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of the visit with the midwife without omitting important information and to produce photographs which can become outdated.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.

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. 

Background: Recent decades have shown major improvements in survival rates after cardiac arrest. However, few interventions have been tested in order to improve the care for survivors and their family members. In many countries, including Sweden, national guidelines for post cardiac arrest care and follow-up programs are not available and current practice has not previously been investigated. The aim of this survey was therefore to describe current post cardiac arrest care and follow-up in Sweden.

Methods: An internet based questionnaire was sent to the resuscitation coordinators at all Swedish emergency hospitals (n = 74) and 59 answers were received. Quantitative data were analysed with descriptive statistics and free text responses were analysed using manifest content analysis.

Results: Almost half of the hospitals in Sweden (n = 27, 46 %) have local guidelines for post cardiac arrest care and follow-up. However, 39 % of them reported that these guidelines were not always applied. The most common routine is a follow-up visit at a cardiac reception unit. If the need for neurological or psychological support are discovered the routines are not explicit. In addition, family members are not always included in the follow-up.

Conclusions: Although efforts are already made to improve post cardiac arrest care and follow-up, many hospitals need to focus more on this part of cardiac arrest treatment. In addition, evidence-based national guidelines will have to be developed and implemented in order to achieve a more uniform care and follow-up for survivors and their family members. This national survey highlights this need, and might be helpful in the implementation of such guidelines.

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.

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

Background and aim: Hospitals in the developed world are increasingly adopting digital systems such as electronic health records (EHRs) for all kinds of documentation. This move means that traditional paper case notes and nursing records are often documented in EHRs. Documentation of vital signs is important for monitoring a patient's physiological condition and how vital signs are presented in a clinical record can have a profound impact on the ability of clinicians to recognise changes, such as deterioration in a patient's condition. Vital signs have received minimal attention with regard to how they are documented in EHRs which suggests that there is an urgent need for this to be examined.

Design, methodology and approach: A mixed methods study was conducted in a 372-bed county hospital in two phases. Phase one was a quantitative study, and was followed by a qualitative study in phase two. The aim of the quantitative study was to examine the vital signs documented in the electronic health records of patients who had previously suffered a cardiac arrest. The aim of the qualitative study was to investigate how medical and nursing staff measured, reported and retrieved information on vital signs. Observations were made and interviews were conducted in four clinical areas.

Findings: The quantitative study found that documentation of vital signs was incomplete in relation to current universal standards for monitoring vital signs, and that vital signs were dispersed inconsistently throughout the EHR. The qualitative study provided a detailed understanding of the routines and practices for monitoring vital signs and demonstrated variation in routines and in methods of documentation in the four clinical areas. Documenting and retrieving vital signs in the EHR was problematic because of usability issues and led to workflow problems. Workflow problems were solved at ward level by the creation of paper workarounds.

Contribution to knowledge: This thesis has shown that poor facilities for the documentation of vital signs in EHRs could have a negative impact on patient safety because it reduces the possibility of good record keeping. This leads to limited availability of easily accessible, up-to-date information, essential for identifying clinical deterioration and, thus, is a challenge to patient safety. Related to this, the thesis has identified possible solutions to usability problems in the EHR. Inconsistent routines and practices were also identified and suggestions were made for how this problem might be approached.

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.

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/

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.

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.

Tidig upptäckt och snabb hantering av riskpatienter har betraktats som det ’första steget i kedjan till överlevnad’ i hjärtlungräddning (HLR)[1]. Patienter uppvisar ofta tecken på försämring av kliniskt tillstånd under perioden före oväntad hjärtstopp [2]. För att förbättra identifieringen av försämring i kliniskt tillstånd hos patienter har många varianter på system för snabb respons införts med fokus på mätning, rapportering och hantering av patienter med avvikande vitalparametrar [3]. Datorjournaler journaler används allt mer inom vården för i stort sett all dokumentation. Däremot är kunskapen begränsad kring betydelsen av dokumentationen i datorjournalen för att upptäcka försämring av patienternas kliniska tillstånd. Syftet med denna studie var att undersöka dokumentationen av vitala parametrar i datorjournalen för sjukhusvårdade patienter, som efter inläggning drabbats av oväntat hjärtstopp.

