Doctoral Theses / Doktorsavhandlingar Institutionen för vårdvetenskap och hälsa

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Dribbling past chronic pain – Evaluating meaningful support through a remote person-centred care intervention
(2025-09-26) Lilja, Veronica
Background: Chronic pain has a profound impact on the persons living with it, their social networks and society. Support is crucial for people living with chronic pain; however, the concept of support is multifaceted. Overall aim: to elucidate the mean-ing of support among persons living with chronic pain and to perform an efficacy- and process evaluation of a remote person-centred intervention that combines tele-phone and eHealth support. Methods: Phenomenological hermeneutics was applied to elucidate the meaning of support (Study I). Inferential statistics were used in the randomised controlled trial Early Accessible Person-centred Rehabilitation for peo-ple with long-term pain (EAPER-P), to compare a composite score of self-efficacy and sick leave rate between a control group (n=30) and intervention group (n=29) (Study II). In a mixed methods process evaluation, the meaningfulness of the EAP-ER-P intervention was investigated and explored (Study III). In a multimethod study, the goals formulated in the EAPER-P intervention, their attainment and the distribu-tion of self-efficacy and sick leave rates depending on goal attainment were de-scribed (Study IV). Results: The meaning of support was illustrated with a football metaphor: balancing between being the most valuable player (being capable) and passing the ball (accepting help to continue being capable) (Study I). A statistically significant difference in the composite score was observed, favouring the interven-tion (Study II). Most participants perceived the intervention as meaningful, especial-ly the person-centred conversations. Talking to a friendly outsider (healthcare pro-fessional) without formal documentation proved valuable, and goals were considered meaningful upon successful completion. By contrast, the non-attainment of goals could lead to negative consequences (Study III). Goals encompassed pain, physical activity and function, other lifestyle habits, career plans and emotional processes; <20% of these goals were achieved. The group that achieved goals had a greater improvement in self-efficacy and a lower sick leave rate compared to the group that did not (Study IV). Conclusion: This thesis offers novel insights into the meaning of support within the context of chronic pain, aligning with a person-centred approach to care. Person-centred care demonstrates efficacy and meaning for individuals expe-riencing chronic pain; however, future interventions require meticulous attention to goal setting and achievement. Further research is needed to understand the influence of medical records and to develop eHealth components suitable for person-centred care delivery.
Outdoor environments at residential care facilities: Needs, wishes, and access for older adults and care workers
(2025-05-22) Liljegren, Madeleine
Introduction: Research studies have shown that contact with nature and outdoor stays can improve health, especially for older adults and care workers. However, statistics from the Swedish National Board of Health and Welfare, 2024, reveal that 80% of the Swedish residential care facilities (RCFs) lack supportive conditions for movement to and within outdoor environments, and 92% of operators lack routines for outdoor interventions. The overall aim of this thesis is to increase knowledge concerning needs and wishes of older adults and care workers in contact with the outdoor environments at Swedish RCFs and the access to these environments at a national level. Methods: Study I is based on individual walking interviews with twelve older adults from three RCFs to explore their needs and wishes regarding outdoor environments. In Study II, focus group walking interviews with eleven care workers at the same three RCFs as in study I, were used to explore their reflections on using outdoor environments for person-centred care and rehabilitation. Study III developed a matrix and manual to map access to outdoor environments, and in Study IV, the matrix and manual were used to map the access across all Swedish RCFs, approximately 2,000. Results: The older adults expressed needs and wishes for outdoor environments at RCFs to be a part of their everyday lives. Care workers saw the potential of these environments as arenas for person-centred care and rehabilitation. A matrix, which included 26 variables, and a manual were developed to map access to outdoor environments. The national mapping revealed limited access to outdoor environments, such as balconies, patios, own gardens, and squares. Furthermore, lack of, and variations in, access were found to be related to geographic location, growing zones, and differences between public and private operators. Conclusion: Both older adults and care workers acknowledge the value of using outdoor environments as everyday environments and arenas for person-centred care and rehabilitation, recognizing their positive impact on health. However, at national level, access to these environments is limited. The results can be used as support in improving public health among Sweden’s oldest population and care workers at RCFs.
