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Objective: To explore rural general practitioners’ (GPs’) experiences of providing care in rural community hospitals (CHs) in northern Sweden.

Design: An interview study, using qualitative content analysis.

Setting: The study was conducted in Norrbotten and Västerbotten counties in Sweden and included eight rural CHs.

Participants: Semi-structured interviews were conducted in 2018 with 15 rural GPs.

Results: Two themes were identified: ‘Being the hub in the patient’s healthcare pathway’ and ‘Offering person-centred care far from hospital’. CHs are suitable for elderly, multimorbid and end-of-life patients, emphasising proximity, familiarity and discharge planning. They serve as primary care and intermediate hospital care hubs, collaborating with general hospitals and municipal caregivers. The rural GPs interviewed, as generalists, value holistic hospital patient care, and benefit from longitudinal patient knowledge. They highlighted these advantages and the cost-effectiveness of the CH model, arguing that it should be extended to urban regions. The rural GPs described their work situation as stimulating, but role conflicts in tight-knit communities, geographical distances and limited medical resources pose rural-specific ethical dilemmas.

Conclusions: Rural GPs value the holistic generalist perspective of CH care and emphasise the high-quality care that the CH setting enables them to provide. Despite rural-specific ethical dilemmas, they value the CH model and are concerned about its closures.

BACKGROUND: In Europe, residential care homes (RCHs) rather than hospitals are the most common care facilities for the older adult and the place where most deaths occur in this age group. There is a lack of knowledge regarding end-of-life (EOL) discussions and how they correlate with symptoms and symptom relief.

OBJECTIVE: The aim was to examine the correlation between EOL discussions and symptom occurrence, symptom relief and prescriptions or PRN drugs against symptoms for care home residents.

METHODS: All expected deaths at RCHs from 1 October 2015 to 31 December 2016 and registered in the Swedish Register of Palliative Care were included. Univariate and multivariate logistic regression were used to compare the RCH residents, or their family members, who had received documented EOL discussions with a physician (the EOL discussion group) and the non-EOL discussion group.

RESULTS: The EOL discussion group (n=17 071) had a higher prevalence of pain, nausea, anxiety, death rattles and shortness of breath reported, compared with the non-EOL discussion group (n=4164). Those with symptoms were more often completely relieved and had more often been prescribed PRN drugs against that symptom in the EOL discussion group. All differences remained significant when adjusting for age, time living in unit and cause of death.

CONCLUSION: The results indicate that EOL discussions are correlated with higher prevalence of symptoms, but also with better symptom relief and prescription of symptom drugs PRN when symptomatic. A possible explanation for this is that the EOL discussion can work as an opportunity to discuss symptoms and treatment for symptom relief.

Background: The population is aging, leading to an increased need for palliative care and end-of-life care. There is a lack of research on the use of video consultations for knowledge transfer between specialist and general palliative care. The aim of this study was to describe healthcare professionals’ experiences of video consultations in palliative care in community homecare and nursing homes in rural areas.

Methods: Individual interviews (n = 11) were conducted with five community nurses, one occupational therapist, two specialist palliative nurses, and three specialist palliative care physicians. The data were analysed using reflexive thematic analysis.

Results: The analysis identified three themes: feeling comfortable with increased availability of specialist expertise; seeing each other facilitates communication; and being supported by physically present care professionals is essential.

Conclusion: HCPs suggest that video consultations are an effective way to increase access to specialist palliative care and provide more equal care to patients with palliative care needs in rural community care.

Background: Moral distress is a problem and negative experience among health-care professionals. Various instruments have been developed to measure the level and underlying reasons for experienced moral distress. The moral distress thermometer (MDT) is a single-tool instrument to capture the level of moral distress experienced in real-time.

Aim: The aim of this study was to translate the MDT and adapt it to the Swedish cultural context. R

esearch design: The first part of this study concerns the translation of MDT to the Swedish context, and the second part the psychometric testing of the Swedish version.

Participants and research context: 89 healthcare professionals working at a hospital in northern Sweden participated. Convergent validity was tested between MDT and Measure of Moral Distress-Healthcare Professionals (MMD-HP), and construct validity was tested by comparing MDT scores among healthcare professionals. MDT was compared with responses to the final questions in MMD-HP. One-way ANOVA, Welch’s ANOVA, Games–Howell post-hoc test and Pearson’s correlation analysis were done.

Ethical considerations: The study was approved by the Swedish Ethics Review Authority (dnr 2020-04120) in accordance with Helsinki Declaration.

