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  • 1.
    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)
  • 2.
    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.
    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.

  • 3.
    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, ISSN 1438-8871, 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.

  • 4.
    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, ISSN 1438-8871, 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.

  • 5.
    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.

  • 6. Cecilie, V
    et al.
    Ekstedt, Mirjam
    KTH, Systemsäkerhet och organisation.
    Challenges related to the Implementation of an Informatics Intervention into Regular Clinical Practice: A leadership Perspective2012In: 33rd Annual Meeting, Society of Behavioral Medicine, 2012, 2012Conference paper (Refereed)
  • 7.
    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)
  • 8.
    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.

  • 9.
    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.

  • 10.
    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)
  • 11.
    Ekstedt, Mirjam
    et al.
    KTH Royal Institute of Technology.
    Cook, Richard I.
    School of Technology and Heath.
    The Stockholm Blizzard 20122015In: Resilient Health Care: Volume 2 : The Resilience of Everyday Clinical Work / [ed] Robert L. Wears, Erik Hollnagel, Jeffrey Braithwaite, CRC Press, 2015, p. 59-74Chapter in book (Refereed)
  • 12.
    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)
  • 13.
    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.

  • 14.
    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.

  • 15.
    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)
  • 16.
    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)
  • 17.
    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, ISSN 1479-5868, 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.

  • 18.
    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.

  • 19.
    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, Carolina
    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, ISSN 1929-0748, 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.

  • 20.
    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.

  • 21.
    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.

  • 22.
    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.

  • 23.
    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.

  • 24.
    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.

  • 25.
    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. 

  • 26.
    Flink, Maria
    et al.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet;Karolinska University Hospital.
    Brandberg, Carina
    Karolinska Institutet.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet.
    Why patients decline participation in an intervention to reduce re-hospitalization through patient activation: whom are we missing?2019In: Trials, ISSN 1745-6215, 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.

  • 27.
    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, ISSN 1568-4156, 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.

  • 28.
    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, ISSN 2044-6055, 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.

  • 29.
    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.

  • 30.
    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, ISSN 1568-4156, 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.

  • 31.
    Grossi, Giorgio
    et al.
    National Institute for Psychosocial Factors and Health, Stockholm.
    Perski, Aleksander
    National Institute for Psychosocial Factors and Health, Stockholm.
    Ekstedt, Mirjam
    National Institute for Psychosocial Factors and Health, Stockholm.
    Johansson, Thorbjörn
    National Institute for Psychosocial Factors and Health, Stockholm.
    Lindström, Morie
    Uppsala University.
    Holm, Karin
    Uppsala University.
    The morning salivary cortisol response in burnout.2005In: Journal of Psychosomatic Research, ISSN 0022-3999, E-ISSN 1879-1360, Vol. 59, no 2, p. 103-111Article in journal (Refereed)
    Abstract [en]

    The results of the present study indicate a dysregulation in hypothalamic-pituitary-adrenocortical axis (HPA axis) activity, characterised by elevated morning salivary cortisol levels, among female burnout patients. Among males, increased cortisol levels were observed among participants with moderate levels of burnout, but not among patients or healthy controls.

  • 32.
    Gustafson, Pelle
    et al.
    Läkartidningen.
    Ahlberg, Jon
    Löf.
    Ekstedt, Mirjam
    KTH Royal Institute of Technology;Karolinska Institutet.
    Lindh, Marion
    Härenstam, Karin Pukk
    Astrid Lindgrens barnsjukhus;Karolinska Institutet.
    Rutberg, Hans
    Linköping University.
    Säkrare svensk sjukvård kräver sammanhållet och uthålligt arbete2015In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 112, no 25-26Article, review/survey (Refereed)
    Abstract [en]

    Despite a development in Swedish patient safety work in recent years, unambiguous results are missing. Here we propose some activities that will result in improved patient safety. Patients and employees are a strong driving force, and should be given a more important role. The level of education in patient safety must be raised in all levels in the system. Efective systems for learning, sharing and follow-up need to be reinforced. The understanding on how the health-care system adapts to varying circumstances, resilience, needs development. The knowledge basis of what constitutes and creates safety in psychiatry, paediatric care, primary care, and in care of the elderly must be developed.