Life in the Shadows of Glioblastoma: Health-related quality of life, psychological symptoms, life situation and support
(2025-05-20) Ståhl, Pernilla
Glioblastoma is a life limiting illness characterised by numerous distressing and progressively worsening symptoms. The patient suffers and so do those closest to them, their relatives. Throughout the course of the disease, care and support are essential. While this need is well recognised, less is known about how the interconnected health-related quality of life, psychological symptoms, and overall life situation within close relationships is affected, what types of support are desired, what kind of support have been tested, and which outcomes have been evaluated. Studies I and II employed a quantitative design. Patients with glioblastoma completed the Short Form Health Survey (SF-36) and The Hospital Anxiety and Depression Scale (HADS) questionnaires pre-surgery (Study I) and longitudinally (Study II), from the pre-surgery phase up to two years post -surgery. The results indicate significant impact on both patients and their relatives, with particularly pronounced symptoms of anxiety reported among the relatives. Study III had a qualitative design and investigated the life situations and support needs of patients with glioblastoma and their relatives. The findings illustrate a changed life situation, including altered family relations, social disconnection and an uncertainty about the time to come. The participants described the value of holding onto what felt most meaningful, setting short-range objectives, and relying on support from relatives, friends, and healthcare professionals. Participants expressed a desire for timely, concrete, and accessible support, as well as emotional and existential care. Clear communication and more responsive feedback were also seen as crucial. In Study IV, a scoping review was to identify existing support interventions for patients with high-grade gliomas and/or their relatives. The interventions demonstrated positive effects, such as improvements in symptoms, psychosocial health, hope, quality of life (QoL), preparedness, and reduced hospital readmissions, along with decreased levels of depression and anxiety. Despite these promising findings, many interventions remain in the early stages of development and implementation. In summary, this thesis illustrates that glioblastoma affects not only the patient, but also their close relationships, highlighting a shared burden that calls for a coordinated care response. The findings underpin the need for support in the physical, emotional, spiritual/existential, and social dimension, that is tailored over time and directed at both patients and their relatives. While promising interventions exist, they require further development, evaluation, and integration into clinical practice. To meet the complex needs posed by glioblastoma, care must be individualised, relational, and firmly embedded throughout the care trajectory, including early palliative care.
Virtual calm room for inpatients with affective disorder
(2025-04-14) Ilioudi, Maria
Inpatient psychiatric care is a cornerstone for people with severe mental disorder who need care during acute episodes of illness. Traditional methods using pharmacological treatments have been the main option to patients. During recent decades digitalization in healthcare has been rapidly increasing and both healthcare staff and end-users should take advantage of innovative methods. The overall aim of this thesis is to gain a comprehensive understanding of the effects and experiences of a virtual calm room among patients and staff in psychiatric inpatient care units. A multi-method approach with both qualitative and quantitative approaches was used in this thesis. Paper I was a quasi-randomized experimental study evaluating the effects of a virtual calm room compared to a physical calm room in psychiatric inpatient care (N=60). Papers II and IV comprised the use of interviews both with patients and healthcare staff to capture their experiences of the virtual calm room. A mixed-method design approach was used in paper III to explore patients’ (N=59) experiences of being offered the use of a virtual calm room when feeling anxious or worried in a psychiatric inpatient setting. The findings highlighted that patients admitted to psychiatric inpatient care reported improved well-being after using the virtual calm room, which shows that it can be a viable alternative to a physical calm room (study I). The participants mentioned that the virtual calm room induced calmness and awareness, obtaining an overall positive experience (study II). In addition, patients’ experiences of its use supported their openness to innovation, and they perceived the virtual calm room as a modern method, but they also emphasized the importance of human interaction as a key factor in virtual reality implementation, highlighting its contribution to enriching their experience and fostering a sense of connection and support during the process (study III). In the last study (IV), healthcare staff reported that the use of a virtual calm room in a psychiatric inpatient setting was a valuable tool for enhancing patient care and therapeutic relationships. The participants had in general positive attitudes and believed it effectively supported patients with affective disorders. However, greater awareness and information are needed to improve staff familiarity and encourage patient use in the future.
Neurovascular Biomarkers for Retionpathy of Prematurity - Methodological and Clinical Aspects
(2025-04-09) Sjöbom, Ulrika
Background: Preterm infants face significantly increased risks of diseases, including retinopathy of prematurity (ROP), a potentially blinding neurovascular eye disease. ROP is caused by abnormal retinal neuro-vascularisation in the relatively oxygen-rich environment outside the womb and is exacerbated by suboptimal nutrition and environmental exposures. Although blood-based biomarkers show promise in predicting and monitoring ROP development, none is currently used in the clinic. Aim: This thesis investigated neurovascular biomarkers in the context of ROP, focusing on the clinical, methodological, and sample availability aspects necessary to advance biomarker research in preterm infants. Methods: • Paper I: A systematic review and meta-analysis of data on blood vascular endothelial growth factor-A (VEGF-A) levels as a vascular biomarker for predicting ROP and the systemic response to ROP treatment. • Papers II–III: Two cohort studies explored the association between serum brain injury biomarkers, particularly neurofilament light chain (NfL), and ROP development in preterm infants. • Paper IV: Feasibility study of a neonatal biobank using left-over clinical blood samples for biomarker research in extremely preterm infants. Main findings: Circulating VEGF-A showed post-treatment changes but lacked predictive value for ROP development. Serum NfL levels during the first postnatal weeks showed the potential to predict ROP in infants born at a gestational age ≥25 weeks but were unrelated to ROP in infants born at <25 weeks gestational age. Left-over clinical blood samples were a feasible resource for ethical biomarker studies. Conclusion: This thesis highlights the potential of biomarkers in neonatal research for disease prediction and treatment monitoring but notes limitations in traditional research methods. It identifies a link between a marker of neuronal damage and ROP development and demonstrates an ethical approach to collecting blood samples for research in a fragile population. These results may help to advance the use of biomarkers in neonatal medicine.
