Inledning: Vid en förvärvad hjärnskada är delaktighet i rehabiliteringen en central del för patientens återanpassning till vardagen och eventuellt tillbakabildande av förlorade funktioner. Delaktighet i vårdförloppet leder till en ökad teoretisk förståelse och praktisk insikt hos patienten. Syfte: Syftet med denna studie var att beskriva hur vuxna personer med förvärvad hjärnskada upplever/har upplevt delaktighet under sin vårdtid på en rehabiliteringsavdelning. Metod: Detta är en kvalitativ studie med beskrivande design med semistrukturerade intervjuer som datainsamlingsmetod. Tio patienter som vårdats minst fem arbetsdagar på en rehabiliteringsavdelning intervjuades gällande frågor om delaktighet under vårdtiden på rehabiliteringsavdelningen. En kvalitativ innehållsanalys inspirerad av Graneheim och Lundman (2012) användes för att analysera insamlad data på latentnivå. Resultat: Utifrån temat ”delaktighet” uppstod tre kategorier: kompetent personal, informerad patient, samt självständighet. Temat ”icke-delaktighet” resulterade i två kategorier: bristfällig information och kontrollförlust. Det var flera av informanternas berättelser som liknade varandra i fråga om delaktighet på vårdavdelningen. Samtliga informanter beskrev att de upplevt sig vara delaktiga någon gång under vårdtiden på rehabiliteringsavdelningen. Det handlade bland annat om att de upplevt att de fått tillräcklig information från personalen angående sjukdom och vårdförlopp, att det fanns kompetent personal som anpassade sig efter patienternas individuella behov och önskemål samt möjlighet till självständighet under exempelvis träning. Ett flertal informanter beskrev även upplevelser av att inte vara delaktiga under vårdtiden. Bristfällig information från personalens sida samt en känsla av kontrollförlust var de huvudsakliga anledningarna till detta. Slutsats: Denna studie kan bidra till en ökad förståelse hos vårdpersonal angående delaktighet under rehabiliteringstiden för patienter med förvärvad hjärnskada. Då vårdtiderna kan vara långa på rehabiliteringsavdelningen är det särskilt viktigt med en god kontakt och bra kommunikation med patienterna för delaktighet och en patientcentrerad vård.

Syfte. Att beskriva sjuksköterskors upplevelse av bedsiderapportering på postoperativ avdelning. Bakgrund. Sjukvården blir ständigt mer specialiserad vilket resulterar i att fler yrkeskategorier blir involverade i patientens vård. Därmed ökar antalet rapporter vilket gör att de behöver bli effektivare och mindre tidskrävande. Bedsiderapportering syftar till att vara patientcentrerad men i vissa fall kan sjuksköterskorna anse att bedsiderapportering bryter mot lagen om sekretess. Metod. Kvalitativ intervjustudie med 9 deltagare. Resultat. Ett övergripande tema kunde identifieras: Bristande följsamhet till lagen om sekretess och patientens integritet. Ur temat framkom två kategorier: Att känna sig maktlös samt Att kränka patientens privata sfär. Slutsats. Studien visar på att sjuksköterskor upplever konflikt mellan att skydda patientens sekretess, integritet och att delta i bedsiderapportering. Ett flertal olika bidragande faktorer identifierades / Aim. To describe nurses experiences of bedsidehandovers at the postoperative unit. Background. Healthcare is becoming increasingly specialized, resulting in several professionals involved in patient care. This increases the number of handovers, which means that they need to be more efficient and less time consuming. Bedsidehandover aim to be patient-centered, but in some cases, the nurses believe that bedsidehandover violate the law of confidentiality. Method. A qualitative interview study with 9 participants. Results. An overarching theme could be identified: Lack of adherence to the law on confidentiality and patient privacy. From the theme emerged two categories: to feel powerless and to violate the patient's privacy. Conclusion. The study shows that nurses are experiencing conflict between protecting patient confidentiality, integrity, and to participate in bedside handover. A plurality of various contributing factors where identified. Keywords. Bedsidehandover, patient-centered, teamwork, work, specialist nurse

