Purpose: To investigate the possibility of constructing a multiprofessional cross-cultural measure of functioning after stroke across categories of the International Classification of Functioning, Disability and Health (ICF). Method: Data on 757 stroke survivors from China, Germany, Italy, and Sweden, including ratings of 15 categories from the Brief ICF Core Set for stroke, were analyzed using the Rasch model. Unidimensionality, reliability, fit of the ICF categories to the model, ordering of response options of the ICF qualifier, and presence of differential item functioning (DIF) were studied. Results: Of the 15 ICF categories, response options for 7 categories were collapsed, 5 categories were deleted due to misfit, and 4 ICF categories showed DIF for country and were accordingly split into country-specific categories. The proposed final clinical measure consists of 20 ICF categories (6 categories were country-common) with an overall fit statistic of χ2180 = 184.87, P = .386, and a person separation index of r = 0.72, which indicates good reliability. Based on an individual's functioning after stroke, the ratings across the different ICF categories can be summed on an interval scale ranging from 0 to 100. Conclusion: A construction of a cross-cultural clinical measure after stroke based on ICF categories across body functions, structures, and activities and participation was possible. With this kind of clinical measure, stroke survivors' functional levels can be compared even across countries. Despite the promising results, further studies are necessary to develop definitive measures based on ICF categories.

Background. In line with patient-centered health care, it is necessary to understand patients’ perceptions of health. How stroke survivors perceive their health at different time points after stroke and which factors are associated with these feelings provide important information about relevant rehabilitation targets. Objective. This study aimed to identify the independent factors of health-related quality of life (HRQoL) from a biopsychosocial perspective using the methods of multivariate regression at 3 different time points poststroke. Methods. Included in the study were 99 patients from stroke units with diagnosed first-ever stroke. At admission and at 6 weeks, 3 months, and 1 year poststroke, HRQoL was assessed using the EuroQoL-5D Visual Analogue Scale (EQ-5D VAS). Consequences in Body Functions and Activities and Participation, and Environmental Factors were documented using 155 categories of the International Classification of Functioning, Disability and Health (ICF) Core Set for Stroke. Results. For a period of 1 year, problems with recreation and leisure, personality functions, energy and drive functions, and gait pattern functions were repeatedly associated with worse HRQoL. Whereas Body Functions and Activities and Participation explained more than three-fourths of the variances of HRQoL at 6 weeks and 3 months (R ² = 0.80-0.93), the variation at 1 year was best explained by either Body Functions or Environmental Factors (R ² = 0.51). Conclusions. The results indicate the importance of Body Functions and Activities and Participation (mainly personality functions and recreation and leisure) on HRQoL within 3 months poststroke, but increased impact of Environmental Factors on HRQoL at 1 year.

Assessing the competence of registered radiographers’ clinical work is of great importance because of the recent change in nursing focus and rapid technological development. Self-assessment assists radiographers to validate and improve clinical practice by identifying their strengths as well as areas that may need to be developed. The aim of the study was to develop and psychometrically test a specially designed instrument, the Radiographers Competence Scale (RCS). A cross sectional survey was conducted comprising 406 randomly selected radiographers all over Sweden. The study consisted of two phases; the development of the instrument and evaluation of its psychometric properties. The first phase included three steps: 1) construction of the RCS; 2) pilot testing of face and content validity; and 3) creation of a web-based 54-item questionnaire for testing the instrument. The second phase comprised psychometric evaluation of construct validity, internal consistency reliability and item reduction. The analysis reduced the initial 54 items of the RCS to 28 items. A logical two-factor solution was identified explaining 53.8% of the total variance. The first factor labelled “Nurse initiated care” explained 31.7% of the total variance. Factor 2 labelled “Technical and radiographic processes” explained 22.1% of the total variance. The scale had good internal consistency reliability, with a Cronbach’s alpha of 0.87. The RCS is a short, easy to administer scale for capturing radiographers’ competence levels and the frequency of using their competence. The scale was found to be valid and reliable. The self-assessment RCS can be used in management, patient safety and quality improvement to enhance the radiographic process.

OBJECTIVES: To describe radiographers' self-assessed level and use of competencies as well as how sociodemographic and situational factors are associated with these competencies, particularly related to work experience.

