INTRODUCTION Providing good communication is at the core of recent international guidelines for improving women's outcomes at birth. Communication barriers are identified as major obstacles to providing effective and equal care among foreign-born women. There is a need for accurate communication tools in antenatal care. The aim of this study was to describe challenges met by researchers when developing culturally sensitive content in a Swedish-Arabic application for communication support at antenatal care in Sweden. METHODS A co-design methodology was used for the development of the application, entailing collaboration between users and researchers in five different phases: users' needs and preferences, development, field testing I, refinement, and field testing II. RESULTS Five challenges emerged: evidence-based information, time frame, realistic photographs, norm-critical perspective, and cultural issues. One challenge was to meet the needs of the users and combine it with information following evidence-based obstetric welfare guidelines. It was also challenging to produce short informational videos that could be adjusted for the duration of the visit with the midwife without omitting important information and to produce photographs which can become outdated. It was also a challenge to portray a less clinical environment and to maintain parents' integrity. It was also challenging to produce norm-critical content from the women's perspective. CONCLUSIONS When developing content of an application for antenatal care, converting content proposals into a finished product is challenging. Collaboration between a cross-disciplinary research team, midwives and target-language women is essential to ensure that the content is usable and reliable.

Good communication is essential for good healthcare. In maternity care, inadequate communication may contribute to poorer outcomes in pregnancy. A large number of Syrian, Arabic-speaking immigrants arrived in Sweden in 2015-2016. A trans-disciplinary team acted as intermediaries between midwives and a technical company to develop a Swedish-Arabic communication app for use in antenatal care. An earlier study describes the creation of the content and the development of the prototype. This paper describes the next phase of the study, i.e., testing the prototype, refining the structure and content, and development of the next version. A user-centred approach with a norm critical perspective was applied. Workshops and observations were performed for interaction between the midwives and the research group, facilitating development from a user perspective. A final version of the app was developed. Future plans are to evaluate the app and produce a Swedish-English version.

A record number of immigrants, many Arabic speaking, arrived in Sweden during the years 2015/2016. Immigrant women have a higher risk of pregnancy complications than native European women and cultural and communicative problems have been identified as a cause of such disparities. Maternity services are under pressure because of language and cultural barriers. Language translation programmes are sometimes used but these are not evidence-based so are not considered safe for use in maternity care. The aim of this research was to create an evidence-based app for communication with Arabic-speaking women in maternity care. User-centred iterative design was used to develop an evidence-based, fit-for-purpose app. Data were collected from midwives in a focus group interview, field observations and workshops. The iterative approach resulted in an evidence-based prototype that is currently being tested in the field.

Objective

The aim of this study was to describe Swedish midwives’ experiences of caring for immigrant women at antenatal care clinics.

Methods

Five group interviews and one individual interview were conducted with 16 midwives working in the maternity care. The interviews were transcribed and analysed with latent content analysis.

Results

Three main categories emerged: 1) Be able to convey and receive information. Communication was influenced by the women's educational level and previous experiences. The interpreter's competence was of great importance, but also if the midwife was able to create a trusting relationship with the woman. 2) Experience other cultures. The midwife's duties and responsibilities differed from the woman's expectations of the visit. The woman's family was of great importance and influential. 3) Midwife's role and work situation. Midwives’ working conditions were challenged and they developed strategies to cope with this; however, they desired support and time for reflection and processing.

Conclusion

Communication difficulties were cultural and linguistic in nature, and required extra care. This can be achieved if the midwife has time, but also support in managing cultural differences. In the future, new communication tools and ways of communicating must be developed.

Målet har varit att göra ett effektivt, integrerande och interaktivt dialogstöd (https://sadima.lnu.se/). Stödet är avsett att användas i mödravårdssam­tal mellan kvinnor med begränsade kunskaper i svenska och svensktalande barnmorskor och är ett komplement till tolk. Samtalsstödet finns på arabiska, engelska, svenska och är fritt tillgängligt på internet.  Vi vill uppnå förbättrad och effek­­tiviserad kommu­ni­ka­tion mellan barnmorskor och kvinnor. Samtalsstödet ska leda till ökad patientsäkerhet med färre komplika­tioner och minskad sjuklighet och dödlighet bland kvinnorna och deras barn, och därigenom öka vårdkvaliteten och effektivisera bru­ket av sam­hälleliga resurser. Avsikten är att sprida och nyttiggöra sam­talsstödet till ansvariga i Sveriges Kom­muner och Regioner (SKR) och samordnings­barn­morskor i Sverige. Stödet består av en del där information kan inhämtas och en del där information kan ges om gravidi­tet, förloss­ning och preventiv­medel. Genom webbsidan ska mödra­hälso­­­vården göras mer jämlik och kom­munikativ, med ökad patientsäkerhet och egenmakt för kvinnor i mödravården.

