Background: Hospitals face an increasing pressure towards efficiency and cost reduction while ensuring patient safety. This warrants a closer examination of the trade-off between production and protection posited in the literature for a high-risk hospital setting (intensive care). Purposes: Based on extant literature and concepts on both safety management and organizational/safety culture, this study investigates to which extent production pressure (i.e., increased staff workload and capacity utilization) and safety culture (consisting of safety climate among staff and safety tools implemented by management) influence the occurrence of medical errors and if/how safety climate and safety tools interact. Methodology / Approach: A prospective, observational, 48-hour cross-sectional study was conducted in 57 intensive care units. The dependent variable is the incidence of errors affecting those 378 patients treated throughout the entire observation period. Capacity utilization and workload were measured by indicators such as unit occupancy, nurse-/physician-to-patient ratios, levels of care, or NEMS scores. The safety tools considered include Critical Incidence Reporting Systems, audits, training, mission statements, SOPs/checklists and the use of barcodes. Safety climate was assessed using a psychometrically validated four-dimensional questionnaire. Linear regression was employed to identify the effects of the predictor variables on error rate, as well as interaction effects between safety tools and safety climate. Findings: Higher workload has a detrimental effect on safety while safety climate - unlike the examined safety tools - has a virtually equal opposite effect. Correlations between safety tools and safety climate as well as their interaction effects on error rate are mostly nonsignificant. Practice Implications: Increased workload and capacity utilization increase the occurrence of medical error; an effect that can be offset by a positive safety climate but not by formally implemented safety procedures and policies. (authors' abstract)

Tracheal intubation in critically ill patients is a high-risk procedure. The risk of complications increases with repeated or prolonged attempts, making expedient first attempt success the goal for airway management in these patients. Patient-related factors often make visualization of the airway and placement of the tracheal tube difficult. Physiologic derangements reduce the patient's tolerance for repeated or prolonged attempts at laryngoscopy and, as a result, hypoxaemia and haemodynamic deterioration are common complications. Operator-related factors such as experience, device selection, and pharmacologic choices affect the odds of a successful intubation on the first attempt. This review will discuss the 'difficult airway' in critically ill patients and highlight recent advances in airway management that have been shown to improve first attempt success and decrease adverse events associated with the intubation of critically ill patients.

Bakgrund:Att vara anhöriga till en person med psykisk sjukdom medför ofta en egen försämrad psykisk hälsa samt kan vara både tidskrävande och kostsamt. Känslor av skuld och skam samt stigmatisering från omvärlden är vanligt förekommande. Anhöriga önskar delaktighet i vården men exkluderas ofta. Det finns nationella riktlinjer och lagar som betonar vikten av anhörigas delaktighet, trots detta upplevs anhöriga ofta påträngande. De finns lite kunskap om anhörigas kontakt med psykiatriska intensivvårdsavdelningar. Syfte:Syftet med denna studie var att beskriva sjuksköterskors erfarenheter av möten med anhöriga på psykiatriska intensivvårdsavdelningar Metod:Studien har en kvalitativ design med induktiv ansats. Sju sjuksköterskor på psykiatriska intensivvårdsavdelningar i Sverige intervjuades enligt semistrukturerade metod. Materialet analyserades med kvalitativ innehållsanalys. Resultat:Resultatet från intervjuerna utmynnade i fyra kategorier: Organisatoriska förutsättningar för att möta anhöriga, Olika syn på anhöriga, Utmaningar i mötet med anhöriga samt Att möta och kommunicera med anhöriga. Diskussion:Resultatet i studien diskuteras i relation till tidigare forskning och Andersheds teori om Delaktighet i Ljuset – Delaktighet i mörkret. I resultatet framkom aspekter som kan tänkas leda till både delaktighet i ljuset och i mörkret. / Background: Being a relative to someone with mental disorder often causes a decreased mental health and can be both time-consuming and costly. Feelings of guilt and shame and stigmatization from the surroundings are common. Relatives’ wishes to participate in care but often get excluded. National guidelines and laws emphasize the importance of relatives’ participation; despite this relatives' often get perceived as intrusive. Little is known about relatives contact with psychiatric intensive care units. Aim: The aim of this study was to describe nurses’ experiences from meeting relatives at psychiatric intensive care units. Method: This study has a qualitative design with an inductive approach. Seven nurses at psychiatric intensive care units in Sweden were interviewed with semistructured method. The material was analyzed using a qualitative content analysis. Results: The result from the interviews developed into four categories: Organizational requirements to meet relatives, Different views on relatives, Challenges in the meeting with relatives, and To meet and communicate with relatives. Discussions: The result is being discussed in relation to previous research and Andershed's theory of Involvement in the light – Involvement in the dark. In the result aspects emerged that can lead to both participation in the light and in the darkness.