METHODS: A cross-sectional design was employed. Radiographers (n = 406) completed the self-administered 28-item questionnaire encompassing two dimensions: 'Nurse-initiated care' and 'Technical and radiographic processes'. The level of competencies was rated on a 10-point scale and the frequency of use on a 6-point scale.

RESULTS: Most competencies received high ratings both in terms of level and frequency of use. In 'Nurse-initiated care' the competency 'Adequately informing the patient' was rated the highest, while 'Identifying and encountering the patient in a state of shock' and 'Participating in quality improvement regarding patient safety and care' received the lowest ratings. In 'Technical and radiographic processes' the highest rated competencies were 'Adapting the examination to the patient's prerequisites and needs' and 'Producing accurate and correct images'. The lowest frequency of use was 'Preliminary assessment of images'.

CONCLUSION: The main findings underline the radiographers' high competency in both 'Nurse-initiated care' and 'Technical and radiographic processes'. The lower rated competencies emphasise the importance of continuous professional education and quality improvement.

MAIN MESSAGES :

• Assessing radiographers' clinical competencies is fundamental for ensuring professional standards.

• Most competencies received high ratings both in the nursing and in the radiographic dimensions.

• The highest rated competencies focussed on information and adaptability to the patients needs.

• The lowest rated competencies focussed on encountering the patient in shock and image assessments.

• Age, years in present position and work place only explained a relatively small part of competency.

PURPOSE:

Patients must be able to feel as much trust for caregivers and the healthcare system at the healthcare centre as at the emergency department. The aim of this study is to explain and understand the phenomenon of trust in the early chain of healthcare, when a patient has called an ambulance for a non-urgent condition and been referred to the healthcare centre.

METHOD:

A lifeworld hermeneutic approach from the perspective of caring science was used. Ten patients participated: seven female and three male. The setting is the early chain of healthcare in south-western Sweden.

RESULTS:

The findings show that the phenomenon of trust does not automatically involve medical care. However, attention to the patient's lifeworld in a professional caring relationship enables the patient to trust the caregiver and the healthcare environment. It is clear that the "voice of the lifeworld" enables the patient to feel trust.

CONCLUSION:

Trust in the early chain of healthcare entails caregivers' ability to pay attention to both medical and existential issues in compliance with the patient's information and questions. Thus, the patient must be invited to participate in assessments and decisions concerning his or her own healthcare, in a credible manner and using everyday language.

Attityder till ätandet

I våra ansträngningar med att utveckla och förbättra det arbete som utförs inom vård och omsorg försöker vi använda handlingar som bedöms vara evidensbaserade. Ofta vet vi, eller i alla fall tror vi oss veta, vilka metoder, åtgärder och program som idag anses vara det mest riktiga. Något helt annat är vad som faktiskt används och görs i det kliniska arbetet. Att fånga vad som görs i syfte att utvärdera resultatet av given vård och omsorg innebär stora utmaningar. Vi kan använda kvantitativa mått på vårdkvalitet som tex. viktutveckling, underbenets omkrets och antal patienter/vårdtagare som fått sitt beräknade energibehov tillgodosett under en vårdperiod. Dessa mått är bra men grova och fångar eventuellt redan uppkomna kvalitetsbrister. Ett annat sätt är att observera vad som görs i olika vårdsituationer men detta arbetssätt medför en hel del svårigheter. Det är etiskt problematiskt, kostsamt men framförallt kommer observationen i sig att påverka vårdsituationen så mycket att det som görs inte blir representativt för praxis. Ett tredje sätt är att studera ”personalens tänkta handling”. Metoden för detta är attitydstudier. En attityd anses bestå av tre komponenter; en känslodel, en kunskapsdel och en tänkt handling. Studier visar att en tänkt handling ofta leder till en utförd handling. Genom att formulera påståenden kring ett viktigt fenomen inom vård och omsorg kan olika personalgruppers attityder till viktiga områden fångas. Resultatet kan därigenom identifiera områden som personalgrupper uppvisar negativa attityder till. Med vetskapen om att negativa attityder har ett starkt samband med vilka handlingar som görs kan utbildningsinsatser sättas in. Ett annat användningsområdet är att före och efter ett förändringsarbete som tex. inkluderar utbildning och ändrat arbetssätt fånga hur eventuellt attityderna till ett viktigt område ändrades.

