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- Carlsson, Eva, 1952-
(författare)
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Communication about eating difficulties after stroke : from the perspectives of patients and professionals in health care
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Stroke is one of the major causes of eating difficulties (EDs). It is one of the leading causes of death and disability and one of the most important factors contributing to health-care costs. There is a clear association between EDs after stroke and undernutrition, where studies have shown that structured screening of eating function among stroke patients can predict nutritional problems as well as need for subsequent institutional care. Reliable and valid instruments that can identify EDs exist, but there is lack of knowledge on how persons experience living with EDs after stroke. Stroke unit care is evidence-based and grounded in multidisciplinary collaboration and continuity of care. The overall aim of this thesis is to explore and describe EDs after stroke as represented by health care professionals in patient records (PRs) and transferred information, and as described by persons living with EDs after stroke. An additional aim is to explore methodological aspects related to the inclusion of persons with EDs and communication impairment in research studies. Both quantitative and qualitative methods were used. Two studies used descriptive designs (I, II), one an explorative design (III) and one applied a methodological discussion (IV). In one of the studies PR data were used (I), in another study data were derived from three sources: PRs, screening of patients and interviews with nurses (II). Persons with EDs after stroke participated in Study III while literature, empirical data and researchers' experiences served as the data in study IV. Data were analysed by categorisation of phrases (I), content analysis (II) and descriptive statistics (I, II), by qualitative analysis (III) and by processing of literature and empirical findings in two research groups (IV). The main findings from the studies on representation of stroke care in PRs (I, II) showed that, despite that >50% of patients in Study I and all patients in Study II had EDs, there were few signs of multidisciplinary collaboration dealing with this problem. Unsystematic screening for swallowing difficulties was routine, whereas screening for nutritional risk and EDs was lacking (I, II). Multidisciplinary discharge summaries proved to have low quality and entailed little information on patients' eating ability (I). The two EDs most frequently documented were swallowing and lack of energy to complete a meal (I,II). EDs were described in vague terms (I, II). In Study II, all patients had swallowing difficulties and most patients had lack of energy to complete a meal. The electronic information transfer tool held information on eating ability for most patients (II), but the nursing staff in residential home care perceived deficiencies in that information, even identifying several EDs not reported at discharge (II). Experiences from persons living with EDs after stroke were presented in one main theme: Striving to live a normal life, including three sub-themes: Abandoned to learn on one's own (little support from health care professionals to learn to handle eating), Experiencing losses (loss of eating functions and loss of valued activities) and Feeling dependent in mealtime situations (III). One major finding from the methodological exploration (IV) is that creative approaches and suitable methods for inclusion of participants with EDs and communication impairment into qualitative studies can be found in the fields of aphasiology and learning disabilities. Another major finding from Study IV is that researchers need good communication skills as well as knowledge in neuropsychology. A general conclusion is that screening for EDs should be routine in stroke care and that a multidisciplinary terminology to express EDs must be developed to provide accurate information transfer. Health care professionals need to enhance their knowledge in nutrition and provide support to stroke patients with EDs with the goal that they can eat and perform meal-related activities in accordance with their habits before the stroke. To gain access to the experiences of persons with EDs and communication impairment researchers need to test participatory approaches when planning for inclusion of those persons.
