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The healthcare sector is fast-growing and knowledge-intensive, and to meet the demands associated with it, nursing students must have high levels of self-regulated learning (SRL), metacognition, and general self-efficacy (GSE). In this cross-sectional, correlational study, data were collected from 216 nursing students through a questionnaire. The aims were: 1) to describe the levels of SRL ability, metacognitive ability and GSE among second- and third-year nursing students; 2) to explore the relationships between the SRL ability, metacognitive ability and GSE of second- and third-year nursing students; 3) and to compare SRL ability, metacognitive ability and GSE between second- and third-year nursing students. Nursing students had moderate levels of SRL ability and metacognitive ability, but lower levels of GSE. Positive relationships between SRL ability, metacognitive ability, and GSE were observed. Third-year nursing students had a higher level of SRL ability but lower levels of GSE, compared to second-year students. In terms of metacognitive ability, no significant differences were observed between the student batches. Interventions are required for the improvement of nursing students' SRL ability, metacognitive ability, and GSE.

Purpose The purpose of this paper is twofold: first, to describe Lean maturity in primary care using a questionnaire based on Liker’s description of Lean, complemented with observations; and second, to determine the extent to which Lean maturity is associated with quality of care measured as staff-rated satisfaction with care and adherence to national guidelines (NG). High Lean maturity indicates adoption of all Lean principles throughout the organization and by all staff. Design/methodology/approach Data were collected using a survey based on Liker’s four principles, divided into 16 items (n=298 staff in 45 units). Complementary observations (n=28 staff) were carried out at four units. Findings Lean maturity varied both between and within units. The highest Lean maturity was found for “adhering to routines” and the lowest for “having a change agent at the unit.” Lean maturity was positively associated with satisfaction with care and with adherence to NG to improve healthcare quality. Practical implications Quality of primary care may benefit from increasing Lean maturity. When implementing Lean, managers could benefit from measuring and adopting Lean maturity repeatedly, addressing all Liker’s principles and using the results as guidance for further development. Originality/value This is one of the first studies to evaluate Lean maturity in primary care, addressing all Liker’s principles from the perspective of quality of care. The results suggest that repeated actions based on evaluations of Lean maturity may help to improve quality of care.

Assessment of students' learning and achievement requires active involvement of participating students, preceptors and lecturers. The lecturers have overall responsibility for both the content of the assessment and students' learning. The aim of the present study was to investigate lecturers' reflections on the mid-course discussion and final assessment that are part of nursing students' clinical practice education. The design was descriptive and had a qualitative approach. Repeated group discussions were undertaken with 14 lecturers at two university campuses in Norway. Five categories were identified: preparing for the three-part discussion, creating a collaborative atmosphere, facilitating student learning, verifying student learning, using the assessment tool to create the assessment discussion; one theme emerged: ‘being able to see and justify students’ learning processes'. Lecturers' reflections on both assessment discussions and students' learning proceeded from a clear pedagogical viewpoint.

Vasoactive intestinal polypeptide (VIP) is a neuroendocrine peptide distributed throughout the human body, including the CNS, where it is particularly abundant in brain regions associated with anxiety and depression. Based on earlier studies indicating that peripheral VIP may cross through the blood–brain barrier, we hypothesized plasma VIP levels to be associated with symptoms of anxiety and depression, as well as brain volume and resting-state functional connectivity in the amygdala, hippocampus, parahippocampus, and orbitofrontal cortex. Plasma VIP concentrations and anxiety/depression symptoms were measured in 37 healthy females. Functional and structural magnetic resonance imaging were used to evaluate functional connectivity and brain volume respectively, and their associations with VIP concentrations within brain regions associated with anxiety and depression. Negative correlations were found between VIP levels and symptoms of anxiety (r = − 0.44, p = 0.002) and depression (r = − 0.50, p = 0.001). Functional connectivity demonstrated significant VIP-dependent positive associations between the amygdala seed region with both the right parahippocampus (t(33) = 3.1, pFDR = 0.02) and right lateral orbitofrontal cortex (OFC; t(33) = 2.9, pFDR = 0.02). Moreover, VIP concentrations were significantly, positively correlated with brain volume in the left amygdala (r = 0.28, p = 0.007) and left lateral OFC (r = 0.29, p = 0.004). The present findings highlight a potential role for VIP in the neurobiology of affective symptoms.

Purpose The aim of the present study was to investigate relationships between sense of coherence, emotion-focused coping, problem-focused coping, coping efficiency, and mental quality of life (QoL) in patients with chronic illness. A model based on Lazarus’ and Folkman’s stress and coping theory tested the specific hypothesis: Sense of coherence has a direct and indirect effect on mental QoL mediated by emotion-focused coping, problem-focused coping, and coping efficiency in serial adjusted for age, gender, educational level, comorbidity, and economic status. Methods The study used a cross-sectional and correlational design. Patients (n = 292) with chronic diseases (chronic heart failure, end-stage renal disease, multiple sclerosis, stroke, and Parkinson) completed three questionnaires and provided background data. Data were collected in 2012, and a serial multiple mediator model was tested using PROCESS macro for SPSS. Results The test of the conceptual model confirmed the hypothesis. There was a significant direct and indirect effect of sense of coherence on mental QoL through the three mediators. The model explained 39% of the variance in mental QoL. Conclusions Self-perceived effective coping strategies are the most important mediating factors between sense of coherence and QoL in patients with chronic illness, which supports Lazarus’ and Folkman’s stress and coping theory.

The aim of this study was to describe the feasibility of a peer learning intervention targeting newly graduated nurses. Feasibility was tested concerning consistency of the theoretical description of peer learning with empirical findings in a new context, compliance and acceptability, as well as usability of a questionnaire measuring the intended future outcome variables.Newly graduated nurses who meet, socialize and share experiences have described supporting each other's ability to cope with stress. Peer learning involves individuals in a similar situation learning from and with each other through interaction. When implementing new interventions, feasibility studies are used to minimize problems in future evaluation studies.Quasi-experimental design with an intervention group, followed over time using descriptive methods. The study was based on the Medical Research Council framework.Repeated semi-structured interviews, a checklist for fidelity and a questionnaire were conducted with 10 newly graduated nurses from January to March 2015. The intervention's main component included pairs of newly graduated nurses working the same shift and having joint responsibility for a group of patients for a period of 3 weeks. The intervention also included 3 months of regular reflection by the pair.Using deductive analysis, the peer learning intervention was found to be consistent with the theoretical description. Due to the compliance and acceptability, there were lessons learnt. The tested questionnaire was found to be useful.This peer learning intervention seems to be feasible in this context. This study will serve as the basis for a future full-scale evaluation study.

BACKGROUND: Studies of peer learning indicate that the model enables students to practice skills useful in their future profession, such as communication, cooperation, reflection and independence. However, so far most studies have used a qualitative approach and none have used a quasi-experimental design to study effects of nursing students' peer learning in clinical practice. OBJECTIVES: To investigate the effects of peer learning in clinical practice education on nursing students' self-rated performance. DESIGN: Quasi-experimental. SETTING: The study was conducted during nursing students' clinical practice. PARTICIPANTS: All undergraduate nursing students (n=87) attending their first clinical practice were approached. Seventy students out of 87 answered the questionnaires at both baseline and follow-up (42 of 46 in the intervention group and 28 of 39 in the comparison group). METHODS: During the first two weeks of the clinical practice period, all students were supervised traditionally. Thereafter, the intervention group received peer learning the last two weeks, and the comparison group received traditional supervision. Questionnaire data were collected on nursing students' self-rated performance during the second (baseline) and last (follow-up) week of their clinical practice. RESULTS: Self-efficacy was improved in the intervention group and a significant interaction effect was found for changes over time between the two groups. For the other self-rated variables/tests, there were no differences in changes over time between the groups. Studying each group separately, the intervention group significantly improved on thirteen of the twenty variables/tests over time and the comparison group improved on four. CONCLUSIONS: The results indicate that peer learning is a useful method which improves nursing students' self-efficacy to a greater degree than traditional supervision does. Regarding the other self-rated performance variables, no interaction effects were found.

