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  • 1.
    Adelsjö, Igor
    et al.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Lehnbom, Elin C.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. UiT The Arctic University of Norway, Norway.
    Hellström, Amanda
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Nilsson, Lina
    Linnaeus University, Faculty of Health and Life Sciences, Department of Medicine and Optometry. Linnaeus University, Faculty of Technology, Department of Informatics.
    Flink, Maria
    Karolinska Institutet, Sweden.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden.
    The impact of discharge letter content on unplanned hospital readmissions within 30 and 90 days in patients with chronic illnessManuscript (preprint) (Other academic)
    Abstract [en]

    Aim: To determine the impact of discharge letter content on unplanned hospital readmissions within 30 and 90 days, and to identify correlations between discharge letter content and quality of care transitions among patients with chronic illness.

    Design: A convergent mixed methods design.

    Methods: Discharge letters from 154 patients recruited to a randomised controlled trial were coded using an assessment matrix and deductive content analysis. The assessment matrix was based on a literature review performed to identify key elements in discharge letters that facilitate a safe care transition to home. The coded key elements were transformed into a quantitative variable of 'discharge letter score'. Bivariate correlations between discharge letter score and quality of care transition as well as unplanned readmissions within 30 and 90 days were calculated. Lastly, a multivariable Cox proportional hazards model was used to investigate associations between discharge letter score and time to readmission.

    Results: All discharge letters contained at least five of eleven key elements. In less than four percent, all eleven key elements were present. Neither discharge letter score nor single key elements correlated with 30-day or 90-day readmission rate. Discharge letter score was not associated with time to readmission when adjusted for a range of patient characteristics and self-rated quality of care transitions.

    Conclusion: Discharge letter score is not correlated with either 30-day or 90-day readmission rate or with time to readmission at 90 days, when patient characteristics are adjusted for.

    Implications for the profession and patient care: Written discharge summaries are not enough to facilitate safe care transitions and self-management after discharge. A person-centred approach, providing written and verbal information to patients, encouraging patient involvement soon after discharge, may be needed to avoid readmission.

  • 2.
    Adelsjö, Igor
    et al.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Nilsson, Lina
    Linnaeus University, Faculty of Health and Life Sciences, Department of Medicine and Optometry.
    Hellström, Amanda
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Linnaeus University, Linnaeus Knowledge Environments, Sustainable Health. Karolinska Institutet, Sweden.
    Lehnbom, Elin C.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. UiT The Arctic University of Norway, Norway.
    Communication about medication management during patient–physician consultations in primary care: a participant observation study2022In: BMJ Open, E-ISSN 2044-6055, Vol. 12, no 11, article id e062148Article in journal (Refereed)
    Abstract [en]

    Objective To explore communication about medication management during annual consultations in primary care. Design: passive participant observations of primary care consultations.

    Setting Two primary care centres in southern Sweden.

    Participants Consultations between 18 patients (over the age of 60 years) with chronic diseases and 10 general practitioners (GPs) were observed, audio-recorded, transcribed and analysed using content analysis.

    Results Four categories emerged: communication barriers, striving for a shared understanding of medication management, evaluation of the current medication treatment and the plan ahead and behavioural changes in relation to medication management. Misunderstandings in communication, failure to report changes in the medication treatment and use of generic substitutes complicated mutual understanding and agreement on continued treatment. The need for behavioural changes to reduce the need for medication treatment was recognised but should be explored further.

    Conclusion Several pitfalls, including miscommunication and inaccurate medication lists, for safe medication management were identified. The purpose of annual consultations should be clarified, individual treatment plans could be used more actively during primary care consultations and efforts are needed to improve verbal communication and information continuity.No data are available.

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  • 3.
    Asp, Margareta
    et al.
    Mälardalen University.
    Ekstedt, Mirjam
    KTH Royal Institute of Technology;Karolinska Institutet;Oslo University Hospital, Norway.
    Trötthet, vila och sömn2014In: Omvårdnadens grunder: Hälsa och ohälsa / [ed] Anna-Karin Edberg, Helle Wijk, Lund, 2014, 2, p. 363-417Chapter in book (Other academic)
  • 4.
    Backåberg, Sofia
    et al.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Djukanovic, Ingrid
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Linnaeus University, Linnaeus Knowledge Environments, Sustainable Health.
    Hagerman, Heidi
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Linnaeus University, Linnaeus Knowledge Environments, Sustainable Health.
    Lindberg, Catharina
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Schildmeijer, Kristina
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Tidöavtalet hotar den sömlösa vården av äldre2022In: Sydsvenskan, ISSN 1652-814X, no 2022-11-09Article in journal (Other (popular science, discussion, etc.))
    Abstract [sv]

    Rätt till fast läkarkontakt kan absolut vara bra, speciellt för diagnostik, bedömning och medicinsk behandling. Men det räcker inte, skriver forskare och lärare vid Linnéuniversitetet.

  • 5.
    Backåberg, Sofia
    et al.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. University of Calgary, Canada.
    Hellström, Amanda
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Linnaeus University, Linnaeus Knowledge Environments, Sustainable Health.
    Fagerström, Cecilia
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Linnaeus University, Linnaeus Knowledge Environments, Sustainable Health. Region Kalmar County, Sweden.
    Halling, Anders
    Lund University, Sweden.
    Lincke, Alisa
    Linnaeus University, Faculty of Technology, Department of computer science and media technology (CM).
    Löwe, Welf
    Linnaeus University, Faculty of Technology, Department of computer science and media technology (CM).
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden.
    Evaluation of the Skeleton Avatar Technique for Assessment of Mobility and Balance Among Older Adults2020In: Frontiers of Computer Science, ISSN 2095-2228, E-ISSN 2095-2236, Vol. 2, article id 601271Article in journal (Refereed)
    Abstract [en]

    Background: Mobility and balance is essential for older adults’ well-being an independence and the ability tomaintain physically active. Early identification of functionalimpairmentmay enable early risk-of-fall assessments and preventivemeasures.  There is a need to find new solutions to assess functional ability in easy, efficient, and accurateways, which can be clinically used frequently and repetitively. Therefore, we need to understand how functional tests and expert assessments (EAs) correlate with new techniques.

    Objective: To explore whether the skeleton avatar technique (SAT) can predict the results of functional tests (FTs) of mobility and balance: Timed Up and Go (TUG), the 30-s chair stand test (30sCST), the 4-stage balance test (4SBT), and EA scoring of movement quality.

    Methods: Fifty-four older adults (+65 years) were recruited through pensioners’ associations. The test procedure contained three standardized FTs: TUG, 30sCST, and 4SBT. The test performances were recorded using a three-dimensional SAT camera. EA scoring was performed based on the video recordings of the 30sCST. Functional ability scores were aggregated from balance and mobility scores. Probability theory-based statistical analyses were used on the data to aggregate sets of individual variables into scores, with correlation analysis used to assess the dependency between variables and between scores. Machine learning techniques were used to assess the appropriateness of easily observable variables/scores as predictors of the other variables included.

    Results: The results indicate that SAT data of the fourth 4SBT stage could be used to predict the aggregated results of all stages of 4SBT (with 7.82% mean absolute error), the results of the 30sCST (11.0%), the TUG test (8.03%), and the EA of the sit-to-stand movement (8.79%). There is a moderate (significant) correlation between the 30sCST and the 4SBT (0.31, p = 0.03), but not between the EA and the 30sCST.

    Conclusion: SAT can predict the results of the 4SBT, the 30sCST (moderate accuracy), and the TUG test and might add important qualitative information to the assessment of movement performance in active older adults. SAT might in the future provide the means for a simple, easy, and accessible assessment of functional ability among older adults.

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    Skeleton Avatar Technique in Assessment of Mobility and Balance
  • 6.
    Berg, Siv Hilde
    et al.
    Stavanger University Hospital, Norway.
    Akerjordet, Kristin
    University of Stavanger, Norway.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden.
    Aase, Karina
    University of Stavanger, Norway.
    Methodological strategies in resilient health care studies: an integrative review2018In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 110, no Part A, December, p. 300-312Article, review/survey (Refereed)
    Abstract [en]

    Resilient healthcare research focuses on everyday clinical work and a system’s abilities to adopt or absorb disturbing conditions as opposed to risk management approaches, which are based on retrospective analyses of errors. After more than a decade of theoretical development and a large quantity of empirical work, the field of resilience is beginning to recognize the methodological challenges related to operationalizing and designing studies of complexity. This paper reviews a sample of empirical articles on studies of resilient healthcare to describe and synthesize their methodological strategies. The review found that data collection by resilient healthcare studies has predominantly been conducted at the micro level (e.g. frontline clinical staff). Data sources at the meso level (i.e. hospital/institution) have been limited, and no studies were found that collected macro-level data. We argue that the methodological focus in the field should increase its embrace of complexity and the adaptive capacities of the system as a whole by integrating data sources at the micro, meso, and macro levels. To improve the methodological designs, we argue that the resilience construct, in which the complexity of multiple levels is integrated, must be developed. Improving the transparency and quality of future resilient healthcare research might be accomplished by reporting thorough descriptions of analytical strategies, in-depth descriptions of research design and sampling strategies, and discussing internal and external validity and reflexivity.

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  • 7.
    Berggren, Karin
    et al.
    Södersjukhuset, Sweden;Karolinska Institutet, Sweden.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden.
    Joelsson-Alm, Eva
    Södersjukhuset, Sweden;Karolinska Institutet, Sweden.
    Swedberg, Lena
    Karolinska Institutet, Sweden;Södertälje Sjukhus, Sweden.
    Sackey, Peter
    Karolinska Institutet, Sweden.
    Schandl, Anna
    Södersjukhuset, Sweden;Karolinska Institutet, Sweden.
    Healthcare workers' experiences of patient safety in the intensive care unit during the COVID-19 pandemic: A multicentre qualitative study2023In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 32, no 19-20, p. 7372-7381Article in journal (Refereed)
    Abstract [en]

    AimTo describe healthcare workers' experiences of preconditions and patient safety risks in intensive care units during the COVID-19 pandemic. BackgroundHealthcare workers' ability to adapt to changing conditions is crucial to promote patient safety. During the COVID-19 pandemic, healthcare workers' capacity to maintain safe care was challenged and a more in-depth understanding on frontline experiences of patient safety is needed. DesignA qualitative descriptive design. MethodsIndividual interviews were conducted with 29 healthcare workers (nurses, physicians, nurse assistants and physiotherapists) from three Swedish hospitals directly involved in intensive care of COVID-19 patients. Data were analysed with inductive content analysis. Reporting followed the COREQ checklist. ResultsThree categories were identified. Hazardous changes in working conditions describes patient safety challenges associated with the extreme workload with high stress level. Imperative adaptations induced by changed preconditions for patient safety which include descriptions of safety risks following adaptations related to temporary intensive care facilities, handling shortage of medical equipment and deviations from routines. Safety risks triggered by reorganisation of care describe how the diluted skill-mix and team disruptions exposed patients to safety risks, and that safety performance mostly relied on individual healthcare worker's responsibility. ConclusionsThe study suggests that healthcare workers experienced an increase in patient safety risks during the COVID-19 pandemic mainly because the extremely high workload, imperative adaptations, and reorganisation of care regarding skill-mix and teamwork. Patient safety performance relied on the individuals' adaptability and responsibility rather than on system-based safety. Relevance to Clinical PracticeThis study provides insights on how healthcare workers' experiences can be used as a source of information for recognition of patient safety risks. To improve detection of safety risks during future crises, guidelines on how to approach safety from a system perspective must include healthcare workers' perceptions on safety risks. Patient and Public ContributionNone in the conceptualisation or design of the study.