  • 33.
    Göras, Camilla
    et al.
    Örebro university, Sweden;Falun Central Hospital, Sweden;Centre for Clinical Research, Falun, Sweden.
    Olin, Karolina
    Karolinska Institutet, Sweden;Turku University Hospital, Finland.
    Unbeck, Maria
    Karolinska University Hospital, Sweden;Karolinska Institutet, Sweden.
    Pukk-Härenstam, Karin
    Karolinska Institutet, Sweden;Karolinska University Hospital, Sweden.
    Ehrenberg, Anna
    Dalarna University, Sweden.
    Tessma, Mesfin Kassaye
    Karolinska Institutet, Sweden.
    Nilsson, Ulrica
    Karolinska Institutet, Sweden.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden.
    Tasks, multitasking and interruptions among the surgical team in an operating room: a prospective observational study2019In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, no 5, p. 1-12, article id e026410Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The work context of the operating room (OR) is considered complex and dynamic with high cognitive demands. A multidimensional view of the complete preoperative and intraoperative work process of the surgical team in the OR has been sparsely described. The aim of this study was to describe the type and frequency of tasks, multitasking, interruptions and their causes during surgical procedures from a multidimensional perspective on the surgical team in the OR.

    DESIGN: Prospective observational study using the Work Observation Method By Activity Timing tool.

    SETTING: An OR department at a county hospital in Sweden.

    PARTICIPANTS: OR nurses (ORNs) (n=10), registered nurse anaesthetists (RNAs) (n=8) and surgeons (n=9).

    RESULTS: The type, frequency and time spent on specific tasks, multitasking and interruptions were measured. From a multidimensional view, the surgical team performed 64 tasks per hour. Communication represented almost half (45.7%) of all observed tasks. Concerning task time, direct care dominated the surgeons' and ORNs' intraoperative time, while in RNAs' work, it was intra-indirect care. In total, 48.2% of time was spent in multitasking and was most often observed in ORNs' and surgeons' work during communication. Interruptions occurred 3.0 per hour, and the largest proportion, 26.7%, was related to equipment. Interruptions were most commonly followed by professional communication.

    CONCLUSIONS: The surgical team constantly dealt with multitasking and interruptions, both with potential impact on workflow and patient safety. Interruptions were commonly followed by professional communication, which may reflect the interactions and constant adaptations in a complex adaptive system. Future research should focus on understanding the complexity within the system, on the design of different work processes and on how teams meet the challenges of a complex adaptive system.

    TRIAL REGISTRATION NUMBER: 2016/264.

  • 34.
    Holmqvist, Malin
    et al.
    County Council of Jönkoping.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet.
    Walter, Scott R.
    Macquarie University, Australia.
    Lehnbom, Elin C.
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. UiT The Arctic University of Norway, Norway.
    Medication Management in Municipality-Based Healthcare: A Time and Motion Study of Nurses2018In: Home Healthcare Now, ISSN 2374-4529, E-ISSN 2374-4537, Vol. 36, no 4, p. 238-246Article in journal (Refereed)
    Abstract [en]

    The objective of this observational time and motion study was to increase our understanding of how nurses in home healthcare currently distribute their work time with a focus on the medication management process. The research was conducted in four municipalities in the southern part of Sweden. Participants were nurses working in home healthcare. The study measured proportion of time, comparison of proportions of time, proportion of time spent multitasking, and rate of interruptions per hour. Of total observed time, 20.4% was spent on medication management and of these tasks the highest proportion of time was spent on communications and dispensing medications. Nurses in nursing homes spent more time (23.0% vs. 17.4%, p = 0.001) on medication management than nurses in private homes. Nurses spent 47.9% of their time completing tasks with someone else, including patients, but had minimal interaction with prescribers. We observed a rate of 1.2 (95% CI 1.1-1.4) interruptions per hour on average and 30% of all interruptions occurred during medication management tasks. Nurses spent 3.7% of their time multitasking. Interruptions while performing medication-related tasks were common, as well as multitasking. Causes and consequences of the results need to be addressed in order to improve the safety of medication management for patients receiving municipality-based home care.