Class of 2012 Abstract / Specific Aims: The purpose of this study is to evaluate and compare clinical outcomes and cost involved with use of poractant versus beractant for the treatment of respiratory distress syndrome (RDS) in a level III, neonatal intensive care unit (NICU) within an academic medical center. Methods: This retrospective cohort study included patients if they were admitted to the NICU for RDS between April 1, 2010 to November 30, 2010 and December 1, 2010 to June 30, 2011 treated with beractant and poractant respectively. Patients were excluded from the study if they were greater than 35 weeks gestational age and survived less than 48 hours. This is a review and the information needed from the patients was submitted in a data extraction form. Data collected included demographic variables (age, birthweight, birth length, gender, and race/ ethnicity), FiO2 measurement, mechanical ventilation time, length of hospitalization in the NICU, the incidence complications in the first 28 days, number of doses given, use of the nasal CPAP, concurrent complications or comorbidites such as pulmonary hemorrhage, bronchopulmonary dysplasia, patent ductus arteriosis, intraventricular hemorrhage, and retinopathy of maturity. Main Results: Data from 27 neonates in beractant and 13 in poractant groups were collected. The FiO2 measurements in both groups were generally similar. However, FiO2 was consistently lower in the poractant group. (p = 0.044 from a runs statistical test) Conclusions: The FiO2 measurement is poractant group was lower compared with beractant group, however the difference was noted to be not statistically significant.

Introduktion: Patientens upplevelser från intensivvårdsavdelningen kan ge upphov till stress som orsakas av flera faktorer. Detta kan påverka patienten lång tid efter utskrivningen. Det är därför viktigt att veta vilka omvårdnadsåtgärder på intensivvårdsavdelningen som stödjer patientens återhämtning. Syfte: Studiens syfte var att beskriva intensivvårdssjuksköterskors uppfattningar av preventiva omvårdnadsåtgärder på intensivvårdsavdelningen som kan vara stödjande för patientens återhämtning. Metod: En kvalitativ metod valdes och datainsamling skedde i form av nio intervjuer med intensivvårdssjuksköterskor, med erfarenhet av uppföljningsarbete, på tre olika sjukhus. Analys av insamlat material, skedde med hjälp av kvalitativ innehållsanalys enligt Graneheim och Lundman. Huvudresultat: I resultatet framkom fyra huvudkategorier som beskriver områden för preventiva omvårdnadsåtgärder: Skapa meningsfullhet, Förklara omvärlden, Skapa trygghet och Förbered framtiden. Konklusion: Studiens resultat visar att kunskap om patientens historia kan användas som grund för att knyta an till patientens vardagsliv. Struktur, förklaringar och råd från personalen har uppfattats stödja patientens omvärldsuppfattning på IVA. Trygghet och närhet från personal och anhöriga anses viktigt för patienten. Framförallt har stöd till patientens inre resurser och anpassande av miljön genom nedtrappad övervakning, uppfattats kunna bidra till att patienten återfår sin självständighet och bättre kan hantera framtiden. / Introduction: A patient´s experiences during intensive care can lead to stress that is caused by several factors. This can affect the patient long after discharge. Therefore, it is essential to know which nursing interventions in the intensive care unit, that best support the patient's recovery. Aim: The aim of this study was to describe the intensive care nurses' perceptions of preventive care measures in the intensive care that can be supporting for the patient's recovery. Method: A qualitative method was chosen and the data collection was done by interviewing nine intensive care nurses with experience in monitoring work at three different hospitals. The collected material was analyzed in accordance with Graneheim and Lundman´s qualitative content analysis. Main Results: The results revealed four main categories in which preventive care measures are especially useful: Creating meaning, Explaining the environment, Creating safety and Preparing for the Future. Conclusion: By gaining knowledge about what is relevant to each particular patient it is possible to adapt care measures based on this. It seems that structure, detailed explanations and advice provided by the staff will help the patient to better assess his/her situation. Being close to staff and family is comforting for the patient. It is a great importance to help the patient regain independence in order to manage the future. It was perceived that this can be done by gradually decreasing the use of technology and supporting the patient´s inner strengths.