Respite for the Troubled Mind - Supportive and Natural Spaces as a Therapeutic Tool
(2025-04-02) Hagerup, Anne
Introduction: Mental health disorders are a major health problem worldwide and are associated with decreased life expectancy, suffering, and economic burdens. A prerequisite for the treatment of mental disorders is for an individual to be in an environment that is experienced as safe and supportive and that can promote health and well-being. Aim: The overall aim of this thesis was to explore the impact of built environments (indoor and outdoor) and integrating nature into therapeutic environments. Specifically, this research assessed the building design of a new mental health facility from the perspectives of personnel involved in planning and design, therapists, staff, and patients. Methods: Based on qualitative interviews with 51 participants, this thesis improves our understanding of supportive and natural spaces as a therapeutic tool. In other words, this research revealed how the physical environment can influence and impact therapeutic work and settings. A new mental health facility in Norway was the subject of a case study that explored the various perspectives of a project group’s members. Specifically, this work assessed the perspectives of those involved with planning and designing the new facility, therapists (e.g., clinical psychologists and psychiatrists), psychiatric staff, and patients. By using various methods like qualitative interviews (both individual and focus group interviews) and photovoice methodology, we aimed to enter the lifeworlds of the participants. Interpretative phenomenological and thematic analyses using van Manen’s existential themes of the lifeworld and a phenomenological hermeneutic approach were used to research lived experiences. Findings: Built environments can be actively utilized as tools in psychotherapy. Environments should not be considered merely as neutral and passive spaces for conducting and receiving psychotherapy. Rather, they should be experienced as places that may regulate and impact both therapists and patients, as well as the relationship between them. Findings from Study II showed that supportive environments influence patients’ mental health and staff’s therapeutic practices. For example, they provide options for novel treatment needs, in contrast to older and more outdated buildings that are perceived to hinder appropriate treatment conditions. Study III uncovered dilemmas between barriers and possibilities of staff’s use affordances, where the new environment offered numerous affordances that could be utilized in therapeutic practices. However, the staff pointed to organizational hindrances in making use of these identified opportunities. Study IV found that patients were able to find calmness, land, and rest in the new mental health facility because of its supportive design. Therefore, they were more open to therapeutic interventions that made the recovery process faster. The insights from this study underscore the importance of considering design features that address the various needs of patients engaged in mental health care. Conclusion: This thesis points to the role of the built environment in mental health care. Rather than just serving as a neutral backdrop, the physical environment actively shapes therapeutic processes and expands therapeutic spaces, patient experiences, and staff practices and should thus be considered a therapeutic tool.
Patient safety and person-centeredness in healthcare for patients with suicidal behavior
(2025-03-04) Rex, Malin
Ensuring patient safety is a cornerstone of high-quality care for individuals experiencing suicidal behavior. Traditionally focused on risk reduction, safety efforts may unintentionally erode trust when overly security-driven. Research highlights the importance of involving patients and relatives in care planning, yet the role of person-centered care in suicide prevention remains underexplored. The overall aim of this thesis was to examine healthcare utilization and explore the potential for person-centeredness in healthcare for patients with suicidal behavior. Studies I and II focus on healthcare utilization, analyzing adverse events and visit patterns related to patients with suicidal behavior. Studies III and IV explore patient and relative perspectives on person-centered care during suicidal crises. Findings show suicidality as a fluctuating, long-term condition requiring flexible care (Studies I–IV). Study I reveals that adverse events stem from systemic issues rather than isolated failures. Study II finds that patients in mental healthcare with a history of suicide attempts have distinct care needs compared to those without such a history. Studies III and IV highlight that patients and relatives see themselves as key contributors but rarely have opportunities to collaborate. The focus on acute crisis management often excludes them, with patients deemed either too well for support or too unwell for shared decision-making. Participants call for care models balancing long-term planning with proactive safety measures to detect escalating suicidality early while promoting self-care and involvement from relatives. This thesis underscores the intersection of patient safety and person-centered care, advocating for a multidimensional approach that integrates person-centeredness into both clinical practice and healthcare system design to ensure safer, more responsive care for patients with suicidal behavior.