Results: The translated Swedish version of MDT was described as relevant to capture the experience of moral distress. The mean value for MDT was 2.26, with a median of 2 and a mode value of 0. The result showed moderate correlations between the MDT and MMD-HP total scores. There was a significant difference when comparing MDT and healthcare professionals who had never considered leaving their present position with those who had left and those who had considered leaving but had not done so, with the latter assessing significantly higher moral distress.

Conclusion: The MDT is an easily available instrument useful as an extension to MMD-HP to measure the real-time experience of moral distress among healthcare professionals in a Swedish context.

Objectives: Symptom management and support of the family members (FMs) are consideredessential aspects of palliative care. During end of life, patients are often not able to self-reportsymptoms. There is little knowledge in the literature of how healthcare professionals(HCPs) assess symptoms compared with FMs.The objective was to compare the assessment ofsymptoms and symptom relief during the final week of life between what was reported by FMsand what was reported by HCPs.

Methods: Data from the Swedish Register of Palliative Care from 2021 and 2022 were usedto compare congruity of the assessments by the FMs and by HCPs regarding occurrence and reliefof three symptoms (pain, anxiety and confusion), using Cohen’s kappa.

Results: A total of 1131 patients were included. The agreement between FMs and HCPs was poorfor occurrence of pain and confusion (kappa 0.25 and 0.16), but fair for occurrence of anxiety(kappa 0.30). When agreeing on a symptom being present, agreement on relief of thatsymptom was poor (kappa 0.04 for pain, 0.10 for anxiety and 0.01 for confusion). The trendwas that HCPs more often rated occurrence of pain and anxiety, less often occurrence ofconfusion and more often complete symptom relief compared with the FMs.

Conclusions: The views of FMs and HCPs of the patients’ symptoms differ in the end-of-life context, but both report important information and their symptom assessments should beconsidered both together and individually. More communication between HCPs and FMs couldprobably bridge some of these differences.

Background: Moral distress has been described as moral constraints and uncertainty connected with guilty feelings of being unable to give care in accordance with one's values for good care. Various instruments to measure moral distress have been developed. The instrument measure of moral distress for healthcare professionals (MMD-HP) was developed to capture the experience and frequency of moral distress among various healthcare professionals. The MMD-HP has been translated and culturally adapted into the Swedish language and context; however, the translation has not been validated. Therefore, this study aimed to evaluate the validity and reliability of the Swedish version of the measure of moral distress for healthcare professionals (MMD-HP).

Methods: Eighty-nine staff from various professions at a hospital in northern Sweden participated in the study. A confirmatory factor analysis was performed to check for consistency with the original version of the MMD-HP. To evaluate internal consistency, Cronbach's alpha was calculated for each domain and for the scale as a whole.

Results: The scale as a whole showed a Cronbach's alpha of 0.96, with a range between 0.84 and 0.90 between the different subscales. A confirmatory factor analysis based on the original four-factor structure showed good fit indices with a χ²/df of 0.67, CFI at 1.00, TLI at 1.02 and NFI at 0.97. RMSEA was at 0.00, and SRMR was at 0.08. A comparison of the total score between three equally large groups of years of experience at the present workplace showed no significant differences (F = 0.09, df = 2, p = 0.912).

Conclusions: We found that the Swedish version of the MMD-HP has shown validity and reliability for use in a Swedish context for measuring moral distress among health personnel.

Background: Patient-reported symptoms of acute myocardial infarction (MI) may be affected by recall bias depending on when and where symptoms are assessed.

Aim: The aim of this study was to gain an understanding of patients' symptom description in more detail before and within 24 hours after a confirmed MI diagnosis.

Methods: A convergent parallel mixed-methods design was used to examine symptoms described in calls between the tele-nurse and the patient compared with symptoms selected by the patient from a questionnaire less than 24 hours after hospital admission. Quantitative and qualitative data were analyzed separately and then merged into a final interpretation.

Results: Thirty patients (median age, 67.5 years; 20 men) were included. Chest pain was the most commonly reported symptom in questionnaires (24/30). Likewise, in 19 of 30 calls, chest pain was the first complaint mentioned, usually described together with the symptom onset. Expressions used to describe symptom quality were pain, pressure, discomfort, ache, cramp, tension, and soreness. Associated symptoms commonly described were pain or numbness in the arms, cold sweat, dyspnea, weakness, and nausea. Bodily sensations, such as feeling unwell or weak, were also described. Fear and tiredness were described in calls significantly less often than reported in questionnaires (P = .01 and P = .02), whereas “other” symptoms were more often mentioned in calls compared with answers given in the questionnaire (P = .02). Some symptoms expressed in the calls were not listed in the questionnaire, which expands the understanding of acute MI symptoms. The results showed no major inconsistencies between datasets.

