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Denna explorativa studie utgår från ett intresse för samspelet mellan den kliniska vardagen och det omgivande samhället. Sju mellanchefer på vårdcentraler och vuxenpsykiatriska öppenvårds-mottagningar har intervjuats i syfte att undersöka deras föreställningar och attityder runt psykoterapi som behandlingsform, exempelvis deras tankar om psykoterapins verkan och tillgänglighet liksom deras medvetenhet om och attityder till en ökande betoningen på evidensbaserad vård. Frågeställningar: 1. Hur beskriver cheferna psykoterapi som behandlingsform och vilka attityder har de till psykoterapi.2. Hur upplever cheferna psykoterapins villkor, exempelvis beträffande gränsdragningar och evidensbaserad vård, och vilka attityder har man. Via semistrukturerade intervjuer har en kartläggning av utfallsrummet gjort genom att svaren har kategoriserats i de områden som framträtt under intervjuerna. Cheferna hade en positiv syn på psykoterapi och ansåg att psykoterapi behövs som behandlingsform. Deras kunskap om psykoterapi och dess villkor skilde sig åt. En misstro mellan beslutsfattare och kliniker beskrevs, liksom en önskan om en mångfald av behandlingsmetoder. Slutsatser var bl.a. att former för att integrera olika typer av kunskap för att öka tilltron mellan sjukvårdens aktörer behövs. / This exploratory study is based on an interest in the interaction between clinical routine and the surrounding community. Seven middle managers in health care centers and psychiatric clinics were interviewed to examine their beliefs and attitudes about psychotherapy as a treatment, such as their thoughts on psychotherapy effectiveness and availability as well as their awareness of and attitudes to a growing emphasis on evidence-based care. Questions: 1. How do you describe the heads psychotherapy as a treatment and what attitudes they have to psykoterapi.2. How managers experience psychotherapy conditions, for example on the boundary issues and evidence-based care, and what attitudes they have. Through semistructured interviews, a survey of the sample space made by the responses was categorized into the areas that emerged during the interviews. The managers had a positive view of psychotherapy and found that psychotherapy is needed as a form of treatment. Their knowledge regarding psychotherapy and its terms varied. Mistrust between policy makers and clinicians were described, as well as the desire for a variety of treatment methods. Conclusions included the need to find ways to integrate different types of knowledge, to build trust between healthcare stakeholders.

Väntetiden för patienter som ådragit sig höftfraktur till operation är ofta lång och kan uppgå till över ett dygn. I första delen av vårdkedjan är det ambulanssjuksköterskan som möter patienter som ådragit sig höftfraktur och omhändertagandet där smärtbehandling ingår genomförs med stöd av upprättade vårdriktlinjer. Ambulanssjuksköterskan har ett ansvar enligt svensk lag att den prehospitala akutsjukvården som genomförs ska vara evidensbaserad. Syftet med denna studie var att undersöka specialistutbildade ambulanssjuksköterskors uppfattningar om möjligheten att bedriva evidensbaserad vård vid prehospital smärtbehandling av patienter med höftfraktur. Detta är en kvalitativ studie med beskrivande design. Resultatet visade att den specialistutbildade ambulanssjuksköterskan uppfattade generellt att vårdriktlinjerna var tydliga och lätta att förhålla sig till. De uppfattade att smärtbehandling var väl fungerande och evidensbaserad. Vårdriktlinjerna var tydliga och lätta att förhålla sig till och informanterna uppfattade att smärtbehandlingen var väl fungerande och evidensbaserad. / The waiting time for patients that sustain hip fractures is often long and can be more than twenty-four hours. The Ambulance nurse provides the first care for those whom sustain a hip fracture.  These patients receive pain management care from the ambulance nurse as recommended by given guidelines.  The ambulance nurse has a responsibility by Swedish law to administer care in an evidence based care, prehospital in the emergency care. The intention of this study was to investigate the specialist educated ambulance nurses current opinions of the possibility to give evidence based care, during prehospital pain management to patients who have a hip fracture. This is a qualitative study with descriptive design. The outcome of this study shows that the specialist educated ambulance nurses believe that the guidelines are clear and easy to follow in general.  Their opinion was that the pain management was functional and evidence based. The guidelines were clear and easy to relate to and the informants experienced the pain management as evidence based.

