Aims and objectives: To describe facilitators and barriers from a patient perspective in communications between patients with obstructive sleep apnoea syndrome and healthcare personnel during the first meeting when continuous positive airway pressure is initiated.

Background: Adherence to continuous positive airway pressure treatment tends to be poor, especially at the initial phase of treatment. Communication between the patient and healthcare personnel has not been studied from the patient perspective, as either a barrier or facilitator for adherence.

Methods: A descriptive design using qualitative content analysis was used. Interviews with 25 patients with obstructive sleep apnoea syndrome took place after their initial visit at four continuous positive airway pressure clinics. A deductive analysis based on The 4 Habits Model (i.e. emphasise the importance of investing in the beginning of the consultation, elicit the patient's perspective, demonstrate empathy and invest in the end of the consultation) was conducted.

Results: Building confidence (i.e. structure building, information transfer, commitment) or hindering confidence (i.e. organisational insufficiency, stress behaviour, interaction deficit) was associated with investing in the beginning. Motivating (i.e. situational insight, knowledge transfer, practical training) or demotivating (i.e. expectations, dominance and power asymmetry, barriers) was associated with eliciting the patient's perspective. Building hope (i.e. awareness, sensitivity, demonstration of understanding) or hindering hope (i.e. unprepared, uncommitted, incomprehension) was associated with showing empathy. Agreement (i.e. confirmation, responsibilities, comprehensive information) or disagreement (i.e. structural obscurity, irresponsibility, absent-mindedness) was associated with investing in the end.

Conclusions: Understanding of facilitators and barriers, as described by patients, can be used to improve contextual conditions and communication skills among healthcare personnel.

Relevance to clinical practice: A patient-centred communication technique should be used in relation to all stages of The 4 Habits Model to facilitate shared decision-making and improve adherence to continuous positive airway pressure treatment.

Adherence to continuous positive airway pressure (CPAP) treatment tends to be low. Brief validated instruments focusing on shared decision making have not been used in a CPAP context. The aim was to investigate factorial structure, categorical functioning of the response scale and differential item functioning across sub-populations of the CollaboRATE and Sure questionnaires among patients with obstructive sleep apnea (OSA) before CPAP treatment is initiated. A prospective design, including 193 objectively diagnosed (polygraphy) OSA patients (68% men, 59.7 years, SD 11.5) from two CPAP clinics was used. Data were collected with the following questionnaires; Sure, CollaboRATE, Attitudes to CPAP Inventory, Epworth sleepiness scale, minimal insomnia symptoms scale, and hospital anxiety and depression scale. Objective CPAP use was collected after 6 months; 49% demonstrated decisional conflict on SURE and 51% scored low levels of shared decision making on CollaboRATE. Unidimensionality was found for both CollaboRATE (one factor explaining 57.4%) and SURE (one factor explaining 53.7%), as well as local independence. Differential item functioning showed both to be invariant across both male and female patients. Internal consistency (Cronbach's alpha 0.83) and composite reliability (0.89) were good. Latent class analyses showed that patients with low decisional conflict and high shared decision making were more adherent to CPAP treatment. CollaboRATE and SURE provided good validity and reliability scores to measure shared decision making and decisional conflict in relation to CPAP treatment. The questionnaires can be used by healthcare personnel as a tool to simplify the assessment of shared decision making.

Sweden has a long tradition of organized national population-based screening programmes. Participation rates differ between programmes and regions, being relatively high in some groups, but lower in others. To ensure an equity perspective on screening, it is desirable that individuals make an informed decision based on knowledge rather than ignorance, misconceptions, or fear. Decision Aids (DAs) are set to deliver information about different healthcare options and help individuals to visualize the values associated with each available option. DAs are not intended to guide individuals to choose one option over another. The advantage of an individual Decision Aid (iDA) is that individuals gain knowledge about cancer and screening by accessing one webpage with the possibility to communicate with health professionals and thereafter make their decision regarding participation. The objective is therefore to develop, implement and evaluate a digital iDA for individuals invited to cancer screening in Sweden. Methods This study encompasses a process-, implementation-, and outcome evaluation. Multiple methods will be applied including focus group discussions, individual interviews and the usage of the think aloud technique and self-reported questionnaire data. The project is based on The International Patient Decision Aid Standards (IPDAS) framework and the proposed model development process for DAs. Individuals aged 23 74, including women (the cervical-, breast-and CRC screening module) and men (the CRC screening module), will be included in the developmental process. Efforts will be made to recruit participants with selfreported physical and mental limitations, individuals without a permanent residence and ethnic minorities. Discussion To the best of our knowledge, the present study is the first attempt aimed at developing an iDA for use in the Swedish context. The iDA is intended to facilitate shared decision making about participation in screening. Furthermore, the iDA is expected to increase knowledge and raise awareness about cancer and cancer screening.

The overall aim of the project was to investigate how decision-making is expressed by experienced nurses in practice. A research questions were to describe how nurses make decisions of measures in practice and another research question were to explore contextual elements related to decision-making in nursing practice.

A problem-solving-model could be used by the nurse to systematize tasks in which she is responsible. Specific competence is required when nurses act from such a model, when it comes to ability to manage information and to make clinical assessments, necessary claims for decision-making on measures.

The theoretical starting point draws on naturalistic decision theory, which is based within a phenomenological perspective. One of the assumptions herein is that actions from experienced nurses are based in intuition and not in rationalistic and analytical mental models.

Participant observations and interviews with six nurses from three differ-ent domains constituted the data. To call on the experience of the nurses, limited decision-making activities, identified from the field notes, served as a spring-board during the interviews. The data were analysed by an inductive content analysis.

The results reveal that nurses uses observation of cues, confirmation of information and acting from strategies, developed from experience, as tools in their decision-making process. Observation of cues emerged as a powerful tool, used by the nurses to as soon as possible get to know the patient. When the nurses used confirmation as a tool, they used it to vali-date their interpretation of noticed cues and to choose appropriate meas-ures. From their experience the nurses had developed strategies which they used to be able to act independently when to choose measures. An-other finding highlighted important environmental elements, such as dis-ruption and procedures the nurse has to do as a part of her professional function, affecting the decision-making process.