Conclusion: Patients' MI symptom descriptions in tele-calls and those reported in questionnaires after diagnosis are comparable and convergent.

Objective: To explore rural hospital doctors’ experiences of providing care in New Zealand rural hospitals.

Design: The study had a qualitative design, using qualitative content analysis.

Setting: The study was conducted in South Island, New Zealand, and included nine different rural hospitals.

Respondents: Semistructured interviews were conducted with 16 rural hospital doctors.

Results: Three themes were identified: ‘Applying a holistic perspective in the care’, ‘striving to maintain patient safety in sparsely populated areas’ and ‘cooperating in different teams around the patient’. Rural hospital care more than general hospital care was seen as offering a holistic perspective on patient care based on closeness to their home and family, the generalist perspective of care and personal continuity. The presentation of acute life-threatening low-frequency conditions at rural hospitals were associated with feelings of concern due to limited access to ambulance transportation and lack of experience.

Overall, however, patient safety in rural hospitals was considered equal or better than in general hospitals. Doctors emphasised the central role of rural hospitals in the healthcare pathways of rural patients, and the advantages and disadvantages with small non-hierarchical multidisciplinary teams caring for patients. Collaboration with hospital specialists was generally perceived as good, although there was a sense that urban colleagues do not understand the additional medical and practical assessments needed in rural compared with the urban context.

Conclusions: This study provides an understanding of how rural hospital doctors value the holistic generalist perspective of rural hospital care, and of how they perceive the quality and safety of that care. The long distances to general hospital care for acute cases were considered concerning.

Background: Ethics communication has been described as a pedagogical form, promoting development of ethical competence among nursing students. The ‘one to five method’ was developed by this research group as a tool for facilitating ethical communication in groups among healthcare professionals but has not yet been evaluated.

Aim: To explore post-graduate nursing students’ experiences of practicing ethical communication in groups.

Research design: The study design is qualitative.

Participants and research context: The study comprised 12 nursing students on a post-graduate course for Registered Nurses focusing on palliative care. After education the students engaged as participants and facilitators in ethics communication in groups, with support from the ‘one to five method’. Data were derived from the students written reflections and subjected to thematic analysis.

Ethical considerations: The study was performed in accordance with the ethical standards in the 2013 Helsinki Declaration and approved by the Ethics Committee of the Medical Faculty at Umeå University.

Results: An overall theme was identified, ‘being supported to achieve a democratic dialogue concerning ethical problems’ and five themes, related to each step of the ‘one to five method’. The themes concerned: putting the experience of an ethical dilemma into words; being confirmed by shared emotions; defining the value conflict using ethical principles; expressing virtues of empathy and raised awareness; jointly finding various action approaches.

Discussion: Regular ethics communication in groups encourages nursing students to actively seek understanding and clarification of ethically difficult situations.

Conclusions: The results indicate that ethics communication in groups could be a way of developing virtues during education. Interventions using the ‘one to five method’ need to be further studied among student groups from other healthcare contexts.

OBJECTIVES: Research suggests palliative care to be translated and integrated in non-specialized palliative care services throughout the palliative care continuum across populations and settings. A need has been identified to build on the existing research literature in order to design strong knowledge translation strategies that can be evaluated in future research. The aim was to map strategies for knowledge translation of a palliative approach to care into non-specialized palliative care services for adult patients. The objectives were to explore the primary research activities, the specific type of knowledge translation strategies used, the research designs and study settings for such evaluations along with the major results thereof, and to identify major research gaps in this area.

METHODS: A scoping review was performed to map the volume and characteristics of research literature (project registered in PROSPERO #2018 CRD42018100663). The ten-year period 2010 to 2019 was searched in six major databases for original articles published in English in which the knowledge translation of a palliative approach for adult patients was evaluated in non-specialized palliative healthcare settings, and all type of empirical data-based research designs. We excluded non-English, non-empirical articles, non-evaluation of knowledge translations, specialized palliative care settings, and other types of publications (i.e. non-original articles).

RESULTS: Most of the 183 included articles focused on patients with cancer who were dying in hospitals and in high income countries. Only 13 articles focused on early palliative care. A palette of different strategies was used to implement palliative care in non-specialist palliative settings; no strategy was identified as outstanding. The majority of the articles had unspecified essential components of the research designs.

CONCLUSION: Previous suggestions for utilization of implementation science for knowledge translation of a palliative approach to care into non-specialized palliative care services are confirmed, and established knowledge translation theories can strengthen the field. To advance this specific field of knowledge, meticulously detailed reporting of studies is required as related to research designs, clarifications of contextual influences and mechanisms at work. Specific systematic reviews and meta-syntheses in the field are merited.