Palliative care consultation services - bridging gaps with general healthcare teams
(2025-01-24) Böling, Susanna
Palliative care consultation services support palliative care practice within healthcare settings outside of specialised palliative care. The overall aim of this thesis was to further our understanding of how palliative care knowledge can be translated into general healthcare settings and the factors influencing the integration of palliative care through palliative care consultation services. Study I mapped the published scientific literature from 2010 to 2019 on strategies for knowledge translation of a palliative approach. Various strategies were applied, and most studies were from high-income countries and focused on the hospital setting and patients with cancer. Study II examined the practice of palliative care consultation services in hospitals. Focus groups were held with consultation services, healthcare professionals from receiving wards, and managers. Variations in consultation practice were found, and some consultants proactively approached receiving wards. They were perceived to contribute with palliative knowledge, enhance cooperation and create space for palliative care. Their proactive practices meant that they provided "no ordinary consultation". Study III investigated factors associated with a palliative care consultation for patients dying outside specialised palliative care settings in their last week of life. Among the 265 129 included patients, 8.2% received a palliative care consultation. A palliative care consultation was more likely for patients who died from cancer (OR 8.55, 95% CI 8.15-8.98) and patients with a higher number of symptoms (OR 1.35, 95% CI 1.32-1.37). Other associated factors were age, place of death, education, healthcare region, living in a single household, and year of death. Study IV examined a clinical quality improvement project for early integrated palliative care within surgical care for patients with pancreatic cancer. The quality improvement practice included palliative care consultations for newly diagnosed patients with advanced cancer. Seventeen healthcare professionals shared their experiences of the project in interviews and observations. The main finding was that differences in perspectives on palliative care, integration and roles created prerequisites for palliative care integration through palliative care consultations. This thesis contributes to our understanding of knowledge translation strategies for palliative care, and of practices, processes, access, and influencing factors of palliative care consultation services.
Prerequisites and effects of an opioid-free anaesthesia pathway in patients undergoing bariatric surgery
(2024-11-20) Olausson, Alexander
Obesity is an escalating public health concern and bariatric surgery remains the only effective long-term treatment for substantial weight reduction. However, bariatric surgery typically involves opioid use during and after the surgery, which can challenge recovery due to undesirable side effects. Although opioid-free anaesthesia (OFA) is a promising alternative, further research is needed to evaluate its safety and impact on long-term recovery, along with sustained opioid-free approaches for managing postoperative pain. The overall aim of this thesis was to evaluate the prerequisites and effects of an OFA pathway compared to conventional opioid-based care and to identify the prerequisites for integrating a person-centred care approach for patients undergoing laparoscopic bariatric surgery. The thesis includes a systematic review and meta- analysis (Study I), two qualitative interview studies with content analysis (Study II & IV), and a quantitative effect study (Study III). The thesis is based on a randomised controlled trial (RCT) in which the intervention included OFA and transcutaneous electrical nerve stimulation as primary postoperative pain management for patients undergoing laparoscopic bariatric surgery. Study II-IV are based on the same population from the RCT, conducted between May 2019 and November 2023. Study I established the prerequisites for an OFA pathway in various surgical contexts, including laparoscopic bariatric surgery. Meta-analysis results indicated reduced postoperative side effects and opioid consumption without compromising patient safety or pain management, compared with opioid-based anaesthesia. The RCT (Studies II-IV) supported the feasibility of the OFA pathway, with quantitative data revealing reduced opioid consumption and comparable pain and recovery outcomes up to 3 months. Qualitative findings revealed similar patient experiences during the perioperative and recovery periods for up to 1 year. Addressing perioperative challenges by integrating a person-centred care approach into the OFA pathway could improve patient outcomes. Overall, this thesis provides valuable insights to advance perioperative care, presenting a safe and viable alternative to conventional opioid-based perioperative approaches.
Improving the hand hygiene of healthcare workers: Exploring the feasibility of an electronic monitoring system
(2024-11-12) Granqvist, Karin
Technical innovations, such as electronic monitoring systems (EMSs), have been developed to promote increased hand hygiene (HH) adherence among healthcare workers (HCWs). The overall aim of this thesis was to explore the feasibility of an EMS for the HH adherence of HCWs. An EMS was installed on a surgical ward to assess the HH adherence of HCWs and provide them with digital feedback on their HH performances. In Study I, the accuracy of the EMS in relation to manual direct observations was evaluated. The results indicated an accuracy of 87.1% with a sensitivity of 90.2% and a positive predictive value of 95.7%. In Study II the impact of digital feedback to HCWs at both group and individual levels on adherence to HH was examined. Mean adherence to HH increased significantly from the baseline phase (37.9%) to the follow-up phase (52.5%, p<0.001). During the baseline phase, no feedback was provided, whereas the follow-up phase included 9 months, when both group and individual feedback were delivered. Studies III−IV were qualitative interview studies based on Grounded theory. In Studie III, the HCWs’ experiences of using the EMS were explored. A main strategy was defined as learning to interact with new technology, which was built on three conditions set by the HCWs, i.e. having trust in the monitoring system, requesting system functionality and ease of use, and becoming aware of one’s own performance. In Study IV, the experiences of the HCWs when implementing the EMS in clinical setting were explored. A core category was identified as collaborating for progress. This category was built on three interrelated categories that influenced each other: leading and facilitating, participating and contributing, and knowing and confirming. Taken together, the studies highlight the importance of a supportive and committed leadership, involving the HCWs in the implementation process. A well-functioning technology is a prerequisite for its adoption in daily work, and feedback contributes to increased adherence and awareness of HH. The findings of this thesis can encourage further development of technical innovations monitoring HH and its future implementation in healthcare.