  • 35.
    Håkanson, Cecilia
    et al.
    Ersta Sköndal University College.
    Christiansen, Mats
    Karolinska Institutet.
    Ekstedt, Mirjam
    Ersta Sköndal University College ; KTH Royal Institute of Technology.
    Sandberg, Jonas
    Ersta Sköndal University College ; Jönköping University.
    Kenne Sarenmalm, Elisabeth
    Ersta Sköndal University College ; Skaraborg Hospital.
    Öhlén, Joakim
    Ersta Sköndal University College ; University of Gothenburg.
    Experience-based knowledge in the care of homeless people with severe illness and complex care needs2014In: Palliative Medicine: A Multiprofessional Journal, ISSN 0269-2163, E-ISSN 1477-030X, Vol. 28, no 6, p. 789-789, article id P396Article in journal (Refereed)
    Abstract [en]

    Background: The number of homeless people in Sweden amounts to approximately 34 000. Of those about 4500 live in streets or shelters. The mortality rate among homeless people outnumbers other groups in the society. Often they have severe, multiple mental and physical illnesses, drug abuse and a variety of complex care needs, including palliative. From an international perspective, research related to care for homeless people with severe illness and complex care needs is very sparse (no Swedish studies have been identified). Among the few that have been found, challenges related to the homeless situation and the illness panorama are reported. From the perspective of the homeless persons themselves, studies report stigmatisation, lack of respect and competence among health-care professionals, and insufficient organisation of health care.

    Aim: The aim of this study is to explore the development of experience-based knowledge among health care professionals and social workers in a unique setting, in which advanced inpatient health -and social care, including palliative care is provided to homeless people.

    Methods: In this on-going qualitative case-study, clinically relevant and applicable knowledge is focused. Repeated focus group discussions and coupled thematic interviews were performed with staff (physicians, social workers, mental carers, nurses). Analysis is performed with an interpretive descriptive method.

    Results and implication: The results, which are currently being processed, will present staffs’ experiences of identification and assessment of individual care needs, specific knowledge development and requirement in relation to palliative care and homelessness, and challenges, obstacles and opportunities for meeting the needs of severely ill and dying homeless people. The results will provide knowledge of importance for the development of care for severely ill homeless persons.

  • 36.
    Håkanson, Cecilia
    et al.
    Ersta Sköndal University College.
    Sandberg, Jonas
    Jönköping University.
    Ekstedt, Mirjam
    KTH Royal Institute of Technology.
    Kenne Sarenmalm, Elisabeth
    Skaraborg Hospital.
    Christiansen, Mats
    Karolinska Institutet.
    Öhlen, Joakim
    Ersta Sköndal University College.
    Providing Palliative Care in a Swedish Support Home for People Who Are Homeless2016In: Qualitative Health Research, ISSN 1049-7323, E-ISSN 1552-7557, Vol. 26, no 9, p. 1252-1262Article in journal (Refereed)
    Abstract [en]

    Despite high frequencies of multiple, life-limiting conditions relating to palliative care needs, people who are homeless are one of the most underserved and rarely encountered groups in palliative care settings. Instead, they often die in care places where palliative competence is not available. In this qualitative single-case study, we explored the conditions and practices of palliative care from the perspective of staff at a Swedish support home for homeless people. Interpretive description guided the research process, and data were generated from repeated reflective conversations with staff in groups, individually, and in pairs. The findings disclose a person-centered approach to palliative care, grounded in the understanding of the person’s health/illness and health literacy, and how this is related to and determinant on life as a homeless individual. Four patterns shape this approach: building trustful and family-like relationships, re-dignifying the person, re-considering communication about illness and dying, and re-defining flexible and pragmatic care solutions.