To identify clusters based on graduating nursing students' self-reported professional competence and their achievement on a national examination. Furthermore, to describe and compare the identified clusters regarding sample characteristics, students' perceptions of overall quality of the nursing programme, and students' general self-efficacy (GSE).A cross-sectional study combining survey data and results from a national examination.Data were collected at two universities and one university college in Sweden in January 2017, including 179 students in the final term of the nursing programme. The study was based on the Nurse Professional Competence Scale, the GSE scale, and results from the National Clinical Final Examination. A two-step cluster analysis was used to identify competence profiles, followed by comparative analyses between clusters.Three clusters were identified illustrating students' different competence profiles. Students in Clusters 1 and 2 passed the examination, but differed in their self-assessments of competence, rating themselves under and above the overall median value, respectively. Students in Cluster 3 failed the examination but rated themselves at the overall median level or higher.The study illustrates how nursing students' self-assessed competence might differ from competency assessed by examination, which is challenging for nursing education. Self-evaluation is a key learning outcome and is, in the long run, essential to patient safety.The study has identified clusters of students where some overestimate and others underestimate their competence. Students who assessed their competence low but passed the exam assessed their GSE lower than other students. The findings illuminate the need for student-centred strategies in nursing education, including elements of self-assessment in relation to examination to make the students more aware of their clinical competence.目的: 此研究旨在根据应届护理专业学生自我报告的专业能力及其在全国考试中的成绩来确定类别。此外还需对样本特征、学生对护理专业课程总体质量的看法以及学生的一般自我效能感(GSE)的已确定特征进行描述和比较。 设计: 一项结合了调查数据和国家考试结果的横断面研究。 方法: 2017年1月,我们收集了瑞典的两所大学和一所大学学院的数据,其中包括179名护理专业课程的应届毕业生。此项研究基于护士专业能力量表、一般自我效能感(GSE)量表以及国家临床期末考试。我们使用两步聚类分析法以确定能力性质,随后进行类别之间的比较分析。 结果: 此项研究最终确定了三个类别,分别说明学生的不同能力性质。类别1和类别2的学生通过了考试,但他们的自我能力评估有所不同,他们分别将自己评定为总体中位值以下和以上。类别3的学生未能通过考试,但他们认为自己处于总体中位水平或更高。 结论: 此项研究探讨了护理学生的自我能力评估可能与考试评定的能力可能存在怎样的差异,这对护理教育来说是一个挑战。自我评估是关键的学习成果,并且从长远来看,对患者安全至关重要。 影响: 此项研究确定了学生类别,其中部分学生高估了自己的能力,部分学生低估了自己的能力。自我评估能力较低但通过考试的学生所评定的一般自我效能感(GSE)要比其他学生低。研究结果表明需要在护理教育中使用以学生为中心的策略,包括与考试相关的自我评估要素,从而使得学生更清楚认识到自己的临床能力。.

Background The shortage of registered nurses is a global concern. Motives to become registered nurses can be to help others, altruism, personal development and career security. Motives in combination with student expectations regarding the role are not explored. Objective To describe students' motives to become registered nurses and their expectations regarding their future profession. Design A longitudinal descriptive design with a qualitative approach was used to follow nursing students in the beginning, during and at the end of their education. Participants and setting A purposive sampling of a group with initially 75 students starting a three-year nursing program at a university in Sweden. Methods A study specific questionnaire with open-ended questions was used in the beginning, during and the end of the students' education. At data collection two and three, a copy of the earlier answers was attached. Data were analysed using manifest and latent content analysis. Results An important profession with career opportunities, interesting duties and team work were described. Students expected diversified duties, possibilities for development and work satisfaction. Increased concerns regarding their upcoming work life was described at the end of the education. Conclusion The students had a positive understanding of the profession and perceived their forthcoming role as interesting. The leading role of coordinating patient care was more comprehensive than expected. Supportive conditions and well planned transition periods could strengthen newly graduated nurses in their professional role and could be an important aspect in the future retention of RNs.

Supplemental Digital Content is Available in the Text. Quantitative magnetic resonance spectroscopy of anterior insula reveals decreased glutamatergic neurotransmitter concentrations in patients with irritable bowel syndrome and hemisphere-specific associations with pain severity and pain-related coping., Irritable bowel syndrome (IBS) is a visceral pain condition with psychological comorbidity. Brain imaging studies in IBS demonstrate altered function in anterior insula (aINS), a key hub for integration of interoceptive, affective, and cognitive processes. However, alterations in aINS excitatory and inhibitory neurotransmission as putative biochemical underpinnings of these functional changes remain elusive. Using quantitative magnetic resonance spectroscopy, we compared women with IBS and healthy women (healthy controls [HC]) with respect to aINS glutamate + glutamine (Glx) and γ-aminobutyric acid (GABA+) concentrations and addressed possible associations with symptoms. Thirty-nine women with IBS and 21 HC underwent quantitative magnetic resonance spectroscopy of bilateral aINS to assess Glx and GABA+ concentrations. Questionnaire data from all participants and prospective symptom-diary data from patients were obtained for regression analyses of neurotransmitter concentrations with IBS-related and psychological parameters. Concentrations of Glx were lower in IBS compared with HC (left aINS P < 0.05, right aINS P < 0.001), whereas no group differences were detected for GABA+ concentrations. Lower right-lateralized Glx concentrations in patients were substantially predicted by longer pain duration, while less frequent use of adaptive pain‐coping predicted lower Glx in left aINS. Our findings provide first evidence for reduced excitatory but unaltered inhibitory neurotransmitter levels in aINS in IBS. The results also indicate a functional lateralization of aINS with a stronger involvement of the right hemisphere in perception of abdominal pain and of the left aINS in cognitive pain regulation. Our findings suggest that glutaminergic deficiency may play a role in pain processing in IBS.

Background The most common cause of clinical incidents and adverse events in relation to surgery is communication error. There is a shortage of studies on communication between registered nurses and licenced practical nurses as well as of instruments to measure their perception of communication within and between the professional groups. The aim of the present study was to evaluate the psychometric properties of the Swedish version of the adapted ICU Nurse-Physician Questionnaire, designed to also measure communication within and between two professional groups: licensed practical nurses and registered nurses. Specifically, the aim was to examine the instrument’s construct validity using confirmatory factor analysis and its internal consistency using Cronbach’s Alpha. Methods A cross-sectional and correlational design was used. The setting was anaesthetic clinics in two Swedish hospitals. A total of 316 questionnaires were delivered during spring 2011, of which 195 were analysed to evaluate the psychometric properties of the questionnaire. Construct validity was assessed using confirmatory factor analysis and internal consistency using Cronbach’s Alpha. To assess items with missing values, we conducted a sensitivity analysis of two sets of data, and to assess the assumption of normally distributed data, we used Bayesian estimation. Results The results support the construct validity and internal consistency of the adapted ICU Nurse-Physician Questionnaire. Model fit indices for the confirmative factor analysis were acceptable, and estimated factor loadings were reasonable. There were no large differences between the estimated factor loadings when comparing the two samples, suggesting that items with missing values did not alter the findings. The estimated factor loadings from Bayesian estimation were very similar to the maximum likelihood results. This indicates that confirmative factor analysis using maximum likelihood produced reliable factor loadings. Regarding internal consistency, alpha values ranged from 0.72 to 0.82. Conclusions The tests of the adapted ICU Nurse-Physician Questionnaire indicate acceptable construct validity and internal consistency, both of which need to be further tested in new settings and samples. Trial registration Current controlled trials http://www.controlled-trials.com Communication and patient safety in anaesthesia and intensive care. Does implementation of SBAR make any differences? Identifier: ISRCTN37251313, retrospectively registered (assigned 08/11/2012).

Background The Swedish healthcare system has an increased need for nurses and physicians, and the number of International Educated Nurses (IENs) and International Medical Graduates (IMGs) seeking job opportunities and a license to practice in Sweden is rising. This study explored how IENs and IMGs describe their experience of getting a license to practice, their perceptions of working in Sweden and of how their intercultural competence is utilized. Method A qualitative study based on semi-structured interviews with 11 IENs and 11 IMGs. The interviews were conducted between 2015 and 2017. The data were analyzed using qualitative content analysis. Results Three main themes were identified: ‘Getting a license – a different story,’ ‘The work is familiar, yet a lot is new,’ ‘Trying to master a new language.’ The time to obtain a license to practice and finding a job was shorter for IENs and IMGs coming from European countries than for those from non-European countries. Some of the experiences of getting a license to practice and of entering a new workplace in another country were the same for nurses and physicians. In general, both IENs and IMGs felt welcomed and used their intercultural competence at work. Lack of language skills was regarded as the main problem for both professions, while workplace introduction was shorter for IMGs than for IENs. Conclusions Problems related to language and culture are often underestimated, therefore organizations and managers employing IENs and IMGs should provide longer workplace introduction to facilitate the acculturation process. More time-efficient language courses specifically adapted to IENs and IMGs could make the transition easier and shorten the time to obtain a license to practice for both professions. Electronic supplementary material The online version of this article (10.1186/s12909-018-1399-4) contains supplementary material, which is available to authorized users.