Spiritual Care Unveiled - Religious Literacy in Palliative Care
(2024-10-23) Lundberg, Emma
Sweden is portrayed as being multicultural and multireligious and at the same time, significantly impacted by secularization and simultaneously highly influenced by secular values. This diversity necessitates that society develop a deeper understanding of these variations. The overall aim of this thesis was to examine variations in place of death in relation to birth country, spiritual care discourses in palliative care research literature, and how healthcare professionals understand, handle and respond to religiosity and spirituality among patients and their family carers in palliative home care settings. The theoretical framework is based on religious literacy, deepened by lived religion and critical religion. Various methods were used: statistical analysis, discourse analysis, focus groups and ethnography. The findings show that foreign-born individuals are more likely to die in hospitals or at home than domestic-born individuals. Region of birth was one of several factors influencing place of death among foreign-born individuals. In the research literature, spirituality was described as enigmatic yet inherently human, with an assumption that every individual has a spiritual dimension. The analysis showed that healthcare professionals are expected to embody specific qualities in order to do spiritual care. Spiritual care was seen as crucial for holistic palliative care, focusing on acts like physical touch, silent presence and listening. In the focus groups, healthcare professionals identified qualities like “providing support” and “being present” as essential for spiritual care. Participants often positioned themselves as secular and non-religious, frequently employing an “us versus them” rhetoric, especially in discussions around truth-telling. In the ethnographic study, religion and culture were ascribed to the ‘Other’, with a notable silence surrounding patients’ religiosity in the encounters. A few professionals challenged these norms by engaging with patients’ spirituality. The study underscores a need for religious literacy in palliative home care, while also recognizing the diverse forms of religious literacy that exist. In conclusion, this thesis highlights the need to move beyond simplistic labels surrounding spirituality and religion, and instead advocates for a dynamic and changing view of religion as practised and contextual. The findings also reveal a gap between the theory and practice of spiritual care. By increasing religious literacy at both individual and organizational levels, healthcare professionals can better approach religious, cultural, and diverse encounters with greater openness and confidence.
Pregnancy complicated by preeclampsia. A closer look at cognitive function, partners' experiences and maternal mental health
(2024-05-22) Thorgeirsdóttir, Lilja Thórunn
Becoming pregnant is a turning point in life. Acting like a catalyst for the parents-to-be, most pregnancies evolve without complications. However preeclampsia, a pregnancy induced syndrome, affects 3-5% of all pregnancies. A common cause of maternal mortality worldwide, there is no cure for preeclampsia other than birth. The overall aim of this thesis was to investigate different repercussions of preeclampsia on the childbearing woman and her partner, the other parent. Paper I is a study protocol describing the design and methodological choices made in a multi-centre study established in Sweden. The aim of this study is to set up a multi-centre database and biobank for preeclampsia research to contribute to safer and more individualised treatment and care. Paper II compares cognitive function in women diagnosed with preeclampsia, stratified by severity of disease with normotensive women. No difference was detected in cognitive function before onset of disease. Women with preeclampsia complicated by pulmonary oedema and eclampsia had impaired cognitive function after onset of the disease. Paper III was a questionnaire-based study aiming to a) study the prevalence of symptoms of depression and/or anxiety after birth in women with history of preeclampsia compared to normotensive women, b) identify risk factors for depression and/or anxiety in women with a history of preeclampsia. The prevalence was similar in both groups. Low birthweight and admission to a neonatal intensive care unit were identified as risk factors for depression and/or anxiety in the preeclampsia group. In Paper IV the partners of women who developed preeclampsia were interviewed about their experiences of being a partner of a woman diagnosed with preeclampsia. Through qualitative content analysis four main categories emerged: being in an unexpected and unfamiliar situation, feeling emotionally stretched, having a split focus, and needing time to process and heal. In summary, this thesis presents results of the effects and consequences preeclampsia can have on the parents-to-be. The studies indicate a need for a more structured follow-up and personalized care for women diagnosed with preeclampsia. Preferably, this should include a model of care that addresses not only the women’s physical and psychological health, but also the mental well-being of their partners.
