Sweden until recently has been spared from major terrorist attacks. Research, however indicates that mass casualty incidents caused by terrorism are increasing in the western world and are expected to continue to increase within the near future. The execution of the emergency response plan and local emergency protocols is ultimately dependent on leadership at the service and unit level. As a result of the terrorist attack in Stockholm on April, 7th 2017 the medical organisation in Stockholm county were put on the highest alert. The emergency department [ED] charge nurses working during this specific event became key players in implementing and organizing the disaster response at the emergency departments. There is a lack of research highlighting the charge nurses´ experiences of leadership during disaster response at EDs following major incidents caused by terrorism.   The aim of the study was to describe the charge nurses´ experiences of managing the initial response to the major incident at emergency departments in Stockholm on April, 7th 2017.   Participants were selected using criterion sampling. All eight EDs in the Stockholm region were invited to participate, of which five accepted. At these five EDs were seven charge nurses working during the major incident and thus available for inclusion. Semi-structured interviews were conducted. Data were analysed using qualitative content analysis.   The results of the analysis yielded to two categories, first the perceived experiences of security consisting of the subcategories, work according to the local emergency response plan, experience and knowledge and controlled information. The second category was the perceived experiences of uncertainty consisting of the subcategories, unclear leadership, disturbances and deviation from the local emergency response plan, lack of knowledge, lack of information and uncontrolled information.   The conclusion from the result was that the charge nurses was in a central position in the response following the event, and that the management of the initial response was successful. In some cases, a need for clarification of the chain of command, extended training and effective crisis communication was identified, which could optimize the disaster management.

Syftet med denna studie var att beskriva ledningssjuksköterskan upplevelser av ledningsarbetet vid svårhanterbara situationer på en akutmottagning. Flertal studier visar att det är viktigt med erfarna och kompetenta ledningssjuksköterskor för att en akutmottagning ska fungera optimalt. Ledningssjuksköterskans ansvarsområde innefattar bland annat att vara akutmottagningens kontaktperson, ha ledningsansvar i händelse av katastrof och stödja medarbetare i att strukturera och organisera arbetet på olika positioner. För att bibehålla och säkerställa god och säker vård är det till stor vikt för sjuksköterskor att de har stabil ledning med ledningssjuksköterskan som ger stöd, verkar för gott samarbete och besitter hög kompetens. Detta i strävan för att finna ny kunskap som kan leda till förbättrat ledningsarbete och därmed ökad patientsäkerhet. Den metod som användes var kvalitativa intervjuer med åtta ledningssjuksköterskor från fyra olika akutmottagningar i Storstockholm området. Intervjuerna har transkriberats och analyserats för att lyfta fram ledningssjuksköterskornas erfarenheter som är relevanta till syftet. I denna studie har ledningssjuksköterskornas erfarenheter sammanfattats i tre kategorier och därmed kartlagt deras erfarenheter i olika aspekter. Analysen gav tre kategorier; upplevda orsaker till svårhanterbara situationer, upplevda känslor och intryck vid svårhanterbara situationer och upplevelse om hantering vid svårhanterbara situationer. De tre kategorierna åskådliggör principer från ledningsarbetet som är känt sedan tidigare forskning men också en hel del ny anmärkningsvärd information. Genom denna studie har det fångats upp att ledningsarbetet påverkas negativt av att ledningssjuksköterskor har arbetsuppgifter som försvårar helhetsperspektivet och därmed orsakar svårhanterbara situationer på akutmottagningen. En annan betydande iakttagelse som avslöjats var att ledningssjuksköterskor anser att sökandet och användandet av riktlinjer försvårar handläggningsarbetet på akutmottagningen. Vidare har denna studies intervjuer belyst konsekvenser av hög arbetsbelastning i samband med brist på resurser som resulterar i att personalens och anhörigas välmående försummas. En ytterligare anmärkningsvärd observation är att en av de inkluderade akutmottagningarna fortfarande är uppbundna med nära patientarbete samtidigt som de har ledningsansvar på akutmottagningen. Detta trots redovisad beprövad erfarenhet att ledningssjuksköterskor behöver vara frikopplade för att kunna hantera svårhanterbara situationer till deras bästa förmåga. Slutligen har denna studies underökningar bevisat att ledningssjuksköterskor upplever att de med erfarenhet upptäcker nya viktiga egenskaper som krävs som ledare vid hanteringen av svårhanterbara situationer. Slutsatsen av denna studie är att det finns möjlighet att minimera svårhanterbara situationer och dessutom effektivisera ledningsarbetet. / The aim of this study was to outline the experiences of charge nurses in their leadership role when dealing with challenging situations in the emergency department. This was done with a view to gain new insights/understanding that would improve leadership (skills) and hence the quality and safety of patient care. Several studies have shown that it is important to have experienced and competent charge nurses for an emergency department to perform/function to its optimal capacity. The responsibilities of the charge nurse are many and include; being the first point of contact for the emergency department, taking charge if a major incident occurs, and to support the staff by co-ordinating and managing the workload