Peripheral nerve injuries result in reorganization within the contralateral hemisphere. Furthermore, recent animal and human studies have suggested that the plastic changes in response to peripheral nerve injury also include several areas of the ipsilateral hemisphere. The objective of this study was to map the inter-hemispheric plasticity in response to median nerve injury, to investigate normal differences in contra- and ipsilateral activation, and to study the impact of event-related or blocked functional magnetic resonance imaging (fMRI) design on ipsilateral activation. Four patients with median nerve injury at the wrist (injured and epineurally sutured >2 years earlier) and ten healthy volunteers were included. 3T fMRI was used to map the hemodynamic response to brain activity during tactile stimulation of the fingers, and a laterality index (LI) was calculated. Stimulation of Digits II–III of the injured hand resulted in a reduction in contralateral activation in the somatosensory area SI. Patients had a lower LI (0.21 ± 0.15) compared to healthy controls (0.60 ± 0.26) indicating greater ipsilateral activation of the primary somatosensory cortex. The spatial dispersion of the coordinates for areas SI and SII was larger in the ipsilateral than in the contralateral hemisphere in the healthy controls, and was increased in the contralateral hemisphere of the patients compared to the healthy controls. There was no difference in LI between the event-related and blocked paradigms. In conclusion, patients with median nerve injury have increased ipsilateral SI area activation, and spatially more dispersed contralateral SI activation during tactile stimulation of their injured hand. In normal subjects ipsilateral activation has larger spatial distribution than the contralateral. Previous findings in patients performed with the blocked fMRI paradigm were confirmed. The increase in ipsilateral SI activation may be due to an interhemispheric disinhibition associated with changes in the afferent signal inflow to the contralateral primary somatosensory cortex.

Aims and objectives In this study, the aim was to understand health care personnel's expectations and experiences of participating in an intervention aimed at the implementation of three assessment scales for fall injuries, malnutrition and pressure ulcers, and the performance of preventive measures in these areas over the period of 18 months. Background Fall injuries, malnutrition and pressure ulcers among older people are challenging issues for caregivers at different levels in the health care system. Design A descriptive design with a qualitative approach was used to follow health care personnel before, during and after implementation of a care prevention intervention. Methods Twelve health care personnel with different professions at the hospital, primary care and municipal care levels participated in a preventive care introduction. Seminars were held at four occasions, with assignments to be completed between seminars. Lectures and group discussions were performed, and three risk assessment scales were introduced. The participants were interviewed before, during and after the introduction. Manifest and latent content analysis were used. Results The main results are presented in the theme ‘Patient needs are visualised through a gradually developed shared understanding’ and in five categories. The work approach of performing three risk assessments simultaneously was perceived as positive and central to ensuring quality of care; it was not, however, perceived as unproblematic. Conclusion The participants as well as health care team members showed a positive attitude towards and described the advantages of being given opportunities for shared understanding to improve patient safety and to provide structure for the provision of good care. Relevance to clinical practice The managerial approach of listening to and acting on issues stressed by health care personnel is important to ensure ongoing and future improvement initiatives.

Changes in brain-gut interactions have been implicated in the pathophysiology of chronic visceral pain in irritable bowel syndrome (IBS). Different mechanisms of sensitization of visceral afferent pathways may contribute to the chronic visceral pain reports and associated brain changes that characterize IBS. They include increased gut permeability and gut associated immune system activation, and an imbalance in descending pain inhibitory and facilitatory mechanisms. In order to study the involvement of these mechanisms, correlations between gut epithelial permeability and live bacterial passage, and structural and functional brain connectivity were measured in women with moderate-to-severe IBS and healthy women. The relationships between gut permeability and functional and anatomical connectivity were significantly altered in IBS compared with the healthy women. IBS participants with lower epithelial permeability reported increased IBS symptoms, which was associated with increased functional and structural connectivity in endogenous pain facilitation regions. The findings suggest that relationships between gut permeability and the brain are significantly altered in IBS and suggest the existence of IBS subtypes based on these interactions., Highlights • Brain-gut interactions are significantly altered in irritable bowel syndrome. • Brain-gut interactions engage pain modulation brain regions in healthy women. • Normal levels of gut permeability in IBS are linked with endogenous pain facilitation.

The Nurse Professional Competence (NPC) Scale with 88-items has been used to measure self-reported competence among nursing students and registered nurses in many national and international nursing research projects. However, a shorter version of the scale with maintained quality has been requested to further enhance its usability.To develop and evaluate the construct validity and internal consistency of a shorter version of the NPC Scale.A developmental and methodological design.The study was based on a sample of 1810 nursing students at the point of graduation from 12 universities in Sweden.The number of items in the original NPC Scale was reduced using several established research steps and then evaluated for data quality and construct validity using principal component analysis and confirmatory factor analysis. Reliability was measured as internal consistency using Cronbach's alpha.The extensive process of reducing the number of items resulted in a version with 35 items. Principal component analysis resulted in six factors explaining 53.6% of the variance: "Nursing Care", "Value-based Nursing Care", "Medical and Technical Care", "Care Pedagogics", "Documentation and Administration of Nursing Care", and "Development, Leadership, and Organization of Nursing Care". All factors showed Cronbach's alpha values of0.70. The confirmative factor analysis goodness-of-fit indexes were for root mean square error of approximation 0.05 and for comparative fit index 0.89.The NPC Scale Short Form (NPC Scale-SF) 35-items revealed promising results with a six-factor structure explaining 53.6% of the total variance. This 35-item scale can be an asset when used alone and together with other instruments it can provide the possibility of more complex analyses of self-reported competence among nursing students and registered nurses.

Aim To examine internationally educated nurses’ experiences of empowerment structures using Kanter's theory of structural empowerment. Background There has been an increase in the number of nurses working in other countries worldwide and concerns have been raised regarding their working conditions. Method Semi-structured interviews were conducted with a purposive sample of 11 internationally educated nurses. Directed content analysis was used to analyse the data and Kanter's theory of empowerment was used as a framework. Results Access to information was generally good. Access to support for their relationship with their managers varied. Regarding access to resources, nurses unfamiliar with clinical leadership found team leadership challenging. Access to in-house learning opportunities were reported as good. Access to informal power was more common than access to formal power. Conclusions The findings support Kanter's theory and demonstrate that internationally experienced nurses encountered varying degrees of access to empowering structures. Access to information and formal power was more general and related to the unit. Access to resources, support, opportunities and informal power were related to both the unit and the informants’ specific situation as IENs. Implications for Nursing Management Managers need to support IENs when having a team leadership role, facilitate encounters between IENs and ordinary staff, and establishing mentorship for IENs.

Studying olfaction with functional Magnetic Resonance imaging (fMRI) poses various methodological challenges. This study aimed to investigate the effects of stimulation length and repetition time (TR) on the activation pattern of four olfactory brain regions: the anterior and the posterior piriform cortex, the orbitofrontal cortex and the insula. 22 healthy participants with normal olfaction were examined with fMRI, with two stimulation lengths (6 seconds and 15 seconds) and two TRs (0.901 seconds and 1.34 seconds). Data were analyzed using General Linear Model (GLM), Tensorial Independent Component Analysis (TICA) and by plotting the event related time course of brain activation in the four olfactory regions of interest. The statistical analysis of the time courses revealed that short TR was associated with more pronounced signal increase and short stimulation was associated with shorter time to peak signal. Additionally, both long stimulation and short TR were associated with oscillatory time courses, whereas both short stimulation and short TR resulted in more typical time courses. GLM analysis showed that the combination of short stimulation and short TR could result in visually larger activation within these olfactory areas. TICA validated that the tested paradigm was spatially and temporally associated with a functionally connected network that included all four olfactory regions. In conclusion, the combination of short stimulation and short TR is associated with higher signal increase and shorter time to peak, making it more amenable to standard GLM-type analyses than long stimulation and long TR, and it should, thus, be preferable for olfactory fMRI.