Rationale: Chronic diseases represent an important health burden that often involves major adaptations to manage the disease on a daily basis. Health professionals, such as the family physician, can help a person acquire more power over his or her health (enablement). While it would be useful to measure patient perception of enablement by the family doctor with a valid questionnaire, existing tools present important gaps. Aim and objectives: This study aimed at developing a self-administered questionnaire to measure the perception of patients with chronic diseases of enablement by their family physician. The objectives were: 1) To deepen the conceptualization of enablement by validating the proposed conceptual framework with patients presenting with chronic diseases and to specify the relative importance of its dimensions; 2) To operationalise the dimensions by proposing indicators of these dimensions (pool of items); 3) To verify the content validity of the questionnaire. Methods: An exploratory sequential mixed-method research design was chosen. The descriptive qualitative study (objectives 1 and 2) used in-depth interviews with 30 patients aged 35 to 75 presenting with at least one chronic disease, having the same family doctor for at least one year and recruited through maximum variation sampling. Taped interviews were transcribed and analyzed using Miles and Huberman's mixed coding method (2003a). A three-round e-Delphi study (objective 3) involved 15 Canadian experts in family medicine, able to read in French. The experts scored the items proposed on a 9-point scale (1 = Inappropriate to 9 = Very appropriate) and could suggest rewording and additions. Items scored 7-9 by the experts were considered consensual and were not presented in the following round. Items that were not consensual after the third round were decided upon by the team of researchers. Results: The partnership (the trusting relationship and decisions to be taken) that develops over time was found to be a major component of enablement. The enablement role of the physician goes beyond the medical consultation to defend the interests and safety of the patient's journey through the healthcare system. The trusting relationship combined with a good knowledge of the person may help the family physician better understand and legitimize the various feelings experienced while offering realistic hope . The family physician is in a privileged position to help patients develop their own expertise . Sixty-six items classified into six dimensions were submitted to the experts during the first round of the E-Delphi method. The first round was completed by 13 experts: 21 items were consensual; 25 items were resubmitted without any modification; 16 items were modified and four were rejected. Forty-one items were submitted during the second round, completed by 13 experts: eight items were consensual; 20 items were submitted without any modification; 12 items were modified and one item was rejected. Thirty-three items were submitted during the third round completed by nine experts: 29 items remained intact; three items were modified and one item was rejected. Conclusion: An initial 61-item questionnaire is proposed.

The task of ensuring Patient Safety is, more than ever, central in Healthcare. The report “To Err is Human” [Kohn et al. 2000], was revealing alarming numbers of incidents, injuries and deaths caused by deficiencies in healthcare activities. The book initiated assessment and change of Healthcare methods and procedures. In addition, numerous reports to Swedish HSAN (Medical Responsibility Board) have shown a high rate of information and communication deficiencies in Healthcare has a direct or indirect cause of incidents, injuries and deaths. Despite numerous of new sophisticated tools for information management in recent years, e.g., tools such as Electronic Health Records (EHR) and Clinical Decision Support Systems (CDSS), the threats to Patient Safety have not been redeemed. Rather to the contrary. Underlying reasons for this paradox are twofold. Firstly, advancements in diagnosing techniques have given rise to increasing volumes of data at the same time as the number of patients has increased due to demographic changes and advancements in treatments. Secondly, the information processing systems are far from aligned to related workflow processes. In short, we do not at present have interoperability in our Healthcare systems. In this doctoral dissertation, we present an in-depth analysis of two different “HSAN-typical” cases, where Patient Safety was jeopardized by incomplete information flows and/or information breakdowns. The cases are mirroring the apprehension of Simplicity, that is, Occam´s Razor of Diagnostic Parsimony. A well-known protocol used in Healthcare and implemented in most (knowledge based) CDSS. This rule of thumb is the foundation for the well-known adage: “when you hear hoof beats, think horses, not zebras”. Hickam´s Dictum is one well known objection to the simplifications of Occam´s Razor stating "Patients can have as many diseases as they damn well please". Of course, this Dictum is harder to implement effectively! In the thesis we suggest a visualization tool Visual Incidence Anamneses (VIA) to provide middle out compromise between Ockham and Hickam but providing means to increase Patient Safety. The findings of our Study for the thesis have resulted in a number of Aspects and Principles as well as Core-principles for future CDSS design, That is, tools and methodologies that will support designing and validating Interoperability of Healthcare systems across patient-centric workflows. The VIA tool should be used as the initiating point in a patient (individual) centered workflow, quickly visualizing vital information such as symptoms, incidents and diagnoses, occurring earlier in the medical history, at different times, to ground further vital decisions on. The visualization will enable analysis of timelines and earlier diagnoses of the patient, using visually salient nodes for visualization of causalities in context. Furthermore, support for customization of the tool to the views of stakeholders, members of healthcare teams and empowerments of the patient, is crucial.