  • 8.
    Bjurling‐Sjöberg, Petronella
    et al.
    Uppsala University, Sweden;Region Sörmland, Sweden.
    Göras, Camilla
    Region Dalarna, Sweden;Dalarna University, Sweden.
    Lohela-Karlsson, Malin
    Uppsala University, Sweden;Region Västmanland, Sweden.
    Nordgren, Lena
    Uppsala University, Sweden;Region Sörmland, Sweden.
    Källberg, Ann-Sofie
    Dalarna University, Sweden;Region Dalarna, Sweden.
    Castegren, Markus
    Uppsala University, Sweden;Region Sörmland, Sweden;Karolinska Institutet, Sweden.
    Condén Mellgren, Emelie
    Uppsala University, Sweden;Region Västmanland, Sweden.
    Holmberg, Mats
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Uppsala University, Sweden;Region Sörmland, Sweden.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden.
    Resilient performance in healthcare during the COVID-19 pandemic (ResCOV): study protocol for a multilevel grounded theory study on adaptations, working conditions, ethics and patient safety2021In: BMJ Open, E-ISSN 2044-6055, Vol. 11, no 12, article id e051928Article in journal (Refereed)
    Abstract [en]

    Introduction

    Since early 2020, the COVID-19 pandemic has challenged societies and revealed the built-in fragility and dependencies in complex adaptive systems, such as healthcare. The pandemic has placed healthcare providers and systems under unprecedented amounts of strain with potential consequences that have not yet been fully elucidated. This multilevel project aims to explore resilient performance with the purpose of improving the understanding of how healthcare has adapted during the pandemic’s rampage, the processes involved and the consequences on working conditions, ethics and patient safety.

    Methods

    An emerging explorative multilevel design based on grounded theory methodology is applied. Open and theoretical sampling is performed. Empirical data are gathered over time from written narratives and qualitative interviews with staff with different positions in healthcare organisations in two Swedish regions. The participants’ first-person stories are complemented with data from the healthcare organisations’ internal documents and national and international official documents.

    Analysis

    Experiences and expressions of resilient performance at different system levels and times, existing influencing risk and success factors at the microlevels, mesolevels and macrolevels and inter-relationships and consequences in different healthcare contexts, are explored using constant comparative analysis. Finally, the data are complemented with the current literature to develop a substantive theory of resilient performance during the pandemic.

    Ethics and dissemination

    This project is ethically approved and recognises the ongoing strain on the healthcare system when gathering data. The ongoing pandemic provides unique possibilities to study system-wide adaptive capacity across different system levels and times, which can create an important basis for designing interventions focusing on preparedness to manage current and future challenges in healthcare. Feedback is provided to the settings to enable pressing improvements. The findings will also be disseminated through scientific journals and conferences.

  • 9.
    Brandberg, Carina
    et al.
    Karolinska Institutet, Sweden.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden.
    Flink, Maria
    Karolinska Institutet, Sweden.
    Self-management challenges following hospital discharge for patients with multimorbidity: a longitudinal qualitative study of a motivational interviewing intervention2021In: BMJ Open, E-ISSN 2044-6055, Vol. 11, no 7, article id e046896Article in journal (Refereed)
    Abstract [en]

    Objectives

    The aim of this study was to describe challenges in self-management activities among people with multimorbidity during a 4-week post-discharge period.

    Design

    This is a longitudinal qualitative study using data from a randomised controlled trial (RCT) of motivational interviewing (MI) sessions.

    Setting

    The RCT was conducted at six wards in two hospitals—one university hospital and one general hospital in Stockholm, Sweden, during 2016–2018.

    Participants

    Sixteen participants from the intervention group, diagnosed with heart failure or chronic obstructive pulmonary disease and at least one other chronic condition, were purposively selected for this study.

    Interventions

    Each participant had four or five post-discharge MI sessions with a trained social worker during a period of approximately 4 weeks. The sessions were recorded digitally and analysed using content analysis. Altogether, 70 recorded sessions were analysed.

    Results

    Self-management after hospital discharge was a dynamic process with several shifting features that evolved gradually over time. Patients with multimorbidity experienced two major challenges with self-management in the first 4 weeks following hospital discharge: ‘Managing a system-centred care’ and ‘Handling the burden of living with multiple illnesses at home post-discharge’.

    Conclusions

    Self-management for patients with multimorbidity in the first post-discharge period does not equate to a fixed set of tasks, but varies over the post-discharge period. Self-management challenges include not only the burden of the disease itself, but also that of navigating and understanding the healthcare system. Hence, self-management support post-discharge involves both aiding patients with care coordination and meeting their gradually shifting disease-related needs.

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  • 10.
    Bredenhof Heijkenskjöld, Katarina
    et al.
    Mälardalen University, Sweden.
    Ekstedt, Mirjam
    Mälardalen University, Sweden.
    Lindwall, Lillemor
    Karlstad University, Sweden.
    The patient's dignity from the nurse's perspective2010In: Nursing Ethics, ISSN 0969-7330, E-ISSN 1477-0989, Vol. 17, no 3, p. 313-324Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to understand how nurses experience patients' dignity in Swedish medical wards. A hermeneutic approach and Flanagan's critical incident technique were used for data collection. Twelve nurses took part in the study. The data were analysed using hermeneutic text interpretation. The findings show that the nurses who wanted to preserve patients' dignity by seeing them as fellow beings protected the patients by stopping other nurses from performing unethical acts. They regard patients as fellow human beings, friends, and unique persons with their own history, and have the courage to see when patients' dignity is violated, although this is something they do not wish to see because it makes them feel bad. Nurses do not have the right to deny patients their dignity or value as human beings. The new understanding arrived at by the hermeneutic interpretation is that care in professional nursing must be focused on taking responsibility for and protecting patients' dignity.

  • 11.
    Børøsund, Elin
    et al.
    Oslo University Hospital, Norway.
    Cvancarova, Milada
    Oslo University Hospital, Norway.
    Ekstedt, Mirjam
    Oslo University Hospital, Norway;KTH Royal Institute of Technology.
    Moore, Shirley M.
    Case Western Reserve University, USA.
    Ruland, Cornelia
    Oslo University Hospital, Norway;University of Oslo, Norway.
    How user characteristics affect use patterns in web-based illness management support for patients with breast and prostate cancer2013In: Journal of Medical Internet Research, E-ISSN 1438-8871, Vol. 15, no 3, article id e34Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Frequently eHealth applications are not used as intended and they have high attrition rates; therefore, a better understanding of patients' need for support is warranted. Specifically, more research is needed to identify which system components target different patient groups and under what conditions.

    OBJECTIVE: To explore user characteristics associated with the use of different system components of a Web-based illness management support system for cancer patients (WebChoice).

    METHODS: For this secondary post hoc analysis of a large randomized controlled trial (RCT), in which WebChoice was tested among 325 breast cancer and prostate cancer patients who were followed with repeated measures for 1 year, usage patterns of 162 cancer patients in the intervention arm with access to WebChoice were extracted from the user log. Logistic regression was performed to identify patterns of associations between system use and patient characteristics. Latent class analyses (LCA) were performed to identify associations among the use of different system components and levels of social support, symptom distress, depression, self-efficacy, and health-related quality of life.

    RESULTS: Approximately two-thirds (103/162, 63.6%) of the patients logged on to WebChoice more than once, and were defined as users. A high level of computer experience (odds ratio [OR] 3.77, 95% CI 1.20-11.91) and not having other illnesses in addition to cancer (OR 2.10, 95% CI 1.02-4.34) increased the overall probability of using WebChoice. LCA showed that both men with prostate cancer and women with breast cancer who had low scores on social support accompanied with high levels of symptom distress and high levels of depression were more likely to use the e-message component. For men with prostate cancer, these variables were also associated with high use of the self-management advice component. We found important differences between men with prostate cancer and women with breast cancer when associations between WebChoice use and each user characteristic were analyzed separately. High use of all components was associated with low levels of social support among women with breast cancer, but not among men with prostate cancer. High use of e-messages, advice, and the discussion forum were associated with high levels of depression among women with breast cancer, but not among men with prostate cancer. For men with prostate cancer (but not women with breast cancer), high use of symptom assessments, advice, and the discussion forum were associated with high levels of symptom distress. However, it is unclear whether these findings can be attributed to differences related to diagnosis, gender, or both.

    CONCLUSIONS: This study provides evidence that different user characteristics are associated with different use patterns. Such information is crucial to target Web-based support systems to different patient groups. LCA is a useful technique to identify subgroups of users. In our study, e-messages and self-management advice were highly used components for patients who had low levels of social support and high illness burden, suggesting that patients with these characteristics may find such tools particularly useful.