Background: Communication in health care is sometimes problematic because of the participants' asymmetrical positions when negotiating the patients' future care. When decisions are made about stroke survivors' care treatment they should be involved despite communicative disabilities.

Method: In a total of five hours recorded talk, data from care-planning meetings with elderly persons surviving stroke, has been transcribed and analyzed. To identify how the actors agreed upon decisions about care efforts after discharge, an inductive analyzing approach was used through the procedure of coding and categorization. By looking for patterns the two approaches emerged.

Findings: Two distinctive approaches appeared in the communicative process, the open-minded and the aimdriven. The open-minded was characterized by questioning, merging information discussing alternative solutions leading to a goal step by step. The other communicative approach appeared to be aim-driven and was characterized by alliances between some of the participants. When the participants were involved in communicative alliances, they seemed to share a predetermined common goal for the patient's further care after discharge. The most significant alliance involved the patient together with relatives. The most noteworthy finding is that of the patient's need for communicative alliances with other participants when negotiating their needs and desires of further care. It was shown the stroke survivors are able to express their life world perspective when they are in alliances with relatives or healthcare professionals.

The overall aim of this thesis is to understand the conditions and prerequisites of nurses’ decision making on nursing measures and their communication in multiparty talk, activities nurses manage in their work. By analysing both environmental elements in nursing practice and how experienced nurses manage decision-making processes, the intention has been to understand how nurses’ competence occurs and is expressed in nursing practice. A specific problem concerns the attention given to the patients’ right to participate in co-operative care planning meetings when decisions are made about their further care and how the conditions for patient involvement and influence become visible in multiparty talk.

In the theoretical framework, it is argued that competence generally speaking concerns the individual’s potential capacity for action in relation to a certain task, situation and context. The expectations as regards nursing competence at work are expressed in work regulations and recommendations; however, the content of nursing education and practice constitutes powerful institutional frames, influencing how nurses are able to perform their tasks. The individual’s cognitive ability, the context-specific and collaborative knowledge, can be seen as additionally elements of nursing competence.

The thesis is based on two different datasets which have generated four sub-studies. Studies I and II focus on the nurses’ decision-making process and the influence of the simultaneous presence of environmental elements. The empirical data consist of 30 hours of participant observation and inter-views with 6 experienced nurses at three different wards. Studies III and IV concern nurses involve-ment in a dynamic communicative process with co-workers, patients and, at times, their relatives including data from audio-recordings of 14 co-operative care planning sessions concerning stroke survivors.

Throughout the four studies, a gap is visible between nurses’ decision making and communication in practice and the expectations of how nurses should manage these activities related to work regulations and the goals formulated in the nursing educational programs. How nurses make their decisions depends on their competence, the complexity of the task and how much they involve themselves in talk with others. The medical perspective dominates when nurses give priority to what should and can be done in nursing activities. As regards patients’ participation in co-operative care planning meetings, the professionals dominate the discourse space. The nurses never openly invited the patients to elicit their own perspective of their illness or care planning. The nurses mostly suggest-ed opinions or asked the patients to confirm these opinions. There is, however a hidden power agenda when patients and relatives try to reach a desired decision. The same phenomenon may occur when patients are in alliances with health care professionals. The above-mentioned issues are discussed in the light of nursing competence and the need for nurses to discuss what it means to be a nurse in relation to institutional frames of power relationships. If the official regulations and recommendations are to be satisfied, there is an urgent need for increased collaboration between nurses, the health care system and the nursing education programs.

Introduction: Stroke survivors often have communicative disabilities. They should, however, be involved when decisions are made about their care treatment.

Aim: To explore and describe how nurses act as moderators of the communication in cooperative care-planning meetings and what kind of participant status the patients achieve in this type of multi-party talk.

Method: Thirteen care-planning meetings were audio-recorded and transcribed. Nurses, social workers and stroke survivors were the main participants for the meetings. A coding scheme was created and three main categories were used for the analysis: pure utterance types, expert comments (EC) and asymmetries. Results The nurses never invited the patients to tell their own versions without possible influence from them. Mostly the nurses gave ECs. The nurses acted as the patients' advocates by talking for or about them. They rarely supported the patients' utterances.

Conclusion: There is an urgent need for nurses to learn how to involve the patients in the communicative process about their treatment. Assessment of the patients' communicative abilities before the care-planning meetings as well as knowledge about how to invite them can improve the patients' participant status.

Aims and objectives. This study will illustrate how stroke survivors, their relatives and different professionals communicated in care-planning meetings when planning care for patients after their discharge from hospital. We wanted to know what topics participants were talking about, to what extent they were involved in the discussion and how the communication was organized.

Background. Communication in health care is sometimes problematic because of the participants’ asymmetrical positions when negotiating how to understand the patients’ future care.

Methods. A qualitative and a quantitative design were adopted with a sample of 14 authentic audio-recorded care-planning meetings. The transcribed meetings were, together with observational notes, analysed from a data-driven approach.

Findings. Five topics emerged. The professionals tended to dominate the discourse space even if their involvement varied depending on the topic talked about. The most noteworthy finding was the patients’ need of communicative alliances with other participants when negotiating their needs and desires of further care. When making decisions two approaches emerged. The ‘aim-driven’ approach was characterized by alliances between those participants who seemed to share a common goal for the patient’s further care. When the participants used the ‘open-minded’ approach they merged information and discussed different solutions leading to a goal step by step.

Conclusions. The importance of strengthening stroke survivors’ participation in care-planning meetings is highlighted. Professionals have to increase their knowledge about how to involve the patients as well as their awareness of how to avoid power struggles between various professionals, patients and relatives.

BACKGROUND: In their practice nurses constantly make decisions in a dynamic context including complex situations. Besides affecting elements related to the decision-maker and the task itself, the setting where the decision-making process takes place are of decisive importance to the quality of the decision-making outcome.

AIM: The aim of this study was to explore environmental elements related to the decision-making process in nursing practice.