Improving Disaster Management in Saudi Arabia Through Collaborative Exercises and Education for Nurses and Other Healthcare Workers
(2024-05-17) Sultan, Mohammed
Disasters have increasingly been shown to have consequences that require swift and effective action from both authorities and society. Specifically, coordination, collaboration, and cooperation have proven to be recurring challenges in disaster management. Saudi Arabia, where the data for this thesis have been collected, has been exposed to various types of disasters, such as floods, annual religious events, and an ongoing war on the southern border. This thesis comprises four studies that use both quantitative and qualitative methods with validated tools to investigate whether tabletop exercises can improve the outcome of disaster management among nurses and other healthcare professionals working during disasters in the simulation’s context. Study I utilised a previously used questionnaire to examine the level of knowledge among healthcare professionals tasked with disaster management. The study found that disaster preparedness was knowledge-dependent, with knowledge being associated with confidence and preparedness. In Studies II and III, tabletop exercises were conducted. A questionnaire (CLU) was used to assess how collaboration enables learning that can be applied at the practical and operational levels. Moreover, another tool (CSCATTT) was used to examine how different collaboration factors facilitate crisis management. The findings demonstrate that the exercises improved practical skills, self-confidence, and the ability to create multi-professional teams, as well as promoting team integration and maturity among personnel. The first three sub-studies were followed by a Delphi study, wherein several experts were interviewed about the role of exercises in the existing disaster medical curriculum in Saudi Arabia. This study revealed the need to strengthen the curriculum with simulation exercises. This thesis emphasises the importance of collaboration exercises involving all personnel engaged in the management of medical issues following an event. The study highlights that increased knowledge and skills enhance self-confidence to work in critical situations. Additionally, tabletop exercises can develop collaboration among authorities and should be integrated into the current disaster medical curriculum in Saudi Arabia.
Patient safety in radiology. Risk and preventive factors in the radiography process
(2024-05-07) Wallin, Agneta
The radiology department plays an important part in health care. The purpose of radiology is to diagnose (or exclude) and follow up health conditions and treatments, and to be used in interventional treatments, through the utilization of radiographic imaging techniques. The pace of technological developments in the field is constantly accelerating and risk for patient safety incidents can exist in every phase of a radiological examination. Measures and understanding to improve patient safety in radiology are important and could have a great effect for patient safety work. The overall aim of this thesis was to identify potential risk and preventive factors in radiology. The data collection consisted of 17 individual interviews with radiographers (study I and II), self-reported Swedish Hospital Survey on Patient Safety Culture (S-HSOPSC) questionnaires completed by 171 radiographers (study III), and 923 risk events drawn from patient safety reporting systems (PSRSs) (study IV). The data were analysed using largely qualitative methods including content analysis and thematic analysis, both inductive and deductive, but also using descriptive statistics. The analysis yielded six risk areas in radiology, based on numerous descriptions of patient safety incidents. Several success factors contributing to patient safety were described, as well as strengths and weaknesses in safety dimensions. The results of the thesis show that all activities in radiology are closely interconnected, interacting in a complex way, and further, that risk and harm are not exclusively caused by activities within the radiology department. There must be awareness that long-term effects of events can occur and are not always related to activities performed in radiology. Preventive factors such as good referrals, teamwork, standardized methods, expertise knowledge and a good patient safety culture have been identified in the thesis. The radiographer has a central role in patient safety work and has good knowledge of risks and preventive factors. Through the radiographer’s ability to detect risks in time, many patient safety incidents can be prevented, and patient suffering avoided. Furthermore, there are many activities in connection with the radiological examination that are not always “known” but that involve external actors in the radiography process. Therefore, the radiological practice and its expertise needs to be visible, with collaboration across the process.
Altering the birthing room - The influence on birth outcomes and provision of care
(2024-01-10) Goldkuhl, Lisa
Giving birth is a complex physiological process deeply influenced by psychological and social elements. A prerequisite for optimising this physiological process is to be in an environment that feels safe and protective. The studies in this thesis are based on an intervention involving the redesign of a birthing room at a Swedish labour ward with features aimed at supporting women’s emotional responses to labour. The overall aim of the thesis was to explore and evaluate how this birthing room alteration influenced birth outcomes and the provision of care. Study I employed an ethnographic study design in which data was collected through participant observations (n=17) and in-depth interviews (n=8) with nulliparous women giving birth in either the newly designed room or a regular birthing room. Study II and III were based on a Randomised Controlled Trial (RCT) evaluating whether the new room improved birth outcomes for nulliparous women (n=406) compared to regular rooms. Study IV was a qualitative interview study exploring care providers’ (n=21) experiences of the implementation of the new room. The RCT (study II and III) was terminated prematurely due to the Covid-19 pandemic, resulting in insufficient statistical power to detect a significant difference between the randomised groups in the primary outcome (a composite of spontaneous vaginal birth, no use of oxytocin infusion, postpartum blood loss <1000ml, and a positive childbirth experience). The secondary analyses showed that women in the new room used epidural analgesia to a lower extent and reported a more positive childbirth experience at 3 and 12 months after birth than women in regular rooms. However, the findings of study I and IV revealed that the room design is not the sole determinant of birth outcomes and women’s experiences. The birth environment is evidently a co-creation involving physical design, human interaction, and the institutional context. It was found that the new room was implemented in a context dominated by biomedical norms, where the approach to childbirth primarily leaned towards a pathological perspective. The new room had the potential to challenge these dominating norms, especially as it reflected a more salutogenic perspective of childbirth. To address the increasing trend of medical interventions observed in Sweden and many other countries, there is a need to acknowledge that merely altering the physical design of a birthing room is insufficient. Hospital organisations and care providers must recognise their role as co-creators of the birthing room atmosphere — a factor that profoundly influences women’s birth outcomes and experiences. Hence, the provision of maternity care should be rooted in the fundamental understanding of how the sensitive physiological process of birth is supported and not disturbed.