  • 12.
    Børøsund, Elin
    et al.
    Oslo University Hospital, Norway;University of Oslo, Norway.
    Cvancarova, Milada
    Oslo University Hospital, Norway.
    Moore, Shirley M.
    Case Western Reserve University, USA.
    Ekstedt, Mirjam
    Oslo University Hospital, Norway;KTH Royal Institute of Technology.
    Ruland, Cornelia M.
    Oslo University Hospital, Norway;University of Oslo, Norway.
    Comparing effects in regular practice of e-communication and web-based self-management support among breast cancer patients: Preliminary results from a randomized controlled trial2014In: Journal of Medical Internet Research, E-ISSN 1438-8871, Vol. 16, no 12, article id e295Article in journal (Refereed)
    Abstract [en]

    Background: While Web-based interventions have been shown to assist a wide range of patients successfully in managing their illness, few studies have examined the relative contribution of different Web-based components to improve outcomes. Further efficacy trials are needed to test the effects of Web support when offered as a part of routine care. Objective: Our aim was to compare in regular care the effects of (1) an Internet-based patient provider communication service (IPPC), (2) WebChoice, a Web-based illness management system for breast cancer patients (IPPC included), and (3) usual care on symptom distress, anxiety, depression, (primary outcomes), and self-efficacy (secondary outcome). This study reports preliminary findings from 6 months' follow-up data in a 12-month trial. Methods: We recruited 167 patients recently diagnosed with breast cancer and undergoing treatment from three Norwegian hospitals. The nurse-administered IPPC allowed patients to send secure e-messages to and receive e-messages from health care personnel at the hospital where they were treated. In addition to the IPPC, WebChoice contains components for symptom monitoring, tailored information and self-management support, a diary, and communication with other patients. A total of 20 care providers (11 nurses, 6 physicians, and 3 social workers) were trained to answer questions from patients. Outcomes were measured with questionnaires at study entry and at study months 2, 4, and 6. Linear mixed models for repeated measures were fitted to compare effects on outcomes over time. Results: Patients were randomly assigned to the WebChoice group (n=64), the IPPC group (n=45), or the usual care group (n=58). Response rates to questionnaires were 73.7% (123/167) at 2 months, 65.9 (110/167) at 4 months, and 62.3% (104/167) at 6 months. Attrition was similar in all study groups. Among those with access to WebChoice, 64% (41/64) logged on more than once and 39% (25/64) sent e-messages to care providers. In the IPPC group, 40% (18/45) sent e-messages. Linear mixed models analyses revealed that the WebChoice group reported significantly lower symptom distress (mean difference 0.16, 95% CI 0.06-0.25, P=.001), anxiety (mean difference 0.79, 95% CI 0.09-1.49, P=.03), and depression (mean difference 0.79, 95% CI 0.09-1.49, P=.03) compared with the usual care group. The IPPC group reported significant lower depression scores compared with the usual care group (mean difference 0.69, 95% CI 0.05-1.32, P=.03), but no differences were observed for symptom distress or anxiety. No significant differences in self-efficacy were found among the study groups. Conclusions: In spite of practice variations and moderate use of the interventions, our results suggest that offering Web support as part of regular care can be a powerful tool to help patients manage their illness. Our finding that a nurse-administered IPPC alone can significantly reduce depression is particularly promising. However, the multicomponent intervention WebChoice had additional positive effects.

  • 13.
    Børøsund, Elin
    et al.
    Oslo University Hospital, Norway.
    Ruland, Cornelia M.
    Oslo University Hospital, Norway;University of Oslo, Norway.
    Moore, Shirley
    Case Western Reserve University, USA.
    Ekstedt, Mirjam
    Oslo University Hospital, Norway;KTH Royal Institute of Technology.
    Nurses' experiences of using an interactive tailored patient assessment tool one year past implementation2013In: International Journal of Medical Informatics, ISSN 1386-5056, E-ISSN 1872-8243, Vol. 83, no 7, p. E23-E34Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Despite evidence of benefits, integration of patient-centered communication in clinical practice is challenging. Interactive tailored patient assessment (ITPA) tools can contribute to a more patient-centered care approach. However, little research has examined the impact of such tools on nursing care once they have been implemented.

    OBJECTIVE: To explore nurses' experiences of the benefits of and barriers to using an ITPA called Choice, in cancer care one year after its implementation.

    METHODS: This investigation is a part of a larger study examining the use of Choice in cancer care. Four focus group interviews were conducted with 20 nurses experienced in using the Choice application. The data were analyzed using qualitative content analysis.

    RESULTS: Three themes and nine sub-themes emerged: (1) "Choice as facilitator for shared understanding and engagement in patients' own care," with three sub-themes: preparing both patient and nurse for communication, shared engagement in care planning, and giving the patients a voice; (2) "enhancing the patients' strengths," with two sub-themes: releasing patient's internal strengths and confirming "normalcy" for the patient; and (3) "new challenges for the nurse," with four sub-themes: organizational challenges, interactions with technology, a need for training in communication skills, and new ethical challenges.

    CONCLUSIONS: Findings suggest that, from nurses' perspectives, integration of ITPAs such as Choice in clinical practice offers many benefits that can contribute to patient-centered care. However, to reap these benefits, use of such tools must receive equal priority as other routines, and require sufficient time, space and competence. Choice also challenged nurses' professional roles and created dilemmas such as nurses' ambivalence regarding patients' levels of disclosure of sensitive issues and the nurses' ability to respond to them. Although patient-centered care is advocated as model for good clinical practice, this is not always internalized. Tools such as Choice may help to make such a shift happen.

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  • 14.
    Carlqvist, Catharina
    et al.
    Karlstad University, Sweden.
    Hagerman, Heidi
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Linnaeus University, Linnaeus Knowledge Environments, Sustainable Health.
    Fellesson, Markus
    Karlstad University, Sweden.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Linnaeus University, Linnaeus Knowledge Environments, Sustainable Health.
    Hellström, Amanda
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Linnaeus University, Linnaeus Knowledge Environments, Sustainable Health.
    Health care professionals' experiences of how an eHealth application can function as a value-creating resource - a qualitative interview study2021In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 21, no 1, article id 1203Article in journal (Refereed)
    Abstract [en]

    Background: The number of patients with one or more chronic conditions is increasing globally. One strategy to achieve more sustainable care for these patients is by implementing use of home-based eHealth applications. Such services support patients to take on a more active role as value-creating co-producers of their own care, in collaboration with health care professionals. Health care professionals have a key role in the value creation process, but little is known about value formation within eHealth interactions, especially from their perspective. Therefore, this study aimed to provide a deeper understanding of how an eHealth application can function as a value-creating resource from the perspective of health care professionals. Methods: Semi-structured interviews were conducted with thirteen health care professionals (nurses, physicians and first-line managers). Qualitative content analysis was used to analyze the interviews. Results: The findings indicate that value formation processes are strongly influenced by the organizational preconditions and by the usability and functionality of technology. The experiences of the health care professionals indicated that value was conceptualized in dimensions of meaningfulness, building of relationships, building safety and feelings of trust. Although these dimensions were mainly expressed in a positive way, such as perceived improvement of medical care, accessibility and continuity, they also had a negative side that caused value destruction. This was primarily due to patient difficulties in using the application or making measurements. Subsequent efforts at value recovery resulted in value creation, but were often time-consuming for the professionals. Conclusions: This study contributes by extending conceptualizations of value to the role of health care professionals and by highlighting technology as sometimes facilitating and sometimes hampering value formation processes. The findings indicate that the eHealth application was a value-creating resource, facilitating proactive communication and supporting patients’ engagement and control over their self-care. However, for the application to become a more valuable resource in practice and counteract inequity in care, it needs to be further developed to be adapted to the needs and preconditions of patients. © 2021, The Author(s)

  • 15.
    Cook, Richard
    et al.
    Ohio State University, USA.
    Ekstedt, Mirjam
    Royal Institute of Technology;Medical Management Centre LIME;Karolinska Institutet.
    Reflections on Resilience: Repertoires and system features2017In: Resilient HealthCare 3: Reconciling Work-As-Imagined and Work-As-Done / [ed] Braithwhite, Jeffery; Wears, Robert; Hollnagel, Erik, London: CRC Press, 2017, 1, p. 111-119Chapter in book (Refereed)
  • 16.
    Ekstedt, Mirjam
    Royal Institue of Technology;Karolinska Institutet.
    Cooping with complexity: sensemaking in specialized home care2017In: Researching patient safety and quality in healthcare: a Nordic perspective / [ed] Karina Aase & Lene Schibevaag, London: CRC Press, 2017, 1, p. 195-209Chapter in book (Refereed)
    Abstract [en]

    In order to understand how safety is created in specialised home care settings, it is necessary to know more about the cognitive strategies used by professionals at the sharp end of practice, to manage problem-solving and decision-making in everyday clinical work (ECW). This chapter aims to contribute to this understanding through the lens of sensemaking theory.

  • 17.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden;KTH Royal Institute of Technology, Sweden.
    Hållbar och säker vård med hemmet som vårdplats2019In: Säker vård: nya perspektiv på patientsäkerhet / [ed] Synnöve Ödegård, Stockholm: Liber, 2019, 1, p. 147-176Chapter in book (Refereed)
  • 18.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Teoretiska perspektiv på patientsäkerhet2019In: Hemsjukvård: olika perspektiv på trygg och säker vård / [ed] Mirjam Ekstedt & Maria Flink, Stockholm: Liber, 2019, 1, p. 23-50Chapter in book (Other academic)
  • 19.
    Ekstedt, Mirjam
    et al.
    KTH Royal Institute of Technology;Ersta Sköndal University College.
    Cook, Richard
    KTH Royal Institute of Technology.
    Långsiktiga investeringar i hemsjukvård skapar förutsättningar för säker vård2014In: 8:de Nationella konferensen om patientsäkerhet, Stockholmsmässan i Älvsjö 23-24, Sept. 2014, 2014Conference paper (Refereed)
    Abstract [sv]

    Ett hållbart sjukvårdsystem kännetecknas av att (människor i) organisationen har förmåga att förutse och upptäcka risker och snabbt kan anpassa sin verksamhet till komplexa situationer på ett för patienten säkert sätt. För att skapa patientsäkerheten i hemsjukvård där många professioner och vårdgivare är involverade behöver vi veta mer om HUR detta går till.

    I denna fallstudie identifieras förutsättningar för att skapa säker vård inom specialiserad hemsjukvård (ASIH). Kännetecken på ett hållbart system visar sig i organisationens förmåga att skapa frihetsgrader för personalen att i skarpt läge prioritera och skräddarsy lösningar. Exempel på organisationens förmåga att hantera olika målkonflikter och balansera sina resurser nära gränsen för säkerhet beskrivs. Studien visar att hållbara sjukvårdssystem bygger på långsiktiga investeringar och systematiskt lärande på olika nivåer i systemet.

    Bakgrund och syfte Hälso- och sjukvården har blivit alltmer komplex och präglas av avancerad teknik och potenta behandlingar. Den medicinska och tekniska utvecklingen har medfört att avancerad vård idag kan ges i hemmen, exempelvis med apparater för syrgasbehandling, dialys, blodtransfusion eller smärtlindring. Det innebär att patienter med en komplex sjukdomsbild, oftast äldre personer med multimorbiditet i allt större grad kan behandlas i hemmet. Den ökade valfriheten och möjligheten att vårdas hemma har ofta idealiserats eftersom den anses öka patienters och närståendes livskvalitet. Men det kan även medföra nya risker. Många vårdgivare och professioner har tillträde till patientens hem och en sammanhållen vårdplan går lätt förlorad. Därför accentueras frågor om hur ledarskap och organisation påverkar patientsäkerhetsarbetet. Även frågor om ansvarsstrukturer, maktförhållanden, samt förekomsten av ett proaktivt förhållningssätt i relation till risker blir aktuella.