ABSTRACT Background: An acquired brain injury can be classified as either a primary brain injury or a secondary brain injury. A secondary brain injury can also be caused by secondary clinical insults, such as epileptic seizures. To date, there have been no studies conducted on whether nursing interventions, such as bathing, oral care and suctioning the endotracheal tube, can cause epileptic seizures when caring for neurosurgical patients in the intensive care ward. Aim: The aim of this study was to explore whether nursing interventions can cause changes in a neurosurgical intensive care ward patient’s EEG pattern. Methods: Qualitative prospective observational study, using descriptive design (non-experimental). There was a total of 12 patients included in this study, all from a neurointensive care ward in the middle of Sweden. The patients were observed using continuous EEG monitoring with video recording all nursing interventions during 48 hours for each patient. The nursing interventions that were conducted were marked and categorised on a data log. The EEG was then analysed by a neurophysiologist, the results of which were also documented on the data log. Results: The total number of nursing interventions that have been observed for all 12 patients are 1170. Of these, 55 percent resulted in a change in the EEG pattern. The changes in an EEG pattern were categorized into one of four categories. The category with the largest percentage of documented changes was muscle artifact. The nursing interventions that resulted in the highest percentage of EEG pattern changes were – Everything at once, Oral care, Hygiene, Change of position and Suctioning the endotracheal tube. A correlation between the duration of nursing interventions and the occurrence of EEG pattern changes was detected. The longer the nursing intervention lasted the more EEG changes were generated. Conclusion: The results of the study show that nursing-related EEG changes can occur. This suggests that nursing interventions may be stressful for the neurosurgical intensive care patient. It is possible that this stress could be palliated by raising awareness among nursing staff of the importance of using sedatives and analgesics before performing nursing interventions.

Bakgrund: På intensivvårdsavdelningen är patienterna ofta så sjuka att kommunikationen med vårdpersonalen kan vara svår. Närstående på intensivvårdsavdelningen har en viktig roll i omvårdnaden. I studierna framkommer att närstående har ett stort behov av information samt att kommunikation, skydd av patient, deltagande och stöd är viktigt men ingen av studierna har utgått från mötet med vårdpersonalen. Syfte: Syftet med studien var att beskriva upplevelser av närståendes möten med vårdpersonal på intensivvårdsavdelningen. Metod: Deskriptiv design med kvalitativ ansats och semistrukturerade intervjuer med nio närstående. Kvalitativ innehållsanalys med induktiv ansats. Huvudresultat: Det framkom fyra kategorier: Att känna trygghet som handlade om att få ett förtroende för vårdpersonalen, att vårdpersonalen visade omtanke, var tillmötesgående och professionella. Att känna otrygghet som handlade om att de upplevde otillräckligt förtroende för vårdpersonalen, att de kände ovisshet i mötet med dem och var oprofessionella. Att ha behov av information som syftar till att närstående önskade få information som var tydlig, förståelig, kontinuerlig, aktuell och ärlig. Att uppleva brist på information framkom då det förekom osäkerhet i informationen och en ovilja hos vårdpersonalen att ge information. Slutsatser: Vårdpersonalen bör få en ökad insikt om hur närståendes behov ska tillgodoses och att de får en ökad medvetenhet om att det framkommer både osäkerhet och brist på information. Det är viktigt att de gör något åt det för att öka tryggheten för de närstående. / Background: In the intensive care unit, patients are often so ill that communication with nursing staff can be difficult. Relatives in the intensive care unit have an important role in nursing care. The studies show that relatives have a large need for information and that communication, patient protection, participation and support are important, but none of the studies have been based on the meeting with nursing staff. Aim: The purpose of the study was to describe experiences of relatives' meetings with nursing staff at the intensive care unit. Method: A descriptive design with qualitative approaches and semi-structured interviews with nine relatives were conducted. Qualitative content analysis with inductive approaches was used. Main results: Four categories emerged: To feel secure was about gaining confidence in the nursing staff, that the nursing staff showed care, were courteous and professional. To feel insecure was about experiencing insufficient confidence in the nursing staff, feeling uncertainty when meeting and being unprofessional. Needing information aims to that relatives wished for information that was clear, understandable, continuous, current and honest. To experience lack of information emerged as uncertainty in the information and an unwillingness of the nursing staff to provide information existed. Conclusion: Nursing staff should gain insight into how to meet relatives' needs and to gain increased awareness that both uncertainty and lack of information exists. It is important that they do something about it to increase the safety of the relatives.