Constructing patient safety. Exploring unsafe care events in hospital settings as reported by patients, relatives, and healthcare professionals
(2023-11-15) Gyberg, Anna
The conditions of hospital care are continuously transformed with advances in medicine and technology, and with organizational alterations influenced by the changing needs of the population. As these conditions affect patient safety, and because adverse events are a global public health problem today, knowledge about how unsafe care is understood and how patient safety can be achieved is needed. The overall aim was to explore the meaning and construction of patient safety. Three qualitative methods were used to analyze the collected data. In Studies I and II, 29 reported adverse events were analyzed using discourse analysis to explore discourses about patients and healthcare professionals. In Study III, 79 complaints were analyzed using qualitative content analysis to explore patients’ and relatives’ accounts of access. Study IV was a constructivist grounded theory study that explored how 12 individuals identified and responded to patient safety risks and adverse events. The findings in Studies I and II showed how the discourses that save lives also had the potential to cause adverse events. Study III showed how patients and relatives struggled to gain access by trying to legitimize their concerns as credible to receiving the care they needed. Study IV showed that the process of understanding patient safety risks started the moment the patients entered the hospital. Their understanding of adverse events kept evolving as long as questions remained unanswered. The lack of answers and recognition of concerns added to the suffering and, in the worst case, caused adverse events. In conclusion, when patients and relatives reached their limits in maintaining patient safety themselves, and their concerns and suffering were not acknowledged, this potentially caused adverse events and long-lasting suffering. The findings suggest that the structures of hospital care need to be evaluated regularly to ensure that they work to include the patients’ and relatives’ understandings of how patient safety can be achieved.
Att mötas utan att ses - om partnerskap och personcentrerad vård på distans
(2023-05-16) Elin, Blanck
The aim of this thesis was to evaluate and describe person-centred care over the telephone to people with chronic obstructive pulmonary disease (COPD) or chronic heart failure (CHF) and to elucidate informal carers’ experiences of support. The methods used in this thesis were related to the specific aims of the included studies. Study I was a randomised controlled trial that evaluated the effects of person-centred care delivered over the telephone to people with COPD or CHF. The evaluation showed that person-centred support over the telephone could mitigate the worsening of self-efficacy without increasing the risk of adverse events for this patient group. Study II aimed to contribute to future empirical analyses of partnership by outlining the social, moral, and cognitive forms of accountability to explore how participants engage in negotiating and establishing partnership in a person-centred care context. Study III was a phenomenological hermeneutical study to elucidate the meaning of the support given and received by informal carers of relatives with COPD or CHF. The meaning of support for these carers is twofold: it is a self-evident strive for the good life of their relatives, and it is a wish to be included as carers in partnership in interactions with healthcare providers. Study IV aimed to explore associations between self-efficacy, and health care and drug expenditure (i.e. direct costs) in patients with COPD or CHF using longitudinal statistical methods. The findings indicate that increased or sustained self-efficacy is associated with lower direct costs. The conclusion of this thesis is that remote person-centred care could, through the jointly achieved process of partnership, mitigate worsening self-efficacy in patients with COPD and CHF. Partnership may also be understood as cooperation between informal carers and their relatives and a wish among carers to be included and recognised by the healthcare system. This thesis is written in Swedish and includes a summary in English.