  • 37.
    Ingre, M.
    et al.
    Stockholm University.
    Åkerstedt, Torbjörn
    Stockholm University.
    Ekstedt, Mirjam
    KTH Royal Institute of Technology ; Mälardalen University.
    Kecklund, G.
    Stockholm University.
    Periodic self-rostering in shift work: correspondence between objective work hours, work hour preferences (personal fit), and work schedule satisfaction2012In: Scandinavian Journal of Work, Environment and Health, ISSN 0355-3140, E-ISSN 1795-990X, Vol. 38, no 4, p. 327-336Article in journal (Refereed)
    Abstract [en]

    Objectives The main objective of the present study was to investigate relative personal fit as the association between rated needs and preferences for work hours, on the one hand, and actual work hours, on the other hand, in three groups (hospital, call-center, and police) working with periodic self-rostering. We also examined the association between personal fit and satisfaction with the work schedule and preference for a fixed and regular shift schedule, respectively. Methods We collected questionnaire data and objective work hour data over 6-12 months from the computerized self-rostering system. The response rate of the questionnaire was 69% at the hospital and call-center and 98% among the police. In total, 29 433 shifts for 285 shift workers were included in the study. Data was analyzed by means of mixed ANOVA, Kendal tau correlations and ordinal (proportional odds) logistic regression. Results The results show that evening types worked relatively more hours during the evening and night hours compared to morning types as an indication of relative personal fit. Relative personal fit was also found for long shift, short rest, and morning-, evening- and night-shift frequency, but only personal fit related to morning, evening and night-shift was associated with satisfaction with work hours. Reported conflicts at the workplace about work hours and problems with lack of predictability of time for family/leisure activities, was associated with poor satisfaction and a preference for a fixed shift schedule. Conclusions The present study shows that periodic self-rostering is associated with relative personal fit, in particular with respect to night, evening, and morning work. Personal fit seems to be associated with satisfaction with work hours and may be a moderator of tolerance to shift work exposure.

  • 38.
    Kyte, Kristin
    et al.
    VID Specialized Univ, Norway.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Instutetet, Sweden.
    Rustoen, Tone
    Karolinska Instutetet, Sweden;Univ Oslo, Norway.
    Oksholm, Trine
    VID Specialized Univ, Norway.
    Longing to get back on track: Patients' experiences and supportive care needs after lung cancer surgery.2019In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 28, no 9-10, p. 1546-1554Article in journal (Refereed)
    Abstract [en]

    AIMS AND OBJECTIVES: This study aims to describe surgically treated lung cancer patients' experiences of coming home after discharge from hospital to expand the knowledge about their supportive care needs.

    BACKGROUND: Existing research reports that patients suffer from a high symptom burden after lung cancer surgery. Such burden has negative impacts on their physical, emotional and social wellbeing. Few studies have explored the surgically treated patients' supportive care needs after being discharged from hospital.

    DESIGN: This study used a qualitative descriptive design, following the EQUATOR guidelines (COREQ).

    METHODS: The information about 14 patients' experiences was collected from semi-structured interviews. The interviews were conducted in their homes within three weeks after their discharge from hospital. The data were analysed using qualitative content analysis.

    RESULTS: The main theme of the study, "Longing to get back on track with their lives", consisted of four categories: "Burdened with problems related to postoperative symptoms and treatment", "Struggling for the needed support", "A pendulum between being in need of support and being independent", and "Striving to adapt to a new way of life". The participants experienced many problems related to postoperative symptoms and treatment. Information and support from healthcare professionals were deficient. Life was characterised by striving to be independent and adapting to a new lifestyle.

    CONCLUSIONS: The findings demonstrate the supportive care needs of surgically treated lung cancer patients. Nurses and other healthcare professionals could offer more individualised support during the first few weeks after the patients' discharge by including them and their caregivers in the discharge planning.