    Denna studie ingår i ett på gående forskningsprogram som syftar till att få en bättre förståelse för hur risker identifieras och hanteras i vård av patienter med komplex sjukdomsbild, när den utförs i eller nära patientens hem. Vi studerar hur vårdsystemen utformas på ett sätt så att det skapar förutsättningar för yrkesutövarna i "the sharp end" att bedriva en säker vård.

    Metod: Denna fallstudie genomfördes vid enheter som bedriver Avancerad Sjukvård i Hemmet (ASIH) inom Stockholms län. Studien är explorativ och vi använder etnografiska metoder för att identifiera centrala processer på individ och organisationsnivå. Vi genomför deltagande observationer med följande tekniker: semistrukturerade observations protokoll, ljudinspelningar, fältanteckningar samt korta individuella intervjuer med nyckelpersoner. Upprepade individuella intervjuer samt fokusgruppsintervjuer genomfrös med patienter, chefer och medlemmar i det multiprofessionella vårdteamet för att fördjupa materialet. Datainsamling och analys sker i iterativa cykler utifrån principer för teorigenererande forskningsmetod som innebär att nya frågor genereras ur dataanalysen som grund för nästa observation/fokusintervju. Transkriberat material från intervjuer och observationer analyseras med kvalitativa forskningsmetoder.

    Resultatet beskriver kännetecken i systemet som bidrar till hållbar och säker vård. Under oförutsedda händelser framkom olika strategier för att förenkla och effektivisera arbetet innanför systemets säkerhetsgränser. Kännetecken på systemets hållbarhet visas genom organisationers förmåga att skapa frihetsgrader för personalen att i skarpt läge prioritera och skräddarsy lösningar. Exempel på strategier och investeringar på olika nivåer i organisationen framkom. Investeringar, i vissa fall genomförda sedan lång tid tillbaka, utgjorde en grund för förmågan att hantera målkonflikter och snabbt fatta autonoma beslut i akuta situationer.

    Slutsatser Ett hållbart sjukvårdssystem skapas genom långsiktiga investeringar på olika nivåer, och ett systematiskt lärande i organisationen. Dessa investeringar kommer till uttryck som frihetsgrader för människor i organisationen att agera effektivt och säkert, när ett system utsätts för ovanlig belastning. Resultaten från studien kan öka kunskapen om förutsättningar för säker vård för patienter med komplexa vårdbehov i sina privata hem.

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  • 20.
    Ekstedt, Mirjam
    et al.
    KTH Royal Institute of Technology.
    Cook, Richard I.
    KTH Royal Institute of Technology.
    Expressions of resilience are dependent on investments in systemic degrees of freedom: A case from specialized in-home care2014In: 3rd Nordic Conference on Research in Patient Safety and Quality in Healthcare, 2014, October 2-3, Stavanger, Norway, 2014Conference paper (Refereed)
  • 21.
    Ekstedt, Mirjam
    et al.
    KTH Royal Institute of Technology, Sweden.
    Cook, Richard I.
    The Stockholm Blizzard 20122015In: Resilient health care, volume 2: the resilience of everyday clinical work / [ed] Robert L. Wears, Erik Hollnagel & Jeffrey Braithwaite, Farnham, Surrey, UK: CRC Press, 2015, p. 59-74Chapter in book (Refereed)
  • 22.
    Ekstedt, Mirjam
    et al.
    KTH Royal Institute of Technology;Karolinska Institutet.
    Dahlgren, Anna
    KTH Royal Institute of Technology;Karolinska Institutet.
    Säker vård även i hemmet en framtida utmaning: [ Safe care also in the home : a future challenge ]2015In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 112, no 22, article id DFI7Article, review/survey (Refereed)
  • 23.
    Ekstedt, Mirjam
    et al.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet.
    Darkeh, Mojgan Haji Seyed Ebrahim
    Karolinska Institutet.
    Xiu, Lijuan
    Forssén, Michaela
    Johansson, Elin
    Karolinska Institutet.
    Ek, Anna
    Karolinska Institutet.
    Svensson, Viktoria
    Karolinska Institutet.
    Ekbom, Kerstin
    Karolinska Institutet.
    Marcus, Claude
    Karolinska Institutet.
    Sleep differences in one-year-old children were related to obesity risks based on their parents' weight according to baseline longitudinal study data2017In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 106, no 2, p. 304-311Article in journal (Refereed)
    Abstract [en]

    AIM: Parental obesity is the predominant risk factor for child obesity. We compared sleep in one-year-old children with different obesity risks, based on parental weight, and explored associations with weight, parental sleep and family factors.

    METHODS: Baseline data from 167 families participating in a longitudinal obesity prevention programme was used. Sleep patterns were compared between groups with high and low obesity risks, based on parental weight, and associations between child sleep and weight status, family obesity risk and parental sleep were explored. Sleep was assessed using child sleep diaries and standard parental questionnaires.

    RESULTS: Later bedtime, longer sleep onset latency and lower sleep efficiency were observed among children in the high-risk group. Child sleep onset latency was associated with the family obesity risk (β = 0.25, p = 0.001), child bedtime with both maternal (β = 0.33, p < 0.01) and paternal bedtime (β = 0.22, p < 0.05) and child sleep efficiency with maternal sleep quality (β = 0.20, p < 0.01). The child's bedtime was weakly associated with their body mass index (β = 0.17, p < 0.05).

    CONCLUSION: Sleep differed between one-year-old children with high or low obesity risks, based on their parents' body mass index, and was associated with the family obesity risk and parental sleep. The child's bedtime was weakly associated with their weight status.

  • 24.
    Ekstedt, Mirjam
    et al.
    Karolinska Institutet.
    Fagerberg, Ingegerd
    Mälardalen University ; Karolinska Institutet.
    Lived experiences of the time preceding burnout2005In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648, Vol. 49, no 1, p. 59-67Article in journal (Refereed)
    Abstract [en]

    AIM: This paper reports a study to illuminate the complex interaction between person and their life world during the burnout development period.

    BACKGROUND: Burnout is a construct describing the psychological state resulting from ineffective strategies for coping with enduring stress in both client and non-client work. Role conflict and role ambiguity, or long-term stress and frustration caused by strain in daily life, promote or exacerbate burnout, indicating that the person's entire life world is involved. There is still a lack of description of lived experiences of the time preceding manifest burnout.

    METHOD: Data were collected from interviews with eight people suffering from burnout and analysed using a phenomenological method.

    FINDINGS: The essential meaning of the phenomenon of burnout is understood as being trapped with stimulating challenges as a self-nourishing drive on one side and with responsibilities and demands on the other. This essence can be illuminated by its eight constituents: inner incentive, feeling responsible, threatened self-image, cutting off, bodily manifestations, psychological manifestations, fatigue and reaching the bottom line.

    CONCLUSIONS: The lived experiences of the time preceding manifest burnout are an ambiguous struggle. Cutting off is understood as a mean to shelter the threatened self-image in a state of vulnerability and weakened strength. Accordingly, a better understanding of how to reach behind the defence of 'cutting off' and thus help to open up for consolation and self-acceptance is an essential skill for nurses, health care professionals and others encountering the burnout sufferers. Furthermore this study illuminates early signs of burnout and an important issue is how to strengthen the individuals' ability to shelter their need for recovery and restitution.

  • 25.
    Ekstedt, Mirjam
    et al.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Flink, MariaKarolinska Institutet, Sweden.
    Hemsjukvård: olika perspektiv på trygg och säker vård2019Collection (editor) (Other academic)
  • 26.
    Ekstedt, Mirjam
    et al.
    Royal Institute of Technology;Medical Management Centre LIME;Karolinska Institutet.
    Kenttä, Göran
    Sömnproblematik inom idrott2015In: Bättre prestation & hälsa med KBT: fakta, inspiration, fallbeskrivningar / [ed] Göran Kenttä, Carolina Lundqvist & Pontus Bjurner, Stockholm: SISU idrottsböcker , 2015, 1, p. 177-199Chapter in book (Refereed)
  • 27.
    Ekstedt, Mirjam
    et al.
    Ersta Sköndal University College ; Karolinska Institutet.
    Kenttä, Göran
    Swedish School of Sport and Health Sciences.
    Återhämtning självklart för elitidrottare …men inte för yrkesarbetare2011In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 108, no 36, p. 1684-1687Article, review/survey (Refereed)
  • 28.
    Ekstedt, Mirjam
    et al.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden.
    Kirsebom, Marie
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Lindqvist, Gunilla
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Kneck, Åsa
    Ersta Sköndal Bräcke University College, Sweden.
    Frykholm, Oscar
    Karolinska Institutet, Sweden.
    Flink, Maria
    Karolinska Institutet, Sweden;Karolinska University Hospital, Sweden.
    Wannheden, Carolina
    Karolinska Institutet, Sweden.
    Design and Development of an eHealth Service for Collaborative Self-Management among Older Adults with Chronic Diseases: A Theory-Driven User-Centered Approach2022In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 19, no 1, article id 391Article in journal (Refereed)
    Abstract [en]

    The increasing prevalence of chronic conditions and multimorbidity poses great challenges to healthcare systems. As patients' engagement in self-managing their chronic conditions becomes increasingly important, eHealth interventions are a promising resource for the provision of adequate and timely support. However, there is inconclusive evidence about how to design eHealth services to meet the complex needs of patients. This study applied an evidence-based and theory-informed user-centered design approach in three phases to identify the needs of older adults and healthcare professionals in the collaborative management of multimorbidity (phase 1), develop an eHealth service to address these needs (phase 2), and test the feasibility and acceptance of the eHealth service in a clinical setting (phase 3). Twenty-two user needs were identified and a web-based application-ePATH (electronic Patient Activation in Treatment at Home)-with separate user interfaces for patients and healthcare professionals was developed. The feasibility study with two nurses and five patients led to a redesign and highlighted the importance of adequately addressing not only varying user needs but also the complex nature of healthcare organizations when implementing new services and processes in chronic care management.

