) and qualitative (papers III-IV) methods has been used. Data was collected from healthcare professionals at 18 acute hospitals (paper I), which on two occasions answered a questionnaire dealing with cardiac rehabilitation efforts. From these 18 hospitals, 240 women who had suffereda first MI (paper II) were consecutively chosen to answer a questionnaire on three occasions on the subject of social support and social network. Descriptive and inferential statistics were used to analyse data over time. Paper III and IV had an exploratory and descriptive design based on an inductive, qualitative content analysis approach. Interviews were conducted with 20 cardiac rehabilitation nurses (CRN) (paper III) and with 26 women suffering a first MI (paper IV).The results showed that patients with MI, and their next of kin, were offered a well-functioning cardiac rehabilitation on both measurement occasions. None of the hospitals offered a CRP that was specifically designed for women (paper I). The women perceived that the extent of general support, support from relatives, and professional support changed positively over time (paper II). The CRNs experienced that women’s recovery was influenced by their ability to cope with the stresses of life, if they wanted to be involved in their own personal care and how they related to themselves, and their opportunities to receive support (paper III). Women experienced that ability to approach the new perspective of life depended on how they embraced the three dimensions; behaviour, i.e. women’s acting and engaging in various activities, social i.e. how women receive and give support in their social environment, and psychological i.e. their way of thinking, reflect and appreciate life (paper IV).In conclusion, the four studies show that women’s recovery after a first MI is depending on factors emerging from an organisational, a relational and an individual perspective. Using knowledge from these three perspectives the possibility of a holistic approach to women’s recovery process to health will increase and the risk of a reductionist thinking will decrease.
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| 8. |
- 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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