Staff Attitudes to Nutritional Nursing Care Geriatric scale (SANN-G skalan) är ett instrument som fångar attityderna hos personal som arbetar med äldre vård- och omsorgsbehövande med avgränsning till ”faktorer som är viktiga för ätandet och näringstillståndet”. Skalan är ett formulär av Likert-typ och består av 18 påståenden. Den svaranden tar ställning till fem svarsalternativ; håller helt och hållet med, håller delvis med, tveksam, tar delvis avstånd och tar helt och hållet avstånd. Påståendena har sitt ursprung från en litteraturgenomgång där antalet påståenden initialt var 63. Efter olika statistiska analyser där bl.a. påståendenas diskrimineringsförmåga testats har antalet reducerats. Vid faktoranalys framkom att påståendena täcker fem delområden; normer, vanor, bedömningar, åtgärder och individualisering. Den första versionen av skalan har använts för att undersöka om attityderna förändras efter utbildning av undersköterskor och sjuksköterskor (n= 151) inom kommunal äldreomsorg och att rutinerna kring måltiderna ändrades. Personalen som fått utbildning och ändrat sitt arbetssätt uppvisade signifikant mer positiva attityder till området individualisering jämfört med kontrollgruppen men inom övriga områden hade ingen förändring skett. SANN-G skalan har använts för att undersöka om det fanns skillnader i attityderna mellan olika personalgrupper. Åttio sjuksköterskor och 104 undersköterskor med tjänst inom medicinsk eller geriatrisk klinik vid två sjukhus ingick. Resultatet visar att sjuksköterskorna hade signifikant mer positiva attityder jämfört med undersköterskorna. För hela gruppen uppvisade 53% av personalen positiva attityder. Studierna indikerar att attityderna förmodligen har sin grund i normer och vårdkulturer, ”det sitter i väggarna”, och utgör en stor utmaning att förändra.

Objective:A positive attitude is assumed to be important in nursing staff’s help and support of elderly people during meals. As there is no specific tool for measuring staff’s attitudes regarding important issues within eating and nutrition, the SANN (Staff Attitudes to Nutritional Nursing Care) scale was developed. The scale was developed and tested in nursing staff working at resident homes, and the number of items was reduced from 63 to 19 with five underlying factors. The aim of this study was to describe how the SANN scale was adapted and tested in nursing staff working in different types of elderly care. Design: The raw 63-item version went through minor changes, and one unclear worded item was excluded. The changed raw 62-item version was answered by 188 nursing staff working at six hospital care clinics and 64 staff working at one resident home.

Results:The analysis reduced the 62 items to 18, and the adapted scale was named the SANN-G scale, G standing for “geriatric care”. A rotated factor analysis gave a five-factor solution, explaining 54% of the variance. The scale achieved good internal reliability, with a Cronbach’s alpha of 0.83. Fourteen items fulfilled inclusion criteria in both the SANN and the SANN-G scales.

Conclusion:The SANN-G scale is practicable for use in staff working in different types of elderly care. It can be used to explore existing attitudes and identify areas with a low degree of prevailing positive attitudes as well as to evaluate whether and how attitudes change after nutritional education and intervention.

Objectives: Negative attitudes in society toward working in eldercare constitute a challenge to educators and care providers. The purpose of this study was to explore, describe, and compare the attitudes of different professional groups toward factors that are important for the well-being of older adults.

Methods: A randomized sample of 210 respondents that included registered nurses (RNs), registered occupational therapists (OTRs), personal benefit advisors (PBAs), and home help assistants (HHAs) was collected from social service agencies in 10 Swedish municipalities. A scale was developed in a six-step process to measure attitudes toward factors influencing elder wellbeing, and the final 22-item Likert-type scale was called the “Staff Attitudes toward the Well-being of Older Adults” scale.

Results: Thirty-three percent of staff responded with positive attitudes <toward working with elders>, and the remaining were uncertain or negative. The attitudes of RNs, OTRs, and PBAs were significantly more positive than those of HHAs.