    RELEVANCE TO CLINICAL PRACTICE: Knowledge of patients' perspectives and experiences of everyday life at home after lung cancer surgery can provide hospital nurses with a better understanding of what is important for such patients beyond hospitalisation. This knowledge should be included in discharge planning.

  • 39.
    Lindblad, Marlene
    et al.
    KTH Royal Institute of Technology.
    Cook, Richard
    KTH Royal Institute of Technology.
    Ekstedt, Mirjam
    KTH Royal Institute of Technology.
    Creating Safe Care in the Private Homes of People with Complex Care Needs: A systems perspective2014In: 3rd Nordic Conference on Research in Patient Safety and Quality in Healthcare, 2014, October 2-3, Stavanger, Norway, 2014Conference paper (Refereed)
  • 40.
    Lindblad, Marlene
    et al.
    KTH Royal Institute of Technology.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet.
    Unbeck, Maria
    Danderyd Hospital ; Karolinska Institutet.
    Schildmeijer, Kristina
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Nilsson, Lena
    Linköping University.
    Development and validation of a trigger tool for use in home care2016Conference paper (Refereed)
  • 41.
    Lindblad, Marlene
    et al.
    KTH Royal Instute of Technology, Sweden;Ersta Sköndal Bräcke University College, Sweden.
    Flink, Maria
    Karolinska Institutet, Sweden;Karolinska University Hospital, Sweden.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden.
    Exploring patient safety in Swedish specialised home healthcare: an interview study with multidisciplinary teams and clinical managers2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 12, p. 1-7, article id e024068Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Home healthcare is the fastest growing arena in the healthcare system but patient safety research in this context is limited. The aim was to explore how patient safety in Swedish specialised home healthcare is described and adressed from multidisciplinary teams' and clinical managers' perspectives.

    DESIGN: An explorative qualitative study.

    SETTING: Multidisciplinary teams and clinical managers were recruited from three specialised home healthcare organisations in Sweden.

    METHODS: Nine focus group interviews with multidisciplinary teams and six individual interviews with clinical managers were conducted, in total 51 participants. The data were transcribed verbatim and analysed using qualitative content analysis.

    RESULTS: Patient safety was inherent in the well-established care ideology which shaped a common mindset between members in the multidisciplinary teams and clinical managers. This patient safety culture was challenged by the emerging complexity in which priority had to be given to standardised guidelines, quality assessments and management of information in maladapted communication systems and demands for required competence and skills. The multiple guidelines and quality assessments that aimed to promote patient safety from a macro-perspective, constrained the freedom, on a meso-level and micro-level, to adapt to challenges based on the care ideology.

    CONCLUSION: Patient safety in home healthcare is dependent on adaptability at the management level; the team members' ability to adapt to the varying conditions and on patients being capable of adjusting their homes and behaviours to reduce safety risks. A strong culture related to a patient's value as a person where patients' and families' active participation and preferences guide the decisions, could be both a facilitator and a barrier to patient safety, depending on which value is given highest priority.

  • 42.
    Lindblad, Marléne
    et al.
    Royal Institute of Technology;Ersta Sköndal University College.
    Flink, Maria
    Karolinska Institutet;Karolinska University Hospital.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska University Hospital.
    Safe medication management in specialized home healthcare: an observational study2017In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 17, article id 598Article in journal (Refereed)
    Abstract [en]

    Background

    Medication management is a complex, error-prone process. The aim of this study was to explore what constitutes the complexity of the medication management process (MMP) in specialized home healthcare and how healthcare professionals handle this complexity. The study is theoretically based in resilience engineering.

    Method

    Data were collected during the MMP at three specialized home healthcare units in Sweden using two strategies: observation of workplaces and shadowing RNs in everyday work, including interviews. Transcribed material was analysed using grounded theory.