METHODS: Six expert nurses, from three Swedish nursing settings, participated voluntarily in the study, which were designed of participated observations in everyday nursing practice. Permission to carry out the study was given by the clinics and an ethical committee. A content analysis was used to analyse the field notes where themes emerged which were found to be environmental elements affecting decision-making process of nurses.

CONCLUSIONS: The most striking theme, environmental elements, included the sub-themes interruptions and the work procedures are presented in this report. The implications of environmental elements, are discussed from a perspective of nurses' competence, where the elements could be seen as a facilitator or as a hindrance to developing nursing competence. It were concluded that environmental elements have to be well considered before knowledge can be reached about decision-making in practice.

RELEVANCE TO CLINICAL PRACTICE: Interpersonal and technological interruptions were features highlighted in the study, features which could jeopardize the decision-making outcome. Therefore, it is of greatest importance that nurses learn to use decision-making strategies to guarantee patient care security and patient care quality.

Background: Atrial fibrillation (AF) is a highly prevalent arrhythmia. Effective communication of risks (e.g., risk for stroke) and benefits to patients (e.g., treatment with oral anticoagulants) is crucial for shared decision making. Knowledge about how patients experience confidence and satisfaction in communication in relation to their health status is limited.

Aim: The aim was to explore factors associated with involvement in risk communication and confidence in shared decision making among patients with AF.

Method: A cross-sectional design was used and 322 patients (39 % women), mean age 67 years (SD 10.3 years) with AF were included at four hospitals in Sweden. Clinical examinations and self-rating scales for risk communication (COMRADE), uncertainty in illness (MUIS-C), depressive symptoms (HADS), mastery of daily life (MDL), as well as physical and mental health (SF-36) were used to collect data after a follow-up visit at the outpatient clinic 3 months post an AF episode.

Results: Paroxysmal, persistent and permanent AF occurred among 32%, 34% and 7% of the patients, respectively. Patients whom had undergone DC-conversion (53%) and had anticoagulants (37%). Seven percent had been treated by a percutan ablation. Heart failure (15%) and ischemic heart disease (12%) were the most common co-morbidities. CHA2DS2-VASc >2 were seen among 62% of the patients. Overall, multiple regression analyses showed that uncertainty in illness and mastery of daily life were significantly associated with confidence in decisions and uncertainty in illness and hypertension were significantly associated with satisfaction in communication. Higher uncertainty in illness and poorer mastery of daily life were associated with poor confidence in decisions. Higher uncertainty in illness and occurrence of hypertension were associated with poor satisfaction in communication. Clinical AF variables (i.e.,symptom or treatment related) or depressive symptoms were not significantly associated with satisfaction in communication or confidence in decisions in the multiple regression analysis. The final models explained 29% and 30% of the variance in confidence in decision making and satisfaction in communication.

Conclusion: In this cross-sectional study, including patients with AF, confidence in decision making and satisfaction in communication are associated with uncertainty in illness, mastery of daily life and hypertension.

Background:

Atrial fibrillation is a prevalent cardiac arrhythmia. Effective communication of risks (e.g. stroke risk) and benefits of treatment (e.g. oral anticoagulants) is crucial for the process of shared decision making.

Aim:

The aim of this study was to explore factors associated with confidence in decision making and satisfaction with risk communication after a follow-up visit among patients who three months earlier had visited an emergency room for atrial fibrillation related symptoms.

Methods:

A cross-sectional design was used and 322 patients (34% women), mean age 66.1 years (SD 10.5 years) with atrial fibrillation were included in the south of Sweden. Clinical examinations were done post an atrial fibrillation episode. Self-rating scales for communication (Combined Outcome Measure for Risk Communication and Treatment Decision Making Effectiveness), uncertainty in illness (Mishel Uncertainty in Illness Scale–Community), mastery of daily life (Mastery Scale), depressive symptoms (Hospital Anxiety and Depression Scale) and vitality, physical health and mental health (36-item Short Form Health Survey) were used to collect data.

Results:

Decreased vitality and mastery of daily life, as well as increased uncertainty in illness, were independently associated with lower confidence in decision making. Absence of hypertension and increased uncertainty in illness were independently associated with lower satisfaction with risk communication. Clinical atrial fibrillation variables or depressive symptoms were not associated with satisfaction with confidence in decision making or satisfaction with risk communication. The final models explained 29.1% and 29.5% of the variance in confidence in decision making and satisfaction with risk communication.

Conclusion:

Confidence in decision making is associated with decreased vitality and mastery of daily life, as well as increased uncertainty in illness, while absence of hypertension and increased uncertainty in illness are associated with risk communication satisfaction.

Children and adolescents receiving services from two professional parties may obtain support with a coordinated individual plan (CIP). The Swedish law prescribes that CIP must incorporate service user participation. This study aims to explore children and parents’ experiences of participating in CIP-process to generate knowledge with practical implications of how children and parents may be involved in the CIP-process. A descriptive qualitative interview study with 13 service users was conducted during November 2014 to March 2016. Data were audio-recorded and transcribed, and further subjected to qualitative content analysis. Three main descriptive categories with six subcategories emerged. The category “Struggle for coordination” includes service users’ need for participation which are limited by professionals’ lack of consensus. The category “Alliance for coordination” points out the importance of relationship and personal support to accomplish functional coordination. The category “Structure for coordination” shows how the structure facilitate service user involvement on a high level. Service user involvement seemed limited by professionals’ actions, but could be facilitated by support of professionals working in the child’s daily life. Structured coordination seems to relieve the pressure on parents, as well as children, but CIP needs to be individually tailored to reach its full potential.

Syftet var att utvärdera samverkan i vårdkedjan genom att belysa om Esther får vård i eller nära hemmet, får lika vård på hela Höglandet, upplever vården och omsorgen som en vårdgivare, har en individuell vårdplan och vet vart hon/han ska vända sig.

Kvantitativ data avseende åldersfördelning, vårdnivå, vårdtillfällen, medelvårdtid, väntetid på akutmottagningen, medicinklinikens rådgivande koordinatorsfunktion och ”Medicin direkt” samt avvikelserapportering har insamlats från befintlig statistik från Höglandets sjukvårdsvårdsområde. Kvalitativ data har insamlats genom fokusgruppsintervjuer med 29 äldre personer > 65 år och 21 vård- och omsorgspersonal inom Höglandets sjukvårdsområde.