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| 2. |
- Florin, Jan, 1956-
(författare)
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Patient participation in clinical decision making in nursing : a collaborative effort between patients and nurses
- 2007
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim of the thesis was to study clinical decision making in nursing. This was performed by evaluation of the quality of nurses’ diagnostic statements and comparison of the concordance between nurses and patients’ perceptions of the patients’ nursing needs, as well as patient preferences for participation in clinical decision making. Further, predictors regarding patients’ active participation were investigated. Quasi-experimental, comparative and cross-sectional descriptive study designs were used to collect data in acute care settings from randomly selected patient records (n = 140), nurse-patient dyads (n = 80), and patients discharged from hospital care (n = 428). Data were gathered using questionnaires and review of patient records. The quality of nurses’ diagnostic statements improved by the means of education directed to nurses and implementation of new forms for recording supporting nursing care planning (I). Discrepancies were found concerning patients and nurses’ perceptions about what constitutes a problem for the patient as well as the severity and importance of acting on the problem (II). Further, nurses perceived that their patients preferred to be more active in clinical decision making compared with the patients’ own preferences for participation (III). Gender, education, living situation, and occupation were identified as predictors for preferring an active role in clinical decision making (IV). The conclusions are that the accuracy of diagnostic statements needs to be addressed and validated further through systematic assessment of the patients’ perceptions and preferences concerning the health situation and preferences for participation in clinical decision making. Clinical implications are that nurses need to involve patients in identifying patient problems of relevance for nursing. Further, nurses also need to be aware of patients’ preferences for participation in clinical decision making in order that they can plan care in accordance with patient preferences and allow participation to the degree preferred by the patient.
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| 3. |
- Göransson, Katarina, 1974-
(författare)
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Registered nurse-led emergency department triage : organisation, allocation of acuity ratings and triage decision making
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Successful triage is the basis for sound emergency department (ED) care, whereas unsuccessful triage could result in adverse outcomes. ED triage is a rather unexplored area in the Swedish health care system. This thesis contributes to our understanding of this complex nursing task. The main focus of this study has been on the organisation, performance, and decision making in Swedish ED triage. Specific aims were to describe the Swedish ED triage context, describe and compare registered nurses’ (RNs) allocation of acuity ratings, use of thinking strategies and the way they structure the ED triage process. In this descriptive, comparative, and correlative research project quantitative and qualitative data were collected using telephone interviews, patient scenarios and think aloud method. Both convenience and purposeful sampling were used when identifying the participating 69 nurse managers and 423 RNs from various types of hospital-based EDs throughout the country. The results showed national variation, both in the way triage was organised and in the way it was conducted. From an organisational perspective, the variation emerged in several areas: the use of various triageurs, designated triage nurses, and triage scales. Variation was also noted in the accuracy and concordance of allocated acuity ratings. Statistical methods provided limited explanations for these variations, suggesting that RNs’ clinical experience might have some affect on the RNs’ triage accuracy. The project identified several thinking strategies used by the RNs, indicating that the RNs, amongst other things, searched for additional information, generated hypotheses about the fictitious patients and provided explanations for the interventions chosen. The RNs formed relationships between their interventions and the fictitious patients’ symptoms. The RNs structured the triage process in several ways, beginning the process by searching for information, generating hypotheses, or allocating acuity ratings. Comparison of RNs’ use of thinking strategies and the structure of the triage process based on triage accuracy revealed only slight differences. The findings in this dissertation indicate that the way a patient is triaged, and by whom, depends upon the particular organisation of the ED. Moreover, the large variation in RNs triage accuracy and the inter-rater agreement and concordance of the allocated acuity ratings suggest that the acuity rating allocated to a patient may vary considerably, depending on who does the allocation. That neither clinical experience nor the RNs’ decision-making processes alone can explain the variations in the RNs triage accuracy indicates that accuracy might be influenced by individual and contextual factors. Future studies investigating triage accuracy are recommended to be carried out in natural settings. In conclusion, Swedish ED triage is permeated by diversity, both in its organisation and in its performance. The reasons for these variations are not well understood.