Vi har analyserat material med språkliga, normkritiska och vård­vetenskapliga metoder. I projektet har appen Sadima utvecklats i två versioner, en första testversion och sedan en andra version som ut­for­mats som en webbsida. För ut­veck­lan­det av den första versionen av appen fick vi medel av Vinnova (2016–2019). Vi arbetade med barnmorskor och skapade en testapp som sedan revide­ra­des och förbättrades suc­ces­sivt genom forskning om kvinnornas och barnmorskornas er­faren­het av att använda samtalsstödet. Det befintliga stödets innehåll är patientsäkrat av läkare och barnmorskor i Region Kalmar. 

Vi har mätt funktiona­liteten i samtalsstödet genom iterativa tester, en­käter och fokusgrupper med barnmorskor och arabisktalande kvinnor, där stödets information har pro­ble­ma­tiserats; det har gällt etnicitet (språk och kultur), klass (utbildning) och jämlikhet mellan kvinnor. Mät­ningarna har granskats och utvärde­rats av referensgruppen för bedömning av funktiona­liteten hos samtalsstödet. Grup­pen har bedömt att samtalsstödet bidragit till bättre förståelse, ökad patient­säkerhet och effektivare vård. 

The goal was to create an effective, integrative and interactive tool for dialogue support (https://sadima.lnu.se/). The dialogue support is intended for use in antenatal care conversations between women with limited knowledge of Swedish and Swedish-speaking midwives and is a complement to an interpreter. The dialogue support on the website is available in Arabic, English and Swedish and is available free of charge on the internet.  We want to improve patient safety, contribute to fewer complications, and reduce morbidity and mortality among women and their children, thereby increase the quality of care and make better use of societal resources. The intention is to spread information about the support via those responsible for maternity care in Sweden’s Municipalities and Regions, and coordinating midwives in Sweden so that it can be utilised by practising midwives. The support consists of two sections, one in which information can be obtained and the other in which information can be given about pregnancy, childbirth and contraception. Through the website, maternal health care will be made more equal and communicative, with increased patient safety and autonomy for women in antenatal care.

We have analysed material with linguistic, norm-critical and care science methods. In the project, the app Sadima was developed in two versions, first a trial version and then a second version designed as a web page. For the development of the first version of the app, we received funding from Vinnova (2016–2019). We worked with midwives and created a test app which was then revised and gradually improved through research on women’s and midwives’ experience of using this support. The content of the existing app is certified as safe for patient use by doctors and midwives in the Kalmar Region.

We have evaluated the functionality of Sadima through iterative tests, surveys and focus groups with midwives and Arabic-speaking women, where the information in the app has been scrutinized with regard to ethnicity (language and culture), class (education) and equality. The evaluation was reviewed by the reference group to assess the accuracy and suitability of the app and confirm its usefulness. The group concluded that Sadima contributes to better understanding, increased patient safety and more efficient care.

للرعاية التفاعلية في مركز رعاية الأمومة.

إبداع متعدد الوسائط في غاية إفادة المجتمع

                      الدعم التواصلي يٌسمى "ساديما" موجود على الموقع الإلكتروني: https://sadima.lnu.se/

الهدف هو تقديم طريقة فعالة ومتكاملة للتواصل.  يتم إستخدام هذا الدعم في مركز رعاية الامومة للتواصل مع النساء اللواتي لديهن معلومات محدودة باللغة السويدية والقابلات السويديات وهذا الدعم التواصلي هو مكمل للمترجم. إنه متوفر باللغات العربية, الانكليزية والسويدية وهو متاح مجانا" على الانترنت. هدفنا هو تحسين التواصل بطريقة فعالية بين القابلات والنساء.

سوف يؤدي هذا التواصل الى تعزيز سلامة المرضى عبر التخفيف من المشاكل الصحية وإنخفاض حالات المرض والوفيات عند النساء وأطفالهن, مما يزيد من جودة الرعاية الصحية ويساهم في إستخدام الموارد الإجتماعية بفعالية. الهدف هو النشر والاستفادة من هذا الدعم التواصلي الى القيمين في البلديات والمناطق السويدية والى النائبين عن القابلات في السويد. يتألف الدعم من جزئين, جزىء للحصول على المعلومات وجزىء آخر لإعطاء المعلومات عن الحمل, والولادة وأساليب منع الحمل. 

