This thesis has set out to investigate the role of music therapy in the form of the specialist Bonny Method of Guided Imagery and Music (GIM) with a view to exploring how meanings related to adjustment from a health crisis (such as cardiac surgery) are depicted in music-supported imagery. Factors shaping clinical interpretations of verbal and musical responses in music therapy practice are often unclear or undelineated. A systematic interpretive process relevant to clinical health care was developed using the Bonny Method of Guide Imagery and Music (GIM), providing a means for exploring the emotional difficulties of coronary bypass patients, who typically recover quickly from physical surgery but often experience residual symptoms such as depression, pain, and anxiety. The interpretive process accessed both verbal and non-verbal texts, playing them against each other in order to find significance for music therapy practice in rehabilitation. A Bonny Method of Guided Imagery and Music (GIM) series was undertaken by patients recovering from coronary artery bypass grafting (CABG), with each session audiotaped and transcribed. This narrative data was analyzed thematically, and grand themes were used to focus further intertextual (semiotic) and Jungian perspectives, in the process of deriving substantial clinical meanings. Results suggested that participants used a wide range of personal, cultural and archetypal texts to convey meanings about their health care situation, including images of the music during the therapeutic process. Clinical change in the rehabilitative process was suggested by grand themes comprising 'Looking through the frame', 'Feeling the impact', 'Spiralling into the unexpected', 'Sublime plateau', and 'Rehearsing new steps' and the further music-related grand theme of 'Sounding the changes'. This project highlights the value of GIM as a vehicle to track clinical change with cardiac patients, based on a systematic interpretive process sensitive to the interweaving verbal and nonverbal texts evident in the music therapy context.

<p>Akut förvirring hos höftfrakturpatienter är vanlig. Den akuta förvirringen kan förebyggas eller kortas och rehabiliteringstiden kan då också kortas. Ett förvirringstillstånd innebär stora påfrestningar på kroppen. Syftet med denna litteraturstudie är att se hur litteraturen beskriver hur man kan ge en god postoperativ omvårdnad och ett gott bemötande till de patienter som drabbas eller riskerar att drabbas av postoperativ förvirring. Till grund för arbetet ligger ett antal vetenskapliga artiklar samt facklitteratur. Trots att den postoperativa förvirringen är mycket vanlig, att den orsakar stort lidande och stora vårdkostnader, saknas tillfredsställande studier som kan ligga till grund för farmakologiska behandlingsrekommendationer. Oaktat detta ges ofta farmaka till dessa patienter. Enligt litteraturen har sjuksköterskans möte med den deliriösa patienten stor betydelse för att förebygga och lindra ett förvirringsbeteende. Eftersom det saknas riktlinjer för omvårdnad av akut förvirrade patienter beror det på den enskilda sjuksköterskans bemötande hur mötet med patienten blir. Den postoperativa förvirringen måste lyftas fram eftersom antalet patienter med höftfrakturer ständigt ökar. Rutiner och vårdprogram måste tas fram eller ses över. Vi måste lära oss att bemöta dessa patienter på ett professionellt sätt. Att möta den förvirrade höftledspatienten på ett etiskt och förberett sätt är en förutsättning för en bra vård.</p>