Objective: The aim of this study was to explore the interaction between interface pressure, pressure-induced vasodilation, and reactive hyperaemia with different pressure-redistribution mattresses. Method: A cross-sectional study was performed with a convenience sample of healthy young individuals, and healthy older individuals and inpatients, at a university hospital in Sweden. Blood flow was measured at depths of 1mm, 2mm, and 10mm using laser Doppler flowmetry and photoplethysmography. The blood flow, interface pressure and skin temperature were measured in the sacral tissue before, during, and after load while lying on one standard hospital mattress and three different pressure-redistribution mattresses. Results: There were significant differences between the average sacral pressure, peak sacral pressure, and local probe pressure on the three pressure-redistribution mattresses, the lowest values found were with the visco-elastic foam/air mattress (23.5 ± 2.5mmHg, 49.3 ± 11.1mmHg, 29.2 ± 14.0mmHg, respectively). Blood flow, measured as pressure-induced vasodilation, was most affected in the visco-elastic foam/air group compared to the alternating pressure mattress group at tissue depths of 2mm (39.0% and 20.0%, respectively), and 10mm (56.9 % and 35.1%, respectively). Subjects in all three groups, including healthy 18–65 year olds, were identified with no pressure-induced vasodilation or reactive hyperaemia on any mattress (n=11), which is considered a high-risk blood flow response. Conclusion: Interface pressure magnitudes considered not harmful during pressure-exposure on different pressure-redistribution mattresses can affect the microcirculation in different tissue structures. Despite having the lowest pressure values compared with the other mattresses, the visco-elastic foam/air mattress had the highest proportion of subjects with decreased blood flow. Healthy young individuals were identified with the high-risk blood flow response, suggesting an innate vulnerability to pressure exposure. Furthermore, the evaluation of pressure-redistribution support surfaces in terms of mean blood flow during and after tissue exposure is not feasible, but assessment of pressure-induced vasodilation and reactive hyperaemia could be a new way to assess individualised physiological measurements of mechanisms known to be related to pressure ulcer development.

Background During the past decade, the concept of Lean has spread rapidly within the healthcare sector, but there is a lack of instruments that can measure staff’s perceptions of Lean adoption. Thus, the aim of the present study was to develop a questionnaire measuring Lean in healthcare, based on Liker’s description of Lean, by adapting an existing instrument developed for the service sector. Methods A mixed-method design was used. Initially, items from the service sector instrument were categorized according to Liker’s 14 principles describing Lean within four domains: philosophy, processes, people and partners and problem-solving. Items were lacking for three of Liker’s principles and were therefore developed de novo. Think-aloud interviews were conducted with 12 healthcare staff from different professions to contextualize and examine the face validity of the questionnaire prototype. Thereafter, the adjusted questionnaire’s psychometric properties were assessed on the basis of a cross-sectional survey among 386 staff working in primary care. Results The think-aloud interviews led to adjustments in the questionnaire to better suit a healthcare context, and the number of items was reduced. Confirmatory factor analysis of the adjusted questionnaire showed a generally acceptable correspondence with Liker’s description of Lean. Internal consistency, measured using Cronbach’s alpha, for the factors in Liker’s description of Lean was 0.60 for the factor people and partners, and over 0.70 for the three other factors. Test-retest reliability measured by the intra-class correlation coefficient ranged from 0.77 to 0.88 for the four factors. Conclusions We designed a questionnaire capturing staff’s perceptions of Lean adoption in healthcare on the basis of Liker’s description. This Lean in Healthcare Questionnaire (LiHcQ) showed generally acceptable psychometric properties, which supports its usability for measuring Lean adoption in healthcare. We suggest that further research focus on verifying the usability of LiHcQ in other healthcare settings, and on adjusting the instrument if needed. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2163-x) contains supplementary material, which is available to authorized users.

Background Telenursing is an expanding part of healthcare, staffed with registered nurses whose work environment is typical of a call centre. Work-related stress has been shown to be a major problem in nurses’ work environments and of importance to the outcome of care, patient safety, nurse job satisfaction and burnout. Today, however, we have a limited understanding of and knowledge about the work environment for telenurses. The aim of the present study is to explore and reach consensus on perceived important obstacles and prerequisites in telenurses’ work environment. Methods A modified Delphi design, using qualitative as well as quantitative data sequentially through three phases, was taken. Data were initially collected via semi-structured interviews (Phase I) and later using a web survey (Phase II-III) between March 2015 and March 2016. Results The findings present a consensus view of telenurses’ experiences of important obstacles and prerequisites in their work environment. Central to the findings are the aspects of telenurses having a demanding work, cognitive fatigue and having no opportunity for recovery during the work shift was ranked as important obstacles. Highly ranked prerequisites for managing were being able to focus on one caller at a time, working in a calm and pleasant environment and having technical support 24/7. Conclusions Managers need to enable telenurses to experience control in their work, provided with possibilities to control their work and to recover during work; shortening work time could improve their work environment. Limited possibilities to perform work might contribute to feelings of stress and inability to perform work.

Accessible summary Employer/workplaces have an impact on mental health nursing staff's general attitudes towards persons with mental illness. Staff have more positive attitudes if their knowledge about mental illness is less stigmatized and currently have or have once had a close friend with mental problem. More favourable attitudes among staff towards persons with mental illness could be developed and transmitted in the subculture at work places. AbstractThere is growing awareness that mental illness is surrounded by negative attitudes and stigmas. The aim of the present study was to investigate factors associated with mental health nursing staff's attitudes towards persons with mental illness. Data were collected from 256 mental health nursing staff employed by one county council and 10 municipalities. The findings show that staff have more positive attitudes towards persons with mental illness if their knowledge about mental illness is less stigmatized, their work places are in the county council, and they currently have or have once had a close friend with mental health problems. The multiple regression model explained 16% of the variance; stigma-related knowledge and employer had significant Beta-coefficients. To account for unknown correlations in data, a linear generalized estimating equation was performed. In this model, stigma-related knowledge and employer remained significant, but a new significant factor also emerged: personal contact, i.e. currently having or having once had a close friend with mental health problems. This indicates correlations at unit level in the county council and in the municipalities. The conclusion is that more favourable attitudes among staff towards persons with mental illness could be developed and transmitted in the subculture at work places.

The objective of this study was to investigate if combined measures of activation in the thalamus and working memory capacity could guide the diagnosis of Kleine-Levin Syndrome (KLS). A second objective was to obtain more insight into the neurobiological causes of KLS.Matched group and consecutive recruitment.University hospital neurology department and imaging center.Eighteen patients with KLS diagnosed according to the International Classification of Sleep Disorders and 26 healthy controls were included.N/A.Working memory capacity was assessed by the listening span task. A version of this task (reading span) was presented to the participants during functional magnetic resonance imaging (fMRI). Activation in the thalamus was measured in a region of interest analysis. A combination of the working memory capacity and the thalamic activation measures resulted in 80% prediction accuracy, 81% sensitivity, and 78% specificity regarding the ability to separate KLS patients from healthy controls. The controls had an inverse relation between working memory capacity and thalamic activation; higher performing participants had lower thalamic activation (r = -0.41). KLS patients showed the opposite relationship; higher performing participants had a tendency to higher thalamic activation (r = -0.35).This study shows that functional neuroimaging of the thalamus combined with neuropsychological assessment of working memory function provides a means to guide diagnosis of Kleine-Levin Syndrome. Results in this study also indicate that imaging of brain function and evaluation of cognitive capacity can give insights into the neurobiological mechanisms of Kleine-Levin Syndrome.

To describe male first-line managers' experiences of their work situation in elderly care.First-line managers' work is challenging. However, less attention has been paid to male managers' work situation in health care. Knowledge is needed to empower male managers.Fourteen male first-line managers were interviewed. The interview text was subjected to qualitative content analysis.Work situations were described as complex and challenging; challenges were the driving force. They talked about 'Being on one's own but not feeling left alone', 'Having freedom within set boundaries', 'Feeling a sense of satisfaction and stimulation', 'Feeling a sense of frustration' and 'Having a feeling of dejection and resignation'.Although the male managers report deficiencies in the support structure, they largely experience their work as a positive challenge.To meet increasing challenges, male first-line managers need better access to supportive structural conditions. Better access to resources is needed in particular, allowing managers to be more visible for staff and to work with development and quality issues instead of administrative tasks. Regarding organisational changes and the scrutiny of management and the media, they lack and thus need support and information from superiors.