Bakgrund: Tidigare forskning har visat att patienter som överrapporteras från intensivvårdsavdelning till vårdavdelning är i en särskilt sårbar situation och att bristfälliga överrapporteringar är ett internationellt patientsäkerhetsproblem. Syfte: Syftet var att beskriva intensivvårdssjuksköterskors och avdelningssjuksköterskors upplevelser av överrapportering av patienter från intensivvårdsavdelning till vårdavdelning. Syftet var också att beskriva vad intensivvårdssjuksköterskor och avdelningssjuksköteskor ansåg vara viktigt vid överrapporteringen. Metod: Studien hade en kvalitativ ansats med beskrivande design. Åtta semistrukturerade intervjuer gjordes med intensivvårdssjuksköterskor (n=4) och legitimerade sjuksköterskor på vårdavdelning (n=4). Intervjuerna analyserades därefter med kvalitativ innehållsanalys. Huvudresultat: Vid analys av intervjuerna framträdde sex kategorier 1) Att se vikten av samverkan, 2) Att ta emot och ge relevant information för den fortsatta vården på vårdavdelningen, 3) Att ge och ta emot information från ett kunskapsområde till ett annat, 4) Miljöns betydelse vid överrapportering, 5) Att ha behov av strukturerad rapport och 6) Att känna ansvar. Intensivvårdssjuksköterskor och sjuksköterskor från vårdavdelning upplevde att brist på förberedelser inför överrapportering försvårade samarbetet. De upplevde att olika information var viktig vid överrapportering på grund av deras olika kunskapsområden. Båda yrkesgrupperna önskade att informationen skulle vara tydlig med relevant information för den fortsatta vården. De upplevde att miljön med frekventa störningar gjorde att information missades och att en strukturerad rapport gjorde överrapporteringen tydligare. De uttryckte också att de har ett ansvar vid informationsöverföringen. Slutsatser: Samverkan, strukturerad information för den fortsatta vården, kunskap, miljö och ansvar kan ha betydelse vid överrapportering och att utrymme för förbättring finns för att öka patientsäker överrapportering av patient mellan vårdinrättningar. / Background: Studies have shown that the patients that are handed over from the intensive care unit to ward are in a particular vulnerable situation, and that deficient handover is an international patient safety problem. Aim: The aim was to describe the intensive care nurse's and ward nurse's experiences of handover patients from the intensive care unit to the ward. The aim was also to describe what the intensive care nurses and ward nurses considered important during the handover. Method: The study had a qualitative approach with descriptive design. Eight semi structured interviews with intensive care unit nurses (n=4) and registered ward nurses (n=4) were conducted. The interviews were analyzed with qualitative content analysis. Main results: Thorough the analyze six categories emerged 1) To see the importance of collaboration, 2) To receive and provide relevant information for the continuum of care, 3) To give and receive information from one level at knowledge to another, 4) The importance of the environments during handover, 5) The need of a structured handover, and 6) To feel the responsibility. The intensive care nurses and the registered ward nurses experienced that lack of preparation before the handover complicated the cooperation during handover. They expressed that different information was important during handover and that they had different areas of knowledge. Both professional groups wanted the information to be clear and relevant for the continued care. They felt that the environment, with frequent interruptions, resulted in missing information and that a structured report made the handover more direct. They also felt that they had a responsibility in the transfer of information. Conclusions: Collaboration, structured information relevant for the continued care, knowledge, the environment, and responsibility can be important during handover and there is room for improvement to increase patient safe handover between healthcare facilities.