<p>The aim of this thesis was to identify important aspects of surgical nursing care, designing strategic and clinical quality indicators in postoperative pain management, investigate content validity, develop and evaluate psychometric properties of an instrument to measure the indicators, test the applicability of the instrument and investigate patient and nurse assessment.</p><p>To identify the important aspects of nursing care which might impact on quality of care in surgical wards, it was conducted 4 focus group interviews with clinical nurses (n=20). A tentative model with 15 categories in 2 dimensions, elements of performance and prerequisites, emerged from the data analysis. The categories were, e.g. detecting and acting on signs and symptoms, informing and educating, promoting relationships, responsibility and attitudes. The model was used as a foundation for developing indicators in postoperative pain management, one in each category, each supported by a literature review. To assess the content validity of the indicators, a questionnaire was compiled and sent to registered nurses with a special interest in pain (n=210) and to a random sample of clinical nurses working in surgical wards (n=321). The groups assessed the indicators as essential for achieving high quality, realistic to carry out and possible for nurses to influence management. The first group validated 14 of the 15 indicators and the second group validated 12 as “major” factors in terms of being essential to achieve high quality of care. The remaining factors were classified as “supportive”. No indicator was discarded.</p><p>To measure the indicators, an instrument was developed and psychometric properties were evaluated. The indicators were converted to statements suitable for a patient questionnaire and were scored on a 5-point scale with higher values indicating higher quality of care. Patients (n=198) answered the questionnaire on their second postoperative day. The inter-item and item-total correlation coefficients were in a satisfactory range, and Cronbach’s coefficient alpha (0.84) supported internal consistency reliability. Four sub-scales, entitled communication, action, trust and environment emerged from the factor analysis with a total variance of 61.4%. The total scale correlated (rs=0.53) with the single item pain-relief-satisfaction question. The patients who reported more pain than expected scored lower on the total scale and the patients who received epidural analgesia reported higher scores on the total scale. A nurse questionnaire, similar to the patient questionnaire, was compiled. The responsible nurse at the time (n=63) answered 196 questionnaires paired with the individual patient. The new instrument appeared to be useful in identifying important areas for improvement both from the patients’ and nurses’ perspectives, based on the number of disagreements (1 and 2). Differences were found among departments. The patients’ assessments on the environment sub-scale and the overall satisfaction question were higher than the nurses’ assessments. The findings suggest initial support for the instrument as a means to measure the quality of nursing care in postoperative pain management. Key words: quality indicators; health care, pain; postoperative, focus groups, psychometrics, questionnaires, nursing care.</p> / On the day of the public defence of the doctoral thesis the status of the articles III was: Accepted; article IV and V was: Accepted for publishing.

<p> </p><p>The aim of the study was auditing medical records examine postoperative blood glucose levels after undergoing CABG surgery. Furthermore the aim was to determine if the ward staff abides the local guidelines frame of reference concerning each ward, regarding blood glucose measurements and blood glucose levels. The study included 70 patients undergoing CABG surgery at the cardiothoracic surgery, Uppsala University Hospital. The study was conducted by retrospective medical record auditing. Studied factors were postoperative blood glucose levels, number of registered blood glucose measurements, a current diagnosis of DM and preoperative HbA_1c. Mean level of blood glucose levels stayed continuously above the local guidelines frame of reference for both TIVA/TIMA and the care ward throughout the continuity of patient care. The number of registered blood glucose measurements per postoperative day at TIVA/TIMA where within the local guidelines. The result showed that the local guidelines frame of reference concerning the ward were not reached. A difference could be seen between patients with DM and patients without DM regarding the previously mentioned factors. Preoperative elevated levels of HbA_1c could have influenced the number of postoperative blood glucose measurements. Recommendations will therefore be too audit the current local guideline that concerns the treatment, therapy goals and the number of blood glucose measurements. Establishing criterions regarding termination of blood glucose measurements and the transfer day between TIVA/TIMA and the care ward are recommended.</p><p> </p>