Discussion: The scale is practical for use in different professional groups with the aim of exploring existing attitudes, identifying areas with a low degree of prevailing positive attitudes and differences between groups, and evaluating whether attitudes change after staff training.

11th INTERNATIONAL NURSING RESEARCH CONFERENCE

Madrid, November 14th – 16th 2007

PAPER TITLE: A Nutritional Nursing Care Model introduced to Elderly People admitted to Resident Homes

AUTHOR/S: Lennart Christensson, RN, PhD and Kerstin Wikby, RN PhD.

WORK PLACE: School of Health Sciences, Department of Nursing, Jönköping University.

ADDRESS: Box 1026, 551 11 Jönköping, Sweden

TELEPHONE: +46 36 101249 FAX: +46 36 101250

E-MAIL: lennart.christensson@hhj.hj.se

Malnutrition among the elderly is a multidimensional concept, involving medical, psychological and social factors. Fulfilling nutritional requirements in residents with eating problems is often a challenge for both the person in need of help and for the care giver.

Objectives: The primary objective of this study was to determine whether educating care givers have effects on the improvement of nutritional status among elderly people, newly admitted to resident homes.

Methods: The study was based on an earlier single-case study, where a model for nutritional nursing care was developed. In this study a pre-post test design was used, including 62 residents in the experimental (20 men, 42 women) and 53 in the control group (14 men, 39 women). The residents were newly admitted to a resident home and were consecutively included in the study. Mean age was 85 years. At admission and after four months protein-energy malnutrition (PEM) was assessed, using a combination of anthropometry (weight index, arm muscle circumference and triceps skinfold thickness) and biochemical measurements (serum protein and transthyretin). Functional capacity and overall cognitive function were also assessed. In the experimental unit, a nutritional nursing care model was introduced and the staff received education about nutritional needs, and how to individualise nutritional care.

Findings: Twenty residents in the experimental and 17 in the control group were assessed as PEM at admission. After four months the number of residents assessed as PEM decreased to seven in the experimental (p=0.004), and to ten in the control group (p=0.1). Motor activity (p=0.006) and cognitive function (p=0.02) increased in the experimental group, while motor activity decreased in the control group (p=0.02). The care givers in the experimental group estimated the extra work, caused by the changed way of work during the meals, to 11/2 minute per resident and day.

Discussion: Individualised actions directed towards PEM residents are in line with the recommendation by the European Society of Parenteral and Enteral Nutrition (ESPEN) and with the Swedish goals of nursing action. Nursing actions towards nutritional problems include more than merely to offer a standard care plan, such as giving oral supplementation. As the nutritional problems often demands a deeper analysis of the underlying causes, individualized nursing actions may be a more optimal approach. This study shows that implementing an individualised nutritional programme increase nutritional status, motor activity and cognitive function in PEM residents. The nutritional care programme was implemented with a minimum of extra work.

Aims and objectives: To identify and describe nursing actions performed by nurses that create a sense of good nursing care in patients with wet age-related macular degeneration.

Background: People who suffer from wet age-related macular degeneration risk central vision loss. Treatment with antivascular endothelial growth factor is the only available option at present that preserves vision and no definitive cure currently exists. Patients feel that they are compelled to accept this treatment because they might otherwise become blind.

Design: An explorative and descriptive design based on the critical incident technique was used.

Method: Interviews with 16 Swedish patients who all had received intravitreal treatment for wet age-related macular degeneration.

Results: Two main areas of good nursing care were identified: 'Being perceived as an individual' and 'Being empowered'. The first area was divided into two categories: being respectful and being engaged. Being respectful was observed when nurses had a benevolent attitude towards their patients and answered questions kindly and politely. Patients saw themselves as individuals when nurses were available for conversation and focused on them. The second area was divided into two categories: encouraging participation and creating confidence. Encouraging participation refers to when nurses provided information continuously. Nurses instilled confidence and trust in their patients by keeping promises and by being honest.

Conclusions: A respectful interaction between patients and caregivers is necessary for patients to obtain beneficial health care.