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| 4. |
- Odencrants, Sigrid, 1955-
(författare)
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The complexity of nutritional status for persons with chronic obstructive pulmonary disease : a nursing challenge
- 2008
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Chronic obstructive pulmonary disease (COPD) is one of the most widespread diseases globally. A commonly reported symptom is impaired nutritional status, which is often discussed in the literature as difficult to assess. Because nurses play a key role in the care of patients with COPD, knowledge needs to be supplemented with clinically relevant methods that can be used for identification of nutritional needs. The overall aim of this thesis is to investigate factors associated with the nutritional status of persons with COPD and to describe the assessment of nutritional status in different settings and for persons of varying ages. Both qualitative and quantitative methods were used. Two studies with descriptive and exploratory designs (I, II) and two studies with comparative (III), and correlational design (IV). In three of the studies participants were persons with COPD (I, III, IV), whereas one involved registered nurses (RNs). Qualitative data were collected using diaries (I), vignettes (II) and interviews (I, II) and analyzed using qualitative content analysis. Data collection (III, IV) included body size and body composition measurements, assessment of nutritional status using the Mini Nutritional Assessment (MNA), the Malnutrition Universal Screening Tool (MUST), the Evaluation of Nutritional Status (ENS), and lung function measurements. These were analyzed using statistical methods. The main findings from the interviews with 13 respondents in PHC in study I showed that eating difficulties alone do not cause reduced nutritional intake for persons with COPD. Eating is only one aspect in a chain of meal-related situations that involve additional physiological and psychological demands. Assessment of nutritional status, performed by 19 RNs, consisted mainly of single observations. For a half of the RNs it was more important to establish trustful relationships with patients than to give nutritional information, while the other RNs had different opinions on when it was best to provide nutritional information and assess nutritional status. Study III findings showed poor nutritional status for nearly half of the 50 older participants. Many who were identified as malnourished lived alone and were dependent on daily community services. Six out of the 81 participants in Study IV were similarly identified as malnourished by each of the three instruments (MNA, MUST and ENS). There was a significant correlation between each of the instruments and body composition, assessed as fat-free mass index (FFMI). The MNA Short Form (MNA-SF) incorrectly identified thirteen participants’ nutritional status as not needing attention for their nutritional status. To be evaluated as ‘in need of qualified help with nutrition’ by the ENS the respondents needed to be identified as malnourished by the MNA. A general conclusion is that nutritional status is complex for persons with COPD and is difficult to measure by currently recommended methods. Individuals’ experiences are important to elicit because some of their experiences, in combination with RNs’ judgement, might serve as a hindrance for nursing care and delay the sharing of important information. The methods currently recommended for identification of nutritional status should be used with caution, and assessment should not depend on one single method. The findings from this thesis can contribute to early accurate identification of nutritional status and prompt interventions that have importance for an improved disease trajectory and better quality of life for individuals with COPD.
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| 5. |
- Mårtensson, Gunilla
(författare)
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The Insider and Outsider Perspective : Clinical importance of agreement between patients and nurses in cancer care concerning patients’ emotional distress, coping resources and quality of life
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: It is a well-known phenomenon that nurses and other oncology staff have a tendency to ascribe patients with cancer more problems and suffering than the patients themselves report. Aim: The overall aim of the present thesis was therefore to gain increased knowledge and understanding of dis/agreement between patients with cancer and nurses regarding their perception of patients’ situation and of the importance of patient-nurse dis/agreement in clinical practice. Methods: A prospective comparative design was used. Data were collected from a sample of 90 consecutively recruited patient-nurse pairs. Each pair consisted of a patient with cancer, newly admitted to a ward, and a nurse responsible for that patient’s care. Data were collected from the pairs with corresponding self-administrated questionnaires on two occasions: directly after the admission interview and on the patient’s third day on the ward. Results: At the group level, a distinct pattern was shown in which nurses ascribed the patients more emotional distress, less coping resources and a lower quality of life than the patients themselves reported. In short, the results revealed the following clinical importance of patient-nurse dis/agreement. With respect to how nurses act in relation to their perceptions of patients’ emotional distress, patient-nurse dis/agreement did not seem to be important; with few exceptions, nurses’ implemented care did not differ when it was directed at more as compared to less distressed patients. Further, nurses’ general tendency to overestimate cancer patients’ problems and suffering had no influence on patients’ satisfaction with received care and nurses’ satisfaction with provided care. However, patients cared for by nurses who underestimated their level of depression were less satisfied with those nurses’ care. In addition, the more frequently the nurse had implemented care characterized by a trusting relationship, the higher patients’ and nurses’ satisfaction with received/provided care. Conclusions: Initial patient-nurse dis/agreement concerning patients’ situation appears to be of little significance to nurses’ caring behaviour and to patients’ and nurses’ subsequent evaluation of received and provided care.
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