    Results

    The MMP in home healthcare was dynamic and complex with unclear boundaries of responsibilities, inadequate information systems and fluctuating work conditions. Healthcare professionals adapted their everyday clinical work by sharing responsibility and simultaneously being authoritative and preserving patients’ active participation, autonomy and integrity. To promote a safe MMP, healthcare professionals constantly re-prioritized goals, handled gaps in communication and information transmission at a distance by creating new bridging solutions. Trade-offs and workarounds were necessary elements, but also posed a threat to patient safety, as these interim solutions were not systematically evaluated or devised learning strategies.

    Conclusions

    To manage a safe medication process in home healthcare, healthcare professionals need to adapt to fluctuating conditions and create bridging strategies through multiple parallel activities distributed over time, space and actors. The healthcare professionals’ strategies could be integrated in continuous learning, while preserving boundaries of safety, instead of being more or less interim solutions. Patients’ and family caregivers’ as active partners in the MMP may be an underestimated resource for a resilient home healthcare.

  • 43.
    Lindblad, Marléne
    et al.
    KTH Royal Instute of Technology, Sweden;Ersta Sköndal Bräcke University College, Sweden.
    Flink, Maria
    Karolinska Institutet, Sweden;Karolinska University Hospital, Sweden.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet, Sweden.
    Safe medication management in specialized home healthcare: an observational study2017In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 17, no 1, p. 1-8, article id 598Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Medication management is a complex, error-prone process. The aim of this study was to explore what constitutes the complexity of the medication management process (MMP) in specialized home healthcare and how healthcare professionals handle this complexity. The study is theoretically based in resilience engineering.

    METHOD: Data were collected during the MMP at three specialized home healthcare units in Sweden using two strategies: observation of workplaces and shadowing RNs in everyday work, including interviews. Transcribed material was analysed using grounded theory.

    RESULTS: The MMP in home healthcare was dynamic and complex with unclear boundaries of responsibilities, inadequate information systems and fluctuating work conditions. Healthcare professionals adapted their everyday clinical work by sharing responsibility and simultaneously being authoritative and preserving patients' active participation, autonomy and integrity. To promote a safe MMP, healthcare professionals constantly re-prioritized goals, handled gaps in communication and information transmission at a distance by creating new bridging solutions. Trade-offs and workarounds were necessary elements, but also posed a threat to patient safety, as these interim solutions were not systematically evaluated or devised learning strategies.

    CONCLUSIONS: To manage a safe medication process in home healthcare, healthcare professionals need to adapt to fluctuating conditions and create bridging strategies through multiple parallel activities distributed over time, space and actors. The healthcare professionals' strategies could be integrated in continuous learning, while preserving boundaries of safety, instead of being more or less interim solutions. Patients' and family caregivers' as active partners in the MMP may be an underestimated resource for a resilient home healthcare.

  • 44.
    Lindblad, Marléne
    et al.
    Royal Institute of Technology.
    Schildmeijer, Kristina
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Nilsson, Lena
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Unbeck, Maria
    Karolinska Institutet.
    Development and validation of a trigger tool to identify adverse events and no-harm incidents in home healthcare2017In: Presented at the 6th World Congress of Clinical Safety(6WCCS), Rome, Italy, September 6-8, 2017, 2017Conference paper (Other academic)
  • 45.
    Lindblad, Marléne
    et al.
    Royal Institute of Technology.
    Schildmeijer, Kristina
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences.
    Nilsson, Lena
    Linköping University.
    Ekstedt, Mirjam
    Karolinska Institutet.
    Unbeck, Maria
    Karolinska Institutet.
    Development of a trigger tool to identify adverse events and no-harm incidents that affect patients admitted to home healthcare2018In: BMJ Quality and Safety, ISSN 2044-5415, E-ISSN 2044-5423, Vol. 27, no 7, p. 502-511Article in journal (Refereed)
    Abstract [en]

    Background Adverse events (AEs) and no-harm incidents are common and of great concern in healthcare. A common method for identification of AEs is retrospective record review (RRR) using predefined triggers. This method has been used frequently in inpatient care, but AEs in home healthcare have not been explored to the same extent. The aim of this study was to develop a trigger tool (TT) for the identification of both AEs and no-harm incidents affecting adult patients admitted to home healthcare in Sweden, and to describe the methodology used for this development.