To describe district nurses' self-reported clinical activities, beliefs about and attitudes towards obesity management; and to examine associations between the variables.Obesity is increasing worldwide and primary care could play a central role in the management.Questionnaire data were collected from 247 nurses in 33 centres.The most common activities performed weekly were; advice about physical activity (40.1%) and general lifestyle advice (34.8%). However, nearly one third seldom/never performed these activities. Approximately half seldom/never performed BMI assessment and even fewer waist circumference (78.1%). Values for the factors Importance of obesity and Personal effectiveness were skewed towards a positive view and Negative view close to neutral. Multivariate analysis revealed that nurses with specialized tasks, longer working experience and higher perceived personal effectiveness performed more clinical activities.Managers need to make efforts to engage all personnel in obesity management; and strategies to increase self-efficacy are called for.

To describe registered nurses' reflections on discussing sexuality with patients.It is known that many diseases and treatments have a negative impact on sexual health. Despite these facts, registered nurses typically do not address sexual issues with patients.A descriptive design and a qualitative approach were used.Interviews were conducted in 2010 with 10 registered nurses. The data were analysed using qualitative content analysis.The themes 'Doing the right thing and doing good', 'Could've, would've, should've: a nurse's conflicting feelings' and 'I just don't talk about it: sexuality as a nontopic' confirmed the notion that discussing sexuality in nursing care is still challenging and difficult for nurses, but also revealed that nurses who do talk to patients about sexual issues do so based on their strong sense of wanting to help. They felt a responsibility because of their knowledge in the area, but the topic also brought out conflicting feelings such as fear and embarrassment. Lack of time, support and places to talk to patients in private as well as prejudice were contributing factors to their not addressing sexuality. Some nurses also felt that sexuality was someone else's responsibility and a taboo subject.Patients' sexuality is still surrounded by silence. But factors exist that can facilitate discussion of sexuality. Nurses have a key role in detecting ill-health. This study suggests that when nurses use their knowledge and go beyond their comfort zone and address sexuality, they can identify patients' sexual problems.Nurses need to understand how their knowledge can help patients who are experiencing sexual problems; they also need support from the workplace and to have access to routines that reinforce the notion that sexuality is a topic worth discussing.

Gut-directed hypnotherapy can reduce IBS symptoms, but the mechanisms underlying this therapeutic effect remain unknown.To determine the effect of hypnotherapy and educational intervention on brain responses to cued rectal distensions in IBS patients.Forty-four women with moderate-to-severe IBS and 20 healthy controls (HCs) were included. Blood oxygen level dependent (BOLD) signals were measured by functional Magnetic Resonance Imaging (fMRI) during expectation and delivery of high- (45 mmHg) and low-intensity (15 mmHg) rectal distensions. Twenty-five patients were assigned to hypnotherapy (HYP) and 16 to educational intervention (EDU). Thirty-one patients completed treatments and posttreatment fMRI.Similar symptom reduction was achieved in both groups. Clinically successful treatment (all responders) was associated with significant BOLD attenuation during high-intensity distension in the dorsal and ventral anterior insula (cluster size 142, P = 0.006, and cluster size 101, P = 0.005 respectively). Moreover HYP responders demonstrated a pre-post treatment BOLD attenuation in posterior insula (cluster sizes 59, P = 0.05) while EDU responders had a BOLD attenuation in prefrontal cortex (cluster size 60, P = 0.05). Pre-post differences for expectation conditions were almost exclusively seen in the HYP group. Following treatment, the brain response to distension was similar to that observed in HCs, suggesting that the treatment had a normalising effect on the central processing abnormality of visceral signals in IBS.The abnormal processing and enhanced perception of visceral stimuli in IBS can be normalised by psychological interventions. Symptom improvement in the treatment groups may be mediated by different brain mechanisms.NCT01815164.

Nursing students' learning process during clinical practice is dependent on the quality of their assessment, and the feedback that is given, however an issue that is very little examined. The aim of this study was to investigate student-preceptor dyads and their experiences of mid-course discussions and final assessment. Data were collected through repeated semi-structured individual interviews with 13 dyads close in time to the assessment discussions, and were analyzed by searching for similarities and differences in their experiences. Both students and preceptors shared the view that the preparations before the discussions caused uncertainty, but they described different reasons. Both students and preceptors meant that the assessment tool was used in a structured way. The feedback mediated to students emphasized what was important to concentrate on in the next part or next period, but less about the individual students' progress. The student-preceptor dyads did not share the view of what content had been in focus in the discussions and there were variations in the details. Conclusions can be drawn that one of the crucial elements of an assessment discussion, to give students constructive feedback in relation to learning outcomes, was not fulfilled.

Background Clinical education is a vital part of nursing students' learning; the importance of assessment tools and feedback in stimulating student learning has been stressed, but this needs to be studied in more detail. Objectives To examine relationships between nursing students' perceptions of using an Assessment tool in Clinical Education (AssCE) during their mid-course discussion and final assessment, the content discussed during these meetings between the student, preceptor and nurse teacher and the students' overall perception of the clinical learning environment. Design A cross-sectional, correlational design was used. Setting and Participants A convenience sample of 110 nursing students from one Norwegian university college with two campuses. Methods Data were collected with self-developed questionnaires and analysed using logistic regression with SPSS and the PROCESS macro for mediation analysis. Results There was a positive relationship between nursing students' perceptions of using the assessment tool AssCE and their overall perception of the clinical learning environment. This relationship was, in turn, mediated by the content discussed during the formative mid-course discussion and summative final assessment. Conclusions Our conclusion is that the assessment tool AssCE supported students' clinical learning and that this relationship, in turn, was mediated by the degree to which the conversation during the assessment meeting focused on the student's knowledge, skills and professional judgement.

Functional magnetic resonance imaging (fMRI) measures brain activity by detecting the blood-oxygen-level dependent (BOLD) response to neural activity. The BOLD response depends on the neurovascular coupling, which connects cerebral blood flow, cerebral blood volume, and deoxyhemoglobin level to neuronal activity. The exact mechanisms behind this neurovascular coupling are not yet fully investigated. There are at least three different ways in which these mechanisms are being discussed. Firstly, mathematical models involving the so-called Balloon model describes the relation between oxygen metabolism, cerebral blood volume, and cerebral blood flow. However, the Balloon model does not describe cellular and biochemical mechanisms. Secondly, the metabolic feedback hypothesis, which is based on experimental findings on metabolism associated with brain activation, and thirdly, the neurotransmitter feed-forward hypothesis which describes intracellular pathways leading to vasoactive substance release. Both the metabolic feedback and the neurotransmitter feed-forward hypotheses have been extensively studied, but only experimentally. These two hypotheses have never been implemented as mathematical models. Here we investigate these two hypotheses by mechanistic mathematical modeling using a systems biology approach; these methods have been used in biological research for many years but never been applied to the BOLD response in fMRI. In the current work, model structures describing the metabolic feedback and the neurotransmitter feed-forward hypotheses were applied to measured BOLD responses in the visual cortex of 12 healthy volunteers. Evaluating each hypothesis separately shows that neither hypothesis alone can describe the data in a biologically plausible way. However, by adding metabolism to the neurotransmitter feed-forward model structure, we obtained a new model structure which is able to fit the estimation data and successfully predict new, independent validation data. These results open the door to a new type of fMRI analysis that more accurately reflects the true neuronal activity., Author Summary Functional magnetic resonance imaging (fMRI) is a widely used technique for measuring brain activity. However, the signal registered by fMRI is not a direct measurement of the neuronal activity in the brain, but it is influenced by the interplay between the metabolism, blood flow and blood volume in the active area. This signal is called the blood-oxygen-level dependent (BOLD) response and occurs when the blood supply to the active area increases in response to neuronal activity. The mechanisms that the cells use to influence the blood supply are not fully known, and therefore it is difficult to know the true neuronal signalling only from inspection of the fMRI signal. In this article, we present a new mathematical model built on the physiological mechanisms thought to underlie the BOLD response. We could successfully fit the model to data and predict the activity caused by new stimuli. By using the validated model we investigated physiological mechanisms that cause different parts of the BOLD response.