Statistiken visar att antalet inskrivna individer i hemsjukvården har ökat, primärvårdsbesöken likaså och antalet läkarbesök i patientens bostad/motsvarande har i det närmaste fördubblats. På motsvarande sätt visar statistiken att antalet inläggningar, medelvårdtid samt återinläggningar har minskat. För åldersgruppen 80 år och äldre har antal besök på kirurgisk mottagning ökat medan besöken på medicinsk mottagning har minskat. I samma åldersgrupp visar statistiken att medelväntetiden på kirurgkliniken respektive medicinkliniken har ökat med 52 respektive 53 minuter. Rådgivningar via medicinklinikens koordinator har ökat samtidigt som överföringen av patienten till akutmottagningen vid Höglandsjukhuset också har ökat.

Resultatet från den kvalitativa analysen visar att Esther känner sig trygg när hon/han behöver hjälp och stöd av vårdgivaren. För ”Esther som individ” innebär samverkan i vårdkedjan tillgänglighet, kontinuitet och aktivitet men också delaktighet, integritet och trygghet. Sitt beroende av andra hanterar Esther genom att använda strategier som eget ansvar, anpassning, acceptans och passivisering. För personalen utgör ramar och villkor som omger deras arbete i relation till Esthers behov av vård och omsorg, faktorer som påverkar samverkan i vårdkedjan.

Slutsatsen är att grundtanken i Esther nätverk finns förankrad i vårdkedjan. Personalens gemensamma synsätt avspeglas i att Esther i hög grad är nöjd med den vård och omsorg hon får och att hon känner sig trygg med den. Trygghet är grundläggande för Esther och innebär kontinuitet, tillgänglighet och att få en individ- och behovsanpassad vård och omsorg genom hela vårdkedjan. Inom ramen för samverkan är detta områden som skulle kunna förbättras ytterligare.

The aim of the study was to describe how nurses make decisions on measures in clinical practice. The data-collection method consisted of audio-taped interviews with six nurses. The interviews were then transcribed verbatim. The questions in the interviews were based on nursing situations observed earlier when the nurses initiated and implemented patient-related measures and the focus was on the nurses' experience of decision making. A content analysis was performed. The results show that the nurses' decisions on measures were based on three themes: observation of cues related to the patient's situation, confirmation of information gathered and implementation of action strategies. The results are discussed in relation to earlier empirical research on decision-making activities in the nurse's clinical practice and the nurse's utilization of knowledge during the decision-making process. It is concluded that the nurse's awareness of the patient's situation, together with a well-founded basis for decisions, can have positive effects on the nursing care provided by the nurse.

In Sweden the health system is nationally regulated and locally provided by 21 regions and 290 municipalities. To meet the shifting paradigm, where the person is viewed as a co-producer of health and care, Sweden has laws, regulations and policies which support the patient as an active partner in the communication with professionals in the system. Coproduction, person-centred care and shared decision making contribute jointly to the paradigm shift. Principles of human dignity and equity must be supported nationally and enacted in the decentralized, regional provision of care. Infrastructures exist or are under development which can support and strengthen care that is co-produced and based in a person-centred philosophy and approach, where shared decision making becomes a reality in practice. A Knowledge management system together with National Quality registries have the potential to form a co-produced, person-centred learning health system, where patients, and next of kin and professionals are included as partners. The joint integration of Shared decision making, Person-centre care and Coproduction into the Swedish healthcare system now looks like a possible way to realize the emerging paradigm.

Background: The supervision process is characterized by differences between the supervisors’ and the students’ expectations before the start of writing a bachelor thesis as well as after its completion. A review of the literature did not reveal any scientifically tested questionnaire for evaluating nursing students’ expectations of the supervision process when writing a bachelor thesis.

Objectives: The aim of the study was to determine the construct validity and internal consistency reliability of a questionnaire for measuring nursing students’ expectations of the bachelor thesis supervision process.

Design & Methods: The study had a developmental and methodological design carried out in four steps including construct validity and internal consistency reliability statistical procedures: construction of the items, assessment of face validity, data collection and data analysis.

Settings & Participants: This study was conducted at a university in southern Sweden, where students on the “Nursing student thesis, 15 ECTS” course were consecutively selected for participation. Of the 512 questionnaires distributed, 327 were returned, a response rate of 64%.

Results: Five factors with a total variance of 74% and good communalities, ≥0.64, were extracted from the 10-item STQ. The internal consistency of the 10 items was 0.68. The five factors were labelled: The nature of the supervision process, The supervisor's role as a coach, The students’ progression to self-support, The interaction between students and supervisor and supervisor competence.

Conclusions: A didactic, useful and secure questionnaire measuring nursing students’ expectations of the bachelor thesis supervision process based on three main forms of supervision was created.

The aim of this study was to explore child health care nurses’ experiences of conducting health dialogues with non-native-speaking parents. In Sweden, it is not routine that all non-native-speaking parents are invited to a health dialogue. Regardless of language and cultural background, it is important that all parents have the same opportunities to participate. The data were obtained through two focus-group interviews and analysed using qualitative content analysis. The results revealed one theme Need for cultural awareness in the health dialogue and two categories: Overcoming feelings of uncertainty, with a need for more transcultural knowledge regarding what health and health promotion mean in other cultures; and Adapting the process of the health dialogue, whereby interpreters need knowledge about the intention of health dialogues and the content of the tool used in the encounter. Transcultural competence is needed in encounters with parents from other cultures.

Purpose: To explore and describe what physiotherapists experience they need to know about patients with non-specific low back pain (NSLBP) to make decisions about intervention.

Method: Four focus groups containing a total of 21 physiotherapists were carried out in Sweden. Interviews were transcribed and qualitative content analysis performed. The manifest content was coded and categorised, and a theme emerged. Extracted symptoms and signs were linked to ICF codes.