    Methods The TT was developed and validated in a stepwise manner, in collaboration with experts with different skills, using (1) literature review and interviews, (2) a five-round modified Delphi process, and (3) two-stage RRRs. Ten trained teams from different sites in Sweden reviewed 600 randomly selected records.

    Results In all, triggers were found 4031 times in 518 (86.3%) records, with a mean of 6.7 (median 4, range 1–54) triggers per record with triggers. The positive predictive values (PPVs) for AEs and no-harm incidents were 25.4% and 16.3%, respectively, resulting in a PPV of 41.7% (range 0.0%–96.1% per trigger) for the total TT when using 38 triggers. The most common triggers were unplanned contact with physician and/or registered nursemoderate/severe painmoderate/severe worry, anxiety, suffering, existential pain and/or psychological pain. AEs were identified in 37.7% of the patients and no-harm incidents in 29.5%.

    Conclusion This study shows that adapted triggers with definitions and decision support, developed to identify AEs and no-harm incidents that affect patients admitted to home healthcare, may be a valid method for safety and quality improvement work in home healthcare.

  • 46.
    Näverlo, S.
    et al.
    Umeå University.
    Carson, D. B.
    Charles Darwin University, Australia.
    Edin-Liljegren, A.
    Västerbotten Läns Landsting.
    Ekstedt, Mirjam
    KTH Royal Institute of Technology.
    Patient perceptions of a Virtual Health Room installation in rural Sweden2016In: Rural and remote health, ISSN 1445-6354, Vol. 16, no 4, article id 3823Article in journal (Refereed)
    Abstract [en]

    Introduction: The Virtual Health Room (VHR) is an ehealth initiative in the village of Slussfors in northern Sweden. Construction of VHRs in other locations is taking place, and the Centre for Rural Medicine in the Västerbotten County Council primary care department has implemented a VHR evaluation framework. This research focuses on evaluation of patient perceptions of the usability of the VHR and its contribution to their health care.

    Methods: Nineteen of the 25 unique users of the VHR during 2014/15 completed a survey asking about their attitudes to their own health (using the 13-question version of the Patient Activation Measure (PAM)), their demographic attributes, and their satisfaction with their visit to the VHR.

    Results: Respondents with lower PAM scores were less satisfied with the technical performance of the VHR, but equally likely to think the VHR made a good contribution to access to health care. In contrast, older patients were less likely to value the contribution of the VHR, but no less likely to be satisfied with its technical performance. There were no relationships between level of education and distance travelled and perceptions of the VHR.

    Conclusions: The research clearly demonstrated the distinction between technical performance of an ehealth initiative and its overall contribution to health care and access. Evaluation frameworks need to consider both aspects of performance. Transferability of these findings to other settings may depend at least in part on the nature of the catchment area for the VHR, with the Slussfors catchment being quite small and the impact of distance on access consequently limited.

  • 47.
    Oksholm, Trine
    et al.
    VID Specialized University, Norway;Oslo University Hospital, Norway.
    Rustoen, Tone
    Oslo University Hospital, Norway;University of Oslo, Norway.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Oslo University Hospital, Norway;Karolinska Institutet.
    Transfer Between Hospitals Is a Risk Situation for Patients After Lung Cancer Surgery2018In: Cancer Nursing, ISSN 0162-220X, E-ISSN 1538-9804, Vol. 41, no 3, p. E49-E55Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Patients with lung cancer often undergo surgery shortly after diagnosis. Despite undergoing extensive operation, many patients are transferred to a local hospital a few days after surgery. Transitions between different levels of care are risky due to common medication and follow-up errors.

    OBJECTIVE: The study purpose was to explore patients' experiences of transfer between hospitals after lung cancer surgery. The study aim was to improve the quality of transitional care.

    METHODS: In-depth interviews with 14 patients with lung cancer (6 men, 8 women) were conducted in the patients' homes. Interviews were audiotaped, transcribed, and analyzed using the hermeneutic analysis method.