Bakgrund: Patientnära rond är ett teamarbete mellan framförallt patient, sjuksköterska och läkare. Ett bra samarbete förbättrar relationen dem emellan. Dessutom har en framgångsrik rond mellan patient och sjukvårdspersonal stor betydelse för att patienten ska kunna få en säker och personcentrerad vård. Därför är det viktigt att få en djupare förståelse för hur patienter och sjukvårdpersonal upplever patientnära rond samt för betydelsen av teamarbetet vid patientnära rond. Syfte: Att belysa vilka effekter patientnära rond har på vårdteam samt att undersöka upplevelsen av patientnära rond utifrån perspektiven från både patienter och sjukvårdspersonal (sjuksköterskor, läkare och medicinstudenter). Metod: En litteraturstudie baserad på 14 vetenskapliga originalartiklar. Databaser som användes i studien var PubMed, Cochrane Library, Cinahl, SBU och SveMed. Resultat: Resultatet av denna studie indikerar att både patienter och sjukvårdspersonal upplever en ökad tillfredsställelse vid patientnära rond. Vidare visar resultatet att patientnära rond bidrar till att sjukvårdpersonal kan ge patienter en proaktiv omvårdnad, att samarbetet sjukvårdpersonal emellan blir mer effektivt och att patientnära rond gynnar medicinstudenters utveckling samt ökar studenters tillfredsställelse med sin utbildning. En utmaning som sjuksköterskor upplever i samband med patientnära rond är tidsbegränsning – framför allt upplever de att det tar tid för sjuksköterskor och läkare att synkronisera och koordinera mötet mellan patient och vårdpersonal samt att tid för dokumentation är bristande. Läkare upplever dessutom att deras autonomi minskas i samband med patientnära rond. Slutsats: Överlag kan patientnära rond vara ett effektivt sätt att främja personcentrerad vård. Patientnära rond har en positiv inverkan på teamarbete sjukvårdpersonal emellan samt bidrar till ökad tillfredsställelse hos både patienter och sjukvårdspersonal. Det finns dock behov av ytterligare forskning om patienters upplevelse av patientnära rond och vilka specifika åtgärder som kan vidtas för att sjukvårdpersonalen ska kunna samarbeta på ett mer effektivt sätt. / Background: The ward round is a team collaboration mainly between patient, nurse and physician. A good collaboration enhances the relationship between them. In addition, a successful round between the patient and the medical personnel is of great significance for the patient to have a safe and person-centered care. Therefore it is important to gain a deeper understanding of how patients and medical staff experience ward rounds, as well as of the importance of team work during the ward rounds. Aim: To shed light upon the effects of ward rounding on healthcare teams and to explore the experience of ward rounds from the perspectives of both patients and medical staff (nurses, physicians and medical students). Method: A literature study based on 14 scientific articles. Databases used in the study were PubMed, Cochrane Library, CINAHL, SBU and SveMed. Results: The results of this study indicate that both patients and medical personnel experience an increased satisfaction during ward rounds. Furthermore, the results show that ward rounds contribute in making medical personnel provide a proactive care to their patients, that cooperation between medical staff becomes more efficient, and that ward rounding benefits medical students’ development and increases students’ satisfaction with their education. A challenge that nurses experience during ward rounds is time limitation – mainly they experience that it takes time for nurses and physicians to synchronize and coordinate the meeting between patient and medical personnel, and also that the time for documentation is inadequate. Physicians also experience that their autonomy is reduced in relation to ward rounds. Conclusion: Overall, ward rounding can be an effective way to promote person-centered care. Ward rounds have a positive impact on teamwork between medical personnel and contribute to increased satisfaction among both patients and medical staff. However, there is need for further research on patients' perception of ward rounding and which specific measures that can be taken for the medical staff to be able to collaborate more efficiently.