Relevance to clinical practice: Patient interviews revealed important information about nursing actions that created a sense of good nursing care in patients with wet age-related macular degeneration. Nurses acknowledged people as individuals and created trust by building partnerships and sharing decision-making. To address each patient's concerns, nurses need to prioritise each patient's narrative and participation by documenting agreements in their medical record. 

Objective

Evidence supports the recommendation for follow-up session(s) for patients after discharge from an intensive care unit (ICU). The aim of these follow-up sessions is to allow patients to express and discuss their experiences and problems following their time in an ICU. To optimise the knowledge gained from the follow-up session experience, it is necessary to describe how patients experience these sessions. The aim of this study was to describe how ICU-patients, experience a follow-up session.

Design/setting

This study adopted a qualitative design utilising semi-structured interviews, and which examined the experiences of seven men and five women. Qualitative content analysis was utilised.

Findings

The participants stated that the information gained from these sessions, which had previously seemed unclear to some of them, was, on the whole, now clarified and confirmed. A discernible difference was found between participants who were cared for on a general ward and those who were cared for on a rehabilitation ward and also were offered a meeting with a counsellor, following discharge their from the ICU. The findings also indicated that participants who were not offered psychosocial support showed a greater need for a follow-up session.

Conclusion

This study has highlighted the need for increasing collaboration between intensive care staff and staff in other units to provide support to this patient group in order to reduce their suffering post intensive care experience.

Background: As difficulties in performing daily activities occur among persons with dementia, their spouses are also affected. This is also true for mealtimes, yet there is a lack of knowledge and research into how couples manage this situation at home. Objective: The aim of the study was to explore and describe spouses’ experiences of mealtimes in couples in which one partner has dementia. Design, Setting and Participants: Ten spouses were interviewed in their home in respect to their experiences regarding mealtimes when living with a partner diagnosed with dementia. To identify themes across the data set, thematic analysis was conducted. Results: One major theme, Recognizing and managing the range of mealtime change, was identified and showed that depending on where the families were in the dementia process their experienced varied. As progression occurred in the partners disease, routines, responsibilities and relationships were affected within the couple. Strategies the participants used tomanage mealtimes at home regarding these problems were highlighted such as getting support from social services, but also strategies they had learnt by themselves. Conclusion: These results generate an insight into what couples face, and their needs for support. Spouses experiences varied which indicates that it is important that support is based on individual needs. Hence, nursing staff should continuously pay attention to couples mealtime situation. Further it increases staff´s knowledge regarding possible solutions on how to involve persons with dementia in mealtime activities and maintain their nutritional intake.

Dementia commonly leads to difficulties in performing daily activities, which can also often affect the ability to prepare and eat meals. As a result, formal support to maintain good nutritional intake might be needed, but there is a lack of knowledge concerning how to support older persons with dementia living at home. The aim of this study was to explore and describe staff views on how to improve mealtimes for persons with dementia who are still living at home. A qualitative descriptive study was performed and data were collected during 2011–2012 through four focus group interviews with staff working in the homes of persons with dementia. Data were analyzed using inductive content analysis. The participants described several ways to improve mealtimes for persons with dementia and advocated adjustments facilitating the preservation of the persons’ independence. Finding suitable actions calls for knowledge about the person and his/her individual situation. Proposed actions were enabling meals at home, taking over, and moving meals outside of the home. In addition, it was found that, the types of meals served to these persons should be as familiar to the individual as possible. The results of this study indicate the importance of using a person-centered approach and meeting the individual needs when supporting people with dementia in regards to their meals when living at home. Individualized care in the home may be expensive, however, it is fair to say that people who become malnourished and admitted to hospitals is even more costly. Furthermore, sharing and reflecting experiences and knowledge can assist staff to identify ways to manage complex situations. Therefore, the use of refection should be a part of staff members’ everyday work.

AIM: To capture the self-description of managing mealtime tasks by persons with dementia.

BACKGROUND: There are several factors that negatively affect food intake in persons with dementia that may increase the risk of developing malnutrition. Difficulties in managing daily activities increase gradually and mealtime tasks like food shopping, cooking and eating often become troublesome. Still, little is known about how persons with dementia themselves experience this issue.

