The aim of this study was to examine to what extent patients remained silent to the health care system after they experienced abusive or wrongful incidents in health care. Female patients visiting a women’s clinic in Sweden (n = 530) answered the Transgressions of Ethical Principles in Health Care Questionnaire (TEP), which was constructed to measure patients’ abusive experiences in the form of staff’s transgressions of ethical principles in health care. Of all the patients, 63.6% had, at some point, experienced staff’s transgressions of ethical principles, and many perceived these events as abusive and wrongful. Of these patients, 70.3% had remained silent to the health care system about at least one transgression. This silence is a loss of essential feedback for the health care system and should not automatically be interpreted as though patients are satisfied. / <p>funding agencies|Nordic Council of Ministers||Swedish Research Council|2009-2380|</p>

The objective of the thesis was to evaluate the quality of diabetes care in the Canadian Forces by determining the extent to which physicians adhere to recommendations outlined in the 2008 Canadian Diabetes Association (CDA) clinical practice guidelines. In addition, the effect of patient age, sex, rank and size of base on quality of care was assessed and the accuracy of a diagnosis of diabetes in an extract of the electronic medical record (EMR) was evaluated. Fourteen bases within the Canadian Forces were selected for investigation, representing roughly half of the Canadian Forces population. Cases of diabetes were ascertained based on laboratory criteria following a chart review. Twenty-one CDA guideline recommendations were considered. The Canadian Forces demonstrated greater than 75% adherence with each of 9 recommendations, 50-75% adherence with each of 7 recommendations and less than 50% adherence with each of 5 recommendations. The overall adherence with all applicable recommendations per patient was 60.3% (SE 0.66). Age, sex, rank and size of base were not important factors influencing guideline adherence. The sensitivity of a diabetes diagnosis in an extract of the EMR was 84.5%, the specificity was 99.8%, the positive predictive value was 85.1% and the negative predictive value was 99.8%. This is similar to the performance of provincial and national diabetes registries. The quality of diabetes care in the Canadian Forces compared favourably with that of the civilian population within Canada and internationally. The creation of a diabetes registry is expected to lead to further improvements in diabetes care.

Background: The Senate of Canada asserts that quality end-of-life care is the right of every Canadian. Yet, little is known about the quality of end-of-life care for dying children and their families. Purpose: The study purpose was to develop and test an instrument to measure parents’ perspectives on the quality of care provided to families before, at the time of, and following the death of a child. Methods: In study Phase I, key components of quality pediatric end-of-life care were synthesized through a systematic review of research literature then validated and extended through focus groups with bereaved parents. In Phase II, instrument items were developed to assess structures, processes, and outcomes important to quality end-of-life care, then tested for content and face validity by health professionals and bereaved parents. In Phase III, the instrument was administered to bereaved mothers from across Canada and psychometric testing conducted. Results: Instrument items were developed based on review of 67 manuscripts and 3 focus groups with 10 parents. The Content Validity Index for the instrument was 0.84 as assessed by 7 health professionals. The instrument was assessed by 6 bereaved parents for face and content validity as well as their cognitive understanding of the items. In the final phase, 128 mothers completed the instrument and 31 of those completed it twice. Initial evidence for test-retest reliability, internal consistency, and construct validity was demonstrated for 7 subscales: Connect with Families, Involve Parents, Share Information with Parents, Share Information among Health Professionals, Support Parents, Provide Care at Death, and Provide Bereavement Follow-up. Additional items with demonstrated content validity only were grouped into three domains: Support the Child, Support Siblings, and Structures of Care. Implications: This study is a significant step forward in comprehensive measurement of the quality of children’s end-of-life care. The instrument provides a mechanism for feedback to health professionals, health systems, and policy makers to improve care provided to families facing the death of a child.

Background: The Senate of Canada asserts that quality end-of-life care is the right of every Canadian. Yet, little is known about the quality of end-of-life care for dying children and their families. Purpose: The study purpose was to develop and test an instrument to measure parents’ perspectives on the quality of care provided to families before, at the time of, and following the death of a child. Methods: In study Phase I, key components of quality pediatric end-of-life care were synthesized through a systematic review of research literature then validated and extended through focus groups with bereaved parents. In Phase II, instrument items were developed to assess structures, processes, and outcomes important to quality end-of-life care, then tested for content and face validity by health professionals and bereaved parents. In Phase III, the instrument was administered to bereaved mothers from across Canada and psychometric testing conducted. Results: Instrument items were developed based on review of 67 manuscripts and 3 focus groups with 10 parents. The Content Validity Index for the instrument was 0.84 as assessed by 7 health professionals. The instrument was assessed by 6 bereaved parents for face and content validity as well as their cognitive understanding of the items. In the final phase, 128 mothers completed the instrument and 31 of those completed it twice. Initial evidence for test-retest reliability, internal consistency, and construct validity was demonstrated for 7 subscales: Connect with Families, Involve Parents, Share Information with Parents, Share Information among Health Professionals, Support Parents, Provide Care at Death, and Provide Bereavement Follow-up. Additional items with demonstrated content validity only were grouped into three domains: Support the Child, Support Siblings, and Structures of Care. Implications: This study is a significant step forward in comprehensive measurement of the quality of children’s end-of-life care. The instrument provides a mechanism for feedback to health professionals, health systems, and policy makers to improve care provided to families facing the death of a child.