A frequently cited reason for poor quality of care in the ambulatory care setting is the lack of optimally designed systems to address care for those with preventive or chronic care needs. Organizational theory suggests that culture plays an important role in the shaping of these types of programs. The purpose of this cross-sectional study is to understand through descriptive and regression analysis of secondary data, the relationship between the existence of cultural characteristics such as collegiality, quality emphasis and autonomy, and the systems employed to improve quality of care within primary care practices. The study uses an integrated theoretical framework consisting of organizational culture, social network and organizational learning theories to better understand the rationale for the relationships. The analysis is an outgrowth of a previous National Committee for Quality Assurance (NCQA) project conducted in Minnesota where 300 staff across 42 office practices were asked to answer questions on a self-report survey to assess the presence and function of clinical practice systems. To evaluate organizational culture, validated questions from the work of Kralewski and colleagues were also asked. Descriptive analysis results showed a large range in consistency of practice system use, with clinical information systems as most used and care management systems as least used. Results of the multivariate analysis showed collegiality and quality emphasis as significantly related to the use of practice systems. More specifically, both collegiality and quality emphasis were seen to positively influence the use of clinical quality evaluation and improvement systems and an emphasis of quality was seen to positively influence the use of clinician reminders and clinical information systems. A statistically significant relationship between autonomy and practice systems use was not seen. As the study shows that culture does influence the use of certain systems for care improvement, it provides an increased understanding and avenue for intervention/change in the continued quest for improved quality of care. Policymakers and practice leadership may want to focus energy on understanding primarily whether the culture of practices places an emphasis on quality and collegiality. Ultimately it may foster the use of practice systems for quality of care improvement.

Made available in DSpace on 2016-08-10T10:54:54Z (GMT). No. of bitstreams: 1 RENATA MOURA DE CARVALHO.pdf: 1383256 bytes, checksum: 4cef8119d9baa087062d9de6420baf42 (MD5) Previous issue date: 2016-02-24 / Over the years hospitals were turning into places with high technology and infrastructure to serve more efficiently a greater share of the population. This process generated depersonalization due to the technicistic nature that these environments became to have. Many environments have become cold, frightening and ruthless reflecting on the quality of life within these spaces. When health care is focused on a child or teenager the patient centered care s issues should be raised as key points to their well-being during hospital stay being important to understand the perception that users and professionals have about the environment they are in. This study aims to explore the perspectives of users and professionals at a Pediatric Oncology Hospital in Goiânia and of regional architects about the contribution of the architectural physical environment for the process of patient centered care. It had as methodology the qualitative research with the theoretical support in Grounded Theory in Constructivist Data by Kathy Charmaz (2009) where the data was obtained from shared experiences and the relationships with participants. It was used as data collection instrument, semi-structured interviews with ten companions, seven patients, six healthcare professionals and three architects. The results highlight six categories: Attempts to adapt; Wear in the hospital; Quality of the functional structure of the hospital; Failures in quality of the hospital s operation; Quality of hospital s physical structure and failures in the quality of the hospital s physical structure. / Com o passar dos anos os hospitais foram se transformando em espaços com alta tecnologia e infraestruturas para atender com mais eficiência uma maior parcela da população. Esse processo gerou a despersonalização devido ao caráter tecnicista que esses ambientes passaram a ter. Muitos ambientes se tornaram frios, assustadores e desumanos repercutindo na qualidade de vida dentro desses espaços. Quando a atenção em saúde é focada na criança ou no adolescente as questões de humanização devem ser levantadas como pontos-chave para o bem-estar durante a hospitalização sendo importante entender a percepção que os usuários e profissionais têm quanto ao ambiente em que estão. Este trabalho tem como objetivo explorar as perspectivas dos usuários e profissionais de um hospital oncológico pediátrico em Goiânia e de arquitetos regionais quanto à contribuição do ambiente físico arquitetônico para o processo de humanização. Teve como metodologia a pesquisa qualitativa com o suporte teórico na Teoria Fundamentada em Dados Construtivista de Kathy Charmaz (2009), onde os dados foram obtidos a partir de experiências compartilhadas e das relações com os participantes. Foi utilizado como instrumento de coleta de dados, entrevistas semiestruturadas com dez acompanhantes, sete pacientes, seis profissionais da saúde e três arquitetos. Dos resultados emergiram seis categorias: Tentativas de adaptação; Desgaste no hospital; Qualidade da estrutura funcional do hospital; Falhas na qualidade do funcionamento do hospital; Qualidade da estrutura física do hospital e Falhas na qualidade da estrutura física do hospital.