  • 29.
    Ekstedt, Mirjam
    et al.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden.
    Lindblad, Marlene
    Ersta Sköndal Bräcke university college, Sweden;KTH Royal institute of technology, Sweden.
    Löfmark, Anna
    University of Gävle, Sweden.
    Nursing students' perception of the clinical learning environment and supervision in relation to two different supervision models: a comparative cross-sectional study2019In: BMC Nursing, ISSN 1472-6955, E-ISSN 1472-6955, Vol. 18, no 1, p. 1-12, article id 49Article in journal (Refereed)
    Abstract [en]

    Background: Knowledge concerning nursing students' experiences of the clinical learning environment and how supervision is carried out is largely lacking. This study compares nursing students' perceptions of the clinical learning environment and supervision in two different supervision models: peer learning in student-dedicated units, with students working together in pairs and supervised by a "preceptor of the day" (model A), and traditional supervision, in which each student is assigned to a personal preceptor (model B). Methods: The study was performed within the nursing programme at a university college in Sweden during students' clinical placements (semesters 3 and 4) in medical and surgical departments at three different hospitals. Data was collected using the Clinical Learning Environment, Supervision and Nurse Teacher evaluation scale, CLES+T, an instrument tested for reliability and validity, and a second instrument developed for this study to obtain deeper information regarding how students experienced the organisation and content of the supervision. Independent t-tests were used for continuous variables, Mann-Whitney U-tests for ordinal variables, and the chi-square or Fischer's exact tests for categorical variables. Results: Overall, the students had positive experiences of the clinical learning environment and supervision in both supervision models. Students supervised in model A had more positive experiences of the cooperation and relationship between student, preceptor, and nurse teacher, and more often than students in model B felt that the ward had an explicit model for supervising students. Students in model A were more positive to having more than one preceptor and felt that this contributed to the assessment of their learning outcomes. Conclusions: A good learning environment for students in clinical placements is dependent on an explicit structure for receiving students, a pedagogical atmosphere where staff take an interest in supervision of students and are easy to approach, and engagement among and collaboration between preceptors and nurse teachers. This study also indicates that supervision based on peer learning in student-dedicated rooms with many preceptors can be more satisfying for students than a model where each student is assigned to a single preceptor.

  • 30.
    Ekstedt, Mirjam
    et al.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden.
    Nordheim, Espen
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. University Hospital of North Norway, Norway.
    Hellström, Amanda
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Strandberg, Susanna
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Hagerman, Heidi
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Patient safety and sense of security when telemonitoring chronic conditions at home: the views of patients and healthcare professionals: a qualitative study2023In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 23, no 1, article id 581Article in journal (Refereed)
    Abstract [en]

    Background: Chronic diseases are increasing worldwide, and the complexity of disease management is putting new demands on safe healthcare. Telemonitoring technology has the potential to improve self-care management with the support of healthcare professionals for people with chronic diseases living at home. Patient safety threats related to telemonitoring and how they may affect patients’ and healthcare professionals’ sense of security need attention. This study aimed to explore patients’ and healthcare professionals’ experiences of safety and sense of security when using telemonitoring of chronic conditions at home.

    Methods: Semi-structured interviews were conducted with twenty patients and nine healthcare professionals (nurses and physicians), recruited from four primary healthcare centers and one medical department in a region in southern Sweden using telemonitoring service for chronic conditions in home healthcare.

    Results: The main theme was that experiences of safety and a sense of security were intertwined and relied on patients´ and healthcare professionals´ mutual engagement in telemonitoring and managing symptoms together. Telemonitoring was perceived to increase symptom awareness and promote early detection of deterioration promoting patient safety. A sense of security emerged through having someone keeping track of symptoms and comprised aspects of availability, shared responsibility, technical confidence, and empowering patients in self-management. The meeting with technology changed healthcare professionals’ work processes, and patients’ daily routines, creating patient safety risks if combined with low health- and digital literacy and a naïve reliance on technology. Empowering patients’ self-management ability and improving shared understanding of the patient’s health status and symptom management were prerequisites for safe care and the patient´s sense of security.

    Conclusions: Telemonitoring chronic conditions in the homecare context can promote a sense of security when care is co-created in a mutual understanding and responsibility. Attentiveness to the patient’s health literacy, symptom management, and health-related safety behavior when using eHealth technology may enlighten and mitigate latent patient safety risks. A systems approach indicates that patient safety risks related to telemonitoring are not only associated with the patient’s and healthcare professionals functioning and behavior or the human-technology interaction. Mitigating patient safety risks are likely also dependent on the complex management of home health and social care service.

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    dataset
  • 31.
    Ekstedt, Mirjam
    et al.
    Karolinska Institutet;KTH Royal Institute of Technology.
    Nyberg, Gisela
    Karolinska Institutet.
    Ingre, Mikael
    Stockholm University.
    Ekblom, Örjan
    Karolinska Institutet;Swedish School of Sport and Health Sciences.
    Marcus, Claude
    Karolinska Institutet.
    Sleep, physical activity and BMI in six to ten-year-old children measured by accelerometry: a cross-sectional study2013In: International Journal of Behavioral Nutrition and Physical Activity, E-ISSN 1479-5868, Vol. 10, article id 82Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    The aim of this study is to describe the relationship between objective measures of sleep, physical activity and BMI in Swedish pre-adolescents. The day-to-day association between physical activity and sleep quality as well as week-day and weekend pattern of sleep is also described.

    METHOD:

    We conducted a cross sectional study consisted of a cohort of 1.231 children aged six to ten years within the Stockholm county area. Sleep and physical activity were measured by accelerometry during seven consecutive days. Outcome measures are total sleep time, sleep efficiency, sleep start and sleep end; physical activity intensity divided into: sedentary (<1.5 METS), light (1.5 to 3 METS) and moderate-to-vigorous (> 3 METS); and Body Mass Index standard deviations score, BMIsds.

    RESULTS:

    Total sleep time decreased with increasing age, and was shorter in boys than girls on both weekdays and weekends. Late bedtime but consistent wake-up time during weekends made total sleep time shorter on weekends than on weekdays. Day-to-day within-subject analysis revealed that moderate-to-vigorous intense physical activity promoted an increased sleep efficiency the following night (CI < 0.001 to 0.047), while total sleep time was not affected (CI -0.003 to 0.043). Neither sleep duration (CI -0.024 to 0.022) nor sleep efficiency (CI -0.019 to 0.028) affected mean physical activity level the subsequent day. The between-subject analysis indicates that the sleep of children characterized by high moderate-to-vigorous physical activity during the day was frequently interrupted (SE = -.23, P < .01). A negative association between BMIsds and sleep duration was found (-.10, p < .01).

    CONCLUSIONS:

    Short sleep duration was associated with high BMI in six to ten year old children. This study underscores the importance of consistent bedtimes throughout the week for promoting sleep duration in preadolescents. Furthermore, this study suggests that a large proportion of intensive physical activity during the day might promote good sleep quality.

  • 32.
    Ekstedt, Mirjam
    et al.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden.
    Rustoen, Tone
    Oslo Univ Hosp, Norway;Univ Oslo, Norway.
    Factors That Hinder and Facilitate Cancer Patients' Knowledge About Pain Management-A Qualitative Study2019In: Journal of Pain and Symptom Management, ISSN 0885-3924, E-ISSN 1873-6513, Vol. 57, no 4, p. 753-760Article in journal (Refereed)
    Abstract [en]

    Context. Pain management education may improve pain control for some patients, whereas individual differences exist. Objectives. To evaluate possible critical components, facilitators, and hindrances for improved knowledge about pain management, in not hospitalized adult oncology patients with pain from bone metastasis participating in a pain management intervention. Methods. This substudy is a qualitative evaluation of the PRO-SELF Pain Control Program, tested in a randomized controlled trial. During six weeks, 87 participants in the intervention group received tailored coaching encounters by a trained oncology nurse. Three encounters for each patient were audio recorded. The encounter between patient's with the largest (n = 12) and lowest (n = 8) change in knowledge about pain management from before to after the intervention was transcribed verbatim and analyzed with qualitative content analysis. Results. The critical components of the intervention were repetition of information, struggling with resistance, use of peer experiences, and keeping track of variations. Facilitators of improvement were patients' trust and preparedness to try new procedures, the patient's self-awareness and body awareness, and taking active role in own care. Difficulties in processing complex information, culturally conditioned behaviors, fear, and lack of knowledge were the most important barriers to the success of the intervention. Conclusion. Education in pain management in cancer patients requires repeated information, allowing time for overcoming resistance related to dysfunctional beliefs and fear. To facilitate the patient's involvement in their pain management, tailored and person-centered education is needed. (C) 2019 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

  • 33.
    Ekstedt, Mirjam
    et al.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Linnaeus University, Linnaeus Knowledge Environments, Sustainable Health. Karolinska Institutet, Sweden.
    Schildmeijer, Kristina
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Backåberg, Sofia
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. University of Calgary, Canada.
    Ljungholm, Linda
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Fagerström, Cecilia
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Linnaeus University, Linnaeus Knowledge Environments, Sustainable Health.
    ‘We just have to make it work’: a qualitative study on assistant nurses’ experiences of patient safety performance in home care services using forum play scenarios2022In: BMJ Open, E-ISSN 2044-6055, Vol. 12, no 5, article id e057261Article in journal (Refereed)
    Abstract [en]

    Objective Safety is essential to support independent living among the rising number of people with long-term healthcare and social care needs. Safety performance in home care leans heavily on the capacity of unlicensed staff to respond to problems and changes in the older patients’ functioning and health. The aim of this study is to explore assistant nurses’ adaptive responses to everyday work to ensure safe care in the home care context.

    Design A qualitative approach using the drama-based learning and reflection technique forum play with subsequent group interviews. The audio-recorded interviews were transcribed and analysed with thematic analysis.

    Setting Home care services organisations providing care to older people in their private homes in two municipalities in southern Sweden.Participants Purposeful sampling of 24 assistant nurses and three managers from municipal home care services and a local geriatric hospital clinic.

    Results Home care workers’ adaptive responses to provide safe home care were driven by an ambition to ‘make it work in the best interests of the person’ by adjusting to and accommodating care recipient needs and making autonomous decisions that expanded the room for manoeuvrability, while weighing risks of a trade-off between care standards and the benefits for the community-dwelling older people’s independent living. Adaptations to ensure information transfer and knowledge acquisition across disciplines and borders required reciprocity.

    Conclusions Safety performance in home care service is dependent on the staff closest to the older people, who deal with safety risks and ethical dilemmas on a day-to-day basis and their access to information, competence, and resources that fit the demands. A proactive leadership characterised by mutual trust and adequate support for decision making is suggested. Managers and decision-makers across healthcare and social care need to consider how they can develop interprofessional collaborations and adaptive routines supporting safety from a broader perspective.

