Background: Knowledge concerning nursing students' experiences of the clinical learning environment and how supervision is carried out is largely lacking. This study compares nursing students' perceptions of the clinical learning environment and supervision in two different supervision models: peer learning in student-dedicated units, with students working together in pairs and supervised by a "preceptor of the day" (model A), and traditional supervision, in which each student is assigned to a personal preceptor (model B).

Methods: The study was performed within the nursing programme at a university college in Sweden during students' clinical placements (semesters 3 and 4) in medical and surgical departments at three different hospitals. Data was collected using the Clinical Learning Environment, Supervision and Nurse Teacher evaluation scale, CLES+T, an instrument tested for reliability and validity, and a second instrument developed for this study to obtain deeper information regarding how students experienced the organisation and content of the supervision. Independent t-tests were used for continuous variables, Mann-Whitney U-tests for ordinal variables, and the chi-square or Fischer's exact tests for categorical variables.

Results: Overall, the students had positive experiences of the clinical learning environment and supervision in both supervision models. Students supervised in model A had more positive experiences of the cooperation and relationship between student, preceptor, and nurse teacher, and more often than students in model B felt that the ward had an explicit model for supervising students. Students in model A were more positive to having more than one preceptor and felt that this contributed to the assessment of their learning outcomes.

Conclusions: A good learning environment for students in clinical placements is dependent on an explicit structure for receiving students, a pedagogical atmosphere where staff take an interest in supervision of students and are easy to approach, and engagement among and collaboration between preceptors and nurse teachers. This study also indicates that supervision based on peer learning in student-dedicated rooms with many preceptors can be more satisfying for students than a model where each student is assigned to a single preceptor.

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 self-management.

Ethics and dissemination The study is approved by the Regional Research Ethics Committee (No. 2014/1498-31/2) in Stockholm, Sweden. The results of the study will be published in peer-reviewed journals and presented at international and national scientific conferences. 

Trial registration number NCT02823795; Pre-results.

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.

I och med covid-19-pandemin förutspåddes ett snabbt ökat behov av personal i vård och omsorg. Ersta Sköndal Bräcke högskola och Socialstyrelsen startade ett samarbete för att skapa en digital avgiftsfri utbildning. Syftet var att ge personer utan vårderfarenhet en introduktion till vård- och omsorgsarbete och att vara ett stöd för vårdgivare vid introduktion av ny personal. Utbildningen utformades i två delar varav Socialstyrelsen ansvarade för den ena och Ersta Sköndal Bräcke högskola för den andra. Högskolan utbildningsdel motsvarar tre dagars utbildning med olika läraktiviteter och kunskapstester. En viktig del i utbildningen är att bidra med kunskap om palliativ vård och döende. Dessa ämnen kan på grund av okunskap omgärdas av rädsla och missförstånd. Efter godkänd genomgången kurs får deltagaren ett kursintyg. I januari 2021 hade 2 172 intyg utfärdats.

The overall aim of the thesis is to increase knowledge and understanding of patient safety in home healthcare.

This thesis has an explorative mixed-methods design, with both qualitative (Papers І and ІІ) and quantitative (Papers ІІІ, ІV and V) methods. Data for Papers І and ІІ were collected at three specialised home healthcare units. The aim for Paper І was to explore patient safety in home healthcare from the multidisciplinary teams and clinical managers’ perspective. Data collection for the study was done through seven individual and nine focus group interviews, a total of 51 participants, and analysed with qualitative content analysis. The aim of Paper ІІ was to explore the medication management process. The data collection was done by observing the medication management process for 27 days, 9 days per unit, and through interviews with the healthcare professionals who had been observed. Data was collected in iterative phases and analysed with grounded theory.

The aim of Paper ІІІ was to develop a trigger tool for structured retrospective record review to identify adverse events and no-harm incidents and their preventability that affect adult patients admitted into home healthcare. Another aim was to describe how the development was conducted. During the development, the trigger tool was tested twice, using 60 and 600 records, respectively, from ten different organisations from nine different regions across Sweden. The same 600 randomised home healthcare records were used for Papers ІV and V. The aim of Paper ІV was to explore the incidence, types and preventability of adverse events using the trigger tool. For Paper V the aim was to explore cumulative incidence, preventability, types and potential contributing causes of no-harm incidents using the trigger tool. Studies ІІІ, ІV and V were analysed with descriptive statistics.