من خلال هذا الموقع الإلكتروني, يمكن لمركز رعاية الأمومة تقديم رعاية متساوية ذات تواصل فعال, مع تعزيز سلامة المرضى والشعور بالإستقلالية لدى النساء. 

لقد أجرينا أبحاث عن محتويات هذا الدعم التواصلي عبر إستخدام أساليب لغوية وعلمية وهي ناقدة للمعايير. تم تطوير الدعم التواصلي "ساديما" على مرحلتين, المرحلة الاولى هي عبارة عن نسخة تجريبية اما النسخة الثانية فصممت كموقع إلكتروني على الانترنت. تم تطوير النسخة الاولى من الدعم التواصلي برعاية شركة "فينوفا" (2016-2019).                        

 قمنا بالتعاون مع قابلات لتطوير النسخة التجريبية الاولى وهي كانت على شكل تطبيق. وقد تم تطويره وتحسينه لاحقاً بعد إجراء أبحاث حول تجربة النساء والقابلات في إستخدامهم للدعم التواصلي. خضعت المعلومات والمحتويات الموجودة في هذا الدعم التواصلي الى إستكشاف من قبل أطباء وقابلات في منطقة "كالمار".

لقد أجرينا أبحاث لتقدير مدى فعالية وظيفة الدعم التواصلي عبر التجارب المتكررة, عبر أبحاث إستبيانية وعبر مقابلات مع القابلات والنساء العربيات. تم بعد ذلك معالجة العقبات اللغوية الناتجة عن الإختلاف اللغوي وثقافة البلد, والخلفية التعليمية والمساواة بين النساء.

عُرضت نتيجة الأبحاث على مراجع مختصة لتقييم فعالية هذا الدعم التواصلي وقد أكدت تلك المراجع أنه قد يساهم بتزويد المرى بمعلومات إضافية وزيادة سلامة المرضى والى رعاية صحية اكثر كفاءة.

Background. Sweden, with a population of 10 million, received approximately 300,000 refugees 2015-2016 (The Statistics Portal 2018), the majority from Arabic-speaking countries, many of whom were women of child-bearing age. Midwives in pre-natal care experienced communication problems despite telephone interpreters. Studies have shown that immigrant women have poorer outcomes in pregnancy (Bollini et al. 2009). This has been linked to communication and cultural difficulties. Although there are many health-related applications (apps), many are not evidence-based (Lewis & Wyatt 2014). AimThe aim of this project was to develop an evidence-based app to promote effective communication between midwives and Arabic-speaking women. MethodsA multi-disciplinary team was formed to develop a bilingual app in cooperation with midwives who worked in pre-natal care. End-user perspectives were prioritised. Data were collected by 1) focus group interviews to determine the objectives of maternity care, 2) observations to gain understanding of work processes and 3) workshops to discuss material with midwives and refine content according to user-needs. All material was further validated by professional midwifery sources.ResultsAn evidence-based, multi-modal, bilingual app with text, images and voiced recordings was developed to use as a complement to interpreters in pre-natal care. Both midwives and the pregnant women feel empowered; midwives do not have to risk inadequate translation by interpreters; women receive accurate information. Women receive information directly from the midwife through the app, rather than depending on an interpreter. ConclusionsThis app contributes to ensuring equity of care within midwifery services. It provides improved communication within pre-natal care to help promote safe pregnancy and delivery of a healthy baby. ReferencesBollini, P., Pampallona, S., Wanner, P., & Kupelnick, B. (2009). Pregnancy outcomes of migrant women and integration policy: a systematic review of the international literature. Soc Sci Med, 68, 452-461. Lewis T and Wyatt J. mHealth and Mobile Medical Apps: A Framework to Assess Risk and Promote Safer Use. Journal of Medical Internet Research. 2014; 16: e210.The Statistics Portal. (2018). Number of immigrants in Sweden from 2007 to 2017. Retrieved from https://www.statista.com/statistics/523293/immigration-to-sweden/

This presentation describes how an app was developed in a multi-disciplinary research team in close collaboration with midwives to improve communication between midwives and their non-Swedish speaking clients. The project aims to promote equal and effective communication between midwives and Arabic speaking women in maternity care. A prototype version of the app was tested in spring 2018 in Kalmar County Council. After revision the final version of the app was produced in December 2018. It is currently being used by midwives in pre-natal care.

Aims and objectives

To investigate reasons for inadequate documentation of vital signs in an electronic health record.