DESIGN: A qualitative study with an ethnographic approach.

METHOD: Ten women and five men aged 69-86 with dementia were interviewed. Interviews were carried out in the informants' own homes and a thematic analysis was performed.

RESULTS: The informants described that they wanted to be independent and that the memory loss was not affecting them to a great extent. Old habits and routines, as well as newly developed strategies, helped them manage mealtime tasks despite the disease. Informants were satisfied with their current situation, even though it sometimes meant that they had changed their way of managing mealtime tasks, for instance receiving meals-on-wheels.

CONCLUSIONS: Persons with dementia seem to be able to manage mealtime tasks and these activities were based on old habits and routines. Independence was highly valued and managing mealtime tasks seems to be one way to appear independent.

RELEVANCE TO CLINICAL PRACTICE:

It is important for caregivers to understand that persons with dementia might not express difficulties in managing mealtime tasks for fear of losing their independence. It is, therefore, important to create a trustful relationship even before problems arise to be able to support the persons when necessary.

Poor nutritional status is common among persons with dementia and negatively associated with subjective health, mobility and mortality. When malnutrition occurs it is challenging to improve the nutritional status. The aim of the study was to investigate if a structured preventive care process could increase body weight, among persons with dementia at risk of malnutrition or malnourished. The structured preventive care process includes four steps which have been registered in a national quality register: 1) Risk assessment by Mini nutritional assessment-Short Form. 2) Team-based analysis of underlying causes (19 evidence-based risk factors) performed by staff including professionals like nurses, nurse assistants, occupational therapists and physiotherapists. 3)  Planning and performing interventions based on the need and problems of the individual (28 evidence-based actions) and 4) evaluation of performed interventions (body weight). A prepost design was used with body weight measured during baseline (0) and follow-up (7–106 days later). In total 526 persons with dementia at risk of malnutrition 176 The Gerontological Society of America Copyedited by: OUP at :: on January 10, 2017 http://gerontologist.oxfordjournals.org/ Downloaded from or malnourished, 65 years and older and with a care contact, were included. Results: 109 persons was registered in all four steps i.e. a team-based analysis of underlying causes have been performed. An improvement in the nutritional status was observed in these individuals (baseline Md 60.0 kg; follow-up Md 62.0  kg; p-value 0.013). No improvement was detected among those missing an analysis of underlying causes. Accordingly, by planning care in a structured way and give individualized interventions based on underlying causes can help improve nutritional status among persons with dementia at risk of malnutrition or malnourished.

Objectives: To describe health care staff members' usage and documentation in a Swedish quality registry focusing on a preventive care process regarding the risk area of malnutrition among persons with dementia. The preventive care process includes risk assessment, analysis of underlying causes, planning and performing interventions, as well as evaluating effects.

Methods: Data were collected from 2 Swedish quality registries, Senior Alert and the Swedish Dementia Register (Svedem). In total, 1929 people with dementia were assessed and 1432 registered as being at risk of malnutrition or malnourished.

Results: Performed nutritional interventions were registered in approximately 65% of cases. In more than 80% of registrations, the analyses of underlying causes were missing. Those who had registered underlying causes had significantly more interventions and the evaluation of the performed intervention was registered. The time between assessment and evaluation depended on care setting and ranged from 0 to 702 days.

Conclusions: Limitations in registration were noted; however, the register allows staff to focus on nutritional care and has resulted in many risk assessments. Rarely people were registered in all steps of the preventive care process. Large variances in when the performed interventions were evaluated makes it difficult to measure improvements.

OBJECTIVE: The aim of the study was to investigate the outcome of change in body weight associated with use of a structured preventive care process among persons with dementia assessed as at risk of malnutrition or malnourished. The preventive care process is a pedagogical model used in the Senior Alert (SA) quality register, where nutrition is one of the prioritized areas and includes four steps: assessment, analysis of underlying causes, actions performed and outcome.

DESIGN: An analysis of data from SA with a pre-post design was performed.

SETTING: The participants were living in ordinary housing or special housing in Sweden.

PARTICIPANTS: 1912 persons, 65 years and older, registered in both SA and the dementia quality register Svedem were included.