<p>This dissertation aimed to investigate the use of electronic nursing documentation as a strategy to improve the quality of care provided to hospitalized patients. The literature to support the use of electronic nursing documentation on the quality of care delivered to patients is limited to date. Additionally, the literature describing the use of information for the delivery of care on paper-based nursing documentation is limited. This dissertation reviews the current literature, investigated the knowledge needed for nurses to know their patients and established categories of nurses' information needs as preliminary work to be able to descriptively compare the use of paper with electronic nursing documentation on inpatient care units within a hospital setting. The main study conducted for this investigation used a mixed-methods multiple case study design, to describe the processes of information use on two inpatient care units, while first using paper and subsequently electronic nursing documentation. Findings revealed the importance of the categories of nurses' information needs for both cases in addition to the use of verbal, paper-based and electronic information sources for the collection, communication and temporary storage of information needs. Additionally, the conversion to electronic nursing documentation introduced new challenges related to three quality metrics: efficiency, timeliness and safety. Recommendations are provided for further evaluation of electronic health records with additional consideration for appropriate hardware devices in the context of the care environment.</p> / Dissertation

Syfte: Syftet med denna studie var att undersöka hur nöjda patienter var med den vård de fått på en klinisk utbildningsavdelning, KUA, och om det fanns skillnader mellan hur nöjda män och kvinnor var med vården. Metod: Data samlades in via enkäter där patienter fick skatta nio olika påståenden samt besvara tre frågor med egna ord. Enkäterna besvarades av 33 patienter. Svaren på de öppna frågorna analyserades med innehållsanalys. Deskriptiv statistik användes för att beskriva patienternas tillfredsställelse med vården. För att påvisa eventuella skillnader i upplevelsen av vårdkvalitet mellan män och kvinnor användes Mann Whitney U-test. Resultat: Resultatet visade att patienterna var mycket nöjda med vården de fått på KUA. Vårdkvaliteten skattades högt och patienterna upplevde framför allt att de blivit positivt bemötta, känt sig trygga vid provtagningar och undersökningar samt fått tillräckligt mycket information inför operationen. Det visade sig att det fanns en signifikant skillnad mellan hur män och kvinnor upplevde informationen de fått efter operationen. De kvinnliga patienterna upplevde i högre grad än männen att de fått tillräcklig information. Slutsats: Vårdkvaliteten på KUA var hög. Det fanns en signifikant skillnad mellan hur män och kvinnor upplevde informationen efter operationen men andra signifikanta skillnader i upplevelser saknades.

Unsatisfactory working conditions and job stress may be indicative of working in a society where work-life balance is a desired, but often elusive, goal (Duxbury & Higgins, 2001; Smola & Sutton, 2002; Sturges & Guest, 2004). Working conditions in the healthcare sector are reported to be particularly problematic and stress inducing compared to other work sectors (Yassi, Ostry, Spiegel, Walsh, & de Boer, 2002). In fact, quality of work life (QOWL) among healthcare workers is believed to have deteriorated to the point where it is impeding the capacity of the system to recruit and retain staff needed to provide effective patient care (Koehoorn, Lowe, Rondeau, Schellenberg, & Wager, 2002). The purpose of the study was to examine the experiences of healthcare staff who participate in QOWL initiatives aimed to provide employees with creative, educational, and fun activities designed to address feelings of stress. This study included thirteen staff members from disciplines that comprise the Health Care Team at a facility specializing in aging and veteran's care. Data were collected through conversational interviews with staff from each of the following disciplines: nursing, recreation therapy, physiotherapy, creative arts, clinical nutrition, social work, audiology, occupational therapy, and pastoral care. The data were deconstructed into common themes through an open-ended process, which lead to the identification of common experiences across the data provided by the staff. Upon further comparison of the themes, it was identified that work demands were believed to detract from care provision and strained manager relations were believed to minimize quality of care. However, a strong professional identity was evident as staff described being able to rise above adversity and use their skills and competencies to provide quality care to residents. The data also suggested QOWL initiatives seem to be valuable because they provide opportunities for staff to interact socially. This interaction helps foster and strengthen connections amongst staff, which they feel transfers to the work place through improved working relationships. Participants described feelings of personal gratification that can be derived from team cohesiveness. They also acknowledged the carry over value that team work brings to residents by way of improved care provision. Furthermore, the relationships that staff members develop with one another were viewed as sources of strength, particularly in times of increased stress. In addition to the social element associated with the QOWL initiatives, these initiatives also seem to address a need for restoration, humour, and balance within the work day. Without planned opportunities for rejuvenation and humour appreciation, participants admitted that they would seldom take the time to incorporate these into their work day. Therefore, QOWL initiatives can provide staff with a reason to take a break and find their balance. The findings indicate the factors affecting QOWL are varied and complex. The findings also indicate that there can be a paradoxical nature to work within a health care setting. Paradoxes exist in relation to the provision of professional care and the provision of minimized care. Paradoxes also exist in relation to the expressed need for restoration, humour, and balance and the low priority staff will place on taking time to fulfill these needs.