    RESULTS: Patients' experience of transfer between hospitals after lung cancer surgery is one of being in a caregiver gap characterized by feeling unprepared and uncertain, feeling unprotected and not being cared for, and suffering because of inadequate organization. Patients are vulnerable and at risk of injury before and during transfer, as well as after arrival at local hospitals.

    CONCLUSIONS: Study findings highlight a rarely considered risk of inadequate care before, during, and after hospital transfer of vulnerable patients. Transition between hospitals after lung cancer surgery is a part of patient care for which there are no policies or care plans and a time during which the borders of responsibility between caregivers are unclear.

    IMPLICATIONS FOR PRACTICE: It is important to develop guidelines for clearly defined responsibilities during transfer between hospitals. Healthcare providers need to plan transfers with the same rigor as they do hospital care.

  • 48. Oksholm, Trine
    et al.
    Rustøen, Tone
    Kongerud, Johny
    Ekstedt, Mirjam
    KTH Royal Institute of Technology ; Oslo University Hospital, Norway.
    Postsurgical transfer between hospitals is a risk situation for lung cancer patients2014In: 3rd Nordic Conference on Research in Patient Safety and Quality in Healthcare, 2014, October 2-3, Stavanger, Norway, 2014Conference paper (Refereed)
  • 49.
    Pedersen, Maria
    et al.
    University of Oslo, Norway ; Akershus University Hospital, Norway.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet.
    Småstuen, Milada C.
    Akershus University College of Applied Sciences, Norway.
    Wyller, Vegard B.
    University of Oslo, Norway ; Akershus University Hospital, Norway.
    Sulheim, Dag
    Innlandet Hospital Trust, Norway.
    Fagermoen, Even
    Oslo University Hospital, Norway.
    Winger, Anette
    Akershus University College of Applied Sciences, Norway.
    Pedersen, Edvard
    UiT The Arctic University of Norway, Norway.
    Hrubos-Strøm, Harald
    Akershus University Hospital, Norway.
    Sleep-wake rhythm disturbances and perceived sleep in adolescent chronic fatigue syndrome2017In: Journal of Sleep Research, ISSN 0962-1105, E-ISSN 1365-2869, Vol. 26, no 5, p. 595-601Article in journal (Refereed)
    Abstract [en]

    Chronic fatigue syndrome (CFS) is characterized by long-lasting, disabling and unexplained fatigue that is often accompanied by unrefreshing sleep. The aim of this cross-sectional study was to investigate sleep-wake rhythm and perceived sleep in adolescent CFS patients compared to healthy individuals. We analysed baseline data on 120 adolescent CFS patients and 39 healthy individuals included in the NorCAPITAL project. Activity measures from a uniaxial accelerometer (activPAL) were used to estimate mid-sleep time (mid-point of a period with sleep) and time in bed. Scores from the Karolinska Sleep Questionnaire (KSQ) were also assessed. The activity measures showed that the CFS patients stayed significantly longer in bed, had a significantly delayed mid-sleep time and a more varied sleep-wake rhythm during weekdays compared with healthy individuals. On the KSQ, the CFS patients reported significantly more insomnia symptoms, sleepiness, awakening problems and a longer sleep onset latency than healthy individuals. These results might indicate that disrupted sleep-wake phase could contribute to adolescent CFS; however, further investigations are warranted.

  • 50.
    Sandlund, C.
    et al.
    Karolinska Institutet.
    Hetta, J.
    Karolinska Institutet.
    Nilsson, G.
    Karolinska Institutet.
    Ekstedt, Mirjam
    Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. Karolinska Institutet.
    Westman, J.
    Karolinska Institutet.
    Group treatment for insomnia and impact on daytime symptomatology associated with insomnia: Analyses from a randomized controlled trial in primary care2017In: Sleep Medicine, ISSN 1389-9457, E-ISSN 1878-5506, Vol. 40, p. E291-E292Article in journal (Other academic)
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