Bakgrund: Diabetes typ 2 är en folksjukdom och kan förebyggas eller fördröjas genom hälsosamma levnadsvanor. Att informera och motivera patienterna på ett hälsofrämjande och preventivt sätt är distriktssköterskans ansvar. Distriktssköterskans nyckelroll är att kritiskt granska evidensbaserad forskning för att uppnå en säker vård av god kvalitet som kan implementeras i praktiken. Syfte: Syftet med studien var att beskriva distriktssköterskors upplevelser av att motivera patienter med diabetes typ 2 till hälsosammare levnadsvanor genom evidensbaserad vård. Metod: En kvalitativ ansats användes. Semistrukturerade intervjuer genomfördes med sju distriktssköterskor. Materialet analyserades utifrån Graneheim och Lundmans innehållsanalys. Resultat: Resultatet i föreliggande studie visar att distriktssköterskorna måste utgå från patientens situation och individanpassa informationen. Genom stöd från distriktssköterskan ska patienten kunna motivera sig själv till att genomföra förändringar. Informanterna i studien belyste vikten av att informera patienten om diabetes samt vilka komplikationer som kan uppstå. För att uppnå en patientsäker vård av hög kvalitet ansåg distriktssköterskorna att evidensbaserad kunskap var en förutsättning. Konklusion: För att motivera patienterna till förändrade levnadsvanor krävs det att distriktssköterskorna informerar och undervisar patienterna om diabetes och hur förändrade levnadsvanor påverkar hälsan. Distriktssköterskan måste finna olika metoder för att motivera patienterna. Det som förmedlas ska grunda sig på vetenskap och evidensbaserad kunskap. / Background: Diabetes is a common disease and can be prevented by a healthy lifestyle. It is the district nurse's responsibility to inform and motivate patients in a health promotion and preventive manner. The district Nurse's role is to critically review evidence-based research to achieve a safe quality care. Purpose: The district Nurse's experiences of motivating patients with diabetes type 2 to healthier lifestyles by evidence-based care. Method: A qualitative approach was used. Interviews were conducted with seven district Nurses. The material was analyzed according to Graneheim and Lundmans content analysis. Results: The approach of the district nurses must be based on the patient's situation and personalize information. Support from the district nurse shall the patient be able to dedicate time and effort to implement these changes. The informants in this study illustrate the importance of informing the patient of diabetes and which complications that may arise. To achieve a patient safe care of high quality the district nurses deemed that an evidence-based knowledge was a prerequisite. Conclusion: To motivate patients to change their lifestyle, the district nurse must pass diabetes information and teach the patient how these lifestyle changes affect the health. The information must be based on evidence-based knowledge.

Background: Patients in the emergency department are not always satisfied with the care received and the nursing care in the emergency department is sometimes described as instrumental and non-holistic. Structured quality improvement work and evidence-based practice are needed. Aim: The overall aim was to emphasize general patients in the emergency department to enhance the knowledge on how they perceive the quality of care and how the care could be improved through collaboration with the healthcare professionals. Methods: Four studies, with quantitative and qualitative designs, were conducted in a Swedish emergency department. Two hundred patients answered a questionnaire, after which 22 healthcare professionals comprising five focus groups were interviewed, and finally 200 patients were included in an intervention study. Results: The following five areas for improvement were identified: “information, respect and empathy”, “pain relief”, “nutrition”, “waiting time” and “general atmosphere”. Of these areas, the healthcare professionals prioritized “information, respect and empathy”, “waiting time” and “pain relief” to be highlighted in the quality improvement work. Although goals and suggestions for changes were stated, barriers to quality improvement at different levels in the health care were detected. The results of the intervention study showed that structured nursing assessment of the patients’ abdominal status and nurse-initiated intravenous opioid analgesic could increase frequency of analgesic and reduce time to analgesic in the emergency department. Patients perceived lower pain intensity and improved quality of care in pain management. Conclusions: An uncomplicated nursing intervention, related to pain management, based on the results from a patient questionnaire and interviews with healthcare professionals, can improve the care process and pain management in the emergency department, as well as patients’ perceptions of the quality of care in pain management. To succeed with continuous quality improvement work, barriers to change should be addressed.