The aim of this thesis was to identify important aspects of surgical nursing care, designing strategic and clinical quality indicators in postoperative pain management, investigate content validity, develop and evaluate psychometric properties of an instrument to measure the indicators, test the applicability of the instrument and investigate patient and nurse assessment. To identify the important aspects of nursing care which might impact on quality of care in surgical wards, it was conducted 4 focus group interviews with clinical nurses (n=20). A tentative model with 15 categories in 2 dimensions, elements of performance and prerequisites, emerged from the data analysis. The categories were, e.g. detecting and acting on signs and symptoms, informing and educating, promoting relationships, responsibility and attitudes. The model was used as a foundation for developing indicators in postoperative pain management, one in each category, each supported by a literature review. To assess the content validity of the indicators, a questionnaire was compiled and sent to registered nurses with a special interest in pain (n=210) and to a random sample of clinical nurses working in surgical wards (n=321). The groups assessed the indicators as essential for achieving high quality, realistic to carry out and possible for nurses to influence management. The first group validated 14 of the 15 indicators and the second group validated 12 as “major” factors in terms of being essential to achieve high quality of care. The remaining factors were classified as “supportive”. No indicator was discarded. To measure the indicators, an instrument was developed and psychometric properties were evaluated. The indicators were converted to statements suitable for a patient questionnaire and were scored on a 5-point scale with higher values indicating higher quality of care. Patients (n=198) answered the questionnaire on their second postoperative day. The inter-item and item-total correlation coefficients were in a satisfactory range, and Cronbach’s coefficient alpha (0.84) supported internal consistency reliability. Four sub-scales, entitled communication, action, trust and environment emerged from the factor analysis with a total variance of 61.4%. The total scale correlated (rs=0.53) with the single item pain-relief-satisfaction question. The patients who reported more pain than expected scored lower on the total scale and the patients who received epidural analgesia reported higher scores on the total scale. A nurse questionnaire, similar to the patient questionnaire, was compiled. The responsible nurse at the time (n=63) answered 196 questionnaires paired with the individual patient. The new instrument appeared to be useful in identifying important areas for improvement both from the patients’ and nurses’ perspectives, based on the number of disagreements (1 and 2). Differences were found among departments. The patients’ assessments on the environment sub-scale and the overall satisfaction question were higher than the nurses’ assessments. The findings suggest initial support for the instrument as a means to measure the quality of nursing care in postoperative pain management. Key words: quality indicators; health care, pain; postoperative, focus groups, psychometrics, questionnaires, nursing care. / On the day of the public defence of the doctoral thesis the status of the articles III was: Accepted; article IV and V was: Accepted for publishing.

The aim of the study was auditing medical records examine postoperative blood glucose levels after undergoing CABG surgery. Furthermore the aim was to determine if the ward staff abides the local guidelines frame of reference concerning each ward, regarding blood glucose measurements and blood glucose levels. The study included 70 patients undergoing CABG surgery at the cardiothoracic surgery, Uppsala University Hospital. The study was conducted by retrospective medical record auditing. Studied factors were postoperative blood glucose levels, number of registered blood glucose measurements, a current diagnosis of DM and preoperative HbA1c. Mean level of blood glucose levels stayed continuously above the local guidelines frame of reference for both TIVA/TIMA and the care ward throughout the continuity of patient care. The number of registered blood glucose measurements per postoperative day at TIVA/TIMA where within the local guidelines. The result showed that the local guidelines frame of reference concerning the ward were not reached. A difference could be seen between patients with DM and patients without DM regarding the previously mentioned factors. Preoperative elevated levels of HbA1c could have influenced the number of postoperative blood glucose measurements. Recommendations will therefore be too audit the current local guideline that concerns the treatment, therapy goals and the number of blood glucose measurements. Establishing criterions regarding termination of blood glucose measurements and the transfer day between TIVA/TIMA and the care ward are recommended.

Akut förvirring hos höftfrakturpatienter är vanlig. Den akuta förvirringen kan förebyggas eller kortas och rehabiliteringstiden kan då också kortas. Ett förvirringstillstånd innebär stora påfrestningar på kroppen. Syftet med denna litteraturstudie är att se hur litteraturen beskriver hur man kan ge en god postoperativ omvårdnad och ett gott bemötande till de patienter som drabbas eller riskerar att drabbas av postoperativ förvirring. Till grund för arbetet ligger ett antal vetenskapliga artiklar samt facklitteratur. Trots att den postoperativa förvirringen är mycket vanlig, att den orsakar stort lidande och stora vårdkostnader, saknas tillfredsställande studier som kan ligga till grund för farmakologiska behandlingsrekommendationer. Oaktat detta ges ofta farmaka till dessa patienter. Enligt litteraturen har sjuksköterskans möte med den deliriösa patienten stor betydelse för att förebygga och lindra ett förvirringsbeteende. Eftersom det saknas riktlinjer för omvårdnad av akut förvirrade patienter beror det på den enskilda sjuksköterskans bemötande hur mötet med patienten blir. Den postoperativa förvirringen måste lyftas fram eftersom antalet patienter med höftfrakturer ständigt ökar. Rutiner och vårdprogram måste tas fram eller ses över. Vi måste lära oss att bemöta dessa patienter på ett professionellt sätt. Att möta den förvirrade höftledspatienten på ett etiskt och förberett sätt är en förutsättning för en bra vård.