Andning och träning i medveten närvaro för personer med hjärtsvikt - studier av erfarenheter och effekter på symtom och tecken, välbefinnande och hälsa
(2023-05-15) Norman, Jonna
Despite care and treatment, many patients with heart failure (HF) are limited by symptoms, such as shortness of breath (SOB) and fatigue, that is difficult to treat. Research shows that slow breathing and mindfulness-based interventions (MBI) have the potential to reduce stress, improve symptoms and physical functioning, reduce anxiety and depression, and improve quality of life. Few studies have included patients with HF and the knowledge on complementary methods for symptom relief in HF is insufficient. The overall aim of this thesis was therefore to explore the feasibility, experiences and effects of breathing and mindfulness-based training on symptoms and signs, well-being, and health in persons with HF. Moreover, the aim was to gain an understanding of the subjective experiences of breathing, SOB, and management strategies in a stable phase of treated HF. Two interventional studies with randomized design and parallel groups were conducted. Stable, but still symptomatic patients with HF, despite treatment, were enrolled. The studies included one visit before and one after the study period, with repeated measures (Study I, II & III). Study I investigate if slow device-guided breathing (DGB) could improve symptoms in HF. Study II explores the feasibility and effects of MBI on symptoms and signs, and study III secondary outcomes on psychological distress and health. In Study IV, a descriptive design and qualitative content analysis, was applied. Data was collected in semi-structured interviews, using an instrument, Experiences of breathing and shortness of breath (Exp-BeSoB), which was developed in the project. In Study I, there was no improvement in symptoms in the DGB group compared to the music listening (ML) group. Participants in the DGB group, who followed (responders) the DGB and learned to breath in a slow pace and increased the exhaling time, reported significantly improved breathlessness and HF functional class, compared to non-responders. An 8-week MBI, in addition to conventional treatment, significantly reduced the impact of fatigue, symptoms of unsteadiness/dizziness, and breathlessness/tiredness related to physical functioning (Study II). Participants in the MBI-group also reported reduced psychological distress and improved general health. Meanwhile, participants in the control group rated their health lower at follow-up (Study III). Findings in Study IV showed varied experiences of SOB. Participants developed strategies for management of symptoms. Three main categories of experiences were identified: Shortness of breath as a threat to life, Difficulty breathing slows down body and traps mind, and Breathing as no problem and not in mind. Overall, results in this thesis shows good feasibility and applicability for DGB and MBI, as complementary methods to alleviate symptoms in peoples with heart failure. Additionally, MBI, may have the potential to reduce self-reported psychological distress and improve health. The findings help to understand the subjective experiences of SOB and shows the importance of clinicians to be aware of patients’ symptom experiences to initiate breathing intervention. The results are of high clinical relevance hence, larger studies are needed to determine the effects.
Development and testing af an observation-based method to assess person-centeredness in healthcare
(2023-04-19) Ekman, Nina
Person-centred care (PCC) has been designated and endorsed as a core competency needed for health care professionals (HCP) to meet the evolving challenges facing health care. The aim of this thesis was to develop and test an observation-based method for assessing clinician competency in the delivery of PCC. Study I reviewed existing PCC direct observation tools (DOT). Few of the identified 16 tools specified their conceptual base, assessed PCC holistically, were rigorously tested for reliability and validity, and none involved patients in their development. Study II aimed to identify observable indictors of PCC through interviews with 12 patients, relatives and HCPs with experience of PCC for potential inclusion in a new DOT. Deductive content analysis was performed based on the Gothenburg Centre for Person-centred Care (GPCC) PCC framework (gPCC). Patients´ first impressions were considered to impact the content, course and outcomes of the interaction and nonverbal behaviours were seen to play a major role in shaping patients’ impressions of HCPs. Study III explored the content and usability of a preliminary DOT assessing PCC competency in four main areas, subdivided in 13 domains and each illustrated by one or more behavioral indicators. Content and usability of the tool were explored using think aloud and probing techniques in 11 patients and HCPs. In general, the participants judged the tool to be easy to use and to satisfactorily cover major PCC activities outlined in the gPCC. Study IV evaluated the inter-rater reliability of a revised version of the DOT. Six HCPs with no training in using the DOT each rated 10 video recorded patient-HCP interactions. Intraclass correlations were fair to excellent range for 13 of the 15 domains. In conclusion, the tool appears promising for formative use in guiding and structuring observation-based assessments and providing feedback to trainees; however, further evaluations are required to support high-stakes usage.
Towards an item bank to measure patient-reported experience of person-centred care
(2023-03-03) Rosenlund, Lena
The reorienting of healthcare towards a more person-centred approach requires new approaches to evaluate care from the patient perspective. The overall aim of this thesis was to explore care from the perspective of people living with long-term conditions, and to develop and psychometrically test Swedish and English items to measure patient experience of PCC. In Study I, items (n = 155) probing patient experiences of PCC was translated, and a mixed-methods design was used for a qualitative item review involving different stakeholders (n = 84). The content, relevance, and acceptability of the items were evaluated in two validation rounds using questionnaires, a focus group discussion, and cognitive interviews. The item review resulted in 57 Swedish and English candidate items probing person-centred care from the patient perspective. Study II employed individual semi-structured interviews to explore communication and collaboration within a patient-professional partnership from the experiences of persons living with long-term conditions (n = 15). Through an inductive thematic analysis, five themes were identified: Adapting and self-managing in daily life, Handling and carrying information, Building trust and continuity, Acting in a flexible and transparent dialogue, and Sharing the way forward. Study III and Study IV were quantitative and used a cross-sectional design. The candidate items retrieved from Study I, were psychometrically tested against the Rasch measurement model in Study III with data gathered from a hospital in Sweden (n = 140). Data for Study IV was collected via a web panel in the UK (n = 501). Initial analyses revealed poor fit with local dependency and multidimensionality. After the removal of poorly fitting items, a testlet solution with clustered items grouped into dimensions of the conceptual model of person-centred care showed fit to the Rasch measurement model. The findings presented in this thesis contribute to a better understanding how care is perceived as person-centred from the perspective of people living with long-term conditions and provides a solution and a set of items for a future item bank measuring patient experience of person-centred care for use in Sweden and the UK.

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