Syftet med denna studie var att beskriva riktlinjer och PM angående smärtbedömning och behandling som finns att tillgå på olika akutmottagningar och sjukhus. Smärta är en av de vanligaste orsakerna till att människor söker sjukvård i Sverige, därför ställer detta krav på sjukvårdens kompetens och tillgänglighet till riktlinjer/ PM som stödjer den vård som ges. En förfrågan om att få ta del av sjukhusens riktlinjer/ PM skickades via ut mail. Dokumenten analyserades och innehållet delades därefter in i sju kategorier som beskrev dess kontext, Definition av smärta, Bedömning/ Skattning av smärta, Behandling, Mål, Utvärdering/ Dokumentation, Smärtombud och Övrigt. I kategorin övrigt tas bland annat den bristande referenshanteringen till riktlinjer/ PM upp. Dokumenten visade en stor variation gällande innehåll och utförande. För att säkerställa en trygg och säker vård av god kvalitet krävs evidensbaserad kunskap, en kunskap som kontinuerligt skall uppdateras och förnyas. Något som sjukhusen enligt lagstiftning har skyldighet att göra. / The purpose of this study was to describe guidelines/ PM regarding pain assessment and treatment that is available in various emergency rooms and hospitals. Pain is one of the most common reasons for seeking medical care in Sweden, therefore medical expertise is required and also access to guidelines/ PM that supports the care provided. A request was sent by email to the hospitals requesting access to their guidelines/ PM. The contents of the documents were analyzed using seven categories which describe its context. Definition of pain, Assessment / Measurement of pain, Treatment, Goals, Evaluation / Documentation, Pain and Other Outlets. The category other outlets include amongst others the lack of reference to the management guidelines / PM. The results showed that the documents varied greatly with respects to content and design. To ensure safe and high quality care, evidence-based knowledge is required, knowledge that is constantly updated and renewed. This is something which Swedish hospitals have a legal obligation to perform.

Acute exacerbation of chronic obstructive pulmonary disease (COPD) is one of the leading causes of hospital readmissions within 30 days. Frequent readmissions negatively affect hospital reimbursements and patient outcomes. Creative strategies, such as COPD care bundles, have been shown to reduce readmission rates according to existing studies. A COPD discharge bundle was developed and implemented at 1 community hospital in response to an identified problem with COPD readmissions. Evaluation of this quality improvement initiative was the purpose of this project study. The practice-focused question was: Have 30-day readmission rates changed following the implementation of a COPD discharge bundle prior to transitioning from hospital to home? The framework selected for this project was the model for improvement. Sources of evidence included existing hospital data to evaluate the change in readmissions. The chi-square test of independence was used to assess the difference in frequency of 30-day readmissions. Pre and post-bundle implementation comparisons of readmission rates showed a decrease for 3 out of the 4 groups compared; these results were not statistically significant. Analysis of the post-bundle intervention groups revealed lower 30-day readmissions for individuals who were bundle compliant versus noncompliant and for those who spoke with a pharmacist within 48 hours of discharge opposed to those who did not; these results were statistically significant. Continued use of the bundle and maintaining the role of the pharmacist was recommended. Reduction of readmissions within 30-days has positive social implications for hospitals through financial gains and for the COPD population by improving overall health outcomes.

Background: Implementation of evidence-based knowledge in healthcare is challenging with success rates less than optimal at times. This is particularly true in the area of pressure ulcer prevention. Attention to use of the affective domain in educational interventions to implement best practices may be part of the solution. Purpose: The ultimate purpose of this study was to compare the use of two different educational interventions on medical-surgical nurses' behavioral intent to use evidence-based practice in preventing pressure ulcers. Theoretical Framework: The theoretical framework for this study was the theory of planned behavior. Methods: This study proceeded in three phases and collected both qualitative and quantitative data for instrument development and instrument testing. The resultant instrument was used to collect data for hypothesis testing in a cluster randomized experiment. Results: The theory of planned behavior was not fully supported in this study. Attitudes toward pressure ulcers were predictive of behavioral intent. Nurses who experienced the affective domain educational intervention showed significant improvements over the control group on attitude and perceived behavioral control. Behavioral intent and subjective norm were not impacted. Conclusions: A reliable and valid theory of planned behavior derived instrument was created. The theory of planned behavior was partially supported. An affective domain intervention has the potential to favorably impact nurses in valuing pressure ulcer prevention, despite any barriers.