Objectives: The objective of the present study was to investigate whether moderately experienced meditators activate hippocampus and the prefrontal cortex during silent mantra meditation, as has been observed in earlier studies on subjects with several years of practice. Methods: Subjects with less than 2 years of meditation practice according to the Kundalini yoga or Acem tradition were examined by functional magnetic resonance imaging during silent mantra meditation, using an on-off block design. Whole-brain as well as region-of-interest analyses were performed. Results: The most significant activation was found in the bilateral hippocampus/parahippocampal formations. Other areas with significant activation were the bilateral middle cingulate cortex and the bilateral precentral cortex. No activation in the anterior cingulate cortex was found, and only small activation clusters were observed in the prefrontal cortex. Conclusions: In conclusion, the main finding in this study was the significant activation in the hippocampi, which also has been correlated with meditation in several previous studies on very experienced meditators. We propose that the hippocampus is activated already after moderate meditation practice and also during different modes of meditation, including relaxation. The role of hippocampal activity during meditation should be further clarified in future studies, especially by investigating whether the meditation-correlated hippocampal activity is related to memory consolidation. Original Publication: Maria Engström, Johan Pihlsgård, Peter Lundberg and Birgitta Axelsson Söderfeldt, Functional Magnetic Resonance Imaging of Hippocampal Activation During Silent Mantra Meditation, 2010, Journal of Alternative and Complementary Medicine, (16), 12, 1253-1258. http://dx.doi.org/10.1089/acm.2009.0706 Copyright: Mary Ann Liebert, Inc. http://www.liebertpub.com/

Background: In fMRI examinations, it is very important to select appropriate paradigms assessing the brain function of interest. In addition, the patients ability to perform the required cognitive tasks during fMRI must be taken into account. Purpose: To evaluate two language paradigms, word generation and sentence reading for their usefulness in examinations of aphasic patients and to make suggestions for improvements of clinical fMRI. Material and Methods: Five patients with aphasia after stroke or trauma sequelae were examined by fMRI. The patients language ability was screened by neurolinguistic tests and elementary pre-fMRI language tests. Results: The sentence-reading paradigm succeeded to elicit adequate language-related activation in perilesional areas whereas the word generation paradigm failed. These findings were consistent with results on the behavioral tests in that all patients showed very poor performance in phonemic fluency, but scored well above mean at a reading comprehension task. Conclusion: The sentence-reading paradigm is appropriate to assess language function in this patient group, while the word-generation paradigm seems to be inadequate. In addition, it is crucial to use elementary pre-fMRI language tests to guide the fMRI paradigm decision. Original Publication: Maria Engström, Marie Karlsson, Marie Crone, Mattias Ragnehed, Wolfram Antepohl, Anne-Marie Landtblom and Peter Lundberg, Clinical fMRI of language function in aphasic patients: Reading paradigm successful, while word generation paradigm fails, 2010, Acta Radiologica, (51), 6, 679-686. http://dx.doi.org/10.3109/02841851003753456 Copyright: Informa Healthcare http://informahealthcare.com/

Study Objectives: The objectives of this study were to investigate possible neuropathology behind the Kleine-Levin Syndrome (KLS), a severe form of hypersomnia with onset during adolescence. Design: Functional magnetic resonance imaging (fMRI) applying a verbal working memory task was used in conjunction with a paper-and-pencil version of the task. Participants: Eight patients with KLS and 12 healthy volunteers participated in the study. Results: The results revealed a pattern of increased thalamic activity and reduced frontal activity (involving the anterior cingulate and adjacent prefrontal cortex) while performing a reading span task. Discussion: This finding may explain the clinical symptoms observed in KLS, in that the thalamus is known to be involved in the control of sleep. Given the increasing access to fMRI, this investigation may aid clinicians in the diagnosis of patients suffering from severe forms of hypersomnia.

The aim of the present research was to study outcomes of use of the OLD@HOME Virtual Health Record with regard to staff opinions about information, communication technology, and satisfaction with work. A quasi-experimental design was used. Staff opinions about the information and communication technology were assessed using a study-specific questionnaire at the test site (n =22) and at other settings in the municipality (n =172). Staff (n =22) job satisfaction, perceived quality of care, and psychosomatic health were assessed using the Satisfaction with Work Questionnaires before and after a 5-month period of testing the technology in an intervention and a comparison group. Staff opinions about the information and communication technology were significantly more positive at the test site compared to other settings in the municipality. For the total scale of quality of care and the factor documentation, there were significant differences in change scores between intervention and comparison groups, with improvements for the comparison group. For job satisfaction and psychosomatic health, there were no differences in change scores between the groups. Participatory design enhances staff opinions about information and communication technology. However, a 5-month test period showed no benefits regarding staff satisfaction with work when compared to a comparison group. On the contrary, the comparison group improved in documentation, and for the intervention group, there was a trend toward deterioration, which may be due to their knowing how to document, but not having time when using both paper-based and electronic systems.

The authors investigated the effect of diazepam on clinically relevant measures from functional magnetic resonance imaging (fMRI) examinations. Twenty volunteers were scanned twice. Using a double-blind randomized study design, the volunteers received placebo on one occasion, and on the other, 5 mg of diazepam. Three functional tests were used: motor, word generation, and working memory. Images were analyzed individually for each subject and the number of activated voxels and the laterality index were calculated. No significant effects related to the drug were detected. In contrast, the motor and working memory tasks showed a significant decrease in the number of activated voxels between Sessions 1 and 2, independently of diazepam administration. These results indicate that diazepam may be administered for premedication prior to fMRI investigations.

Knowledge about the neural underpinnings of the negative blood oxygen level dependent (BOLD) responses in functional magnetic resonance imaging (fMRI) is still limited. We hypothesized that pharmacological GABAergic modulation attenuates BOLD responses, and that blood concentrations of a positive allosteric modulator of GABA correlate inversely with BOLD responses in the cingulate cortex. We investigated whether or not pure task-related negative BOLD responses were co-localized with pharmacologically modulated BOLD responses. Twenty healthy adults received either 5 mg diazepam or placebo in a double blind, randomized design. During fMRI the subjects performed a working memory task. Results showed that BOLD responses in the cingulate cortex were inversely correlated with diazepam blood concentrations; that is, the higher the blood diazepam concentration, the lower the BOLD response. This inverse correlation was most pronounced in the pregenual anterior cingulate cortex and the anterior mid-cingulate cortex. For subjects with diazepam plasma concentration > 0.1 mg/L we observed negative BOLD responses with respect to fixation baseline. There was minor overlap between cingulate regions with task-related negative BOLD responses and regions where the BOLD responses were inversely correlated with diazepam concentration. We interpret that the inverse correlation between the BOLD response and diazepam was caused by GABA-related neural inhibition. Thus, this study supports the hypothesis that GABA attenuates BOLD responses in fMRI. The minimal overlap between task-related negative BOLD responses and responses attenuated by diazepam suggests that these responses might be caused by different mechanisms. Funding agencies: Linkoping University; County Council of Ostergotland

ObjectivesTo investigate different professionals’ (nurse anaesthetists’, anaesthesiologists’, and postanaesthesia care unit nurses’) descriptions of and reflections on the postoperative handover.DesignA focus group interview study with a descriptive design using qualitative content analysis of transcripts.SettingOne anaesthetic clinic at two hospitals in Sweden.ParticipantsSix focus groups with 23 healthcare professionals involved in postoperative handovers. Each group was homogeneous regarding participant profession, resulting in two groups per profession: nurse anaesthetists (n=8), anaesthesiologists (n=7) and postanaesthesia care unit nurses (n=8).ResultsPatterns and five categories emerged: (1) having different temporal foci during handover, (2) insecurity when information is transferred from one team to another, (3) striving to ensure quality of the handover, (4) weighing the advantages and disadvantages of the bedside handover and (5) having different perspectives on the transfer of responsibility. The professionals’ perceptions of the postoperative handover differed with regard to temporal foci and transfer of responsibility. All professional groups were insecure about having all information needed to ensure the quality of care. They strived to ensure quality of the handover by: focusing on matters that deviated from the normal course of events, aiding memory through structure and written information and cooperating within and between teams. They reported that the bedside handover enhances their control of the patient but also that it could threaten the patient's privacy and that frequent interruptions could be disturbing.ConclusionsThe present findings revealed variations in different professionals’ views on the postoperative handover. Healthcare interventions are needed to minimise the gap between professionals’ perceptions and practices and to achieve a shared understanding of postoperative handover. Furthermore, to ensure high-quality and safe care, stakeholders/decision makers need to pay attention to the environment and infrastructure in postanaesthesia care.