Aim: The overall aim of the thesis was to illuminate the meanings of intensive care units’ patient rooms as a place of care for critically ill patients and their loved ones. Moreover, it was aimed to develop photovoice as a data collection method for research in ICU context. Methods and materials: Data has been collected using photovoice methodology in combination with research interviews for all three empirical studies. In total 37 people participated. Nine patients, fourteen loved ones and fourteen nurses from three ICU settings. Study I examined the perspective of loved ones, for this purpose a phenomenological hermeneutic method rooted in the philosophy of Ricoeur was chosen. Study II and III examined patients’ respectively nurses’ perspective. Both studies are phenomenologically orientated guided by a reflective lifeworld approach rooted in continental philosophy. Study IV is a theoretical paper focusing on employing photovoice as a data collection method in ICU context. Main findings: The tone and touch of caring is vital for how ICU patient room is materialized for patients. The interior design and furnishing has a great impact on the wellbeing of the loved ones and also the support they can offer the critically ill patient. One major finding is that the ICU patient room is a taken for granted place for health care providers and the impact of it upon caring, patients’ and loved ones wellbeing is not reflected over. It also seems unclear who is responsible for the environment of ICU once it has been built. The environment of ICU affects nurses’ ability to care for the patients and their family in a genuine way and to promote their wellbeing during a fragile time in life. Conclusions: There is an urgent need to translate research findings into clinical practice in order to improve the environment of ICU patient rooms. There is also need of further research and policies for transforming the hostile environment of the patient rooms to a healing environment more conductive to people’s recovering process. / <p>Akademisk avhandling som för avläggande av filosofie doktorsexamen vid Linnéuniversitetet försvaras vid offentlig disputation, 13 juni 2014, klockan 14.00 i sal Wicksell, Hus K, Växjö</p>

This thesis focuses on the relationship between technology and caring in technologically intense environments. The overall aim was to uncover the meaning of care in those environments as experienced by patients and caregivers. Moreover, the study aimed at finding a deeper understanding for the almost total dominance of technology in care in intensive care. The thesis includes three empirical studies and one theoretical, philosophical study. The research was guided by a phenomenological and lifeworld theoretical approach. Research data consist of quantitative parameters and qualitative interviews with caregivers and patients. Data was analysed and synthesised with aim of seeking meaning through openness, sensitivity and a reflective attitude. The goal was to reach the general structure of the phenomenon and its meaning constituents. The result shows that an intensive care unit is a cognitive and emotionally complex environment where caregivers are juggling a precarious handful of cards. Despite being constantly monitored and observed, intensive care patients express that they feel invisible. The patient and the apparatus easily meld into a unit, one item to be regulated and read. From the patients’ perspective, caregivers demonstrate keen vigilance over technological devices and measured parameters, but pay scant attention to their stories and experiences. Technology, with its exciting captive lure and challenging character, seduces the caregivers and lulls them into a fictive sense of security and safety. Technical tasks take precedence or have more urgency than caring behaviour. A malaise settles on caregivers as they strive for garnering the security that technology promises. Yet simultaneously, insecurity creeps in as they read the patient’s biological data. Technical tasks take precedence over and seemingly are more urgent than showing care. Listening, inspiring trust, and promoting confidence no longer have high priority. Trying to communicate ‘through’ technology is so complex, that it is a difficult challenge to keep in perspective what or who is the focus; ‘seeing’ or caring. Technology should be like a catalyst; do its ‘thing’ and withdraw ‘unnoticed’. This thesis has contributed in gaining deeper knowledge about care in technologically intense environments and the impact of technology. The main contribution is that caregivers need to be aware that the roar of technology silences the subtle attempts of the critically ill or injured person to give voice to his or her needs. In conclusion, the challenges for caregivers are to distinguish when to heighten the importance of the objective and measurable dimensions provided by technology and when to reduce their importance. In order to magnify the patients’ lived experiences. It is a question of balancing state-of-the-art technology with integrative and comprehensive care, of harmonizing the demands of subjectivity with objective signs.