Result: Physiotherapists’ clinical reasoning represented a broad view on low back pain (LBP) including codes from all ICF components. The participants argued for individualisation of intervention to a specific patient’s problems. A theme of case complexity emerged, involving three levels: easy case, characterised by impairment in body function with close relation to specific body structures; complex case, characterised by impairments in body function, particular mental functions, activity limitations and participation restrictions, particular management of activity level and very complex case, characterised by impairments in body function, activity limitations and participation restrictions, and contextual factors, with help-seeking behaviour as a particular feature.

Conclusion: The physiotherapists’ clinical reasoning reflected a broad view on patients with NSLBP, with variations related to case complexity. The use of ICF codes contributed to understanding that the physiotherapists applied a broad perspective on NSLBP as a health condition as well as to knowledge about how physiotherapists’ understand patients with NSLBP.

Physiotherapists’ use of the ICF in clinical practice might facilitate identification and assessment of specific patient’s back pain problem as they occur in daily life and therefore be helpful in rehabilitation planning. Findings might also have an educational value.

Purpose: To investigate how physiotherapists talk about the choice of intervention for patients with NSLBP, particularly how professionals manage clinical encounters that may be experienced as challenging.

Method: Discourse analysis was performed of four focus groups’ talk. Twenty-one experienced physiotherapists working in primary health care in southern Sweden participated.

Results: Four focal themes appeared: Responsibility for health and health-related problems; Normalization – what counts as a normal back pain problem in relation to living an ordinary life; Change process – how to lead one’s life; and Individualization of the intervention in relation to the individual patient but also from the physiotherapists’ point of view. The themes shape an over-arching pattern of Problem-solving – which concerned both the professional task and the back pain problem, and was related to varying case complexity. This may have implications for the intervention the individual patient will be offered and on outcome.

Conclusions: Physiotherapists’ attitudes and approaches seem to entail components of professional and personal values which may influence patients’ access to health care, with a risk for unequal assessment and intervention as a consequence. We argue that enhanced physiotherapist-patient collaboration, including patient-led problem-investigation, is a prerequisite for improved outcome in terms of patient satisfaction, and for physiotherapy development. Future investigations of patients’ roles in specific face-to-face encounters are needed.

Background. Today health and social care delivery are largely team based but the question remains whether the voice of the user is perceived as a team member or merely as the recipient of the care. There have however been few efforts to understand or change the smallest interprofessional frontline units who generate the actual service, i.e. the microsystems.

Purpose. This paper presents preliminary findings regarding descriptions of constructions of user participation in a multiparty negotiation context.

Materials and methods. The material consisted of ethnographic field notes and audiotapes from observations (n=8) of interprofessional team meetings in one clinical healthcare microsystem. The teams included the user and health professionals, e.g. medical social worker, physician and psychologist. The users who participated in the observed team meetings had all long-term mainly physical conditions.

Findings and discussion. Preliminary inductive analyses of observations of interprofessional team situations involving users indicates identity constructions in multiparty talk where the user is beheld primarily as a loyal and active member of the team. Discussions will relate to how user participation is learned and constructed by users and health professionals in collaborative care at the microsystem level.

Summary: This article reports on an empirical research study exploring and describing variations in how front-line practitioners perceive service user participation (SUP), specifically in interprofessional practice. The settings comprised three Swedish health and social care organizations where the professionals worked in interprofessional teams: a program for chronic pain rehabilitation, a program for surgical treatment of obesity, and a short-term municipal home for older adults. The qualitative study design was informed by a phenomenographic approach and conducted as semi-structured individual interviews with 15 professionals representing nine professions, including social work.

Findings: The main findings show seven qualitative variations in understanding of SUP: 1) inclusion in activities and social events, 2) obtaining guidance, 3) having self-determination and choice, 4) getting confirmation from and contact with professionals, 5) negotiating for adjustment, 6) personal responsibility through insight, and 7) circumstance surrounding SUP.

Applications: The interprofessional dimensions discerned in the meaning attributed to SUP are mainly described in terms of amplified opportunities for participation. An interesting aspect of the findings is that in all the variations of perceptions of SUP, there are potentials to reverse to their opposites, that is, paradoxes that can be termed ‘the dual faces of service user participation’. These aspects stress the need for continuing reflection on practices among both front-line practitioners and managers in empowering and paternalistic processes and on constantly improving organizational and policy conditions to facilitate SUP.

This paper reports on empirical research exploring and describing the variations in service users' conceptions of service user participation (SUP), specifically in interprofessional practice. The social work practices in which front line workers were using interprofessional teamwork were explored at three Swedish welfare institutions. Service users included individuals with chronic pain disorders, obesity conditions or in need of short-term placement in elder care facilities. The qualitative study design was informed by a phenomenographical approach and conducted as semi-structured individual interviews with twenty-two service users. The main findings suggest five qualitative variations of service user's conceptions of SUP: (i) information transmission; (ii) choices and decisions among resources; (iii) comfortable relationship and communication; (iv) interaction for increased understanding; and (v) conditions for service user participation. The findings highlight the importance for the interprofessional team of social workers and other professionals to recognise the various ways of experiencing SUP by service users. The findings thereby support the possibilities to understand and to take into consideration the individual service user's conceptions of SUP in interprofessional practice.

Objective: Health education programs using group learning sessions for patients with long-term conditions have been tested, but not evaluated. In order to evaluate such sessions, the purpose was to explore experiences from patients with long-term conditions after participating in group learning sessions.

Methods: A descriptive design based on qualitative content analysis was used. Interviews were conducted with 19 patients with different long-term conditions, and participants were asked about their experiences after taking part in the group learning sessions.

Results: Sharing experiences with one another gave them opportunities for learning. Patients described a metaphorical "expanded window," which opens in the group learning sessions; comparable to encounters during regular visits to health care providers. The nature of the learning environment that follows the educational model, together with describing lived experiences, allowed patients to share capability and resources, which was found to be foundational.

Conclusions: The health education program as a format was important for shared learning. The facilitator can support the learning by structuring the format, but most essential was sharing experiences that facilitated each patient's learning that can aid the support of individual self-management.