between all the different areas in the department. Financial cutbacks to the Swedish health care system have led to reorganisation and increased demand on the emergency departments. To continue to deliver good quality and safe care it has therefore become even more important for frontline health care staff to have/receive clear and stable leadership from a highly competent charge nurse who supports and reinforces teamwork. This was done with a view to gain new insights/understanding that would improve leadership skills and hence the quality and safety of patient care. The method used in this study was semi-structured qualitative interviews with eight charge nurses from four different emergency departments located in Stockholm. The interviews have been processed through a qualitative manifest content analysis to highlight the charge nurses’ experiences in relation to the aim of the study. The charge nurses´ experiences have been summarised into three categories to capture the different perspectives; i) perceived reasons for challenging situations, ii) feelings and impressions associated with challenging situations, and iii) coping abilities in challenging situations. The three categories revealed similar findings to earlier research studies into leadership skills but also unravelled a lot of new notable information. This study shows that effective leadership is prevented when the charge nurse has got multiple responsibilities that distract from gaining an overall overview of the department. This in turn creates challenging situations in the emergency department. Another important observation was that the charge nurses’ found that the localisation and usage of guidelines further complicated rather than improved the work in the emergency department. Furthermore, the interviews highlighted the consequences of the financial cutbacks within the health care sector that have had negative implications on the wellbeing of staff and patient relatives. A pertinent finding was that one of the emergency departments in this study still expects the charge nurse to be responsible for hands on patient care whilst maintaining an overview of the workflow in the emergency department. This despite the proven importance of the charge nurse to give her undivided attention to provide effective leadership. Finally, this study has shown that charge nurses found that with experience they discovered new abilities that are required to provide effective leadership in challenging situations. In conclusion this study showed that there are opportunities to minimise challenging situations from arising but also to improve the efficiency of the leadership work.

Bakgrund: Arbetsmiljön i akutsjukvården, som många gånger är krävande och hektisk, kan vara påfrestande för ledningssjuksköterskan då de innehar en nyckelposition för hela sjukhuset. När det råder crowding på akutmottagningen och resurserna inte räcker till för att möta patienters vårdbehov är det är direkt livsavgörande att personalen som omhändertar kritiskt sjuka patienter besitter hög kompetens och känner sig trygga i sitt arbete. För att säkerställa och bibehålla en patientsäker vård är det av stor vikt för personalen att de har en ledningssjuksköterska som verkar för gott samarbete, ger stöd och handledning. Syfte: Att undersöka ledningssjuksköterskans erfarenheter och hantering av crowding på akutmottagningar. Metod: Studien utfördes på två akutmottagningar i Sverige och kvalitativ metod innehållande enskilda intervjuer valdes då ambitionen var att undersöka ledningssjuksköterskors erfarenheter och hantering av crowding på akutmottagning. Kvalitativ innehållsanalys användes vid analys av textmaterialet. Resultat: Studiens fynd omfattade fyra kategorier och dessa var; Patientosäkerhet vid crowding, Strukturella förutsättningar, Upplevelsen av crowding och Att leda vid crowding. Diskussion: Ledningssjuksköterskor på akutmottagningen blir ofta utsatta för hög arbetsbörda och tidspress då det råder crowding. Kollegors kompetens och stöd från arbetsgruppen är av stor vikt för att klara av att upprätthålla patientsäkerheten. Ett förbättrat stöd från ledningen, erfarenhet och adekvat utbildning ger ledningssjuksköterskan bättre förutsättningar för att hantera crowding. / Background: The working environment within the emergency department, which in many cases are demanding and hectic; can be strenuous for the charge nurses as they hold a key position in the hospital. When there is crowding in the emergency department and the resources are not sufficient to meet the patients' care needs it is directly vital that the personnel who take care of critically ill patients must possess high qualifications and feel secure in their work. To ensure and maintain patient safe care it is of utmost importance for the personnel to have a charge nurse who initiates good collaboration, gives support and guidance. Aim: To investigate the charge nurse experiences and management of crowding at the emergency department. Method: The study was performed at two emergency departments in Sweden. A qualitative method consisting of separate interviews was used as the ambition was to investigate the charge nurses' experience and management of crowding at the emergency department. A qualitative analysis of content was used for the analysis of the body of the interviews. Results: The findings of the study comprise four categories: patient insecurity during crowding, structural prerequisites, experiences of crowding and to lead during crowding. Conclusion: The charge nurses at the emergency department are often exposed to extensive workload and time pressure due to crowding. The colleagues' competence and support from the team are of utmost importance to maintain the safety of the patients. Improved support from the management and adequate training give the charge nurse enhanced prerequisites to deal with crowding.