The results showed that the clinical managers and the multidisciplinary teams considered patient safety as associated with their common mind-set of safe care, based on a well-established care ideology. This mindset included the establishment of a trustworthy relationship with patients and relatives. At the same time, provision of care in a home was characterised by weighing values against each other, between risks and patients’ and relatives’ autonomy and wishes. Other typical contradictory values were between collecting measurements for different quality registers (directives from policy-makers as a measure of quality and safety), or taking time for patient needs. Strategies and behaviours, such as not following routines, to get around problematic processes were the result of conflicting goals that either promoted or prevented patient safety (Papers І and ІІ). Results from Study ІІІ showed that the empirically tested triggers identified more triggers compared to several other studies and thus formed a rich material for validation. More than a third of the patients in home healthcare were affected by adverse events (37.7%), most of which were deemed preventable (71.6%). Most adverse events (69.1%) were temporary and led to that the patient required extra healthcare visits or led to a prolonged period of healthcare. The most common adverse events were “healthcare-associated infections, falls and pressure ulcers (Study ІV). Almost every third patient (29.5%) was affected by a no-harm incident, one-fifth of which were deemed preventable (21.2%). The most common types of no-harm incidents were “fall without harm,” “deficiencies in medication management,” and “moderate pain”. “Deficiencies in medication management” were deemed to have a preventability rate (98.4%) twice as high as “fall without harm” (40.9%) and “moderate pain” (50.0%). The most common potential contributing cause of “fall without harm” was “deficiencies in nursing care, i.e., delayed, erroneous, omitted or incomplete care”. For “deficiencies in medication management” and “moderate pain” the most common contributing cause was “delayed, erroneous, omitted or incomplete treatment”. Of the total number of no-harm incidents, the most common contributing causes were “deficiencies in nursing care, treatment or diagnosis” and “deficiencies in communication, information or collaboration” (Paper V).

The conclusion is that patient safety is generally strengthened by the fact that clinical managers and multidisciplinary teams have a common approach to safety built on an internationally and national well-established care ideology, which forms a “dyad” with safe care. In home healthcare, patient safety is formed by the team creating a trustworthy relationship with patients and their families and involving them as partners in their own care. Additionally, the trigger tool and associated manual adapted for home healthcare may be a valid method for identifying cumulative incidence, types, preventability and contributing causes for adverse events and no-harm incidents. Such patient safety knowledge can be used to develop valid process indicators for systemic failures, as well as outcome indicators for structured evaluation and lead to proactive patient safety work in home healthcare.

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.

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.

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) twostage 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 nurse, moderate/severe pain, moderate/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.

Background: Patient safety in home healthcare is largely unexplored. No-harm incidents may give valuable information about risk areas and system failures as a source for proactive patient safety work. We hypothesized that it would be feasible to retrospectively identify no-harm incidents and thus aimed to explore the cumulative incidence, preventability, types, and potential contributing causes of no-harm incidents that affected adult patients admitted to home healthcare.

Methods: A structured retrospective record review using a trigger tool designed for home healthcare. A random sample of 600 home healthcare records from ten different organizations across Sweden was reviewed.

Results: In the study, 40,735 days were reviewed. In all, 313 no-harm incidents affected 177 (29.5%) patients; of these, 198 (63.2%) no-harm incidents, in 127 (21.2%) patients, were considered preventable. The most common no-harm incident types were “fall without harm,” “deficiencies in medication management,” and “moderate pain.” The type “deficiencies in medication management” was deemed to have a preventability rate twice as high as those of “fall without harm” and “moderate pain.” The most common potential contributing cause was “deficiencies in nursing care and treatment, i.e., delayed, erroneous, omitted or incomplete treatment or care.”

Conclusion: This study suggests that it is feasible to identify no-harm incidents and potential contributing causes such as omission of care using record review with a trigger tool adapted to the context. No-harm incidents and potential contributing causes are valuable sources of knowledge for improving patient safety, as they highlight system failures and indicate risks before an adverse event reach the patient.

OBJECTIVE: Home healthcare is an increasingly common part of healthcare. The patients are often aged, frail and have multiple diseases, and multiple caregivers are involved in their treatment. This study explores the origin, incidence, types and preventability of adverse events (AEs) that occur in patients receiving home healthcare.

DESIGN: A study using retrospective record review and trigger tool methodology.

SETTING AND METHODS: Ten teams with experience of home healthcare from nine regions across Sweden reviewed home healthcare records in a two-stage procedure using 38 predefined triggers in four modules. A random sample of records from 600 patients (aged 18 years or older) receiving home healthcare during 2015 were reviewed.

PRIMARY AND SECONDARY OUTCOME MEASURES: The cumulative incidence of AEs found in patients receiving home healthcare; secondary measures were origin, types, severity of harm and preventability of the AEs.

RESULTS: The patients were aged 20-79 years, 280 men and 320 women. The review teams identified 356 AEs in 226 (37.7%; 95% CI 33.0 to 42.8) of the home healthcare records. Of these, 255 (71.6%; 95% CI 63.2 to 80.8) were assessed as being preventable, and most (246, 69.1%; 95% CI 60.9 to 78.2) required extra healthcare visits or led to a prolonged period of healthcare. Most of the AEs (271, 76.1%; 95% CI 67.5 to 85.6) originated in home healthcare; the rest were detected during home healthcare but were related to care outside home healthcare. The most common AEs were healthcare-associated infections, falls and pressure ulcers.

CONCLUSIONS: AEs in patients receiving home healthcare are common, mostly preventable and often cause temporary harm requiring extra healthcare resources. The most frequent types of AEs must be addressed and reduced through improvements in interprofessional collaboration. This is an important area for future studies.