INTERVENTION: A national preventive care program including individualized actions.

MEASUREMENTS: The Mini Nutritional Assessment-Short Form was used to assess nutritional status at baseline. Body weight was measured during baseline and follow-up (7-106 days after baseline).

RESULTS: 74.3% persons were malnourished or at risk of malnutrition. Those at risk of malnutrition or malnourished who were registered in all four steps of the preventive care process, increased in body weight from baseline (Md 60.0 kg) to follow-up (Md 62.0 kg) (p=0.013). In those with incomplete registration no increase in body weight was found.

CONCLUSION: Using all steps in the structured preventive care process seems to improve nutritional status of persons with dementia assessed as at risk of malnutrition or malnourished. This study contributes to the development of evidence-based practice regarding malnutrition and persons with dementia.

Aims and objectives.  To develop evidence-based guidelines for adult patients in order to prevent urinary retention and to minimise bladder damage and urinary tract infection.

Background.  Urinary retention causing bladder damage is a well known complication in patients during hospital care. The most common treatment for urinary retention is an indwelling urinary catheter, which causes 80% of hospital-acquired urinary tract infections. Appropriate use of bladder ultrasonography can reduce the rate of bladder damage as well as the need to use an indwelling urinary catheter. It can also lead to a decrease in the rate of urinary tract infections, a lower risk of spread of multiresistant Gram-negative bacteria, and lower hospital costs.

Design.  An expert group was established, and a literature review was performed.

Methods.  On the basis of literature findings and consensus in the expert group, guidelines for clinical situations were constructed.

Results.  The main points of the guidelines are the following: identification of risk factors for urinary retention, managing patients at risk of urinary retention, strategies for patients with urinary retention and patient documentation and information.

Conclusion.  Using literature review and consensus technique based on a multiprofessional group of experts, evidence-based guidelines have been developed. Although consensus was reached, there are parts of the guidelines where the knowledge is weak.

Relevance to clinical practice.  These guidelines are designed to be easy to use in clinical work and could be an important step towards minimising bladder damage and hospital-acquired urinary tract infections and their serious consequences, such as bacteraemia and the spread of multidrug-resistant bacteria in hospitals.

This study aims to determine if systematic use of bladder scan accurately identifies more women with postpartum urinary retention compared with diagnosis using clinical signs and symptoms, alone. A prospective, quasi experimental study was performed at the Department of Obstetrics and Gynecology, County Hospital Ryhov, Jönköping, Sweden. A total of 252 women participated in this study; they were women who gave birth between the period of March and April, 2011. One hundred and twenty-six women were included in an experimental group, they received ultrasound scanning of post-void residual bladder volume for identification of urinary retention; patients were catheterized if post-void residual bladder volume was ≥400 ml. A control group of 126 women, matched by parity and age, were also included. The latter group were catheterized on clinical signs or symptoms of urinary retention. Twenty-one women in the experimental group were identified as having post-void residual bladder volume ≥400 ml compared to 9 in the control group, verified by catheterization (p < 0.05). Eleven women in the experimental group had covert urinary retention with a post-void residual bladder volume of 400 to 1200 ml. No woman who gave birth by caesarean section was identified with postpartum urinary retention. Univariable logistic regression analyses identified seven risk indicators of postpartum urinary retention: first pregnancy, delivery with use of ventouse, oxytocin infusion, epidural analgesia, second stage of >120 min, active pushing >30 min and perineal tear. Oxytocin infusion and perineal tear were independent risk indicators in a multivariable regression analysis. Systematic bladder scanning identifies more women with postpartum urinary retention in women with vaginal delivery than diagnosis by clinical signs and symptoms, alone. Oxytocin infusion and perineal tear are independent risk indicators for urinary retention in new delivered women.

Objective: To investigate patients who called the emergency medical services (EMS) for primary healthcare (PHC) problems.

Design: A retrospective and exploratory patient record study from an EMS perspective, comparing two groups: those who were potential candidates for PHC and those who were not. All data were gathered from EMS and hospital records.

Settings: The study was completed at the EMS and five hospital areas in the western region of Sweden.Subjects: The patients (n=3001) who called the EMS in 2011. Data were missing for 10%.