ObjectivesThe purpose of this study is to compare communication patterns in calls subjected to a malpractice claim with matched controls.SettingIn many countries, telephone advice nursing is patients’ first contact with healthcare. Telenurses’ assessment of callers’ symptoms and needs are based on verbal communication only, and problems with over-triage and under-triage have been reported.ParticipantsA total sample of all reported medical errors (n=33) during the period 2003–2010 within Swedish Healthcare Direct was retrieved. Corresponding calls were thereafter identified and collected as sound files from the manager in charge at the respective call centres. For technical reasons, calls from four of the cases were not possible to retrieve. For the present study, matched control calls (n=26) based on the patient's age, gender and main symptom presented by the caller were collected.ResultsMale patients were in majority (n=16), and the most common reasons for calling were abdominal pain (n=10) and chest pain (n=5). There were statistically significant differences between the communication in the cases and controls: telenurses used fewer open-ended medical questions (pConclusionsThe present study shows that telenurses in malpractice claimed calls used more closed-ended questioning compared to those in control calls, who used more open-ended questioning and back-channel response, which provided them with richer medical descriptions and more information from the caller. Hence, these communicative techniques are important in addition to solid medical and nursing competence and sound decision aid systems.

Background and aimsIrritable bowel syndrome (IBS) is a common gastrointestinal disorder characterized by abdominal pain and altered bowel habits. The societal costs of the disorder are significant, as are its negative effects on quality of life. Medical treatment options are limited, but psychological treatments such as hypnotherapy have proven to be effective. Important pathophysiological mechanisms include disturbances in brain processing of visceral sensation and expectation of visceral sensation. Increased sensation of stimuli (hypersensitivity) is present in a subset of IBS patients to distensions in the lower part of the gastrointestinal tract, indicating a probable important pathophysiological mechanism in IBS. The overall aim of the thesis was to further study the central pathophysiological mechanisms involved in IBS. Specifically, we aimed to identify differences in brain response to standardized repeated rectal distensions and expectation of these stimuli between IBS patients (with or without perceptual rectal hypersensitivity), and healthy controls. Furthermore, we aimed to investigate IBS patients´ brain responses to standardized rectal distensions and expectation of these stimuli after either a successful course hypnotherapy or educational intervention.MethodsFunctional magnetic resonance imaging (fMRI) data were acquired and analyzed from 15 IBS patients with visceral hypersensitivity, and 18 IBS patients with normal visceral sensitivity (papers I and II). In paper III, fMRI data were analyzed from IBS patients who reported significant symptom reduction after either a course of hypnotherapy, or an educational intervention. FMRI data from IBS patients and healthy controls were also compared.ResultsThe findings reported in papers I and II suggest, that the differences in brain response between IBS patients with and without rectal hypersensitivity, can be explained by changes in brain response during the course of the experiment. Even though the brain responses were similar between groups during the early phase of the experiment, they became substantially different during the late phase. The IBS patients with rectal hypersensitivity demonstrated increased brain response in several brain regions and networks involved in visceral sensation and processing. In contrast, IBS patients with normal rectal sensitivity exhibited reduced brain response during the late phase of the experiment. As reported in paper III, similar symptom reduction was achieved for both treatments. The symptomatic improvement was associated with a reduction of response in the anterior insula, indicating an attenuated awareness of the stimuli. The hypnotherapy group had a reduction of response in the posterior insula, indicating less input to the brain, possibly due to changed activity in endogenous pain modulatory systems. In patients who reported significant symptom reduction following treatment, the brain response to rectal distension got more similar to that observed in healthy controls.ConclusionsThe results from papers I and II indicate that a subpopulation of IBS patients lacks the ability to habituate to repeated rectal distensions and expectation of these stimuli. Results from paper III indicate that the abnormal processing of visceral stimuli in IBS can be altered, and that the treatments probably had a normalizing effect on the central processing abnormality of visceral signals in IBS.

Background: Among staff working in elderly care, a considerable proportion lack formal competence for their work. Lack of formal competence, in turn, has been linked to higher staff ratings of stress symptoms, sleep disturbances and workload. Objectives: 1) To describe the strengths and weaknesses of an e-assessment and subsequent e-training program used among elderly care staff who lack formal competence and 2) to study the effects of an e-training program on staff members' working life (quality of care and psychological and structural empowerment) and well-being (job satisfaction and psychosomatic health). The hypothesis was that staff who had completed the e-assessment and the e-training program would rate greater improvements in working life and well-being than would staff who had only participated in the e-assessments. Methods: An intervention study with a mixed-methods approach using quantitative (2010-2011) and qualitative data (2011) was conducted in Swedish elderly care. Participants included a total of 41 staff members. To describe the strengths and weaknesses of the e-assessment and the e-training program, qualitative data were gathered using semi-structured interviews together with a study-specific questionnaire. To study the effects of the intervention, quantitative data were collected using questionnaires on: job satisfaction, psychosomatic health, psychological empowerment, structural empowerment and quality of care in an intervention and a comparison group. Results: Staff who completed the e-assessments and the e-training program primarily experienced strengths associated with this approach. The results were also in line with our hypotheses: Staff who completed the e-assessment and the e-training program rated improvements in their working life and well-being. Conclusion: Use of the e-assessments and e-training program employed in the present study could be one way to support elderly care staff who lack formal education by increasing their competence; increased competence, in turn, could improve their self-confidence, working life, and well-being. A. Nilsson och M. Engström delar förstaförfattarskapet.

To characterize PIV and RH at different sacral tissue depths in different populations under clinically relevant pressure exposure.Forty-two subjects (65 years), 38 subjects (≥65 years), and 35 patients (≥65 years) participated. Interface pressure, skin temperature, and blood flow at tissue depths of 1, 2, and 10 mm (using LDF and PPG) were measured in the sacral tissue before, during, and after load in a supine position.Pressure-induced vasodilation and RH were observed at three tissue depths. At 10 mm depth, the proportion of subjects with a lack of PIV was higher compared to superficial depths. The patients had higher interface pressure during load than the healthy individuals, but there were no significant differences in blood flow. Twenty-nine subjects in all three study groups were identified with a lack of PIV and RH.Pressure-induced vasodilation and RH can be observed at different tissue depths. A lack of these responses was found in healthy individuals as well as in patients indicating an innate susceptibility in some individuals, and are potential important factors to evaluate in order to better understand the etiology of pressure ulcers.

Aim To elucidate first-line managers’ descriptions and reflections regarding their staff's access to empowering structures using Kanter's theory of structural empowerment. Background Good structural conditions within workplaces are essential to employees’ wellbeing, and their ability to access empowerment structures is largely dependent on the management. Method Twenty-eight first-line managers in elderly care were interviewed. Deductive qualitative content analysis was used to analyse data. Results Managers perceived that staff had varying degrees of access to the empowering structures described in Kanter's theory – and that they possessed formal power in their roles as contact persons and representatives. The descriptions mostly started from the managers’ own actions, although some started from the needs of staff members. Conclusion All managers described their staff's access to the empowering structures in Kanter's theory as important, yet it seemed as though this was not always reflected on and discussed as a strategic issue. Implications for nursing management Managers could make use of performance and appraisal dialogues to keep up to date on staff's access to empowering structures. Recurrent discussions in the management group based on such current information could promote staff's access to power through empowering structures and make job definitions a strategic issue in the organisation.

Background The current paper presents a pilot study of interactive assessment using information and communication technology (ICT) to evaluate the knowledge, skills and abilities of staff with no formal education who are working in Swedish elderly care. Methods Theoretical and practical assessment methods were developed and used with simulated patients and computer-based tests to identify strengths and areas for personal development among staff with no formal education. Results Of the 157 staff with no formal education, 87 began the practical and/or theoretical assessments, and 63 completed both assessments. Several of the staff passed the practical assessments, except the morning hygiene assessment, where several failed. Other areas for staff development, i.e. where several failed (>50%), were the theoretical assessment of the learning objectives: Health, Oral care, Ergonomics, hygiene, esthetic, environmental, Rehabilitation, Assistive technology, Basic healthcare and Laws and organization. None of the staff passed all assessments. Number of years working in elderly care and staff age were not statistically significantly related to the total score of grades on the various learning objectives. Conclusion The interactive assessments were useful in assessing staff members' practical and theoretical knowledge, skills, and abilities and in identifying areas in need of development. It is important that personnel who lack formal qualifications be clearly identified and given a chance to develop their competence through training, both theoretical and practical. The interactive e-assessment approach analyzed in the present pilot study could serve as a starting point.