Early recognition of patients whose condition is deteriorating is essential to prevent cardiac arrest. To detect signs of deterioration, a patient’s vital signs, such as temperature, pulse, respiratory rate and blood pressure, are monitored. Poor design of vital sign charts is given as one of the reasons for deficiency in recognising patient deterioration. Little is known about the impact of documenting vital signs in electronic patient record (EPR) systems. The aim of this study is to examine to which extent the EPR supports the documentation of deterioration in patients at risk of in-hospital cardiac arrest. The poster reports on the pilot study which was performed to test the adequacy and appropriateness of the data collection tool and to examine the appropriateness of the data collected for statistical analyses.

Vital sign documentation is crucial to detecting patient deterioration. Little is known about the documentation of vital signs in electronic health records. This study aimed to examine documentation of vital signs in electronic health records. We examined the vital signs documented in the electronic health records of patients who had suffered an in-hospital cardiac arrest and on whom cardiopulmonary resuscitation was attempted between 2007 and 2011 (n = 228), in a 372-bed district general hospital. We assessed the completeness of vital sign data compared to VitalPACTM Early Warning Score and the location of vital signs within the electronic health records. There was a noticeable lack of completeness of vital signs. Vital signs were fragmented through various sections of the electronic health records. The study identified serious shortfalls in the representation of vital signs in the electronic health records, with consequential threats to 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.

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.

Aims: The overall aim of this study was to explore nurses’ perceptions of using an electronic patient record in everyday practice, in general ward settings. This paper reports on the patient safety aspects revealed in the study.

Background: Electronic patient records (EPR) are widely used and becoming the main method of nursing documentation. Emerging evidence suggests that they fail to capture the essence of clinical practice and support the most frequent end-users: nurses. The impact of using EPR in general ward settings is under-explored.

Method: In 2008, focus group interviews were conducted with 21 registered nurses (RNs). This was a qualitative study and the data were analysed by content analysis. At the time of data collection, the EPR system had been in use for approximately one year.

Findings: The findings related to patient safety were clustered in one main category: ‘documentation in everyday practise’. There were three sub-categories: vital signs, overview and medication module. Nurses reported that the EPR did not support nursing practice when documenting crucial patient information, such as vital signs.

Conclusions: Efforts should be made to include the views of nurses when designing an EPR to ensure it suits the needs of nursing practice and supports patient safety. Essential patient information needs to be easily accessible and provide support for decision-making. 

Electronic patient record (EPR) systems have a huge impact onnursing documentation. Although the largest group of end-usersof EPRs, nurses have had minimal input in their design. Thisstudy aimed to review current research on how nurses experienceusing the EPR for documentation. A literature search was conductedin Medline and Cinahl of original, peer-reviewed articles from2000 to 2009, focusing on nurses in acute/ inpatient ward settings.After critical assessment, two quantitative and three qualitativearticles were included in the study. Results showed that nursesexperience widespread dissatisfaction with systems. Currentsystems are not designed to meet the needs of clinical practiceas they are not user-friendly, resulting in a potentially negativeimpact on individualized care and patient safety. There is anurgent need for nurses to be directly involved in software designto ensure that the essence and complexity of nursing is notlost in the system.

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.

Inadequate design and poor user-interface are given as reasons for unsuccessful implementation of electronic health records (EHR) [1,2]. However, rather than designing more suitable technology, the trend has been to 'muddle through' [2] and to urge health care workers to adapt to poorly designed systems [3]. This may work to some degree but little is known about the impact this could have on patient safety. The design of vital sign charts has an impact on the ability of clinicians to detect deterioration in patients' clinical status [4-6]. Changes in a patient's vital signs may indicate a lifethreatening event [7,8] so charts should be user-friendly to support clinicians in decision-making [9,10]. The aim of this study was to examine the documentation of physiological vital signs in an EHR. In this paper, we present the results regarding accessing information on a patient's physiological vital signs.