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  • 34.
    Ekstedt, Mirjam
    et al.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden.
    Schildmeijer, Kristina
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Wennerberg, Camilla
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Kalmar County Council, Sweden.
    Nilsson, Lina
    Linnaeus University, Faculty of Technology, Department of Informatics. Linnaeus University, Faculty of Health and Life Sciences, Department of Medicine and Optometry.
    Wannheden, Carolina
    Karolinska Institutet, Sweden.
    Hellström, Amanda
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Enhanced patient activation in cancer care transitions: protocol for a randomized controlled trial of a tailored eectronic health intervention for men with prostate cancer2019In: JMIR Research Protocols, E-ISSN 1929-0748, Vol. 8, no 3, p. 1-13, article id e11625Article in journal (Refereed)
    Abstract [en]

    Background: Prostate cancer has increased in incidence worldwide and is the leading cause of cancer death in 24 countries. The most common treatment is radical prostatectomy. However, surgery is associated with postoperative complications such as urinary incontinence and sexual dysfunction, causing decreased quality of life. If survivors are encouraged to be more active in self-care management, the symptom burden may decrease and quality of life may improve. An electronic health (eHealth) intervention based on motivational behavioral theory has been developed for this purpose.

    Objective: This study aimed to compare the effectiveness of standard care in combination with a tailored eHealth and mobile health self-management support system, electronic Patient Activation in Treatment at Home (ePATH), with standard care of adverse effects of prostate cancer treatment (urinary incontinence and sexual functioning) in men undergoing radical prostatectomy. The secondary aim was to test the effect on patient activation, motivation, overall well-being, and health literacy over time in and between groups.

    Methods: A pragmatic multicenter, block-randomized controlled trial with 2 study arms, standard care (control) and eHealth-assisted standard care (intervention), for patients undergoing radical prostatectomy. For 80% power, a sample of 242 men will need to be recruited.

    Results: Recruitment started in January 2018 and is expected to be completed by August 2019. Data collection will be completed in August 2020. The first cross-sectional results from this trial are anticipated to be published in January 2020.

    Conclusions: With the increasing number of prostate cancer survivors, attention should be paid to rehabilitation, psychosocial care, and support for endurance of self-care to reduce suffering from adverse treatment effects, poor quality of life, and depression because of postoperative complications. This project may increase knowledge of how patients can be supported to feel involved in their care and returning to as normal a life as possible. The anticipated effects of ePATH could improve health outcomes for individuals and facilitate follow-up for health care professionals.

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  • 35.
    Ekstedt, Mirjam
    et al.
    Oslo University Hospital, Norway;KTH Royal Institute of Technology.
    Stenberg, Una
    Oslo University Hospital, Norway.
    Olsson, Mariann
    Karolinska Institutet;Stockholms Sjukhem.
    Ruland, Cornelia M.
    Oslo University Hospital, Norway;University of Oslo, Norway.
    Health Care Professionals' Perspectives of the Experiences of Family Caregivers During In-Patient Cancer Care2014In: Journal of Family Nursing, ISSN 1074-8407, E-ISSN 1552-549X, Vol. 20, no 4, p. 462-486Article in journal (Refereed)
    Abstract [en]

    Being a family member of a patient who is being treated in an acute care setting for cancer often involves a number of challenges. Our study describes Norwegian cancer care health professionals' perceptions of family members who served as family caregivers (FCs) and their need for support during the in-hospital cancer treatment of their ill family member. Focus group discussions were conducted with a multidisciplinary team of 24 experienced social workers, physicians, and nurses who were closely involved in the patients' in-hospital cancer treatment and care. Drawing on qualitative hermeneutic analysis, four main themes describe health professionals' perceptions of FCs during the patient's in-hospital cancer care: an asset and additional burden, infinitely strong and struggling with helplessness, being an outsider in the center of care, and being in different temporalities. We conclude that it is a challenge for health care professionals to support the family and create room for FC's needs in acute cancer care. System changes are needed in health care, so that the patient/FC dyad is viewed as a unit of care in a dual process of caregiving, which would enable FCs to be given space and inclusion in care, with their own needs simultaneously considered alongside those of the patient.

  • 36.
    Ekstedt, Mirjam
    et al.
    Oslo University Hospital, Norway ; Stockholm University ; Karolinska Institutet.
    Söderström, Marie
    Stockholm University ; Karolinska Institutet.
    Åkerstedt, Torbjörn
    Stockholm University ; Karolinska Institutet.
    Sleep physiology in recovery from burnout2009In: Biological Psychology, ISSN 0301-0511, E-ISSN 1873-6246, Vol. 82, no 3, p. 267-73Article in journal (Refereed)
    Abstract [en]

    This study aimed to investigate the role of sleep physiology in recovery from burnout, in particular the relation between sleep and changes in fatigue and whether those changes would be related to return to work. 23 white-collar workers on long-term sick leave (>3 months) due to a burnout related diagnosis and 16 healthy controls were subjected to polysomnographic recordings at baseline and after 6-12 months' rehabilitation. Occupational status, subjective sleep quality, fatigue, anxiety and depression were assessed. Recovery from burnout was accompanied by improved sleep continuity. Significant interaction effects were seen for number of arousals, sleep fragmentation, sleep latency, sleep efficiency and time of rising. The burnout group improved significantly on all symptom variables although the post-treatment levels did not reach the levels of the controls. Recovery from fatigue was related to a reduction of the arousal from sleep and was the best predictor of return to work.

  • 37.
    Ekstedt, Mirjam
    et al.
    National Institute of Psychosocial Factors and Health.
    Söderström, Marie
    National Institute of Psychosocial Factors and Health.
    Åkerstedt, Torbjörn
    National Institute of Psychosocial Factors and Health ; Karolinska Institutet.
    Nilsson, Jens
    National Institute of Psychosocial Factors and Health.
    Søndergaard, Hans-Peter
    National Institute of Psychosocial Factors and Health.
    Aleksander, Perski
    National Institute of Psychosocial Factors and Health.
    Disturbed sleep and fatigue in occupational burnout2006In: Scandinavian Journal of Work, Environment and Health, ISSN 0355-3140, E-ISSN 1795-990X, Vol. 32, no 2, p. 121-31Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The purpose of this study was to investigate sleep with polysomnography and self-ratings and the diurnal pattern of sleepiness and fatigue in a group suffering from severe occupational burnout.

    METHOD: Twelve white-collar workers on long-term sick leave (>3 months) and 12 healthy controls with high and low scores on the Shirom Melamed Burnout Questionnaire (SMBQ) were included. A 1-night polysomnographic recording (after habituation) was carried out at home, and sleepiness and mental fatigue were rated at different times of the day for weekdays and the weekend. Precipitating factors at the time of the illness at work and real life were considered, and different dimensions of occupational fatigue were described. A repeated-measures analysis of variance using two or three within group factors was used to analyze the data.

    RESULTS: The main polysomnographic findings were more arousals and sleep fragmentation, more wake time and stage-1 sleep, lower sleep efficiency, less slow wave sleep and rapid eye movement sleep, and a lower delta power density in non-rapid eye movement sleep in the burnout group. The burnout patients showed pronounced sleepiness and mental fatigue at most times of the day for weekdays without reduction during weekends. The precipitating factor was occupational stress (psychiatric interview), and work stress indicators were increased.

    CONCLUSIONS: Occupational burnout is characterized by impaired sleep. It is suggested that impaired sleep may play a role in the development of fatigue or exhaustion in burnout.

  • 38.
    Ekstedt, Mirjam
    et al.
    Oslo University Hospital, Norway; Stockholm University, Sweden.
    Åkerstedt, Torbjörn
    Stockholm University, Sweden.
    Planerad vila förebygger överträning2010In: Svensk idrottsmedicin, ISSN 1103-7652, no 1, p. 14-17Article in journal (Other (popular science, discussion, etc.))
    Abstract [sv]

    Utvecklingen från naturlig trötthet till utmattning följer ungefär samma förlopp vid mentalöveransträngning som vid sjukdom eller fysisk överbelastning. Genom att aktivt prioritera ochplanera in tid för vila och återhämtning förebygger man överträning och utmattning.

  • 39.
    Ekstedt, Mirjam
    et al.
    Karolinska Institutet ; National Institute for Psychosocial Factors and Health.
    Åkerstedt, Torbjörn
    Karolinska Institutet ; National Institute for Psychosocial Factors and Health.
    Söderström, Marie
    Karolinska Institutet ; National Institute for Psychosocial Factors and Health.
    Microarousals during sleep are associated with increased levels of lipids, cortisol, and blood pressure2004In: Psychosomatic Medicine, ISSN 0033-3174, E-ISSN 1534-7796, Vol. 66, no 6, p. 925-931Article in journal (Refereed)
    Abstract [en]

    Objective: Previous work has demonstrated a link between restricted sleep and risk indicators for cardiovascular and metabolic disease, such as levels of cortisol, lipids, and glucose. The present study sought to identify relations between polysomnographic measures of disturbed sleep (frequency of arousals from sleep, total sleep time, and sleep efficiency) and a number of such indicators. A second purpose was to relate the number of arousals to mood, stress, work characteristics, and other possible predictors in daily life.

    Methods: Twenty-four people (10 men, 14 women; mean age 30 years), high vs. low on burnout, were recruited from a Swedish IT company. Polysomnographically recorded sleep was measured at home before a workday. Blood pressure, heart rate, morning blood sample, and saliva samples of cortisol were measured the subsequent working day. They were also recorded for diary ratings of sleep and stress, and a questionnaire with ratings of sleep, stress, work conditions, and mood was completed.

    Results: A stepwise regression analysis using sleep parameters as predictors brought out number of arousals as the best predictor of morning cortisol (serum and saliva), heart rate, systolic and diastolic blood pressure, total cholesterol, high-density lipoprotein (HDL)-, low-density lipoprotein (LDL)-cholesterol, and LDL/HDL-ratio. Work stress/unclear boundaries between work and leisure time was the best predictor of arousals among the stress variables.

    Conclusion: Consistent with sleep restriction experiments, sleep fragmentation was associated with elevated levels of metabolic and cardiovascular risk indicators of stress-related disorders. Number of arousals also seems to be related to workload/stress.