BACKGROUND: Supervisors play a key part as role models and supporting the learning during residents' post-graduate medical education, but sometimes lack sufficient pedagogic training and are challenged by high demands in today's healthcare. The aim of this study was to describe the strengths and areas for improvement identified in the supervision process by residents and supervisors in post-graduate medical education.

METHODS: This study included supervisors and residents working at departments and health centres who have used a web-based questionnaire, as a part of the Evaluation and Feedback For Effective Clinical Teaching (EFFECT) model, during the period 2016-2019. Descriptive statistics and content analysis were used to analyse ratings and comments to describe strengths and areas for improvement in the supervision process.

RESULTS: The study included 287 resident evaluations of supervisors and 78 self-evaluations by supervisors. The supervisor as a role model, being available, and, giving personal support, were the three most important strengths identified by the residents and supervisors. Residents in primary care also identified the role modelling of general practice competence as a strength, whereas residents and supervisors in hospital departments addressed supervisors as energetic and showing work was fun. The area with the need of most improvement was, Giving and receiving feedback.

CONCLUSIONS: To be able to give feedback, residents and supervisors, needed to see each other in work, and the learning environment had to offer time and space to pedagogical processes, like feedback, to improve the learning environment.

Background Young adults increasingly seek help for mental health problems. In 2016, a district psychiatric centre in Norway started a brief treatment program to provide early and effective help for moderate depression and anxiety. Aim Exploring patients' and therapists' experiences of brief therapy, especially how the time limitation influences the treatment process. Methods Individual interviews with 12 patients and focus group interviews with eight therapists analyzed using systematic text condensation. Results The results constitute five themes: (1) Time-limit as a frame for targeted change, (2) Clarifying expectations and accountability, (3) Shared agreement on a defined treatment-project, (4) Providing tools instead of searching for causes, and (5) Learning to cope-not being cured. Conclusion Time-limitation in brief therapy appeared to play a positive role, helping the therapists to structure the therapeutic process and strengthening patients' motivation. Shared understanding and activation during brief therapy may reinforce patients' responsibility and expectations to achieve individual goals. Brief therapy can be viewed as the start of a personal process towards "mastering life as it is". More research is needed to investigate the patients' long-term outcomes after treatment and to shed light on the potential for, and limitations of, mastering everyday-life.

Purpose - The purpose of this paper is to understand how organisational culture influences the intentions of primary care staff members (PCSM) to engage in research and development (R&D).

Design/methodology/approach - The participants (n = 30) were PCSM employed in a care centre in south-western Sweden. The study had an observational design with an ethnographic approach. The data were collected by means of observations, interviews and analysis of documents.

Findings - The results revealed the perceptions of PCSM in two domains, research and clinical practice, both of which existed at three different cultural levels: visible (structures and policy), semivisible (norms and values) and invisible (taken-for-granted attitudes).

Research limitations/implications - It is difficult to conduct a purely objective ethnographic study because the investigation is controlled by its context. However, it is necessary to highlight and discuss the invisible level to improve understanding of negative attitudes and preconceptions related to the implementation of R&D in the clinical setting.

Practical implications - By highlighting the invisible level of culture, the management of an organisation has the opportunity to initiate discussion of issues related to concealed norms and values as well as attitudes towards new thinking and change in the primary health context.

Originality/value - This paper is one of the very few studies to investigate the influence of organisational culture on the intentions of PCSM to engage in R&D.

Purpose: To illuminate user experiences of schizophrenia, reasons for receiving antipsychotic medication, and encounters with mental health services.

Design and Methods: 24 semistructured qualitative research interviews with schizophrenia patients treated with 3-monthly paliperidone palmitate across Scandinavia were synthesized in qualitative content analysis.

Findings: Participants describe considerable challenges in everyday functioning. Simultaneously, they rate their current mental and physical well-being high and seem satisfied with their lives. These pathways indicate personal recovery.

Practice Implications: The participants emphasize the importance of trustful relations with healthcare professionals, therapeutic conversations, antipsychotic medication in a 3-monthly formulation, and support from relatives.

Agenda for collaboration or an agency agenda? Professionals’ experiences of colla­boration according to a coordinated individual plan (CIP)

An increasing number of children and adolescents develop complex needs that require simultaneous action by different professionals. Several reports state that efforts for these children and adolescents have become increasingly specialized and fragmented. Since 2010, there are statutory requirements for collaboration according to a coordinated individual plan (SIP) between health care and social services. Pre-school and school can after regional agreement be involved in the co-ordination as equal partner. Collaboration in line with CIP is expected to offset the fragmentation for benefit of the service users’ ability to monitor and comprehend interventions. The aim was to investigate professionals’ experiences of CIP. The study consists of qualitative analysis of 12 focus group interviews with a total of 71 staff with different professions in health care, education and social services about their experiences of CIP. The results indicate that the participants act according to their core mission: nurturing, teaching and investigation. Two main categories with four sub-categories each appeared in the analysis. The main category, hindering factors, contains the categories: different mandates and requirements, requirements for presence initiative, questioning and censure, and timelines and prioritization. The main category of facilitating factors contains the categories: similar interpretation of common agreement, mutual respect and shared learning, common terminology and documentation, and willingness to collaborate. The analysis indicate that CIP was perceived as alternating between, on the one hand, a pro-active and service-focused tool, and on the other hand, a competing and compelling professional instrument.

BACKGROUND AND OBJECTIVES: There is a need for improved clinical outcomes, and a useful tool in this endeavor is the use of National Quality Registries (NQRs). To learn more about the impact of NQRs, a National Collaboration Project was formed. This follow-up study had 2 aims: first, to describe the value and learning of a National Collaboration Project focusing on the use of NQRs in collaboration between universities, health care organizations, and the regional registry centers; and, second, to describe what activities are still ongoing.

METHOD: A qualitative design was used to obtain a detailed description of the extent to which project leaders perceived that the goals had been achieved after participation in the national project. A qualitative descriptive content analysis was performed.

RESULTS: Four main categories were found. The context proved to be crucial for how the local projects were formed and developed. Networking was highlighted as an important part of learning. Another mentioned part of learning was the change planned and implemented in the curriculum to promote the use of NQRs. Finally, the importance of anchoring and spreading the lessons learned was also stressed.