Aim To study associations between staff members' self-rated structural empowerment in mental health care, organisational type, and the ability and willingness to work according to evidence-based practice. Method Questionnaire data were collected from 253 mental health staff members. Result Multivariate logistic regressions analyses revealed that participants who scored higher on opportunity (OR 2.5) and were employed by the county council (OR 1.9) vs. the municipality were more likely to report high evidence-based practice ability. A generalised estimating equation taking into account unknown correlations within units found opportunity and resources to be significant predictors of evidence-based practice ability. Regarding evidence-based willingness, increased odds were found for higher scores of opportunity (OR 2.2) and being employed by the county council (OR 2.9). The generalised estimating equation also found resources to be a significant predictor of evidence-based willingness. In both organisations, the values for empowerment were moderate. Conclusion Structural conditions such as access to opportunities and resources are important for creating supporting structures for practice to be evidence-based. Implications for nursing management Our results emphasise the managers' essential role in creating empowering structures, and especially access to opportunities and resources, for their staff to carry out evidence-based practice.

OBJECTIVES: To present a method for generating reference maps of typical brain characteristics of groups of subjects using a novel combination of rapid quantitative Magnetic Resonance Imaging (qMRI) and brain normalization. The reference maps can be used to detect significant tissue differences in patients, both locally and globally. MATERIALS AND METHODS: A rapid qMRI method was used to obtain the longitudinal relaxation rate (R1), the transverse relaxation rate (R2) and the proton density (PD). These three tissue properties were measured in the brains of 32 healthy subjects and in one patient diagnosed with Multiple Sclerosis (MS). The maps were normalized to a standard brain template using a linear affine registration. The differences of the mean value ofR1, R2 and PD of 31 healthy subjects in comparison to the oldest healthy subject and in comparison to an MS patient were calculated. Larger anatomical structures were characterized using a standard atlas. The vector sum of the normalized differences was used to show significant tissue differences. RESULTS: The coefficient of variation of the reference maps was high at the edges of the brain and the ventricles, moderate in the cortical grey matter and low in white matter and the deep grey matter structures. The elderly subject mainly showed significantly lower R1 and R2 and higher PD values along all sulci. The MS patient showed significantly lower R1 and R2 and higher PD values at the edges of the ventricular system as well as throughout the periventricular white matter, at the internal and external capsules and at each of the MS lesions. CONCLUSION: Brain normalization of rapid qMRI is a promising new method to generate reference maps of typical brain characteristics and to automatically detect deviating tissue properties in the brain.

We aimed to study the effect of a potential default mode network (DMN) dysfunction on language performance in epilepsy. Language dysfunction in focal epilepsy has previously been connected to brain damage in language-associated cortical areas. In this work, we studied generalized epilepsy (GE) without focal brain damage to see if the language function was impaired. We used functional magnetic resonance imaging (fMRI) to investigate if the DMN was involved. Eleven persons with GE and 28 healthy controls were examined with fMRI during a sentence-reading task. We demonstrated impaired language function, reduced suppression of DMN, and, specifically, an inadequate suppression of activation in the left anterior temporal lobe and the posterior cingulate cortex, as well as an aberrant activation in the right hippocampal formation. Our results highlight the presence of language decline in people with epilepsy of not only focal but also generalized origin.

BackgroundBrain tissue segmentation of white matter (WM), grey matter (GM), and cerebrospinal fluid (CSF) are important in neuroradiological applications. Quantitative Mri (qMRI) allows segmentation based on physical tissue properties, and the dependencies on MR scanner settings are removed. Brain tissue groups into clusters in the three dimensional space formed by the qMRI parameters R1, R2 and PD, and partial volume voxels are intermediate in this space. The qMRI parameters, however, depend on the main magnetic field strength. Therefore, longitudinal studies can be seriously limited by system upgrades. The aim of this work was to apply one recently described brain tissue segmentation method, based on qMRI, at both 1.5 T and 3.0 T field strengths, and to investigate similarities and differences.MethodsIn vivo qMRI measurements were performed on 10 healthy subjects using both 1.5 T and 3.0 T MR scanners. The brain tissue segmentation method was applied for both 1.5 T and 3.0 T and volumes of WM, GM, CSF and brain parenchymal fraction (BPF) were calculated on both field strengths. Repeatability was calculated for each scanner and a General Linear Model was used to examine the effect of field strength. Voxel-wise t-tests were also performed to evaluate regional differences.ResultsStatistically significant differences were found between 1.5 T and 3.0 T for WM, GM, CSF and BPF (pConclusionsMost of the brain was identically classified at the two field strengths, although some regional differences were observed.

We analysed the characteristics of all malpractice claims arising out of telephone calls to Swedish Healthcare Direct (SHD) during 2003–2010 ( n = 33). The National Board of Health and Welfare's (NBHW) investigations describing the causes of the malpractice claims and the healthcare providers' reported measures were analysed using Qualitative Content Analysis. The original telephone calls themselves, which had been recorded, were analysed using the Roter Interaction Analysis System (RIAS). Among the 33 cases, 13 patients died and 12 were admitted to intensive care. Failure to listen to the caller ( n = 12) was the most common reason for malpractice claims, and work-group discussion ( n = 13) was the most common measure taken to prevent future re-occurrence. Male patients ( n = 19) were in the majority, and females ( n = 24) were the most common callers. The most common symptoms were abdominal ( n = 11) and chest pain ( n = 6). Telenurses followed up on caller understanding in six calls, and mainly used closed-ended questions. Despite the severity of these malpractice claims, the measures taken mainly addressed active failure, rather than the latent conditions. Third-party communication should be regarded as a risk. When callers make repeated contacts, telenurses need to re-evaluate their need for care.

Summary Background Preceptors play a critical role in the process of developing nursing students' knowledge, skills and ability to make independent and critical judgments, however relatively little is known about what aspects are associated with nurses' performance as preceptors. Objectives To investigate structural conditions and professional aspects of potential importance to nurses' perceptions of their performance as preceptors, and to evaluate the validity and reliability of a questionnaire measuring nurses' perceptions of being a preceptor. Methods The study had a correlational design. Total population sampling (N = 1720) in a county council district in central Sweden was used to screen for nurses with recent preceptor experience, 933 nurses responded (response rate 54%), of those 323 nurses fulfilled the inclusion criteria. The present findings are based on data from 243 of these subjects. Data were collected with a questionnaire and analyzed using multiple regressions analyses, exploratory factor analyses and reliability coefficients. Results The results show that aspects such as receiving feedback on the function as a preceptor, being able to plan and prepare the clinical education period, receiving support from unit managers and having specific supervision education explain 31% of nurses' overall view of their performance as preceptors. However, structural conditions and professional experiences could not explain preceptors' use of reflection and critical thinking when acting as preceptors. These findings are discussed within the framework of Kanter's structural theory of power in organizations. Further, the psychometric evaluation showed that the questionnaire is a valid and reliable instrument for measuring nurses' structural conditions for and perceptions of their performance as preceptors. Conclusions Structural conditions such as feedback and support seemed to strengthen nurses' general view of their performance as preceptors but did not seem to facilitate nurses' work toward the aim of higher education and helping nursing students develop critical thinking.

In this study we investigated the correlation between individual linguistic ability based on performance levels and their engagement of typical and atypical language areas in the brain. Eighteen healthy subjects between 21 and 64 years participated in language ability tests, and subsequent functional MRI scans measuring brain activity in response to a sentence completion and a word fluency task. Performance in both reading and high-level language tests correlated positively with increased right-hemispheric activation in the inferior frontal gyrus (specifically Brodmann area 47), the dorsolateral prefrontal cortex (DLPFC), and the medial temporal gyrus (Brodmann area 21). In contrast, we found a negative correlation between performance and left-hemispheric DLPFC activation. Our findings indicate that the right lateral frontal and right temporal regions positively modulate aspects of language ability. funding agencies|Stahls Foundation||Strategic Research Area of the Center of Medical Image Science and Visualization (CMIV) at Linkoping University, Sweden