  • 40.
    Ekstedt, Mirjam
    et al.
    KTH Royal Institute of Technology.
    Ödegård, Synnöve
    KTH Royal Institute of Technology.
    Exploring Gaps in Cancer Care Using a Systems Safety Perspective2015In: Cognition, Technology & Work, ISSN 1435-5558, E-ISSN 1435-5566, Vol. 17, no 1, p. 5-13Article in journal (Refereed)
    Abstract [en]

    Gaps in the continuity of care may appear as losses of information or momentum or as interruptions in the delivery of care. To systematically improve patient safety, we need to know more about how gaps in the continuity of health care are identified and mitigated. This study seeks to describe healthcare professionals’ understanding of how they anticipate, detect and handle gaps in cancer care. Ten focus-group interviews and two individual interviews were conducted with a total of 34 cancer-care professionals (physicians, nurses, managers and administrators)from three counties in mid-Sweden. Various specialties in cancer care were covered: primary care, inhospital care, palliative care, advanced home are, and children’s care. Interviews were analyzed inductively using qualitative content analysis. The results show that patient safety in cancer care is dependent on a resilient organization that is capable of anticipation, monitoring, adapting and learning at all levels of care. The professionals anticipated gaps in situations where contacts between healthcare providers were limited and when they were faced by time or resource constraints. The extent to which aps could be managed by professionals at the sharp end was largely determined by their bility to adapt to complex and unexpected situations in their daily work. The management of gaps was perceived differently by managers and clinicians, however. The study also indicates hat the continuity of care could be improved by patients’ participation in decisions about reatments and care plans, and by a mutual responsibility for the transfer of information and knowledge across professional boundaries. These results are discussed from a resilience ngineering perspective, and they emphasize the management’s responsibility to address gaps identified in the system. Designing resilient healthcare organizations enables professionals at  the sharp end to prevent human error or mitigate its consequences.

  • 41.
    Ekstedt, Mirjam
    et al.
    KTH Royal Institute of Technology.
    Ödegård, Synnöve
    KTH Royal Institute of Technology.
    Patients Safety in cancer care from a systems perspective2012In: The 2nd Nordic Conference in Patient Safety and Healthcare: Book of Abstracts / [ed] Anne Hjøllund Christiansen, Henning Boje Andersen, Knut Borch-Johnsen, Technical University of Denmark , 2012, p. 76-77Conference paper (Refereed)
    Abstract [en]

    It has long been an accepted knowledge that structural issues are important for patient safety. The organization of cancer care is divided into many specialties, clinics and levels of care, making patients particularly vulnerable to medical mishaps. It is clear that practitioners at "the sharp end" (physicians, nurses, technicians, pharmacists and others) have to cope with a complex, rapidly changing care, highly advanced technology and potent treatment, and in particular, with the “gaps” of discontinuities, that complexity spawns. 

    One question that needs to be addressed in relation to this complexity is whether existing laws, rules and guidelines regulating cancer care cover issues of responsibility sufficiently throughout the entire continuum of care. Another one is to what extent professionals at “the sharp end” have the opportunity to follow guidelines for patient safety. 

    Gaps often occur between different organizations or health-care providers, or when responsibility is transferred within an organization. However, it is through an increased understanding of practitioners' normal ability to bridge gaps that safety is increased. 

    We know little about how practitioners identify and bridge gaps that occur within the cancer-care continuum, from the patients´ first visit to their general practitioner, through hospital care and transmission to advanced home care. Therefore, the aim of this ongoing study is to perform an exploration of gaps in the cancer-care continuum and the way practitioners anticipate, detect and bridge them, as a means of pursuing robust improvements in patient safety. 

    Methods and materials 

    Twelve qualitative interviews (individual or in group) were performed with healthcare professionals working with various healthcare providers in cancer care in three county councils in central Sweden. The participants were managers, administrators, secretaries, medical doctors, general practitioners, district nurses or nurses in patient care, palliative care or advanced home care. A total of 28 persons were interviewed. The participants were instructed to describe situations when they managed to avoid risks of medical injury, or situations where they failed to prevent human errors. The interviews were transcribed verbatim and analyzed using a qualitative latent and manifest content analysis method. 

    Preliminary results 

    This study is currently under analysis and final results are planned to be presented and discussed at the meeting. This study will contribute to the discussion with some patterns of the complexities and hazards in cancer care that practitioners at the sharp end have identified. 

    Preliminary findings deal with issues of communication deficits within the organization and between different levels of care, unclear guidance and lack of knowledge among practitioners, technical challenges and lack of resources, hierarchies and attitudes that impede patient safety; and the fact that cancer patients often face a variety of actors in a complicated chain of care, without someone taking a clear and collective responsibility for their care. 

  • 42.
    Engström, Ingemar
    et al.
    Örebro University, Sweden.
    Hansson, Lars
    Lund University, Sweden.
    Ali, Lilas
    University of Gothenburg, Sweden.
    Berg, Jenny
    Swedish Agency for Health Technology Assessment and Assessment of Social Services, Sweden.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Engström, Sven
    Region Jönköping, Sweden.
    Fredriksson, Maja Karrman
    Swedish Agency for Health Technology Assessment and Assessment of Social Services, Sweden.
    Liliemark, Jan
    Swedish Agency for Health Technology Assessment and Assessment of Social Services, Sweden.
    Lytsy, Per
    Swedish Agency for Health Technology Assessment and Assessment of Social Services, Sweden.
    Relational continuity may give better clinical outcomes in patients with serious mental illness - a systematic review2023In: BMC Psychiatry, E-ISSN 1471-244X, Vol. 23, no 1, article id 952Article, review/survey (Refereed)
    Abstract [en]

    BackgroundContinuity of care is considered important for results of treatment of serious mental illness (SMI). Yet, evidence of associations between relational continuity and different medical and social outcomes is sparse. Research approaches differ considerably regarding how to best assess continuity as well as which outcome to study. It has hitherto been difficult to evaluate the importance of relational continuity of care. The aim of this systematic review was to investigate treatment outcomes, including effects on resource use and costs associated with receiving higher relational continuity of care for patients with SMI.MethodsEleven databases were searched between January 2000 and February 2021 for studies investigating associations between some measure of relational continuity and health outcomes and costs. All eligible studies were assessed for study relevance and risk of bias by at least two independent reviewers. Only studies with acceptable risk of bias were included. Due to study heterogeneity the synthesis was made narratively, without meta-analysis. The certainty of the summarized result was assessed using GRADE. Study registration number in PROSPERO: CRD42020196518.ResultsWe identified 8 916 unique references and included 17 studies comprising around 300 000 patients in the review. The results were described with regard to seven outcomes. The results indicated that higher relational continuity of care for patients with serious mental illness may prevent premature deaths and suicide, may lower the number of emergency department (ED) visits and may contribute to a better quality of life compared to patients receiving lower levels of relational continuity of care. The certainty of the evidence was assessed as low or very low for all outcomes. The certainty of results for the outcomes hospitalization, costs, symptoms and functioning, and adherence to drug treatment was very low with the result that no reliable conclusions could be drawn in these areas.ConclusionsThe results of this systematic review indicate that having higher relational continuity of care may have beneficial effects for patients with severe mental illness, and no results have indicated the opposite relationship. There is a need for better studies using clear and distinctive measures of exposure for relational continuity of care.

  • 43.
    Flink, Maria
    et al.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden;Karolinska University Hospital, Sweden.
    Brandberg, Carina
    Karolinska Institutet, Sweden.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden.
    Why patients decline participation in an intervention to reduce re-hospitalization through patient activation: whom are we missing?2019In: Trials, E-ISSN 1745-6215, Vol. 20, p. 1-7, article id 82Article in journal (Refereed)
    Abstract [en]

    BackgroundDespite worldwide interest in reducing re-hospitalization, there is limited knowledge regarding characteristics of patients who chose to decline participation in such efforts and why. The aim is to explore reasons to decline participation in an intervention using motivational interviewing to reduce re-hospitalization through patient activation for persons with chronic obstructive pulmonary disease or heart failure.MethodsThis study uses data from 385 patients who were asked about participating in a randomized controlled trial; of these, 232 declined participation. Data on age, gender, and diagnosis were collected for those who agreed to participate and those who declined. Reasons to decline participation were collected for those who were asked to participate but refused. The stated reasons to decline were analyzed using content analysis, and the categories identified were used for the statistical analysis.ResultsThe main reasons for declining participation were having sufficient support (17.5%), no need for support (16%), being too ill (14.6%), and lack of time for illness-related activities (14.2%). A statistically significant negative association between age and willingness to participate was found (odds ratio=-0.03, 95% confidence interval 0.95-0.99).ConclusionsThose who agreed to participate were younger than non-participants, and non-participants either lacked time for illness-related activities or did not have the energy needed to become involved in the intervention.Trial registrationClinicalTrials.gov, NCT02823795. Registered on 1 July 2016.

  • 44.
    Flink, Maria
    et al.
    Karolinska Institutet, Sweden.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Kontinuitet och integrerad vård2019In: Hemsjukvård: olika perspektiv på trygg och säker vård / [ed] Mirjam Ekstedt & Maria Flink, Stockholm: Liber, 2019, 1, p. 267-280Chapter in book (Other academic)
  • 45.
    Flink, Maria
    et al.
    Karolinska Institutet, Sweden.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Patienters delaktighet för säker vård2019In: Hemsjukvård: olika perspektiv på trygg och säker vård / [ed] Mirjam Ekstedt & Maria Flink, Stockholm: Liber, 2019, 1, p. 191-207Chapter in book (Other academic)
  • 46.
    Flink, Maria
    et al.
    Karolinska Institutet;Karolinska University Hospital.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet.
    Planning for the Discharge, not for Patient Self-Management at Home - An Observational and Interview Study of Hospital Discharge2017In: International Journal of Integrated Care, E-ISSN 1568-4156, Vol. 17, article id UNSP 1Article in journal (Refereed)
    Abstract [en]

    Introduction and objective: Despite recent interest in care transitions, little is known about how patients are prepared for the self-management tasks following the hospitalization. The objective of the study was to explore how discharge information is prepared and provided to patients in the transition from hospital to home. Method: The discharge process at three hospitals in Sweden was observed over 12 days spread over ten weeks. In total, 30 discharge encounters were observed followed by interviews with patients and professionals. Data were analysed using qualitative content analysis. Results: Much time, effort and resources were used to prepare the discharge; home-going teams and registered nurses planned the practical and social aspects of the discharge and the physicians compiled a plain-language discharge letter. Less focus was given on the actual discharge information to the patients. The discharge encounters lasted for a median of 4: 46 minutes and the information had a retrospective focus with information on the hospitalization period, though omitting self-management tasks and lifestyle advice. Conclusion: The discharge letter constitutes the basis for all patient information at discharge. The focus of the discharge encounter needs to be extended beyond mere information to include patient understanding, motivation and skills for self-management at home.