Syfte: Att undersöka sjuksköterskors uppfattningar om avvikelser i vården och om bakomliggande orsaker till dessa samt inställningar till avvikelserapportering och -hantering. Studien syftade även till att undersöka uppfattningar om hur nyanställda sjuksköterskor påverkas av rådande inställningar till detta på en vårdavdelning. Metod: Kvalitativ metod med explorativ design. Bekvämlighetsurval tillämpades och data samlades in med hjälp av semistrukturerade intervjuer med sex sjuksköterskor från en medicinsk vårdavdelning på ett svenskt universitetssjukhus. Dataanalysen genomfördes med fenomenografisk metod. Resultat: Sjuksköterskornas generella uppfattningar om förekommande avvikelser inom vården kan sammanfattas som säkerhetsbrister för patienter och personal. Orsakerna till avvikelser kan indelas i flera kategorier varav ”hög arbetsbelastning” är den mest omfattande. Närapå samtliga orsaker kan härledas till brister i organisation och/eller ledning. Att avvikelser inträffar anses allvarligt men mänskligt och ofrånkomligt. Sjuksköterskorna har olika attityder till avvikelserapportering t.ex. att man ser det som ett led i förbättringsarbetet eller utser syndabockar. Generellt uppfattas att avvikelser underrapporteras. Ett antal faktorer såsom graden av säkerhetsrisk, tidsbrist samt tvivel på uppföljning uppfattas som avgörande för om man väljer att rapportera en avvikelse eller inte. Sjuksköterskorna efterfrågar feedback och information om rapporterade avvikelser. Nyanställda sjuksköterskor uppfattas påverkas starkt av andra sjuksköterskor gällande attityder till avvikelser såväl som avvikelserapportering. / Aim: To examine nurses' opinion about errors in their profession and the underlying causes of these. A further aim was to study attitudes towards error reporting and to examine whether more experienced colleagues’ opinion concerning error making and error reporting had any effect on newly employed inexperienced nurses. Methods: The study was qualitative with an explorative design. Convenience sampling was applied and data was collected by semi-structural interviews. Six nurses from a medical care unit participated in the study and data was analyzed with a phenomenographic method. Results: The major category of nurses' views about error making included lack of patient safety and working environment issues is another category. It could all be summed up in one major category called ”lack of safety” including both patients and personnel. Several categories were identified as causes of error making, among those high workload is the most frequently mentioned cause. Nearly all of the causes can be traced to lacking in organization and/or management. The fact that errors occur are regarded as severe but human and inevitable. Several attitudes towards reporting errors were emerged from the data, for example regarding it as a tool of improvement work or finding scapegoats. The most common view was that errors are underreported and a number of factors regarding nurses' willingness to report the errors were found, for example severeness of the error, lack of time and doubt in follow up. Nurses wished to get feedback and information about reported errors. Inexperienced nurses were highly influenced by their senior colleagues concerning both error making and error reporting.