CONCLUSION: Using NQRs in multidisciplinary education is successful in many ways, but this study shows that certain factors need to be in place to make it work in practice.

Background:

In the procedures of surgical pathways it is important to create opportunities for developing active forms of engagement and extending the patients’ health maintenance knowledge, which is essential in nursing. One way is to understand more about the concept of coproduction.

Objective:

The purpose was to use experiences from spinal surgery patients’ narratives to explore the conceptual model of healthcare service coproduction.

Method:

A prospective qualitative explorative approach was performed and analyzed in two phases with inductive and deductive content analysis of data retrieved from five focus group interviews of 25 patients with experiences from spinal surgery interventions.

Result:

The findings indicate that mutual trust and respect, as well as guidance given in dialogue, are two important domains. An illustration of how to apply the conceptual model of healthcare service coproduction was revealed in the descriptions of the three core concepts co-planning, co-execution and civil discourse.

Conclusion:

This study highlights what is needed to reach coproduction in healthcare services concerning patients with spinal disorders. Development of care plans that focuses on co-planning and co-execution is recommended which are structured and customizable for each patient situation to make coproduction to occur.

Introduction: Interventions that support patients to handle the emotional and medical aspects of a long-term health condition is important. One way is to use peer-support groups, to help patients solving problems, increasing their knowledge and making decisions.

Aim: was to investigate the impact on shared decision-making, empowerment and coping after participation in group-learning sessions for patients with long-term conditions (N = 42).

Design: An intervention following a health education programme based on group-learning sessions was established. Eight different programmes were held in five different departments at a regional county hospital in Sweden.

Methods: Questionnaires were analysed using paired-sample t-test.

Results: Results showed that patients might have better opportunities to be more active during their patient encounter after attending the group learning sessions. Interventions directed to patient activation may be one key in future healthcare management, especially concerning long-term conditions. Empowering patients is central in healthcare, and using different approaches is important.

What does this paper contribute to the wider global clinical community? 

• Patients with long-term conditions should be encouraged to share their knowledge to others, which can give support in managing their disease
• Group-learning sessions can add a perspective of patients' lived knowledge which is one of the key aspects concerning treatment of patients with long-term conditions

Introduction

Three-monthly dosage of paliperidone palmitate entails longer time to relapse after discontinuation, is similarly tolerable and safe compared to monthly injections of paliperidone palmitate and is beneficial for the caregivers. However, few studies have so far explored in depth the patients' experiences with paliperidone palmitate medication every three months, or with switching from monthly to three-monthly injections of paliperidone palmitate.

Material and methods

A qualitative study based on individual interviews with persons with schizophrenia who receive three-monthly paliperidone palmitate in Norway, Sweden and Denmark. Data was analysed according to qualitative content analysis.

Results

Twenty-four patients, 16 men and 8 women, took part in individual interviews. The patients' mental health care professionals mainly recommended the switch to three-monthly paliperidone palmitate, and few or no disadvantages were described. According to the patients, three-monthly paliperidone palmitate had several advantages, such as less frequent injections, less administration and planning and less focus on the illness. In addition, the participants described feeling more stability, being more physically and socially active, and that improvement processes were supported. For some, the use involved practical and economic challenges, and some worried whether the medicine ?wore off? before the next injection. According to the patients, switching to three-monthly paliperidone palmitate did not influence the frequency or content of patients? interaction with health care professionals.

Conclusion

Switching from monthly to three-monthly injections with paliperidone palmitate seems to be experienced as advantageous for patients with schizophrenia.

Aim: The aim of this study was to describe nurses' experiences of a recently implemented quality register, Senior Alert, at two hospitals in Sweden.

Background: In Sweden, in recent decades, a system of national quality registries has been established in health and medical services for better outcomes for patients, professional development and a better functioning system. Senior Alert (SA) is one quality registry, aimed at preventing malnutrition, pressure ulcers and falls in elderly care.

Methods: The study comprised a total of eight interviews with nurses working with SA at the ward level. The interviews were analysed using manifest qualitative content analysis. Respect for the individuals was a main concern in the study. All persons who were asked to participate in the study consented to do so.

Results: One category 'Patient Advantages' and three subcategories 'Conscious Persevering', 'Supporting Structure' and 'Committed Leadership' were identified to describe staff experiences of implementing SA.

Conclusions: Implementation processes need to be sustainable at both staff and managerial levels. A key factor in implementing and using a quality registry in prevention care could be described as keeping the flame burning. However, further research is needed on how patient advantages could be developed using other quality registries in order to improve care from a patient perspective.

Implications for nursing management: The results of this study could help other organizations implement quality registries or other change processes, for example new guidelines and treatment. Strategies concerning organizational structure and committed leadership could increase the usefulness of knowledge systems on all levels, which could enable continuous learning and quality improvement in health care.

Aim: To describe (i) the topics participants talk about, (ii) the use of discursive space in consultations between patients with atrial fibrillation (AF) and their nurses and physicians, and (iii) the frequencies of the ways the patients, nurses and physicians introduce the topics.

Methods: Data were collected from 23 videotaped consultations concerning patients with AF as well as physicians and nurses, respectively. To obtain a description of topics discussed, the transcripts were analysed using content analysis. The patterns of dominance for the respective topic and participant were explored from the framework of analysis that treats dominance.

Results: Four topics were used by both nurses and physicians in the consultations. These were ‘pathophysiology’, ‘diagnostic procedures’, ‘treatment’ and ‘activity’. In the nurse–patient consultation an additional topic, ‘routines related to the physician’s responsibilities’, emerged. With respect to the number of words and turns, the distribution of the discourse space was almost equal between the nurses and patients and unequal between the physicians and patients. The healthcare professionals initiated the topics more frequently compared to the patients, whereby the medical approach recommended in the guidelines for AF could be recognized. The patients were the dominating initiators in the topic ‘activity’, which refers to the adaptation of activities in daily life in relation to the AF.

Conclusions: The medical-driven agenda dominates over the patient-driven agenda in consultations between healthcare professional and patients with AF. The patients initiated the conversations when discussing living with AF and were more talkative during conversations in nurse consultations.