  • 47.
    Flink, Maria
    et al.
    Karolinska Institutet;Karolinska University Hospital.
    Lindblad, Marlene
    Karolinska Institutet;KTH Royal Institute of Technology.
    Frykholm, Oscar
    Karolinska Institutet.
    Kneck, Asa
    Karolinska Institutet.
    Nilsen, Per
    Linköping University.
    Årestedt, Kristofer
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Kalmar County Hospital.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet;KTH Royal Institute of Technology.
    The Supporting Patient Activation in Transition to Home (sPATH) intervention: a study protocol of a randomised controlled trial using motivational interviewing to decrease re-hospitalisation for patients with COPD or heart failure2017In: BMJ Open, E-ISSN 2044-6055, Vol. 7, no 7, article id e014178Article in journal (Refereed)
    Abstract [en]

    Introduction Deficient hospital discharging and patients struggling to handle postdischarge self-management have been identified as potential causes of re-hospitalisation rates. Despite an increased interest in interventions aiming to reduce re-hospitalisation rates, there is yet no best evidence on how to support patients in being active participants in their self-management postdischarge. The aim of this paper is to describe the study protocol for an upcoming randomised controlled trial (RCT) of the Supporting Patient in Activation to Home (sPATH) intervention. Methods/analysis The described study is a randomised, controlled, analysis-blinded, two-site trial, with primary outcome re-hospitalisation within 90 days. In total, 290 participants aged 18 years or older with chronic obstructive pulmonary disease or congestive heart failure who are admitted to hospital and who are living in an own home will be eligible for inclusion into an intervention (n=145) or control group (n= 145). Patients who need an interpreter to communicate in Swedish, or who have a diagnosis of dementia or cognitive impairment, will be excluded from inclusion. The sPATH intervention, developed with a theoretical base in the self-determination theory, consists of five postdischarge motivational interviewing sessions (face to face or by phone). The intervention covers the self-management areas medication management, follow-up/care plan, symptoms/signs of worsening condition and relations/contacts with healthcare providers. This RCT will add to the literature on evidence to support patient activation in postdischarge selfmanagement. Ethics and dissemination The study is approved by the Regional Research Ethics Committee (No. 2014/149831/ 2) in Stockholm, Sweden. The results of the study will be published in peer-reviewed journals and presented at international and national scientific conferences.

  • 48.
    Flink, Maria
    et al.
    Karolinska Institutet, Sweden.
    Tessma, Mesfin
    Karolinska University Hospital, Sweden.
    Cvancarova Småstuen, Milada
    Oslo and Akershus University College of Applied Sciences, Norway.
    Lindblad, Marléne
    Ersta Sköndal Bräcke University College, Sweden.
    Coleman, Eric A
    University of Colorado Denver Anschutz Medical Campus, USA.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden.
    Measuring care transitions in Sweden: validation of the care transitions measure2018In: International Journal for Quality in Health Care, ISSN 1353-4505, E-ISSN 1464-3677, Vol. 30, no 4, p. 291-297Article in journal (Refereed)
    Abstract [en]

    Objective: To translate and assess the validity and reliability of the original American Care Transitions Measure, both the 15-item and the shortened 3-item versions, in a sample of people in transition from hospital to home within Sweden.

    Design: Translation of survey items, evaluation of psychometric properties.

    Setting: Ten surgical and medical wards at five hospitals in Sweden.

    Participants: Patients discharged from surgical and medical wards.

    Main outcome measure: Psychometric properties of the Swedish versions of the 15-item (CTM-15) and the 3-item (CTM-3) Care Transition Measure.

    Results: We compared the fit of nine models among a sample of 194 Swedish patients. Cronbach's alpha was 0.946 for CTM-15 and 0.74 for CTM-3. The model indices for CTM-15 and CTM-3 were strongly indicative of inferior goodness-of-fit between the hypothesized one-factor model and the sample data. A multidimensional three-factor model revealed a better fit compared with CTM-15 and CTM-3 one factor models. The one-factor solution, representing 4 items (CTM-4), showed an acceptable fit of the data, and was far superior to the one-factor CTM-15 and CTM-3 and the three-factor multidimensional models. The Cronbach's alpha for CTM-4 was 0.85.

    Conclusions: CTM-15 with multidimensional three-factor model was a better model than both CTM-15 and CTM-3 one-factor models. CTM-4 is a valid and reliable measure of care transfer among patients in medical and surgical wards in Sweden. It seems the Swedish CTM is best represented by the short Swedish version (CTM-4) unidimensional construct.

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  • 49.
    Freilich, Joel
    et al.
    Karolinska Institutet, Sweden.
    Nilsson, Gunnar H.
    Karolinska Institutet, Sweden.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden.
    Flink, Maria
    Karolinska Institutet, Sweden;Karolinska University Hospital, Sweden.
    "Standing on common ground"-a qualitative study of self-management support for patients with multimorbidity in primary health care2020In: BMC Family Practice, E-ISSN 1471-2296, Vol. 21, no 1, p. 1-12, article id 233Article in journal (Refereed)
    Abstract [en]

    Background Multimorbidity, the co-existence of two or more chronic conditions in an individual, is present in most patients over 65 years. Primary health care (PHC) is uniquely positioned to provide the holistic and continual care recommended for this group of patients, including support for self-management. The aim of this study was to explore professionals', patients', and family caregivers' perspectives on how PHC professionals should support self-management in patients with multimorbidity. This study also includes experiences of using telemedicine to support self-management. Methods A mixed qualitative method was used to explore regular self-management support and telemedicine as a tool to support self-management. A total of 42 participants (20 physicians, 3 registered nurses, 12 patients, and 7 family caregivers) were interviewed using focus group interviews (PHC professionals), pair interviews (patients and family caregivers), and individual interviews (registered nurses, patients, and family caregivers). The study was performed in urban areas in central Sweden and rural areas in southern Sweden between April 2018 and October 2019. Data were analyzed using content analysis. Results The main theme that emerged was "Standing on common ground enables individualized support." To achieve such support, professionals needed to understand their own views on who bears the primary responsibility for patients' self-management, as well as patients' self-management abilities, needs, and perspectives. Personal continuity and trustful relationships facilitated this understanding. The findings also indicated that professionals should be accessible for patients with multimorbidity, function as knowledge translators (help patients understand their symptoms and how the symptoms correlated with diseases), and coordinate between levels of care. Telemedicine supported continual monitoring and facilitated patient access to PHC professionals. Conclusion Through personal continuity and patient-centered consultations, professionals could collaborate with patients to individualize self-management support. For some patients, this means that PHC professionals are in control and monitor symptoms. For others, PHC professionals play a less controlling role, empowering patients' self-management. Development and improvement of eHealth tools for patients with multimorbidity should focus on improving the ability to set mutual goals, strengthening patients' inner motivation, and including multiple caregivers to enhance information-sharing and care coordination.

  • 50.
    Frykholm, Oscar
    et al.
    Karolinska Institutet.
    Flink, Maria
    Karolinska Institutet.
    Lindblad, Marlene
    KTH Royal Institute of Technology.
    Ekstedt, Mirjam
    Karolinska Institutet;KTH Royal Institute of Technology.
    User-centered design of integrated eHealth to improve patients' activation in transitional care2016In: International Journal of Integrated Care, E-ISSN 1568-4156, Vol. 16, no 6, p. 1-8, article id A338Article in journal (Refereed)
    Abstract [en]

    Introduction: The burden of chronic diseases is expected to escalate worldwide. Despite extensive use of emergency rooms and specialized care of persons with multiple or chronic diseases, the majority of the time care is managed in the patient’s home. For patients, living with chronic illnesses can be highly demanding, requiring them to manage their symptoms, disabilities and complex medical regimens at home. Effectively functioning in the role of self-manager requires a high level of knowledge, skill, and confidence. In order to handle these challenges, new models for care are required.

    eHealth solutions, successfully implemented in everyday clinical practice have shown significant effects on symptom management and self-efficacy, improving quality of care. Despite the wide proliferation and everyday use of consumer technology as well as eHealth solutions, the contribution of eHealth solutions in enhancing patients’ activation in self-management of their care is an underdeveloped field. Therefore, we undertake a long-term project of developing an eHealth solution where patients and care-givers are active stakeholders, and in parallel, paving the way for clinical ownership of the eHealth solution, in order to evaluate it in a randomized controlled study. The aim of this abstract is to describe the user-centered design in the development of an eHealth service.

    Theory and Method: We report process data from an ongoing study; aiming to improve transitional care by focusing on patient activation and participation during the critical post-hospitalization phase. We draw upon principals of the evidence-based Care Transition Intervention, which will be integrated into an eHealth solution, as a ‘digital coach’ to support patients’ self- management. We have identified four pillars that will form the foundation of the eHealth solution: care plan, medication self-management, symptom management, and contact information to relevant care-givers.

    In the first phase of the project, we have utilized a user-centered design process by engaging patients and care-givers in interviews, workshops and design activities. Results from these activities are documented in user-centered material such as patient journeys, effect maps, and prototypes of the eHealth solution. This material has been directly fed into the development of the technical solution, making us confident that the proposed solution will solve concrete user needs. At the same time, we make long-term collaborations with the care-givers and departments, from where the eHealth solution will be distributed to patients in the study.

    Progress report: A number of observational and design activities have been conducted with both patients and care-givers, at two different hospitals. User context has been documented in patient journeys, which describe a typical patient’s journey from first symptom through medical evaluation and treatment, up to living with the disease or complications of the treatment. The patient journey describes, in different stages, how the patient´s feels, their contact with health care, what information they receives and requires, and what examinations and treatments they undergoes. Visualizing health care from the patient’s perspective in this manner helps identifying gaps in e.g. information needs and to position the eHealth solution in situations where it can solve concrete needs. Furthermore, user needs have been captured in effect maps, which connect hands-on needs or functionality with high-level goals (e.g. ultimately enhanced patient activation and reduced re-hospitalization). As of now, in the second phase of the project, development of technical solution has commenced, and we are planning for pilot testing in the next couple of months.

    Discussion and conclusions: eHealth solutions play an important part in improving activation and awareness. However, it is not simply solved by the sheer introduction of eHealth solutions we have learned that it requires:

    - Successful implementation in the health care processes, as personnel should feel an ownership of the eHealth solution in order to perceive it as an effective tool in their communication with patients and collaboration with other care givers.

    - Presentation of relevant feedback to patients, in order for them to learn about their own disease and symptoms, and to be actively engaged in self-management at home Using motivational gamification in eHealth solutions will help to capture patients’ interest to take active role in their own care, and to motivate patients to learn and maintain self-management knowledge and skills.

    - Fitting it into the existing eco system of technical solutions for health care as well as patient- and lifestyle-centered applications.

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