Main outcome measures: The frequency and the clinical characteristics of the patients who called the EMS and were actually potential candidates for PHC.

Results: Of a total of 2703 patients, a group of 426 (16%) were assessed as potential candidates for PHC and could thus be treated at a level of care other than the emergency department. Patients who were classified as suitable for PHC were found at all priority levels and within all symptom groups, but were younger and healthier than the other group.

Conclusion: Numerous patients seeking help from the EMS do not end up at the most appropriate level in the healthcare system.

Implications: In the EMS, guidelines are needed to enable pre-hospital emergency nurses to assess and triage patients to the most appropriate level of healthcare.

There is a lack of qualitative studies exploring the phenomenon of positive ethical climate and what is perceived as promoting it. Therefore, the aim of this study was to explore and describe actions that acute care ward nurses perceive as promoting a positive ethical climate. The critical incident technique was used. Interviews were conducted with 20 nurses at wards where the ethical climate was considered positive, according to a previous study. Meeting the needs of patients and next of kin in a considerate way, as well as receiving and giving support and information within the work group, promoted a positive ethical climate. Likewise, working as a team with a standard for behaviour within the work group promoted a positive ethical climate. Future research needs to investigate other conditions that might also promote a positive ethical climate.

Aim. The aim was fivefold: to describe Swedish nurses' perceptions of moral distress and determine whether there were differences in perceptions depending on demographic characteristics and to describe the usability of the Moral Distress Scale in a Swedish context. Further, the aim was to describe Swedish nurses' perceptions of ethical climate and the relationship between moral distress and ethical climate.

Background. Moral distress has been studied for more than two decades and the Moral Distress Scale is the most widely used instrument for measuring it. Moral distress has mainly been studied in relation to nurses' characteristics, but increasing attention has been paid to contextual aspects, such as ethical climate, that could be associated with moral distress.

Design. Descriptive, with a quantitative approach.

Methods. The study used two questionnaires: the Moral Distress Scale and the Hospital Ethical Climate Survey. The study was carried out at two hospitals in Sweden and included 249 nurses.

Results. Both level and frequency of moral distress were low, however level of moral distress was high in situations when the patient was not given safe and proper care. Generally, the frequency of moral distress was lower than the level. Of the situations on the Moral Distress Scale, 13 of the 32 were considered irrelevant by 10-50% of the participants. The more positive the ethical climate was perceived to be, the less frequentely morally distressing situations were reported.

Conclusions. Since a positive ethical climate was associated with less frequent occurencies of moral distress, it should be investigated what contributes to a positive ethical climate. To be used in a Swedish context, the Moral Distress Scale needs further revision.

Relevance to clinical practice. Open dialouges at wards are encouraged regarding what practices contribute to a positive ethical climate.

Background: Chest pain is a common symptom among patients contacting the emergency medical services (EMS). Risk stratification of these patients is warranted before arrival in hospital, regarding likelihood of an acute life-threatening condition (LTC).

Aim: To identify factors associated with an increased risk of acute LTC among patients who call the EMS due to non-traumatic chest pain.

Methods: Several databases were searched for relevant articles. Identified articles were quality-assessed using the Scottish Intercollegiate Guidelines Network checklists. Extracted data was analysed using a semi-quantitative synthesis evaluating the level of evidence of each identified factor.

Results: In total, 10 of 1245 identified studies were included. These studies provided strong evidence for an increased risk of an acute LTC with increasing age, male gender, elevated heart rate, low systolic blood pressure and ST elevation or ST depression on a 12-lead ECG. The level of evidence regarding the history of myocardial infarction, angina pectoris or presence of a Q wave or a Left Bundle Branch Block on the ECG was moderate. The evidence was inconclusive regarding dyspnoea, cold sweat/paleness, nausea/vomiting, history of chronic heart failure, smoking, Right Bundle Branch Block or T-inversions on the ECG.

Conclusions: Factors reflecting age, gender, myocardial ischemia and a compromised cardiovascular system predicted an increased risk of an acute life-threatening condition in the prehospital setting in cases of acute chest pain. These factors may form the basis for prehospital risk stratification in acute chest pain.