Rationale: Atrial fibrillation (AF) increases the risk of stroke and it can be reduced by treatment with warfarin. Some patients consider that warfarin is a stressful treatment with undesired effects and the perceived barriers include unwillingness to take it. Knowledge of patients resisting warfarin treatment may be useful for the potential threat to maintaining shared decision-making in the consultation as a central tenet of person-centered medicine.

Aims and objectives: To identify how patients resist treatment with warfarin and how cardiologists respond to patients’ resistance. The co-constructive perspective of this work analyses the consultations by emphasizing the clinical communication strategies of both patients and cardiologists.

Method: Eleven videotaped consultations, in 4 different hospitals, were selected for analysis. Treatment interactions regarding warfarin between patients with AF and cardiologists were analysed, according to the methodology of conversation analysis.

Results: There were 4 types of resistance from patients for accepting treatment with warfarin. These included “Giving reasons for their resistance”, “Suggestion of another treatment option by the patient”, “Stating a treatment preference” and “Questioning or challenging the cardiologist’s treatment recommendation”. The cardiologists’ responses to the patients’ resistance included “Repeating the treatment recommendation”, “Negotiation with the patient”, “Providing additional information on the recommended treatment” and “Extending the explanation for the purpose of taking the treatment”.

Conclusions: By showing resistance, patients are thought to want to participate in their treatment decisions and an awareness of patients’ resistance to treatment enables cardiologists to address the patients’ experience-based views on their treatment and individual concerns as part of clinical strategies to increase the person-centeredness of medical intervention.

Background: Cancer has consequences not only for the sick person but also for those who have a close relationship with that person. Greater knowledge about how family members manage the situation in the period immediately following the diagnosis means greater opportunity to provide the best possible support for the family. The purpose of this study was to explore management strategies that family members use when the patient is in the early stage of treatment for advanced cancer.

Methods: Twenty family members of cancer patients were included in the study shortly after the diagnosis. The patients had been diagnosed 8-14 weeks earlier with advanced lung cancer or gastrointestinal cancer. The data were collected in interviews with family members and subjected to qualitative latent content analysis. Through the identification of similarities and dissimilarities in the units of meaning, abstraction into codes and sub-themes became possible. The sub-themes were then brought together in one overarching theme.

Results: The overall function of management strategies is expressed in the theme Striving to be prepared for the painful. The family members prepare themselves mentally for the anticipated tragedy. Family relationships become increasingly important, and family members want to spend all their time together. They try to banish thoughts of the impending death and want to live as normal a life as possible. It becomes important to family members to live in the present and save their energy for the time when they will need it the most. How participants handle their worries, anxiety and sadness can be categorized into seven sub-themes or management strategies: Making things easier in everyday life, Banishing thoughts about the approaching loss, Living in the present, Adjusting to the sick person’s situation, Distracting oneself by being with others, Shielding the family from grief, and Attempting to maintain hope.

Conclusions: The findings revealed that the family members have their own resources for handling the early stage of the cancer trajectory in an acceptable way. There is a need for longitudinal studies to generate knowledge for designing evidence-based intervention programmes that can prevent future ill-health in these vulnerable family members.

Mot bakgrund av behovet att påskynda nyanlända personers etablering på arbetsmarknaden avser rapporten bidra till att utifrån erfarenheter, kontakter med andra samt svenska publikationer, beskriva hur det växande behovet av auskultation/praktik och praktiktjänstgöringsplatser kan tillgodoses. Detta kan även och bör beröra ett flertal andra utbildningsgrupper. Rapporten avser att identifiera sätt att förbättra och effektivisera lärande och handledning. Målet är att skapa ett underlag för det fortsatta arbetet avseende professionella praktiker, lärandemiljöer och lärandemetoder. Rapporten kan dels vara ett stöd i att skapa en gemensam hållning inom landsting, regioner och kommunal hälso- och sjukvård vad gäller utbildningsområdet, dels fungera som ett underlag i den fortsatta dialogen mellan intressenterna inom området.

Rapporten innehåller tre delar; en bakgrund, ett case som används som utgångspunkt samt en avslutande del med slutsatser och rekommendationer.

I bakgrunden beskrivs den teoretiska ramen om lärande i professionella praktiker samt olika perspektiv på adepters lärande i vårdpraktiker. Synen på adepternas lärande i vården varierar beroende på vilket perspektiv som tas. Under senare decennier har antalet yrkesgrupper ökat i antal, utbildningsnivåer höjts och antalet områden med krav på specialistkompetens ökat. De professionsutbildningar som mer eller mindre har praktiska utbildningsmoment inom hälso- och sjukvård presenteras och utlandsutbildade personers specifika utbildningsbehov med hänsyn tagen till svenska regelverk och individuella omständigheter beskrivs.

Case Region Jönköpings län (RJL) beskriver hur lärandet med olika förutsättningar och stödjande funktioner kan se ut i en hälso- och sjukvårdskontext. Adepters lärande i vårdpraktiker konkretiseras och därefter beskrivs de funktioner och infrastrukturer som bidrar till förutsättningarna för deras lärande. För att skapa bra förutsättningar för adepternas lärande beskrivs därför lärandet utifrån ett systemperspektiv. Med hjälp av ett mer omfattande exempel på organisering och genomförande av utlandsutbildade, beskrivs läkares lärande inom primärvården Bra Liv där Nässjö utbildningscentrum har ett specifikt utbildningsuppdrag.

Slutsatserna och rekommendationerna är kopplade till att uppdraget är komplext och har dessutom en avsevärd tyngd då dess innebörd troligen kan få konsekvenser för hälso- och sjukvårdens framtida prioriteringar och styrning. Utbildningsuppdragen bör betraktas utifrån vårdverksamheternas perspektiv. Stöd och förutsättningar för nyckelfunktioner måste tydliggöras, i såväl mikro-, meso- och makrosystemen, Med ett transparent system kan samverkan för god och effektiv kvalitet förbättras i de olika utbildningsuppdragen, avseende professionella praktiker, lärandemiljöer, lärandemetoder och stödjande och ledande infrastrukturer.