Överrapportering är en process då patientspecifik informa­tion förmedlas till sjuksköterskan i början av ett pass. Över­lämnande sjuksköterska formar innehållet i överrapporter­ingen efter det behov som framkommer under överrapporter­ingen. Kvaliteten i vården återspeglas av vårdkvalitet utifrån vårdindikatorer och patientens tillfredsställelse. Brister i över­­rapportering kan leda till skada eller till och med död för patienten, då information i överrapporteringen exempelvis är inkomplett. Syftet med studien var att belysa överrapporter­ingen mellan sjuksköterskor relaterat till kvalitet i vården. Studien utfördes som en litteraturstudie där resultatet grund­as på femton artiklar. Resultatet belyser överrapporter­ingen i tre kategorier nämligen tillvägagångs­sätt i över­rapporter­ing, överrapporteringens innehåll relaterat till kvalitet och prakt­iska och sociala aspekter på över­rapport­er­­­ing. Över­rapport­er­­ingen innehåller betydelsefull information som sjuk­sköter­skan använder i sitt arbete. Brister i överrapporter­ingen kan därför inverka i vårdarbetet och påverka kvaliteten på vården. Ett behov av ytterligare forskn­­ing på området är önskvärt, då det finns fler forskningsfrågor att utveckla. Över­rapporter­ingen bör även belysas i utbild­ningen till sjuksköterska, då detta skapar möjligheter för förändring i omvårdnadsarbetet. / Handover is a process where patient specific information is given at the beginning of each shift. The nurse that delivers the handover forms the content depending of the need that emerges during the course of the handover. Care quality is reflected by the quality of health care that emerges from care indicators and patient satisfaction. Deficiencies in handovers can lead to injury or even death for the patient when for example the information in the handover is incomplete. The aim of this study was to explore handovers between nurses related to the quality of care. The study was conducted as a literature review and the result is based on fifteen articles. The result illustrates handover in three categories, procedures in the handover, handover content related to quality and practical and social aspects of handover. Handover contains significant components that the nurse´s use in their line of work. Deficiencies in handovers may therefor affect nursing care and the quality of care. Further research in this area is needed, because the research is not well developed. Handovers should be highlighted in nurse education, because it creates opportunities for changes in nursing practice.

Documentation in electronic journals is perceived as time consuming and sometimes technically difficult to handle, but also leads to an improved quality of care. Objective: The purpose of this study was to investigate nurses' perceptions of documentation with a focus on timing, technique and quality of care and whether any differences in these perceptions were dependent on age. Method: Quantitative descriptive cross-sectional study in the survey form, 28 nurses at a university hospital in central Sweden participated in the study. Regression analysis was performed with Spearman's rank correlation coefficient. Results: Electronic documentation takes 30 to 60 minutes for most nurses and half of them considered it a reasonable time. Computer skills were good enough for most, but the computers and the electronic patient record system Cosmic were experienced to work less well or badly in half the study group. Two-thirds of the studygroup agreed partly or more to that the quality of care is adversely affected because of the time documentation takes from the patient care. However, about half of the study group agreed that electronic patient records increase health care quality and patient safety. Care plans were used to a great extent. Young nurses rated themselves significantly better than the older ones to handle a computer in their daily work. Conclusion: A variety of problems and perceptions exist in connection with electronic documentation. Continuous development of technology, documentation systems and the use of care plans can contribute to the continuing high quality of care and patient safety. / Dokumentation i elektronisk journal uppfattas som tidskrävande och ibland tekniskt svår att hantera, men leder även till en ökad vårdkvalitet. Syfte: Studiens syfte var att undersöka sjuksköterskors uppfattningar av dokumentering med fokus på tidsåtgång, teknik och vårdkvalitet samt om eventuella skillnader i dessa uppfattningar fanns beroende på ålder. Metod: Kvantitativ deskriptiv tvärsnittsstudie i enkätform, 28 sjuksköterskor vid ett universitetssjukhus i Mellansverige deltog i studien. Sambandsanalys utfördes med Spearmans rangkorrelationskoefficient. Resultat: Elektronisk dokumentation tar 30 till 60 minuter för de flesta sjuksköterskorna och hälften ansåg att detta var en rimlig tid. Datorvanan var tillräckligt god hos de flesta, men datorerna och dokumentationssystemet Cosmic upplevdes fungera mindre bra eller dåligt hos hälften av undersökningsgruppen. Två tredjedelar instämde delvis eller mer i att vårdkvalitén påverkas negativt på grund av den tid dokumentation tar från patientvården. Ungefär hälften instämde i att elektronisk dokumentation bidrar till en ökad vårdkvalité samt patientsäkerhet. Vårdplaner används i hög utsträckning. Yngre sjuksköterskor skattade sig signifikant bättre än äldre på att hantera en dator i det dagliga arbetet. Slutsats: Flera olika problem och uppfattningar föreligger i samband med elektronisk dokumentation. Kontinuerlig utveckling av tekniken, dokumentationssystemen och användandet av vårdplaner kan bidra till en fortsatt hög vårdkvalitet samt patientsäkerhet.