Health care today harms too frequently and routinely fails to deliver its potential benefits. Significant evidence suggests that high quality primary care can positively affect health outcomes. I explored three related topics mentioned frequently in current United States health reform €“ Electronic Health Records (EHR), physician profiling and Medical Home. An investment in these areas is expected to significantly improve quality of care and efficiency; however, there is only a patchwork of evidence supporting such claims. To achieve EHR promises, my research employed a standardization lens to study the dynamics between EHR embedded structures and primary care processes. Using grounded theory, a standardization dynamics model was created describing the influencers, conditions and consequences of the process state. A matrix of two conditions, information exchange and patient complexity, identified four distinct pathways that require a different balance between standardization and flexibility. The value of such pathways is that they frame choices about how to use embedded IT structures to support effective delivery processes. Physician profiling is an emerging methodology used in health care quality improvement programs. Efforts to measure performance at the individual physician level face a number of challenges, including the need for sufficient sample size to support reliable measurement. A process for creating a physician profiling model was developed, and a model designed for a case study site. Results indicate that reliable physician profiling is possible across care domains using a hierarchical composite model. Patient-Centered Medical Home (PCMH) is a new care delivery approach for providing comprehensive primary care that seeks to strengthen the physician-patient relationship. This exploratory study utilizes Pearson correlation coefficients to test four hypotheses about relationships between two sources of data: (1) PPC-PCMH Survey results that measure adoption of PCMH structures and (2) patient experience data from Massachusetts Health Quality Partners (MHQP). The results showed that the PPC-PCMH structures of access and communication were negatively correlated with the related patient experience measure. This study contributes to the literature by addressing deficiencies in how EHR-enabled processes, physician profiling models and Medical Home constructs are measured, to support improved outcomes.

Background: Type 2-diabetes is a growing public health problem that cause suffering for people living with the disease and it is expensive for the Swedish healthcare system. The diabetes specialist nurse is often the person who stands for the continuity in the diabetes care and therefore has a big inpact on the outcome. The aim of this study was to describe the diabetes nurse’s experience of nursing care for adults with type 2-diabetes in primary care. The used method is qualitative. Eight diabetes nurses were interviewed with semi structured interviews and the content was analysed with qualitative content analysis. The result showed obstacles, dilemmas and possibilities experienced in diabetes care. Conclusion: There is a winning in knowing about obstacles, dilemmas and possibilities that can be experienced by diabetes specialist nurses in order to maintain a good diabetes care. The experienced obstacles and dilemmas needs to be continuously studied in order to keep evolving the diabetes care.

The purpose of this qualitative pilot study is to explore the patient perspectives about what it is like to receive a bed bath. Examining studies of bath basins versus alternative methods has shown a decrease in the spread of nosocominal infections. However, there is not sufficient evidence evaluating the patient perspectives of assistive bed bathing and interactions with nurses and nursing support staff. This information can provide healthcare providers, especially nurses, with a better understanding of patient perspectives and values. It also supports the national healthcare approach towards patient-centered care.