Children undergoing surgical procedures often experience pain in the recovery room where parents are typically responsible for managing children’s distress. Research suggests that parents’ behavior influences children’s distress; however, no study has used time-window sequential analysis to examine the likelihood of parents’ reassurance and children’s distress interactions. The purpose of this study was to utilize time-window sequential analysis to examine the likelihood of parents’ distress preceding and following the start of children’s distress. Participants included 148 families with children 2-11 years old undergoing outpatient surgery. Reassurance was positively associated with children’s distress, but sequential analyses revealed that children’s nonverbal distress was significantly less likely to start and stop following parents’ reassurance and children’s verbal distress was significantly less likely to occur after fathers’ reassurance. These data suggest that reassurance does not prompt distress to start; however, it may maintain children’s distress.

Syfte: Att undersöka hur musik som omvårdnadsåtgärd påverkar patienten fysiskt och psykiskt pre-, peri- och postoperativt. Metod: Deskriptiv litteraturstudie. 12 artiklar inkluderades som granskades, analyserades och sammanställdes. Sökningarna utfördes i databaserna PubMed och Cinahl. Huvudresultat: Resultatet visade att musik i samband med operation påverkar patienten både fysiskt och psykiskt på flera olika sätt. Musik lindrar framförallt oro och minskar smärtupplevelsen. Viss påverkan kunde ses på vitala parametrar såsom minskning av puls, blodtryck och andningsfrekvens. Stressreaktionen i kroppen påverkas också till viss del genom att kortisolnivån minskar av musiklyssnande. Musik kan också reducera depression i samband med operation. Slutsats: Musik påverkar faktorerna oro, smärta, stress, vitala parametrar och depression positivt hos patienter pre-, peri- och postoperativt. Musik som omvårdnadsåtgärd i samband med operation kan vara ett bra komplement för sjuksköterskan att använda sig av i omvårdnadsarbetet för att lindra patientens lidande. / Aim: To examine how music as a nursing intervention affects the patient physically and mentally pre-, peri-and postoperatively. Method: Descriptive study. 12 articles were included that were examined, analyzed and summarized. The searches were conducted in PubMed and Cinahl. Results: The results showed that music associated with surgery affects patients both physically and psychologically in various ways. Music soothes especially anxiety and reduces pain. Some effects could be seen on vital parameters such as reduction of heart rate, blood pressure and respiratory rate. The stress response in the body is also affected to some extent by cortisol level decreases when listening to music. Music can also reduce depression associated with surgery. Conclusion: Music have a positive effect on the factors of anxiety, pain, stress, vital parameters and depression in patients pre-, peri-and postoperatively. Music as a nursing intervention associated with surgery can be a good addition for the nurse to use in the nursing process to relieve the patient's suffering.

Postoperative urinary retention (PUR) is a common problem seen after surgery, particularly after orthopedic surgery. There has been a great deal of research done surrounding the causes of PUR and the optimal treatment for PUR, all with conflicting results. Little research has been done with orthopedic nurses to find out how they actually treat PUR, and on what information they base those treatment decisions. Evidence-based practice has been gaining popularity recently and highlights the need for nurses to make treatment decisions based on sound research, patient preferences, clinical expertise, and taking into consideration health care resources and the clinical setting (DiCenso, Ciliska, & Guyatt, 2005). This study investigated nurses' views on the definition of PUR, how they assessed for PUR, how they treated PUR and what they based their treatment decisions on. Ten nurses who worked on orthopedic units were interviewed using a semi-structured format consisting of four questions. The interviews were recorded and then transcribed verbatim by the student researcher. Qualitative description, as described by Sandelowski (2000), was used to analyze data. All nurses defined PUR fairly similarly. Various contributing factors for PUR were mentioned, some that were studied in the literature, and some that were not. Each nurse had a slightly different way of treating PUR, and 'ward routine' was also described differently. Study results point to a need for more research and education in the area of PUR so that all nurses are treating PUR in the same manner based on the same sound knowledge base.