Background

Monitoring vital signs is crucial to detecting and responding to patient deterioration. The ways in which vital signs are documented in electronic health records have received limited attention in the research literature. A previous study revealed that vital signs in an electronic health record were incomplete and inconsistent.

Design

Qualitative study.

Methods

Qualitative study. Data were collected by observing (68 hr) and interviewing nurses (n = 11) and doctors (n = 3), and analysed by thematic analysis to examine processes for measuring, documenting and retrieving vital signs in four clinical settings in a 353-bed hospital.

Results

We identified two central reasons for inadequate vital sign documentation. First, there was an absence of firm guidelines for observing patients’ vital signs, resulting in inconsistencies in the ways vital signs were recorded. Second, there was a lack of adequate facilities in the electronic health record for recording vital signs. This led to poor presentation of vital signs in the electronic health record and to staff creating paper “workarounds.”

Conclusions

This study demonstrated inadequate routines and poor facilities for vital sign documentation in an electronic health record, and makes an important contribution to knowledge by identifying problems and barriers that may occur. Further, it has demonstrated the need for improved facilities for electronic documentation of vital signs.

Relevance to clinical practice

Patient safety may have been compromised because of poor presentation of vital signs. Thus, our results emphasised the need for standardised routines for monitoring patients. In addition, designers should consult the clinical end-users to optimise facilities for electronic documentation of vital signs. This could have a positive impact on clinical practice and thus improve patient safety.

Workarounds are commonplace in health care settings. An increase in the use of electronic health records (EHR) has led to an escalation of workarounds as health care professionals cope with systems which are inadequate for their needs. Closely related to this, the documentation of vital signs in EHR has been problematic. The accuracy and completeness of vital sign documentation has a direct impact on the recognition of deterioration in a patient’s condition. We examined work flow processes to identify workarounds related to vital signs in a 372-bed hospital in Sweden. In three clinical areas a qualitative study was performed with data collected during observations and interviews and analysed through thematic content analysis. We identified paper workarounds in the form of hand-written notes and a total of eight pre-printed paper observation charts. Our results suggested that nurses created workarounds to allow a smooth workflow and to ensure patients safety.

Background

Health care in Sweden aims to be equal. In antenatal care, women who do not speak Swedish have a higher rate of maternal and infant mortality (Essen et al. 2001, Wahlberg et al. 2013). Cultural and communicative problems have been identified as one reason for this disparity. Due to recent immigration, Arabic-speaking women (ASW) have been identified as a vulnerable group. Technology has the potential to solve language and cultural barriers (Haith-Cooper 2014). A pilot study in which midwives were interviewed suggested that an ‘app’ for a tablet with multimodal components could be an aid to cultural and linguistic understanding (Axelsson et al. 2016).

Aim

The aim of the project is to identify women’s and midwives’ information needs and cultural issues, and subsequently, to develop an app with norm-critical design for interactive communication in antenatal care (ANC). The app will serve as a complement to interpreters and provide essential information about ANC.

Method

Two data collection methods will be used. The first is to observe meetings between midwives and pregnant women. The second is to interview midwives in focus groups so that they can freely express their wishes. Following this, a trial version of the app will be constructed, which will then be tested and evaluated iteratively in midwifery practice. The material will be analysed in workshops using linguistic and norm critique methods.

Results

The app is expected to improve and ensure the quality of ANC for ASW and improve their understanding of pregnancy, fetal development and parenting. It will hlep midwives to be sure that women have been given the correct information and improve patient safety. We will improve our own understanding of the risks in communication that can arise when two parties do not understand each other, and of how communication can be promoted through an app.

References

Essen, B. et al. (2001) Increased perinatal mortality among sub-Saharan immigrants in a city-population in Sweden.  [Dissertation]. Malmö and Lund: Lund University; 2001.

Haith-Cooper, M. (2014) Mobile translators for non-English-speaking women accessing maternity services. British Journal of Midwifery. 2014; 22: 795-803. http://www.magonlinelibrary.com/doi/abs/10.12968/bjom.2014.22.11.795

Axelsson, C. et al. (2016). ”Det kan bli så mycket fel”: Förstudie om barnmorskors upp­levelser av kommunikation med gravida kvinnor utan funktionell behärskning av svenska. Kalmar/Växjö: Linnéuniversitetet.

Wahlberg, A. et al. (2013) Increased risk of severe maternal morbidity (near-miss) among immigrant women in Sweden: a population register-based study  Epidemiology. 2013 Department of Women’s and Children’s Health, International Maternal and Child Health, Uppsala, Sweden