Sammanfattning Bakgrund:Preoperativ helkroppstvätt syftar till att förhindra postoperativa infektioner.Forskningen kan idag inte uttala sig om att klorhexidintvål är ett bättre alternativ än vanlig tvål att använda vid den preoperativa helkroppstvätten för att förhindra uppkomsten av postoperativa infektioner. Det ställs krav på att vården ska bedrivas evidensbaserat för att kunna ge en säker vård till patienterna. För att den evidensbaserade vården ska kunna implementeras kliniskt krävs väl utformade riktlinjer. Riktlinjerna kan ge stöd och klara direktiv för vårdandet av patienten. Syfte:Att systematiskt bedöma och jämföra kvaliteten i kliniska riktlinjer som innefattar preoperativ helkroppstvätt utifrån AGREE II.  Metod:En empirisk studie med kvantitativ forskningsansats av icke-experimentell design. Urvalet utgjordes av en region i Mellansverige där 46 riktlinjer inkluderades som beskrev den preoperativa helkroppstvätten. Bedömningen av kvaliteteten i riktlinjerna genomfördes med hjälp av AGREE II och en jämförelse mellan de fyra olika verksamhetsområdena utfördes med analytisk statistik i form av Kruskal-Wallis test.  Resultat: Huvudfynden i studien visar på att det inte fanns någon tydlig information och syfte i riktlinjerna om preoperativ helkroppstvätt samt att det varierade avseende vilket medel som används till duschen. Det fanns en tydlig brist i vad informationen i riktlinjerna baserades på.  Slutsats: Det påvisas tydligt att det som stod i riktlinjerna inte var grundade i evidens. Sverige bör på nationell nivå ta ställning till hur den preoperativa helkroppstvätten ska utföras. Vidare bör forskning bedrivas om preoperativ helkroppstvätt är en del av det preventiva arbetet mot postoperativa infektioner. / Abstract Background: Preoperative bodywash aims to prevent surgical site infections. However, there is no evidence supporting that chlorhexidine soap is a better alternative for preoperative bodywash than plain soap in the prevention of surgical site infections. The requirement is that the care must be conducted evidence-based in order to provide a safe patient care. Well-designed guidelines are required so that the evidence-based care can be implemented clinically.  Aim:To systematically evaluate and compare the quality of clinical guidelines for preoperative bodywash using the AGREE II instrument. Method: A quantitative empirical study with non-experimental design. The sample was made of a province in Central Sweden. 46 guidelines describing the preoperative bodywash were included. Using the AGREE II instrument the assessment of the guidelines where obtained and presented with descriptive statistics. The comparison between the sections within the province was carried out by using the Kruskal-Wallis test.  Results: The main finding in the study shows that there was no clear scope and purpose in the guidelines on preoperative bodywash and it varied in terms of which agent was used for the shower. The development of the guidelines where inadequate in its rigour for development. Conclusion:The gap between what research concludes and what is performed still exists in the guidelines. A national board should take action to developing nationwide guidelines regarding preoperative bodywash. Further research should be conducted if preoperative bodywash is part of the prevention against surgical site infections.

<p>This thesis presents perspectives and experiences of different stakeholders and their ways of reasoning around pregnancy and pregnancy care. Data were generated from individual interviews with 25 health care providers, 18 women and 6 traditional birth attendants (TBAs) as well as 11 focus groups discussions with women, men and TBAs. </p><p>The challenges experienced by health care providers in their provision of antenatal care, while attempting to change antenatal care through routines proven to have medical value, are highlighted. Changing some long established routines, such as weighing and timing of visits, proved difficult mostly because of resistance from the users of care, whose reasoning and rationale for using care did not correspond with the professional perspectives of care. </p><p>Women also combined biomedical and traditional care. The women used the clinic to receive professional care and assurance that the pregnancy was progressing well and used TBAs, who are believed to have supernatural powers, for cultural forms of assurance and protection. The health care staff did not appreciate these aspects and discouraged women using TBAs. Midwives had problems to change routines of care because of their stressful working situations and the expectations of the women.</p><p>In addition, they described the paradoxes in providing antenatal care in the context of HIV and AIDS. The caregivers were aware of the magnitude of HIV and AIDS and yet did not have any information on the HIV status of the women they cared for. This also caused fear for occupational transmission. HIV/AIDS is highly stigmatised in this area and women used various strategies to avoid testing.</p><p>The study emphasised the need to broaden the conceptualisation and practice of evidence-based care to incorporate different types of evidence and include realities, knowledge and perspectives of not only the beneficiaries but also those implementing change as well as local knowledge. The necessity of reorganising the health care systems to accommodate the new challenges of the HIV/AIDS epidemic is also emphasised.</p>